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HomeMy WebLinkAbout030-2078-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 499245 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: Sifferle, Victoria I St. Joseph, Town of 030 - 2078 -60 -000 CST BM Elev: Insp. BM Elev: T Description: Section ( rown /Range /Map No: CST BM Elev: Insp. BM Elev: t/✓� 1 C_ 5 C 33.30.19.663 TANK INFORMATION ELEVATION DATA rX TYPE MANUFACTURER S CAPACITY STATION BS HI FS ELEV. Septic Benchmark F 4DQ W utk -� FI r..� Alt. BM 1. Io5 r f 8 , Z F. ice. Col Aeration Bldg. Sewer Holding St/Ht Inlet , St/Ht Outlet K INFORMATION L. 5 1 `/ •'J TANK SETBACK TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet 7, y S e , Z,.. 3 Septic C3t- Bettom - 7. 5 . I ; i 173 rte O � Header /Man. *V . q L• L FI 7z5 Sid /5 �4 gz./ Aeration s e Dist. Pipe Holding Bot. System 4l . Z y/. PUMP /SIPHON INFORMATION Final Grade ' 94, Manufacturer Ge ^and St Cov ` J Z b s clq • / 5 Model Number —_.,_ — __.____.._ _.._ 5' 3 - TDH Lift Friction Loss System Head TDH Ft I / d __ V .'(.' Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length j No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 2 I FQ Z �rL��, SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR 1 2"a a C' Type Of System: 7 Z6 � �-- UNIT Model Number: CQ►��,� -�o 3 � a � DISTRIBUTION SYSTEM Header/Manifold q Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) \ \_ Length lE1 Dia I Length \ Dia \ Spacing \ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over / Depth Over xx Depth of xx Seeded /S dded j xx Mulched Bed/Trench Center 5 5 Bed /Trench Edges Topsoil Yes No \Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 582 Burr Oak Lane Hudson, WI 54016 (SW 1/4 SE 1/4 33 T30N R19W) Oak Knoll Lot 6 , , ^ Parcel No: 3 1.) Alt BM Description = C ► � Cd Ja.'_ e Z-- 2.) Bldg sewer length = , E j � • � 5 hGiM. �QT+d�l amount of cover Qt-- I Use revis Required? for additional in Yes ' No ' / 13 forma tion. ` W Date Insepctor's nature Cert. No. SBD -6710 (R.3(97) Safety and Buildings Division County J 201 W. Washington Ave., t 76 0 2 x 7162 C li t7 t scons Mir Madison, W1 5370 Sanitary Permit Number (to be filled in by Co.) i V (608) 266 -31 9 ? zyl S Department of Commerce — Plan I-D. N Sanitary Permit Application In accord with Comm 83.21, Wis. Aden. Code, personal information you provide cct Address (if different than mailing address} may be used for secondary purposes Privacy Law, sl 5.040)(m) o J SS 2 Q � cc cam.. �. I. Application Information — Please Print All Informatio �/ r/ arcel # 9 � Block # Property owner's Name S , .� NOV 0 9 2006 '/// C, 0 ] C-� -' 1 Pr operty on Property Owner's Mailing Address ST. CROIX COUNTY S 8a /' V ° + .!� .., Section J Ciry, State Zip Code Phone Number circl C- DI T a x2l II. a of Building (check all that apply) Subdivision Name CSM Number y P 1 or 2 Family Dwelling - Number of Bedr ooms ❑ public/Commercial - Describe Use !" a w f ❑City_ ❑Villag� owns of ❑State Owned - Describe Use i TII Type of Permit: (Check 013ft one box on line A. Complete line B if applicable) A. ❑ New System lacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System Date Issued B. [I permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List previous Permit Number and Before ExTiration Plumber Owner � � ^- IV. a of Po System: Check all that a ) r G on - Pressurized In- Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ssurized In- ound ❑ I Iolding Tank [] Peat Filter ❑ Aerobic Treatment Unit. Recirculating Sand Filter ❑ Recirculating ulating Synthetic Media Frlte g r hin Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain V. Dis ersayrreatment Area I ormation: Design Flow (gpd) / Design Soil APPlicati Rate(gpdsf) DisP �ea Required (sfl Dispersal Azea /posed (sf) S �` E�� ' Cap acity in Total Number o Manuuffac=r Prefab Site reel CCC Fiber T Plastic VI. Tank Info Concrete Constructed Glass Gallons Galllons of Units New wasting 14 _ 1 �✓ �� Tanks Tanks YJ Septic or Holding Tank o2`� .� j � <� Aatob= Treatment Unit Dosing Chamber VII. Responsibility Statement- T, the undersigned, assume responsib for installation of the POWTS shown on the attached plans Pl s Name (Print) Plumber's Signature MPIMPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) VIII. Coun /De artment Use Out Sanitary Permit Fee (includes Groundwater Date su Issuing ant Signs (N tam ) 4 Approved ❑ ' approv _ Surcharge Fee) N - ❑ van !lesson fo3 Henial C) � // /b y � DL Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1. Septic tank, effluent Mter and dispersal cell must all be es / ma)nta)nad as per management plan provided by plumber. 2. Ak setback requirements must be maintained as per applicable code / ordinances. i Attach complete plans (to the County only) for the system on paper not less than 81/7 x 11 inches in size SBD -6398 (R. 01/03) P I DDRESS PLAN ' PROJECT Victoria Sifferle 582 Burr Oak Hudson Wi 54016 SE 114 SE 1 /4s 33 /T 30 19 W TOWN St. Joseph COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 11/9/06 BEDROOM 4 CONVENTIONAL XXX IN- GROUND SSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 900 # of chambers 36 BENCHMARK V.R.P. Bottom of Walkout door ASSUME ELEVATION 100° Filter BEST Filter ❑ BOREHOLE O WELL - H.R.P. Same as Benchmark Plans Designed Using SYSTEM ELEVATION 90.3/90.2 4.5' be qrade @ B-2 Conventional Powts Manual Version 2.0 Vent > 6» ARC 36 Biodiffuser of Cover Leaching Chamber Burr Oak Scale is P = 40' with 25.0 ft2 of Area unless otherwise 5' Long 1111 noted 3 6 „ Grade at System Elevation W 1 55' 200' Please note: ST is under the deck, has a Existing 4 horizontal access and a vertical clearance of Bedroom House 3'.Tank is able to be maintained from the manhole opening B. M. 20' 40' 30' 15' Old System has failed nd is backing up in T Ouse Vent 18' X 48' Bed \u� Please note: 20' v35' a valve will be installed if possible! >50' to 15' ST Filter Tank property line 45' 45' 15' B -1 Vents 20' 2 -3' X 90' Cells with >3' Spacing % Slope ' Property Line P T PLAN PROJECT Victoria Sifferle DDRESS 582 Burr Oak Hudson Wi 54016 SE 1/4 SE 1 14S 33 /T 30 19 W TOWN St. Joseph COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 11/9/06 BEDROOM 4 CONVENTIONAL )00C IN- GROUND *SURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 900 # of chambers 36 BENCHMARK V.R.P. Bottom of Walkout door ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL * H. R. P. Same as Benchmark SYSTEM ELEVATION 90.3/90.2 4.5' below grade @ B -2 Plans Designed Using Conventional Powts Vent Manual Version 2.0 jLong ARC 36 Biodiffuser Leaching Chamber Burr Oak Scale is 1 = 40' with 25.0 ft2 of Area unless otherwise noted 3 6 „ Grade at System Elevation well 5' 200' Please note: ST is under the deck, has a Existing 4 horizontal access and a vertical clearance of Bedroom House 3'.Tank is able to be maintained from the manhole opening B.M. 20' 40' 30' 15' Old System has failed and is backing up in T house Vent 18' X 48' Bed Please note: 20' 35' a valve will be installed if possible! >50' to 15 , ST Filter Tank property line 45' 45' 15 ' B -1 B -2 Vents 20' 2 -3' X 90' Cells with >3' Spacing B -3 % Slope Property Line RECEIVED Wisconsin Department of Con mer* 0 V 0 9 2006 SO VA T N SPORT Page of Division of Safety and Building in accordance with C m 85, I . dm. C ST. CROIX COUNTY County t Attach complete site plan paper not less than 8 1/2 x 11 inc es in size. Plan mu include, but not limited to: v t (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 030 - 2- 7 Please print all information. Review by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 1;71616 Property Owner Property Location Govt. Lot 5 1/4 1 5 14 /4 S ?T N R E (or W Property Owners Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ City C3 Village Town Nearest Road C W it ) s, t u d ❑ New Construction Us <, / Number of bedrooms Code derived design flow rate 0%�C 1n` GPD *eplacement El Pub or commercial - Describe: Parent material ��LLf dT c�a�' Flood Plain elevation if applicable General and recommendations: Y • (��( »mac/ f r O' 2 System Type f� f t7/yur' 'J System Elevation F-11 Boring # Boring L J a Pit Ground surface elev` �7 ft. Depth to limiting factor /—�4 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 ca viz ` z' 't'— -$ 2 0-60 ` _,4 1, i 0 [' o 1 ,I a t t) 7 n; a Boring # ❑Boring � '_.Z.� ® pit Ground surface elev. ft. Depth to limiting factor /o` o 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 3/ L 6 p t 5 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 1 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Sig a CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address 61 Date.Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 �� 715 - 246 -4516 i Property Owner _ Parcel ID # Page of ❑ Boring # p ❑p77 Boring �``] !L1 Pit Ground surface elev. (J ` 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 0 *0#2 M , / a t( l l Z- F—I Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure ' Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 Boring # E] Boring F ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon ')epth 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 1150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 130 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. SOD -9330 (R6/00) l Property Owner _ Parcel 1D # Page of Boring # ] Boring �^ M Pit Ground surface elev. J ft. Depth to limiting factor in. S A ate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff#2 M fl l l Z- F-1 Boring # Q Borin ❑ pit Ground surface elev. R Depth to limiting factor )n• Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 F-1 Boring # ❑Boring ❑Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon ')epth Dominant Color Redox Description- Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efl#1 'Eff#2 Effluent #1 = BOD, > 30 1220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BOD, < 30 mgil. 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. SOD -8330 (8.600) Soil Test Plot Pl Project Name Victoria Sifferle un Bird Address 582 Burr Oak Hudson Wi 54016 TM #226900 Lot 6 Subdivision Oak Knoll p e 11/9/06 SE 1/4 SE 1/43 33 T 30 N /R W Township St. Joseph Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Walkout doorsill System Elevation 90.3/90.2 *HRpSame as Benchmark Burr Oak Scale is 1" = 40' Well unless otherwise 5, 200' noted Please note: ST is under the deck, has a Existing 4 horizontal access and a vertical clearance of Bedroom House 3'.Tank is able to be maintained from the manhole opening 4 B.M. 20 40' 30' 15' Old System has failed and is backing up in T house Vent 18' X 48' Bed 35' >50' to 15' property line 45' 45' B -1 B -2 20' B -3 r �s 3 %� slope 9 Property Line i ST_ CROIX COUNTY ZONING OFFICE CERTIF ICATION 5TWT2PMT FOR UT:LI2ATION OF AN EXISTING SEPTIC TANK This is to C*rtify that have inspected the septic tank presently serving the LLXi 'J residence locat e4l at: _'.f, 5 �„ w , at . Croix Sec. 3 �, T 3 0 * R�_ 40 r Town vz t� S County, Wisconsin. t2pcn inspection. I certify that I have found tho tank and baffles to be in good condttiou, and it appears to be f=oti.oning properly. :set tiMe stxviced o,/ [ s 4 2 0-0 (0 Did flow back occur from absorption system? Yes No (if no, skip next line, gallons sc►isstttee Approximate volume or length of time: 4 _____.... Capacity: ! a sv C=ztzuc Pr afab Concrete -X__.._ Steel _Other Manufacturer (it 3aw,,*m) : Age of TAMk (if known) c (5 lure ;Name please Print �f le-,2- 6 T T t 1eF�� _ L sense Sumter Date) Foam to be cm*jeted by 1icenBed plumber (a. 145.06, Wisconsin Statutes) or licensed disperser (NR 113 'Wisconsin Administrative Code) plumber (applying for sanitary. permit) Certification: in accepting the ab*V* atarVnenl- xsgardiug exi:etiag ptic task ogrtdiCion, Y certify that the tank, to the best of my knew , will Conform to the requIrements of TLHR 63, •his_ Adm. Code (except o inspection opening over outlet baffle). S ignature r�21MPRs ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer () � C 6 �L \ Mailing Address 11 � Dd �` �(1j 1 `� Property Address (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number a . D - 7 _6 v V vv LEGAL DESCRIPTION 1 1 /a S � O N R_L_�_.W, Town of Property Location � /a , Sec. , T `� , Subdivision Oct– f�- � i Lot # Certified Survey Map # J , Volume — , Page # Warranty Deed # �/ � —� � � ,Volume A ,Page # Spec house yes no Lot lines identifiable es no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Gomm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the prope .} described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATLft OF APPLICANT(S) DATE * ** Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan Option #1. If system fails, determine cause of failure, use alternate area and install new system in tested replacement area. Option #2. stall system at a lower elevation, by removing chambers, removing biomat, an install new system. Option#f3. No adequate area is suitable for replacement area, and system elevation cannont be lowered. Install holding lank as last resort. 3. Replace any other failing components as needed. Plumber: Shaun Bird 715- 246 -4516 St. Croix County Zoning 715 - 386 -4680 Pumper Tom Mondor 715- 246 -5148 Shaun Bird #226900 Z•d d09 :90 l0 to qed 8 1 58 STATE B lk K AR OF WISCONSIN FORM 3 - 1998 I,+ KATHLEEN H. WALSH QUIT CLAIM DEED REGISTER OF DEEDS �i ST. CROIX CO.. MI ----- ent Number - — RECEIVED FOR RECORD s This Deed, made between � ��IM� �j 01/06/2006 12:20PH QUIT CLAIM DEED I� EXEFPT # 8M ii Grantor, REC FEE: 11.00 and ;j TRANS F FE Y 1C�_ �11� lyt� 1C �! CC FEE: i -- -- PAGES: 1 I� Grantee. J, Grantor quit claims to Grantee the following described real estate in �4 County, State of Wisconsin: Record,rig Area !, Name Return Address Address I I v �► 'e l� + ©nk 1`� vi b j Md lvwn-, Q Q / 5e6 n (CY) b Parcel Identification number (PIN) j This homestead property. �I (is) (is not) 4� I i I I I Together with all appurtenant rights, title and interests. �! Dated this im day of ii -- 1( E U • -S lF�'ER.L�,_ (SEAL) (SEAL) (SEAL) (SEAL) { l I i II AUTHENTICATION ACKNOWLEDGMENT it Signature(s) -- - State of Wisconsin, County. authenticated this day of Perso ily came before me this day of I� Y 1 �G the above named i. i TITLE: MEMBER STATE BAR OF WISCONSIN to I (If not, me known to be the person S who execut ore going j ( ! j authorized by § 706.06, Wis. Slats.) instrument and acknowledge the same. r THIS INSTRUMENT WAS DRAFTED SY I ," , N aruaaaiug M /J / at I Not State of n vt My tt Q{j�sfart'f A Re (If not. sbaW- •e'xpiretion dater R (Signatures may be authenticated or acknowledged. Both are not j necessary) I , Names of persons signing In any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wni;onsm Le" &ank Go., k.c. II QUIT CLAIM DEED FORM No. 3 - 1998 Miwaukee, wis i� p zo 200 100 ..�. - -- 0 iO4 NOTE ALL LINEAR MEASUREMENTS HAVE BEEN MADE 5 - 6 S . 72` S89 r TO THE NEAREST ONE HUNDREDTH OF A FOOT, ALL 3I,7Z ANGULAR MEASUREMENTS HAVE BEEN MADE TO THE NEAREST MINUTE AND COMPUTED TO SECONDS. (D � r O 3 • , \ 7 -8 a I� t . \ � • ' • r�� �' �J ��, u ARTHUR L. WEGER R.L .S. N0. S - 96 3 DATED THIS Z DAY O 1"�-- 19 7 5 , ' � Ir �rrnrrHry q a ° 0 Ns�'''.,,, '•. .- �.• :�' -. ' • ARTHUR L C WEGERER 5.9.53 ELLSWORTH • \ WIS. G' \ ''� 4 o 1cp \ x . � -to r ` 1 , to Lo co 6 ' a 040 E M UNPLA O N ......... .h W LAND w �.,. .......... 0 7 (ao _% 0 %. 0 v B , in 420.00' 288.22' COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 800 - 962 - 5227 FAX - 715 - 962 4030 E I f ST, CROIX ZONING REPORT NO.: 38726/41 PAGE 1 5T, CROIX COUNTY REPORT T DATE#' 3/29/93 C"THWSE DATE RECEIVED: 3/25/93 HUDSON, WI 54016 ATTN#' THOMAS C. NELSON .r OtiNEfi: Mark Grossman i LOCATION#' 58? Burr Oak, Hudson i COLLECTOR: M. Jenkins DATE COLLECTED#' 3 -24-93 i' TIME COLLECTED: 2:30pm "SOURCE OF SAMPLE. Outside faucet "r DATE ANALYZED:3-25 -93 TIME ANALYZED #'2 #'00pm COLIFORM: 4 /100 ml INTERPRETATION#' Bacteriologically SAFE Coliform Bacteria /100 mi � 0 LAB TECHNICIAN#' Pam Gane �y ICI Approved Lab No. 19 fi �•1NPEPIN &ENT , C Means "LESS THAN" Detectable Level Approved by'* ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 i Pd4937- a / q- ST. CROIX COUNTY ZONING OFFICE 911 4th Street Hudson, WI 54016 Telephone - (715)386 -4680 The St. Croix Co: Zoning Office offers the service of septic and water inspection to Lending institution, Realty Firms, and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING -------------------------------- FEE:$ 85.(7}__ (For nitrates and coliform bacteria) WATER TESTING ------------------------------- FEE: $ (VOC'S) SEPTIC SYSTEM INSPECTION --------------------- FEE:$ 25.00 � ~ PROPERTY OWNERS PROPERTY OWNERS ADDRESS A94 / /C ITY : &[ a.1CLr1A-y Legal Description _1 /4 , 1/4, Sec. , T N -R W, Town of Subdivision —'— ,Lot No. 42 Subdivision FIRE NO. C J LOCK - BOX NO. Color of house Realty sign FA PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e.,, COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. -If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual request in services : 7� ��f; / f ;U44Z Telephone No. 523 F7 REPORT TO BE SENT TO :� w CLOSING DATE: signature• COMMERCIAL TESTING LABORATORY, INC. ' 514 4n Street, P.O. Box 526 Colfax, Wisconsin 54730 715 - 962 -3121 800 - 962 - 5227 I FAX - 715 - 962 - 4030 i j ST. CROIX ZONING REPORT NO.. 39'223/01 PAGE 1 5T. CROIX COUNTY REPORT DATE: 4/09/93 COURTHOUSE DATE RECEIVED: 4/06/93 HUDSON, WI 5 016 ATTN. THOMAS C. NELSON OWNER. Mark Grossman LOCATION, 582 Run OLd, Hudson COLLECTOR. M. Jenkins DATE COLLECTED. 4- -03 -93 TIME COLLECTED; 3.00pn SOURCE OF SAMPLE. Outside faucet NITRATE -N. 2 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Nitrate - Nitrogen, mg /L � 10 9 .4 tb LAB TECHNICIAN. Pam Gary r ` �2 C,� WI Approved Lab No. 19 co �h .0 0 ' .NDEDEN � F hr 4 VZ(r 1 !n �® f Means "LESS THAN" Detectable Level Approved by. PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY ZONING OFFICE 911 4th Street Hudson, WI 54016 Telephone - (715)386 -4680 The St. Croix Co: Zoning Office offers the service of septic and water inspection to Lending Institution, Realty Firms, and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. t WATER TESTING----------- --------------------- � FEE : $ 85 . tI0 � (For nitrates and coliform bacteria) WATER TESTING --- --------------------------- FEE:$185.00 (VOC'S) SE1'TIC SYSTEM INSPECTION --------------------- FEE:$ 25.00 PROPERTY OWNERS NAM: PROPERTY OWNERS ADDRESS _ > a_ �,n1�C : Legal Description 1/4, 1/4, Sec.' , T N -R �tW, Town of _ ,Lot No. ,Su di ison �' — c FIR d 30 2f� /_' (o 3 624 E NO. ' �� LOCK BOX NO. G- ! Color of house Realty sign ? Y;a2 Firm: I PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e., COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. I WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. -If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requestin services Telephone No. REPORT TO BE SENT TO: w CLOSING DATE: Signature: 'I I ST. CROIX COUNTY ~ WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386 -4680 I March 25, 1993 Sharon Raley Edina Realty 700 - 2nd St. Hudson, WI 54016 Dear Ms. Raley: An inspection of the septic system on the property of Mark Grossman, located at 582 Burr Oak, Hudson, WI was conducted on Mar. 24, 1993. At the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon, as we receive them back from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Should you have any questions, please contact his office. S'ncerely, , Q S Mary J. Jenkins Assistant Zoning Administrator cj :. 3 � d cn i z w z oN W N ,7' 3 0 - nJ A a, O r%) 0-0 Q^ z a= ti O ► fD ro O a W W 41 W �'.' 3 O T_ et 3 O K � � L OD O co CD w La W 3 Q O O O N O NO • CD cn CO OD c 3 W W.,. 0 • Or o o w Q M O d O (D N r h "O W O C J CD y ZWZ O D a z O, o' CD • W Z_'+ N N W Ci _ r( c ro m w m a n 3 Z 7 p z W 0 7 A z 7 n�i a G7 o 1 OD w w a z 3 3 r" m ° m n � c 7- 3 (D- 7 T 43v v c x �cn oZ �d f O l< W Qo CD m W L U1 7 O Sl fi ch O N N CL 'I N n O W fQ i a CD in 6 CD Op � W O CL '� Parcel #: 030 - 2078 -60 -000 03/24/2005 10:44 AM PAGE I OF 1 Alt. Parcel #: 33.30.19.663 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner VICTORIA P SIFFERLE SIFFERLE, VICTORIA P 582 BURR OAK LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 582 BURR OAK LA SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.760 Plat: 2234 -OAK KNOLL ADD SEC 33 T30N R19W OAK KNOLL ADD LOT 6 Block/Condo Bldg: LOT 6 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 33- 30N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 1004/231 WD 07/23/1997 877/610 07/23/1997 8661239 07/2311997 759/182 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 6373 224,900 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.760 66,200 155,100 221,300 NO Totals for 2004: General Property 1.760 66,200 155,100 221,300 Woodland 0.000 0 0 Totals for 2003: General Property 1.760 38,900 128,900 167,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 121 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 f ' • AS BUILT SANITARY SYSTEM REPORT ;�dNER , TOWNSHIP 'SEC. 5 T N, R 1Q W °.0. RE , ST. CROIX COUNT WISCONSIN. UBDIVISION , LOT! LOT SIZE 1/9 ctc .^fi w 4P PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYST ' 5'0 , Zo 3c e zo L d t > PTIC TANKS) /z,�' MFGR. - f CONCRETE / STEEL �f NO. of rings on cove Dept ?� DRY WELL "'ENCHES NO. of width length area =D no. of line width /7 length ,S' area r. 2 . depth to top of pipe } �, o s�REGATE _3 IRK RATE AREA ROUIRED =off � AREA AS BUILT T, sciaimer; The inspection of this system by St. Croix County does not imply complete mpliance. with State Administrative Codes. There are other areas that it is not possible =t inspect at this point of construction. St. Croix County assumes no liability for ystem operation. However, if failure is noted the County will make every effort to termine cause of failure. '.EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. 'INSPECTOR _ I i DATED A) 17 13 PLUMBER ON JOB LICENSE NUDE v REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM San.itaky Peam.it -' V f State Septic 75 NAME c��a�0 - c3 ���� �� — T owns h.i p �a` St. Ctco.ix Coun Locat.ion % ob %, Section 7 -= T3-K, R/? W SEPTIC TANK Size ga tonz. Numbers 96 Compattmentz Distance F&om: Wet t___ 1.2% ox gneatek ztope jt Bu.itding / ix. Wet.Cands t. Highwatett _ it. DISPOSAL SYSTEM Distance F,%om: Wett 12% on gneate stope Bu.itd.ing _: p it. wet.2and.6 - F t. H.ighwa.te& it. FIELD DIMENSIONS: Width 06 tte eneh � �� St. Depth o5 noeh be.L'ow tite t� .in. Length o6 each tine it. Depth o6 tock oven t.ite .i n. Numbetc, o6 tineb Depth of x.ite below grade �e lin. Tota.2 .length of tine, - =' � ��. Stope o6 ttceneh in pets 100 it. Distance between tines it. Depth to bedtcock Totat ab.bo&bt.ian a&ea _ jt Depth to gnoundwatetc it. Requi&ed ateea it PIT DIMENSIONS: Numbers. o6 p.it.s r G&avet aAound pith yeb no ,a Outside d.iamete� t Depth below .inlet it. 2 Totat ab n a ea it z a Area equ.itee it rn r I INSPECTED, ' TITLE ' v� APPROVED DATE 197 REJECTED ,DATE 197 t t EH 115 AMP WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS / LOCATION: _54_5 '/a, T,6_ %4, Section _U, T312N, R I? Wor V Township or Municipality ,,�`��`t g.5 —r Lot No. 69" Block No. —, �E} !C �a D/� County „�. Subdivision Name Owner's Name: Mailing Address: Ave. 20`, 4/ M• Ae•_e, SSZ_ 0 5� TYPE OF OCCUPANCY: Residence X No. of Bedrooms _ - Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS — SOIL MAP SHEET — SOIL TYPE " QAA* A-I d - lei PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P - .2 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B _ / 6 " our' 7F6 N �.Sf cgs 7 2 ?16 - " �3 rPd B-3 9 AitrccC. - 174� /,"-tS, 24- J / � „ /4 e S 7 66 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indi to nrm of square feet of absorption area needed for building type and occupancy. �l� �' "" G[ <'' - �r f a � AhM AL, in icate scale or distances. Give horizontal and vertical ref r nc of . Indicate slope. Apr 4 is X � � t N �O r .. �j 6y G a? - SA f Cis 1 h i 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and bell Name (print) Certification No. Address Was sjn6O Name of installer if known CST Signatur COPY A — LOCAL AUTHORITY PL,B67 State and County State Permit # Permit Application County Permi for Private Domestic Sewage Systems County * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY ailin Address: B. LOCATIO Section 33, T.jO N, R & (or) — Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township , C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family X Duplex No. of Bedrooms No. of Person D. TYPE OF APPLIANCES: Dishwasher ­ 2< , YES NO Food Waste Grinder _ YES k NO # of Bathrooms_? — Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY ap Q Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation X Addition_ Replacement, Prefab Concrete X *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / 2) 3) / Total Absorb Area sJ�. ft. / NewA Addition Replacement *Fill System 8 . " 40 /Yd Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length 415�� Width V" Depth Tile Depth 3F� " No. of Lines 3 Seepage Pit: Inside diame r Liqr id Depth Tile Size N Percent slope of land Distance from critical slope - 70'* 1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Ce ified Soil st // NAME A. ;M C.S.T f 9 and other information obtained from er- � owner ). Plumber's Signature MP /MPRSW # /Q3 Phone # 7�f 86`.36� 3 Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). ~ • Pd1✓/ ti ebr .�- t • AG v e Irkt y C r x / . O z� led �R98' z Do Not Write in Spa Below OR DEPARTMENT USE ONLY /7 Q Date of Application - ` Fees Paid: State , 0 0 Count Date ( Permit Issued /RQ tl-- (date) r1 C -7 S Issuing Agent Name Inspection Yes:_XNo Valid# Date Rec'd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 ' 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 s � _+ � r � � 3 � � N ` . i TM. I I 1 0 I :. _ � _- ; _ � • �. . ,� ,� f �c� , f �� '� i ' �, - - - -- � TRANSFER FORM SANITARY PERMIT PLB 6 State Permit # Sanitary in� #k Ul0 l County Sanitary Permit Transfer Date 4 9 3 —7 o Original Permit Issuance Date _ A. Property Location: %. Sectio T j5 *jvr) W Lot # _ City Subdivision Name, Nearest Road, Lake or Landmark BLK # Village Townsh i B. TYPE of Occupancy:. mmercial Industrial Other (Specify) Single Family Alex No. of Bedrooms Variance C. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks - .4 -- ,Prefab Concrete Poured -in -place Steel Fiberglass Other(Specify) New Installation Replacement LIFT PUMP TANK /SIPHON CHAMBER" Total gallons Prefab Concrete Poured -in -place — Other(Specify) D. EFFLUENT DISPOSAL SYSTEM: Percolation Rate ""' Total Absorb Area sq. ft. New ✓ Replacement Altemate(Specify) Seepage Trench : � /, No.Lineal Ft. Wiidth�A —Depth Tile Depth(top) No.'Trenches Seepage Bed: A� Length Width � �'�, Depth�Tile Depth(top) ': 7�) No. of Lines Seepage Pit: nsid diameter Liquid Depth No. Seepage Pits Percent slope of land grs Distance from critical slope .� E. WATER SUPPLY: Private ❑ Joint ❑ Community ❑ Municipal Present Sanitary Permit Holder Phone No. Sanitary Permit Transferred To: Phone No. Name / I Name _� `� Address L Addres p� —is . zi p 3 �b zip m 1, the undersigned, do hereby certify that I have reported all revisions to the sanitary permit and that all revisions are in accord with section H 62.20., Wisconsin Administrative Code and that I have sized the effluent disposal system according to the EH -115 prepared by the Certified Soil Tester and /or any additional soil tests that may have been required. Plumber's Signature MP /MPRSW # Sy Phone Plumber's Address Oe Information obtained from (owner or agent) PLAN VIEW: Provide sketch below of any revisions to original sanitary permit. Include direction of slope and all distances in accord with H 62.20. Well location shall be included on the sketch. Indicate or dimension location of all wells, on the property or neigh- bor's ro ert . 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