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Wisconsin Department of Cgmmerce
Safety and Buildings DivisioR PRIVATE SEWAGE SYSTEM y:
ri , Count
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 353277
Permit Holder's Name: ❑ City ❑ Village ❑ Tj@wn of: State Plan ID No.:
aulton Ron I Town of Hudson
CST BM Elev.:- Insp. BM Elev.: 7 Description: Parcel Tax No.:
tv-&* I = 020- 1320 -00 -000
TANK INFORMATION ELEVATION DATA y4• i ��
TYPE MANUFACTURER CAPACITY STATION y _ s ,,)BS HI FS ELEV_
Septic [ lZ� gITV Benchmar �) 2,a-o 1 ,2
Dosing - - - Alt. BM
Aeration Bldg. Sewer X
r
Holdi St/Ht Inlet. g
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet
Air
Septic >too � f -- NA Dt Bottom 2(.95 $b - }S
Dosing �` NA Header / Man. 4 a s 9Z - ?s
Aeration NA Dist. Pipe I g o.bo
Holding Bot. System 3
r -
3 � — $8•RS"
PUMP SIPHON INFORMATION Final Grade
Manufacturer and St cover
Model Nu er GPM
p ;s TDH Lift L S TD
Ft 47g/. �3
F ain I Length/L(IZ I Dia. Dist. To Well
SOIL TION SYSTE 5 ¢� (Z • �/� ( �;� (Z - `f `F —
��
TRENCH Width r Len th No. Of renches T No. Of Pits Inside Dia, Liquid Depth
D IME DIMENSION
SYSTEM TO P ! L BLDG WELL LAKE / STREAM LEACHING Manua tur r:
SETBACK CHAMBER
INFORMATION Type Of e Num er:
System: t� 's OR UNIT twc
DISTRIBUTION SYSTEM
Header / ganifold a Distribution Pipes) �Hoie iz e x Hole Spacing I Vent To Air Intake
Length Dia. Length Dia. Spacing
a
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only o }
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.) Inspection # : 0/ F/ ,I ;��c�pn #2: `I✓ /5 /CID
Location: 726 Crosby Ro d, Hudso DWI �40 6 (NW1l4 SW !4 28 T29N R19W 8.29.19. 6 cr
1.) Alt BM Description = S e- f &&t-v
�- 3D
2.) Bldg sewer length= N
- amount of cover = p �, ., I � t a
_ ...
- s
a"n�revl Ibn required? ❑ Yes N 03 /Z o3
Use other side for additional info r ation..
s
SBD -6710 (R.3197) D tr ""L (T, -?tg�p Inspector's Signature Cert - No.
I�
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
TT
141
-4- -44
1
F 3
a (
1 4
3 F
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4 -4
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_M.��,......- 4..,.F.�.. e..a„ _..,.......�.#�_....m, - ......- 1......,
Vi sconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
P o Box 7162
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162
• 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. r (ti
• See reverse side for instructions for completing this application ,.; : , tate Sanitar,,y Permit Number
353 a�-�-
Personal information you provide may be used for secondary purposes Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
-= St3te Plan Review Transaction Number
I. APPLI ATI N INFORMATION -PLEASE PRINT ALL INF RMATION
Property 95kner Name Propert Location
ilJatlA �j tA.L1i4, S a �j T Z , N, R /I Ajor) W
Pro rt� wner's Mailing Ad ress Lot Numb Block Number
City, Stat Zip Code f Phone Number Subdivision Name or CSM Number
O, D oZ ( SI` /_— i2s
11. TYPE BUILDING: (check one) State Owned ❑ !t Nearest Road
Public 1 or 2 Famil Dwellin - No. of bedrooms ° Tow OF
III BUILDING SE : (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 1 Q 0� a 6 —0Q
2 ❑ Assembly Hall 6 [] 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 PERMIT: (Check only one box on line A. Check box online B, if applicable)
A) 1 qew m 2 E] Replacement 3 E] Replacementof 4_ C7 Reconnection of 5_ [3 Repair of an
- ------ -------- System _ _________ _ __ Tank Only______________ Existing System -------- Existing --- - stem
B) A Sanitary Permit was previously issued. Permit Number 351 Z4-r - t Date Issued I 9
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 n T 43 E] Vault Privy
14 E] System-In-Fill / = 6 3 "0 1 ,
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Ele final Grade
Required (s ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) l le on
7 3, 4- ee Feet
aclt
VII. TANK in Ca allons Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks I - f
Septic Tank or Holding Tank ^ l 00 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 061 ❑ 1 ❑ 1 ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb s a e' (Pri t) Plum 1 /MPRSW No.: Business Phone Number:
&7,t40 ,.
a O
Plumber's Address (Street, Cit , State, I Code):
IX. COUNTY / DEPARTMENT USE ONLY
I - [:] Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued issuin p Agent Signa re (No Stamps)
K Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination ILP --&— D Gb \
X. CONDITIONS OF APPROVAL / R FOR DISAPPROVAL:
QX 40 C,� S� 4
SBD -6398 (R.12/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary for 2 years.
p ermit is valid o two a
Yp Y
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 oe 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.
i
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 sizing information.
-- ---- - ----- ----- ----- - ---------- ----- - ---------- -- -------------- ------------------------------------
GROUNDWATER SUR�HARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practijces which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
I Sf0-^ 11 4kky f > —t -`. � tA
Safety and Buildings Division
Ai sconsi � _ SANITARY P ERM {T APPLICATION 201 W. Washington Avenue
P o Box 7162
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the system, on paper not less Count T
than 81/2 x 11 inches in size. 1
• See re erse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ! Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)).
State Plan Review Transaction Number
I. APPLI ATI N INFORMATION - PLEASE PRINT ALL INF RMATION
Property,OAner Name Property Location a
N tU. /4 5 LU 1/4,S p� �j T , 1 p , N, R / '? k(or) W
Pro rt6Owner's Mailing Ad res Lot Numbgt , ` Block Number
city SStat / zip Code Phone Number Subdivision Name or CSM Number
11. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road
Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 7
III BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s)
1 ❑ Apartment/ Condo 6 o g 3t7 —
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. hNew 2 ❑ Replacement 3, E] Replacementof 4_ C] Reconnection of 5. (] Repair of an
- ______ystem ________ System __________ ___ Tank Only Existing System Existing System
B) A Sanitary Permit was previously issued. Permit Number 3� Date Issued 1Z � 2 1
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 _ f 1 43 ❑ Vault Pnv
14 QSystem -ln -Fill — 7, 7' /y 3 �, ; 761 A
VI. ABSO RPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Ele . Final Grade
p� Required (s ft.) Proposed (sq. .) (Galstday/ A. ft.) (Min. /inch) �r l 1e17ation
V 7S0 f 63, c2 Feet
Cap acit y
VII. I NFORMATION in gallo Total # of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper.
New Existin Gallons Tanks concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank , (,� "" /7oQ J ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 0_0 ❑ ❑ I ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1 the undersigned, assume responsibility for in tallation of the onsite s wage system shown on the attached plans.
Plumb a e' (Pri t) Plumb 'Sign ture: ( /MPRSW No.: Business Phone Number:
/
Plumber's Address (Street, Cit ,State, I Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitarf Permit Fee (Includes Groundwater ate ssue Issui Agent Signature (No Stamps)
o Approved E] Owner Given Initial Surcharge Fee) ` ,, f]
Adverse Determination
CC) X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (RA2I99) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS ,
1. ni r permit is valid for two 2
Asa to ( ) ears.
YP Y
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 s<iptic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimenta 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 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.
I
Bridgeland Dev. co.
NW�,$W� 828- T29N• -RM _
town of Hudson
lot #24 -St. cRoix E First Addn..
r N
i V =401
1 EM.= top of 1" pvc pipe el. 1 00.00 '
Ait. DM.= top of tel ped(large) @ el. 100.801
lei
O ,._
�' 910
_w �
m4- 1�
/,R goo
go
(,tee w S � A �� Pa�c
Wisconsin Department of Industry, S AND SIT E V A T I O E P O R T Page 1 of 3
Labor alkuman Relations
D ivision or$afety & 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
St. Croix
not limited to vertical and horizontal reference point (BM), direc>(ie9raad, %o of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance t e<stl,rga 020- 1320 -00 -000
APPLICANT INFORMATION- PLEASE PRIRTr 4�NFO NATfON R VIEWEDBY DATE
PROPERTY OWNER: PROP `ERTY LOCATION
Bridgeland Dev. Co. `, GOVT. LOT NW 1/4 SW 1i4,S28 T 29 ,N,R 19 E5(or) W
PROPERTY OWNERS MAILING ADDRESS r e ? LOT # BLOCK # SUBD. NAME OR CSM #
11736 117th. St. ]. 24 na St. Croix Estates First Addn.
CITY STATE Z IP CODE ,'PHONE NUMBPO ' ❑CITY [ ®TOWN NEAREST ROAD
Lakeville, MN. 55044 (612098w5QWi --,,L: I Hudson Crosby Dr.
fc] New Construction Use [ Residential/ Numb6r ottmq o * [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial descri '_ f
Code derived daily flow 600 g pd Recommended design loading rate • 7 bed, gpd /ft ' 8 trench, gpd /ft
Absorption area required 8 58 bed, ft 750 trench, ft Maximum design loading rate • 7 bed, gpd /ft • trench, gpd /ft
Recommended infiltration surface elevation(s) starting @ 95.90 ft (as referred to site plan benchmark)
Additional design / site considerations trenches 3150' below grade loweer trench 4.50'below grade
Parent material outwa h 3' S9 Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem k7 S El ❑ S ELI E3 E3 ❑ S ® U LA ❑ U ❑ S ® 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 Trench
.................
..................
.................
..................
1 0 -34 10yr2 /2 none 1 lmsbk mfr c,•w if .4 .6:.
1
2 34-4S 10yr4 /4 none sil 2csbk mfr gw if .5 .6
Ground 3 49-985 7.5yr4/6 none ms Osg ml na na .7 .8
elev.
94 ft.
Depth to
limiting
factor
q
+98"
Sao .
Remarks:
Boring # 1 0 -9 10yr3 /3 none 1 lcsbk mfr gw if .4 ' .5
U 2 9 -21 7.5 r4/4 none sl 2mgr mvfr gw if .5 .6
3 21 115 7.5yr4/6 none ms Osg ml na na .7 .8
Ground
elev.
9 4.9 ft.
Depth to rr
limiting 8 � t) fro
factor
+115"
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200 ve. New R4cWond, WI 4017
Signature: Date: 3 -16 =2000 CST Number: m02298
PROPERTY OWNER Bridgeland Dev. Co. SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # 020- 1320 -00 -000
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounokry Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -6 10yr4/3 none sl 2mgr mvfr gw if .5 .6
3
2 6 -88 7.5yr4/6 none ms Osg ml na na .7 .8
Ground
elev.
9 8.1 ft.
Depth to '
limiting s
factor
+88 --
Remarks:
Boring #
1 0 -9 10yr4 /3 none 1 2msbk mfr yw if .5 .6
4 2 9 -22 7.5yr4/4 none sil 2msbk mfr gw if .5 .6
3 22 -33 7.5yr4/4 none co s Osg ml yw na .7 .8
Ground
elev. 4 33 -88 7.5yr4/6 none ms Osg ml na na .7 .8
9 9.4 ft. —
Depth to -
limiting
factor
+88
Remarks:
Boring # 1 0 -9 10yr4 /3 none sl 2myr mvfr gw if
.5 .6
5 2 9 -86 7.5yr4/6 none ms Osg ml na na .7 .8
Ground
elev.
99 ft.
Depth to
limiting
factor
+86
Remarks:
Boring #
Ground
elev. i
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Bridgeland Dev. Co. 1554 200th Ave.
CSTM2298 NW4SW4 S28 T29N - R19W New Richmond, WI 54017
MPRSW -3254 town of Hudson (715) 246 -6200
lot #24 -St. cRoix EstATES First Addn.
X =40'
top of 1" pvc pipe C el. 100.00'
- BM.= top of tel ped(large) @ el. 100.80'
VIII
d�
1 0
.o
9 10
o v s d2d.
Gary L. Steel
3 -16 -2000
OP Safety and Buildings Division
Visconsin S ANITARY PERM APPLICATION 2 1 Box Washington Avenue
Department of Commerce In accord with Comm 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 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application
IPrivacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Prope Owner Name Property Location
(,t,(I /a W 1/4, S a g T a , N, R I ?,�(or) W
Property Owner's Mailin Addres Lot Number ck Number
City, St a Zip ode Phone Number Subdivision Name or CSMNum
d 1 (
II. TYPE OF BUILDING: (check one) ❑ State Owned !t Nearest Road
E3 Village
Public 9 1 or 2 Family Dwelling - No. of bedrooms g TownOF
III BUILDING USE (if building type is public, check all that apply) ParceI T ax Nubers) pso
1 E] Apartm Condo V 0
2 ❑ Assembly Ha 6 E] Medical Facility/ Nursing Home 10 C] Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 E] Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel /Motel ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check on ne box on line A. Check bo/Ifii if applicab le) • q) 1, New 2 ❑ Repl 1 t 3 [] Replaceme4. E] Reconnection of Re
it of an
__System System ____ ____ - -_ Tank Only - Existing Syste _+� _____ ing System
B) ❑ A Sanitary Permit was previously 1 ed. Permit Num / Issue
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized ributi rme her
11 ❑ Seepage Bed 21 ❑ Mound 3 Sped a 41 T k
12 Seepage Trench 1 4 4 _ f 22 ❑ In- Ground Pr ure 4 rivy
13 E] Seepage Pit s' 4 utt Privy
14 ❑ System -In -Fill _ ayX3 S '�-- , -
VI. ABSORPTION SYSTEM INFORMATIyo(sq_
1. Gallons Per Day 2. Absorp. Area 3. Area 4. Na Lo. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Pro ft.) (Gals/da s ) (Min. /inch) Q Elevation
CO Caut r Beet Feet
a
VII TANK in g tai # Of r Prefab. Site Fiber- Exper.
INFORMATION Ilons Tanks Manufacturers Nam ncrete con steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank arl ` /,;? ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Ch amber ❑ ❑ 1 ❑ I ❑
Vlll. RESPONSIBILITY STATE M T
I, the undersigned, assume res risibility for installation of the onsite s wage system shown Nthttached plans.
Plu er' Name: (Print) JPI u mbe ' Signatur (No Stam MPRSW No.: Business ne Number:
Z / r"k
Plumber's Address (Street, City, Sta Zip C
—
IX. COUNTY/ DEPARPA ENT USE ONLY
❑ Disa roved S itary Permit Fee pncludesGroundwat r Eg ate Issuin g AentSignat a {No Stamps Surcharge Fee) pp ❑ O er Given Initial p? Adverse Determination
S � t 1 '. X. C NDITIONS OF APP VAL / REASONS FOR DISAPPROVAL:
L
LA.* BSI t h
Y
SBD -6398 (R. 4/99) 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 insi4i
5. Onsite sewage systems must be properly maintained. `fhe 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 ere the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family . elIing.
III. Building use_ If building type is public, check all appropriate boxes that apply.
IV. Type f ermit. %)eck only one on line A. Complete line B if permit is for tank re cement, reconnection, or repair_
V. Typ of s Check appropriate box depending on system type.
VI. Abso Lion sys i rmation. Provide all information requested for nup ers 1 through 7.
' r ,�
VII. Tank inf matio I' the cap ci eve new /or existing tank, lisli�f�e total gallons, number of tanks and
anufact is na to site c strutted and tank r terial. Complete for all septic, pump /siphon and
hol ng tan for this s erime I approval onlyfanks received experimental product approval from
A V
VIII.* Re ili sta t. I (ling pi er is to fill in na license number with appropriate prefix (e.g. MP, etc.),
addres d hone nu er. Plumber m t sign applicati . film.
IX. County/ ' partment Use Only.
X. County/ Department Use Only.
Complete plans and specifications not s [er than 8 112 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, d4kv n to scale or with complete cliMensions,locatiori of holding tank(s), septic
tank(s) or other treatment tanks; b4&ing sewers; wells; water mains/wa r service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system area$; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specificdVns for pumps and controls; dose volume;
elevation differences, frictign "16ss; pump performance curve; pump model an'd pump manufacturer; D) cross section
of the soil absorption sys em if required by the county; E) soil test data on a 1 1 $`+form; and F) all sizing information.
k
r.
---- ------- -- -- --- ---------------------------------------- ---- --- -------___--____________----
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater. 3
The monies collected through these surcharges are used for monitoring groundwater contaminatio 'nvestigations
and establishment of standards.
0 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labo. -end Human Relations ,
Division of Safety & B'uildings in accord with ILHR 83.0 ode
COUNTY
Attach cmolste site plan on paper not less than 8 1/2 x 11 inches i ' e an must inclu St. Croix
not limited to vertical and horizontal reference point (BM), directio /o of sl t ,eMle or / PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest r pr` = °•'' pending
4°:1, R VIEWED B DATE
APPLICANT INFORMATION— PLEASE PRINT ALL INFO ~ TION 5 {� -
PROPERTY OWNER: PRO��ft 'LOCATIOg, '
Brid eland Dev. Company c" - GCt kll :� /� 1i4,S 28 T 29 N,R 19 kor) W
PROPERTY OWNER':S MAILING ADDRESS �r &�b�LO BD. NAME OR CSM #
11736 117th St. s Addn.
CITY, STATE ZIP CODE PHONE NUMBER GE ETOWN NEAREST ROAD
Lakeville MN, 55044 (61L 98 -5000 so Crosb Dr.
i ] New Construction Use [x] 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 .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) 104.8 ft (as referred to site plan benchmark)
Additional design/ site considerations alt. area = 105.5' system el.
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND tN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ®S 13U ®S ❑U ®S ❑U :7S El U1 ®S ❑U ❑S FLIU
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 Twich
1 0 -15 10 r2 2 none I 2msbk mfr UK
2 15 -31 10 r4/4 none sicl lfsbk mfr 9W if .2 .3
Ground 3 31 -84 7.5 r4 6 none s 0sa ml na na .7 .8
elev.
108 ft.
Depth to
limiting
factor 84
Remarks:
Boring #
1 0 -12 10 r3 3 none sl 2mcfr mvfr QW if .5 .6
Li 2 12 -80 7.5 r4 6 none 19 0SCI ml na na .7 .8
Ground
elev.
107 ft.
Depth to
limiting
factor
+80"
Remarks:
CST Name: Please Print Phone:
Gary L. Steel 715 - 246 -6200
A ddress: 1554 200tAa ave., New R' hmond WI. 54017 m02298
Signature: Date: CST Numbw:
O� . 6 -25 -96
PROPERTY OWNER Bridgel and Tnev- rn . SOIL DESCRIPTION REPORT Page 2 '.of 3
PARCEL I.D. # pendincl Lot #24
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoundEvy Roois GP /f�
in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. Beal Tmerch
'_..3 1 0 -15 1 1 2msbk mfr cfw if .5 .6
2 15 -24 10 r4/4 none sicl lfsbk mfr gw if .2 .3
Ground 3 24 -38 7.5 r4 4 none cos osg mvfr 9w na .7 .8
elev.
10 ft. 4 38 -82 7.5 r4/6 none s osg mvfr na n a .7 .8
Depth to
limiting
factor g 2,
+82"
Remarks:
Boring #
1 1 0-15 10 r3/3 none sl 2msbk mfr gw if .5 .6
4
2 1 15-84 7.5 r4/6 none s osg ml na na .7 '.8
Ground
elev.
10
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 1 0-16 10 r2/2 none 1 2msbk mfr gw if .5 .6
Uj 2 16 - 10yr4 /4 none sicl lfsbk mfr gw if .2 .3
3 1 28-34 7.5 r4/4 none sl 2m r mvfr gw na .5 .6
Ground
elev. 4 1 34-80 7.5 r4 6 none s oscl ml na na .7 .8
108 ft.
Depth to
limiting
factor
+80
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
l
t
Y ,
STEEL'S SOIL SERVICE
Gary L. Steel Bridgeland Dev. Co. 1554 200th Ave.
CSTM2298 NW4Sw4 S28- T29N -R19W New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246 -6200
T Z lot #24 -St. Croix Estates First Addn.
N
1 11 =40 1/
BM.= ROW survey stake C el. 100'
3�
A _
e r
,1� r
k 13 3
Ga ry L. Steel
6 -25 -96
STEEL'S SOIL SERVICE
Gary L. Steel
CSTM2298 1554 200th Ave.
MPRSW-3254 Now Richmond, WI 54017
(715) 24$-6200
To whom it may concern;
This soil evaluation was conducted to satisfy a zoning requirement,
it may or may not be satisfactory for your use. The location of the
system may or may not be as shown, as pest lot lines had not
been established at the time of the test.
Gary L. Steel
Sep -91 -99 10:30A r_vc
V' - "CE LA OSS SECTION AND SPECIFICATIONS
4" CI VENT PIPE 12" MTN. ABOVE GRADE E Y�►Z'y PROOF
� 25' FROM DOOR. WINDOW OR
FRESH AIR INTAKE JUNCTION BOX APPROVED
WITH CONDUIT
MANHOLE
FINISHED GRADE 4• CI RISER W/ pgp�,OC
6" MIN. WARNING 1
A80V E C AD E_ ---_
14 14
M I 1
18" IN. 6" MAX.
INLET f
WATER TIGHT SEALS GAS_ •
v T TIGHT
Cr PIPE BAFFLE A SEAL APPROYED
3' ONTO �" LM JOINTS W/
SOLID -;-- ' ON PIPE 3' 0
SOIL C ' � SOLID S0I
PUMP OFF ELL1l. FT. 1
OFF " RISER
D PERMITTED
IF TANK
MANUPACTUI
3" APPROVED BEDDING UNDER TANK HAS APPRO'
SPECIFICATIONS CONCRETE PAD
!EPTIC / DOSE
TANK MANUFACTURER: NUMBER DOSES PER DAY:
TAN S22r SEPTIC 00 00 GAL. .
DOSE VOLUME INCLUDING
® GAL. FLOWBACK: �GAL.
ALARM MANUFACTURER: - a -�c_a� 8 0 Q
MODEL NUMBER: CAPACITIES: A = a�, INCHES =
SWITCH TCH TYPE.
e = _?_ 1?�
PUMP MANUFACTURER: INCHES =
MODEL NUMBER: _E C INCHES= r
SWITCH TYPE:
D ° INCHES
REOUIRED DISCHARGE RATE .3� Gpm PUMP [ ALARM WIRING AS PER ILHR
VERTICAL DIFFERCHCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 16.23
• HiNIMUM NETWORK SUPPLY PRESSURE /
�_ FEET
• / _ FEET FORCENAIN X SYS — FT/ 100 �FT. FRICTION FACTOR '� FFET
TOTAL DYNAMIC HEAD _ ,�FET
INTERNAL DIMENSIONS OF PUMP TANK./o, ET
LENGTH WIDTH _ +_� DIAMETER
LIQUID DEPTH � !�
I ' :IGNED:
LICENSE NUMBE7t :
n •.ww.
M ODEL -0MOD
Vertical Sump P ump EPO4 — EP05
Su bmersible Effluent Pump
>. '.
t : 4
F
.n
I '
i
Pump Specifications
METERS FEET
'/3HP
Up to 40 GPM — - -" — MODEL: 3871
Discharge size 1 NPT 9 30 � -- _ ++
Solids: %* maximum 8
25 � I
Motor r
- - - -- -
Single phase: 115V C3 6 z°
Materials of Construction - --
U
Brass /thermoplastic a 15
Features and Benefits o - i3•'
•Top suction eliminates a
f
impeller clogging. 0 2 1 - - f � -_
*Corrosion resistant f - - -- - - - - -� - -- -- -
construction. ° t - l
o 0 10 zo 3 ao w US GPM
-Float actuated switch. ° z � 6 8 10 i .04.
CAPACITY
METERS FEET
,� 25 — Pump Specifications Features and Benefits
MODEL -- ' „ o and 'h HP • EPO4 impeller- semi -open design
°
a
Up to 60 GPM with pump out vanes to protec
51 15 Maximum head to 32 mechanical seal.
Z Discharge size 1' 12° NPT • EP05 impeller - enclosed design
3 ' 10 Solids 'i� maximum for improved performance
.__- _ Motor
• Rugged glass - filled thermoplastic
� 5 . All motors feature ball casing and base design provides
', ° -- - -- --- - - - - -- bearing construction superior strength and corrosion
°
0 5 10 is 20 25 30 35 60 U S GPM resistance.
0 2 6 8 1omM Si phase rials of Construction .Cast iron motor housing for
CAPACITY Mate efficient heat transfer. strength.
Cast Iron
Thermoplastic and durability.
Stainless steel • Corrosion resistant threaded
stainless steel shaft.
• Available for automatic and
manual operation.
• CSA listed models available
All Models are designed for continuous operation and feature stainless steel hardware.
06126x'1996 22:24 3039732442 JOLENE DAJLTC)k,PT PAGE 02
Doe 02 99 1Ot42a Pete Wanke 1715) 748 -2356
ST CROIX COUNTY
SEPTIC TANK MAINTEN AGREEMENT
AND
OWNERSHIP CERTIFIC FORM
Owl) ,u/Huyn ... e
M& agA4iiic r; I (�G'� ,� � 4 � :iZ
"� ,cs 7
v cutiofl rcqdw fmm p{acmag Department for new coastr�resitin)
Cirr Mete
I T p IdexttJctuion Number
prof rty i r t:a _ nn /`� `1•, �L Sw T. N t — VJ, Town of �.
lot
Cee- feed Sat Map # � — � Volnine Page M
Wai 'testy =J : :I R � � U -- Volume page #
Spc hati'3e C . pea,�no Lot linos id#%Wifiablt•� yes D >
SU
tmpc sad aB10*0awesaf Your Asp* system coald mean io in ptsamston !&hare to handle whites. PIW"n - OW011ase
guard .,ta of pad V .i iC oxt the st:pde ttmlc "gry three yea," ec sebaer, if ateedad by a barred pumper• What Y" Pat W26) ,: syetess
oast :that ft It 1aa0 of the .:wpm tacit es a oeatts M sags in 1b,e .wars diWOW Sys* -
The : � :t3y oww ..gyees to arbmit to SL CTobt Losing D4PUmisat J cutoifiaatioa fotte�!sipmd by w owoez ,iad by a
attar: plumb ,r, ymaep�ber, rubithdt[+ tmbetOtel leeasedpump,v enflnng tl ast( 1) dttoa- sittwartvwatCtdisp6j "lsYet=
is io ; tap+x �K :ms itlQ toaditsoa aetdrot (2j saRuirspeetioaand pwnpiog (if acc4trgary).� +mac tad4 ►s lest than 't±ttdga
Uwcr kc tta&,r 0. ltd have terd go stove t+ quavtut w sad riles to emioi w tt privsw sevnge disposat system -mta Ae'- huidar s
gst [it- tb„ hgam, .a ; set by the : kpttmaMA0(cotateetce sad the Deputment of Natusa[ 0-twuatw, Stow of wiscumio. Gr. +; cstios
staot, ; tbd j Vti�c system bas beenwsiot+tiaad aWSt.De'camtrteted sari retasraad w t!w St. C.rsix Coasry Zoaiag: O[fiet. voithia 30
days ,f iho tlszc . =ea expirad in. date.
_
DAB
GI APPLIWT
C';I ?,EIF10N the a.'tttecr(s} sf
i (wi:) cs• Rfy the at[ statemats oo this fstm ace tcue w the best of my (out) iMOW1ed9c, Y (we) as ( atu )
r r >, t' ih tic ,r,ribd a ve, by v,ttuc Ufa warranty deed r,eeomded is Ragrstec of Debris Of&=
S I 3Z)[tE trt A!p!i It A!
f wow*** • pay ier. �rowiga that is rnia- tepzestatedmsy ttsu!t in the $eoitary pcmut being ccvakedby the 2otaiat Dcv&�i"
•• Il . avae p(P o :his applies Ion a gtatnpsd wsaanty decd (rota the A480tam of Deeds cifice
a tatty of Ok cenitiod saroy tRap if tsfeteme is made in the wananty dasd
,. ., •on ccct f yp r;r
VOL 1455PAGE 527 1
610IL
Document Number WARRANTY DEED REGISTER OF DEEDS
This Deed, made between, ST. CROIX CO., WI
PATRICK P WESTERHAM and JANELLE L WESTERHAM RECEIVED FOR RECORD
husband and wife Grantor, 09 -10 -1999 1:30 PM
and, RONALD L DAULTON and JOLENE A DAULTON
IiAMrr DEED
HUSBAND AND WIFE, Grantee. EXEMPT N
Witnesseth, That the said Grantor, for a valuable consideration of one dollar and CERT COPY FEE:
COPY FEE:
other valuable consideration conveys to Grantee the below described real estate in TRANSFER FEE: 186.00
St. Croix County, State of Wisconsin. RECORDING FEE: 10.00
This is not homestead property. PAGES: 1
Together with all and singular hereditaments and appurtenances thereunto
belonging;
And Grantor
warrants that the title is godd, indefeasible in fee simple and free and clear of
encumbrances except easements, covenants, and restrictions of record, Recording Area
Name and Return Address
and will warrant and defend the same. Al Kallenbach, lot National Hank
(Parcel Identification Number) 2200 Crest View Drive
020 - 1320 -00 Hudson WI 54016
Lot 24, St. Croix Estates First Addition in Town of Hudson, St. Croix County, Wisconsin
P
Dated is day of 1999
'P CK P WVSTEKffAM • JA LLB L ESTERHAM �. �e O
,I B
A
AUTHENTICATION ACKNOWLEDGMENJ o eI
Signature(s) / rl/ES >�'�- /{�IrY STATE OF WISCONSIN ���.,�r��'�.... �.•'
COUNTY ST. CROIX p� i� SC01A.�``�
Personally came before me this al of
P
authenticated this )9 of above named JANELLE L WESTERHAM to
vjaj me known to be the person(s) who executed the foregoing
instrument and acknowledge he ame.
signature �+
type or print name si -
type or print name j !£
TITLE: MEMBER STATE BAR OF WISCONSIN Notary Public County,.
(If not, My commisslon is permanent. (If not, state expiration date:
autharized by §70e.0e, Wis. State.) - Z� ^ �)
THIS INSTRUMENT WAS DRAFTED BY 'Names of persons signing in any capacity should be typed or
Robert F. Wall printed below their signatures.
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
'Dec 01 99 09:56a Pete Wanke (715) 748 -2356 p.5
•,••. - - ..�.au �v...v ..+twv� JULtNt i�L1JL.lUi'�,F'? a"'Al�. {aj
L
sr,oe' 1
• ' � +�7T.4g� �
s
• ,A c6�t+•ee e. 583 'SO 02
awr1eM 26 $ it
L OT 26 ,
ow bow t� t.sr accts t 3 ■
i s
verso ot'� s• . `
A
,
LOT 27 '
�� ti � � ht � Ot � ► y
9 , LOT 26
'� • s,n .ewes
8,p dr. ta: S!►IT
f 9� e,�,r • ss. rr
LOT 25�
4� ,or,ru 66.ra.
�
1.90 k'. Cat;. [9 ■i
ja i
t
�Q(T 2
.2111 A
Ib
Ip
.y I► rL { � °' ��
b , 6u N. R. ,• �- ///
LOT 21
R� 86,206 so, FT.
2.0 Ac. like 9
01.54 10. PI
i f v
'a
ee' '
■ LOT 23
i � s. it at f r,
tw
».+�.
go f l.