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CD I CD a q t-j °oei �T Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count t* Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitn ygy No.: Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)). JJJJJGG Permit Holder's Name: ❑ City ❑y� I1aga nTown f: State Plan ID No.: alantine, Terry ki icklnnlc Township CST BM Elev.:- insp. BM Elev.: BM Description: Parcel Tsuc ��67 -90 -000 l0 v w c 6 ; TANK INFORMATION ELEVATI N DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Ve se r S v Benchmark _DDI - - -- Alt. Aeration`" J Bldg. Sewer I^PLL) Holding <�)Ht Inlet l TANK SETBACK INFORMATION ( >t Outlet rG TANK TO P/ L WELL BLDG. Air I to ntake ROAD Air Septic X6'0 r > s-1 t3" NA in — NA Header/ Man. Eldin Dist. Pipe Bot. System r . PUMP / SIPHON INFORMATION Final Grade turer nd St cover Model Nume- GP T - Lift Friction S stem TDH t L oss ead ,----' [ Force Length Dia. :�L = D, , ,t To Well SOIL ABSORPTION SYSTEM ( gW TRENCH Width Length N 0.O f Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION D M EN SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHI ufacturer: SETBACK INFORMATION Typeof CHA R Moe Nu System: lc co— OR UIVI 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 El No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present etc.) Ins ection Inspection Location: 1436 Oak Drive, River balls, Wl 54022 (SE 1/4 NW 1/4 24 T28N R1 8W) - 24.28 18.376 1.) Alt BM Description= %)(, Gev�r 2.) Bldg sewer length= a(w,osf foo' 6t cov��u1 r,,,9 1- 2 � - amount of cover 0 ba..r 1 0 6'e) y 6�ed",&Ld Plan revision require ft ❑ Yes No Use other side for additional information. 60 a , V L SBD -6710 (R.3/97) Date( nspedor' i ature Cert No r� ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: x , x ° r . { f { : R i i r p m, F " r — ° } E f a f � x P ,. °s. ° m,...,.z»..,. ,. a ....m ° t a e t e r i p a x x x ry� t 1 f i 1 c t—" " ! a �.,.»`.. d � a x f . f # � e °. s 3 ; e x f r { a t � s f d r e S Safety and Buildings Division SANITARY PERMIT APPLICATION 20 W. Washington Avenue * P O Box 7162 N *I s consin Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 vi x 11 inches in size. 5 • See reverse side for instructions for completing this application State Sanitary Permit rT umber '3 5 - __ - >' - 55 -- 2- Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan Review Tran cC tuber C �pt,t S h APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N I r �- SOMI Property Owner Name Property Location 1/4 /4, S T, N, R$ E o Property Owner's Mailing Address Lot Number Block Number r/ 3 6 �-- City, Statg Zip Coe Phone Number Subdivision Name or CSM Number TY PE OF BUILDI NG: (check one) ❑ State Owned CI Cit Nearest R d o Village JocP ublic or 2 Family Dwelling - No. of bedrooms own of rt J l !'' Ill BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) d Lt . 'off$- ( , 17 �n 6 .-- 1 ❑ Apartment/ Condo 6 '7 - dod 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. ❑ Replacement 3. ❑ Replacement of Reconnection of 5_ [3 Repair of an _ ----- System -- System - Tank Only Reconnection System _ Existing S�fstem - - - - -------------------------------------------------- - - - - - -- 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 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 15. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation Feet Feet pa VII TANK Ca cat allo in Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name concrete Con- Steel glass Plastic App New Existin strutted T nk Tank Septic Ta or Holding Tank ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ 1 ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for i stallation Of the onsite sewage system sh wn on the attached plans. Plumber's Name: (Print) Plumber' re: (N s) MP /MPRSW No.: Business Phone Number- 1 d� Plumber's A dress treet ity, State Zip Co IX, C11 4RTRAFfJT USE ONLY ❑ Disapproved nitary Permit Fee (Includes Groundwater D ate Issued ssuing Agent Signature (No Stamps) flZrA roved Surcharge fee) pp ❑ Owner Given 25 ZA Adverse Determination fib —?I?-- X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.12199) 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 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 ciiunty prior to installatiorT 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 se. If buildi t is p ublic, check all appropriate boxes that apply. 9 g YP P P I' B if permit is for tank replacement, reconnection or repair. IV. Type of permit. Check only one on line A. Complete line pe p p YP P Y V. Type of system. Check appropriate box de depending on system type. YP Y P 9 Y YP VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the cap acity of ever new /or existing tank, list t � P Y Y he total gallons, number of tanks and manufacturer's name indicate prefab or site constructed and tank material. Complete for all septic, pump and P P P 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.), r r must sign application address and phone number. Plumbe us s g pp tion form. a IX. County/ Department Use Only. II � 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 i i systems; r lacement system areas; and the location of the building served tanks; distribution boxes; so absorption ep y g , - 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. i r Safety and Buildings 1340 E GREEN BAY ST STE 300 SHAWANO WI 54166 TDD #: (608) 264 -8777 N visconsin www.commerce.state.wims Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard Secretary March 22, 2000 CUST ID No.226900 ATTN: POWTS INSPECTOR ZONING OFFICE SHAUN R BIRD i �� ! 7 , §T CROIX COUNTY SPIA 1008 192 ND AVE - 1 W1 CARMICHAEL RD NEW RICHMOND WI 54017 r,.._° „ - HU)9SON WI 54016 RE: CONDITIONAL APPROV PLAN APPROVAL EXPIRES: 03/2 /2002 P Identification Numbers 4 -'�c� Transaction ID No. 302781 t Site ID No. 187615 Please refer to both identification numbers, SITE: �s Site ID: 187615 4 ` above, in all correspondence with the agency, ST CROIX County, Town of KINNICK I.43 d VER DR, RIVER FALLS 54022 SE1 /4, NW 1/4, S24, T28N, R18 Facility: TERRY GALLENTINE STORAGE / WORKSHOP 1436 OAK RIVER DR, RIVER FALLS 54022 FOR: Description: CONNECTION TO EXISTING SYSTEM FOR TERRY GALLENTINE Object Type: POWT System Regulated Object ID No.: 653177 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.0 1(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following condition shall be met prior to issuance of the sanitary permit: • The County shall verify that the septic tank is located at least five feet from the existing shed. This approval does not include any plumbing that is upstream of the septic tank. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/instal lation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 03/15/2000 .•v. h—�_ FEE REQUIRED $ 130.00 FEE RECEIVED $ 110.00 KEIT A WILKINSON, POWTS PLAN REVIEWER BALANCE DUE $ 20.00 Integrated Services (715) 524 -3630, FAX: (715) 524 -3633 , M -F 7 AM - 3:45 PM Make checks payable to KW ILKINSON @COMMERCE. STATE. W LUS COMMERCE. WiSMART code: 7633 cc: TERRY GALLENTINE Safety and Buildings 1340 E GREEN BAY ST STE 300 SHAWANO Wl 54166 TDD #: (608) 264 -8777 NVisconsin www.commerce.statemi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary March 22, 2000 CUST ID No.226900 ATTN: POWTS INSPECTOR ZONING OFFICE SHAUN R BIRD ST CROIX COUNTY SPIA 1008 192 ND AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 RE: CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 03/22/2002 Identification Numbers Transaction ID No. 302781 Site ID No. 187615 SITE: Please refer to both identification numbers, Site ID: 187615 L above, in all correspondence with the a enc . ST CROIX County, Town of KINNICKINNIC; 1436 OAK RIVER DR, RIVER FALLS 54022 SE1 /4, NW1 /4, S24, T28N, R18 Facility: TERRY GALLENTINE STORAGE / WORKSHOP 1436 OAK RIVER DR, RIVER FALLS 54022 FOR: Description: CONNECTION TO EXISTING SYSTEM FOR TERRY GALLENTINE Object Type: POWT System Regulated Object ID No.: 653177 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following condition shall be met prior to issuance of the sanitary permit: • The County shall verify that the septic tank is located at least five feet from the existing shed. This approval does not include any plumbing that is upstream of the septic tank. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 03/15/2000 FEE REQUIRED $ 130.00 FEE RECEIVED $ 110.00 KEITH A WILKINSON, POWTS PLAN REVIEWER BALANCE DUE $ 20.00 Integrated Services (715) 524 -3630, FAX: (715) 524-3633, M -F 7 AM - 3:45 PM Make checks payable to KWILKINSON @COMMERCE.STATE.WI.US COMMERCE. WiSMART code: 7633 cc: TERRY GALLENTINE PLOT PLAN PROJECT Terry Gallentine ADDRESS 1436 Oak Drive River Falls Wi 54022 SE 1/4 24 2 1 i/ 4 1/ 4 S /T 8 R 8 TOWN Kinnickinnic COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE3/13/00 GPD 160 CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1350 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1080 Bed Size 18'X 60' BENCHMARK V.R.P. Base of Shed Siding ASSUME ELEVATION 100 ❑ BOREHOLE O WELL *H.R.P. Septic Tank SYSTEM ELEVATION 92.3 -1 Weiser COUHL NEED 7 - D Vent 5' 1350 Gallon Septic 18' X 60' Bed Tank, inspected and S E C C baffles are still in place 34' ST 30' 50' Well Storage Intercepto Building/wor Main Phed at home shop, 1 floor Existing System is oversized for drain, I current and future usage. employee 4" building Sewer Please note: all records of Building Sewer is to be insulated after 30' from 95' Pro existing system are sent with building, due to the lack B uilding Sewer these plans, please return of >42" of cover copies of existing system, they were sent for reference material only. Sewer Proposed 30'X 72' inspection of existing system Storage Building, found baffles to be in place, with 1 floor Drain, l no ponding was found in bathroom, 2 system. A boring test was employees. done to inspect soils and were found to be consistent with existing soil test. Owner owns entire 40 >100' Acre Parcel, all property lines are >300' except for road Conditionally Oak Drive ''" DEPARTMENT OF COMMERCE DIVISION OF SAFETY AND BUILDINGS ' 1 1 E CORRESPONDENCE 3o2 �$I r PLOT PLAN PROJECT Terry Gallentine ADDRESS 1436 Oak Drive River Falls Wi 54022 SE 1/4 NW 1 /4S 24 /T 28 N/R 8 W TOWN Kinnickinnic COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE3/13/00 GPD 160 CONVENTIONAL X04( IN -GRO ESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1350 LIFT TANK SIZE DOSE TANK SIZE HOLDING &Nk SIZE LOAD RATE .5 ABSORPTION AREA 1080 Bed Size 18'X 60' ---"- BENCHi{ kRK` V.R.P. Base of Shed Siding ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. Septic Tank SYSTEM ELEVATION 92.3 -1 Weiser CORRRECTION NEEbED Vent 5' 1350 Gallon Septic SEE CC�EEpO�jDE�:jCE 18 X 60 Bed Tank, inspected and baffles are still in place — — — — — 34' ST 30' 50' Well Storage Intercepto Building/wor Main 12' at home 6' shop, 1 floor Existing System is oversized for hed drain, l current and future usage. employee 4" building Sewer L I _j Please note: all records of Building Sewer is to be 95' pro existing system are sent with insulated after 30' from B uilding Sewer these plans, please return building, due to the lack copies of existing system, of >42" of cover they were sent for reference material only. Sewer Proposed 30'X 72' inspection of existing system Storage Building, found baffles to be in place, with 1 floor Drain, l no ponding was found in bathroom, 2 system. A boring test was employees. 3 done to inspect soils and were found to be consistent �1 with existing soil test. Owner owns entire 40 >100' Acre Parcel, all property lines are >300' except for road v.o .lv.T.S. Con ditionally Oak Drive _t 4l' 'i . DEPARTMENT OF COMMERCE DIVISION OF SAFETY AND BUILDINGS A LE CORRESPONDENCE 3v2Z � l RECEIVED PLOT PLAN PROJECT Terry Gallentine ADDRESS 1436 Oak Drive River Falls Wi 54022 9 SE 1/4 NW 1 /4S 24 /T J28 aR 18 TOWN Kinnickinnic COUNTY ST. CROIX MPRS Shaun Bird 2 900 DATE 2/23/00 BEDROOM N/A CONVENTIONAL,- I*G D PRESSURE CONVENTIONAL LIFT HOLDING TANK LIFT TANK SIZE DOSE TANK SIZE MOUND SEPTIC TANK SIZE HOLDING TAN S1 LOAD RATE ABSORPTION AREA # of chambers 4 . IL BENCHMA&K V.R.P. of Shed Siding ASSUME ELEVATION 100 ❑ BOREHOLE O WELL *H. R. P Septic Tank SYSTEM ELEVATION Na -1 Vent 5' 1350 Gallon Septic 18' X 60' Bed Tank, inspected and baffles are still in place 34' ST 30' 50' Well S torage Intercepto Building/work Main 12' t home 6' shop Existing System is oversized for hed current and future usage. 4" building Sewer Building Sewer is to be 95' pro insulated after 30' from B uilding ewer -r building, due to the lack r r r13 of >42" of cover cc , olN� Proposed 30' X 72' Storage Building, s ps j with 1 floor Drain, 1 bathroom but no r'' d cS pU� employees. 3 Owner owns entire 40 >100' Acre Parcel, all property lines are >300' except for road Oak Drive N ot1 CG� w Safety and Buildings 1340 E GREEN BAY ST STE 300 SHAWANO WI 54166 TOD #: (608) 264 -8777 isconsin www.commerce.statemi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary March 02, 2000 CUST ID No.226900 ATTN.• Plumbing INSPECTOR MUNICIPAL CLERK &JA UN R BIRD TOWN OF KINNICKINNIC 0088 192 ND AVE 179 STATE ROAD 65 NEW RICHMOND WI 54017 RIVER FALLS WI 54022 -5714 RE: CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 03/02/2002 Identification Numbers Transaction ID No. 298788 Site ID No. 187615 SITE: Please refer to both identification numbers, Site ID: 187615 above, in all correspondence with the agency. ST CROIX County, Town of KINNICKINNIC; 1436 OAK RIVER DR, RIVER FALLS 54022 SE1 /4, NW1 /4, S24, T28N, R18 Facility: TERRY GALLENTINE 1436 OAK RIVER DR, RIVER FALLS 54022 FOR: Description: Private Interceptor Main Object Type: Sanitary Drain & Vent System Regulated Object ID No.: 650383 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: Comm 83.07(1)(b). This approval does not include the private onsite wastewater treatment system. Refer to the before - mentioned code paragraph for requirements on POWTS submittals. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 02/28/2000 ✓��������� FEE REQUIRED $ 60.00 FEE RECEIVED $ 60.00 CURT WENDORFF , PLUMBING PLAN REVIEWER BALANCE DUE $ 0.00 Integrated Services (715) 526 -9056, FAX: (715) 524 -3633 , M -R 7:15 - 17:00, F 7:15 - 11:15 CWENDORFF@COMMERCE.STATE.WI.US WiSMART code: 7657 cc: THOMAS L BRAUN, PLUMBING CONSULTANT, (715) 634 -3026, MON. 7:45 -4:30 TERRY GALLENTINE „ - - ° -_ - - -- Safety and Buildings 1340 E GREEN BAY ST STE 300 SHAWANO WI 54166 TDD #: (608) 264 -8777 Viscons n www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary March 02, 2000 CUST ID No.226900 ATTN: Plumbing INSPECTOR MUNICIPAL CLERK SHAUN R BIRD TOWN OF KINNICKINNIC 1008 192 ND AVE 179 STATE ROAD 65 NEW RICHMOND WI 54017 RIVER FALLS WI 54022 -5714 RE: CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 03/02/2002 Identification Numbers Transaction ID No. 298788 Site ID No. 187615 SITE: Please refer to both identification numbers, Site ID: 187615 above, in all correspondence with the agency. ST CROIX County, Town of KINNICKINNIC; 1436 OAK RIVER DR, RIVER FALLS 54022 SE1 /4, NW1 /4, S24, T28N, R18 Facility: TERRY GALLENTINE 1436 OAK RIVER DR, RIVER FALLS 54022 FOR: Description: Private Interceptor Main Object Type: Sanitary Drain & Vent System Regulated Object ID No.: 650383 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: Comm 83.07(1)(b). This approval does not include the private onsite wastewater treatment system. Refer to the before - mentioned code paragraph for requirements on POWTS submittals. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 02/28/2000 FEE REQUIRED $ 60.00 FEE RECEIVED $ 60.00 CURT WENDORFF , PLUMBING PLAN REVIEWER BALANCE DUE $ 0.00 Integrated Services (715) 526 -9056, FAX: (715) 524 -3633 , M -R 7:15 - 17:00, F 7:15 - 11:15 CWENDORFF cr COMMERCE.STATE.WI.US WiSMART code: 7657 cc: THOMAS L BRAUN, PLUMBING CONSULTANT, (715) 634 -3026, MON. 7:45 -4:30 TERRY GALLENTINE Safety and Buildings 1340 E GREEN BAY ST STE 300 �+ SHAWANO WI 54166 TDD #: (608) 264 -8777 isconsin www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary March 02, 2000 CUST ID No.226900 ATTN.• Plumbing INSPECTOR MUNICIPAL CLERK SHAUN R BIRD TOWN OF KINNICKINNIC 1008 192 ND AVE 179 STATE ROAD 65 NEW RICHMOND WI 54017 RIVER FALLS WI 54022 -5714 RE: CONDITIONAL APPROVAL Identification Numbers PLAN APPROVAL EXPIRES: 03/02/2002 Transaction ID No. 298788 Site ID No. 187615 SITE: Please refer to both identification numbers, Site ID: 187615 above, in all correspondence with the agency. ST CROIX County, Town of KINNICKINNIC; 1436 OAK RIVER DR, RIVER FALLS 54022 SETA, NW 1/4, S24, T28N, R18 Facility: TERRY GALLENTINE 1436 OAK RIVER DR, RIVER FALLS 54022 FOR: Description: Private Interceptor Main Object Type: Sanitary Drain & Vent System Regulated Object ID No.: 650383 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: Comm 83.07(1)(b). This approval does not include the private onsite wastewater treatment system. Refer to the before - mentioned code paragraph for requirements on POWTS submittals. A copy o ill be on -site during construction and open to inspectio hich may include local inspectors. All permits required, 1 prior to commencement of construct. �Q Inquiries `� t the telephone number listed below, or at the address on this let _ e DATE RECEIVED 02/28/2000 Sincerely, G-- FEE REQUIRED $ 60.00 ---� FEE RECEIVED $ 60.00 CURT WE � r � BALANCE DUE $ 0.00 Integrated l (715) 526 -! 15 - 11:15 CWENDO. _ �f WiSMART code: 7657 f�Y L cc: THOM),� . n&AUN , PLUMBING CONSULTANT, (715) 634 -3026, MON. 7:45 -4:30 TERRY GALLENTME v " x PLOT PLAN PROJECT Terry Gallentine ADDRESS 1436 Oak Drive River Falls Wi 54022 SE 114 NW 1/4S 24 /T 28 R 18 WN Kinnickinnic COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 2 /23/00 BEDROOM WA CONVENTIONAL IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers BENCHMARK V.R.P. Base of Shed Sidin ASSUME ELEVATION 100 BOREHOLE WELL O H.R.P. Septic Tank SYSTEM ELEVATION n1a -1 Vent f5 1350 Gallon Septic 18' X 60' Bed Tank, inspected and baffles are still in place —_ _— _ _— — 34' ST 30' 50' Well S torage Intercept M Building/work Main 12' at home f 6' shop Existing System is oversized for hed current and future usage. 4" building Sewer ' d Building Sewer is to be 95' 1 s ^� insulated after 30' from Pro building, due to the lack uilding Sewer of >42" of cover f` ' Proposed 30' X 72' Storage Building, -5 G �'r�E with 1 floor Dram, 1 S� bathroom but no employees. 3 Owner owns entire 40 >100' Acre Parcel, all property lines are >300 9 except for road Oak Drive " Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County w include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location �" V �+ Govt. Lot � 1/4 /4,S T� N,R E ( r) W Property Owner's Mailin ddress Lot # T lock# Subd. Name or CSM# /Y- City State Zip Code Phone ❑ Number city El Village L;;�–Town Nearest Ro G ❑ New Construction Use: ❑ Residential / Number of bedrooms _ Addition to existing building lacement .Public or commercial - Describe: ��� % / _'_ {. /�o�+ a �l o. Ora-41t,41 Code derived daily flow _/ gpd / Recommended design loading rate J i bed, gpd /f1 `� trench, gpd/ft Absorption area required -ban —bed, ft &_7trench 2 Maximum design loading rate J bed, gpd /fl trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations �� ` Parent material G � >f� c /rx.�/� Flood i5lain elevation, if applicable /� /�l ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system}S ❑ U -� S E3 U _S E] U ❑ U E:] S 8.U_ ❑ S 0 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench Ground 3 2 Z f2 � ft. Depth to limiting factor Remarks: Boring # Sa',, '.•'.R , Ground elev. ft. , Depth to limiting factor in. Remarks: VAd ame (Please Print) Signature Telephone No. s Date CST Number � UrU v w SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boren # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots 13 Bed ,Trench Ground elev. ft. Depth to limiting factor in. ' Remarks: Boring # 13 , I Ground elev. ft. , Depth to p , limiting factor 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 # ; Ground elev. ft. Depth to limiting factor ' Remarks: Boring # 1, ' 1 6 , n �� < Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name Terry Gallentine Shaun Bir Address 1436 Oak Drive River Falls Wi 54017 CS #226900 Lot - - -- Subdivision - - - -- -- Date 2/23/00 SE 1/4 N W 1/4S 24 T 28 N/R 1 8 W Township K'innidAnnic E] Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Base of Shed Siding System Elevation 92.3 *HRP Septic Tank -1 Vent 5' 1350 Gallon Septic 18' X 60' Bed Tank, inspected and baffles are still in place 34' ST 30' 50' Well ft- �— — — S torage B uilding/work 12' a t home 6' shop Existing System is oversized for hed current and future usage. Owner owns entire 40 95' Acre Parcel, all property lines are >300' except for road Proposed 30' X 72' Storage Building, with 1 floor Drain, 1 bathroom but no employees. >100' Oak Drive f � i IprRAN'S! D8m DOCUMENT NO. VOL ��1.�jP APE 51'2 a' Larry . Patton and Lind Patton, Grantor, conveys and warrants to Terrance Lane GallentineKantes, the following described real estate in St. Croix County, State Of Wisconsin: REGISTER'SCFRSE * *also known as Terrance L. Gallentine and Anita L. ST CRUIX CTY..WI x Gallentine, hAe d a(d wife as arvivoxsdp marital property ,34 ,' Southeast Quarter of the Northwest Quarter (SE' /4 of NN /h) Of Section JUN l 3 1997. Twenty -four (24), Township Twenty Eight (28) North, Range Eighteen ¢. (18) West. 9:30 A M This deed is given in satisfaction of the land contract dated d D November 23, 1987, recorded November 24 1987, in volume 797, pages 487 -489, as Document No. 432470 NAME AND RETURN ADDRESS q ST. M VAUD ITLE OM M, NC. � P.O. 90X 138 218 N. MAN ST T NsFE L? RN81 fAIJ S, .M 51022 f Parce I enti ication Number (PIN) This is not homestead property. Exception to warranties: All easements, restrictions and rights- of -vay of record, if any. Dated this IfA day of June, 1997. y _(S�) (SEAL) Larry A. tton f _(SEAL) 4 1 1 N Y O (SEAL) f on AU&JEN NTICATION ACKNOWLEDGMENT i OF WISCONSIN Signature(s) STATE Be. COUNTY ) authenticated this , 39_ Per Wally came before me thi 4 day of day of � h �, , 19 the above named Larry A. Patton and Linda A. Pot on t kn to ),q. a eon(a) who executed the f eqo inettu ; owledge the same. a � , TITLES MEMBER STATE BAR OF WISCONSIN (If not, 1 authorized by §706.06, Wis. State.) a Not PuHtiC �); County, Wis. T828 21185><1A01'IT 108 DIU1TPiD D!: NY � T e t FZ� not, exp ration data: Stuart J. Krueger " y Rodli, Beaker, Boles 6 Krueger, S.C. PO. Pox River Falls, WI 54022 4-4�_- 4 ' REPORT ON INSPECTION OF SANITARY PERMIT # c513,_5 Name and Address of Permit Holder Person /Persons at Site (2 )Date of Inspection ame, ress, o. o installing Time of Ins ection ing p umber p 6c4c G'Co 4 11, 3 INSTAL ATIOY CONSISTS OF: (Septic Tank [] Seepage Trench n Dosing Chamber ❑ Seepage Pit M Seepa a Bed ❑ Holding Tank []F Sy stem [)BENCHMARK: (P ermanent reference Point) escribe: Elevation of vertical reference point: Slope at site: c - ))MATERIAL AND DEPTH OF SEWER: -))SEPTIC TANK: Manufacturer: %_. �t;t� Liquid Capacity: A r / Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: )DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? []YES ❑ NO Wired? ❑ YES ❑ NO ! HOLDING TANK: Manufacturer of gallons construction ; depth to the cover ft; If septic tank is being used are baffles removed? 0 YES ❑ NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ N0; Wired? ❑ YES ❑ N0; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material Distance from building to vent l) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe - elevation ft; bottom of seepage pit elevation ft. 10) SEEPAGE BED SIZE: ; ft width; 'ft length; tile depth; .4 T� l i.neal feet ti 1 Q ; 17 ) ft to residence; // < l ft to well ft to i of or property line; ft to ordinary high water mark of lake or stream; ��'% ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. SEEPAGE . Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. 12) Has system been installed in area indicated on EH 115? YES [)NO 13) Has system been installed in floodway? [:]YES NO Floodplain? ❑ YES .] NO )ILHR -SBD -609 N. 8 Signature of Inspector: / AS BUILT SANITARY SYSTEM REPORT t��c 1 F tom-' WNS S . � T c.� N, R I S , S . CROI COUNTY N . UBDIVISION LOT LOT SIZE PLAN VIEW istances & dimensions to meet requirements of H62.20 -- SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM • �, 6 I di a e NotthjArrow SCAL i ;EPTIC TANS) ��•� �' MFGR. �> ,tZN CONCRET K _ STEEL N0. oT rings on cover Depth 'UMPING CHAMBER SIZE PUMP MFGR. — ML NO. GALLONS TRENCHES NO. of width -- length area 4ED NO. of lines width length area depth to top ot pipe 1 Ir PITS vutsiae diameter total pit area ,GGREGATE 1� ERK RATE AREA REQUIRED AREA AS BUILT )isclaimer: The inspection of this system by St. (Croix County does not imply :omplete compliance with State Administrative Codes. There are other areas that .t is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if -Lailure is noted the .ounty will make every effort to determine cause of failure. ;REASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. INSPECTOR f� L )ATED _ ( 11" LUMBER ON JOB CENSE NUMBER EH 115 Rev.9i78 �0 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: :, ' 1 1 /, Section-2Y,T=N,RZE (or W)�Township or Municipality �+ t Lot No. , Block No. County St, Owner's /Buyers Nam l • e: S' Iv on me n n Mailing Address: ' TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL - X EFFLUENT DISPOSAL SYSTEM: NEW _ REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MAD : SOIL BORINGS ^, PC C96) PERCOLATION TESTSn -" C P/ SOIL MAP SHEET NAME OF SOIL MAP UNIT tf r' 11a PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL RATE BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN i P— P— P— SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED' IN INCHES B— b 6 '' 9 '" ILL N11 it it J!�l 37 XT 8n nkse; 1 510 , T-ige B .2'' / R T gh 54bioilly t_.11 A-6 > nbuiTY3'�R-TiGr r PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy ,Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. ' 0 D I � G I e ay o l gt Q� �•� Dell no t N not f a sc Bore //o /es flt r C. Xole s' o c ; e . Elev •4 Base -if PC Phil U S J "' ' � • Q c� Po ut4r `� cv QC' c� t 1, the undersigend, hereby certify that the soil test on WsAf drg Cmre made by e in acc rd with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location test ho s are correct to the best ,of my + knowledge and belief. ter; ) e 0 ct �j 1 hrtG� FI L° id awa Scre 5it� of r Name (print) l Certification No, Address Name of installer if known_ _ Copy A —Local Authority CST Signature )6' rl I State and County State Permit # PLB67 Permit Application County Per it # for Private Domestic Sewage Systems County 'DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY n l Mailing Address: e I ge h far (t"y �Y S �c�� B. LOCATION:_' / 4 �l� /4, Section T R E (or) , Lot# City _ Subdivision Name, nearest road, lake or landmark Blk# Village � � /T-' / � Township _ e r C TYPE OF CUPANCY: Commercial "Industrial "`Other (specify) — 7 �`Variance Single family Duplex No. of Bedrooms No. of Persons �Lb 1 1q0 D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder _YES _NO # of Bathrooms Automatic Washer YES NO Other (specify) _ E. SEPTIC TANK CAPACITY /I" _ Total gallons No. of tanks "Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement _ Prefab Concrete —r 'Poured in Place _ Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) — 2) 3) Total Absorb Area sq. ft. New Replacement "Fill System Seepage Trench: No. Lip. Feet Width Depth Tile Depth No. of Trenches — Seepage Bed: Length b 0 Widt Depth Tile Depth M No. of Lines 3_ Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope Mo 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 Test p NAME 6MctSr�n C.S.T. # "N0 O and other information obtained from_ (owner /builder). Plumber's Signature MP /mPRSVv,* Phone Plumber's Address Ac e ael. AFTI PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). � 9� S laFe s1° �O1';c kef. Elev, Q s c- o{� p o I,n r tree Do Not Write in Space Below - FOR DEPARTMENT USE ONLY Date of Application 7 -/ 40 Fees Paid: State 35: ' x. Cunt o`t.` Dave Permit Issued /Re}eeted (date) _Issuing Agent Nat Inspection Yes_X_No Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Roviearl nata R/t /7R s REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM Sanitary 1'er.mi t 113 State Septic go 7 NAME Gp e►� _S�4N Tree �5 Towns h� p ►�►h� a JC �y1/9�� L' St. Croix County j Location Section Lot N SuEidivizion SEPTIC TANK Size � ;'� :��\ gat to nb Numb e o6 co mpahtmenta Distance 6h om: We.t.t � � Buitding C l2$ Atope Highwaten PUMPING CHAMBER Size pt.ton,& __ ..Pump Manu jacxur.e Mode,t Numbers HOLDING TANK t • Size ga.t.tonb Number. o6 Compar.tment Pumpers A.taAm System Distance 6r:om: We•t•t Buitding 12$ b.tope Highwaten ' ABSORPTION SITE Bed�, Trench Distance. 64om: We•tt � ��� Buitding 1.2$ b tope ---� Highwatev ABSORPTION SITE DIMENSIONS J Width o 6 .tr.ench 6t Req u.i , %ed area 4' 6z Length o j each tine li 6t Depth o6 /Lo ck b e,tow ti to in Numbers o6 ti.-ne,6 Depth o6 tock oven tite �� in To tat .teng-th o6 , tines / 6x Dept o6 .ti to b e,tow grade--A in Distance between ti ne ? ! bx S.tope o � in. pen 100 j ; Tota.t abb ohpti.on area ri 6z Type o6 Cover.: Paper. or 6thaw C PIT DIMENSIONS �0 d Numbers o6 pi" 3 around pit.6 yeb no � �v • Outside d.iameten Depth be.tow in.tet 6t Tota.t abbonption area At Area %equited 6.t INSPECTED BY A1 l TITLE APPROVE �1 DATE 19 8_ REJECTED DATE 198 REASON FOR REJECTION Y r F 1 i I ti Ap 00 4� •� rte+ �z �00 (� N � H N � V V) � V � M � O C N • Aim o 8p1g Amon A� —� N O . N O � bl5 ogbuo4S p -� C M is. C' eS 0 M 0 �i C � � V a t pC, x CM Q c�l_ (11F� 0 b O ��� L l a zo LN cn w U4 N b O H w � z; r N p O O ti ti M b L O N C L h: -\e O O 6 mo 0 C L N OO CL ED 0 pO y i' O p Obi � E2 z C VOA I O OU4= @ d CIO fli h .@. CD 43 Z tr 3 CL o� @� y m aL y o N o O O N v- C Q O MO • : . O N N X O O o > °( o n C L f6 OLL `y = Z @ slnz C t4 ` V, L Q. 7 @ i C C LL C @ N rn O �. LL O N a Q7 � N • O N to 'O N C Q= d 0 Q UO N N Q U 00 Zb N co V N a) Z h Z N E 00Z, O « O O ° E v` z am N C O O Z 7 % ° c v a o o Y Y y Z v c ° c U7 i- P O m Z O N c E P E N M O N O O U Q1 a cy m V) a a� N N • d cn O m N C � O © Z m Z o Z m Z .. c 00 i! d N A M �' N .. R 0 U- CL ° V Q 'm y C N O !O r p hh ,, . 0 -Z 0 CL ° "rJ Z o y alp U ' ~rN-~ a CU �w Z N ►i LL 0 0 Z n x O O O •ny ;� o.o.a Daaa > (o (mil 6! V to N I O O V) v N ._I U > m O } m } @ CO d1 o O O 'p Q O O "L7 I( M m d 1 0 m Q) � to ro QI � in 0 3 @ h c 'O U1 C O O `o G E o 00 4 rn ~ w a Q c ° o rn a .E � V N P y E 0 (o C C C 0 O_ N CJ7 0 G 0] H O N C N O Y 7 F� 2 C N O O Z7 M 2 7 O to t N C_ N O p y E @ @ U O O O N O @ • *"� ,�+' O N Y CJ N O Z N� d' in U Z N Z T - L IL a; Ri CDa rr �� E L y s R Lo1 A �a2,i'',o0) 0 ONv r sysT��t �ivsT��lE� si r. Z i - � ct � s N oTt 1'5 0,0 C tl �- 1 1p QA't - - uT s YS l~� ('S STC - 104 ....� AS BUILT SANITARY SYSTEM REPORT,' it OWNER ADDRESS 1 q 3 G OAI< Z R '•, , � u t:- 12 f:�0 -5 S Ll © 2. SUBDIVISION / CSM P'VF of * LOT SECTION ) T 2.9 N -R (�> W, Town of k � 1 C r`.vN C� ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM S,e�e., SEpE�hTL '�I o T' �i r4ti1 ORIGNAL INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. s • CST ' S Via �' s P � l o.� tJ• �o . 4` 0 �4 G.2 Gi,vE . BENCHMARK: G( E A r to Z r t d 0. O I ALTERNATE BM: J! OT pr f t' A.) I'S tf e"b e'b 4 G�2 t`'� `F 100(, 5 - poZe0 DC !'+ r= Its. t3 , SEPTIC TANK / DOING PMMW.L N Manufacturer: Lys �,�aer�e Liquid Capacity: �a�n Setback from: Well 3 House loo y Other Pump: Manufacturer Model# Size ---- Float seperation Gallons /cycle: Alarm Location SOIL ABSORPTION SYSTEM ` Width: Length 79 Number of trenches 2 Distance & Direction to nearest prop. line: Setback from: well: House 49 Other / 5� Ttt c TA" k , A AP 1n4ca- Ld U Ek ( ELEVATIONcS� Building Sewer 11;L -04a ST Inlet. 1 • ? 1 ST outlet /0 ` 7 • PC inlet /� PC bottom_ Pump Off Header /Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: q "? S PLUMBER ON JOB: RoSER - r 4L8tom-lC' LICENSE NUMBER: " P"S 33 0 7 INSPECTOR: MA 3/93:jt 2, � - 43 U/ 7 _ I 0 T ID14AII 3G �3�ORM5 t -lt�g s 1 coo 2-, yo 4 �J e fST of jzb No I fs4tes � .2b 5'x79 1 `ET To s'x79' 1091 5 1,577 G���U�TI'O�US TR�X sys Top l P'p Top Pft z FojA DE per. (V ENT) ( OK � coves A " /07.30' 10 - 10 0 / /o. 3 " - 2 i A51 6, wr&7 vAj D E7e 1 i ` z�zq A(/G / 9 1S 7 P11 1,06- I /fyfeE7 &47F P,'007tr7tr w/ Ty pMk FA-QP,lC C5T'5 13i4 = T OF �a ►► S (7 E 1 e p No pop `i'O ORIGINAL 5eALE tit ! ao, Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM County: Labot and Human Relatioru INSPECTION REPORT ST. CROIX Safety anal Buildings Division ` (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Pe A L 1V 11�tr:, TERRANCE /ANITA El City 11 village R Town of: State Plan o.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: A 0 u J TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic d_o--o Benchmark 11d. q3 /pp, Dosing Aeration Bldg. Sewer Holding St / Ht Inlet a•4 �' /O Y, 96 I TANK SETBACK INFORMATION St /Ht Outlet TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet Air Septic >a S' j8 ' ��,� ' y5 NA Dt Bottom Dosing NA Header / Man. �' o 3q 3 ' Aeration NA Dist. Pipe 3.a 3 ! 0 7, X63, 3 , Holding Bot. System -og" io s /0 3 PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM Fricti S stem TDH Lift L Hy a DH Ft Forcemain Len gt Dia, Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J 1 `3 DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O f CHAMBER Model Number: System:yyc�.�a /U8 `1 'v OR UNIT DISTRIBUTION SYSTEM Header 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 o7a —o? y ` Topsoil ❑ Yes El No ❑ Yes ❑ No ! COMMENTS: (Include code discrepancies, persons present, etc.) r LOCATION: Kinnickinnic.24.28.18W, SE, NW, Oak Drive Plan revision required? ❑ Yes ❑' No n Use other side for additional information. SBD -6710 (R 05/91) Date 6"1 n'spectocs Signature Cert. No. SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY 7• C/e6 / STATE SANI RYPERM T # -Attach complete plans (to the county copy only) for the system, on paper not less than E S 8% x 11 inches in size. ❑ Check if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER 6 PROPERTY LOCATION �/ �7 n l t��v� V I Atii 4 A� G,4 &FAA/ < F 5F %, A10% S 7 T T 2 N, R id E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Iq3 o K 'PA2 C ITY, �f ST ZIP C 6 2 PH fl-5 N o f 4e(o SU NDIVIS I ON NAME / Q R NU I. TYPE OF BUILDING Check one) � NEAREST ROAD III. ) State Owned Z O VILLAGE: ❑ Public L71 or 2 Fam. Dwelling-# of bedrooms — PARCE TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ 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. TY�EOP -EOF PERMIT: (Check only one in line A. Check line B if applicable) L"J A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit## Date Issued V. TYPE OF SYSTEM: (Check only one) 5yS?` -ee.,4 -/ D Non ,, P,,rees/ssurized Distribution Pressurized Distribution Experimental l fj d Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure r 43 ❑ Vault Privy 14 ❑ System -In -Fill 2 iWu da e/ f d 5" )('15 ()JO VI. ABSORPTION SYSTEM INFORMATION: l d % O 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE b REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION 30 t'a� �I S c . � /o 4e76 F eet l os. Feet VI CAPACITY I. TANK Site in aa ons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank ZV Lift Pump Tank/Siphon Chamber /v El Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) /MPRSW No.: Business Phone Number: b � Plumber's Address (Street, City State, Zip Code): &5_57 O / �vj?r'� /0• #V Pro .,/ - 40 0, 01 IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved SaniT Permit Fee (includes Groundwater ate Issued Issuing Agent Signatu No Stamps) L urch arge Fee) S d Approved El Owner Given Initial • f � •/ (� -! III Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD- 6398(R.08/93) 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 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. 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 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 & 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 p y a g dd ess P ov de 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. 111. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in #1 -7. VII. Tank information. Fill in the capacity of every new and /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 8% x 11 inches must be submitted to the county. The tans must include the following: A lot Ian drawn to scale or with complete P 9 ) P plan, p to 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. i 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, ground- water contamination investigations and establishment of standards. I i SBD -6398 (R.11/88) NO• p,Pb �°Ty L�:v� f I i � 07 d 2. • 13 J. flo � � 7 Q Gs �j�- /4 cc OAS lb s /sT 7p i Fi v y 3` s' PRap os�D �a► � ,�, �� well p'PF 000� 3 � S (3 L 0 6 �e 5 127OLF - EIv�T i'o� 107.0 � h T E LE VATr'ok)s e b 5 163. y0 SCALE l = y C33 /oq 60 w y i 3 . v ' • = Beick' o' yO 0 46w 7; eocl,� /2.70 Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12' Above . fin es ' /O 7, p Above Pipe 4 Cost Iron L� ! Vent fIpe' r 10 Final Grade Synthetic Covering Min. 2' Aggregate Over Pipe Distribution -- Tee Pipe 0 0 0 0 0 , y Aggregate o Pertbrated Pipe Below 8eneoth Plpe o — Coupling Terminating At Bottom Of system Fresh Air Inlets And Observation Pipe n+ -- Approved Vent Cap Minimum 12 Above Final Grade Above Pipe 4' Cost Iron 'to Final Grade Vent Pi0s Synthetic Covering Min. 2' Aggregate Over Pipe Distribution + -- Toe Pipe 0 0 0 0 0 Aggregate o Perforated Pipe Below Beneath Pipe o — Coupling Terminating At Bottom► Of System Wisconsin Depa:RwIofIndustry, SOIL AND SITE EVALUATION REPORT P of 3 Labor and Human Relations — Division of Safety a 6u Kngs 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 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. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION -el )ey �r,4�rE".� �-:NE GOVT. LOT 5-- 1/4 Nw1 /4,S a �T 2 - 0 0 ,N.R /d p E (a) W PROPERTY OWNER':S MAILING DDRESS LOT TT LOCK # SUBD. NAME OR CSM # / & oA MAILING P,4.-e aF Yo 14ckc C IT Y, vew �� s y0 /r E ( P 19 �i57 R (2 K 6 []CI • �NILLAGE N NEAREST ROAD /Y 7 1�1�t/N1•C.k /;vt�I'G 1 04 IUD [&J Construction Use [<R esidential / Number of bedrooms Z-• [ ] Addition to e xisting building I ) Replacement [ [ Public or commercial describe Code derived daily n 300 gpd Recommended design loading rate bed, gpd/ft trench, gpd/ft Absorption area required / bed, trench, 111 Maximum design loading rate • S bed, gpdfit • Co trench, gpd* Recommended infiltration surface elevation(s) -sue P ' 3 ft (as referred to site plan benchmark) Additional design / site considerations NSF T't'E'" S D,v S d w POo 4,OX Dg's T,;A *13 v 7"1 P t material SG S P - 11A';v {1'114P s Flood plain elevation, if applicable • f - ft 'C- ,v e S = Suitable for or syst la U Mato ❑ U IN c�UN�o U EssURE nT G9!►DE� U s IN FILL HOLDING TA =Unsuitable for s stem L t � � ' ' S S L7 L'i'S LA'S D'S O U ❑ S at SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bmifty Roots GPD /ft [3 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed lerrdl /y to yip y /5 /,k, ,� �.e cs /7` •�? Ground G y��G /o Yet S/� • S• �� S ��2. r r 77. • S elev. /04 ft _ Depth to i limiting factor ,► [ i Remarks: Boring # 0 - 5 ICYR S f �++► yR �.Q r s f. 7 i 2 -- 13 S- 2 U /0 W y /!K 15 /�+•r %j G�.� �' S /f • 7 • � C, D Y t Sly ----- p, S cQ,2 C s Ground elev. fL 1. b - /b /t G f� '—" t N� S. O , S GQJQ -- •S �S /03 Depth to limiting fa ctor L it Remarks: T Name: -- Please Print Ems' •� Gl T Phone: Add ress: GSS 4'�E'i / /P • �f vOSo.J Cv 719r4y 2-!0 - f CSrly .2y, Signature: Date: CST Number: Le/-V 6 �` F ORIGINAL PROPERTY OWNER T G� ' SOIL DESCRIPTION REPORT Page Zof 3 PARCEL I.D. fr Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rfiench 3 0 -/1.. /o Pe 3 — S / ,rte ar'�- 1. fi . yA�tr Ground C' -�/ /6�� �P -S• d. S 6P elev. Depth tD limiting factor p Remarks: Boring # A O- y / 0 f //P 3l _ /s /"w, yit d� S 2'F • 7 • o 13 /3 �i �sy� y� g,P�v ��y �, �fe �s 71 .�. Ground elev. /oY/P //3. 0 ft. Depth to limiting fatU ry F7 Remarks: Boring # ,4 - s- 10 31Y /S 0-1 Ground /0 el ev ft. Depth to limiting fac Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: eon 000nio ncmm t • i i ' 1 f q '� f : t. No•. ,a,Pop� �Ty L�:v6' S7' /a Ir y �0 3 j ol d � . a �F } 3 , V III E LE VA 'o �l 4 `r T� �JS � � 5 S CALE : 1 : y 33 / w Li ol i �N •grPF4 I3 — — � �b �F,� cC� /oz.. �O • OA le fin. STC -105 �0 �CAt� SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County / OWNER/BUYER V'V'&A Le — a ti d &t ►J a- MAILING ADDRESS �Gl Yi! & v I PROPERTY ADDRESS 14 /9 OQ k— brz 1 v-i ' (� q . (location of septic system) Please obtain from the Planning Dept. CITYISTATE PROPERTY LOCATION 114, 114, Section_, T 2 b N -R ' W TOWN OF I )Q ' % Vt VI *' l C k') V\ 1A ' I CJ ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP _ ,VOLUME , PAGE , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge and scum. 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 DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: (� DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, Wl 54016 11193 S T C - 100 • 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. ------------------------------------------------------------------- Owner of property e U U a. Q� 0.LAJ & 1 ( 42t-� * itll � Location of property 1/4 1/4, Section _,T Z N - I W Township IZHA� vt Mailing address V r T5 W % ' , o Address of site a& — Moe -L 06- k- 0t,V`e� Subdivision name Lot no. Other homes on property? Yes No Previous owner of property LCk V`� D ill Total size of property U eye S Total size of parcel yo a cye Date parcel was created— 6-14A, Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes V No Volume 2 f7 and Page Number y d 7 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 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 owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the o fice of the County Register of Deeds as Document No. 't32 4*7Q , 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 the office of the County Register of Deeds as Document No. ignature of A licant Co- Applicant /Ci Dat o f Signature Dat of Signature J� { 4 A_ .__ •____ _ __^ _. q _ t tAvL DOCUMENT N o. STATE BAR OF WISCONSIN FORM 11 — 1982 THIS SPACE RESERVED FOR RECORDING DATA 1 LAND CONTRACT ` Individual and Corporate (TO BE FO ALL TRANSACTIONS WHERE OVER 432470 $25,000 IS FIN N ET AN N OT NON - CONSUMER REGISTERS OFFICE �! Contract by and between ---- ------------ - ------------------------------------------- ARRY A POTTON and ST. CROIX CO.. WI 41 Recd for Record 1 LTNDA A. PO-TON _ 1 I I) - -- - - - -- - — - -- - -• - -- --------- -- ----- - - - - -- - - -.... ("Vendor", NOV 2 �98� whether one or mare) and _.. TERRANCE LANE- GAL]TINE ------- 1(:30 •----------------------------------------------------------------------------------- ----------------------- - - - - -- of M --------------------- ------------------------------ - - - - -- ( "Purchaser ", whether one or more). �' r f! Vendor wells anc( agrees to convey to Purchaser, upon the prompt and full per- formance of this contract by Purchaser, the following property, together with the I i rents, pirofits, fixtures and other appurtenant interests ( all called the "Property" -- - -__ _� � I 5t . Croix --- _- _ -_ -_•- County, State of Wisconsin: RE TURN TO Terrance Lance Gallent ne I ' in 2303 Kennedy Street, N E. I Mi nneapol is, MN 55413 �! SE! NW Section 24 Town 28 North _ 1, p Range 18 West, together with 300 shares of stock in The Federal Land Bank of St . Tax Parcel No . ... ............................... Paul presently valued at $5.00 per share II associated with Iran #4623671. I it i i I I I 1 ' G is not This .............. .............. homestead property. � is (is not) Purchaser agrees to purchase the Property and to pay to Vendor at ....their residence the sum of $-- Q,.5.QQ " 00------ --- -- ----- ------ -------- - ------ in the following manner: (a) $. � ?�b... b 0 .-------- •- •-......- •- -- -..... at the execution of this Contract; and (b) the balance of $- 37 } 000. 00__ ______________ together with interest from date hereof on the balance outstanding from time to time 1 ' as follows: $29,551.61 shall be payable in annual installments due on 12/1- 'of: each year coTrmencing 12/1/88. Interest shall accrue at the same rate charged to Vendor by The Federal Land Bank of St. Paul on loan #4623679 and the amount of annual ! payment shall correspond to the amount of Vendor's payment to The Federal Land Bank, and shall be paid direct to The Federal Land Bank by Purchaser. See i Addendum. 1 i Following any default in payment, interest shall accrue at the rate of ------------ % per annum on the entire amount I in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire principal balance) . 1 Purchaser, unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonably antici- pated annual taxes, special assessments, fire and required insurance premiums when due. To the extent received by Vendor, I� Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for payment of �I taxes, assessments and insurance will be deposited into an escrow fund or trustee account, but shall not bear interest 1 unless otherwise required by law. �I If Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any amount may be prepaid without premium or fee upon principal at any time In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of principal, and interest land in gnrh rnsr arrrninr irfo,r,+ f +i, f •, .•t j- 1 ..11 1 - - -�" 79'1 PAGE 488 Purchaser promises to pay when due all taxes and assessments levied on the Property or upon Vendor's interest in it and to deliver to Vendor on demand receipts showing such payment. Purchaser shall kee the improvements on the Property insured against loss or damage occasioned by fire, ex p tended coverage perils and such other hazards as Vendor may require, without co- insurance, through insurers approved by Vendor, in the sum of $..full ._ Z11Sllxk7ble ..VOIUQ.., but Vendor shall not require coverage in an amount more than the balance owed under this Contract. Purchaser shall pay the insurance premiums when due. The policies shall contain the standard clause in favor of the Vendor's interest and, unless Vendor otherwise agrees in writing, the original of all policies covering the Property shall be deposited with Vendor. Purchaser shall promptly give notice of loss to insurance companies and Vendor. Unless Purchaser and Vendor otherwise agree in writing, insurance proceeds shall be applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair to be economically feasible. Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to keep the Property in good tenantable condition and repair, to keep the Property free from liens superior to the lien of this Contract, and to comply with all laws, ordinances and regulations affecting the Property. Vendor agrees that in case the purchase price with interest and other moneys shall be fully paid and all conditions shall be fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to the Purchaser, a Warranty Deed, in fee simple, of the Property, free and clear of all liens and encumbrances, except any liens or encumbrances created by the act or default of Purchaser, and except: .II1L1111 CI jpc� 1.. d11d_OZI].[1;.._... ordinances_,.. easements._for_pub2ia.uti_d ies. grid._ 19 -------- , - - - - -- if--any ........................... -----•----•--------•---._...-----•------••-•---•----- •------- •---------- • - -•... ------•----------•-•--- ••- ••-------- •-- •----- • - -•••- . ...................................................................•------- .- ...--- ...---- •---- - - -• -- ............. .......................... .......................... -------------------•-------•-------------------...--------------•--•-------------•--•---•----•--........-........_..----....----•-•---.... ........._.._...._-- •--- ....... Purchaser agrees that time is of the essence and (a) in the event of a default in the payment of any principal or interest which continues for a period of ---- 30.. days following the specified due date or (b) in the event of a default in performance of any other obligation of Purchaser which continues for a period of .3 -0 ..... days following written notice thereof by Vendor (delivered personally or mailed by certified mail), then the entire outstanding balance under this contract shall become immediately due and payable in full, at Vendor's option and without notice (which Purchaser hereby waives), and Vendor shall also have the following rights and remedies (subject to any limitations provided by law) in addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Contract and Purchaser's rights, title and interest in the Property and recover the Property back through strict foreclosure with any equity of redemption to be conditioned upon Purchaser's full payment of the entire outstanding balance, with interest thereon from the date of default at the rate in effect on such date and other amounts due hereunder (in which event all amounts previously paid by Purchaser shall be :forfeited as liquidated damages for failure to fulfill this Contract and as rental for the Property if purchaser fails to redeem) ; or (ii) Vendor may sue for specific performance of this Contract to compel immediate and full payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser shall be liable for any deficiency; or (iii) Vendor may sue at law for the entire unpaid purchase price or any portion thereof; or (iv) Vendor may declare this Contract at an end and remove this Contract as a cloud on title in a quiet -title action if the equitable interest of Purchaser is insignificant; and (v) Vendor may have Purchaser ejected from possession of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any action under (i), (ii) or (iv) above. Notwithstanding any oral or written statements or actions of Vendor, an election of any of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and all costs and expenses including reasonable attorneys fees of Vendor incurred to enforce any remedy hereunder (whether abated or not) to the extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in- curred, and shall be included in any judgment. Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser consents to the appointment of a receiver of the Property, including homestead interest, to collect the rents, issues, and profits of the Property during the pendency of such action, and such rents, issues, and profits when so collected shall be held and applied as the court shall direct. Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any of Purchaser's rights under this Contract or by option, long -term lease or in any other way) without the prior written consent of Vendor unless either the outstanding balance payable under this Contract is first paid in full or the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract soley as security for an indebtedness of Purchaser. In the event of any such transfer, sale or conveyance without Vendor's written consent, the entire outstanding balance payable under this Contract shall become immediately due and payable in full, at Vendor's option without notice. Vendor shall make all payments when due under any mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser makes timely payment of the amounts then due under this Contract. Purchaser may make anv such payments directly to the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on this Contract. Vendor may waive any default without waiving any other subsequent or prior default of Purchaser. All terms of this Contract shall be binding upon and inure to the benefits of the heirs, legal representatives, successors and assigns of Vendor and Purchaser. (If not an owner of the Property the spouse of Vendor for a valuable consideration joins herein to release homestead rights in the subject Property and agrees to join in the execution of the deed to be made in fulfillment hereof.) Dated this ............... - •--•---•- ...... - -- day of ........... ... November. 19..$_7.... -- (SEAL) . - - - -- -- at-- �_v� ........... ..(SEAL) * - Terrance - L.arle . G_ .. l tine * Larry A. Potton -- ----- - - -- ----- • - - - - - -- -•--- •- .......... •--- - -- ---- -- - •- -...., ---- ••-- •• - - -- (SEAL) ........... (SEAL) * --- • - - - • -- ----- - ----- •- - - - - - -- • --- - - •....._• . - - - - - * ...... Linda _A.._Potton................. • -- • • - - •• - - AUTHENTICATION ACKNOWLEDGMENT Signatpr,gApj, " -Terr ante.. Lane__ Galleatir�_,____ - -_•_ STATE OF WISCONSIN Lar�r T�JP en. 9 Linda A. Potton 88 • •''� ........................... •- -• - -.: __ County. November 87 a e i. li of__________ _____ 19,_. Personally came before me this ................ day „of % the'"aliove named ..... .Stu . J: eger ' 't___________ __L� __}-- _ -• - -- y.__ - -- . TITLE: ME11 STATE BA OF WISCONSIN ... ....................... (If not, _d________ tats.) _________ __________________ ______•. - - - -• - -•-- ••.... authoriz to me known to be the person ----- -. who , ex 1 executed the 1 ed by § 706.06, Wis. S e foregoing instrument and acknd�vledge tife s6 Q. ` THIS INSTRUMENT WAS DRAFTED BY '''I »•�� („��,1• �`�1l •-- •- -Stud 'i_..J - -•Kr Leger---- ---•------ - --- --•---- ---•-....... " * ............................................................... .......... Attorney.. . ............ .. Notary Public -•---- •-- ••- •-- •-- •- -•• -•- - -• -- •• - - -- _.County, Wis. (Signatures, moy be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary,) *Names of persons signing in any capacity should be typed or printed date: .......................... ............................... 19.........) below their signatures. 1 / 9 ! PAGE 48J ADDENDUM TO POTTON - GALLENTINE LAND CONTRACT Purchaser agrees to make a payment of interest only on the $29,551.61 for the period November 23, 1987 through November 30, 1987.on December 1, 1987. The remaining balance of $7,440.39 shall bear interest at 8.0% per annum, and shall be payable in annual installments of $1,109.00 due on December first of each year commencing December 1, 1988. Purchaser agrees to assign payments due under the Conservation Reserve Program on approximately 13.1 acres which have qualified for the program to secure payment. Vendor agrees to pay the cost necessary to qualify 13.1 acres of the property for the Conservation Reserve Program. Purchaser shall be responsible for all maintenance expense after the property is initially qualified for the program. Vendor agrees that upon payment in full of the contract price all their interest in their Federal Land Bank stock shall be assigned to Purchaser. Purchaser understands that under present Federal Land Bank policy the value of the stock would be applied to the last remaining balance on the loan and would be cancelled. Dated this oU day of November, 1987. L rry Potton i dtz2) Linda A. ton 6 T � e — E a - ane 1 entine I � �Co 0 3 ° 0 3 M (D a) c c c L p N N "D C O _ O LO � 7 CL co m c $ o in w I I d 0�g.. 9 �zrn a� N a CO OD _ O X 7 0 € O � R (D ° r 'm�' z a`) y rn p a 0 0 O f'i C z tw @ V Z 0'v__ 7 fa 'U c CO z r 7 f0 C 7 LL C N. D7C @ LL C 3 $ v Oy�a�o d Q U wa u>N $ Q ti I c v z E to 0 r 0 = a CD c o ca N�uwi am am j o 0 _ oz c L I u 05 a o Y o " 4 o to H � E C' E € m a� m CD Z U =m =m (D CL CL US (D y a) f6 ° a� • Ai d U r d cn r 10 N c c Q z m z 0 O ° z 4) O w o 0 N I I z I �1 ; 1 3 d N OD Im I @ LL .. .. C a N d a ` O N C a R c In > 4 at N 0 at N L 0 0 � oo C. a o� IO ' @N h > j m N to fA o o N I�J ZL 3 r r n m o • �1 " N> � 0000 0 a. � IL IL IL O v, to .0 r . Cl) o o w o 0 o O N N J V — C C Z N f6 r� i O c M � O E Q °. o ° '9 O ° '9 ° a m m y m O 'O m O N O U 'O d QI �' t4 tD 'O Q) A CO m Cl) co O ��, ,, C CO ~ d a) H C V d O p O p O) M C «6 'e N m 1� DD c to o m { C p 0 c N LO M H N C Cl) y O N Q) In C y • �, N v C O o C C N O ' 0 G 0 fu O N Y ! C9 z — m C9 M O Z 0 w U IL I ~ E I EL a • c. d d d c c Y c E 0 c i c o R 3 :° o '.4 0 A V C. O m V to V Parcel #: 022 - 1067 -90 -100 12/07/2005 12:23 PM PAGE 1 OF 1 Alt. Parcel #: 24.28.18.376B 022 - TOWN OF KINNICKINNIC Current X ST, CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - GALLENTINE, TERRANCE LANE TERRANCE LANE GALLENTINE 1436 OAK DR RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): • = Primary Type Dist # Description ' 1436 OAK DR SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 28.220 Plat: 3857 -CSM 14/3857 SEC 24 T28N R18W SE NW (EZ -U- 1124/625) Block/Condo Bldg: LOT 2 BEING LOT 2 CSM 14/3857 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 24- 28N -18W SE NW Notes: Parcel History: Date Doc # Vol /Page Type 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 88552 352,600 Valuations: Last Changed: 08/11/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.000 80,000 218,500 298,500 NO UNDEVELOPED G5 23.220 58,000 0 58,000 NO Totals for 2005: General Property 28.220 138,000 218,500 356,500 Woodland 0.000 0 0 Totals for 2004: General Property 28.220 86,000 161,300 247,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 557 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 O� s FILED Z MAY 2 4 2000 ► 3 KASHLEEN H. v?'ALSH A UG ` 42000 `� SL °coo f 2:3 6+00 ST. CROIX COUNTY L SURVEYOR' CERT I F I ED SURVEY MAP BE I NG THE SE 1 i4 OF THE NW 1 1 4 OF SECT ION 24, T. 28N. , R. 18W. TOWN OF KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN PREPARED FOR NORTH QUARTER CORNER SECTION 24 - FOUND o FOUND I* IRON PIPE TERRY GAL L ENT 1 NE I * IRON PIPE o _ N54 42 49 E, 0.32 �w FROM CALCULATED w o POSITION.(LARGE FALLS 4' S. AND 12' . UNPL LANDS �' w BOULDER OBSTRUCTS - W. OF OLD FENCE PO CORNER POSITION). NORTH LINE OF THE SE -NW O p � NW CDR. I — s89 0 31'24"E 1325. 18' m SE -NW (0 � NE CDR. SEPTIC SE-NW \ WELL•❑ H SE O LOT 2 Z 14 1,229,285 28.22 ACRES SO. FT. • y 27.99 AC. EXC. RI W J y1P (A Z y w 1,219,344 SO. FT. r rn AA S89 58' 19' E_ : m n 440. 00' c° O O n CA - ° rn :n o Z M W n °D ttvv S89 19" E 495. 00' W : f 14 A c©n 0 1 LOT I o N 6.60 ACRES 4 LOT 3 ° � 287,338 SO. FT. C ,-' 3� 6. 35 AC. EXC. RIW r, 1k� 5 00 ACRES $ p, n FA LS I I' W. 0 276,560 SO. FT. SEPTIC G o p 1 217, 789 SO. FT. . C N-5 FENCE S'' a�, 4. 70 AC. EXC. R.- iv_ 204, 702 SO. FT. �! A UILDING w SHEDS LINE SW CO" . _ ............ _ .. , SE -NW o S8 °53' 54'W $ S T ,4C1(, 10 1325. 79' 8 6 89 0 58' 19" E 4 9.99' �„ . 81' o 494 ss' l N89 ° 58 I9" W _ 7� — w a " 495. 00`' ' 1325.. 83' - -- —Q — -- — Ch 26,-> 2. 33 N89 ° 58' 19 "W !325.83' SE COR. o 5303 .97' SE -NW rn i O WEST QUARTER CORNER EASTIKST QUARTER L 1NE w w SECTION 24 - SET UNPLATTED LANDS ro ro PK NAIL FROM TEES ...........•••••••••• LANDS QUARTER CORNER ROVED SECTION 24 - FOUND OIX COUNTY ALUMINUM CAP Planning nina and parks Com,mi!ter• MAY 2 4 2000 LEGEND If not recorded with 30 days of O SET I " X24" IRON PIPE WEIGHING approval date approval shall be 1.13 L BS. PER LINEAR FOOT n huN C 0 NSti� N JAMES M. WESM spa BEARINGS REFERENCED TO THE EASTiWEST smwww,. QUARTER LINE, SECTION 24. MEASURED AS VA Q SYSTEM) 819' E. (ST. CRO I X COUNTY COORD. O �V SUR v 1 " - 3 00' gUltpW O 150 300 600 SHEET 1 OF 2 JAMES M. WEBER S -1804 NELSEN -WEBER LAND SURVEYING 2000025A THIS INSTRUMENT DRAFTED BY JIM WEBER DATED `�` `� _?_ �o Vo1.14 Page 3857 �� 4 4 ilr u'I ✓Iti °yl V " �' � I P 11 a��� � �rv�yu 1r, � � l`4 r a � ' a srr�, ��r�rr e r i , u „� I i�� + k � I t r � n I wp- i 6 i'yY y '3� x i t y , 1 w r � r t AS BUILT SANITARY SYSTEM REPORT s O.WNE R{ ADDRESS TOWNSHIP k �� — SEC. W N, R�W ST. CROIX COUNTY WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances & dimensions t meet re of H62.20 - -- ---- ______ - - - -- 5HQW EVERYTHING WITHIN 1Q0 FEET OF SYSTEM Vol I din o thj Arrow j S L : SEPTIC TANK(S) MFGR. i CONCRETE STEEL Ott. of rings on cover Depth PUMPING CHAMBER SIZE I PUMP MFGR. R ML NO'. GALLONS Per Cycle TRENCHES NO. of wigth length area BED NO. of lines width length area dept to top o . pipe NUMBER OF II::I����A Outsi a ameter total pit area AGGREGATE PERK RATE A REQUIRED AREA AS BUILT Disclaimer: The inspection of this system by St. Croix ..-Cdu.nty does not imply complete compliance with State Admin4strative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM., INSPECTOR - DATED l6' PLUMBER ON JOB LICENSE NUMBER �/p 6 � s x I i VII r i �ti' ,{ "as, 5 rfS +, �t '. i: K' ,Y• Y-.. � { 4 A y i a +Sr"c2`l '� { `'.`,lP'S',xS+�. ,,t �"'.{ �a ' 4 .�' i {«h 1. I 1r f t� r. , i ,, �y January 3 , 1980 �. � 1009 West *ae +. ver Falls, WI 5402 irl - Pion idsntifi�#t\ton ono. 9d��o�2 Deer Mr. Wanga 44; Gotdon Ttar Products Coop. »�{ sowaget pl spo l 5E I/4, tIW 1l4 Ssctl+ar► ,24.Z2tl#��.9t13W Town of Kinniki'nnlck',; Wisconsin r St. Croix County x: `E�taettinatior: of plumbing plans and specifications for the above- mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes, and Chapter H 62, Wlsccnsin Administrative Code, the plumbing plans and specifications are approved -. con tingent upon compliance with the s tipu lat ions indicated on the plans and the, fol lowing code sect Please revi your codes for the requi rements � of each "Won-noted. i. tt 62.2014),(b) 1. Percolation and sail boring tests - Distribution and depth. 2. N 62.20 8. Construction detail of soil absorption sy stem. � 3. H 62.20 (4) (4) Inlet and outlet piping and Joints. 4. w 62.40 (g) 7. g6i U , abs orptlon, systems - Vents. y. The architect, professional enginscar, rb Metere designezr, owner or plumbing contractor shall keep at the construction site one set of plans w bearing the stamp of approval of the department. ' aw } YP � a .Aa . � x '••�•' � � •#�:: ai P S�.y� � !h "'1�1 t.j � hp t •. wf�1 iii .v qq �yy r ii Oar � iz tip' i 3 �s i�yty 7iT�d;SiTlia.�ti# — y L �• ,3 :ti, 4}� � Iit t ytiTi j `1 ', . { u 2� i�� 1 zti{ta � 4A^ � Wit ? ' i3'J $ ^ I t :lis i a3ver ti i�t t 1 � y� 101 UI VI 5 6 V i1S !i l w { 5ta O .10 � tikM � P` w'.$ �� t _. Y, n,0 12 + �'!'10Fa+`� �"'"•' } t bye Ct � ]� • .� y nQ� I.,�t iF��i ��.� � At i ��• ,is � � . �� -. �� � fpi ♦ i�� � i : x;:rJ 'i�' 2 ="w�x ,'.y'q•.� "z�� its �� � ` °f:�i� �� P n s `; •� ! asY" i ? �^ : �jG. r 3.P ._ '1 i L: �a''i '�'r 4 c i 0J . t � } M y S f � + .• .. f s d. . F ..�'', 4.'� • Nk. ..' � F. ;;��f� s' ix� i .�3 fi►`EU�F...� ;f y 't J 1,�'t iir +�:+'� 4'i F i C$ iii @� 6S b k t v p` WAI kv, �$ , � .ix i d ry �. {u} -• , L � l #s l y r / t.. Y � e i i .Z 4 St w, '� W j15 Red. 9178 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES r • P.O. BOX 309, MADISON, WISCONSIN 53701 jh11 i LOCATION: �` ' /a, r � /o, Section_ ,T N,RZ4E (orQY,)Township or Municipality '1? 1 ? ' C ■ C Lot No. , Block No. County - re l Owner`s /Buyers Name: S , ivi on me Mailing Address: . TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL _X EFFLUENT DISPOSAL SYSTEM: NEW REP ACEMENT ALTERNATE SYSTEM OTHER • rnu _ QnRj 1GS. ---PERCOLATION TESTS 43 8 - 8 REPORT ON INSPECTION OF SANITARY PERMIT # 0 3 1 Name and Address of Permit Holder Person /Persons at Site (2 )Date of Inspection ame, ress, Icens o. o ns a Ong plumber Time of Inspection 3 INSTAL ATIO CONSISTS OF: �� jC< Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit Seep a Bed ❑ Holding Tank [] Fill System ermanen re erence o�n escri e: Elevation of vertical reference point: 4 / Slope at site: _ (5 )MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: �., Liquid Capacity• c Tank Inlet Elevation: # ft to lot or property line: Tank Outlet Elev: # ft to well: (7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute horsepower brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? []YES ❑ NO . 8 HOLQING TANK: Manufacturer construction Of gallons ; depth to the cover ft; If septic tank i being used are baffles removed? YES [] NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ NO; Wired? [:]YES ❑ NO; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft to ft diameter; ft liquid depth; residence; ft to well; ft to property line-, ft to ordinary high water mark of lake or stream; greater than ft to edge of slopes seepage pit inlet pipe - elevation ft; bottom of seepage pit elevation ft. (IO) SEEPAGE BED SIZE: ft width; -- ft length; the depth; 1 i.neal feet tile; r/ ' ft to residence; r-4- -z,' ft to wel 1 ; /, ft to lot or property line; _ ft to ordinary high water mark of lake or stream; fi! es ��' ft to edge Of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEP Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage re trench ft. (12) Has system been installed in area indicated on EH 115? RYES []NO (13) Has system been installed in floodway? ❑ YES ONO Floodplain? []YES NO DILHR -S5D -609 N.0 8 i Signature of Inspector: /. r �� t • ~� � � � � L 4 '�., � ! , :. � A . '� e _ ,, .. Y _ i .i �- � .. �i� � s � J � � � 1 ' rJ. � � � � � i i F ` .. .. -� • t S _ _ ..,.., . -, . 1 ,.�: t:� . -, ��� � "" , } '4 � .., : �; ii State Permit County Per it # � State and County County Permit APPlicatio a System Domestic Sewa9 for Private D # I ?LB67 ra te plan I.D. � S VAL REQUIRED _-- p,PPRO if Required Nailing Address' *pENOTES STATE l Received from State roya Date APP j PROPERTY ('�� City A. OWNER OF 1 `� , ' R E tor) Lot# - Village ' 011. T �`O glk# 'Township .- y, Section lake or landmark + /'_ -- road, *Variance_ - -- LOCATION: -h f " nearest ecify) B' Name . 1 11% * Qther (sP S C} �tV ►ndustrial No of Persons___ -- o;- o f Bathroom Commercial # FANCY; of Bedrooms YES` O T pE OF Duplex NO Waste Grinder Single family _ YES - - Dishwasher her (spec TYPE OF APPLIANCE YES - -NO o f tanks D Washer ____ No. atic Total gallons No Prefab of tanks_ - Concrete Autom TANK C APACITY Total 9allons lacement {t. SEPTIC ReP sq. E. tank capacity s ecify) Area *Ho {ding Addition_ ot 21- -3) ___`_ oral Absorb New Installatio Steel No. o f Trenche Place percolation Rate stem Depth - - - -. -- *Poured in Fill System Tile Ines 4+ DISPOSAL TEM: L c SYS Depth a o• of EFFI -DENT Replacement _ __- W,dth _._- - Depth L - Tile Size A F- Addition Feet D i sta nce Tile slope New! N Li d DePth� from critical Seepage Trench: Wit — • id Depth----' ce Bed: Length Liqu Section N62.20, Seepag diameter is in a ccord 'N' prepared Pit: Inside � re ported the EH-� 15 rep Seepage o f land I have s ystem from slope the information Percent i nformati on disposal Y that the effluent infor hereby certify sized :� �?� and other ned, do and that the 1 have d l , u ndersigne d, ode, C g.T • # Administrative Code, 3 # Wi s co nsi n the Cert�f ed Soil (ownerlbuilder). Phone MPIMPR # with NAME 1 all accord obtained from i 0 and distances in Signature direction of slope pl p (i pl `s Address below Provide of system sketch well). PLAN VIEW "62.20, including REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM S ani. atan y P e nm.it 11 State Septic in NAME G43 �je►1 � Townbh.ip ihni t�, �C 1 )1r) f e Sat. Cnoix County Location ,SS Section Lot Su6'd.iviz ion SEPTIC TANK Size 1 1Z gattona Numbers o f companatmenfi6 j D.iztanee Snom: Wets. —'�-- Bu.itd.ing 6? �. L2$ e.Cope H.ighwaten PUMPING CHAMBER Size g aC�ana .._...Pump" Ma�u�ac�cinet r `��{ ; Mode Numbers _.._. , HOLDING TANK Size ga.ttonb Numbers o6 Compan.tmenatb Pumpers A.tanm Sy.6tem Di6 tance 6nom: We.t.0 Bu.itd.ing 12% .a.tope .Highwaten ' ABSORPTION SITE Bed � Tnench D.idatanee roam: W et 2 Bui.td.ing 15 t.2$ atope -� Highwaateh ABSORPTION SITE DIMENSIONS Width o atnench � � far Requited area Sat Length o6 each Une 6t Depth o6 tack be.tow ti.te in Numbers ob ,t.ineb � Depth o6 tack oven tite in Tota.t .tengath o6 tine.6 / 1 haw Depth o6 at.i.te be.tow gtade in D.i.aatance between .tineb bat S.tope o6 t4eneh .in. pen 100 6t!Z Toatat abb onpat.ian area 4*1 -_6x Type as Coven: Papers an ein aw� PIT DIMENSIONS Numb en o 6 pith -GA ave.t anound p.iatd yee no Out6ide d.iam eaten t Depth be.tow in,tex 6t Toata.t abb onpation area bar Area nequi.ned bar INSPECTED BY l' TITLE APPROVED DATE / 198 REJECTED DATE 198 REASON FOR REJECTION . w • A � f 1 I i r V i I � I � i