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028-1013-95-100
Wisconsin: r- v�.rtment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety ar` ding Division t INSPECTION REPORT Sanitary Permit No: 483966 0 GENEL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal infoi:Yration 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: Burns, Gary Rush River, Town of 028 - 1013 -95 -100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: I �,c�gf,� p 1 --, 1 11.28.17.70A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. �- 5 Septic S nchmark Dosing P� Alt. BM Aeration lb I Bldg. Sewer 3.9$ Holding V St/Ht Inlet G7 � TANK SETBACK INFORMATION St/Ht Outlet TANK TO 1 P/4 WELL BLDG. Vent to Air Intake ROAD Dt Inlet "N Septic G ' ' 9Z / Dt Bottom Dosing Header /Man. �Z 9z zb za 3. Co w Aeration Dist. Pipe 3 • D , To Holding B . System r. System X16 lie 163.A 5.a'� Final Grad PUMP /SIPHON INFORMATION l I. 17 X0.3 • 2 - 1 Manufacturer `` Demand St ++ p Z GPM Model Number TDH Lift Friction Loss System Head TDH Ft /Z 4:5 a, z� ni 1 2•73 Forcemain Len th / Dia. Z/ Dist. to Well 7Z J SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/ BLDG WELL LAKE /STREAM LEACHING Manufacturer. 1 INFORMATION CHAMBER OR Type Of System: UNIT Model Number: � DISTRIBUTION SYSTEM Header /Manifold « Distribution x Hole Size x Hole Spacing t to Air Intake Pipe(s) _ Length YL Dia 44 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 Fm] Yes t No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / i Location: 1905 50th Ave ue Baldwin, WI 54002 (NW 1/4 NW 1/4 11 T28N R17W) NA Lot 1 Parcel No: 11.28.17.70A 1.) Alt BM Description = �' "r 5 ` ��� ��+�� <<� �•( �t 2.) Bldg sewer length = } �� / N �� GG✓4t5�� - amount of cover 5 i r - Plan revision Required? Yes No Use other side for additional information. E SBD -6710 (R.3197) Date Insepct s Sig re Cert. No. commerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 � �`� i s c o n s i n Madison, W1 53707 62� Sanitary Permit Number (to be filled in by Co.) Department of Commerce .) 8 Sanitary Permit Application State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application f Wi _ roject Address (if different than mailing address) submitted a the Department of Commerce. Personal information you pr, vide i S�dWEdary / �� �� ur oses in accordance with the Privacy Law, s. 15.04 1 m), Stats. I. Application Information Please Print All Informatio Property Owner's me �_ Parcel # . e I S AU G 162010 Property Owner's Mailing AdItess ST. CROIX COUNTY Property Location t , D- PLANNING & ZONING OFFICE Govt. Lot ` - l ' 76 ,4 City, tate Zip C de Phone Number A /In 1 , 911 , , ld /,�' �, i l�fer`� /Y !N / <, Section TN; R Eo 1li II. Type of Building (check all that apply) Lot # $9.1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name n .4 Q Block # El Public /Commercial - Describe Use K ❑City of CSM Number ❑ Village of ❑ State Owned - Describe Use �� � � �� — L l l/ 2 Town of EM L— V e lc III. Type of Permit: (Check only otle box on line A. Complete line B if applicable) A. ❑ New System y ❑Replacement System KTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) B. ❑Permit Renewal ❑Permit Revision El Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. lype of POWTS System/Component/Device: Check all that appl Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil; a a ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 7-; 0, / 500 /5'ts0 /o VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units t o $ v New Tanks Existing Tanks //�� c y �✓ o, r �I a v Ln C7 a to Septic or Holding Tank t_ O, p r D D CIS e `' Dosing ( I_ Jr- � VII. Responsibility Statement- I, the undersigned, as Fume responsibility for installation of the POWTS shown on the attached plans. Plu ber' Name (Print) PI b s Signature MP/MPRS Number Business Phone u ber Plumber's Address (Street City, State, Zip de) VIII. County /De artment Use Onl Approved isapproved Permit FFeee Date I ued Issuing t Signatur v er Given Reason for enial $ ✓ D IX. Conditi asons for Disapproval 3 iii �1RIN�; 7: t3epNc tank, ill mss t all f ilt e r and disperse{ cell mus a{ be services 7 maintained as per management plan provided by plumber. f 2 IA9- s4&Wk•tegtiirements must be maintained o c e e system and submit t the Coun ly �� �not 1 s Hran 8 [ %'. 1 igches in size t / I / tJ� SBD -6398 (R. 02/09) Valid thru 02/11 5 J �. 5 � I a •�.� ��;�t,1,a..�c1cL.. �f 5 ! + IN 1 a � — r --- rR c rr Q } Q 0 e 0 O 2,6ed IPC�r 7 T',R 7o 7'R� S eR w c ri s ae) cy 7 u ' 1 _ (Y I .. l 1 3©: 3 - alp 7 - 98 PL pL �h 5 1eqt S SS'q N e o f 5 7. lyvdsoon Z11,3 0 /9.z Sec, 1't COMBINATION SEPTIC /DOSE CHAMBER TANK & PUMP SPECIFICATIONS PER COMM 84.25 CODE CHANGES 2/1/2004 Access Opening, not top of cover, Access Opening, not top of cover, must eidend to a point no greater ' must eidend at least ? than 6" Below Finished Grade ' Above Finished Grade Cover %with Locking Device y (typical) i Finished Grade i , Min. 23" s d F Access Opening Min. 23" Access Opening r = E r Oulet Effluent Filter Union Inlet Baffle Pump --, Two Compartment Septicr'Pump Tank SPECIFICATIONS TANK MFR. DOSES PER DAY: 3 TANK SIZE: SEPTIC /°Od GAL. DOSE VOLUME: GAL. DOSE Soa GAL. (INCLUDES FLOWBACK & <20% OF DWF) ALARM MFR: CAPACITIES: A = 33 INCHES = '51.4 GAL. MODEL # Switch type: B = _2_INCHES = 1l' (0f GAL. PUMP MFR: Go ✓��� C = 12 — INCHES = GAL. MODEL #: 6 6S SWITCH TYPE: D = INCHES= 3 � '25 GAL. REQUIRED DISCHARGE RATE Zb GPM PUMP & ALARM WIRING PER COMM 83.43(8)(e) VERTICAL DIFFERENCE BETWEEN PUMP OFF & DISTRIBUTION PIPE (LIFT) _ 12. Y5 FT. MINIMUM NETWORK SUPPLY PRESSURE (DISTAL & NETWORK PRESSURE) _ + A)A FT. 3b FT. OF FORCEMAIN x /-fib FT. /100 FT. FRICTION FACTOR ...... _ + D. L$ FT. TOTAL DYNAMIC HEAD (TDH) _ 12- FT. INTERNAL TANK DIMENSIONS: LENGTH ; WIDTH ; LIQUID DEPTH 61 MP /MPRS SIGNATURE: LICENSE NUMBER: D � Z � 4 ;o 69j„ AS 93" m REQD D c 57" n z D 0 m N I ;a n m v 0 UP 56" m i 4" CAS 3" 61 „ 5 .. / \. N m x p p m rri rn m \ o 51" c 1 N Li 0 UP 53" N 4" CAS 4 m c c � m < o z D 54° i ° m N �o r r v C z< z z o 0 —) ?r, A --1 o c �mi z D �m x_ 0 m z z�� c vv 0�z DIZ iA moZ mD A 0 C 0D0 z m x v rtn v D Nv v O G�O - c° ° mp m o m 9= N 0 C D mOp rnD0 v � � - = i0�r N O c(f) D r � C �p 0 OZ G7N =1 N C r� Z N (n 11Z(A 0).. a r O ZG) rn �Zi� n I r� � �F j aptp N O 00 D � N :t to � v 0D< Z OD co co � � W -i (n -4 p r -I0 ���_a a U z �... _ UDI �I C'DO� NmD I D r NN (A O O x m �, n UI U1 Z C V1 V1 v� D r ' a a C W m m - W n �° Z p - Z- I Z DD m ,F, mp (n O °0� (� O z o O C m N r r D O ° ; ao o D �� i >O b' m D v m m v rn m pp H D �� �� Z Z D z p -I y :U� C �7 O Vl O Z -{ D _ D ( .'"'1i O - r1 0 0 A z O ,� Z C m 3-0 � jo O m ° n � ° - =1 � 0 z m m °m cn C7 D 0 — 7 O `. r C F - I Z 0 r O m Z" I ;o m Z r m \ cn W1000 /500 -MR m DRAWN BY: SME SCALE: 1 4 " =1' -0" PRE -POUR: ° SEPTIC MANUAL MI ENER conCRETE REV. W3716 US HWY 10 MAIDEN ROCK, WI 54750 DATE: JANUARY 2010 DATE:. POST -POUR: \ Z ° REVISED JAN. 2010 800- 325 -8456 FILE: w10D0 /500 -11R HGOULDS PUMPS Submersible Effluent Pump M OD EL EPO4 & EP05 Series APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermo- ■ Bearings: Upper and lower Specifically designed for the grade turbine oil for plastic enclosed design for heavy duty ball bearing con - following uses: lubrication and efficient improved performance. struction. • Effluent systems heat transfer. ■ Casing and Base: Rugged • Homes Available for automatic and thermoplastic design provides AGENCY LISTING • Farms superior strength and corrosion • Heavy duty sump manual operation. Automatic resistance. Canadian standards • Water transfer models include Mechanical 0 Motor Housing: Cast iron for c Fe # LR38549 • Dewaterin i Float Switch assembled and g' us g preset at the factory. efficient heat transfer, strength, and durability. Goulds Pumps is ISO 9001 Registered. SPECIFICATIONS FEATURES ■ Motor Cover: Thermoplastic • Solids handling capability: N EPO4 Impeller: Thermo- cover with integral handle and 3 /4' maximum. plastic semi -open design with float switch attachment points. • Capacities: up to 60 GPM. pump out vanes for mechanical ■ Power Cable: Severe duty • Total heads: up to 31 feet. rated oil and water resistant. • Discharge size: 1 1 /2" NPT. seal protection. • Mechanical seal: carbon- ' rotary/ceramic- stationary, BUNA -N elastomers. • Temperature: METERS FEET - -- - 104° F (40° C) continuous 10 140° F (60° C) intermittent. • Fasteners: 300 series 9 30 _ ; ..- - ; _ _ s GPM stainless steel. • Capable of running 8 25 FT dry without damage to 25 components. °a = 6 20. _ Motor: • EPO4 Single phase: 0.4 HP Z s 115 or 230 V, 60 Hz, 1550 0 15 ____ ___ ;____ _: . _ _ _ - - - RPM, built in overload with a a "7 E EP05 I automatic reset. o • EP05 Single phase: 0.5 HP, 3 101 - - _ - - - 1 -- - - -- - -- - - - 115 V or 230V, 60 Hz, 1550 EPO4 RPM, built in overload with 2 automatic reset. • Power cord: 10 foot 1 standard SJTW with three prong 0 00 10 ._._ _ - 30____ 40 _ _ _ so -- GPM grounding plug. Optional 20 , foot length, 16/3 SJTW with o 2 4 6 8 10 12 m3 /h three prong grounding plug (standard on EP05). CAPACITY Goulds Pumps 02005 ITT Water Technology, Inc. ITT Industries Effective January, 2005 w 83871 s SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER L_4z_e Jec "I j - .">l ADDRESS: 15 / 14-s l „ S742,,R i FIRE NO: LOCATION: 1/4, I 1/4, SEC- T 2.9 N - R 12 _W, rr TOWN OF : _ /` yS �, y e� ST. • CROIX COUNTY SUBDIVISION: - 712 L NO. IVd 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 septic tank pumper. What you Put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system St. Croix County residents may be eligible to receive a grant to help with the cost of the replacement of a failing system, which was in operation prior to July I 1978. St Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to the St. Croix County Zoning 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 wastewater disposal system is in proper operating 'condition and (2) after inspection and Pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system-in accordance with the standards set forth, herein, as set by the Wisconsin DNR. certification form must be completed and returned to the St. Croix County zoning Officer within 30 days of the three year expiration date. SIGNED: J I. DATE. `r Zee St. Croix County zoning Office 911 4th St. Hudson, WI 54016 1 F FILF-D MAR 191992 Z JAMES O'CONNELt Fiegtster I= 4 84683 ` s1 crolx o C ER T I E I ED S UR V E Y MA P Located in the NW 1/4 of the NW 1 /4 of Section 11, Town of Rush River, T28N, R 17W, St. Croix County, Wisconsin. Owned by W .Ronald Moe 1934 Cty Rd N UNPLATTED LANDS Baldwin, Wi. 54002 _ — N 1 /4 Corner NW Con O S 89' 53' 32 "E ID Section 11 Sec. I 1 co = 170.00' _ �D LEGEND o Q - 50TH _ ON 89'53'32 ^W — AVE. -- — _ _ — Section corner monument 370.00' M S89053,32 "e Berntsen cap. in 2444.06' • 1 "X24" Iron pipe weighing a iN JL $ N Q i 1.68 lbs /lin. ft. set. ZI ---- �• -•• -,- Bearings referenced to the sr to Q J 1 North line of the Northwest n ip O W quarter of Section 11, LJJIV N N e t O assumed S89 * 53'32 "E LLI LOT 49,210 Square Feet (1.13 Ac) 0 O O Q I Including right -of -way. z 1 Z U) d 43,600 Square Ft. (1.00 Ac) A Excluding right -of -way. Y 170.00' �I N 89 '53'32 "W SCALE IN FEET I "= 100 1 9vzZu UNPLATTED LANDS O 100 200 300 o e ST. X N calsvpr era Surveyed for: Dale Jensen 2onh� and c/o First National Bank of Bald. Pants Coewmit W 1/4 corner Section I1 990 Main Street a -st recorded Baldwin, Wi. 54002 h6%WM0ditA4ffEMENT ON REVERSE WAmoval shell be DESCRIPTION rod i void A parcel of land located in the Northwest quarter of the Northwest quarter of Section 11, Town of Rush River, Township 28 North, Range 17 West, St. Croix County, Wisconsin, described as follows: Beginning at the Northwest corner of Section 11; thence South 89 degrees 53 minutes 32 seconds East 170.00 feet (bearings assumed); thence South 01 degree 14 minutes 04 seconds West 289.53 feet; thence North 89 degrees 53 minutes 32 seconds West 170.00 feet; thence North 01 degree 14 minutes 04 seconds East 289.53 feet to the Point of Beginning, containing 49,210 square feet (1.13 acres) more or less, and being subject to all easements, restrictions and covenants of record. I, Harvey G. Johnson, registered Wisconsin Land Surveyor, hereby certify that I have surveyed and mapped the above described property; that such plat is a true and correct representation of the exterior boundaries of the land surveyed; and that I have fully complied with the provisions of Section 236.34 of the Wisconsin Statutes, the St. Croix County Subdivision Ordinance, and the Town of Rush River Subdivision Ordinance to the ee ��V4rofessional knowledge, under- standing and belief � � y eo /ys�y,�� Harvey G. Johnson S -1899 �$ Johnson Surveying, Inc. _+ HARVEY G. ` P.O. Box 91 JOHNSON rA s - 1699 O Hudson, Wi 54016 ���[� �. H DS fl This instrument drafted by: ���( � " ���`•` 4921978 C� �i� 0 SU R V *0 88 111111% Vol. 9 Page 2458 i - - VOL 1520PAGA 103 STATE BAR OF WISCONSIN FORM 1- 1999 KATHLEEN H. WALSH 1 Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Deed, trade between Dale R. Jensen and Mary C. Jensen, RECEIVED FOR RECORD husband and wife, as survivorship marital property 06 -19 -2000 9s30 AN WARRANTY DEED Grantor, and Gary T. Burns, a single person, and Julie A. Conover, a CERT C M ERT COPY FEE: single person, as joint tenants, COPY FEE: TRANSFER FEES 630.00 RECORDING FEEL 12.00 RAGES: 2 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): See attached legal description. Recording Area Name and Return Address THOMAS A. McCORMACK Attorney at Law 1020 10 Ave. PO Box 2120 Baldwin, WI 54002 028- 1013 - 95-100 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This Is homestead property. (is) (iwmut) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements, highways, utility rights and reservations of record, and will warrant and defend the same. Dated this 1 6 t h day of June 2000 l� r • Dale R. Jensen C r r Mary C. ensen AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. ST. CROIX County ) authenticated this day of 2000 1(pT� t day of Personally came before me this June , 2000 the above named Dale R. Jensen and Mary C. Jensen r -- TITLE: MEMBER STATE BAR OF WISCONSI ( AL 1f not, il. to be the persons) who executed the forcgoing authorized by § 706.06, Wis. Stats.) �` �nent and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY : r n- e -____ _ Timothy J. Scott Notary Public, State of Wisconsin B akke Norman, S.C. - New Richmond, WI 54017 y Comini ion is permanent. not, state expiration ate: (Signatures maybe authenticated or acknowledged. Both are not necessary.) ) • Names of persons signing in any capacity must be typed or printed below their signature. Proressionea Ca11pH y, Fond au Lac, wl STATE BAR OF WISCONSIN e00-6e5-2021 WARRANTY DEED FORM No. I - 1999 got 1520PAGA01 LEGAL DESCRIPTION 1) Lot 1 of Certified Survey Map filed March 19, 1992, in Vol. 9, page 2458, located in part of the Northwest Quarter of the Northwest Quarter (NW -1/4 of NW -1/4) of Section 11, Township 28 North, Range 17 West. 2) Part of the Northwest Quarter of the Northwest Quarter of Section 11, Township 28 North, Range 17 West described as follows: Commencing at the northwest corner of said Section 11; thence S89 °53'32" E (assumed bearing referenced to the North line of the Northwest Quarter of said Section 11, which bears S89 0 53'32" E) 170.00' along said North line of the Northwest Quarter, also being North line of Lot 1 of Certified Survey Map, Vol. 9, page 2548, Doc. No. 480683, to the point of beginning, also being the Northeast comer of said Lot 1; thence S89 °53'32" E 20.00' along said North line of Northwest Quarter; thence S01 0 14'04" W 368.01'; thence N 89 °53'32" W 190.00; thence N01'14'04" E 78.48' along the West line of said Northwest Quarter to the Southwest corner of said Lot 1; thence S89 °53'32" E 170.00' along the South line of said Lot 1 to the Southeast corner of said Lot 1; thence NO 1 ° 14'04" E 289.53' along the East line of said Lot 1 to the point of beginning; the North 33' thereof being existing 50' Avenue right -of -way. LOCATION: RUSH RIVER,11.28.17, NW,NW, 50TH AVE ,Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: l,ab ?r and flyiman Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village § Town of: State Plan ID No.: JENSON DALE RUSH RIVER CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9200167 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark I Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet ir Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/SIP HON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer: SETBACK CHAMBER INFORMATION Type O Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/ Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil C1 Yes C] No ❑ Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) I I Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: } SANITARY PERMIT APPLICATION ' OiLHR In accord with ILHR 83.05, Wis. Adm. Code CIT STATE SANITARY PERMIT # –Attach complete plans (to the county copy only) for the system, on paper not less than �� 6tf X 11 InCh@3 In SIZ@. ❑ Ch rf revisio n previous; application —See reverse Side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION IVO %4 /1�(�' /a, S �J T = N, R ` E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING (Check one) El State Owned VIL � �0, NEAREST R hD ❑ Public IS 1 or 2 Fam. Dwelling –# of bedroom PARCEL N R( ) 111. BUILDING USE: (If building type is public, check all that apply) Q f l3 °fs / ©� 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash .50 Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSOR 6 AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) / /01/s ELEVATION t'} 16 I,S�D /, /OO.S Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank / ", eR 1W I I Li L1 F1 Lift Pump Tank/Siphon Chamber m VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) <" MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): �O74 s 7- .9 - _ rn GcJ =f c�c� IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued �Sgt Signature (No Stamps) /1 Approved F Owner Given Initial �/s' Q& rchargs Fee) 6 Adverse Determination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) 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 may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by 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 & Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary•Permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(&) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8'% 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, ground- water contamination investigations and establishment of standards. I SBD -6398 (R.11/88) r - PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP 4 "C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER ? 25' FRCM DOOR, WINDOW OR FRESH 12 M "'i• AIR INTAKE GRADE I y "MIN. IB "M10. I ® "MIAI.\ --- - - - - -- I�JI_F:1 PROVIDE I - - - -- " AIRTIGHT SEAL I I I APPRO`JEC JOINT A I I i I APPROVED JOINTS W /C.Z. PIPE. I I I W /C.S. PIPE EXTENDIAJ(. 3' I I ALARM EXTENDING 3' OQTO $OLID SC.;. $ I I ONTO SOLID SOIL I I C i I ON I I PUMP -� - -� y OFF So D CONCRETE BLOCK RISER EXIT PERMITTED ONLJ IF TANK MANUFACTURER HAS SUCH APPROVAL SPEGIFICATIC)JS SEPTIC AND DOSE TANKS MANUFACTURER: NUMBER OF DOSES: 1 �.� PER DAB TANK :IZE : j. �� ` ® �AL'L // �� ® ONS DOSE VOLUME INCLUDI BACKFI.OW 1"2 GALLONS ALARM MANUFACTURER: ..5J E7L Pte_ /�10 MODEL NUMBER: / © Z /Y 40 CAPACITIES: A= 3 ' 2 INCHES OR 32 L X6 ll/ / ALLONS SWITCH TYPE.: • `e Uny B = 2 ' INCHES OR /ell 9 GA' - LOUS PUMP MANUFACTURER Zo Ug-R C! 6 r- ` � / 93 INCH1. 5 OR 1 / MODEL NUMBER: D- T INCHES OR _—LLQ GALLONS SWITCH TYPE: �c'R 11[ k)z NOTE: PUMP AND ALARM ARE TO 9E. PUMP DISCHAR4E RATE 222 GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE Br PUMP OFF AND DISTRIBUTION PIPE.. ' FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . 2.5 FEET + 3B FEE O FORC MAIN X 1 F 3j / oofr.F RI CT ION FACTOR. FE TOTAL DYNAMIC HEAD = FEET or ' INTERNAL DIMEWSIONI: OF TANK: LEN ////nn GTH ;WIDTH ;LIQUID DEPTH S /� SIGNED : LICEMSE NUMBER: DATE:.=�Z -11�- I ' R 4'/m 6'/ ` AD CAPACITY CURVE 4 HE 5/8 - W W LL "57" _ "59" SERIES - -�— a / g 25 1 1'/s - 11 NPT 4 6 20 O a I S - V � 15 a - z o a J a o to .Z —� 3 t. 2 5 TOTAL DYNAMIC HEAD/ FLOW PER MINUTE EFFLUENT AND DEWATERING HEAD CAPACITY UNITS /MIN 0 FEET METERS GAL LTRS US 10 20 30 40 50 5 1.52 43 163 GALLONS 10 3.05 34 129 LITERS 0 80 160 15 4.57 19 72 FLOW PER MINUTE 19.25 1 5.87 11 0 0 i CONSULT FACTORY FOR SPECIAL APPLICATIONS l • Piggyback Mercury Float Switches *Available with special cord lengths of 15', available. 25', Wand 50'. • Variable level long cycle systems *Alarm systems available. available. a Duplex systems available. Standard cord length - automatic 9 ft. SELECTION GUIDE Standard cord length - non - automatic 15 ft. 1. Integral float operated mechanical switch, no external control required. 2. Single piggyback wide angle mercury float switch or double piggyback mercury 57/59 SERIES I Control Selection float switch. Refer to FM0477. Model Volts -Ph Mode Amps Simplex Duplex 3. Mechanical alternator 10 -0072 or 10 -0075. M57/59 115 1 Auto 8.0 1 or 1 & 7 — 4. See FM0712 for correct model of Electrical Alternator, "E Pak ". N57/59 115 1 Non 8.0 2 or 2 & 6 3 or 4 & 5 5. Sinsor mercury float switch 10 -0225 used as a control activator, with "E -Pak' D57/59 230 1 Auto 4.0 1 or 1 & 7 — duplex (3) or (4) float system. E57/59 230 1 Non 4.0 2or9A6 3or4 &5 6. Four (4) hole "J- Pak', junction box, for watertight connection or wired -in simplex or 2 pump operation, 10 -0002. 7. Two (2) hole "J- Pak', for watertight connection or splice, 10 -0003. 57 Series - Wt. 27 -.3 H.P. 59 Series - Wt. 29 -.3 H.P. CAUTION For information on additional Zoeller products refer to catalog on Combination Starter, All Installation of controls, protection devices and wiring should be done by a qualified FM0514; Piggyback Mercury Float Switches, FM0477; Exectrical Alternator, FM0486; Mechani- licensed electrician. All electrical and safety codes should be followed Including the cal Alternator, FM0495; Alarm Package, FM0513; Sump/Sewage Basins, FM0487; and Simplex most recent National Electric Code (NEC) and the Occupational Safety and Health Act Control Box, FM0732. (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump, �. 3280 Old Millers Lane Manufacturers of .. . p Z Z711-Z1Jff 0 P.O. Box 16347 a Louisville, Kentucky 40216 (502) 778 -2731 a FAX (502) 774 -3624 �QuAUrr 0 UMP9 TIN 4 C l L j l - l 13 l , REPT131 RUSH RIVER ST. CROIX COUNTY ZONING PAGE 1� 08/27/92 11:17 REQUESTS FOR INSPECTION WORK SHEETS FOR: 8/27/92 AREA: NJ' Activity: A9200167 8/27/92 Type: CONVSEPT Status: PENDING Constr: Address: RUSH RIVER,11.28.17, NW,NW, 50TH AVE Parcel: - - - Occ: Use: Description: 149319 Applicant: JENSON, DALE Phone: Owner: JENSON, DALE Phone: Contractor: LICKNESS, CHRIS Phone: 684 -3730 -------------------------------------------------------------------------------- Inspection Request Information..... Requestor: LICKNESS, CHRIS Phone: Req Time: 15:08 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION -------------------------------------------------------------------------------- Inspection History..... Item: 00012 FINAL INSPECTION I FILED ` MAR 191992o- Z JAMES O'CONNELL Register of Deeds 480683 U 1 SL Croixco.. o CE R T Zr Z S UP VE Y MA P Located in the NW 1/4 of the NW 1/4 of Section 11, Town of Rush River, T28N, R 17W, St. Croix County, Wisconsin. Owned by: W .Ronald Moe 1934 Cty Rd N UNPLATTED L ANDS Baldwin, Wi. 54002 __ .— — --- — — - — — — N1/4 Corner NW Core 3 89 5 0 32 "E io Section 11 S cc. I 1 -- _ - /t--- - LEGEND `� 0 T ��(0 0 170. 0 0' o cfl M N 89 "53' A — -� i % %0.00' Section corner monument m I S83 °S3'32' "E Berntsen cap. - 2444.06 • 1 "X24" Iron pipe weighing �Im Zmc 1.68lbs /lin. ft. set. zi m j _ N pl N N a�W . co L .. -- .. ®- . - - - -•1 -• -: 3 dl Bearings referenced to•the Ln i North line of the Northwest p I o rn (6 quarter of Section 11, UJLO N IV w± assumed S89 "E LOT 49, 210 Square Feet (1. 13 Ac) 0 0 Q Including right -of -way. z 1 z N J1 43, 600 Square Ft. (1.00 Ac) s 170.00 z� Excluding right -of -way. 1 h 89 so W C CALE IN FEET I "= 100' lim. 9'92_ w y _ UNPLATTED LANDS � '— — r ---- +� rJ 0 loo 200 300 n w - v N S� O COL ve do Surveyed for: Dale Jensen Zoning and c/o First National Bank of Bald. Posits Committee W I /4 corner Section 11 990 Main Street Baldwin, Wi. 54002 r: -it recorded U0EhW8SyAafEMENT ON REVERSE ?!j%;rS 1 da al?,novat shag be DESCRIPTION ivA & : tad A parcel of land located in the Northwest quarter of the Northwest quarter of Section lI, Town of Rush River, Township 28 North, Range 17 West, St, Croix County, Wisconsin, described as follows: Beginning at the Northwest corner of Section 11; thence South 89 degrees 53 minutes 32 seconds East 170.00 feet.(bearings assumed); thence South 01 degree 14 minutes 04 seconds West 289.53 feet; thence North 89 degrees 53 minutes 32 seconds West 170.00 feet; thence North 01 degree 14 minutes 04 seconds East 289.53 feet to the Point of Beginning, containing 49, 210 square feet (.1. 13 acres) more or less, and being subject to all easements, restrictions and covenants of record. I, Harvey G. Johnson, registered Wisconsin Land Surveyor, hereby certify that I have surveyed and snapped the above described property; that such plat is a true and correct representation of the exterior boundaries of the land surveyed; and that I have fully complied with the provisions of Section 236.34 of the .Wisconsin Statutes, the St. Croix County Subdivision Ordinance, and the Town of Rush River Subdivision Ordinance to the be ohrMy,�rofessional knowledge, under - standing and belief. � � ✓z ell Harvey G. Johnson S -1899 Johnson Surveying, Inc. HARVEY G. P.O. Box 91 JOHNSON Hudson, Wi 54016 Z $ • HUDSO _ ur e .t drafted b ✓ 4921978 •i��: y . .. .. y' ✓ ✓ ✓�� � SU Vol. 9 Page 2458 ' C Ross SP -c- ?`, .� o l = , e h Fresh Alf Inle/e And Obeervallon Pipe ( T— Approved Vent Cap Minimum 12" Above Final Grade 4" Cool Iron 20 - 42" Above Pipe — Vent PIPS To Final Grade Month May Or Synthetic Covering Min 2" Aggregate Over Pipe _ Oletrlbullon ^ o o — Tee PIPS 6" Aggregate a Perforated Pope Belo* Beneelb Pipe — Coepling Terminating At 0 Bottom Of Syelem o OCA L-ei 6 0 1'c /? le J 1, " 07F Mack n7�n DIS►RIgUTIrJIJ FIFE TO BE AT LEAST IIUCHES BELOW ORIGIMAL GRADE AA11j AT LEAS rZO jUGHES BU7 LIO MORE THAIJ 42 RICHES BELOW F11UAL GRADE MAXIMUM WN of EXCAVAT1 FA oM OWIWAL 6RAoF. WILL BE -L._ HUGHES t"IMUM ®EPt - H OF EXCgVATicN PROD 0�161MPj „ G WILL BE !>R INCHES S I G Af E D LICEWSE DUMBER: DATE: C OCUM7Nr NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA • r ii r STATE BAR OF WISCONSIN FORM 2-1982 I ?, 482289 LIPFR 946PACE366 -_ REGISTER'S OFFICE W. ltcnald r1oP drib Boncri:P J. ?Moe., husband and wife, as oinl tenants $T. CROIXCO, WI .i ..... ............ :. -• - - -- .......... ...................... d Recd for Record .................................................................................. ...•- ••- .......•- •............. APR 211992 conveys and warrants to .Kax-y.. gA,....... .. ..... husband .. and .. wife_,..as . .survivorship_ms : � a1,._p�opgnty... Ot 3'45 P. M .............•--•--•••-•..............-•--••••-•-••••.......•-•-••---........... .._....-- •..........•- ••- ...... ............................_'_.._................ ......_..__.......................... .......................... RETURN TO i ..... �. ................................................... ............................... .. ......................... ..................................................... ............................... the following.described real estate in ............. ..Croix................. County, i State of Wisconsin: Tax Parcel No: I' Lot 1 of Certified Survey Map recorded in Volume 9 of Certified Survey Maps, II page 24 - 58 as Document Number 480683 as recorded in the Register of Deeds Office for St. Croix County on March 19,1992, being located in the NW} of the NW} of I; Section 11, T28N R17W, Town of Rush River, St. Croix County, Wisconsin. I! . rcce Fier %tith a right of first refusal as to the balance of said Northwest �I Qua rteir of Northwest Quarter (NWI of NW *) pursuant to an unrecorded Earnest M oney Cor.tract between the parties dated April 21, 1992. A 0V TEE �I i I l � u l ii I I This ....... :Ls ...QQX ......... homestead property. i (is) (is not) !� Exception to warranties: i I7a!ed this .................. day of .................... April....................................... 19.92.... t. I; l'Y ................... `O" :... (SEAL) ...................... (SEAL) J W Ronald Moe ........... ............ ..................................... ................ ..........................• - -- .......................(SEAL) • .....................(SEAL) Bonnie J . Moe I - II AUTHENTICATION ACKNOWLEDGMENT Oignature(s) ............................. ................... .I........_._ STATE OF WISCONSIN ss. i .---• - • - • ..............•----....----............. ........------------ •. .......... St ........................ authenticated this ........ day of ........................... 19...... Personally came before me this ..... !.....day of ... ... A ril ......... ............... 19.92.. the above named •- ......................• •-- ••• •••• •-- ........ - - - -• W. Ronald Moe and Bonnie J Moe -------•-••---••••-••---•••• ...........................•-•................--•••- TITLE: MEMBL•'P STATE BAR OF WISCONSIN - •--• -. ...-•--•-•- ----•--••-•.. • .........................•-•----...---....-- (If not . ............................................................ ....._.._.......•-••--••......................... .................•-- ........... authorizes: by § 706.06, Wis. Stets.) to me known to be the p erson 5 .......... who executed the foregoing instrument and - acknowledge the same. Yi THIS INSTRUMENT WAS DRAFTED BY i ,••., Keith Rodli ......... �' .... " ' "'" " "' ............ 4Notaubli Rivet Falls, WI 54022 �� � . to, -------- ------------ - - - - -- •••••••-•-•-....-•-•-- •-- ••---- ...._...- ••- •- -• -••- c . ...... - (uigratul•es may be authenticated or acknowledged. Both sion is permanent. (If not, t are not :.ecce_ary.) date: NOWY %&A OfVft0QS Ai °.'•Lames of persona signing in any capacity should be typed or printed below their signatures. f� �N' ••.,, of w - s 1 WART: A NTY DEED STATE 3An OF WISCONSIN Wisconsin L egal €3laR1V „IpC .” FORM No 2 — 1992 Milwaukee. Wisconsin • t , S 1 c - loo 'Phis application form is to be completed in full and signed by t" OtOler(a) 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 Location of property /V 1 1/4 W 1 ,0 114, Section' T ?$ N -R_JZW .Township Hailing address _J_q 1 S2- A/P X7 -4 Address of site -r 4,4 Z / r Subdivision name r ?D- Lot no. J other homes on property? y No w Previous owner of property 0 11 010 e. Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _ Yes Is thin property being developed for (spec house)? Yes No Volume_ 9 a nd Page Number -2 - 4 /,:FP as recorded, with the Register of Deeds. -------------------------------------- -- -- - -- - - - - - - - - --- - - - - -- - - -- -- - INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRIUITY DEED which includes a DOCUHENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE ItEGISTLR OF DEEDS. In addition, a certified survey, if available, ;would be helpful so as to avoid delays of the reviewing process. If the deed description references to a certified survey Map, the certified survey Hap shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of ny ( our) knowledge that I (we) am ( are) the owner (s) of the property described in this information form, by virtue of A warranty deed recorded in the office of the County Register of Deeds as Document Ho. ?D and that I we + ( ) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system,, and the same has been duly recorded in the office of County Register of deeds as Document Signature of p�l cant•' Co -appl cant Date f gnature Date of Signature r r - o r" a c W N — o "' A � ` o V o fi 2. /- trz: O j O O 'f1 d a no 7 h N -n rp 7 �o 1 Z , � j N o p v Z; 0-:3 o d (/" /� cm c 0 o C oo v+ N G c (f s o ° o G cu ._. JJ S :3 < III c o ,. 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