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HomeMy WebLinkAbout020-1148-80-000 e O N y 00 4 ° ° w � � � I b N I I � I I � I I � I I � I c h I I h a o m z aa) z rn c z° LL C LL C O L O Q w E Q Cc � m Cl) I y M I z vi iri c c Z m 4) (D m M�U) am am I o I c t7 co O Z c c ,- > > d Z o c o c z E c E a� N N d 3 co co a) m °' N (? • a) O a C0 r C p Q z m z z H z �_ d m I ,• y c I ° N N cD a Q) o a �s a o v !mil O N_ y a) N d N O a CO N E G 0 o N N _> v 3 3 3 ° I o ° cn o z � I N O O O N � a. :3 _ N J U rn rn Q) 0) rn } N N O c9 O O w O O O w " E Q) ° :3 m _ 3 m ¢ in (D v _d ¢ > ?n co co Ln ° U) w 3 w E O C ° L N 7 N � O O O w a) E C m C tl d 0 0 1 V ao ~ N m v°, € c m c oi • � O M= J M - � • c4 a m .2 !, d m c d d c A L) CL !Oin O in C) r - AS BUILT SANITARY SYSTEM REPORT OWNER I G et cr ` � h u �� `ITOWNSHIP H u JSail SEC .3 . -R ff W ADDRESS /l� J�7ac�Sa - h / - -ST. CROIX COUNTY, WISCONSIN. SUBDIVISION Gaup it y $!1e V LOT I LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM N a t N th rr w BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: 00 • Slope at site: fT �G SEPTIC TANK: Manufacturer: W1 y c A Liquid Capacity: 1 0 doo °I FOTI 4-4 Number of rings on cover Tank manhole cover elevation. i Tank Inlet Elevation:. 1 0 3 0 Tank Outlet Elevation: 00 PUMP CHAMBER Manufacturer: �e _Number of gallons Number of gal. pump set for a cycle_ /-I- gallons; Total capacity of distribution lines /1//1- gallon: size of pump 4 _ head; gallon per minute _�(/ -�-�—_, horsepower /fl/ ibrand name of pump and model number / /1- . > Type of warning device /V HOLDING TANK: Manufacturer /v A Number of gallons / V/4- Elevation of manhole cover Al ` Type of warning device A/ IT SEEPAGE PIT SIZE; // /- Number of pits feet diameter feet liquid depth seepage pit inlet pipe - elevation / bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines , width t 2 , length t a tile depth 4 le A SEEPAGE TRENCH^ width /� length PERCOLATION RA E A/°t R^ AREA RtQUIRED C6 AREA AS BUILT G 0 INSPECTOR DATED PLUMBER ON JOB OC LICENSE N UMBER Al J2 � l a Lu DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LAAO,R & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7989 BUREAU OF PLUMBING MADISON, JAI 53707 El CONVENTIONAL ❑ALTERNATIVE State Plan LD. Number: Ilt axipnedl ❑ Holding Tank D In- Ground Pressure 1:1 Mound NAM PERMIT H LDER : ADDRESS OF PERMIT HOj.D INSPECTION DATE: BENCH MARK (Permanent re once point) DES BE IF DIFFERENT ROM PLAN: REF. PT. ELEV.: CST REF, PT. ELEV.. Name lumber: MP /MPRSW No.: Sanitary Permit Number: 9 z - 3 SEPTIC T K /HOLDING TANK: MANUFACT ER: r , LIQUID CAPACITY: TANK INLET ELEV.: TANK O TLET ELEV.: ARNING L LOCK IN COV i e�5 PROVIDED: PROVI L aLJ� 1 f GL �� l �'e Q�L ❑YES ONO O BEDDING: VENT DIA.: VENT MATL.: HIGH A NUMBER OF ROAD: ROPERTV WELL: [U.LSIN.: V ` T F SH 1 r ALARM: FEET FROM y LIN p ,r / AIR INIT' OYES NO ❑YES ONO NEAREST G ( l "' S DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. MP /SIPHON MANU WARNING LABEL LOCKING COVER PROVIDED: - PROVIDED: FACTU DYES ONO DYES ONO OYES ONO. GALLONS PER CYCLE: PUMP AN C NT L ERA NAL: UMBER F PROPERTY IWELL. BUILDING: VENT O H (DIFFERENCE BETWEEN FEET FR M LINE: AIR INLET: PUMP ON AND OFF) ❑YES �DNO NEARE SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of p!Av % ­ ' LENGTH: DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall ce until FORCE the soil is dry enough to continue.) MAIN C NVENTIONAL SYSTEM: WIDTH: LE N TH: NO. DISTR. PIP SP�tCIN(i 1 >I('PITS. LIQUID BED /TRENCH TRENCHES / MATERIAL: PIT DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTR I F DISTR. PIPE IST . PI A IAL' NO. DISTR. UMBE OF WELL: BUILDING: V NT TO FRE��FFII BELOW PIPE : ABOVE f.OVER: ELEV. INLET ELEV. END '} / PIPES LI r 1i AIR 1 ETw f L ( 0( `/ NEAREST 7 f MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems i make certain that it ., ON REVERSE SIDE. SHOW ELEVA- meets the criteri medium sand. TIONS MEASURED. ❑YES NO OIL COVER TEXTURE: PERMANENT MAAKE IS: OBSE TION WELLS DYES ONO YES ONO DEPTH OVER TRENCH /BED DEPTH OVER TR N H/ ED DEPTH OF TOPS SODDED. SEEDED: MULCHED. CENTER: EDGES. F ✓ DYES "' ONO DY ONO I OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO.OF L ERA SPACING GRAVEL UE H BELOW PIPE - : FILL DE TH A9 V CO R: BED /TRENCH TRENCHES: DIMENSIONS f MANIFOLD Pump MANIFOLD DISTR. PE MANI O MATERIAL O. DISTR DIST I DISTHIBUIION PIPE MATERIAL & MARKING ELEV. ELEV.. DIA. j ELEV.. PIPES DIA_ ": ELEVATION AND / DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED. ZOHRft C MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS /DYE NO DYES DNO COMMENTS: ERMANENT MA OBSERVATION W LS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: LAY L_)NO OYES ONO NEAREST 0 1 0WI&S, ClAt LrJ -IL,,Lk o4 La G , 7�7 Sketch System on Ret n in county file for audi� V Reverse Side. SIGNATURE /, I L DILHR SBD 6710 (R. 01/82) /!A/� DEPARTMENT OF APPLICATION SAFETY &BUILDINGS INDVSTRY,' FOR SANITARY DIVISION LABO AND' PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, seated and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. PrkdA rty Owner: I Mailing Address: L u noG rah 7 14 Al l pof sa Hudsoh W15 C Property Location: V pityrh -or Township: / County: l �' 6 %s 3tTZly N/R or !'1u� .J l S4h 014( Lot Number: Blk No.: Subdivision Name: / Nearest Road, Lake or Landmark: State Plan I.D. Number: O G 6 u n iLi (Gi t� V I �1a t' (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance ❑ Other (specify) Bedrooms: �1 or 2 Family * State Approval Required. 3 TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY flOd ( v HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit q C Q ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): rivate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Sign ;l re: MP /MPRSW No Phone Number: ID ©u 9 l a f 5 f " raft Plumber's Address: A Name of Designer: rw 1G a O( COUNTY /DEPARTMENT USE ONLY SignatuV6 of Issuin Ag t: Fee: C Date: APPROVED Sanitary Permit Number: XtJ ❑DISAPPROVED J / sS R s n for Disapprove : Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink- Owner, Goldenrod - Plumber DILHR -SBD -6398 (N.03/81) - S C3 Z e zi lb n Tit /\ , O CA _ a O � � \ '%% � r T Qom_ �� DEPARTMENT QF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS DIVISION HUMAN NDLATIONS PERCOLATION TESTS (115) _ 6 �MADI P.O. O 53 69 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP /PoR�}F@FPAttFTi'- LOT NO..BLK. NO.: SUBDIVISION NAME: N�' 1 / 4 5,1- 1 / 4 33 /T29 N /R /9 E (or #,lewse io ----- co srD 1/ /� COUNTY: BUYER'S NAME: MAILING ADDRESS: s ®/Y�L,1J ��VD �P6.1/ 7/S /�lic/�a /_sow/ /Y, 4� so USE DATES OBSERVATIONS MADE NO. BEDRMS.: ICOMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1 PERCOLATION TESTS: 54 Residence 7 n� /n IgNew ❑Replace I �21 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) � S DU ® S ❑U �S ❑U ❑ S u a S �J`U eamxe N'rld&;o e ". If Percolation Tests are NOT required DESIGN RATE: 9 If any portion of the tested area is in the ' / under s.H63.09(5)(b), indicate: Z 4ss 2 Floodplain, ind icate Fl elevation: /y PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) / o e B- /o ,s �Y ®yam 7 9d ¢� J�i� �8 f B- 96 /o. /, $ Al /VE 7 9 x 4z,° 641g !gn .6 B -3 9� /02.6 ivs,v 47' _Z4 OF B- + /9-4 l0 7, 2 Noil/E 7 /� o B- S 43 / 09, 4- n1,0 4vE /38 12 /2 jg r' /4 B- 114 06.3 4re&/ 7 114 2' ig J .a, PERCOLA f N TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD P ERIOD 3 PER INCH P- P- P- P -_ P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and r tical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the dire ion and percent of land slop . E X /S Ti by SYSTEM LEVATION Alo. e _ h- _ T Al r j I E { F i � r t , , .._ �� E --- --- _ - >� _ - _ IN E , I /Yu� ���Lac.orrv�v 4 4 ; SLPE r'Ec.v7 F } f E /♦ j 3 € j/ Xsr'i . /// , . I I, the undersigned, hereby certify that t soil tests reported on this form were made by me in accord with the r d es and ds specified in the Wisconsin Administrative Code, and that the data corded and the location of the tests are correct to the best of my knowle L D r9 NAME (print): TESTS WERE COMPLETED ON: ADDRESS: 10 CERTIFICATION NUMBER: IPHONE NUMBER (optional): CST SIGE: DISTRIBUTION: Oria ;nal a-i one copy to i -ocal Authority, Provei w z0wner and Soil Teter. ,1 46 A t - )) V1 5- c _ 'I a s n 4 0 CROIX COUNTY ZONING UEI'ARTMCN •�► AS BUILT SANITARY REPORT `b Owner P ter Address T / �t City /State 1 1�� S(�OUt4N Legal Description: Lot -ZO_ Block Subdivision/CSM # '/� sr V st, , Sec. 3 T , 1 r Q V * /It .�, 2N -R Town of _ /II,, C&On PIN / SEPTIC TANK —DOSE ChIA1VIBER -- HOLDING TANK INFORMATION: �' A fn Tank manufacturer Wigs t� y sf /Orto _/ Size STS / Pump manufacturer - Setback from: House Well P/L, 9f 1 Alarm location Model (HOLDING TANKS ONLY) Setbacks: Service Vent to fresh air intake Meter locate Water Line Alarm tion SOIL ABSORPTION SYSTEM: Type of system: n u�i Width -3 2 i Setback from: House _ f6, W /o 2 p/I, �n� Number of Trenches —""' -- Vent to fresh air intake a ELEVATIONS: Description of bencbmar Description of altemat benc Elevation Elevation Building Sewer . ST/HT Inlet ST Outlet. PC Inlet PC Bottom eader/Manifold °' Top of ST/PC Manhole Cover �- Distributio fines O / O ( ) Bottom o System ( ) () ( ) Final Grad O O ( ) Date of installation -�jp 2crmit number I State plan number � Plumber's si ature cr<. —` License number ,2 y sl Date Inspector Complete plot plan O� � � N N 7 J ^` n C i n rb th � � o Z4 F � 8 c► � { o OZ) 4 ^t � h o � R x 1 A b tr • Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division count y ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3ir'99904: Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. 6 Permit Holder's Name: ❑❑ Cit ❑❑� Village Town of: State Plan ID No.: METZLER, MATTHEW /LEFEBVRE, DEN SHU6SON CST BM Elev.; Insp. BM Elev.: I BM Description: Parcel TUB�-1148 —$0 -000 tv tJLIJ TANK INFORMATION EL VATION DATA A9800252 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ( Benchm rk 'p , f� /0. tov Dosing Aeratio Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. /(o-// 2 Aerati Dist. Pipe Sgt /0/ .o 7 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade O Manufacturer Defili and D �T37 1041 , - 7 Model N er GPM V aJ oG - TDH Friction S ste TDH Ft ass a Forcemain Length FDi. Dist. To Well SOIL ABS TION SYSTEM BED AjREN Width Length qq o. Of enches PIT No. Of Pits Inside Dia. Liquid epth DIMENSIONS �Ll o DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAC G Manufacturer: INFORMATION Type O / CHA ER Model er: System. p �tP Qp OR UNIT DISTRIBUTION SYSTEM Header/ Manifold I Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length_ Dia. Length 91 Dia. 7v� y Spacing SOIL COVER x Pressure Systems Only xx Mound Or At- ra y Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes El No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) �`4 �8' '3 Y C. G LOCATION: HUDSON 33.29.19.796,SE,SE 576 TWIN OAKS CIRCLE j) [ OWCI ,� Ve " V /ke�, CVOVf)ed '; 4C045 a+k f)v( � I4q g Plan revision required? ❑ Yes 'bd No Use other side for additional information. 1 2 - SBD -6710 (R.3/97) Date Inspector's Signature NNo. N VI SANITARY PERMIT APPLICATION 201 Washington Ave. scons P.O. Box 7969 Department of Commerce In accord with ILHR 83 .05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. St. Croix • See reverse side for instructions for completing this application State sanitary Permit Nu er II � m The information you provide may be used by other government agency programs E] Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. C R r,,� /) u � ��, State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location Matthew Metzler /Denise Lefebure SE1 /4 SE1/4,S 33 T 29 ,N,R1g )W Property Owner's Mailing Address Lot Number Block Number 576 Tt�7in Oaks Circle 10 City, State Zip Code Phone Number Subdivision Name or CSM Number Hudson WI 54016 ( ) Coun r - ,d II. TYPEOOBUIL DING: (check one) ❑ State Owned ° -city, Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town OF Hudson Twin Oaks Circl III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 3 1q . `9 1 C] Apartment/ Condo 0(40 +� /� _ �( R f 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 5. ❑ Repair of an _________ System____ _________TankOnly______________ Existing System ________ Existing 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 121ISeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade 50 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation '7 5 >Z (� �D d Feet /D 3, S' Feet au V11. TANK Cap t in gallo Total # of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name concrete st acted Stee glass Plastic App Tanks Tanks epticTank m Qp / G(, re s ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ I ❑ 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) Plu is Signatu e: No Stamps) /MPRSW No.: Business Phone Number: MP Paul Steiner 22.4.1 425 -5544 Plumber's Address (Street, City, State, Zip Code): N8230 945th St, River Falls, WI 54022 IX. COUNTY / DEPART USE O ❑ Disapproved S nary Permit F (Includes Groundwater Date I ssued Issuing Age Si `r t e (No Stamps) � e!. Approved f Owner Given Initial Surcharge Fee) /V J� y` /s Adverse Determination 4?j X. CONDITIONS OF APPROVAL/ REASONS FO DISAPPROVAL: SEID -6398 (R 11/96) 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: I. 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.), j, 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. 0 . t � N � 4 o � � C. N � / N W w J -- `�l v � V N1 3 Q � t„0 v C Q o u � v L a a a y Q U �7 Clo Ike t i -jo (� i w O C 4 w ti i- t V .,a " I ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the Aloft kex) A-d z /Pr residence located at: 1/4, - 1/4, Sec. 33 , T�N, R7W, Town of �t:�G�soK Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced utt, kiterurL Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity ra 9a �. Construction: Prefab Concrete Steel Other Manufacurer ( if known) : Age Tank ( if known) : 83 /� KV ( � fain cJ LS t- &).#; (Signature (Name) Please Print M -P 2.2 3 (Title) (License Number) (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — -- — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Qitl(.) StPrhee Signature MP /MPR•6 yJ7 5/88 V S 1 C - 105 SFIN WTANK MAINTEINANCE, AG RE' F' N1 K'NT St. Croix Count) r MAILING ADDRESS PROPFIZIN ADDRESS (location of wl)tic system) Please obtain from the Plammill, Dept. CITY/�STATE, svi PRON -AZIN LOCATION 1/4, Section %V TOWN U1 ST. CROIX COUNTY, NVI S11111DINIVAON LOT NUMBEAZ VOLUME 3, PAGE IT9, LOTNUMBLIZ.1-1—t lillptolwl use and 1111111irlultice ol"your septic system could result III its picinaltire failure to handle I'l oper m aintenance consists of ptitilpillp, out the septic tank every three year or sooner, i f needed by lI*(-(-II';Od septic tank pullipf-t. What you put into the system can affect the function of the septic tank as a Iff"'11111clit stage in the waste disposal system. m ay be eligible to receive % maxinitim of 60% of the cost St Croix Comity residents Ill ve a grant for . I I or replacement of a failing system, which was in operation prior to July 1, 1919. St. Croix County acceptcd this pro•ram in Aiijii- III agree .,t of 1980, %villi the 1equiretrient that owners of new syste s , r to keep their system properly maintained. I lie property owner agtves to submit to St. Croix Zoning a certification four, 6gnrd by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying III a t ( the on s11t' w;1stewatel disposal system is in proper Operating COIlditi011 and ("') alter inspection and plimplill" (if necessary), the scpfic tank is less than 1/3 full of sludge and scum U\Vv, the undersigned have read the above requirements and agree to fll;lllll;illl the I)Itv, scW-l (ii-po--ril system III accordance with the standards set forth, herein, as Net by the Wisconsin DNH Cef it f icat loll stating that yout septic has been maintained must be completed and fctiirned 10 the S1 Croix Comity Zoning Officer within 30 days of tile three ree yea expiration date SIGNI,:,l) ���� . DA Ili.: (;t, ( mix Coollty Aolling ()I h( (;ovi-milwill (c ntcr 1 101 ('milm-luirl Road Mid VJI '0016 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------- owner of property MA - Qk &%Z MILTZ-U- 0 -AC -4)15 c. E--a $ Vk Location of property � � 1/4 5 j 1/4 , Section 3 3 , T N -R f C W Township Mailing address 5 -r Lp zry o AKs c�a-c c �c� �nl u �y- �'f Of (0 Address of site !/ ,/ Subdivision name Coun +M'K -50 -50 "fiQ l',� Lot no. l� other homes on property? Yes _)_ No r..Cy4- Previous owner of property � ,4sp/l� k,¢"'u NA_SM Total size of property a D [ Act fS Total size of parcel Date parcel was created , Are all corners and lot lines identifiable? _Yes No Is this property being developed for (spec house) ? Yes _ K No Volume 6 7 and Page Number (Qka as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in th office of the County Register of Deeds as Document No. 15-6L -9 3 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the o fice of the County Register of Deeds as Document No. Sign ture of Ap 1 cast Co- Applicant � -(7 4 U t Date of Signature Date of Signature . -r STATE BAR OF WISCONSIN I'OnM 2 - 19xQ V WARRA DEED DOC.OMIENT NO. V,ll 1 ?67pAr[* REGIST�RI OFFICE ST. CROIX CO„ WI me -- - -__- ^rge —r— Mason - and_Xaren,_S_Mac�ra .s - husbazxL -- -- -_ Rei'd W Rt ;c*d - - - -- -- - -- - - - - -- OCT 0 2 1997 I- - - -- - -- _ - -- - - -- - com-cys and warants to Matthew R Metzler and -. Tl mi se jam - _ 9:30 A M _— Lef ebvre Join Tenants — Re gi s ter * of�fl G w u ds I THIS SPA,;E RESERVED FOR RECORDMG DATA �i --.- -- �! NAME AND nErURN AODREdS the fAlo%%ing descrit lcal estate In _. -c r,; v Cnc;3ay: J State of Wisconsin: ATTN: Mortgage Dept. First National Bank of River Fails PO Box 166 River Fails, WI 54022 020- 1148 -8 _ PA 1 ,CEL :DENT,FICAT!ON NUMBER Lot 10, ODuntryside Village in the Town of Hudsm, St. Croix county, Wisconsin. i AN , FER I i, This 13 tomestead property. Ea.eption to warranties: Easements, re strictions and rights - - way of record, if any. { i Dated this - 24th day of !) ) -September _ , .— --- - -..- _ -. AD, 19 - 93 ­ I� -- - - - - -- (SEAL) _ - -- -- -- - - - -- (SEAL) - - - -- - - Ge Mason _ J - - - -- _ (SEAL) - L� -- - - - -- (SEAL) - _ - Ka S. Mason AUTHENTICATION ACKNOWI.EDGMEN 'r �� Si) nattrc(5) Sift[ o r ltdOGCOft , TEXAS �� ss - _-.- Cou e iti llclu li:llC 1 d\;> r n - n�H -- .S n[) arr> .the aunt namrd t i t — - - - - -- - - - -- G F. _Mason and Kare S. - - i ; ' - - -._- - -- - _ - - -- -- _ less husband and w ife, - -- T;TL.E NINNIBER STAI E BAR OF WISCC :SIN (If authon_ed by § \V1s Slats) n;e r ur. to be ;he person __ \,h,, cxc,u the forcgulr.,, the ;a:c:c. THIS INSTRUMENT V,'A pRAFTED BY Attorney- Kr1:-st4Pi-- 9g1and - - -- -- s -: 4 �i Harris ti,l,nat i> n;a) q,, aut Ile Ili catcd or acs „o cicdr:\ Both arc 'n,t `1r rnnmawru (If not, :a„ r <pir,tu„n '11h } I4 orch 03. i001 __ :v',Pr�r•, AS BUILT SANITARY SYSTEM REPORT OWNER ' , �� a` `` h u /�' 4TOWNSHIP SEC .T, qV -RW ADDRESS / t� M ! L� Ae /5 eh / � ST. CROIX COUNTY, WISCONSIN. SUBDIVISION C IkJ, y $111 yl ' LOT r LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I di at N r h rr w BENCHMARK: (Permanent reference Point) Describe: �'W Gvrnp� ]�r4n��riyA� �oc� / ! G Elevation of vertical reference point: U Q r 0 Slope at site: SEPTIC TANK: Manufacturer: wlc'S(" Liquid Capacity: t 0 :v C al Number of rings on cover Tank manhole cover elevation: Tank Inlet Elevation:. U Tank Outlet Elevation: 0 Z,Y PUMP CHAMBER �L Manufacturer: �`' Number of gallons Number of gal. pump set for a cycle /t/ I-1' gallons; Total capacity of distribution lines ///I- gallon: size of pump /f" head; gallon per minute horsepower IV ;brand name of pump and model number Type of warning device / HOLDING TANK: Manufacturer A/ Number of gallons Elevation of manhole cower /V ; Type of warning device"' 41 SEEPAGE PIT SIZE; /V Number of pits /" feet diameter /✓� feet liquid depth seepage pit inlet pipe - elevation /4//F bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of line width length e C tile deptl , 4i , / I f I l A SEEPAGE TRENCH' width /" length PERCOLATION RA L �„ AREA RtQUIRED G D AREA AS BUILT G C � INSPECTOR DATED PLUMBER ON JOB 5 LICENSE N UMBER �' 3 Z- i r l DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ❑CONVENTIONAL ❑ALTERNATIVE I Stele Plan l.D. Number: E] Holding Tank El In-Ground Pressure ❑ Mound (1/ «epnW l NAM PERMIT H LDER: ADDRESS OF PERMIT HO�.D NSPECTION DATE I: /s /V, '7-x'3 2 BENCH MARK (Permanent re once point) DES BE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELE V. Name lumber: JMPIMPRSW No County: n.lwv Ptrmlt Number SEPTIC T K /HOLDING TANK: MANUFACT ER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LA LOCKIN COV J r 5 PROVIDED: PROVI 0 (✓� IG? 'YES ONO El BEDDING: VENT DIA.: VENT MATL: HIGH WA NUMBER OF ROAD: PROPERTY I WELL: BOIL ING: jVeNT FF{ESH \ ' ALARM: FEET FROM LIN f ` AIR IN j 1 4 DYES NO DYES ONO NEAREST CL �� fir h DOSING C AMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. MP /SIPHON MANUFACTUfj WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ❑NO ❑YES 1:1 NO I DYES ❑NO. GALLONS PER CYCLE: PUMPANDCONTROL OP ONAL: UMBER F PROPERTY WELL BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FR M LINE AIR INLET PUMP ON AND OFF) ❑Y NO N EARE SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of pl wing LENGTH J OIAME TER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall ce a until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: JLE TH. N F DISTR. PIP SP{�CING V 1 *PITS LIQUID BED /TRENCH J TRENqHES . / MATERIAL: DIMENSIONS C PIT GRAVEL DEPTH FILL DEPTH UISTH PI PF DISTR. PIPE ISTR. PIP MA tAL' NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: V NT TO FRE$$HH BELOW PIPE : ABOVE COVER. ELEV. INLF ELEV. ENO 2 PIPES L AIR I ET. / L • `I Z FEET FROM ` 6 r NEAREST 7 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems t make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑YES El NO meets the criteria.. r medium sand. A TIONS MEASURED. OIL COVER TEXTURE PERMANENT MARKERS: OBSE TIONWELLS El YES ONO YES 1:1 NO LCEN TH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOI �' SODDED SEEDED MULCHED TER: EDGES f ❑YES ' ❑NO ❑YES / ONO DYES — ]NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO.OF LA E SPACING GRAVEL DE BELOW PIPF ` FILL DEPTH ABOVE COVER. HA t BED /TRENCH TRENCHES / DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PE M MATERIAL fNODISTH DIST I DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION ANO ELEV. ELEV. DIA ELEV. IPES DI A. DISTRIBUTION INFORMATION HOLE SIIF HOLE SPACING DF41LLEQ OHHECIt Y MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED vLnNs CJYE ❑NO COV ❑YES ONO COMMENTS: ERMANENT ARK OBSERVATION W Ls: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE. C) L ` I 0Y I -]NO DYES CJ NO _ NEAREST �/ ® L-yt, a,�� Sketch System on L' fo Reverse Side. Re t n in county file for audi 7 � •�`,}\� SIGNAf UHF ' [ITLE r DI LHR SBD 6710 (R. 01/82) !✓ �` - l �I DEPARTMENT OF > APPLICATION SAFETY &BUILDINGS INDUSTRY FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PL13 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. Pro Owner: I Mailing Address: p J� offal un�G �'�h 7t, /HichBat56 N Hl lson W;.5 rG� C Property Location: V Gisy, Vilieele -or Township: r County: C 1 C P G 6' /4S 33,T 2-q N/ R I (or l`t u �S ©h ,J r Lot Number: Blk No.: Subdivision Name: r / Nearest Road, Lake or Landmark: State Plan I.D. Number: C G jj 10 U '7 (I _ (� Q V 1 �U /t — (If assigned) TYPE OF BUILDING Number of ❑ lic ❑ Variance ❑ Other (specify) Bedrooms: 2 Family * State Approval Required. 3 TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 1 600 HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit q ❑ Alternative (specify) ❑ Seepage Trench Water Suly: Owner's Name as Listed on Soil Test Report (If other than present owner): t�Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signs re: MP /MPRSW No.: Phone Number: ID oLA 1 &4 5 f "r, f �ccq oC /►1P -5' 3 (2�� — Z.3� Plumber's Address: Name of Designer: ,vc w r C, �� w� ^S COUNTY /DEPARTMENT USE ONLY Si t u of Issuin Ag t: Fee: / /' o Date: i APPROVED Sanitary Permit Number: T,4 4 q GL V J ❑ DISAPPROVED TS Fields& for Disapprove : Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink- Owner, Goldenrod - Plumber DILHR -SBD -6398 (N.03/81) a TIC raw Tn _ o 4 �~ F77 '' CIN llt4 - oc 4 cr. %Z, 7;m \. L V � --� _ � # , v1 --- ----_. < n �. � � �' `^ -- y � ( v�, Q � 1 � � � j � � � � e � I � ,� � .s � � �„ -.�. � C o. "- � �� � o �? 1 � s .,, � � � � j� � � � f f° r ��'' i ' f ..� "�'� `. � � � t_ -.� t .,� . -�.. O ,� �_ �,� �, � -...� ,� ^, � � o o ,�- �' �" \ G � y s � \ � s � �"' r C �"�.1 .�� "�> �, �` � � ,,� o. U 1 .� 7� , ���~ �� � .w,�� t ,}t, I `�, DEPARTMENT QF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY LABOR AND PERCOLATION TESTS (115) �� _ D DIVISION ISON WI 3707 HUMAN RELATIONS (1-163.090) & Chapter 145.045) LOCATION: SECTION: TOWN /Mt}N+B�P/tttT'i' LOT NO.: BLK. NO.: SUBDIVISION NAME: /VE '/ -54 33 /T29 N /R /9 E for /�7�Gloso/Y /a �(� , s/oea' 1/ //r COUNTY: BUYER'S NAME: MAILING ADDRESS: S T o/Y,4 ZZ111/,0ZW,,C 45So / /1� �c/ so,l/�✓ /s o/ USE DATES OBSERVATIONS MADE NO. BEDRMS.IOMMERCIAL DESCRIPTION: PRO FI ES I TI NS: A ON TESTS: Residence /)� iz ❑Replace /2//7 ; n IF RATING: S= Site suitable for system U= Site unsuitable for system f /f CONVENTIONAL: MOUND: IN- GR PRESSUR :SYSTEM -IN -FIL]HOLDING TANK: RECOMMENDED SYSTEM: (optional) ❑U ® $ ❑U �$ ❑U ❑ $ �U ❑ S 1Z I eeltlile N`r AL ". %2'X fD' If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5) (b), indicate: 6 ASS 2 7 I Floodplain, indicate Floodplain elevation: i� PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDRO K IF OBSERVED (SEE ABBRV. ON BACK.) B B- 2 96 /� /, 8 No NE B 3 ivy . Ns,vE / 9 2 AI B 4- 144 /d 7, 2 /1 oil/,E B- 1,3,� /G9 4- Ao NE B- 6 / /-}L 6.3 4fe Al 11r (, PERCOLA I N TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. P PERIOD R PER INCH P- P- P- P- P- d T P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and r elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the dire ion and percent of land slop SYSTEM LEVATION /Do- s -D,2ry rt/A / /ODO �L TE.�iUA TE' O -� 4d p r, A ' � e LE9END 8 ,�' IN Ze9 7 E'X 15' 7 4/ 4r41C S, L�l, Cam, TPAA/sF Mme' 1I CZ eE I, the undersigned, hereby certify that t soil tests reported on this form were made by me in accord with the r d as and ds specified in the Wisconsin Administrative Code, and that the data r corded and the location of the tests are correct to the best of my`knowle L d rQ NAME (print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION UMBER: PHONE NUMBER (optional): o2z ,SAS =sB La T/o