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020-1334-80-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 563840 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Stalvi , Paul & Deborah Hudson, Town of 020-1334-80-000 CST BM yev: Insp. BM Elev: BM Description: nn ` Section/Town/Range/Map No: IL, 8'A" oo , S~ Z md~ ~ Omw _ - two 27.29.19.1768 -2 64 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. oj&kev Septic Benchmark C36 .ss L~t2 ~A~/5TH ~ Alt. BM W EISE2 ~I Aeration ' 3 .D D fi S Ou 1 HoldixtT- / St/Ht Inlet SUHt utlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Vei ewe t Septic I I I p / Dt Bottom A/ 1 9 3l-1 "e- Header/Man. ~y ^'Z~► 4,9f 3D / L? ration Dist. Pipe Holding tot. System 2 p q~' gyp, / Fin Grade PUMP/SIPHON INFORMATION . S64* 51 1WS' 86 ` Manufact er De Aand St Cover ~Et/ 1 Model Numbe iC ao C;"S:6- , (c. 3.2-7 ?g.0'11 oot TDH Lift F i ss System Head TDH Ft t Lk 3,3 Z q;7 9 / f Forcem Length Dia. Dist. to Well Lc CgcJ Cr ocK, 0,2-4 D r SOIL ABSORPTION SYSTEM / t2u1 BED/TRENCH Width / Length No. Of Trenche PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS a 'ePL 0) SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: L~Q TO INFORMATION CHAMBER OR -1 Tf Jystem P-- -71 UNIT Model umb@r:~ DISTRIBUTION SYSTEM c Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe() ..5- / Length Dia Leng Dia Sp g SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over F-psoil Depth of xx Seeded/Sodded )x Mulched Bed/Trench Center Bed/Trench Edges ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:/ / t3 Inspection #2: Location: 664 Red Maple Lane Hudson, WI 54016 (SE 1/4 W 1/4 27 T29N4 R~1~9~W) adl nds P e Lot 2i~ ~PPar~liNo:U2i49~1:Wt ~l 1.) Alt BM Description = ~ jAk ~~~y Q_ hr O-~oe~~e gL96'Ow~ . 2J Bldg sewer length teQsf- Lo = ~ 6WA~ Cie- - amount of cover = 5)T. %J " 0--, S) PdyJXL sus &Q. ip iwt r Plan revision Required? ❑ Yes ~J No Use other side for additional information. Date, (R.3/97Date, ((Cert. NG ~t wad County ( Safety and Buildinft St. Croix a i 201 W. Washington Ave., P. Sanitary Permit Number (to be filled in by Co.) a~= Madison, WI 53707-7162 'Ah 16 2013 Sank, it Application CRD/k co State Transaction Number In accordance with SPS 383.21(2), ode, submission of this form to the appropriate governn etal unit Na is required prior to obtaining a sari it. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m Stats. $ L Application Information - Please Print All Information Property Owner's Name Parcel # Paul & Deborah Stalvi 020-1334-80-000 7 Property Owner's Mailing Address Property Location 664 Red Maple Lane Govt. Lot city, side Zip Code Phone Number SW NE _ section 27 _ (circle one) Hudson, WI 54016 715 386-2564 T 29 N; R 19 E or W IL T of Building (check all that apply) Lot # 1 or 2 Family Dwelling - Number of Bedrooms , tt 3 k/ 28 ✓ Subdivision Name GX L S 77 t'v lA" Block # (4 a dl ~rl-, ❑ Public/Commercial - Describe Use Na 0 City of ❑ State Owned - Describe Use CSM Number ❑ Village of Na li Ij n of Hudson III. Type of Permit: (Check . Complete line B if applicable) A, ❑ New System Rlacement System Tteatment/Holdin Tank Replacement Only 0 Other Modification to Existing System eP 8 Y g (explain) B. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: (Check all that apply) on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade Mound 2 in. f itable soi M d < 24 in. of suitab l -A 12,1 ❑ Holding Tank ❑ Other Dispersal Component n vice exp am s2 It V. Dis Tsai/Treatment Area Informa ' : 45 Infiltrator "Q-4 Plus" Stan chambers & 6 endca s Pol Lok PL-525 effluent filter ion Design Flow (gpd) Design it Application 1spe a equl ispetbal 71008 pmpa"6~ 450 Gpd 0.5 Gpd/Sq. Ft. 900.00 sq. ft. 930.60 Sq. Ft. 93.00 VI. Tank Info Capacity in Total # of Manufacturer , Gallons Gallons Units s~ New Tanks Existing Tanks ✓ U H rn w0 A- Septic or Holding Tank 1,000 1,000 1 Wieser Concrete X Filter canister 1 Wieser Concrete X Dosing Cbamber ( .1 1 VII. Responsibility Statement- I, the ae igned, assu a responsibility for iustalia t POWTS shown on the attached plans. Plumber's Name (Print) Plumber's ignattue / MP/MPRS Number Business Phone Number James K. Thompson J MPRS 30021 715 248-7767 Plumber's Address (Street, City, State, Zip Code 340 P ulson Lake Lane, Osceola, WI 54020 VI . Coun /De artment Use Only Approved ❑ Disapproved Permit Feed Date I sued ruing Age t Sign ❑ Owner Given Reason for Denial $ J • ` 3 ~~~~Y✓~ IX S I UMProval/Reasons for Disapproval d 1. Septic tank, effluent filter and , l dispersal cell must be SQr_Yiced /.maintained V 4 ~ Cv~ . as per management plan provided by plumber. uiremen s must be main acne ttseh to complete puns tar trite system sad submit to the Comity only on paper not less than 8112111 inches is size SBD-6398 (R. 11/11) 1 Conventional POWTS Index & Tilte Sheet Project Name: Stalvig 3 bedroom Replacement Conventional POWTS Owners Name: Paul & Deborah Staly!& Owner's adress: 664 Red Maple Lane, Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 28, Plat of Badlands Prairie Legal Description: SWl/4 NE 1/4, Sec. 27, T.29N., R. 19W., Tn. of Hudson, St. Croix Co., WI. Parcel ID 020-1334-80-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Septic/Filter Tank Cross Section Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of Existing Septic Tank Page 11 Waranty Deed Attachments: Soil Evaluaiton Report Mater PI lRes t r cted Service: James K. Thom son, DSPS Credential #3 Signature: Date: /S Z O/3 Page I Of 11 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01/01) ~ EX~Sd n~ elU/a~ on Cale: #2.337 A/le ./460/a.ti_-~& /d, fed ~/c fie. Arofbse.d ol,3~per~/Ce//T~tc(3,~ ✓lc~~kbor;r►q O //u.a/Son tel. 55x06 &e"s 0163')((03'4~ce0✓2-0 ` ~wcli t/ Lo~lB p/a~oFC~Xid~ana(5 /57 5 wA)e,9 f sec. Z7, &T,cZ 2?,1. /f& .2, T. Ole? ~lerf 6o be 646 . (frD;X God 404 n~opase.d ~,zsN'co,-x.r'~. ~ ~ oao-/33s~ ~o-~ °`°g~4`' ~ ~ • beer,..- / ~o~oBSCd 6-- 4 -6o E yvo ' ~C~d I-, 6&V r /00• SS, EX,134 cJe!( 1 / 0 d 6w i ~ ~rw~s~arSCmncrr~i' /'CF3ic~¢./~G~ i w/ po lylAe"o[-szs snf \ 1 p oo"-7 6ra~k lawn Y a~ 3'X.s7j'wY f/. C13AG Sa(tc.~nd.~ ` u" 64s, n~Yf~a /e uzo4rce ¢1F1! = y. - Py .2- W / U STAL,_, VIG DISPERSAL CELL SIZING CALCULATIONS 1. (3be&wmsx100 gallons estimated flow)(1.5 design factor) = 450.00 Gp~i design flow 2. Infiltrative capacity of native soil = 0.5 gpd/% ft. 3. Absorption area required: 900.00 M. ft. 4. Absorption area as proposed: 930.60 4, ft. (4$chambers total) Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4 Plus" end cap = 5.10 sq.ft. EISA 900.00 sq. ft. - (6 endcapsx5.10) = 869.40 sq. ft. 869.40 sq. W20.00 = 43.47 chambers required Number of trenches: 3 0,15 chambers Pgftench Trench width: 2.83' Trench length: 6_ x. _.00' Trench spacing: 9.00' on center Total system area w/ 9' center spacing: 21.00'x 63.00' I Pg. 3 of 11 Soil Absorption System Cross Section q 7. ~~ft Q 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap ft Leaching - ► Chamber 93 0o ft System Elevation .2.83ftU ft ft Soil Absorption System Plan View 4,3 ft x.~r3 ft (p,~ ft Leaching Trench 1 Chambers 4" Dia. Trench 2 Header Vent Or Observation Pipe 11111 Trench 3 Leaching Chamber Specifications Manufacturer And Model ,Cc+i✓~Q--~~S~Sn~a,rc~/ EISA Rating _2-0.0 sq ft per chamber Soil Application Rate o•SZ.gpd/sq ft 4~V-0 gpd Design Flow O.SU Soil Application Rate - o-W-V EISA = f-" Chambers 3 rows of /S chambers each. Page of 1~ Conventional Septic System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code C.eneral The conventional septic system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with SPS 383.54(Ixe). Septic tank to be located within 150' of service pad, with bottom of tank to be 515' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1 /3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two-year schedule by use of diversion valve. Effluent to be diverted from new cell to old Drainfield at 2 year anniversary of new system installation. Old drainfield to be utilized for a 1 year period. Effluent dispersal to be alternated between systems on a three year rotating basis thereafter. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the St. Croix County Zoning Department at (715) 386-4680. Pg. 5 of 11 Filters PL-525 EFFLUENT FILTER ( 1 Polylok, Inc is pleased to add its new commercial filter to its existing line of quality effluent filters.The PL-525 is rated for over 10,000 GPD Alarm ~ I-q( Accepts PVC (gallons per day) making it one of accessibility extension handle the largest commercial filters in its l class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1/16" removed for cleaning, the ball will filtration slots Rated for over float up and temporarily shut off 10,000 GPD the system so the effluent won't leave the tank. No other filter on the market can make that claim! Accepts 4" & 6".. SCHD. 40 Pipe ~j PL 525 Maintenance: The PL_ 525 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning. It is recom- h rnended that the filter be cleaned t every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs Gas deflector servicing. Servicing should be done by a certified septic tank Automatic shut-off pumper or installer. _ ball when filter is removed 1. Locate the outlet of the U.S. Patent No# 6,015,488 septic tank. 5,871,640 2. Remove tank cover and pump tank if necessary. PL-525 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the tank. Make sure all solids fall 4 or 6 outlet pipe. If the filter is not centered under the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover. 0 i a32 D n n m A mDD 00 mNi-4 ~mf D mmZD Nr-iZ DmD C) C', rnAr ~n D' NOD NN 6,. ~ 37 O 2" z -i - n m z ~ U r a r n D = mD 0 Z ° \ 18" MIN. < < m D r O Z 37 _~22„ n e~ N D. m C m n Ai D V)n _ D Z (A _ I r N D N m n W I'1 Am D r n 0 OT~ C/~"~ D r' N `J Z D M C m M C~ D rrl 'u D r T UO O r7 m D D D z r (!l c- O Z ~ Ln FILTER CANISTER DETAIL WIESER CC(1CAETE scALE:3/4° I' REV No. j DRAWN 8Y:SWT Z SEPTIC MANUAL W3716 US HWYIO. MAIDEN ROCK. WI 54750 DATE: JANUARY 2008 REV. JAN. 2008 800-325-8456 FILE: SHEET 13 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/ Mailing Address Property Address"'ne (Verification required from Planning & Zoning Department for new construction.) City/State 14--els , 1.")/, Parcel Identification Number ©,;zD 33 ~6 ' 4:Tb LEGAL DESCRIPTION Property Location Sw 1/4 1/4 , Sec. T ~N RW, Town of Subdivision Plat: Lot # ; . Certified Survey Map # A4 , Volume Y14 , Page # 44. Warranty Deed # 'TxG 77 (before 2007)Volume , Page # Spec house ❑ }Wno Lot lines identifiable es ❑?~P SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber 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 Safety And Professional Services 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 Planning & Zoning Department within 30 days of the three year expiration date. 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. Number of bedrooms SIGNATURE O LICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK T is to ce Mit, h at I have insp cted the septic tank presently serving the '6~i residence located at: 5 w '/4,/4, Section, own N, Range___Zg_W, Town of So r , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service... u-i . .2zld Did flow back occur from absorption system? Yes ✓ No (if no, skip next line.) + Approximate volume or length of time: gallons ;~-O minutes Capacity: ddU a-Q Construction: Pre tab Concrete Steel Other Manufacturer (if known): ge o ank (if known): 16' y1--s. icensed Plumber Signature) (Print Name) i' /Y1, P ,P,s 3CI421 (T' (License Number)/NqZMPRS /S e2d/3 ate) 67- Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) . / 2,00 ACRES Dc,~b $ro - 87,169 SQ- FT, ~ tv/19-75' ra - _ - ]L' ems-: r z 2K 2.07 ACRES ~j • ' 89,965 SQ. FT. , a wY • F M 4„, ' r~ . -...~r+ ~"`"i♦ rte. r~ ice. ~ • • ~ i ti ~f f RED - " STATE BAR OF WISCONSIN FORM 1 - 1998 8 2 6 7 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS Document Number ST. CROIx Co., MI This Deed, made between Diane Ellingson, sin le Grantor, RECEIVED FOR RECORD and Paul B Stalvi and Deborah L. Stalvi4. husband and wife, Grantee. 06/06/2006 08:50AN Grantor, for a valuable consideration conveys to Grantee the following WARRANTY DEED described real estate in St .1 Croix County State of EXEMPT it Wisconsin (the "Property"): RC FEE: 11- 00 TRANS FEE: 855.00 COPY FEE: CC FEE: PAGES: 1 Recording Area Name and Return Address j RETURN TO: Burnet Title 7550 France Ave. S. First Floor dina, MN 55435 TTN: Post Closing Central 020 1334 80 000 Parcel Identification Number (PIN) This , homestead property. (is) (is not) Lot 28, Badlands Prairie in th4 Town of Hudson, St. Croix County, Wisconsin. i Together with all appurtenan rights, title and interests. Grantor warrants that the tit[ to the Properties good, indefeasible in simple fee and free and clear of encumbrances except Dated this 26th day of May, 20 6. (SEAL) (SEAL) I ) lane A. Ellingson I (SEAL) (SEAL) I AUTHENTICATI N ACKNOWLEDGMENT Signature(s) State of Wisconsin, } ss. St. Croix County authenticated this day of , Personally came before me this 26th day of May, 2006 the above named i Ellingson, single to me known to be the person * who executed the foregoing instrument and TITLE: MEMBER STATE BAR F WISCONSIN acknowle a the same. (If not, authorized by §706.06, Wis. Stats' - n L J 1 THIS INSTRUMENT WAS ORA TED BY Notary Public, St to of Wisconsin Coldwell Banker Burnet/Robert icholson 1301 Coulee Road My com Issigqn is permanent. (If not, state expiration date: Hudson, WI 54016 ~1 6-29665 4ENnv SWAT71NA (Signatures may be authenticat d or acknowledged. NOTARY PUBLIC Both are not necessary.) STATE OF WISCONSIN " Names of ersons sl nm in an aat must be ed or Printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc_ WARRANTY DEED FORM No. 1 - 1998 Milwaukee, Wis. 1 oft s ` 2337 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal (BMA direction and St. Croix percent slope, scale or dimensions, north snow, and d~stance to nearest ros1i~ Parcel I.D. O A1334-8"W Please print all inform n. C~ Pemonal information you provide may be used for (Privacy Law, s. 15. m)). Revi By U~~ -7 e Ll 7 1.0 Property Owner f Pope on Paul & Deborah Stal ' Go SW 1/4 NE 1/4 S 27 T 29 N R 19 W Property Owner's Mailing Address IW7 Lot #l,~_p BI # Subd. Name or CSM# 664 Red Maple Lane 28 N na BAdlands Prairie City State Zip Code Phone Number J City _I Village !e Town Nearest Road Hudson WI 54016 (715) 386-2564 Hudson Red Maple Lane J New Construction Use: a Residential / Number of bedrooms 3 Code derived design flow rate 430 GPD ✓l Replacement J Public or commercial - Describe.na Parent material Glacial Outwash Flood plain elevation, if applicable na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.5 gpd/sq.ft./day loading rate. Recommended infiltrative surface elevation = 94.00'. a Boring # J Boring 16 Pit Ground Surface elev. 96.08 ft. Depth to limiting factor >93" in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 1 0-11 1Oyr3/3 none I 2fgr mfr cs 2fm,lc 0.6 0.8 2 11-33 10yr4/3 none Ifs Osg ml gs 2fmc 0.5 1.0 3 33-49 1Oyr4/4 none Ifs Osg ml cw 1vf,f 0.5 1.0 4 49-61 10yr416 none fs Osg ml aw - 0.5 1.0 5 61-93 10yr5/4 none Ifs Osg ml - - 0.5 1.0 2 ] Boring # J Boring F Pit Ground Surface elev. 97.35 ft. Depth to limiting factor ,98„ in. Soil Application Rate Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Roots GPDIft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr313 none I 2fgr mfr cs 2fm,1c 0.6 0.8 2 10-23 1Oyr4/4 none sl 2fsbk mvfr Cw 2vf,fnm 0.6 1.0 3 23-46 1oyr4/6 none Ifs Osg ml cw lvf,f 0.5 1.0 4 46-64 1Oyr4/6 none fs Osg ml aw - 01.0 5 98 10yr5/4 none s Osg ml - - 0.7 1.6 S eJ• 9 • br7 ` 32. Ili /tom 3.0 2. 2 , off * Effluent #1 = BOD? 30 < 220 mg/L an TSS >30 < 150 g!L ent #2 = BOD mg/L and TSS < 30 mg/L CST Name (Please Print) nature: CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, 154020 7/4/2013 715-248-7767 Property Owner Paul & Deborah Stalvli Parcel ID # 020-1334-80-000 Page 2 of 3 Boring # --1 Boring 3 ]Boring Pit Ground Surface elev. 9S.93 ft. Depth to limiting factor >91 in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOW `Ei#1 *Eff#2 in. Muraell Qu. Sz. Gont.Color Gr. Sz. Sh. 1 0-14 lOy1312 none SO 2fgr mvfr cs 2fmc 0.6 0.8 2 14-29 1 Oyr4/4 none Sil 2fsbk mvfr cw 2fm,1 c 0.6 0.8 3 29-35 10yr4/6 none gr sl 2fsbk mvfr cw 1 vf,fm 0.6 1.0 4 35-41 10yr4/4 none Ifs Oeg mi 9w - 0.5 1.0 5 41-91 10yr5/4 none fs Osg ml - - 0.5 1.0 F-I Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. 50,7 Application Rate Horizon Depth Dominant Color Redox Description Texture Stnicture Consistence Boundary Roots In. Mureell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#I 'Efr#2 i F-I I Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rabe GPDMI Horizon Depth Dominant Color Redox Description TextureStructure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ' Effluent #1= BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD5 <_30 mg/L and TSS 4S.30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (K07/00) A.C.E. Sow & Sb EVAMUon3 ■ Soi% era/ua~~~4,~ ♦ EXiS~i~g elWa~or~ • ~ocrz V Or-o,4 0 e;r 3, cafe: / -D' 2X7 ~/opased u~,~se~Concr~[ IOCV. .F; i &3 uhf( Syrs-b`r" / / /I ~'sr, oulst'=Y7. 1 d d' V AreA I / l t ' / Irr 1 ~.d / I ,Pes~cl¢~ce. Sl ~ r r r / r oroe'l 6rask lawn by-s, ~~rty-~i2 ,G ce - 9f(( .3W3 C) ° gl~ o o a p N a 0 w t3 E ''n m m = •O -'vm c m N L v m m m E N CD co y N y CD N X r _p Co'. O En ui.o A! ~p N C y O .y.. p C Cl (D N C y O .0.. C C (D .m-. 00 N y O)~O m E-••° O.O yOL C E y m Q Y ' y m o.mIn ai . y O y CA y m LO LO 3'D yew -a cc CD E ayi ayi ~E m E-0 Ty M C p w C p a L=p•CSY V:° 02 *R .2 C) L) (a -0 LO Z CL 75 co m m o m m U. 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ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and st- Cro i x percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # o)o -/U7 -da APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes P ' cy w11. 1) (m)). Property Owner .,Prop Location t \,J' f~a. G~M1(t; Co E 1/4 NW 1/4,S T N,R (or) W ~ Richard Stout 2 7 29 19 Property Owner's Mailing Address Lot # lock# Subd. Name or CSM# 1353 Awatukee Trail Badlands Prairie City State Zip Code F~hofa Nu : a Nearest Road J City El Village [j Town ❑ Hudson WI 54016 (~71 )549, ud~ n Hill Farm Rd [R New Construction Use: ®Residential / Nu of pf beffragrrfs Addition to existing building ❑ Replacement ❑ Public or commercial-~{es~iHe:l _J Code derived daily flow 6 0 0 gpd Recommended design loading rate _7-bed, gpd/ft2-_g___trench, gpd/ft2 Absorption area required R 5 R bed, ft2 7 5 trench, ft2 Maximum design loading rate 7 bed, gpd/fl2_. 8 rench, gpd/ft2 Recommended infiltration surface elevation(s) 9 6 . 3 0 ft (as referred to site plan benchmark) Additional design/site considerations Parent material Glacial deposit 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 Lks ❑ U [ S ❑ U S ❑ U ❑ S U ❑ S 9 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 1 0-6 10 r3 2 2 6-4 10yr3/4 none sl lmbk mvfr cs If Ground 3 40-91 10 r4/ none ms os Ml r R "7 elev. 9 9 .-2-0-ft. Depth to _ limiting factor 91 in. Remarks: Boring # 1 0-8 10 r3 2 2 2 -42 10yr3/4 none l 1mbk vfr s if .4 5 3 42-9 10 r4 6 n Ground elev. 101 .20 ft. Depth to - limiting factor _g 4 in. Remarks: CST Name (Please Print) Signature Telephone No. r re rGt V! "--e- ke° y Address Date CST Number '5F 9 I r- a SOIL DESCRIPTION REPORT "?ROPERTY OWNER Richard Stout Page 2 of 3 PARCEL I.D.# 30ring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 10 r3 2 none L 2mabk 2 16-48 10 r3 4 none 1 around 3 48-92 1 0yr4/6 none ms sg ml Cs 1.7 - . 8 Elev. 100.30t. Depth to imiting actor -92-in. Remarks: 3oring # 1 0-14 10yr3/2 none L 2mabk Mfr GS 2f -5 -6 q 2 4-4 10yr3/4 none sil mabk fr s if .5 .6 3 4-9 10yr4/6 none ms sg 1 s - .7 .8 around elev. 99.5-Q--ft. Depth to imiting actor CL-L-in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # 1 0-8 10 r3 2 none L 2mabk Mfr CIS 2f _5 '-6 2 8-4 10 r3/4 none sil 2mabk mfr CS 1f 1.5 ..6 5 3 40-90 10yr4/ none ms osg ml Cs .7 -.8 Ground elev. 101--Oft. Depth to (imiting factor 9 0 in. Remarks: t3oring # around :lev. ft. ' Depth to ':imiting !actor in. Remarks: SBDW-8330 (R. 08/95) l =f gZa.9 dG,d.:d,~ ~~a7~it~GrJ fOD~ o m~ 2z s 1 1 i s S.toy~ '7r °'/c S L a g~f 0 III- ase- P~' P ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner l-rM M l L~Fit- Address City/State Legal Description: Lot Block Subdivision/CSM # Sec. I-n,, T~ N-R4!~t_W, Town of PIN # SEPTIC TAN DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer i (kt15Ci2 Size ST/PC P0`4 09' Setback from: House 2 ~ Well 3'1 P/L Pump manufacturer Model Alarm location - (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system.:~)(ELUUTat Width 3 Length Number of Trenches Z--- Setback from: House 4'9 " Well $ S ' P/L Vent to fresh air intake ELEVATIONS: Description of benchmark A14 /L /N 7`/L iff- Elevation d n Description of alternate benchmark _t c., fl o P Z3/0 C ,tL Fd vN .pO/W Elevation 101 y" i.. Q Building Sewer ST/HT Inlet log ' 'G ST T n PC Inlet Outlet - ~ ~ f PC Bottom Header/Manifold ^ -7' 3,Y!- `tc.,9Z_ Top of ST/PC Manhole Cover Distribution Lines (w) to, 3 T, 9 j Bottom of System ( ) 1 l ( ( ) 12,3 ( ) Final Grade ( ) 1,40 )j-'40:5S,9 Date of installation / / Permit number State plan number Plumber's signature- 7"' ~Zq~. License number ; `<-Wi Date "W/-~bl?k Inspector Complctc plot plan K 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. Wore : ft v 110 -1 PL VI W ~ Hort ~ 1 NS1~~~D V/f P~ ry 0 ye INDICATE NORTH ARROW .P 3 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety a.~d Buildings Division County INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary31 m6th Personal information you provice may be used for secondary purposes [Privacy Law, x.15.04 (1)(m)]. Permit Holder's Name: ❑ City Village Town of: State Plan ID No.: MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T61-416 1334-80-000 TANK INFORMATION ~+AAtA QtV[`_2~0~IA MOPELEVATION DATA A9800245 F1,20 ' TYPE MANUFACTURER CAPACITY STATION BS HI /FS ELEV. Septic ~dG~ Benchmark Dosing Aeration Bldg. Sewer Holdi j9 St /Inlet (r' ' TANK SETBACK INFORMATION St/$t Outlet X71 TANK TO P / L WELL BLDG. Aeintake ROAD Dt Inlet M Septic eeV. NA Dt Bottom Dosing - NA Heade Aeration F.."'NA Dist. Pipe Y Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand i o-del Num GPM TDH Lift Fri m TDH Fib ss ea Forcemain -6eDia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT-----__ No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 DIMENSION SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING ° °Mdnu acturerr LL„- M M SETBACK INFORMATION Type O CHAMBER i~~+-v'-Cent}; ~ Model Number. , System: OR UNIT, DISTRIBUTION SYSTEM Header r0 Distribution Pipe(s) _ x Hole Size x Hole Spacing Vent To Air Intake Length _/T Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of Tx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes El No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 27.29.19,SE,NW 664 RED MAPLE LANE h, j ~ Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: , - - - - - - - - - - - «-..c a .a e~ _ e e e . 1 E s j Safety and Buildings Division 14 SCO/1S%►1 SANITARY PERMIT APPLICATION 201 W30 ingtonAvenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. S4, CcOj • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes Checkk i5vili to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner NamQ ~roperty Location 1f1f~L ~ 5 1/4 to/4, S 2 T N, R E (or& Property Owner's Mailing Address Lot Number r Block Number e~ City, State Zip Code Phone Number Subdivision Name or CSM Numbe 14 u50 L4 1 S o 43 ) f r 2 11. TYPE F BUILDING: (check one) ❑ State Owned It~ Nearest Road VII age A <D iJ ^ ~d / e Public 1 or 2 Family Dwelling - No. of bedrooms Town of t-1/•J ~l r L. 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo lo Z / 3~ D 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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ Repair 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 12 ® Seepage Trench 'S 1 DE W)fl Rr 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 0 /NF1411R ATO R_ 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft_) (Min./inch) q Elevation D T L $ I Z 3 Feet 9Sf Feet VII. TANK Capacity gallons Total # of r Prefab. Site Fiber- Exper- INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank C~ 5 E . ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No mps) MP/MP SW No.: Business Phone Number: 3 9'4 Plumber's Address (Street, City, State, Zip Cod 67o MKT D E 04 D 14 L-PT 0N I< e~ IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitar Permit Fee (includes Groundwater RDate ue I suing A n Signature (No Stamps) XApproved ❑OwnerGiven Initial PlllirgeFee) ~ Advers e Determination i X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, plumber SBD- 6398 (R.1 1/97) INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4_ Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection,or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address.and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and. specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue `*sconsin In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County iy than 8 v2 x 11 inches in size. e • See reverse side for instructions for completing this application State Sanitary Permit Number X15858' Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Property Owner NamQ~~ Property Location 114 14,S Z? TZ ,N,R/ E(r W Pro erty owner' Mailing Address Lot Number Rlcck Number _X V XD A, City, State Zip Coe Phone Number Subdivision Name or CSM Nu ber 11. PE BUILDING: (check one) ❑ State Owned ❑ City Nearest Road Village 1A-,1&.t o- Z Y Public 1 or 2 Tamil Dwelling - No. of bedrooms Town OF 14 .S III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~II D 1❑ Apartment/ Condo d _ Al ~ LLT -%0 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.VNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System Tank OnlyExisting 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 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) 9L.3 Elevation L6 L OQ $ eetl ?gf Feet VII. TANK Capacity acitns Site Total # of Prefab. Fiber- Exper. INFORMATION New g Existing Gallons Tanks Manufacturers Name Concrete strutted Con Steel glass Plastic App T nks Tanks C Septic Tank or Holding Tank II150 j SE ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ 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 nature: oStam s MP/MPRSWNo.: Business Phone Number: A fg 03~W 39G- 8 ~v@--L 1 Plumber's Address (Str et, Cty, State Z pfode): .-r- I . COUNTY / DEPARTMENT USE ONLY I S' ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved E] Owner Given Initial 01> Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD- 6398 (R.11197) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber i INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. 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 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. SAM 0 i<<fl glfi)I-AND t P-6~_iF:-- 92, 3c 3 Slo C, O-r z Y x.07 04C• a IV Z~fee o r tt)t op 1 ~ 13 t ~ P zz5 i Z,~ Pvc. = ~~~~z i V H s a. ° co c~ c co r a~ N o x Q ~ cu o, in co -o Cn N N Q. ca CL o El CY) a) cu E F= go) V C, O 0 O ca Iz ca n a) =3 x ~ O v v. O N O O X A L N cb E N CL .2) -a > 10 Q x m a) O C V O C -C a) C 0) a CU N> la) a) a o f cam EO:O r= u a - g. l RAS Q) a? ® ® ® ® .4 N.Qi co LO C\j W 1 ii W N $ a~ D ~1 y T C`a S E s 4 ~ r 1 co g 0D b x< ® UH. V r~i > ~ s •zv:~ W Cl) rn ' E LF p UJ `o M~ ul~ ,C , r c o ao Z ° U R o F co UJ T [ W Q Y tv -t J wisponsin DepartmeM of Commerce SOIL AND SITE EVALUATION page l of ' Division'of Safety Safety and d Buildings Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ~ C include, but not limited to: vertical and horizontal reference point (BM), direction and -S try percent slope, scale or dimensions, north arrow lion and distance to nearest road. Parcel I.D. # S 19 APPLICANT INFORMATION ` se prin It ft tion. Reviewed by Date Personal information you provide may secor ~ ( . s. 15.04 (1) (m)). Property Govt. Lot_ C 1/4/ ~/1/4,S 7 T g,? N,R f Mor) W Property Owners Mailing Addre , T CROr ~Y Lot Block# Subd. Name or CSSM# 20NcoUN7Y ~OGt'/f?G( i~ City State El E] Village 121 Town N6ar rest Ro6ad city New Construction Use: Residential / Number of bedrooms 3_y Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow Ov gpd Recommended design loading rate -±--7 bed, gpd/ft2 L ~Ltrench, gpd412 Absorption area required _,-bed, ft2 7-!d trench, ft2 Maximum design loading rate bed, gpd/ft2~trench, gpd/ft2 Recommended infiltration surface elevation(s) ft(as referred to site plan benchmark) Additional designtsite considerations eh y. Q / Z• > 61~,~~ Parent material t /4C r ~c ( 0 y Lwce S A Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure TAT-Grade System in FlII Holding Tank U = Unsuitable for system ®s ❑ u IR s ❑ u ® s ❑ u ❑ u ❑ s la 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 6 0 Z /a,/"- .5"/ rc46 L~r e--5 to '6 Ground -S t3 Yvl ( C 5 . 7 . elev. ass , F . Depth to limiting factor /30 in. Remarks: Boring # Z - o 3 t~ca 6f m t S , tU rV16 ~-S S Ground 7 O f ellq 'W-5 6 C elev. ~Qft. Depth to limiting factor i-IlLin. Remarks: CST Name (Please Print) Signature Telephone No. ~~Gr ~~'lvvYta .off f ~ -$~Gt3 Address Date CST Number SOIL DESCRIPTION REPORT 2 PROPERTY OWNER Page PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots sC (1 Bed , Trench rV 1 o ( Sin m e (I^~ . r 1C7 2 t!K-35 r > c S 1-~ Ground 3$ i3f G YYI Wt C - ' 7 ' elev. la7~ft. ' Depth to limiting factor A/Lin. A Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 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: SBD-8330 (R. 07/96) SC'a le l = G/ -iy -98 s~ y s~ 7T" '>.6,n e lou. $ N vG ` / 00 r 1 reaf IN n Y ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer AVZI_~,4_0_ Mailing Address ox Property Address 6 (v q e4 jo 101 tom. 1_/_/1 / F (Verification required from Planning Department for new construction) Ca City/State P V DS o ff W Parcel Identification Number d 2 /33 y~ $d LEGAL DESCRIPTION Property Location 5 F. %4, I/4, Sec. 2 7 , TZ9 N-R_jf, Town of gyoso zSubdivision 21+ D 4,411 P -5 h R 4112 / £ , Lot it 2~ . Certified Survey Map # 6-4- 10 140 , Volume Co , Page # 9 Warran Deed # S~ D //O , Volume 3 2 7 , Page # y~ Spec house LR yes ❑ no Lot lines identifiable V yes ❑ no SYSTEM MAINTENANCE- Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards.. set forth, herein, as set by-the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to-the St. Croix County Zoning Office within 30 days of the three year expir . n date. A APPLICANT DATE 4:10WNER 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 ropehy described abov b virtue of a warranty deed recorded in Register of Deeds Office. 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 fror, the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed STATE BAR OF WISCONSIN FORM 2 - 1952 WARRANTY DEFLD DOCUIMD':T 1`10. r C W1 -_Ric RAfIU- Q L_aT0LL1___ JUN 4 N 998 8:30 A conveys and warrants to - - - Re, IBr of a THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in County, S Rl" e /if / L L f & State of Wisconsin: Po 'Tax /f1 Lots 17, 27, 28, 39 and 40, Plat of Badlands H4P0C6j" %W S /6 Prairie, Town of Hudson, St. Croix County, Wisconsin. PARCEL IDENTIFlCAMN NUMBER TRANSFER i This _i_5___n_Qt homestead property. (is) (is not) Exception to warranties: easements, restrictions, rights-of-way and covenants of record, if any. Dated this __2 0th - day of May A.D., 19--_q-&-. Richard. Qa(SEAL) (SEAL) (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. authenticated this --day of _ 19-- Personally came before me this 2Qtb day of Ma 3c 19-9$-, the above named - Rirbard C1_St<nvt - TITLE: MEMBER STATE BAR OF WISCONSIN 0I not. authorized by 4706.06, Wis. Stats.) r to me sown to be the person who executed the foregoing or ir` m mat and acknowledge the same. THIS IN ;TRUMFagT WAS DRAFTED BY ~~0"f11FdY _ Janet P. Stout ; --1J53 Awatutkecr--Tr. - - = F'tfii}t.Y`' c- virginta R. Gartman - _W1 _5401.5-- -r1 ticc~ry Rablic -_St. Croix _ _-.-Count)'.~ti'is. (Signauirts na a) be authenticated of a k ledgct4 e ~I .r fro cam!Tli,_ u n is permanent. (If not. state explratlalla date. necessary) _.-----January. 30 2000 • N'-,-or }sons cyrmg,: Jn) up31it) slo:'u!d b. tjrxd r .mtd Y- thc.r ;ign,u ur;-: STATE BAR OF A%1~CVV*c.xsnLw _%3-.Co.1nc. WARRAN II ULED Form No. 2 - 1 MM3J. ee. 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