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HomeMy WebLinkAbout026-1012-95-000 v 0 6o d 0 M O w tl Q O N O L I Ol O C d 3 I O N z o O 'O C Z N LL c a c 3 = C O (0 Q C C N > Cl) Ix co E CO 7 V N v' v H z a m 0 0 o Z a c r = cn o N I.- 0 I Z i S E -o O 7 co N N C C U CY N a •� d = L co 0 z z 0 U N n � c E N o R L I U c d o c 0 a o - a 5 ° z _ • � g C IL z . N a (A - U rn rn o �i I O � 0) z I N N N O L O O _ 7 co N d n a p d Q z U) N Ci O r 7 w O O W W c w c °0 3 N Ln O V N V a 0 K C N "t ° 10 4. Li E c Q1 N d N co w C N N M U y M O C O U cO L O -q X CO CM 0 z z T L Cn �t a e a • a m 2 m 'N a E c c r r A 09L oaici Wisconsin' Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT 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)]. ST. CRO IX Permit Holder's Name: ❑ City ❑ Village k Town of: State Plan o.. BERNING, MELVIN RICHMOND CST BM Elev.: Insp. BM Elev.: 7 TM Description: Parcel Tax No.: G26 - 1012 95 000 TANK INFORMATION ELEVATION DATA A9900207 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. Air to I ntake ROAD Dt Inlet ir 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 Forcemain Length Dia. mead Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type of CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil El El No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 4.30.18.47C,NE,SW 1141 175TH AVENUE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert No ADDITIONAL COMMENTS AND SKETCH ,. SANITARY PERMIT NUMBER: ' ., ... 4 m. F F a I j � s e......,. _ e ,.... ..a ...m _. .. .. ..._.. ,_ �. i I se ' �� r e E @ I F f ( I i E � S � 2 � t .... m« t �. .. � m t i t a a f j 7 � E I � r 4 m a na r q @ k S i 2 E I i e @ 5 ! e . e.. ...a.., �mem ..., «...,. ., ... _ e ` ..s m .,e . . .. ,, e... m. m .mm 3 i f } E � � 3 ...... . ._,,.,,s e ' 3 I ... _. 3 e � 4 Safety and Buildings Division V6 onsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County /+ r than 8 112 x 11 inches in size. Cro k • See reverse side for instructions for completing this application State Sanitary Permit Nu ber Personal information you provide may be used for seconds purposes E] Check i f revision to rev"i s application Y P Y secondary oses P P [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property O ner N e property Location E1 /4 5W 1/4, S L_ T 3 O, N, R/ (6 E (or)© Property Owner's Mailing Addres Lot Number Block Number l Z[ City, State Zip Code Phone Number Subdivision Name or CSM Number R, w d� c f LJ S � (7/<) U6 -Sc> 11. TYPE OF B I DIN : (check one) ❑ State Owned o Lit Nearest Ro d Public 1 or 2 Family Dwelling- No. of bedrooms 4 W To OF / ✓Yt G1 UL III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 4. 2JO - 4, c- 1 ❑ Apartment/ Condo Q _ C 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. Q New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. Repair of an ------ System -------- System ------------- Tank Only_______ ___Existinc System ExistiggSystem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Di ibution Pressurized Distribution Experimental Other 11 Seepage Be l01 �( 21 ❑ Mound 30 E] Specify Type 41 C] Holding Tank 12 Seepage Tre 22 ❑ In- Ground Pressure / / I 42 ❑ Pit Privy 13 ❑ Seepage Pit I (�1 L, cT 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. 1 7. Final Grade 5D Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 7 '� . Feet ► / Feet Capacit VII. I NFORMATION in allo s Manufacturer Total # of r s Name Prefab. Site Fiber- Exper. Gallons Tanks anu Concrete Con- Steel glass Plastic g App New Existin strutted Tanks Tanks SepticTa o an 0 /DA7 n ❑ ❑ ❑ ❑ ❑ Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for i stallation of the onsite sewage system shown on the attached plans. n + s Name: (Print) P}aaakwlvs Si a u e: (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address (Street!, City, State, Zip Code): / r ✓lit o LIJ IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Si re No Stamps) pproved ❑ Owner Given Initial urchargeFee) / Adverse Det erminatio n 1dT 7, V X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: a SBD- 6398 (R.1 1197) 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. 11. 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. V11. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all 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. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the }fie, residence located at: � /, Sec. T R Town of [2, C�) , plc\ , St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced - Maw Did flow back occur from absorption p system. Yes No (if no, skip next line. Approximate volume or length of time: a , 5a gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known) �rilCn,1 Age of Tank (if known): (Si a ur (Name) Please " Pt/1 nt T ( (Lic nse umber) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer p (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature MP /MPRS ®��_ Wisconsin . 09partment of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page L of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 Inches In size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and s — r , C R 0 f Y- percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # � Q 0oC ^ 6 1 l s��o� — 75 - 000 APPLICANT INFORMATION Please print all information. t Date Personal infom►ation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location C r• r Govt. Lot tjE1/4 55(.01 /4,S y T 3 ,N,R / E (Oro Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 1 1 41 7.5 * � A V t- City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road et,.3 1c.knoh t�2 5 (715 )-1Y6 -5038 R�C'h 75fi vs ' sV0 el, c.t"o► New Construction Use: ❑ Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement tt ❑ Public or commercial - Describe: Code derived daily flow 750 gpd Recommended design loading rate bed, gpd/ft trench, gpd1ft Absorption area required - - bed, ft trench, ft Maximum design loading rate — bed, gpd/(l trench, gpd/ft Recommended infiltration surface elevation(s) 5 9 It (as referred to site plan benchmark) Additional design/site considerations Parent material 0 V G 1A !b o. e — C'3 0 1 U-4, plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System i Holding Tank i U = Unsuitable for s ❑ s❑ u ❑ s u 0s 0 u El s❑ u E:1 s D U CS Cl u" SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g in. Munsell Qu. Sz. Cont. Color F51 Gr. Sz. Sh. Consistence Boundary Roots Bed Trench i 0 -Ia W-I 7.5y/, L Ground 3 ) .�1) 7,5 elev �.l n ,;t5 76 1 1 RY) 5 t_ S ' .6 S 5 -4,5 5 Y RLWY - SL Depth to limiting factor _k5 _in. f► _ Remarks: 19 °� -�- -' o r 12 AC- - Boring # Ground • elev. ft. ; Depth to limiting ` factor In. Remarks CST Name (Please Print) Signature Telephone No. -'�', S a- V- �. . � 7IS -ayg -35g� Address -.. � Date CST Number �o � + U-)X 5- a -9 a 6 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of ' PARCEL I.D.0 Boring # Horizon Depth Dominant Color Mottles Texture Structure consistence Boundary Roots Geplft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Ground elev. Depth to limiting factor in. Remarks: Boring # .... i._ Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. It. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) beC4N% r Pa e C. 3 NJ P, E$ (�fl►1hi4 �'a�' a- c, C ixi r G z- L_) T d , 3 � � as + I GA rayG h o o S t O f r%r s' V) i l� r7 r i KL 4 i 1 l ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer � I I�nfn ►.�r Mailing Address I /yl Property Address (Verification required from Planning Department for new construction) CitAtate -Q1�L � m` A Parcel Identification Number moo,? , �1 - 2 c LEGAL DESCRIPITON Property Location hLf %., /., Sec. T -R �� �LSW, Town of _ y2, " ky),,. -.d Subdivision Lot # Certified Survey Map # Volume . Page # Warranty Deed # _ �,� (pVQ Volume Page If Spec house ❑ yes 14 no Lot lines identifiable.) yes [I. no SYMAMMNANCE Improperuseandmaiat ==ofyurscpacsyst mcoaldr=kisitsprcmatzaMfa aretohandlewastes.Properm mtenance f � CVMY woe years or soon ; if modod by t li pamper What you put into go system dw septic U* ftcxtme stage is Cc viaste diisposal_s uem Ile properW owner agrees to submit tto St Crobc Zoning Department a =tificxtiou fomr, signed by &o ow= and by a P i npk=bcrresWctedphmibaoriho=sedp mpervawyiag¢lit(l)eeon- itewadm-d=&i)oulsystem is in Proper opezatiag condition andtor (2) after inspection ad pmp fey). &e septic•tu&.is less .diner If3 full of sludge. set the Oxkrsigreed have read the above required aad agree to maintain the private sewage disposal system wiHr the standards orth, herein. as set by the Department of Commerce and the Department of Natural s�tirug � Your septic has been mai Resour Resour St of Wisconsin.. Certification ntained must be completed and retuned to &c St. Cmix.Couaty Zoning Office within 30 days of the Hmx year expiration date. SIGNATURE OF CAS DATE OWNER CERTIN'ICA1'1<ON the I (we) certify that all statements on this form are true to the best of m (our) knowledge. I (we) am (are) the owncx(s) of property described above. by virtue of a warranty deed recorded in Register of Deeds Office. SIGNA OF APP DATE « « « « «« Any information that is mis- represented may result in the sanitary Zoning Departm �' permit being revoked b the Zoni eat. « « « « «« «« 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 1160 255 oo k - - � O II r FAfT Y �+a26 jCo 7 A Sure Bar d Wrsm�aain F"­ 2— 1982 �A7 `10 WARRANTY DFJD _ 1 L1fA DOCUMENT NO. VOL f G24 — , Linda J. Tiwe, a single person, I F x�.^sta aOt O .P.� it - w Yews ad wa u 1 — �ielY2.c J Berning and ,Connie L _. G Berm hus band an -ife. as survivorslu � �p�p - 1 --marital �r rty _ G -- U, —`-- P. Kr isti ne 0. st Bo x 359 p3 land P. Bo 'll ' soon n. -- -- - -- Hudson WI 54016 the follow' descnbed real maw ..St Croix I ' C.—Y. Stan, of W' i I (parcel Ideotificanon Numbm) 1 I Part of the NEIL of SW} of Section 4, Township 30 North, Range 18 West, St. CLO1X � .�I County, Wisconsin, described as follows: Cementing at the NE corner of SW} it of Section 4- 30 -18; thence 330 feet Wly along the North line of the SW'y section jl line to the point of beginning; thence continuing in a Wly direction a distance of 330 feet; thence South at right angles a distance of 660 feet; thence Fast a distance of 330 feet; thence North at right angles a distance of 660 feet', , 'I to the point of beginning. h The purposes of re- recording this warranty deed is to correct the grantee's name. F $_ 7 I i This._ As h..—.d progeny. 0.1 { E— pnonmsra —ie,: Easements, restrictions and rights -of -way of record, if any. Febru .- -._..__ .1995... 5E ,� -� t t I J c_ 1 Linda J :hoe -- FEB "5_1856 - � - .� ----- - . —__ .__.__ -_ -_ ISEALI — -._ . .---- _ -___— ISEALI . I� 9 3O A.f9 I ju AUTHENTICATION ACKNOWLEDGMENT I • STATE OF W 1SCONSR: amh"li ted Ihra ... day of _- 19 urs day of 19 95 me ands nam d sin gle arson, 'I TITLE: MEMBER STATE BAR OF WISCONSIN ,r I mo - ,��►� ST. CROIX COUNTY WISCONSIN ZONING OFFICE r r r r r N r r■ Noon` ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 May 26, 1994 Mr. and Mrs. Donald Pabst 1141 175th Avenue New Richmond, Wisconsin 54017 RE: Water Inspection Results for Residence located at 1141 175th Avenue, New Richmond, Wisconsin Dear Mr. and Mrs. Pabst: Enclosed is the original test results from Commercial Testing Laboratory, Inc. for water inspection of the above property. If you have any questions with regard to said report, please let me know. incerely, -James K. Th mpsonv Assistant Zoning Administrator mz Enclosure I �. dG' MMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715- 962 -3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 t f ST. CROIX COUNTY ZONING OFFICE REPORT NO.** 62528/01 RAGE 1 ST.CROIX CTY GW.CTR REPORT DATE: 1 23/94 1101 CARMICHAEL ROAD DATE RECEIVED« 5/18/94 HUDSON, WI 54016 A't'TN. THOMAS . S NELSON OWNER: Donald 6 Barbara Pabst LOCATION: 1141 175% Ave., New Richmond COLLECTOR: jim Thompson DATE COLLECTED+ 5 -16 -94 TIME COLLECTED: 4 +00pm SOURCE OF SAMPLE DATE ANALYZED +5 -18 -94 P tAIVE O TIME ANALYZED +2 +00pm n 1 1A Y 6 1994 4 COLIFORM,MFCC+ 0 /i 00 ml 6 T Roi;; INTERPRETATION+ Bacteriologically NITRATE -N+ 8 ppm Above 10 ppm exceeds the recommended Public Drinl,ing Water Standard. Coliform Bacteria /100 ml Nitrate- Nitrogen, mg/L LAB TECHNICIAN+ Ram Gane D ,. \NDEDENI) WI Approved Lab No. 19 t ,0 < Means "LESS THAN" Detectable Levet. Approved by'. 4 PROFESSIONAL LABORATORY SERVICES SINCE 1952 3 ST. CROIX COUNTY ,. WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 _ — (715) 386 -4680 May 17, 1994 Mr. & Mrs. Donald Pabst 1141 175th Ave. New Richmond, WI 54017 Dear Mr. & Mrs. Pabst: An inspection of the septic system serving your property at the above address was conducted on May 16, 1994. This inspection was based upon a surface inspection of said system and did not involve any excavating or chemical analysis. Accordingly there may be hidden defects in the system not discoverable by this inspection. Most septic systems consist of a septic tank which traps the solids and greases from the sewage stream and then allows the remaining sewage effluent (liquid) to drain into a subsurface drainage area. Once the liquid reaches this point it seeps away by percolating through the soil surrounding the system. Failure results when the soil surrounding the system becomes plugged with microscopic bacteria and sludge, which form a clogging mat. As time goes on, this clogging mat becomes progressively thicker, allowing less and less liquid to seep away from the system. When this clogging becomes severe enough, liquid sewage is trapped in the drainage area, a condition known as ponding, and results in backup of sewage into the structure or the discharge of sewage to the ground surface. At the time of inspection, your system appeared to be functioning, but not at full capacity. I noted that there was approximately 4 1/2" of sewage effluent ponded within the drainfield. This indicates that the lower portion of the system has begun to clog and has reduced the ability of the sewage effluent to drain away from the system. Because the failure of a septic system is a progressive process, I cannot predict how advanced this clogging is, and therefor how long this system will continue to dispose of sewage effluent. Neither can I predict how soon the system will fail completely. I want to stress that I cannot guarantee or warrant that this system will continue to function properly in the future. In an effort to rolon the system's life, I recommend that steps P g Y be taken to minimize the wastewater flow from the house which enters the system. For example, repair any leaking water fixtures and /or replace them with water conserving fixtures, reduce time spent in the shower, wash clothes and dishes only when there is a full load, use a washing machine with a suds saver feature, etc. I would also recommend that the septic tank be pumped at a minimum �� Co PD 1 of once every three years. Please feel free to share this report with anyone who may have an interest in its findings. Should there be any questions or concerns that I can clarify, I can be reached at this office between the hours of 8:00 am. and 5:00 pm., Monday through Friday. ncerely, ames K. Thompson Assistant Zoning Administrator cc: file 4 ST. CROIX COUNTY ) WISCONSIN ZONING OFFICE 1 r r r r r r r r ■ - ,O,, $ CROIX COUNTY GOVERNMENT CENTER .,. , 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 SEPTIC INSPE 'A'T VT REQUEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. ❑ Water (VOC's) $185.00 JX Septic $50.00 Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria retest $15.00 Owner: Donoatcct Requested by: Li naa- i Inge- Address: i l Li i 195�th, Avp Address: 2 24 S iK+t-, St. New Richmoha.k1Z ZIP 5 of ZIP 5 1(0 Telephone N (2 i ) 2410 - f0 220 Telephone N°: (�) 3$� -92'71 Property address ( Fire N° & Street) : I 1 ) Xtk A ve . �,I,, ocation• ;, ;, Sec. , T�(ZN, R W, Town of eW 1eicArv, (9 SZ2 0AaC e¢c ; j) Realty firm: NONE Lock Box Combo: NaNE Closing Date: 6 , 4 &/911 b 2& .-/0> 2 `51" C� TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* (pou •15i8e- Wake. lines are, o- zcess Water sample tap location: or sa� skte cf Is the dwelling currently occupied? 9 Yes ❑ No If vacant, date last occupied: Age of septic system: 9.1 .ears ( pu} ih b,j Yawtrs i rn 1Jew Septic tank last pumped by: —` nv,Var Kenn_ "' 12DA Date: Previous Owner's Name(s): -per„ s h n t. d o `Pa bst s . Have any of the following been observed? ❑Y XN Slow drainage from house. ❑Y WN Sewage Back -up into dwelling. ❑Y DIN Sewage discharge to ground surface or road ditch. ❑Y ION Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. �/ OWNERS SIGNATURE: DATE: 499 7 1/94 I OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION 1 N TO BE COMPLETED BY INSPECTION AGENCY System design & /or permit on file? OYes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system V w grd OAt -Grd ❑Mound Approx. size ' X ' - av ity ❑Dose ❑Pressurized Ft .2 6 @BL ❑Trench Well t Molding Tank OOutfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: ❑House OWell C 1in4??�- OOther DozeA tank �UTetbacks: OHouse ❑Well ❑Prop. line ❑Other OLocking cover OWarning label ❑Pump /Floats ❑Alarm OElec. wiring Soil Absorption System Setbacks: ❑House 13Well65< ❑Prop. line (�<OOther OPonding: Q,S -x Discharge: General commen' a( d F' INSPECTORS SKETCH OF SYSTEM LOCATION I Inspector Title b� S - +k � v A parcel more particularly described as follows: Commencin g at the Northeast corner of the Southwest Quarter of Section 4- 30 -18; thence 330 feet Westerly along the North line of the Southwest Quarter Section line to the point of beginning; thence continuing in a Westerly direction a distance of 330 feet; thence South at right angles a distance of 660 feet; thence East a distance of 330 feet; thence North at right angles a distance of 660 feet to the point of beginning. 7, • 0 EXP ve•�/ - Acfi y t T 2'f fT fi � Fr Imo- IS T �ZFr