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HomeMy WebLinkAbout020-1129-00-000 Wisconsin Department of CommerLe PRIVATE SEWAGE SYSTEM county: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538770 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. parcel Tax No. Permit Holder's Name: City Village X Township Hudson, Town of 020- 1129 -00 -000 Whitemarsh Brian K. & Ma Section/Town /Range /Map No CST BM Elev: Insp. BM Elev: BM Desc ion: /' 17.29.19.605 TANK INFORMATION ELEVATION DATA TYPE MAN FA TURR CAPACITY STATION BS HI FS ELEV. Septic 1 , - Benchmark Do>s I � f ' Alt. BM Aeration Bldg. ewer / Iry — Holding ► SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION I TANK TO P/L WELL BLDG. Vent to Air Intake ROAD le Septic ��/ -t-1 D T �r 1 ade / n. �� 1 D i9 _ D >35� 5t , r S' y Dist. Pi y Aerat -- Holding ;ot. Syst T �rJ �� 04 1 3 , Final Gr de . PUMP /SIPHON INFORMATION t Manufacturer 2 Demand GPM St Cover � R1' 4 Z v `( '7 i(, [� 'LPi✓ 1 'f Model Number TDH Lift Friction ystem Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM PIT DIMENSIONS No. Of Pits Insi Liquid Depth Ir BEDITRENCH Width I Length P No. Of Trenches DIMENSIONS SETBACK SYSTEM TO P/ BLDG WE LAKE /STREAM CHAMBER OR M INFORMATION T � e Of System: I Moer: I Gib � ' DI BUTTON SYSTEM Hole Size x Hole S x a ing ent t Air Intake 1 Header/ nifold n tion r _ I ��� 5l Pipe(s) Spacing Length Dia Length Dia SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Mulch xx De th of xx Seeded /Sodded Depth Over Bed/Trench Edges Topsoil Y No `:.] Yes No Bed/Trench Center - -" : l COMMENTS: (Include code Ins ection #1 2'S 20 1 1 Inspection #2: discrepencies, persons present, etc.) p Location: 424 Park Lane Hudson, WWII 54016 (NW 1/1/,4, NLE' 1/4 17 T29N R19W)) Park View Estates I Lot 24 Parcel No: 17.29.19.605 1.) Alt BM Description = 1 fl7 ""' "" '�":" m t -Olit. 2.) Bldg sewer length = >_ - amount of cover = Plan revision _ Yes Use other side for tional� formation. o L-- —� Date Cert No q Insepctor's Signature SBD -6710 (R.3/97) , - RECEIMED 4- gov a and Buildings Division f III i a)". ington.Ave., P.O. Box 7162 iR7 AY 3 , ff w . son, Wl 53707-7162 Ify p Number (to be I illed in by Co.) la 573 tion Number Sail in a ,., Ka td*ncc , vitjj a. Comm. 93.21(2). Wis. Adm. Code, submission of this form to the appro In Unit L.1 requiral prior to obtaining a sanitary partnit. Notet Application forms for state-0 Project AddmsB (if emnt this I Twiling w1dress) submitted to Ile Dqmrtnwnt (if COIamOrce. Personal information you provide may be use 1 0, dary 1pft — plane Print All InforM Parcel _�r_el j.��Ovjn_j r Mailing Ad Be Location Zip Code phoneNumber Y41. Secti on-17— Lot H or 2 Family Dwelling -- Number of E f 10 �odidluj (0"k city oillcowncil-Doscribe Use_ Townof r It: (Check Sply one box an line A. Complete line B if 111 only [I other Modification to Exilld 1 9 System (explain) A ' El New System cement System - 1 - reatment/Holding Tank Replacement List Previous Pen PernA Renewal El Permit Revision 171 Change of Plumber 0 PermitTransfer to New (Check aft that 30011Y) , 0111c i s t i P low L other Elpretrcatm ice (explain)------- Dc Flow Qpd) Design Soil Application ftatqgpdsi� A _# Manufacturer Gallons Gallons Units fiaks V , j. Respon 1hul Sl 1, the undersigned, astanke s ihilit y for ["situation of 4PR9 Number Business Phone Number P1 er's to Nan e (Print) (street, C ta Me artmentUs permit Fee t ignat Di 6V Date Ifflued Ipproved 612 owner Given Reason _for Denial likessons far Disapproval cl)spersal cell must all be serviceo maintained as per management pro�ided by plumber. 'L-0 twi 2. All setback *uirernonf# b maintained 4"�7 All a MIX as per to rim 77 PLOT PLAN PROJECT Brian Whitemarsh ADDRESS 424 Park Lane Hudson Wi 54016 1/4 1 /4S 17 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5/22/11 BEDROOM 4 CONVENTIONAL )00( IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 44 BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 93.0/92.5 4' below qrade Well is to meet all Scale is 1" = 40' setbacks required by unless otherwise Vent WDNR noted >6 „ Quick4 Standard -W of Cover Leaching Chamber Plans Designed Using with 20.0 ft2 of Area Conventional Powts 12 „ 5.8ft ^2 /pair of end caps Manual Version 2.0 4' Long 34" Grade at System Elevation Vx , valve is to be Well 15' mstalle ' Weeks 261 possi septic tank Existing 4 Bedroom / , 35' House 25 `B -1 5' B.M.* 20' 2 -3' x 88' cells 30 with >3' spacing 10' B -3 >25% Slope 5' Drainfield location 50' 5% Slope 15' B- Vents Park Lane 75' Cd�� 75' o k Property L; Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715- 246 -4516 Date: 5/22/11 Owner: Brian Wh' emarsh Locationl,A AM14 S17 T29 N,R19W Lot 24 424 Park Lane Hudson System type: In- ground absorbtion system(conventional) Manuals Used: In- ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4 -5. Maintanance and Contingency Plan 6. Filter Specification heet Signature License numb PLOT PLAN PROJECT Brian Whitemarsh ADDRESS 424 Park Lane Hudson Wi 54016 1/4 1 /4S 17 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5/22/11 BEDROOM 4 CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 44 BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 93.0/92.5 4' below grade Well is to meet all Scale is 1" = 40' setbacks required by unless otherwise VjGrade WDNR noted >6 „ uick4 Standard -W of Cover eaching Chamber Plans Designed Using ith 20.0 ft2 of Area Conventional Powts 8ft ^2 /pair of end caps Manual Version 2.0 4' Lon at System Elevation 34 A valve is to be Well 1 5 , stall ine Weeks 261 possi septic tank Existing 4 Bedroom i' 0, House �B -1 5' 35 25 T 10' B.M.* 20' 2 -3' x 88' cells IF 30' with >3 spacing 10' B -3 >25% Slope 5' Drainfield location 50' 5% Slop B- 15' Vents 75' Park Lane 75' Property Line Cross Section of Quick 4 Standard -W Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard -W Leaching Chamber with 20.0 ft2 of Area per Chamber 5.8ft ^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 96.5' L34 Grade Vent 4' Septic Tank L 5' 4' Long Grade at System Elevation 34 Grade at System Elevation 34" Spacing 5' 2 -3' x 88' Cells Observation tubeNent Same on other end Located at ends of Cell A 22 chambers per cell B System elevations: A__93.0 B 92.5 I x Wisconsin Department of Comme +� SOIL VALUATION RE P R IV. Page of 3 Division of Safety and Buildings in accord I VMV6mm 8 Wis. Adm. Code jr C ry . Attach complete site plan on pape of 14%1 8 /2 Me i . Plan must include, but not limited to: vertical a horizontal ection and Parcel I.D. percent slope, scale or dimensions, rth arfoNn�, distance to nearest road. Please p p� ormation. R ew Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). C� 5 Z ; Property Owner Property Location QA/ 4 X y Govt. Lot N fF- 1/40/4 S/7 T 2!Z N R E Property Owner's Mailing Address / Lot # Block # Subd. Name or CSM# 02 ft L• CL �IJZJ o7� /� l �7` ��jv„ City State Zip Code Phone Number C] city /OY91ge Town Nearest Road -��4 1 ❑ New Construction U esidential /Number of bedrooms Code derived design flow rate GPD Replacement P ublic or nmeraal - Describe: -- - - -- - -- — - - -- - -- Parent material Flood Plain elevation if applicable ft. an recornmend System Type G "�'b /�lf 7 System Elevation M Boring # Boring pit Ground surface elev. b ' ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 1 a - V 1,4,,- s v Z- y 3 b �- D.�- Le , v 44 �L Boring # ❑ Boring & �j� Pit Ground surface elev. ' � ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 ff#2 rJ f • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please PnnO re CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 5 �;; � ��—� --1 715- 246 -4516 Soil Test Plot Plan Project Name Brian Whitemarsh Shaun B' Address 424 Park Lane Hudson Wi 54016 CS #226900 Lot 24 Subdivision Parkview Estates 1st. Date 5 /11 1/4. 17 T 29 N /R W Township Hudson r - J Boring 0 Well PL Property Line County ST. CROIX IL BM or VRP Assume Elevation 1.00 ft. Bottom of siding System Elevation 93.0/92.5' *HRPSame as Benchmark Scale is 1" = 40' unless otherwise noted Well 15' Existing 4 1 Bedroom 35' House 25' 30' B -1 5' T B.M.* 20' 30' 10' B -3 >25% Slope 95' —No. Drainfield location 50' 5% Slop 5' B -2 Park Lane 75 ' 75' Property Line W fr p O O O UJ 0 U- LL LL Z!200(D Z W H O +— � z � Cn LL Ep Ep LU 00 n- LL U LL - ti N I Y O a y00 Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the end. of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the syn'tem. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan Option #1. If system fails, determine cause of failure, use alternate area and install new s sted replacement area. Option #2 Install system at a lower elevation, by removing chambers, removing bioniat, stall new system. Option #3. No adequate area is suitable for replacement area, and system elevation cannont be lowered. Install holding tank as last resort. 3. Replace any other failing components as needed. Plumber: Shaun Bird 715- 246 -4516 St. Croix County Zoning 715- 386 -4680 Pumper Tom Mondor 715- 246 -5148 Shaun Bird #226900 ST. CROIX COUNTY SEPTIC TANK MA]NTBNANCE AGREEMINT AND OWNERSHIP CERTIFICATION FORM OwnerBuya t Property .Add ws — (V ,m zeq=od from pismmg & Zoamng Depart that new mom.) Car /gam Parcel Idemtifieetioa Numbe - fin? OL Prop .-ty Loc, roan V4 , Sec. , T �N R/� e W, Town of � SubdrdAm _ .� /� j P.[ r� S �,� zL f�i ,!/►'`� ' Lot # o� CertMed Su rvey Map # "' __ Volume Page # ty Wanan Deed # � I M q Volume � _ _ V Page # ' ' Spec hams no Lot lines idanti usbl yerl ye"�� �� no SYS7t'EM N mAM`* : MAM ADD OWNER CER�`nt?Cs'!'fiON pee me and Maintenance of yota septic Mum could redolt in its PranMwt Marc to ba idle motes. P20M noaiataxame a msisfs of pumping out the septic molt every tltaeee yam or sooner, ifneeded, by a liowmd paamp What 3'°11 PW hm floc synftm can affect ft ft=AM of ire septic u* as a acatmanrt stage in be Waste disposal system. Owaar moaftemmoe nespostssbiiifila are specified in fCamao. 83.52(2) and in Mapter 12 - St Croix C MAY 9amft°zy onn omCe. T,a p Mpedy ownea agwea to submit to St. Croix County Plw ag & Zoning Departo>nnt a cardficstion goon uped by the ova- and by e � = a sW pbm*w. jomaymm ph=ber. acted ph unber or a licensed pumper v g flat (1) the M wastewater die pond system is inp Haar operattag condition and/or (2) after inspection and pumping (ifDa`0assaay). the septic tank less titan 1/3:0 ill of dodge: rfwe, the nn knigead have reed the above requ nmanix and qp -to maim the padvato wwWdivpow' stan&ues on f wft best, as eat by do Degla stmt of Comwom and yips Department of Nattud Reroaroes, $tuft of Wisoom hL C.erwicatioa a !sting that your septic system has been mmantemed unmet be completed and rawned to to St. Crok County PUMM 8t ZDMMS D%w mat whbin 30 days of the three yeas dam date. Lhwe mr fy that all st abetmmss.an this Soren are true to the beat of my/ow kwwledg& Dare atdare the ownaa(s) of flue px0petty dssn ibed above, by virtue of a wauanty decd reoorded = Reglater of DeedS Office. Nuntber of bedroo I O A IC (S) DATE * **A,ny iai'br ration flat is miesqursented may result in the sanitary permit b ft re+ ke d by the Pluming &.Zoning Departaitt- • «'` lade with t WS apps a recorded wwwly deed ftm the Reppi w of Deeds Office and a copy of the cwtified survey map if reftn=e is m ade in the weo arty deed. ow tt8�o5) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I LL have inspected the septic tank presently serving the Zri`av wn�� ! -/ residence located at: Section T N, R Al W, Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. mast time serviced: 3A a 0 1/ 1)j-d flow back occur from absorption system? Yes _ No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other t4anufacturer: (If known) :'age of T (If known).: (Si n ture) (Name) Please print _ (Title) (License Number) --------------- Date Form to be completed by licensed plumber (s.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 c ify that the tank to the best of my knowledge will conform to th th of ILHR 83, Wis. Adm. Code (except for. inspection In 0 g over outlet baffle). Name Signature -c-/ i P /MPRS - INTHE N . V I . .� E •VN U�dpl "t' D �S OWN. � 3Y: Y'A � lSfloN N �fl-ILL R(V R < ,�. --- ��6 :2Q i2 125:23 23 :0 O'0 IN _ .. .;5�T10ld1T T23t+1 rc19,Yi � � C 1 ARCS a -f 3 38 ads.. 2 3i ,CRFS Ar ti _� s 278.0 5„F 12 ; 27 160. DOCUMENT No. II �� T.I. SPACE RESERVED FOR RECORDING DATA (� ;t WARRANTY DEED IE i t STATE BAR OF WISCONSIN FORM 2 -- 1982 ! ii VOL 9 rh t �y If /� n �3 - -' REGISTER'S 0FGIe," I - -_ - -- ST. CROIX CO., W1 and ..E3ar.ba -r -a-- 3 •-- E1 -1 1st••--- • - -• -- i __...Ylu band- ..an -d wife -- -- - - ---- ..- - - -- -- _ - i t s Recd for Record I I - - - - - -- ° - -- - - - - -- ------------- - - - - -- j JUN 191992 II - -.. .. - ...................... conveys and warrants to _.- ._ inTYliterrca.rsYl_ -anr3_ -Mar_ � 11 :30 A. 1iA --- -- -an -- -- --- ----- - -- --- -- -- --- - - ---- 0 -- ...- • -..__. .. .... _...._ ............... - - -.......... = - -- - -erof s .. . - -- Resist Deed _. -- ........................ _ . . RETURN�TO °-_ - .._... ._... .... ................ . . .....- _..._ - - -... _._..... _. ._- ___- _- __- .._._. . the following described real estate in ...... S_t__- Cr _Qix. ..................connty, State of Wisconsin: Tax Parcel No: -------- -------- ---------- ---- Il L•ot u 4, ParkV ew Estates First Addition in the ` QWn of Hudson, St. Croix County, Wisconsin. �� II FEE I � This ......... 1.S .............. homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights -of -way of record, if any. Dated this --- ---- �.V day of .... June .............. °° ................................. 1 19..9. ��d�,e��......... ........ ...(SEAL•) .��` ra r E _... ........(SEAL) Max E. Ellis * UU - -- • --- -- ----------- -- --- •--- - •- --- Baba -• �•.- - i l i s (Sr ^.AL) . ......... ... .__...._.. .._ _... .(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signatures) ... max-- �� ---- E -1_i s............................ STATE OF WISCONSIN ) Barbara J. Ellis ss. County. authenticated this -((Q day of-_.._-__ Ji;6ne-- - - -••• 19.__.92 Personally came before me this ---------------- day of ii iL�1 M-S -- ...-----•------ ---- -- --•- 19 .... --- the above named ----------- (. KriIs n CJg land II ---- --- -t........... ............... ......... ..................... -----------..._.... ............................... l TITLE: MEMBER STA'i-F, BAR OF WISCONSIN ________________________________________ _________________________ __ ___• it (If not. -•-------•--•------•--•------------------------ authorized by § 706.06, Wis. State.) to me known to be the person ------------ who executed the II en;•egoing instrument and acknowledge the saine. I� I THIS INSTRUMENT WAS DRAF7E CI BY i) Kristina Oaland ------------- -•--- - -- --- -------- .......... .... _......... --... ....... .- ----- -- --- -- - - -- - ----- -------- --- -- - - ---• ------------ y at La ,-., * Il i) At. crnc ------------ --- - -- -- - ---------- •-------- - - - - -- ------- ---- - - - - -- - - -- Notary rublic .... ... .County, Wis. I (Signsitures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration sre not necessary.) date: .__- --- ------------------ •--.... .... 19 ......... II 'Names of Uenio rigni.w fn any cnnaciiy iii—xii.i bi, cylx or t•I'inic.i boio.e ii—ii. aiunuiu,c 11 I; la WARRANTY X)Er:D STATE DAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. FOAM No. R— 19R2. - Milwaukee. Wisconsin . g. 0 ® 0 CD @ � § i § ƒ o / o CD i / E § F \ % \ g e ` § ƒ /\ k k k o B% ° ° t ° 6 ■ E E ® 0 8 i ® ■ 2' � � 2 « ¥ > i % r RL � m 5 m CO CL r: 2 C ou CD a \ S S I, . � � ® \ \ g � wi ! / _§ q R n r a � 00 0 z 0 0 0 is ■ . � 7 0000 " o / ) § § k 2 \ \ M J 2 7 « w 0 � } \ § 7 \ � \ { / § . m = @ CD ] i w / CL & e . E . j B i k z m ■ . \ CL + R Z ■ 2 d E § 2 k r z © R z , . % k w ' ; C) cc k FD. z % a i § $ _77 � � § a x b A c E � 7 . � k < \ ? ° % « � §E � �/ Parcel #: 020- 1129 - 00-000 12/05/2005 03:10 PM PAGE IOF1 Alt. Parcel #: 17.29.19.605 020 - TOWN OF HUDSON Current X: CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner BRIAN K & MARY L WHITEMARSH O - WHITEMARSH, BRIAN K & MARY L 424 PARK LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): " = Primary Type Dist # Description * 424 PARK LA SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.380 Plat: 2274 -PARK VIEW ESTATES 1ST ADD SEC 17 T29N R19W PARK VIEW ESTATES 1ST Block/Condo Bldg: LOT 24 ADD. LOT 24 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 17- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 956/30 07/23/1997 773/448 07/23/1997 722/339 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.380 86,500 216,000 302,500 NO 05 Totals for 2005: General Property 3.380 86,500 216,000 302,500 Woodland 0.000 0 0 Totals for 2004: General Property 3.380 46,300 221,200 267,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 139 Specials: User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 'LATER t, _ ,, �, TOWNSHIP r - SEC. -� T N R .3. ADDRESS ST. CROIX COUNTY, ' WISCONSIN. •3DIVISION LOT - T- -. LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 7. - - t ^TIC TANK(S) CONCRETE STEEL NO,--of rings on cover Depth DRY WELL .'NCHES NO. of width length area no. of lines width - 1'ength — I area �- depth to top of pipe JREGATE ::K RATE AREA REQUIRED ti AREA AS BUILT '- • a ;claimer: The inspection of this system by St. Croix County does not imply complete % pliance with State Administrative Codes. There are other areas that it is not possible / inspect at this point of construction. St. Croix County assumes no liability for tem operation. However, if failure is noted the County will make every effort to - ermine cause of failure. 4 :ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTE.4e' • DATED PLUMBER (JN JOB LICENSE NU11BER c ' RF POP,T OF ITISPECTIO ?l - -I? , �DIJIDUAL SEUAGE DISPOSAT. SYSTEM Snnitary Permit 7 ., State Septic TOWNSHIP At.6roix County SEPTIC TAB -i Size gallons. 'cumber of Compartments Distance From: Well ft. 12% or greater slope �'' f1. Bui lding ' ! – ft. „..�.._ Wetlands f: Ilighwater ft. DISPOSAL SYSTMI Tile Field or Seepage Pit(s) Distance F- ft. rom: tell 12 %,or greater slope” ft Buildingft. Wetlands FIrLn Ht. i f ghwater �-- ft. Total length of lines ,��°. Number of lines Length of each line Jft, Distance between lines ft. Width of the trench ft, Total absorption area sq. ft. Depth of rock below t' P ile'... -in. DP th of rock over tile in.. Cover aver -rock, Depth of tile below grade ��in. Slope of trench in "per 100 ft. Depth to Bedrock­----_.. ft. Depth to ground water ft, PITS (lumber of pits Outs'de di eter °fit. Depth below inlet — ft. Gravel a *pit ." P es no. : Total absorption area sq. ft. .Square feet of seepa_e' Z nch bottom area required `'square feet of ee a e P g- area required Inspected b ,� �' Title. V X. . Approve Date 197 j J Rejected Date , n17 EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: W / W+/,, Section T,21N, R � 11(or) W, Townshi p or Municipality � t • �S o �� Lot No. �, Block No. � , 6 dl y b," C Owner's Name: _ Subdivision Name County Mailing Address. i f f 'n S' n/, i n TYPE OF OCCUPANCY: Residence C-- No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW L__— ADDITION REPLACEMENT DATES OBSERVATIONS MADE: S IL BORINGS y �� �— 7 _ PERCQLATION TESTS l SOIL MAP SHEET SOIL TYPE. PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL DROP IN WATER LEVEL, INCHES RATE BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN P- J ?� P –) , P3 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES NUMBER INCHES CHA RACTER OF SOIL WITH THICKNESS, INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) i B 01 7 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable ar as. Jndicate number o uare feet of abs ne a needed for building type and occupancy. or distances. Give horizontal and vertical reference poi ts. ndicate slope. 1 h 1 r ,. i t N � s State and County State Permit # Permit Application County Per # _ for Private Domestic Sewage Systems County * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY - Mailing Address: D AI� K� L t.Aj -. R rt- R �- B. LOCATION: VJ % '/4, Section T '1 N, R E (or) W Lot# City _ Subdivision Name, nearest road, lake or landmark Blk# Village P A R K _ _V F s -- ,4 — � E S Towns C. TYPE OF OCCUPANCY: Commercial * Industrial * Other (speci *Variance Single family Du lex P No. of Bedrooms 3 No. of Person D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder 'YES NO # of Bathrooms/ Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY I b0 Total gallons No. of tanks * Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement _ Prefab Concrete * Poured in Place Steel Other (specify) F. EFFLUEf�FT DISPOSAL SYSTEM: Percolation Rate 1) /—S- 2) r S 3) 1 S Total Absorb Area 6 sq. ft. New �/ Addition Replacement *Fill System Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches _ Seepage Bed: Length /'L Width — YT Depth 14 _ Tile Depth - 1 JA`�_ No. of Lines Z Seepage Pit: Inside diameter Liquid Depth Tile. Size Percent slope of land Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Soil Tester, ,� 1 NAME R l C k A R b �� , 4 6 P K I M S C.S.T. # f LI J3 and' other information obtained from i (owner /buil ! Plumber's Signature 6 0. r 7 MP /MPRSW# 1✓1/� 5 4 3 L Phone # _ 2 Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). 1 _ G ?� C Sr � 7 ill � We 160