Loading...
HomeMy WebLinkAbout028-1031-10-000 o c f ° ' m . d C ° fD I C> > i o e 3 •"► T n T M 0 m o o o rn m o m v�', o o w c t • m g a c owo 3 c c � rn y OD 4° i-•i I a a y CD N W Z n y N O ^ 0 0 n y O y! CO O O C A fD w a o S D o oo w 3 N y a w w a ° o I Si M Si co ° m In v D F. x v> [ D a 2 to 23 � O IW m y Ic nw�i 3 p o c o Y' I O CL c c M, °o CA CL o w o w h o w tQ oo� cc CO nrtn V co w w 7 7 T O C 00 O C 0 ( a � !r� O O N 1 - 3 O i A p � Z N� c cn a toNNO D " T a O N cr m w N < CD K 1D a (r CD 3 d » 3 m N N CD O l� c a ? �+ o• � n _0 CD CD I m m a' C c c (D a 3 3 5 CD m " 9 I z :3 o A n O 3 I n A z 0 Z -� N oo m cn CL tD � Z ° ° z , a m I v I N ` I X01 G) I n a 7 0 a co $ � fD N C I 3 N C a a O o ° 3 CD z ai I CL EL EL q y m i a Er v . I A N A I CD I m N v I o o N b I m (D O 0 Wisconsin Department of Commerce Safety anq Buildings Division PRIVATE SEWAGE SYSTEM Count y 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)]. 363853 Permit Holder's Name: ❑ City ❑ Village ❑ TcMvn of: State Plan ID No.: Dahlke, Richard I Rush River Township CST BM Elev.; Insp. BM Elev.: BM D scription: Parcel Tax No.: Dv 1,0 4) 7 D 6,_ ) S 4i 1 028 - 1031 -10 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic i� ; ; - u Benchmark .5r Z 1015. SZ / 6)0 Dosing Lj e ,'d Alt. BM q 3, re Bldg. Sewer S, 06 %7LA 1 3.7)( Ht Inlet TANK SETBACK INFORMATION Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet lk Air Intake 2 Septic NA Dt Bottom I q 7 � Dosing NA Header / Man. Vi"t Ir Dist. Pipe ing Bot. System e � W. 2,1 PUMP/ SIPHON INFORMATION 4j X , Final Grade Manufacturer Demand St cover -1" , q p Ar4 Model Number 2 - ?&PM Ca 1, K TDH Lift W, Sy Friction o / stemZ ,- TDH1Z,11 Ft mead L oss - Forcemain Length#W. Dia. p �r Dist. To Well SO ABSORPTION SYSTEM E / RENCH Width Length . r No. Of Trenches PIT No. Of Pits Inside Di Depth NSIONS DI SYSTEM TO P/ L BLDG WELL LAKE / STREAM C Manufacturer: SETBACK C INFORMATION Type Of o e Number: System: i� OR UNIT DISTRIBUTION SYSTEM Header / ManPld v Distribution Pipe(s) I x l x Hole Spacing Vent To Air Intake Length � Dia. 2 Length 21• Dia. �1 r Spacing C/0 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 Ye ❑ No [] Yes [] No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #H pection #2:. fl3 / co Location: 196 Highway 63, Baldwin, Wl 54002 (NE 1/4 NE 1/4 25 T28N R17W) - 25.28.17.193A 1.) *BM Description = 1 If cbr, crete s�" ''x�' d0&" I - L 2.) Bldg sewer length= U ; X wj' ',f `A 6 -" $' Z - amount of c r (a 16' 40,,.,46vk fo Can vac d i (pv- 3.) contour = - 4•5'S ' j •3� 13- I� - , s�y.���l. q4.7,q 4.0� O T 4f Goc/�i (.lL Y�� �}l f RG+� ` °� bt v " 6, qo 8• sec 6 e-(e ms oP �4tc S Plan revision required? Yes [No Use other side for additional information. D 0(� t SBD -6710 (R.3/97) Date Inspedor'sSignature Cert. N ADDITIONAL COMMENTS AND SKETCH + SANITARY PERMIT NUMBER: W E { q 1 P I �• � I c i i l l a�3 m _ CA � t a� i �ISCAL "; Safety and Buildings Division lVstonsin SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County / �Q / )( than 8 112 x 11 inches in size. �' • See reverse side for instructions for completing this application State Sanitary Permit Number 36 3 ?s3 Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N 4 Property O r Na e P opert Location CJ i>fy4 � 1 i4, S Z S' T ON, R (or Property Own is Ma' ling Add ess Lot Nu b Block Number W e* City, Stat Zip Code Phone Number Sub ivision Name or CSM Number (sim) �•U 2 1 ( --ti - c cr S� Z II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It I Nearest R Public 211 or 2 Family Dwelling - No. of bedrooms ° Tow OF I?U - 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax NumbeA(s ./► . n 6 ' Lj 3A 1 17 Apartment/ Condo 0 — 10 ! � 0 0 O V 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 Fine B, if applicable) A) 1. ❑ New 2 hd Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------ ______ystem 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 21XMound ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 01 y T t 42 ❑ Pit Privy 13 []Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gall9ps Per Day 2. Absorp. Area 3. Absorp. 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) glj ?vation 6 > fv Feet tb Feet VII. TANK Capacit gallo Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank I,�� ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber — ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume respo sibility for installation of the onsite sewage system shown on the attached plans. Plumber's Na : (Printt))/) Plumber' ignature• amps) MPAMkT W No.: Business Phone Number: 0 t nt L" Z T Plumber's Address (Street, � , State, Zip Code): CC..�. IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved �anitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) %Approved I ❑ Owner Given Initial Surcharge Fee) gj!L� Adverse Determination �S 1 5 - X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: � Y SBD- 6398 (R.11197) 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 a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer [Renewal Form (SBD -6399) to be submitted to the 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete# of bedrooms if 1 or 2 Family Dwelling. 111. 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. Ty of system. Check appropriate box de depending on system YP Y P 9 Y 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 sign application form. IX. 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. ---------------------------------------------------------------------------------------------------- i GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK presently tank tic This is to certify that I have inspected the septic p y servin g the 0C6A-A P V Q4LK5 residence located at: / IJC L- %, �Jl&_ Sec. ZS , T Z b N, R __J:2�_ W, Town of �ti( r' P-wC1* St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced , -'7Z+- O 0 Did flow back occur from absorption system? Yes No (if no, skip next line. Approximate vo�l or length of time: gallons minutes Capacity: / 64-. Construction: Prefab Concrete > K '- ' Steel Other Manufacturer (if known): Age of Tank (if known) : 4 SS Zeg-� L 5 ®�✓ (Sign ure) (Name)) Please Print A� Zo (Title) (License Nu er) -5�- - �� (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (ewaof4im-6 �T Nam �fL �l� VS I-AJ Signature MPRS 6 MP/ 3 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 I April 15, 2000 CUST ID No.267341 ATTN: POWTS INSPECTOR WEGERER SOIL TESTING & DESIGN ZONING OFFICE 421 N MAIN ST ST CROIX COUNTY SPIA PO BOX 74 ICHAEL RD RIVER FALLS WI 54022 X" '� Il}DSON WI 54016 A RE: CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/15/2002 , " Identification Numbers ." TraneaCoon ID No. 309 161 'te ID No. 190065 ' r SITE: Ple,�sofer to both identification numbers, k -N) ?C* ab v.in e, all correspondence with the agency. Site ID: 190065, Richard Dahlke - ()PF, St. Croix County, Town of Rush River NEIA, NEIA, S25, T28N, R17W �� �/' �� p ;.._ �• " Facility: Richard Dahlke Existing Residence FOR: Description: Three Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 657759 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. • The existing septic tank must be inspected for structural soundness, size and baffles and must be brought into conformance with the requirements of ch. Comm 83, Wis. Adm. Code. If it does not conform a state approved tank must be installed. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. , Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 04/11/2000 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 Oerard 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 WSMART code: 7633 T'ITtE S �1-EE r • Page of 6 MOUND SYSTEM FOR A 3 BEDROOM RESIDENCE LOCATED IN THE 1' 1/4 OF THE Mr 1/4 OF SECTION zS ,T N, R '_ 7 W, TOWN OF �� S Z�V �lZ , ST, c_M tX COUNTY , WISCONSIN . INDEX RECEIVED PAGE 1 'of 6 TITLE SHEET App 1 0 2000 PPAGE 3 of 6 PLAN VIEW-CROSS SECTION SAI' ETY PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT & BLDG$ p��� -PAE 5 of 6 PUMPING CHAMBER PAGE 6 of 6 PUMP PERFORMANCE CURVE PREPARED FOR _V116 �A lGl w+ r v3 :. _ P 0•• • sally I w , w I s vaDt_ �� ®� MtiR G pf �pM .U.D1N ►� .1 N P p �NCE. PREPARED BY SEA CO WEGERER SO = L TEST S NG AND . DES 2 13M SE= I CE ++ ;. ••. F.O. BOX 74 421 N. WAIN ST. RIVER FALLS. VI 54022 ANT4;)H 4 WflG%REH EiS:HH iH, : � Y 1 ••rr•.�~M r1 y 1 tiOlt #" M Ll 4.) a JOB NO. -� PLOT PLAN / Page Z of fo - 1"= I y 60� sep-n c I - Tn� a ;� /4. $ - ��J• �� of N N N 6q, ti� s ou G W \ �,� L ci3 \ n) \ k S/ Z \►eti.�r• �Ctq3 6 O'w M%jR LrL.. 43 -5' or- Qeo LrL . a�•S) 14 ✓/ ►"1141 eL WO. O ON C.okjcxrk, surB -- �c -. c�� oK, �o`r1 -, cry of s/D�� __ v w �L�. _ -% wl zs oO MUSe Tf�� r7 pM )1j PLPTeE IF 1r is cGOE _ �-tpRi Tti 6 -f hl PYLL R-% Per4'T l r- kjor 1T M U sT BE k7i- �LA-Cjzl�b ")-W :.�.�•v- -1000. Gf�t--- 'T'�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 be Vppp gallon capacity manufactured by LST1►y G �k - �U �? �'P�1 'M 8 E _ISO aft,W �2 CObtJ C(Z 1'tY7t�c , 5. Bench Mark S Ste' PraoU� 6. Divert surface water around system to prevent.ponding at the uphill side. '' Page 30f Approved Synthetic Covering 'FrS7 C. 3; Distribution Pipe Medium Sand H -- G Topsoil — — -__= F E 1 e v Cj 3 J � E p e S % Slope Bed Of 2 - 2 %2 Force Main Plowed Aggregate From Pump Layer U(T Cross Section Of A Mound System Using E I t A Bed For The Absorption Area F il� Ft. G 1.O Ft. A Ft. H 5 Ft. Linear Loading Rate= c(.b GPD /LN FT B U Ft. Design Loading Rate= iz.�.GPD /SQ FT I `10 Ft. J 8 Ft. K ti� Ft. A! to Y & t e - Pos+i iv L _� Ft. off- - f W 3 Z Ft. L_ Observation Pipe �-- 8 K - - A I - - - 4 L- - - -- ----- - - - - -- W a T - - -- in -------------- - - - - -- Force Ma Distribution Bed Of 2 2 2 Pipe Aggregate I Observation Pipe Permanent Markers (Anchor securely) Plan View Of Mound Using A Bed For The Absorption Area Page ) Of b Perforated Pipe Detall / 0 End View Perforated End Cop PVC Pipe Install permanent at end of each lateral Holes Located On Bottom, Are Equally Spaced Q S PVC Force Main Q PVC Manifold Pipe Distribution Ppe Lost Hole Should Be i Next To End Cap End Cap P 2L .7 Ft. Distribution Pipe Layout S _� Ft. X 4Q5 Inches Y 4'D Inches Hole Diameter L -1 Inch Lateral 1 Inches) Manifold Z Inches Force Main Z Inches # of holes /pipe 1 Invert Elevation of Laterals c t S -© Ft. Place lst hole 1Z " from center of manifold with succeeding holes at 4Z) "intervals. Last hole to be next to the end cap. PUMP CHAMBER CROSS SECTIOIJ ARID SPECIFICATIOMS ' PAGE S OF 6 VENT CAP 4" C.Z. VENT PIPE WEATHER PROOF APPROVED LOCKING MANHOLE 10' FROM DOOR, JUA1CT10lJ 80X COVER WITH WARNING LABEL iNDOW OR FRESH 12 MIU. I AIR INTAKE I GRADE L-L Q. Z S $ 1 18' MIN. COtJDUIT �-'- ________ 18 "1r11A1.� -- - - - - -- - • PROVIDE I - - - -- INLET � AIRTIGHT SEAL ( I I v APPROVED JOI NT A Tank construction shall comply I I APPROVED JOINTS with COMM 83.15 and COMM 83.20 I I I I I ALARM 8 I 1 I I 1 ON C I I 1 CLEV. g6_oo F7 PUMP —� '-� � OFF D CONCRET DLOCK 3" APPROVED - RISER EXIT PERMITTED ONLY IF TAWK MANUFACTURER HAS SUCH APPROVAL gEppl Nre 5PEGIFICAT10MS 005E . LUI2 CpI.JCZE TANK MANUFACTURER. NUMBER OF DOSES: 3 ' y PER DAy TANK 51ZE: GALLONS DOSE VOLUME z �j0, 3 ALARM _- MA4UFACTUFLER: S • J . �'��C�jZD S`IST�j S IWCLU011JG 6ACK /LOW: GALLONS MODEL A1UMBCR: 101 "uj CAPACITIES: A= 11 ILICHESOR GALLONS SWITCH TYPE: CVlZ� g = IIJCHES OR � - G�LLOUS PUMP MANUFACTURER: C= b 1t 1 INCHES OR 13p'� GALLONS MODEL NUMBER. - SR1 4 D- IKCHESOR b GALLONS SWITCH TYPE: M�Z L 'I MOTE: PUMP AND ALARM RC TO 6 I. g MINIMUM DISCHARGE RATE 32-76 GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE DETWEEN PUMP OFF A1,10_DISTRIBUTION PIPE., q FEET + MINIMUM NETWORK SUPPLY PRESSURE . , , . . .... .. 2.50 FEET + FEET OF FORCE MAIN X 2 FYoFT.FRICTION FACTOR_. L' FEET TOTAL MJIJAMIG HEAD = 13 - .FEET DIAMETER u INTERNAL DIMEIJSIOW; OF TANK: LENCsTH ;WIDTH - ;LIQUID DEPTH BOTTOM AREA 231= GAL /INCH ZQ O S ' G AL /INCH AS PER MANUFACTURER = .._. 40 Series S� 410 HP Effluent and Grain Water Pumps Performance Curve MODEL ME40 EFFLUENT PUMP CAPACITY LITERS PER MINUTE 0 50 100 150 200 250 300 350 40 12 35 10 In �j 30 Z 25 8 ' "' 2 20 6 J 4 ' 0 F 5 2 0 0 0 10 20 0 50 60 70 80 90 100 A GALLONS MINUTE F.E. Myers, A Pentair Company • 1131 Myers Parkway, Ashland, Ohio 44805 -1923 419/289-1144 FAX 419/289 -8858 Telex 98 -7443 K3326 7/91 Printed in U.S.A. WCi= TOTAL HEAD IN FEET V61 9LbEJ1 O cn O Ul O Cil O � o 0 o � 0 N O m - -_ C7 O ---- ------ D - 0 D w C7 ° w — H O D � -D H D o r H O Z (n 3 O m m o .0 N � Z 7 ° C Z o C N -i m m ° c O W N O CO O W z O 0 O O — N W L9 a J m co TOTAL HEAD IN METERS ° Labod Human Rela g department Industry, Labo a SOIL AND SITE EVALUATION REPORT P 1 of ' r _ Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm: {;ode d i couNrY S7° C..(Z�} lx. Attach complete site plan on paper not less than 81/2 x 11 inches ins Pi 'must nclud but not limited to vertical and horizontal reference point (BM), direction a Jo di slope, - ARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road Al APPLICANT INFORMATION- PLEASE PRINT ALL INFOR ATION ` " ~� IEWEDBY DATE PROPERTY OWNER: RO A t 8=2ew OF la�C /4,S 2S T 1`3 ,N,R 1 E (0, W PROPERTY OWNERS MAILING ADDRESS • CAT # B # $ D AME OR CSM # ` ot 6 � J`( b 3 CITY, STATE ZIP CODE PHONE NUMBER OWN ' NEAREST ROAD �3P\�OWuv w) SLlooz nIs) 68(1 -33oy ZVQEZ tiAW4 6 3 [ ] New Construction Use N Residential / Number of bedrooms 3 [ ] AdditiQn to existing building 14 Replacement [ ] Public or commercial describe Code derived daily flow L O gpd Recommended design loading rate -- ! - I bed, gpd$ - trench, gpd1ft Absorption area required 3 S bed, ft 3Z S trench, ft M mum design ading rate -5 bed, gpd /ft •� trench, gpd/ft Recommended infiltration surface elevation(s) qq- S w,rgs•ro (as referred to site plan benchmark) Additional design /site considerations w l8 x. %4 a e5�, , y, Lrvt k u P4 t'Z ` pt= S" 1:-I LL Parent material L u sy r - , Lkd4 hr t u, Flood plain elevation, if applicable rygA It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN RLL HOLDING TANK U = Unsuitable fors stem ❑ S O U RI S ❑ U ❑ S [RU I [Is ®U ❑ S oU ( ❑ S [@11 SOIL DESCRIPTION REPORT Consistence Boundary Texture Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft I I I in. Munsell Cu. Sz. Cont Color Gr. Sz. Sh. Roots Bed Trends i; Vvi:3'iaryri. 1 ) D -b Z 1jL_ 3l3 all ZMSbk M.� cS - •S, Ground 3 73 3Y Z -S`t IL 31 y S � & SV V), \ elev. ft y=? 3 . �.S �IIZ Jly LS U S9 yn\) f1_ Depth to limiting factor ?1.3 Remarks: Boring # p -� �,p � 2. 313 � . s I J Z'FS wl'� �g l.� . S •� s° Z 8 z3 1wip- V/y 3 13 3y - 7S7231y — SI ZinS�k MUf'h Ground elev. 3 T3 rL y/ M S — - L `. S C 3 A. It Depth to s y� -S l `� f Z S/ f + S T, L c_1 on, M+. , - QP - Z limiting factor Remarks: CST Name.— Please Print Phone: Arthur L. We erer 715 - 425 -0165 egerer Soil Testing & Design Service -P.O. Box 74 River.Falls,WI 54022 Signature: Date "v g � CST Number:. •� 7 o 220254 PROPERTY OWNER "Z)f N"L \M ,, SOIL DESCRIPTION REPORT Page? of 3' PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft in. Munsell Gr. Sz. Sh Consistence Roots Qu. Sz. Cont. Color . Bed Tnch �� 3 0`•lR — si l 2, sbk vnf� c S �� •S ................. Z g -zS to �i R. a/6 s i 1 Z►n sbh vn�('�- C ►�, - - S . (, Ground 3 2S 3 5 t�`fR VIC I Sbh elev. n 9 S S ft• �S-(s - 1_S`�2 51� cl � stl Depth to I limiting factor Remarks: Boring # 31Z 3 6 k M ip ZU 10 Y 2 Ground 3 -�IU S `i2 3L�/ 1S 1L Shtz lvt`FI^ rQw _ .-! .� elev. VL ft. Depth to — limiting factor Remarks: Boring # Ground elev. f t. i Depth to limiting factor Remarks: 3oring # M 1: ; .-M around , ;lev. : ft. )epth to imiting actor Remarks: I �.. O P L T PLAN Page 3 of 3 ---' SCALE 1"= �p ' I tir U R• !v � Z �t.s�TV�z.� nt-i.s �A • � )< % a -- 1 i M 6 2S'/ ,\ dYZ \ 13 1 JU WLIR � \'� ` \ —300 �t S % Lr CO 6 OoN'1pvR �,t, R3.5' g ,3 30'C1 Iy'L d F (3� 0 J sn tf EL tW - - LS 0).j 80rTU-1 CAnP SIbJAiG_ ✓w kn- s wl-r o'F muse . a G-$ 6 Z • ( 715 ) 47.5 _ 01 65 CST Signature Date Signed Telephone No. CST # ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND O RSHIP CERTIFICATION FORM "' Owns u r IILL!c —_ lU 4` — I! l 1 t-F.L (C -- -- Mailing Address J�2 /'e - ' ff/c7o _- /Tt. Property Address (Verification required from Planning Department for new construction)_ _ - -___ OZ —d ©a City /State ���u/� icJ Parcel Identification Number - OZ - 13 _ - I_..WAL D ESCRI>QT�ON Property Location -- - -_ - -_ ' /., _ -_— %., Sec. - 2) gAJ N -R/ W, Town of4S{i — - -- - - e w/ Subdivision Lot # - - -- Certified Survey Ma Volume - _ ,Page 7 �j Warranty Deed # S( Volume PaKe -_ - Spec house 0 yes Ik— no Lot lines identifiable 0 yes L no SYS TEM MAINTEN Improper use and maintenance of your septic system could result in its premature failure to handle w astcs. Pieper rnainteuance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper what you put into the systern 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 licensedpumper veri fying that (1) the on - site wastewater disposal 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 Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the slandaid� set forth, herein, asset 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 Oftice within W days of the three year expiratio tc. -- IV--/ i Z9 OU AIURB OF - — DATE OWNER CERTIFICATION I (we) certify that all !iV this form arc true to the best Of my (our) knowledge I (we) all] (are) tilt owner(s) of c rscrlb vc, y vi ue f a warranty deed recorded in Register of Dccds Oti SIG ATURE OF A PLICANT 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 ` • DOCUMENT NO. WA RAI7 i DEED THIS SPACE RrscRvao PON RccORO.Na DATA 3879 STATE BAR OF WISCONSIN FORM 2 -19a VOL b 1J �A�«31� REGISTSRS OFFICE ' ST. CROM CO., WIS. fl"-nc A. Wer•nlLuid and Patrice Don t k,.,a k/a ( fatt_tcer �t._Dt�hrkr1 husband and wife as Ree , d. for Record ft 20th joint, tvr1:«lt, . _.. day of S ep t A. D. j923 i ........ ...................... Ot 1 :00 P M. a conveys and warrants to ...�1C.fkAi'� .�.... Da)tlk4,_ Ji)nlce, M. - - ., - - -.- r Dahlke, htishan& alai. wife a-� mint . t nants ................. _ ... .- ... -.... ..._ ......... ................ _ ....... .- ....... .- ...... ........................ 0"Wr N Deeds .... ... .... ..... ....... .... .... ................ V . ........ ...... RCTURN TO .... .- .. .. -. .. .._.....' -- ' . .. ............ ... .. .. .............. ......... the following described real estate in ...... ...Ap...Cro x ................. ....County, State of Wisconsin: Tax Parcel No: ........................... Part of the Northeast Quarter of the Northeast Quarter (NEI of NED of Section Twenty -five (25), Township Twenty-eight North (T28N), Range Seventeen West (R17W), more particularly described as Lot One (1) of Certified I Survey Map filed September 21, 1982 in Volume "51', page 1212 as document number 379824, Office of the Register of Deeds for St. Croix County, Wisconsin. r 1- This .. . -_, iS. Welt_ - - -_ homestead property, (Joy (is not) Exception to warranties: Dated this _ _ T - Vvt ..... ---------- . .(SEAL) SQQ� 19- 3 . day of . _.. / _...._ ..... - - - --- - "'c /�C ....(SEAL1 Brent A. Wer•nlund .. - ..(SEAL) �.uCC� !1!._ lL`�'TGtZcCCL�C/ (SEAL) Patrice NI. Dohnalek .... ... ... ....... .... ...... . ' AUTHENTICATION ACKNOWLEDGMENT Signature(s) ............................ • ........ ....................... STATE OF WISCONSIN ... Sty _Cr'o ... .. .........County. authenticated this ........ day of ........................... 19._.... Personally came before me this ..... !.) ------- day of ................. .... .. ........... 1 19 -.r.). the above named , ._.. -flr:t nt_.;�,._.ktierzrJuad ._and- Patr_L . Dru>als k -------- - -• - -- --------- •--- •------- --------- - ..... ••....... ...... a.. Fair :i ct _ H..._Doluutl ck..--- •-- ..... -... -- .... TITLE: MEMBER STATE BAR OF WISCONSIN (If not, • ........ ...................... •- ••..... authorized by 1 706.06. Wis. Stats.) to me known to be the person ----- execukthe foregoing instpuijent and a t c}rnow;e0V'1helame.o"-.'•, T415 INSTRUMENT WAS DRAFTED BY � - - -- /- � - -- , � t- ...: :. J . .._, Thcxnas A. }IcCo- ---- -- f Q -- •- -- -- -- ---- ---•-- , . - - - ... � s. . �.. -. . X 990 Hi l lcr eat Street. ... � .( 3 --- -•-- Baldw +n - s - -W1-- )40 ••--------- --- - -- --- -- ---- Not Public ..... r { . - :. Y ,.'tCounly, 1 S .- �_.- :.�.: -�-� . (Signatures may be authenticated or acknowledged. Both Sty Commission is permanent. (If Re��tlto expirat 1 on are not necessary.) •• / date: -.. F .) .... ........._. 19 G: 1 .) •Names of prrnoro signing In am cagacitY should bM typed or printed h.inw their iEnaturm �( ® � e� �� - -�� � STATE BAR O! WISCONSIN FORM No. 2 — I jmZ Stock No 130002 J FILED w SE a1 X982 w 3'791524 - «. �o CERTIFIED SURVEY MAP ERENT WERNLUND Part of the Northeast 1/4 of the Northeast 1/4 of Section 25, Township 28 North, Range 17 West, Town of Rush River, and also part of the North 112 of the Northwest fract- ional 1/4 of Section 30, Township 28 North, Range 16 West, Town of Eau Galle, St. Croix County, Wisconsin o Indicates 1 x 24" iron pipe weighing 1 .13 lbs. /lin. ft. set a UN LA NDS M NS I/4 LINE o� S 1- 53'07 E 207:93 1055.39' N o O I W W O ��� 0 ° h F •W C N I I m Cr M °s@ O Cox N W W W = W z U W 1 0 O U) of W M ^ _ J } N — W O U P O I Wt0 0 N q) U JU 0 0inW Va� OI OM Mp QF� 3 � Q N 1^ DO Wz M a4 Q,LL tr) aZ0 W `° W °i I z> U' U f� Cj V —M >- j U Q Z d (A � °� •N y N N 0 O F - O Im a Q z I S I� 5 3dT' 258.0'n �� `� tv to ° ° W �n O M m zI - N m I r 33.18' 24.82 � �° f .� Z I'- fro O W Z Z F• -,, p d- W N U M 3 CO 33.18' 432.75' .-1 0' Z 1- WW N I O N U F - 0 JOQ O Q W = UI 1- O ci I o ;NI W o N LL zI 0 W M N 3 Z W U N I I tD '� t 0 Q nI ki W s •i �: S 00° 00' 00" E 7 36 63' Q W to °4 N U. J mI to 0 Q Z Ve v W Ir N W 3 W I W z _ M I V1 H �\ 0 3 I ~I W W to Q a J U. Q Z I' ir cc �I M cc z I o ?� a� Q t- N z U. 1-) J 3 0 -; I N I0o W m a c0 W O N to WI QZzz I ICI~ G o °0 O; Q (n ° O Z N z N l- } M m t0 O O O z Q 1W �� M N ! t W F- — Q I �I N U _ 1 3 O O N j � o V N) I--W.. r I� I O GOWN tn Z M a tp -� O Z M col ci . tti co a = I ° _ '� In � N W O Ico MI P� rn z C1 1 0 o. a o m y M ^� N 655.93' LJ 4 o �I v3 M I� 622.85' ' 668.85' '� - -- z I S00° 00 00 E 1316.78 O W N 00 00'00" E 1317.08' o to ° WEST LINE NW FRAC. 1/4 SEC -30 S00° 394.45' ° S00 00 00' E 522.70 / S00° 00 00"E 400.00 361.45 I O IM I a ttq 3 0- M 3 a_ J Q 0 �0 OO N I� a N I W I `O 111111111111111111///q o 0 0 o W z O -, J ���````°•� O '/ / * � O K W Z O I N 0 I N M — a l a _.i �. j z (> z W Q I O I F- N Z ..�'° JAMES L. "� ° I �� o z _ `� M a'` ' APPROVED Z �► ° d MURPHY _ d �v z � �� I rn � a N = 5 -1042 e = N� - WU W ''°' 'o = 0 SEP 81982 �► Z N N y �' RIVER FALLS, ;• ~ ° ~ —° . 0 W O M i /•' ��� u0 "�: O CI ION : — - 1-0 �o �� F al W a S1. i ::Ur!( l JUtr'TY .�, o v z z ° O \ \ \\ /� O h Z(. COMPAEHENSIVE ►AIYCS PLANNING M (\ W 0 W 01 a 11 �•- "" \ \ \\ \ V AND ZONING GOMWITEE 0 W O O IIIIIIIkNH I '3 z } t J N 00 38"W 1317.76' z _QNPLATTE L ANDS Vol. 5 Page 1212 Certified Survey M St. Croix County, Wisconsin. (DESCRIPTION ON REVERSE) • „mwr A AS BUILT SANITARY SYSTEM REPORT OWNER �� `jq,�� �p�f 7��' TOWNSHIP SEC . -RZZW ADDRESS ,O ST. CROIX COUNTY, WISCONSIN. SUBDIVISION �i� LOT LOT SIZE PLAN VIEW" -►., 7 8 Distances and dimensions to meet requirements of H63 6 n t9 SHOW EVERYTHING WITHIN 100 FEET OF SYSTE _. �Q D 5� ,q , ✓� 40 No. 2 � � z' I di at N Dr h rr w BENCHMARK: (Permanent reference Point) Describe:- o� �{ �' Elevation of vertical reference point: /00•0" Slope at site: �°J SEPTIC TANK: Manufacturer: Liquid Capacity: /000 Number of rings on cover : CAI X' Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: ,/11� Number of gallons_ Number of gal. pump set for a cycle gallons; T to capacity of distribution lines gallon: size of pump head; gallon per minute horsepower ;brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning d ice SEEPAGE PIT SIZE; Number of pit feet diameter feet liquid depth s eepage it inlet pipe - elevation bottom of seepage pit elevation 4 feet. SEEPAGE BED SIZE: number of lines width /z� length 5'Z� tile depth 32 r " � SEEPAGE TRENCH.: width_ /t/� length jQ PERCOLATION RATE ,2 AREA REQUIRED ��� AkEA AS BUILT S INSPECTOR DATED /D 'Z SS PLUMBER O N JOB I e SO/I LICENSE NUMBER Jr 9523 1 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOi!Z969 BUREAU OF PLUMBING MADISON, WI 53707 EN CONVENTIONAL El ALTERNATIVE State Plan l.D. Number: (If assigned) ° ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECT D Richard Dahlke RR#I , Baldwin, WI /0 - -$S - Z• 3v BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF, PT. ELEV.: 1 NE �4 NE 4 > Section 25 > f T28N R17W Town of Rush River Name of Plumber: MP /MPRSW No. County Sanitary Permit Number: Everett Boldt 4489 St. Croix 43662 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK IN YLEV, : TANK OUTLET ELEV I VY ES G LABEL LOCKIN COV . � A � EDPROVI ❑NO O BEDDING: VENT DIA.: VENT MATL.. NIGH WATER NUM ER OF = ROAD: PROPERTY WELL: BU DING VENT TO FRESH f f ALARM. FEET FROM LI AIR INLET. DYES NO 1 E]YES ONO NEAREST DOSING CHA BER: MANUFACTURER: BE DDING. LIQUID CAPACITY. PUMP MODEL. PU ON MANUFACTURER: WARNING LABEL LOCKING O P ❑YES ONO YES ❑NO NO GALLONS PER CYCLE: PUMP AND CON NUMBER .(JF PR OPERTV WELL BUILDING. NTTOFRESH (DIFFERENCE BETWEEN FEET FROM LIr#C -- AIR INLET PUMP ON AND OFF) El NEAREST C/r SOIL ABSORPTION SYSTEM. Check the soil moisture at the cogA of wing FORCE LENGTH DIAMETER I MATERI'AL AND MARKIN or excavation. (If soil can be rolled into a wire, constructio all cease until MAIN the soil is dry enough to continue.) It CONVENTIONAL SYSTEM: WIDTH. LENGTH. NO. OF DISTR. PIPE SPACING. COVER J INIIDE OIA.. #PITS. LIQUID *e aT� kH TRENCHES. M IAL: PIT DEPTH: �DlMENSrf�NS /.2 -- !r GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO STR N1.1119BER D PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES ABOVE OVER EL V T E V. EN - PIP S. FEET NUMBER LINE AI INLET. � a NEAREST /&V Al / MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES El NO meets the criteria f di sa TIONS MEASURED. SOIL COVER I TEXTURE PERM ENT MARKERS OBSERVATION WELLS / ❑YES ❑NO ❑YES ❑NO i DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSbIL. DDED. SEEDED: MULCHED. CENTER. EDGES: S ❑N DYES El NO OYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: Ar BirOrTFIE 1C1i !" LENGTH TRENCHES: ATERA SPA GRAVEL D PTH BELO PIPE FILL DEPTH ABOVE COVER MANIFOLD PUMP MANIFOLD DI R. PIP M NO. DISTR. DISTR, PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV.: DIA.. EV.. PIPES: DIA.: EL X/`A'I GIN A we O�EfOfii HOLE SIZE HOLE SPACING DRILLED C ECTLY VER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑NO DYES F-1 NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER PROPERTY WELL: BUILDING: FEET FIB LINE: DYES El NO ❑YES ❑NO tEAEv�''e L . 234 ��� ' �• �/ .- �S4 s i�Z- Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DI LHR SBD 6710 (R.01/82) ...� r Wwlsconsln APPLICATION FOR SANITARY PERMIT ^`1`j D ' L H / O B OUNTY � OEPRRTmEr1T OF (��� ��� UNIFORM SANITARY PERMIT # InOUSTRV, LR90R 6 HUMR RELRTIOnS 1y J? — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8 %x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERT OWNER MAILING ADDRESS CAa i PROPERTY LOCATION etfiW. A'Z 1 /4 11 /4, S .:�5 T, N, R/ 1 (or Q TO W� O h e r LOT NU BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER tl A TYPE OF BUILDING OR USE SERVED • 10l , Q la O ZZ Z 1 or 2 Family Number of Bedrooms: 3 LJ Public (Specify): � THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. X Seepage Bed ❑ Seepage Trench U Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: ee- S IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total *of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for in lation of the private sewage system shown on the attached plans. Name of Plumber (Print): ignatu MP /MPRSW No.: Phone Number: ►���e o� ,gyp 1 (7 .3378 Plumber's A s: Name Designer: l� COUNTY /DEPARTMENT USE ONLY Signatu of Issuing Agent: Fee: Date: ❑ Disapproved 0O q ❑ Owner Given Initial Approved Adverse Determination eason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber i INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. • TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. Form - S T C JUU Owner of Propert ' - Y .Location of Property � �✓ Section _, r,2,? N k17 W Township �i'Ve,^ Mailing Address 5yd02- Subdivision Naaae -� Lot Number NA Previous Owner of Property Total Size of Parcel Date Parcel Was Created Are all corners identifiable? Yes No Include with this aPplication one of the followin Certified Survey Map .Deed .Land Contract, or .Other I:agal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (ourl knowled9e; that I (WO) am (are) the owner(s) of the property described in this information form, by virtue of a warranty dead rpco in the Office of the , - County Register of Deeds as Document No.- ; and that I (we) Presently own the proposed site for the sewage diVosal system (or 1'(we) have obtained an easement, to run with the above described property, for the construction of said system a same has been duty recorded in the Offi of h ty Repist�r o ends, Document No. ), /E NATURE OF OWN R SIQNATU OF Co WNER 41F APPLICABLE) DATE SIQNCD DATE SIQNED DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IND DIVISION 'LAB AND PERCOLATION TESTS (115) MADISON BOX 3;0; HUMAN RELATIONS LOCATION: SECTION: ITOWNSH IP /MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: r.ic 1 /,NEE/ 25 /T2d N/R z7E (orEW -1iush Riv r COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: St. Croix Brent Wernlund Baldwin, Wi USE DATES OBSERVATIONS MADE NO. BEDRMS.: ICOMMERCIAL DES RIPTION: S: STS: [EDResidence r ®New ❑Replace l 7 gust 26, 1 98 AUg 26, 1 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) lils ❑U [K ❑U I S ❑U I [IS E4 I ES ❑U I C o n ventional DESIGN RATE: ST EL If Percolation Tests are NOT required If any portion of the lot is in the under s.H63.09(5)(b), indicate: 91' 9" Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS Soil type COD -2 SiAl map sheet 94 BORINGI TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER IDEPTH IN, ELEVATION OBSERVED EST. HIG HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B -1 84" 95'7" None 6 TS 36 "sl 48 as B-2 64" 95 '2" None 6" is 30" sl 48" as B-3 1 64" 96'10" None 6" is 30" sl 48" as B-4 108" 96 None 4" is 24" sl 80" cs B 108" 98' 8" None 4" i s 24" sl 8 0" as B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD2 PERIOD PERINCH P_ 1 6" No 10 " " 5 2 min P- 2 1 " No 10 5 " " " 2 min P- 3 61 No 10 5 " 2 min P- P- Notes UDDer side ot site shal be cut a rox " P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION X _ m= _..._ _... __ ..,_.._..X- .. G wx 6 � r _... . . ... tN � 1 �o 3 I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Stephen L. Aaby 26 August 1962 ADDRESS: CER FIC TION NUMBER: PHONE NUMBER optional): Box 254, Woodville, Wi 1 4 0 698 -2407 CST SIGN TU E: iON: Original -Local Authority, 2nd page - Bureau of Plumbing, 3rd page - Property Owner, 4th page -Soil Tester. ,D -6395 (N. 03/81) i •� • DOCUMENT NO. W ARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 ------------- Brent A. Wernlund and Patrice Donalek aJkfa _ �i I� Patrice M. Dohnalek, husband and wife as -- ----------•--------- 1o1nt. tenants-- - - - - -- ------------------------------- - -•• -. --- •••......---- •- _ - -• -•- -----------------------------------------------------------------------------------------------•--------•-•- Dah k Aw!. Janice M. conveys and warrants to ..... � C11aiC S1 _E,.. ..._..._�__ ..._ . ........... ....... .............. Dahlke ,- ..husband_and_wi_fe. -as _jD at._tenants- ___.__._____...._ . .... .... ... ............ ....•--•-----••---•-----....._......_..._.---••-.....-- .. ................... -------------- ................... .--- .----- ..........--------------------------------------------------------------------------------------------- ') RETURN TO ......... ....................................................... I' .. _ .. ..... . ... ......... ....•--- __.- ___----- __- __- __- ..._. -__ - _____---- ____._ ___._ ...... . ;.- -- - ._77"', _ .._. _ _ the following described real estate in ..___.... .5t,__ CrQ N ... ......... ...... ...County, State of Wisconsin: Tax Parcel No- ------ ------------ ------ - - ---- Part of the Northeast Quarter of the Northeast Quarter (NE' - of NE4) of Section Twenty -five (2$), Township Twenty -eight North (T28N), Range Seventeen West (R17W), more particularly described as Lot One (1) of Certified Survey Map filed September 21, 1982 in Volume II S " , page 1212 as document number 379824, Office of the Register of Deeds for St. Croix County, Wisconsin. i ii 1 i j This ___._____is__not.___..• homestead property. j' (i* (is not) i Exception to warranties: n i ------------------- day day of - - -- 2 -� - ---- -- --- ....... --- - - - - -- 19 •- 3- Dated this ' i i ------- -- - - - - - - X - - -- -------------------------------------- (SEAL) Brent A.-Wernlund - - -------------------------------- -- - - -- - -- - - • • - - - - (SEAL) - - r�2� !/1 �110� !----------- --- ---- ---- •-- --- ----- --- •• ---• - - 11 - - - -. (SEAL) Patrice M. Dohnalek ............... .................................................. -------- - - - - -- - -- --- ..- ...... -- - - - - -- - - - -- it AUTHENTICATION ACKNOWLEDGMENT Signature(s) ............................. ............................... STATE OF WISCONSIN i ss. ------ St.--- Crnix -------- Count y. authenticated this ........ day of ........................... 19 ...... Personally came before me this ..... 1 > ..... day of "l._e_______________ 19-1-5– the above named ... - -•. •--.--...•---------- •.._......••--- •--- •- - - - - -. = -- lirent..A,.. Hiera]- uud.And_-Patr-ijce. - Donal e-k a a /k /a -Patrice - M.-- Aoxuialek---------------------- TITLE: MEMBER STATE BAR OF WISCONSIN autho authorized by § 706.06, Wis. Stata to me known be the person ..... § --- who executed the I foregoing ` inst u ent and ac ow]edge the game. THIS INSTRUMENT WAS DRAFTED BY �. i - Thomas A. McCormack.. i 990 Hillcrest Street �1. S'� _- L�. -_ �: r.� -1- -- --- p.---- - --- (Signatures may y y be au d or acknowledged. Both My a Commiss on is permanent. (If not state expiration are not necessary.) date: -- • - --•-- � -- �.. I *Namur of persons signing to any capacity should We typed or printed below their signatures. 1 HGMi1lsrComperry STATE BAR OF WISCONSIN Stock No. 1 3002 FORM No. 2 19S? r ' I �' '�► cep r ,,,�� � Zti rD LA uj CA �4 CA -Ilp DO w N 0 IZ> It n f a -M -- w 'ice � 4 13 C 0 "+ m `0 ift ! n k Ic -_ 4- - 3 � L 3 � + N�w m - o 0