HomeMy WebLinkAbout020-1349-01-000 V �
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Perm IX
33 8 9 88
Personal information you rovice may be used for secondary purp ( Privacy La s.15.04 (1)(m)].
Per itND1dQ{ ", N1{1�HARD El City �Vi Town of: State Plan ID No.:
CST BM Elev.: 1{1 Insp. BM Elev.: BM Description: tt1! 11VV Parcel Tax No.:
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TANK INFORMATION ELE ATION DATA a, tQ , e233: Zq, L ^ 7
TYPE MANUFACTURER CAPACITY ATION BS HI FS ELEV.
Septic r Benchmark
Dosing a Ud 1. 4 S�
Aeration Bldg. Sewer 3. Z 9_
Holdin 0/ Ht inlet 7 1 • 5
TANK SETBACK INFORMATION A /Ht Outlet �_s
TANK TO P/ L WELL BLDG. Ventto ROAD D et
Air Intake
Septic Z f AJ4 AJ q' NA Dt o D
DosiKL NA Header / Man. 6 • SZ 9 Y r 3
Aeration N Dist. Pipe -7fDd 50
Z
Ho g Bot. System tz L ,
PUMP / SIPHON INFORMATION Final Grade /
Manufacturer Demand
Model Nu be GPM
TDH L oss ead TDH Ft
orcemain Length Dia Dist. To well
SOIL ABSORPTION SYSTEM
Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
M I N DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of / Mode Number:
System: �� /(/� OR UNIT
DISTRIBUTION SYSTEM
Header /Man fold I, Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length � Dia. Length l / Dia. Z� z 1 Spacing J T - 2 2 2 - Z 2 1 4�
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: — HUDSO ��/jN 26.29.19,SW,SW 70 A &B / BLUE JAY LANE
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Plan revision re Qired? i Yes El No
Use other side for additio al information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code
Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. f
• See reverse side for instructions for completing this application State Sanitary Permit Number
--7 to C 1 &- r6-
Personal information you provide may be used for secondary purposes E] Check if revision 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
Tc, 1/4 .5,,�,) 1/4, S aa Tip , N, R E (or6ll
Property Owner's Mailing Address � Lot Number Block Number
G+�oc7 CC /va. i � l
City, State Zip Code Phone Number Subdivi on Name or CSM Number
u YoiG (hi s - A r -0 a4✓s
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ut Nearest Road
E3 Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF kd54P1r/ .t rve
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) �G
1 E] Apartment/ 0;2o -I � ► '
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 H New 2 ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an
______System System Only System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 E] Mound 30 ❑ Specify Type 41 [ Tank
12 Seepage Trench 22 ❑ In- Ground Pressure r f 42 ❑ Pit Privy
13 ❑ Seepage Pit C� x 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) �r J r - Q E�y ig
y, 'Yd Feet 7, O Feet
Cap acit y
VII. TANK in Ca allo
g Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existin structed
Tanks Tanks
tic T k /GSa El
1:1 El 11 Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: Stamps) MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, Stale, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Ag ign ture (No Stamps)
ge Fee) pproved [ Given Initial �a 5. j r,h,r '
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
ti
INSTRUCTIONS '
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4_ Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years. -
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
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.
VIL 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
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 siting 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.
1
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Wisconsin Department of Commerce �ND SITE EVALUATION
Division of Safety and Buildings �� Page ( of
Bureau of Integrated ServicesC�rdaflC ILHR 83.09, Wis. Adm. Code
'l e
County
t
Attach complete site plan on paper not less 6n.$ 1 1 /2 x F ize. Mari ust
include, but not limited to: vertical and hori n't*referen d t (BIVI), direct h a d St. Croix
percent slope, scale or dimensions, north a r,4w %and location a distance to ear st road. Parcel I.D. # jQ9
�......•4
APPLICANT INFORMATION - Ple�si l)? int ak4 ation. t Reviewed by Date
Personal information you provide may be used for seVonda,fy puoMWGrGr IC&w, st1-,p (1) (m)).
Property Owner ' f., -' a �, Property Location t �
Richard Stout '�;� / t� Govt. Lot 5'4! 1 /4,S i2 (r T,Z 4 1 ,N,R / y E (or
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
1353 Awatukee Trail 1 I Brown's Ridge
City State Zip Code Phone Number ❑ City ❑ Village E:X Town Nearest Road
Hudson WI 54016 (715)549 -6731 Hudson Meadow Lane
® 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 . 7 bed, gpd /ft - trench, gpd /ft
Absorption area required 643 bed, ft 563 trench, ft 2 Maximum design loading rate ' 7 bed, gpd /ft2 *8 trench, gpd /ft
Recommended infiltration surface elevation(s) % / ��� ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material G 1 a n i a l DPPo-, i t Flood plain elevation, if applicable ft
S = Suitable for system I Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for s I ® s ❑ u ® s ❑ u ER s ❑ u 13s ❑ u ❑ S KI U ❑ s )C1 u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -1 10yr3/2 Sil 2mabk mfr cs 1F .5 -.6
�7 Sd 2 10-38 1 0yr4 /4 Sil 2mabk mfr cs .5 .6
Ground 3 38 -90 10yr4/6 Ms osg ml .7.;8
elev.
Depth to
limiting
factor
9 0 in.
Remarks:
Boring # -)
1 0 -10 10 r3 2 Sil 2mabk mfr cs 1F '':5 ;.6
2 2 10 -90 10 r4 6 Sil 2mabk os I°
�roGnd
elev.
4, f ft•
AF11- Z 5_
Depth to
limiting
factor
_&)_�)_ Remarks:
CST Name (Please Print) Sig ture Telephone No.
William Schumaker (71 5) 386 -31 21
Address Date CST Number
1070 Scott Rd Hudson WI 54016 y' !f a.2 ?51
SOIL DESCRIPTION REPORT
PROPERTY OWNER Ri ehard st - )ut Page ;Z or
PARCEL I.D.#
Boren # Horizon Depth Dominant Color Mottles Structure 2
Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
3 1 0 -6 10 r
jr'7, 7U 2 -36 1 0 r4
Ground 3 36-110 1 0 r 4
elev.
/ ft.
Depth to
limiting
factor
Remarks:
Boring #
1 10-24 10 r3 2 Sil 2mabk
4 2 24-45 10yr4/4 Sil 2mabk mfr Cs .5�.6
3 48- 10 10yr4/ Ms OS9 ml .7' .8
Ground
elev.
/e ft.
Depth to
limiting
factor
1 1 O in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # 1 0-20 1 0yr3 /2 Sil 2mabk mfr Cs 1 F . 5' .6
5 2 0 -3 10yr4/4 Sil 2mabk mfr .5; .6
...........................
...........................
3 6 -1 8 10yr4/6 Ms osg ml .7.8
Ground
elev.
ft.
Depth to
limiting
factor
1 18 in. Remarks:
Boring #
..........................
Ground
elev.
ft. '
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 9,`.c.4 aied S 7-d a
Mailing Address 7` -L18e— �`G� 4/-� �• r �y6 /�
Property Address 202 A ,� R
(Verification required from Planning Department for new construction) C.
City /State G A. , - Parcel Identification Number Q --
.[5'r.✓
LEGAL DESCRIPTION
Property Location �� '/4, V '/4, Sec. G' , '1;2V_N -R Town of o l 0 0- 1
Subdivision gn w, 6 Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # S 1V `/ 3 7 , Volume 1 3.3 , Page # of G
Spec house ❑ yes J no Lot lines identifiable W yes ❑ no
SYSTEM MAINTENANCE
Improper r use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
P
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.
e sewage disposal system with the standards
e above requirements and a g spo y
Uwe the undersigned have read the q agree to maintain the privat
, im
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 of the three year expiration date.
'Gnx 77
SIGNATURE OF APPLICANT 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 above, b virtue
.�off -a warranty deed recorded in Register of Deeds Office.
QJX0-& - n.
— '5 /1 E) / ",
SIGNATURE OF 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
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the foo""m
State ^/Wisconsin.
020-1072-38
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T-'at part of q-SW- Sec 26-I29N-R19W described as follows: Lot 1 of Certified
Sucv \ Map recorded in Vol. 11 of Certified }Iaps, page 3036 as Doc. No.
538112. Together with a 66 foot uuueaa eauerent from Kinney Road to the Easterly
boundary of the above described property.
TRANSFER
FEE
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page / 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 8 1/2 x 11 inches in size. Plan must include, but c lecu
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 REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
q 40 GOVT. LOT w 1/4 S•w114,S2 T ,N,R E (orj�V
PROPERTY OWNER' :$_AILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
j� b� ?d
CITY, STATE ZIP CODE PHONE NUMBER OCITY OVILLAGE DOWN NEAREST ROAD
(�] New Construction Use [ Residential / Number of bedrooms 3 [ J Addition to existing building
j ] Replacement [ ] Public or commercial describe ..-- --
Code derived daily flow Y,S'O gpd Recommended design loading rate , 7 ed, gpdt t gpd/ft
Absorption area required 45�3 bed, ft S63 trench, ft Maximum design loading rate _ bed, gpd /ft trench, gpd/ft
Recommended infiltration surface elevation(s) 4 3 S ->I ks r ft (as referred to site plan benchmark)
Additional design / site considerations ,id0V'E�
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND 7 71aN71 7 UND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem [Ll S 0 U EIS O U S ❑ U ❑ S PU Os O U I [Is �a U
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 jTrench
Ground Z -
elev.- i
j} ft.
Depth to 9_ .) L
limiting
Remarks: 3 L 74P-
Boring #
2e 0
:.
Ground
elev. L
it.
OF
Depth to
limiting
T - 5
factor
ST 3 zv 7 s s 6 s
i V
FT VPA
NiY
Remarks: 2 T O ev r d
CST Name:- Please Print Od= .-RTf Phone: T - f
Address:
F112 Y !S 313
l Signature: /� Date: CST Number:
PROPEgTYOWNER SOIL DESCRIPTION REPORT Page .2 ofd_
PARCEL I.D. #
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
Ground
elev.
Depth to
limiting
factor
Remarks:
Boring #
?ice ........,.
Ground
elev. 2 15 L --
P ft.
Depth to
limiting
factor
Remarks:
Boring #
�tf FA
Ground
elev. Z _/ _ S 4 G S S6
_
Depth to
limiting 3 _ 7. G Gtr L �'
factor
Remarks:
Boring # -
t
Licens tKk ter & PMum er
Ground Road
ft.
elev. q Phon fto d 49.3
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
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DAVE Foam PLUMBING
Ucemed Perk Tester Z Plumber
#3233 93289
Fa arty Heig�hh Raed
ROBE S WIS ONSSI" 54023
Phne 749-3656
This instrument drafted by Michael Erickson .fob No. 95 -65
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HUMBIRD HILLS THIRD ADDITION
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N00 037102 11W / - 7 NO0 0 37 1 02"W 604.62' N00 0 37 1 02 11 W O ►-h
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Wisconsin Department of Commerce M Count v TE
PRIVATE SEWAGE SYSTEM Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST . eR%CIX
Personal information you provice may be used for secondary purposes (Privacy La K s.15.04 (1)(m)]. 338988
PerrV{Djc T'i N ff6H ❑ City_rlVillaa e Town of: State Plan ID No.:
CST BM Elev.:- Insp. BM Elev.: BM Description: tiUp 1V Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Lriction System TDH Ft
Forcemain Length oss Dia. hhii Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D IMENSIONS DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING manu INFORMATION Type of CHAMBER model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 26.29.19,SW,SW 703 A &B BLUE JAY LANE
1"
6 ,�
Plan revision re it ?
a u ed Yes No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
Safety and Buildings Division
�Sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue
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 81n x 11 inches in size.
• See reverse side for instructions for completing this application state sanitary Permit N uu mber �'�/
Check if revision to previous application
Personal information you provide may be used for secondary purposes 3 8 us a
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
Td 114s,�,) 1v4, S aa T �� , N, R E (or)�V
Property Owner's Mailing Address .�� Lot Number Block Number
Wcc7 e-e /Vu ,
l
City, State Zip Code Phone Number Subdivi 'on Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned 0 I Nearest Road
la e
9
Public 1 or 2 Famil Dwellin - No. of bedrooms Vil Town OF ofd
5,p - ,l Yde c
��
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑Apartment /Condo
0 ao - 13gj -o l �•� _ I�, I87�
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 H New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
______System ________ System_____________ Tank Only______________ Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Checkonlyone)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ( Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure ,, r f 42 ❑ Pit Privy
13 ❑ Seepage Pit Ct� 1 _� x tf I' 43 ❑ v ault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 1 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) � J rQ E v��igcl
Feet 7. O Feet
Ca Hll VII TANK in g Total # of r Prefab. Site Fiber- Exper
INFORMATION New Gaons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App Tanks strutted
tic T tk C$Q t ❑ ❑ ❑ ❑ El
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature- Stamps) MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, Stale, Zip Code):
7f - �'a A/�j ,.j !J,
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate
Ea4kpp p Issuing Ag ign ture (No Stamps)
roved O wner Fee)
Adverse Determination
Owner Given Initial �a �� / j vv,V
`G
-!
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
ARM R3Qft (R 9I IQ71 DfSTFAUTM: Original o county, One copy To: Safetv & Buildinos Division. Owner. Plurnhor
ST CROIX COUNTY
0� SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 7"-
Mailing Address ,l,�iJa 7`� yB� sue .J. Sys /C
Property Address 203 4 0 6 ,6 c �7,�, - k�wW
(Verification required from Planning Department for new construction) G
City /State V- . Parcel Identification Number 4220 r
LEGAL DESCRIPTION
Property Location 5;) 1 /, % <, Sec. N_ Town of
Subdivision Lot #
Certified Survey Map # Volume , Page #
Warranty Deed # 8 / `y 3 7 Volume /3.33 , Page #
Spec house ❑ yes no Lot lines identifiable JZ yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, journeyman plumber, restricted plumber or a 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 the St. Croix County Zoning Office within 30
days of the three year expiration date.
ktim M
I IGUX
SIGNATURE OF APPLICANT / /0 / 99
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 above, b virtue of a warranty deed recorded in Register of Deeds Office.
QX 0 t
SIGNATURE OF 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
1
Parcel #: 020 - 1348 -02 -999 05/19/2006 05:05 PM
PAGE 1 OF 1
Alt. Parcel #: 020 - TOWN OF HUDSON
Current n ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
LOTS 1 THRU 13 BROWN'S RIDGE '99 O - BROWN'S RIDGE '99, LOTS 1 THRU 13
TOWN HUDSON
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 42.184 Plat: 0134 - 13ROWN'S RIDGE 1 99
SEC 26 T29N R1 9W PT SW 1/4 Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
26- 29N -19W SW
Notes: Parcel History:
Date Doc # Vol /Page Type
01/05/1999 595123 7/35 PLAT
2006 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 04/06/1999
Description Class Acres Land Improve Total State Reason
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 12/04/1998 Batch #: PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00