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S'I'. CROIX COUNTY ZONING I)EI'A1U'MEN'I'
AS BUILT SANI'T'ARY REWORT
Owner /1_46!
Address _ 7>j
City /State 14 y m S a N w 1
Legal Description:
Lot Z_ Block -° Subdivision/CSM 11 t A L,� .I `� /[ rk f E
Sec. 2 7 , W c � N -R!1_0, Town of H L) bs PIN N t
SEPTIC TANK DOSE CLAMBER — HOLDING TANK INFORMATION:
Tank manufacturer U E Uhet. Size ST/PC t 0 Setback from: Douse Well 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: lf /L ?lZA"�8�. Width Len ,
, gth 2-S Number of Trenches
Setback from: House _Col Well 131 P2 '6D • Vent to fresh air intake 0 'a E'40 .
ELEVATIONS:
Description of benchmark V C P / Pr E t'. -, 9,1
Elevation pp
Description of alternate benchmark -To f- o r e /40 y t f D 0 _ 0 �f o S Elevation o
a0. I i
Building Sewer STM Inlet ' ST Outlet ' PC Inlet
PC Bottom Header/Manifold / S, 3 % q 3_ ` Top of ST/PC Manhole Cover
Distribution Lines (A) /IT 4
Bottom of System (Q 7•Q3 ' p� (�) ��,�3c� i ( )
Final Grade
Date of installation / / Permit number3l 7 Y State plan number
Plumbers si nature '
g �� �'" `�� �C License number S' 3400 Datc f� /5�tf
Inspector Conipldc pin( plan
. f
i
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.
— 13 t
PLAN VIEW
Z
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INDICATE NORTH ARROW
Wil
i
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county:
6,,afety ari ,d- Buildings Division
INSPECTION REPORT ST. CR nTV
GENERAL INFORMATION (ATTACH TO PERMIT) Sa ryPer
Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. Y5874
Pr Holde s fpig,
C. HUDSON llage Town of: St a Plan ID No.:
CST BM L EI EE evv - S AM Insp. BM Elev.: BM Description: Parcel Tax No.:
020 - 1335 -90 -000
TANK INFORMATION ELEVATION DATA A9800262
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �_� �... C °. A�11L °'at ��? Benchmark
D U V�
Aeration Bldg. Sewer
Holding St /F Inlet
TANk SETBACK INFORMATION St /ytf Outlet G
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header/ �6, 5 , -�V'
Aeration - y NA Dist. Pipe
Holding Bot. System I a�
PUMP/ SIPHON INFORMATION S ^ L 9 Z, :> Final Grade
>T
Manufacturer Demand E `'
Model Number GPM
TDH Lift Friction Syestem TDH Ft
Forcemain Length Dia. — J ad
Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O Model Number:
System: OR UNIT
DIS TRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia, I Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
[ Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed / Trench Center Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 27.29.19,SW,NW 773 WILFRED RD— BADLANDS PRAIRIE LOT 39
o P61 0 Dg r V' 1 - , ,r Ivt ��+�°' r� � �F � °I J t '� 'r 1 (`Y i"I " .!1 t ',Alz t.._ ,ti ' .� Q y �7 . � . �.C:: v�11Y ° ✓ Y�< r 'n
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
Safety and Buildings Division
NVisconsin SANITARY PERMIT APPLICATION 201 B Washington Avenue x 7302
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 8112 x 11 inches in size. CS - (/d% ? e
• See reverse side for instructions for completing this application State Sanitary Perm Number
Personal information you provide may be used for secondary purposes heck if rl oM3 /to previouSr a lication
[Privacy Law, s. 15.04 (1) (m)]. S tate Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Pro erty Owner N me Property Location
IV 14 /a, S 27 T , N, R E
Pr � �Owner's ling dress Lot Number Block Number
City State Zip Code Phone Number Subdivision Na a or CSM Nu er
R.
( >
(. Y B ILDING: (check one) E] Vil State Owned �t� Nearest Road
age II II '
Public 1 or 2 Family Dwelling - No_ of bedrooms own OF
III. BUILDI USE: (If building type is public, check all that apply) arcel Tax Number(s)
1 ❑ Apartment/Condo o Zo
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,�/Ne 2 ❑ Replacement 3. E] Replacementof 4 ❑ Reconnection of 5. ❑ Repair of an
_�_'m________ S ystem_ _ ___________Tank Only___________ - __ Exist' QSystem ________ ExistingSyst
B) nitary Permit was previously issued. Permit Number Date Issued �3
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 E] Seepage Bed 21 El Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage TrenchS JI JVOEK -22 [] In-Ground Pressure 42 [] Pit Privy
13 Seepage Pit (�/ ���- �,� �� 7 1 )4�.f Z! 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
t ^ Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Q i Elevati
40 3 s' 7 'Z• . �" 7 2 • Feet 0 1 S Feet
Capacit
VII. TANK in Ca gallo Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App
New Exist in structed
Tanks Tanks
e Holding Tank ❑ El 1:1 11 1:1 mp Tank /Siphon Chamb ❑ ❑ 1 ❑ T ❑ ❑
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: (No Stamps) MP /MPRSW No..: Business Phone Number: WPALI
Plumber's Address (Stre���t State, Zip Code)-
6 p r Nr f 1.
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issuing Agent Signature (No Stamps)
Surcharge Fee) l i e
pproved ❑Owner Given Initial ��-� G� yl
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
r
Safety and Buildings Division
� ,■ SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
6onsin 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 S f C
than 8 1/2 x 11 inches in size. V - 6 I )C
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes p 3
Check if rev . t o wds a plication
[Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Property Location
L/ 2 kA /a �I /a, S ;� ") T a , N, R /9 E (o W
Pro erty Owner's Mailing Address Lot Number Block Number
M
� 3
City State Zip Code Phone Number Subdivision Name or CSM N ber ' ,*
40 015 to t S o/ (.3 ) z 17� 1lD"NfD S A I fLI JE S )a
II. TYPE BUILDING: (check one) ❑ State Owned it M st Road
Public 1 or 2 Family Dwelling - No. of bedroom ° Io w a n OF L) �O a f2 41a III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax
Number(s)
1 ❑ Apartment/ 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 box on line A. Check box on line B, if applicable)
A) 1 New 2 _ E] Replacement 3. ❑ Replacement of 4: E] Reconnection of 5. E] Repair of an
_System ________ System_____ ________T
______ l�r______________ Existing System ---- -- ________ E xistin g 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
1;M Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. '7. Final Grade
/ Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
7
' 57 0 7 5 Cj 5' 0 9 7 Feet Q 8 O Feet
Capacity
VII. TANK in Ca gallo Total # Of r Prefab. Site Fiber- plastic Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App.
New Existing structed
Tanks Tanks
ep is Tank} 1 El 1:1 1:1 1:1 1:1 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) Plumbe4 s ignature: Stamp MP /MPRSW No.: Business Phone Number:
t Icy C V 01 f! ,L f'�5 -d3 � 7i 3 �L� e 19 'k,
Plumber's Address (Street, City, State, Zip Code): /
IX. COUNTY/ DEPARTMENT USE ON
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Ag Pt Signature (No Stamps)
X App roved Surcharge Fee) ❑Owner Given Initial 1 $Q �Oa � g6
Adverse Determination V
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 IRA 1/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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Wisconsin Department of Industry SOIL AND SITE EVALUATION
_abor end Human Relations Page 1 of 3
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
0.)_0 -/070 - 0 /0
APPLICANT INFORMATION - Please print Rev' l Date
Personal information you provide may be used for secondary urpo$as (Privacy Law, s 444 (m)). fik
Property Owner Property Location
Richard Stout }r� Ga L'qt 1/4NH7 1/4,S T
SW 2 7 2 9 N.R 1 9 (or) W
Property Owner's Mailing Address Q `. Lot #, Bloc k# Subd. Name or CSM#
1 352 Awatukee Trail �,FR �O�Y 39 Badlands Prairie
City State Zip Code Phone NumbetO 6 ❑ OY ❑Village 91 Town Nearest Road
Hudson WI P 4016 , -7`5,) a,00%731 Hudson jState Hwy 12
(X New Construction Use: ® Residential / Number oT edroo`ms 3-4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 6 0 0 gpd Recommended design loading rate • 7 bed, gpd/ft — 8 trench, gpd/ft
Absorption area required R .9 R _ bed, ft2 7-)o trench, ft 2 Maximum design loading rate . 7 bed, gpd/ff 8 trench, gpd/ft
Recommended infiltration surface elevation(s) 94- 1 0 n (as referred to site plan benchmark)
Additional design /site considerations
Parent material C,1 fir- i a 1 da{10 S if Flood plain elevation, if applicable ft
S = Suitable forsystem Conventional Mound In Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system [R S El 1�1 ❑ U [� S ❑ U ( S ❑ U ❑ S Nu El S [X U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /n2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
1 1 0 -1 7.5 r2.5 1 none L 2mabk mfr cs 2m .5 - .6
2 12-42 10yr3/4 none sl 2mbk mvfr cs if .5 -.6
Ground 3 42-S 0 10yr4/ none ms osg ml cs -- .7 .8
elev.
98.91
Depth to
limiting
factor
_-c g in.
Remarks:
Boring #
1 0 -1 7.. -5 r2.5 1 none L 2mabk mfr cs 2m .5 .6
2 12-Z2 10yr3/4 none sl 2mbk mvfr cs if .5 '..6
2 --
3 42-E9 10yr4/ none ms osg ml cs -- .7 - .8
Ground Ar~ �Q r r'1/ f" $ C
98 . llev.
n.
9 5V
Depth to
limiting
factor
$c- in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
1,4 ;? B G�����d1 A l 2 '7 2 27 #f 0
r
Richard Stout SOIL DESCRIPTION REPORT P age 1 of 3
' ?ROPERTY OWNER g
PARCEL I.D.#
3oring # Horizon Depth Dominant Color Mottles Structure 2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
3 1 0-12 7.5yr2.5 1 none L 2mabk mfr cs 2m .5 .6
2 112-44 10vrVA none sl 2mbk mvf
around 3 1 44- 1 11 10 r4 none ms os
aev. — —
98.0 ft.
epth to 41 f3W
miting
actor
9 1 in.
Remarks:
3oring #
1 0 -1 7.5 r2.5 1 none L
4 2 12-44 10yr3/4 none sl 2mbk mvfr cs if .5 -.6
3 44-90 1 0vr4/6 none M�, M1
around
alev.
9 7 .2kft.
)epth to
imiting
9 �tor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Boring #
1 0-1 7,5yr2,5_/1 none L 2mahk mfr 2m
5 2 12 -44 10yr3/ none sl 2mbk mvfr cs if .5 .6
3 44 -90 10Y 4/6 none ms osq ml cs
Ground
elev.
9 9 . 2 O ft. -'F' IV 7 6 U / . o eil
Depth to
iimiting
factor
_ U— ' n. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW -8330 (R. 08/95)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer A/ /LZ E�
Mailing Address 8 <0 r
Property Address 7? W L C E d A0
(Verification required from Planning Department for new construction)
City /State yD S - 0 N Parcel Identification Number
LEGAL DESCRIPTION
Property Location 5 %4, 1 /,, Sec. Z' , T y N -R I C Town of 1 y 4 D SON
,ubdivision Lot # 39
Certified Survey Map # S�otO 14- Volume Co , Page #
Warranty Deed # S$ d/ O Volume 3 2 7 , Page # w y f
Spec house J Z yes ❑ no Lot lines identifiable Ixyes ❑ no
SYSTEM MAINTENANCE
Imp*er 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 licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection, and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards..
set forth, herein, as set by - the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to St. Croix County Zoning Office within 30
days of the three year expiration date.
1� 7
GNATURE Or APPLICANT DATE
Q_"ER CERTIFICATION
S, tia
• :'r4 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 ropbM ;detcribed above, by virtue of a warranty deed recorded in Register of Deeds Office.
,
NATURE OF' hi: .,�T 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
;ATE GAR OF WISCONSIN FORM 2 — 19s2
T • y• ` WARRANff DEED
,t•��{{ .n
-- - - -- - - - -. -- -- - - -- - - - - - -- - - - -- - - -- - -- a (( RKV her
—RIO HAR O._ -0 .�_ST41L'_ -- __.__. -- JUN 0 2 1998
- - - -- — - - -- - - - - -- ----- - - - - -- - 8:30 A
conveys and warrants to
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following de A:rihed real estate in - - -- t �__.Cro ice. - - - -- Count): S 0 9,ht je5 /0
State of Wisconsin: PO 80y `f(
Lots 17, 27, 28, 39 and 40, Plat of Badlands / ,0sow ZW0 ,, 4 4 0 /L
Prairie, Town of Hudson, St. Croix County,
Wisconsin.
PARCEL IDENTIFICATION NUMBER
� S3 0�FER
FEE
This— ._1_nS1t __ homestead property
(is) (is not)
Exceptiontow•arranties: easements restrictions, rights -of -way and covenants
of record, if any.
Dated this day Qt�1 _^ day of — MaLy , A.D., 19
Richard 0_..__St_o (SEAL) _ (SEAL)
----,-- (SEAL) — (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. C roix County
authenticated this day of - -__. 19_ Personally came before me this -_2A_ day o
Ma y 19 -n —, the above named
Richard 0 —Stout
TITLE: MEMBER STATE BAR OF WISCONSIIN __ —_ --
(tf not, — - -- - - - -- \%�
authorized by §706.06, `Nis. Stats.) �#;.•' � to me krowm to be the person who executed the foregoing
4 : '• ! run lit and acknowledge th
THIS INSTRUMENT WAS DRAFTED BY t,o�Y1� �' y
Janet P. Stout ,' '""
— k353 Awatuke — Tz - - - - - -; F'j;L�e`' c- virgtnta R. Gartman
Huai son,_ Wi . 54016 _ _�/► r�' N,v2ry NiNic, --- St . Cr - - -- Gaunty, Wis.
(�J 71 w�) 6. atnh, m�atrd or ..._brumledgeti�84a} .zry �, sue Ms amain: ton is permanent. (If not, state expiration date:
reces s,.r ; J ..�•..... -- _- .____._ January _30 -- 21100, . ;� __ -.)
• tip,;,., :.( } .;. -..n: <; {n m� �r. an? iape.in thudd M :, µd or Enn!rd 4'ow rhea ;i�ma: urn
STATF. BAR OF lot << Wrscx,s.n Leo ft, Co. t-C.
R'a tiRA] FY l�E i_ D Form No. 2 — 1 Mtw'3,i K. Wa
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