HomeMy WebLinkAbout020-1136-30-000 (2)a
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AS BUILT SANITARY SYSTEM REPORT
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PLAN VIEW
SHOI^I EVERYTHING I^IfTHfN 100 FEET OF SYSTEM
spz sof^4 ?1 or Pa4*
'- 1r)L<;' t-t.,'.i:
,
OR\G\N
TNDICA ARROI^]
Provide setback and elevation information on reverse of this form'
Provide 2 dimensions to center of septic tank manhole cover'
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4a P oF 922/-i/k 14 T cR4 ct?,/O o.o
BENCHHARK:
A RNATE BM:Vsr 7ay' s af Z fr/-7 tc 7+uts .+5
5 /ht,/t)2,u p/rt u
SEPTIC TANK / P
C2L D
ManufacLurer: N€La '
/ IIOLDING TANK INFORMATUI{P C}IAMBER(, /€Se R c€.
ION
/Lo d d(--e
lLrE E FS €€ .
---{,i
grrid Capacity 8oo
Setback from:WCIL> UO
Pump: Manufacturer /v+
Float seperation
.o/D- tj
House l>€t-rr - 72' Other
Model #
GaIlons/ cy cle:
S ize
Alarm Location
y:A O{^-,sorr, ABSoRprroN syETEM TRe<tc Ae-s
[.Iidth:5 7s Number of trenphes Z
Distance & Direction to nearest pfop. Iine:
setback from: werl , 9>' uouse 32 other
/,/, ll , /((, s nr; loo LR -- 7 ?, 37
EIJE\IATIONS
{:;'{if"r, ?s 6
PC inlet //- PC bottom --- Pump off
Header/Mani fold Bottom of syst em
7Q.5e ,TFe Dc.L
Existing Grade 75.o Fina1 grade ?5 0 /o rrs T?e<tcS
F t t's ft*>Cr
Building Sevrer
Z €xr'5 FrntC:-
ST outlet 7{,6 7
I I f i,t..;,'jrrl
DATE OF INSTALI.,ATION :
PLUMBER ON JOB:
i-),q -i- 1?
p€tu Coo #S€/fr c frt/r<
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.tl+'lt-qf
LICENSE NUMBER:
ts.54016
ROBENT ULBRIGHT
M|}UIJ ,T,qBTALLER A DESIGNER LIC. NO. 00663
HOITESITE SEPTIC PLUMBING CO 2 fryaK ,€r^tGS -
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t varE s EWAG E SYST E Miffii?',ffiU:J,*['" tNsPEcrtoN REPSRT
GENERAL INFORMATION (ATTACH TO PERMIT)
TANK INFORMATION
TYPE MAN U FACTU RE R CAPACITY
Septic
Dosing
Aeration
Holding
TAN K SETBACK INFORMATION
PUMP / SIPHON INFORMATION
SOIL ABSORPTION SYSTEM
ELEVATION DATA A9300233
rjrrtaaarlr
EJFnv il villase f rown of
!Dr rtrtrnrrrt fnrJnlrle (. EivE llrrrIIQ
Permit Holder's Name
WISTBMEEv-:--'Thip.-EM Elev-:"-"--
ou nty
anita
ftateT-Ff,ilV6:
ParcelTax No
fr1/r -11ac.-afr-rfafr_
TANK TO Ptl WE LL BLDG Vent to
Air lntake ROAD
Septic NA
Dosing NA
Aeration NA
Holding
STATION B5 HI F5 ELEV
Benchmark
Bldg.Sewer
5t / Ht lnlet
5t / Ht Outlet
Dt lnlet
Dt Bottom
Header / Man
Dist. Pipe
Bot. System
Final Grade
Manufacturer Demand
GPMModel Number
TDH Lift Friction
Loss
Svstem
HeacJ TDH Ft
Forcemain Length Dia.Drst. To Well
BED / TRENCH
DIMENSIONS
Wrdth Length No. Of Trenches PIT
DIMENSIONS
No Of Prts lnside Dia Liqurd Depth
SETBACK
INFORMATION
5Y5TEM TO PIL BLDG WE LL LAKE / STREAM LEACHING
CHAMBER
OR UNIT
ManuT5cturer
Type Of
System:
ModelNumber
DISTRIBUTION SYSTEM
Header / Manifold
Lenqth Dta
@
Length Dia Spacrng
x Hole Srze x Hole Spacing vent fo Air lntake
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over
Bed / Trench Center
Depth Over
Bed / Trench Edges
xx Depth Of
Topsorl
xx Seeded /Sodded
fl Yes D No
xx Mulched
IYes DNo
COMMENTS: (lnclude code discrepancies, persons present, etc-)
LOCATION: HUDSON 20.29.19. 673
Plan revision required? [ Yes D No
Use other side for additional information.
5BD-6710 (R 05/91)Date lnspector's Stgnature Cert No
TLHFI SANITARY PERMIT APPLICATION
ln accord with ILHR 83.05, Wis. Adm. Code
-Attach complete plans (to the county copy only) for the system, on paper not less than
81Ax 11 inches in size. 1
-See reverse side for instructions for completing this application.
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
COUNTY5T cf o/'x
application
STATE PLAN I.D. NUMBERa+
PROPERW OWNER' Til; " i''7 ^, S/rfir,?b u R
PROPERTY LOCATION .t .aiW;;' iili, i zo r 21,N, R I ? e o{O
PROPERW OWNER'S MAILING ADDRESSql ? lql/atr /4a^-r 4 LOT#o/BLOCK #
CITY, STATE
l1-u3fia,,t 2tr.ZIPCODE9lsG PHONE NUMBER
(38fe$3rO SUBDIVISION NAME OR CSM NUMBER-a i6iJ"77'D';F"'-:-', > nJ *22 r p^t
II. TYPE OF BUILDING:one)H u?sa^t NEARESTState Owned L VILLAGE:
f] prbti"*.,1 or 2 Fam. DwellingrS of bedrooms
lll. BUILDING USE: (lf building type is public, check all that apply)ozo^//36-3o
r E Aoucondo
z E Assemblv Halt
3 E Campground
+ lJ Church/School
s E Hotet/Motet
6
7
I
I
trtrtrtr
Medical Faci I ity/Nursing Home
Merchandise: Sales/Repairs
Mobile Home Park
Office/Factory
1 0
1
2
3
trtrtrtr
Outdoor Recreational Facil ity
RestauranUBar/Dining
Service Station/Car Wash
1
1
1 Other: Specity
IV. TYPE OF PERMIT:(Check only one in line A. Check line B if applicable)
z. Weplacement 3. E neptacement ofSystem Tank Only
A) 1.E New
System
4 Reconnection of
Existing System
5. E Repair of an
Existing System
B) fl n Sanitary Permit was previously issued. Permit #Date lssued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental
30 E Specify Type
Other
11
12
13
14
Bed 21 E Mouno
22 Z ln-Ground
Pressure
2- fPAuA,st
41
42
€
Holding Tank
Pit Privy
Vault Privy
E+c# {'X 76 rIItr
VI. ABSORPTION SYSTEM INFORMATION:72,F ?G.f,
2. ABSORP. AREA I E. NASONP. AREA I
ryy\"(sqft) l"W'7t'on)I
4. LOADING RATE
(Ggls/daylsq. ft.),y
5. PERC. RATE
(Min./inch),u4
le.
lz
SYSTEM ELEV.7. FINAL GRADE
ELEVATION7tr<, Feet/,5 Feet
VII. TANK
INFORMATION
CAPACITY
in gallons Total
Gallons
#ol
Tanks Manulacturer's Name Prefab Site
Con-
structed
Steel Fiber-
glass Plastic Exper.
App.New
T ks Tan
Septic Tank or Holdino Tank /(oo L eog5 ,(
L Q,ahgfe e)
VIII. RESPONSIBILITY STATETIENT
l, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print):
Po&er ?/blra^T (No Stamps)#/MPRSW No.:
33oz
Business Phone Number:
1?rS \jr6-&kS
Plumber's Address (Street, City, State, ZipCogS O' tuAlL "ftY ,fuoro,t Ost E S loz
IX. COUNW/DEPARTMENT USE ONLY I
Mo,.o
Disapproved
Owner Given lnitial
Adverse Detarmination
(lncludes Groundwater
Surcharge Fee)
ng
--------r
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:I
SBDS398 (formerly PlbST) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
Etr:
lL,
Plumber's
EE
INSTRUCTIONS
A sanitary pe,'mit is valid for two (2) yeais.
Your sanitary permit may be renewed belore the expitation date, and at the tir)9 ol renewal arry rrew
criteria in the Wiscons;n Administrative Code will be aptllicable.
All revisiorts to this perrnit musi be approveJ f,y ihe pei.mii ,5surig authcrity
Changes in ownersh;p Dr plumber requires a Saiitary ?ermrl 'I i'4n5fe; /fi-^'11'v,,31 Foim (SBD 6399 j io tJ,-:
subnritted 1o the (xr,rnt), prior to irrstallation. .
Oosrte se!\:rJ3 sy5l,-,rrs rl ri-,..;t be prop€r,y:rri,,rlj.r: j(.i. 'i;g. :"r'- 1lrl.'ir'rrr..i i:^ 1.'::. -'':c !,.'r' 's ','-1','
pumi)er whenever necessary, usually every 2 to 3;,93t'5.
ll you have questions concerning your onsite seyiage sysiem, contact your local code administrator ot the
State o, Wisconsin, Safety & Buildings Division, 608-266-38'15.
To be complete and accurate this sanitaiy permit application must include
Property owner's name and mailing address. Provide the legal desc(aption and pa/cel tax nr/mber(s) ot
where the system is to be installed.
Type ol building being served. Check only one and complete # ol bediooms il 1 or 2 Family Owell nq
Building use. ll building type is Public, check all appro[,riate boxes that apply
Type ot permit. Check cnly one in line A. Complete line B il permit is 1or tank replacernent, reconnection, or
rePair.
Type oI system. Check appr6priale box depending on systenr tvpe
Ab.rrot:cn systijm ir':torntatiar't. Pirvide all intrlyr.tr<'1 iequesl,::J i't l' 7
Ta,ii inIOi.inatir.)1,. Fiii in t:re oap3, ;iy Cl €vai,/ 1.lw Ji'J.':ll er:":i.,-- i::.t. .rt ttr .'. .ri g, ili:'; :1,.r'r i . ,;
ta.tkS ani i.ranulacturer'$ na,rre lit..ljcato prr,la-l r-r :,,,ie ij!,f i,,rj, r'- i':... ir.rr. .i:1 :;, al. (;ui: ': iti..:t,t dii
Septrc, pLinp/rsrf,hon and h(\ldirg l:rr:ks fo ii ': :.yrlir:r!1. Chrick i,(.i' ',i- , . rii!':r..) /'lr 6r i .r t':i,r" 'crL:iv.-r
experlilie:,tal pr3du,.i apprilval lrom DlLhFr
icspc'rSif'rtrry staterr':a^t !nstailirr,. itlufl^h-Ar ': {. iiiFr,;-'e",.: ,"", .. ';, ,-r'|e'l ,' rr', al.f\r')t.':a',. '',-l:t rr.;
MP, etc.), addreris and phgn(: nuft:t,a.r. Plumlrr:r r.',t.: ):.li ..r,i..i'. ii,'r ;, ,r,
Countyi Departmeni Use Only
County,'D€partm.:1t l-se On iy
1
2
4
5
6
.
Il
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tx
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COn,1'!'!ri l,lai:::..1'.(! -fi{!a fir-r:li'.rr I lOl srlalle' i! .i :' r1,ri1:! .,,r -,,r 1r'r ,.i-: ,r i.i i-r r.a '-t:-::. l-..
F:a,n\ r,:,j,.t i,rciUdt,':1,. r,..i;nt. .g i ,!o::"d.r (: !. ir i:-'i, . .irr+r' - , ',-, ..,i
!r,j,\!ir-il l.ij,ii$,J :rti-ri:. l:r'1k...:1 ..r,r,,rer irohilliqi. -1nkr.: O{ l!: :,..}J,r.j. ,,t'li', ,,:r -. -. .; i..
Sittsdi',i rt,-l lal,-:-, r)r,D1f,,i, .-,-,|.'.rT tark-q d;<i,ii,,',,,,'' i',.v-i .,.,, .t,-
i:f.)as' alrlij ll\e i-)cali+ri Olihe:]ui:,1 ;!.r' Ser,la.': -l ;-., ':r .: .. .. - i'1.../' '-, i-',"; "' i '
0) complr,te spe;r{icitt,ons !oi frur,.)s anC cdntrois; Juse i/oiur'rlj, rri.r,iJ )r r:,i:.. .rr,'ier, ?rio'.,a!r .is-:.. i,r,, i
perforrnance curve; pump model and pump manufacturer: O) iross seciion.Jl tre sor: abeorpticn sirste(r ii
required by the county; E) soil test data on a 115 form; and F) all sizrng intorm..lron.
G ROUN DWAT EB SUF.CHA RGT:
1983 Wis.ic.nsr Acl 410 rnclrrded the cr*ation oi 3urfhar(,i.: l{c:.;) lor,., 'ri!'i r-;;ir ,rl
regul3 ed piartices \ rhich aan "ffect
gicr!ndwatri .
The crorr;es aollectec thro(rSli ih€!!'surcnarges .,r. 'rie;j l!,: rrji)ii,(..::,- i,:j.lx'r("yal,
water co,rtaminaiion invesrigirlir)ns and establishn,enl uf -i;i.,. i!rd r
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Wsconsin Deparhrent of lndustry,
Labo.r and Human Relatiors
Division of Safety & BtildirBs
SOIL AND SITE EVALUATION REPORT
in accord with ILHR Bg.0S, Wis. Adm. Code
Pags I ol 5
Attach complete site plan on PaPor not less than 8 1t2 x 11 inches in size. Plan must inctude, but
not limited to vertical and horizontal reference point (BM), directiop a16y,of slope, scale or
dimensioned, north arrow, and location and distance to rrear'est road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
ROAD/ lteat ?D
COUNWsT, cRp,'{
PARCEL I.D.I
PROPERW OWNER:{on i trf4ru -sPfiiuHauR.
REVIEWED
PROPERWLOCATION
GOW. LOT i/tu 1t4 /uAu4,SZJ) T.Zq ,N,R I7 E(@
PROPERW OWNER':S MAILING ADDRESScl/l/4 //e Utezot RO LOT,(r/BLOCK f SUBD. NAME OR CSM Ilor//aut P,'20 c 2u4 AoDrr
CITY. STATEi."ui)u 0tts ZIP CODE54or4,PHONE NUMBER
l7/5t 3?O - 53 / o Ecfi LI-AGE OWN
UDSaxt
code derived diitl frow G Oo n6 1 Bu Pu Recommende{ design loading rate
Absup[on area required bed, flz 75o trendr, tt2 lvlaximum design loading rate
I I Addition to existing tuilding
,U..+ ,plain elevation, if applicable fr
7)?a-o4, a tAddational design / site or6ideralions U5€ Zo t G- .u4f ? o c.:
Recomrnended infi ltration s urface elevation (s )4o// 2€af Bo X
ft (as refened to site plan bendrmark)
Public or commercial describe[(1 nepncement il
-rt -yeo, gpd/n2 ' .l-rend, gpotP
Z-*,gqnz , ,L rcrfii,r'oo^,
parentmaterial SCS fg B uRk A.IRD 7- - p,.rreD
I I New ConsfuAion Use I Resirlential/ Number ol bedrmms 3 * 2e +t
s-ez Pg- =
forSuitableS
UnsuitableU
COtIVENIIOtIALMS DU
MOUNDES trU
IN.GROUND PRESSUREs uu AT.GRADEEs tru SYSTEM
S
INtr FILL
U U
l-tolDtNG
trS
SOIL DESCRIPTION REPORT
Boring #
Gromd
elal.
70 .r., O n
5
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Deph lo
limiting
fulgfi ^,t>/o g'
Remarks:7,r4t .t's .//d4ce+tr 7o E(/57/DA sfsE-y -
Hcrizon Depth
in.
Dominant Color
Munsell
MoUes
Qu. Sz. ConL Color
Texture Structure
Gr. Sz. Sh.Corsistence Bqrdny Roots GPD/ftz
Bed TIdl
4 o- ///o lt >/u */2,'m, 1/,nt't 4-r Lf NP ,t i,)
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elar.{(/q{,
Boring #
Gtound
Deph to
limiting
lactd //,pf
ft.
Remarks:
4 0-/)-1:o /r< '/,fr/2 ,*.,, "flt .tn vf/Q CS ?+/?5 C
B )- )L s yP r//s/),f, s ak 4.+ R e5'2
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Name:-Please Print
G 5S
Signature:Gf&^* ?4.lLt44f 0ale:C$T Number:
0i?tG|NAL
5r/
PBOPEBTY OWNER f!rl,<t hbo R SOIL DES( TION REPORT
PARCEL I.D.
/of 6 / /tzt//ot"t /?tPGF T
Boring #
P.g. 3 ot 3
GF];i2Roots
Ground
e|gt,.
74, o? n.
Deph to
limilirgW
Remarks:
Horizon Depth
in
Dominant Color
Munsell
MoUes
Qu. Sz. ConL Color Jexture Structtlre
Gr. Sz. th Corsistence Bqfiry
Bed TIdr
,? zr'4dacD
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f
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[t.
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lactor
Remarks:
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elev
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factor
Remarks
Boring #
6:;i:
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tr
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lactor
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PLAT. DR._{,J,UC
' -Le'rlrrr:This is g5f*q'Land Survey )(etz
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- Lot 64
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i :_.':- . a' ,of wilIo* Ridge 2nd Addition'a- .'
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Th e 'iot ., <I ?t' r -' .!t_rnensLonand deeds bf'coun
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should not be used as a su rvey.
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ST. CROIX. COUNTY ZONING OFFICE
CERTI FI CATI ON STATEMENT
FOR UTILTZATION OF AN EXISTING SEPTIC TANK
cert i fy that I have inspected theThis is
servlng
to
the fom 5P4//v hbuR
sept ic
res ldence
/7
tank present Iy
located at:
Town o f
have found the
appears to be
// lD r/ 4,
ffuo-fo^,
/UA L/ 4, s "". Zo ,
or length of tlme:
Upon lnspectlon, I certify that I
R w
Yes_No_( 1f Do, sk i p
next I ine )
a 1 lons mi nutes
Other
r2f "I
tank and baffres to be ln good condltlon, and it
functlonlng properly./77 3Last tlme servlced
DId f low back occur
Approximate volume
from absorptlon system?
Capaclty:
Constructlon: P
Manuf acurer ( i f
Age of Tank (if
re fab Concrete
known): k/E/(-g
k nown /73/
tee I
fi6w*( ?4ai
(Signature)
AP/? 5 33oa
(?"8€? r ?//bR/'ch f
( Name ) P lease Pr i nt
,14/RS S3o)
(TitIe)(License Number )q-)-7 3
( Date )
Fornr to beor Licensed
completed by
Disposer ( NR
llcensed plumber (s.145. 05,
113 Wisconsln Administrative
wlsconsln Statutes )
Code )
Plumber (applying for sanitary permlt) certif ication:
In acceptlng the above statement tegardlng exlsttng septlccondlition, I certify that the tank to the best of my knowledgeconform to the requirements of ILHR-83, tJis. Adlm. Code (except
inspection opening over outlet baffle ) .
tank
wi 11
for
Name
5/BB
Po6tr7- hrhrcicl,-#,/MPRS slo )lgnature
I
t s T c L05
SEPTIC TANK I{AINTENANCE AGREEHENTSt. Croix County
Iot{NER/BUY E'D T4^
(
2 fR+^t 5 Prtiat lfuuK
ADDRESS 0tal IRE NUI'TB
crTY/STAT At6 ZTP f o
PRoPERTY LocATroN: NtP L/a,MU L/4, sEcT:rot, b , *-L? n aJ{ w
TOWN OF 0 So^z St. Crolx County,t
SUBDIVISION 'taith,o ftt
St. Croix co. Zoning Office911 4th St.
Hudson, WI 54016
LOT NUHB ER Aq_T
Improper use and naintenance of your septic system couldresult in its prenature failure to handle wastei. propernaintenance consists of pumping out the septic tank every thleeyears or sooner, tf needed by a licensed septic tank purp"r-. Whatyou put int,o the system can af f ect the function of tfrl siptic t""i'as a treatmelt stage in the waste disposar system. iSt. Croix County residents may be eligiUfe to receive a grantfor a maximun of oot of the cost of re-placement of a faiii;;system, which $ras in operat,ion prior to .fufy L, l97g. St. Crolicounty accepted this program in August of 1980, with therequirement that owners of aII nehr. syitems agree to keep theirsystem properly maintained. '
. Tl;, R.roperty owner agrees to submit to st. Croix Zoning acerti f ication f orm , E igned . by the o(^rner and by a mater plumber ,journeyman plumber, restricted plumber or A Iicenlld- -furnper
verifying that ( 1 ) the on-site wastewater disposal system - ir lnproper operating condition and (2) after inspection and-pumping ( ifnecessarY ) , the septic tank is less than i/l f u].I of -slidge andscum.
r /lle, the undersigned have read the above requirenents andagree to maintain the prlvatei se$rage disposal system'ln accordancewith the standards seL forth, herein, as-set by the Wisconsin DNR.Certif ication stating that your septi.c has been maintained must becompleted and returned to the St. -Crolx Co. ZonLng Offlcer wtthln30 daye of lne three year expiratlon date.
SIGNED:
DATE:/
a
,I
"sfc-1oo
'This appllcatlon fgrl- l: to be conrplete-d in fulI and signed bythe owner ( s ) of the propertv
-
uetn! -o-evliop;.- -;y''i;ui'"1'ur"r""
wlll onlv resurt rn ierays_ i,r-ilr"'pIiilr rssuance. should thlsdevelopment be iirtended for ."=if"-rv owner/contract#, lspechouse), thenra second-ro,n strouio-iJ .lt"rn"d and conpreted whenthe property'rs sold-.and -"ut"itIJa'i" thls orflci r,ith theappropriate deed recording.
Owner of property {am 4 5 0,+/,uFRe,rt u
r,ocatiSn of ' pro perty Pu-L/4 o, ,/0,sectionU , r-Zf n-nJ_L w
Township
Haillng address
OlVilf /&J
/fuasct,,t k)/'5,t 7Or a
Addrese of slte {a4
SuMlvlsion name
Other homes on property?"= ,,\i no
/r_cy'
v
PrevLous o$rn€r of property ot,D R*rr/st-ay
Total. elze of pareel /;O l Aer-
Date pareal .hraa created
Are all eornrrs and rot llnes ldentlflabre? X Yes _ No
rs thls property belng deveroped f or ( spec house ) ?_yes {*o
:;'B::S""uPageNumberSi7''.'l"ordedw1ththeRegleter
. INCLUDE T{ITH THIS APPLICATION THE FOLLOWING:A I{ARRA}ITY DEED whlch includes a DocuHENT ruHBER, voLt Ir{E A}ID pAGBilu}IBER & TIIE SEAL oF THE REGTsTER oF DEEDS. rn additlor, acertified survey, lf avairauie, would be herpfur so as to avoidderays of the revi.e.wL.ng proceas. rf tha deed descriptionreferences to a certlfte& 3urr"y Map, the c""[riled survey Mapshall also be required.
ture of a Co-applicant
lt
PROPERTY OI{NER CERTITTCATION
r ( we ) cert Lf.'y t!.! ar r statemeirts on thls f orm are true to thebest of ny (our) knowredge that r (we) .am (are) the owner(s) ofthe property described r; thls lnfornatlon form, by vLrtue of a
; : : ffi " : I sI E $,. J""." ",qp f,, ?:9 "
:
=,
"i*' t"*t" T .,# li " = "
* I iown the proposed s lte f or the sewage di;;.;;i.- "i=t.* or r ( we )obtalned an easenent, to trn the a-bove descrlbea property, f orthe constructlon of. sald system, and the same his 'ueeri duryrecorded ln the of f lce of c6unty' negGter of deede aB Docunent
,
Slgna
Da e fsl at ure
lcant
Da of Slgna
dJr'//OA/ rt
a
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stATE BA? CP WISCONSIN IdOBX l-I6a rr'. *r. rr...ivrD ro. rrcoru,ro o r^
WAhIIANTY DEEO" 391713 r,'r [i8{i*"53?
Doed, mrdo bctrccn A. Rr Bbrtelsen aka nrc$IEf;S OrilCt
sr. ciotx co., wElrnel4 q. Eerlel sen and Vl.r.qh-la--4. ..8?.f._t_e_ig?.n,.---.-..-.--.--""'hubbaiid iittt ilffe. -'-"" ""for keaord rhi3, 9th
.;..II&6i-.!i.;..ii.iii+'r+ijf_. ?n!t_..tii..ie i s; q,ra 1 ir,auf;: G-h'
--- .iiii;uiia";iia.-ij,f;"e;" jiii;'c't;iia;tJ;"-"--
do, ot-j.r_AD. I gg4
ll:3O A m
- - - wil;;il#;.;';;; -.;;;;;];;;i;;; ;#:'J:
cony.ya to Grarto tha ,ollorirt dc.caib.d raal c.trta itr
Co$ty, St t ol Wi!(nD.i!i
5E;' C;dri"'---'-
130 S. Barstow St.
Eau Cl aire, .UL. =54701--- -
Trr P.EC Nor ..-.--
FEE
Lot 64, lflUou Ridge second Addltion to the toun of, Hudson
subjact to recorded oaserents and cotenants.
rrrir -. -- il.-ltg!-...-. -.. -. - hom..t .d prolcrty.(ir) (i. not)
Together eith rll aod linaul.r tha h.tlditah.[t .nd appurtln.ncaa th.Eunto b.longinS;
werr.nl! thrt iha titl. i! lpod, indefeaibl. in fee limple and fr.c.Dd clesr of sncumbrances €rccpt
.nd sill rvatrrnt and dafend th. !.m€.
Datcd thir .....2..l.q....---....-.....-.-..-..-........... d.y of Harch ........................., rr..91
...(sEAL).....(sEAL)
A. R. Bertelsen
(SEAL)A.Rl",t}.-n (SEAL)
. Vi,rginia A. Bertelsen
aurEtNttcatto!t ACENOWI.EDOUENI
Siaisturc (!)sT.l.TE OF WTSCONSTN )st. crolx I tt'
-..-..--.County. ,
Penonally c&n. befor. lrc thi. .-..?li-...--a.v ot
-..-.--Yil9ll..--..-..----.-..-...-.... 19..91-- rh. .boy. Dsm€dA. R. Bertelsen and Virginia A. Bertelsen
authentic.ted thit ..----.-d.y ol--..-..--.---.-..--.-----., 10--.
:l
TITLE: EMBER STATE BAB OF WISCONSIN
.X. 6 ol t.B,nr tifii.a in iny..n*il, 'h,rl,l F l!r-n i. r.rir[n n-l.r'!!r.[ -irn.lrrd
WARRAN-IY DEED sr,tTE BtE (l1' $ts(o\st!{FORII !,G l-lrrr t.,.-n.in r-,^t 0hrl Ca tne
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AS BUILT SANITARY SYSTEM ITEPORT
Ot^IN ER 1'OWN SHIP
ADDRESS ST. CROIX COUNTY, T{ISCONSIN.
SUBDIVISIO OT LOT SIZE
PLAN VIEW
Dlstances and dimenslons Eo meet requiremenEs of H63
SHOII EVERYTHING WITHIN lOO FEET OF SYSTEI'{
sEC.brAN-R 11 w
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In dic aE(N h rr rw
DrfLr
BENCHMARK: ( Permanent
Elevatlon of vertical
SEPTIC TANK: ManufacEurer:
Number of rlngs on cover :
Tank Inlet Elevatlon:
Describe:
_Slope aE site:
reference
reference
PoinE)
po inE :
'*hc Liquid CapaciEy:lJ0Ci
_Tank manholc cover elevatlon:
Tank Outlec ElevaElon:
U
PUMP CHAMBER
llanufacturer:Nunber
Number of ga1. pump seE for a cycle_
gallon: siz" "tdlsErtbuElon l1nesgallon per rninuEe ; horsepower ;brand name of pump
and model number
Type of warning devlce
HOLD ING TANK: I'{anuf ac Eurer Number of gallons
EIevaElon of manhole cover
Type of Lrarnlng devlce
SEEPAGE PIT SIZE;Nurnb e r o f pits_ feet diameEer_
feet11qu1ddePth-seePagePl.tinIetPj.Pe-e1evat1o'-
boctorc. of seepage plE el eva t i-o n f eet.
SEEPAGE BED SIZE: number of l j.nes _ wldth-length-tile depth
wid th length
AREA REQUIRED AREA AS
INSPECTOIT
PLUMBER ON JOB
LICENSE NUI"lBER
SEEPAGE T RENCH:
P ERCOLAT I 3N RAT E
5DAT ED ?
f,
a-
t
)r1
of gallons
gallons; To@
pumP- head;
U ILT
/
DEP IRTME\r OF INDUSTRY,
LABOR & HUMAN RELAT]ONS
i.o.'eox.;gou
MADISON, WI 53707
INSPECTION REPORT FOR
PRIVATE SEWAGE SYSTEMS
F cortvENTtoNAL E nlreRNATtvE
E HotOing Tanh rr Tl ln-Ground Pressure E Mound
SAFETY & BUILDINGS
DlVISION
BUREAU OF PLUMBING
State Plan l.O. Number
(lf assrgned)
NAME OF PERMIT HOLOER
Arnold Bertelsen
ADORESS OF PERMIT HOLDER
St. Croix Heights, Hudson, WI
INSPECTION DAIf,:fnt*t /i,l o
BENCH MAaK (permanent reterence pornt)D€SCRIBE lF otFFERENT rnoMpuatr Town of Hudson
Ridge IINW NW, Sec. 20, T29N-R19W, Lot 64, Willow
n(r. pr. eIev
l.t,
".r Pr ELEV
MP/MPRSW No
Richard Ho kins 1059
Co
St. Croix
Sanrtary Permrt Number
38480
SEPTIC TAN OLDING TANK
C P'&t NrtLMANUFACTURER coLOCKIN
PROVI
NO
LIOUID CAPACITY
I 1-{1J
TANK INLET ELEV
?oo.C7
TANK OUTLET ELEV
?tr.'(3
LA8
ED
YES
EEDDING
Eyes Dno
VENT DIA tl4
HNTFBE
IR INLET
VEN TL
LARM
E ves
FEET FROM
ER OF ROAD FI /
-'//
DOSING MBE
sor L ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing
or excavation. (lf soil can be rolled into a wire, construction shall cease until
the soil is dry enough to continue.)
MANUFACTURER BEODING
E ves E rvo
LIOUID CAPACITY PUMP MODEL PUMP/SIPHON MANUF ACTI.'8ER
EYes Druo
WARNING LABEL
PBOVIDED:
E ves E r.ro
LOCKING COVEB
PROVIDED:
GALLONS PER CYCLE:
(DIFFERENCE BETWEEN
PUMP ON AND OFF)
PUMP AND CONTROLS OPERATIONAL
Eves Eruo
NUMBER OF
FEET FROMNEAREST*
LLPROPE R TY
LI NE
8U I LDI NG VENT TO FRESH
AIR INLET
FORCE
MAIN
MATERIAL AND MARKINGL E NGTH IAMETER
ENTIONAL M:
ot IAL.L{2'l L7
Iwrotnl/aBEO/TRENCH
D!MENSIONS
NO OF
TFEl\, T..lL DISTR. PIPE
/-YtNc
It)
PIT
N D
PROPEBTYSit *"lL/l'"'il'ilwNUMBER OF
FEET FROMNEAREST+
t?i{
I
OUND SYSTEM:
PRESSUR IZED DISTR IBUTION SYSTEM :
ELEVATION
DISTRIBUTION
INFORMATION
COMMENTS:
7"5{
lo 7 '55 p\c&7 y'r
to 5
1 G7 o
Sketch System on
Fleverse Side.
7tr
l0 rl5
5.15
Mound site plowed perpendicular to slope
and furrows thrown upslope:
D ves Eruo
Check the tex
mound syst
meets the
of the fill material
make certain
or medium san
.-1 PROVIDE A DIAGRAM OF SYSTEM
/ orv REVERSE stDE. sHow ELEvA-
h+oNs MEAsuRED.
NETEXTURE
Eve Errro
SE OBSERVATION WELLS
tr ves E nro
H BEO EEDED ULCHFDIJ E PTH IL ED
CENTER
YES
LE NGTH FILL OEPTH AEOVE COVEBIOTHLATERAL SPACI TH BE
t1 D T
N
G D F
Eves ErvE ves fJ rrro
TR E NCH ES
OF
DEPTH OVEFI TR
EDGES
BED/TRENCH
DIMENSIONS
L
ELEV
PUMP
ELEV
DISTRIBUTION PIPE MATERIAL & MARKINGMANIFOLO
orA.
AN ERIALL
PIPE
DISTB. PIPE
ELEV..
f[STR. PIPE
DIA,:
LE SIZEH OLE SPACING ILLED CORRECTLY COVER IAL
Eruo
ERMANENT MAR WELL BUILDIN
DS AP
N E ves ''
D ves n r,ro
ALLRI
PLANS
NE
PROPERTY
LINE
EvEs fluo
NUMBER OF
FEET FROM
ta in
DrLHR SBD 6710 (R. O1/82)
county f ile for au
7o
7
Z. P/tS
,, 91
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Owner of
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Ma1ling,
Propercy .+
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/ E,afr/r.*/z
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Prevlous Owner of properEy €a"r,%&n,
ToraI Slze of parcel / 2 / 4.tes
Date Parcel- y.rs Creace<j U.!e
A.re ;:riI corners lclenclflabIe? X yes_No
Include wlclr rhls l.tt)pl-icati on one of che f ollowing:
.Cerrlfled Survcy Map
. Deed
.Land Cont,racEf or
.OEher Legal Docurnenr wtrlch descrlbes Ehe properEy
PROPERTY OWNER CE RTIF ICATION
0(Wr) cenif y that all sratsmenrs on rhi s form are true to the best of G (our)knowledge;that l3 (we) ry| (are) tho ow ner(s) of the property described in thisinformatio
ogister of Deods as Docunrent No
n form, by virtue of a warranty eed recordod in3r's-9ay'C.ounty R
the Off ice of tlre
; and that f (we)presontly own th€ proposed site for tho sewage di sposa I systom (.er+{we}+ave
d
SI(]NATU'{E F OWNER
o
SIGNATU F COOWNER (tF APPLTCABLE)
6 3
DAI E SIGN o DATE. 5 IGNLI)
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DEPARTN'ENT OF
IN DUSTffY,
LABOR AND
HUMAN.RELATTONS
APPLICATION
FOR SAN]TARY
PERM IT
(PLB 67)
ra I
SAFETY & BUILDINGS
DIVISION
P.O. BOX 7969
MAD|SON, Wt 53707
Attach plans for the rystem on paper not less thanS% x 11 inches in size. lnclude a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points dust be shown, All appropriate separating distances and physical characteristics as specified in chapter
H'&3, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. lf designed by a Master
Plumber, the date. signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Prooertv Owner:
h/tzta.il.,-lh ,{r/r,- )ts,2;r ronlhshipCounty:
IT NrR (or) W
P
%
Lot Number:6q Blk No.:
/r//r 4*e-TTu4"Subdivision fVIrnG NeaiesIRoaU ll-a-i<e oi Landmark :afl- 4 lrAState Plan l.D. Number:(lf assigned)
TYPE OF BUILDING
E Puutic* E Variance* E Otrrer (specify)*
E t or 2 Family *State Approval Required.
Number of
Bedroo v
TOTAL
GALLONS
NUMBER
OF TANKS
PREFAB
CONCRETE
POURED.IN
PLACE STEE L FIBERGLASS NEW
INSTALLATION
REPLACE.
MENT
OTHER(Specify)
SEPTIC TANK CAPACITY t (-
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFF LUENT DISPOSAL SYSTEM
PERCOLATION
(Minutes per inch):
*8nPROPOSED (Square feet) :
ABEA p..tttt* E Replacefl Alternative (specify
[s"tn.se Bed tr
E see
Seepage Pit
page Trench
E Experimentalment
)
Water Supply:
Aprtr.t, E Joint D pubtic
Owner's.Name as Listed on Soil Test Report (lf oth er than present owner):
5a hcL
l, the undersigned. hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name o{ Plumber:frol-rJ w Ao,til rhS
iilP/MPRSW No.:
/o 97
Phone Number
t2/fr 2y6 5?2,
-Plumber's a 7 1---V-
2Z/^l
Name of.Desioher:4-.2-,/al ,eZ-)
COUNW/DEPARTMENT USE ONLY
Sionature of lssuino
flonela"ff),frr,,/,*'toa Date
6-lb-F3 q
tr APPROVED
DISAPPROVED
Sanitarv Permit Number3r lra
Reason for Disapproval
Alternate course(s) of Action Available
Change of ownership, building us€ or plumber requires a Ssnitary 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
D! LHR€8D6398 (R.07/81 )
,b)
E-L,*/
DEPARTMENT OF
INDUgTRY,I ,
LABOh AND "iIUMAN RELAT'IONS
J'"'
'-""':-
REPORT ON SOIL BORIilIGS AND
PERCOLATTON TESTS (115)
(H63.09(1 ) & Chapter 145.045)
SAFETY & BUILDINGS
D IV ISION
P.O. BOX 7969
MADISON, WI 53707
zuaDtvtstoN NAME
kl,'//,tr,l ,4,'lC- -T
LK. NO.Itor No.:lBle,/ I
TOWN S H I P/ t\4{J.u}+{roA Ul++'/ ,4u J tou
LOCATION: ,/ ut Vofrrl/q o /TfrN/R/'d ro,
AMNR
rNo /t
ADDR
S*s
COUNTYqt Croix
USE DATES OBSERVA ONS MADE
PROFILE DESCRIPTIONS6-;- es
PTR_Co_IATION TESTS
6 -'l- fs
f<:.'/ haf
BResidence
NO. BEDFIIVIS.:3 COMMERCIAL DESCRIPTION
tt/n ,8 ru.* I Replace
R ECOMME DED SYSTEM:(optional)
O*t
CONVENTI ONAL
KS t]U
MOUND
8S trU
-FILLElvl-l
Utrs
D+
RATING: S= Site suitable for system U= Site unsuitable for system
IN
,s3 I*L
trS DU
lf Percolation Tests are NOT required
under s.H63.09(5) (b), indicate:
DESIGN RATE
,U/A
U
lf any portion of the tested area is in the
Floodplain, indicate Floodplain elevation
IN
eJ
OLD
K
UN ER-r$tcl+ffiHRELEVATIONOBSERVEDEST. HIGHEST
BORING
NUMBER
TOTAL/
DErrH-$+,
B-/
n),5'
@ lo/.L',t"/o*, u
IF OBSERVED (SEE ABBRV. ON BACK.}
1)_98/
LOR, TEXTUR , AND DEPTH
-f/+
WITH THICKNCHARACTER
TO BEDROC
/oo,6'/"/a,"t 2-7.s'2 t tB.L 7, 5'M
Io /_c+3,9 -Ss/B-3 7.€'@ /ctrs, / '/csya 7 ),9,
,{ouaB- L{
'7.{',
flTW 7?,1,
7 ?.i',//
h
+3,o _s7f,g'tlot "-B-r ?. d,w
B
PR F LE DESCR IPTIONS
PERCOLATION TESTS
P.
DEPTH 't+Jcr+EE
WATER IN HOLE
AFTER SWELLING
TEST TI DRO L.IN H S
INTERVAL-MIN P_E_
3 6 C 6
RATE IVINUTES
PER INCH
t/,3',,r/o z3
p-L Y, L,,t/o ^f 2 ,/q a y'z-2 //z-o1
p-3 y,/ ,Ea -r I 3 3 7
P-
P \
PLOT PLAN: Show tocations of percolation tesrs. soil borinEs snd the dimensions of suitabl€ soil areas. lndicate scale or distances. Oescribe what are t he hori
zontal and vertical elev6tion referenc€ points and show their location on th€ plot plan. Show tha Surface elevation at all borings and the direclion and percenl
of land slope.
SYSTEM ELEVATION /n(e* I
A B,A,
ilI.:l,.i'(s i
/.,)
_l
7/"- 'U t //ot-'?
,(e F.I r+t il"- 5,E.
/Lr
76,7
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/. oT /'/.- ({*u /7')
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l, the underrigned, hereby cenity that the soil tests reported on this form were mad€ by me in accord with the procedures and methods sp€cified in lhe Wisconsin
Administrative Cod., and that the data recorded and the location of th6lests are correct ro the best of my knowledge and belief.
NAIVIE (print S WERE COIJIPLETED ON
ER'TIFICATION NUMBER/{7
6-FS
PHONE NUMBER (optional)
3!eADDR
c(
Jr
TSI ATUR
fTISTRIBUTION: Original and one copy to Local Autlrority, Propcrty Owner anC Soil l-estt:r
DILHR.SBD-6395 (R. O2IB2I _ OVER _
a
TEST
NlMBEE
P-/
PFRIC)D 1 PF RIoD :i
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