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HomeMy WebLinkAbout020-1289-90-000 ST. CROIX COUNTY ZONING DEPA 1�1 AS BUILT SANITARY REPORT e_\ e LLEiV ED Owner Address f' Y ? ! City /State Y - 1 � ST CROIX� t ^�' COUNTY ZONING OFFICE Legal Description: Lot A6 Block — Subdivision/CSM # 'W� ''t4j, ' , Sect -�, TZN -RZW, Town of PIN # SEPTIC TANK -- HOLDING TANK INFORMATION: Tank manufacturer _ Size ST' Setback from: House I!P Well Zt P/L — Pump manufacturer .,uci Alarm location (HOLDING TANKS ONLY) Setbacks: Service road �tofre ntake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: r Width f _ Length . C Number of Trenches �- Setback from: House Well PAL Vent to fresh air intake ELEVATIONS r Description of benchmark . I' <� 4, ' 1 Elevation 4d. Description of altematebenchgar Elevation -- Building Sewer 95, Z ST/HT Inlet 0 2— ST Outlet IOy ! PC Inlet PC Bottom - Header/Manifold . 2 Top of ST/PC Manhole Cover 105. 22 - Distribution Lines( ) /OZ d , k ) spa, Bottom of System ( ) /OD. yp" ( ) pj: 2_ ( ) Final Grade Date of installatiog/O / / ,S Permit num er JF ,.C/S9Zd State plan number Plumber's signature License number �-�- ICl Date 17 Inspector � ��(I � r/ Complete plot plan NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of -the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. (- PLAN VIEW ro � Q = ld��► /00.0 - -r f'c f¢Lr „_ ?3 o Gig'- r• T S J O O /0 6 INDICATE NORTH ARROW Wisconsin Department ofCommerce PRIVATE SEWAGE SYSTEM county Safety and Buildings Division ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar�P1ern�i� nth-: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. ' y 6TT,b ol `! `'MuCTION [ketb ❑ Town of: State Plan ID No.: CSTBM Elev.: Insp. BM Elev.: BM Description: Parcel !l bL'1289 -90 - 000 TANK INFORMATION ELEVATI DATA A9800309 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. S pti Benchma k /6. `g I!o•G8 14b Dosing (�, g M 41, C6 /vG -&d' Aeration Bldg. Sewer S.`� /pS o Holding St * Inlet G -33 /OS/. 1 TANK SETBACK INFORMATION ►,s ts•Q,� 0 P& Outlet 16 e/•/ TANKTO P/L WELL BLDG. 'be tt Airint ke ROAD Dt Inlet Sep 78 20 .2 C NA Dt Bottom Dosing A Header /Man. 7•�(� IO3.2 Aeration NA Dist. Pipe 7 S.&V Il'.8'S /0/. �o.r1 •.se— X06 '3 Holding Bot. System Ty �� 01 - S PUMP/ SIPHON INFORMATION 'nal G ade ' 4 - 't & o Z or► i 0 • 7 Manufacturer Demand Model Number G T Friction S Ste TDH Ft L oss Forcemain Le id. Dist. To Well SOIL ABS TION SYSTEM BED RE Width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liqui pth DIM N S 5 cam- DIMEH I N SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHIN Manufa INFORMATION Type O CH ER Moe er: Syste 100 � ) (�a—� O UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) /, x Hole Size x Hole Spacing Vent To Air Intake Length IS ' Dia. Length Dia. A Spacing SC, H A S I 'Z -yo! 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.) oi l LOCATION: HUDSON 26.29.19,NW,SE 746 N. MEADOW DRIVE 4 7 Plan revision required? ❑ Yes g No n 1 Use other side for additional information. 1Z �'t I�,crQ �( SBD 6710 (R.3/97) Date Inspector's Signature Cert. N o. V i siconsin SANITARY PERMIT APPLICATION 01 E W B 8 "Si °n P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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. • See reverse side for instructions for completing this application State Sanitary Permit The information you provide may be used by other government agency programs ❑ Check it revisib�pr1svious application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION �— Property Owner Name Property Location &L �� 1/a 1/4, S A T , N, R E (ol� Property Owner' Address Lot Number Block Number City, tate �� Zip Code Phone Number Subdivision Name or CSM Number 11. TYPE F L_ DING: (check one) E] State Owned a v illa a Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms f _ Town of 4t.33f///tJz i 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) „ p_ - ICS � ` I 1 E] Apartment/ Condo D'Z ^ l 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 0 New 2_ ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5_ ❑ Repair of an _____System ________ System____ _________TankOnly______________ Existing System ________ Existing System B) A Sanitary Permit was previously issued. Permit Number Date Issued 12 V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 []Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Z Seepage Trench 22 ❑ In- Ground Pressure 1 / 42 ❑ Pit Privy J` 13 ❑ Seepage Pit ' — KA!7 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. 17. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) , d ; vVPwyn .Lb f , � , f' Feet . 1 ,9Z . a Feet VII Capacity TANK in gallo Total # of Prefab. Site g Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con steel glass Plastic App New Existing structed Tanks Tanks Septic Tank El El 11 1:1 Lift Pump Tank /Siphon Chamber E3 ❑ I ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation Xlhe onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's SignatuV(NN amps ) MftMPRSW No.: Business Phone Number: D 7 - m en's Address (Street, Ci , State, Code ,,T 0 9 7 — A .C OUNTY/ D PARTM NT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued I suing gent Signature (No Stamps) A roved Surcharge Fee) pp []Owner Given Initial Q b , c,Q Adverse Determination (� IV X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) - DISTRIBUTION: Original to County. One copy To: safety R Buildings Division. Owner, Phwdw o - w 1 1p 'A IR 0 o� s c� °O a a f' J n � " n � � v � A t I Q t pt c - , b Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749 -3656 W . i E tit y• ,tp � Li x 4 � � yet � � t �� -• � t j 'c !`h. �" �'.., / X C A k � O v �r4T- IIM��M>„r'C' ��Y { v{i.YS s }>� ;+ y,,,ti`t.•� J� /¢ ..-0� `b .f's S i I0 / le m, 'DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, P.O. BOX 769 i LABOR AND PERCOLATION TESTS (115) HUMAN RELATIONS MADISON WI 53707 (ILHR 83.090) & Chapter 1451 LOCASIO : SECTION:T p q TOWNSHIPHvfffAttetP:4t+1rY: OT NO.: BLK- NO.: SUBDIVISION 1/ 1 3 Y NAME: PE .uG r�ti ? �� 1/4 -2& /1;1 N/R t f E fort W H U ►P..So>J / f{ t &-t(- 1`diEAZo (4 S]M - COUNTY: MAILING ADDRESS: ! -+ C RO( 40/1)(0 / 0 - 7 z6P 66 Q.J7y T-n. A , n ua 9 0 , J w t s sva•c USE - . ' - 5" DATES OBSERVATIONS MADE Pg NO.BEDRMS.: COMMERCIAL DES RIPTtON: r� I R FILL I D E SCR IP T IO NS : i5 I 91 TU> IS� (� TS: esidence 3oR e{. (New ❑Replace 1 l 5C -5 Cry EMM R T- U tZ IC t►h PD ' RATING: S- Site suitable for system U= Site unsuitable for system • r ONNVVEQNTIONAL: MOOUUNcD: IN-GROUND-PRESSURE: (► S SYSTEM -IN -FILL OLDING TANK: REC D S S rk( %onaP �o>< os o� @S o� D�7 �1/ ��? �U �s ou i57Ri t�Ttcrir SIGN RATE: If Percolation Tests are NOT required DE If any portion of the tested area is in the 2 ` under s. ILHR 83.0915)(b), indicate: F indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGR T TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) r � 0-/;z 10 fZ4_13 51, �7 /ocvcP /.z '- 36 " 1 `!�g 51 b B- + � n 1 05 10 `10 � / 4- -r`9 ; 36 "- / / ©„ /o YAP _�5/f' - 91";o '713 '5, p /owEo -iy "/o ye Y/y s /nrr�,a B- Z � l s 10 "0 2 > I ! 5 CS B- 3 2 r D-/2� / 413 5 /owE j /�-2p "/4%� Vl'. S 1 q�?Z4 > /^h9�, za - s5 /o i�.Py /ycs; 55 /off, /0 Y,e y/ M /7. 6F 57 5 r v A B- L ) 0 - io^ /o y 3 S. P cvEO� /C9 -/,p io y y t✓ s� 4q l,P e- f +► lol, ee It-0 Il ? tr�,e ' �� -vo" -7.s ��e yet✓ 5/, /.� 4a ,_ //00 " YR '/ s P 6� - /ca "/a Y/e , lr� gR, B - S �2Q X02,(2 ? ZO »rtvf2� /6 - 3 v " /r�Y/f' Ylyl 1 f p-p- 1.4' 35' -may' /o YA y/y e 3 ..,^ r µ+ v t; G y r_ /2 � ., p?tic C' /� v�47�ooS PERCOLATION TESTS ,, yR S/-/ �, ,,� S. TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLIN INTERVAL -MIN. P RI D t PERIO PER INCH P _ I y /os o i P- 2 yg" 'to /03. S' 2 Y3 P 72 102,5 — 2— 61 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. ' TIC4'� �Q� Q /l�v� Ti� iV �K — ' F SYSTEM ELEVATION. 4 74 I ? ! 3, L - 1, the undersigned, hereby certify that the soil tests reporte6 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): ITES WERE COMPLETED ON: 1 HOMESITE S EPTIC PLUM81NG _Gp.__– — ` U �� /7 (� 4 ADDRESS: 655 O'NEIL RD,, HUDSON WIS.54016 CERTIFICATION NUMBER: PHONE NUMBER( tional): ROBERT UL3RIGHT � 4 2- 3 e(P - s ( S I VIS. MA ER LIC. NO. 3307 M.P.R.S. CST SIGN w 1 MfNN. INSTALLER & DESIGNER LIC. NO. 00663 DISTRIBUTION: Oriqinal and one copy to Local Authority, Property Owner and Soil Tester. i i i u Y� \ fA ' A 110 3 \\ ; I 54EC - L g(E VATS o v - /00 � - L O T-- 3 y PLOT PLA/,) HOMESITE SEPTIC PLUMBING CO. • = 13AG,�ya� ,arTs 655 O'NEIL RD., HUDSON, WITS. 54016 f t x = new C �O C,q r l "i $ IS. MASTERPLUMBER LIC N n O.3307 P. S 2 4,F'2 "" INSTALLER & GESIGNER LIC. NO. 00663 k . 6 j 1 r: }}� T 1 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM i Owner/Buyer <, Mailing Address Property Address 7 (Verification required from Planning Department for new construction) City /State `7 1 iyr _ w Parcel Identification Number C —1 r LEGAL DESCRIPTION Property Location ./l/t -tr 1 / 4, > /% ' / 4, Sec. 2 N -RAW, Town of Subdivision Z /i /i , Lot # .J?' G Certified Survey Map# , Volume . Page # Warranty Deed # 7'�5� , Volume Page # Spec house ❑ yes ❑ no Lot lines identifiable 53 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 masterplumber, journeyman plumber, restricted plumber or a licensedpumper 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 Depa nt of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintaintrAmust be co eted d returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed /�tOrc s4c 3) 6 7.s . i S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER k� ADDRESS — 2 f� ' FI NUMBER CITY /STATE lM G-T- ZIP jyvlj►' PROPERTY LOCATION:ij1 /4, X 1/4, SECTIO T=�? N -R_W TOWN OF , St. Croix County, SUBDIVISION J LOT NUMBER 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 septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60a 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary) , the septic tank is less than 1/3 full of sludge and SCUM. I /We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Officer within 30 days of the three year expiration,da e. SIGNED: Q "a DATE: � St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 S T C - 100 This application form is t PP o be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. should this development be intended for resale by owner /contractor,(spec house), thenia 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 i Location of property l/4 S X 1/4, Section �T 2— N -R�W Township Mailing address __� ��`• Address of site Subdivision name L Lot no. 3, Other homes on property? yes No Previous owner of property Total size of parcel _ Date parcel , was created 1 9 Are all corners and lot lines identifiable. Y No Is this property being developed for ? Yes (sp ec house No P ) Volume 9 Page Number '�I'/ 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 & 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 he office of the County Register of Deeds as Document No. b and that I we ( presently II I ) P Y 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 recor" in the office of County Register of deeds as Document No . % -� Q Signatu f applicant Co- applicant Date of Signature Date of Signature OIL THIS SPACE RESERVED FOR RECORDING DATA DOCUMENT WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-1982 495885 I qll� ...... .. ............. 1111 REGISTEFt' FF1 E' GLENN WAXON and VYCELLA M. WAXON ............ ST. CROW., W1 ........... I .......................... -- ......... ...... .............. ................. Ree'd for Record husband and wife .... I ................................... ..... ........ ................................................... - .... .................... MAR 1993 Grant .............. ..................... ............. ................... Grant ors, - .................. ............... ............... ........................... - .... .... __ ........... a t 1.20 P.'M I ... A ................ 0 1 e conveys and warrants to •PPJ4� ..Niallpoo.ta ... C.Q.rP-0.r'a-tJ-0ML'.. ..................... Register of Deeft F1 E' 1993 P 'M k e]edS .............. ............. .............................. ........................................ ..................................................... .......... ............ .................. RETURN TO .... ..... ...... I ....... ............ .......................... - .............. ...................... --------------- ----------- �S'E - - Ci6ii --._..- . .-- •- ------` — ------- - I the following described real estate in ................................................ C . ounty, State of Wisconsin: Tax Parcel No: ------------------------------ I II Lot 36, HIgh Meadows III, in the Town of Hudson. i (i MAN SFETI $ �rr�• j I t II This is not ......... homestead property. I (is) (is not) Exception to warranties: Subject to easements, reservations, restrictions and rights-of=way of record, if any. 8th March .......... 19.9.3..... ........... day of ................... I ........ ......... ............. Dated this .. ... . ..... .... ................. II (SEAL) ......... .......................................................... (SEAL) ................................................. -- - Glenn. -A,-..WfL:Kpn. ........... ...... L .................................................... (SEAL) .......... ......... ............................. ............ mpn ..................... AUTHENTICATION A C K N 0 Wir L r G M IBM Signature(s) ------------------------------------------------------------ STATE OF WISCONSIN ---------- St. Croix ................... County. -r,4 --------- . ' es authenticated this ........ of ------------ - --- -- ........ 19._..._ Personally came before me this ..... . ..._ day of March 19 9 3 .. . the above named ...................... I ..... Glenn A. Waxon and Vycella M. Wa?yRn ......... husband --------------------- ..... ........... .................... ......................... &. e --- ........... TITLE: MEMBER STATE BAR OF WISCONSIN ............. .. ................... - 00 -- ---- (if not ---------- ------ ----- --------------------------------------- ................................. 0- authorized by § 706.06, Wis. Stats.) rn � the foregoing instrument as to me known to be the pe o exec p ao 0 edge the same. THIS INSTRUMENT WAS DRAFTED BY . ....... ..... B r ... Attq:rqg-y ...... ..... . . .... ... ... ...... .............. MUDGE, PORTER & LUNDEEN,.S.d'. ........... Hudsim. WL - 5-4-016L -------------------------------------------------- Notary Public ----- St. Croix ....... ounty, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is . .......... .. permanent , - I . f - not, state expiration are not necessary.) date: ........ P) - •7/ .................. ..•..•........... 19. . •Names of persons signing in any capacity should be typed or printed below their signatures. �— BEARINGS ARE REFERENCED TO THE EAST -WEST N 1/4 LINE OF SECTION 26, ASSUMED TO BEAR 00 N89 °3722 "W. D � z • N m 0 Z w lr V � N W / N UNPLATTED LANDS WEST LINE OF THE SEI /4 OF SECTION 26 p pp O 1 8' 24 " E 8 v• O 200.00' 212.00' 246.20' 2' U O N N y X, m 0- O , y (0 _ W l __ A y Co A A N l0 A e AN O A o t 0 A w O to CD O w w p p v A p ti D— C p v A N p N N m o Y w N N A N N N m Lpi ^ {� - m N JS m y V 1 m N �f V f J 0 m m 246 .20' - - A — 200.00' -- - 212 .00' -- — - - - -- - — In Iz73.o6 W �, w EADOW - - DRIVE - - -- m w � NOOO 18'13 o INN " W w 300.45 -- r - -- 308.50' - -- - - - -- A C 95 6' i i so, ON .� I O D I� � IM Z D z....... co 0 p O O O o 0 O N 0 � O z N DN z 0 N n0 Q O 0) 1D N (�j N z ( `�' o m N i N O I Q q m � H m � I N ' L sTrR3>Ipartki b�I�s 1�us r�6 • 29 . 19 , N W0AT StWAGE tM RD • County: Labor and'Human Relations INSPECTION REPORT Safety and Buildings Division ,GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit o.: Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.: Elev.: nsp. Elev.: BM Description: 7 � Parcel Tax No.: TANK INFORMATION ELEVATION DATA A930002 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi ng Aeration Bldg. Sewer [ Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to i ntake AD Dt Inlet , Air Septic NA Dt Bottom Dosing NA 4 Header an. Aeration NA NqXpe Holding B . tem PUMP / SIPHON INFORMATION final Gra Manufacturer Demand Model Number GP TDH Lift Friction System TDH L oss t m Forcemain Length Dia. Dist. To wen SOIL ABSORPTION SYSTEM BED/TRENCH Width Length I No. f Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS __ DIMENSION S SETBACK SYSTEM TO P/ L DG WELL LA KE / STREAM LEACHING anufacturer: INFORMATION Type O CHAMBER del Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pi (s) x Hole Size x Hole Spacin Vent To Air Intake Length Dia Length Dia. Spacing SOIL COVER x Pr ssure Systems Only xx Mound Or At -Grade Systems Only Depth Over De h Over xx Depth Of xx Seeded/ Sodded xx M ched Bed /Trench Center B /Trench Edges Topsoil E] Yes [I No El Ye El No COMMENTS: (Include cod discrepancies, persons present, etc.) LOCATION: HUDSON 26 29.19,NW,SE, LOT 36, KINNEY RD. Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert No. SANITARY PERMIT APPLICATION '701LHR I n accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY-PERM -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ sion 8% X 11 inches in size. Ch to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. P PROPERTY LOCATION 4 ., WI4 s ' /a, S ,� 6 T , N, R E (or PROPERTY OWN'S MAILING ADDRESS LOT # BLOCK # tj CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER tv ®/ 3 11. TYPE OF BUILDING (Check one CITY : NEAREST ROAD Chk �y' ( ) State Owned 1 3 GE - , ❑ Public L 1 or 2 Fam. Dwelling —# of bedrooms 2 A L TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## _ Date Issu V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 [� y seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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 16. SYSTEM ELEV 7. FINAL GRADE REOUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day /sq. ft.) (Min./inch) 49/ /p /, p � LEVsTIpON SO S . p .,S Feet Feet VII. TANK CAPACITY Site in oallons Total At of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank �� 6201C L 5-3 1 El F1 Lift Pump Tank/Siphon Chamber Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewpi3p system shown on the attached plans. Piu bar's Name (Print): Plum 's Signature: (No Sta INPIMPRSW No.: Business Phone Number: r ' 32-2 7 s6 r rixgUCOUNTYIDEP er's Address Stree , ity, State, Zip Code): r ca p USE ONLY Disapproved San' ry Permit Fee (Includes Groundwater Date I ssued �Aq Signature m Approved Given Initial // �O Surcharge Fee) ❑ Owner / Adverse Determinati X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTf3Y, DIVISION LABOR AN D HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATIO N: SECTION: TOWNSHIP�W*I:1�Y: M N0.:6LK NO.: Sti3DIVISION NAME: �/ ala /T4 N/R 0 E (or$ W H u PSor,.) H f IS-ff M��naws� COUNTY: MAILING ADDRESS: S-t. C12nf K �� .v lvi`IXo/v 7Z- t:� COU,07y '-o. I3 , N U D S'aa W 1 S Sya /G 1 USE 3 Al -' 2 S DATES OBSERVATIONS MADE Na BEDR : COMM R AL DESCRIPTION: TS: I pResidence 3 op, 4 & / New / ❑Replace JU'�E l`f ' l S (� Q) J'Uy� t S 1 '� + VR 9 AhtDl '. RATING: S- Site suitable for system U- Site u for system EMM R 7 s ONVENTIO AL: IN- GROUNDPRESSURE: SYSTEM -IN -FILL OLDING TANK: RECOMMENDED SYSTE to Clonal) SE) U IMOUND: S CCU D S CJU ❑ S CCU EIS �UfzEA.'CAes - w r �120P /30 tsr �avr lRcn+ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.0915)(b), indicate: GG.4 S S 1 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H TO GROUt DWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION - OBSERVED EST. HIGR TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) A O- O 4 wfP ' o r i "/ o �" 3 � / I z Y J' s 1 . sar r _ /4 , 4 P , B- (! o . 0 � l!D f9 , 3G ry- //0 16 YR / d 1 Sf /o Y/, '113 /S7, P440 &,C) ; b' /9 ~ /O y'? Y/y S B- Z is IO S.Co2 > S *,MVfR; I Its' /o %es /y C s 2 D -/2' /o K,< 413 Y b /o w�v� /�'-2p " /a 8_ J Q //NJ 9x nr+VFR, 2D -§ S /oyx.'I/ilC5 5 - /0, /0 Y,f' Y G A4 . aF . S. 5 1 gR i% I/ R B- o-ro^' /o 3 S ow� /o- i�Q "io ,� e n g !01. 'wo � 1 � ? VAR ; j � -vo - 7. / e y/G st iee / wq,e, �„ ; d,v gyp o_Co „/ yk' g/3 s P S . - - /C, "/a YR , 9R, B- 5 t 2 " © �� �` > ( 2. 0 ».tvfle /0 /0 YR y /y s, 1 f pe g ,° fR ; 3 /o YA y/r/ W 3 A" ,,,. v , p-?n c /�v T /cwS PERCOLATION TESTS /0 YR S-`,/ �. x }} TEST DEPTH. WATERINHOLEY TEST TIME 015P IN WATER LEVEL-INEHES RATE MINUTES t NUMBER INCHES AFTERSWELLIN INTERVAL -MIN. PE fl PERIOI15 PER INCH P _ 1 y /,55 < o? Y P. 2 // ^ 'h0 10 S. 5 ' < 2 X3 P. 72 - - 102 -� Z ,✓ 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. / ,ee' `-& to Q r 1/1PP10 TiL� - ,-v C& / F' 5 SYSTEM ELEVATION. �ow�sr TX's' -ucGt - �'�• So I T e- p S 1 l , R S C _ 1, 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 I Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME Iprint : ITESTS WERE COMPLETED ON: HOIIIESITE S F = PTI� p�@)lyC,.�. ADDRESS: CERTIFICATION NUMBER: PHONE NUMBERIo tiomil): - 655 O NEIL RO., HUDSON, WIS. 54016 � 4 $ 2 ROBERT WRIGHT 3 �. � y JMBER LIC. NO. 3307 M.P.R.S. CST SIGN 1,11NN. INSTALLER & DESIGNER LIC. NO. 00663 DISTRIBUTION: Origsnal and one copy to Local Authority, Property Owner and Soil Tester, r I - i M I • t< I ( 0 _ I V a A-0D0 PT - j t Oe vAT r oA ° 10 l �f � 1± T 3 - k x� PLOT PLA,J HOMESITE SEP'CIC PLUMBING CO. D 655 O'NEIL RD., HUDSON, WIS. 54O16 ROBERT UL9RIGHT c S T ff X � � /o 6 A r id N 5 AILS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. 3 '"T1. INSTALLER & DESIGNER LIC. NO. OD663 I GT�iit 1 Vlr JVIL. I�VRII�Ve7 n 1�V DIVISION I_ AWF I A PERCOLATION TESTS (115) '` - P.O. $OX 79G9 HUMAN 01 I48 * _` 1 ' x , M_6370Z,', (ILHA 83.09111A Chapter 1461 �.�• 3 �/ MADISON t' ! l TOW SHIP/MtifMfefP>4L-f�Yt ! ! &. r V 4 UP / T�1 NI 0 r lore W H u PS-O j I` H *ff ' N� ^AO�S_3:1r` C 5- •G17ot' K �� ti 40i9XoA) 72. (o CoUaTY '-v. Ili v 0 S'aa W 1 $ SVO DATES OBSERVATIONS MADE t s f. pgNldet►ta '' .3 cop, g- �✓, ,®New ❑Replace s 14 l 199( J' a t IG A. i tt�� EtiM „ R u n k tih aD1` - I RATINS, is Site suitable for sy stem UN SIte unsuitable for S ystem R T • fOL s J MOUND:_ - OLDI A K: RECOMME DED SYST :1 nal } S CCU 0 S U ❑ S U S U RE•ua v ` t P° oft yea 11 Ftiftb ation Tests are NOT required DESIGN RATE; It any portion of the tested area is In the undef f ILH1183.091S11b1, Indicate: e_ &,j S l Floodplain. indicate I'loodplain elevation: �� PROFILE DESCRIPTIONS 90 ELEVATION ' N , KI EPT I IN, a t0 8 E E ABBRV, ON BACk,I B. �0 5 -to /to 4" -f A' x �r�11 r �[ s � �,�y �� -' �- 11 .L. a I 40 "tor 4 j oW& ; /.z I -t o " / o YW y/y !F 1g. 2.4 'fl yid Y 17 a lei , sF , , 61 MIA, v B , , Q s p o w., o .i 0 "41*40,pv y ,r O ; v�it /� 7.5'YR !' /G s' /, /w►y /M J o'�- r o•C� / Y 3 Ar �. 5:° i - la 1,12 I z 0 r»t of R r o • y ,..� a yR y/� ,{ '� i 1 ,,/r -e, p, '0 Fog F 57 , nr , w r j C' y 1 2 ,0 0 mfr YEV.}r /etas PERCOLATION TESTS /g Le M/ A.Aw. X. Is S LL N N TE RVAL -MIN. E I CH E oZ, i Z P. ,. P . y „ �� j f , PLOT hLANf Show localons of percolation tests, Soil borings and the dimensions of suitable tail areas, Indiesta Ntele of distances. 0490*4 what are the rwri r tontal Nti*ftiael alavetlon reference points and show their location on the plot plan. Show the surface elevation at all bwMp and the direetion end percent TiEl t r of ler+d ttepe{f, /1 �i'G -�, e A) C& /p /. p ' ti41AW,6 7 XEiu cGt.' ..' 9 e S- f SYST M ELSV TION 7 7 �il/ T S L w f T.Pt" �u - ... ►giPs� _ f 'fit ' : r 1, the uW*tt{an , hereby certify that'lhe' tall tests reported on this form were Mack by me In accord with the procedures and methods specified in the Wisconsin Adrhfiilf' ailvi t6dl, and that tlib. dAl►eebMed and the location of the tests are correct to the best of my knowjadge And belief, NAMB z ' z ,, -.• ,asa:.yv, r ='swwla, ,'. • c � `� wv,v , „" W COMPLETED ON: ! —7 i NOfAESiTE S�P 1S; PL11618tNC�CO. . A !. M ERIo ton: i. • d N NU 8 CERTIFIC PNO i � CERtIF CAT ON NUMBER: 0 NEIL fi0, HUDSON WIS. _ , i , l,10 8 �-y g �.. t � fluent uL&,cflt 3 �Ca � 1 a � � W IN. WER PLWBER LIC, N0.3307 kt.P.fi.S. SI ORATUR 1,11NN, WALLER 6 OEWNER W. N0.00663 (� DISTRIBUTIONS Onp,nal and one copy to Local Authority. Peopet ty Owner and Soil Tester. k .. <�, � ►���.y Lamb - • .va , L v T Gi:u �- 1 i; i ' � I \ i Q AD q I'll V U0 rV cb . t' k 1 s IA 6 ' 5 �t o StT, 54EC-L Co u'Du Vr VeVATr /00. 4- L o r � I � � r J ' HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 �D Cl BERT ULBRIGHT c S T fl Z `f &' 2. l TioN �► S WIS. MASTER PLUMBER LID. NQ. 3307 M.P.R.S. '�'► @I. INSTALLER 6 DESIGNER LIC. NO. 00663 t I ` L • 1 —o 4 N 0 i I ' L I - : f r 9 i Nw 0 t - f w ,: 0 i -P 1 � � I i r � G I a 1 I I n _ _ 016 a 4 I I Q LA z f II L N y j f I �• w I ' O _r N , o .o u r , a to 9 \ / , M ? o , C7 o . -V� K% n . o Z � 1 J 4 *A cn Ir t o J N, 11 4 IA 1 fff 0 t Z r N wl 3 N �• sJ,�= � c g — 1 z � J v J •-� �' � 1 1 — CA 1 1 -� Md sea r� V\ L