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P P� » 8 8 CL 8 C) � % Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 430131 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: Lutterman, Bill & Debbie I Troy Township 040 - 1218 -80 -000 CST BM Elev: Insp. BM Elev: BM Description Section/Town /Range/Map No: / Cc 08.28.19.1059 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing tic/ Alt. BM Aeration — Bldg. Sewer v' �}- . _ Holding S t Inle S t Outlet TANK SETBACK INFORMATION Sc 4 — ( . 31 • �5 TANK TO P/L WELL BLDG. Vent to it Intake ROAD Dt Inlet Septic ` %�� Dt Bottom / lJ Dosi , I Header /M n. "� Aeration Dist. Pipe 2 b q3' Holding Bot. System 2 Z. PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover / . p II 7 Model Nu r — C, t� D TDH Lift Fri ' n I asb` System Head TDH Ft r Forcemain Le Dia. Dist. to Well SOIL ABSORPTION SYSTEM/ Z 4 / / �/ BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 7 / SETBACK SYSTEM TO P/L k5 BLDG WELL LAKE /STREAM LEACHING Manufactur r — I ' INFORMATION �� CHAMBER OR r, C� TL ,,6-A m: 3 V �� / UNIT Model Number: DISTRIBUTION SY M p� d 1 0—,` Header /Mani>old IDistribution Hole Size x Hole Spacing Vent to Air I ke It Pipe + s) 6 / �/ L _ Length Dia Spacing_ I SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over [ Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil X Yes No _I Yes COMMENT (Include code discrepencies, persons present, etc.) Inspection #1:�/ 3 3 Inspection #2: Location: 424 Red Brick Road Hudson WI 54016 ( NW 1/4 NW 1/4 8 T28N R19W Clearview Addn. Lot 6 Parcel No: 08.28.19.1059 1.) Alt BM Description = Ste' C JiiS4 Cie d Cw. � 2.) Bldg sewer length = .pil(�l`j'r7`� -L - amount of cover = Plan revision Required? j Yes Use other side for additional information. / S � SBD -6710 (R.3/97) Date Insepctor's Sig ture Cert. No. - ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner,,. _v /�� Q�� ►JOE LU7�7�'�/�/t'lr�� ,34 " 067 ,6 City /State Legal Description: [lot t P Block Subdivision/0 Cllr ' 017 AJ /T pL, Sec , T N -R W, Town of _ 'rR PIN # 0 yo ' /ZW g - ( ?6 •Q`Z SEP TIC TANK -- DOSE CHAMBER -- BOLDING TANK INFORMATION: � /05 Nt W s•T. "7.S a W . Tank manufacturer 60/ &SEk Size ST/PC.. Setback from: Hous Well ff5 P S Pump manufacturer Model . Alarm location (IIOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SYS7t I )PA 50.44" /2 -x Si SO IL ABSURI' PION SYSTEM lp e Tyne of system: Width 3 Length ?S Number of Trenches Setback from: House WelI P/L Vent to fresh air intake > $O ' ELEVATIONS To P (Veil c /oa •� Descri of benchmark Elevation Description of alternate benchmark Fell 'OF 01,0 5 .7 - • /gluts • Elevations Building Sewer ST/HT Inlet ST Outlet PC Inlet N &W ,vet, PC Bottom Header /Manifold Top of ST /PC Manhole Cover Distribution Lines P- 44 7— 7 1: (t4 Bottom of System( ) ( ) ( ) Final Grade ( ) ( ) ( ) NIA---- Date of installation / / Permit number State plan number Plumber's signature License number -1243-)_5 Date -3 Inspector r ! n� ORIGINAL Complete plot plan GD l�A 111f'N7 i> SS 72 CO C � 1�l 41+5 G &FT" /.v 7.40 ' 145 IN4 % v L�r :' ��l i �i� ZVX_t2. L4FT /w / l we at , I A CIE,Aa0T `` wr9-S W SIAII&W 4 - rip of av� ' G• 501 Izf 41 �l A < I I � 9z `, I it I � d I, I I , I _ .. I L o t d J m z c Q rn x (� (AN� OD n o -p J � <co N CD o m o °� n m M D it \ C37 M - 0 co J mMm c d c� ( a) M K 1I ld p Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430131 0 GENERAL INFORMAVON (ATTACH TO PERMIT) State Plan ID No: Personal information you provide 4rlay be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Lutterman, Bill & Debbie Troy Township 040 - 1218 -80 -000 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown /Range /Map No: 08.28.19.1059 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet SVHt Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil g p �] Yes !—] No [_] Yes n ]No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 424 Red Brick Road Hudson, WI 54016 (NW 1/4 NW 1/4 8 T28N R1 9W) Clearview Addn. Lot 6 Parcel No: 08.28.19.1059 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required ?i Yes ', No Use other side for additional in nformation. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. Safety and Buildings Division County Sf X M 201 W. Washington Ave., P.O. Box 7162 MW Madison, WI 53707 - 7 Site Address n _O Department of Commerce Sanitary Permit Application Sa ta Permit Number !!�� In accord with Comm 83.21, Wis. Adm. Code, personal inform yat provido °; Check if Ii4esd�pli V / may used for secondary purposes Privac w sl } I. Application Information - Please Print All Information State Plan I.D. Number N /.d Property Owner's Name Parcel Number J/ �tb - /;../P0 T o - e Prop Owner's Mailing Address -t t` Pro R N rty Location i / I � � .... ...- ._. 14 54• S T N, R 4k 7 City, State Zip Code Phone Number Lot Number Block Number /f V,PJ0) �/ s , . S 091(e ✓ _ ~ Subdivision Name CSM Number O C 7 C / &-V H. Type of Building (check all that apply) ✓ n ❑City 4`1 or 2 Family Dwelling -Number of Bedrooms S� Y� ❑Village ❑ Public /Commercial - Describe Use ❑ State Owned �owttship 7��y Nearest Road 80?tek ;u III. Type of Permit: (Ch on line A (numbering scheme for internal use). Complete line B if applicable) A. 1 ❑ New 1 System 3 ❑ Replacement of FEExisting Addition to For County use S st Tank Only S s tem B. Check if Sanitary Permit Previously Issued Permit Number ued q aaST im IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44 )( - Pressur In- Gro und 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unij 49 ❑ Recirculating 30 ❑ Other V. Dis ersal/Treatment Area Information: /./ S n Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min./Inch) q2X_ Elevation jo n / / •vs 9Z � ,sue 7 r 10 14 vs VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 50 ie-ftf� /750 2— 4j1 � �( Dosing Chamber V ��/ •J ,n I ',, �\ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum is Signature /MFRS Number C Business Phone Number (� Plumber's Address (Street, City, State, Zip Code) +&ze -s 7G 7 VIEVCounty /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued su' gent Signs o Stamps) Surcharge Fee) ❑ Owner Given Initial Adverse Determination Conditions of Approval/Reasons for Disap rova ��j,��� _��,g�-- - t 8( (R. Plete (to the ) the on not less than 81/2 s 11 in alze 05101) _ P . M-B1110-I1 & ASSOCIATES CO. 655 O'Neil Road • Hudson, WI 54016 Reg..ves gne►s of Engrneerh,g systems 715- 3136 -51 85 Privale Sewage consvllanls PROJECT INDEX / G PLAN ID # /V /j¢""� DATE Z7 _ OWNER n / 33/ 1 PHONE A DDR E s s yZ y �' l3iPi'C /�� • Up�S'o -�.� S yo/ LE GAL D ESCRI PT ION TOWN OF r;eOY �S� • t�cO r JC COUNTY Cs'rM iP Zr /6i 7` 2Z�i 3 ?S LOCAL AU'TIIORITY/ SUPERVISION S -4dI X Zd.V ., A.) G- i9 1 o G.A_ PROJEC DESCRIPTION: -- Z / N� ) S 7 _' . 13Ws `a W4 - s>r.e r w . ti 77 rlWtV MP RS THIS POWT SYSTEM SMALL RDQ 1� .� INCORPORATE PER COMM. 1 ` 83.44(2)c A PROPER ZABEL Ulbricht & Associates FILTER MODEL # . Private Sewage Consultants 2812 10th Ave. Spring Valle 1 54767 p , g Y 2 . 1 1 f3i oDi' � frts' �2 Pg.l SIZING WORKSHEET P9.2 SYSTEM PLOT PLAN Pg.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. Pg . 4 r' n rr to we rr 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. III b 11 A y N AV w 1 0 Mill n x W 1 O o 1 I _ --o ANC nl / I I f1t ja J IO ;�� Io 1�O ; I � I I 1 I ! J I•.- -- - - -- _.. 4 -_ fill I � °l I ! , -4� ca � o l5z� � � y wo= rn m o o mo m D * c Dm �o � v� M \ m o m e 2 Nncn I� � 03 17 c k, • � � C�lcv��17ED O jA V l-,07r Iff r &M S o CI O SS SEC T10 A) W544) 6 13 i oDI'1� 5S4!� CA 3 v i c/S/1 EC T/o c.) 1 4,,A_e Iff 9� , q3 ° 1 y z TAM OVER: See Reverse Side for Vent/ Observation Pipe Details. An observation pipe may serve as a combination observation/vent pipe providing it terminates in ` the same manner as required for vent pipes. See Figure 6. Vent cap Roblin bend Cap , IFII 12" min. •� 12" mill. Filial grade Aggregate istribution lateral r b typ M►• ~'- System elevation Figure 6— Vent and combination observation/vent pipes Leaching chamber tops are at or below the original grade. Leaching chambers are lace irectly on the bottom of the distribution cell. The locations of leaching chambers are in accord nce with Table 3 of this manual. Observation pipes are installed in the distribution cells and are provided with a means of anchoring to prevent them from being lifted up. Observation pipes extend from the infiltrative surface for stone aggregate systems or from the inside of leaching chambers to a point at or above finish grade. The portion of the observation pipe below the distribution pipe for stone aggregate systems is slotted while the portion above the distribution pipe is solid wall. Observation pipes for leaching chamber systems are attached to the chambers in accordance with the chamber manufacturer's printed instructions, extend from a distance >— 4inches above the infiltrative surface through the top of the leaching chamber up to or above fmish grade and terminate with a removable watertight dap. All observation piping has a nominal pipe size of 4 inches. See Figure 5. j . Water tight cap ,�- 4" min. dia. �� Top of leaching Repair couplings chamber.._ Slot r 1 � ` 6" min. 6.. mill. Infiltrative surface 4" min. Water Closet Collar Bar (11" min. dia.) Figure 5 - Observation pipes Vent pipes, if installed, connect to the upper r half pp of the gravity flow distribution laterals and extend tip to at least 12 inches above finish grade. Vent pipes terminate with the vent opening facing downward by the means of a vent cap or fittings. Vent caps must allow a free flow of air between the distribution lateral and the atmosphere. All vent pipes has a nominal pipe size of 4 inches. f u u 7CU O jA AN/. iff 1 - c 7 3- CRo SS Sk c Tio v o 21.5�'U R OWNER's MAINTAINCE OF SEPTIC SYSTEM ~? ^ r POWTS (landowner) is reponsible for proper operation and maintenance of this system. servicing Regular periodic inspections and is necessary for the safe healthy operation of. this syste:a. Tile owner is required by code to submit all necessary maintenance /inspection reports to the controlling authorities. SPECIFIC CONTACT AGENTS * Governmental authority/ inspectors: ST elf 01 )( Cry. 3�� • yG�l� 7- uJviv G- ��P T • . * Licensed installer, responsible for maintenance "Users" manual: Providing an operation/ � Licensed serv�ce / inspection agent other than installer: 7`Y PV1g Au &-- (!;d . ? 0 * Electrician for pump, electric controls, wiring units: IMPORTANT OWNER MAINTENANCE REQUIREMENTS i• Winter traffic (sledding area shall not be ' 8110veting, etc.) across the or frost c the cell, freezingpupmtheesystem. Discontinuos useeInatheinto winter (a vaeactlon trip, resulting in no water use) can also lead to freeze ups. Z• Water conservation needs to be exercised! Or system can be hydrolical.l.y overloaded and destroyed. This system was designed for a maximum wastewater flow of ']s 0 gals. daily. 3. POWTS are not designed to accomodate wastes from a garbage. .• disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. '!• If a power b►ttage occurs, or a pump ,fails, it may result I" a temporary overload of effluent being pumped into the cell, which may adversely impact the cell (leakkge). It is recommended that a licensed pumper empty the dosing tank, • t ailowing the pump to return to do sing the Consult your installer immediately for advicerect amounts. 5 . Neglect of the vegetative cover erosion preventive) can lead to failureells insulation & traffic also can destroy t lie system. m REGULARLY WA'T'ER T11E VEGETATION OVER A It ISECF,SSARY Tp SYSTEM! ! Effluent in alone to maintain a {;he system beneath IS NOT sufficient crass cover. 6. Periodic inspections by the owner, or his agents necessary. Inspection i Pipes and ports have been incorporated lnto the system: on the mound basal area Inspection pipes), cleanout terminals on thef T level laterals, at each ti pressurized out. p - for flushing and cleaning the laterals '1'lle filter system in the tanks ground cover /manllol)• onl .e (via a locked above Person should be y a licensed properly quali6led & severe performing this work which involves health safety risks. Evidence of effluent system's treatment cell shall also be regulard lyInspected. Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ` of 3 Division of Safety rind Buildings in accordance with Comm 85, Wis. Adm. Code Cep/ Attach complete site plan on paper not less than 8 1/2 x 11 inches ir"irerPlarrmust` include, but not limited to: vertical and horizontal reference point (W4), direction and p J.D. v O , �Z /f�• �Q �-� percent slope, scale or dimensions, north arrow, and location and diitanceto nearest ioad: (S Please pint all Information. Revieheo Date I Personal information you provide may be used for secondary purposes (Privao t.aw.'s.15.04 (1) (m)). (� Property Owner , Property Locatio , p q /3 % �/ ? �E L v ttER M�} N �. Lot i/4 N 1/4 S 0 T Z N R /I it (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# yiy /C�E`D j3 R�'o� c / -Ru��w ,40Dr•,7 - i�.c� City State Zip Code Phone Number ❑ City ❑ Village 0 Town Nearest Road ffv�So /v /. Syo /l OW Ro Y SiPick ❑ New Constriction Use: KResidenfial / Number of bedrooms Code derived design flow rate GPD Replacement ❑ Public or commercial - Describe: Parent material 54&VY Qu T S A— Flood Plain elevation if applicable ft. General co mmen t s mend ti q /E FOR A C O * ,V V6 V 7 ,¢ L and recommendations: *, W,+ r E'S 7 �� S(f i T1! i46 4 '�tiD P OW 7 • 044) 5 y5 r2E j 5 ;,V GOQE 4aAf 11;j v r 5 o i cS To ffe LE7�7� r4 ❑ Boring , D �2 . © # Pit Ground surface elev. 9 7 10 ft. Depth to limiting factor //o in. S� �•i ,ration Rate Horizon Depth Dominant Color Redox Description Texture Structure consistence Boundary Roots GPDM in. Munsep Qu. Sz. Cont, Color Gr. Sz. Sh. •Eff#1 `Eff#2 i o - // /o yR . S L Z .S Amfi2 w 3 f • S o •32 /00 Y16 2,^, 6k 4f41• 4- . 5 . $ S O YO 0 . s e t P- s • _7 /• s D, • o N S 9 © �s ❑ Ong Z # 0 Pit G ce elev. a ft. icing factor > / V in. Appl ication Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDM In. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I •Eff#2 3 -5 - d.� cs /• IM s/ S . �. -7 2 =-- it i • Effluent #1 = BOD > 30 220 mg1L and TSS >30 < 150 mg/L • Effluent #2 = BOD < rng/L and TSS 130 (Plea mglL CST Na C 1 y me a Print) Signature � R (• a I 2? N 3 J 1 R 74 Address /� Date Evaluation Conducted Telephone Number Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 ORIGINAL Gv� -aMA.J s Property Owner Parcel ID # Page Z of 3 F- 31 �� # E] Boring Q JW Pit Ground surface elev. 7 "' �� ft. Depth to limiting factor > /S In. Sol &Wmation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff In. Munsell Qu. Sz. Cont. Color Gr. Sz. h. •Eff#1 • Efr#2 o • id ye SQL ,� /ybi� 4, �3 f . Z . 3 hit A4�'/2 X 1, a.S / Y a Boring ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth' Dominant Color Redox Description Texture Stnxture Consistence ndary, Roots GPD ff In. Munsell Qu. Sz Cont. Color Gr. Sz Sh. •Eff#1 •Eff#2 F1 Boring # Boring ❑ , nd ❑ Pit Grou surface elev. ft.. Depth to knitiing factor in. Sort Appl =3bon Rate Horizon Depth Dominant Color Redox Description. Texture Struct Consistence Boundary Roots GPD/ff In. Munsell Qu. Sz Cart. Color Gr. Sz Sh. •Efl#1 •Eff#2 Boring # ❑ Boring ❑ Pit Grou surface elev. ft. Depth to limiting factor in. Soil Rate Horizon Depth Dominant Redox Description. Texture Stnx*" Consistence Boundary Roots G in. Munsep Qu. Sz Cast Color Gr. Sz Sh. •Etf#1 'Eif#2 Effluent #1 = BOD > 30 1220 mg& and TSS >30 1 150 mglL • Effluent #2 = BOD < 30 mg& and TSS 5 30 mglL 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. Sa60330 (R.60) 1 w � � I � 0 r I � s r' r � N D a N x a s NA) Z kh o Q c �1 � e C � ti ST. CROIX COUNTY ZONING OFFICE / ViCr PD, Y CERTIFICATION STATEMENT ffopS0A, FOR UTILIZATION OF AN EXISTING SEPTIC TANK 4W• This is to certify that I have inspected the septic tank presently serving the / 11 / L 4,0 N F v tesidence located dt: 1/4, N iv 1/4 Sec. ' � � TLO N, R // p W, Town of 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. Last time serviced 2 - �� 3 Did flow back occur from absorption systerm??- Yes X No (if no, skip Approximate volume or length of time: �J gallons next l es Cap aci ty: Construction: Prefab Concrete X Steel Other Manufacurer ( if known) : Age of Tank (if known) : / 1� / Ulbricht & Associates Private Sewage Consultants 2812 10th Ave. (Signature) (Name) P1 (Title) (License Number) (Date) Form to be Completed by licensed plumber (x.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 �. �l`j� /�L/� Signature 2ZC eI 1 s - +fP /MFRS 5/88 Ulbricht & Associates Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 I� S'T' CROIX COUN'T'Y SEPTIC 'TANK M A INTENANCE AGREEMENT AND OWNERSIIIP CERTIFICATION FORM Owner /Buyer ill �E�3� U 7t7t,5'k 1-i,4-,4_,7 3 A; ' d 7 Mailing Address /' 7 /� � �/� /�Clt II O 2i f" Property Address 5G (Verification required from Planning Department for new construction) City /state Parcel Identification Number - 000 LEGAL llESC1t1P'1'lUN ,-1 Q Property Location ' /.+, Sec. , T N -R W, Town of ��� Subdivision C (,5r yJ�_w /�P, T/ 0 A-) , Lot # Certified Survey Map # , Volume , Page # WArranly Deed # � - z , Volwne ,Page # Spec house U yes X110 Lot lines idenlifiableAyes O no SYS'T'EM 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 lank 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 plintiber, 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. lhve, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards i j DOCUMENT NC' ;T.kTF' NAR OF Wl SCONSIN FOI:JI :-1982 rm,i ir—c. ncsewvm TOR 4CCOMD4MG DATA QUIT CLAIM DEED • 4'7,'72 , VOL 9244E 215 REGISTER'S OFFICE DELTA CONSTRUCTION COMPA,'VY, a ST. CROIX CO Minnesota corporation, •• WI Grantor _ __ - - - - - -- - - - - - - -- -- - Recd for Record 2 6 1991 quit claims to . -. WILLIAM P. LUT'TERMAN and DEBBIE LUTTEFMAN, D t. 10:15 A. M .husband and wife as survivorship marital property, _ Grantee _ Re0ter of deeds --- - - - - -- -- - ---_. __... the iollowin' described real estate in _ _ St. Croix County, State of 1Fisconsin: , TO Tax Parcel No: _ .... Lot 6, Clearview Addition to the Town of Trov, St. Croix County, Wisconsin. Thi.v is not homestead pruperv. I.XA (Ii not) Dm 'd till., 21st day of NoVC'. r 19 91 I I (SF:ALJ (SEAL) i • DELT,A C(. CO ?IPANY By VirgL1 FcAorenko ot A UTHENTICATION ACKN0WL1;DtiSWNT Signacure(s) _ STATE OF WISCONSIN ' ss. St -.. Crum. ..... .---------- County. withcnticated this day of _.. 1, _ - -- Personally came hefore me this ..__.. ... 1_day of November 19. 91. the above named Virgil Fodorl2nku TITIY: MEMBER ,TA'FF BAR (IF WI:;( ON IN ( If not. a.rti•.nri:•�vi bt' 71)I;,r11;, �t - i;. �t;tt;.l -- - - .. to nu• kri :, n to be tie Pc. <on - who executed the fors ,rin� h, >h'un:cnt :wd ::rknowlcd t ile same. MI '-F7 FD F1Y W111ard A- ,attorney Barry C. Lundeen / I �ijp� C rY Pub$ GILBER'r, mLhGE, PoKIL'R u LCNUGI'.y Sate di •�hscim ry 110 Second Street, Hudson, (JT 54016 Not:uc Puhlir St. Cart. County, Cis. ontir:u,d -�r ;ukrtw. if 1,,,1. I{„ tl, M- C,n::ui�? ion is pcnr;:•.r It riot. st. `e expiration <.WT ct., \rat IDLED r�lr nor •rk FUNK No I _i, >_ "l —KI". e. Ns. N 0 V W N N 89 ° 31' 30" E 464.10' C-4 Q W 1 .14' 0 3 Q i 2 36 227.96' I Z a 1 0 t i 1 � f- 1 W WI 0 O �1 CD pp J i �Q lu ; z 1 z ' 3 I W QI s = �I to H 0 6 �W t W 5 L; _ > O � � 1 92,303 S0. FT. 8 0 96 ,22 8 SO. FT. a W on 2.12 ACRES Z 2.21 ACRES J l - -� - e 8 V ~ Wt N li in W W 1 p WI m ul a> O1 � I IL � 1 1 O 01 1 .; so' L- -0 M —' 128.06 – �I — — 228.00' - -- PUBLIC \ ROAD 2 _----- - -_ 0� M v YHA �� REVISED THIS 12th 1991. ;ENT TANGENT LING BEARING HUDSON, WIS. ^ i ) 02#10"W S88 43 , < '9/y 4 SU �JE���3 33514391V v " NO 0 1 ' 1 " tf to M 0 7 8 W 9 �h : 1841W N37 "W There are no objections to this plat with respect to 3 11 1 39 "E S00 0 17'18 "E Secs. 236.15 236.16, 236.20 and 236.21 (1) and (2), '17'18 " N33 051'42 "W Wis. Stets., and IIHR 85 of the Wis. Admin. Code as provided by Sec. 236.12 (6), Wis. Stets. ?51'42 "W N50 "W 0 08 0 08 "M S88 0 35'43 "W Certified this A y 0 35 1 43 "W N00 11 W Department of Agriculture, Trade i Consumer Protection Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM Count : S afety and Hyman Relations ngs Division M �l CTION REPORT St . Croix S1$'ty an �,uildi NW, NW, g , 2 8 , 1 Sanitary Permit No.: GENERAL INFORMATION Lot 46, � Brick Rd. 149225 Permit Holder's Name: ❑ City ❑ Village 0 Town of: State Plan ID No.: Bill & Debbie Lutterman Troy CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: �f 1059 TANK INFORMATION ELEVATION DATA 2p 9 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S Benchmark 9A D —= / /o 2, tai' O Aeration Bldg. Sewer Holding St /t Inlet ' TANK SETBACK INFORMATION St /)K Outlet / 4 TANK TO P/ L WELL BLDG. Ventto ROAD at-M1 Air Intake Septic > ' NA ULSeffom Do NA Header f -AA.a= 8, 97,9 Aeration NA I Dist. Pipe 9 ' 9 7 11 ' Holding Bot. System p 96 ' PUMP/ SIPHON INFORMATION Final Grade S /O /,3I Manufa Demand d i ✓ Jam, 13 odel Number GPM TDH Lift Friction Sy TDH F Forcemain Len gth Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width r Length // No. Of Trenches P o. Inside Dia. Liquid Depth DIMENSIONS 66 DIMENSION SETBACK SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING anufaaurer: INFORMATION Type O� �- I CHAMBER Moe N System: �� OR UNIT DISTRIBUTION SYSTEM Header /Meff44k_ „ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _&� Dia Length �j f Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over „ xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center `f z Bed /Trench Edges G4Z Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) �.�( ,f •t�? "b `6`"n - c notes - -e•, d � e le i Plan revision required? ❑ Yes Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t ' t f v i E SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couNTY DILHR STATE SANITARY PERMIT # – Attach complete plans (to the county copy only) for the system, on paper not less than ❑ � � /Gy� 8% x 11 inches in size. C eck i re i o o p evious application –See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Z o � w'/a ' /a,S T ,N,R E(o wy PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # k4 e -- CITY TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Lj II. TYPE OF BUILDING (Check one) CITY NEAREST ROAD State Owned ❑ VILLAGE . fjO ❑ Public ❑ -# 1 or 2 Fam. Dwelling of bedrooms 3 PARCE TAR MB ,( `) Ill. BUILDING USE: (If building type is public, check all that apply) D 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. [K New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an E9--A System Tank Only Existing System Existing System B) E9 A Sanitary Permit was previously issued. Permit # — 2 Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 M 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 _0 1 7 " 1 D Feet /04 3 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks 1 Tanks structed Septic Tank or Holdina Tank O O f S Lift Pump Tank/Siphon Chamber Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumb 's Signature: (No S mps) rPRSW No.: Business Phone Number: umber's Address , State, Zi ode): IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signatur Stamps) 0 1 Approved El owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD -6398 (formerly Pib -67) (R. 11/88) 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 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. III. 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 DILI1R. 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. 7h : monies collected through these surcharges are used for inon fo ing gro €,odwater, ground - waiear contamination investigations and establishment of standards. SBD -6398 (R.11/88) SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code COU NTY STATE SANITARY PERMIT # -Attach cofiplete plans (to the county copy only) for the system, on paper not less than q [7 9 ,g 9 ��Cyy 8% x 11 inches in size. ❑ Check if revision to preAs application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. " P RTY OWNER PROPERTY LOCATION t L L� (ti '/a (� Y4, S , N, R 6 E (DOW PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # a. 1 CITY STATE ZIP CODE PHO E MBER SUBDIVISION NAME OR CSM N}JMBER 11. TYPE OF BUILDING: Check one CITY �-- N EST RO P ( ) State Owned VILLAGE L T. 41 A6 =NQ ❑ Public El 1 or 2 Fam. Dwelling- # of bedroom L u Ill. 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.[&�I ew 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) i 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.) PROPO;ED (sq. ft.) (Gals /day /sq. ft.) (Min./inch) ELEVATION oL Feet \ Feet VII. TANK CAPACITY Site INFORMATION in allons Total ## of Prefab. Fiber- Exper. New istin Gallons Tanks Manufacturer's Name ncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank _ e- Lift Pump Tank/Siphon Chamber El I L1 El El I El Fj VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP /MPRS No.: Business Phone Number: l( I t Tfn Plumber's Address (Street City, tats, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater al e Issued Issuing Agent Sig ure (No Stamps) Approved ❑ Owner Given Initial 00 Surcharge Fee) /0-/(f- Q/ Adverse Determination 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 INSTRUCTIONS ' 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; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction toss; 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. I SBD -6398 (R.11/88) V1 SEPTIC TANK MAINTENANCE AGREEMENT r St. Croix Coun y w 014NER /BUYER � ROUTE /BOX NUMBER ' /' [Al Fire Number d CITY /STATE ZIP i L� ' �"' PROPERTY LOCATION:' �G', Section =_, T No R 9 W. Town of St. Croix County, Subdivision V,� -Q -� Lot number!,_,. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed' 's'e t'ic tank um er . What you put into P P the system can aFFect t e :unctiono - t - G S eptic tank as a treat - g ment a in the waste disposal s y stem. St. Croix County residents be eligible to recieve a grant for a maximum of 607. of the cost.of replacement of a failing system, wh c was in operation prior to 1, 1978. St. Croix County owners of new to keep their system properly that properly owner � maintained. The property owner agrees to.submit to St. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or..a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and .(2)•after inspection and pumping (if nec- C Certi three year expiration. y 0 I /WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as-set by the Wisconsin Depart -' ment of Natural Ree Zoning Office within � and returned to th of the three year expiration date. SIGNED DATE - T St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386 -4680 Sign, date and return to the above address. DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED STATE BAR OF WISCONSIN FORM 2 -1982 47 4568 REGISTER'S OFFICE ST. CROIX C I David R. Knighton Recd for Ric U I✓ 1 at 3:00 P conveys and warrants to Regis w Of Deidi William iam P. Tiit and i7PhhiA Ta,}}emrman, hn1band an wife ails airrvi vnr�hJ p Jnar. i:tal nropprtat And nr±l to rnnSt_n Tnt i en I^nm a MIST Cnr i nn RETURN TO the following described real estate in St.Croix County, State of Wisconsin: Tax Parcel No: Lot No. 6, Clearview Addition Subject to Declaration Establishing Protective Covenants and other easements of record. This is not homestead property. (is) (is not) Exception to warranties: th Date ; ihi day of October 19 91 r (SEAL) (SEAL) * David R. Knighto (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGEMENT Minnesota Signature(s) STATE OFt SS. Hennp- i n County. Personally came before me this 9th day of authenticated this day of ,19 October , 19 the above named Da vid . Knighton ton * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person who executed the authorized by § 706.06, Wis. Stats.) foregoing instru ent and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY (-"N /"�' David J. Butler, Attorney 6625 Lyndale Ave.S, Richfield, A'1r1 55423 Suite 618 Notary Public Countyi PMi. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state ex , piration � are not necessary.) dat • y 1 , 19 ) *Names of persons signing In any capacity should be typed or printed below their signatures. ' �fAIIP f�lC • AMfII�� WARRANTY DEED STATE BAR OF WIS , QNSIN ALTORSO ASSOCIATION FORM No. 2 -19 M' s1�11w11 s Roe Madison, Wisconsin 53704 I APPLICATION FOR SANITARY PERMIT S T C - 100. This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, ( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - t r Owner of Property Location of Property /1/L-A ', Section , T Zvi' N -R /9 W Township Hailing Address � r Address of Site �iJh (LL-1 Subdivision Name- �'�t /c.��� .Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes V 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 refer- . ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATIO I Vue) ceAti.6y that att atatementb on thi6 6onm ate tlLue to the but o6 my (out) knowledge; that I (we) am (ate) the owneAk) o6 the pnopenty de�scAibed in thiA .in4o4mati.on 6onm, by vi tue o6 a waAAanty deed heconded in the 066.ice o6 the County Regi6ten o6 Deeds a-s Document No. ; and that I (We) pneaentey own the pnopoaed 6 to bon the s ew age d Apoiat s ystem (on I (we) have obtained an easement, to nun with the above de6 cA ibed pnopeh ty, bon the consdtnuc ti.on o6 said b ydtem, and the tame has been duty %ecotded in the 066.ice o6 the County Regi6teA 06 Deeds as Document o ent V SIGNATURE 01# SIGNATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED °t INDUS TR Y, OF RE PORT ON SOIL BORINGS AN D SAFETY &BUILDINGS INDUSY, DIVISION LABOR 74ND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS 0LHR 83.0911) & Chapter 145) LOCATION: SECTION: OWNSHIP /M6 +emFACYFi': O.:BLK. : SUBD ISION NAME: '� l� /a AId 1 /a /T .2g N/R (or o LOT r I/'0&w W TR'S BUYER' AME: MAILING AD RESS: ^ol✓ /�� �oti,s -�e��� 'fj "— ' USE DATES OBSERVATIONS MADE NO. BEMS.: 1COMMERCIPJL DESCRIPTION: I� =DReplace PROF L ESC PTIONS: ER ATIO TESTS: �esidence Amew L RATING: S= Site suitable for system U= Site unsuitable for system C 'N S E I L: MOUND: ❑U IN -GRI PEl URE: SYSTEM -I LHO : RECO / , S EM: ption ) If Percolation Tests are e NOT NOT DESIGN RATE required If an portion of the tested area is in the under s. ILHR 83.09(5)(b), ind9ate: < Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSER ED (SEE ABBR . ON BACK.) 2 /. l S rs n S . L 7 6.+ s, , ,cl., y r� B - 2 B 3 L� � > 7y�� ,/. #%'A / /./7 has 1 i 3,7f8�,s � o s'f 3g3 Q„s B - 7. q 1, o�, yz � 7 Y L B - SS 6 s�' ,9L /soh /,.zsB.�s /, 3372a ^s �, , B- PERCOLATION TESTS A. TEST DEPTH TER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER I AFTERS LLING INTERVAL -MIN. PERT D 1 PERIOD 2 P R PER INCH P_ IS-0 to P_ 1 4 . 8 C 3 P- P_ P_ 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. ^P7 O 'r SYSTEM ELEVATION E I�_a19P� Flo - _s� �€ �>r- - 2 �? �_. - _ - F &; _'.� l_ - _.._ __ i- _ `�E� e ,E�fifio� e o � 3 3 3 i E ri 3 r ' x � E I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the pro r e Z s 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 NAME (p 'nt TESTS WE PE CO PLETED ON: kl� e' I R 1kn �kl �?/ 4 /f/ ADD SS: CERT ICATI N NUMBER: PHONE NUMBER (optional): IvY (;�,L4 9J al" 6j, 51J)7/4 - eO 0 CST IG DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. If DILHR -SBD -6395 (R. 10/83) — OVER — 16 ,-- _ _ _ INSTRUCT FOR COMPLETING FORM 115 - SR - 63 To be a complete and Accurate soil fiesta, must incls'Jde: 1 . Complete legal description; 2. The use section must clearly indicate this is a reskfencze'or Commercial project; 3. MAX IMUiM numt)er of bedreorms of cornrylercial use Planned; 4. Is this a new or refalacement systeilr; . Complete the suitability ratting boxes, A SITE IS Sllll - ABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shov.rr here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE: diagrarn accurately Iocating your test locations, Drawing to scale is preferred. A sr.parat.e sheet may b0 used if desired; B. Make sure your benchr,aark and vertical elevation re =ference point are clearly shown, and are permanent; B. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) noes not apply, place N.A. in the appropriate box; 11. Sign the forrn and place your current ad dress and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, I ABBREVIATIONS FAR CERTIFIED SOIL TESTERS Sail Separates and Textures father Symbols st Stone (over 10") BR Bedrock cob - Cobble (3 - '10 ") SS — Sandstone gr Gravel (under 3 ") LS — Lirnestone s — Sand HG7vlr — High GYounclkvater cs ..__ Coarse: Sarnd Perc Parcolation Rate reed s Medium Sand tea Well 1 fs Fine Sand Bldci -- Building Is Loamy Sand > Greater Than sl — Sar,dy Loarn .._. Less "an I ...... Darr, Bn -- Brtavvra �'S l Silt Loam BI Black sr -- Srit: Gy _..- Gray cr _Clay Loan) Y -- Ya;Ilcsvv scl Sandy Clay Loarn R - Rea_ sicl ._ Silty Clay Loam rnot — Mottles sc — Sandy Clay vv :'- 'r ith sic Silty Clay.- fff •- fevv, fine, faint C - Clay co cgmmon, coarse pt Pea narn Many, mediurn rn - "Muck d -- distinct. P _.._ prorninent I-IWL High water level, Six general soil textures surface :eater for lirtuid wvaste disposal L'iaJl — Bench Mark t/RP Vertical reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county orthe Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. J R B-L .- 6 7 P' �T,� r,� i'o SECI��-) N N A M Ems' C1 h;, � Lu4e - r�,, ,�.N.... NAM � � �� � ►� � . �� t; A ION , - _ _.......... L) n E ......: YE_._ . �___ - - -- __(off--- ----�• i�� � • �► �.v Caz NE N a, (/� �• ' I J If lut i - S, , 7 B RV P I I. F RESH All INLL.I'S A ND OBSE A C P t: F � o Cl:O. SE CTION Approved Vent Cap •. Minimum 12" Above Final 4" Cast Iron Above Pipe Vent Pipe z To Final Grade ► E' Marsh Itay O Synthetic Covering - - -�... Min. 2" Aggr.eyfil — Over Pipe + � Distribution �— �--- Tee i Pipe _........_. Aggregate \��/ Perforated Pipe Below 7 U 1)encath Pipe � Coupling Terminating T �� -- ._. �_.._ ..._ . Bottom of System ____ As i N y CJ fQ ` l 7 r �• Qp 1 ry CD r ° r .. •-r S �o l Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749 -3656 4 //2 aOly x } r /..� �k �- � acs Of �o � ;e T l S , /I l3 rn AsSu�.►r I CPO •O. �ri/rr� �i ✓ Nr y s - 4* - c X .. ,�o r ► h T d per /pr eo rmfr /f _ SANITARY PERMIT -'e • cm COUNTY � DILHR TRANSFER /RENEWAL UNIFORM PERMIT # (PLB 67 -T) PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: / tl 4'�q I 9 PROPER f/ LOCATION: CITY: S ,T N,R } E f o OWN O OT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE O LANDMARK: R 1 } /} } PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUMBER'S SIGNATURE: PREVIOUS PLU ER'S NAME (IF CHANGED): a., R f, ecs PLUMBER'S ADDRESS: BKEVIOUS PLUMBER'S ADDRESS: o e 9 - J�� 4vz MPIMPRSW NUMBER: PHONE NUMBER: AV /MPRSW NUMBER: PFTONE NUMBER: S jr40 . c ) p ( 8W — 6 vqZ SIGNA URE OF 1SSU1N ENT: DATE APPROVED: DISTRIBUTION: Original - County Copy - Bureau of Plumbing Copy - Owner DILHR -SBD -6399 (R. 5/8 Copy - Plumber