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HomeMy WebLinkAbout030-1083-40-400 O C Si :E ! $ '0 0 d 10 7 's � M — 1 chi m w o 0 O ° N N o � p ° � m � c ° w � � • 3 3 � = o 3 `�� �oQ r-i I w c iS D m ro 1 " w o Z Z N c ca co co a o y =1 0 o N CO w I co 0c (D o o m� 3 H o S w co m D v' d m co Ct d C m I3 cn 1 �y' o ��✓ co CD N N N N { O to 0 y to C ! V Q Z 000 000 3 .. W N CL z .. D CD 0 0 3 d 7 !1 W d N I (O N CD a �' m I z = a � I ( 6 -1 �A Z J O A Z I y � ! y a z 0 fn -I N w� ao� *Z co og o � m I fA !R z `� I D m I C4 w � I D a m c a I w v c f o a o a 6 a I fD I I o 0 I f N I I v a I 1 I 3 I I N I I o V I I a I o 0 CD m aro o ti o b I 0 N 0 r • DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P,O ;,BOX 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number W4 S, SW'w, S29, T3ON -R19W ® CONVENTIONAL ❑ ALTERATIVE (11 assigned) Town of St. Joseph ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound E L ADDRESS on OF PERMIT HOLDER: INSPECTION DATE: Tim Persico, Jodi Kre 41$ Perch Lake Ride Hudson 4JI 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST EF. PT. ELEV.: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: Zappa Bros. Inc. 3395 St. Croix 119450 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: I TANK OUTLET ELEV: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST —♦ DOSING CHAMBER: MANUFACTURER: I BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑ YES ❑ NO I ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NE AREST --- 00- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowingl FORCE LENGTH: DIAMETER: I MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE rISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: LEV. END: PIPES: FEET FROM LINE: AIR INLET: NEARE 1 MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: L_ � ❑ YES [::] NO ❑ YES F-1 NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV: ELEV.: DIA.: ELEV: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO 1 ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY [ WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES LINO NEAREST —♦ Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD -6710 (R. 06!88) Zolling Administrator SANITARY PERMIT APPLICATION 51L HR I n accord with ILHR 83.05, Wis. Adm. Code COUNTY (2 04 . �.......,. 3T STATE SANITARY PERMIT # o nly) s a -Attach complete plans (to the county copy o y) for the s ystem, on p aper er not less than / /9 [,/ 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Y4 %4, S c T p, N, R E (or) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # G CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) ❑ State Owned O VIL : NE EST ROAD .a JQWU PS , i ❑ Public ®1 or 2 Fam. Dwelling - , # of bedrooms PARC TAX NUMB 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System. Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. 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 3 . , Q Feet . p Feet VII. TA 7 CAPACITY Site in allons Total # of Prefab. Fiber- Exper. New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel structed glass Plastic INFORMATION App Se tic Tank or Holdin Tanks Tanks Tank o h a"CAA=�� M Li I = Lift Pump Tank/Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): "j Plumbe ' Signature: (No Sta s) #P/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Cod " V l rJ IX. COUNTYIDEPARTMENT USE ONLY + Disapproved Sanitary Permit Fee (includes Groundwater Date I ssued - issuing Agent Signature tr Stamps) Approved El Owner Given Initial -ILD1 Surcharge Feel Z/ l N � A Dete rmination � X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber i l it INSTRUCTIONS r- 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(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, Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. 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% 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; 8) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) APPLICATION FOR SANITARY PERMIT STC -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. ------------------------------------------------------------------------------- 1 Owner of property l /`s� « r, Location of property `J GO 1/4 6W /9, Section ��_ T _Z� -R W Township _ S�Sefl}1 Mailing address ' Z'/1�� , Address of site Subdivision name "' L AK,9, Lot number Previous owner of proper tZ' _� ( 'S 16 - 0 / U L �106 Total size of parcel 3 . 1 - 9 f-G • Date parcel was created 1(1A- rC,V1 a C ( Are all corners and lot lines identifiable? -,9- Yes No Is this property being developed for resale (spec house)? Yes X No Volume -_ and Page Number (� as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. --------------------------------------------------------- PROPERTY OWNER CERTIFICATION 1(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. L1� r1 76 ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same ha been duly recorded in the Office of the County Register of Deeds, as Document No. /,a�_ Sig a ure of Owner �:� Signature Co -Owner (If Appli able) 9 Date of Signatu a Date of Signat re CERTIFIED SURVEY MAP LOCATED IN PART OF THE SW} OF THE Sly} AND THE NW} OF THE SW}, ALL IN SECTION 29, T30N, R19W, TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN. OWNERS Roger Ruelin JoAnn Persico Bruce Peterson f 4 n1�;v�iJ. 505 Galahad Rd. 131 -A Willow La. Rt. 3 Box 56 North Hudson, Wi. Hudson Wi. Hudson, Wi. WJ CORNER 54016 54016 54016 �`y'•' - , SECTION 29 T30N, R19W ='Y� A G 14 LEGEND ;' Z 407 FOUND, ST. CROIX COUNTY SECTION CORNER MONUMENT. I KU cm, i Wi s. o SET, 1 x 24" IRON PIPE WEIGHING 1.68 POUNDS PER LINEAR F00` ' � - L b .Fd,RI`�p SUIR �.Ss Q CURVE IDENTIFICATION NUMBER ``a��tEg�i�sG9 unplatted- lands- owned -by - platter / p I� o — — � W H S89 000122 11W 770.00' o 382.69' 307.31' 80.0' ) o N 690.00' �© 4 W a °j C..3 4 h W 3 I L� . LLJ 167,368 sq. ft. (3.84 ac.)INCLUDI'1G R/W ti 157,119 sq. ft. � EXCLUDING R/W © 4 o Co (3.61 ac.) a o W O N 2 O Z J 2 287.02' 258.87' cc 545.89' s3.u7' ��' W W W ,.� 3 m 3 �c 146,294 sq. ft. INCLUING R/W (3.36 S53 \ 013101 ac.) r \ 10. 100.00 3 N53 °13' 01 "W, 100.00' �\ r^ 135,840 sq. ft. EXCL66i G R/W (3.12 a) 84.5511) N89 °00' 22"E' \ 8.1 ' \ z N 306.891 300.00' 15.45' © 51.29' 606.89' •�`� �i W \ - -- -- - --- N south line of the` 30 o� \ �` ` ✓ 0 167,830 s . .G NWJ of the SWJ R/W ti I ' o \ d '� q' ft (385 ac.)INCLUDIN° -' 158,667 sq. ft. (3.64 ac.) EXCLUDING R/W - \• o Cr F N W N89 000122 11E 665.77' ° \ x , 631.13' 34.64' j _ 1 �\ a o\ a 164,472 sq. ft. (3.79 ac.)INCLUDING R/W CP W - 155,811 sq. ft. (3.58 ac.)EXCLUDING R/W -� 3 \ 615.36' 34.64' 785.96' 165.36' N89 000122 11E 650.00' \ unplatted - lands - owned - by - platter s 66 FOOT WIDE PRIVATE ROAD EASEMENT C. _ I I o ' t o Cn SCALE IN FEET 200 100 0 200 SW CORNER SECTION 29 this instrument drafted by Douglas Zahler job no. 88 - 17 T30N, R19W i i �I ' M I °'' j ij I TV 1 'asuadxa OTTgnd P aq pTnoM .zagjpaaagq S4SOO aOeua4UTPw 'peog OTTgnd P su A4TTpdT3TunW e Aq .zano U@NP4 ST APMPPON agPATJd aq4 JI •'SlauMo buTuToCpp aqq Aq ege.z -o.zd pa.zpgs aq TTegs 'peOJ pzPPUP - 4s P Se .zo - 4ez4ST -uTwpV buTuoZ aqq Aq TPAOadde SqT J94JP APMPpog agPAT'd ago Io s4SOO aOuP — LGgUTPw TTV 'APtApPOH 9 4PAT Jd P ST dew STg4 u 0 U MOgS AP MpPOJ aqy :aJO a - 4Pp abegAN 'D uaTTV s e Fz s 'awes buTddpw pup buTAaAans uT xToaD 'qS go Aquno' ag. 3O aOUPUTPJO UOTsTATpgnS pupa ago pup sagngpqs uTsuoosTM aqq go 6£•9£Z .zagdpgD JO SUOTSTAOid quaiino aqq ggTM paTTdwoo ATTnj OAeg I 4Pg4 !pagTjosap pup paAaAans Aippunoq joTjaqxa aqq JO UOTgequasazdai goajjoo P ST dPW AaAang paTjTglaD STq 4pq 'p.zooaj 3o squawaspa .zaggo TTe 04 4oaCgns pup SpaaQ JO J@gSTbaU AqunoD xTOID 'qS aqq 3O aOTJJO aqq UT abpd awnTOA uT papiooa.z peep P uT pagTzosap se 4uawaspg peoS agPATId apTM gOOJ 99 P o4 goaCgns pup g4TM Ja44a501 'buTuuTbaq 3o quTod ag-. 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CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM T� �n Reaonery 51- ,�R000st.o ' � Rf000�eo �ifoieStD �,�,pFvt �iit iva wk'( 0 QVI a �"AAU `v r� © ✓E< / oo f�icc ?o �E To wesr $� S3 " {knp�i ' Ccr r 4- 0,7 SOL1L7 4 INDICATE NORTH ARROW -LAI ., OA TKEE lvo ScAGE BENCHMARK: Describe the vertical reference point used /-/i*�,c iN V c9A.0 TcF Elevation of vertical reference point: /Oo ' Proposed slope at site: T SEPTIC TANK: Manufacturer: LJ,eSC.r Liquid Capacity: Number of rings used: _� Tank manhole cover elevation: /© S- 7 Tank Inlet Elevation: A ./k' Tank Outlet Elevation: /0 /• $6 ' Number of feet from nearest Road: Front,O Side, Rear, 0 g�7' feet .. From nearest" property line Front 1 0 Side ,Q Rear, � 5 feet Number of feet from: well building: 04O' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) L SEE REVERSE SIDE i 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, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: L LeV 9s 70 ' Trench: Width: Length: S Number of Lines : Area Built: Fill depth to top of pipe: 3_S Number of feet from nearest property line: Front, O Side, O Rear, Ot. Number of feet from well: &"7 Number of feet from building: S/!� (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: 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 T ANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: y � Plumber on job: License Number: 3/84:mj d r 1 M •} f«t N1�jMf +M{fi4.w,iw .M1MlY..�NI �» ...... ........ ............... • . ,. 1 Al a do Sam i ire 11 TslMiiD • *, �I�..�MiM. 000roya to Qraaba tffalloUowiaf doaeeib�i sod **W is Atiw... c Q.X. •,.-. �. r 08=4Y. sta4 of Wbomodn: 1 A parcel of land located in the SWk of the SWk and ' °thief li SWk of Section 29, T30N, R19W, described as follors: Certified Survey Map filed March 21, 1989 in Vol. T ,fI Page 2081 as Document No. 446270.. ... F Tw .... 1 .4 Set.......... roowabad property. a Toned a wifi an sod Na Meaditaaway Sad a anou tborwoda � ' d.�e�ar Aad...... #? Qh..J ke RidBf,... ..P�4 JC1 .rt�ksiP .................... ). warraW Nat tie title L food. iadetwibb in fw sbR* and free wd clear of , easements, restrictions and rights -of -way of record, am ww wareaat Sad ddond the Saone, Dated ..... .......... ............................ day of ........ March ...... .2 .'r ..... bYl .................. ... . Eger. 17 • n.. Ruelin .... ............................... .(SEAL) • A �.. .... Bruce ... T.....P m � Q%tiL..��lr ......................... (SZAL) ............................................ w • OAnn Persico I .......« .................................................... • }� AUTININIfTIOA AO=>KOwL>tnd>)t= fit•) ....Rnger...Ruelin 2e . __� w Bruce . T T. ......................_..' Ana_.Persic8;srs or WISCON Peterson �• < �, q ..St. Croix ,• (� a ba tkie ........day of.XgLrch............. 10.. &9 I'onoaa0 cam �. beftm w ' may . ....... . . . ,, :: (t ` a , .r ��..,d�e.,. ' ..... ?eb.>~uAry. ................... ..Q2aausi...Lunsien. ................... ....... ........ .................. .w.;,;,�':! r } 2TMZ: MEMBER STATE BAR OF WISCONSIN . 0$Ai' . Ruel�xi,...�IAlan.�' .................... .ru... .... � ...P.R .r>�on - ..., .... ....... to as knower to be am poraon J •• `` # 'Y" INVO WNUff WAS WAFM w ' ""was iaettusent and a& 'Y"14 � Kristina 0 1 n ......................... " g a 4 Lundeen • z �w�Ii. ♦�•, ,. •' \`ft�1 t;•+F���i y R ��yy 3 t STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER Jo ROUTE /BOX NUMBER FIRE NO. CITY /STATE 6T, UCf0bkT ��b� ��� W1 5 ZIP PROPERTY LOCATION: 50 1 /4 e c ) CO_ 1/4, Section _ f T _ & J(2 N, R Town of St. Croix County, Subdivision LAMP r`IG�U(? Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 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 verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department 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. SIGNED DATE oT 3 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS . INDUSTRY'!, 1 G DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 79 HUMAN RELATIONS (1-163.09111) & Chapter 145.045) ,p � TOWNSHIP /�X: OT NO-:BLK. NO.: SUBDIVISION NAME: N 1 /4 Q/4 29 %TAN /Rll for � a I lt ter 11 - 11 � '�� +: ►/r: , r►� COUNTY: OWNER'S NAME: MAI LING ADD SS: c�oIX 11 M h i m ) b E DATES OBSERVATIONS MADE $ : COMMERCIAL DES RI710New S: A O TESTS: Residence (A ❑Replace A R� l! 24 / W9 SO IL% E A&L -I - c A NaZ- AM��y r Ste' Site suit for s U- Site unsultable for system Q c !' y � . �.1�1i LJV l�J` V IN S 11 U J YSIEM ElS WU RE CO MM ENDED VE.hR asl C_ o If Percolation Tests site NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.090)(b), indicate: (- L -ws;'5 / ( Floodplain, indicate Floodplain elevation: /JQ r --• PROFILE DESCRIPTIONS BORING TOTAL 12EU J RQUP DWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER ELEVATION OB V S TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 8.79 d I �. g. S a & ILSL 76 " MS �� nt $ems, ! ' ' i AY L R.S Z6 "� T$Qti/'1S B- ,off 0 4 - 7 - No ut;. > 9 0t$ ° 8LSL3 B- 3 )3:ZS /us .r3 ~ P,4-s4-TS �3`kRNN� At T f_,'e MS z 5 "RaNcs �- 114Aa /8% P I fj C > 1 - 5a 4 P, t_S LTS B S' 1 .o5 10 ,z 6 NoNE h> /�,o "t�L l 13r2,., 7 ►�trl�R, I�tS z q ~ r lt�r�IC� B_ PERCOLATION TESTS TEST �g H WATER IN HOLE TEST TIME D R L V -1 CH S RATE MINUTES NUMBER AFTERS WELLING INTERVAL -MIN. PERIO t PERIOD PER INCH P- 3 20 r4 NIE t$. / 04 /' 4 '1 $ .O p Z.zO o "97•% 16 /'/7Z I Z / 4 8. P- q •1 0 hi f ol&- 0 1 ' Z 1 � Z P- E1- VAT IC) A r Rc P• 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- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION g� S T f 60" g -3 66 p �. I d �� r 11 N i i A TN l � `_711--n ass i • A �cENLCLINE I �' ` SS - gAr )'�O i - 1 I ar_vl GQ v.► A • / (� �� -1 I i�l.lr�kn`1rJ>v► � IOC3 ,UU I, the undersigned, hereby certify that the soil tests reported on this m fe by me accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. print): TESTS WERE COMPLETED ON: 1 _ A , AVE - \ 36WNSo USG �u�VC / �NL __— f k) ZS /9 _- CERTIFICATION NUMBER: PHONE NUMBER (optional): '/ ' // 3s6 -qo� 0� sc�>`,ra S Nu�soti W� 540/6 7� -- CST SIGNATURE: UTION: Original and one copy to Local Authm uy Prnl,ei ty owner and Soil Tesler, D-6395 (R. 02/82) - OVER - PRO jre-T Ato 5 tAl IC / /Nl N�/� S ► c o f hno :!!� ( Tx aoa A/aA -rH � wn/ OF S 'r m� 1pff PRo pE2 r�i � ive ST CROIX C ouNTY J L, � pRaposF PL,oT A.v 4f eo5 Y Rr:,ac^( c /o ij 4AJ5 PRnPoSCO {�oPoSED v ' pRORE►fT'/ (� A-, ' t Nl ore S coM ' 7if s� a3 .d 30 4 5 ATE f yam �PvPL�y NE �• a Q 5/ 3R " OAK 7--Pt.0" Sc7u ,-M t�2vPETrY� i cJ� FRF'SH AIR INUFT AND OBSERVATION RIFE Y �- - :4a:lt: ! ! IF<<_ is "ENT i'!FE 1, :574 lrtAR'..F Nr`.;r OR : =1irNT!- lETI;; COVERING nrS!(ait ;E9+i 2 °' AG+:iFtE G:41L- _� 1' - - -- ` DATE: WSTRIBUTION PIPE TEF SOIL IESTING BY: VA Tlx: N BED 6 AGGREGATE � 1 C'ai'n$ PER SC)IL, FENE TH ?IPF ! — F'ERFORAlEb PIPE BELOVII #Mr a AT BOTT f_ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420513 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Persico, Tim St. Joseph Township 030 - 1083 - 40-400 CST BM Elev: Insp. BM Elev: r2� pti on: t90 / 00.0 � Y" vr� n TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic p �' Benchmark Ttr 12 1 w Z. zoo /0 On v Dosing Alt. BM Aeration Bldg. S9w0 YL�� W `a Holding ✓ �, TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L ` WELL BLDG. Vent to Air Intake ROAD Dt Inlet S , Septic Dt Bottom Do n / Header /Man. Yti Y Aeration Dist. � Z 3.3 G) 1 6 �G� Holding Bot. System PUMP /SIPHON INFORMATION Final Grade Gi Manufacturer �— — QQmand St Cover GP S Model Number TDH Lift riction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width I Length , o. Of Tre PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS T SETBACK SYSTEM TO P/L JBLDG IWE LL LAKEISTREAM L ACHING M ctur INFORMATION CHAMBER O . 0 Typ f System: J / UNIT Model Number: DISTRIBUTION SYSTEM + r/ did A oc (, Header /Manifold i Distribution �J I I x Hole Size— x Hole Spacing Vent t Air Intake P() �[ Len is !t Lengt r h u� Dia / c�4n 7 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded j xx Mulched Bed/Trench Center � Bed/Trench Edges Topsoil Yes No Yes m !l No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: J// L D Z Inspection #2: J / Location: 418 Highland View Hudson, WI 54016 (SW 1/4 SW 1/4 29 T30N R19W) NA Lot 1 Parcel No: 29.30.19.302E 1.) Alt BM Description = dF� /� 2.) Bldg sewer length - amount of cover = , J/ Q Use other side for additional information. _ - —� Plan revision Required? Yes _ o SBD -8710 (R.3/97) Date Insepctor's Cert. No. Signat re i ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner G O S y � • 531S' City /state UOSO� l�lJ/ • y6/ (� Legal Description: Z0� Lot �_ Block sobpdi njcSM # Weo //®/ 7 P# . /, t/4 , Sec.Z�, T30 N -RL�_W, Town of 6r, PIN # ' 0 30 -100 0 3 . y0 • Yev SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: r•5 r/N Cr— /�D S > SO >so Tank manufacturer Gy Size ST/PC / Setback froth: House 3 Well P/L Pump manufacturer A Model Alarm location (BOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location �V SOIL ABSORI'TION SYSTEM vDi�UStO'"� s• Type of system: Width Length 6 7 Number of Trenches Setback from: House 37' Well -9 P/L / 2' Vent to fresh air intake > Z5 ( -to Po or C& ) ELEVATIONS o o&D csrs Tar O F Description of benchmark �( /��U�f • t'G 4 f C f Elevation Description of alternate benchmark = To P 4 /C S& I T. Elevation 101..70 Building Sewer N ST/IIT Inlet / ST Outlet PC Inlet PC Bottom Header /Manifold Top of ST/PC Manhole Cover Distribution Lines Bottom of System( ) ( ) ( ) Final Grade ( ) ( ) ( ) 0Ct- 3 < y .z -�- U // Date of installation / / Permit number Yzo 51 3 State plan number 'V! Plumber's signature 7 > 66 U License number Z �"�¢ 37 5 Date /IJOU• Inspector yp0 Z Complete plot plan + Ulbricht & Associates Private Sewage consultants 655 oweil Rd. Hudson, Wis. 54016 I � r f - �S. AJ /U0 0) 0 4 4 or of ,ol THIS POWT SYSTEM SHALL ,J = T . j /' INCORPORATE PER COMM. f A4 q jl I , 83.44(2)c A PROPER ZABEL �� FILTER MODEL # f f � + j J et , 0() /00' ✓�/ � jl yl (W d, r w l3 ste r�R T4N� GO ��cr Pf -NW . o 00,7 9 1,) GE i 15 ys re , a S I % 7 L , Al 22 Sl1Q,C�5 CG,3 — rO Tif L- f iy T %O,vS To �ipo f3 ox - `'� '' y �• - 70 9 3 .70 Safety and Buildings Division Cotmiy rN *hsconsin 201 W. Washington Ave., P.O. B ox 7162 5 � • C/t�0 x Madison, WI '33707 - 7162 SNe Address �0 �� Uepartm6nt of Commerce fttlDSo.✓ Sanitary Permit Application Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal informstion you provide 1--fzd �� 3 may be used rot second ses Ptivac Lars 113. 1 m ❑ Check if Revision I. Application Information - Please Print All Inrormation ---- �-- ._.___.• „ Shte Plan I.D. Number /.- Property Owner's Name "V Tl �I 4 J r7o /' � i 5 � e 0 Parcel Number �. /� 0 3 0 • /0P3 Property Owner's ailing Address / / Ui �"� Property Locadon City. Stare B sw 14-S .Z y 30 Lot Number T N. R Zip Code y, / Block Number CSM Number II. Type of Building (check all that apply) p1 .: o jV/ z I or 2 Family Dwelling - Number of Bedrooms J Ocity Public /Commercial - Describe U�spt Village U State Owned l / 3� \ J , 4��MJt'�9a 0TOWnship n a 1 ` Nearest Road rC ill. Type of Permit: C one box on Ii e A 7(nu me for internal use). Complete line II If applicable) New 2 Replacement System ❑ Rep Addition to For County use S stem shk 0111 Check if Sanitary Permit Previously issued Perm bate Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for Internal use) 441 ' Non -Pressurized In-Ground 110 Mound 47 d Sand Filter 50 C{ Constructed Wetland 22 ❑ Presnirized In- Ground 41 0 Holding Tahk 48 O Single Pass 51 ❑ Drip ine P 45 ❑ At -Grade 46 d Aerobic Treatment Unit 49 ❑ Recirculating 3o ❑ Other V. Dis ersal /Treatment Area Information: Design now (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate Rernuired Proposed Rate Gals. /Da s/S .Ft. yf� ( Y 9 ) (fvtin./inch) Y �l ""'D' Final Grade Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Gallons Gallons of Tanks Steel Fiber P19Stic t New Tanks s % Concrete Constructed Blass Tanks tanks Septic er Holdin6 Tank bosiog Chamber / �� VII. Responsibility Statement- i, the undersigned, III a reaponsibWty for hrslattallou of We POWT3 shown on the attached plans. Plumber's Name (Print) Plumber's St nature MP7MPRS Number _,� Business Phone Number. �. T-- ,- , - � � Z z 4 3 - -5 . 7 /S'v��C' /� S Plumber's Address (Street, City, State. Zip Code) (osS 0 ' f. R o . 17�v AJ 4 1. S'yol VllI. Count /De artment Use onl r Approved [I Disapproved ' Sanitary Permit Fee (includes Groundwater Date Issued Issuhtg Agent Signature (No Sta Surcharge F ) rnps) d Owner Given Initial Adverse 1) tetmivadon 2 IX. Conditions of ApprovalfReasons for Disa prov c-, .�.� �--- � tom- �� C Atfae eomplet pens e e ona � �J e m per m eehes le a Ytii,`.f s, SDD 398 (R. 05(01) i r Z � R� q s ; a w OZ 2 D � N 'gS ; W a , of l oi !� C� /0/.70 I, � � � f ► i quo ; � �� NEt ,8v // v,4 /� r✓ o ' °I obi f /o f � IL i �Yi570-2 P ° o CS T'5 To f t . B, 7 -,*/0 OF Y cam, FoR vl '4 Sa, Go 7 Gi �u1z 13v1 Uri _---_ �1 fpn ,f-f /l �"/ :� „v (3 fJS�/�t�iLT- �pjAv/2. Ni4 OAk' T/'. 6e- /3rtk Go T S A � D r ,ULDnICUIT & ASSOCIATE CQ. 655 O'Neil Road • F Judson, WI 54016 neg..bestgners of Fngineering Systems 715 -386 -8185 Private Sewage Consuila►►Is PROJECT INDEX PLAN ID Nl+ ��" • 2 �� Z BATE OWNER -rl /VI . l��IS /� �-fJ PHONE 5't1,57' 53 l S 5 � A vb R E s s ��.y12 b/i 4 /�' U1�S' o•v 4!/. S yDi l LE DESCRI PTION .407A #/ CS'y yy4ej_70 /ID% 7, ��, .2o W S W ma c- o f 7 7 3 6X� PIN o 3 0 . 10P3 . yo . y� TOWN OF ST --- � D`S � = %' "'L/ COUNTY ✓ GtOlx C19 I '. W. e IS, 0 A) A—' Z LOCAL AUTIIORITY/ SUPERVISION ! JT PROJEC DESCRIPTI e5"x: S7- ;A) /sQ. S / 5 I iV Gdf�E �.49 �i i¢,v T S oiG S �� %/ 1N j,, lei ,4 / U,�¢ G_q P12z6 f 7�,44,GGt, Gei11S 5110 40 rFass� s ' ��� /3 oX o,v SLOB- - GO,cJ 7 &RS . . THIS POWT SYSTEM SHALL ' I INCORPORATE PER COMM. Uibricht & Associates 83.44(2)c A PROPER ZABEL Private Sewage Gonsuitants FILTER MODEL # - ! 8� D G55 0-Nall Rd. Hudson, 4yis. 58016 pis � zzCe3�S / , v N� M 2 �us s z�4/3 �'� T3�Si� P/4 o Pg.l INFILTRATOR SIZING WORKSHEET ET P9.2 SYSTEM PLOT PLAN I P9.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. P9 .4 " „ It 1, 11 11 P9.5 OWNER MANAGEMENT PLANS & ZABEL FILTER SPECS P9.6 (OPTIONAL) CROSS SECTION AND SPECS FOR DOSING TANK. PG.7 (OPTIONAL) PUMP PERFORMANCE SPECS. The attached plans and specifications are based on "In- Ground Absorption Component Manual For Private Onsite Wastewater Treatment Systems." (Version 2.0) SBD= 1075- P(NO1 /01. k -R II A 0 c c r n y 17 M� PtLllq gOlt ID i I � i �� 3 o i ' °� y ~ C4)0 /o /. 7v = 1 '69 L ON G' A 010 B- 7 i y • cz , �� �' � ,v Try r _ 7D � F Fo/� A use v Sd ► Go T 130 // VA 5 NM 3 V) !U� 3Fr �l5rRNCar d T ° °�, AP �' �,� ' of Cge U p P i iff A N 9 f1� 9a •U SE Tiolo o f= TIVC1 11V �/ z- - 7e 4 TU�5 ' /-3i C)- , � Gu ��� 3/. / 5 Q� F r T T l L p-liL s L t:7-e' 7'41 ,v ew 1,vsp Ec T/o v /0 /`'-- 1 ff lei o sc� . 90 wt Ale 7 -- C �3 �AD -reV .s ysTEM � hT "f-R � p� M r o 11 10 ,_ _ 3 o F&,q f o cep ( ,AP A k� �Pp otr�l� U T cif jd Iff_ V// 1 �.A c y CRa SEC Tio� ©F IA- W idZ, 3�• / 5eV, FT To T f L. M4, R ' s MAINTAINCE Of .-• : ...,.:; -.^ ' SEPTIC SYSTEM _ i'OWTS (landowner I M maintenance'of t}�isssreP °nsible for proper operation and servicin ystem. Regular periodic inspections and g is necessary for the safe health Y operation of, this system. The owner is required b y code to submit all necessary maintenance /inspection reports to the controlling ,authorities. SPECIFIC CONTACT AGENTS * ST_ CRO X c; Governmental authorit ' Y/ i nspectors : 7 - ON/ 3o - 7V * Licensed installer maintenance " ' responsible for providin Users manual: g an operation/ 3G P/05 * Licensed servdce / inspection agent other than installer: rr9 7 p Ro/e6-41v 3 (n • - a * Electrician for pump, electric controls, wiring units: IMPORTANT OWNER MAINT ENANCE RE UIREMENTS ' i• Winter traffic (sledding, shoveiring, etc. area shall not be permitted across the the cell, freezing , or frost can /will penetrate into (a winter o up the system. Discontinuos use in the lead to freeez ez u pss, . trip, resulting in no water use) can u also 2• Water conservation needs to be exercised} Or system can be h Ydrolically designed t: overloaded and destroyed. is hem was for a maximum wastewater flow of sys '. 3 . POWTS are not desi y_ �- JD gals. daily. disposal unit to accomodate wastes Any introductivnr any other unnatural sourcesrof wastebale destro t of such waste mat Y his system. erials will overload and 4' in a overl Power 6�itage occurs, o temporary r a Pump,fails, it may result cell oad of effluent,'befn which may adversely impact the cell pumped into the recommended that a (leakage). It is ' allowin licensed pumper empty the dosing tank, Consu Your the pump to return your installer tO dosing the correct amounts. Immediately for advice. 5. Neglect of the ve erosion getative cover (the cells insulation &' traffic also ecanvdestro lead to failure. Compactioc, or heavy REGULARLY WATER THE VEGETATIONsYstem. It IS NECESSARY TO the system beneath IS NOT OVER A SYSTEM!} Effluent in grass covwr. sufficient alone to maintain a ' � 6 • Periodic Inspections by the owner necessary. Inspection °r his a Into t}le s pipes and gents, is syst Ports have been incor inspection pipes) on the basal mound Pvrated laterals , cleanout terminals ron ( effluent level out. ' at each tip - for flushin The filter the pressurized ground system in the 1 and cleaning the laterals cover /manhole). On1 tanks (via a locked Person should be y a licensed above severe performin Properly Ives health safety risks, g this work which system's tre,-3tment Evidence of effluent involves health cell shall also be Ponding in the �� regularly inspected. o Wisconsin Department of Commerce SOIL EVALUATION REPORT P age 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must County St. Croix 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. 0 3 v / 0 F3 ' y0 - y 60 Please print all information. R by Date Personal information you provide may be used for secondary purposes (Privacy Law, S. 15.04 (1) (m)). e' Z Property Owner Property Location SW 29 ■ Tim Persico Govt. Lot 1!4 SW 1!4 S T 30 N R 19 Property Owner's Mailing Address Lot # Block # Subd Name or CSMW MR W6 1 418 Highland View 7 Highland Hills .Zp City State Zip Code Phone Number ityy nVitiage ■Town Nearest Read Holton W, ( ) 549 - 5315 Highland View New Construction Use Residential/ Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD El Replamnent [I Public or commercial - Describe: Parent material I ocssover Qiliwaah ganrlg Flood Plain elevation if applicable NA ff General comnxw Es and L Boring # a Boring El Pit Ground surface. elev. 97.05 ft. Depth to limiting factor >96 in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Etf#1 *Eff#2 1 0 -8 1Oyr3 /3 Is lmsbk mvfr cs 2f .7 1.2 2 844 7.5 4/4 s Osg ml cs if .7 1.2 3 44 -96 7.5 4/6 s Osg ml _ - .7 1.2 �e •fe b . (o 2 Sorfng # 95.90 >94 E] Pit Ground surface elev. _ ff. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlflr in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 1 0 -8 10yr3 /3 - is lmsbk mvr cs 2f .7 1.2 2 8 -22 1 7.5 4/4 s Osg ml cs - .7 1.2 22 -84 7.5 4/ - - _ 3 yr 6 s Osg ml .7 1.2 A r, 12.0 ' Effluent #1 = BOD > 30 220 mg1L and TSS >30 150 mg/L - < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) CST Number Thomas C Nelson 227387 Address Date Evaluation Conducted Telephone Number 1432 120th Street, New Richmond, W1 10/13/02 715 -246 -2454 IYTF lf�1l. TAn MA\ Property Owner Parcel ID # Page 2 of 3 Boring I.J Boring # pit Ground surface elev. 90.75 ft. Depth to limiting factor >90 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 1 0 -3 10yr3 /3 - Is lmsbk mvfr cs 2f .7 1.2 2 3 -10 7.5 4/4 - s Osg ml cs - 1 .7 1.2 3 10 -90 7.5yr4/6 - s Osg ml - - .7 1.2 O 3 6 F Boring # Boring Pit Ground surface elev. _ fL 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. "Ef1#1 •Eff#2 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 " Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 = BOD < 30 mg/L and TSS < 30 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. S1313- 8330Test (R.07 /00) Pat` 5049 �h��lOhNNth'�01 � De h y � www.c ?PhMth �A��I�tSiSh.CPM 715 246-2454 TIM IPERSICO � es► Bence ....... ........... B m I To VCrl l t � P p� ©o � Q � � To? of e I 044 0 t,, ' 1 0 70 1 97.05 a t33 X0,75 1 10 So DoT Z- 9 Ad 3 0 . � w Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNE TOWNSHIP �7 �e?cEo ll SEC. T 30 N -R /9 W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT ' 2 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /00 - OVC2 xj e ,0RaG0sz'o L- 1A.AC (� �Lj P Ro /oScl� / jiLL 'C �iCoo �ifoioStP O �' hP•fvl �i t i va wikY �0 SLOP.£' �� T SIg� • v GR�MZ < ''llw a 0 Vz< To wzsr CctT 1 3.q" ►� i �" /o SL.oPe� .C•SJ� ' S p u�Tl -E INDICATE NORTH ARROW A4kil ITAI PRn��Rry '' // �.• OA Tii4e' : /vo Sc ALE BENCHMARK: Describe the vertical reference point used AJ,414 iN V'• 0,4.t T�c� Elevation of vertical reference point: /00 ' Proposed slope at site: T SEPTIC TANK: Manufacturer: 1,J14fSZ;< Liquid Capacity: j,- j V0 . Number of rings used: �_ Tank manhole cover elevation: /0 S- h7 Tank Inlet Elevation: �./ ' Tank Outlet Elevation: /0 /. $G Number of feet from nearest Road: Front 1 0 Side,(D Rear, O _y "r7' feet • From nearest-property line Front,OSide,ORear, $ feet Number of feet from: well building: 070' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 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, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: L L 9S• 70 ' Trench: Width: /�' Length: 6 Number of Lines: :_ Area Built: !f .Pt Fill depth to top of pipe: 3.S Number of feet from nearest property line: Front, O Side, O Rear, �t. � ' e 2, Number of feet from well: / / "' Number of feet from building: Sal (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: 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: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: V Plumber on job: License Number: 9� .2".E 1,W 3/84:mj ST CROIX COUNTY SEPTIC 'TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer _r//ki 7 Top / • PJ /G6 ` 5- 31S Mailing Address y��� y � %�_� Uf D� / Sy0 / tom ,4 i •r4' Property Address /�_ (Verification required from Planning Department for new construction) City/State Parcel Identification Number �3 /Oc?3 -yo• LEGAL DESCRIPTION Properly Location Sw Y,, Y *, Sec. , T 3D N - R W, Town of Subdivision pw - p d G•A't(:�C- �if�G – �—� , Lot # Certified Survey Map tf % % 6e ;' - y , Volume / ,Page # 2 c Warranty Deed ff �y� , Vohune g3 & , Page # 3 / 4 Spec house U yes A no Lot lines identifiable yes O no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of um in t p p g Out the septic lank every three years or sooner, if needed by a licensed urn et. What y ou put into the system p p Y p Y 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 of a licensed pumper verifying that (1) the on -site was(ewaterdisposel 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. i/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards I forth, herein, as set by The Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification slating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year exp+ atiou date. SIGNATURE OF APPLICANT DATE OWNER C I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) Am (are) the ownet(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. S iNA•IURE OT APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** include with this applfeatton: 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 • ST. CRO I X COUNTY ZONING OFFICE tA91, 2,0 CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the —1 /A4 PA P'66r— residence locat.:d dt: Sol 1/4, 1/4, Sec. ' A , T N, R i9 W, Town of 57- T� Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. - 5 7 A /7 r,,o,-/ Last time serviced Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: /6 Construction: Prefab Concrete Steel Other Manufacurer (If known) Age of Tank ( if known) : (Signature) (Name) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm. Code (except for Inspection opening over outlet baffle) Name t�o /3E'I2T 7,1d�J/�i�I Signature /4� �/ � MP /MPRS 5/88 0 GT. 2 01 � �• • • v w��1 •rA11• "W w ��� .wM i •�� � yaF,. . „� Ss i +. Few � rFS. L a t � # p E � �aat.> i. QS��:.. �t:... ��31�Q1!. .�lB�..T��DQ��3C..�n.,��:g,�►R4 ': � '�,�. �: ....................... ............................................................ w ................................... • !C e TWA w sib firasew, toe a VaImble emai& ation.... � &4 a.. �4.. �irF)41'�P. .. a. eeaMya to Grantoo tbs toiiswing daoAW loaf atab is 41a ............ �• r Coasty, state of Wisconsin: Tam Paraal No.. ;e G. j A parcel of land located in the SA of the SW% and the N* f SA of Section 29, T30N, R19W, described as follows: Lot Certified Survey Map filed March 21, 1989 in Vol. 7 k i4 Page 2081 as Document No 446270. WOM k• , 1 ' 1 This ..4 $ ..AQ.ti.. boomatead l • is ppy y, . ) ( not) � � '. x '• �,,: TsBstbae with all and Pere Lake R d g brad P masts and ap nrtaoanus tborwato bska..i f warr..gndwe tb�'tit4 iad�fiagaWl� ..�. ............. » in tot aimpla and free and clear of .. nenmbraneas ' easements, restrictions and rights -of -way of record, if any; .i aad will warraat and defuad eba same. � weed tbb ............. ................................... day of ....... March ...... ..... 1..... .... ..., if r.� Li t � K .... .............. (SEAL) `.... <: I ! • . Bngex.. Ruelin ..... ............................... • ....Bruce.. T. Psteeraoa �;L'� '� • .. ..... ... ............. •................ ... JSJi3 .(SEAL) •• i : s � . ..$lAI.) r i JoAnn Persico 3 ........................... ............................... • .... ............................. AQTZ11INTICATION AO =IfOW r . LisOQ>tt>i1t �.. j5 8ipslusa(s) . ATE OF C 0'� WISCONSIN r. B ......_. T....Peterson i ox. S t . Croix an of ebeetie/ted wL ........dq .MBI'c , 1f..8.9 Personally came baton sa i ......tom.. .... ............ . ....... �e..,aCia... ..Pebxu�ary ................. .4... ».... t' ty abet Sam" a moi �. •....Kz�latixia ..Qgla�nd...irunsi en. T .. ......- El .....•.• ...... ........ ».......... TITLE: NEIIBER STATE BAR OF WISCONSIN . 8o8> �i.... Ruellzi,... J?oAtan ... P.R7.1.U'...,..,,,. . .... ...... P.VtAex ,Still ......................... ;; satbo by ;' �iie:oe. RiiL siai:.) ..................... _ #. . . ..... to me known to be the person §.......... who ogaesOsa tw TMIa INITIIYMaNT WAS D11AR[D By forftWne instrument and acknowiedp tbs ago& y i Kristina Ogland Lundeen ......... ............................... l!►�� F �i Ya nn /f1, .} . � .. . y . , ��+u be anUmmtbbd or adoowib�, sotto My Commission �'�tpsrm� T'G t • .state ..... Iis. Y !. )iMwrO .+ F. V.: • data: ....J 1f...aQ.) ' •isaw i! Pon" slaslsa to g -so* •A W N " M prkw 1dM isal atatsAS A ■xy W _ Ma il" i i l V RLED UAR$I IJ9 s act 4462'70 Ica, LOCATED IN PART OF THE SW} OF THE SWJ AND THE NWJ OF THE SWJ, ALL IN SECTION 29, T30N, R191 TOUN OF ST. JOSEPC, ST. CROIX COUNTY, WISCONSIN. Roger Ruelin JoAnn Persico Bruce Peterson 505 Galahad Rd. 131 -A Willow La. Rt. 3 Box 56 �•g6� ®�Q WJ CORNER North Hudson Wi. Hudson Wi. Hudson Wi. SECTION 29 54016 54016 54016 L a� T30N, R19W I=NY EN LEGEND 7 2 FOUND, ST. CROIX COUNTY SECTION CORNER MOPIUHENT• I HUDSON, ;� t o SET, 1" x 24" IRON PIPE WEIGHING 1.68 POUNDS PER LINEAR F00% �, 0 CURVE IDENTIFICATION NUMBER ��f unplatted lands owned by platter _ i -------------------------- - - - - -- / � is o w f- S89o00'22 "W 770.00' '— 382.69' 307.31' 80.0' 690.00' © / U O 5 C' N —` 167,368 sq. ft. (3.84 ac.)INCLUDING R/W o / U UJ 157,119 sq. ft. 0 _ C EXCLUDING R/W (3.61 ac.) = C) - o W O 2x7.02' 258.87' 545.89' �• °' c <r 33.07' 1 W W W 146,294 sq. ft• INCLUDING R/W \ am (3.36 ac.) S53 0 13 1 01 11 E, 100.00' 135,840 sq. ft. N53 R/W N53o13'O1 "'. 100.00' (3.12 ac.) 84.55' (8" " ` o N8 o00' 22 "E 18' ` o \ 306.89' 300.00' 15.45' Q� 51.29' 606.89' �.�'�• U � cr !1 — N south line of the` ,ti `'' +___ -- - -- o NW,J of the SW} \d° 6 167,830 sq. ft. (3.85 ac.)INCLUDING R /l'1 �\ 158, 667 sq. ft. (3.64 ac. )EXCLUDING R/W -�� .� �O\ LU N8000 11 E 665.77' o 0 631.13' 34.64' N �� 164,472 sq. ft. (3.79 ac.)INCLUDING R /t9 •A 155,811 sq. ft. (3.58 ac.)EXCLUDING R/W 785..96' 165.36 1 615.36' 1 . ` 34.64' N89 11 E 650.00' �() unplatted lands owned - by - platter \ A ° WVED 66 FOOT WIDE PRIVATE RCAD EASEMENT 0 0 o m MAP 71 1989 o •-+ o °' SCALE I 1 F E T � COM�E3�+s�� �atus PLnruv� 200 100 0 200 TSSECTION W CORNER 29 T30N, R19W this instrument drafted by Douglas Zahler job no..38 -17 Vol. 7 Page 2081