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HomeMy WebLinkAbout020-1037-40-000 i AS BUILT SANITARY SYSTEM REPORT OWNER (,x J c � 4 0 4 ` TOWNSHIP u Gr S� y SEC . T ;_3-RMW ADDRESS U ¢ f 5 11- 1"O ST. CROIX COUNTY, WISCONSIN. rU ors y �D SUBDIVISION W 44 Jet /'A t //� ' LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Ar I di r w BENCHMARK: (Permanent reference Point) Describe: T Z' s G✓ l at�Cor 'le ^ /flu r 4. lne Elevation of vertical reference point: rG 0;6U Slope at site: 017e SEPTIC TANK: Manufacturer: W/o 4 C Liquid- Capacity: 1 0 0 0 Gf I Number of rings on cover Tank manhole cover elevation D 1, 1 0 Tank Inlet Elevation: Tank Outlet Elevation: q7, ef- ^ PUMP CHAMBER Manufacturer: A Numbrer of gallons Number of gal. pump set for a cycle //4 gallons; Total capacity of distribution lines AID- gallon: size of pump head; gallon per minute 1 (¢ horsepower /1/ ;brand name of pump and model number Type of warning device I/"A HOLDING TANK: Manufacturer Number of gallons AIA Elevation of manhole cover ; Type of warning device Al / �� �I SEEPAGE PIT SIZE; Number of pit feet diameter feet liquid depth /V 4 seepage pit inlet pipe - elevation ti.4- bottom of seepage pit elevation V feet. SEEPAGE BED SIZE: number of lines �{ width length 3 6 tile depth SEEPAGE TRENCH: width_ I length /V "� PERCOLATION RATE f AREA REQUIRED — AREA AS BUILT Grp INSPECTOR DATED O / PLUMBER ON JOB LICENSE NUMBER 44 Jl 57 '� :3 Z 4 I n f w an All t r 14 ,, )of o , � C \ J C d (�''� vCr trGA (C1Ln r °71 DEPARTMENT OF INDUSTRY,' INSPECTION REPORT FOR SAFETY & BUILDINGS LABOF & INUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.Q. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 EN CONVENTIONAL E] ALTERNATIVE Slate Plan ID.Number. (if assigned) ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSP C ION DATE: Randy Deal 8th St. N., Hudson, WI .11, /6 fY BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.: NW% NEh, Section 18, T29N —R19W, Town of Hudson Name of Plumber: MP /MPRSW No County: Sanitary Permit Number: Doug Strohbeen 5732 St. Croix 43722 SEPTIC TANK /HOLDING TANK: 1 MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER O D PROVIDED: PROVIDED: /.1 OYES ONO OYES ❑NO BEDDING: VENT DIA.: VENT MATL.'. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING VENT TO FRESH 'J4 ►1 0- r ALARM'. FEET FROM 7s LINE •�, 3 l � AIR INLE ,.' YES ONO YES ❑NO NEAREST 3 L / / I/ DOSING CHAMBER: MANUFACTURER. T7G L IQUID CAPACITY. PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: S ❑NO ❑YES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY IWELL. BUILDING: JVENTTOFRESH (DIFFERENCE BETWEEN FEAT FROM LINE AIR INLET: PUMP ON AND OFF) DYES 1 NO NEAREST' SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH onMETER 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: E WIDTH: LENGTH NO. OF DISTR. PIPE SPACING. COVER INSIUE DIA.. #PITS: LIQUID " ITr�E C t `J / TREN�r M FEr PIT DEPTH- 14k NS � ! / Y GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N0. DISTR UMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BE LO �IPES ABOVE COVER. EL INLET. ELEV. END PIPES .LINE: �� AIR INLET . % 9!• .5 l ,�s v NEARES °�" , MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS OYES ONO DYES F-1 NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL'. SODDED SEEDED. MULCHED. CENTER EDGES. DYES ❑NO DYES ONO OYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: NO.OF LATERAL SPACING'. JGRAVIEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: . ^AiKi,G�lFl�s7l+�' ' "I. MANIFOLD PUMP MANIFOLD DISTR, PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING'. ELEV.: ELEV: DIA.. ELEV.. PIPES. DI A. Ei AND IISiiIBi1T1�71N r HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED F A 40N-1 , PLANS ' DYES ONO DYES 1:1 NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FRk3M LINE: ❑YES ❑NO DYES El NO I NEAF Sketch System on Retain in county file for audit. Reverse Side. SI NATU DILHR SBD 6710 (R. 01/82) ��' E ::: : :: APPLICATION FOR SANITARY PERMIT r OUNTY (PLB 67) UN IFORM SANITARY PERMIT an RELRTIons / 9 .9 ." - 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 PRO QWNER / MAILING ADDRESS o q Gil /2 C G 8 74 5 � � PROPERTY LOCATION CATION / f/ / / W Al W1 /4 Vr 1 /4, S / � , T� �N, R / yFW� T o F: !4 a C / � O LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER r<ar-lC� liahe TYPE OF BUILDING OR USE SERVED 1037 `161 Od or 2 Family Number of Bedrooms: I E-1 Public (Specify): THIS PERMIT IS FOR A: El , 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. L! Seepage Bed ❑ 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 7 6 GO Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: W 0 rr 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 l+ Manufacturer: /I— PERCOLATION RATE ABSORPTION AREA' ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROP P OSED ` ( / Square Feet) 6 : J / D Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Sign at re: MP /MPRSW No.: jPhone Number: '0 o td l'e S S f ro r P n ' cg�—u� AA- 5 13 2 1 al 7) 31 3 Plumber's Address: ' ' A ,�/ L .¢ Nam/'e) of Designer: j 1V � G e /1 4 1 "v ! 7 / 01 7 GV6K S HD!GCCn COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved - p El Owner Given Initial (O 17 .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 Form - 5 T C 100 Owner of Property ,Location of Property Section => ,T N R , W Township - Mailing Address Subdivision Name Lot Number Previous Owner of Property Wa I, 1i 6, 1 t � rl-i; Total Size of Parcel Data Parcel Was Created Are all corners identifiable? L11-1 Yes No Include with this application one of the following .Certified Survey Map .Deed .Land Contract, or .Other I:agal Document which describes the property PROPERTY OWNER CERTIFICATION I (WO certify that all statements on this form are true to the best of my (our). knowledge; that 1 (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. • ; and 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 same has been duly recur in the Office of the County Register of Deeds, as Document No. _3L4 !" NG TIJitE Of i SIGNATURE OF CO.OWNER (IF APPLICABL.EI DATE SIGNED DEPARTMENT OF I REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, � DIVISION LABOR HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.0911) &Chapter 145.045) LOCATION: SECTION: T /MUNICIPALITY: LOT NO.: B K. NO.: SUBDIVISION NAME: '/ '/a /T 29 N/R l9 E (> >yvpso•� 3 SM f�E COUNTY: OWNER'S BUYER'S NAME: MAILING 10 ADDRESS: s�Z401A R tiD ep s,�. ti�- #Vo1fo� was . USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: P FILE DESCRIPTIONS: PERCOLATION TESTS: Residence New ❑Replace .�o�. 3 RATING: S= Site suita for system U = Site unsuitable for system s` J �/y/NE�/ L .4.1. ONVENTIONAL: MOUND: IN- GROUND-PRESSURE: SYSTEM -IN -FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ©S ❑u ®S ou ©S ❑u H ❑S au EIS DU If Percolation Tests are NOT required DESIGN RATE: lFloo If any portion of the tested area is in the under s.H63.09(5)(b), indicate: indicate Floodplain elevation: / Qjhi4 /.V�ifL/) PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER -IN T• CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- 2 ' �,� /00. yi ,— ,v.�s ion' kl- AJ . -6y. Zs, 12f-I ZYlaA). 45" B- 3 ��0/ Ioo.Qy — > / •3,3 °�3�1-Gy:GS /,f 'G1, . �S /p'6.P�S / 0,f L ' ' / >�� .yz'?N - 6y.�s' io�'iCN mss, .33'� B- -0 o/'S ��, B- t D` 1 �o� > d , O ' J � BA e �s s � • seP ' l�; �s. • 6 7' C . ,� w� y B- PERCOLATION TESTS TEST DEPTH WATER NHOOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERINTERVAL -MIN. PE RIOD 1 PERT D 2 P PER INCH P_ �o i L P - P - G /� T S r 61 "a'" P- /N P _ V I I O 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. /3a 77oM of 134P Ey, LiE A ,r,4--T�y SYSTEM ELEVATION �w— /w/f- o /3 oe� - ' T E t i ...... _ ..._ t ..... _. _.. ... _..__ " . ..._.._ t __.. f I t t_ 3 l E 77 F I E 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): N � TESTS WERE COMPLETED ON:: D57' �d cl ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): C T SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02182) — OVER — ` REPORT ON SOI 13ORiNGS 7 PERCOLATION TESTS 1 1 L aj �4Jr cJr1�Y `7� �1.�1.U'J�p PLOT PLAM PR03 I T• D. C AP Ef s7T,i . ��- DArE 9-3-,'3 so�eue -y. 9oyeR : HOMESITE TESTING CO. rAT.3, O'NEIL ROAD BOB UJI8 A te Ici, HUDSON, WIS..-.- 54016 C S 0 2 YfZ PROPOSED HOUSE MUST' 6r 2.r., Fr. pe MpRE FiPOM ,qLL TEST f},PE�95. QRo poSE o !• yea M vSr L! r 50 F T o� Iwxr FfOO l X 341 TEsT r9�PE�S, • = e��/�OE' P /T O = E�' / s T /.�1(r LUELL �(� �E�G /OCRTIDAIf s yi4�l� A`v�E�PFD o,Q S �i0lJ EL /j GXES �o, >z . 6 M MFR r• V4,01 c�►G �EfE,P�n1cE' Po a7 ft P 7• a.4 St T OW Li.tJ, , I " PI A 6- /;? e lo v LEGEND e/Eil,424A/ D` v fPr IC EF �T 0 6 ,0 F� 0. r JI f. R s � � ■ J o f r;- tor liPO N /,�GU" /3 t Uf f G� •ut— — ~.� Fc r,-v r) HOME MARKETING CONCEPTS 386 =5602 206 'Second St Hudson, W1 612-436 l 387.151 N 81-43 p063.6� . 269 32'•S? t� — 33 323.5 - - 5 5 .3 4 — � I' I - 0 23 • 54 0 •. i j a� \ 0,x;5, L. 0 h L S 6 6 ( m J r I LOT- 4 a ' � 1 m 1 1 2.00 ACRES 1 1 33.01' 289. 27' f) o f„ `- \ 88° 45'-0S'W Q / N 322. 28' j 1 V 50 o 7.99 ACREW d P���� , . ' � •,`,� J `�� F , ANA HOUSE \777 E 42. 55'_ i i'ric e List Date 4 Exp. Date X23,000.00 WN 122 1831DECI 31183 LOT 5 & 6 Addr Krattley L ana, Hudson leap ;Coded -93 Dist. l )XStreets Township I -Acres Lo 6 -3 Lot Size 320X404.80 GRear JR Side Front IL Side ^ L C SS Lake Front? Topog. HEAVILY WOODED Zoning 4 Restrictions: ` ( )Gas [ )Pvd. Str. ()dEaserrwnts [ )C /Bus CO. [ )wtr. [ )Curb [ MTrees [ )Septic TEMCT C [ )Elec. [ )S/Walk [ JUJeils N /by [ streams RT- - 1 O'IrE1L ROAD [ )Sewer [ )Fence [ takes bc)Sign [ )Abstract [ ITorrens [ )Perc. tests ( )Storms Taxes Ppec. Assess. Present Financing Payments Legal Desc & RemaeksNEk— NWk —NE Sec. 18, T29N R19W L ot 5 — $14,000.00 — 2Acres — Size 323.54X295.0 1 i SB Comm 4% Kister WANDA MILLER Ph. 386 -8040 Brkr. ERA —Home Mkt # 100 jPh. 386 -5802 jPoss. Date CL . r HOME MAPJM #1NG CONCEPTS r T-ty. Q4•4V �e f A�DTAc4 NT to 10 4IVUA OWN a Vat F�c S 4' � -r w �h $A fs4-„ Noorl w4- o �� V• Ta p o� �.�� Boa_ , sz • B o ��... S � 1`�ac..k 1� o Q d Z Ll H OIDN vEa� R� Ew too C LA LA a-, law o w n C4 N t N� P o � s 'f P o ST. CROIX COUNTY ZONING DEPART�� AS BUILT SANITARY REPORT Owner �,4vp PE4 L i { r f Sl Propert Address -5 1 City /State N • II S OA,) w/ ' \) Legal Description: Lot 3 Block Subdivision/CSM # 38 l`3/ l � bOl * S / V k '/ NC ' /4, Sec. /9, T_�±N -R_�ZW, Town of /f yOS D.J PIN # 0 2. ° ' 1 7 ' 4e;:P - o vv SEPTIC TANK DOSE CHAMBER -- HOLDING TANK INFORMATION 15 67 - ? , /0 0'a a - I (..Id manufacturer ���-� 4 • Size ST/W / Setback from: House 30 Well ( PAL Pump manufacturer N Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location /f ! �S ". G,� S�' f]�vi.v�>�`� �'�'l7`/�►i¢T`��S SOIL ABSORPTION SYSTEM , Type of system: R �'V S Width 3 Length 0 Number of Trenches Z Setback from: House - Well / P/L 1 3 Vent to fresh air intake -> SO 81 Fr ' ( w�ST ELEVATIONS To CGenfr-�) o� Description of benchmark EGG e1 ti 6r Elevation Description of alternate benchmark Td e 42 19 X 1S77v G - .S "TTG T Elevatio Building Sewer ST/HT Inlet ST Outlet J PC Inlet PC Bottom �� Header/Manifold Top of ST/PC Manhole Cover r Distribution Lines () Z ' 7-Q Bottom of System (() Final Grade ' Date of installation � / / Permit number 3 � I �' ` State plan number Plumber's signature �K License number 22 3 Da te - / / 0 Inspector w C/l�✓ Complete plot plan ` r 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 I % /.,)G- 7��sV77c7 1, G � � So INDICATE NORTH ARROW � T v 0 0 - � N c 3 'Xl1 a I a l -o1 d4i•��� AN- 0 0� v - S o� , Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y' 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 Law, s.15.04 (1)(m)j. 15t. told file: & DOREEN [i6jt6 ' c�6#I1age []Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel b$b]L-:1037-40 - 000 laces 0 TANK INFORMATION ELEVATION DATA A9800583 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic & Q) Benchmark 1 11 101.37 10Z> Dosing � S3� g Zgq► Aeration Bldg. Sewer Holding �- 4W+t Inlet oi'Ylax 4.7 9a. TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Se tic X } NA Dt Bottom Dosing — _ — NA Header / Man. ..— Aeration ., NA Dist. Pipe 9.1 .Y r q�• / g a• sl Holding - ' Bot. System �o•� 9a.�S PUMP/ SIPHON INFORMATION Final Grade 40- 257, D Manufacturer Demand Model Number - GPM TDH Lift Friction System TDH - Ft L oss ead Forcemain Length Dia. — Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length ,SD No. Of Trenches PIT No. Of Pits Insid Dia Liquid Depth DIME ION DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type � Mode Number: Syste o?J �7 CHAMBER OR UNIT DISTRIBUTION SYSTEM / �; /� l i Header J Manj old q Distribution Pipes) x Hole Size x Hole Spaci Vent To Air Intake Length F [��,_'_ Dia. Length a 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 ❑ es 9_No COMMENTS: (Include code discrepancies, persons present, etc.) 3�5d4 J V 3xP- � LOCATION: HUDSON 18.29.19.157F6,NW,NE 351 CASPER DIRT - LOT 3 Y Plan revision required? ❑ Yes No p� -761 Use other side for additional informat on. �(� g I I i i SBD -6710 (R.3197) Date Inspector's ignature � . Safety and Buildings Division Vsconsin SANITARY PERMIT APPLICATION 201 Box Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County S7" C p—D rK than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary P mit Number 3' jpq a- Personal information you provide may be used for secondary purposes ❑ Check It revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATIQN INFORMATION - PLEASE PRINT ALL INFORMATION Pro erty O er Name Property Location ov Au 4Y 5 QD ,(, L 1 1/4, S T 2 , N, R E (0 W Property Own s Mailing Address Lot Number Block Number l k Ci t� �/ Zip Cq�� Ph �e� Subdivision Name o CSM Nu jig / S I. TYPE OF B IL G: (ch one) ❑ State Owned [3 Cit Nearest Road Lj Public 1 or 2 Family Dwelling - No. of bedrooms 3 ow OF 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo / 5 ' ll - / - 5 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. eplacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. Q Repair of an System ________ System____ _________TankOnly______________ Existing System _________ExlstlngSystem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) 171-i G�� - � $jj��� %�� ��LTJC�f 727 S Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type //fDo 41 ❑ Holding Tank 12 eepage Trench �❑ I rou 42 n Pre surd /J?�.� s Q Pit Privy 13 ❑ Seepage Pit T '� �M (. 43 ❑ Vault Privy F 14 ❑ System -In -Fill 2 71444(a-5 44e,�,_ 3' K 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/da /sq. ft.) (Min. /inch c Elevation . 57- �/ Feet ZO -d Feet VII. TANK Capacity gall Total # of r Prefab. Site Fiber- Ex p er INFORMATION Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic A p p New Existing strutted Tanks Tanks Septic Tank or Holding Tank ,I ��� / ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 1 ❑ 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) Plumber's Si ture: (No Sta s) /MPRSW No.: I Business Phone Number: 71 R03 2�L4�� �C 330 7 - :Z - 2 - 6 E - 2 5 3 1/-, Plumber's Address (Street, City, State, Zip Code):6-75 S O , (,Mt ( Sao IX. COUNTY/ DEPARTMENT USE ONLY Q Disapproved I Sanitary Permit Fee (Includes Groundwater ate ssue Issu "ng Agent Signature (No Starpps) Approved Q Owner Given Initial Surcharge Fee) Adverse Determination l , p X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11 /97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber r A _ v., 1 1 N -- X -------- - - - --' cr� 0 c �z i N �o` �- W N O ?�� B oa N o' P n �_ �iNi s QED 3 w scf . � 0 9iP,4�L s ysTEM Clfo SS SEC T © TiP��s ZIS�w G- �N i L Ttf 4 7 alit/ Iff sc� . Iv F�71 N 1,. ,f'W't D 7 4A'-K y , �i� 1 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 NP , 1 0010 / s 66 l / — residence located at: %UA 1/4, Nti 1/4, Sec. / T R // W, Town of f VVY-o - 1 Upon insx trion, 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 No (if no, skip next line) Approximate volume or length of time: gallons ,__?O minutes Capacity: /0-,Tf, S -s ' / v Construction: Prefab Concrete Steel Other Manufacurer ( if known) : %�5�� �O�G -G1� -C 1 �9 - Age of Tank (if k n o wn) : l D rf Ulbricht & Assx ►aces Ar — Prh►ate Sewage consuitants 6S5 O'Neil Rd. All- 540 (Signature � (Name) Please Tint M R5 (Title) (License Number) (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). / -8P( tl Signature MP /MPRS Z2 375 Name g��� ?c 5/88 Wisconsin Department of Industry SOIL AND SITE EVALUATION Labor and Human Relations Page / of " 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 T Include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # oao - 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 ^� Property Location y ,9,4AI �LN� � ,P E�iV ✓� �- Govt. Lot NW 1/4A 1/4,S /6 T2q ,N,R /? E (or(D Property Owner's Mailing Address Lot # I Block# �ubd. Name or CSM# �/ c�Sp so.� �•�' 3 csm Sp31 f 1/0/. s p . 1370 City State Zip Code Phone Number ( 7�S )•�O ty ❑ 9 �� Nearest C�S /t'fO.rJ ,J�je El Ci Villa LJ Town ❑ New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement F1 Public or commercial - Describe: /I/�,P = lj I ?EGp As 41 6 V 4 Code derived daily flow y 5 _ 0 gpd Recommended design loading rate N �/� bed, gpd/fl g am - trench, gpd/ft Absorption area required bed, ft2 ��C 3 trench, ft 2 Maximum design loading rate' /bed, gpd /fl — U trench, gpd /tt Recommended infiltration surface elevabon(s) 9i' 2 S r ft (as referred to site plan benchmark) Additional design /site considerations $e&- NOTES /jE�6� Parent material Sfj 'p eV T' 1 Sh4— Flood plain elevation, if applicable / ft S = Suitable for system Conve tional Mound In- Ground Pressure AT -Grade System ' Fill Holding Tank U= Unsuitable for system Ets❑ u LA'S ❑ U �❑ u Q s ❑ u [f El u ❑ s ETUr SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots Bed ,Trench In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. o,s /OYX 'P'3 the 4 Xv1 ,0 / 1 cs 11r- Y_/5 Ground 3 7 s�/y/e� yl�G s G/� S �� �'if r . 7 • 8 elev. ft /ol /C �( 7 3 /D Depth to limiting factor s / VS72Z�'1 /S A/ •ntv ✓`GI' ; Remarks: 12 �¢�/ !� /�!'GD•yiVEGT Ef> //� �j Ui���1 7�Dle �UflG+,e �'Zf . . Boring # a 1 0 Ye 2- /3 / p 2 z lo Y, yl4 4 64e O s eX C5 _ . �• S Ground 1 0051 6 , elev. 95.�ft. Depth to limiting factor Cj,S. ain. Remarks: CST Name (Please Print) Signature Tel hone No Address Date CST Number Associates 'F • 3 0 ' f 22 X03 ? S Private Sewage C 665 O'Neil Rd. Hudson Wis. 54016 . 4. PROPERTY OWNER DEA�G S 3 SOIL DESCRIPTION REPORT page Z of PARCEL I.D.10 o :)- -1037 - ya ' &vv Boring Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench /o yi e 2 — s� l,eshe:5 v6e s Z f . << .. s y s io y)e 3 1c( — s 1 1 7 e y he 44-6e cs if • �(; �j elev and 7•.S yie ! l s .S G� L' S • 7 .Zj Depth to limiting 'a factor ! — Remarks: Boring # a MO , Ground elev. ft. , Depth to limiting factor In. Remarks: Horizon Depth Dominant Color Mottles Structure PD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor In. Remarks: Boring # Ground elev. ft. , , Depth to limiting factor In. Remarks: SBDW -8330 (R. 08/95) I i v . � V\ w ro o r J i I � � I �' __._____ --- -- -_ G y -� • 0 w e n o�� I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Dwyer A4A, 1 1, C . Pi5" L f 17 Mailing Address -351 445AE�pSD ,-.) YW (/nsO•v Property Address (Verification required from Planning Department for new construction) City/State h101PSo,� � ' O 2 O ' 163 - 2 Y Parcel Identification Number LEGAL DESCRIPTION of ti4n­7 44 Property Location tik ' /4, N � y,, Sec. �g , T - ? N -R � W, Town of Subdivision C , Lot # Certified Survey Map # 3 - ,Volume , Page # 1-3 Warranty Deed # Volume &70 , Page # gg Spec house ❑ yes g Lot lines identifiable B 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, 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF OPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 7 0 SIGNATURE OF 4<PPLICANT DATE * * * * ** Any information that is mis represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed I - r DOCUMENT NC> y/App wNTY DCCT ,1 THIS S /ACE RES( RV[D FOR RCCOROING DATA j iSr ;TE BAR OF WISCONSIN FORM 2 - 1082 { VOL RI:t'SISTLRS OFFICE WANDA M. MILLER, a single woman, a /k /a Wanda Mae $7 Miller, formerly known as Wanda M. Cas�erson Re.:'d. f frp� 16th .this � d ^ - -y Lf_..D A.D. I9 83 ,nve)'s an(: aerrants .o DALL C. DEAL and DOREEN J. G! 4:20 P Jyl RAN 4 11EA7... hasband. a as 3oi.n.t. tenants._. _ , in considerati -on of $23,000.00, .. �•atar.t awe ... ..... ....... the following described real estate in .. St,, ,Croix. Count), State of Wisconsin: Tax Parcel No:- Part of NE4 of NW4 and NW's of NE4 of Section 18, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin, described as follows: Lot 3 of Certified Survey Map filed November 21, 1983, in Vol. 5 of CSM, Page 1370, Doc. No. 389319, in the office of the Register of Deeds for St. Croix County, Wisconsin. TOGETHER WITH and SUBJECT TO non - exclusive private roar: easement 66 feet in width, being 33 feet on each side of the following described centerline thereof: Ccmmencing at the section corners of Sections 7, 12, 13 and 18, T29N, R19W; thence North along the West line of said Section 7 a distance of 474 feet to the centerline of an existing town road known as Krattley Lane; thence N62 °21'E 240.0 feet along said centerline of the town road; thence N86 290.0 feet along said centerline of the town road; thence S81 §20'E 197.0 feet along said centerline of the town road, to the POINT OF BEGINNING of the centerline of said 66 f,ot wide road easement; thence S15 ° 09'E 276.0 feet; thence S63 °24'E 411.7 feet; thence S43D55'E 156.9 feet; thence S53 352.6 feet; thence S34 feet; thence S20 feet; thence S76 feet, more or less, to the NW corner of Lot 1 of Certified Survey Map filed September 28, 1978, in Vol. 3 of CSM, Page 702, Doc. No. 352047, in the office of said Register of Deeds; thence continuing along the North lines of Lots 1, 2 and 3 of said This is homestead property. (is) (is not) (DESCRIPTION CONTINUED ON BACK) Exception to warranties: Crated this day of December 19 83 . (S AL) 1�. �- �.... (SEAI., .Wan 3a M. Miller _ (SEAL) (SEA1.) tom.„ ........... C6e$,THENTICAT10N ACKNOWLEDGMENT 6 ��..4' - - STATE OF WISCONSiN N o tcT ..._.... _.�._1 ._:�..'--_._.._.. ( 3. -- ST._ CROIX_ _. Count 1 �1Cut Q�leii tj . day of. ___.. , 19._ _ Personally- came before me this - % �l dzp of :9�.' •11... ••.• •' 4 o December _ . 19$3 the above :.amod ••.- ls. - -. ••x. .::... ........_. . OF V0 -- - -- Wanda. M.. Mi 1.1 r,_ personally - to me to.-be-,th person _ as Wanda ._.. .. - -- -._ .. -- - _ _ same. person MEMBER STATE BAR OF WISCONSIN Mae Mi ller and formerly known as (if not... _ . Wanda P1. Casperson, authorized by § 70( Wis. Stats.) to me known to he the Per�nn uFo executed the fors Nn� rn tram, nt ;uwj, i6ncaL d / /�C thr -a'n. . :i'RU'•! =NT W >S GRAF -FJ ELY William J. Gilbert, Atty. GWIN, GILBERT, GWIN, b1UDGL' t'ORTER William J. Gill;ert Hudson WI .5.401.6. (Si nah re= may he a_:t1 enticated or ri, .cl•'t�ed. H,.r �1 � r.;r i -in rn .. �aR*1.t�av"X:d7S7f5{riSX^ n*e not necessary_) - I . V.� WARRANTY DEE,) .; - 'A.F: BAR (;F W 6790 �a CSM in Vol. 3, Page 702, which is contiguous with said private 'oad centerline, on the following bearings and distances: S76 166.0 feet; thence S54 °04 103.6 feet; thence N66 °02'E 254.13 feet (previously 7' recorded as 255.2 feet in a certain Quit Claim Deed recorded in Vol. 499, Page 439, Doc. No. 316964); thence N81 89.42 feet to the NW corner of Lot 3 of said CSM in Vol. 3, Page 702, being also the MI corner of Lot 1 of said CSM in Vol. 5, Page 1370; thence continuing N81 °45 323.54 feet to the NE corners of Lot 3 of said CSM in Vol. 3, Page 702, and of Lot 1 of said CSM in Vol. 5, Page 1370, being also the NW corner of Lot 4 of said CSM in Vol. 3, Page 702; thence South 295.0 feet along the E line of said Lot 1 of said CSM in Vol. 5, Page 1370, and W line of said Lot 4 of CSM in Vol. 3, Page 702, to the NW corner of Lot 3 of said CSM in Vol. 5, page 1370, being the parcel conveyed herein as described above; AND also including all of the cul -de -sac shown on said CSM in Vol. 5, Page 1370. SUBJECT TO the restriction that Grantees, and their heirs, successors, assigns and personal representatives, as owners of said 'nt 3 of CSM in Vol. 5, page 1370, shall be obligated to share a ith other property owners in the maintenance costs of said Private road as long as it remains a private road. Grantor reserves an easement over the same private road easement described above, including that portion on the parcel conveyed herein, for access to, and running with Lots 1 and 2 of said CSM in Vol. 5, page 1370. I i l' F/ b o o 389319 CERTIFIED SURVEY MAP LOT 3 C.S.M. VOLUME 3, PAGE 702, LOCATED IN THE NE 1/4 OF THE NW 1/4 AND THE NW 1/4 OF THE NE 1/4 OF SECTION 18, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, N WISCONSIN. OWNER WANDA MILLER LEGEND RT. 2 ST. CROIX COUNTY SECTION CORNER MONUMENT KRATTLEY LANE WITH BERNTSEN CAP, FOUND. HUDSON, WI. • 1" IRON PIPE, FOUND. NW CORNER N 1/4 CORNER • 3/4" IRON PIPE, FOUND. SECTION 18 SECTION 18 S88 0 57'03 "W 0 1 "x24" I -RON PIPE WEIGHING 1.68 LBS./ LINEAR FOOT, SET. 162N2' W E rn rn O ~ y ALL BEARINGS ARE REFERENCED TO w x co ALL THE NORTH LINE OF THE NW 1/4 g�I TRACTS ASSUMED TO BEAR S88 0 57'03 "W. 323.54 (A S81 SE14F I PRIVATE ROAD E o EFF �f 2 z ; 100 50 0 100 20 0 L4 in w LOT 1 i '� 1 CA 90,434 SQ . FT.) INC. ROAD o co r x 10 APPROVED 1 2.08 ACRES r" 1 FILED D N ) N f G 64,877 SQ . FT.) °' NOV 181983 NOV 211983 1.49 ACRES EX. ROAD �t ) p 1 m JA&Z5 O' CONNELL - 1 ST. CROIX C TY boot of Moods CURVE DATA 1 p C.OMPAF7fENS1YE PARKS �u NNIN 111 Ix Co.oty, r O= 105 / PRIVATE 1 N AND 20NING COMMITTEE t.00mia of to R= 80.00' // I 1-9 L= 147.75' ROAD to 8 C= 127.63' EASEMENT N `�' O° Cg S47 "w S88 0 45 1 05 "W 322.28' In y TB= N79�55'09 "W 127.23' 1 x S05 "E w 0, 289.27' 321. 81' N t° 33 I r S89 15141"W w -1-, ° O CURVE DATA - CURVE DATA w o L= 12014' 22°, p =54 °Ol' 19" R= 80.00' R= 80.00' Z 1� w L= 167.89' L= 75.43' O L' C= 138.73' C= 72.67' 1J - CB= S65 0 51'30 "E CB =N27 000'39.5 "E x to TB= S05 "E TB= N54 "E 1 U' IN N54 0 01 1 19 "E NORTH � Ir LOT 2 4N z w LOT 3 ° ix 127,323 SQ.FT.) N0 �p 'p I> 0 co INC.ROAD ox o in 2 ,9 :2 ACRES ) y 130 426 SQ . FT . ) 00 i _q x � p ' INC. ROAD ° - 118,975 SQ.FT.) 0 _ ° O_ 2.99 ACRES ) - il 2.73 ACRES )EX.ROAD 128,942 SQ.FT.) 2.96 ACRES ) EX. ROAD nj v t 0, �S EXISTING HOUSE 320.27' 322.28' N88 0 45'05 "E 642.55' UNPLATTED LANDS OWNED BY OTHERS ------------------------------- THIS INSTRUMENT DRAFTED BY DOUGLAS ZAHLER Volume 5 Page 1370 JOB NO. 78 - -11 -183