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HomeMy WebLinkAbout020-1157-00-000 {$ 28 7� 22 jk G / 0 2 /E m \ C). \ 7/ ) 7o / £\ o a) a) z £ C 0 1 6 Z k / z k U. � _ « 2 2 0 a \ .\ m / ) E < e ± � $ o / n I Cl) CL a m " % % 0 / z a c CL ■ / § z j 2 2 \ \ $ J a § $ \ U) = 7 / 7 2 / m e r © e 5 4) 5 N cc a) I co ƒ -� kJ § 7l m § $ ' / , § - Q _ z ca z z co z .. .. } » a k � � 2 � w k k k k \ ^ $ E ) { \ § k 2 } .0 \ § k a } m . a 2\ k = e¥ k k \ . E w Ff ) t - $ 0 2 2 2& 2 x 2 / \§ m 2 2 2 §§§ o a) _ » m m z / R \ $ & ) § § \ a § a \ £ 2 § = 2 E 2 \ § 2 C: J $ e o. e <2 a 2� 2 # », m 2 < z m : o § 2 m ° § c Lo■ g 0 C E 0 E — — E E 6® k « 0 J § 7\ 9 Q & & \ /& )_ �/� ) § ƒ§� 2 6§ $ 8 )¥ 2 [§ 2/@ 2 c . w k/] �* Cl) 0 2; o o a{ o— I ,o « o z_ I o n o z 3 z E « � � . % IL . I a » CL » CL E k� ( k ( § k Q u a■ o■ u o u , f AS BUILT SANITARY SYSTEM REPORT 1 OWNER ,/VI CZC TOWNSHIP H"44 0 t% SEC.LTMN -R y W ADDRESS ��Q ST. CROIX COUNTY, WISCONSIN. SUBDIVISION VI('" , 's L�OT U 3 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM - i r Indicate N r h rr w BENCHMARK: (Permanent reference Point) Describe: T ° ' (� � � " n GoNnCr Elevation of vertical reference point: �D a,0 U Slope at site: SEPTIC TANK: Manufacturer : Liquid Capacity : __e � 19cl l Number of rings on cover : Tank manhole cover elevation: Tank Inlet Elevation: A �, Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons 1 1 1 - � Number of gal pump set fora cycle_ AI'4 gallons; Total capacity of distribution lines ,4 gallon: size of pump I V 4 head; / gallon per minute /VA horsepower ;brand name of pump and model number AIA ; Type of warning device i { - + HOLDING TANK: Manufacturer Number of gallons lv ,4- Elevation of manhole cover Type of warning device A SEEPAGE PIT SIZE; IV /� Number of pits /A IP feet diameter /" feet liquid depth A,-11- seepage pit inlet pipe - elevation bottom of seepage pit elevation A/ 4- feet. SEEPAGE BED SIZE: number "f of line width length 36' tile depth SEEPAGE width A length PERCOLATION RATE AREA REQUIRED G `S AREA AS BUILT INSPECTOR_ - DATED PLUMBER ON J LICENSE NUMBER A4 1 Z I� I. r T a 0 tit DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & H RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING + MADISON, WI 53707 � nCONVENTIONAL ❑ALTERNATIVE State Planl.D.Number: Fa te ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPECTION OA Mike O'Keefe RR #2, Green Mill Lane, Hudson, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. P .. CST REF. PT, ELEV.: NW SE, Sec.17,Lot 83,Park View,T29N- R19W,Town of Hudson Name of Plumber I MP/MPRSW No Coumy: Sanitary Permit Number: Douglas Strohbeen 5432 St. Croix 43700 SEPTIC TANK /HOLDING TANK: MANUFACTURER: 1 LIQUID CAPACITY: TANK irTLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING CkER PROVIDED: PROVIDED „ YES ❑NO ❑YES NO BEDDING: IENT DIA.: V .: HIGH WATER NUMBS O ROAD: PROPERTY WEL BUILDING: VENTTO FRESH K ALARM * LINE. J AIRINLET. YES ONO C / OYES ONO NEARESrT �"'�V Z� o6 5 DOSING CHAMBER: MANUFACTURER: BEDDING: J LIQUIO CAPACITY PUMP MODEL PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ]NO OYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATI ONAL NUMBER OF PR OPERTV JWELL BUILDING. I VENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LI AIR I NLET: PUMP ON AND OFF) OYES El NO NEAREST' SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of lowin T LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until F the soil is dry enough to continue.) MAIN' CONVENTIONAL SYSTEM: _ �bSN 'WIDTH: LENGTH. TRENCHES DISTR. PIPE SPACING. COVER L' PIT' .INSIDE DIA.. #PITS: LIQUID GRAVEL DEPTH FILL DEPTH ID11TRP I PE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR UMIER dF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER. ELEV. INET ELEV. END _ PIPES �"1WP.TI'I QM LINE 1 AIR INLET. �. 9 2 ' .0 Z5 U -l : ' N EST MOUND SYSTEM: I 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- meets the criteria for medium sand. TIONS MEASURED. ❑YES NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS. DYES 1:1 No DYES ONO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED. I MU -1 LCHED. CENTER EDGES: [:]YES ❑ ❑ YES NO YES NO YES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: dlt.�II�5� "1�I Clllil�x ! . MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. fSTR, PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV: DIA.: ELEV.: PIPES: A.: IT�� HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED IlxtE ®#11�d I►I�I PLANS. ❑YES NO El YE S ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMB1wR PROPERTY WELL. BUILDING. FE E"!ER�QA LINE: ❑ YES 1:1 NO ❑ YES El NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. 4F A [G]ATU TITLE. DILHR SBD 6710 (R. 01/82) `' unsconsiin APPLICATION FOR SANITARY PERMIT 'C�DILHR 1 p c 1 COUNTY � oewaaTmenT oc �PLB V �" UNIFORM SANITARY PERMIT # InOUSTRV, LQ9ori 6 HUTRn riELHTlons 17 — 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 size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS 'm I h "" 0 - ffP c (,- ►+Q> � G�� � ��� �- � ®Soh Ger S'l`Gl� PROPERTY LOCATION 1 c/ w 1 /4 5414, S / 7 , T 2 R 1 ! EIM) TOW oF:' LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER /�oP�� vn rw er to �pS147- C0 h /�f �1 L--0 AO TYPE OF BUILDING OR USE SERVED V or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: [11 New 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. 5Seepaye Bed E:1 Seepage Trench ❑ Seepage Pit ❑ Holding 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 Q Q O Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: f +� IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic / Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQU IRED (Square Feet): PROPOSED ( Square Feet): 1 3 / ` 5 G 1 © 0�4rivate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Na a of Plumber (Print): Signature: MP /MPRSW No.: Phone Number: iyo �v o 1t eel ��'►, M�_y 43 .�y�7 3� Plumber's Address: Name of Designer: 1 1 7 &4 ��f � Ddw 5 ra COUNTY /DEPARTMENT USE ONLY Signat re of Issuing Agent: F e: Date: Disapproved El Owner Given Initial �O �i {y o` 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 Morin - S T C 100 2 f G Owner of Property C " .Location of Property ,�w �t 7 �� Section 7 ,T N R ( W Township - 'Fja Mailing Address Zleje° 1��� - Subdivision Name A/ Lot Number g-!t<;e2 Previous Owner of Property Total Size of Parcel /., ? -, Date Parcel Was Created Are all corners identifiable? Yes No Include with this application one of the following .Certified Survey Map .Dead .Land Contract, or .Other Vagal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty de#1 recorded in the Office of the County Register of Deeds as Document No. � !� V i Aand that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the some has been duly recorded in the Office of the County Register of Deeds, as Document No. ). SIGNATURE of OWNan SIGINATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNEO DATE SIGNED DOS T REPORT ON SOIL BORINGS Y &BUILDINGS I DUST, OF NRY tS �Cf t� ', DIVISION LABOR AND PERCOLATION TESTS (11 A P.O. BOX 7969 HUMAN RELATIONS #� �� ��OM SON, WI 53707 (H63.090) &Chapter 145.045) z LOCA SECTION: n OWN HIP /MtifiM91?AtF ': LOT N NO.. DI O E: COUNTY: OWNER'S BUYER'S NA E: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: �r PROFILEDESCRIPTIONS: ER A ION TESTS: Residence / ❑New AReplace So: / Miser soar RATING: S= Site suitable for system U= Site unsuitable for system 4 ,s' k rAyz low6l CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: S STEM -1 -FILLHOL ING TANK: RECOMM NDED SYSTEM: (optional) .D S ❑U 19S ❑U 1� S ❑U ❑ S NU ❑ S]U C �'. / 'X3�` If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ssrr under s.H63.09(5)(b), indicate: I Fl in Floodplain elevation: /V PR FI E DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER•IN6161" CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 3 mss'' /o o.2' A 4 I , .Bhs i . rol Is a / On M tj S B- B- B- PERCOLATION TESTS TEST DEPTH � WATER IN HOLE TEST TIME DROP IN WATER LEVEL- INCHES RATE MINUTES NUMBER 41 AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- • d L.-3 P- a d P- .2 •L ._.3 P -- P- P- PLOT PLAN: 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 slope. SYSTEM ELEVATION X0. P. 3 i s l I _ 7 ` 7 I f r�(S 1 E C T l tN a i i 4► . r V 4 I 4— f 5 I f x � 3 PLO I 6� _+ k Ie �_ . I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print : TESTS WERE COMPLETED DO N: A19AU4iJ al-114 ?-o0-R3 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST TUBE: • � 1 jj kN-.: ,, Original a one copy to Local Authority, 'Pr mic- -y Owner anti Soil Tester. n 182 Lot Y� S�steoil - A 8AI i 5 Na V c f7'1 � 1 / S w L•7� Gor�t�ro� t p "I Lv rt 4 f i "A? j ff/_ /oG,u� L Cl Botts 0314 - hoe)- � o Pc��s�� 9oZ1o�) I n 1 S� Al ► °�� E�� Al �8 l � L3 !D' �bA1 S ou �' Lvt Z rho e �� —c. v ) � � ` .� � Q Q � � � ? � %' �" _ .� � � � �, ( � a � � ",, ( , � 1 I �� � � L � .� � � � � � `� � � � I � { r �, �. ,�� .� � r � � ^- � � k 0 y� �° ,o �Q' ��`� r -� s �f � � � T� 0 � -� o fi ..n `� f r , f F r w e - t _. v � _ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law s,15.04 (11)(m)]. 315877 Permit Holder's Name: I ❑ City E] Village Town of: State Plan ID No.: CARPER, WILLIAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Taft NQ _1157 -00 -000 TANK INFORMATION ELEVATION DATA A9800265 I TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake 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 Lriction System TDH Ft Forcemain Length Dia. H 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 17.29.19.877,NW,SE 457 GREEN MILL LANE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert - No. Safety and Buildings Division r.� ■�r■r,t SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. �,.S D 1 7c, • See reverse side for instructions for completing this application State Sanitaryy PPermiitt Number The information you provide may be used by other government agency programs ❑ Check if revi3Rfn to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION — ""— Property O er Name Property Location � n Wl/4 C 1/4,S �', T Z� ,N,R 1 _ 1 E(ore Property Owner's Mailing Address Lot Number 7��umber C Sta a Zip Code Phone Nu�m c r on ame or Number divisi N CSM N v. '541 ��• (3g`)W7 1 i = ro 11. TYPE OF BUILDING: (check one) El State Owned cit o N Road Vil � la e wi,sl , Public or 2 Family Dwelling - No. of bedrooms T wn 9 F m t L��� ._ o � III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 i1 , al • I E] 1 Apartment/ Condo / 1 lJ � Z _ //6-7 1 (DOO QQ 2 F1 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 Factor 13 [] Other: specify ❑ ❑ Y IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B, if applicable) TeV_(A _. [. A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 ARepai r of an System 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 J<Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation so 6, 2 " C3) `•}•O Feet 96 ,«eet Cap acit y 1/I1. TANK in gallo Total # of Prefab Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete con- steel glass App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank I I d9d0 ) bpQ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I I I ❑ I ❑ 1 ❑ ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. khrwilut:'s Name: (Print) _FIr+RbeF:a Signature: (No Stamps) Business Phone Number: & - - ZI�6 A ress Str City, State Zip PP.lyirbers dd ( 1 2 pLi Cod 6+ , 11,,, w' � • s��� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Iss Ag ent Signature (No Stamps) Surcharge Fee) e - /1 C) �Approved [ Given Initial (y!� 00 0 °vv Adverse Determination DlJ Y2J X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Di—ion, 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, con tact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. _ 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 8 112 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 A FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the — VI , C' residence located at: 1/4 Sec. _ , TZ�j N, R Town of �-�'atwoQ 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 Did flow back occur from absorption system? Yes_\k_No (if no, skip , next line) Approximate volume or length of time: SGa gallons minutes Capacity: (CbOo t Construction: Prefab Concrete Steel Other Manufacurer (if known): Age of Tank (if known): (Signature) (Name) Please Print (Title) (License Number) -& Izlts (Date) Form to be completed by licensed plumber (x.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 Inspection opening over outlet baffle). Name Signature MP /MPRS 5/88 N S�'7'�" � SotG �vqlv,� -Tro,J �,i+P " �'�'�� • � /�T' " �C- �-vv�,v Wisconsin Department of Industry SOIL AND SITE EVALUATION l 3 Page of Labor and Human Relations Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County 51T 4 ^d , y Include, but not limited to: vertical and horizontal reference point (BM), direction and ICN /� percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # oz-o • 1157. 67 ra APPLICANT INFORMATION - Please print all Information Reviewed by Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner /i ,� A Property Location c a (� • ( 4 kpe Govt. Lot /P&/ 1/4 S G 1/4,S ? T 2•! Q ,N,R Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 'Y5'7 6->ee-eO /qlW g3 a I4, Q_s� 3`' Aa�r ' Ci / ty staate Zip Code Phone Number Nearest Road �T r/i'��'` �r/�• .S�D��1 6�) °��� E] City v El Yillage Town ❑ New Construction Use: esidential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow yP gpd Recommended design loading rate 7 bed, gpd/ft trench, gpd/ft Absorption area required bed, ft c 5 (03 trench, ft Maximum esign loading rate bed, gpd /ft2 gpd /ft Recommended infiltration surface elevation(s) Gx SyST ' 1 7 7 L " 0 It (as referred to site plan benchmark) Additional design /site considerations Parent material Sol �� y D (9 Tiv -," Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S ❑ U I ❑ S ❑ u ❑ S ❑ U ❑ S ❑ U I ❑ S ❑ U ❑ S ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground lo 4S / • 7 elev. D Depth to limiting fac r ; in. . Remarks: Boring # 13 Ground elev. ; n. Depth to limiting factor In. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number A ssociates 13 ' IT piivate Sewage ons Ws O'Neil Rd. Hen, Wis. 54018 AL ORIGIN ... SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.ff Boring # Horizon Depth Dominant Color Mottles Texture Structure 2 Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ids , Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # =MA Ground elev. ft. Depth to limiting factor in. Remarks: Boring # .k Ground elev. ft. Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) r:. V1 I I \t I 3 � �(3 � — 37 130 Wn.� -� lD� l ro GO T l' G oT $ C� 30 • = 1!y1fe-�e4o'e P r— Utbrlcht & Af4 B�Cbtiautt imi pfws Sawey 05 O'NSH pd.;�4pi6 Hudson, Ms• Of _ ST. CROIX COUNTY WISCONSIN 1 ZONING OFFICE "� " " " " " ■� ■•� ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 i� µ (715) 386 -4680 AFFIDAVIT OF SYSTEM REJUVENATION Property owner: \,k l M E a 1 Address: Day time phone: (�) 396•60 - Parcel I. D. # 6 ZC) - If 67 - 00oo 0 Legal Description of property: A( J) ; 6E ;, Sec. 1-7 7�/ II T. q N. , R. W Tn. of /`1v%,Ct'o"I , St. Croix County, WI As owner of the above described property, I acknowledge that the septic system serving this residence (is /Jamumoby undersized by current code standards. I understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. signature: Date: 5/97 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 1 Property Address (Yerificatioa rMircd from PUMiag Deparfrneat for new construction) City/State v. cZxbt LKY , , Parcel Identification Number 2 20 ' / /S 7- 00 p C � 1LWAL DESCRIPTION Property Location t� L.A %, /. Sec. 11 . T W, Town of Subdivision 7n, Lot # Cer(�f' ied SmTey Map # Volume . Page # Witt ranty Deed # S `10 ro Volume 6, 9 Page # Spec grouse ❑ yes no Lot lines iden0 ble yes ❑. no ��►�A'IIN"i�NANt� luwqxr useand ofy=szptiasgstCmooaldrCsdkii tsp r -: . .. tohandtewaste s.PropermaWtaancc consists of paaipiag out the septic t mk every throe yeas or sooner; if Eby I Pampm- What you pat.into the system can affroct&e -f MCtioa of die ape taalc ftamunt stage in dw a esstedisposatsgskn. Mic pmpert agrees to sal6nrit to St C,oac Zug Department a caffim ioa fomr. signal by 6c ownec and by a st P 7 pt�t+ictodpD=baor:Fi�o wdp=pwvc fyiogthat( I)& eoa-citeiaastewatordisposalsystem is is proper opuating condition and/or (2) after inspection, and paarping.(if neecssaty), the Sept rct wkIs less than W - fa11 of sludge. . $ro vndc dpodhave read the above roquic=cats sad s = to aQaiatzia th e private sewage disposal systaai with the staadstds Set .ts set by &c Department of O� Department meree and the of Natal Rmmwes. State of Wisconsin.. caomtion stating that your septic system has ban maiatainod mast be completed and nbamad to the St. Croix County Zoning Offiice within 30 days. of the three year expiration. date. SIGNATURE OF APPUCAxe DATE OWNER CERT�TCA.TfON I (we) certify that all statements on this form are true to the best of my (our) kaowledge. I (we) am (are) the owner( of the prnpety desarbcd above. by virtne of a warranty deed moor+ od in Register of Deeds Office, SIGNATURE OF APPLIC DA « « « « «« Any infoanation that is tnis may tesutt in the unitary permit being revoked by the Zoning Department. 00 •• Include with this RMUCatloa: a 60mTed warranty deed 8rom the Register of Dads office a copy of the cmejod survey map if reference is made in the warranty deed S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property bei devel Y g p d. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (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 \a1 Location of property l l 1/4 6E 1/4, Section /'7 ,T 2 N -R W Township Mailing address Address of site Subdivision name � Lot no. Other homes on property? Yes_'( No Previous owner of property Yes_)(_ Total size of property J,'18 Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _ Yes No Is this property being developed for (spec house) ? Yes No Volume Qr and Page Number 2 Ci - Z-- - as recorded with the Register of Deeds. ------------------------------------------------------------ INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. 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 Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. 3 Cl EC10 6 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. c Signature df App-' ant Co pplicant - �- 945 - 7- - �0 Date of Signature Date of Signature 1• Jr ^. 'F � Ci"' � x q '� _ •� s''.. . � �,�� a ws y. Nor Tow SPAY' vloomlx VOW A - 3 m xaJ ( ° r z�r fo and c Q ® R�. +� '1�.. G � R.4RRff4. Mfr{. ♦..�.♦ »...M+. .Mf «....... .....M.. +» - +.. �� � � � ��� J 4J t 111 19 �. Cary r •ertrww tfi ` r IJ! ..�.��. f .... . ». .r .....w ----­------------ e • �MCZhba� ` T�a� Mtat! �1t tot $3„ Fark View Estates _Third ` Addition to the Town of Hudson. f! f qq ( This ......j g ................ homestead property. I t f Exception to Warranties: i `t Subject to easements, reservations and restrictions of record. t' Dated this ................................................ day of 19.. ' ............ . i F � ; t ............ .... ........ ........... ........ ... .. ... .. .. :...•(SEAL)._.. (SEAL) • ----------------••-•------ --- --------- .---- -•----- ---- -- Cdr.- S . _ .._Q NYC ��S 0 ................... j .................... »-- -• °...... -- .(SEAL) 0' • . ....... (SEAL) ' BECKY KELFE t s ......... .......................... ••--- ......_------ •- •-- -..... -- ----- •....... �.........._................. AUT131INTICATION ACHNOWLSDOMI:NT ------------------------------------------------------- STATIC OF WISCONSIN if At. — Croix authenticated this ........ day of ----- »---- -------- -- - - - - -1 19 ...... rarsonaliy came before me this .A.RtA ..... day of E _Au gust .............. Ig__ 84. the above named :? ............. ................................... Mi�h $. O' Q� �Ce • .. -..... .----------- ........- •--- _• - -•- - - -• _.._ , ------ -• - -- ........... - ! TITLE: MEKBER STATE BAR OF WISCONSIN (if not ------------------------------------------- - • -- -- - -- ..... .......... -- .......... ,r oE r. authorised by I 708.06, Wis. States) to me im Pe rson oWn to be the e7ty b�e�eutiasii� t) foregoing strument and ackn� o eio*Ne V THIS INSTRUMENT WAS DRAFTED BY It,' N STEPHEN J. DUNLAP ..•.........• .............................. - ----- --- --- -- - -• -- Hudson, Wisconsin - - ...... •----------------------•--....--- --•..................• °•...._. Nota -,: public -- - . t - ' ..Cro - ix.. (Signatures may be authenticated or acknowledged. Both My C ommission is / permanent. (If not; state�ia are not necessary.) date. (/ '� -- - - - --- - -... _. + oN&woo of per ons sisnins in any capseity sbuula be typ-t or printed below tbrir m a4411.rTT r+tKr1 STATE BAR o r 'Yf:Ie.( O?G ac. ^ ^ ^•:'•_ r. a n: -