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Home My WebLink About020-1337-50-000 ST. CROIX COUNTY ZO ER AS BUII,T S RT Owner P Address v 4 4, , JV� �j City /State ti Legal Description: s' Lot _ S Block Subdivision/eSM ,(/ a '/4 '/4, Sew - ,TAN -RZW, Town of IN # B 2 0 — f ?3 7 -- � SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC /.?ov / Od Setback from: House �3 Well P/L .� 9 Pump manufacturer Aleel; Model T D Alarm location j 8i&fiE (HOLDING ONLY) Setbacks: Service ro Vent intake Water Line Meter location Alarm loca ' SOIL ABSORPTION SYSTEM Type of system: ZF2y Width s Length Number of Trenches Z Setback from: House >/� Well Z� P/L i2 • Vent fresh air intake 2MM ELEVATIONS Description of benchmark 7a.' olc A�kt- ,*yEr Elevation , o Description of alternate benchmark Tm,j e,-" &,*, 7' 1 Elevation Building Sewer ST/HT Inlet fry 2 - ST Outlet fS', o PC Inlet l�'YpL PC Bottom pA 3 Header/Manifold Top of ST/PC Manhole Cover Y�- Distribution Lines () 21.9 () Ott ( ) Bottom of System O P ? I O Q 7. ( ) Final Grade () /D/. D () A04 d ( ) Date of installation Permit ber Z_?MM State plan number Plumber's signature License number // "O Date Inspector i o, L L Complete plot plan � . ZAN I _ t�l Ny NOTICE: Plea e ovide th3%o b "wing: • : "an vie- etch sho everything within 100 feet of the system. • Two,laorizotal referen poin�S`to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW N� � i WC) s - y� ' �*AF,4 A415 I INDICATE NORTH ARROW ( \ � 4 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division Count 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)]. 338806 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: BAST, KERNON HUDSON CST BM Elev. - . Insp. BM Elev.: BM Description: Parcel Tax No.: pv / ) 020- 1337 -50 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY ! STATION BS HI FS ELEV. Septic `e_� Benchmark OS. 1 7/ Dosing Aeration Bldg. Sewer 8 Holding �Ht Inlet /p -?jg ?r, TANK SETBACK INFORMATION S Ht Outlet 0,.7 qt; v/ TANK TO P/ L WELL BLDG. Ve Intake ROAD Dt Inlet �l /g 9 3 Septic > ?.p t ' NA Dt Bottom Dosing >r� 1q2 Y Z� NA Header /Man. -g AV,6¢ Aeration NA Dist. Pipe 39• Holding Bot. System p,=a �� rg PUMP/ SIPHON INFORMATION Final Grade 2..r— Manufacturer Demand Model Number epp ®, GPM o TDH Lift Friction q S stem TDH O�Ft >; �� Loss l H Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM ti ED /TRENCH Width / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth 1 DIMENSIONS � 7.2 1 DIMEN I N SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type of CHAMBER model Number: ~ System: CQ,v OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution PtSejs� I x Hole Size x Hole Spacing Vent To Air Intake Length _[O Dia. Z it Length E = s S � Dia. Spacing L �� q(Zx1p 1 30 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 No COMMENTS: (Include code discrepancies, persons present, etc.) ' W lam ' z? �.lG ,T3 7.oG LOCATION: HUDSON 1 9. 2 19,NW,NE 988 DROVER TRAIL ,6 W4*A te Se� Plan revision required? ❑ Yes ❑ No Use other side for additional information. (o Z q 57 . �. SBD-671 0 (R.3/97) Date Inspector's Signature Cert No. r c ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: w.� w _.- - T. � I I 3 t 3 i E [ 1 - T - 1 - . E e. ° . °„ e` ✓mme °P° ° ° ° °� ... ..,. °.am° se»ne. °. °, i i x a � E MT f t FT, f � 4- - j - E f ° s e 3 � B � ° x } 7 & I °. a q mm _A..., ., 6 i x � i 6 S_ � i t ..B.. { � k t ° i e 3 € 3 E i b m e3 .... ,. ,,, e °� °. °® t ds. _ 7 m � ................ ... _.. .a..3. ,s,..., l TA ®. . °. °. ° I 3 t I � i 2 e x F 3 ,. . -,a.P. .. ._...,.m � a 3 xx Al Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 201 Box Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code 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. I sr c' • See reverse side for instructions for completing this application State Sanitary Permit Number 3J� �vG Personal information you provide may be used for secondary purposes V Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location p 61/4 A M I C 1/4, S L T N, R E (o Property Owner's Mailing Address Lot Number Block Number Z de C J ..�� City, State Zip Code Phone Number Subdivision Name or-Q9ht1T0/1f69' G S3d'16 > 2 7 75 II. TYPE F Iii (check one) C] State Owned !t� Nearest Road VII age Public 1 or 2 Family Dwelling - No. of bedrooms _ Town OF A 46PY VAI ceM III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo m20— —�Q ?A- . o - 1 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 S ❑ 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. ❑ Replacement 3 [:] Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an System ________System _____________ Tank Only______________ Existing System ________ Existing B) A Sanitary Permit was previously issued. Permit Number 33846 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 0 Seepage Trench 22 ❑ In Ground Pressure I 0 42 ❑ Pit Privy 13 ❑ Seepage Pit 3._Jl" V 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 75'0 S 97, 8 r Feet Feet Ca aclt VII. TANK in allo Total # of Prefab. Site g Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete con Steel glass Plastic App New Exist in strutted Tanks T nks Septic Tank or "W4g4ewk 2� 4V4C El 1:1 1:1 1:1 1:1 Lift Pump Tank r El 1 1:1 El El 1:1 VIII. RESPONSIBILITY g I, the undersigned, assume responsibility for installation of th onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stam ) N04UPRSW No.: Business Phone Number: 1 V-r A J I A umber's Address (Street, City, State, Zi Code): 30 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing A nt Signature (No Stamps) roved pp []Owner Given Initial SD"t'' Surcharge Fee) l00 R / Adverse Determination J 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 address. Provide the legal description and parcel tax number(s) of where the system is to be installed. It. 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. Plumper 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 inchesmust 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. &-3 I 9 ` h 10 � l A r r — DoT ,aES X — /3p�c.rc9G I � �aivv LeT' Co�cv�X 646 7 s'� r,� ►yr s. �. CO�'a +0�1J �OlQQ - - itNt� / tfzlb cLEd. = P79 ,�o7y T,Cc,vc�t�S /Q/z J PAC F c; F PUMP CHAMBER CROSS SICTICIIJ AMD SPECIFICA'riOkj5 / VEIJT CAP y' C.I, VEVT PIPE WEATHERPROOF APPROVED LOCKING � JUAICTIOIJ BOX MANHOLE COVE 4S, = R0.^1 DOOR, F sir WIMDOW OR FRESH 12 "MIU. AIR IMTAKE GRADE I I Y MIN. COUDUIT _ _ _ _ IQ 18 "M1AI. v \`� - - - -- _ -- - \ 11, IAILET PROVIDE AIRTIGHT SEAL I * ALARM a I II I o *APPROVED i oN JOINTS WITH i ELEV. FT. APPROVED PIPE —_� 3' ONTO PUMP OFF D SOLID SOIL CONCRETE BLOCK RISER EXIT PERMITTED OIJLy IF TAUK MAIJUFACTURLK HAS SUCH APPROVAL. SEPTIC E SPECIFI DOSE TA1JK5 MAIJUFACTURER: �� IJUMBER OF DOSES: 2 - PER DAy TAUK SIZE : _, GALLOMS DOSE VOLUME ALARM MAMUFACTURER: S, f , "Sca" T.eQ IMCLUDING BACKFLOW: GALLONS MODEL MUMBEu /off 4 - 1 r ) CAPACITIES: A= /T INCHES OR CALLOUS SWITCH T`JPE: !*& �G °�T g c C INCHES OR GALLO►JS PUMP MAN UFACTURER: DLlG bY C = M ATCHES OR GALLONS MODEL MUMBER: E,20 O le- D = - INCHES OR -� GALLONS SWITCH TYPE: �T sLtE�2CC�.t WOTE: PUMP AND ALARM ARE TO BE MIAIIMUM DISCHARGE RATE Ve _ GPM INSTALLED OM SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEU PUMP OFF AAIO DISTRIBUTIOAI PIPE.. S; FEET ('r - o z d` T + MIIkJIMUM METWORK SUPPLY PRE/S�SURT,E /, , , , , . , , 2r5- FEET + __t � __ FEET OF FORCE MAIN X . `.&. 1 - /pp rtFRICT10k) FACTOR.. FEET ' - TOTAL DyiUAMIC. HEAD = _ FEET IUTERMAL DIMEIJSIOWs OF TAWK: LF-KIGTH - ;WIDTH ;LIQUID DEPTH SIGIJED: / ,' LICEOSE UUMBE : • � ' R DATE: MODEL • • .04 EP0 Vertical sump Pump Submersible Effluent • • 3 i >ar,; GOULDS "= c � t ! +. o Pump specifications METE flS FEET 1 /a HP 10 MODEL: 3871 Up to 40 GPM Discharge size 1 NPT" 9 30 Solids: yd' maximum 6 25 Motor Single phase: 115V 6 20 Materials of Construction 5 Brass/thermoplastic = 4 ,5 EP05 Features and Benefits J ,° *Top suction eliminates EPO4 impeller clogging. 2 5 • Corrosion resistant construction. 0 0° ,0 2 0 30 no 5o usa+, • Float actuated switch. 0 2 4 6 0 ,° 12 m'AW CAPACITY j METERS 26 Pump Specifications Features and Benefits MODEL DVP03 4 /,6 and 1 /2 HP • EPO4 impeller- semi -open design 6 20 Up to 60 GPM with pump out vanes to protect 5 Maximum head to 32' mechanical seal. Lj 15 • E11 impeller - enclosed design z 4 Discharge size i , /2' NPT for improved performance. 3 ,o Solids: /a maximum i • Rugged glass - filled thermoplastic 5 All motors feature ball casing and base design provides bearing construction. superior strength and corrosion 0 - ° s ,o ,5 zo zs 30 3s no °.s.°PM resistance. Single phase: 115V .Cast iron motor housing for ° 2 �pppCITY e • 10 Materials of Construction efficient heat transfer, strength, Cast iron and durability. Thermoplastic Stainless steel • Corrosion resistant threaded stainless steel shaft. i • Available for automatic and manual operation. • GSA listed models available. I All Models are designed for continuous operation and feature stainless steel hardware. r - Wis oAsin Department of Industry SOIL AND SITE EVALUATION REPORT Page / of Labor and Human Relations g ? Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 17. not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. - / APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION R I BY DATE 7 PROPERTY OWNER: PROPERTY LOCATION ��/p/(/ GOVT. LOT 1114V 1/4 , 4--114,S T N,R E (qrlip PROPERTY OWNER':S MAI ING ADDRESS LOT # I BLOCK # SUBD. NAME OR£9*# r — G S xwl<& CITY, STATE ZIP CODE PHONE NUMBER [- ❑VILLAGE MOWN NEAREST ROAD �j New Construction Use Residential / Number of bedrooms Addition to existing building j J Replacement [ J Public or commercial describe Code derived daily flow 4�90 gpd Recommended design loading rate bed, gpd/f: trench, gpd /ft Absorption area required S7 bed, ft ;!:� trench, ft Maximum design loading rate bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation(s) 9 Mi ye ft (as referred to site plan benchmark) Q7. f ` Additional design /site oonsiderations Parent material Flood plain elevation, if applicable - ft S = Suitable for system CONVENTIONAL I MOUND IN ROUND PRESSURE AT -GRADE SYSTEM IN FILL 1 HOLDING TANK U= Unsuitable fors stem I J OS ❑ U j 0s ❑ U ps ❑ U S❑ U ❑ S PL ❑ S V II SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmr& 9T Ground 3 27- -' elev. l p ft. p Depth to limiting factor 2v Remarks: Boring # 2 2– 7-5�:Vl 1IRL 4k2 /F ?i+ i Ground ®Srr elev. ldF,& '? ft. Depth to limiting fact or 6 Remarks: CST Name:— Please Print Phone: Address: 30 Roger)? /?. Signat e: ate: CST Number: J` 1 D r - - 'RROPFA*OWNER JAE= SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # 9-20 — /.9A 7 — .S"V Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench p .., Ground 3 - - L S M 8' elev. G kh t — .� Depth to limiting factor 7 F2 Le Remarks: Boring # - 2 0 -- z Z s �ay.6 7 S- .s �'1cS sG ryiG i. Ground _ M4 7 Depth to -S 7 -A . C- L - - limiting factor Remarks: Boring # Ground: 3 !v S L _ elev. 3 1� ft. Depth to 0S it limiting factor Remarks: Boring # f fi Gr1� m ry oveA L mcAo a 4� L Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) le x , Ile � //� �✓l�L,C OuT GAVE Foamy pwAA K Lk eased Pork Testo & plumber #3233 #3 is Road SOT RO$EV S 3615654023 �/b A #i ,70? O �� ' F TC• / x - = 71eICXC /-/, 407E f1-% f X Safety and Buildings Division SANITARY PERMIT APPLICATION . n Ave. wiSCOnS %n Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • 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. e7. 4ffiaz)c • See reverse side for instructions for completing this application State Sanitary Permit Number 3 - 3 88oc The information you provide may be used by other government agency programs E] Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property Owner Name Property Location &l1�a 1 /4, S T , N, R E (or Property Owner's Val Iin Address Lot Number Block Number S ZQ City, State Zip Code Phone Number Subdivision Name or @5f li A- w o � > 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ itr T earest Road age Public 1 or 2 Famil Dwellin ❑ il - No. of bedrooms Town OF O ezael A2904 III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers) 14 z-9. iq I 1 ❑ Apartment/ Condo m20 — S 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] Replacement of 4, ❑ Reconnection of 5 E] 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 0Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit /Z X' 72- 43 ❑ Vault Privy 14 ❑ System -In -Fill 1,11MA 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 �v Jr d y Q Feet p Feet Capacit VII. TANK in Ca gallo s Total # of Prefab. Site Fiber- plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass App. New Existing structed Tanks Tanks ep Ic Tan k J/ F ❑ ❑ -❑ ❑ ❑ Pump Tank r .� Et I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ Vill. RESPONSIBILITY STATE M ENT AL4c o rr.*rV.A -,X' PDw N --AACA 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 St ps) MPRSW No.: Business Phone Number: �- Z•i- ! lJgO Plum er's Address (Street, City, State, Zip ode): G✓ r S' 04 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date I ssued Issuin ent Signature (No Stamps) (Approved E] Owner Given Initial oz57 Surcharge F ee) Adverse Determination Pct X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: I S004M (RA tom) DISTMUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber l 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: 1. Property owner's name and mailing address. Provide the (legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one 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 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 location f i t i n tanks; distribution boxes; soil absorption P tion s stems; replacement system areas; and the o the e bu d g 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. r • I -i r • t • DAVE FOGERTY PLUMBING licensed perk Tester & piumber #3233 #3289 Foggeerty Heights Road ROBERTS. WISCONSIN 540 Phone 749 -36 6 97 At law s / 4: 0 0 e f r/ �6t �•ST� io ' k = Bo2r.Nt'- s.7"'. L Uv 3 V .` 3o i Y e. ¢ a I ' f ' � N Fog / � �'/� C� GC /Zir•L � j�' �,��s �f /vc.,v jC�� Cl PAGE (;F PUMP CHAMBER CROSS SECT 101,1 AMD SPECIFICATIOkiS VENT CAP `"C.I. VEMT PIPE WEATHERPROOF APFROVED LOCKIRIG � Z5� F ROM DOOR, JUiJCTION BOX MAIJHOLE COVER ri WWDOW OR FRESH IZ "MIU. AIR IAJTAKE I GRADE I I `i" MIN. CONDUIT _ _ _ _ 18 "MIN. - -- - -_ 11� LkJL PROVIDE _T AIRTIGHT SEAL i { *� A { { 11{ { III ALARM a � II I i c *APPROVED i oN JOINTS WITH I ELEV. FT. APPROVED PIPE —_� 3' ONTO PUMP -� ` OFF D SOLID SOIL CONCRETE BLOCK RISER EXIT PERMITTED OIJLy IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC f SPECIFI DOSE TAWKS MAN UFACTURER : (.LUMBER OF DOSES: ` y PER DA_4 TANK SIZE : _�_/JL� _ GALLONS DOSE VOLUME ALARM MANUFACTURER: i G INCLUDING BACKFLOW: ,3 GALLONS MODEL ► J UMBER: `a ��GtJ CAPACITIES: A _ INCHES OR - 6 w - d GALLONS SWITCH T!IPE: /d.- rC.. 4 2EZ�6. B c , INCHES OR ' a GALLONS PUMP MANUFACTURER: _�s�.� Pr,Oc C = 1 4 iurNES OR jo?Q GALLONS MODEL NUMBER: __ w F_ n -3 )tj D =_LINCHES OR U_ GALLONS SWITCH TYPE: G yIi/,irra i/ NOTE: PUMP AMD ALARM ARE TO BE ell MINIMUM DISCHARGE RATE �n GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY PKESSUR , , . . . , _ --� - FEET + - FEET OF FORCE MAIN X�_:lG ' _ FACTOR.. FEET TOTAL DyWAMIC. HEAD = FEET IMTERNAL DIMENSIONS OF TANK: LEIJGTH ;WIDTH , ;LIQUID DEPTH SIGI`IED: LICENSE NUMBER: DATE: __ Performance Submersible Effluent FOGERTY PLUMBING Curves 4 PERK TESTING, INC, Pumps P.O. Box 130 ROBERTS, WI 54023 METERS FEET 100 S ERIES: 3885 30. .. ..... ... S IZE: 1 /4 * SOLIDS 1_ ._ .... �_..... �.._ (._.... RPM: VARIES ..... ....... 80 5 GPM t 5% .... .. . . . . ........ .. ......... . . ... ...... ........ . . 60 Z ......... . ...... .... .... .... i . ... .... 40 0 ..... ...... ...... ........ ..... .... .. 10- 'Z 4 20— ........ ....... 0 0 2110 40 60 80 I 100 120 140 160U.S. GPM 0 10 2 30 M3 /h FLOW RATE [qGOULDS PUMPS. INC. WATER TECHNOLOGIES GROUP SBECA FALLS NEW YDRK 13148 METERS FEET 120 SERIES: 3885 SIZE: 1 /4 " SOLIDS 35- RPM: 3450 110 5GPIA 100 30- 5 FT W 25- 80 70 20- Z 60 15 50 .......... I . . . ...... ........ 0 40 .. .. ........ ... . ........ 4 10 30 . .......... . . .. ... ... . ..... -- 20 5- ....... . . .. .......... . . .... ..... . .. . . ...... ..... . .... 0 - 0 0`10 20 30 40 50 60 70 8090 100 110 120 U.S. GPM 0 10 20 30 M3 /h CAPACITY FIFective Jul 1993 1993 Goulds Pumps. Inc. SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE. PRIN I ED IN 0 S.A. C38853.150 W. S, Wiseonsip Department of Industry S O i L AND SITE EVALUATION REPORT Page 1 of 3__ Labor and Human Relations Division of Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but St- rrni not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 020- 1020 -90 APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT ITT 1/4 NE 1/4,S 12T 29 N,R 19 - (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # I SUBD. NAME OR CSM # 948 LaBarge Rd. 9 na Gra CITY, STATE ZIP CODE PHONE NUMBER []CITY [ EfOWN NEAREST ROAD ( M cCutcheon Rd. jc ] New Construction Use [X] Residential / Number of bedrooms 3 [ ] Addition to existing building I ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd /ft2 . 8 trench, gpd /ft Absorption area required 643 bed, ft2 563 trench, ft Maximum design loading rate • 7 bed, gpd /ft .8 trench, gpd /ft Recommended infiltration surface elevation(s) 101.85 ft (as referred to site plan benchmark) Additional design / site considerations alt. site system el. = 101.6' & 100.20' Parent material o utw gh Flood plain elevation, if applicable Aa ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem 1 ® S ❑ U ®S ❑ U ® S ❑ U [R S ❑ U ® S ❑ U ❑ S CCU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed jTmnch .................. ................. .................. ................. .................. '...1...' 1 0 -14 10 r3 3 non 2 1 14-80 7. 5 r 4 4 none Cos os Ground elev. 10 5.45 ft. Depth to limiting factor 43.8 . Remarks: Boring # 1 0 - lQyr4/3 none kA I ?m Mfr 2E 2 11 -25 10 r4 6 none sl Ground 3 25 -50 7.5 elev. 4 L O-84 7. 105 ft. t'"•, `, 1 w: ,� Depth to limiting' factor + 84" - Io v i Remarks: ST CROlX -, CST Name: -- Please Print Gary L. Steel Phone: 715- 246 - 6206;'' >`'',. ZtN111`f(30SOE r`.; � Address: 1554 200th. &v . New Richmo d WI 54017 Signature: Date:1�Yurt►Uer' infl�8 5 -1 -97 PROPERTYOWNER KPrnnn Bast SOIL DESCRIPTION REPORT Page 9 of _ PARCEL I.D. # 020- 1020 -90 Boring # Horizon Depth Dominant Color Mottles Texture Consistence Baxxiery Roots Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 1 0 -15 10 r3 3 none sl 2msbk mvfr cs 2f .5 .6 2 15 -34 10 r4/4 none sil lcsbk mfr gw if .4 .5 Ground non na na .7 .8 elev. 105 ft. Depth to limiting factor + 82 11 ?jal.L` ^7 Remarks: Boring # <' 4 2 23-38 10 r4 4 none sil lcsbk mfr if A .5 Ground 138-80 cos 0SCI ml na na .7 .8 elev. 10 ft. Depth to limiting factor +80" Remarks: Boring # mfr 2f A .5 5 no ne sil lcsbk mfr gw if .4 .5 Ground 3 - na na .7 .8 elev. 10 ft. Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. Depth to limiting factor j Remarks: SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Kernon Bast 1554 200th Ave. CSTM2298 NW4NE4 S12- T29N - New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246 -6200 lot #5 -Grass Range Addn. N 1 =40' BM.= top of NW lot stake C el. 100' Alt. BM.= top of steel post C el. 106.90' I pia i �1Z W CPO y Gary L. Steel 5 -1 -97 y . ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerABwq Mailing Address Property Address (Verification required from Planning Department for new construction) City /State 1411SiVi, 4A-kr- Sllrlt Parcel Identification Number > K ?7 -. LEGAL DESCRIPTION Property Location 1 '/4, i` '' /,, Sec. / _W, Town of S Subdivision Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 5 2 :z !j s' , Volume t' N , Page # Spec house ❑ yes 0 no Lot lines identifiable yes ❑ no SYSTEM MAI 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days f the three year a pira ' n date. SIGNATURE OF AWICANT DATE OWNER 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 property described ove, y virtue of a warranty deed recorded in Register of Deeds Office. i1_GNA'RJRE OF AFWCANT 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 it `" w OOCUAtEHT NO: Tww vcs WKWVNo soy iKee DWS DA - t Ill;f t$ � Off' N�� 2-!m , Is GMCE now swr%�.Wd s R.w. wff� ��.!Ifw�Iff{fN• i� S ..w...Ti ` {' T..w..3.0 P,tfr ; .1dWfIHf ^ .3. ai..+twv •„,,,9,�,.,........ s+ �Z,.yd�1Y' -Z. T w +}rw,aT�"aWNNwjr��'a'"`f'��.� �Ilxff•. •.swwr.. _.w....e.. -w�' �1�� ' 6� . �k brYa'. yy !a., �y...� � rW� W •: + M ^ �[�f ' 2 ' w">e ^ t�_ .f+wT. TMb+ •7.MH of s �. IJ.�aRT R�' .S •r.+.wl+r».I.n........� .. 'NCH {� '.. .'• ^.±Z. it x y . �� . .u, d r� { ��.qr^ A y .Yp _ T . > �� ,�.a `�"'"' Tt•'.� i.� �n�Ifft. Rl,T+.r•+ ..... ¢.......e�- -�-"ei .a'.•. K � � R ¢ A �� N.S w y. �ppr+ 5.� Y .� K Y sa ".,�� . !4►.'�r'r a C'' F � Y �i �sywri r" 2 GZQ. 1Q39 -tQ tjp' r „ F,; 1+" .6..;.'.,- 3.41.s. ti > 8 Y ' '"ir. .r.4:'x 7c .�.: F� •I�a��;. ' d�"' l�a+Ct��q,A �d' � -f9 '�1C� ;Pr pmt � ��• ;� •in ` rte �6 t f'I+i�,a ti "'.'". f Y t 'i C •.Y - ` $s dk' }"' { +� 's?, :., $ ,+ -+ ^ u e '., f f y.� ".*` ' ' v� C!' $sue �� +� -r3'. 9XC prat o'�SOaa X lnT in Val. 9900, - �`a; ;p�� 1■ 9 a�0ag� a ao b t cy xfnn of a : 3d lands � s„. - +_S tra'.aKiy r�r'4' `.�' .� - ,f. » ,'�• s r �.. ..;«- - n• ' s s t psi stttt' ;aura for the �y , Tn•'3�'2 �` . - K c� -• ; .. -{�' � '�'��r _ �• x �" �i ' � . . - >~ , -•.te _ "r � .. {� � ;� 1�:. ��,, r.e^ t ..y. R` +'• S' +rP. .t \ V O., F "` Q- w u1z �0 / — 92 n -gy 'A O O L AGE A9 m n LO n l y �/r ��,, O x ° m I t l C1 N N r OD OD Z OD w 1 W 0 1 0 0 p N/3o 349. \ w 01143 "E p Q N M 04! 33 r I x OD, \ O I 0) 0 N l0 N 9 t0 O � ` O O W N D —� MM 0;U to c ^i �� \ -n n N 0 W O OD a C r \\ H N w I OD n O D 0 1 FA O \\ ; r cn • n ► \ w m p M w �m 0 r1i I c I \ nl \ m z 1 \� m 1 82.39' < 479.26' 1 95.00' S60 "E 824.26' o� O ocn 3 r O _ 2 LO _ 1 0 6 I - -- — - -- — v► cn z o O Vol . PG. 1 68 Z 0 A o N _ OD O v O N W RI M M - N m -4 1 N map (plat) is subject to State, County and v N OD Z N aD w �gulations (i.e., wetlands, minimum lot size, n m °= :) re purchasing or developing any parcel contact 0 3ffice and appropriate Town Board for advice. STRUMENT DRAFTED BY ED FLANUM.