HomeMy WebLinkAbout020-1349-09-000 Q
, g
0
o°
a
O
a I
I
� I
o
N
Ll
y N \ I
O y w 7
Z N =O 1i
a z 3 _
7 m O
LL O X
ct
I
Z N
rn U) = °o
2
z m m Cj w a m
N H (n
O Z
V 0 O
m Z rn c
H rn m
N U O
o K
}� N O O O
• L L m _
C 0 U t' °
O O N Q . N
Z F- z 0 Z O
N LO E c
d
m C H >
O O
Y
_ d i a� m
3 Q) o o a E
o c N N N
M 0) m F- F- F-
CL
N o N CO a) o)
N F U oo m D
'6
Q o
n!V o a� o
❑
U' �n C ) E
m n- °
c 0 0 N
m a z cr o
R
06 3
!�1 E
� O CC O LO c '2 U N > N O
°' ° 3 m a� 5 c " IL o O
o o
L 0) � U t� E C
O O
04 a) 0 • ''+ N O 3 O Cl)
00 O O O iii V
O N 2 (n Cl) O z — z lA
zi
5.
rz
a `a w
CL
,� E C d c
s
h \tab
j
:a
3
5
y'?v.
ST. CROIX COUNTY GOVERNMENT CENTER
1 101 CARMICHAEL ROAD, HUDSON, W/ 54016 715- 386 -4686 FAX
PZ@?CO.SA /NTCRO /X... US WWW. CO INTCROL WI.U5
r
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
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)]. 338923
Perr9,iftj`01{'; NICHARD El Citfifl il6l a Town of: State Plan ID No.:
CST BM Elev.; Insp. BM Elev.: BM Description: t1U� 1V Parcel Tax No.:
TANK INFORMATION ELEVATION DATA - - 0,7 p p C2
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic M� f , fd nchmark J. r7 -��
Dosi ng
Aeration Bldg. Sewer dG � )
f gg C Z �S r CJv
Holding �Ht Inlet 5• L �/ , 33
TANK SETBACK INFORMATION 61 Ht Outlet 3_ �
TANKTO P/L WELL BLDG. Ventto e ROAD D �
Septic r
> 2 0 0 , lo 1 7 " NA Dt m
Dosing NA Header/ Man.
Aeration NA Dist. Pipe 7 f f,
it
Z /0- 3
Holding Bot. System
I Z Q -1-1 i G
PUMP / SIPHON INFORMATION Final Grade -SS f2.0 L
Manufacturer Demand
Model tuber GPM
TDH Lift riction S stem H Ft
L
Forcemain Length Dia. Dist, To Well
SOIL ABSORPTION SYSTEM _
BED / E Width Length No. Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N (� r Z DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of CHAMBER r t r 7 I `— OR UNIT Model Number:
System: 4yt , z
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) a ci ?—I x Hole Size x Hole Spacing Vent To Air Intake
Length I V Dia, Length I�i Dia. 2 ?? Spang Z � � Z � 2 9 /
> Goo
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.) ;z A q • I q ' I ASS
LOCATION: HUDSON 26.29.19,SE,SW 735 A & / BLUE JAY LN — BROWNS RDG LOT 9
(J`" a� SC 0 ' P pda /r c�rGth 2 9�j g
3. '� (• k in o� c Wlrf .r0ol� ✓G .f/ c. S�/STu"'�
Pluired YesJ No
Use other side for additional information. Z 7- 2 / c 4. (p 46J
SBD-6710 (R.3/97) Date Inspecto 's ignature Cert. No
1
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
°
S
a
2 °
a
{
i
a
4
q
e
4
t
t
E
4
3
i
1
a
F °
° a
I
i.
P
i
e °.
x E °
4 P
°
i
3
1
a 3
_ a n
3 3 f
} q §
,
SANITARY PERMIT APPLICATION Safety and Washington Avenue
n
. 201 W. Washin
N V I scons i n 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 �e r-* r
• See reverse side for instructions for completing this application State Sanita Permit Number
Personal information you provide may be used for secondary purpose ❑ Check if revision to previous application
IPrivacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
C may, /e ?'" /4 XA) 1 /4, 5 a T r N, R f E (oreo
Property �' Owner's Mailing Address Lot Number Block Number
.6 L!J eG'rGl a- -e— t/«
City, tate Zip Code Ph one Number Subdivision Name or CSM Number
II. TYPE O BU ILDING: (check one) ❑ State Owned V o It( rest Road
C1 Vil age
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF G N - - c ,
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. R New 2. ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an
______ System________ System_____________ Tank Only______________ Existing System _________ExistingSystem
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 R[ Seepage Trench 22 ❑ In- Ground Pressure , t 42 ❑ Pit Privy
13 ❑ Seepage Pit C- S X 1 1 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) 8d', e.. Elevation
�6G sa // Feet 9l' 57 Feet
acit
VII. TANK in Ca gallons Total # of r Prefab. Site Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete strutted Steel glass Plastic App
Tanks Tanks
Septic T g I a n 2 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 1 ❑ 1 ❑ 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's Signature: (No Stamps) AJIPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip ode):
--,? 6 scoZ' s
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Surcharge Fee) ssue Issuing A nt Signature (No Stamps)
Approved ❑Owner Given Initial - oa /� M 17r
Adverse Determination 1 " ���
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 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.
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 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) crosssection
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 9 roundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
II h
�7 r a 62 7 - SG�%��5��/� 5',7C / Yi lQ 9 Bvb ��l �' , o �'��.J cJ ef/ - ALd s�ti
/v
j G
�S
4-�
_�
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Divisiop of Safety and Buildings Page of
Bureau of Integrated Services in accord ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x i1N t�6s in size Plan must County
include, but not limited to: vertical and horizontal refer ca� 6int (BM dAction and S � , r'o (�
percent slope, scale or dimensions, north arrow, and `
p p al�dn and d r road\
Parcel L D. #
APPLICANT INFORMATION - Please pr/�7taill informaiion. tQr18 R ie / yved by Date
Personal information you provide may be used for secondary (Priva F7/X 5.04 (1) (rrq).
Property Owner ^ " NG OfFfC Property .Location
1 i _ , W 5F 1 /4Sk) 1 /4,S, .& T q ,N,R l Cf E (or) VYJ
Property Owner's Mailing Address ( Block# Subd. Name or CSM#
City State Zip Code Phone Number ❑ Vill age Town Near st Roa
1-�-v o r W � 0 ( (7 /S > 5-Y17,& 2 ❑ city c�lso� � 1, X A.A-
New Construction Use: EgResidential / Number of bedrooms L Addition to existing building
Replacement El Public or commercial - Describe:
q
Code derived daily flow i 0 0 gpd Recommended design loading rate 7 bed, gpd /ft t__E5_ trench, gpd /ft
Absorption area required _12- D (R bed, ft / trench, ft Maximum design loading rate • 7 bed, gpd /ft 6 gpd /ft
Recommended infiltration surface elevation(s) PC, ra h/ elf-U. $g . ft (as referred to site plan benchmark)
Additional design /site considerations &g.
Parent material G (�'__ \ o. kl- 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 [9 S ❑ U ®S ❑ U [A S ❑ U Cgs ❑ U ❑ S [4 U ❑ S ® 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
10 3A S I
Ground o S s vv) C� 7
elev.
92 y uz -� 1 -4/0 — M a s w► 1 S -- . 7 .
Depth to
limiting
factor
11rin. I I $ �+'
Remarks:
Boring # '.
o - 10 1 0 y r L _ s. 1 W.a 6 k r i
o� Z o3 O r /� — � l ab yv�-�r C — ,�
3 31' U r _ S r, L �--rn-bk YY 1
Ground y y 1 � yyl OS tM CS ,
elev .
Depth to
limiting
factor
600 in. Remarks:
CST Name (Please Print) Signature Telephone No.
Addr ss Date CST Number
7
PROPERTY OWNER — n c � 4 SOIL DESCRIPTION REPORT Page - J-- of
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 Z 16 hA
Ground 3 ZO- iovr4 — S rn 1 e�s
elev.
Depth to
limiting
factor
Ila
Remarks:
Boring #
C, -r lay r 311 - S,' ( 1 m a b -� r- a- I - . e- ..�
t U rS /`1 — - ;,S &I r-
Ground 7 l OS m 1
elev.
9! Y-1 Lr
Depth to l
limiting f�
factor
/o 1 in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence k o unday Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # _ o - — S i 7 vn m c- Grrouundd / j MS Q 7
elev.
Depth to
limiting
factor
/OZ. i Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
h� �S f - L crf - �1
JIM ev 76 Off"
Q a , �vc o: 0 ,
8
8S K
v
mot. ,Q.cAC cis
p �t'Mct r.� IQ-f.Q� I
I
v
SOIL DESCRIPTION REPORT Pa 2
PROPERTY OWNER Richard Stout e of g
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 -18 10yr3/2 Sil 2mabk mfr cs 1F .5'.6
2 18 -48 10yr4/4 Sil 2mabk mfr
Ground 3 48 -98 10yr4/4 Ms os ml
elev.
9 ff" — j!! L-f ff.
Depth to
limiting
factor
9 8 in.
Remarks:
Boring #
1 0 - 1 10 r3 2 Sil
2mabk 1P
4 2 18- 8 10 r4 4 Sil 2mabk mfr
3 48- 8 10 r4 4 Ms
Ground
elev.
Depth to
limiting
factor
9 8 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 0-113 1 0yr3 /2 Sil 2mabk mfr cs 1 F
.5 . 6
5 2 18-48 10yr4/4 Sil 2mabk mfr .5; .6
3 48- 10yr4/4 Ms 0Sq ml ,7',
Ground
elev.
fC�Qft.
Depth to
limiting
factor
9 8 in. Remarks:
Boring #
..........................
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
� v c
;2 , G GJ. I /.�'1`/� z / z %CCU, �
. , f k & ZJ , `72 L rA %t to S
SGa�
`I V
i
f ,
I �
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer /91 c G e-r d
Mailing Address /? 5 .�r�k
Property Address
(Verification required from Planning Department for new construction) S(NLC_
City /State .L Parcel Identification Number el t20 L? 1 - 0 �l
LEGAL DESCRIPTION
Property Location ,'% V4, V4, Sec. aa' , T W -' N -RAW, Town of ,/ "d.�a.�/_
Subdivision � 4- s oP' , cA-41-9 , Lot #
Certified Survey Map # _ , Volume . Page #
Warranty Deed # Ste/ 4" 7 , Volume 133 , Page #
Spec house ❑ yes IR no Lot lines identifiable A] 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 roP e rh' owner a g re es to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
P �
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
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.
E / /�/
SIGNATURE OF APPLICANT
DA TE
* * * * ** 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� �~��
VOL JL'�'�.�Mk /1)
w�;�
STATE BAR uFmScowsn poxw 2- 1982
^^`^°^"`^�-' wuunAwTY ocso
DOCUMENT NO.
'_[auid �l {zers-0o__._-_-__--__-__' -^--�
------------�--------'--------'- ---------- -----��- S/ �N� CO WI
-
CRUX
------------- -- ---�------------------��'- r
,"".os and ",,,,.x°."-_�1�� 3�uu� �UN2 2 1998
����� ��e � am�������L----- O'OO A
-_ . M ,
_�c���cc� ---------'------- '
-- -----'-----�------- U ��.K�.. �} j
--------''---------- ------- -�----------------- Rej;:416f of Deeds
-------------------'------------------------�---�--' -..�SPACE oesy"^o ~OR nEco^�., 3'.^r^
------�----'-- ------ __-_-'____-___ ~-,"n"^zu°Es
'hcuk`mngJm'n|vJnu|uu/,.n_ St^, / Croix Couui/
��x:b�/
�,u"(w,,wm" ^
That part of S- Sec. 26-T29N-B19Q described as follows: Lot 2 of Certified
Survey �p recorded in Vol. 11 of Certified Sucvey �|aps, page 3036 as Doc. �o, '
53811' - . Together wi a 66 foot access eaoetoent from Kinney Road to the Easterly �
!
boundary of the above described property. `
TRANSFER
FEE
`.
`
�
mis -_ =``` �»uo jp�`p
xzo '^ �
c^'p^*�""onzmxcs 8xiotin 6i�-hwuys, easements and ri�hts of way of record.
~�
96
Dated 'xu a June A /q q&
(ssAo ocAu �
-David
�
ocAu -----_� (SE-ku �
'
^ ~
^
auTosNr/CATI0N Acmnov/LsocxxsNr ^
'`~^~ of -^'``'-'''
�
=owv/uouu.,.u""/ m us~c^|� ���' ^"hu "x this u^/ Of
June ,�e above =ned
- ---� - ---- - �---- 11^�du a q -- _
n/nu'wmn,u/c BAP orm'�u`*';Iw
70(- 0(, xI< � �
/
� uccucney David J~ cstree�/__
�V+I�x�us���cr�e�, �u�aon, \J ��[�(.u���Y
r /^^
'~�`~2 1 1 ,^
F _
i 1.0 . 'b L u/'a 1 • a... ... ... • ....r
- -.- -- - - - - - - - - - - - - - - - - -
THE DISTURBAr
OF WISCONSIN
PUBLIC BODIES
9 E 2650.33'
2085.22'
S89 2085.75 DEDICATED TO THE PUBLIC
— — —
— 4 .
. �5fi69'
422.7$'
............... ......
� 12'- -I j---� W I
i s c o l � i
.� w I 10
cu
2.500 AC. m
00 2.711 AC. m
108,915 SQ. FT. 3 a N SIN 118,076 SQ. FT, N
Wo w
F� ' I I u
5 � 0 6- � N U ih
l I ¢ I a
CD — — — — —Z 6
LO
• 89'24'12r'EZ9711' - "
33.17' S89'50'20 "E 407.65' c 11-
AC t�
SQ. FT, c 38.80' o
0 o
E LOT N c
N89 "W Z
3 66,09' 9
3.030 AC.
N N M 131,986 SQ, FT, 00
W o TWIN HOME LOT
Z cu
W W
0 0
V �*
� � 8
3 W
3.120 AC,
X ~ 135,892 SQ. FT. 182.94'
4.
w o TWIN HOME LOT N N89'09
°
w Z (S89'10
✓ �-►
Z .-.
J J A £
�' ND cP
14J CD
3
;T❑RM WATER '-
RETENTI ❑N A EA 3
H.W.L. = 005,0 W
5 ' 288 o LOCATIO-' .
166,2 ' o
EN CH IV7 �' ? SECTIOA
MARK 6 S6 �
DATUM 929 1,'' 619 2 3.72
15
4 ,00'
s�
Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: IX
Personal information you provice maybe used for secondary purposes (Privacy La x.15.04 0)(m)J. 338923
PernziUjRfts NW CHARD ❑ Cat [] Town of: State Plan ID No.:
CST BM Elev. Insp. BM Elev.: BM Description: U U1V 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
TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet
Air Intake
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 Friction System TDH Ft oss
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D IMENSIONS DIME N 1 N
SETBACK
SYSTEM TO P/ L BLDG I WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type of CHAMBER Mod 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
F ver Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
ench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 26.29.19,SE,SW 735 A &B BLUE JAY LN — BROWNS RDG LOT 9
r"
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 fR.3/971 Date Inspector's Signature Cert. No
r A /� A � A te/. .,�1 d •�_
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
isl>co
Department of Commerce � In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302
v vv - 1 "��8 / Z ' 1 ,11 Madison, Wl 53707 -7302
• Attach complete plans (to the county c only) for the system, on paper not less County ,
than 8 112 x 11 inches in size. 57'_e rA Y
• See reverse side for instructions for completing this ap lication State Sanita5Permit Num ber
Personal information you provide may be used for secondary pur oses ❑Check if revision t Ope( Z 3
p o previous application
(Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
51/4 XA)1 /4, S o2 ,�- T . 10 1 , N, R f E (ore/
Property Owner's Mailing Address Lot Number Block
Number
,3 7� A l li e, 102e R a m ,tea l
City, tate Phone Number Subdivision Name or CSM Number
j-d c jZipCod ( > gy p,.
Y F B ILDING: (check one) [I State Owned ✓ ❑ It Barest Road
❑ Village
Public 1 or 2 Family Dwelling No_ of bedrooms Town OF G ,8� a c .* c
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo C 2.o — " I �' l 4q — 09 —DOD/ /
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. R 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: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 05eepage Trench 22 ❑ In- Ground Pressure , t 42 ❑ Pit Privy
13 ❑ Seepage Pit i /- S X 113 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) gd' %T Elevation
1 0 ! jl. //,3 Feet 9� �SFeet
Capacit
VII. TANK in allons Total # of r Prefab. Site Fiber- Expev
INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete st con Steel glass Plastic App
Tanks Tanks
Septic T g nk f/ ❑ ❑ ❑ ❑ 1 ❑ __L_4 _d
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
IQ —I
Plumber's Name: (Print) Plumber's Signature: (No Stamps) / PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip 11 ode):
d�lJ C: o �d1 Sr o �v . ri
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Datelssued Issuing A nt Signature (No Stamps)
Ap / Surcharge Fee)
pp ❑Owner Given Initial ��,� oa �� t l I
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD 6398 (R_11/971
DISTRIBUTION: O to County. One copy To: Safety & Buildings Division, Owner, Plumber
�
r pr I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address _ l? ,:5 3 , Z 2 /C� g S r - 40 <` a !6
Property Address 73 u
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number OHO- 12�l D 9
LEGAL DESCRIPTION
Property Location _,5A-. ` /4, '/4, Sec. aC , T Q N -R. W, Town of A,"
Subdivision oj:�!± Lot #
Certified Survey Map # , Volume . Page #
Warranty Deed # Ste/ Volume /333 , Page #
Spec house ❑ yes IR no Lot lines identifiable 0 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.
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