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HomeMy WebLinkAbout020-1347-40-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT p 7 ' Owner Property Address / .E' t k City /State N to D s 1 ' o y o (�O ;vT Legal Description: Lot ?-!4 Block Subdivision/CSM # )/Q W E '/, . /,�, T �N -R / ,Town of Al cs 'd �f PIN # O 2 _ 3 17 -4,0 -0.v PTI TAANK DOSE CHAMBER — HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC sd/ Setback from: House S Well P/L Pump manufacturer Model Alarm location i (HOLDING TANKS ONLY) Setbacks: Service road `-- Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM T yr e of Width Len L 3 7 Number of Trenches �- system: Setback from: House 40 " Well I 5 A P/L o Vent to fresh air intake // S " ELEVATIONS r Description of benchmark 4T r I L4C cog atfrg Dad ot.-6(' &a Elevation 00 Description of alternate benchmark P 6 --r Aft AN 00(. 06 A-- ;;?,7 2. Elevation oI t -ri r, Af j S " f p p 0 #I4 r 14 �o yfQ IC Building Sewer te , yC = `M• Z ST/HT Inlet 4P 399' ST Outlet t, = qq'� z PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines ( ) - 7, 03 = 11 - 51 Bottom of System () q, 7'Z = y.$-b () �• '� �' = 9� ( ) Final Grade () `� , 5` _ 1 00, 1 ( ) 4 1, = t ao I ( ) Date of installation / 0 / 60 P ermit number ; S 4/ 4 � 5`2 7 State plan number Plumber's si nature AaJ ►ft � License number Date Inspector Complete plot plan �+ I 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. K fk 1 V F— PLAN VIEW 4 1 sjnUsE �F_ LL 0 ' r ir--� ;. -- T rt r N M E 5 •• ' G Yr ` r � JI. X Y 4 Y INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: IX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344527 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MILLER, SAM HUDSON N _ CST BM Elev.:. I I Insp. BM Elev.: BM Description: Parcel Tax No.: �(5D ID 1 0-0.0 � __ S 020- 1347 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �� ZS Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet a _ 96­ TANK SETBACK INFORMATION St/ Ht Outlet SU TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 15, 65 j f NA Dt Bottom Dosing NA Header / Man. 99, Aeration NA D+ u eipe Q',(�O Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade $,25' Y L. S - 0 Manufacturer Demand 3 /D�• Model Number GPM TDH Lift Friction Syste H Ft oss Forcemain Lengt la. Fi Dist. To Well SOIL ABSORPTION SYSTEM 1z BED/TRENCH Width Length No f T nches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S I I DIMENSION �nuf r SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING I t �u: �' c SETBACK CHAMBER INFORMATION Type O , el Number: System: CPvu/- 20 5 OR UNIT Le DISTRIBUTION SYSTEM Header /Manifold u Distribution Pipe(s) _ x Hole Size x Hole Spacing Vent To Air Intake Lengtf�g� Dia. Length — Dia. Spacing 7 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,SE,SW 737 PACKER DRIVE — HOMESTEAD LOT 24 , o tlA� 4' -e— I a° V►►til c t o Plan revision required? ❑ Yes Cg No I 5 Z 6 Use other side for additional information. 3 I D 0D SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. I ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: Jij e a s e — _,._ i 3 L f i a e. a 4 __.: �_ E e _ �a e ,� ... _ _r J _ A - A -4 !14 -&-4 E I } T " AA- 1 — � � T � m - 1 - 1 3 t f x r F e r Pq eem m ,..— ... ,,.�.: ..�.... r »m ... ..: .e. ._ e _. my .. � ' t e. a �m E e 1 f 7 4 V 3 � e c � .ern .._... _.... a i .�e e a .. e 3 f z Safety and Buildings Division Vi sconsin SANITARY PERMIT TIQ`N 201 W. Washington Avenue , , P O Box 7162 Department of Commerce In accord with Comm Adm. Code Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) forth ss'tem, i4}1ot less 'Count than 81/2 x 11 inches in size. c • See reverse side for instructions for completing this a atio r ` OW State Sanitary Permit N Personal information Number y ou p rovide may be used for second � �S� y p y ry purposes � .- ST C �TM /` C eck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. f° late Plan Review Transaction Number I. APPLICATION INFORMATION -PLEASE PRINT AL �DJ RMATI --N� Property Owner Name r lit tion 1 ttL� / 1/4,S j � T 2 �,N,R / Property Owner's Mailing Address Lot Number Block Number it Q Y # Z Cit , State Zip Coe Phone Number Subdivision Name or GSM Number U II. E BUILDING: (check one) E] State Owned Nearest Public 1 or 2 Family Dwelling - No. of bedre 1� �1� , �� 111 BUILDING - USE : (If building type is public, check all that a 1 [1 Apartment/ Condo - 7 a �d� 2 ❑ Assembly.Hall 6 ❑ Medical Facility/ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sale ��ln restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park f service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Ch, ...,ox on line B, if applicable) A) 1 _New 2. ❑ Replacement 3 ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an - -- _ 'Sy!s em -- _ - - __ - System __ _________ __ Tank Only Existing System ______________ Existing System - _ - - -_ -- B) A Sanitary Permit was previously issued. Permit Number 3 y 5� - - 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)KSeepage Trench LE #e_ µ 22 ❑ In- Ground Pressure 10 , 42 ❑ Pit Privy 13 E] Seepage Pit X 7 5' 43 ❑ Vault Privy 14 ❑System -In -Fill 5 ,$ 5Q /x1E W t N .2 - L 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 4 , 0C __11 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) qc Elevation I ''L. 3 ICJ • d Feet Feet Cap acit y VII. INFORMATION in g Total # of Manufacturer's Name Prefab. Con- steel Fiber- plastic Exper. New Existing Gallons Tanks Concrete structed glass App. Tank Tanks Septic Tank r Holding Tank ' W " Vim. ❑ ❑ ❑ ❑ ❑ I p Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ 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 o Stam ) MP /MPRSW No.: Business Phone Number: IM I ►Iti` 4o t4 t! Z z �'0 3 3 l0 Z Plumber's Address (Street, City, State, Zip Code): 010 v PLOA 7 A w OsgR Wi `r w IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination r� r CON ION OF APPROV L // E NS,FOR a P VAL: SBD -6396 (R.12/99) DISTRIBUTION: Original to County, One copy To: Safety & Division, Owner, Plumber INSTRUCTIONS I 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: 1- Property owner's name and mailing .io'drzts. Provi 'e "he legal description and parcel tax number(s) of where the system is to be installed. II- Type of building being served Check c,nl,; and -c;-�-iplete # of bedrooms if 1 or 2 Family Dwelling. III Building use. If building type is public, -i,e(k 1� appropriate boxes that apply. IV. Type of permit- Check only one on line A. Con l,ne B , f 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. 'V11 Tank irifQrmation- 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 - MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans acrd 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 holdingtank(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 . f - j PWek- E7v, V E r iS o IV 13 � � K !ll D b ►�- � IT] - 7 (.F1A/C X.E -5 -- 3 7 /2 -- e#r}41 C/4--N c� c - 7 oTi¢ L. r•^ s � 1 v / __ _ v• a % Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 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 County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, an od distance to nearest road. " w Parcel LD.# 020 - 1347 -40 -000 APPLICANT INFORMATION - p/ �on. R viewed B Date Personal information you provide may be us Zr ndary purses (PrivAcll LaJ� s. 15.04 (1) (m)). Property Owner Property Location Miller, Sam ! �ovt. Lot SE 1/4 SW 1/4 S 11 T 29 N,R 19 W Property Owner s Mailing Address ^,? Lot # Block # Subd. Name or CSM# 00 P.O. Box 151 r 01 X 24 Home Stead City Stat " ,Ziq Code RAb)tWi'i'16ber ❑ City ❑ Village NTown Nearest Road Hudson WI �541.6z j9 %l7.6`` Hudson Packer Drive ❑ New Construction Use: ❑ ehtial� /Tii�rber drooms 4 ❑Addition to existing building ❑ Replacement ❑ Public o`t describe Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ftz .8 trench, gpd/ft Absorption area required 857 bed, ftz 750 trench, ft um design 4 ading rate .7 bed, gpd/ft .8 trench, gpd/ft Recommended infiltration surface elevation(s) 95.00' e ' ' ft (as referred to site plan benchmark) Additional design / site considerations Install trenches using h capacriy infiltrat rs. 196rease trench length if silt inclusion is found at system elev. while Parent material Glacial outwash Flood plain elev ation, if applic NA ft S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system M S [I U N S❑ U ❑ S❑ U ®S ❑ U [IS M U ❑ S H U SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ;Trench 1 1 0 -28 10yr3 /2 None sl 2msbk mfr cw 2f,lm 0.5 0.6 2 28 -38 7.5yr4/4 None gr.ls Osg ml aw 2f &m 0.7 0.8 Ground 3 38 -53 7.5yr4/6 None is Osg dl gw - 0.7 0.8 elev 101.41 ft 4 53 -125 10yr5 /6 None s Osg dl - - 0.7 0.8 Depth to , limiting factor , q2 >125" Remarks: 2 1 0 -29 10yr3/2 None sl 2msbk mfr cw 2Qm 0.5 0.6 2 29 -42 7.5yr4/4 None gr.ls Osg ml aw 1%m 0.7 0.8 Ground 3 42 -52 7.Syr4l6 None Is Osg dl gw elev - U. 0.8 _ 98.76' ft 4 52 -127 10yr5 /6 None s Osg dl - - 0.7 0.8 Depth to limiting factor l L 1 >127" Remarks: CST Name (Please Print) Signature: / Telephone No. James K. Thompson � 715 - 248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, 020 2/1/00 3602 1177 4 " �MPERTY OWNER: Miller, Sam SOIL DESCRIPTION REPORT »77 Page 2 of 3 1 I.D.# 020 -1347- 40-000 A.C.E. Soil & Site Evaluations Depth Dominant Color Mottles Structure C�/ftz Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz sistence Boundary Roots Bed � Trench 3 1 0 -17 10yr3 /2 None sl 2msbk mfr cw 2f lm 0.5 0.6 2 17 -32 10yr5 /4 None sil 2msbk mfr aw 2f &m 0.5 0.6 Ground elev 3 32 -44 7.5yr4/6 None gr.Is Osg dl gw - 0.7 j 0.8 97.11' ft 4 44 -92 10yr5/6 None s Os dl gw - 0.7 0.8 Depth to 5 92 -124 10yr6 /4 None s Osg dl - - 0.7 0.8 limiting factor >1 Remarks: 4 1 0 -24 10yr3 /2 None sl 2msbk mfr cw 2f,lm 0.5 0.6 2 24 -41 7.5yr4/4 None gr.ls Osg ml aw 2f &m 0.7 0.8 Ground elev 3 41 -50 7.5yr4/6 None Is Osg dl gw - 0.7 0.8 94.79' ft 4 50 -96 10yr5/6 None s Osg dl gw - 0.7 0.8 Depth to 5 96 -125 10yr6 /4 None s Osg dl - - 0.7 0.8 limiting factor >125* Remarks: 5 1 0 -16 10yr3 /2 None sl 2msbk mfr cw 20m 0.5 0.6 2 16 -32 7.5yr4/4 None gr.ls Osg ml aw 2f &m 0.7 0.8 Ground elev 3 32 -39 7.5yr4/6 None Is Osg di gw - 0.7 0.8 96.66' ft 4 39 -80 10yr5 /6 None s Osg dl gw - 0.7 0.8 Depth to 5 80 -121 10yr6 /4 None s Osg dl - - 0.7 0.8 limiting factor >1 K - 5 otX Remarks: a Ground elev Depth to limiting factor Remarks: I A-6 • to C-aixi P Leo. 6 0 V Owner: S a..r, mg resiVince Sy0 /G $eMl, w1e 7`o 10/Qf -r I4 -, d u>� S.N. Assu.► e %�` _ a SEys�Sw`y See. A, T. z9 /l 8� a.-I i c it s.r. &6,1wet dwe-e= /cc 23 R. 19 cj., ?'n. o� h(u- c,/sor►, t),T. ou,eCci = 97,310 C/'O %C eo 5.T i ilie zr 97 V / � SZS d T 2 v' 99' 5 / cp C d 7- QG V) 2 f vi E, c� M co R [� x co 'UD G ca S N CL i0 w l'J T V I tt C N .� Y+ ~ O .0 ca 0 ... �l h b U X 4 N t td N O CL gds X Co U p N G U C M N > O a) Q � cu MLT- E x. W 4 i ® ° ® Z u l Syr v ca WO � 1 ,1 :• , C D a � Safety and Buildings Division . V PERMIT APPLICATION 201 W. Washington Avenue 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 ` �� than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Property Owner Name Property Location JLLE �jE 1/4 5 W/ 1/4, SI I T 2 , N, R/ 7 E (orYW Property Owner's Mailing Address Lot Number Block Number It , Sta a Zi Coe Phone Number Subdivision Name or CSM Numbe Y II. TYPE F BUILDING: (check one) ❑ State Owned ❑ it N arest Road lage ❑ vil Ej Public 1 or 2 Family Dwelling - No. of bedrooms Town OF Vkk Q•• a III BUILDIN USE: (if building type is public, check all that apply) Parcel Tax Number(s) I I. . 19 - I S! - 19 1❑ Apartment /Condo D zo q 3 7 7e -*{ca 000 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. �g New 2 E] Replacement 3_ E:] Replacement of 4. E] Reconnection of 5. E] Repair of an TSystem________ System____ _________TankOnly______________ Existing System ________ ExlstlnqSystem 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 Seepage Trench aL r= At 14 22 In- Ground Pressure j 42 ❑ Pit Privy 13 �j Seepage Pit 2 3 X 75` S�ol Ek4W ❑ Vault Privy 14 ❑ System -In -Fill 31 . $ SQL Z 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 (s ft.) Proposed (sq. ft.) (Gals/d�/sq. ft.) (Min. /inch) �./ Elevation, TL - 3, 2 "' G " Feet 100,00 Feet Capacit VII TANK in gallo Total # Of Prefab. Site Fiber- plastic Exper. INFORMATION New Existing Tanks Manufacturers Name Concrete st ti Steel glass App. Tanks Tanks eptic Tank IdiRS XaRli I boo I E I SEP— ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ty ❑ I ❑ I ❑ 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' Signature: (No Stamps MP /MPRSW No.: Business Phone Number: © E L C. U ` Z Z $ 3 6 o/v '� Z. Plumber's Address (Street, City, State, Zip Code): ^ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved itary Permit ee (Includes Groundwater ate I ssued IssuWntS' re ( No Stamps) Approved ❑Owner Given Initial Surcharge Fee) Adverse Determination 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 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 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. 111. 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) Grog 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. j f 7- Z a l PIPE looloo t-2 D � �'f rrt • i t3' � L �. z4) rtR►V�N1 5 >><�S e J4 14 o4 TQT A L_ L x O E E E ! C c6 rz r 4) N O X r �M co O O 0 o ca d . N Q. co a U co 0 (D = F- c o 0 0) CL ci � u = a) i% �000 ~= � ° � Z. o a> x n o �ro ioE o a � -i a �ia > -2� c — c X m N 0 c V c-0 �V C o t o Ea CO c0 a) 7 Q. a) a cu N C O U) Q O J N Ll � O •� 2 U 'a jS 05 HI R 4 L! � W Po- co Li Z o � Q / V U U ® O � V) ` ® ® ® r n 0 1 U co J. ® .6, U I� z pg W w _ �v L v 3 O � o co E • t _ CU X O Q) co m co O W � An U o o ((1 c t q W c T A^ CIO W (V U r r y v� J N Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page I of 3 Divisi6n of safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not less than 8 x 11 inches In size. Plan must County hdud e, but - not - limited to: vertical and horizontal reference point (BM), direction and St, Croix pelucliEwupt; u iulcnlaluna I tit ul tit 1uw, all Id 1 vx; gku at d6ta(1t:;u to fleafetst wad. Parcel I. D.# APPLICANT INFORMATION - P1 a k 4w r'n'fa io n. Personal information you provide may be used fol purpoelPrivacy LaW,"k. 15.04 (1) (m)). RM(lviewed — Dy Dat v I Prope 1 t. f,r" 1P-roaeftv Location Mld'Eg, SAM / vt. Lot SE 1/4 SW 1/4 S 11 T 29 N,R 19 W Property Owneft Mailing Address 0 L}�t # 1 Block I Subd. Name or CSM# r I TROUTBROOK RD 24 I HOMESTEAD City State Zttp Code r City Vill age Town ldea►est Road Hudson Hudson LABARGE I . 3 Z]Aftn existn to to g bL v N Use: r7 Replacement tub=ic " ��escdbe A— Code Uenvea aairy now gpo Recommended design loading rale—i — bed, gpd1tf---L-- trel10, gPdff Absorption area required , q I bed, fF 54j- trench, ft Maximum design loading rate t bed, - trench, gpdfle Recommended infiltration surface elevation(s) as ge-r At-st'%jr r ft (as referred to site plan benchmar Additional design / site considerations Parent material /Qf5S owei 0" 9 Flood plain elevation, If applicable — S U ft 0­ A —4,. c—&— cm Corwont al C-ou -A. -Holdinfrg- Tank Guitable lbi —rsyste-111 ' r' U=Unsuitable Or system I v S S Z U Z U 0 S Z U YS C4 U I .. .... U ❑ S El Z d IS I DE S C RIPTION DEPORT Dq mW Color 11oftles. GPDfie rizon * Dominant Texture Structure lConsistence8ounda I Roots I St ... Ho. In. Mown Qu. Oz. CUIIL W101 %.711. St. fi. Bed Trench i 0-30 1 0Y V-V I Insilik JnV ?� 1 , .5 2 1 36.31 1 loyr - sbk i m i a- I C w Ground 3 391.417, O ,) p, I 5 6/4 elev 4 .70 i nn M Z 7T De* limitin f 6 � � 7 Remarks: 10 10\1f Z / I I M 5 h j< IM C w L k Ic o I F . Ground 3 o lix 413 .1 FIF7 i c/i - 1 2 Fe 1 6 v-0 1 n CLU q2,60 4 Depth to 5 j I v factor I 7 Remarks: -jCSTNiiiW(PWase Print) Signature Telephone No. Thomas C. Nelson 715-246-2454 jAddress Environmental BY Design Date CST Number Ref # 1432 120th Street, New Richmond, W1 54017 9/19/99 227397 55 PROPERTY OWNER: MILLER, SAM SOIL DESCRIPTION REPORT ss Page 2 of 3 PARcELizi Ens By De sim j Depth j Dominant Color j Mottles j Structure j I j GPD/W Horizon 1 i ' 1 p 1 Qu. Sz. Cont or I Texture G Sz 1 onsistence Boundary I Roots I Bed Trench � � I Color 1 I �: IUr ll0��� 2 I i ISI IIn5tW I'"'v slew 12 1'5 2 l j:f( or l I I I ' ►� ��u��J, 3 �.*jia r I -- I / 1205 IMFr C c.J I IIS ► � elev Y I f `t ��.. / i�� 1C c/q S O J 11 \ 1 1 r _ I � • yC s++4s !rs -' __ limiting factor 6 1 1 1 7 Remarks: A ! jb.�c�i 1o z j j j�ms i m v IC I2� C S , Ground 3 .. s f (pi 0 s I P1 I I. — I -- I, '7 ,$ 9� I ► I I I i Depth to 5 1 1 factor 6 � 7 I ce Remarks: I 5 1 p .30 }b r z/1 SI i rgofr LLJ ! ? 0" Ito r 4 '� I 15�I 1 r1 Sbu lrl r i CLJ 1 �, lev 3 `1 • S r 4 I�I — 5 b S ►"1 i elev ��� y I I I l I j 7 9° 1 I 1 4 I 1 1 I I I IIepth to 5 r r l r r ! r r I limiting factor 6 -� 7 ! Remarks: ! I I 4 I I I I f Ground I I I I I I I Im V Depth to 1 firnifin ---T— factor r I r i I I I I I i I I I Remarks: I D E 51GN ENVIg �Y 1432120 STREET, NEW RICHMOND, WISCONSIN 715 - 246-2454 PROJECT NAME HOMESTEAD LOT;, PAGE 3 DESCREMON SE 1 /4 SW Y, SECTION 11 T__ N, R 19 W TOWNSHIP Hudson COUNTY St. Croix Wisconsin b"` T �✓ n �o�rJ�' b3 , Q o � D IC N G � asT Z , 3 9 I b f 2 �-► p 6� SCALE I" = Tom Nelson BM1. Ij Cor2-h< 2 luC7 �b� �� �o+ 0 227387 BM2. k 0Q o� e�cst� ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 56¢ - !ti( !V Mailing Address Property Address - 7 3 7 Pty e- K 5 r2 1) a- E (Verification required from Planning Department for new construction)_ City/State U 0 S C N yJ 1 Parcel Identification Number C> zO ' 3 7 3 Q ` 0 0 O LEGAL DESCRIPTION Property Location e F7 % +, 1 A, Sec. � T Z N -R l� Town of HU V SO N subdivision (A a A& E 2 ZTF j !� 0 , Lot # . Certified Survey Map # ,S9 0 / , Volume Page # 3 a Warranty Deed # �y y , Volume 6C Page # Z 9 Spec house l�1'yces ❑ no Lot lines identifiable yes [I no SYSTEM / NANCE 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 licensed pumper verifying that (1) the on -site wastewaterdisposal 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 St. Croix County Zoning Office within 30 days of the three year expiration date. ATURE APPLICANT DATE .QWNER CERTIFICATION '-iti d'(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 ; described above, bA virtue of a warranty deed recorded in Register of Deeds Office. ///� TURE OT APPLICANT 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 ' � '- .. � r 1 l ; 1; 1I: � �� I.�1•r) \SIX F•1,( :>t I - t:;,z ., _ .. .... » .. �. .... , WA 'CLY DE TWS; Deed, ­.­I, L, twee1, oI1.� t „i t I ie and Sao," i R. l.il l ie, husb;,nd and t: fQ lira:•'.,,r, Ili: Ili A .aid Jam L. `tillCr, a si nr;le FE.'rsou • t;ru)tee, �% ThaL tiw >.a!d (;rautor, for a valuable cunsldcrat.un Ri'l•, •r !J co 1%, , < n, ill .uttee the fulluwu des. Abed real estate in S.t . ro 1 X t''U1.1" Male of WISCU,sul: See attached description. Tax ! arcel No: _ ............. ...... ........... FFF? TRAM Yo E� This is [lot humest—ti pruperty. ts its uotl To,t, "ti with all and rtnj; d lr the htredltaments and app irtcu..nces . reunto I — nging; Ai,d Ronald L. Willie and Nao;ni R. Millie ..:,'rant, mat the title is (;w,d, Ir.,,eie...IL:c in fet simple acd free .,1.1: il•:.,t • entumhr;..l, e; can pt easements It c and ri;hts -of -way of rz2.:Ocd, ,nd %4-!l t and defend it e �.,me. :I ;lied tin, d.ly ui `larch r7 I (SEAL) , 'Srr%C4 4- L1 t �L (aEALj Ronald L. Willie (J:.AL) / .6t °� r tom" �G. / .`/ L G <c'f- ISEALJ . Naomi R. Millie AUTHENTIC 1'PIoN ACKNOWLEDGMENT STATE OF 1`, I-z CON 51N ............. rrs. _. .... ........... ....._.. . ------ _ ..... ._.. ,�.t,. CrO12L ..... County. authentir:ued this day o +.' 19 "._ Pers unc..: cante bef-e me this .::1 ...- day of _.. `1arc;h., ly `�v -, the above namcrt ..Roclald..�.t -.W i.11ze. and.. ... .._ ....... - � 1 TITLE: NIEN1 STATE 11.%I.' <iF 11 "ISCoNSIN lI author; . by ; 7 ,ot l u -i, 11 I;. >t:,t,.) to me known t„ i,e the pi•r, -n _S. _ wim executl the furze oing instr .n,,rt and . the same. THIS •. .rNUVLN W%AS C1 -' kJ i •r\ .. .."•.• C. L. Gaylord, attorney _ 7- River Fall-s, k'I 5401 _ ic:," I';I �• ` ..k c ✓ ' couut\, Wis. I l::, I• .c he ft"th JI l'umuu Si, r. Is, pizrnl(Ini•nt. ( f ndt, .Cae t piration ..,r}.) date: ,'' ..� ..,/• / /r�' ltl �J 1t :�1:It� \71" n4:1. I1 �1•. , �It Ill' \t�l�,'II \.I\ 1 "Ic11, o. I -173 � •w .i.rr. a.0 ;'X! . A parcel of lana located in the SE -1/4 of the cy -1/4 and in part of 4 0 the St -l'4 of the SV -1 Wes / f Section 11, Township. 29 Korth, F�ngE 19 t. 7o',n of Hudson, being further described as follows: beg nning at the S -1/4 corner of said Section 11; thence Kb 29'03 "1:, along the South line of the Sk -1/4 of said Section 11 237�.39 feet; thence K02 2F '06%, 1322.62 feet, to the Korth lire of the 5 -1 /1 of the 51; -1/4 of Section F o the � ll; t.Er:E �� �C� E, alcn_ said Korth line, 244b.�4 fEEt to the Kurth -�cuth 1/4 line of said Section 11; thence S00 34'16"1:, alone said Korth -South 1/4 line, 1325.65 fEEL to the point of beginning. Parcel contains 73.32 acres ( 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 S1; -1/4 of the S1: -1/4 of Section 11 and in part of the SE -4!4 of the SE -1/4 of Section 10, all in Township 29 Kurth, RanfE 19 West, Town• -pf Hudson, being, further described as foltows: Corr.mencinZ at the S -1/4 corner of said Section 11; t? nce KE9 29'03 "W, along the S ath line of the S�: -1/4 of said Sec::_.. 2376.39 felt; thence NO2 g 26'006 1256.54 feet to the point of bEF.innini; thence continuing KG2�26'06 "M, 66.06 feet to the Korth lint of the S -1/2 of the SW -1/4 of said Section 11; thence Kb� 35'50 "6', along the Korth line of the S -1/2 of the SW -1/4 of said Section 11, 179.28 feet to the NE corner of the SE -1/4 of the SE -1/4 of Section 10; thence K99 41'39 "W, along the Korth line of the SE -1/4 of the SE -1/4 of said Section 10, 1318.24 feet to the We q line of the SE. -1/4 of the SE -1/4 of said Section 10; thence S00 25'39 "h', along said West line, 66.00 feet; thence S89 "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, 1318.32 feet to the E line of said SE -1/4 of the SE -1/4; thence 56935'50 "E; or, a line bEinc 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 heg,inning. Parcel contains 2.27 acres (96,9..6 Square FEED and is sutiect to right -of -way for town road a suLJEct to all easements of record. (Scott F.oaCj ar. T .,c fnreori- eacc °.-, ^_ t.. d 'N4 13.U' i Warless i.11 U.q' I /1 133' 4 51 (9Iq 3 U 4Jt PLATTEA LAND "W" LINE OF THE sl /x OF THE SWW ® S89'35'50 "E 2448.54' :• it�:o' xxo.op' xl CO2 •'^ — 640.00'— / y! $ I a u I 8 ' 2 1. .1665.0) n 07 20 0 31 17 A 1 94,311 !P R UID AMC$ { 42.00 Ac i0.►T1 104,030 10. FT / - (141. AC S DO ,► 1O / �., 114t,2SD O.fT.) kmol Of 16 013 J M1 i 3 1• Q7. � .�• r �•� /� .� ua ' C R 4 Ci IT.ss ^, X02 1 3, KI / C 1 aom �` �' Fes' ♦ � \ � \ l � • � •�•IS F4 1 8 YJ 49" 19 \ Il pf 1 1 — y , 5 xs. 4CRp ' ' i 17 Y 18 / 2.34 #AM .'�, / of 64330 a0. A v •�� 2.07 ACRES y1 • fJ Q k / Z W N h f l ao� SO.f[ Q.. (s 33' S3' ° -' -- - -- - .• 100.00' p •• �Z+" aY T :.:wPACKE 3 ale W �' t � w 4a. J / •••••�� �' C 1 I1 N r..._ �� 8 2� fi r, x.30 K F 26 8 /�' I 1 2 r 103,509 SIX R. � a I 3.95 ug1ES / ,�� W/ 1.97 ACRES n UID AMES t J In p 5 aw $ !0 R. N6 W2 SD. 00.527 100,679 St?. T. Ip4,290 rr / ,109 ab 'L IN2.9, 1 16x261 � 010 'O �1 loo3l z 1 (901 �— \ " 66.01 409.22' 2999.4 - 9. E L 1 V 49' , 4 1 US41 N89'29'03 2378.39' SOVTW LM OFTK SLAIN \ fI$I,% O �\ - - - Ba, SftT10M - -- RC1a� FROPO�E;` PLAT OF ,kASS RV46= -- - - - - -- - - --