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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
INSPECTION REPORT ST C RC IX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary5ejrg
Personal information you provice may be used for secondary purposes [Privacy LavA s.15.04 (1)(m)].
PerrigT1otdgK) N4knICHARD ❑ CitHO]/Alon ❑ Town of: State Plan ID No.:
CST BM Elev.:- Insp. BM Elev -: BM Description: Parcel Tax No.:
a r
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic f �U I `lBenchmark
Dosing Al l 9 Yh �, - '�. y
r ' e `
Aeration Bldg. Sewer r 3. -aa
bed
Holding Ht Inlet Y 7, r _ 3
TANK SETBACK INFORMATION ®/ Ht Outlet _
TANK TO P/ L WELL BLDG. VenAo ROAD D L I�et-
Septic %() 7(6c) Z NA m
Do ing A Header /Man. f,UJ 93.0
Aeration A Dist. Pipe M �e i i• +�
Hol Bot. System 11a o:oo
- 96 9 4 40C
PUMP/ SIPHON INFORMATION Final Grade
T� - Tz S_ �I/ . Z
Manufacturer and Sf 3. 9�
Model N UM PM
TDH Lift em DH Lrlc S st T Ft d —7—
oss Fo main Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED E Width t Length No. OTrenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM N Z0 DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER 7s0 i ���� .� .--- OR UNIT Mode Number:
System: ee-t,; J �Glp
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Z Dia y� Length N� Dia. ?2 ' 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 731 A &B BLUE JAY LANE
tf a = sf o/e d ,bld - fewer
Q2 -4. 3 z �y �' a't' CS l4 Sr Vftc �br:�f e� <cIQ} �ov�s
fS 3 } 1.1 J
P=s' 7:_ 13.G - 11 0
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
k SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
I
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
It i consin SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P O Box 7302
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. .5, Cyst X
• See reverse side for instructions for completing this application State Sanitary Permit Number
33�2�
Personal information you provide may be used for secondary purposes [ if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Proper3tg Owner Name Property Location
1 /ash 1 /4, Sagg TBlo , N, R/ 9 E (or)o
Property Owner's Mailing Address r Lot Number Number
l F Y AC ;,
City, State I Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !t Nearest Road
Public 1 or 2 Famil Dwellin - No. of bedrooms ❑vil
Town OF 16f $O'` � q, v
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. U New 2 ❑ Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5_ ❑ Repair of an
______System ________ System Tank 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 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 .Seepage Trench 22 ❑ In- Ground Pressure / 42 ❑ Pit Privy
13 ❑ Seepage Pit 3) S X S 1< 43 ❑ Vault Privy
14 ❑ System -In -Fill 5-ee_ X * h
VI. ABSORPTION SYSTEM INFORMATION: 1-7
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 14. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq.. ft.) I (Gais/day /sq. ft.) (Min. /inch) 9Go a d Elevation
� ;=a" . _0 , CO w Feet 43, 7'd Feet
Ca acit
VII. TANK in allo Total # of Prefab. Site Fiber Ex p er.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete strutted Steel glass Plastic A p p
Tanks Tanks
epticT k Ile; 1 4 T P- 4J ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamberl I I ❑ 1 ❑ 10 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) FIWWPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Z' Code):
' _ G z i
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Surcharge Fee)
�ZS Groundwater ate Issu Issuing Age t Sig ature (No Stamps)
ff ❑Owner Given Initial eo
Adverse Determination �ca !/
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 selvage 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.
ll. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number_ Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 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 all 5 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of —
Bureau of Integrated Services in acco ft#•s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1 ex nches in L'
Parcel Plan mud County
include, but not limited to: vertical and horizontal r ke poin ( tion and
� '' i 1
percent slope, scale or dimensions, north arrow, � e?ar ation a t6�8i I.D. If
APPLICANT INFORMATION - Please t allinfgfmitio :� Reviewed by Date
Personal information you provide may be used for secon p("oses (P I s. 15.04 (1).,(m) j. G I I b
Property Owner, '� . y OFFICE Property Location
r' } GLot w 1 /45tiV 1 /4,S a(p T CI,N,R E (or V
Property Owner's Mailing Address .- Lot # Block# Subd. Name or CSM#
13 -e e w
City State Zip Code Phone Number ❑ City El Village [X Town Neares oad
W o/ 10 1 4 /Y > S, -(v v !uc 4 a
New Construction Use: X Residential / Number of bedrooms Addition to existing building
Replacement p El Public or commercial - Describe: 4 S_ bed, Code derived daily flow t V o gpd Recommended design loading rate a4L bed, gpd(fi2_____Ltrench,
gpd /fie
Absorption area required / Z ,8(O bed, ft // trench,,ft2 Maximum design loading rate �� bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) – P—r i m a ry C l U Z_ d ft (as referred to site plan benchmark)
Additional design /site considerations 14Lt-. cf-ru. q0. ?_
Parent material &ICLO (11 C4 Jas Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system I Xj S ❑ U [id S ❑ U Ys ❑ U I ®S ❑ U ❑ S Ej? U ❑ S W U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
I
o -I / - ; I 1 w► GS -
Ground I Z 16y r 31 JS I CIS - 7
elev.
i6ir / — �- c\s W I CS — -
Depth to
limiting
factor
7
/ 01 in. �{
Remarks:
Boring #
1 0 r Z- - S G r- C S 1
lm qR yn
Ground j/3 d r W1 C
elev.
q3--
Depth to
limiting
factor
-7 jj_�-in. Remarks:
CST Name (Please Print) Signaturg Telephone No.
wt o- .e r 7! S - ,) ?- DU
Address Date CST Number
o r -� . ,# Sc� ref a z - 3 a Ci
I
PROPERTY OWNER
SOIL DESCRIPTION REPORT Page of
,
�
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
g Texture Consistence Boundary Roots
y� in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
J
C i L
a6 S —
Ground 3 S —
elev.
9'�n y * :: � Q j oyr -- s ascz 1141 C-
Depth to
limiting
factor
Lain. b
Remarks:
Boring #
b i a CS J-�
/ — nso,
Ground J
elev.
9
Depth to
limiting
factor
,Nb 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 #
r!j v7 V i VY� C S
Ground
elev.
q z. mo
Depth to
limiting
� f ctor
in. Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
2 ' G a rd l-,o+
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
• . Divlsian wf afety and Buildings � �� P of l
Bureau-of Integrated Services in rdn 83.09, Wis. Adm. Code
D
Attach complete site plan on paper not less than, 1/2 x 11 inche s size. Plan must County
include, but not limited to: vertical and horizon)&l ref2rence Jhit10 and l �GJ t�, St. Croix G
percent slope, scale or dimensions, north arrohv, arid location'a(1d d`44Ace to neare t oad.
arcel I.D. #
p
APPLICANT INFORMATION - Plea a tnt all � i' t.
�! ! %' v Reviewed by Date
Personal information you provide may be used for se purposec )P ri}wmLaw, s. 15. 1 (m)).
Property Owner '' , p p6 perty Location
Richard Stout r '` - . - -r•- _ ovt. Lots j6 S
1 /4GJ :2Q 1/4,S �G T ,N,R /d E (ordl
Property Owner's Mailing Address -- Lot # Block# Subd. Name or CSM#
1353 Awatukee Trail 8 Brown's Ridge
City State Zip Code Phone Number ❑ a El Village KI Town Nearest Road
Hudson WI 54016 (715)549 -6731
Hudson IMeadow Lane
KI New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 450 g pd Recommended design loading rate • 7 bed, gpd /fi • 8 trench, gpd /ft
Absorption area required 643 bed, ft trench, ft 2 Maximum design loading rate * 7 bed, gpd /fi * 8 trench, gpd /ft
Recommended infiltration surface elevation(s) Ti y l.S 1 F's ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Glacial Deposit Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system I ® S ❑ U ®S ❑ U ®S ❑ U ® S ❑ U ❑ S ® U ❑ S E] U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -6 10yr3/2 Sil 2mabk mfr cs 1F .5..6
.........................:
...........................
2 6 -3 10yr4/4 Sil 2mabk mfr .5'.6
Ground 3 3 6 10yr4/6 Ms osg ml .7 .8
Y9 lev.
�sft.
Depth to
limiting
factor
9 6 in.
Remarks:
Boring #
1 0 -6 10 r3 2 Sil 2mabk mfr cs 1F .5 .6
2111, 2 6-30 10 r4 4 Sil 2mabk mfr .5 .6
3 30- 1 r4 6 Ms I OSCT ml 1 .7'.8
Ground
elev.
Depth to
limiting
factor
9 6 in. Remarks:
CST Name (Please Print) Signature Telephone No.
&Zi llii_aimm Sbhumkker ' (71 5) 386-3121
Address Date CST Number
1070 Scott Rd Ntdsbn WI 54016 ,` �� �,�
SOIL DESCRIPTION REPORT
PROPERTY OWNER Ri nharr qtrnit Page offf—
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0 -6 10 r4/4 Sl 2mabk mvfr Cs 1F
2 1 6-9E 10 r4 6 Ms 0SQ ml
Ground
elev.
9s ft.
Depth to
limiting
factor
--9-6_
Remarks:
Boring #
1 0 -6 1
4 2 6 -9 10 r4/6 Ms Ogg ml
Ground
elev.
Depth to
limiting
factor
9 6 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 -8 1 0yr3 /2 Sil 2mabk mfr CS .5 .6
5 2 8-30 10yr4/4 Sil 2mabk mfr .� .6
3 30-99 10yr4/6 Ms osg ml .7 .8
Ground
elev.
Depth to
limiting
factor
9 9 in ' Remarks:
Boring #
Ground
elev.
ft
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
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I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address f3 s3ii✓ 2- t'w.Ye e rr
Property Address %
(Verification required from Planning Department for new construction) S �V I C•
City/State A d. E, , 1 Parcel Identification Number 0 ;2,f - 13 4 1
LEGAL DESCRIPTION
Property Location Sr) '/4, S4d '/4, Sec. ?C . T a? N -R Zy W, Town of 6 ' d so"ej
Subdivision A6bg & 4.-e— , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # 413,7 , Volume 123 Y Page #
Spec house 21 yes AL no Lot lines identifiable Uie yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restrictedplumber 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.
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, by virtue of a warranty deed recorded in Register of Deeds Office.
Qj - 0- it, (J�j ,- S" 1 /0/ q9 '
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
-581.437 , TArE BAR of ikllsCONSIN FORM 2 - 1`
WARRANTY DFIED
DOCUMENT NO U4
VOL 133 PA
rQwI)L.amt Kristine N. - Brown. as his OFPCE
R EG
--Afe- ST. CR CO., W1
co 9
n%c)s and warrams to 2 2 1998
,iic��rd 0. Stout -and_ JUN
Stout, husband and wifp_,_qs s_t vivorship narital
8:00 A
2K,?pejjy
.-,. -4 , ! 4 1'%
SPA -ESEPIED F()A
1 ,N0 �EIUAN ACII:'�ESS
the G ilou in d, scrihvd re.il estai, 1 7"Unt%.
State of Wisconsi
020 - 1 07 2 -30
EN TI F i - A C 1 4 N'_ i P - C
Pi3t part of Sec. 26-T29N-R19W described as follms: Lot 1 of Certified
Surrey Map recorded in Vol. 11 of Certified Survey '-laps, page 3036 as Doc. �o.
538112. Together with a 66 foot access easement fror:i Kinney Road to the Easterly
boundary of the above described property.
TRANSFER
FEE
is [lot
'%(KX 1, 17.01
Existing highways, easet and ri of wny of record.
dav (A June L)
C)aicd this
srAL)
�SEALI 6EAL)
AUTHENTICATION ACKNOWLEDGMENT
'�Ipal mc(O
Bute of Wisconsin,
-
d'1\01 a:
:re icf,re alc :!,I dx' o!
P
I-o !Vl'�011 S
d -w''I".]
-. 0'C -111�
MAUREEN K.
"."A, C)HAPIED BY
KISH r
Attorney David J. Es trees ;11 -
3Q4 LocusL Street., Ilij-d-,Vin
Vii
7
J41 L
C
_ lJaVa arras a Arai
y THE DISTURBAr
OF WISCONSIN
PUBLIC BODIES
3 E 2650,33'
2085.22'
s89.50'20 " 2085.75 DEDICATED TO THE PUBLIC
422.78'
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2.500 AC. c) N " a t ) � un 2.711 AC. m
N 0 M a
108,915 SQ. FT. 3 I I N :nl6 118,076 SO. FT.
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L)
006 t0 N I ¢ N
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I 66' to
• 89'2�'1�'''EZ97,llr
33.17' S89 "E 407.65' c 11-
v
AC 38.80' o
SQ. FT,
CD
o •
E LOT a N89.50'20 "W Z CD
66.09'
• 3 9
w 3.030 AC.
N ti M 131,986 SQ. FT, `
OD
w W o TWIN HOME LOT 4
C3 ti
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3 W 8
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w 3.120 AC,
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