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Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Count CROIX
INSPECTION REPORT
GENERAL INFORMATION (A TT " TO MIT) Sanita,(ys� r�p // o.:
Personal information you provice may be used for seconda pur w, s.15.04 (1)(m)].
Permit Holder's Name: � I ❑ _CDy ❑ _Viii e Town of: State Plan ID No.:
ACASSE, R.W. j�jJjO
CST BM Elev.: Insp. BM Elev.: BM Desc ipt is / Parcel dy N o.1314 - 10 - 000
--- _ ag, / S87
TANK INFORMATION ELEVATION DATA A9800414
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic .�t Benchmark
a
Dosing
Aeration Bldg. Sewer a'
Holding St /Ht Inlet x,79
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet
Air Intake `?', " X 3 7
Septic NA Dt Bottom
Dosing NA Header / Man. r
Aeration NA Dist. Pipe
Holding Bot. System $ `35
PUMP / SIPHON INFORMATION Final Grade
41- 1 r .., `• .. 4 , f 11
Manufacturer Demand
Model Number tpo J —/ GPM
TDH Lift Friction System TDH Ft
m ead
Forcemain Length Dia. 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
INFORMATION Type of i j U4j,8 CHAMBER Mo 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
Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 28.29.19,SW,NW 774 CROSBY DR — ST. CROIX EST LOT 1°
f �
4
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 1 A ,
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
Safety and Buildings Division
Vi scons i n SANITARY PERMIT APPLICATION 201 W. Washington Avenue
I n O Box 7302
Department of Commerce n 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 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3aoon
A
Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLI ATI N INF RMATI N - PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
A a-aa.
1/4 1/4,S X 8 T , N, R/ E (or)�
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
( ) S
. TYPE BUILDING: (check one) ❑ State Owned ❑ it( Nearest Road 7 7
❑ VII
Public 1 or 2 Family Dwelling - No. of bedrooms Town n OF of t+
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
o moo /s�Y - ta'
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. Q New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an
------ System ________System _____________ Tank Only______________ Existing System ________ ExlstiggSystern
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 KSeepage 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) I Elevation
ys !� • CL. 911 ` Feet d Feet
Capacit
VII. TANK in Ca allon
g Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons an Manufacturers Name Concrete Co Ste glass Plastic App
New E istin strutted
Tanks T nks
Septic Tank or Holding Tank 1� E. ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ I ❑ I ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sew ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) P/ PRSW No.: Business Phone Number:
S & ''
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Ground:L te Issued Issuing Agent Signature (No stamps)
)4Approved E] Owner Given Initial 16 Surcharge Fee)
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
PAf F G F
PUMP CHAMBER CROSS SECTIOIJ AND SPECIFICATIOKIS
VEUT CAP
4"C.I. VENT PIPE
WEATHERPROOF APPROVED LOCKINIG
> JUNICTIOAI BOX MANIHOLE COVER
- 25' FROM DOOR,
WINDOW OR FRESH I2 "MID.
AIR INTAKE I
GRADE I
I
co1JDUIT
18 "MINI. -
�� --
11�
IAILET PROVIDE I =_
AIRTIGHT SEAL
* I A
I
� I I
I I ALARM
6 I II
I 1
c *APPROVED i i oN
JOINTS WITH i
ELEV. FT. APPROVED PIPE
3' ONTO PUMP OFF
0 SOLID SOIL
CONICRETE CLOCK
RISER EXIT PERMITTED OIJLH IF TAUK MAUUFACTURE.R HAS SUCH APPROVAL-
SEPTIC E SPECIFICATIOUS
DOSE
TAUKS MAMUFACTURER: - e S'TG�� (DUMBER OF DOSES: – PER DAS
TANK SIZE: / GALLONS DOSE VOLUME
ALARM MAUUFACTURER: INCLUDIMG BACKFLOW:
GALLONS
MODEL IJUMgER: CAPACITIES: A- 3 juCHE5 OR 3S,?.S GALLOUS
SWITCH TYPE: eW
TT / 5 = INCHES OR GALLOU
PUMP MAMUFACTURER: C _ �'S IAICHES OR l y�� `sGALLOUS
MODEL DUMBER: D= �_ INCHES OR IlQ GALLONIS
SWITCH TYPE: * e NOTE: PUMP AMD ALARM ARE TO BE
MIMIMUM DISCHARGE RATE _ GPIA INSTALLED OW SEPARATE CIRCUITS
VERTICAL DIFFEKEAICE BETWEEU PUMP OFF AUD DISTRIBUTIOM PIPE., _1,e�_ FEET
I
+ MINIMUM NETWORK SUPPLY PRESSURE . , _ _
FEET
i + / �D FEET OF FORCE MAIN X , �D� F . %?
0o iL A1 FRICTI0 FAC70R.. v3 FEET
TOTAL D9 JAMIC. HEAD — FEET
I
IMTERNAL DIMEAISIONI: OF TA►JK: LENIGTH ;WIDTH ;LIQUID DEPTH 3e ?3
I
5 IGNIF f):
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Wiscon ^in De;;artment of Industry SOIL AND SITE EVALUATION REPORT, , .'_ Pag 3
Lalw, and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
-- sty jCr
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but o v ,
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or L I.D. # J J
dimensioned, north arrow, and location and distance to nearest road. e�
APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION R ?'#dtzC}Fl�OE
PROPERTY OWNER: PROPERTY LOCATION 91
John Rauchnot GOVT. LOT SW 1/4 NW 1 /4,S 28 T 29r-- -, 19 XR(or) W
PROPERTY OWNER':S MA!IING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
527 Co. Rd. #UU 1 na St. Croix Estates
CITY, STATE ZIP CODE PHONE NUMBER OCITY OVILLAGE MMWN NEAREST ROAD
Hudson, WI. 54016 (715) 386 -3052 Hudson I Crosby Dr.
[ )I New Construction Use [ x] Residential /Number of bedrooms 3 [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/0 - 8 trench, gpd/ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate . 7 bed, gpd/ft .8 trench, gpd/ft
Recommended infiltration surface elevation(s) 94.78 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, it applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem 13 S E3 U I L3 S O U IDS CI L ®S ❑ U O S ® U [3 S M
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Motdes Texture Structure Consistence Boundary Roots GPD /ft
..................
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Trt &
.................
..................
.................
..................
1
1 -8 10yr3 /2 none 1 2msbk mfr cs if .5 .6
2 - 17 10yr4 /4 none sicl lfsbk mfr gw if .2 .3
Ground 3 17 -82 7.5ry4/6 none S Osg ml na na .7 .8
elev.
97 ft.
Depth to
limiting
factor
+82"
Remarks:
Boring # 1 0 -9 10yr3 /3 none sl 2mgr mvfr gw if .5 .6
2 2 9 -80 7.5yr4/6 none Cos Osg ml na na .7 .8
Ground
96 e83 ft.
Depth to
limiting
factor
+80
Remarks:
CST Name:— Please Print Gary L. Steel Phone. 715- 246 -6200
re 200th. ve., New Ric ond, WI. 54017
Signature: Date: 11 -2 -95 cst m 02298
r
^ 9
PROPERTY OWNER John Rauchnot SOIL DESCRIPTION REPORT Page 2 of 3
PARCELI.D.# pending
Boring # Horizon I Depth i Dominant Color Mottles I Texture I Structure Consistence �Bourcily I Roots Bed Tft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
1 0 -9 10yr4 /3 none sl 2mgr mvfr gw if .5 .6
3!
2 9 -21 7.5yr4/4 none is Osg mvfr gw if .7 .8
Ground 3 21 -84 7.5yr4/6 none Co S Osg ml na na .7 .8
elev.
98 ft.
Depth to
limiting
factor
+8 4"
Remarks:
Boring #
1 0 -1J. 10yr2 /2 none 1 2msbk mfr gw if .5 .6
4 2 11 -23 10yr4 /4 none sicl 2msbk mfr gw if .4 .5
3 23 -35 10yr5 /4 none sil M na Cs na np .2
Ground
elev. 4 35 -84 7.5yr4/6 none co s Osg ml na na .7 .8
98 ft.
Depth to
limiting
factor
+84"
I
Remarks:
Boring #
1 0 -7 10yr2 /2 none 1 2msbk mfr gw if .5 .6
5 2 7 -26 10yr4 /4 none sicl lfsbk mfr gw if .2 .3
3 26 -80 7./5yr4/6 none Cos Osg ml na na .7 .8
Ground
elev.
96.8
Depth to
limiting
factor
+8 0"
Remarks:
Boring #
Ground
elev. I
ft.
Depth to
limiting
factor
Remarks:
can.na�nrct ns�2t I
STEEL'S SOIL SERVICE
Gary L. Steel John Rauchnot 1554 200th Ave.
CSTM2298 SWgNW4 S28- T29N -R19W New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246 -6200
lot #1 -St. croix Estates
t
N
1 " =40'
BM.= top of 1 steel pipe C el. 100'
Alt. BM.= top of steel fence post C el. 103.4'
, 3xt `pt o 2 Z�
• t 20.
2�
�x-
�a- 37a
Gary L. Steel
11 -2 -95
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer _�, ta: t A(2.4 i1 �. t^_ u -ti"t , Q,►
Mailing Address / 7. Z. o a A k L jn j I A L& rat � Ye � b
��
Property Address d ► `ej ' . ' — A,
(Verification requited from Planning Department for new construction)
City/State 1j tern -,, Parcel Identification Number Q.;2 0 — 3 / 4 1 ,
LEGAL DESCRIPTION
Property Location 6AQ_ 1 /,, IV IV 1 /,, Sec. Z-F T 4 4 N -R _9_W, Town of t-1t�r 5
Subdivision Lot #
Certified Survey Map # . Volume . Page #
Warranty Deed # �S'�l 9� Volume 1.Z2 5 . Page # 3 �9
Spec house ❑ yes qV no Lot lines identifiable A' yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site 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 the St. Croix County Zoning Office within 30
days of the three ear expiration date.
SIGNA OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
operty describ above, by virtue of a warranty deed recorded in Register of Deeds Office.
/2/
GNATURE APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
556199
DOCUMENT NO. STATE BAR OF WISCONSIN PORN 2 -1982
WARRANTY DEED ty
�1� TER'SC�� ��
Bridgebnd I on Conumey_a nrCsnta �� CN D W�
1 1 990
conveys and warrants to _ 10:45 R.
# Richs LaCasse db/a R W. LaCame Homo aL... `I! L�.A�1►
►,a ; :Stv d Mods
the following described real estate in St Croix County, State of Vocousin
Lot I St. Croix Estates in the Town ofHndaort, St. Croix County, Wisconsin.
k
z�
TRANkff n
This is not homestead property.
+ (it) OR
Exceptions to Warranties:
Dated this 241h day of Edm mrv. 19 97
�r
�l
(SEAL) ._ - (SEAL)
• s nt _ _
(SEAL) _. .(SEAL) ,
AUTHENTICATION ACKNOW LEDG M ENT
Signatures authenticated this dog of STATE OF MINNESOTA
19 Dakota County
Personally came before me. this _ 24jh—day of
*_ Eftafy. 1997 the above named
y
TITLE: MEMBER STATE BAR OF WISCONSIN Neal Krraaniak _
(if not.
authorized by 706.06. Wis. Stats.)
This instrument was drafted by _
to me known to be the person who cxc ulW the
P bdg and Dcvclooment Comp= foregoing instnunent and adamledgcd the same.
20 iccnic Tr. Suitc B. Lakevilk. MN 53044 � 11 1�
- (Signatures may be authenticated or acknowledged. Darla J_ uer
Both arc not necessary.)
Notary Public Dakoo _ _ County. MN
My commission experts Janrruy I, 2001).
tam .. tttluaY D31 .20=W DAKOTA COUNTY W C mrason Expres an
'Names of persons signing in any capacity should be typed or primsed below their signatures. S112 �m' 00.1 1
WARRANTY DEED STATE BAR OF WISCONSIN, FOR M NO. 2 -1982
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