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HomeMy WebLinkAbout020-1126-10-000 _ y Form S T C - 104 g AS BUILT SANITARY SYSTEM REPORT OWNER S f TOWNSHIP t j & j nC5 j SEC. T .�N -R� ADDRESS /D, (3f �'X ZI T. CROIX COUNTY, WISCONSIN �t eau tt SUBDIVISION q �; LOT LOT SIZE z • 3 ��� ✓� PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 8 /00 '- IE— M B A .o f r F. S So 31 s /arc 3$ LY 5 C-a 1 e- 'V4 / Zo ;st &Q �ofY1?u/ o),t f. 01 A i i A ssa yne-A i � r N INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used J Elevation of vertical reference point: Zap= Q p.O Proposed slope at site: 15% SEPTIC TANK: Manufacturer: (,U;� Liquid Capacity: `QOD d i - — Number of rings used 'Tank manhole cover elevation: 7e Tank Inlet Elevation: 1 Y.Z 'N) Tank Outlet Elevation: �y,o i Number of feet from nearest Road: Front,O Side, Rear, O feet From nearest property line Front,O Side,a eC Rear , _ �� feet Number of feet from: well building: ? / 6 1 "u �W ' (Include this information of the above plot plan)( 2 reference dimensions to septic tank SEE. REVERSE SIDE PUMP CHAMBER /I/ r Manufacturer: Liquid Capacity: I Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan) SOIL ABSORPTION SYSTEM Bed: << u� iaNa Trench Width: Length: 3G Number of Lines : - - Area Built: ? Fill depth to top of pipe: Z Number of feet from nearest property line: Front, O Side, ® Rear,0 Vt. ? Number of feet from well: 3 Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). " HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number ?of feet from nearest property line: Front, ' 0 Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: r t Alarm (anufac ur er: or Inspector: Dated: _ Z Z r Plumber on job: License Number: 3 �_ 3/84:mj DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY, LABOR & HLhMAN RELATIONS PRIVATE SEWAGE SYSTEMS P.G. BOX 7969 BUREAU OF PLC .G MADISON, WI 53707 IX CONVENTIONAL 1:1 ALTERNATIVE State Plan l.D. Numb ec ' El Holding Tank ❑ In- Ground Pressure ❑ Mound (If assigned) NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE Sam Mitten Tnaut&tood Rd., Hudson, All � BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT, ELEV.: SE SE,Sec.7,T29N -R19W, Lot 48,Eagte Ridge,Town of Hudzon Name of Plumber: MP /MPRSW No County: Sanitary Permit Number: Dougtaz StAohbeen I 5432 St. ctoix 436 81 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: (10 0 l O O / ! ' Z. D 0 YES ❑NO ❑YES ONO BEDDING: V ENT DIA.: VENT MAT L.. HIGH WATER BEIi gOAD: PROPE RV WELL: BUILDING: VENT TO FRESH � 1 AL NIJM ARM: ❑ FEET FROM /� / LINE: ` � ? /LAIR 7T YES ❑NO - DYES NO NEAREST (( /� T V+rnv DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. J PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: 71 N ONO OYES ONO I DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER O F PROPERTY WELL. BUILDING. JVENTTOFRESH (DIFFERENCE BETWEEN FEET FRt3M LINE AIR INLET: PUMP ON AND OFF) ❑YES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH. NO. OF DISTR. PIPE SPACING. COVER INSIDE CIA.. *PITS: LIQUID BEO /TRENCII / q TRENCHES ' M� /j� PIT DEPTH: DIMENSIONS ` � f ( ��VJJ i�I GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER ELEV. INLET EL VEND PIPES. FEET FROM LINE: 40 AIR INLET: o NEAREST`. o MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES ❑N meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS. OYES ONO DYES El NO DEPTH OVER TRENCH /BED 1EPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED: CENTER. DGES. ❑YES ONO I OYES ❑NO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BEDITRENCH WIDTH: LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER _D131AENtONS '.i MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.: ELEV.. DIA. ELEV.. PIPES. DIA.: ELEVATION AND InSTAIBUTION W FORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑YES ONO ❑YES El NO COMMENTS: PERMANENT MARKERS: J OBSERVATION WELLS: NUMBER OF! PROPERTY WELL: BUILDING: FEET FROM LINE: El YES 1:1 NO OYES 1:1 NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: ITIT6 DI LHR SBD 6710 (R. 01 /82) 1 �� wlsconsln �2 APPLICATION FOR SANITARY PERMIT + � DILHR OUNTN oERRRTmEnT (PLB 67) UNIFORM SANITARY PERMIT # InOUSTRV, LRBOR 6 HUMRn RELRTIOnS / ry� — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /2x 11 inches in siz —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MLr ING A DD RES /0 i �/� r 1 4 r ����/� U� vii �i S PROPERTY LOCATION /' G+T —Y-- E 5r1/4,S 7 ,T� BW) rev/ v�rO- / N, R TOWN OF: LOT NUMBER BLOCK NUMBER SUBDIVISION NAME rNEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TY,P Q V / BUILDING OR USE SERVED Z / ld 1 or 2 Family Number of Bedrooms. J L1 Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. [Y'Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank /Siphon Chamber /4 Holding Tank capacity Manufacturer: �� i • 5 - IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic 0 1. Gallons Tanks Concrete Constructed Septic Tank Capacity 1 Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): �/ 4 y L� Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. ___­ Na of Plumber (Print): / Signature: J I MP/MPRSW No.: jPhone Number: , 41 4L2 Plumber's ddress: " % Name of Designer: /V 4 U/ r �h n, w y I� l 7 C Ci 6`..CI COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Disapproved l / I El Owner Given Initial - &/4-a C,,, f�-V Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber L DEPARTMEN. 01 SAFETY & BUILDINGS INDUSTRY �, I 4 ''s , ORT ON SOIL BORINGS AND DIVISION LABOR AND Q � / ERCOLATION TESTS ( 115 P.O. BOX 7969 HUMAN RELA NS Al 8D \ MADISON, WI 53707 LOCATION: N: OWNSHIP/ LOT NO.:BLK• NO.: SUBDIVISION NAME: S E '/ t '/ (p 1 4V /X-1 I e COUNTY: OWNER S NAME: MAILING ADDRESS: Cra ; x 11 Le USE DATES OBSERV IONS MADE NO. BEDRMS.: DESCRIPTION: NS: IPERCOLATION TESTS: Residence j/ New El Replace `�� _ D3 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND•PRESSURE: SYSTEM -ENF TANK: RECOMMENDED SY TEM:(optional) ®,S ❑U ®,S ❑U ZS ❑U ❑ S ❑ S ZU r v,.� v c;�• � i•r.Q� �d �' 36 ` If Percolation Tests are NOT required re DESIGN RATE: SYSTEM 4 If any portion of the lot is in the under s.H63.09(5)(b), indicate: �/ �(/ Floodplain, indicate Floodplain elevation: �/� Pu FILE DESCRIPTIONS rte• BORING TOTAL/ DEPTH TO GROUNDWATER4NQ+tE3 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH.Hd, ELEVATION OBSERVED E T. CHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) .T, �- r8n S /. S Bn ��5 "''�'r J �. / E3n C's f B -3 ,S�i : ,'4rti�S '��� S/� ���b'n Cs ��•r.� • yA„ s E S,Bi /, / 9 �? s B;, cs +�r /.7 B- PERCOLATION TESTS TEST DEPTH' WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER 14Efs AFTER SWELLING INTERVAL -MIN. P RIOD 1 PERIOD 2 PERIOD PER INCH P _ > 5. 0 P- 3 , b' P- P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. .3 Xi . S Bpi .S�/ .2.5 Bit /C-5 !— = SYSTEM ELEVATION q�?• �i �'r'� /. d�,dn CS r, , ( dry f S , . i� . -- �... 1 / 0 ` ( �`8_ CAI y _._ , 3.. ` N • • t S S6t f7 r ti _ __ j_E e� m _ " i r 3 I I e !, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. I � NAME (print): TESTS WER�E COMPLETED ON _ ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(opuund,,. d � t C NATURE: DISTRIBUTION: Original -Local Authority, 2nd page - Bureau of Plumbing, 3rd page -Prop rty Owne�, 4th page -Soil Tester. OILHR -SBD -6395 (N. 03/81) r v ' Jr 5� �') Al III � r S' y (i P L � f R� fJ E7 f S Ale At (J •�' lt/ �' ®, 5" Gar. / o f C n c t• Ott (16 ck Aioe) o Pprcf f 8d7�—o F/ 1 ), 66 - �Vvfe - 4PCe f. 4 -cc-041-1 11 1, to -000 fn Ve .4 / 4 � � t #� g 5� oak' 4 tr y t� L •� R�, 8aK - d i4fl� O�'A��A S tit/ L o g o k g f f are C o /- C �61 L't-�aln, © 1 Oxf 2 a To �Huk '4 L D G to��' Ac e d�ti6r� �ht �' caSl + fi t "C'41 6 so� p rr� / SI c a ar'r a'y s r DUr/ U �, / V �� h no se yac " 1 � d�� r 6�rP�, r,� C i x z cn H ST C- 105 r z a SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z ty a OWNER /BUYE 4 �° ROUTE /BOX NUMBER 7jj �r ,7i� /Wt- Fire Number CITY /STATE - ZIP PROPERTY LOCATION: 1 4, F_ 1 4, Section_, T R W, Town of lzeatso St. Croix County, Subdivision, Lot numbe Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con - sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. Ho E I /WE, the undersigned, have read the above requirements and agree z „ to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart - �+ ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 I 715- 796 -2239 or 715 - 425 -8363 Sign, date and return to above address. a APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequaoies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractgr,( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -.- - - - - - - Owner of Property 5 rz Y Location of Property — 5 E— i t E jy, Section �_ , T .29 N - R c7 W Township d ,�l Mailing Address Z r a7 f (ct- tj r cx Subdivision Name F Q a Aq Lot Number c/ fJ Previous Owner of Property - Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable ? Yes No Is this property being developed for resale (spec house) ? Yes �� No Volume <05-0 and Page Number 3 y� as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Deed 2. Land Contract • 3.• Other recordings filed with the Register of Deeds Office In'addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. ----- ----------------------------------r----- PROPERTY OWNER CERTIFICATION I (We) eenti6y that att dfiatemente on xhid 6onm cute .tnu.e t the bed.t o my (out) knoweedge; that I (we I am (ate) the owneh (d ) o 6 the pnopen ty ded eh,i.bed in .thin .in 6o nm , by vchtue o6 a wannanfiy deed neconded in the 066.ice o6 the County Regidten o6 Deedd ab Document No. and that I (we) pnedenfity own the ptopoded d.c to bon the sewage d14 po.6ZF6yAtem (on I (we) have obtained an easement, to nun with the above deacAi.bed pnopenty, bon the con6.t4a.ction o6 aa.id d ys.tem, and the dame had been duty neconded in the 066.ice o6 the County Reg.i d.ten o6 Deeds, as Document No. _39 5/ 1 SIGNATURE OF OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED I � 7 �8 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 Z la t A/1 say` Irl oaIr /ck residence located at: 1/4 Sec. _ , T a29 N, R _ y W, Town of ,S'n P1 Upon inspection, I certify that I have found the tan affles to be in good condition, and it appears to be functioning properly. Last time serviced 0 U Did flow back occur from absorption system? Yes NoX(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: �QQ Construction: Prefab Concrete _ Steel Other Manufacurer (if known): W ei S of A of Tank ( if known) : ahotd �6 y' em L (Signature) (Name) Please Print M P - '�?2 6741st (Title) (License Number) b V/ (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (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 inspe ion opening over outlet baffle . Name Cj S f - e e �h Y' Signature MP /WWS 1 5!h � 5/88 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. Permit Holder's Name: ❑❑ Village Town of: State Plan ID No.: KIRKPATRICK, DANIEL & MARY N CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T.al:1126 -10 -000 /a Q U TANK INFORMATION ELE ATION DATA A9800561 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic J Benchmark Dosing 5 r -f tom Aeration Bldg. Sewer f Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. A ir ir i to ROAD Dtl et Antake 7 Septic NA Dt Bottom Dosing NA Header /Man. <va, iv. a T Aeration NA Dist. Pipe 31 Holding Bot. System / Z PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft L oss H ead Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of mo Number: System: ��_, /O A, 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 [] Yes C] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 07.29.19.577,SW,SE 388 KRATTLEY LN — EAGLE RDG LOT 48 Plan revision required? [:]Yes Cj'No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Vi sc�nsi n SANITARY PERMIT APPLICATION 01 E wasnngton ve'sion In r i . m. P6.0. Box 7969 Department of Commerce acco d with ILHR 83.05, W s Ad Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County " than 8112 x 11 inches in size. . e • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Nu mber I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property Owner Name �✓t , Property Location /i �GtY i k/ 1/4 6E 1/4,S 7 T �`� , N, R 19 W Property Owner's Mailing Address Lot Number Block Number roL* e �QnC- Fl City, State Zip Code Phone Number Subdivision Name or CSM Number d son W T 5g ol Io 1 (715) Eagle t?I G1/ e 11. TYPE OF BUILDING: (check one) ❑ State Owned Nearest Road Public k 1 or 2 Family Dwelling - No. of bedrooms t& Town OF 44CA 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. A Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 _ ❑ Repair of an - _____ System _______ System___________ __Tank Only_ ____________ Existing System _________Exi - yytem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: .(Check onlyone) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Q Seepage Trench 14V I fft for 22 ❑ In- Ground Pressure � r r 42 ❑ Pit Privy 13 E] Seepage Pit $��f e w laic � ��� 3 x ✓ " 43 ❑ Vault Privy 14 ❑ System -In -Fill 3 t.g ,4 ,( v,,A VI. ABSORPTION SYSTEM INFORM ION - 70 Z. 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 11 15 0 75o 7 Ito 95,35 Feet 98, 7 Feet Cap acit y VII. TANK i Ca allo s n Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons an Manufacturers Name concrete Con- Steel glass Plastic App New Existin structed T nk Tanks tic Tan — l000 �kl /xY ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ I ❑ 1 ❑ 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) Pl is Si7 5te)-n e: (No Stamps) MP /MPRS�KNe.: Business Phone Number: au,L ei ner' 6/ e r Plumber's Address (Street, City, State, Zip Code): A199,30 ?I-16 9'GGZ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued ISS U7 4 nt Signature (No Stamps) .Approved ❑Owner Given Initial /(j�/� Surcharge Fee) / Adverse Determination / C(/ �� (t ���� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: (W ,s btAy;r- c ssD4M (A.t lies) DISTRIBUTION: or4nat to County, one co To: Safety s stirdings Dhoisean, owner, Pkwd . ?Ian �i Bm o se rAr ner o-V ecr,c,rer - �e— per6 o e1. ►co s c OA e, W¢ l( lVCu)u�l 1 4 �jon ►oo. So g a !S► B " v 1_n+ Lrn� � -- SIc1 Incl ( n - + i I fYcc 4t erg c� All " STilliZv-)h�,afi/ x ��� Cl ra • _Q . (34 ,r x I (' r 7,51 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations DIVisionn q!Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code * f COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 020- APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION RIEWEDBY DATE W 6 PROPERTY OWNER: PROPERTY LOCATION Barry Marlett GOVT. LOT SW 1/4 SE 1/4,S7 T 29 ,N,R 19 * (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 388 Krattley In. 48 na Ea le Rid cfe CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®TOWN NEAREST ROAD Hudson, WI. 54016 (715)386 -7706 Hudson ( ] New Construction Use [ x] Residential / Number of bedrooms 3 [ ] Addition to existing building fK] Replacement [ ] Public or commercial describe Code derived daily now 450 gpd Recommended design loading rate ._ bed, gpd /ft _ trench, gpd/ft Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate .5 bed, gpd /ft _&_ trench, gpd /ft Recommended infiltration surface elevation(s) 95.35 ft (as referred to site plan benchmark) Additional design / site considerations 45x20' bed Parent material stream terrace Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors ste 1 13 S ❑ U ❑ S C$ U CR S ❑ U I ❑ S saLU ❑ S CCU ❑ S 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 Trer>d1 <' 1 0 -12 10yr3 /3 none fill na na 2m no n 2 12-24 10yr2 /2 none 1 lcsbk mfr gw lm .2 .3 Ground 3 24-40 10yr4 /4 none sil lcsbk mfr gw if .2 .3 elev. 9 8,7 ft. 4 40 -84 7.5yr4/6 none fs Osg mvfr na na .5 .6 Depth to limiting factor +84" o � Remarks: Boring # 1 0 -10 10yr3 / 3 none 1 2msbk mfr gw 2f .5 .6 2 2 10 -36 7.5yr4/4 none co s Osg mvfr gw if .7 .8 3 36 -88 10yr4/4 none s /ms Osg mvfr i�aa /r1�•, .5 .6 Ground elev. �\ 99 ft. F �O �r Depth to .7 limiting 1 s r factor c Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715 246 - 6200 Address: 1554 200th ye. New Ric and WI 54017 Signature: Date: CST Number: m02298 9 -22 -98 PROPERTY OWNER Barry Marlett SOIL DESCRIPTION REPORT Page 2 6f 3 PARCEL I.D. # 020- 1126 -10 �.� 1� Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bondary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 4h4 . 1 0 - 10yr3 /3 flf 7.5yr5/6 fill na na gw 2f np np 2 12-2E 7.5yr4/4 none co s Osg ml gw if .7 .8 Ground 3 26-8S 7.5yr4/6 none fs Osg mvfr na na .5 .6 elev. 9 9.8 ft. Depth to limiting factor �J Remarks: Boring # 1 0 -8 10yr3 /3 none 1 fill mfr gw 2f np `np 2 8 -18 10yr3 /3 c2d 7.5yr5/6 1 fill mfr gw if np inp 3 18-36 10yr4 /4 none 1/ fs lcsbk mvfr gw na .4 .5 Ground elev. 4 36-82 10yr4 /4 none fs Osg mvfr na na .5 .6 99 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) r STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 BArry Marlett New Richmond, WI 54017 town o w n o f Hudson S7- d29N -R19W (715) 246 -6200 town o lot #48 -Eagle Ridge i N 1 11 =40 1 BM.= top of se corner of concrete patio C el. 100' Alt. BM.= top of door sill @ el. 100.50 I k t (fi Gary L. Steel 9 -22 -98 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �ah ,Qecky X/ /<pli7�ric% Mailing Address 3gg /�� /ty L u., e #u AVPt r Property Address S u rn e `/ (Verification required from Planning Department for new construction) City /State /7 K 4 o1' , W� Parcel Identification Number a a O " 11'26 - /0 LEGAL DESCRIPTION Property Location Sw r /4, SE ' / a, Sec. T . T g N - R `� W, Town of A4 �s o^ Subdivision 64 e le �� �9 a , Lot it 1 /9 Certified Survey Map # . Volume , Page # S$ 8 S �S / 3 6 3 , 305— Warranty Deed # Volume Pa Pa Spec house ❑ yes X no Lot lines identifiable h 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 licensedpumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage 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 r exp date. SIGNATURE OF APPLIGKNT 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 desc ' d abov , by virtu warranty deed recorded i Re i er of De s Office. SIGNATURE OF APPLIC 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 - t Vrot 1:363 ma ln- 10 f o r V, ��0 STATE BAR OF WISCONSIN FOR%I 2 - 1982 WARRANTY DEED DOCUMENT NO. 5T. CROIX COO WI Barry C. Marlett and Patricia A. Marlett, Ro4'4 Nr NveQ h usband and w e, OCT 0 7 1998 q.'oo A M conveys and warrants to _ Daniel D. KirkpA 'k and Mary R. �� O.W., Kirkpatrick, husband nd wifeR R+ to d THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADD the following described real estate in St Croix ant)'• y f �l� 1 State of Wisconsin: 1`l 0 20- 1126 -10 -000 PARCEL IDENTIFICATION NUMBER Lot 48, in Eagle Ridge, Town of Hudson, St. Croix County, Wisconsin. TRANSFER 3 555• F This _ is homestead property. (is) XXKKK Excep to warranties: Easements, restrictions and rights -of -way of record, if any. October 98 Dated this h _ — day of _ A.D.• 19 (SEAL) -, _ (SEAL) « Barry C. Marl — _ Patricia A. Marlett - - - - -- - -- - -- \;EAU - -- (SEAL) AUTHENTICATION ACKNOWLEDGMENT State of Wisconsin, Signaturr(s -- - - - - -- - - - -- -- - - - - -- cc _ - - -- — -- -- St. Croix C wilientirated this - -- dat of _ __ -- -, 19— �" >'r:alh carne hrfore ❑te this n O day of October 19 _, the above named _ Pat A. _ 1 - IrLE. MEMBER SIAIE BAR OF \ \ISCOINSIN PpUlI❑ _- -- - -- - - - -- — 6t�Y - - -- - tIf not. - - - -- (3rt Public f W isconsilt' awhollz' d by b -0h or. \ \:s Star: , 'vt)tary „., to he the person _ —_ \cho cse:uted the otegoutl , „ nd arkno%%ledg ;h same THIS INSTRUMENT 4VAS pRTJ FC BY _ Attom -y Kristina Ogland flit Hudson, WI 54 016 - f' _ -- .- -- County, \\'Is I t ma not c:, 1 d 1, s oI; Is nt III not rate z nrA.t Ion datr (Signatures mac hr aotl nticatcd or a, kn , \ Ie. << Both are - t, ,t •, ,IAIT IIAR,It 1) DI DCtD Farm \o i i i CC) }U � W o t l1 W' U �� UZ �y , t u u ' QO Q N �� ti N a0 —' � �Q N � �� .t ^ t Q N — O w F 0 2 qt a o � Z It Q I �l V �h 110 O �� W e v 'n � Op� o © V °O �� N M w a � ( O °° h 4 2� 6 ° � j tO tO w \ � M w rn Q 0 090,J I 1 � 0 9 S °08 � 9 tv �tv cp � - 30 V Z O O nN �B, - N 33 Q ° 6 , co S6 2 0 0 co 40 cr V 0 !OO w �S S IP A � N � _� - . , W cc X00 L a \0 � O_ O\ 0 5 ; N �- `�. 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