HomeMy WebLinkAbout020-1335-60-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner 'SAM &4 -46x-
Property Address 7 " ca/4 1r`4 .0 D 4?04
City/State 14 tA) 4o t l w , fit/ O f L
Legal Description:
Lot 3(.► Block --- Subdivision/CSM # ROQ 14
'LC t /arm '/4, Sec. r, 7, Tj�N-It Town of 6(62,a Z VJ PIN # b Z o - / 3 3 S- Gd
e PTI�fANK DO SE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer 15.F /L Size ST/PC l00( Setback from: House Well 4 " Z P2 '71
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: 0F f 1 V ITdR . Width Length Number of Trenches
Setback from: House y 6" Well l/' P/L 35 Vent to fresh air intake 81
ELEVATIONS
Description of benchmark To P a F W t I- L- Elevation 1 b ' O
Description of alternate benchmark - To P -o+ Q 10 C- r' v 1,W 047 t V h' 4,/ • 70 Elevation 9`' . S
Building Sewer ST/HT Inlet �, yo ST Outlet i °' Z �� ` C Inlet
PC Bottom Header/Manifold �3 • a y Top of ST/PC Manhole Cover (D y Z 7 , 7Z
Distribution Lines( ) ! 3 f3 (O,y
Bottom of System ( ) �S • Co Z ` �� S g() �' , ��� ' �� S$ ( )
Final Grade () ���QZ- - +.� ) =`�� ( )
Date of installation J S/Permit number 3/ S'9 C State plan number
,
Plumber's signatur License number - CS :5 ' Date
Inspector
Complete plot plan
J 1
i t
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.
I
PLAN VIEW
i
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INDICATE NORTH ARROW,
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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar y320269:
Personal information you provice may be used for secondary pu ❑ rposes [Privacy L , s.15.04 (1)(m)). Name: Permit
MILLER, Holde SAM HUS�Nllage Town of: State Plan ID No.:
CST BM Elev.; Insp. BM Elev.: BM Description: Parcel TM' 1335 -60 -000
TANK INFORMATION EL VATION DATA A9800455
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark %" ` 7
Dosi ng 2 L! a �;
Aeration Bldg. Sewer ,.
Holding St /MV Inlet
TANK SETBACK INFORMATION St / Outlet ';tj V 10
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 7 / > 5 ' S ���' NA Dt Bottom
Dosing NA Header /Man. F9. [ 3 7 �
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer --' Demand �1a c� &o
�-.!, r r; (I �, I a, s 49, 5
Model Number GPM
TDH Lift ,, L ction System TDH Ft
H ead
Forcem Length Dia. Dist. To Well
SO ABSORPTION SYSTEM
BED/TRENCH Width r Lengtth, r No. O Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION `a DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type O /7v.c CHAMBER , .? Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
x Seeded / Sodded xx Mulched
Depth Over Depth Over xx Depth Of x
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes C] No C] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 27.29.19,SW,NW 749 WILFRED RD— BADLANDS PRAIRIE LOT 36
r.
Plan revision required? ❑ Yes [klo
Use other side for additional information. lO
SBD -6710 (R.3/97) Date s d s Signature Cert. No.
Safety and Buildings Division
*6onsin SANITARY PERMIT APPLICATION 201 Bo Washington Avenue
Department of Commerce In accord with ILHR $3.05, Wis. Adm. Code
Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
Z ' 1 V
Personal information you provide may be used for secondarX purposes ❑ Check it revision to preyiousSpplication
[Privacy law, s. 15.04 (1) (m)]. - 7 A M WI,Ifm 1 Rd
off l,� '`C State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property Owner Owner Name Property Location
1 4 1 tz_ 5tcAMAIW /a TL4 ,N,Rl? E(o
Property Owner's Mailing Address Lot Number Block Number
Cit , State Zip Code Phone Number Subdivision Name or CSM Numb
z0 w� of 1 (3,y ) K 6
II. TYPE F B IL DING: (check one) ❑ State Owned ,,3 [I Cit Nearest Road
ag
Public 1 or 2 Family Dwelling - No. of bedrooms v 1 e own OF 4�0_3C Fit IyL F Arp
111. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) A7. OZ • 1 9• /
1 [] Apartment/ Condo
DZa- X335' - 90- oo
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 pC New 2 ❑ Replacement 3_ ❑ Replacement of 4 ❑ Reconnection of 5_ ❑ Repair of an
______S� stem ________System _____________Tank Only______________ Existing System _________E - - -- - 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
12Veepage Trench 22 ❑ In- Ground Pressure 42 E] Pit Privy
13 E] Seepage Pit ip /VH I T'ft � ®/L.. Z x x she Z 43 ❑ Vault Privy
14 ❑ System- In-Fill
V ABSORPTION S YSTEM 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) Elevatio9
50 s',4 3 .1'7 'L� • �( �� � Feet 4 S Feet
VII. TANK Capacity g allon s Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons an Manufacturers Name Concrete Con' Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tan X 1000 1 W C_ (Sf X_ ❑ ❑ ❑ ❑ El
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ ❑
VI11. 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 Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
/\/I I � A F- LL
Plumber's Address (Street, City, State, Zip Code):
d 7® v f04.E H v O ":-. Q m {,fir` i
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No-Stamps)
CJ E] Surcharge Fee)
/ d / Approved Owner Given Initial �b ozs7 g
Adverse Determination 1 7 8
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Environmental BY Design
Attach complete site plan on paper not less than 8'/s x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix _
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.#
APPLICANT INFORMATION - Please print all information. Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). y v
Property Owner Properly Location
MILLER, SAM Govt. Lot SW 1/4 NW 1/4 S 27 T 29 N,R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
TROUT13ROOK RD 36 Badlands Prairie
City State Zip Code PhoneNumber City [] Village ®Town Nearest Road
Hudson WI 386 -8692 Hudson State Hwy 12
N New Construction Use: Z Residential / Number of bedrooms 3 ❑Addition to existing building
❑ Replacement F� Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/fl2 8 trench, gpolitz
Absorption area required 643 bed, fF 562 trench, ft? Maximum design loading rate .7 bed, gpd/fl? .8 tr ench, gpolft
Recommended infiltration surface elevation(s) 88.60' ft (as referred to site plan benchmar
Additional design / site consideration
Parent material Loess over outwash sands Flood plain elevation, if applicable na ft
S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system MS o U ® S❑ U ® S❑ U ❑ S® U EIS ®u ❑ S® U
SOIL DESCRIPTION REPORT
goring# Horizon
Depth Dominant Color Mottles Structure GPD/fl
in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistenc Boundary Roots Bed Trench
l 1 0 -17 10yr3 /2 - sil 2msbk mfr cs 2f .5 .6
2 17 -34 10yr4 /4 - Is 1 msbk mvfr cs if .5 .6
Ground 3 34 -51 7.5yr7/4 - s Osg mi cs - 7 ' 8
elev
95.91 ft 4 51 -105 7.5yr6/4 - cs Osg ml cs - .7 .8
Depth to 5 105 -12 7.5yr7/4 - s Osg ml -- - .7 .8
limiting
factor
>125"
Remarks:
2 1 0 -13 1Oyr3 /1 - A 2msbk mfr cs 2f .5 .6
2 13 -33 1Oyr4/4 - sil 2msbk mfr cs if .5 .6
Ground 3 33 -48 7.5yr7/4 - s Osg ml cs - 7 8
elev
95.85 ft 4 48 -110 7.5yr6/4 - cs Osg ml cs - .7 .8
Depth to 5 110-125 7.5yr7/4 - - osg ml - - .7 .8
limiting
factor
>125"
Remarks:
CST Name (Please Print) Signature: Telephone No.
Thomas C. Nelson 715- 246 -2454
Address Environmental By Design Date CST Number Ref #
1432 120th Street, New Richmond, WI 54017 9/21/98 227387 39
PROPERTY OWNER MILLER, SAM SOIL DESCRIPTION REPORT ® Page 2 of 3
PARCEL I.D.# Environmental Bv Desi
Depth Dominant Color Mottles Structure GPD/fF
Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. � o risisteric Boundary Roots
Bed Trench
3 1 0 -19 10yr3/2 - A 2msbk mfr cs 2f .5 .6
2 19 -30 7.5yr7/4 - fs Osg ml Cs - .5 .6
Ground
elev 3 30 -35 1.5yr6/4 - cs Osg ml cs - .7 .8
91.49 ft 4 35 -100 7.5yr7/4 - s Osg ml - - 7 8
Depth to
limiting
factor
>100'
Remarks:
4 1 0 -22 10yr3/2 - A 2msbk mfr cs 2f .5 i .6
- 2 2242 1Oyr4/4 - sil 2msbk mfr cs 1f .5 ' .6
Ground
elev 3 42 -52 7.5yr7/4 - fs Osg ml cs - .5 .6
91.64 ft 4 52 -96 7.5yr7/4 -- s Osg ml - - 7 8
Depth to
limiting
factor
>96
Remarks:
5 1 0 -21 10yr3/2 - sil 2msbk mfr cs 2f .5 .6
2 21 -33 10yr4/4 - sil 2msbk mfr cs if .5 .6
Ground
elev 3 33 -48 7.5yr7/4 - fs Osg 1111 cs - .5 .6
89.70 ft 4 48 -98 7.5yr7/4 -- s Osg m1 - - 7 8
Depth to
limiting
factor
> 98u
.�77VV Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
r
I� rL
Lot 3 (o
S u '/y n w /y 5 2 7 T a
Q�c� �c,
3.8 ( I c re
�
s iop�
ro d
U ;e
weN Tan K
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l = LI 0
Varit Top a�wgI If Cas,nc FIV = 1 aC ) . 0 o� ► ar•-� he1S
���� Top CST" 2273V
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 54
I � `
Mailing Address
Property Address Fe,G
-- - _---
(Verification required from Planning Department for new action)
i
City /State ► U fl 5 ®1.) W Parcel Identification Number (� .3 ° Ap C)
" LEGAL DESCRIPTION
Property Location '/4. %4, Sec. 67 T N -R__(LW, Town of
I �
subdivision M N DS I R., _ L4
�
Certified Survey Map # 0 14e Volume t6_ , Pa # r7e
:Warranty Deed # s7 4 Volume O Z Page # 3 g
3y
Spec house yes O no Lot lines identi.. yes O no
SYSTEM MAINTENANCE -
Impk9per use and, maintenance of your septic system could result in its premature failure :c handle wastes. Prope.
consists of pumping out the'septic tank every three years or sooner, if needed by a licensed pumper. What you put into the sys tor.;
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, 3 by the owner ^ by a
roaster lumber journeyman plumber, _
p , J ymanp be , restnctedplumber or a lrcensedpumper verz , mg that (1) the on si >tewaterdisposa': --,
is in proper operating condition and/or (2) after inspection and pumping (if necessa :,`, the septic tank". loss than 1/3 ft
Uwe, the undersigned have read the above requirements and agree to maintain the Y: age disposal system with the standards
set forth, herein, asset by the Department of Commerce and the Department of Natural Rsources, State of Wisconsin. Cerr'ication
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Of '
days of the three year exp io date.
-Z 13d� 8
TURF F
APP
r
LIC
ANT
j4'fINER CERTIFICATION
s i" . we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) - (are) the owner(s) of
the ropbi'ly abov b virtue of a warranty deed recorded in Register of Deeds Office.
7 13019
Z ATURF, tW M T
* * * * ** Any information that is mis- represented may result in the sanitary permit' revoked by the Zocuu.; Department.
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the tified survey map if reference is made in the warranty deed
/v `/ov/
VOL
5`74345
STATE BAR OF WISCONSIN FOIRM 2 — 1982 I�
WARRANTY DEED
DOCUMENT NO. It i
- - -= -- SECS w1 , _ �,r. c Fitt
cQ , wi
RICHARD 0 STOUT ���� �� ���'
MAR 0 5 1998
conveys and warrants to SAM E. MIT.LER , a s i nQ_1_ a p>rson . 8:00 A
Roolqfor of s4
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS —
the following described real estate in St. Croix County, 5 A !aE �
State of Wisconsin: ao )C
Lots 19, 20, 35, and 36, Plat of Badlands /Y�QSm►+f W! 5"yolk
Prairie, Town of Hudson, St. Croix County,
Wisconsin.
PARCEL IDENTIFICATION NUMBER
RAN8$FER
FEE
J
I
1
This is not homestead property.
(is) (is not)
Exception to warranties: easements, restrictions, rights -of -way and covenants
of record, if any.
Ij
Dated this 4th day of March A.D., 19 Q 8
(SEAL) (SEAL)
* Richard 0. Stout
(SEAL) (SEAL)
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix
County
authenticated this day of , 19 Personally came before me this 4th day of
March 19 9 R above named
Richard O_ Stout
I *
I
TITLE: MEMBER STATE BAR OF WISCONSIN ��R'SCI{'►�
(If not, ��` •., f�.,
f authorized by §706.06, Wis. Stars.) 1 pYARY me known to be the person who executed the foregoing
':�•
t iistrume and acknowledge the same.
it THIS INSTRUMENT WAS DRAFTED BY ?
if Janet P. Stout ;�`• F'UE3�- %
' O * Virginia R. Gartman
�I Hudson, Wi. 54016 ��w ;`�` ^ Notary Public, St. ('.rOlX County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date
i; necessary)
January 30, 2000
" Names of persons signing in an c should b t y p ed or p rinted below their signatures.
i; P 8 8 Y P Y Y YP natures. P 8
STATE BAR OF WISCONSIN
WARRANTY DEED WisCar�
Form No. 2 — 1982
%)'UN ST. CROI
WIS CONSIN.
4ATCH LINE -
- EE
E 543.
, G) 88
686.00
'
.42.2.;
42.24
T
39
CID
0
3.64 ACRES
ill 158,6'7 S0. FT
S 89'59'ot" E 693 30 .
205m
8
38
95.
2 4 0
bz v
C 4 .394 sz;. - r
to
37 36
11 69 ACRES M 3.73 A CRES 374 46
SO. FT. to 162,387 SO FT.
'tL
ELEVAPCf
FOR ,OT— in I
%
M (361
S84". 3*28" LINE
f33: E rb.
0
L
0
f
13\
-71
12
�'30 IRO I'A�: 27
'2 9
a 9
0
13
THL
"o ACPES 14 15
t 87 SQ. IT
THL o S89*59'13"E
3.00 ACRES
130,681 SO, FT.
THL 3 96.
3 0 0 ACRES
130.672 SO, F-
N 50-oc'/
' Wisconsin Department of Commerce J �5��% "` d AIi �/�, _ c ► ig (� (.�(r'5�v� fount
Safety and Buildings Division PRIVA AGE SYSTEM y
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar PermitNo.:
Personal information you provice may be used for secondary purposes [Privacy Law, $A5.04 (1)(m)). � 15951
Permit Holder's Name: ❑ Cit E] Village Town of: State Plan ID No.:
ILLER, SAM HUDSON
CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.:
020 - 1335 -60 -000
TANK INFORMATION ELEVATION DATA A9800
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St / Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outle
TANK TO P/ L WELL BLDG. Air I to, ROAD Dt Inlet
ir
Septic NA Dt B m
Dosing NA H er /Man.
Aeration NA ist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer De nd
Model Number GPM
TDH Lift Friction i System T Ft ea
Forcemain Length
Loss Dia. Fi Dist. well
SOIL ABSORPTION SYSTEM
SED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIMENSION
SETBACK
SYSTEM TO / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Dist tion Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia ength Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (In de code discrepancies, persons present, etc.)
LOCATION: HUD N 27.29.19,SW,NW 749 WILFRED RD — BADLANDS PR LOT 36
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
i
r
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County _
than 8 1/2 x 11 inches in size. - ,c/w/
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check iI revision to previous application
(Privacy Law, s. 15.04 (1) (m)I. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Pro erty Owner Name Property Location
(LL B-- 14 I V uA /4, T ,N,R /9 E (o0
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Numb
L) � II. TYPE F BUILDING: (check on E] State Owned ❑cit Nearest Road
[] v age OO � //��
Public or 2 Famil Dwellin - No. of bedrooms Town OF U S N V u —.v
Ill BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo d Z - r 33 S "
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 _ bfi 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 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
12XrSeepage Trench 22 ❑ In- Ground Pressure r 42 F1 Pit Privy
13 E] Seepage Pit t7 / N F(TYc fPc 2 �� X 7 43 E] Vault Privy
14 ❑ System -In -Fill a Qtr c, 1c lrJ e✓
VI. ABSORPTION SYSTEM INFORM TON:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17 F na l Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) q Elevation
0 - 15 70 - 741 » _ / ��Q Feet 9 8.0 Feet
VII. TANK in Capacit llos Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks I _
Septic Tank 000 WC ISIE ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 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 Signature: (N Stamps) MP /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
o a H 4 Iii 1-jr A, At
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater I D ate Issued Issuing Agen Stamps)
roved r Owner Given Initial ne Surcharge Fee) c� /
Adverse Determination / 6 0 OD / �f OD / !30 `8
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SRD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety 8 Ruildings Divi. ion, Owner, Plumber
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f w igconsin Department of Industry SOIL AND SITE EVALUATION
tabor and -Human Relations Page 1 of 3
Division of Safety and Buildings 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
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
A20 - 16
APPLICANT INFORMATION - Please print all information Reviewed by Date
Personal information you provide may be used for secondary purposes (P c,� Law, s. 15.04 (1) (m)).
Property Owner ! t ; Property Location
Richard Stout Govt. Lot SW 1 /4NW 1/4,S 2 7 T2 9 N.R 1 9 XH{(or) w
Property Owner's Mailing Address ` -`��� to # Block# Subd. Name or CSM#
1353 Awatukee Trail
� �. 3 Badlands Prairie
City State Zip Cod Phone Nu ep Nearest Road
( F� .; [], ity ❑ Village U Town
Hudson WI 5401 - ',( 7�S') 7 3 I State Hw y 12
U
New Construction Use: \ ci t be
[� Residential / Numb�l�of bedrooms, '3�4 4 Addition to existing building
❑ Replacement ❑ Public or commercial - Desc{ibe-
i'
Code derived daily flow 6 0 0 gpd Recommended design loading rate 7 bed, gpd/ft2_• $_trench, gpd/ft
Absorption area required 8 5 8 bed, ft 2 750 trench, ft 2 Maximum design loading rate • 7 bed, gpd/ft • 8 trench, gpd /ft
Recommended infiltration surface elevation(s) Q� , q 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 I Ej S ❑ u I Us ❑ U E� S❑ U ❑ S '-�] U ❑ S g U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench
1
2 12 -42 10 r4 4 none sl 1mabk mvfr cs if
Ground 3 42 -90 10 r4/6 none ms osg ml cs -- .7 .8
elev.
97. ft.
Depth to - - -- - -- — __ --
limiting
factor
9-0--in.
Remarks:
Boring #
1 0 -12 7.5 r2.5 1_ none L 2mabk mfr cs
2 2 12 - 36 1 0yr4/4 none sl 1 mabk mvfr cs if .4 5
3 36 -89 10yr 4/6 none ms osg ml cs -- .7 .8
Ground
98 . 5 ft.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
G✓�` a s� SG u d �' q lc- ^ 3' G °- t
Address Date CST Number
' SOIL DESCRIPTION REPORT
PROPERTYOWNER Richard Stout Page 1 of 3
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
3 1 0 -1 7.5yr2.5 1 none L 2mabk mfr Cs 2f .5 .6
2 13-40 10yr4/4 none S1 1mabk mvfr Cs if .4 .5
around 3 40-89 10yr4/ none ms osg ml Cs -- .7 .8
3lev.
9 9 . fin.
depth to
imiting
actor
8-9—in.
Remarks:
3oring #
1 0 -18 7.5yr2.5 1 none L 2mabk mfr Cs 2f .5 ;.6
4 2 18 -90 10 r4/6 none ms osq ml Cs if .7 -.8
around
,lev.
9 7 .5.9 n.
depth to
imiting
actor
9 0 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 0-24 7 . 5yr2.5 1 none L 2mabk mfr Cs 2f . 5 .6
5 2 24 -60 10 r3/4 none sil 2mabk mfi CS 1f .5 .6
3 60 -115 10yr4 6 no ms osg ml Cs -- .7. .8
Ground
alev.
9 6 . 1 9 ft.
Depth to
limiting
factor
t S in. Remarks:
3oring #
Ground
elev.
n.
Depth to
limiting
factor
in.
-- Remarks:
SBDW -8330 (R. 08/95)
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