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HomeMy WebLinkAbout024-1019-50-100 � �k���� J % ; E 7 k T° 1 2 ID r = s _ z \ � I ° § < ° S 2 .- e f - 2 / \ $ :, \ § R 0 o _ £ ' ® � % = m § i ` { < / § /ƒ 2 J@ f ƒ 6 0\ 4 ; : C N E @ v > E % $1 4 E e, R % 1 a C CD CL § 42 _ 0 / §�� � ;ƒ o o C E C C. oc] ■ 7 2\ 0 0 0 k : - R e g § (a CO) CA 0) ° 11 -0 3 : z § f � / g > >o ƒ C M . 2 CD / � } / _ ■ o ■ z m z 9 � ƒ w T g 2 CD ; 0 CL / / \ . z o k \/ / § CD \ �/0 E 0 E � � k «§ , $� K $ � }/ ƒ = m a � @E � � a \ = K o CD § \ D° 8 2 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count .Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 363893 Permit Holder's Name: ❑ City ❑ Village ❑ X Town of: State Plan ID No.: Pleasant Valle Townsl ip C BM W > hq Insp, BM Elev.: BM Description: Parcel Tax No.: 024 - 1019 -50 -100 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ki d ' , i r', 1 Benchmark Dosing P t c 1S Poo Alt. BM p 9 lion Bldg. Sewer HoWing S / Ht Inlet TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. Ventto ROAD n e Air Intake Septic Lr 5 y NA Dt Bottom Dosing NA Header if Man. Ae NA Dist. Pipe 6 . /S �9 Ing Bot. System PUMP/ SIPHON INFORMATION p Final Grade , Manufacturer Gd emand St cover Model Number 6 ! QwGPM TDH Lift ?, -4 Friction �/' SysterrL TDH j Forcemain LengthZSU Dia. 2 /' Dist. To Well SOIL ABSORPTION SYSTEM BED / T NC Width Length No. Of T ren hes No. Of Pits Inside Dia. Li uid Depth DIMEN S 2- ��a DIMEN S I SYSTEM TO P/L BLDG WELL LAKE /STREAM LEA Manufacturer: SETBACK C MBER INFORMATION Type O ] 7 OR UNIT Model Num System: DISTRIBUTION SYSTEM Header / Ma Id t Distribution PipeO / x Hole Size x Hole Spacing Vent To Air Intake Length / Dia Z Length 3 Dia. Spacing AM ( 3 ---- SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded 1 Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes No COMMENTS: (Include code discrepancies persons present, etc.) Inspection #1: q //97 Inspection #2: } /I I / v v Location: 1726 30th Avenue, Hammond, WI 54015 (SE /4 SW 1/4 16 T28N R17W) 6.28.17.1080 -Lot 2 1.) Alt BM Description= b+ 60J� i' �•' 44.* �Ccm� 2.) Bldg sewer length = 31 It 4 a /1#/ G{� - amount of c over = - 7 Z 3.) contour = 4 /, / • 9S C T — ; li . ?, �.) YP Plan revision required. ❑ Yes �] No Use other side for additional information. if (� SBD -6710 (R.3/97) Dat Inspector's S ature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e e Q 3 9 _ e „ e F 3 x = E n t a 4 i Safety and Buildings Division V SANITARY PERMIT APPLICATION 201 W. Washington Avenue sibonsin P o Box 7302 In accord with tLHR 83.05 Wis. Adm. Code - Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on etjot less C my than 8112 x 11 inches in size.:` r' =.''`" ( CR4 I y� • See reverse side for instructions for completing this app (cation �{ `ji� 5tirt Sanitar g; PO Personal information you provide may be used for secondary purposes ^� 4 C eck if revision to previous application [Privacy Law, s. 15.04 (1) (m)l. �R�yF� Qtr ., �; a Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL MX' ON d = 31ST �Z Propert ner Na a Property o�a3 on R44 / 44 : '+ - 4, S f�J T N, R E Propert Q Mailing A r es Lot Num be r Block Number 7 2_ P4 1 L14 L Cit , to L ,, k I Zip C 6 � PhoneLNumbqr � Subdivi on Name or N ber , 6 o' TF TYPE OF BUILDING: (check one) ❑ State Owned 3 a Its/ S0. e Nearest gad n ❑ Vil �4 Al h 6 .� ff � Public 1 or 2 Family Dwelling No. of bedrooms Town OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 0 a(i_ 101`9 — 1 ❑ Apartment/ Condo D fib. zr- C+, Io$C- 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, Ig 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 Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution' Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 V Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 []Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit S X 43 ❑ Vault Privy 14 ❑ System -In -Fill ko C.,4,,�) VI. ABSORPTION S YSTEM INFORMATI 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade n Required (s ft.) Propo / d � q. ft -) (Gals/d y /sq- ft.) (Min. ch) Elevation /i �rJ d� I/ r �p 0 Feet 5 Feet Capacity VII. TANK in Ca g allons Total # of Prefab. Site Fiber- _ Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete st acted steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank )5f ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ ❑ ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage m shown on the attached plans. PlyMbeir I s Name: (Print) Plu b r Signature: (No t ps) j MP/PTPRSWNjo,.�Business Phone Nu er: Plumbers Address jStr Ci 1;y, ate, Zip k_J Ale IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee (Includes Groundwater a e ssued Issuing Agent Signature (No Stamps) s ,Approved ❑ Surcharge Fee) Owner Given Initial 32��� Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: « = SBD- 6398 (RA 1/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit 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 dr plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: 1. 'Property, owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must gign application form. 1X. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump 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 Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 .'\Visconsin www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary May 15, 2000 CUST ID No.691727 ATTN• POWTS INSPECTOR ARTHUR L. WEGERER ZONING OFFICE 421 N MAIN ST ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 RE: CONDITIONAL APPROVAL Ideit�ficaticn Ninbers PLAN APPROVAL EXPIRES: 05/15/2002 Transaction ID No. 315972 Site I No. 191 905 SITE: Pleaserefer ta`bith identiiCalrxon nutbexs, Site ID: 191905, Marsha Hague Proposed Residence above, i all co respondence, ith fhe agency.' St. Croix County, Town of Pleasant Valley SETA, SWIA, S16, T28N, R17W FOR: Description: Three Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 662963 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The following conditions shall be met during construction or installation and prior to occupancy or use: • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. CAUTION: Wis.stats 145.135(2)(b) indicates that the approval of a sanitary permit is based on regulations in force on the date of approval. The effective date of COMM 83 revisions is expected to be July 1, 2000. Thus depending on the type of system and your design, this plan approval may not be eligible for sanitary permit approval if submitted to the issuing agency on or after July 1, 2000. Note: There is a. otp ential for a law suit that may delay the effective date of the code so this status may or may not change. 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. ARTHUR L. WEGERER Page 2 5115100 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 05/09/2000 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 Gerard M. Swim BALANCE DUE $ 0.00 POWTS Plan Reviewer - Integrated Services (608)- 785 -9348, Mon. - Fri. 7:15 AM to 4:00 PM jswim@commerce.state.wi.us T ICE s Z. �. Page of 6 MOUND SYSTEM FOR A 3 BEDROOM RESIDENCE LOCATED IN THE S E 1/4 OF THE S W 1/4 OF SECTION T 7 , 8 N, R W, TOWN OF \ ���p�T �( p��'l{ , S`f -, C�Za COUNTY, WISCONSIN. LOT Z: p INDEX PAGE 1-of 6 TITLE SHEET PAGE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW -CROSS SECTIO �� PAGE 4 of 6 DISTRIBUTION PIPE LAYO� o PAGE 5 of 6 PUMPING CHAMBER �� ` PAGE 6 of 6 PUMP PERFORMANCE CURVE 44 o, PREPARED FOR 1�,�Pr1ZS�l-R �� U C �t�{ S , btu�sto►J Sr. � Z ..�.c , 2o�TS, wl S�toZ3.�� ll co ntlitto , - �pEFPR� � Ny s,aN FI7E 'A= BY ENGE GOR? EgP SEA WEGEF:EF:Z SO I L TEST I NG sq AND . DES I (3M SEFRV I ( c'D�S / P.O. BOX 74 421 K. MAIN ST. RIVER FALLS. KI 54022 WEGFREn 715-44 tou3F • ti4 �sIG�`� JOB NO. O 0 - l \ q I PLOT PLAN Page Z of Scale 1 "= 60 ' . w4XJTOU2 Yl pr Tzcyc� L 49A v 12 S ° fo I I � 1 0 ►JpT C1r1DF�e.T �3M olZ I N> � ..{3 �o 1- zs I 3 j 10 v N J �] 3 � u 3D O'er Z Pl- B�"1 t F L --- • (4 0- 313 D1Z1^�► - V , N CO SE ftT - Lvt ZS 1=-zt1m `Qmhr- - _._ 1 �E sT � 3p `TT t fl V �, NOTES 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install permanent markers at end of each lateral. ( ?- required) 3. Install 4" observation pipes with approved caps. ( 2 required) 4. Septic tank to belZlw 8o gallon capacity manufactured by � � asA - P1� -PAT 5. Bench Mark 3M* ( _ t� L , Lbo oN S'triGtt , 3Iq 1 u 1_ c - ii Pe w7 Lrn - H _ 3M itz- L q4 -S , << k k 4 w 6. Divert surface water around mound to prevent ponding at the uphill side. Page 30f b Approved Synthetic Covering t�sTN► c 33 Distribution Pipe Medium Sand _ Topsoil H_ �G F Eled. Q `3.00 D - 3 E b S % Slope Force Main Plowed Trench of z " -2 %2" From Pump Layer Aggregate (undisturbed D Ft. Soil E 1 -Z.5 Ft. Cross Section Of A Mound System Using F o•8 Ft. I Trench For The Absorption Area G N• Ft. A S Ft. H I- S Ft. B S Ft. I \Z Ft. Linear Loading Rate= 6 GPD /LN FT i Ft. Design Loading Rate= O3SGPD /SQ FT K 11 Ft. L C1.7 Ft. W - IS Ft. L J Force B K Main • ou s�1� W Distribution Trench Of 2 2 Pipe Aggregate Permanent Observation 1 Observation Markers Pipes (Anchor securely) Mound Using I Trench For Absorption Area Page `� Of Perforated Pipe Detail 0 End View End Cop ) Perforated J_� l bXe PVC Pipe Jo i�o `a ��a �' as Install permanent-marker at end of each lateral Holes Located On Bottom, Are Equally Spaced Q End Cap PVC Force Main Distribution Pipe Lost Hole Should Be Next To End Cap Distribution Pipe Layout ' W� X (` J chPs Y Inches Hole Diameter lly ch Lateral 1 ch(es) Force Main aches # of holes /pipe 1-L Invert Elevation of Laterals c ) q -S Ft. "Zx1. n = 1 4.0V >L Z_ Z € _U8 GP', Place 1st hole ��� from tee with succeeding holes at 3 6t r intervals. Last hole to be next to the end cap. Combination Sept:ic-Tank and PUMP CHAMBER CROSS SECTION AND SPE ' PAGE S OF (� VEIJT C WEATHER PROOF JUUCTIOW box `"C.Z. VEIJT PIPE APPROVED LOCKING �:- 10.' FROM DOOR, MANHOLE COVER PVIV 'dINDOW OR FRESH u'AR►JIW6 LAKE(, A�_RIIJTAKE S co�cu�r Q 14 5� ` j I Y' MIU. ` -- �. 18•MIU. _ y "►NSVert�ol.� pI?� � _ 11� J_ 1 l.ILET w /FhVZn(.*r e.R-P PROVIDE AIRTIGHT SEAL Approved - joint w/ • Tank c A Approved I III I II onstruction I II I joint w/ PVC pipe shall comply with ALAR PVC pipe ILHI 8) 3.15 and 33.20 6 I II I I C I I om I LLEY. S FT. PUMP --�, OFF r D COUCRETE J BS.r q4 BLOCK RISER EXIT PERM11TED ONLY IF TAUK MAUUFACTURER HqS sucH APPROVAL SEDD:NQ r:OD t ry SEPTIC f SPECIFICATIOUS DOSE TAWK5 MALW FA&URCR: Y`'11.iA%ASTEW Al T NUMBER OF POSES: P E K DA4 3 ' 3 �- TANK SRC : \Z ll0 1800 GALLOWS DOSE VOLUME r ALARM MAUUFACTU INCLUDIIWG 6ACKFLOW: `NA GALLONS MODEL LUMBER: IN tiw CAPACITIES: A- 15 3\S SWITCH T�PC: ��'2CUVZ...L/ _ IAICHCS OR GALLpys 8 = INCHES LVZ11 G(LLOUS PUMP MANUFACTURER: GAUL -DS C: 2 IUCHE5 OR IS SOS CALLOUS M OOEL NUMBER: D- \Z 2'SZ.60 INCHES OR CALLOUS SWITCH TYPE: IJOTE: PUMP AMD ALARM A E TO E � MINIMUM DISCHARGE RATE 2-S.08 GPM INSTALLED OM 5EPARATE CIRCUITS VERTICAL DIFFEILENCE bETWECAJ PUMP OFF A PIPE.. 13'SD FEET + MWIMUM AJETWORK SUPPLY PRESSURE 2.50 FEET + FEET OF FORCE MAIN X 11 F 0 FLFRICT1oU FACTOR.. 5'1I FEET TOTAL OtiIJAMIC HEAD = Z l_71 F EET As per manufacturer 2-k.CN S gal /in. Liquid depth 3s 'I • • 1^1P P�zFO�Zw� C� Gv1 Goulds Submersible Effluent Pump 3871 EPO4 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. dry without damage to heat transfer. ■ Motor Cover: Thermo las- • Effluent systems P • Homes components, A tic cover with integral handle Available for automatic and • Farms Motor: manual operation. Automatic : 0.4 and float switch attachment • EPO4 Single phase HP, • Heavy duty sump 115 or 230 V, 60 e: 0.4 H0 models include Mechanical points. • Water transfer RPM, built in overload with Float Switch assembled and ■ Power Cable: Severe duty • Dewatering preset at the factory. rated oil and water resistant. automatic reset. ■ Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearin g 115 V, 60 Hz, 1550 RPM, construction. Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo- • Solids handling capability: automatic reset. plastic Semi -open design 3 /4 ° maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP CanadianStanda►dsAssociffilon i • Total heads: up to 24 feet. with three prong grounding ` • Discharge size: 1' /2" NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- (CSA listed model numbers • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in "F' or "AC ".) rotary/ceramic - stationary, three prong grounding plug improved performance. BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides - 104 °F (40 °C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 • Capable of running' + dry without damage to s 30 components. Pump: EP05 8 • Solids handling capability: c 25 maximum. w 7 i • Capacities: up to 60 GPM. _ ZI 3 i • Total heads: up to 31 feet. 6 20 • Discharge size: 116" NPT. z 5 • Mechanical seal: carbon- 0 15 rotary/ceramic - stationary, _j 4 +` V BUNA -N elastomers. o I EP.05� • Temperature: 3 10 104'F(400C)continuous i 140 °F (60 °C) intermittent. 2 EPOa _. 5 1 ! •- 0 00 10 20 I 30 40 50 GPM 0 2 4 6 8 10 12 m'/h CAPACITY n loos rr ['q� o. I. Submit to non - enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin municipalities for new 1- PERMIT APPLICATION Safety and Buildings Division and 2- family dwellings (Wis. Stats. 101.63 (7) & 101.65 (3)) SEE INSTRUCTIONS ON BACK OF YELLOW CO)�Y. t Personal information you provide may be used for secondary purposes. [Privacy La Last Name First Name Middle I Sa- - C fax s Wo o �v' Street Address ` City State Zip Code Telephone No. (Include area code) H Awt rnvN 0 71.5- 71q -3aG7 I'�O.IECOCA 8 Building Address Subdivision Name Lot # Block # 2. Legal Description Parcel No. 1/4, 1/4, Section T N, R E or W wr 1 Family ❑ Forced Air Furnace ;9 Radiant Baseboard or Panel ❑ Heat Pump ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: ENERG O x Nat. Gas L.P. Oil Elect. Solid Solar Space Heating ❑ ❑ ❑ ❑ ❑ Water Heating ❑ ❑ ❑ ❑ ❑ 777 7777= T . CNSTCTIO 5.'OU1�ILIATION ` y g ❑ Site Constructed X Concrete ❑ Masonry ❑Treated Wood Manufactured ❑ Other (specify): iA T * �14IATED BIDING COST M , Living area 900 Square Feet $1 �' I vouch that all the above information is correct, and understand that the issuance of this permit is for - administrative purposes only. I understand that onsite construction inspections will not be performed by the municipality, but that the Uniform Dwelling Code, Chapters Comm/ILHR 20 -25, still applies to ali;new 1- and 2- family dwellings and must be complied with. I understand that the issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. d Cam T . Applicant's Sign' ure Date Signed MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISI OF SAFETY AND BUILDINGS K T ❑ Village ❑ City Coun o ❑ Cf: IS�S�UTNG RiS I + �.. own { < ' ' mum NUI}3ER, # �,� ,, c _f -;� S: w ,� _ ,� Dwelhn Lca ..� . a•a' �% PERMIT" I9SUED 'tYz SBD -8254 (8.2/98) White - Issuing Jurisdiction Pink - State Within 30 Days Yellow - Applicant I INSTRUCTIONS The, owner, builder or agent shall complete and provide all required information on the application form down through the Signature of Applicant block. This data is used for statewide statistical gathering a new one- and two- family dwellings, as well as for local administration. When completed, shtn t to'lpcal municipality having jurisdiction. Plan review or building inspections will not be ' performed by tbke municipality. PERMh REQUESTED: A, <• ,Fill in building address. • Fill in legal description of lot, subdivision name, lot number and block number. PROJECT DATA: • Fill in all numbered project data blocks (1 -7) with the required information. All data blocks must be filled in, including the following: 1. Type - Check only "1- Family" or "2- Family" if that is what is being built. In other words, do NOT use this form if only a new detached garage is being built, even if it serves a one or two family dwelling. 2. HVAC Equipment - Check only the major source of heat, not any supplemental sources. Mark central air conditioning if present. Only check "Radiant Baseboard or Panel" if there is no central source of heat. 6. Living Area - Include any finished area including finished areas in basements. For two - family dwellings, include total combined areas. 7. Estimated Cost - Include the total cost of construction, but not cost of land or landscaping. SIGNATURE: • Sign and date application form. ------------------------------------------------------------------ ISSUING JURISDICTION - This must be completed by the AUTHORITY HAVING JURISDICTION. Check off MUNICIPALITY STATUS of issuing jurisdiction, such as town, village, city or county. Fill in MUNICIPALITY NUMBER OF DWELLING LOCATION. If issued by a county, indicate the specific municipality number where the dwelling will be built. Fill in name of person issuing permit and date building permit issued. PLEASE RETURN PINK COPY WITHIN 30 DAYS AFTER ISSUANCE TO (You may fold along the dashed lines and insert this form into a window envelope.): Safety & Buildings Division P O Box 2509 Madison, WI 53701 -2509 Wii Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations I)Msion of Safety a Buik5ngs in accord with ILHR 83.05, Wi Adm. Code COUNTY complete site an on T Attach con pl plan paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BAH direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. PE1`►Ol nl6 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION R 6 l )/ Y DATE �C, PROPERTY OWNER: PROPERTY LOCATION %aL W 1.� F 116ff bM 'SEE 1/4 S W 1/4,S 16 T Z% ,N,R kZ E PROPERTY OWNER'.S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # \^j \' Zg9 I 89 o TTl 1: . Z I — cS M CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ,MOWN NEAREST ROAD F t u �2 1 _Jt t_� w I -S Y o zt (1►SI u Z S. S L ZI Pl .` K v rat, 3 0 - T* IN K New Construction Use [Xj Residential / Number of bedrooms y [ ] AddittQn to existing building j [ Replacement [ J Public or commercial describe Code derived daily flow 6 0 O gpd Recommended design loading rate __ Ly bed, gpd/ft — trench, gpd11t Absorption area required S bed, ft S tJ O trench, ft Maximum design bang rate • S bed, gpd/ft • � trench, gpolft Recommended infiltration surface elevation(s) �► a t • o ft (as referred to site plan benchmark) Additional design/ site considerations w/ S'x Ga wt f}v, \2. n f= S - A-'p FiLL . Parent material G LNQ_ I- Pct_ `n L\_ Flood plain elevation, if applicable Q. A • It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U =Unsuitable for stem ❑ S SU S❑ U ❑ S O U El S U ❑ S �U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed re Xh D`� Ib`I1Z 31 2 Z. `f Sh ��1 Q.S \ S ?a..'``�.: Z 8 -Z6 t 0 `'t ti 3 / so - S i i Z'E S �lr, vn '�t- C S - • S � Ground 3 2 �, -37 Z - S 1 -117- , 31y - ) , 5 1 - if? S /g W1 `F t- Cw - • Z - 3 elev. °I '-'2 it S 1 -1 IZ V �;. S `f tZ s /g C O w Z Depth to limiting factor Z, n Remarks: Boring # 0 -10 \ v�2 3 .1z - s lI Z'F S �>T vh�h a g 1 ,5 •� S Z Zo zo o \t P_ 3 f 3 zo Zq - )-S`1 fz 31 y — c S\ k >nik CS Ground elev. Z9 S S S `� R- yl y f1 2 5 Sc-� o'M +01- - - Z °IA ft Depth to limiting factor Remarks: CST Name: — Please Print Arthur L. We erer Phona' 715 425 - 0165 V ress: - egerer Soil Testing & Design Service - P.O. Box 74 River Falls,WI 54022 Signature: Date CST Number. z✓' °t.7 -ZSl- ► _Z7- 98 M00576 PROPERTY OWNER LVtQ - SE SOIL DESCRIPTION REPORT Page ZoP. PARCEL I.D. �1Vb L/V 6 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. jed er� I 0 - a loK¢- 3 i z - S - Z, �bk �� � - s 1 b Ground 3 Z$_�p 5 ? �Z 31 y 1 e-S1� �i 5 elev, t d `i 1Z 5 l Z c � - It cz s 1'6 S t c. I - Z . a bt Yn `� ^ — - �l ' • S °n...o 4 yb -�g � Depth to limiting factor � Remarks: Boring # E3 Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # [3 Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) PLOT PLA Page - of 3 SCALE 1 "= yp ' r �r A 1 s vtw_itJ 8 "Y"Mm OF Bes eTtkv . c19. r 3 �LaIZ•O' - � lv o� - car -► � rt-c1- otz. 3 � g.5 W tl. -t a) I cn L s•y I zs rVOr L MNz P-e-1' Olt � f i 6;. f 'T' LZP� ST Z S ' 4 r-1 r-� o v ►vp . i, so' - 4 3. r�uvtip �v�71} f� V �U3 y. Ftilvl LOT- uiveS - To B-Z� f)T I_L=r,ST S')—: ► tnu0hv S_ ZLe\\j . too,p' o S "MGti,3IV Arc PtPlc w / L/t'J°I-} _ Ip o k' �w11Z- Sw —SE S t'C ac 1'1p t1+ 5T. S°ht� 1 =8op' t� �i''�IOrJ SltJ1'�LH a� -mil- I ( 715 ) 425 -0 fi5 M00576 CST Signature a Date Signed Telephone No. CST # • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT l AND OWNERSHIP CERTIFICATION FORM owner/Buyer .e� -1 A Np6U F Mailing Address I S, J) i V l S I O N 'r't, , #� Z (Verification required from Planning Department for new construction)_ Pr h City/State A U t Parcel Identification Number C / fv LEGAL DESCRIPTION /b Z�: /�-. �pdr,- Property Location 15f— V4, LJ '4, Sec. o T _N -R W, Town of P1E ZG of VQ�2 Subdivision . Lot # r . Certified Survey Map # j H7 - 4 - � 2 0 , Volume Page # 341 (a Warranty Deed # V � � �] , Volume Page # Spec house ❑ yes Nno Lot lines identifiable & yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary) , the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. /1R/ SIGNA F ANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 11 SIGNATURE W APPLIC DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed Al 1 F ILED e MAR 0 Al 1998 ► 2 — 3''20 s�a>�era nos c r � (A UN - -- I'll Nd � m -^ - m nz CA WEST' LINE OF THE SE1 /4 OF THE SWi; 4 � �.. t� � I ICJ �• _ Z � to © D f-•. FENCELINE (TYP; _ OG N00'21 50 "E 925.39' C;AI) r I ?� n s 'o H N I ' '�. , FENCEUNE tS E�5 . ...�� I L I Z ei -, fU $92.72' ("� 70 ' Q " C I p,p �/- FROM LOT CORNER W 32.67' 0�0 X f U --I m = IJT as m 1 \ a- � > -- — _ o Ln Z 2 892.72' fix, r) Cz -+ < rq m e 31.80' 508.51' 384.21' rrl _ a o _ m 0 508.21' 384.51 w 892.72' W Z F e r rn 4 w L m (n 'N ". ('i . tV �D 00 p. c�D m m w w w � `� 4 U3 i > • o o m , t " `�" `' W LA ! . Z 7> to OD co N N00'21'50 "E 923.46' V A �, f` E '•r 00 892.72' rn 30.74 , - i C,+ Ln do rn Vb I k`•I l C 3 r*T . f r 1 801'12'39 "E 595.35 o m c o rn - -U � o —I 251 mm� �_ C-< X 2 M O QR e gg f Jy a 2 ri z �_ a �' ' I Im 0 �' > o r �' m `� LA `L � mi O > C C y O OA 0 O w I s ,, • ly { 6 O f T Swt •P .+ I t EAST LINE E 4 / �► ''" —, I i + I f I� — N00 *20 *12 E CA Cat I ur - - ;To ru �W r ly I� z 5245.32' C f P � - ---� -e 1 WEST LINE OF THE SE1 /4 —'� Z j w J rr �, -- — -- -- - _ N00'20'1 2"E 472.87' 0 � o N (N01'27'30 "W. 452.35') z © cN cn * N01'31'04 "W 452.48' cn z o^> C O'� r °° z tv D 423.36' z 29.12 O0c � N CO O CD z z .a'- `° O0 ' ° ' fn A A W i Document Numuer WARRANTY DEED REG(;f g 'bF 7lCl This Deed, made between Glen M. Wiese, a married $T. CRC X CO., wl person, Grantor, and Marsha L. Hague, a Single person, 'tr '��� Grantee. APR $ 4 1998 Witnesseth, That the said Grantor, for a valuable 9:30 A consideration conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: Part of tha Sr of SW -1/4 of Section 16, Township 28 amo Recorditv " R Arm at North, Range 17 r,Pages Croix County, Wisconsin N ama srxt R e tu rn Address described as follows Certified Survey Map filed WESTconsin Credit: Union March 4, 1998 in Vol. 3416, as Doc. No. 574320. p.o. Box 126 Z �/_ /� . _�� Baldwin, Wi. 54002 TT 28'. /CF'G 02410!9-90 (Owcet Identification Nulmtw) Grantor ^Iso gmats to Grantee an easement way, for access to said lot, over the South 50 feet of that roadway extending North from 30"' Avenue and lying between Lot3 2 and 3 of said survey map. By acceptance of this deed, Grantee agrees to be jointly responsible with the owner(s) of Lot 3, for the maintenance of said 50 feet ar:cesswray and to maintain 4 in good condition, sharing the costs thereof equally between the owners of Lots 2 and 3. This stall be a covenant to run with said Lots 2 and 3 and shall be for the benefit of, and tending upon, all future owners of said lots. TRANSFER r , This is not homestead property. Together with all and singular hereditaments and appurtenances thereunto belonging; And Glen M. Wiese warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants, restrictions, and rights -of -way of record, if any, and will warrant and defend the same. Dated this ILA day of April, 1998. he-- 1114 • *Glen M. Wiese AUTHcNTICATION ACKNOWLEDGMENT- Signature(s) STATE OF WISCONSIN ST. CROIX COUNTY Personally came before me this - 9998, the above named Glen M. Wiese to me known to be the person(s) authenticated this _ day of 1998. who executed the foregoing instrument and acknowledge the i T. 9 p, typeor l� name int TITLE. MEMBER STATE BAR OF WISCONSIN Notary Pubrlic Coun , State of W*consin. (If not, My commission expires _ c) authorized by §706.06. We. Stats.) - 'Narties of persons signing In any capacity should be typed or printed below _ THIS INSTRUMENT WAS DRAFTED BY thsa signatures. C. L. Gaylord, Attorney at Law River Falls, WI 54022 (Signatures may be authenticated or ccluvwledged. Both are cat necessary) k4ormabon Prolea"w --K Compaq Fond du Lac, Wisconsin 80046&202+