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024-1010-96-000
C pi f C w 3 d G Ln PD C C CD (D n 3 CD 0 (D 0 M cn g -i g z o r l cn g - g z o a o o ~~1 d m cn O O E n d N m M O N tD 74 N y N 7 3 m a N 7 3 m 00 j r} C1 z 0 N N ~D 1" n m N O N O .7 N N c = m N L N c a p v Q A) ca CO O O CO n 7 = m ° a 3 7 n 0 1 N A O N p CD C pCO , C: w 3 N N OD V 3 w CO yl< 0 CD p D d CCD 0 1 0 ID 0 oz D eo a> d to D CD 4 C/) CD co CD N a o o W m C a W o o n V 3 ccnn c°n a l 3 O -4 -4` tir 2 CD cp 0 ! N CO CO 3 CD pOp pOo 3 N OOD OD 3 N A? 3 3 fO'! c lV L 9 a °°z 000 z 000 (~i) gg J T =r ~5: cn O (A (a m O En 3 rr3:: 0 o d c° O D Cn o m » V CD C. 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O .0 C VC .O. m CD 0 a.'< o o -a 3 CD -@ 3 O, ~ = v, 3 -~c0i 3 0 j c C O N C O CD- @ m d O 41 0 0 3 A O V (D O Op O~ o O N oo ao i N y Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 453404 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m) Permit Holder's Name: City Village X Township Parcel Tax No: Kizlik Ricky I Pleasant Valley, Town of 024-1010-96-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 07.28.17.56C TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic i~V Benchmark Dosing AI~ a~orn5 1 j b 7~ Aeration Bldg. Sg er Holding / SVHt Inlet 10 JA~111`1 Cl Z top jp ~p• St/Ht Outlet .30 nn TANK SETBACK INFORMATION TANK TO P/L WEE BLDG. Vent to Air Intake ROAD Dt Inlet % Septic Dt Bottom (/H Dosing Header/Man. 7 Aeration Dist. Pipe Holding Bot. System C<tAl Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St cover t V~- GPM i S Model Number V TDH Lift Friction Loss System TDH Ft A, ` Forcemain Le Dia. Dist. to well SOIL ABSORPTION SYSTEM ('Y -d S BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over _TT Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges psoil ff ~ Yes No Id =YesE COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / W 149 Inspection #2: Location: 458 County Rd. J Hammond, WI 54015 (S 1/4 NW 1/4 7 T28N R1 7W) NA Lot 1 Parcel No: 07.28.17.56C 1.) Alt BM Description = ~jk {ry{.~ ' t,}~f~ "yLG t S~/fl'~ 2.) Bldg sewer length -amount of cover = ea,~ v{~' 1 ~fD a s ill(' `I- Plan revision Required? Yes [4'/No Use other side for additional information. SBD-6710 (R.3197) Date Insepctor's Signatur Cert. No. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit Na=,,+,,-- 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 1/15-3 ~{G Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. T Permit Holder's Name: City Village X Township Parcel Tax No: / CkC U Pleasant Valle Township 024-1010-96-000 CST BM Elev: Insp. B Elev: B escription: Section/Town/Range/Map No: d-n SfS 07.28.17.56C TANK INFORMATION LEVATION ATA TYPE AN FACTU ER CAPACITY STATION BS FS ELEV. Septic Q O Benchmark Dosing j~ r / (ti ~J % 77 Alt. BM 6f flit%1~ / 11 S `1 Aeration Bldg. Sewer Holding S Ht Inlet TANK SETBACK INFORMATIO !aP- Q-z-- ~d1.t -~.oC ~Ht ©utle I 9S. 7 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet ~O Septic Dt Bottom / J C Dosing h.Qgder/M J~ a . v>~ a~.G (3.39 Aeration Dist. Pipe S~ a Holding Bot. System S y/~ 0761- Final Grade t PUMP/SIPHON INFORMATION S Manufacturer Demand St Cover yy~~ GPM ` df 3~ ! O Model Number r~ 2 TDH Lift Friction Los Head TDH Ft Force ength Dia. Dist. to Well SOIL ABSORPTION SYSTEM `A~ ~g Goa - j? BED/TRENCH Width Length No. O ches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM ACHING Manufacturer: INFORMATION CHA R Typ Of System: 7 _ Model Number: `f~ ~2cJ S DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 ~t E Yes Rd No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /Z V Inspection #2: Location: 458 Co t Rd. J Hammond, WI 54015 (SW 1/4 NW 1/4 7 '28N R17W) NA Lot Parcel No: 07.28.17.56C 1.) Alt BM Description = -TO1P (/t/Vj &~c t 2.) Bldg sewer length A~►^~'LUaQ - amount of cover = A~ LA-L 644 A-~o,?ri n S 1~-!/Y► Plan revision Required? L-; Yes] No Use other side for additional information. SBD-6710 (R.3/97) Signatur Cert. No. •JH'"5 ~ ~ n p ~,QiY~P~ QYL y ~n~~~~ ; y ^n r ~ ~ s l ~~;n~ - ~f~s ~T 0N0 0vi0 3-0 0 Lo1 o (D (D CD m m 3 3 ~ ~ ~ 3 r: I z m 3 m a ° o' Q m= 3 w o CA - v N A 0.4 C. Z 0 0 r i o o ai o ( C.A m y o trAl N N C = N` N j C p o f ' O 1 CD -4 N n j O O N N Q Cf 7 0 < a °o ((OD ° o o T Q' m n W c m V V O (A,11 b (~I 3 7 N W 3 3 fA w O 'a '0 c 0 c m cn D a c w CO z D eo ma y W ° v o W a ~ v 3 m o o a 3 n M (on Q 3 o `Ov N L O m ;3~ N CL a N 2 a 0'. 3 1 m o 3 0 r cn co co 30 y .P ? = 3.~~ Q "44 • ~ a a m z 000 z OOO~II ~o ?ea D o cc m "0 v, o 3 I~ 0 O c I vi. 11 . 3 N 3 6~1 N G 3 6N~1 (O CL M CL N .3► W z Z 3 ~i 7 (CD O 0 = D 0 0 7 a = j :3 O m c N C C (D C D a o m CD Z Z O O A z m j y C ~ y C i ~ L*. N d 0 d A j (C~ N W C V W M < 01 M c. W z A Z7 3 3 z y to v v i~ W W CD 0 Cc) 0 (CD ? N CD > CO CL (3D C C '-OO• 0-0 0 (ZD d (3D y8Fmx n (DaCD m3ma* a m cn S 3 a5~ m N Q m c y o ='a CD o awl o:3 m c -i oa- w U) CD m3°no a 3 'D CDC4M o a m m m U~ f m 5' m 7? M C m O' C N n" N a O 3Xva =~av~,ma)=r m M= =Pma~ o M. ( m m 3 -+m= v s CD s o m 0 f a m- o i 3 ~fc) :D =11 S -0 m v CD ° o (o nay tv v m o =r m 3 (OD CD fO 3 o C, -0 CD 7 0 o ? m CD j a CL w CD m 0 c C)0 0 E o CD ° °o w 0NO 3-0 n r~ d ro O o e'o A v H' :r 9 0 ~ 4h g - *1 CD W 3 N O N O d O N O -4 N ro O N O• H x ao o d 3O CD ro N (D C fD O C eD O -4 O O O CD a 4~ m C-) 7 N O i O C c o cn z cn z D U) z co z D o° j N co D co, D co (O D cD D N a ? C CL a :3 :3 W o. n W O O O O N C_ 2 0 0 0 0 0= m e N o c a c I 3 ~ !mil d OOO`ro cn co cn cn z ~ = s s co N CA o o D 3 3Q 3a- Mvv,Ln o m ro ro m m m m ego o 3 to - - - - ro w 3 3 3 3 ' 7 W o 3 O ° oai O m y x a 3 !i D y m ro y ro ro N C ro .Z7 R C ro C p ro ro N j 'p 7 c 7 ro Q a .O N 6 a -p ry a ° c 3 O c 3 7 N 3 eD N 3 eD (6 I ~ N C a(EO _ :3 3 y ~ y c ; O :3 A z 0 0 eD -w ro a i Q 7 O CDD O A (OD O (n N N = . N . T ¢ V ro CD w CD CD m ro ro G co co 0 p N C CL z - CD (D j cnD s y C •rr zzC d N N N N ~ j w < CD I ~ I CD M CL p' a N. ~ O ;c' d CL a N. p 3' d 0 a ro< a o < oa ro< a o (D Q Q eD o CD - S. N Wy aao o WpOOj 7 aao o 6 N a 7* p y N 7 y 0 Cc O C cz m N CD O C 0) N cn a M M N 7 e1 N 07 CD ro y < CD '0 ro r p' < CD 0 0) CL -0 =0 MM a C= :3 :3 CD =r 3t W p o N K _a W ° o N K a a 1 ;o N , 0) 0) .Z) N . 0) = A < z7 < CDm I N E D p 7C N N C CD 0 7c N p 3 O= dC ~ B= N F, C e CD . 3 3 3 Oi. 3 m 3°03 m ti c p p a C O O a O ° v ° ° o 7 " CD ro A O 3 O 3 N t-j O Op O O O C) CD a, C:) CL 0 Cl O Safety and Buildings Uivisiun County 201 W. Washington Ave., P.O. Box 7162 cv',d, u ~~j~n~~ Madison, Wl 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266.3151 3 6 y Sanitary Permit Application State Plan I.D. Xber In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s15.U4(lXm) a _ Project Address (if different than mailing address) 1. Application Information -Please Print All Iatfoamation R C Property Owner's Na the J1U II.j4 Parcel0 kor ` Block k Property Owner's ailing Addreis PropertyLocation O ~ it t City, Stam Zip Code Phone Number Lam=. t.5ection 177 rv1 d lJ ~3 CJ / S (circle or) j U. Type of SuildinS (check all that apply) T . _ N; RZ~B o 1 r' 1 or 2 Factil Dwelling - 2.(3 P016-1 q~w~ t;b rY n8 - Number of Bedroor~ 1,~Subdivision Name Public/Commercial - Describe Use State Owned - Describe Use _ 0 .1/V(7 t j~ 1 I]Cit% r-Niliage ❑Township of III. Type of Permits (Check only one box on line A. Complete line B if applicable) A' ❑ New System ❑1 Replacement system reatmend ~H°td; Replacem Y__ ❑ Other Modification to Existing System B. ❑ Permit Renewal ] Permit Revision ❑ Change of C Permit Transfer to New List Previous Permit N tuber and Date Issues Before Expiration Plumber Owner /06- e Ce C r TD i IV. Type of POWTS 4 stem Check all that R ply) Non -Prauarized IwGround ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 im of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tanis ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating S nthotic Media filter ❑ Leach' Chamber ❑ Drip Line C Gravel-less Pi ❑ Other (ex in) . V. D rsal/Treatment Area Information: Design Flow (gpd) Design Soil Applkat ,n Rate(Sw Dispersal (st) Dis put-Arta-Prop~0d (afl System Elevation VI. Tank Into I Capacity in Tonal Number .racturer P b Site Steel Fiber Plastic Gallons Gallons of Units o rete onstrucred ! Glass Now Existins ,✓nL Tanks Tanks - Septicc or Holding Tank J~(L I Aerobic Treatment Unit Dosing Chamber , VII. Responsibility Statement- I, th! t'tndwitignad, assume responstbility for tallation of the PO'WTS shown on the attached pians. Plumber's Na ma (Print) Plumber's Si gnsture . NSPRS Number Business Phone Number ll.'s to, $c.Li caLn st Ile t Plumber's Addre as (Street, City, State, Zip ; Sc Code) c774_j(~eL 1-71A VIII. ount /De artment Use Only V pprovpd 11 Disapproved SanityryPermit Fee (jrip~ g Croundwater Dam Iss g Agent 'gnature No S ) Surcharge Fee) d ❑ Owner Given Reason for Denial { IX. Conditions of ApprovalMeasons for Disapproval A omy! ptaw (to the County only) run tbs system on paper not loss tbaa $I/3 x 11 luehas In aiae SBD-6398 (R. 01/03) PAGE) OF Z NAME: L U Z 1 k. LOT# LEGAL DESCRIPTION:`1/4_1/4,S T_,N,R, E(or)W SCALE: l ►t v + -~v S c ELEVATION: L BM I DESCRIPTION: BM 2 ELEVATION: BM 2 DESCRIPTION: SYSTEM ELEVATION: SYSTEM TYPE: Sew- iq s;~,,•, ,'l 0 r 1 a 49S'~- OlVe4 ~n Q may- ca ~ - I SIGNATURE: DATE: c dC = ACA -i"a O 6- zrn0r CO) %-0 Cl) Cl 0 Z 0. r- m O Z ic n1 ❑ o m oo ;u Cl) Orn CR X m w r ?O O x O Z 0 m TC 2 CO) N m 0 m O x C/) Z c V C O z D MiImiIIij c Z Cl) O -n - o = 00 X ~ O w r - Z N O m r r C? rn~n z~ z v Cl) - C ~ O m CO) CO) = z v N m m 0 C N X 0 mi Mo- m -n CA -n < O -q Z F) O v III m z O v C C ao Z m ~3_vvav Cl) Z Z O D m Q M 0 affic'so 0 m ms i g~~ e FIE LT1 Cn ; a - dI w 3 0. CL z to~ r so N O 5 Z County Sanitary Permit Application 1-1 ST. CROIX COUNTY WISCONSIN In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER (Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016-7710 (715)386-4680 Fax (715)3864686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size. CC un Sanitary Permit # ❑ Check if revision to previous application i. Application Information - Please Print all Information Location: 6 - Property Name ^ K ~l I 1/4 /~/~1/4, Sec l l zj - l T N, 7 R E (or) W roperty Owner's Mailing Address Lot Number Block Number L-f g C6 UN ity, State Zip Code Phone Numer Subdivision Name or C.SM Number g&rimo tlcr~- S o1s 7-70 -2q33 -7/19 q3 35-325 Type of BuIlding: (check o e) amity ❑ Villageow/n of 13 1 or 2 Family Dwelling - No. of Bedrooms: VA Publr mal (describe use)- 3 ❑ State-owned L 7_L/ u ( LI+V ( Ne est Road n 11. Type of Permit: (Check only one bo on line A. Check box on line B d applicable) / Parcel Tax Nu ber(s) a A) 11.0 Repair 12'P(Reconnection 3.❑Non-plumbing . ❑Rejuvenation Sanitation s 6) ermit Number ~1 Date Issued h s State Sanitary Permit was previously issued /y 6e - / (p 4 N~ rypp~f POWT System: (Check all that apply) Ked P X S 3 Non-pressurized In-ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other \ . Dlspersal/Treatment Area Information: (p, J, 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. stem Elevation 7. Final Grade T Required Preposed;EXj-.M IsJday/sq.ft.) (Minfnqh) Elevation I (J 3 a O- r7 )1-11A -3 It q(0 T Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete strutted glass Tanks Tanks .11 1 000 100 L ❑ ❑ a ❑ ❑ ❑ ❑ ❑ ❑ 1. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenaGoMnstallation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) Plumbers S' nature tamps): MP/MPRS No. Business Phone Number 1ja71~ 1 s 3kC-~31-e'/ Plumbers Address (Street, City.S]tate Zip Code) 177 111. County se Only Disapproved Sanitary Permit Fee ate Issued ssuing A ent Signal stamps) Approved Owner Given Initial Adverse or Determination Conditions of Approval/ 1 Z S k ,vi./ 3.912 t cz- --A &,Vtj 41.a e- -Aru~ '741hir- Pa~j't k-A g~a- 4- 14 L 6.1 2 P 3 y 8 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., VI Document Number Document Title RECEIVED FOR RECORD St. Croix County 07/08/2004 12:5@PK Occupancy Affidavit AFFIDAVIT EXEMPT # REC 1(.1 cKE J, A o ff,9RR A, TRANS z t~ FEE: 11.00 ~I Y TRAFEE: Name - Owner Typed or printed COPY FEE: CC FEE: being duly sworn , states, under oath, that: PAGES: 1 1 te/she is the wne ~art owner of the following parcel of land located in St. Croix Wisconsin, recorded in Volume /0 23 Page 3 / Document NumberRZJyS8t. Croix County Register of Deeds Office: Recordi Area Name and Return Address A parcel of land located in these / of the /ditty, of section -7 KA Aky Pmx) iZlc rr K 12[. I PC. '4 T 11_ N - R W, Towa of QS d it St. Croix N 5 $ J County, Wisconsin, being duly described as follows (include lot n d. and H AM M ON "N W, 540 / 5, subdivisionl(.'SM or detailed legal d ption): i' or I O~ CSC ~-{353Z°~~va(. RfAp- (PIN) 7 Parcel Identification Number (PIN)( 5(P C As owner of the above described property, I acknowledge that the septic system serving this residence is stz d for a 3 bedroom home, or a design flow of _q,'a--Dgpd. The design flow is calculated by assuming 150 gpd for 2 individuals per bedroom. There are currently ,h_ occupants living in this residence; j~2_ occupants are permitted based on the design flow. Therefore the septic system serving this residence is code compliant. However, I understand that If there are intentions to exceed the number of permitted occupants, the system will need to be modified to acoomodate any increased wastewater flows and/or contaminant loads. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. Dated this day of a~ e JAy WiZ 1-1 V- P- R l 1. AUTHENTICATION ACKNO MENT ) Signature(s) STATE OF W N SIN audw*cated this day of ,St. Cro ix County. ~ Personally came before me this day 00 the above TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me kno m to be the person(s) who e d, +l@,f m9 + authorized by § 706.06. Wis. Stets.) Instrument and adTaMedge the same. .•~`''C~ i., THIS INSTRUMENT WAS DRAFTED By .y Notary Public, to Wisconsin, p (Signatures may be aut wdicated or adcrwMedged. Both are not My Commissbn pemtianent. If not, st$t~~ I r~ necessary.) Date: 08 "THIS PAGE IS PART OF THIS t.EGAL. WCUMENT - DO NOT REMOVE" V* kWbRndba n* be ompfeted by s br7aNtef: doamud Alt= addrt~SS, and aff(T IlsQ dA4. 00terk*ftffMn890WWi ~w+dS the grans ft causes, kpd desp>prloa, eta r wy be placed on dill *W pope of dw doaemg oraey be plead on adddIOWPpes Of" dovunwnt n2tC Use of Ws cow page adds orte Pepe to ywdocum&W ad 5100 to the roo9009 be, W wwsh Sraltbs, 59- 617. o _0 0 r- (4 0 D Z 9 m m z co X o o m =Ir m C N < a 5 9 O 0 ~l rn - O r -n n ~X 0 X° c D y z C) irl Z -A W 55 --j G)rn m ~i O;u z p m C m U) z O COO -n c M n J Cn n o Cl) c < C7 l z Cn zZ m o z G) n m Re Ors dam m CL m o m ;wj 94 Rig to , 0-0 co v §i is 93. " rp m m as, B!" z1. wB. qp -1 p ms m~ y~ 581 11 ~a g m s r, loo rn a~ a~ w mm~ w X =r _ W c0 OQ O 2 o g o W ° ,Z ,o Io 1~ &s 1 1 m! 9 r a< la - > lu J, -W 15 rn 2 6' ~H o$mm Z 0 0 ~ r 3 'O Z a zmz C Z 0~ a D D n Z Zz Z m r C 0 D o o F Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County (!o rr 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 Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 02,q- 6 D - (-6 Please print all information. Re ' ed (Dante Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.14 (1) (m)). C11" 3~ 0 Property Owner Property Location rr L Govt. Lot s~ J 1/4 O 1/4 S 7 T.? N R,7 E (or& Property Ownerig Mailing Address Lot # Block # Subd. Name or CSM# ~a 3532 i~~3 f City State Zip Code Phone Number ❑ City ❑ Village Town Neatest Road New Construction Use: p Residential /Number of bedrooms Code derived design flow rate y a GPD Q Replacement ❑ Public or commercial - Describe: Parent material flu -'--J C. S Flood Plain elevation if applicable / ft. W-4 2 tom' t Genera corttrnents -t u, e- 2Q Po r t.l!~ and recommendations: [c) (.tf -2 0'+" v- So, 6 t o ICir ^ o\ Cc,ndduc-4&J r S L~ ~r~aayar'koe yLe Soy+~ or ~n S t 1h 3 Q, (o oo ve, -5c. I' it, k 2 i ~ r• S irYl Boring , S S~ iS lq ❑ Go PI CCCI.Qiu c~ Boring # y L C trom~,, a ~J' Pit Ground surface a v. ft. Depth to limiting factor in. Old C4- Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 St` Yn4- CS V t S z ro? .SrtA Yn Ski- 3 Y-7 tC, S O.S~' S - 1 7 as - of q6, s 9 ST' - 3 0p"1 ,'L / fr D,, / W-od d S r 4- ivt a Boring # ❑ Boring Id- `O lt/ go. O ay- ❑ pit Ground surface elev. ft. Depth to limiting factor in. Solt Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 1220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 130 mg/L and TSS < 30 mg/L CST Name (Please Print nature CST Number Ad a w, S VV`a L3 Address Date Evaluation Conducted Telephone Number it 2~7 -'1 S Yom vf'-Z~ -0 71.S'-760-dZ Property Owner _ Parcel ID # Page of a Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/fF in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 ❑ Boring # Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/M in. Munsefl Qu. Sz. Cond. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 < 150 mg1L • Effluent #2 = BODE < 30 mg& and TSS < 30 mg1L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. ssn-e330 (eA100) PAGE_OF Z NAME: ~ U Z t IC LOT# LEGAL DESCRIPTION:`]/4_1/4,S T_,N,R,_E(or)W SCALE: 1"= -1cs Sc~` ELEVATION: BM 1 DESCRIPTION: BM 2 ELEVATION: BM 2 DESCRIPTION: SYSTEM ELEVATION: SYSTEM TYPE: } A4 n r1 So~'I 4e~-~ ' 4~ Q ~ 9, c~ SIGNATURE: h DATE: 10, i to O 3 - n d n ti p 0 5 0. (D 13 a a a c C 3 ~ 'may n K M ~ ° a a ~ o N O N 0 3 O N 0 co N fID ° N N SD y a (aD C) CY N O Z 0) , O 7 o `D < cn r►~s G 7 2L O 10 R CD CD CL Q. cn Ot l< p ° r 00 OD C n C n S C~ cn Z cp z D 0 Z w z D o R. I t1> < D o a 0 D rn' D cc3 D cn' D m a CD (A d ? CD m W m m C~ m C~ v Q. a a a a a ° O a Ln 0 0 0 0 " L 0 N L II v l Q 0 0 0 3 1 y co 65 3' c a a a y -0 "0 O O O O O O Y cn cp ~-q c) c) -0 stn' Z S S O S s vi to cn o f !/1 W cn j D 3 3 3 3 v _v cn m Cv C v, 0) N N 0) C lD m N <D w N CD CD CD (D m 3 (DD CD A 3 3 3 3 W 7 CD 0 O m 0 77 a > >c Q. 0 0 x,,< 0 0 x. O a o a ~.CD c m ~.CD CC' m m g I 6:320 _ 3 v g m' w .Z7 CA m 'gyp N 0 O `D 'DN O N 'm c 0 a 'D O N O N' • x~ C x~ O C CD o m o CL 3 o 0 o m a 3 7 3 5 o- DN CD o~ v m cn cD W n 7< y =3 CZ O 0 y :3 :3 C6 O y O A Z n O d -w O G7 M C C o o~ o o Qa a p z N y o-0 A N y o'O A i 9 0 M CD 3 SC m M CD co ~E- CO 0 0 3 0 3 CO -1 -4 c~D0 ooEc~o°c W m a m cND y c 6w a$ ov, a a z . 7 (D v U) (D A ;0 N CD O O ~~pp n a N O C~ C Cz H H < co co CD O .Z7 O ;0 ~ I a ? 0 W 7 W 0 CD (D 7 N a 7 N a •0+ O N? (O-D OD OD. c3D a_ a a_ a 0' C 0 O< X O_ Er o m :3 o F v r. Q. 0 CD CD 0. 0 0 v L m0=mow cog - O ID - 7 06 Ul CD - 00 0 o a 5.3 9£ o a m CL (D !I N a CD N N N Dl a 7 S tll O o C C 7 W 23 3 fD X DD y V CD a W 0 a a o CO =r :3. 9 66 2.:y 0 N p3j N ~ N ~ p 7• ~ go m 0 n.~N 3 3 0 0mo, ~ti 0 0 oma,< o 3 m `O 0 w N CCDD 3 0 CCD CCD : o A Q O o O o o !v b m m m j oa w 0 o p o o p I o °A° o y °O °O °n 0 0 L 0 N 'i 0 5 P 44 767? 1 FROM :SCHUMAKER PLUMBING FAX NO. :7153863121 oar aa; oa MUN i1:s3 F..ts. Tie t66 4698 ST CRI c(i MIN 011 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 06/29/2004 10:25AK mant hlurnber Docu t Title AFFIDAVIT EXEMPT # St. Croix County REC FEE: 11.00 TRANS FEE: Afridevit of Reconnection to Existing POWTS COPY FEE: C FEE: PAGES: 1 ~~~►~i=y J. Kizl('ac Ko-rry A. Kizi-tic Name - pwrer) Typed or printed braing duly swom , :;bites, under oath, that; I, He/she is the owner/pan owner of the following parcel of lard locntcd in St. , Crops CAttury, Wiscansin, racordtd in Volume /C Page vomit tt Nurnbcr B:i t• Croix County Register of Deeds Office! Jieaa *7 a,,d Rcturn Add" .712-L-1 A parcel of land located in th ~ K of the ~W'/, of Section 7 K r{ (L R A '1' j_ N - R _I Z W, Town of p4cot1c4 do U~ %Lc z . St. Croix 458 O Rd - T County, Wiscaosia, bc4 duly 4*=bed as founwe (molude lot no. and t'{ h M M o N D W I j o I snbdlvisloaXSM or detailed legal deeodpdon): IC~' I Da / b1 a _ R 16 - 0o o GSM V o t . r7 P,,,, 1q43 Parcel Identifluffon Num0w (121 N-) bock tract #k r{ 3 5 3 a q Aa 9rmer of ytp vs d*WbW property, r ao mM941W abet me e4otinp~~ ~P~~ti on cite wastawl"r Treatment System (POwrs) servkv tiwa rosidenra ed by current co" 0=12m% for 6,~ bectroa►i'I' farTNtY dweUirlg• The system o9rnponer►b tiers bac7, irgpoo0od and oertlfied b eaneed QvW piumber to be In good Son &JA and appRar be WAtt ar>irtg pturmrty. There wee no indication of faaure i.e. pending or surfacing of wasWimter in the dinVibudon portion of the yamm at to Itne of InspeCdOn. I undwAU na ttud the Isauence of a 9ounty wohery permit to allow the recorinedlam of the sgft syttom doae not imply that the system masts eumM Code gJaV nttt remerds, ra does it imply that the sy gtem will mi-Airwe to function after it is pt$aed tuck In eetvlde. I also admowledge chef 1 wit.- disclose thts infnrmatlon to any fiAum Wila trttameted in purchasing this property. Dated 1hi6 ~O ~Y of Of- .4 Q) - e At1TME"CATION ADICNOWLEDGMENT 6ignplure(c) STATE OF I ) )as. ankeamd die _day or st, Gssls County. ) 7Ai Porsonaly cs;rne balore meWw-u„^d-Y the oho .r r .ter - ~y~~•%~- il~~~r TITLE: mCIVISER STATE BAR OF WISCONSIN to rirp known to Do Me parson(s) who ex~mW v ~ A ' =WRY T708.06, Wis. Sto o Instrument pw a&jwv twigs the Fame. '.13 ( '1 a f' r~ Y rH1S NSTRuMENT WAs oRA.FM By yr i, , a Notaty Pubk, tare sin (SW wren may be suther 10114 or admW edged. 69th are rat w Comma on O L if not, statq'~t `t'r' • F~ `i nerxeyaty.) Date: ' " "THIS PAw ARTPIS OF TNi& LEGAL DOCUMENT - 00 NM RE11110v E" - TWS Ldbnnstioa muse be, crorrtlalsated by 1JAMXter at We Asms a return address. And M Rf cequlro4. 00wh /arimdion such as 0* < gm+hr0 ClaumA loW daampAory err. atey be Plow on fiva SWIM;* old* oxwnont or may bo #food on additional M" oftee eeamfivAL M tvisaonlllt stAturasr Sa T. doawwd: WL We ofthIS cwvr'pop edda ono pap to ya r dOerRneht aMT I& i 86/15/2604 85:40 17156844630 ALWIN EXC INC PILE 01 ST CROIX COUNW SEMC TANK MAIWSNANCE AGRP-M"Xr AM) {)wM=M II' CSRTH CATION FORM . / ` (Z1tyC chvwn3u yw Ri ck c~t,d Karr , Mail ft Addrom 4 5 8 d Ra rn m. on d (.v S 4 0 t Pmpeaty A .t,ra 4 5 U l C ~d V 1-lu-m m a nd w t 54015 (Ve o4tiao awand amm pb=ft D ia[ W- patW k%m iCeWm Number ..~~,_°~g' j 56 C. 02 ~f - ~ W ~t T ~8 N 17 W. Town of ccS 0-n fi Y41 ft..,q Location sEVh Sec- E AU Subdvilion - - * Warnnty Deed 46,~ 7 `~cP . voigme v X33 _ pagc # 3 / . spw Lassa o yea Lena Lot Um id bia ~ y= D no ~peperwe sadaf7aaragfliesyalru oaftld tswit in its pnea»oft~e LttiMals basdlawrsales. Afaper oeatdRe of pfarfpiad ofr; the sepdo fast oreey tbtm ya w aaoretr, it hoed 1 by a tioaasod pmagw. What you put iaoo dfs erawm ~ V~w sow the lbax - of tae npda w* n s tsr- - atap in an ~Vale dirp ont 4710M `)l The p owty owe= -p i l i b o AwA to SL Cboix Zraag Dgwbn at s Altlt4 f~pes by at awm and masWPlVxmbw,jo p ota~dpbmdwaralioeasedpnmperre=it~rim~thst(t)l>sse-dle.ra~ewatecdispae+lry~J it i ptapar opewt~ coaditiatt sadly (2) sl4ar la~aal{oa sad Ali (if reoesaty), the attldic tmt it Ina than V3 lWl of ' Mmi the mdlnlpasd bttfro tad tl`a abo+tare ameots Brad tapses b vaaitmm rba9tliraee mw'+ts I ; "w th• esodaids set fork bsoio. now by d w DqW mmad of C7oawmerroe mod the Depatlfneat of Nett LVI Resaomm Soft of Wimcood& Cstdl4"m maeod that yvor mr{ttic bas faaiaMired taaet be oatoptaad mad moused atlm Er. ctoix Camty Zoshe onke wpb w da ai da>a sra itl K, li.G.. (o 17l ° A DATE t (we) oaiti[y tart: aN a.lmom as dta Long we am to *A ban of my (ow) lmowWp. I (we) am On) da owattq) of t ubm of deed rwoa im Rermt of Dat & 0Wke. 6,17, o A DATE A*y iaibta dW tW is rsW49piaaaledar y tiettllt la the saoiEsty oak beiab mvaked by the Zaaint Dapataneat• udwat With dit sproait ow a of n"d w narty am $ Am ow R:esbw of Do*& office a cW of So audlied wrttey snap it rofemm" w mode it the wanasty deed LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02 REAL ESTATE TOWN OF PLEASANT VALLEY COMPUTER NUMBER 024-1010-96-000 Parcel Number 7.28.17.56C OWNER NAME: First RICKEY J & KARRY A Last KIZLIK PROPERTY ADDRESS: Hse # 1/2 PD --Street Name-- Type SD Apartment 458 CTY RD J SECTION 7 TOWN 28N RANGE 17W '/4160 '/40 Line Description Line Description TOTAL ACREAGE 9.360 PLAT LOT BLK 01 SEC 7 T28N R17W SE NW 10AC 15 02 LOT 1 CSM 7/1943 16 03 EZ-UT-1196/526 17 04 EXC CTY HWY PROJ 95-J-1 18 05 19 06 20 07 21 08 22 09 23 10 24 11 25 12 26 13 27 14 28 F1-General, F4-Prev. Parcel, F5-Next Parcel, F7-Valuations, F8-History, F10-Exit I r UIpQMAOYT NO. A'A''E lpu %M?iGE9 Ua wu~ res a ►eR iweww M~• 502748 am cum ano REGISTER'S OFFICE w..... _r»w «.._«..w Nw...w... ST. CRM CO, Wt Je'fre"ir JUL 29 ~N.MtiriWii .e»««««•w... _..r_w...w«N r...w r at •....«.....r...«... rr• ««...w«.w...•..• wr.N.» ..............ws.s...r•.w....• k. aL . f1~11tdfl?NM as" d Wbumb z Sea 7 T28N R17W SE - NW 10AC s-.r.rzrrr. LOT I CSN 7/1943 7.28.17.56C TM rend was zwi, corm , Sh no o si-e r I' lisp (f tm) DEW oft .........22 iq of -July ........._...rw........«.......1193 - 'Afts 0 .zlik «....._«...~Sfe~►ra Rarry A. Rialik i. yf...S~...Biaii,k...... «tssA~.) ..._....~....r.rr._. r...«wtf~El►Ll avTZXX'r CAVIGN ♦o><>NrO~L>>OO>YSfItT Ninnesota I pL NJN.w..«r..w.M•.NM.. .~..i~~.N.N.......~uy - ff Nr...Nr...w.r..««..r u w... twooQTmly~_ 11 bwdhn m~ na . yN. ..AIW d .7affrav izl~k w TlTt.1s:1tna" ST>TS us or VISOONKN •,...,iEatY•y.-~1c1~~-s' jYS b wM: MwR b he an vw=O... .w morel *9 lwr J bg bobummb "d do mom THM PWMW t WAf =UWM O rr - ...~Nrw.ww..M w_...Ne_...w.... r !3tVdS~Y. ' a NN R 71 f/td• Be* la iR ~M~c itiife 711 Form -ST C - 10 AS BUILT SANITARY SYSTEM REPORT l ,c f J 0 n) TOWNSHIP ~C SQ.I" SEC. T a~ N-R2W OWNER J ~r r L l ('01 ADDRESS ( 6"'' ST. CROIX COUNTY, WISCONSIN . /rid "It SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r. ~ss'~ 1.1 ~'inN © 1~ ~ I~C CAP, b ~ ~ f ' -7 1 }lease j I a t INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: f~''L-C4 ; tLiquid Capacity: Z'lw Number of rings used:- Tank manhole cover elevation: I Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front, Side,O Rear, O feet From nearest property line Front,0 Side,O Rear, O feet Number of feet from well ~%G O , building: /C (Include this information of tie above plot plan)( 2 reference dimensions to septic tank) SEE REVERSq,,S,IDL PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: Length: Number of Lines: Area Built: Fill'depth to top of pipe: i Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: 121A5!f Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: L Alarm Manufacturer: O Inspector: c.~ Dated: Plumber on job: License Number: 36 3/ 3/84:mj L a DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 SE4,NW4,S7,T28N-R17W CONVENTIONAL DALTERNATIVE stt8ePlan 1,D.Number: Town of Pleasant Valley D Holding Tank D In-Ground Pressure El Mound CTY N NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: I Jerry Liddle Route 1, Box 262, River Falls, WI 5402 s ( 0; 3c7 BENCH MARK (Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber: MP/MPRSW No.. County =,be, Thomas A. Wang 3231 St. Croix 2 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL JLOCK:DIENGD COVER ~t PROVI ED PROVy~ G~ /0 t J YES ONO DYES LrNO BEDDING. VENT DIA. VENT MATL. HIGH WAT R INUMBER OF ROAD: PROPERTY WELL. JIUILIII~ VENT TO FESH C ALARM FEET FROMLAIR INLIT DYES NO l OYES NO NEAREST ( 1~ DOSING CHAMBER: MANUFACTURER' BEDDING'. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON NUFA TORE WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: EYES ONO DYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: U BER OF PR OPERTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN F T FROM LINE AIR INLET PUMP ON AND OFF) DYES ❑N N AR EST 10 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until F FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH. NO. OF DISTR. PIPE SPACING COVER INSIDE CIA #PITS LIQUID BED/TRENCH TRENCHES. ERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO DISTR. NUMBER OF PROPE T WELL BUILDING VENT TO FRESH BELOW PIP S~ ( ABOVE COVER ELnE V. INLEQT ELEV. ND'. PIP66l LINE / ut AIR/!PL 7 FEET FR r 7 .GNU . J of NEAR ESTO--► / ~ MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ONO SOIL COVER TEXTURE PERMANENT MARKERS OIISEHVATION WE LLS DYES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DSODDED ["U'L MULCHED CENTER EDGES. DYES ONO DYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVEN BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL IMT-D-ISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.. ELEV.. CIA. ELEV. PIPES ID I A.. DISTRIBUTION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS DYES NO DYES ONO COMMEWS: PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF PROPERTY WELL BUILDING ,,(\IV,v✓ FEET FROM LINE: DYES ONO DYES NO NEAREST S~ g (00. 0 S 00, C, Top y~ =,1 . - 3 PPe - - - Sketch System on S 0 , ounty a dit. J Reverse Side. S l -r ATURE'. TITLE Zoning Administrator D I L H R S B D 6710 (R. 01/82) =Zw H1~ SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code STAT~SANITARY PERMIT # -Attach complete, plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION ii 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES NO PROPERTY OWNER ~p PROPERTY LOCATION l~ % k) , S TN, R E (o W PROPER Y OWNE 'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME Y, STATE ZIP COnDEn PHONE NUMBER 77 CITY e~~Zh NEARES OAD, LAKE OR LANDMARK ❑ VILLAGE II. TYPE OF BUILDING OR USE SERVED: 4/(iG Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. N Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3.F_1 An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. 4 Conventional b. E] Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. 54 Seepage Bed b. ❑ Seepage Trench c. El See a e Pit /?-X49'_3' 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRQj (Squ re Feet): PROPOSED (Square Feet): / 5 3 ~ Feet KPrivate ❑Joint El Public VI. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank O D Y S7'- ❑ Lift Pump Tank/Si hon Chamber ❑ ❑ 1 El Fo= El 1 VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. P7K45 's Name (Print): Plumb ignature: (No Stamps) MP/MPRSW No.: Business Phone Number: / A Na Designer: Plumber's Ares tre t, ty, tate iR Code): A41-o/ Vlll. SOI TEST INFO ATION Certi 'Tester (C T) MM4 CST Tkh CST's ADDRE?S (Street, Cit , tate ip C059) Phone Number: 'Opp IX. COUNTY/DEPARTME T USE ONLY ❑ Disapproved S nitary Permit Fee Groundwater Date Is ing Agent Signature (No Sta s) 'S[,4pproved ❑ Owner Given Initial II M rcharg^Fee Adverse Determination `~U ~ Z) 6J' X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT' x APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper wheneve? necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description where the system is to be installed; It. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. ---------------------------------------------------------------------------------------------------------------------------------7------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the i rtf result of over 2 ears of steady negotiation and public debate. The groundwater blll \ Y Y Groundwater included the creation of surcharges (fees) for a number of regulated practices which Wiscorl¢in's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buriedreasure is used in your building is returned V the groundwater through your soil absorption u; system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to t`, groundwater find adminis- tered" by the Department of Natural Resources. These funds PFe used for mon!toring grou,,,J- t water, groundwater contamination investigatir:ns and est= t?lishment of standards uroundwate!, i_'s worth protecting. SBD-6396 R.03/86) APPLICATION FOR SANITARY PERMIT STC - 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 U' ? Location of Property Section Tc2j~'_ N-R W Township 4,da;0_Ll~ f~ Mailing Address Address of Site Subdivision Name Lot Number Previous Owner of property ~L°rr--. Total Size of Parcel ~lI Cre- S Date Parcel was Created Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number 14/L as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 (We) cetr.a6y that att 6tatement6 on this botcm ahe tAue to the best ob my (ouk) k.nowtedge; that I (we) am ( ahe ) the owner (.s) o6 the pto pen ty de6 cA bed in thins inbonmati,on boron, by vi tue ob a waA&anty deed h o>t ; ded in the Obb~.ce ob the County RegisteA ob Deeds as Document No. P3 Y~5 and that I (We) pttesentty own the pJloposed .bite bon the sewage dispoze (otc I (we) have obtained an easement, to nun with the above descAibed properrty, bo& the conttcuction ob said .system, and the tame has been d_ufy uco&ded in the Obbice ob the County Reg-ustetc ob Deeds, as Document No. ) i GNAT OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED J _ V6cp / l SF X! S7 7;T k P 1 F' M /n 0-or) er w/tv r . CouPb• r h~ 3 0 O 3 S~ ~P~ r7' Sfie' JAI 5leu. 93, ~o i 61 1 lob E],4b p 6a s'~o d3 d 0~ N i _ _ - - I l ~ _ _ _ r : z N • ~ y 9 S T C -.105 r ' a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d (WNER BUYER TClrl/ FC'1 ~ y ROUTE/BOX NUMBER Fire Number .CITY/STATE ZIP PROPERTY LOCATION: k, ~_k, Section, T ~U N, R_Z2 W, Town of X"h ZC l1.fil1~ , St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I/WE, the undersigned, have read the above requirements and agree cza to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- hd ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office P.0 Box 98?- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEeARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDPSTR)-, DIVISION LABOR AND CC P.O.BOX 7969 HUMAN RELATIONS PERCOLATION. TESTS (11J) MADISON, WI 53707 09(1) & Chapter 145.045) LOCATION: ~ SE TION:~PPN r (o) W TOW ~P~I~NI~IPgrI~T e LOT NO.: BL~ ]SUBDIVISION NAME: COUNTY r:W ER~ BUYER IA E4 1 ` W (/dJ-"RE O d 5 Ili?k I d `O 0 USE C DATES OBSERVATIONS MADE NO.BEDRMS,: COMMERCIAL DESCRIPTION: ~r PRO IL DE RI TIONS: AT ESTS: Residence ❑ New RW Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUNOPRESSURE: SYSTEM-IN-FILLHOLDING TANK: rRE60MM E NDED SYSTEM:(optional) D S DU N S ❑U ❑U ~ S ©U D S ©u Og If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DE H I ELEVATION OBSERVED ES IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) pp B- ~.-~0 f - -~0' 8I S - ,66 d.Qa II. L° B- a~ ~ S f' Qr 5,z 1606(-91 OQr,~ 6fn s spa ~e~1 ~s .f B- biause S VCr B- 3 ~0 9b.s'd R -S , ~O f ew 6- 7Vfrn 0oqr5 e PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERT D 1 PERT D2 P R OD3 PER INCH P- 3 . o.) D v / a' P- `d.ao 3P 3 P- DD / P-. P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent --of-land slope. SYSTEM ELEVATION 3, 5d , F~~ TE 3- V r F, I _ _e "-4'0'e'6 t __74-4 T'" -f64 At ! I IP _ I 4N , N { l ~ t 1 I ~ 1 € ~ l f r C.T V N I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief, NAME (print : TESTS WERE COJVIP TE ADDRESS: CERT ICA 10 UMB PHONEN R(o tionaq: e a tl" 99/e CST SI URE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester! DILHR-SBD-6395 (R. 02/82) - OVER - M INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 ' To be a complete and e soil test, your report must include: 1. Complete legal descrit."i 2, The use section rm t I n€Iicate 3ther this is a re or commercial project; 3, MAXIMUM number of bedrooms or r rcial use plant t; 4. Is this a new or replacement syste-- S. Complete the suitability rating bc~ . SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 0, PL,.ASE use t` :vi, tions shown here for writing profile descriptions and completing the plot plan; 7. °~-1 E" A LEr""' ~ ;ram acc,'rately locating your test locations. Drawing to scale is preferred. A you I elevation L; L3, Ceall ap,.c 1 , names, Idre 1temp .ion , I as ;aropriate; 10. ?tiora (such as flood , ion) does not apply, ,dace N.A, in the apt r-: riate box; 11. m and place your cur;; at e 1 your certificati. in number; 12. Mr le,bla copies and distribute i 1. ALL SO'- i S MUST BE FIL TH THE LOCAL AUTHORITY WITHIN 30 DAY ~ COMPLETION. 9AT101"r . UERTIFIED SOIL TESTERS Textures; nibols st - 10„j cols 10"1 Ie Ts~t.n ~t sit Y t3 M V[It I TO THE OWNER: ' il test report is C!,, re in securing a sand y uraty or the Deg r rn., r ~s v i r oiorn of this So- ~ tho field grin) In ov mit iq~ ;o tem and a permi' ,n mu be sui or r a hermit. the sawt ~ t to f y rction_ _ _ i a co w n w 0 O c~ ` o 0 3 VOz S ~H~ E-i ~Z~ " co En E--l > 00 -73 00 1 10 I N N C7 1 N N cy 11 1~0 9 ~J R+ O N O ca 1 ctf O z S r+ m { W co 4-J 4J a) A J > H O > 'C3 N O a xLyi a cs ' t . 17 3 3 S 3 2 - IoJ~ ff CFIZTIFIM SURVEY MAP N 114 CON; SZC. t-, 7:8N, JERRY AND KARM LIDDLE jr 17 w, t COaNr r-'SUNVEYOR'S M O N.J Part of the Southeast 1/4 of the Northwest 1/4 of Section 7, Township 28 North, Range 17 West, Town of Pleasant Valley, St. Croix County, Wisconsin. C4 2 rd U N PL A T T ED LANDS p~ 01ndicates 1" x 24 iron pip s 994 47'87"E E43.43' `a 60t . I B 33 ~ weighing 1.13 lbs./lin. ft. ec 5'T set. 41. %I % z~ UWNf:Ei' S ADURES;; : Route 1 DWELL INO 0 0., 3 r Hammond, WI 54015 hOl ^ Q GARAGE 1 2 w w~~° 'h C_S. M. . Lori `♦♦,~11N1111tI~h J(~ n sH[o T ` Ih~ _VOL._ t ♦ I 1 ; N 89.47'27" W `♦~\SCONS/4,~' 111 8.05' a pA~af-990 W ° cor i 1~ O A 40 S = W MU Y CC : 'R o x +as, ?94 so. FT. c w a) t S NE r + 9.447 ACRES y, S • y. 4II,$01 SO. FT. = o N 't RhLE~i F LtS~i Jk► 2 0° Wisc. • JI X ieF JQ~~~ LAND ,S♦.•♦' $ o i8 Laurence W. Murphy X 3a.o ' Registered Lr,nd Surveyor e10.41' . a N 89. 47'27"W- i4 .ii7 O W E/W I14 LINE ,`--J~ ti N UNPLArrED LANDS SCALE 200' . S 4 0 50' /00' t00' J00' 400' 600' r. r u 3 2 w Q t t S I14 CON. SEC. 7, reex, RI7w /RAILROAD SPINE SErJ N Description: That certain parcel of land located in the Southeast 1/4 of the Northwest 1/4 of Section 7, Township 28 North, Range 17 West, Town of Pleasant Valley, St..Croix County, Wisconsin, more fully describ d as follows; Commencing at the North 1/4 corner of ~ said Section thence S 0 7, 0 00100"W (assumed bearing on the North/South 1/4 line of said Section 7) a distance of 1961.49' to the POINT OF 13MINNING9 of the parcel to be herein described; thence continue on said line S 00000',00"W 677.00'; thence N 89047'27"w 6113,113' an the Rast/West 1/4 line of said Section 7; thence N 00 00'00"E 677.00'; thence s 89047127"F. 6113.43' to the POINT OF BEGINNING, containing 10.000 acres, being subject to easement over Easterly portions of said parcel for C.T.H. "J" R.O.W. purposes and also being subject to easements of record. weighing 1.13 lbs./lin. ft. set. O'WNER'S ADDRESSs Route l OWELL1N0 Hammond, WI 54015 h o G} ca qa cE •°j CAS. M. L OT ! ``~~,1111111111Sh1 v D sHEO V DL•4 1 N 09 47 17,~W \$CONS ci I= e.ta• a 3 _PA61 998 Lor 10.0 LAURE M W MU , Y ; cc I IR °o X 4iS.5 so. rr. I w ° Z G? 1 $ ' i. "a ~ X NET + 9.417 ACRFS h ` w 4 //,SO/ SO. Pr o = o ' • { N RIVER F LLS, i A Z a w +Z ~F ' WISC • a 1 x L ANA o° Z V o k N . Laurence W. Murphy X 33.0 Registered Lrnd Surveyor 6io. 43• 1. W It _ 09. • -J wN 47'17"W 043.43 UNPLArrED LANDS t SCALE I"# 100 h 0 SO' too, zoo, 300' 400' 600' 1 w u 3 ~ It w 4 S 114 COA. SEC. 7, r?SN, 917W V Z /RAILROAD SPIKE seri Description: That certain pnrcel of land located in the Southeast 1/4 of the Northwest 1/4 of Section 7, Township 28 North, Hange 17 West, Town of Pleasant Valley, St..Croix County, Wisconsin, more fully deseribV as follows; Commencing at the North 1/4 corner of said Section 7, thence S 00 00100"W (assumed bearing on the North/South 1/4 line of said Section 7) a distance of 1961.49= to the POINT OF BEGINNING, of the parcel to bs herein described; thence continue on said line S 00000!00"W 677.00'; thence N fay 47"27"W 643.113' on the East/West 1/4 line of said Section 7; thence N 00 00100"E 677.00'; thence S 89047'27"E 6113.43' to the POINT OF BEGINNING, containing 10.000 acres, being, subject to easement over Easterly portions of said parcel for C.T.H. "J" R.O.W. purrioses and also being subject to easements of record. Dated: February 24, 1988 State of Wisconsin) County of Pierce) I, Laurence W. Murphy, Registered Lond Surveyor, do hereby.gertify that by direction of the Owners, Jerry and Karen Liddle, I have surveyed and divided the lands shown hereon in accordance With official records, Chapter 236.34 of the Wisconsin Statutes and the Ordinances of St. Croix County; and that this mat: and description are a true and correct representation thereof. Vol. Page 11413 Certified Survey Maps St. Croix County, Wisconsin ST. CRW COMM 00kT%E4EN0Mrant8PLM"r 144D lf3MNG C01y1Rr WF -Y ,x - X78 ~h y APPLICATION FOR TOWN BUILDING PERMIT tProperty owner: P'cy-- Ki2i ►y- Contractor/Agent (if not owner:) r i L~ h. 1~ ~o 'Mailing address: L/5 Cf %-1 fit( `J Mailing address: 5k~ttnc►0t-J w~ . ~yo►5/~y t Daytime phone: Ir 796 Daytime phone: O 7 „ / 7,-~. Property location: 1/4, ZQj 1/4, Sec. T. 5'6 CN•, R. W,, Town of PleASq.v'~ ~/Ct ~e i` L` Computer / pl O . C_ ~0 parcel TI-1 T ?Zoning District: ~i16 V l ~y J,✓,C'i"t . g . Type of Town Buildine Permit (Check one of the following L Single-family residence ( ) Farm Buildin ' Seasonal Dwellin g OCommercial Building OAccessory Building ( )Industrial Building g ()Remodeling I_Application Check List: The following is a list of submittal requirements for a town-building permit per Article 17.70 (3) (b) of the St. Croix County Zoning Ordinance. It is important to submit a complete application, as it will help town officials review the request efficiently. To ensure your application is complete check off the box as you complete A general written statement that specifically identifies what is being requested. A statement indicating whether or not a private water or sewage system is to be installed. Fa Indicate the type of occupancy (single-family dwelling, personal storage, Ag. related, etc...) CeSITE DEVELOPMENT PLAN SUBMITTED ON 8'% INCH BY I I INCH PAPER complete 'site plan showing at a minimum the location of the following: Identify and label any slope 12% or greater, Dimensions and area of lot, - Location of any structures with distances measured from the lot lines and centerline of all abutting streets or highways, ~w Location of any existing or proposed on-site septic systems or private water supply systems within 100 feet of the construction s: ' 4 Location of the ordinary high watermark (OHWM) of any abutting navigable waterways and show all setbacks from the n"x}s OHWM Location and landward limit of all wetlands, specifications and dimensions for areas of proposed wetland alteration. ~a-~ • " ~,~^,Existin Wand proposed topographic and drainage features and vegetative cover, x Location of. floodplain and floodway limits on the property as determined from floodplain zoning maps used to delineate floodplain`areas, - Location of existing or`future access roads And any other unique limiting condition of the property Ld ' THl BUIDING SITE MUST BE STAKED. The Deputy Zoning Administrator will view the site to ensure compliance with the .agree to withdra this ieation ' bstantive false or incorrect information has been included. na t~. LS--/i-~y Date I revtew'oitly veri tes tha I ie'project complies with the applicable St. Croix County Land Use Ordinances. This is not an phcation fora Uniform Dwelling Permit or to install a private onsite wastewater treatment system. itlss $ nce bate: / `iratid'n bate: Permit # The applicatioq,.materials will remain on file with the TOWN. 00 r~ S f ecj