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026-1118-13-000
• iscuhsin Department of Commerce afety and Buildings Division PRIVATE SEWAGE SYSTEM Count{ Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitgr sywNo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3JJ Permit Holder's Name: ❑ City ❑ Villa e ❑ own of: State Plan ID No.: D errick Construction Ric Township - CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.: GO 0 —026- 1118 -13 -000 TANk ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 2 --O Benchmark Dosing Alt. BM o 6U.0� Aeration Bldg. Sewer Holding St /Ht Inlet • S - 0 cm,5-p' TA NK SETBACK INFORMATION St/ Ht Outlet 7. 7- Qf •13 TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet Air Septic > 5-0 ( NA Dt Bottom Dosing NA Header / Man. Aeration NA s� Holding Bot. System PUMPASIPHON INFORMATION Final Grade Manufactur Demand St cover qg 90 ' Model Number GPM TDH Lift L riction tem TDH Ft For ain I Length Dia. Dist. To SOIL ABSORPTION SYSTE 13 A, e4c.�- B401,_ Width I Length , No Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN N 3 ,ZS 1- 3 DIMENSION SYSTEM TO P/L I BLDG WELL LAKE /STREAM LEACHING Manu tur r: SETBACK CHAMBER s � . S1&1>1 INFORMATION Type O I o e Number: System: jfl F- ,3,`) OR UNIT du DISTRIBUTION SYSTEM Is U Header�yani old N Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length \e-e— Dia. n Spacin ^- ,ISM SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only ter Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: CIB / /BD Inspection #2: �---�— Location: 1422 174th Avenue, New Richmond, WI 54017 (NW 1/4 SW 1/4 l� T3PN R18W) - 01.30.18.693 Willow Valley - Lot 13 1.) Alt BM Description = 1V1/4' 2.) Bldg sewer length = �. 2`i. 0 q = 9S 36 q g� q�, oz ' - amount of cover = �� "t � c 4O ►'` f ""'°� C/ � j = °IS 3D q 9� o Z' � S Plan revision required? ❑ Yes tg[ No Use other side for additional information. 1 05 1 ©3 CD (p A SBD -6710 (R.3/97) Date Inspector's Signature Cert No ADDITIONAL COMMENTS AND SKETCH r SANITARY PERMIT NUMBER: , i F � , 3 i e 1 t s . f r i � "Y 3 a , , E a t s i i A =, M i 1 S . .0 3 E a E { � t � i I E ; p # L F i P $ n 3 4t-r z2 /4ve icati I S fety &Buildings Division In accord with Comm 83.21, Wis. Adm. o 201 W Washington Ave. N See reverse side for instructions for completing plica�f'' � ZQOO ` PO Box 7302 Personal information you provide may be used for s c a.y pllt �es r adison, WI 53707 -7302 Dep6 ment:6f- Commerce [privacy Law, s. 15.04(1)(m)] ST apl(6ubmit c m I ted form to county if not iNT state owned. Attach complete Tans to the county copy o r stem, on a les * size. Coup State Sanita� Pelmit Numh'r Chec f revision to pro ' a ication State Pl mber I SV I. Application Information - Please Print all Information Property Owner Name Property Location r \�d*-\� —j^ ►'�C.� Wt/4S.01/4,S ` 3 T36N. R19 W Property Owner's Mailing Address Lot Number Block Number I soy N w l9s Po Bo A- City, State Zip Code TPhoneNumber Subdivision Name or CSM Number S r s Co a w .,.3 o `� II. Type of Building: (check one) ❑ City ,g I or 2 Family Dwelling - No. of Bedrooms : ❑Village Public/Commercial (describe use) :_ l�'I'own oj, c i ❑ State -Owned r �" Nearest Road 3 3 x C� • Z r _ 5 Pa I Num s III. Type of Permit: Check on1v one box on line C box on line B if a licable A) 1. New 2. ❑ Replacement 3. eplacement of 4. 5. 6. ❑ Addition to stem System Tank Only Existing System B) permit Number �O Date lss ed OKA Sanity Permit was previously issued 753 IV. Type of POWT System: (Check all that apply) Non- pressurized In -ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland • Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dis ersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (GalsJday /sq. fQ (Min-tinch) Elevation o lo hampf I . 1; 91f 9j ?, r VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con - Con- glass New Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned. assume responsibility for installation of the POWTS shown on the attached plans. Plumbees Name tint) P be' Sign ture s ps): MP/MPRS No. Business Phone Number t S �3 7 Z't oZ- ��t Plumber's Address (Street, City, State, Zip Code) Z" O% ow Oi IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) V Approved ❑ Owner Given Initial Adverse Syiharge Fee) Determination c � o� _ X. Conditions of Approval /Reasons for Disapproval- , C r ` 1, irSje 'r''i -laeo I AvE r l e'►� $ Icati R EMAU fety & Buildings Division In accord with Comm 83.21 Wis. Adm. Co 201 W. Washington Ave. See reverse side for instructions for completing plicaVV ] z00� �-- PO Box 7302 N visconsin sopernal information you provide may be used for s c ary pr►r� r adison, W[ 53707 - 7302 �epnrtments6 Commerce [privacy Law, s. 15.04(1)(m)] S1 pa(tSubmit c m l led form to county if not TY state owned. Attach complete plans to the county copy o r ystcm, on Pa les I CEin size. County State Sanitt;- Permit Number ly Chec f revision to pre ' a ication State PI mber t I. Application Information - Please Print all Information L Property Owner Name y Property Location YL r L01/4 %k) 1/4,S T3 N, RAT W Property Owner's Mailing Address Lot Number Block Number I sos H W W (P Pogo A- City, State f Zip Code Phone Number Subdivision Name or CSM Number S II. Type of Building: (check one) ❑ City I or 2 Family Dwelling - No. of Bedrooms : ❑ Village Public /Commercial (describe use):_ qrrown ❑ State- Ow_n_ed � Nearest Road b _p f, J 3 3 r J ZS _ �. Par 1 Numb s �d0 c7 III. T e of ermitt: Check only one box on line Ch box on line B if applicable A) 1. New 2. ❑ Replacement 3. Replacement of 4. 5. 6. ❑Addition to stem System Tank Only Existing System B ) Permit mber Date Iss ed XA Sanitary Permit was previously issued 75 3 7 IV. Type of POWT System: (Check all that apply) hNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland • Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (GalsJday /sq. ft.) (MinJinch) i Elevation (Doo I&bgf ) o t . $ --- 91f Q�. r VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks Faso 1 V3�.�%Qv T ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for instapatipri of the POWTS shown on the attached plans. P mbees Name rint) P be s S=tures : M P/NIPRS No. Business P Nrumber 15 13 -5 Plumber's Address (Street, City, State, Zip Code) Z`'` u � •a c� t (.�S S f IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) (Approved ❑ Owner Given Initial Adverse S harge Fee) Determination r o�oZ CrD X. Conditions of Approval /Reasons for Disapproval• • A 3L ! , , : i f I } s I I I i i I t : A�-T Tb�, s , t , t — i : t , • I , , f I ' I I , t f f ! I I I { ! I s I , • v I i I I t i I , I � I , I i • I i , • V , I f I I ` I .. �i I! I, I� I f• i , I • i s f I • : I I i f I i Ljj 1-4-1 L J D A 1 LJ -1 1 lz T 1 1 L TA-4-1.0 1 1 T. 1- [A- L 1 L 1 J A Ad . I T _ 110 1, 1 L Ad JA TA JI, TF-71-- A.T. 11 1 L-14-4-T.; i -J. L; -L IA ii � I I � I � i I I � 1 177 ily A - 17 fill - A_ 1 VA 1_ PHI_ T F! r T jar Ca CL CL Z o 3 a � � ICE CD CD cn a - CD i x 7m :.� ° - n r' C7 su N n� o. co _ ) Q-,' a. � r- c Q c v n c O " ° (U a• r- v� C/) CD cr C O n ° -, 1 W (D N• � 0 `G N (D n C J (] x Q N 3 1II V 3 (D r p- - '_ a n ° " %< (n X 00 n) Oo N 16 CA r _ C CL - a% C N O < �' c C O �^ Invert I V —}� m = CD w Ja 0 �� ' 1 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County C r0\ Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must 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. _ I I 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 �v ru c x Govt. Lot of \k) 1/4.SW 114 S Property Owner's Mailing Address ^ Lot Block # Subd. Narp�or CSM# S v - Q � \ City I State Zip Code Ph ne Number ❑ City ❑ Village Town Nearest (? ad c –'g ( '7 1 CIS ) a I ,,p New Construction User[ Residential / Number of bedrooms Code derived design flow rate DO GPD El Replacement ❑ Public or commercial - Descri e: Parent material .�,�� S S t7,r�.� t� e c i o. \ 6A (k hS k Flood Plain elevation if applicable ft. General comments and recommendations: © Boring # ❑ Boring QU �� 9 Pit Ground surface elev. ! O% 1 ft. Depth to limiting factor .1 -- 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. r •Eff#1 'Eff#2 D- J CJ /o m — ® Boring # Boring Pit Ground surface elev. _ I X L5 ft. Depth to limiting factor g6 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 �m v- C 03?' s, l .,�• Sbl rn r C� .� .� 31 Sf /o /n$b Gam% • Ii d 5 /-96 Effluent #1 = BOD > 30 5 220 mg/L and TSS >30 5 150 mg/L .',Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L T Name (Plea rint) ig CST Number � r t- . 5 oa Address Date Evalua ' n nducted Telephone Number . Property Own '2�r`.c �Y.� Parcel ID # �,";—� ��1 - Page 0 Boring 1�1 Boring # QQ � Soil licatton Rate P GPD/ Pit Ground surface elev. _ 7 ft. Depth to limiting factor .�_ Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots fE Eff#2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 0 -/ O / rn 5)K r cuJ � a [] Boring Boring # Depth to limiting factor in Soil lication Rate E] pi Ground surface elev. ft. p Roots t= Horizon Depth Dominant Color Redox Description Texture Gr. Sz� h Consistence Boundary •Eff#I Eff#2 in. Munsell Qu. Sz. Cont. Color Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate ❑ Pit Horizon Depth Dominant Color Redox Description Texture Gr. ct re Consistence Boundary Roots •Eff#1 fEff#2 in. Munsell Qu. Sz. Cont. Color ' Effluent #1 = BOD > 30 220 mg/L and TSS >30 _< 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 5 30 m g/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. SBD -8330 (RAM) I ' cic -A / J I W iE � , I I I ! I I I _ f r _ r I I � 1 � i � i � � � � ! i I � I ��• E i ' ' i I I r I I t if I f I I I f I � I 1 }} t t ! f : i i � Ir , e —rt— � 1 t , { ----------- fi • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer — kCC �V4�u �-c�.� V— Mailing Address �� V�?O )rl �- ; { /i 1. t- nti a to r> �4 S 4 1 Property Address 001 V � (Verification required from Planning Department for new construction) City/State U- Identification Number o" - 1'0 a% - q0 - %O Oa LEGAL DESCRIPTION Property Location t %., 5 1 /,, Sec. i . T -710 N -R t g W, Town of CAA^-4' <3 64- Subdivision 4 =`^� ��' Lot # Certified Survey Map # . Volume , Page # Warranty Deed # _ `�L �� , Volume �° S , Page # Spec house ❑ yes Xno Lot lines identifiable Xqes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and' by a masterplumber, journeymanpl*nber, restrictedplumberor a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, erein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating t your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o thre ear e t . . • ? c7 Z) NATURE OF APPLICANT DATE OWNER CERTIFICATION I e) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the =; of a warranty deed recorded in Register of Deeds Office. 7 / / SI NATURE OF APPLICANT 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 pl civ , _ . 1 . `lIV SwVv i5 cpS P .Q f« � D l o'17' ST_0('o �wc T Cake -1c�al �q0 c 1 lases � CAJQ s �`�� . s �s _�,� as i'7 gPn __. - - -- ,tom l � 3� v. I - — - -- I I I I I I I : : I O i O — .l l J»nU( �- °pro= E c` o Zf >'a C X c6 N i - O V OQ ^ A A I M cV I N O C d O O) = U O 0 co O C U f � 0 `_ I Q U N C - O CL 'p w Cn I s Q '.a cu CL t N � c c N U J N V N -C C X `. 0 b C)) O 2 N O cll i p J J a 2 In (n (n l < I — - t]. • • • • . j 1 L1 1 Cb ® C A V J) A Ady� A �d6� O c I r; (•fie 3 I W p J > E •` } tu Q z � • µl y ♦V � LL co 1 0) {-.. r T S h 11 • 1 oaoy c C: w � }� I . t I Wlsoonsirvf?eparbrlent of commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safely and Buildings in accord with Comm 83.05, Wis. Adm. Code Enviromneotal By Des Attach complete site plan on paper not less than 8% x 11 inches it size. Man must include, but not timded to: vertical and horizontal elf ctirlt_(BM), direction ands St. Croix percent slope, scale or dimemsions, north an and distance to nearest road. parcel I.D.# APPLICANT INFORMATION - print i information. Persotwl k1bmwtion you provide may be R ' Law, s: 15.04 (1) (m)). By Date Property Owner --r � Property Location LM Derrick Construction Inc. `' i j/! Rv 2'3 ,h„ CvovL Lot NW 114 SW 1/4 S 1 T 30 N,R 18 W Property Owner's Mailing Address - of # Block # Subd. Name or CSM# r • s coax 13 Willow Valle 1505 H 65 CDJ City State ti Cod POWW ifrt�6et ,< City ❑ Vlllane ®Town Nearest Road New Richmond Wl 017: .,� Richmond 14OThSt. ® New Construction Use. ® R esi � AuA v of bedrooms 3 []Addition to existing building [] Replacement F1 Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate • bed, gpdfiF •6 trench, gpd/W Absorp area required 900 bed, fF 750 trench, iF Maximum design loading rate .5 bed, gpd/ft2 .6 tr ench, gpd/fF Recommended infifiration surface elevabon(s) 102 & 100 It (as referred fo site plan benchmar Additional design / site consideration 1,2,4 Parent material Loess Over Glacial Outwash Flood pla elevation, if applicable NA ft S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fat Holding Tank U= Unsuitable for system 0S o U N S❑ u N S❑ U 1 N S❑ U CIS N U ❑ S N U SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Co nsistence Boundary Roots GPDIfF Boring# in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench �1 1 0 -13 10yr3 /2 - sit 2msbk mfr cw 2f .5 .6 2 13 -32 1Oyr4/4 - sil 2msbk mfr cw if .5 .6 Ground 3 32 - 58 7.5yr4/6 - s Osg ml cw - .7 i .8 elev 104.45 ft 4 58 -90 7.5yr6/5 - fs* Osg ml - - .5 .6 De�th to l limiting factor >90 Remarks: W/ Pockets of s 7 5yr5/8 7 5yr5/6 & 7.5yr4/6 2 1 0-10 10yr3/2 - sil 2msbk mfr cvv 2f 5 6 2 10 -26 10yr4 /4 - sil 2msbk mfr cw if 5 6 Ground 3 26 -36 7.5yr4/6 - ifs 2msbk mvfr cw - 5 6 elev 10510 ft 4 36 -59 7.5yr5/6 - s Osg ml cvv - .7 .8 Depth 5 59 -90 7.5yr4/6 - sl 2msbk mfi - - .5 i .6 limiting factor >90 Remarks: CST Name (Please Print) Sgnature: Telephone No. Thomas C. Nelson 715- 246 -2454 Address Environmental By Design Date CST Number Ref # 1432 120th Street, New Richmond, W1 54017 1/20/99 227387 189 l PROPERrnPWr1ER: DeRickca� ion rm. SOIL DESCRIPTION REPORT ,ee Page 2 of 3 PARCEL I.01- Enviromxatat ByDesism, Depth Dominant Color Mottles Structure GPD/W Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz Sh. nsistence Boundary Roots Bed ' Trench I , 3 t 1 0-7 10yr3 /2 - sil 2msbk mfr cw 2f .5 .6 2 7 -18 10yr4/4 - sil 2msbk mfr Cw if .5 i .6 Ground elev 3 18 -34 10yr5/8 - s* Osg ml cw - 7 8 100.64 ft 4 3449 10yr5 /6 - fs Osg ml - - 5 i 6 Depth to 5 49 -80 7.5yr4/6 - s Osg ml - - 7 ? 8 limiting factor >80 Remarks ' v'/ pockets of s 7.5yr5/6 & 5yr5/8 t 4 4 1 0-6 10yr3/3 ' - sil 2msbk mfr Cw 2f .5 .6 2 6-19 1Oyr4/4 - - scl 2msbk mfi Cw if .4 '. .5 Ground elev 3 19 -35 7.5yr4/6 - sl 2msbk mvfr Cw - .5 .6 103.08 ft 4 35 -57 7.5yr4/6 - is 2msbk mvfr cw - 7 8 fp 5 57-67 7.5yr5 /6 • - s Osg ml cw - .7 .8 limiting factor 6 67 -90 7.5yr4/6 ' - Ifs 2msbk mvfr >90 - - 5 '• 6 Remarks: { 5 , , 1 0 -11 10yr3/2 , - sil 2msbk mfr Cw 2f .5 ; .6 2 11 -26 1Oyr4/4 - sil 2msbk mfr cw if .5 .6 Ground elev 3 26 -60 7.5yr4/6' - ifs , 2msbk mfr Cw - 5 6 100.69 ft 4 60 -80 7.5yr5/6 ' - s Osg ml cw - 7 8 Depth to limiting factor >80 Remarks: Ground elev Depth to limiting factor Remarks: ` ENVIgONMENT BY DE 1432120th STREET, NEW RICHMOND, WISCONSIN Last saved by Thomas Nelson 715- 246 -2454 Willow V aRey NMI PAGE 3 NW '4 SW Y4, SECTION 1 T 30 N. R 19 W y o TOWNSHIP Richmond COUNTY St. Croix Wisconsin S o Z�— Lo l f a d I c..cres RX S SCALE 1 =40 Tom Nelson BM 1. NE LOT CORNER Top of iron pipe ELEV. 100' 227387 BM 2. Ground Surface next to lath w/ ribbon El" 104.25'/ 4 � ►� - -- - 140 srR ---- -- — etc CO etc .scry'c .aa � ,9cQ 4 -z V sty . 1.1 •� 3 53' 41 t RU I I I �o ; I m I pur arl �rruor versa!' i �� i I - t----- - - - - - { LOT it HIM :H 1 t ,na •;,. ?+� ��r,�� �..�q•.+�. + � xa �� A , rt � .. �: �`�,. , r�� , �i��� —�' "�.: 4.. tx.� , i Safety and Buildings Division N* SANIT ARY PERMIT APPLICATION 2 01_W. Washington Avenue P O Box 7302 Department of Commerce In accord with Comm 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 than 81/2 x 11 inches in size. — • See reverse side for instructions for completing this application state sanitary Permit Number Personal information you provide may be used-for secondary purposes [I - Check if ievision to previous apbricat�ion (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEA E PRINT ALL INF RMATI N Pro erty Owner Name Property Location 5 T, N, R for) W Property caner ailing ress Lot Number Block Number A City, State._,` " ( Zip Code Phone Number Subdivis on afne or CSM Number (, ) 1 s . E ( NG: (check one) ❑ State Owned 44rcel Itr Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 17 Town OF 1 III BUILDING SE: (If building type is public, check all that apply) Tax Num er s) r �f� GnZ 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility I 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 []Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3. [] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an __,_System ________ System _____________ Tank Only______________ Existing System _ _ q Svst B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 RSeepage Trench 22 0 In- Ground Pressure 42 0 Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons 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) Elevation (? !v Q Feet C),S Feet 1 1 VII. Capacit TANK in gallo 5 Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Ezistin strutted Tanks Tanks Septic7ankj r ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber El 1:1 ❑ 1:1 El El VIII. RE, PONSIBILITY STATEMENT ,.,,_&jffjj pdersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PF me: (Pr' t) Plu mber's Signe ure: No Stumps) MP /MPRSW No.: Business Phone Number: -J Pl u — n . ess ( treet, Ity, tate;Zip Corley r IX. COVNTY / D P TMENT.USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ss _e u R d jIssuiiV6 Aggnt Signature (No Stamps) Surcharge Fee) J E2 ❑ Owner Given Initial - (, Adverse Determination r te . `;- / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -8398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS I I 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, 600-26.Q-3151.. _ To be complete and accurate this sanitary perrhit application must include: I_ Property owner's name and mailing address. -Provide the legal description and parcel tax number(s) of where the system isto be installed. r II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use_ If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number . of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2x 11 inches must be submitted to the county. The.plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if�required by the county; E) soil test data on a 115 form; and F) all sizing information. --------------------------------------------------------------------------------------- - - - --- - - - - -- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. - ` Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue 14; - P O Box 7302 Department of Commerce In accord with Comm 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 than 8 112 x 11 inches in size. cz `T (� ` • See reverse side for instructions for completing this application State 11 sanitary Permit Number Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location Y ) 114 S T .. i N, R r W Property caner s ailing Address ot Number Block Number City, State,, Zip Code Phone Number or CSM Number T YPE MOM NG: (check one) ❑ State Owned o It Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 0 ,rown OF III. BUILDING SE : (If building type is public, check all that apply) Parcel Tax Num er(s) 1 ❑ Apartment/ Condo I 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Facility y 9 y 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2, E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5_ ❑ Repair of an XSystem - _______System ___________ __Tank Only_____ _______ Existing System ___ -____ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 EZSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill r s_` VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons 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) Elevation l CSt ?) r Capacity /o Feet •' <- Feet` VII. TANK in allons Total # of Prefab. Site INFORMATION g Gallons Tanks Manufacturer Name Concrete Con Steel glass Fiber- Exper. Plastic App New Existin structed Tanks Tanks Septic Tank.or �— (� "� } + ' ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ El El ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI mber's Name: (Pr t) Plumber's Signature' (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address ( treet, City, State, Zip Code)- l r--- rf1 c✓ 1 [ n / r 1 j i IX. C N Y / D PA TMENT USE ON I] Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue issuing Signature (No Stamps) ! []'`Approved ❑ Surcharge Fee) Owner Given Initial - < c,,> Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:.` I SBD -6398 (R. 4199) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership 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. ll. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7_ VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ' 1Y2- 2 / 7 Safety and Buildings Division Visconsin SANITARY PERMIT APP!tt N 201 W. Washington Avenue P 0 Box 7302 In accord with Comm 83.05 Wis. Adm. Code Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the s�0em, tot les3 unty n than 8 112 x 11 inches in size. 1 �.. �., �► y - `� a • See reverse side for instructions for completing this ap )t� ion t sanit Pe T 1 ! '3 J Personal information you provide may be used for secondary purposes` ` c j �rd.� heck if revision to previous app) lon [Privacy Law, s. 15.04 (1) (m)]. �.� F OC G AC ;' State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT AL \ \\ RMAON Pr rty owner ame r t © �h / 4eat 5 T , N, V'S 9%r) W 1 Prope Owner's Mailing Address pO R Lot u er Block Number City, S Zip Code Phone Number Subdivision N r�e or t �mb li C)( ( t5) V II. TYPE OF BUILDING: (check one) ❑ State Owned E] cit Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms o volage ` �, S d� III. BUILDING USE (If building type is public, check all that apply) Par �11 x Numbers) ,;L - 1 1 O C 0• 1 [] Apartment /Condo — 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursi Home 10 E] Outdoor Recreational Facility 3 C] Campground 7 ❑Merchandise: Sales pairs 11 El Restaurant/ Bar/ Dining 4 [] Church/School 8 E] Mobile Home Par 12 E] Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 E] Office/ Factor 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one b/onli A. Check box on line B, if applicable) A) 1. 14( New 2 E] Replacement Replacement of 4_ E] Reconnection of 5_ ❑ Repair of an - ___System ________ System Tank Only Existing System Existing System B) E] A Sanitary Permit was previousPermit Number Date Issued V. TYPE OF SYSTEM: (Check only on Non - Pressurized Distribution ressurized Distribution Experimental Other 11 [1 Seepage Bed 21 [] Mound 30 [] Specify Type 41 []Holding Tank 12'rSeepage Trench 22 C] In-Ground Pressure 42 [] Pit Privy 13 ❑ Seepage Pit (P) 3 r X 100 43 E] Vault Privy 14 ❑ . System -In -Fill ` `t 1, i+ *G rv - u ' �l VI. ABSORPTION S YSTE FORM ION. 1. Gallons Per Day 2. A orp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Re fired (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation ��� 1 �� j -- ro oZ . Feet SOS Feet Ca acct VII. TANK in allons Total # of site steel INFORMATION g Gallons Tanks Manufacturer's Name Concrete Co g ass Plastic Appr_ New Ex structed Tanks Tanks ept c Ta r 5 i rS ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Climbed 1 ❑ ❑ ❑ ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersiojed, assume responsibility for installation of the onsite sewage system shown on the attached plans. P mber's Name: (Pr ) PI tier's Sign ure: No S mps) MP /MPRSW No.: Business Phone Number: U t s 71 s a .5 1 Plumber's Addres treet, Cit , St�t�, Zip Code �"� N V, af c 1, SZ r IX. COUNT /DEPARTMENT USE ONLY pp ❑ Disapproved Sanitary Permit Fee (includes Groundwater P60670101a Issued Issuing A nt Signature (No Stamps) p ro SurchargeFee) ❑ Owner Given Initials Adverse Determination r fV0 I X.s�DI�TI R FOR DISAPPROVAL: /-P 7 SBD -6398 (R. 4/99) 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 Admi -n strati've Code will be applicable. 3. Affrevisions 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 1 5. Onsite " Th sewage systems must be properly maintained. e 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. - -- I To be complete and accurate this sanitary permit applicati4rr,must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.j 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 $ 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 E) soil test data on 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation_of surcharges (fees) for a number of regulated practices which c n effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigati ns and establishment of standards. _PICT p ,! .err c � - �� n/w'J �Sw�lcf S 1 30 N 1Q l � 4 a a f � �" Ctc Q Q m NE LOS 6��� t 50 g h /0 -,, A 8rJ` W4� Itisy a -- � IM��1,�iuZ► gyp, _� �, G��i DIY► c� I I i Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, Wis. %{dm. Code Envir� By Design Attach complete site plan on paper not less than 8'/ x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal referspee @M), direction and O1X $t. Croix percent slope, scale or dimensions, north arr� j l0ati&n and distance to nearest road. parcel I.D.# 0.2c. - J )kq Cr - 15 - APPLICANT INFORMATION - rintA, information: • P R iewed B Date Im Personal information you provide may beonda 7C i y Law. s: 15.04 (1) (m)). Y Property Owner r 'Property Location Derrick Construction Inc. ^. f f ('vovt. Lot NW 1/4 SW 1/4 S 1 T 30 N,R 18 W Property Owner's Mailing Address S r L of # Block # Subd. Name or CSM# 1505 H 65 r cou N 13 Willow Valle City State \ zi '4odP"&w Fmv ❑City El Village ®Town Nearest Road New Richmond WI 417. s ' Richmond 4 140Th St. ® New Construction Use: ® Resi i of bedrooms 3 ❑Addition to existing building El Replacement Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .5 bed, gpd/ffs 6 trench, gpolfP Absorption area required 900 bed, W 750 trench, fie Maximum design loading rate •5 bed, gpd/RZ .6 tr ench, gpolfP Recommended infiltration surface elevation(s) 102 8c 100 ft (as referred to site plan benchmar Additional design / site consideration 1,2,4 t material Loess Over Glacial OutWash Flood lain elevation, if licable NA it le for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank table for system NS ❑ U ®S ❑ u ® S❑ U N S❑ U ❑ S ®u ❑ S M u SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft goring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 1 1 0 -13 10yr3 /2 - sil 2msbk mfr cw 2f .5 .6 2 13 -32 10yr4/4 - sit 2msbk mfr cw if .5 .6 Ground 3 32 -58 7.5yr4/6 - s Osg ml cw - 7 8 elev 104.45 ft 4 58 -90 7.5yr6/5 - fs* Osg ml - - 5 6 De ?th to t 1 limiting factor ° I >90 Ls • y Remarks: W/ Pockets of s 7.5yr5/8, 7.5yr5/6, & 7.5yr4/6 2 1 0 - 10 10yr3 /2 - sit 2msbk mfr cvv 2f .5 i .6 2 10 -26 1 Oyr4 /4 - sil 2msbk mfr cw 1 f .5 .6 Ground 3 26 -36 7.5yr4/6 - ifs 2msbk mvfr cvv - 5 6 elev 105.10 ft 4 36 -59 7.5yr5/6 - s Osg ml cw - .7 .8 Depth o 5 59 -90 7.5yr4/6 - sl 2msbk mfi - - .5 .6 limiting factor 2, >gp Remarks: CST Name (Please Print) Signature: —_ Telephone No. Thomas C. Nelson 715- 246 -2454 Address Environmental By Design Date CST Number Ref # 1432 120th Street, New Richmond, WI 54017 1/20/99 227387 189 s OROPERTV OWNER: Derriok Construction Inc. SOIL DESCRIPTION REPORT ties Page 2 of 3 PARCEL I.D.# Environmental By Design Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 1 0 -7 10yr3/2 - sil 2msbk mfr cw 2f .5 .6 2 7 -18 10yr4 /4 - sil 2msbk mfr Cw if .5 .6 Ground elev 3 18 -34 10yr5 /8 - s* Osg ml cw - .7 ; .8 100.64 ft 4 34-49 10yr5 /6 - fs Osg ml - - 5 i 6 Depth to 5 49 -80 7.5yr4/6 - s Osg ml - - 7 8 limiting factor >80 Remarks: * w/ pockets of s 7.5yr5/6 & 5yr5 /8 4 1 0 -6 10yr3/3 - sit 2msbk mfr cw 2f 5 .6 2 6 -19 1Oyr4/4 - - sci 2msbk mfi Cw if .4 i .5 Ground elev 3 19 -35 7.5yr4/6 - si 2msbk mvfr Cw - . 5 .6 103.08 ft 4 35 -57 7.5yr4/6 - is 2msbk mvfr Cw - . 7 .8 Depth to 5 57 -67 7.5yr5/6 - - s Osg ml cw - 7 i 8 limiting for 6 67 -90 7.5yr4/6 ' - ifs 2msbk mvfr - - 5 6 >90 We-mark's": 5 1 0 -11 10yr3 /2 sil 2msbk mfr Cw 2f .5 .6 2 11 -26 1 Oyr4 /4 ' - sil 2msbk mfr cw 1 f .5 .6 Ground elev 3 26 -60 7.5yr4/6' - Is , 2msbk mfr cw - .5 .6 100.69 ft 4 60 -80 7.5yr5/6 ' - s Osg ml Cw - 7 8 Depth to limiting factor >80 Remarks: Ground elev Depth to limiting factor Remarks: ENVIg BY DE 1432 120th STREET, NEW RICHMOND, WISCONSIN Last saved by Thomas Nelson 715 -246 -2454 Willow Valley r z PAGE 3 NW % SW %, SECTION 1 T 30 N. R 19 W TOWNSHIP Richmond COUNTY St. Croix Wisconsin � ? r O 0 a -cres Td� � SCALE 1 =40 Tom Nelson BM 1. NE LOT CORNER Top of iron pipe ELEV. 100' 227387 BM 2. Ground Surface next to lath w/ ribbon ELEV 104.25' I . r cd i — .l l lJanUI —� c Cd �D p �E � c t C CD C C � i N > co vi .D _ a.2 c N X m M 3 U— L d N } u> a) cu � U M ; co :2 o N T cri c0 0- = OL EL 2' U Q U V1J a A ro �a i N = O ` 0 :3 I a) C U a) CL - 0 co }} i N - 0 J J 0- N LO 0- 1 i R W i dJJa JJ� r J d ' J � i / o i r. W W , -Q U ` C `) x T i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer VL- 1c,t c-, �a S (►'w� ©� y� uu EL. - � , Mailing Address �� �- J�'- , V_--t - e -� kA r -,, s Property Address V (Verification required from Planning Department for new construction) rboap City /State Identification Number 11 - 1 —COE5 LEGAL DESCRIPTION 01.30. 16. (O 3 Property Location N`" %a, 5" ' / a, Sec. i T - �O N -R V W, Town of c-4-O� 0 Subdivision Lot # Certified Survey Map # , Volume . Page # Warranty Deed # t'L 11 :z Volume �° $ . Page # Spec house ❑ yes Xno Lot lines identifiable X7es ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site 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 standards set forth, erein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating t your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o thre ear e t . x / 77 / 0 ,0 NATURE OF APPLICANT DATE OWNER CERTIFICATION I e) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro describ abo�q, of a warranty deed recorded in Register of Deeds Office. ! / 7 SI NATURE OF APPLICANT 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 W.".S. COMPANY ' Ms NOMONSK FALLS, WISCONSIN .. ,.� Q 2=00 800'1, i1i PAaE i)1) STATE OF WISCONSIN ST. CROiX? ` � COUNTY, CIRCUIT COURT PROBATE BRANCH SALE OF REAL ESTATE OF PERSONS UNDER LEGAL DISABILITY —DEED BY GUARDIAN WHEREAS, On application to the Circuit Court of At Croix County, Wisconsin, to sell all right, title and interest of Leo T. Domke, also known as Leo Domke Spendthrift , in and to the real estate hereinafter described, such proceedings were 4r+cefs= AI{iaer== wxW9omPe4twt._--1— had that the undersigned was duly authorized as gene -al. guardian to proceed in said matter; �•Inse rt ��pe eiaf ior+'6erreret�'} and whereas, the undersigned, as such guardian, has done or caused to be done all things necessary and required to be done by law in such cases made and provided, before conveyance of such real estate may be made; and whereas, the undersigned, Lois Hanr3rahan, formerl Lai s Aspl Lnrl , as such guardian, was n_ duly authorized by order of Court herein dated on the 16th day of Deember 19 --B-6, to execute, acknowledge and deliver to Derrick Construction, Inc. a deed of conveyance of all the right, title and interest of said Spendthrift in and (I rfsErtr'fdl =" tJY''"ITLI7RQTEL�nt =.�'1 to said real estate: NOW, THEREFORE, 1, the said T.ni s Handrah fnrmtmr1 T.ni s Aspl nnA an , �7 z , by authority of the Court above named and in my capacity as such guardian, in consideration of the premises and of Sixty ThnllSdnd__($(;0 ' 0n0 n) ------- ------ ----- - - - - -- Dollars to me in hand paid by the said Derrick Construction, Inc. , do hereby grant and convey unto the said Derrick Construction, Inc. all the right, title and interest of the said Leo T. Domke, also known as Leo Domke Sppndt-hri ft , in and to the following described real estate in St - Cral x I mar %mae_ „ ar TAzmTTWL nT County, Wisconsin, to-wit: The Northwest Quarter of the Southwest Quarter (NA of SA) of Section One (1), Township Thirty (30) North, of Range Eighteen (18) West. ST. CROIX 00,,1WRSj 'm'd. for Reaord tt* 2nd 192 -A =#gay o'f a n. A. p 19� a -A (0—H.2n A ad B@W File No. i r YY ` A15... � i?."'� . �- ��,• .. .: .. .. .. •i ?�'. � .. ,� .. ... _ .yr icy ; o:+ .. 1 I L-- - - - - -- I l I saoor�r gear aortraro arra 1 I� ci oil i 3oi' I�� I iiar { ► I f 1 I • I � I l s "ioi I �1 - - - -- L-- , tt ,ssop --- --� - -- - - - - -- I 1 1 to - 9Z w of i Sir e �1 � � � k rte' to i I 241' 330' ! 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