HomeMy WebLinkAbout020-1345-60-000 ST. CROIX COUNTY Z, ON M DEPARTME '` '
AS BUILT S� JTARY REPORT
Owner -53A Y" LC. r"
Property Address 70 s `.
City/States C) S O x
Legal Description:
Lot 4— Block ' Subdivision/CSM #M
S w ' /4 w ' /4, Sec. lam, T N -R�? & Town of Hy D38N'_ PIN # O 2D - �S –lesG– U o�y
SEPTIC T DOSE CHAMBER -- HOLDING TANK INFORMATION
r i r
Tank manufacturer W E - 1 S AL Size ST/PC 1 Setback from: House z8 Well PAL, 6
Pump manufacturer Model
Alarm location --
(HOLDING TANKS ONLY)
Setbacks: Service road - Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: LEA IF 'P 204P _ / Z--
yp y Width � 3 Length � Number of Trenches
Setback from: House !j I , Well 0 S P/L = S Vent to fresh air intake 8S t7
7
ELEVATIONS
Description of benchmark toP of PH o NFE 1�'` Ep C-Ator 3 1 Elevation
Description of alternate benchmark P O B IOc IC FOd AIp A-110 N = 3 7 -5 -1 Elevation CIO
. ••�
Building Sewer �`� ' s ST/HT Inlet I►��`'- �� S ST Outlet 'ZS ' ��' 35 PC Inlet
PC Bottom Head anifo d 93 '�Z " Top of ST/PC Manhole Cover
L W�
Distribution Lines ( ) 70 3 ' q O �i • 7 D ' 9 3 9 ( }
Bottom of System O Z•� O ��+ Z c t , 'S
Final Grade () S�� 7 S�'� �� b () S, ��0 9 7,
Date of installation /tl/ Permit number 3 M 7 State plan number
f
Plumber's signatur License number 2 LS03 4o Date / / p
Inspector 1
Complete plot plan
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
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INDICATE NORTH ARROW
Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 22010 B W in Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. 9� r'p
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information ou p rovide may be used for second V t `7
y p y ry purposes V heck if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Propert Owner Name, Property Location
uJt/ ".) 1/4,S1 T2!7 , N, R E (
Property Owners ailing Add ess Lot Number Block Number
Cit , tate W Zip Code Phone Number Subdivision Name or CS Nu b r
0,64 a Va /to L > 14 40 AF
IUTYP OF BUILDING: (check one) ❑ State Owned E] It� n earest Road ��
Public 1 or 2 Family Dwelling - No_ of bedrooms j Tow OF
III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number( t' A 1. V . i to
1❑ Apartment/ Condo Z� l 3 r i1 V00'" d O
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 box on line A. Check box on line B, if applicable)
A) 1. Snew 2 ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5 ❑ Repair of an
ystem System Tank Only Exist System Exi ti Sy em
B) ❑ A Sanitary Permit was previously issued. Permit Number 'Date Issued Cfl^
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
12Weepage Trench M.kW 22 ❑ In- Ground Pressure �. 41 42 ❑ Pit Privy
13 ❑ Seepage Pit iz fK rfzrt.d"Tb A— ZK `? �` 43 ❑ Vault Privy
14 ❑ System -In -Fill :210E wl e _APW,,t it
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
0 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
- 7_ '7 4.3 �- t Feet 7.5 Feet
VII. TANK Capacit gallo Total # of r Prefab. Site Fiber- Exper.
INFORMATION New Existing
Gallons Tanks Manufacturers Name Concrete strutted steel glass Plastic App
Tanksl Tank
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 0 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
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' Signature: o Stam MP /MPRSW No.: I Business Phone Number:
KF, 0NF-11 P. zlrb 3
Plumber's Address Street, City `tate, Zip Code):
b
. COUNTY / DEPARTMENT USE ONLY
[] Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing n si na i, re (No Stamps)
,Approved ❑ Surcharge Fee)
Given Initial tom" f
Adverse Determination ( U
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11 /97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing-tank, list the total gallons, number of tanks and .
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII_ Responsibility statement. Installing plumber isto fill inn ' ame, license number with appropriate prefix (e.g. MP,.etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
l
Safety and Buildings Division
Vi sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P.O 'Box 7302
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County 1
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application state sanitary Permit Number
a"l
Personal information you provide may be used for secondary purposes Pr4eck i revision to previous application
(Privacy Law, s. 15.04 (1) (m)]: jO State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
c- 93( /4{ j 1/4, S T , N, R E
Prope y caner' M i ing Add ss Lot Number Block Number
`a;
City, Slate Zip Code Phone Number Subdivision Name or CSM Nu ber
11. BUILDING: (check one) ❑ State Owned [] It ea rest Road
' Villa e
Public 1 or 2 Family Dwelling - No. of bedrooms Town of 4t,,li J ' , "� / a
Ill. BUILDING SE : (If building type is public, check all that apply) Pa cel Tax Numbers) r,
1 ❑ Apartment/ 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 box on line A. Check box on line B, if applicable)
A) 1. Iqjy`New 2 ❑ Replacement 3. ❑ Replacement of 4, ❑ Reconnection of 5_ ❑ Repair of an
7 'system System ------- - - - - -- Tank Only ------ - --- -- Existing System -- - - - -_- Exl tin Sys m
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 []Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 RSeepage Trench�t 22 ❑ In- Ground Pressure ,r 42 ❑ Pit Privy
13 Seepage Pit vi /ly E"// T - K A - 43 ❑ Vault Privy
14 ❑ System -In -Fill :ZK, '..`, Y°f ' 4,,- ! Of,' A t;
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
'-" 7 Z-C` 7 r,-, - -. Z . Feet 7- 5' Feet
VII. TANK Capacit g allo ns Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete st noted Steel glass Plastic App
Tanks Tanks I _
Septic Tank or Holding Tank V I Z � 0, ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamberl I ❑ I ❑ Ill 1 ❑ 1 1:11 ❑
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 ignature: (Mo Stamp ), MP /MP No.: w� y� Business Phone ( N / umber:
P umber's Address (Street, City, State, Zip Code):
,f
IX COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issuing A t i ln , at e (No Stamps)
surcharge Fee)
Approved ❑ Owner Given Initial 00 t w / Iq
Adverse Determination IT 00
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
$BD- 6398 (R.11/97) DISTRIBUTION: original to County, One copy To: Safety & Buildings Division, Owner, Plumber
;.. :. INSTRUCTIONS
S
4 .
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in.the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit mustibe approved by the permit issuing authority.
4. Changes in ownership or plumber requires a SanitaryNtibit Transfer/ Renewal Form (SI #D -6399} to be submitted to the'
count prior toinstallation
Y
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licer sed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151. -
To be complete and accurate this sanitary permit application must include;
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system into 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 online A. Complete line B if permit is for tank replacement, reconnection, or repeir.
V. Type.of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
, VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks,received experimental product approval.from
DILHR.
Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form. ,
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
------------------------------------ ------------- --------------------------------- ------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards. `
i
Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord vvith Comm 83.05, Wis. Adm. Code
Rnvircxrmental Ry Design
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must [Re;#o�pd,py
include, but not limited to: vertical and horizontal reference point (BM), direction and $t. Croix
_
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. .#
APPLICANT INFORMATION - Please print all information. lute Personal inf ormation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). �VI
<���
Property Owner Property Location
Miller Sam Govt Lot SW 1/4 SW 1/4 S I I T 29 N,R 19 W
Property Owner's Marling Address Lot # I Block # Subd. Name or CSM#
Troutbrook Road 6 Homestead
City State Zip Code PhoneNumber E] City ❑ Village ®Town Nearest Road
Hudson W - 1 54016 Hudson j Labarge
I New Construction Use: Residential / Number of bedrooms 3 ❑A ddition to existing building
u Replacement u Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpdMl? .8 trench, gpd/W
Absorption area required 643 bed, fP 563 trench, lts Maximum design loading rate .7 bed, gpd/fts .8 finch, gpd/fF
Recommended infiltration surface elevation(s) Ca 3�- ft (as referred to site plan benchmar
Additi design / site consideration This is a supplement to the original soil test so that system could be installed deeper
t Parent aterial Loess Ov er glacial Outwash Flood lain elevation, ff licable NA fit
le for system Conventional Mound !n Grr+und Pressure AT Grade System in Fill Holding Tank
table far system S❑ u S U F S U ❑ S U ❑ S E U ❑ S E U
SOIL DESCRIPTION REPORT
Burin Horizon Depth Dominant Color Motties Structure GPD/ft
g# in. I Munsell I Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots I Bed Trench
1 1 0 -9 10yr2 /1 - sil 2msbk mfr cvv 2f .5 .6
2 9 -34 1Oyr5/8 - sil 2msbk mfr cvv If .5 .6
Ground 3 1 34-136 7.5yr4/4 - s Osg ml - - .7 8
elev
136.33 ft
Depth to
limiting
factor
>136 1 1 p 1
Remarks: These bore holes evaluated to a greater depth so as to accomWate a deeper system
1 0 -9 10yr2/1 - sit 2msbk mfr cw 2f .5 .6
2 1 9 -33 i 10yr5 /8 i - i sil i 2msbk mfr i cw i if i .5 .6
Ground 3 133 -52 7.5yr6/6 - l s On ( ml I ew I - I .7 .8
elev —
e6.10A 4 1 52 -61 7.5yr6/4 - s 1 Osg 1 Dal cw 1 - 1 .7 .8
Dept lo 5 ! 61 -1361 7.5yr5/4 1 - s Osg ml 1 - j - j .7 .8
limiting
factor sa
>136
b
Remarks:
CST Name (Please Print) Signature: Telephone No.
Thomas C. Nelson 715- 246 -2454
Address En vironmental B Eles ign Date CST Number Ref #
1432 120th Street, New Richmond, WI 54017 4/29/99 227387 225
PROPERTY OWNER: lyliller, Sam SOIL DESCRIPTION REPORT I n5 I Page 2 of 3
PARCEL 1.11A Environmental Bv Design
Horizon Depth Dominant Color Mottles I Texture I Structure (Consistence! Boundary Roots GPD/tfi
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 1 0 -9 10yr2/1 - sit 2msbk mfr cw 2f 5 .6
2 1 9 -29 I 10yr5 /8 I - I sil I 2msbk I mfr I cw If I .5 .6
Ground
elev 3 29-40 I 7, 5yr6/6 I - ( s ( Osg I ml I Cw - I 7 8
98.53 ft 4 140-57 I 7. Syr6 /4 - I s I Usg I ml I cw I - I 7 .8
Depth to 5 57_13$ I 7.5yr5/4 - s Osg I ml - I - I 7 8
limiting
factor
38 I ( I I I I
I fi b ' I I I I I
Remarks:
i
Ground I I I I I I I I
elev
Depth to
limiting
factor
arks:
Ground
elev
Depth to
limiting
l I I I
factor
Remarks:
Ground
elev
Depth to I I I I
limiting
factor
I I I I I i
Remarks:
S
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: I - M T „
Personal information you provice may be used for secondary purposes [Privacy Law, S. 15.04 (1)(m)]. "1 15 o n o ti
Permit Ho Name: E) Cit E] Village [2 Town of: State Plan ID No.:
MI SAMI HULL -^'K
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
( (t"7 I op' I _j
TANK INFORMATION ELEVATION DATA A9900099
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic A (� T z SD Benchmark �. (d• (a3. t
Dosing ,d l 103• '� 3 OSr" /06.3 y
Aeration Bldg. Sewer /,03.3,6 7- SK �t
Holding St /Ht Inlet (b; i�,7b 9 �w�i
TANK SETBACK INFORMATION OirOutlet
TANK TO P / L WELL BLDG. A I to ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header /Man. (0�>.3C,
Aerati NA Dist. Pipe (p�, 3 `3 ri5 9 j •7�
Holding Bot. System /6 3,35( _
1' 2z a Z;
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand - 4 L,k,,,I - (03 30 g• ?a 3 G�
Model Num GPM (,q
TDH Lift Friction S m TDH F t
Forcemain Length Dia. Dist. To well
SOIL ABSO ION SYSTEM
BED Width f Length No. 21- enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS "• DIMENSION
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREA LEACHING M nuf
INFORMATION Type O ( CHAS. M ummm r
Syste 2 y
DISTRIBUTION SYSTEM
Header / M Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length !� � Dia Length_ Dia. Spacing f� �� S �v f_
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) c /. re
LOCATION: HUDSON 11.29.19,SW,SW 705 PACKER DRIVE - HOMESTEAD LOT 6
A
Plan revision required? [ Yes E] No _ q Use other side for additional information. I q (`C Alu
�J SBD -6710 (R.3/97) Date Inspector's Sig ature Cert No.
t
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 201 B W shington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 - 7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size. 54L Cr61
• See reverse side for instructions for completing this application state sanita rry e i 'umber
Personal information you provide may be used for secondary purposes ❑ Check . it revision to previous application
IPrivacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Propertv,Own er Narpq Property Location
S(jl,Jl /4 S t 114, S T Z , N, R /9 E (o
Property Owner's Mailing Address Lot Number Block Number
A ct * / S' / elo
City, State Zip Cod Phone Number Subdivision Name or CSM Number
W / 4 ( ) Z7t�+ E ,l
II. TY PE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest Road
Village ` �
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF U O EA VZ E
III BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s)
�3y�� - 191%0 1 E] Apartment/ Condo 4$M4
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 box on line A. Check box on line B, if applicable)
A) 1 — New 2 E] Replacement 3. E] Replacementof 4 E] Reconnection of 5. [] Repair of an
-__ /'System System _____________ Tank Only __ Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12�eepage Trench l Ek 7 22 E] In-Ground Pressure 42 E] Pit Privy
1 Seepage Pit X /NF/tT,eAToil - IX 3 X 7 S 43 ❑ Vault Privy
14 ❑ System -In -Fill 'tit 8 SQ F?` Sto gruim PFIL 14; e
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) Elevatio
S(_o 7 3 ,•o 7 Feet 4 SCf.O Feet
VII. TANK Capacit gallons Total # of Prefab. Site Fiber Exper.
INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete st acted Steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ ❑ 1 ❑ I ❑
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 S ps) MP /MPRSW No.: Business Phone Number:
r .' Q Xt `-6-v 2 - 2 - 5'0 3 (o 1 3 for Z.-
Plumber's Address (Street, City, State, Zip Code):
c o o t k k0 4 0
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa " arjr Permit Fee (Includes Groundwater a I ssue n t Si atur (No S s)
4( A " pprove ❑Owner Given Initial Surcharge fee)
Adverse Determination ��5�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: dioo
Y
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS `
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line .B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII_ Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Environmental By Design
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.#
APPLICANT INFORMATION - Please pr/nt all information. R iewe B y Date
Personal information you provide may be used for secondary purposes (Privacy �a0�4 s. 15.04 (1) (m)). a Ij
Property Owner �• Property Location
MILLS SAM .' 1/f vt. Lot SW 1/4 SW 1/4 S 11 T 29 N,R 19 W
Property Owner's Mailing Address ; It # Block # Subd. Name or GSM#
TROUTBROOK RD A i 6 Homestead
City State Zip Code PWm r �' City E] Village ®Town Nearest Road
Hudson WI 38t�b Hudson LaBarge
® R /Numb ms 3 ❑
New Construction Use: M Addition to existing building
F Replacement ❑ Pu cb�i ,- e
Code Derived daily flow 450 gpd _ Recommended design loading rate - .2 bed, gpdtf 2 L $ trench, gpd/ft?
Absorption area required bed, fl 5Utrench, ft Maximum design loading rate / 2 bed, gpd/ft- . tr ench. gpolft?
Recommended infiltration surface elevation(s) ° l S ° ° ft (as referred to site plan benchmar
Additional design/ site nsideration
Parent material 7O h Flood plain elevation, if applicable -AA -- It
S= Suitable for system Co ventionai Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system S ®u S® U ❑ S Z U ❑ S® U EIS ®U ❑ S® U
SOIL DESCRIPTION REPORT
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary oots GPD/fts
Boring# in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ry Bed ; Trench
.................
1 1 0 -9 10yr2 /1 - sil 2msbk mfr cw 2f .5 i .6
2 9 -34 10yr5 /8 - sill. 2msbk mfr cw If .5 .6
Ground 3 34 -98 7.5yr4/4 - s Osg ml - - 7 8
le
t C d - ft.
Depth to
limiting
factor
>98
Remarks:
2 1 0 -9 1Oyr2 /1 - sil 2msbk mfr cw 2f .5 .6
2 9 -35 10yr5/8 - sd 2msbk mfr cw if .5 .6
Ground 3 35 -50 7 -5616 - s 059 m1 cw - .7 .8
elev
t7& .l7 4 50 -60 7.5yr6/4 - s Osg ml cw - .7 .8
Depth to 5 60 -65 7.5yr6/6 - s Osg ml cw - 7 ! 8
facto 00 6 65 -1 7.5 5/4 - s Os ml .7 .8 - - i
factor Yr 8
; o�C
Remarks:
CST Name (Please Print) Signature: -�---- Telephone No.
Thomas C. Nelson 715- 246 -2454
Address Environmental By Design Date CST Number Ref #
I432 120th Street, New Richmond, W1 54017 8/20/98 227387 73
PROPERTY OWNER MILLER, SAM SOIL DESCRIPTION REPORT 0 Page 2 of
PARCEL LD.# . Environmental By Design
Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont Color exure Gr. Sz. Sh. Bed : Trench
1 0 -8 10yr2 /1 - sil 2msbk mfr cw 2f .5 .6
2 8 -28 1Oyr5 /8 - A 2msbk mfr cw if .5 .6
Ground
elev 3 28 -41 7.Syr4/4 - s Osg ml cw - .7 .8
LP 4 41 -56 7.Syr6/4 - s Osg ml cw - .7 .8
Depth to 5 56 -98 7.5yr6/6 - s Osg ml - - 7 i 8
limiting
factor
p
Remarks:
4 1 0 -12 10yr2 /1 - sil 2msbk mfr cw 2f .5 .6
2 12 -28 10yr5/8 - sil 2msbk mfr cw if .5 i .6
Ground
elev 3 28 -51 7.5yr7/4 - s Osg ml cw - .7 .8
- -
4 51 -61 7.5yr5 /4 cs Osg ml cw .7 i .8
Depth to 5 61 -64 5yr6/8 - s Osg ml cw - 7 8
limiting
factor 6 64 -71 7.5yr6/6 - s Osg ml cw - .7 .8
7 71 -98 7.5yr5/4 _ s Osg ml - - .7 .8
Remarks:
5 1 0 -9 1Oyr2 /1 - Sill 2msbk mfr cw 2f 5 ! 6
2 9 -21 10yr5 /8 - A 2msbk mfr cw if .5 .6
Ground
elev 3 21 -34 7.5yr5/6 - s Osg ml cw - .7 .8
4 34 -98 7.5yr6/4 - s Osg ml - - 7 8
Depth to
limiting
factor
Remarks:
Ground
elev
Depth to
lir►ti{ing
factor
Remarks:
4
J � ENVIgONMENTRL BY DE51GN
1432 120' STREET, NEW RICHMOND, WISCONSIN
715- 246 -2454
PROJECT NAME fIOM£ST£AD L' ° PAGE 3
DESCRIPTION SW % SW %, SECTION 11 T 29 N, R 19 W
TOWNSHIP Hudson COUNTY St. Croix
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SCALE I"= 40 � Tom Nelson
BM 1 . -CelepKovvw e(epko 0 CSTMO2605
BM 2. �j�r\t 4 e �� ��- ��b'� �I tbvn Amp a1 Iro pc�.
i
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
1
OwnerBuyer
Mailing Address 1 0 dDX
Property Address 70i¢��� �2/ l/t
(Verification required from Planning Department for new construction)
City/State/ 4C,) / Parcel Identification Number a Z d /3 SAS — (00
LEGAL DESCRIPTION
Property Location St-IJ '' /4, �-' '/4, Sec. , T 2-9 N -R W, Town of y!�
subdivision (4 cowl �- TFA 0 Lot # � .
Certified Survey Map # S9 O I — ,Volume 7 , Page #
Warranty Deed # IL/ / 2 3' , Volume $ , Page #
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, journeyman plumber, restricted plumber or a licensedpumperverifying 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 St. Croix County Zoning Office within 30
days of the three year expiration date. q
SIGNA OF DATE
I. OWNER CERTIFICATION
' 1''(we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
ro pey. described above, by virtue of a warranty deed recorded in Register of Deeds Office.
t0
/Y
ATURE PLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
> V. V1 L, 13: \It Ilia N FO 9
It l - 113 2 •, - ,c. +., q q..oq::., .+•
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Tliis Deed. +, ,►, t. ,twcel, Bona lc f_. i 1 I ie and
Nao ; R. t,il l ie, husband and
l;ral:.;n IU: ill A.
.,m) Sam C. `tiller, a sin4le. person ,
Gr•ultec,
W itnesseth , That the :aid (;raator, for a valuable cunslderat•un
U, ti1.,11tee the fullown ; dee1.'rlbed real estate to
(- runty, StatC of WISCLnsln:
See attached description.
Tax l .ucel NO: .. .... ...........................
i
TRAFEf?
j EE
I
I
This is not. hunlestr..d property.
(la) Us not)
Togvth.er with all and sing-Aar the heredrtaments and appurten..nces .:xreuntu be. •aging;
And Ronald L. Willie and Naomi R. Uillie
- , :u•rmit> tr,at the title i.i in fc•e Simple and free .,1,1 clral ,,• eneumbr:..I,e; except
easements, restrictions, and ri _vhts -of -way of recocd,
,.nd will t, art ant and defend it a >ame.
dated tnla j� d:1y Of larch 19
96
r7
(SEAL) [eti�c n �• t1.� `/ �cL (SEAL)
• Ronald L. Willie
(S -.AL) e. LCG (SEAL)
Naomi R. Willie
AUTHENTICATION ACKNOWLEDGMENT
STATE OF %%ISCONSIN
r ss.
. ...I .... _ .............. ........ .......... ........ ....... .....
S.t.. Croix .. -.... County. „
authenticated this ....da • of ...... 19.... Persuma came befw nle this _4l _.....day of
MA rs h., 19 9-t the above named
. ..... ........... ..Rana .............. .• .
__ ... _ ... _ .. ..... ...Na.Qmi.R,...Yi1.l,i.e ...............................
TITLE: 51ESI ER s A T E B.\It ('IF WISCONS1 ----- -- --- - -- ... - ... ...... ...
....- ...-
t If nut. _.. _. .
authorized by a "aW.0% 11 St:,t.,.) to me known t,, i,e the per -..n .S. wlru execut -d the
foregoing instr .ment and allLilowlcdge the sume.
TH1T `I sr N L. P. r, ? I . IN AB. C% c -7t i Y .
• r \t.
C. L. Gaylord, a.tto_r.ney �r)lll,x/L //1r•7-
{
River Falls, k4 . I -. 54022 _.. Not... v I'ab,jr t t� county, Wis.
JIB ('umnu.,m i9
kic 0Arttipnhnt- (If ' ndt, State expiration
I�In,:,tl.r. r,,,. >• be u1tF ..nL�:.t..l ,r :,,r.mn\b- :,..d. It.,th - 1
r.• cot t-, .:,ry.) date: > t.... /'rJ'_ 19 7.)
aft r, k OF \1'h,'U \a1N
1�ARilA CT]' Dt6U I )k \I N•. I- 178:
A parcE1 of land located in the 5f -1/4 of the SW' -1/4 and in part of
the SM - li4 of the SW -1 /4 of Section 11, Township 29 !north, R,ngc 19
Wett, 10t,n of Hudson, being further described as follows:
betanning at the S -1/4 corner of said Section 11 thence
KS9 19'0'I along the 5 uth line of the S6; -1/4 of said Section 11,
Of th-9 fEet; thence NO2 g26'06% e
1322.62 fet to the Nerth line
Of the S -1 /2 of the S1,' -1/4 of Section 11 ; tF.E- �E o ; , 5' JG
said North line, 2446. frzEt to the North -`cuth 1/4 line of�said
Section 11; thence S00 34'16"i;, along said Ncrth -South 1/4 line,
1325.65 fEEt to the point of beginnirq. ParcEl contains 73.32
azrEs (3,193,674 Square feet) and subject
record. to all e E
ase,rlts of
Together with and subject to an easement for ingress and egress
located in part of the EW -1/4 of the SW-1/4 of Section 11 and in
part of the 51. -3/4 of the SE -1/4 of Section 10, all in Townshir, 29
Korth, Range
fol 19 Crest, TOwn of Hudson, being. further described as
Iowsc COT`U ericin^ at the S -1/4 corner of said Section 11; t! ace
f\t y, 29 ' 03 "W, along the South line of the Sb: -1/4 of said Sec::_.. -
237c.39 felt; thence NO2 26'06 "1. 1256.54 feet to the point of ,
bcg.innini; thence con :1nuint NO2 26'06"M, 66.06 feet to the Korth
lino of the S -112 of the S of said Section 11; thence
Kra 35 "W', along the North line of the S -1/2 of the SW' -1/4 of
said Sectio.1 11, 179.28 feet to the NE corner of the SE -1/4 of the
SE -1/4 of Section 10; thence N59 41'39 "W', along the North line of
the SE -1/4 of the SE -1/4 of said Section 10, 1318.24 feet to the
Wes a line of the SE -1/4 of the SE -1/4 of said Section 10; thence
S00 25'39 "W', along said West line, 66.00 feet; thence 589 "E,
on 6 line being 66 feet distant Southerly and parallel to the North
line of the SL-1/4 of the SE -1/4 of said Section 10, 1 -316.32 feet
to the E line of said SE -1/4 of the SE -1/4; thence 569 "t; or.
a line beinz 66 feet distant Southerly and parallel to the North
line of the S -1/2 of the SW-1/4 of said SEC
tion 11, 162.54 feet to
oint of beg,innint. Parcel contains 2.27 acres (95,9..6 Square
FEEt� Erl is sut'3ect to right-of-way c
sul -jECt to all ease c-nts of record.[ for totin road (_Cott Foad) or
fore or l' 7 ea5:E°._. t _ .; -( .C_L•_. .E.
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LOCATION SKETCH
1101 Carmichael Road
Hudson, WI 54016
Phone: (715) 386-4680 St. Croix •
Fax: (715) 386 -4686 Zoning Department
Fm
To: Tammie From: Shawna Moe
Fax: 386 -9281 Date: September 21, 1999
Phone: 381 -5000 Pages: 2
Re: Inspection Report — Homestead Lot 6 CC:
❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
*Comments:
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
o e Bon von ST. CROIX COUNTY GOVERNMENT CENTER
"■ - ", 1101 Carmichael Road
Hudson, WI 54016 -7710
_ -4
(715) 386-4680
September 21, 1999
First Federal
Attn: Tammie
201 S. 2 nd Street
Hudson, WI 54016
RE: Septic Inspection for Sam Miller located at 705 Packer Drive,
Homestead Lot 6, Town of Hudson, St. Croix County, Wisconsin
Dear Tammie:
A septic inspection of the above referenced property was conducted on April 21, 1999.
This rop e rtY is located in the SW% of the SW'/ of Section 11, T29N -R19W, Homestead
p
Lot 6, Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this
septic system was found to be code compliant for a four (4) bedroom home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
F`Rod E inger
Zoning Specialist
/sm