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020-1353-08-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 197 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. City Village X Township Parcel Tax No: Permit Holder's Name: 020-1353-08-000 Eisenmann, Fred Hudson, Town of CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: . 36.29.19.2008 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1200 Benchmark FYI slim 6� T, Alt.BM Dosing f, UV Aeration � ^^� `� Bldg.Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Dt Bottom Septic Header/Man. Dosing Aeration Dist. Pipe Bot.System Holding Final Grade PUMP/SIPHON INFORMATION �t1 C b ► Manufacturer Demand St Cover GPM Model Number 3 s R Lift Friction Loss System Head TDH Ft emain Length Dia. Dist.to Well Et j— SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHAMBER OR Manufacturer: INFORMATION Type O System UNIT Model Number: DISTRIBUTION SYSTEM S Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air In a Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only xx Mulched th Over De Depth Over xx Depth of xx Seeded/Sodded p Bed/Trench Edges Topsoil Yes , ;] No Yes % No Bed/Trench Center COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: D / / J Inspection#2: 1/4 NW 1/4 36]�29N R19W) Cottonwood Rid a Lot 8 / Parcel No: 36.29.19.2008 Location: 636 Hillary Farm Road Hudson,WI 54016(SW 1.)Alt BM Description= Av.-.� co / r/"e�iJ1 dip I' a°� o resi. �+•�.`. c.� �t sc l,� tiC Z� 2.)Bldg sewer length= pl,, G cy G �n5 4-C -amount of cover= � (h�X- Li /10 1 eh��� 18y..�� f o.�ICSl 1p - - �L3 7 Plan revision Required? L] F° No Yes � � tv Use other side for additional information. — —— _ ._------- Date Insep is ign re Cert.No SBD-6710(R.3/97) ST. CR O NT Y Land Use Planning&Land Information t�scvll sw Resource Management Community Development Department Monday, August 11, 2014 Fred Eisenmann 636 Hillary Farm Road Hudson, WI 54016 Regarding septic inspection for Fred Eisenmann. Location of Property in St. Croix County: Municipality: Hudson, Town of Subdivision or Plat: Cottonwood Ridge Certified Survey Map: i Lot: 8 Address: 636 Hillary Farm Road Dear Applicant: A septic inspection of the above reference property was conducted on August 07,2014. This property is located in the SW 1/4 NW 1/4 of Section 36, T29N R19W, Cottonwood Ridge (Lot 8 ), Hudson, Town of, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a 4 bedroom home. Additional Notes: Repair for a broken forcemain out of existing septic/pump chamber and repair of a crack in concrete dividing wall between chambers. If you have any questions regarding this, please contact our office at 715.386.4680. Sincer R an' rn ton Zoni g Specialist cc: file I Phone 715.386.4680 Government Center, 1101 Carmichael Road, Hudson, WI 54016 Fax 715.386.4686 www.sccwi.us/cdd www.facebook.com/stcroixcountvwi cdd co.saint-croix.wi.us • . : � ii iiiiiliiiliiiiiiiiii����i�iii 8 2 4 5 9. 1 0 Tx:4201185 DOCUMENT NO.. EASEMENT 999126 BETH PASST REGISTER OF DEEDS ST. QROIX CO., WI THIS EASEMENT,made by Earl.K.Fox.and Carol A. Fox.as Trustees of the RECEIVED FOR RECORD Earl K.Fox and.Carol A.Fox Revocable Trust' 07/24/2014 12:22 PM grantor(s)convey an easement as described below to EXEMPT Frederick G.Eisenmann III.as Trustee of the Frederick G.Eisenmann 111 REC FEE: 30.00• Trust.dated May 13.2005 PAGES: 1 . grantees)for.the sum of $1.00 and other valuable consideration for the purpose of septic system Other persons having an interest of record in the property: None Return To: Loberg Law Office ' 359 West Main St. Ellsworth,WI 54011 Tax Parcel No:020-1353-07-000 An easement for septic system over part of Lot 7, Cottonwood Ridge,described as follows:Commencing at the Southeastedy comer of said Lot 7,Cottonwood Ridge,thence N13°18'25'•E along the lot line between Lots 7 and 8 of Cottonwood Ridge a distance of 316.70 feet to the Northwesterly comer of Lot 8 of Cottonwood Ridge,thence. N71006'57'W 15.00 feet,thence S13°18'25•'W parallel with the.Easterly line of said Lot 7 to the Southerly line of said- thence along he Souther) line of said Lot 746 the point of beginning. Lot7,thence Southeasterly a o g t y P • St. Croix County, Wisconsin. This easement shall terminate upon failure o f th e existing septic s stem. • (Signature) (Signatur ) Far_ Fox Truste (Print Name) ( rint N e) I I "(Signature) (Sign u e) _Card A Fox Trustee (Print Name). (Print Name) Sub sc' agElo re me this Public) ( YP Notary Print or Type Na e, Nota Public. (bate Commission Expires) THIS INSTRUMENT DRAFTED BY: LOBERG LAW OFFICE-: Jens H.Loberg Q D C°CAJ St.Croix County Page 999126 Pa e 1 of'1 PLOT PLAN ' Page z of 6 Scale 1"= 50' i LOT L 1),jE WD..L_-�O BE f1rr LzftST So Fzom KIOU► O r J F�nJO 1°cT L 51 ZS' F ujM `T%jk. 5 J 7 1 J 10 OF { h I a z$' I I. I I I., r I I' t I 1 z I MOT C.ZY-VPRe.T OR. IC / M F � i NOTES: •1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install permanent markers at end of each lateral. ( Z required) 3. Install 4" observation pipes with approved caps.. ( - required) 4: -Septic tank to be N-Lrio/sao gallon capacity manufactured by 5. Bench Marks 'a"*I- EL lOC1.0' oN -MP of 1"r-) PtPl-- UX C_OPVj t - - t°ml Bh - e- 1Q1ss\aKj mw Plp� kr tS eAtwez of l l: 6. Divert surface water around system to. prevent .ponding at the uphill side. [qGOULDS PUMPS Submersible E e Pump MODEL : : x,eu eries u"ucxe� PROSURANCE AVAILABLE FOR RESIDENTIAL APPLICATIONS. APPLICATIONS ■Shaft:Corrosion-resistant, Single phase(60 Hz): can be operated continuously Specifically designed for the stainless steel.Threaded •Capacitor start motors for without damage when fully following uses: design.Locknut on all models maximum starting torque. submerged. • Homes to guard against component •Built-in overload with ■Bearings:Upper and • Farms damage on accidental reverse automatic reset. lower heavy duty ball bearing • Trailer courts rotation. •SJTOW or STOW severe duty construction. • Motels ■Fasteners:300 series oil and water resistant • Schools stainless steel. power cords. ■Power Cable:Severe duty • Hospitals •'/3—1 HP models have rated,oil and water resistant. p ■Capable of running dry NEMA three prong Epoxy seal on motor end • Industry without damage to provides secondary moisture • Effluent systems components. grounding plugs. barrier in case of outer jacket ■Designed for continuous •1'/2 HP and larger units have damage and to prevent oil SPECIFICATIONS operation when fully wicking.Standard cord is 20'. Three phase(60 Hz): Optional lengths are available. Pump submerged. •Class 10 overload protection p � •Solids handling capabilities: MOTORS must be provided in ■0-ring:Assures positive %"maximum. separately ordered starter sealing against contaminants •Discharge size:2"NPT. ■Fully submerged in unit. and oil leakage. •Capacities:up to 140 GPM. high-grade turbine oil for •STOW power cords all have AGENCY LISTINGS •Total heads:up to 128 feet lubrication and efficient heat bare lead cord ends. TDH. transfer. Tested to UL 778 and ■Designed for Continuous ® CSA 22.2 108 Standards •Temperature: ■Class B insulation on By Canadian Standards 1041(40°C)continuous '/3-1'/2 HP models. Operation:Pump ratings are Association 1401(60°C)intermittent. ■Class F insulation on 2 HP within the motor manufacturer's ce US File#LR38549 •See order numbers on models. recommended working limits, Goulds Pumps is ISO 9001 Registered. reverse side for specific HP, voltage,phase and RPM's METERS FEET 40- 130 7 - SERIES:WE available. E1 5H SIZE:3/0 SOLIDS — --+ —' 35 120 — J -� r-- 17 RPM: 5007---I FEATURES 110 wiz H — I I �— 30 100 5GPM i ■Impeller:Cast iron,semi- —�— - - — open,non-clog with pump- 90 s Fr out vanes for mechanical 2s Bo seal protection.Balanced for smooth operation.Silicon a 20 70 r o H bronze impeller available as o 60 _.r. an option. a 15 s Woo H -- — — ■Casing:Cast iron volute ° 4 --r - -- -- -- I — type for maximum efficiency. 10 30 to M__. _- 2"NPT discharge. 20 ■Mechanical Seal:SILICON 5 CARBIDE VS.SILICON - 7H CARBIDE sealing faces. ° °0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 GPM Stainless steel metal parts, BUNA-N elastomers. 0 5 10 15 20 25 30 35 m3/hr CAPACITY Goulds Pumps ©2004 ITT Water Technology,Inc. ITT Industries Effective December,2004 vwwv.goulds.com w 83885 County Sanitary Permit Application ST.CROIX COUNTY WISCONSIN rd with Chapert 12 St.Croix County Sanitary Ordinance PLANNING&ZONING DEPARTMENT formation you provide ma be used for secondary purposes ST.CROIX COUNTY GOVERNMENT CENTER [Privac (1 1101 Carmichael Road „n 4 k Hudson,WI 54016-7710 r,. (715)386-4680 Fax(715)386-4686 Attach(complete plans for the system on r not less than 8-1/2 x 11 inches in size. Cpuntp'.$° t #/ ❑ Check if revision to previous application Applllcatlo 4orination-Please Print all Information Location: AAA Property Owner Name .SL J 1/4 N 1/4,Sec So N, R W Property Owner's Mailing Address Lot Number Block N-0 156r ity,State Zip Code Phone Numer ubdivision Name or CSM Number if ype_0 Building: (check one) Mity ❑Village WJ ;vwrrof 1 or 2 Family Dwelling-No.of Bedrooms: j� ❑ Public/Commercial(describe use): i �_ /T Cif-CY/s( ❑ State-owned Nearest Road I.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Z: Parcel Tax Numbers) A) 1.111146pai r ❑ Reconnection ❑Non-plumbing .❑Rejuvenation �j�j Sanitation 6 / 6,9 B) Permit Number / Date Issued estate Sanitary Permit was previously issued 3���Pt!p� �/3 r p IV.Type of POWT System: (Check all that apply) ❑ Non-pressurized In-ground WI-IM"O'und Z 24 in.suitable soil ❑ Mounds 24 in.suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wet an ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating .DiopersallTreatment Area Information: 1.Design Flow(gpd) 2. Dispersal Area 3.Dispersal Area 4.Soil Application Rate 5.Percolation Rate 6.System Elevation 7.Final Grade Required Proposed (Gals./day/sq.ft.) (Min.Anch) Elevation 6L /Iq 1. Tank Inform ion Capaicty in Gallons Total #of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks '— eG� ADO / cS CGnn� ❑ ❑ ❑ ❑ 11.Responsibility Statement I,the undersigned,assume responsibili r repair onnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A icense is not required for terralift re r or the install tion of non-plumbing sanitation system. Plumbers Name(print mber's S' nature(no sta IV/MPRS No. Business Phone Number L.•rs / s s--- 3w� �S- Z yd°-TT�7 Plumbers Addr s(Street,City,State, C � e) L 4 e3 a- 5 D Ill.County Use Only D' approv Sanitary Permit Fee Da a Issued Issuing nt Sig ture o t *'Approved iven Initia Adverse t j Det ination T X.Conditions of Approval/Reasons for Disapproval: Rev:8/05 July 30,2014 A.C.E. Soil & Site Evaluations James K.Thompson 340 Paulson Lake Lane Osceola,WI 34020 Department of Safety&Professional Services Credential#30021 Mater Plumber,Certified Soil Tester,Plumbing Inspeetor, POWTS Maintainer,Erosion Control Inspeetor DNR Certified Small Water System(OTM/NN)Operator#62098 Fred Eisenmann 63611illary Farm Road Hudson,WI 54016 RE: Existing septic system evaluation—Fred Eisenmann property located at 636Hillary Farm Road,Hudson,WI., Lot 8 of Cottonwood Ridge,NWU4SE14,Sec.366,T.29N.,R.19W.,Tn of Hudson,St.Croix Co.,WI., parcel#020-1353-08-000. Mr.Eisenmann: At your request, I have conducted an inspection of the septic system serving the residence at the above address. The inspection was conducted on the afternoon of July 20,2014,and was based on a surface evaluation of the system. This is a mound system which transmits wastes from the house by gravity to a septic tank. The waste then flows through to a pump chamber and is pumped up into the mound,draining away through the underlying soil. For general reference proposes,I have attached a copy of the County Inspection Report completed at the time of the system installation. The septic/pump tank was emptied by Powers Liquid Waste Management on July 23rd, 2014. At that time, it was discovered that effluent was traveling between the two chambers. My inspection on the 24d'revealed that the dividing wall between the two chambers had pulled away from the exterior wall of the tank and was allowing effluent to seep from the septic side of the tank to the pump tank side. It was also discovered that the forcemain leaving the pump chamber was broken. It was also noted that the locks and locking chains were not attached at either tank manhole. The mound dispersal component(drainfield)appears to be operating properly and is in compliance with Wisc. DSPS Administrative Codes. There currently is no effluent ponded within the system nor are there any indications that this portion of the system is not functioning properly. There was no evidence observed indicating past system failure. This inspection did not involve physically excavating into the system. Accordingly, there is a possibility of hidden defects that were not discovered by this inspection. The failure of a septic system is a progressive process and its useful lifespan greatly depends on how the system is used and maintained. Accordingly,I cannot predict how long the system will continue to dispose of sewage effluent. In an effort to prolong the system's life, steps should be taken to minimize the wastewater flow that enters the system. Those steps would include the use of water conserving fixtures,reducing shower times,washing clothes and dishes only when there are full loads,using a front loading washing machine or one with a suds saver feature,regularly pumping the septic tank,etc. Thank you for the opportunity to provide this service. If there are any questions or concerns that I can address,or if I can be of further service,please feel free to call me at(715)248-7767. Sincerely, James K.Thompson Dep't of Safety&Professional Services Credential#30021 Cc: file Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: ST CRUIX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344665 PeTjSoElcieNN, FREDERICK & RENEE ❑ City ❑ Town of: State Plan ID No.: NN ti 2`fo `fs i = T►�eMSa�-(�,. D. CST BM Elev. t Insp. E Elev.: B Description: rcel Tax No.: d d L lj �j GT `r /� �bY 020 - 1353 -08 -000 TANK INFORMATION _ ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 25 Z U p Benchmark �. O� �� Cj Dosing Ae Bldg. Sewer 33 3 Holding Ht Inlet 9 , TANK SETBACK INFORMATION et TANK TO P / L WELL BLDG. Air i to ntake ROAD D t Air Septic 50 / ZSi -.--. NA Dt Bottom Q �`, 3 V Z. Dosing 6p/ 3 3$ NA Header/ Man. 3,Y9 Q3• -7-Z G 3 -S A Dist. Pipe p Holdin Bot. System '2 1 PUMP/ SIPHON INFORMATION Final Grad .Y/ be ` �8 + c-- ��. Manufacturer Demand Model Number �G�J GPM 4yO.4 �� o7 D TDH Lift . j Friction i�� Mes terr�.s TD 1,Z� Forcemain Length 'L8 Dia. Z� Dist. To Well SOIL ABSORPTION SYSTEM Ke /<12 N Width / Len th I I Of PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufa r: SETBACK CHAMBER INFORMATION Type Of o umber: System: 3 8 OR UNI DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) e f — x Hole Size tr x Hole Spacing Vent To Air Intake Length Ak= Dia. Length Dia. /2 Spacing f c 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 36.29.19.2008 636 HILLARY ARM ROAD — LOT 8 bur .� 09 � i� � • q q ��� {// ,�. � /n�,�. 6 3 0 a� a✓ 3Pwe-r r 0� dove,- Plan revision required? ❑ Yes KNo s� Use other side for additional information. 9 ! • * S� SBD -6710 (R.3/97) D to t 6t pe Insc ors Signature Cert . No. "f D •- ,I a �eEL -- ✓ Safety and Buildings Division *6consin SANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis: ASm._ Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less ounty than 8 112 x 11 inches in size. ' • See reverse side for instructions for completing this ap p C cation '�' �Z st a Sanitary Permit Number Personal information you provide may be used for secondary purposes p' neck if revision to previous application (Privacy Law, s. 15.04 (1) (m)] <'p� & X� � TION �n i �s u / C� � r S to Plan I.D. Number I. APPLICATION INFORMATION PL ASE PRINTAL1' NF 7/ O ZER Property Own Name P erty Lotatio E : 1.41 141, ,A411)CS T,_) rNrR// Aor)W Property Owner's Mailing Address. I,Qt b Block Number �, ✓ City, State Zip Code Phone Number SubdivisioLyWe or CSM Number L .t d ( rte s -s� I. TYPE OF BUILDING: (check one) ❑ State Owned It Nearest R d village Public 1 or 2 Famil Dwellin - No. of bedrooms Town OF III BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) 2Z _ ,^ t � e� 1 f Apartment/ Condo !�' f o _ 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. rtf New 2 ❑ Replacement 3 ❑ Replacement of 4. ❑ Reconnection of S ❑ Repair of an Sy/ tem ________ 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 WMound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure r r 42 ❑ Pit Privy 13 Q Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: o- 1. Gallons Per Day . Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade equired (sq. ft.) ,Proposed (sq. ft.) (Gals/day /sq. ft.) in. /inch) evation Feet Feet VII Capacit . TANK in allo Total # Of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete C on- Steel glass App. New Existin structed Tanks Tanks Septic Tank or Holding Tank O O ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ROO -- ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb 's Sig ture: (No S a PRSW No.: usiness Phone Number: s� Plumber's Address (Street Qypate , Zi Code IX. COUNTY / DEPARTMENT USE ONLY Q Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination � � 2-� s3 c) � X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ` ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner4 Cuye - /yy \CZ/Y��� Mailing Address ��LQCQ ►`�� �/Yl� 14 w S Property Addresses � (Verification ' , \ required from P g Department for new construction) City /State (JAPA I W � Parcel Identification Number LEGAL DESCRIPTION Property Location Std %4, NW V4, Sec. a p T aqN N -R- I _W, Town of Subdivision W n a G�` P , Lot # � . Certified Survey Map # , Volume , Page # Warranty Deed # a h-1 Volume 144(a Page # c J Spec house ❑ yes no Lot lines identifiable 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, 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. cj 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. §IGWATrME 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 • �I r Safety and Buildings Division • ViSC011S%11 SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue Department of Commerce In accord with ILHR 83.0 5, VVr.'A� &de — P 0 Box 7302 Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on pa r not Less ounty e I than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this apphiation " ' ^? st a Sanitary Permit Number Personal information you provide may be used for secondary purposes a S "t C �� C} heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. I , y� �9 to Plan I.D. Number 1 I. APPLICATION INFORMATION - PLEASPRINT A ION 7/ ZYa Property Own Name a,, erty LcKatio 1/4.�M1 ; S T� , N, R 19 �(or) W Property Owner's Mailing Address. t b' Block Number 22 I-N 4 City, State V Zip Code Phone Number Subdivision a or CSM Number LtiL 0/f/ , 56 11. TYPE F BUILDING: (check one) ❑ State Owned It Neargst R d r 1VJ i l lage Public 1 or 2 Famil Dwellin - No. of bedrooms own OF III. BUILDING SE: (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. rq' New 2 ❑ Replacement 3. E] Replacementof 4. C] Reconnection of 5. ❑ Repair of an System ....... _ System Tank Only Existing System Existing System _____________ ______________ ________ B) C] 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 OMound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure r-' i 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: - 1. Gallons Per Day . Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System � Elev. 7. final Grade / Required (sq. ft.) roposed (sq. ft.) (Gals/day /sq. ft.) in. /inch) evation 600 5-o d - Feet — Feet Cap acity VII TANK in Ca allo s g Total # of Prefab. Site Fiber- Exper_ INFORMATION Gallons Tanks M anufacturer's Name Concrete Con- steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank / 20 01 — Q ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber -- I P3 601 ❑ 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) Plumb 'S Sig ture: (No S a / PRSW No.: I pusiness Phone Number: zY# 7� a v 73 ) a6 g - ,5' Plumber's Address (Street C tate,Zi Code �� ��� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) jgp kpproved []Owner Given Initial Surcharge Fee) Adverse Determination o C_ 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: f. Property owners nameand "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 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; Q 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. Safety and Buildings 2226 ROSE ST LA CROSSE WI 54603 -1905 �- TDD #: (608) 264 -8777 N *isconsin www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary August 16, 1999 CUST ID No.267341 ATTN: POWTS INSPECTOR WEGERER SOIL TESTING & DESIGN ZONING OFFICE 421 N MAIN ST ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 08/16/2001 Identification Numbers Transaction ED No. 240457 Site ID No 178712 SITE: Please refer to both identification numbers,' Site ID: 178712 above, in all correspondence with tbo agency, St. Croix County, Town of Hudson SW1 /4, NW1 /4, S36, T29N, R19W Subdivision: Cottonwood Ridge Facility: La Casse Custom Homes — lot 8 FOR: Description: Four Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 485197 % r5 The submittal described above has been reviewed for conformance N ith ap�l Wi4cons�Adminis,trative Codes and Wisconsin Statutes. The submittal has been CONDITIONALL Al k-�� The following conditions shall be met during construction or installatio ann prior' �occupancy.or use: • A Sanitary Permit must be obtained from the county where this project i�ted in'; ecQordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. A copy of the approved plans, specifications and this letter shall be en -site during cor_striction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation /operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 08/05/1999 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 Gerard M. Swim BALANCE DUE $ 0.00 POWTS Plan Reviewer - Integrated Services (608)785-9348, Mon - Fri, 7:15 AM - 4:00 PM jswim @commerce.state.wi.us WiS14' A,pf,� 'de: 6x33 Page of 6 f MOUND SYSTEM FOR A y BEDROOM RESIDENCE LOCATED IN THE SW 1/4 OF THE NW 1/4 OF SECTION 36 ,T 1 N, R 19 W, TOWN OF SAN , gam-, cCLoy COUNTY, WISCONSIN. 1 oT 8 OF c_b) jOt")tiJ wb tzvD Cam. INDEX PAGE l "of 6 TITLE SHEET PAGE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW -CROSS SECTION: PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT PAGE 5 of 6 PUMPING CHAMBER PAGE 6 of 6 PUMP PERFORMANCE CURVE PREPARED FOR LA C^s S E 40 9� Arl. 1 S r1 C CUTc�}�1N 2Qf� ° ,� y 4h 99 `9 e�O PREPARED BY WEGEE:ZEF;Z SO I L . TEST S NG �� ;p oll AND . 0� I3 E S i GN STr=F;Z V I C E F.U. BOX 74 421 N. VAIN ST. �' ARTHUR L RIYEP FALLS. MI 54022 WEGERER G81.5 P 115 -42`,, -0165 GLSWGRTH, F � WIS. IF • °� SIGI JOB NO. I PLOT PLAN ` Page z of 6 Scale 1 "= w att_ Zo SE PrT LZftS't So' FiZO M MO Uu -D r J 5 F J � f J V% I I g 1 v Zs �N`� I o DoT eow.�neT a� 1 is k s U� NOTES \ -l. Elevations shown are existing ground elevations unless otherwise noted. 2. Install permanent markers at end of each lateral. ( required) 3. Install 4" observation pipes with approved caps.. ( Z required) 4. tank to be ZOO /Boo gallon capacity manufactured by 5. Bench Marks � Ff - . �oo�o' av 'luP o f l�� p�P� �T aowv s 3 FYk, Bh - Ez..101•Ss `O NRUQ PIPE h'r Imo. C*RQEZ. of LoT . 6. Divert surface water around system to prevent.ponding at the uphill side. i Page 3 Of 6 Approved Synthetic Covering Distribution Pipe Medium Sand � . Topsoil - H G - - - -J � Q F Elev* l oz. g E D u b p % Slope Force Main Plowed Trench of k"-2-2 From Pump Layer Aggregate y Undisturbed D 1.0 Ft. Soil E \°O Ft. Cross Section Of A Mound System Using F 0• ° v Ft. 1 Trench For The Absorption Area G Ft. A S Ft. H 1.5 Ft. B 1 pp Ft. I _� Ft. Linear Loading Rate= 6-o GPD /LN FT J Ft. Design Loading Rate =o Z6 GPD /SQ FT K l0 Ft. L l?-0 Ft. • - W Z3 Ft L Force B K Main 1 W M Distribution Trench Of 2 — 2 2 Pipe Aggfegate I f Observation Permanent Pipes Markers (Anchor securely) Mound Using I Trench For Absorption Area Page ' Of Perforated Pipe Detoil 0 End View End Copj ) Perforated PVC Pipe Install permanent at end of each lateral Holes Located Gn Bottom, Are Equally Spaced Q End Cap * PVC Force Main 4 Distnoulian Pipe Last Hole Should Be Next 7o End Cap Distribution Pipe_ Layout P 1 s Ft. X �o Inches Y 3p Inches Hole Diameter "Y Inch Lateral 1 11 7- Inch(es) Force Main Z Inches # of holes /pipe Z,O Invert Elevation of Laterals 103.2 Ft. Place 1st hole S� from tee with succeeding holes at , intervals. Last hole to be next to the end cap. 1 Combination Septic-'Tank and PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS PAGE S OF VEIJT GAP WEATHER PROOF JU►JCTIOU 50X 4'C. I. VENT PIPC APPROVED LOCKING 110 FROM DOOR.. MANHOLE COVER wl - .iINDOw OR FRESH wAR►.)1►J6 L.�BEL. A!K IMTAKE S coraDuTT tj � S , ^ - GKI� _ `f�MIU ELI lV . 7 PROVIDE i - - - -- IA1LE T =— '[ — AIRTIGHT SEAL lluSiCCtlor 4FFL�S I I I ! v ({ APPROVED JOlA1T - A { APPROVED W /C.T. PIPF Tank construction I II( w /c.z. PIPE p0c JOINT. _ I I ! ALARM shall comply with ILHP ()3.15 and 33.20 I3 j i I f oN C i I I CLEV �' FT. PuMP� -'� . ` OFF D CokICKETE ��,�� j BLOCK K15ER EXIT PERMITTED OIJLy IF TA/JK MANUFACTURER HAS SUCH APPROVAL 3,•ApPRo,Ft7 SOD t >uG SEPTIC E SPEC.IFICATIOUS DOSE 3 -�� TAWK MANUFACTURER: >`�'3 IJUMBER OF DOSES: PER DAZ TA W K 51ZC: � la DO GALLOWS DOSE VOLUME r .5 ALARM MANUFACTURER: INCLUDII.IG O ACKfLOW: GALLON: MODEL ►DUMBER: 1 Cs 1 �`�w CAPACITIES: A= l IAICHESOK '1 1 "• t3 GALLO►J5 SWITCH T:JPC: 'I -AiDz a Y 5= Z IWCHES OR L I L 1 4LLOA15 PUMP 1KAMUFACTURER: GOU LAS C= I u CHES OR 189' S GALL0IJS MODEL MUMBER: 'L�Pp-S D= a INCHES OR 1 ' 65 ' GALLOA55 SWITCH TYPE: LZ��f MOTE: PUMP AUD ALARM ARC TO 6E MIAJIMUM DISCHARGE RATE GPM LL ( INSTALLED OIJ 5EPARATE CIRCUITS VERTICAL DIFFERENCE DETWEEIJ PUMP OFF AUO..OISTRIBUTIO►.t pIPE.. \I � s3 fEET + M11.1tMUM NETWORK SUPPLY PRESSURE . . . . . , . . , . . 2.5 O FCET T y- �' FEET OF FORCE MAIN X y ' 4 F pr t ,FR1CTIOtJ FACTOR.. � FEET -- TOTAL M JAMIG HEAD = 1b'�-1 FEET Pump chamber DIAMETER — Y INTERLIAL, DIMLWSIOW� OF TANK: LEM&TH ;WIDTH — ;LIQUID DEPTH 3$ BOTTOM AREA - 231= GAL /INCH AS PER MANUFACTURER = ? I: GAL /INCH Goulds Submersible Effluent Pump 38 71 EPO4 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas- • Homes components. tic cover with integral handle Motor: Available for automatic and and float switch attachment hos P, •Farms • EPO4 Single e: 0.4 H manual operation. Automatic p oints. • Heavy duty sump 115 or 23 V, 60 e: 0.4 H0 models include Mechanical • Water transfer Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant. automatic reset. ■ Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, construction. Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo- • Solids handling capability: automatic reset. plastic Semi -open design 3 14" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. CO- Canadian Standards Association • Total heads: up to 24 feet. with three prong grounding • Discharge size: 1 NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- (CSA listed model numbers • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in " F" or "AC ".) rotary/ceramic - stationary, three prong grounding plug improved performance. BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 ° G) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 I •Capable of running I 1j J I dry without damage to s 30' , I ��. - 5GPM components. i t� Pump: EP05 a ' +-2.5 _ 25 • Solids handling capability: 0 ' 3 /4" maximum. a z W . • Capacities: up to 60 GPM. _ • Total heads: up to 31 feet. 6 20 I • Discharge size: 1 NPT. Z 5- 16.1 • Mechanical seal: carbon- ' rotary/ceramic- stationary, 0 4 15 i P05 BUNA -N elastomers. o y 6.8 • Temperature: 3 10 104 0 F (40 °C) continuous I EPO4 140 °F (60 °C) intermittent. 2 5 1 � 0 00 10 20 30 40 50 GPM L -L L 0 2 4 6 8 10 12 W/h CAPACITY ©1995 Goulds Pumps, Inc. Effective May, 1995 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 e bor and Human Relations vision 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 St. rraix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # 0-4 - 000 � dimensioned, north arrow, and location and distance to nearest road. 020- 1353 - 1 APPLICANT INFORMATION- PLEASE PRI N TION REyIEWE BY T r PROPERTY OWNER: PROPERTY LOCATION LaCasse Custom Homes, I /!'�' GOVT. LOT SW 1/4 NW 1/4,S 36 T 29 N,R 19 FK(or) W PROPERTY OWNER':S MAILING ADDRESS SUBD. NAME OR CSM # l iff Cottonwood id e 521 McCutcheon Rd. g CITY, STATE ZIP C E!, PHONE NUMBE CITY ❑VILLAGE *]TOWN NEAREST ROAD Hudson, WI. 54016 lL - , Hudson Ct . Rd. "N" [ ij New Construction Use [X] Reside "I / Numberoomq< ( Addition to existing building (] Replacement [ ] Public or merc % Code derived daily flow 60 0 gpd design loading rate • 4 bed, gpd /ft •5 trench, gpd /ft Absorption area required 500 bed, ft 500 trench, ft Maximum design loading rate .4 bed, gpd /ft .5 trench, gpd /ft Recommended infiltration surface elevation(s) 102.65 ft (as referred to site plan benchmark) Additional design/ site considerations system el. based on area el. of 101.65' Parent material glacial drift /limestone upland plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for stem 11 S 19 U ®S ❑ U ❑ S c U ❑ S au ❑ S � U ❑ S CR 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 -9 10yr4 /2 none 1 2csbk dsh cs if .5 ( .6 2 9 -20 10yr4 /4 none sicl 2msbk mfr qg, 1 .4 .5 Ground 3 20 -39 10yr4 /6 none scl 2msbk mfr gw na .4 .5 1 4 39 -60 10yr4 /4 c2p 7.5yr5/8 scl 2csbk mfr na na .4 '.5 Depth to limiting factor 39" Remarks: Boring # 1 0 -10 10yr3 /3 none 1 2msbk dsh cs if .5 .6 2 2 10 -30 10yr4 /4 none sici 2msbk mfr gw if .4 .5 3 30 -65 10yr4 /6 c2d 7.5yr5/8 sl 2csbk mfr na na .5 .6 Ground elev. 1 1 Depth to limiting factor 30" Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. Ave,, New Richmon WI 54017 Signature: Date: 7 -23 -9 9 CST Number: m02298 PROPERTY OWNER ILaCasse Custom Ham es SOIL DESCRIPTION REPORT Page 2 -of 3 PARCEL I.D. # 020 - 1353 -08 -000 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 Y 0 -10 10 r3/3 none ms dsh cs If 3 gong 2 10 -27 10yr4 /4 none sicl 2msbk mfr gw if .4 .5 Ground 3 27-34 10yr4 /6 none scl 2msbk mfr yw if .4 .5 1 4 34 -60 10yr4 /6 c2d 7.5yr5/6 scl 2csbk mfr na na .4 .5 Depth to limiting factor 34" I Remarks: Boring # Ground elev. ft. — Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # ................. Ground '. elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) ` Y STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 LaCasse Custom Homes, Inc. 4NW4 S36- T29N -R19W New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246 -6200 lot #8- Cottonwood Ridge N 1 " =40' BM.= top of SW lot stake C el. 100.00' Alt. BM= top of NE corner survey stake of lot #4 C el. 101.55' Q \ 1� � 0 5 � Gary L. Steel 7 -23 -99 I , l e *isif'Win Department of Commerce Division of Safety and Buildings SOIL AIfi , , UATION W,$ Page of 3 Bureau of Integrated Services in accordaqc� with - s. ILHR 83.09;.• is. Adm. Code , Cr ounty Attach complete site plan on paper not less than 8 1/2 x 11 ing6sjh` size. t m �- ° \ - include, but not limited to: vertical and horizontal reference p inf direction and S 4. C f percent slope, scale or dimensions, north arrow, and location and dista£j(rt'b npaost'AieRh ' rcel I.D. # } ST CR COUNTY APPLICANT INFORMATION - Please print all inormati eviewed by Date 98NING OFFfC, Personal information you provide may be used for secondary purposes (Pr cy(l„aw, s. 15.04 1) (m )). Property Owner mo t` rpqe�ty 9io& ion t In 0, J+ of . 5W 1/4, /4,S 36 T Z, C( ,N,R t Gt E (or) o Property Owner's Mailing Address Lot ## Block # Subd. Name or CSM# cA r . U o Q City State Zip Code Phone Number ❑ City ❑Village ER Town Neare oad cC w I I Syol (7 /S )S y 4 -Co 73 o u a ' s o Co ri �aocL Y, 93 New Construction Use: Residential / Number of bedrooms 3 - e l ( Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow LrJ 00 gpd Recommended design loading rate ! bed, gpd /fi o 6 trench, gpd /ft Absorption area required 1� bed, ft /CCTJ trench, ft2 Maximum design loading rate 1 .5 7— bed, gpd /ft o 6 trench, gpd /tt Recommended infiltration surface elevation(s) q Z ! U ft (as referred to site plan benchmark) Additional design /site considerations A41( Fil?4 Covthor /^ Parent material LZ GG" ( C U (�JS`, - s k Flood plain elevation, if applicable ft S = Suitable for system Conventional Moun In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S pa U S ❑ U � S U ❑ S U ❑ S ®U ❑ S ® U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench I o- S to r3,/ 5i 1 G w.C CS I .S� • (o S- l to r'/H - Prot (- C S - As • <o Ground 3 / - I v Y 3 C- Z 16 S i C. M me-� C5 elev. QQft. Depth to limiting factor 3 / in. Remarks: Boring # v-? Icu 3/3 st V rAqb r C I -� . S • b 3 2I t ry/ ZP Z r 4 11 5,' 1 3 V C - M m��► Ground elev. 9 "fir t• _ r .. I Depth to limiting r � f ctor in. Remarks: CST Name (Please Print) Telephone No. Address Date CST Number �/� l �S'YGZ� -� -ter 8S - 3 0 S4 / �_J_. SOIL DESCRIPTION REPORT 1 PROPERTY OWNER S40 u l Page J__ of 3 PARCEL I.D.# Boren # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 /Z !o / -' f m r C �- a- Jo , 4 rVZV s i r` I C S r .57 6 Ground zb z$-.3q toy 1 C 2 � r f 3 ir c-M r✓\ C-S C - S elev. & y0 Depth to limiting factor Remarks: Boring # .......................... .......................... .......................... Ground elev. ft. Depth to limiting factor 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 # Ground elev. ft. Depth to limiting factor ' Remarks: Boring # .......................... ........................... Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) o •�� cSfovl P a l l X 8tyl v. 1&0 wu; I I 10 aa 7 i � bG CTU •U S l'�e v � J a ` iy J BMr / a 1 � ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner ouye, Mailing Address �J n d . w �,�/YLt� � � 7 Property Addresses q O (Verification required from P ing Department for new construction) City/State ( I Parcel Identification Number LEGAL DESCRIPTION Property Location St) '/4, Nu V., Sec. 3�0 . T aqN N -R_ j W, Town of Subdivision ��'(1.� �� c' �-�� , Lot #. Certified Survey Map # , Volume —, . Page # Warranty Deed # L) , Volume 1�14 l_ —. Page # c J Spec house ❑ yes no Lot lines identifiable 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 1 masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that ( ) 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 113 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. giG&ATCkE 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 surve y ma if reference is made in the warranty deed p /a STATE BAR OF WISCONSIN FORM 1 — 1982 607$27 WARRANTY DEED KATHLEEN H. WALSH VOL 1446 PAGE 15 REGISTER OF DEEDS DOCUMENT NO. ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between RICHARD 0, SM011M and 08 -02 -1999 8:00 AM TANPT P - gTC1tiT hncbnnA and wife WARRANTY DEED EXEMPT N Grantor, CERT COPY FEE: and E r. VTc U„1 u TE' A . COPY FEE: TRANSFER FEE: 128.70 husband and wife, RECORDING FEE: 10.00 PAGES: i Grantee, Witnesseth That the said Grantor, for a valuable consideratio conveys to Grantee the following described real estate in S} C ko i X THIS SPACE RESERVED FOR RECORDING DATA County; State of Wisconsin: NAME AND RET ADDRESS Lot 8, Plat of Cottonwood Ridge, Town of Hudson, St. Croix County, Wisconsin. 020 - 1110 -20 -000 PARCEL IDENTIFICATION NUMBER This is riot _ homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions, rights -of -way and covenants of record, and will warrant and defend the same. Dated this 29th day of Jul y ,1994 Richard 0, StIou t (SEAL) (SEAL) C) (SEAL) (SEAL) ■ AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. authenticated this day of 19 Personally came before me this 9 day of .Tti 1 , 19 the above named Richard O. Stout and Janet P. Stott TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stars.) to me known to cuted the foregoing instrume d I�d g e CO THIS INSTRUMENT WAS DRAFTED BY KE J. 21 71 Janet P. Stout wa u ee Tr. Hudson, Wi 54016 Nota Public, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My or i sion is permanent. (If not, state expirati If necessary.) 76 • Names of persons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED Form No. 1 — 1982 Milwaukee, Wis.