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ST. CROIX COUNTY ZONING DEPART 9 �:.
AS BUILT SANITARY REPORT r `�
Owner
Property Address L/ r' 1
City /State IE0 dfo '� �� oq 1 ;
oau �
Legal Description:
Lot Block Subdivision/CSM #
Sec. '� , TAN -RAW, Town of �7 PIN - Za -Ov&
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer L4-)&A4- SiM�C / Setback from: House L Well 1,0 P/L lod
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: Width Length `7 Number of Trenches -z-
Setback from: House Y_ Well / /z� P/L / Oo Vent to fresh air intake
i
ELEVATIONS
Description of benchmark �P- Gw Elevation
Description of alternate benchmark 5 4. d yx Elevation
Building Sewe ST/HT Inlet 00 ST Outlet 3 PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover b
Distribution Lines
of System
Bottom Sys () () ( )
Final Grade
Date of installation/Z / 1NPermit number 353111 State plan number
Plumber's si ature � License number cf'Z Date/
Inspector o
Complete plot plan �
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
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INDICATE NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y
Safety and Buildings Division
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)]. 353141
Permit Holder's Name: ❑ City ❑ Village (0 Town of: State Plan ID No.:
Ju lia Town of Troy
CST BM Elev.:-
Insp. BM Elev.: BM Description: Parcel Tax No.:
�°� • O 0 0 •O , VA *- 1, 040 - 1023 -20 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 3•� o3. , u 1 6M.0 r
Dosing Alt. BM ` , t�- Z Z " /0033
Aeration Bldg. Sewer 3 3S 3. `` 1 4- ,Z
Holding t/ Ht Inlet o r
g mil• 4� 0 99. v '
TANK SETBACK INFORMATION St/ Ht Outlet r 2 " q 133
TANK TO P/ L WELL BLDG. A ir ir I ntake ROAD Dt Inlet —
A
Septic o .�p r r -- NA Dt Bottom
Dosing NA Header/ Man. G. Z3 9G,
Aeration NA Dist. Pipe S3 �K C14,4, }'
Holding Bot. System 8 qS 3 3
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PUMP/ SIPHON INFORMATION Final Grade .SS C - ( Z_
Manufacturer Demand St cover I •Gz r } r /?- n n/. 3$
Model Number GPM
TDH I Lift Iction System Ft
Loss me
For In Length Dia. Dist. To Well
SOIL ABSORPTION SYSTE IZ- d,,�,,,�J
JWHiilli-CT Width r Le r No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth
DIME I N 3 DIMEN ION
LEACHING Ma uf� turf ef:
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM -
INFORMATION Type Of f r CHAMBER Model Number:
System: OR UNIT �u
DISTRIBUTION SYSTEM
Header/Manifold k Distribution Pipe(s) I x Hole Size cing Vent To Air Intake
Length Dia. Leng Dia. pacing
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.) Inspection # 1: MI q /11 Inspection #2:
Location: 487 Virgil Road, Hudson, WI (SW1 /4, SE1 /4 Section 5 T28N -R19W) - 5.28.19.79A
Plan revision required? ❑ Yes D4 No
Use other side for additional information.
SBD -6710 (R.a/97) Date Inspector's Signature Cert. No
r.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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• Safety and Buildings Division
S ANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
Vi sconsin
In accord with ILHR 83.05, Wis. Adm. Code P 0 Box 7302
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on p v u6 l� 6
than 8 1/2 x 11 inches in size. "� _? �•
• See reverse side for instructions for completing this application r- -[ �f Sa t4 ermit Number
Personal information you provide may be used for seco dary purposes • check it ' ` i top .O appfi' cion
[Privacy Law, s. 15.04 (1) (m)]. u�� v� F t
/ ( d stat Ian D umber
I. APPLICATION INFORMATION - PLEASE PRINT AL INFO TI r C
Prope�XOwner gamep �
1i T4, ZS r N ' R /17 4 (ors
Property Owner's Mailing Address Lot N of Block Number
City, tate J Zip C de Phone Number Subdivision Na a or CSM Num r
❑ It Nea est
Road
I!. TYPE BUILDING: (check one) ❑State Owned village
Public 1 or 2 Family Dwelling - No. of bedrooms_ Town OF //a �t/ /
III BUILDING USE: (If building type is public, check all that applyu W04AA.0 Parcel Tax Number(s)
1 ❑ Apartment/ Condo 7
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 1R New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
System_______ System -- _TankOnly Existing System________ Existin�S�rstem
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12)& Seepage Trench 22 ❑ In- Ground Pressure 42 E] Pit Privy
13 E] Seepage Pit C 3 7 0 43 ❑ Vault Privy
14 E] System-In-Fill ,2rf dl! 3 (• �5
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
16 ] D 7 3 • Feet ?8. �/ Feet TANK Capacit VII• INFORMATION in gallo Total # of Manufacturer's Name Prefab. Con steel
Fiber- Plastic Exper.
New Existing Gallons Tanks concrete strutted glass App.
Tanks Tanks
s ❑ 10 ❑ ❑ ❑
Lift P ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum e �C � r's Name: (Print) Plumber's Signature: (N Stamps) M PR
P /M_ SW N2 : Business Phone Number:
` x� �5a ?r - 77 z 3 zr
i f�-rw
Plumb )f is Address (Street, City, State, Zip Co e): ,
0 XW 0�
a /-* 7
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuin %��J_(/ nt Signature (No Stamps)
[Approved [] Owner r Given Initial S —p, Surcharge Fee) ! � b c /� ���'
q
Adverse Determination
. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL. /r7o
SBD- 6398 (R.11197) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years. '
2_ Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608 - 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family,Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) 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.
JOB / GU �4 �2 �/L a 0(,-_S
TIMM EXCAVATING 1
SHEET NO. � OF
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY ` ^ \ DATE
(715) 772.3214 (715) 386 -5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 p Inc.. Groton, Mass. 01471. To Order PHONE TOLL FREE 1- 800 - 225.6380
• Wisconsin Department of Commerce OR's AND SITE EVALUATION Page 1 _ of 3
LOi vlsion of Safety and Buildings ith Comm 83.05, Wis. Adm. Code
Certified Soil Testing
Attach corriplete site plan on paper not less than 8'/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. - - ---- - - -- -
Parcel I.D # 40 -10232 (05.28.19.79A)
APPLICANT INFORMATION - Please print all information. - - - - - --
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Rgewo By Date
t
Property Owner Property Location
Cernoho Julia Govt. Lot SW 1/4 SE 1/4 S 5 T 28 N,R 19 W
Property Owner's Mailing Address Lot # # Subd, Name or CSM#
455 CT HW FF _ _ _ tB locl 1
City State Zi Code PhoneNumber City Village XTown Nearest Road
Hudson WI 5016 715 - 386 -3476 C, Tro CTHW FF
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 -5 bed, gpd /ft • trench, gpd /ft
Absorption area required 900 bed, ft' 750 trench, ft- Maximum design loading rate - bed, gpd /ft • t rench, gpd /ft
Recommended infiltration surface elevation(s) 95.9 ft (as referred to site plan benchmar
Additional design I site consideration install 2 - 27 x 75' Sidewinder, Hi- capacity "turtle- shell" trenches on nominal 97.9 contour
Parent material sandy /loamy outwash 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 for system X F-1 U ® S❑ U N S❑ U X S iJ U I-_! S U LJ S ,2s U
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -5 1 IOYR 2/2 - sl 2 m gr ds cs 2flm .5 .6
2 5 -15 10YR 2/2 - sl 1 m sbk ds cs I m 4 .5
Ground 3 15 -33 1OYR 2/1 - sl 2 m sbk dsh cw 1 m
.5 .6
elev i
98.3 ft 4 33 -52 l OYR 4/4 - sl 2 m sbk mfr cw 1 m .5 .6
Depth to 5 52 -61 ! l OYR 4/4 - s 0 sg dl Cs - . 7 .8
limiting p '
factor
6 61 -78 IOYR 5/4 c3 7.5YR 5/8,5/3 scl 0 m mfr CS ]III NP .2
61" 7 78 -86 I 1 OYR 4/4 - mcos 0 sg ml - - .7 .8
Remarks: - - - -?- - - - - - -- - = - - - -- - - - - - -- - -
2 1 0 -5 1OYR 2/1 - sl 2 m gr ds cs 2f1 m .5 .6
2 5 -10 r 1OYR 2/1 - sl I f -m sbk ds cs I .4 .5
Ground 3 10 -22 1 OYR 2/2 - is 1 m sbk ds gw if .7 .8
elev - - -- - -- -- -- — -- -- - -- - -
_ 97.3 ft 4 22 -78 l OYR 4/4 - s/mcos 0 sg dl - - 7 .8
Depth to
limiting _
factor
78"
Remarks: occasional inclusions 10YR 5/4 scl (typically 1 -4" thick and 8 -14 ") long in horizon 4
- -
CST Name (Please Print) Signature: Telephone No.
Henry F. Grote 715- 665 -2681
Address Certified Soi: Testing Date CST Number Ref #
P.O. Box 57, Knapp, WI -54749 8/16/1999 222774 1231
PROPERTY OWNER:- Cemohous, Julia SOIL DESCRIPTION REPORT Ny page _? of 3
PARCEL LD.# _ 40 -10232 (05.28.19.79A) Certified Soil 1t
Horizon P Texture onsistence Boundar Roots GPD /ftz
Depth Dominant Color Mottles Structure
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -7 l OYR 2/ 1 - sl 2 m gr ds cs 1 f/m .5 6
2 7 -25 10YR 3/4 - ls/lmcos 1 m sbk ds cs 1m .7 h
Ground 3 25 -66 10YR 4/4,3/4 - s/mcos 0 sg dl cw If 7 b
elev
-
_ 97.9 ft_ 4 66 -80 10YR 5/4 c3p MYR 5/8,5/3 scl 0 m mfr - - NP .?.
Depth to
limiting - - - -- - - -- -
factor
i
Remarks: ouzo - vanes r m m s a w ew sman inclusions sell in norizon T occasional gr & cob below
4 1 0 -4 l OYR 2/2 - sl 2 m gr ds cs 1 f/m .5 .6
2 4 -16 l OYR 2/2 - sl 1 m sbk ds gs IM 4 .5
Ground 3 16 -53 l OYR 4/4 - sl 2 m sbk dh cw I m .5 .6
elev --
100.3 ft 4 53 -77 l OYR 4/4,4/6 - s 0 sg , i dl cs if .7 .8
Depth to 5 77 -80 10YR 4/4,4/6 flp 7.5YR 5/8 s 0 sg ml cs - .7 .8
limiting
factor 6 80 -84 IOYR 514 f2d 7.5YR 5/8,5/3 scl 0 m mfr - - NP .2
77
Remarks:
5 1 0 -4 1 IOYR 2/1 - sl 2 m gr ds cs I f/m .5 .6
r
2 4 -15 IOYR 2/1 - sl 2 f -m sbk i dsh cs lm .5 .6
Ground 3 15 -30 l OYR 4/4 - sl 2 m sbk dh I cw 1 m .5 .6
elev
99.1 ft 4 30 -40 l OYR 4/4 - s 0 sg dl cs - .7 .8
Depth to 5 40 -85 l OYR 5/4,4/4 - mcos 0 sg dl - - 7 8
limiting
factor
> 85• K
i
Remarks: occasional gr a cob in nonzon
Ground _
elev
Depth to
limiting
factor Note: variable depth to moderate structure sandy roam mdicafes a shallow system sized of 0.6 gpd /sq ft for a trench even though some of the
system elevation will encounter sands or loamy sands @ 0.8 gpd /sq ft
i
Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer G e ktdjc�r,�
Mailing Address C4 e
Property Address j "j
(Verifica ion requireg from Planning Department for new construction)
ll5
City /State Au 9m 141 // Z Parcel Identification Number. ()% A 16 Z 0 0
LEGAL DESCRIPTION
Property Location 4 5 ij ' / <, ' /4, Sec. , T N -R_�± Town of ra
Subdivision Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # Volume , Page #
Spec house ❑ yes 21 no Lot lines identifiable ;N yes ❑ no
SY STEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
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. c� q
® r ,
NATURE 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
e property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
T ATURE 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
DOCUMENT NO. STATE BAR OF WISCONSIN- FORM 2
WARRANTY DEED
THIS SPACE RESERVED FOR RECORDING DATA
3 REGISTI L '
ST. CRoO ,< -
Edith E. Cer a single person
BY THIS DE ED, _ R @C , d fcr f = 7Th
and yri erno - fious an��a�r- i`c �?�ece �t1cr 71
is wife and - in 1h r ow n behalf - -- day oi __.--- --_
Grantor conve s nd wart nts to lrgl Cernohous
uia �ernoFious, �iusband and wife asp
joint ten ants, - - -- - — -- -
- - -- - -- - ..Grantee s - - - -- - --
for a valuable consideration. - - -. RETURN TO
— 5t — Cr
the following described real estate in County, State of Wisconsin:
Tax Key #
The Southwest Quarter of the Southeast Quarter This is - homestead property.
of Section Five(5), Township twenty -eight
(28) North, Range Nineteen (19) West
and
All that part of the Northwest Quarter of
the Northeast Quarter of Section Eight (8),
Township Twenty -eight (28) North, Range
Nineteen (19) West lying North of former
State Trunk Highway 35 , now County Highway
FF, EXCEPT: Beginning at the intersection of
the North right of way line of C.T.Highway FF
and the East line of said Northwest Quarter of
the Northeast Quarter; thence North along said (p 7
line 435.6 feet; thence West parallel with the
highway 200 feet; thence South parallel to the
East line of said Northwest Quarter of the North -
Excepti eof,t.rQMaKter 435.6 feet; thence East 200 feet
to the Point of Beginning.
Executed atTown of Tro_ yy, St. Croix Countlf, 30th da of October_ - - 19 71,
l'
SIGNED AND SEALED IN PRESENCE OF '1 i C �I �� (SEAL)
E ith E. Cerno ous
r
-__- (SEAL)
' .Cyril Cernohous
(SEAL)
1 Patricia Cernohous
-- - - - - -- -- - -__ - _ _ -- - _ - (SEAL)
Edith E. Cernohous, Cyril Cernohous and Patricia Cernohous
Signatures of - - --- - - - - ---- - -. _._..__- - - - - -- - -__. -- - -.. - -- - ---�_-
his wife _
30th October 71
authenticated this ._.___ - -- _ .- day of_- _ -_ -_ -- _ 19_
ohn D. He woo
Title: Member State Bar of Wisconsin )f&CMdOF%XX
Authorized under Sec. 706.06 va.
i.
STATE OF WISCONSIN
- -- - -- County. ss.
Personally came before me, this_____________-- - - - - -_ day of 19.__,
----- - - - - -- -
the above named — -- - - - - -- - - -- - - - -- ------ - - - - -- - - --
to me known to be the person_ who executed the foregoing instrument and acknowledged the same.
This instrument was drafted by
Heywood and Hayes, Attorney Notary Public County, Wis.
Hudson, Wisconsin
The use of witnesses is optional. BOOK 7, E My Commission (Expires) (Is)
----- ---- -- ----- .- - - - - - -- to-- - - - - - -- _
Names of persons signing in any capacity should be typed or printed below their signatures.
M C. MiIIICarprry�
WARRANTY DEED —STATE BAR OF WISCONSIN, FORM.N6. 2 — 1971