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024-1021-95-000
0 CO) ° 2 7 c k\\k& / CD . § _ _ \ FF 0 { m { ( f ' @ \ \ � G Q �a:m' » \ } / \ § / \ § 2 k Q§ e @ / o< a§ 2 ° �aa= \t2 !< < -6 § \ ) ƒ ? @ / \ i \ ƒ 9 \ ` y E E . g g ( § \ { , c v > C R ° � E ? t m R G\\ / \ 2 \ C 10 \ / § 2 / \ / 7D \ \ § 0 r 0 ; CD c § \ / o 0 o M cn 2 E E E § \ o \ / \ o v o R A \ § \ ; \m � ( k � \ , . � F rr t = I I o .. \ Q , 2 ` - @ / } J w to o m \ } \ \ / 7 E � E \ ■ \ $ § - I 0 0 FF § \ / { 3 _\ d \ \ ® C D » «`§ CL (n. % \ Ee r E i y % CL �0 � /} $ 3 .. . � r � @ \� » . $ � K � . cz � I ■ g ° \ / \ \ \ \ ' \ k Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 399522 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)]. 6 - 76 1 � 1 Perot Holder's Name: City Village X Township Parcel Tax No: Afdahl, Gerald Pleasant Valley Township 024 - 1021 -95 -000 CST BM Elev: Insp. BM Elev: BM Description: ( Do, 0 1 i c y o-o ' TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark f3oo Jiro, Z) Dosing Alt. BM Aeration Bldg. Sewer (3 Q� Q , 7� Holding St/Ht Inlet ! `f• 1 9`t. 83 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom 5 D k g .off .33 Dosing Header /Man. / 4 1 / Aeration Dist. Pipe C I / /.n Holding Bot. System 13 Q ' 1 10 Final Grade C � PUMP /SIPHON INFORMATION Manufacturer nn nn Demand 61 Cover Q / e GPM t, JDT Cc��c/ 1 D `�l L I Model Number # i 3 }- 2 b (� 3, p o3. la CZ). O �. TDH Lift ` Z O I Friction L sss System Head3 S TDH t 2 to .g Forcemain , Length I Dia. Dist. to Well .o z " �- SO A SORPT ON SYSTEM •3 C> D•`�S� BE Width Length N-C We . Of Tomes PIT DIMENSIONS No. Of Pits nsdde Dia. Liquid Depth DIMENSIONS I I - i s SETBACK SYSTEM TO P/L 1 BLDG WELL LAKE/STREAM LEACHIN acturer INFORMATION T Of S stem: , CHAMBER O ype y e2 �_ DN del Number. R4 DISTRIBUTION SYSTEM m ic- q4 , o$ Header /Manifold Distribution fi x Hole Size l t � x Hole Spacing Vent to Air Intake Pipe(s) 3 / :34 +/ Length Dia Length 2 q , I taGQ is �' Spacing le 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 [a Yes � No Flo Yes [] No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: Inspection #2: Location: 355 162nd Street Hammond, WI 54015 (SE 1/4 NW 1/4 17 T28N R1 7W) NA Lot Parcel No: 17.28.17.120 1.) Alt BM Description = y � 2.) Bldg sewer length - amount of cover 3.)Contour= %,0$C �•�6 u� �— �b�.3 t -�,I� 4 Q. � - lob E.9 leer. - an re ision Required? [] Ye No Use other side for additional information. J SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. f Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 *i4consin Madison, WI 53707 - 7162 Site Address Department of Commerce Sanitary Permit Application Sanitar Pe rmit ms —z Z In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision may be used for secondary purposes Privacy law, s15. 1 m I. Application Information - Please Print All Information is I State P1an�D. Number 7 ,5 Property Owner's Name � N Parcel Number - Z G e.► A -Polo, RECFIVE ` "" � 2 �!- /0 9,/- ' 9s-, o o v Property Owner's Mailing Address Oc perry Location 1 5 54 3 l l AV - , �` ' f ?� C i4 ' S / T� O N. R I E City, State Zip Code one N41M Y ot Number Block Number C ' opp v% Subdivision Name CSM Number Hamrne)hd, W� U o II. Type of Building (check all that apply) �''" ❑Ctty ® 1 or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public /Commercial - Describe Use ($Township P I ea,5C,.M a- ❑ State Owned Nearest Road /tU a n-,, ' 54. III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. I R New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use sy stem T ank Onl Exist' Existin2 S stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering sche a is for internal use) 44 11 Non - Pressurized In- Ground 21? Mound (9 X S� 5 47 ❑ Sand Filter 50 ❑ Constructed Wedand 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Dispe rsal/Tteatment Area Information: = S 3 3 Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate( Gals. /Days/Sq.Ft.) (Min./Inch) Elevation 9� - �� 9 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 16W / i e r Dosing Chamber ( o VII. Responsibility Statement- I, the unde ed, a nsibility for installation of the POWTS shown on the attached plans. T ber's Nam ) PI s Signa MP/MPRS Number Business Phone Number aa3 yes-' ��s Plumber's Address (Street, cily, State, Zip e) V QbdV I -e U VIII. Count /De artment Use Onl Approved C1 Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Initial Adverse Determination IX. Conditions of Approval/Reasons for Disapproval 1. Effluent filter to be installed and maintained per manufacturer's recommendations. 2. Site to be carefully plowed to a depth of 12 inches to break up the platy structure reported. 3. Property is zoned Agricultural. This is the first residence on the 80 acre parcel in section 17 that existed in 1982 Attach complete plans (to the County only) for the system on paper not less than gla x 11 hwhes in size SBD -6398 (R. 05101) Safety. and .Buildings 4003 KINNEY.COUL COULEE RD LA CROSSE WI S4601 -1831 a m TDD # ro (608) 264 =8777 cons, www.commees V tate ili:usJsb ^• '`. r, Department of Commerce www.inrisconsin.gov �`� :% Sco McCallum, Governor Philip Edw. Albert, Acting Secretary October 02, 2001 % & T CUST ID No.691727 N.- POW7'S Inspector ARTHUR L WEGERER ZONING OFFICE WEGERER SOIL TESTING & DESIGN SERVICE ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 10/02/2003 Identification Numbers Transaction ID No. 676492 SITE: Site ID No. 636376 GERALD AFDAHL Please refer to both identification numbers, 162ND ST above, in all correspondence with the agenc TOWN OF PLEASANT VALLEY ST CROIX COUNTY SETA, NW 1/4, S17, T28N, R17W FOR: DESCRIPTION: THREE BEDROOM MOUND SYSTEM OBJECT TYPE: POWT SYSTEM REGULATED OBJECT ID NO.: 812880 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: I • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01101) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0" SBD - 10706 -P (N.01 101). I • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the Mound manual, and section VI of the pressure distribution component manual are complied with. A copy of this letter including instructions and information relating to proper use and maintenance of the system must be given to the owner and each subsequent owner upon completion of the project. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. • Access to the filter for cleaning ust be provided per Comm 84 product approval conditions. Maintenance g P P P PP information must be given to the owner of the tank explaining that periodic cleaning of the filter is required • Limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. ARTHUR L WEGERER Page 2 w 10/2/01 . • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). In addition, the owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.52(3) The activities relating to evaluation and monitoring mechanical POWTS components after the initial installation of the POWTS in accordance with an approved management plan shall be conducted by a person who holds a registration issued by the department as a registered POWTS maintainer. • 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. 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. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, FEE REQUIRED $ 175.00 FEE RECEIVED $ 175.00 BALANCE DUE $ 0.00 Charles L Bratz POWTS Plan reviewer II- Integrated Services WiSMARTcode: 7633 (608) 789 -7893, Mon. -Fri. 7:45 AM to 4:30 PM cbratz @commerce.state.wi.us cc: GERALD AFDAHL TITLE SHEET Page I of 7 MOUND SYSTEM FOR A 3 BEDROOM RESIDENCE This plan has been prepared in accordance with the Mound Component Manual SBD- 10691 -P and the Pressure Distribution Manual SBD- 10706 -P (N.01 101) (N.01 101) LOCATED IN THE SE, 1/4 OF THE NW 1/4 OF SECTION 11 ,T 2 -8 NY 7 W, TOWN OF D- LL S- (I'M I COUNTY, WISCONSIN. INDEX PAGE 1 of 7 TITLE SHEET PAGE 2 Of 7 SYSTEM MANAGEMENT PLAN 'r �� PAGE 3 of 7 PLOT PLAN ��0 Dy O PAGE 4 of 7 PLAN VIEW -CROSS SECTION � PAGE 5 of 7 DISTRIBUTION PIPE LAYOUT Oy� PAGE 6 of 7 PUMPING CHAMBER CROSS SECTION PAGE 7 of 7 PUMP PERFORMANCE CURVE %I PREPARED FOR PREPARED BY v►IECCEF.<ER Sv I L .TEST S NG AND. . DES Z Gfi�i S�RV = CE P.O. Box 74 421 N.Main St. River Falls, WI 54022 Phone 715 - 425 - 01658. Fax 715- 9F 5 64 � • R aRT ;iq i. 'X11 P .� ElS.S4'lCi17 H, neon jft 4APPROVED ... DEPMR Bff OF C(MMERCE 8EE CORRESPOND CE - JOB NO. ()1- 137 I - - �� .�K � v� �. �` � ,,( A � �I r = A.I�u`�S� .a ' a Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code Page Z of Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution Svstern No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October - February) dictate that the mound be heavily mulched for frost protection. Influent quality into the mound system may not exceed 220 mg /L BOD5, 150 mg /L TSS, and 30 mg /L FOG. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manual W4Q-U4RZ v ri? 6 #,H grid local or state rules pertaining to system maintenance and maintenance reporting. 58D - 1p6gl� P (^IVoI /01, No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage curs or by removing biologically clogged adsorption oc and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions about the operation or maintenance of this system should be directed to: The County Zoning Office at 1 iS— The system installer at 115- 6�$ STPCI�J The tank manufacturer at The effluent filter manufacturer at x'01) - Z-2 j _ S ZA TL The pump manufacturer at 8C�0 - �Z�_ PU+ ip Z0 EWER PLOT PLAN Page 3 of � Scale I"= Si) ' — st y � J r 3 �I :Y _71� �o woT eot�tp'R�T O AI ntSl�n'ZZ `rRis q(taq CN 91 Y" P \ - s. 1 ►1 l 1� , 6 1 q \ r q 7 M �� Coti.►muR . qb.0 ? � • Ems- g� RUB N'Z*� Prop Yy l.►wE • aM�r3 J l aM�-� J �wi' i LL.�Op.p 01V 'NQ S.S`lYC�I. 6'Dlq- wooD F � Po�T• — 8►t3 �t:100.3' NOTES: " 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install 4" observation pipes with approved caps. ( Z required). 3. Septic tank to be N4jo 6S gallon capacity manufactured by w l L CU t�1 C J/ 1)- -10 0 Z P�s LrL R L 4. Bench marks : S ptQ U s �. Divert surface water around system to prevent ponding at the uphill side. Page ± Of —] Approved Synthetic Covering ASTH C33 Distribution Pipe Medium Sand Topsoil --, y' -H r `7 • —J I 3 E � i b cl % Slope Distribution Cell of- Force Main Flowed 2" to 2 " Aggregate From Pump Layer 0 V.)Q� Ft E Z. SI Ft. CROSS SECTION OF A MOUND SYSTEM F o - g Ft G O -S Ft. A Ft. H 1 -0 Ft. Linear Loading Rate= 9-0 GPD /LN FT B S Q Ft. Design Loading Rate= 0,3(,GPD /SQ FT j � 6 Ft. J Ft. K Z Ft. Ai t a L Ft. Vf— ' �'aTn W 3 3 Ft. ' j - Observation Pipe g K �r — - - - -- – -- _ _ - - -= - - -� A c4- -- $ - - -- --- - - = - -- -------- - - - - -- — - -- 6 Force Main w L - _ - - -- _ ------ -_ - - - 2 - L Distribution , • pi of Z to s aggregate Observation Pipe (xnchbr securely) ' ' PLATT VIEW OF A MOUND SYSTEM Distribution Pipe Layout Page S of 7 Place the holes at the bottom of the distribution pipes at equal spacing. Remove all burrs from the pipe and 'holes. Extend the end of each lateral up with the use of long turn or 45 fitting to a point within six inches d the final Bade. Terminate the ends of the laterals with a valve; cap or . threaded plug. Provide access from final grade for the valve, threaded cap or threaded plus. T`-1 P -1 Ct3 L... LZJS S. S'��- 71111y PVC FVC PVC Lateral Manifold Lateral x x x x x/2 xQ 1 x x x x Uteraf Length — Lateral Length — Distribution Line N\� -- h Itu S • PvC wQCC: — i o— _ P �_ Ft. Hole Diameter 3116 Inch 5 3 Ft'. Lateral 1 - Inch(es) X 3 L4 Inches Manifold Z - Inches Force Main " Z` Inches l of holes /pipe_ Invert Elevation of- Laterals 48.2 Ft. x o . 6 6= S. gnu 6- 3s 6 6pw� - Combination 5epiac; Tank and PL! CHAMSER CRO55 SECTIOM AND SPECIFICATIONS ' PAGE G OF - 1. -VENT CAP - WEATHER PROOF JUAJCTION BOX . 4 VEAIT PIPC APPROVED LOCKIIJG : 10' FROM DOOR, t COVER I-J V - i1WDOW OR FRESH Z tuA(ttJ1A1G L1�6EC_. �sP''L'C101J �JP` CptaputT H•tCtnr., recap ALP- IIJTAKE r f Mw FI IU LSIRD ZL �� i I ' � _ _ •�' 18 M - - ,� --- - - - = rte 18•nJIJ. --- - - - - -- INLET a" PROVIDE AIRTIGHT SEAL SfiFfL� Approved zfaEL- uwTft I I'I Approved joint w /_Ipp ��I joint w/ PVC pipe 'I II AL&RA PVC pipe Js I I F___ - -J _ PUMP — " OFF p COMCKETE ITTL • 53.0 0' bt-OCK - RISER EXIT PERMITTED OI.JLy IF TANK MALWACTURER HA.S SUCH APPROVAL 3"A9F'Qorap BFDD t tv4 SEPTIC F SPEC.IFICATIOUS DOSE TAAJK MALJUFACTUfZER: W��5CTZ COQC- R.� NUMBER OF DOSES: S ' I PER DAB TAWK SJZL : 1000 / 6 SO GALLOkJS DOSE VOLUME r ALARM MAAJUF SLjg S INCLUDIAJG 6 ACKFLOW: IOZ G ALLONS MODEL 1JUMBER: IOt �w CAPACITIES: A= 306 • IAJCHCS OR GALLONS SWITCH TZPE: R�f g = Z- IAJCHES'OR Gy LLOL45 PUMP MANUFACTURER: C= 6 IUCHES OR 1 pZ GALLOUS MODEL NUM1jER: X37 D WCHES OR Zy r GALLOJJS SWITCH TYPE: NOTE: PUrt AUD ALARM AR -- E 5E "D MINIMUM DISCHARGE - RATE 35 .6 G INSTALLED pN SEPARATE CIRCUITS VERTICAL DIFFERENCE 6ETWEEJJ PUMP OFF AWD..DISTRIBUTIOAI PIPE -. FEET + 7t+#tMU WETWORK SUPPLY PRESSURE FEET a� FEET OF FORCE MAIM X � �1 F j ���� too fzFRtCT1ou FACTOR_. FEET TOTAL OtI JAMIE HEAD = 111 FEET As per manufacturer gal /in. Liquid depth 3$�" l J C N. cu �Z V E l7P-GC -� ct= - 7 --r4 13/16 7 7/16 --� W W HEAD CAPACITY CURVE MODELS 137/139 6 1!8 - MODELS 137/139 FL Meters Gal. Ltrs. , a f I 5 1.52 93 352 ° ° a 13/16 25 10 3.05 79 299 5-20 15 4.57 64 242 ° a( 20 6.10 36 136 ° 1 1 !2" - 11 t/z NaT 0 15 25 7.62 8 30 4 137,139 30 9.14 - 10- Lock Valve: 26 ft. � 2 5 Ill 3 o � U.S. GALLON 10 201 30 40 1 50 60 70 60 90 100 1 110 LITERS 80 t60 240 320 400 1 1 4 0 FLOW PER MINUTE 1 1 " 1 009921 SK373 �D• ;r CONSULT FACTORY FOR SPECIAL APPLICATIONS • Three phase pumps are available in 200/208V, 230V or 460V. • Variable level control switches are available for controlling single and three • Electrical alternators, for duplex systems, are available and supplied with phase systems. an alarm. • Double piggyback variable level float switches are available for variable • Mechanical alternators, for duplex systems, are available with or without level long cycle controls. alarm switches. • Over 130 °F. (54 °C.) special quotation required. • Combination starters are available for 3 phase pumps. • Refer to FM0806 for 200° F. applications. • Control alarm systems are available for 1 phase pumps. 137 Series - 47 lbs. 139 Series - 51 lbs. SELECTION GUIDE Single Seal Control Selection Listin s 1. Integral Float operated 2 pole mechanical switch, no external control required. Model Volts - Ph Mode Amps Simplex Duplex CSA UL M137/139 115 1 Auto 10.7 1 or 1 &8 - Y y 2• Single piggyback variable level float switch or double piggyback variable level N1371139 115 1 Non 10.7 2 or 2 & 7 3 or 5 & 6 Y Y Float switch. Refer to FM0447. BN137 115 13Ncn 1 10.7 - Y Y 3. Mechanical alternator M -Pak 10.0072 or 10 -0075. Refer to FM0495 137/139 230 5.8 1 or 1 & 8 1 - Y Y E 4. Combination Starter. Refer to FM0514. E137/139 230 5.8 2 or 2& 7 13 or 5& 6 Y Y H137/139 200.20 6.2 1 & 8 I Y N 5. See FM0712 for correct model of Electrical Alternator E -Pak. 1137/139 200-208 6.2 2 & 7 I 3 or 5 & 6 Y N 6. Variable level control switch 10 -0225 used as a control activator, specify duplex J137/139 200.20 2.6 2&4 I 3 &4 or 5 &6 Y Y (3) or (4) float system. F137/139 230 2.6 2&4 3 &4 or 5 &6 Y Y G137 460 .a 2 &4 13 &a or N N 7. Fo ur (4) hole J junct ion box, for wate rtight conn action for hardwired sim plex G139 460 3 Non 1.4 1 2&4 1 3 &4 or 5 &6 N N Operation, 10 - 0002. ' No molded plug - Single piggyback switch included. 8. Two (2) hole J - Pak, for Watertight hardwired Pconnection or splice, 10 Pumps must be operated in upright position. CAUTION Three phase units require a control switch to operate an external magnetic or combination starter. All installation of controls, protection devices and wiring should be done by For i on additional Zoeller products refer a qualified licensed electrician. All electrical and safety codes should be tr catalog on Combination starter, FM051a; Piggy Variable Level Float Switches, FM0477: Electrical Alternator, FM0486; Mechanical Alterna- followed including the most recent National Electric Code (NEC) and the tor, FM0495; Alarm Package, FM0732; and Sump/Sewage Basins, FM0487. Occupational Safety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL T0: P.O. BOX 16347 Z A Louisvile, KY 40256. Manulactuesof. SNIP T0: 3649 Cane Run n Ro Road � Louisville, KY 40211.1961 MP `O (502) 778. 2731.1(800) 928 -PUMP FAX (502) 774 -3624 Wisconsin Labor and Human R l aco� 15�' SOIL AND SITE EVALUATION REPORT Page \ of DivisioP of safety F, Buildngs in accord with ILHR 83.0 IS. - ►�1. ��'�/ s -�� COUNTY Attach complete site plan on paper not less than S 1/2 x 11 inches in r . rr atti de, butt aJ S 1 • C2U \X not limited to vertical and horizontal reference point (BM), direction 9p'of slo or 4 �ARCEL I.D. dimensioned, north arrow, and location and distance to nearest roa � �._ O Z \ 1b Z, I APPLICANT INFORMATION- PLEASE PRINT ALL INFOR ON REVIEWED BY DATE `�!, r PROPERTY OWNER: P PE G E L-D f� �,D 1zJRr p g F} L 1 /4,S t T ZZ ,N,R \Z E (of9W PROPERTY OWNER':S MAILING ADDRESS NAME OR CSM I \ 3S`Rt 6vi^, CITY STATE ZIP CODE PHONE NUMBER ❑C GE SrOWN ' NEAREST ROtD cwt WlUfJ1� k1 l 5 �I,U15 (71 S) � g6 _ SS3 Z PL'�SPc1U�' V ft"l.� �'f t � Z. n S�►'. [>4 New Construction Use [w4 Residential / Number of bedrooms 3 [ J AdditiQn to existing building j Replacement [ j Public or commercial describe Code derived daily flow LVSy gpd Recommended design loading rate bed, gpd /ft - trench, gpd/ft Absorption area required 3 bed, ft trench, ft Maximum design loading rate S bed, gpd /ft - trench, gpd/ft Recommended infiltration surface elevation(s) c1 1 It (as referred to site plan benchmark) Additional design/ site considerations 11 j S 1 * A - L p ULI W/1zgV C &1evT w x x " - YA I N ,ZO YoF 5*&4� ) Parent material \-- o t�: o v LZ G L-fie.. PrL, 1 Lk- Flood plain elevation, if applicable - M A ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem [i s O U EIS ®U ❑ S ®U [IS ®U I ❑ S M U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft to W in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ITmr& 60il- I a S - S .(O S Z 6 Z l I o H R 316 S ;1 Z - `F sbk wi.�r e - . S • � . s Ground 3 , Z.1 -29 1.542 MY 1 •S�t l i S e\ z. elev. S.o ft. l *URL h1 1 OF Cacao .AGS ry Iv Depth to 542 MUST Se `i 1:� TO f 4 limiting factor ct t,.?P P 3TZ'A:fTv1Ze R L:cwwp,IG OF c .'S - 0: `S Remarks: Boring # Z Z . - ) -16 trw-m - Vtz f 3 16 3 Z � . S �t t�.1/f .S Ll V - S/� �I l as b►� m 'Ft- - Z- - . z Ground y elev. 9 - 3 ft Depth to limiting factor >+6 4 Remarks: CST Name: - Please Print Phone: Arthur L. We erer 715 425 - 0165 dress: egerer Soil Testing & Design Service - P.O. Box 74 River.Falls,WI 54022 Signature: - �7 Date: 3 _ (40 O CST Number: 0 • 220254 1 PROPERTY OWNER SOIL DESCRIPTION REPORT Page? of 3+ PARCELI ol:q— 10 — R$ Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft •, e w in. Munsell Qu. Sz. Cont. Color Consistence Boundary Roots Gr. Sz. Sh. Bed rerxh �( 2 LZ ��` t 1M'r►� �t.S � S f is 3 x °` — s I Z`Fa —bk Ground 3 —gyp `i •S k( 4/! l elev. y �sKtz sA8 I �c_sbk � �4. . Z , 3 •z a - 1-y ft. Depth to limiting factor E 2 0" ; i Remarks: Boring # Ground j elev. ft. Depth to limiting factor Remarks: Boring # ; Ground elev. i It. _ t Depth to € . limiting factor Remarks: 3oring # _ _ around alev. ft. )epth to imiting actor Remarks: _ PLOT PLAN Pa 3 of 3 SCALE 1 "= SO y � J IL j a o ,� o T eut^�aPr� UYL � AI Bv�lp Pr6Ltz 4 ntSTWQ6 - MIS MZ;J J Z., J i � i e1q S c n�.no�uu- ELI r LIN E J 1 g *ti�l # - IZL wo.p W - mi> - of S.S `ITO -U, 6 "DIA. wooD FeJcE Po J T• er►#3 eL _ - - f' --- -�"uSE ho :-8E f5-7. LIST 2.5'1�•ur't �" _ _._ __ _ O C) J ZZO2 sIq d. 3 -Is -0 ( 715 ) 4 2 5 -n A s - CST Signature Date Signed Telephone Na. CST # ST CROIX COUNTY ' SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer C e ra I d A � 01 a h 1 Mailing Address 1 5 w Property Address d 54 (Verification required from Planning Department for new construction)_ City /State ��(� W� Parcel Identification Number 6 19 9L - gs 00v LEGAL DESCRIPTION P " + Property Location �' /., 1�' W ' /., Sec. � � . T t�N -R � W, Town of Subdivision . Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 5 ( t L , Volume G U Page # Spec house ❑ yes no Lot lines identifiable Y4 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 syst em. by The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and.a_ mastorplumber, joumeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdispo ysten is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 fu of sludge. Uwe, 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 o the three year expdate. /A �116101 S ATURE OF AP LICANT DATE OWNER CERTIFICATION t h e owners) of I (we) certify that all statements on this foam are true to the best of my (our) knowled I ( we ) am (are) t rt7y described a v by irtue of a warranty deed recorded in Register of Deeds Office. /l he SIGNATURE OF LICANT 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 1060PAs! 152 DOCUMENT W.). STATE BAR OF WIS(ON[N •f)101 11 -198^_ IS SFA�,l R f ' FOR OAT. LAND C5NTRACT Inds* •i;-.j and to,p.t• 'R E OVER ro h i F( R , i I IUAN�Al r1-sN.11 IVII.- 5J511'769 ii $271,1100 Li FINA%4 KI) NNII) IN -4 111KIt NONA'WNSCMER ST. CROIX Co., W; Contract, by and between P-C! -------------- -------- --------_------------- - JAN 13 1994 -------- --------------------- ------------- - -- ---- ............ ("Vendor", 8-30 A. whetl.er one or more) and-P.cr _�I_d ..... . .. A. Afclabl and Sharon ........ at ........... J. Afd and wife, ane Kurt Aft; Aabl ...... ------------- ....... ("P whether one or wore). V Zt! _ - of Deeds Vendor sells and agrees to convey to Purchaser, upon the prompt and f.111 p-r- formance of this contract by Purchaser, the following property, together with the rents, profits, fixtures and other appurt"nant i ntcresta (all called the "Property"), in -------- ----- ---------- Croi ........... ..... .. County, State of Wisconsin: RET.LRN TO Tax Parcel No. Northwest Quarter of Southeast - uarter ( of SF4) of Section Eight (8), and the (East Half of Northwest Quarter (E� of M14) of Section Seventeen (17), Township Twenty-eight (23) No. Range Seventeen (17) West vv Al Al This is not homestead property. OWE (is not) Purchaser agrees to purchase the Property and to pay to Vendor at vanC'.or -- - --- -- -------- . .... ... ------ _ ......... the sum of $ ... 72 _t.QQjae0.Q ----_--------------- ------ in the fc manner: (a) s.7A 500 -.. .. .. .... at the execution of this Contract; and (b) the balance of $ 64 5_00._QQ ---------- -- together with interest from date hereof on the balance outstanding from time to time at the rate of S1 --- (60)_ ..... . per cent per annum until paid in full, as follows: annual payments of $10, 384 50 payable December 31 , 1994 and on the same date of each year thereafter. On the fifth anniversary date of this contract, the interest rate shall be adjusted to the current agricultural loan rate with a three year maturity at the First National Bank of Baldwin, less 2.7%. The annual payment shall be adjusted to reflect the same rate of amortization of the loan in effect. prior to adjustment. Provided, however, the entire outstanding balance shall be paid in full on or b theeiqht ---- (a_) - �Y4 y.e.ar-s --- from-d-at-e-hpreof.- ( the maturity date). Following any default in payment, interest shall accrue at the rate of N % per annum on the entire amount in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire principal balance). 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, Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for payment of taxes, assessments and insurance will be deposited into an escrow fund or trustee account, but shall not bear interest unless otherwise required by law. Payments shall be applied first to interest on the unpaid balance nt the rate specified and then to principal. Any amount may be prepaid without premium or fee upon principal at any time ftfter._J.aLn_uar_y --- 1 ..... . 19.95... pcsvfi 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, an, interest (and in such case accruing interest from month to month shall be treated as unpaid principal) is less than the amount that said indebtedness would have been haa the monthly payments been made as first specified above; provided that monthly payments shall be continued i n t. event of credit of any procee !3 of insurance or condemnation, the condemned premises being thereafter excluded herefrom. Purchaser states that Purchaser is satisfied with the title as shown Ly the title evidence submitted to Purchaser for examination except: Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall be retained by Vendor until the full purchase price is paid. Purchaser shall be entitled to take possession of the Property on ...... da t,e --- o-f --- cl.o-s! ng ............. IQ --------- •Crti- Out One. LAND CONTRACT - Individual and STATE BAR OF WIS('(AfSIN Wi--in Leza! Bank Co. Inc. Corporate FORM 'N".. It - 1983 1993 real estate taxes will be paid bX Vendor. Purchaser to pay all sarsequent real estate taxes.(]�;O Purchaser promises to pay when d all taxes and a ,. :,• �1tu wtu erty or upon Vendur'e interest in ;t and to deliver W Vendor on demand receipts showing such i•aynn•nt- Pr!rchaser al,all keq the improvements on the Pruperty st -or,d against loss or damage tleci�*,.ned by fire, ex- lcndied coverage perils and such other hazards :.s Vendur mu): ro,rlu.nr, without co-insurance, through insurers approved by Vendor, it the sum of rf111 Jn.sv 70M0_Y4lke_ , but Vendor shall not require covers ggea in an amount more than the balar.e owed wader this Contract. Purchiiser shalt pay if ru urs premiums when dua. l'he poll. iea shall contain the itau..dard clause in favor of the Vendur's interest an wiles Vendor otherwise agrees in writing, the original of all policies covering the Property shall be deposit.- with V.-ndor. Purchaser shall promptly give notice of loss t, insurance companies and Vendor. Unless Purchaser And Vendur otherwise agree in writing, insurar. -e proceeds shall he applied to restoration or repair of the I'roFarty damaged, provultd the V.ndor deems the restorit�cn repair to be economically feasible. Purchaser covenants not to commit waste nor allow waste to he committed on the Property to keep the Property in yowl tenantable conditioa and repair, to keep the Property IYee from bens superior •o tke lien of this Contract, and to comply with all laws, urd`s.anr•w aad regulations affecting toe Property. Vendor agrees that in case the purchase price with inter, st wld other moneys Pr:all be fully paid and all conditions shall he fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to the Purchaser, a R Deed, in fee simple, of the Property, free and clear o: all liens and encumbrances, except any liens or encumbrances created by .hw act of default of t'ur•,aascr, and except: _.......__ -... - .. -.._ .... . -._... _ ._. ........ .. _ ....._......_.. . -- . .....1. - - ----- . -- --- . - - ---- . . ... .... ... .. ... .... •• ............... - ._... -- -- -- -- __..- ._...._ _. -._.._ ... - _ _... ....._.._ . - ---- --- Pur. baser agrees that time is of the essence arid ta) in tl.e ryeut of a default in the payme.it of , ny principal or interest which continues for a period of ...6.0... days follow• in z iiie - :pecifiA due date or 1 u) in tFe event o f a ,iefault in performance of any otuer obligation of Purchaser which con tine, -, for a period of ...60. -. days following written notice thereof by Vendor (delivered personally or niailed by certified mail), then the. entire outstanding balance under this contract shall become immediately due and payable in full, at Vendor's ,pti n ar.d without notice (which Purchaser hereby waives), and Vendac shall also have the following rig! and rcmcdies (subject to any limitations provided by law) in addition to thus- provided by law or in equity: (i) Vendor may, at his option, termina,.e this Contract and Purchaser's rights, title and interest in the Property and rc.over the Property back through strict foreclosure with any equity of re,iemi;tion to be conditinaod upon Purchaser's full paysgent o ' the ultire outstanding balance, with interest thereon from the date of default at the rate in effect on -uch date arid other sinounudue hereunder tin which eventall amounts prev ;ously paid by Purchaser shall be foreteited as liqui daro:wus for failure to fulfill this Contract and as rental for the Property if purchaser fails redeem) ; or I:I' Vendor may sue for s;ecific performance of this Contract to compel immediate and full payment of the entire outstanding bala ce, with int, rest thcrtron 2t the rate in effect ve the date of default and other amounts due here-.inder, in which event the Prol rty shall be auctioned at judicial saie and Purchaser shall be ];able for any deficiency: or (iii) Vend )r rr.:y- sue at law for 'he ent:r unpaid purchase price or any portion thereof; or (iv) Ve-tdor may declare this Contract at an end and iennn-e t.hi- Contract as a cloud on title in a quiet -title action if the equitable interest of Parc•haser is insignificant: and (yi Vend. r ma, have Purchaser ejected from p•, =esaiun of the Property and have a receiver appointed to collect any rent,, issue; cr profits during the pendency of and action under (i), (ii) or (iv) above.Plotw'thstanding 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 c ^eta and exper.;es including rea.;onable attorneys fees nr Vendor incurred to enforcea -iy rwuedy hereunder twhether abated or nut) to the extent not prohibited by taw and expenses of title evidence shall he 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 intere , to cc. "ect 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 sour• shall direct. Purchaser shall not transfer, sell or convey any legal or t ,citable interest in the Property (by assignment of any of Purchaser's rights under this Contract or by option, long -term le:tse or in any other way) without the prior written consent of Vendor unless either the outstanding balance payable udder this Contract is first paid in full or the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract solely as security for an indebtedness of Purchaser. In the event of any such transfer, sale or con 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. Vend. .r shall make all payments when due under and- mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchas ^r) or under any rote secured thereby, provided Purchaser makes timely payment of the amounts then duo under this Contract. P may make any such payments directly to the Mortg:,gee if Vendor fails to do so and a., payments so made by Purchaser shall be considered payments made on this Contract. Vendor may waive any default without waiving any other subsequ :it )r prior default of Purchaser. All terms of this Contract shall he binding upon and inure to the benefits of the heirs, legal representatives, successors and assigns of Vendor and Purchaser. (It 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 .. f S day of ..January. - _.. -.., 19 9 (SEAL) . :"G '/ .. ........... _ _..(SEAL) * ..liarl. y.. Af('ah.l - - -- - - - - - - - -- ... ' ._.. Gerald_ A I. _Af.dahl - . c -- - - - .... . (SEAL) (SEAL) Kurt Afr?ahl Sharon J. Afdahl -- - - - -- - - - - ...... . .. - - - --- - - - - -- _ .. ... ....... .. ................ -- - - - - -- AUTHENTICATION ACKNOWLEDGMENT Signature(s) --------------------------------------------------------- STATE OF WISCONSIN as. ------- •---- • - -• -- - • - - - -- ----- ------ --- -------- - - -- ---------- - - -• - -- St . Croix .... - - - - -- Coun .. authenticated this -. ------ day of------------ --------- - -- - -- 19 ...... Personally came before me this .7 ... ........ of JanuaF - -- --- •-- • - - - -r 19 -_ 9A the above named - ------------------ - - - - -- --------- - - - - -- --------------------- •-- •-- ••- ........ Harle Afdahl • Kurt_..Afdahl. Gerald A. Afdahl and Sharon - -- - - - -------- . TITLE: MEMBER STATE BAR OF WISCONSIN J. Afdahl s . (If not, ----- ---- ---- ----- •- ------- ---• -- --- -- ---- --•---•- - - -_ .. ....................... ....... ............................... -- -- ......, . authorized by § 706.06, Wis. Slats.) 1 to me known to be the person S .......... who ec the, foregoing instru t and acknowledge the m 0 THIS INSTRUMENT WAS DRAFTED eY Thomas A. McCcrmack .................. __ -........... --- 1 . - .- .... J -- •--- -- ............... 1 -•---------•--------••------ - ------- -•- _-- ----- ---•-----•--•• Notary Public TQ Cr`..... . iTL { (Signatures maybe authenticated or acknowledged. Both My Commission is permanent. (if not, state VWPw"etS are not necessary.) date: ._ 'O 3 *Names of persons signing in any capacity should be typed or printed below their signatures. ~ LAND CONTRACT — ladhldaal and Coryer.te — State $ar of lilsconsin; Fars Ne. it — 193E 3 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 SECOND PLYf Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] `y .'4 0 ie 4 i.;.i �'4 t, : d '..f Gyre c;.y Last Name First Name Middl nitial �, Q Street Iddress 1 " City State Zip Code Telephone . Incl a co Building Address Subdivision Name Lot # Block # X55 1 0 ' 1 j a - Uijnry1" d U)� Legal Description q Parcel No. 1/4, 1/4, Section T D N, R 7 E or�W� , s 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump ❑ 2 Family ❑ Boiler Central AC ❑ Other: ' Nat. Gas L.P. Oil Elect. Solid Solar Space Heating ❑ ) ❑ ❑ ❑ ❑ Water Heating ❑ ❑ ❑ ❑ ❑ ❑ O x FO>ITNDA'TION Site Constrticted Concrete ❑ Masonry ❑ Treated Wood ❑ Manufactured ❑ Other (specify): 01 � )TT ` A`TED ilumDING'C 'ST T. Living area = f5 50 Square Feet $ 1 70 , ob o d 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 all 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. k. a 4� �_ 2 ow - . pplicant's Signaturt Date Signed MUST BE COMPLETED BY THE MUNICIPALITt B&FORE FORWARDING PINK PLY TO THE STATE WV PION OF SAFETY AND BUILDINGS ' I A To ❑ Village ❑ City ❑ County of $ SUING JURISD h VTCIN)CCIP IT 3 # J 5 5 hs y if��Dweiling PERMJ�T ISSUED3 Y: s �� D,ATE u A ISSUED. SBD -8254 (R 4/99) 1f%C 1 1110n a 1oi�n1n'r1nni (0 ` i 1 Submit to ,non- enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin muniFxpalitjes 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 SECOND PLY Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] MEE== Last Name First Name Middle Initial Street Address Till S y Cite State Zip Code Telephone No. (Include area code) Building Address Subdivision Name Lot # Block # Legal Description -} Parcel No. 1/4, 1/4, Section �`` T N, R E W l i: 10 1 Family ❑ Forced Air Furnace ❑ Baseboard or Panel ❑ Heat Pump ❑ 2 Fan it ❑ Boiler ❑ Central AC ❑ Other: Nat. Gas L.P. Oi(_ Elect. Solid Solar Space Heating ❑ ❑ ❑ ❑ ❑ ❑ Water Heating ❑ ❑ ❑ ❑ ❑ ❑ ❑ Site Constructed ❑ Concrete ❑ Masonry ❑ Treated Wood ❑ Manufactured to the WI UDC; not U.S. HUD code) ❑ Other (specify): I all , 2 n R I Living area / = Square Feet $ 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 20 -25, still applies to all 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. A licant's Signature �t •G� .� ` Date Signed MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS Town ❑ Village ❑ City ❑ County of: # 5 F - ©° SBD -8254 (8.2/00) Distribution: ❑Ply 1 - Issuin Jurisdiction ❑Ply 2 -Municipality Forwards to State If New Dwelling ❑Ply 3 - Applicant MUNICIPALITY FORWARDS TO STATE WITHIN 30 DAYS IF NEW DWELLING 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 on new one - and two - family dwellings, as well as for local administration. Prior to submitting this application to the municipality, obtain any necessary sanitary or zoning permit from the county. After completing this application, submit it to the local municipality having jurisdiction. Plan review or building inspections will not be performed by the municipality. PERMIT REQUESTED: • 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 4 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. 4. Complete type of construction. Use this form for site -built homes or homes built to the WI UDC requirements. Do NOT use this form for a manufactured home that was built to the U.S. HUD requirements. 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. 1 --------------------------------------------------------------------------------------------------------------------- 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 FORWARD SECOND PLY 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