Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
026-1000-95-000 (2)
O 5i f O m E c -°�' O `r1 ID m 3 m m o m'D w -o m m /04 tD r n N N IN co (7 0 to n O O j D N CD O\ O.. (1 L I� t€s O O d O 3 �' W 7 N m m- C .... CD m v W V p eo O C O 0 -O C: O m O CO (� W a Ul O co cn y n D m e O o p . o m 3 ° � O 7 V1 7 7 o N O C N C ' O V C y A d a N N O. C J O v C O. CD '? !. C COO K O _ (1 CD -4 a m Z O O O i :cT; 0- .� >. O 0ra Z 0 0 0 3 n O O O T v_ a In cn cA a ¢ c N N y m m cr D cn a' cn N CD O n (D m m N CJ1 C (C -' v m= a m= 4 a O N 3 o n CD m D D Q O D D o O a O co m co • C C CD ro x c c p Z m A z O C 3 Z w 03 03 m a z a � a 3 a � ° o o z w N m y � CD CD A W N W N CD N =" 3".Z D ( cn (D� m � m O ? 3 n 'O G) LT - m W G CD N C C _ CD W CD D. C �' O. 9 . O O. T N CD o CD co 3 0 7 n O N O -O 3 C1 O O , 4 m oNCD CD m ` m m O Q CD a X Z: m0 �cu N A =3 C/) n ,N cn cn .i CD O O c Qo d Ot p 0° O p b CD CD O Wi§consin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 499237 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information ou provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Nam& City Village X Township Parcel Tax No: Green, David I Richmond, Town of 026- 1000 -95 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 01.30.18.5D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER � CAPACITY STATION BS HI I FS ELEV. Se tic 3, 5 Benchmark 3,yl 7 8esit�g Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic > Z5 ' Z5 ' 7...1 t Z f Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION 3 '� X Manufacturer s.. Demand St Cover GPM 1 2 , 77 Model Number vev,, Z TDH Lift Friction Loss System Head TDH Ft 7 y7 y • O Z Forcemain Length I Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia I 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 Yes No Yes No G re W% 114L LX , persons ae g ection # 0 4 1 (-5 / bv�.- Inspection #2: / ! COMMENTS: (Include co a discrepencies, persons presen t, tc.) �i sp Location: 1427 Cty. Rd. K New Richmond, WI 54017 (NE 1/4 N\N 1/4 1 T30N R18W) metes & bounds Lot Parcel No: 01.30.18.5D P 1.) Alt BM Description = ! x• S� r °�c� I f ' "�' ettJ t �// 1 __ 7 � C 0 j e—, 2.) Bldg sewer length = vevj "5 Z ci1o0J_4�_ - amount of cover = C o J Z. S 7 - - - -_ - -- - -- - - -- L$3- Plan revision Required? Yes No 1 °�i ` 7 S) Use other side for additional information. _ ] - - J Date Insepc is Sig ure Cert. No. SBD -6710 (R.3/97) Safety and Buildings Division County, ��; 201 W. Washington Ave., P.O. Box 716.. ' A" Madison, WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.) rsconsin (608) 266 -3151 A 1 , 7 9 z Department of Commerce S Plan I.D. Number Sanitary Permit Applicatic 3 3 6 v In accord with Comm 83.21, Wis. Adm. Code, personal informaiion you provide ect Address (if different than address) may be used for secondary purposes Privacy Law, sI5.04(1)(m) l X I. Application Information — Please Print All Infor n RECEIVED # /yZ 7 � -- Parcel # Lot # - Block # Property Owner's N / l 7 2006 021 • 95- Property Location Property Owner's Mailing Address / 7 - ST. CROIX COUNTY � y., Section City, State Zip Code Phone Numb �i / i 5 C)� 0) T� N; R /U E o 1. II . ype of Building (check all that apply) � Subdivision Name VCSM Number r 2 Family Dwelling -Number of Bedroorns� � ❑ publicicommercial - Describe Use [ICity_OVillagp ownship o [] State Awned - Describe Use r III. Type of Permit: (Check only one box on line A. omplete line B if applicable) A. ❑ New System t System ❑ Treatment/Holding Tank Replacement Only Cl Other M9 dif[it5si "tb Eiti'3itl$ S�stwr+ " -::, . st Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑Permit Revision ❑Change of El P Transfer to New -7 � � �� ' Before Expiration Plumber Owner IV. T of POWTS S stem: Check all that a ❑ Non - Pressurized In- Ground [] Mound > 24 in. of suitable soil ❑Mound <24 in. of suitable soil ❑ At- r I race c Fil te iksr 0 mo w Constructed Wetland [3 Pressurized In- Ground Tank Peat Filter ❑Aerobic Treatment Unit 11 Recirculating Sand Filter ❑ Drip Line ❑Gravel -less Pipe ❑Other (explain) Recirculating Synthetic Media Filter ❑Leaching Chamber V. Dis ersal/TreatmentArca Information: Elevation Design Flow ( Design Soil Application Rate(gpFb N Dispersal u ired (sf) Dispersal Area Proposed �(sf)U= "_. VI. Tank Info Capacity in Total er Manufacnuer Prefab Site Steel Glass F ber Plastic Gallons Gallons nits Concr ete Constructed New Existing Tanks Tanks Septic or Holding Tank: Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- L the undersig ssume responsibility for installation of the POWTS shown on the attached plans Business Phone Number MP/NIPRS Number P ' Name (Print) Plum � store Z Plumber's Address (Street, City, State, . ode) VIII. Coun /lle artment Use Onl �, / Sanitary Permit Fee (includes Groundwater Date su lssuin gent Si a (No S grApproved ❑ Disa Surcharge Fee) � od O(o ❑ O er ' en Reason for Denial DL Conditions of ApprovaUReasons for Disapproval J 7 ( 7 d 6C SYSTEM OWNER: `3 QC�� �� f� 1. Septic tank, effluent fitter and d!e{tf ,�' �' dispersal cell must all be services I maintained - 7K . �-Ak 6k 2- t a b as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code, ordinances. y ) / mac mj �-- 13k, zs Attach complete plans (to the County only) for the system on papa not less than 81/1 Y l I inches in size SBD -6398 (R. 01/03) �° A'n Soil Test Plot Plan 'Project Name Dave Green Shaun: " it Address 1427 Cty Rd K New Richmond Wi 54017 C �0120/06 ' #226900 Lot Subdivision - - - - -- -- - - - - -- Date NE 1/4 N W 1/4S 1 T 30 N /14 W Township Richmond Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Siding System Elevation none *HRPSameasBenchmark Scale is 1" = 40' unless otherwise noted Willow River This lot was filled in 1950, to build it up above the river, no area was suitable for Old Steel tank is rusted out testing in 1985 and has not and is no longer water tight! change! No roperty Line (not Existing 3 Bedroom House Suitable t o scale) 800' B M area for well testing Current' has >42" of Cover � Z� c Tank was installed in 1985 Existing "steel" holding tank Shed Property Line 150' Driveway to act as a service road Lowlands swamps Driveway County Road K COPY - Soil Test Plot Plan Project Name Dave Green Shaun: it Address 1427 Cty Rd K New Richmond Wi 54017 Ce012 #226900 Lot ---- -- Subdivision -- ------ Date 0/06 NE 1/4 N W 1/4S 1 T 30 N /R18 W Township Richmond Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Siding System Elevation none *HRpSame as Benchmark Scale is F = 40' unless otherwise noted Willow River This lot was filled in 1950, to build it up above the river, no area was suitable for Old Steel tank is rusted out testing in 1985 and has not and is no longer water tight! change! No Property Line (not Existing 3 Bedroom House Suitable to scale) 800' B M * area for W ell testing Current" has >42" of Cover Mick 5 t Tank was installed in 1985 Existing "steel" holding tank Shed Property Line 150 Driveway to act as a service road Lowlands swamps Driveway County Road K Wisconsin Department of commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code l 5 � Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County o / include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 6 2 (p - ! DDa - c/ 5 Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location l G Govt. Lot N2�7 114/4 S I T 3O N R l 8 E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# City S e, Zip C e Phone Number ❑ City ❑ Village own Nearest Road ❑ New Construction Use. esidential / Number of bedrooms Code derived design flow rate Replacement ❑ Public or commercial - Describe: Parent material ri l�f Ci .1.cQ 544- -� 4 v Flood Plain elevation if applicable 11// 4 ft. General comments and recornmendations: System Type /�y/ GG c-�, j`- System Elevation Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Boring # F-1 ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff #2 • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) re CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 r� .� 715- 246 -4516 I Property Owner _ Parcel ID # Page of Ong # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure ' Consistence Boundary Roots GPDIff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil - Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 • - > < Effluent #2 = BOD 30 and TSS 30 Effluent #1 - BOD > 30 < 220 mg/L and TSS 30 _ 150 mglL e < _ mglL. < _ mg/L. The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. SBD4330 (8.6/00) f - ArcIMS Viewer Page 1 of 1 +aJUID 1 L- - - - - -- 1 - - - - - -i NEWECE MCND =--------------- - - - - -, L- 4 ------- � l ti �. 31 32 1 . F TN ST ,4 - -- - - -- — -- �_ K r p- 5 RAIRIE �JJJ r j TN R I C M N. http: //72.21. 230.178/ website /LRPortal /ARCIMS/MapFrame.asp ?PIN= 10/31/2006 I 1 4916 CSM 16 -4433 501/448 M -030 491 DUNn G AWAY K 513.98 466.69 LOT1 5C 5D r s � r 5A F y: unk OUTLOT 14 " *` N k`y1k3' xN.:tif` }k ArcIMS Viewer Page 1 of 1 13 12 EST V 9 ., 31 fi 181 r =RStE. sZA i L 191A CSM 16 -4433 Mae as TN STAN sc Cori ' ..� 5D 26 2r J 4 . j ti i ars { r SA Fl Lora 29 -10 TN RICHM0ND NW- NE z NE W M = OND ` �..,� La n http: //72.21. 230.178/ website /LRPortal /ARCIMS /MapFrame.asp ?PIN= 10/31/2006 i 11/02/2006 17 :50 17157237111 HUFFCUTT CONCRETE PAGE 01 82/13/2886 18:32 7152231491 JAKE- PLUMING PAGE 83 T 9 F � 6A Yu 0 x ;+ A • g `e i /� 4 •p A � x `r m $ v �s A r ao in W3 z� 3 E E E E a v s do ''. 3 � •� _' �° � on ..` p c S Y R C ' O in s s g � •Q ro co . N . W I f L'd dZE :tO l0 5Z U !,5 E3 3 7 5 8 7 KATHLEEN H. WALSH REGISTER OF DEEDS Document Number Document Title ST. CROIX CO.. MI RECEIVED FOR RECORD St. Croix County 10/30/2006 08 -.66 Holding Tank Agreement HOLDING TANK AGREEMENT EXEMPT # State Plan Transaction Number - 1 3 3 C_ REC FEE: 13.00 TRANS FEE: l ay t -J C - � r e E'. n COPY FEE _ CC FEE: Name - (Owner) Typed or printed PAGES: 2 Being duly sworn, states, under oath, that: 1. He /she is the owner /part owner of the following parcel of land located in St. Croix County, Wisconsin recorded in Volume $0S Page ql ` Document Number 3 - St. Croix County Register of Deeds Office: Recording Area A parcel of land located in the 1�- _ '/4 of the U_W 1 /4 of Section Name and Return Address 1- 30.- i8 , T f; ` ,__ N - R 1_ W, Town of Shaun Z3d r d � i Ch rno ,n A , St. Croix County, Wisconsin, being too `01 , W= Spat 7 duly described as follows (include lot no. and subdivision/CSM or detailed legal description): e.. fi - ff a C � Parcel Identification Num er (PIN) Agreement Date: - 6 S+ We acknowledge that application is being made for the installation of (a) holding tank(s) on the above described property or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, a municipal sewer cannot now serve the property, or any other type of private onsite wastewater treatment system as permitted under Comm 83, Wis. Admin. Code, or § Ch. 145, Wis. Slats. As an inducement to the county to issue a sanitary permit for the above - described property, we agree to do the following: 1. Owner agrees to conform to ail applicable requirements of Comm 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59. Slats., the governmental unit (Town) may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Slats. 2. The owner agrees, pursuant to Comm 83.54(2) and Comm 82.40(3)(e), Wis. Adm. Code, to have a water meter installed in the structure. The water meter shall be installed by a plumber authorized by the Department of Commerce to make such Installations, with said Installation complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter the above- described property on a regular basis to read and/or inspect the water meter. 3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank, The governmental unit shall notify the owner of any costs that shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file • copy of the contract with the governmental unit. The owner further agrees to rile a copy of any changes to the service contract, or a copy of • new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems certifies that either a municipal sewer or a private onsite wastewater treatment system that complies with Comm 83, Wis. Adm. Code serves the property. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner that will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) - Please Print Subscribed and sworn to before me on this da HAP IN, CJ q v o 2 - 0 0 foyer 2` l 200 0 Notari d is n e(s) Not�t 6 Governmental Unit Officia a�, & �e z Plea Wrinl �� My Commission E�xpir�es /� j�IS / ,& A( 4 , . /ff�r (,1 i/ ► V , C � ! I � ' •crrrOF n a �G Co r. Governmental Unit Official Signature Drafted by: 5 A Z L A �Q Personal information you provide may be used for secondary purposes (Privacy Law s. 15.04(1)(m)l "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE" This information must be completed by submitter. document title, name & retum address, and PI (if required). Other information such as the granting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. I tf Role Use of this cover nage arlds one no tQ your document and $2.00 lofhd rarOrdinc a WIsconsinStatutes 19_917- and David G. Green and .Karen M.. Green. husband and wife, as SurViv0r$hip marital Reg4terofDeeds orooerty, Grantee, Witnesseth. That the said Grantor, for a valuable consideration RfT1aN !O :once. s to Grantee the following described real estate in St. Croix County. Mate of Wisconsin: Tax Parcel No: ...- All that part of the Northeast quarter of the Northwest quarter (NE 1/4 of NW 1/4) of Section One (1), Township Thirty (3n) North, Range Eighteen (18) West, lying North of the Willow River, FXCEPT the following described parcels: 1. That parcel described in Warranty Deed to William F. McDermott and Norma McDermott, dated July 25, 1973, and recorded on August 8, 1973, in the office of the St. Croix Countv Register of Deeds in Volume "501" of Records on Page 449 as Document No. 317835. 2. All that Part lvirq East of a line running North and South and Parallel with and 466.69 feet West of the Fast line of Sall Northeast quarter of the Northwest quarter (NF. 1/a of r1W ./ 'i r.ANSF O EJ�E This is. not, . ... homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And grantor.... warrants that the titie is good, indefeasible in fee simple and free and clear of encumbrances dfl2re}St and wi;l warrant and defend the same. Dated this . .......... .._.. y of March 19. B8 day _ .. ` �` (SEAL C.. _ (SEAL) �� . t c.:L t� r� L._d._ - ) Gordon B. Green Evel Green (SEAL) _ (SEAL) AUTHENTICATION ACKNOWLEDGMENT SiLmature(s) .....Qf ... Gclr.d ........... STATE OF WISCONSIN and A lyn Green as ....._.._.. ..... .............. ..... ........ ............................... ....County. auth ed this ...:...day of,._..!'S C .......... 198 d• .8_ Personally came before me this ......... ......da of ! 19........ the above named L.�..� ........... ...t.,�...._ ...�. . •.......G.... ..... KnukS. Q) 7� ........ ............................... ......... .... ......... ............. ........... TITLE : A)B3Q@c]Il�90ClP81i4c ........ ............................... (If not ....... Nota>;y...P..uh.hiG ....... 4 . ..... ._ ---- -....- - - -- ....- _ -.. authorized by 9 706.06, Wis. State.) to me known to he the person ........... who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT-WAS DRAFTED BV, BAKKE, NOR�N &. SCHUMACHER, S. C. ......... -- ........................ 12 tage J)r ve' ..... ...... .- ... New ... Richmori d,-. Wl'.S.401� .............I....... Notary Public ................. ... -County, Wis. (Signatures may he authenticated or Both My t'nmmission is permanent. 1[f not, state expiration are not necessary.) G date: ....... _......... -_ •tame! of persona signing in any cavaeity should be taped nr printe below• their signatures. 2 of 2 WARRAW" D =ED STATE ^ BAR OF ert4CONSIN wi•enn.in Legal Black Co. Inc. HOLDING TANK SERVICING CONTRACT contract Date This contract is made between the — ^_______________ Holding Tank owner(s) Name(s) Pumpefs Name A) TA) C— t We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal descriptions:) - w S'?-J( -�- 3 w R4 O F . 0 � N oC r4 �t 4110 9 (,u c�� E t >\1 ►� I✓ n)u, c.0 i nl �yluwi�5 1. The The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement required in Ch. ILHR 83.18(4) (b), Wis. Adm. Code and with the County of LL�E�r 0 ) K 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. S. The pumper agrees to submit to the local governmental unit which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the County, a report for the servicing of the holding lank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; C. The location of the property on wNch the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect untl the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local governmental unit and the County named above within ten (10) business days from the date of change to this service contract. i Owner(s) Name(s) (Print) t Owner's ture(s) Subscribed and swom to me on this date: � r ` �9 S Dale Pumper's Name (Print) t Pumpers Signature � b , �JC6�4% OF G %�. , wrs , D , 10 cl mmission Expiratiion Pumper's Registration Number 61s,� g '54 Drafted by � � Safety and Buildings 4003 N KINNEY COULEE RD commerce.Wl.gov LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 i s c o n s i n www.commerce.wi.gov /sb/ www.wisconsin.gov Department of Commerce Jim Doyle, Governor Mary P. Burke, Secretary October 25, 2006 CUST ID No. 226900 ATTN.• POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1008 192 ND AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 10/25/2008 Identification Numbers Transaction ID No. 1336260 SITE: Site ID No. 719800 Dave Green Please refer to both identification numbers, 1427 County Road K above, in all correspondence with the agenc Town of Richmond St Croix County NE1 /4, NW1 /4, S1, T30N, R18W FOR: Description: Holding Tank / Three Bedroom Object Type: POWTS Component Manual Regulated Object ID No.: 1103886 Maintenance required; 300 GPD Flow rate; System: Holding Tank Component Manual, SBD- 10571 -P (R.6/99) 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. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Holding Tank Component Manual for Private Onsite Wastewater Systems" SBD- 10571 -P. (8.6/99). • A notarized Holding Tank Agreement between the local governmental unit/Municipality and the property owner is required prior to the issuance of a sanitary permit. A Holding Tank Servicing Contract may also be required if no other service provider for the holding tank has been identified. • A service drive or road is to be provided to the service access opening or pump out port. The minimum, ; measured distance required is 25 feet.` • The existing POWTS must be properly abandoned per Comm 83.33 Wisc.Adm. Code. • A Sanitary Permit must be obtained from the county where this project is located in accordance with the CIE cc's requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the POWTS 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. Stat SHAUN R BIRD Page 2 10/25/2006 • Comm 83.22(7) 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 Owner Responsibilities: • 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). • 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 83.55 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. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/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. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 60.00 Fee Received $ 60.00 Balance Due $ 0.00 Charles L Bratz POWTS Reviewer II, Integrated Services WiSMART code: 7633 (608)789 -7893 , 7:45 am - 4:30 pm Monday - Friday charlie.bratz@wisconsin.gov cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 Cover Page RE CEDED OC 1 8 2006 Shaun Bird SAFETr & B UILDINGS Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715- 246 -4516 Date: 10/18/06 Owner: Dave Green Location: NE1 /4 NW1 /4 S1 T30 N,R18W 1427 Cty Rd K Richmond System type: Holding Tank Manuals Used: Holding Tank Component Manual Page# 1. Cover Page 2. Holding Tank Plot Plan 3. Holding Tank Cross Section 4. Maintance and Pqntingency Plan Signature License nu 4r 226900 i, : D EYAN' '; f GS ,� i =`- PONDENCE��L PLOT PLAN PROJECT' Dave Green ADDRESS 1427 Ctv Rd K New Richmond Wi 54017 NE 1/4 NW 1/4S 1 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX SYSTEM ELEVATION TBD 3 BEDROOM CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK XXX MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 2500 LOAD RATE ABSORPTION AREA # of chambers BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION 100' ❑ BOREHOLE O WELL - H Same as Benchmark Willow River Scale= 1/4"= 1 O' This lot was filled in 1950, to build it up above the river, no area was suitable for testing in 1985 and has not change! Tank is 10' above river elevation, and will not need to be anchored Property Line (not to scale) Existing 3 Bedroom House B. M. °Well Old Steel tank is rusted out Currently has >42" of Cover Existing "steel" holding tank and is no longer water tight! To be pumped and buried Tank was installed in 1985 Weiser 2500 gallon LP HT Shed 150' Driveway to act as a service road Lowlands Driveway Tank is to be properly bedded and provided with lockdown cover with County Road K approved warning labels BOLDING TANK CROSS - SECTION Approved Weather Proof - Cap Junction Box Approved Locking Manhole Cover 4,+ C.I. — With Warning Label Attached Vent Pipe 1 Minimum 12" Final Grade + 4" Ai � vt� Minimum + f Approved Joint, 18" Minimum + Water Tight- i + _ Seal Higha ' SPECIFICATIONS _- - _ _ _ t TANK New Existing Approved Join Manu aer . w/ C.I. Pipe Blind C.I. Tank Size: 3 Gallons Extending 3" Plug `2� ` Onto Solid So ALARM Manufacturer: - Model Nur_iaer: tj i,- .tom. Z' -="�_ Switch Type �} NUMBER OF BEDROOMS GALLONS PER DAY 3 G?�7 3" of Bedding Under Tank Owner's Name:-4-/k ve...- ,�► f .,/ f Address:/ o / s t 4o/ / Legal Di scri pti o r ,,� t 0 /2- � Townsh t ip �/I ni ipal ity: Coun : te. — PLUMBER /DESIGNER Signature: License Number: Date: H&bfi iQ TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System ( POWTS) has been designed. ant is to a b l e SB tolled 05 -P maintained according to.� Z 83, Wis- Admin. Code, the Holding Tank Component 6/11/1 99g), and the 1 � County Sanitary Ordinance. 1. This POWTS is designed to accommodate an estimated domestic wastewater flow of gpd. 2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3 Each time the wastewater in the second tank reaches a level of 12° below the inlet invert (at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis_ Adm. Co d 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verity that the alarm system functions and manhole locking devices are present ' Discrepancies are reported to the owner Hance and Comm 83 cor action. Wis Adm. Code. 5. actions shall comply with the county sanitary 5. Ail service events or inspections of this POWTS shall be reported to the county within 10 business days. 8. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes from this holding tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a falling POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any . reason without being in full compliance with OSHA standards for entering a confined space. �`rr "atmosph "re within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWTS fails and cannot be repaired, a Code or s pllia a replacsment holding tank Connection may be installed in the same location (a now sanitary perm req to municipal.services would also be considered at this time if they are deemed available to the property. 9. if this POWTS is replaced or its use discontinued, .components no longer in use it shall be abandoned in accordance with Comm 83.33 Wis. Adm. Code. ` problem with or q uestion about th" installation, the f flowing persons should be contacted: 10. If there is a p g Phone: a. ller ........................... � � s✓�i ' — 9 s — f Insta Phone: - 7j, ` , b. Service Provider ............ .... .�vr ' "''� Z � Ph one. lJr -- c. County Zoning or Health Dept� Cr ` �.. 23 d 11. Project Transaction Number: G / J Z-% c t 9 7 U5C�5 �04 AR& � V al� � 119C I ( 9 7 77 � 7, G N s� '777 . , o g? ol 0 2 2 � (D . � [[ 0 t E e i +_ E_ \ U) k § \ \ , / \ \ § } ƒ 2 § § § § . a CL ; R: 0 — ' ; c © / § ƒ % E S: >; i �C 0 r r / }� � § 0 n r co a E : � # � � � o o o \ �- -n g § § CO) CO) § \ / § ID { � ii ° OD � Q _ � 2 g ( t � CD .. � m � 0 § \ 0 $ � 7 2 c a CD =r . E & \ \ / � / § \ Z: z E ; G) F! ■ T 2 § E § z k F z co z 2 i k � § .. � \ � � F % / � � $ � ƒ . . , f � 7 � 2 ƒ 00 CD \ _ 0 % $ § , � � - _ owe S05 WE 415 TNI! 9f 11.:C RESCRV CO FOR RECOROiNO DA7A • pOCUmENT No STATE BAR OF WISCONSIN FORM 1 — 1982 WARRANTY DEED REGISTER OFFICE ST. CROIX CO., WI c',or<jon R. Green anti Recd for Record This Deed, made between Evelyn Creen, husband and wife,_ as marital Ifj�tt A� propertv, with right of survivorship, Of 10 :35:� M Grantor, and David G. Green and -Karen M.. Green, husband and wife, as survi.vo>;shin marital �� R-g;sler of Deeds property, Grantee, Witnesseth That the said Grantor, for a valuable consideration RETURN TO eonve_ s to Grantee the following described real estate in St. Cr oix County, State of Wisconsin: Tax Parcel No: . . .... ............. ... ........ All that part of the Northeast quarter of the Northwest nuarter (NE 1/4 of NW 1/4) of Section One (1), Township Thirty (30) North, Range Eighteen (18) West, lying North of the Willow River, F`CCF.PT the following described parcels: 1. That parcel described in Warranty Deed to William F. McDermott and Norma McDermott, dated Julv 25, 1973, and recorded on August 8, 1973, in the office of the St. Croix Countv Register of Deeds in Volume "5nl" of Records on Page 449 as Document No. 317835. 2. All that part lvirg East of a line running North and South and parallel with and 466.69 feet West of the Fast line of said Northeast auarter of the Northwest quarter (NE 1/4 of NW /d). i iANS� O This - _1S_ not - .... ._ homestead property, (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And ..grantor... - _ -- ..._.. -.... warrants that the titie is good, indefeasible in fee simple and free and clear of encumbrances dfK*t and will warrant and defend the same. Dated this day of ... _ _ March 19_ 88 (SEAL) _. t Z t c '� ti ) _G _�._ :- _ �`'. (SEAL Gordon B. Green Fvelvn Green .._... - .. .. ..... • .... (SEAL) _ __.. . _ .._._..- .(SEAL) • AUTHENTICATION ACKNOWLEDGMENT Signature(s) ...._Of --- Go- rd2ri.. R- .--- green STATE OF WISCONSIN , and E�elyn Green ss. ----- --------------------------------------------------- ' ----- -•- - -- ------ - -----.County. auth ,ed this _..:_ of Q ...__. -_, 198.$_ Personally came before me this .._...--------- day of l r ------•--- ------•-- ------ --•- ------------ 19-- -- ---- the above named ------------------------------------------ - - -- --- -- -- - -- ------ --- - ---- ' G • - Knut s_Qn -------------- - - - - -- - - - - - -- -- - - - - -- - - - -- --- ----------- - - - - -- - -- -- - - - -- ------ - - - - -- - - -- - - TITLE: )$AAb00< 1SC0= 4R - - --- - -- - - -- -------------- -- -- ...... -- - -- - -- (If not, ------ XQtary__pLl)?j„ii'`.. - authorized by 1 706.06, Wis. Stats.) ' to me known to he the person --- ------- .. who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT -WAS DRAFTED 6f BAKKE, NOR'.K'AN &. SCHUMACHER, S. C. - ---- - - - - -- - - -- - - 12(30 Heritage ; Drive --- - - - - - ....... New. - .Richmond f -.- WI --S.>01 ----- - --••-------- ------ Votary Public .... _. ......... _ _County, Wis. (Signatures may be authenticated or Both My Commission is permanent. ((f not, state expiration are not necessary.) T G. date: _ _._.- ...._..__ _ 12 .Names of Persons signing in any capa should be typed or printed helnw- their siRnatun . WARRANTY DEED STATE BAR OF WISCONSIN Wi= con =in t.ecal Blank Cn. Inc. FORM No. 1 — 1982 Mil —ikee. Wia. 0 C a k rr 0 7 Iƒ /ƒ 0 ) K \�� S Qf _ e 2 } m § a { ° § 2 j k ; « / § f \ 8 CO 2 G ( I m > ° m ` � & � CD :f ■ - a ID \ 7 % \ CD 10 10 \ 2 $ £ \ 170 CL ® § $ k � / k k£� g E c � } 0 2 0 3 o Z -0 ` 2 § § § § ; 2 \ @ E § k E g ® 9 § e 2 \ N) ( k . \ , E SN S § § { z \ g - m CD co ( - ƒ ID \ � CL � F CD z 0 \ @. § 0 ® / \ ; l ^ m ) ^ k � k ( [ / � \ 0 7 G) c CD a # o 0)E °_ � j /. � % $ � ca� � ; / �@ � g 2 � � 0 5 * % \ _o § � 2 � � � MC ANDREW,'JAMES NE NW, Section 1 996 W. 8th St. T30N -R18W New Richmond, WI 54017 Town of Richmond San.Permit #79201 9 -16 -86 C. Powers Holding Tank, Repl ement INS ALLED - 9 -17 -86 Form -STC- 104 _s AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T ,N -R W ADDRESS 1&/ A) i �s't - ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT �� LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r G a INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used �/ �/ `11 eW l rj Elevation of vertical reference point: zDtq p Proposed slope at site: 1 0 4 11 TANK: Manufacturer: Liquid Capacity: © ©o (4A v Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,O Rear, O feet From nearest property line Front 1 0 Side 1 0 Rear,0 feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) S EE REVERSE SIDE 1 PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,0 Vt. Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: - i- Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: �_ Elevation of bottom of tank: / ��•� -rte Elevation of inlet: Number of feet from nearest property line: Front, O Side, Q Rear, Ft.1 10_ Number of feet from well: � . Number of feet from building: �s � Number of feet from nearest road: Alarm Manufacturer: r ' Inspector: Dated: Z Z Plumber on job: ,Q License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BO`X 7969 BUREAU OF PLUMBING MADISON, WI 63707 ❑CONVENTIONAL MALTERNATIVE I State Plan 1. D. Number: )GI Ricilding Tank ❑ In-Ground Pressure ❑ Mound 11 A 18 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE: James Mc Andrew 996 W. 8th St., New Richmond, WT 54017 q — /7 '64 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV. NE NW Section 1, T30N —R18W, Town of Richmond Name of Plumber. MP /MPRSW No Cnunly Sanitary Permit Number: Cal Powers 1563 St. Croix 79210 SEP TIC TANK /HOLDING TANK: t MANUFACTURER LIQUID CAPACITY TANK INLE T LEV. 1 PROVIDED 1 1AIIII OUTLET ELEV. WARNING LABEL LOCKING COVER ,��' ®�© ` . PROVIDED - (� _9 ZES ❑NO ❑YES ❑NO BEDDING. r NT DIA VENT MATT HIGH WATER NUMB OF. ROAD. PROPERTY WELL BUILDING. VENT TO RESH FEET FROM �G ALARM LINE AIR IN YES ❑NO YES ❑NO NEAREST DOS NG CHAMBER: MANUFACTURER 7ING LI OUIDCAPACIIY PIIMV MODEL POMP,SIPFION MANU U I AC I f1EII WARNING LABEL LOCKING COVER PROVIDED PROVIDED S ❑NO ❑YES ONO I DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDINI; V NT TO FRESH / LINE AIR INLET. (DIFFERENCE BETWEEN j � T FEET FROM PUMP ON AND OFF) �J i� 1 i ` >© YES ❑NO NEAREST -0. SOIL ABSORPTION SYSTEM. Check thesoil mois ureat the depth of plowing FORCE I I Nl,Tfl I IIIA1,11 1E11 1 11AII HIAI AND MARKIN(, or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIOTH LENGTH NO OF Ulsrit FIVE Si'ACINI, COVEN IN51I;L DIA -PITS LIQUID BED /TRENCH: s TRENCHES MATERIAL' PIT DEPTH DIMENSIONS GRA VEL DEPTH FILL DEPTH DISTIL PIPE UISTH PIPE DISTR. PIPF MATERIAL NO UISI11 NUMBER OF PROPERTY WELL BUILDING V NT TO FRESH 8FLOW PIPES ABOVE COVER FI TV IN It I I ELEV E.ND PIPF S FEET FROM LINE AIR INLET N EAREST- MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES ID NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PIHAIANINTMAHIClHIS UHSEHVAIIONIVELLS DYES ONO DYES 1:1 NO DEPTH OVER FRENCH BED DEPTH OVER TRENCH HF. I7 1 111PTIM110)F TOPSOIL SOODf I> SFF Df D MULCHED CENTER EDGES DYES. ❑NO ❑YES ONO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH HE LOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD OISTR IP PE MANIFOLDMATFRIAL N() ISTH D DISTH PIPE DISTRIBUTION PIPE MATERIAL &MARKING ELEV. ELEV DIA ELEV. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHf Lit Y COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES El NO ❑Y ES ❑NO COMMENTS: PERMANENT MARKERS OBSERVATION WELLS NUMBER OF PROPERTY WELL. BUILDING. FEET FROM LINE ❑YES ❑NO [DYES D O __ NEAREST Sketch System on Retain in county file for audit. Reverse Side. ae' SI AT E TITLE DILHR SBD 6710 IR. 01/82) DILHR S ANITARY PERMIT APPLICATION cO TY In accord with ILHR 83.05, Wis. Adm. Code S ATE SA ITARY PERM IT # —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUM R 8% x 11 inches in size. � � o 5 J —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER PR PERTY LOCATION y ' /4 ` %,S T ,N,R E(orX�X@ PROPER OWNER' MAILING ADDRESS LOT NUMBER BLOCK N MBER SUBDIVISI N NAME C' Cl STA E ZIP CO E PHONE NUMBER CITY NEAREST R AD, OR DMARK VILLAGE : J 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. ® Replacement c. Re lacement of d. Reconnection of e. ❑ Re P ❑ p ❑ air of an P System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit ## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. ❑ Conventional b. [Z Alternative C. ❑ Experimental 2. a. ❑ System- b. 0 Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Feet [K Private — ]Joint ❑ Public CAPACITY VI. TANK Site in allons Total # of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New xisting Gallons Tanks Concrete structed glass App. Tanks I Tanks Septic Tank or Holding Tank 7 ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signat e: Stamps) MP /MPRSW No.: Business Phone Number: � Z, ti� J lum is Address Street, Cl State, Zip Code T. Name of Design r: S S ,aLl:z VIII. SOIL TEST INFORMATION Ce ' led Soil Tester ST) Name CST # CST's ADDRESS Street, City, State, Zip Code) Phone Number: IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved I syan'tary Permit Fee Groundwater S charge Fee ate Issuing Agent Signature (No m Approved ❑Owner Given Initial Adverse Determination V n e � X. COMMENTS /REASONS FOR DISAPPROVAL: r77 SBD -6398 (formerly Plb -67) (R. 03186) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If ou have q uestions concerning o�_rr private sewage s ster contact our local code administrator or the Y q .� Y P Y Y State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1 -6; VI. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County /Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. ------------------------ ------------------------------------------------- - - - - -- I - - - - -- -- --------- - - - - -- ------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of _:ver 2 years of steady negotiation and public debate. The groundwater bill Cro d Ater, — included =he: creation of surcharges (fees) for a number of regulated practices which Wisco ih'S can effect groundwater The surcharge took effect on July 1, 1984. All of the water that buried ieasure is used in your building is returned tc the groundwater - through your soil absorptlr°m u ' system or the disposal site used by your holding tank pwtpe =. a The - rionies ::olie through these surcharges are credited a the groundwater fund adminis- tered by fie Department of !natural R_ These funds w used for .:ior Loring ground- � water, groundwater contamination in%estigations and establishment of standards Sroundwater, it's worth protecting. SBD -6398 (R.03/86) DEPARTMtNT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS IH63.09111 &Chapter 145.045) L - TOW N5 IP /Mb'1`007YALITY: OT O.:BLK. .: SU8DIV ION NAME- )Vt �/ ��/ /T H /R /; E for NTY: R'S /BUYER'S AMA I I UD ROSS: USE DATES OBSERVATIONS MADE [ j - Np.BEDRMS•: CO MER A E C PTO N Residence ❑New Replace I y f > ` t'1 r RATING: S- Site suihble for system U- Site unsuitable for system / QrE 1 ®� . I M OU N D : a � ®� IN G S� -I ®INGTANK: RECD /-) SYSTEM: (optional) S U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: j 1 Floodplain, indicate Flo od plain elevation: PROFILE DESCRIPTIONS BOFi�IVG L P H UN TER -I CHES CHARACTER OF SOIL. WIT THICKNESS, COLOR, TEXTURE, AND DEPTH ER IN, EVATION R RV D EST. HIG TO BEDROCK IF OBSERVED (SEE ASBRV. ON BACK.) B- m 4 .. 1' - c 6- 1 PERCOLATION TESTS DEPTH , WAT R IN HOLE TEST TIME DROP WATER LEVEL-INCHES RATE NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOT s P. P- P_ P_ P. ll L lP. PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ' zonal and vertical elwation reference points and show their location on the pot plan. Show� surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 2 -` RtULI' tO rr A i f ,•/ 12 �' ► -,1�� � I s A 4 - �l�eoc 7 �IUMU;�'I� SE1:f10N . 1 f r i t Al ` �'/ tN �f r ; 1 I , I ' 1' e rted on this form were me in accol�d'�ii�h the it�t7fods specified n Isconain 1, the undersigned, hereby certify that the soil tests r po Code, and that the data recorded and the location of the teste4re correct to the best of my knowledge and belief. NA 7i): TESTS WERE COMPLETED ON: Sig fi/A) r A R CERTIFICATION NU R: PHONE NUMBER(optlebnali: NGN UR Ai DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. -',` DfLHR -SBD -6395 (R. 02/82) -OVER - W Y :7 r .,_ .r .._ _ .. ... .. 1 a M .. r C � az 1� �+-•� -rte : - _ .. _. _ .. 9 �.f�-- .�k� r yy r r i a v. 1. /i `.. 't r. Aw , � I Q pt �Uj2CL lZf AR S O � pp S 1 �RY TETY ;Jp e JJ f'��r� 1 J(j J it lc:SP j V VAI n 60 • :Y .a AU98 ,. t NOI.DLNG TANK CROSS- SECTION AND SPECIFICATIONS Approved Approved Locking Vent Cap Weather Proof Manhole Cover Junction Box 4" C.I. 12" Min , Vent Pipe I Final Grade I 4 Min 1 I � I Approved Joint Joint 18" Min Water Tight Seal High Water . 1 Alarm Switch SPECIFICATIONS Approved Joint w/ TANK Manufacturer: ,��(. C.I. Pipe Tank Size: Gallons extending 3' ,Onto ALARM Manufacturer: Solid Soil Model Number: Switch Type NUMBER OF B OWNER'S NAME: ADDRESS: LEGAL DISCRIPTION: ,,e_'%, % k,Sec. F ✓ ,T, N W TOWNSHIP /MUNICI PAL ITY: COUNTY: LICF.NS E NlJMPF..R ' DATE. AUG 12 1986 f /i +ry '�� SEC1I0N Taft t_U D FPARTfv1F r OF !;,'r) ✓IS10 f i a JF SAFE i JD 1, i ♦�' �� � • •,i,� >�� ,e. w: �� _� �. �s� i— _ .-. Document No. This space reserved for recording data HOLDING TANK AGREEMENT gree ent Date Y, /._ Y� This agreement is made between the County or Local Governmental Unit I Holding Tank(s) Owner(s) I T /j /N 1 ,WD 1' , ' . 1 (Called Municipality below) I We acknowledge that application is being made for the installation of (a) holding tank(s) on the following property, (Provide legal land description:) SO1/T30 /R18 ACRES 7.000 PCTA 1.30.18.50 SEC. 1 T30N R18W Zhat pt Of N( NW Lyinc) N of River & Return To E of a LN = to and 360' E of � LN NE NW & L� tng V4' of a IN = to and 466.9' W of E LN IE NW as in Vol 535/147 or that continued use of the existing premise requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, State; As an inducement to the County of S T ` " ` Y — _— _ to issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. It I IR 133, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in se. 146.13 an,: 146.14, Slats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner b� placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.2E !30) (d), Stats., agree 7, to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any change, to the service contra t or .; copy of a new service contract with the municipality an( the county within ten (10) business days from the date of cha ge to the service con ,act 4. The owner agrees to contract with a perse licensed under Ch ! H 11 3, Wis. Adm. Code wh( shall submit to the munici; slity S.-Id to the county a report in accord with s. ILHR 83.18 (4) (. 2., Wis. Adm. Cody for the servicing on a se niannual basis. In the case of registration under s. 146.20 (3) (d), Stats., the owner shall sub fit the report to the m ,nicipahty and the county. 5. This agreement will remain in effect only until the local governm ntaf unit responsible for tho regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owne The owne shall submit the agreemi the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit t cjAtA1 Uthe agreemew to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) (Print) I Owner(s) Signature(s) 8 ! Subscribed and swb N@h this date: I Municipal Official Name (Print) / � Municipal Official Signature Notary Public commission expires: JOPNN HOP � ✓✓✓111 1 zCc it'z"� Nei ry Public Muni ci�l�o�� (P��,�,i ! �> ,5_ g State A Wiscons SBD -6123 (R 10185) This instrument was drafted b, the State of Wisconsin nonartrnent of Industrv. Labor and Human Relations, Bureau of Plumbing. sl\lix�� .fit.' , w i:'.f rf til • j V^ � �' � �� z H ST C- 105 r 9 :4 H SEPTIC TANK MAINTENANCE AGREEMENT ' `t o St. Croix County z a 7� T F A LL n /U1c �j, jr a,} OWNER /BUYER �5 � ROUTE /BOX NUMBER Fire Number s CITY /STATE N u' /i i'c h iii c L.V.1 ZIP �Jv l / PROPERTY LOCATION: /l /E 1 4, /1J 1 4, Section I T 3 0 N, R id W, Town of ITi C k rM c it s St. Croix County %' Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St." Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. o E I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. S I G' N E D tw�'t . DATE _ 61 St. Croix County Zoning Office P.O. Box 98• Hammond, WI 54015 k 715- 796 -2239 or 715 - 425 -8363 Sign, date and return to above address. APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property 07 1V1 e A � ✓• r �-�j Location of Property /yet 4 / 4 V 4, Section / , T ?d N - R /� W Township 171 C �1 bm 6V j J T. C Y O 1 X C ci &I T Mailing Address W e IV /Ti C- m d% CV.T Subdivision Name Lot Number Previous Owner of Prooerty ��► r C . / N 60 t #- 5 ,i ( Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number as recorded with the Register of Deeds IN CLUDE WITH THIS A PPLICATION ONE OF THE FOLLOWING C :I Warranty Dee 3. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. -------------------------------------------- PROPERT OWNE CERTIFICATION I (We) eenti.6,y that aU Statement6 on .th.us 6o4m wte tAue to the but o6 my (ouA) knowXedge; that I (we) am (one) the owneh ob the pnope&ty de c&ibed in .thus in6o4mati.on 6Y)4m, by vi4tue o6 a wa4Aan-ty deed neeonded in the Oj6ice o6 the County Regtist?A oA Deeds as Document No. __; and that I (we) pnesen ty own, the paoposed �6 to Jon the sewage di,6 oaa-e syhtem (on 1 (we) have � obtained an e,zzeme", to nun with the above desetribed pnopenty, bon the eon,6PLucti.on )6 said system, and the same has been du4 in the OAAice of the County Reg-csl en of Deeds, as Document No. ). S 1' T a o-f E. 4 L L E L► /L1c A P4 v SIGNATURE OF OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE) 9 DATE SIGNED DATE SIGNED y DOCUMENT NO. STATE BAR OF WISCONSIN -FORM 2 I 1•IAnHANTY DEED I' r �' VOL 5.�� P;1 t ��� ACE RESERVED FOR RECORDING DATA BY THIS DEED Earl C. Pede rson._,__ a single Ina _ EST. STE co., �^l Rexrd for Rccmd tl;ts_______ _ day cf I A.D.19 Z6 Grantor conveys and warrants to._ E. Allen McAndrew and Anne u 0 A F1 ! _ Psi. McAndrew _husband and wife, as joint tenants, r � � Grantee S _ _ for a valuable consideration --- _. _ - - -. RETURN TO the following described real estate in __ _._S t • CrOiX County, State of Wisconsin: i All that part of the Northeast quarter (NEk) Tax Key u of the Northwest quarter (NWh) cf Section One (1)p Thiq is homentend property. Township Thirty (30) North, Range Eighteen (18) West, �I lying North of the Willow River except the following ii described parcels: �j 1. That parcel described in Warranty Deed to William F. McDermott and t Norma McDermott dated July 25, 1973, and recorded in the St. Croix County Register of Deeds office on August 8, 1973, in volume 501 of Records on Page 448 as Document No. 317835. 2. All•that part lying East of a line runnin o Y g N and South and g parallel with and 466.69 feet West of the East line of said Northeast quarter (NEI4) of Northwest quarter (NWW4) . I 'i' . NSFER Exception to warranties: F EllE 1! Executed at.. — _ _ Ri chm ond, Wi c u C011Sln , MZreh T , > 7 fi ! c_I. �i SIGNED AND SEALED IN PRESENCE OF G ' c �_` _ ,C •` �.t -`- � ! _ _(ST ?Al.) Earl C. Pederson N/A f I .. .�sl•:nt.) I I t 1� N/A � (sF.nl.) I I Signatures of _. - -- -_ Earl ._.._ _ . Pederson authenticated this day of .. . _ March - le►,. 76 �! G. E. Norman �I Title: Member Slate Bar of Wisconsin err 011-1 —FX"y -A Itaxi r.P4- wroekr- Soo...700.flb -r+io li STATE OF WISCONSIN 4 N/A } ss. County. l j� Personally came before me, this N /A I I the above named N/A I N/A I to me known to be the person who excewed the ` rry„ ng in:arumvnl and rncktnewledged the %ame. 4 N A'R ° ffl�Y% , & BAKKE ii New Richmond, Wisconsin 54017 Nolary Public The ure of witnesses is optional. Mi, CommL:aion (I•;xpin•s) (Is) L II I ! Names of persons signin l; in nay cnpncity shrrul.1 he typed ,,r prrnled heln•u their •II•nat ure•s. -- —. s Ii.Nll..r'.v,vtvnrvi