HomeMy WebLinkAbout020-1345-90-000 ST. CROIX COUNTY ZONING DEPAR
AS BUILT SANITARY REPORT a
Owner LLf L
Property Address 7° Z P A c K_ l,XL I y E
City /State w 17 ILI
Legal Description: �S r -
Lot ' Block — Subdivision/CSM # &Y>
'l. ' /a, Sec. , . T N -R W, Town of PIN # 6 6 -13 YS - 4 10 -c am
S EPTIC TANK DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer 1,0 5 Size ST/PC / / Setback from: House - 31 Wel 7s /L 2-$
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: LE A N Width � � Length Number of Trenches
Z
Setback from: House 333' Well 73' P/L Vent to fresh air intake o =
ELEVATIONS
Description of benchmark 1 ' MID CT J I o t ' ` lm, Oa ' _ SU Elevation / 00,
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet tp ST Outlet - 7. c S PC Inlet
PC Bottom r Header/Manifold '7 7d � " Top of ST/PC Manhole Cover V , 3 0�, ,
Distribution Lines () I d ( ��� () / 1 ( )
Bottom of System O (, 5 b'�l� (I � j '
� 4 _
Final Grade () S , (O
Date of installation / V/ Permit number 3Cd Z a State plan number
Plumber's signature License number Date - k6l l l
Inspector
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
r
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z q'
INDICATE NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CR IX
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 338
Permit Holder's Name: []City ❑ Village Town of: State Plan ID No.:
MILLER, SAM HUDSON
CST BM Elev.:- F nsp. BM Elev.: BM Description: Parcel Tax No.:
/d P s 0
TANK INFORMATION LEVATION DATA A9900083
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic f ( 6 00 Benchmark D
9 a •R d
Dosing b D �Qq
Aeration Bldg. Sewer 2 "oa
c l
Holding St /Ht Inlet q 08
TANK SETBACK INFORMATION St/ Ht Outlet s �(
TANKTO P/L WELL BLDG. Vent to ROAD
Air InipdC�
Septic Z Y Fj I NA D
Dosing NA Header / Man. Z Z
Aeration N Dist. Pipe
Hol& Bot. System H 41
PUMP/ SIPHON INFORMATION Final Grade 6
Manufacturer Demand �o ej
Model Number GPM
TDH Lift Friction System TDH Ft
l oss Forcemain Length Dia. FFii Dist. To well
SOIL ABSORPTION SYSTEM a
BED RE Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN IONS DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA Manufacturer:
SETBACK /h / .1 a d
INFORMATION Type O AM Model Number:
System: v 33 OR UNIT Ld ` ca
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pi e(s) x Hole Size x Hole Spacing Vent To Air Intake
i
Length 14--r- Dia. � Length Z_ Dia. A ' ¢ Spacing /V A N -f' S
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.)
LOCATION: HUDSON 11.29.19,SW,SW 702 PACKER DRIVE — O E TEAD LOT 9
gW\ + 6-� ko6k
5 �tIrDPt`s" ' �S a ( �r4I" p�
( 0 tl auev
Plan revision required? ❑ Yes No
Use other side for additional informatj on. v q
SBD -6710 (R.3/97) Date nspector's Sig ture Cert. No.
F
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
I fiscons i n In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302
Department of Commerce Madison, WI ' 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County C �v
than 8 112 x 11 inches in size. T
• See reverse side for instructions for completing this application State Sanitary PPeerm�it Number�
Personal information you provide may be used for secondary purposes W check it 1'evision t6P, vi Ss application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Numb
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Pr pert Location
.5A LL `2,. 5U_A/4 � 1/4, S 1 T Z , N, R E (o W
Property Owner's Mailing Address Lot Number Block Number
P o x J � p 1 7 1
Citj, State f Zip Code Phone Number Subdivision Name or CSM Number
w ) 'Z 7 &ep YoW a
II. TYPE.OF BUILDING: (check one) ❑ State Owned Cit Nea rest Road
Public or 2 Family Dwelling- No. of bedrooms own o
1 f H ajoso W 4,K L(L. LVE
III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 Apartment/Condo D Z 0 / 3 0' 0 a a
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 online B, if applicable)
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an
______System ________ System _____________ Tank Only --------- _ __ Existing System ________ Exlstin System
B) ❑ A Sanitary Permit was previously issued. Permit Number 3 Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 1.C f 22 [] In-Ground Pressure � � 42 ❑ Pit Privy
13 [�] Seepage Pit JI N etlP -f c/ r� /Np IMArw *�,X 3 Y 7 43 ❑ Vault Privy
14 ❑ System -In -Fill 3 IF S S Q FT ilk e- /t 70 rAL c #AM i,e'rC. S
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
t� Required (sq. ft Proposed (sq. .) (Gals/day /sq. ft.) (Min. /inch) q Elevation
'7 S V 7,,50 3 Z /� / 9S� Feetl 10 I,ad Feet
VII. TANK
Capacit g all on s Total # of r Prefab. Site Fiber-
INFORMATION g Gallons Tanks Manufacturer Name Concrete Con- Steel glass Plastic Exper
App
New Existin structed
Tanks Tanks
Septic Tank p ❑ ❑ ❑ ❑ ❑
L ift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
[, the undersigned, assume responsibility for installation of the on site sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (N tamps) MP /MPRSW No.: Business Phone Number:
40 D 044j Z-Z so 3 60 39 ez. ,..
Plumber's Address (Street, City, State, Zip Code):
16 v E iQ .*f V R V Z404 Will _r /
IX. OUNTY/ DEPARTMENT USE ONLY
M I I ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate I ssued IssuinZAn =(No
Approved E] Owner Given Initial e 7/00 Surcharge Fee)
Adverse Determination d /<
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 IRA 1 /97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
e ,
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 isto 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 3
s Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
A.C.E. Soil &Site Evaluations
Attach complete site plan on paper not less than 8'/2 x 11 inches in size. Plan must Coun
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow,
sions n a d. St. Croix
°�10o and distance to nearest roa
Parcel I.D.#
�.
APPLICANT INFORMATION - r ` #a tidn. Re a By ate /G
Personal information you provide may be u (� ndary pu ses (P s. 15.04 (1) (m)).
Property Owner �� EI VEO ; w Property Location
Miller, Sam Govt. Lot SW 1/4 SW 1/4 S 11 T 29 N,R 19 W
Property Owner's Mailing Address e , 9 ❑ Lot # Block # Subd. Name or CSM#
Fz
Trout Brook Road ST 399 — 9 NA Plat Of Homestead
City t Zip umber ❑ City ❑ Village ❑Town Nearest Road
Hudson hV 6- Hudson Packer Drive
❑ New Construction Use: r rooms 3 ❑Addition to existing building
Replacement ❑ Pe
ub be
Code Derived daily flow 450 gpd Recommended design loading rate •5 bed, gpd/ft .6 trench, gpd/ft
Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate .5 bed, gpd/ft .6 trench, gpd/ft
Recommended infiltration surface elevation(s) 96.95 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Outwash Flood plai n elevation, if applicable NA ft
S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system ®S ❑ U M S ❑ u ®S ❑ U ® S ❑ U ❑ S ®U ❑ S ® U
SOIL DESCRIPTION REPORT
Boring# Horizon
Depth Dominant Color Mottles Structure GPD/ft
in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consisten Boundary Roots Bed Trench
1 1 0 -10 10YR3 /2 None is 2 fcr mvfr gs 2f 0.7 0.8
2 10 -21 10YR4 /2 None sl 2 m sbk mvfr cs 2f 0.5 0.6
Ground 3 21 -32 10YR4 /4 None sl 2 m sbk mfr gs if 0.5 .06
elev
99.14'ft 4 32 -48 10YR5/4 None Is O sg ml gs if 0.7 0.8
Depth to 5 48 -120 10YR6/4 None s O sg ml - - 0.7 0.8
limiting
factor
> 120"
Z'a
Remarks:
2 _ 1 0 -9 10YR3 /2 None is 2 f cr mvfr gs 2f 0.7 0.8
2 9 -20 10YR4 /2 None sl 2 m sbk mvfr cs 2f 0.5 0.6
Ground 3 20 -36 10YR5 /4 None is O sg ml gs If 0.7 0.8
elev
100.95 ft 4 36 -126 10YR5/4 None s O sg ml gs if 0.7 0.8
Depth to _
limiting
factor
>12 6"
Remarks:
CST Name (Please Print) Sign re: Telephone No.
James K. Thompson 715- 248 -7767
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, Wl 54020 4/20/99 3602 1001
PR0PERW0VMER. Miller _ Sam SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.# A.C.E. Soil &Site Evaluations
Depth Dominant Color Mottles Structure GPDIft
Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz Sh �o nsistence � Boundary Roots
Bed ;Trench
3 1 0 -10 10YR3/2 None Is 2 f cr mvfr gs 2f 0.7 0.8
2 10 -20 10YR4 /2 None sl 2 m sbk mvfr cs 2f 0.5 0.6
Ground
elev 3 20 -28 10YR5/4 None is O sg ml gs if 0.7 0.8
102.99 ft 4 28 -122 IOYR5 /4 None s O sg ml gs if 0.7 0.8
Depth to
limiting
factor
>122"
Remarks:
4 1 0 -9 10YR3 /2 None _ Is 2 f cr mvfr gs 2f 0.7 0.8
2 9 -26 10YR4 /2 None sl 2 m sbk mvfr cs 2f 0.5 0.6
Ground
elev 3 26 -38 IOYR5 /4 None Is O sg ml gs if 0.7 0.8
103.13 ft 4 38 -120 IOYR5 /4 None s O sg ml gs If 0.7 0
Depth to
limiting
factor
>120"
Remarks:
5 1 _ 0 -6 I OYR3 /2 None Is 2 f cr mvfr gs 2f 0.7 0.8
2 6 -16 7.5YR3/4 None gr. Is O sg MI cs 2f 0.7 0.8
Ground ---- 1-
elev 3 16 -72 10YR5 /4 None is O sg ml gs If 0.7 0.8
104.92 ft 4 72 -125 1OYR6/4 None strat. s O sg ml gs if 0.7 0.8
Depth to
limiting
factor
>125"
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 2201 WashingtonAvenue
Department A 41 sconsin
of Commerce In accord with iLHR 83.05, Wis. Adm. Code 0 B 3
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. • 6
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes C] Check if r to app icacion
lPrivacy Law, s. 15.04 (1) (m)). State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Pro erty Owner Name Property Location
W
�L t-154, k) 1/4 Z W1 A, S T Z f , N R /9 E (o�
Property O ner's Mailing Address Lot Number Block Number
Cg 't, State Zip Co 4e Phone Number Subdivision Name or CSM Nu ber
OsG W o8% ) 7. - 7 rr I q .0 AJ .0 S7"EI D
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ C It( Nearest Road h n
Public 1 or 2 Family Dwelling- No. of bedroom E] v OF U N e- 1/1c, �,
�
Ill. BUILDI U E: (If building type is public, check ail that apply) rceI Tax Number(s) III 2A .. 1 ISSZ.
1 E] Apartment/ Condo 0 Z d 3 7S 7O — 00
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
1V. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1, New 2. ❑ Replacement 3_ ❑ Replacement of 4. [:] Reconnection of 5; ❑ Repair of an
System - _______System _______ ___ ___ Tank Only _____________ Existing System _____,__ Existing
B) 0 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 NJ Seepage Trench 22 ❑ In- Ground Pressure 42 Q Pit Privy
13 []Seepage Pit !iiC /N ! /�M0W-. / D R W I N AW4, 43 Q Vault Privy
14 ❑ System-In-Fill a X 3� >< 7 91,
VI. ABSORPTION SYSTEM INFORMATION: 51 _2V
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
-S-0 Required (s ft.) Proposed (sq. .) (Gals/day /sq. ft.) (Min. /inch) Elevation
S 40 Z C� `� Z 9 b Feet 1 Feet
VII TANK in allo Cap (t n s Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete strutted Steel glass PlaOc App.
Tanks Tanks
e tic Tan ODD � 1:1 11 11 El 11
Lift Pump Tank /Siphon Chamber [] E] ❑ E] ❑
VI11. 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 Sta s) GftS-0 MPRSW No.: Business Phone Number:
�. S ONF_ L.C_ �' 7 is= 3g�, -g{,yZ
Plumber's Address (Street, City, State, Zip Code): Z. �'O 3 2,
1 6'7 O Nv IlV7" I Its _1
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent ature (No Stamps)
A roved Sur
Adverse Determination cfiarge fee)
"K Approved Owner Given Initial � � Oc, /�
�� �/ l
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11 /97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
1
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 isto 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 print all information.
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). eyed Date G
AAA IP-
Property Owner Property Location
MILLER SAM Govt. Lot SW 1/4 SW 1/4 S 1 T 29 N,R 19 W
Property Owner's Mailing Address Lot # BI ck # Subd. Name or CSM#
TROUTBROOK RD 9 1 Homestead
City State Zip Code PhoneNumber ❑ City ❑ Village ❑Town Nearest Road
Hudson WI 386 -8692 Hudson l LaBarge
❑ New Construction Use: ❑ Residential / Number of bedrooms 3 ❑Addition to existing building
❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate 0 bed, gpd/fts r trench, gpolfts
Absorption area required �-j 2 ) bed, ft' S" trench, ftz Maximum design loading rate 0 bed, gpd/fF - w ench, gpd/ftz
Recommended infiltration surface elevation(s) 1 7 s It (as referred to site plan benchmar
Additional design / site consideration a� 1
Parent material � o e s 5 o J cn o L) c Js d Flood plain elevation, if applicable ft
S= Suitable for system Conventional Mound In - Gro nd Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system s ®u S ®u S ®u ❑ S ®u EIS ®u ❑ S ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/fF
Boring# Horizon in Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ! Trench
1 1 0 -12 l 0yr3 /3 - sl 1 fsbk mvfr cw 2f .5 .7
2 12-47 7.5yr5/6 - s Osg ml cw if .7 .8
Ground 3 47 -120 7.5yr5/4 - s Osg ml - - .7 ' .8
elev
' e l l
�°
Depth to
limiting
factor
>120
Remarks:
Z 1 0 -18 1Oyr2 /1 - sil 2msbk mfr cw 2f .5 .6
2 18 -41 10yr4 /6 - sil 2msbk mfr cw if .55 i .6
Ground 3 41-48 10yr4 /5 c2f5yr5 /6 sil 2msbk mfi cw
elev
95 9 4 48 -124 7.5yr7/6 - s Osg ml - - 7 8
Depth to
limiting
factor
>124 r a'
Remark
CST Name (Please Print) Signature: Telephone No.
Thomas C. Nelson
715 - 246 - 2454
Address Environmental By Design Date CST Number Ref #
1432 120th Street, New Richmond, Wl 54017 8/18/98 227387 70
ENVIg ONMENTHL BY DE51GN
1432 120 STREET, NEW RICHMOND, WISCONSIN
715 - 246 -2454
PROJECT NAME HOMESTEAD PAGE 3
DESCRIPTION SW % SW %, SECTION 11 T 29 N, R 19 W
TOWNSHIP Hudson COUNTY St. Croix
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SCALE 1' Tom Nelson
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer S A W( L L_Jr�
Mailing Address
Property Address IF/Z. 4. WE
(Verification required from Planning Department for new construction)
City /State 14 U t Parcel Identification Number O Z �— � 3 y S- �! �'" c o o
LEGAL DESCRIPTION
Property Location 5 w ' /4, LL) 1 /4, Sec. , T Z'1 N -R % W, Town of u S Ol/
zSubdivision A O rK tr .IT9 D , Lot # /
Certified Survey Map # 4 I 4 / 3 , Volume 7 , Page # 3
Warranty Deed # / 2- :17 Volume , Page # v� 9
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
master plumber, journeyman plumber, restricted plumber or . a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, 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 Zoning Office within 30
� QA he three year expiration date.
F APPLICANT DATE
?:. 1ER CERTIFICATION
'-�.' I'(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
�the rop, .,described abfive. by virtue of a warranty deed recorded in Register of Deeds Office.
If
(iR KTME OF kPPLICANT 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
\IL ,; •,c STATt. bAlt (IF WISCONSIN FORDS l - 1862 " • ,•• c acn.,. • elJ:oeo.ti.J UAT♦
WA `I DE
This Deed, tll>•d, b, tw---e�t
Iona t( L. i 11 ie and
Nao; -t. R. tail l ie, husband and
l ,
liran:,r. 10:30 A.
.,nd Sam E. `tiller, a single p.ersou ,
, Gr•Intcv,
Wltnesseth, That :he :aid (;raptor, for a valuable considerat.on
eo.lv.•,+ to (:rantce the folluwu.g des. rilted real estate in S. t.,
Croi1( ec,u ru
C ,unto, State of K•Isconsut:
See attached description.
TRAWER
This is no t.. . homest.•ad property.
(i.) (Is not)
Together with all and singular the htredltaments and appurtcn•,nces .:.crruntu Gv: ,aging;
And Ronald L. Willie and 'Naomi R. Millie
uarrant, tr.at the title is good, tide fe,,.+tble in fee simple and free at,u elect ,' eneumbr:,o.es cx,:vpt
easements, restrictions, and rights -of -way of record,
.,nd %% I![ Nartant and defend tie unie,
hated tilt. day of `larch 18 96 .
(SEAL) , Nn\c 4 t� �• cti. t�i�tt (SEAL)
Ronald L. Willie
(SLAL) /':fc f <G- .� /_ c Lac (SEAL)
Naomi R. Willie
AUTHENTIcA ACKNOWLEDGMENT
Signature(s) ....- __ .... ................. STATE OF U ISCONSIN
89•
. I ......... ............. ... .......... ..........
.......S.t.. Croix ....... t'ounty. „
authepticatcd this . .....day of ......, 19..... Person:.,.; came bef�ce me this .....day of
................. ... H.A. C h., 19 96.. the above named
... _ ... ............ ..... - --
.__.......Ro.na 1.d._.L... Vii . l.ie - ..slid ..... .... - •• - - -• •
• _ _._- .- ........ ............N.aQml. ft....l?il.l .................
TITLE: JIF.SSBER STATE Batt (-F WISCONS14N .............
(If nut, -.. ...
authorized by ; 7(16.C4, 11 St:,t..) to me known t,, i,e the per -,an .S.. .... who executed the
foregoing instr .went and,.gl.kgowlcdge the same.
THIS 'V aTRUMENr WAS Oi .f .EJ IIY ter\
-C. L. Gaylord . ...
. A.t torneY
River Fa lls, ly.l, -- 54u2z Not:, \ Pill �.i...:�. "3/� l i_. County, Nis.
t11 •l,:,tLn In.. }• he -mli,vnticaud ur JlY ('011111li.0im, iyrp1krnt►thl•nt. (If`n .tute expiration
date: •> -..�:, f'y� /rJ`�: , 19 4 � )
N :\l.ItA \T5' OGt.D +f •. I. \It OF 1 %* "'n \a11 I 1::— I. Co i•.c.
tUk�l :�e. f — 17tl1 Ni,ar.Ar,•, M,.
i
J
r r- ..
A parcE of land located in the SE -1/4 of the SV -1/4 and in part cf
tF:E SV -1; 4 of the SV -1/4 of Section 11, Township 29 'north, fir }nEc 19
t►e;t. - ,Ln of Hudson, bEinc further described as follows:
bet nning at the S -1/4 corner of said Section 11; thence
237 E. 29'03';;, along the 58uth line of the Sk -1/4 of said Section 11,
23739 feCt; thence K01 2 1322.62 feet to the North lire
of the 5 of the S1,' - 1 /4 of Section 11 t�f �C c G - c�,.�
said forth linE, 2445. :4 fEEt to the North -iCuth 1/4 line�of
Section 11; thence S00 3x'16 "i:, alone said Korth -South 1/4 line,
1325.66 fEEt to the point of bEg,innirq. ParCEl contains 73.31
acres (3,13 ,674 Square feet) and subject to all ease:-,Ents of
record.
Together with and subject to an easement for ingress and egress
located in part of the fW -1/4 of the SW -1/4 of Section 11 and in
part of the SL-3 of the SE -1/4 of Section 10, all in Tounshi f, 29
h urth, RanpE 19 West, Town of Hudson, being further described as
folIow•S: COM mericin^ at the 5 -1/4 cornEr of said Sectior, 11; t� nce
NEE 29 "W, along the 58ith line of the S4: -1/4 of said Sec.:_.. '
2376.39 fErt; thence K02 26'06 "W 1256.54 feet to the point of
DEt.innint; thence con;;nuint K02�26'06 "i, 66.06 feet to the north
lin& of the S -112 of the SV -1/4 of said Section 11; thence
N69 35'50 along the Korth line of the S -1/2 of the SW -1/4 of
said Section 11, 179.26 feet to the NE corner of the SE -1/4 of the
SE - 1/4 of Secti.,n 10; thence NS9 41'39 "W, along the Forth line of
the SE -1/4 of the SE -1/4 of said Section 10, 1318.24 feet to the
Wesa line of the SE -1/4 of the SE -1/4 of said Section 10; thence
S00 25'39%, along said West line, 66.00 feet; thence S69 "E,
on a line being 66 feet distant Southerly and parallel to the Korth
linE of the SE -1/4 of the SE -1/4 of said Section 10, 1118.32 feet
to the E line of said SE -1/4 of the SE -1/4; thence 569 "E; or.
a line bEinz 66 feet distant Southerly and parallel to the Korth
line of the of the S1.' -1/4 of said Section 11, 162.54 feet to
tF,c oint of beginnint. Parcel contains 2.2i acre (Q5,9..6 c;,L�re
FEE
t� anal is sutiect to right-of-way for town road (Scott head) ana
subjEct to all easements of record.
t.
a
d
' 211.0' 11 p1 66.66' 47.64' 11141'066 16641'46'1 C •••• 1 117.66' 36'31'46• .
X11.14' ; 21�1fN1 ISI H.11' 157.14' 14441'HN 14: a 11.31 7 167,66' /T 17'46
r W."' u 64644'".666 N.M' 14.34' 1/1077'464 U1146'll'1 Ill." VIVO
117.0' asaw uft.23.5N 171.46' 1",46' U441'U66 166 4 111.11' 20
ill 111."' 0 140"'Yal 171.0' 1".46' r6 masm'U'1 1 411.66' 35
121.0' 14 uAllu.s01 40.14' ULU- 01 bU%I'N't 4 111,66' 3011
6 3'11.0' 012'31 05 66.0' 0.0' IU41'N'1 11141'11'1 � � 1 1 411.66' 21
1 . 211.0 4066'0' 1W f'1 112.26' 1M.U. u144'U'1 x141'664 1 QL11' 4ftlsH
133.11 U%#U' w41'll.s'1 U."' U.M. 11141'16 x1071'22 j Il• 1 1)).66 U074
211.0' 3ft a1 351,17' 141.11' 171 01 33.14 1 161,11' )1
w.w 4066'13 144 111.0 W." 06666 14144 31.31 1 133,11' 11
1. 611.30 6074 sulu'u.6 ums, 61.0' sN "1
(:• °3'14.0 u/0'U' 11MV4'3461° 16.13' 31:.3' 3144 "1
'114.30 14 a1 31.46' 11.11' 141075'6601 13046'464 q
111.off uOulu 111 213.71 243.11 131 115
714.0' 46 461 us.11' 131.25' U1071'14 114
UNPLATTED L ANDS
-- - - - - - -- - - -- --
"MTN 1011 or TW wt OF TIR All sev 35' 60' 1 24461.34'
470. 00' q w.00 466 so' 410.0
1 1 1104.64' -
7 3X16
am 00" A 8
100042 Iq n I � ( '064 A0111 �+f / � 2.77
42.266 K) i . *&is7 w aT aty 116.1
Y Q'j i► 11°.706 40.rL) f 4 2.23 M 1 8 t 12.4
1114,
i43 4n Ats ` / !J , aT 3M AC
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106.462 rt: ` � V. •' ^ W.432 ao . R.
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all.
so
060 1 411
13 '
is
L44 AOS/ 124
►� ,' \11 ;466 M 'T I '
.10 .,.
LID Arne / 460201
8 11440 Sa n 'y 3r I// ` /i 3
�' 2x Am"
24.2w 30
�� \
°0 N��«•w ,q /62: x,31
N 1 ' \ \ 631 as a Ito /
SAO. M' 7 1,w, \ /476 1 aL K10
.; _
4 ACRES
uw sosPC R Ir;,
ss
• am AGILE
.4 t AMT! 1, I w
4
At _
463 C L All
1 237' AOt3
A \ 113"46 >0. R .A..7� - FT-7 -•I
All V� A i
_ A2
ran $ to" \ 1 6t. w SQ rT
6'031. \ - 1414. 41' I /
W? 41' M! 3 9'
•N . IOVr14 UN[ Or T14 3MV4 ►.616!'29 03'w 2376.39'
UNPLATTED LANDS
- - - -' 7'5 'l --
LOCATION SKETCH �'