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042-1043-40-000 (2)
x County Planning and Zoning WeAnerday, May l8�1011 aN:08:57 PMSt. Croi Page I of I Detail Sanitary Information Computer M. 042-1043-40-000 Sub/Plat: NA Section: 16 Parcel #: 16.29.18.246G Lot: 4 TNIRNG: T29N R18W .. � Municipality: Warren, Town of CSM: Vol. 01 Pg. 216 114 114: NE 114 NW 114 Owner: Siedschlag, Brian & Sheryl 1127 100th Avenue Roberts, WI 54023 State Permit: 199833 Issued: 09/10/1993 POWTS Dispersal: Non -Pressurized In -ground Permit: New County Permit: 0 Installed: 10119/1993 POWTS Detail: Trench - Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuerllns ector As Built Plumber ether Requirements Additional Notes MoneyOwed 1000 gal. Weeks tank to 2 trenches 5' x 92' each - $0.00 Jim ThompsonYes Nechvilie, Henry BOA #60-92 approved driveway variance shows Jim Thompson Signed Off: Yes site plan with a conventional POWTS and area for mound replacement Maintenance Notification Scheduled Pump Date Pumped Notification 10/19/1996 8/9/2005 04/20/2006 8/9/2008 5/19/2008 5/19/2011 5/13/2010 Parcel #: 042-1043-40-000 N 06/22/2005 04:53 PM PAGE 1 OF I Alt. Parcel #: 16.29.18.246G 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner SIEDSCHLAG, BRIAN E & SHERYL A BRIAN E & SHERYL A SIEDSCHLAG 1127 1 OOTH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 1127 1 OOTH AVE SC 2422 ST CROIX CENTRAL SID 1700 WITC Legal Description: Acres: 6.420 Plat: N/A -NOT AVAILABLE SEC 16 T29N R18W 6.42 A IN N 1/2 NW1/4 Block/Condo Bldg: LOT 4 CSM VOL 1/216 ORD (5.54A IN NE NW) (.88A IN NW NW) Tracts): (Sec-Twn-Rng 40 1/4 160 1/4) 16-29N - 1 8W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 962/411 07/23/1997 914/204 07/23/1997 521/410 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Description Class Acres Land RESIDENTIAL G1 6.420 52,700 Last Changed: 10/22/2001 Improve Total State Reason 170,500 223,200 NO Totals for 2005: General Property 6.420 521700 170,500 223,200 Woodland 0.000 0 0 Totals for 2004: General Property 6.420 521700 170,500 2233200 Woodland 0.000 0 0 Lottery Credit: Claim Count: I Certification Date: Batch #: 552 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 S T C - 104 AS BUILT SANITARY SYSTEM REPORT M,,�NER_ ADDRESS SUBDIVISION CSMV LOT SECTION- T N-R W Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM C", lei INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. ALTERNATE BM: y SEPTIC TANK / PUMP CHAMBER / HOLDIVG ..TALK INFORMATION Manufacturer: Li quid Capacity. r Setback from: Well House - others' Pump: Manufacturer Model# Size Float seperation Gallons/.cycle: V Alarm Location `:SOIL ABSORPTION SYSTEM Width: Length Number of trenches �.--�-- Distance & Direction to ne 1 crest prop. _ i'ne . M r Setback from: Well:.; N� House '� `� Other k S . i Vim' P T i .. k. ELEVATIONS Building Sewer ST Inlet; ST outlet PC inlet PC bottom Pump Off Header/Mani fold got torn of system Existing Grade Final grade ." .s r 1 DATE OF INSTALLATION: . • it _-.�.:.!/ fi PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt LQQ&TJQ8�artWJ&RRMus4_f?* 29-18,,24*VATE SEWAGE SYSTEM Labor and Human Relations INSPECTION REPORT Safety and Building� Division (ATTACH TO PERMIT) GENERAL INFORMATION Permit Holder's Name: ❑ City E] Village Town of: �Insp-81111 Elev.: ev.: A N lid A'rinikl BM Description " F1 FVATION DATA A9300239 /0� :, LANK 111,411-UrMl TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_ Septic -S Benchmark Dosing Aeration Bldg. Sewer Holding St W Inlet TANK SETBACK INFORMATION St/ Hf Outlet TANKTO P L WELL BLDG. Vent to Air Intake ROAD Dt Inlet P Septic NA Dt Bottom Dosi ng NA Header/ Man. V V Aeration NA Dist. Pipe Holding A Bot. System PUMP SIPHON INFORMATION Final Grade Ma'-hufacturer— t Demand Model Number GPM TDH Lift Lift Frictio --IS IF 10 � s —te I stem d d TDH t e Forcemain L Length Dia. ja Dist- To Well SOIL ABSORPTION SYSTEM — I BED/TRENCH Width Length No. Of Trenches PIT P. its Inside Dia. D' Liquid Depth DIMENSIQNS DIMENSIONS _! tv%wwfacturer-. SYSTEM TO P/L BLDG WELL LAKE /S LEACHING SETBACK CHAMBER M-P&<Number: INFORMATION Type Of Ilk^ ( OR UNIT System: -�- ���i DISTRIBUTION SYSTEM Header / _MVTMftft_ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- 1/ Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only -;�. Depth Over 1 Depth Over if JV xx Depth Of xx Seed ed 150'dded No xx Mulched E] Yes E] Na 4ied /Trench Center 33 -,:p &@+/Trench Edges 3 Topsoil El Yes [] - COMMENTS: (include code discrepancies, persons present, etc.) LOCATION: WARREN 16o29.18a246E Plan revision required-) es E] No I -FL/P7 On formation. Use other side for addi X-3 I FLO SBD-6710(R 05/91) Date Inspect Cert- No, ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: rLuEncorlon SANITARY PERMIT APPLICATION 7��113 I L H R In accord with ILHR 83.05, Wis. Adm. Code —Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. —See reverse side for instructions for completing this application. 1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION PROPERTY OV�NER'S MAILING ADDRESS LOT # Q COUNTY STATE SANITARY PERMIT # aheck if revision to previous application STATE PLAN I.D. NUMBER T. N, R E (or),w BLOCK # CITY, 71P CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER " [a CITY 111. TYPE OF BUILDING: (Check one) El State Owned Q VILLAGE: 171a E]Public ❑El 1 or 2 Fam. Dwelling—# of bedrooms - PARCEL TAX NUM nmwmn� III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 1:1 Medical Facility/Nursing Home 3 El campground 7 El Merchandise: Sales/Repairs 4 El Church/School 8 1:1 Mobile Home Park 50 Hotel/Motel 9 El Off ice/Factory IV. TYPE FPERMIT: (Check only one in line A. Check line B if applicable) NEAREST ROAD 10 ❑ Outdoor Recreational Facility 11 ❑ Restaurant./Bar/Dining 12 El Service Station/Car Wash 13 0 Other: Specify A) 1. New 2. ❑Replacement 3. ❑El Replacement of 4. [1Reconnection of System System Tank Only Existing System B) El A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental 11 0 Seepage Bed 21 El Mound 30 EJ Specify Type 12 E�Seepage Trench 22 0 In -Ground 13 El seepage Pit Pressure 14 El System -in -Fill 5. 0 Repair of an Existing System Other 41 ❑Holding Tank 42 ❑Pit Privy 43 ❑Vault Privy VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA ft.) 3. ABSORP. AREA PROPOSED (sq. ft.) 4. LOADING RATE (Gals/day/sq. ft.) 5. PERC. RATE Min./inch) 6. SYSTEM ELEV. .+n 7. FINAL GRADE ION ELEVATION / REQUIRED (sq. No 961 t02Feet 1 Vill. TANK CAPACITY in gallons Total # of Manufacturer's Name Prefab. site Con- Steel Fiber- glass Plastic Exper. App. INFORMATION New xisting Gallons Tanks concrete, structed Tanks Tanks — 1 1,0) A# a F1 Septic Tank or Holding Tank Lj L] Lift Pump Tank/Siphon Chamber Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) Mp/MPRSW N: Business Phone Number: Pldrfte'r dress —(Str-6et,-C'iy-t-y,—State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY Issuing Ag nt Signature (No Stamps)) Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Surcharge Fee) Approved F-1 owner Given initial Adverse Determination I IN, X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 4r, 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. I 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. nsite 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, contac . t, your focal code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed, 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacr7liment, reconnection, or repai r. V. Type of system. Check appropriate box depending on system type. VI. Absorption systern information. Provide all -information requested in #1-7. VI 1. Tank information. Fill in the capacity of every new and/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, I' (rz 1CC--,1S9 rijiMber with appropriate, r, MP, etc.), address and phone number. Plumber must sign application "' form, f g, X County/Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than x 11 inches must be, submitted to the c-c-)wnty, 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; 13) 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, ground- water contamination investigations and establishment -'of standards. SBD-6398 (R. 11/88) ff � Lummorimn QAKIITA12V DFOUIT APPI WATMM m MW W= = = -- - - - -_ M---- - --- - --_----A-- �JLHLHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 81/2x 11 inches in size. El Check if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION 1/4 S T N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) Li CITY NEAREST ROAD L J State Owned 0 VILLAGE' El- TOWN OF: 0 Public El 1 or 2 Fam. Dwelling--# of bedrooms PARCEL TAX NUMBIESR�() 111111. BUILDING USE: (If building type is public, check all that apply) Ai_ 1 El Apt/Condo 2 El Assembly Hall 6 El Medical Facility/Nursing Home 10 El Outdoor Recreational Facility 3 1:1 Campground 7 El Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining 4 El Church/School 8 ❑ Mobile Home Park 12 El Service Station/Car Wash 5 Q Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A). El I New 2. DReplacement 3. E]Replacement of 4. E Reconnection of 5. El Repair of an System System Tank Only Existing System Existing System 13) El A Sanitary Permit was previously issued. Permit# Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 El seepage Bed 21 [:1 Mound 30 0 Specify Type 41 Ej Holding Tank 12 El' Seepage Trench 22 El In -Ground 42 0 Pit Privy 13 El seepage Pit Pressure 43 El Vault Privy 14 El System -In -Fill V1. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ?eet Feet Vill. TANK INFORMATION CAPACITY in gallons Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- Plastic glass Exper. App. New Existing Tanks Tanks strutted Septic Tank or Holding Tank Ell, F1 El D I Lift Pump Tank/Siphon Chamber I f EJ I Lj [:j F71 Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): A/�lA-VPlumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: ir A *, v, Plumber's Address (Street, City, State, Zip Code): NNW IX. COUNTY/DEPARTMENT USE ONLY F-] Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued 11, Issuing Agent Signature (No Stamps) Approved F-1 Owner Given Initial Surcharge Fee) I Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the 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. 8. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. 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. IL 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 in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/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.), 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% 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 tanks), 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11 /88) IMMEMM RANITARV PFRRAIT APPU-lr.ATInN Paman"slamn In accord with ILHR 83.05, is. Adm. Code COUNTY �k 0 'K STATE SAN PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. Check if revision to previous application C if -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER g I a / r� 51 1 -5 c' 14 At- 6-, AZ (7 PROPERTY LOCATION / V LP 1/4 Y41 S T,:� N 9 R E i(o r) PROPERTY OWNER'S MAILING ADDRESS Q d�_ LOT # BLOCK # C , j.,Cv X CITY, STATE STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER L L 1111. TYPE OF BUILDING: (Check one CITY NEAREST ROAD State Owned E.] VILLAGE ka_,� �Vo,�v I E]Public El .3 OWN QL. Z 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S) ME BUILDING USE: (If building type is public, check all that apply) )y 1 El Apt/Condo 2 E]Assembly Hall 6 El Medical Facility/Nursing Home lo Eloutdoor Recreational Facility 3 El campground 7 El Merchandise: Sales/Repairs 11 0 Restaurant/Bar/Dining 4 El Church/School 80 Mobile Home Park 12 El Service Station/Car Wash 5 El Hotel/Motel 9 1:1 Office/Factory 13 El Other: Specify MEMNON IV. TYPE PERMIT: (Check only one in line A. Check line B if applicable) TYPE A) 1. 2. ❑El Replacement 3. ❑El Replacement of 4. El Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit# Pate Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 El le"pag e Bed 21 El Mound 30 ElSpecify Type 41 ElHolding Tank 12 QSeepage Trench 22 D In -Ground 42 ❑Pit Privy 13 1:1 Seepage Pit Pressure 43 1-1 Vault Privy 14 El System -In -Fill VIM ABSORPTION SYSTEM INFORMATION: AB SORPTION 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE 1.'G REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION L 4� 9 7? I 9e) Feet Feet 11. TANK V VII T� INFORMATION SOMEONE CAPACITY In gallons Total Gallons #of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- glass Plastic Exper. App. New xisting Tanks Tanks strutted Septic Tank or Holding Tank vr' er El a- Ll Lift Pump Tank/Siehon Chamber I I I L Lj 11 Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. vi Business Phone Number: Plumber's Name (Print): umber's Signature: (No Stamps) MF:r/MFAS_W No': 41 7'Y .3 73-2 2— Plum ber's A#dress Street, City, State, Zip Code): .40 Y 6 7 MUSEUM! IX. CQVNTY DEPARTMENT USE ONLY r-1 Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Ag nt Signature (No m Surcharge Fee) Approved ❑ Owner Given initial .311 Adverse Determination MEN X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS r t 1. :� A*sanitary permit is valid for two (2) years. 2. Your' sanitary permit may be renewed before the expiration date, and at the 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. Cnsite sewage systems musf be properly maintained. The septic tanks) must -be pump'ed 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 & Buildings Division, 608-266-3815. 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. 11, Type of buildin being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. ,Check only one in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and man facturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/si hon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), 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% 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 tanks), 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 Qianufacturer; D) cross section of the soil absorption system if . required by the county; Eysoil test dataal'--e4. i7 : prrn; and fl all sizing information. G-1110UNMATtW 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 usedJor monitoring groundwater, ground- water contamination investigations and establishment ofstari�ards. ` �e a J••'1 5 i S13D-6398 (R.11/88) J 4[ I r /3 T, C Ty 5 � � L i8 �� � 1 < �'—1 lob �� �do d<.SJ�tI�E 3o�•t �-3 �o� s6' /'Q�,� Fyn ur�� ell ---s SANITARY PERMIT APPLICATION DI L H R In accord with ILHR 83.05, Wis. Adm. Code COUNTY WCUMM STATE SANITARY PERMIT# —Attach complete plans (to the county copy only) for the system, on paper not less than I 81/2x 11 inches in size. El C/ec f vision ous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION N, R E (or) W + 'Ed Sc4Z jc !4 1/49 S T PROPER . TY OWN MAI ING ADDRESS, LOT # BLOCK # ) 7vtie Cl ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSIVI NUMBER 6); S /L3 7-�7 ) 3AY19 X 1 0 CITY NEAREST ROAD 11. TYPE OBUILDING: (Check one) El State Owned C],VILLAGE : OR Tr%UWUKI 7�6 A PARCEL TAX NUMBER(S) Public Zr 2 Fam. Dwelling—# of bedrooms--,,3 BUILDING USE. (if building type is public, check all that apply) 1 ®AptlCondo 2 El Assembly Hall 6 ❑Medical Facility/Nursing Home 3 E] campground 7 EJ Merchandise: Sales/Repairs 4 El Church/School 8 ❑ Mobile Home Park 5 F] Hotel/Motel 9 ❑ Office/Factory IV. TYPE OF..,PERMIT: (Check only one in line A. Check line B it applicable) w A) 1. TYPE 2. ❑[:1 Replacement 3. El Replacement of System System Tank Only B) El A Sanitary Permit was previously issued. Permit# EEEEEEVNNNM� V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution 11 El seepage Bed 12 PoSeepage Trench 130 Seepage Pit 14 ❑System -In -Fill Pressurized Distribution 21 ❑Mound 22 El In -Ground Pressure 10 ❑Outdoor Recreational Facility 11 0 Restaurant/Bar/Dining 12 ❑Service Station/Car Wash 130 Other: Specify 4. El Reconnection of Existing System Date Issued Experimental 30 ❑Specify Type 5. El Repair of an Existing System Other 41 0 Holding Tank 420 Pit Privy 43 0 'Vault Privy VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA REQUIRED (sq. ft.) 3. ABSORP. AREA PROPOSED (sq. ft.) 4. LOADING RATE (Gals/da /sq. ft.) 5. PERC. RATE 6. (Min./inch) SYSTEM ,041 ELV?FINAL GRADE J Z_Aefet 1. la V11. TANK INFORMATION CAPACITY in gallons New xisting Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Con- structed Steel Fiber- glass Plastic Exper. App. Tanks Tanks Septic Tank or Holding Tank 1000 Lift Pump Tank/Siph on Chamber Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber' Signature: (NoStam s) MP.&PRSW_No.7") Business Phone Number: h-*19 : 7 Plumber's Address (Street, C1 State, Zip Code): V_ IX. COUNTY/DEPARTMEN USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater Date _ J& u s ed issuing Agen h fir F� Approved F-1 Owner Given Initial Surcharge Fee) X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: 6 SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. Z Your sanitary permit may be renewed before the expiration date, arld at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit roust be approved by the permit issuing authority. 4.. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form, (SBD F,3gg? to be submitted to the county prior to installation. 5. Cnsite 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 & Buildings Division, 808-266-3815. 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. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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. Vl. Absorption system information. Provide all information requested in # 1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the fatal gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for .211 septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), 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 311� 111 inches must be submitted to the county. The plans roust include the following: A.} plot plan, drawn to �icale r rA#ith CornPiete dimens=one location of bolding tank-(si sep tip tanks C,�r' other reat�'��=�f`rt tanks; b , Ming ���a���Y:�� ' Cyr lnsiw°"ter� ... streams and 1,-,3.kes; p, imp or siphon tanks; distribution boxes- s EI , , ;ems; replacement systern areas, and the location of th��.yn building served S) horizontal' in d ,..,,ec l_ t 4 :,.��p� �S¢� � o� F' .� jy 'N F.Y u ! i i .., W L F -.!. r F.. x i T]: E Fyn f �'' completes specifications for puiri s and co�atro ls• ur-n �. � i x `�` p P � �, dose �`�il e; sPump pertorn ranee cY�.4rve; pump model and purnp rnanufaCturer, D) kJ the s0R' absorption system-= required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1 ?3 Wisconsir. Act 410 included the creation of sui-charges •, 4 regulated practices which can effect groundwater. i i = Firl�l�.p r i =4_�L i•i.f yl 4�ilh Yf these si. rchaf• ge,�; a.tnuo1 ing w' tLit- contamination investigations and est<abhshment of strAndards . S6D-6393 (R.11/88) of saletl/ in accord with ILHR 83-0bs Wig. Adm. Code --5 oel "rc �73 9tP 2 h "orrlolete site plan on paper not less than 8 1/2 x 11 incites in size. Plan must incl ude, but not limited to vertiw.,aj.and horizontal reference point (BIM). direction and % of slope I. scale or Itorth ffrow, and location and distance to nearest road. 7-S- APPI,l(;A,.NT INFO PMATION-P LEASE PRINT ALL INFORMATION &11eX/C-1 ell r1a -41/ PROPERTY OWNER: of 4-- PROPERTY OWNER%$ MAILING ADDRESS 9 L 70''° 67S --t-- QTY, STATE ZIP CODE PHONE NUMBER 60/,, S74/0 2,3� 715 7�1 COUNTY J14"r. /* PMCEL I.D.- # I REVIEWED BY DATE PROPERTY LOCATION GOVT. LOT /$/E 1/4 INC--` 1140S /C/e T 2-f INIR 40 E (o6) LOT M I BLOCKY SUBD. NAME OR CSM 0 CICIT-y [:]VILLAGE' O(OWN NEAREST RPAD -- w4R,ez�, 1 III r�v �►1-t— I---- -- -- - Now Consnc6on Use j\1 Residential /Number of bedtooms � l Replacement Public or Commercial describe Addition to existing bit in Code derived daily lior gpd Recommended design loading rate 12V bed, gpd/f,2 - �trenDh� gpd/ft2 Absorption area requif,ed �Al bed, It2 700 trench, 112 Maximum design loading rate &� _bed, gpd,ft2 6 jerO, gpd/ft2 Recommended inflIttapon surface elevation(s) P,6- ft has referred to site plan benchmark) Additional design /sit@ considerations Parent material �-57 g 9 lf,,e t2 /-5- -- 7- a,.* btlr -Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN -GROUND PRESSURE AT-GRADG U = Unsuitable for system 0 S 0 U S El U 0S OU WS OU + SOIL DESCRIPTION REPORT bring # around lev. It. epth to n6ig Iclof � /410 )ring # ound )V. pth to iting r SYSTEM IN FIL� Ds��juK[Is 2U R ern arks: d��.=v-�. �.. S �s' �-s Q �� %, i' / • :-�. S . ,��,,��'`�y�` f Remarks: -:5; z.vzy - - --- :/ S-1 Name: —Please pfint 1 1=1E Sr:r I K—;-PL[MV11Nk3W. Phone: 7 855 O'NEIL RD.. HUDSON. WIS. W16 5;7 1dress: R I 9nalure: -NIS. MASTER PLUMBER X. NO. 3307 M.P.R.S. mtNN. m, rALLER & DEMNER X. NO, OOW Date: CST Number- _. r .. � . r. � . _ � �.+ .... r o,. �,► r� uI � 1 4 1 � 1 1 �./ { '1 1 i �.. ► � i 1 PIACEL 1.D. 9 Kaye � of o Remarks: r J I ■ f 6 J I Remarks: �' ��� -� �'' �"�,�`l,� �,�.� �' ��,�' � r�? O .:;4.0 f-' 4 7 - Y13 =_ - /s S/ o,-(, /�,s6k In, IC-4 3vf • 5'j. S yl�' 3�z 1-3, -� �o �,e y — si i,�, sdK � rye �S �f . �; s 13, 36. Yk /o /k Y-/o , 5/ z 4 sbr (9!o Y/l/ /12 r m arks : / 4= /"-7 0 ��. �, Z�) e-0 ,4 71e- . f 01,5. p r ' r �f 5 7- i r r�'�• � � - alb /3loo.3 G Vie Z:w1flAwf /34 I 13 /11,vs rr 1?4a- v,&.' rt.0 rod=- lel-©4u.1p s y s 7-e A l s ti o r-rd rg- 13 -- / - /'trot< e&7 C e,-4-f 4E 7 1.0." e* A -)I f� r IId f s4.00;4 Y3.- 7 0 ' ; v -ro Z3: L V4 7-10,00 HOMCSITE SEPTIC PLUMBING CO. 855 O'NEIL RD.. HUDSON, WIS. 54016 ROBERT ULBRIGHT CS 7- 7/ .7- 'Y H)G. MASTER PLUMBER LIC. NO. 3307 M.P.A.S. MrNN. INS-I'ALLER & DESIGNER LIC. 140.00663 Ram '2cee'x . 3 3 p� -0 of Y3/ 7 o ivorc S�''IPo�Pr�.v7- 70- 5r. :5 DATE WaterPro Supplies Corporation 15801 W. 781h Street Eden Prairie, MN 55344-1894 Telephone- 612-937-9666 WATS- 800-752-8112 Fax- 612-937-8065 PROJECT 06 /V Uv Zl r fc /I /' I N t--- 7 Pr-o geot- 0 / el t Iry P :, AL 41f :3 Jo- r!l "Ov � a h:%- 400, I& S 2 / c,/— tiHh loo, 3 pet T-Z p PAGE OF PUMP CHAMBER CROSS SECTIDKJ AMD SPECIFICATIONS VEQ'T CAP 10-C.I. VEMT PIPE: WEATHER PROOF JUMMOKI BOX Z!5' FROM DCOR, Iz MILL *01DOW OK rRESH 04A IMTAKE GRADE CoKiDulT 1*4 LET PROVIDE AIRTIGHT SEAL AV kPFF,0VEID JOIN A -L. pf PE tXTENDIM& 3 CWTO SOLID SOIL c" PUMP D clk COKICKETE BLOCK RISER EXIT PERM11TED OIQL� IF TAKIK MAKIUFACTURE.R HAS APPROVED LOCKING MANHOLE COVER APPROVED jolKiTs w/c.l. PIPE EXTEMD1MG 3' OKITO SOLID SOIL SUCH APPROVAL 3 P E C I F I C, A T 10 M S TAKIKS MA�JUFACTUR.Ep,:.-ALIaL W/ABER OF DOSES: —PE:F, I)A,!j TAMK SIZE E o G'A LLD �J S DOSE: VOLUME'. —GALLOMS ALARM MAMUFACTURER: CAPACITIES*. h= ;Z./ -1kJCHES OR 3;2, GALLOUS MODEL UUM13ER: �-- -IMCNES OR GALLOWS v SWITCH TAPE. _ .� ,,�' t�CL- C= IMCHES OR ,..� � ..� IMC-14ES OR GALLOUS PUMP MAIkJl-JFACTURi:R'&'— o D= MC)I-)EL- kIUM5F-R*- �4 NOTE: PL)MP AND ALARMARE TO 5E U IMSTALLEP OM SEPARATE CIKCUITS bWl-l(-'H T9PE. PUMP DISCHARGE. RATE GPM E E: T -*A:KTICAL DiIrVER-EkICC 5F-TWE:E:kl P[AMP OFF AUD DISTRIBIJTIOj PIPC-- 4 MIUIMUM METWORK SUPPL-9 PRESSLIKE + F E E T OF FORCE MAI IQ X 2 r >10/0 FT. F9 I CT IOM FAC--rOR. F EF- T 4, TOTAL 01�UA^IC HV.At) -- ZZ 6 FF.ET MTERMAL DIMEWSIOMS OF TAUKO L E ;WIDTH DEPTH 22 77 SIGK)E D'. LICEMSE IJUMBER'- DATE'v STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County /V C A OWNER/BUYER 0 FIRE N. 0 ROUTE Sax NUMBER 1111� - � CITY/STATE PROPERTY LOCATIO N: /V/-71 4 N Section 2-61 T. N, R W, Town of St. Croix County, Subdivision "I Lot No. improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system* St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. i/wE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the st.Croix County Zoning Office within 30 days of the three year expiration date. S I GNE5j6��VI/A DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, W1 54016 (715) 386-4680 Sign, Date, and Return to above address 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 in for resale by owner/con'tractor,(spec house), thenia 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 AN Location of property 1/4 AIAJ114, Section T_ � )N-R Township Mailing address Address of site L42�4&.A tk-#-- Subdivision name Lot no. Other homes on property? yes Previous owner of property Total size of parcel C pi'r Date parcel -was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number 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 & 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 the office of the County Register of Deeds as Document No. . 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 office of County Register of deeds as Document No. -0 u-"Signature of applicant-" Date of Signature Co -applicant Date of Signature 0 DOQINT NO. 00 486832 e . NSIN FC?R%4 2-14842 STATE QAR OF \NISCO F-ED WARRANTY D - - "V 10 *1 9 6 2 `?'A�. Gerald L.: Nadeau ------------- - ----------- Brian dschla and Sher A. convoys and war, ants to Br ian Siedschla_husband and wife gj THIS SPACE RESERVED FOR 8Ecos;DIING DATA REG�S��awiCE Wd ks INA AUGO 61992 10:40 A. Doe& pjETUf;m TO the following dwrdeemr"I Ostste in St. Croix County, State of Wisconsin. Tax Parcel NO: ----------- ien 161 Township 29 North, Range 18 Westo Part of the N 1/2 of NW 1/4 of Sect T-IIII 4 of Certified survey Map St. Croix County. Wisconsin described as follads: fj.lEj February 3, 1976 in 7101. 1, page 216a DOI No. 331389. CRAN This is not hornestead property. (is) (is not) Exception to Warranties: Easements, covenants & restrictions of record. 92 day of Dated this . ........ III (SEAL) --(SEAL) AUTHENTICATION Signatu(e(s) authenticated this_____ day of TITLE:MEMBERSTATE BAR OFVyISCONSIN (If not, Slat authorized by 706 W' HIS NSTRUM IS Y ---------- (Signatures may be authenticated Or acknowledged. Both are not necessary.) 111 • 101 1 .......... . .... ACKNOWLEDGMENT STATE OF WISCONSIN as Ca f County. arsonally came bef ore me thisday Of 19- the above named U \A who ex0Cuted the to me known to be the persond and ack i ge I oing instrument kia P.- 10 VI-0 1 6: Nwyt,*ry Public iratj PAY Commission is permanent. (If kot, at V ':00 dO' 41 4�v,� dato' S92 NTF 0021 N&MOS Of persons signing in any capaI -should be lvp*d or printed b*10*1 t"O" "Gowwwres N91C0 Tax FaTM P.O_ BM 102n& (j"W 8", WI54307-02M •STATE. SAM OfWIIISCONZ'" WARRANTY DEED Ferro No 2 — '282 Wisc%unsin Department of Industry, SOIL AND SITE EVALUATION REPORT Labor And Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code .5r7- _5>f Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (13M), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. 6�,v S1 7-4-- APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION P 60el, F1 r .1-r/0 ✓ Page of -5 COUNTY 1;0r61 PAR CE D. # D �-1aS����o -�� REVIEWED BY DATE J / .,OL1 _T40--AyJ_e, � G - le - -;.2' PROPERTY OWNER: PROPERTY LOCATION ,.giel4v D -5 *,C- GOVT. LOT 1/4 AW 1/4,S Ze T 2-f N,R E (o 01� PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK# SUBD. NAME OR CSM # 71'"Z_le L I CITY, STATE ZIP CODE PHONE NUMBER []CITY EIVILLAGE OfOWN NEAREST ROAD I Gv1' - (715) 7yf-3Yelee- 1 141 4tf 44e�v 1 //6 tir.". ,f I 1A New Construction Use Residential / Number of bedrooms 2 Addition to existing building �f i I I Replacement Public or commercial describe Code derived daily flow ys0gpd Recommended design loading rate NI�_bed, gpd/ft2 trench, gpd/ft2 Absorption area required /44 _ bed, ft2 700 trench, ft2 Maximum design loading rate 111A bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) �' 6-, 3 ft (as referred to site plan benchmark) Additional design / site considerations 5L-k-E- PS 3 Parent material #1vB6v' S# P1,41*v-r Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL,,, MOUND IN -GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for system El S 0 U El S El U Cas 0 U V1 S El U EIS OU ED S 91 U IA-.,) 0,4P4 -1 ra — Z) A-ft A."k Is a Aft. A-% i a b IoNk a N AW% r dW* Boring # Ground elev. /0 /_YL ft. Depth to limiting factor A. /too - Boring # Ground elev. /o/art Depth to limiting factor Horizon Depth n.. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 Bed ITru& o-ice �o y�e 3L3 a,M,, � �-e �s > f � 2 11 _57 �v 4, 54 r Remarks: _5" -{ f o-111 IoYe,313 /j� y' 30 �O/',P 4/ � S/ 1sht< �,,,-f � CS2- 2--f Y j - S /3z 30 -3 7syk 5/la � /S °/�^-1R m,ll- %S f-F � ',. ±' 3 3p- e/5 loyle c, sGo /or� 1�) C, S� ,N.,� � x .�' 400, 00,0-9(9 /0 ye of 0 2�54- e 5 '7�� _57 Remarks: y CST Name: —Please Print Co. 06 P5 1 855 O'NEIL RID.. HUDSON, WIS. 54Prone: 016 '30 — /Sp 1 Address- nVCCni VLDniun i Vile. MASMR PBE __ LUMR LIC_ NO, 3307 M.P.R.S. Signature: WWI . MTALLER &DESIGNER LIC. 140.00663 Date: CST Number: PROPERTY OWNER /3., 512�P5cAZ2�-6-- SOIL DESCRIPTION REPORT PARCEL I.D. # 0 Page of Ground elev. /0 O•�( ft. Depth to limiting factor Ground elev. Depth to limiting factor Boring # .......... Ground eiev. f t. Depth to limiting factor Boring 4 Ground elev, ft. Depth to limiting faqtc�i ,a rr Remarks: gE- je9Z- ',rl V-�-� luyle 313 X13 04 -5-7 3 161. 0 --------- -r,< .7ap yX 21) 64, Remarks: ' -� of,'�'� �", �.,'",',C.` ..."" .,,mac ' , . 7 47- I Md M,� /s Remarks: 7 �, J 311. ioR yy - /0 L! � s/ � �, � 6.� �r+ �,e _. Cis 3 �f . y , _ S/ l,f, sbK eyv-rd(" c5 of , � ',, 411. SbK /�"''�,F � S /vim , y.� S i JL � a n.. �/ _ i c' I i Remarks: SBD-6330(R-05/92) ,earl' /of-/ 10, /CPO 0 124 aZ-& 7; -A) o OF 213 e- 4-4 5 7- ale loo,36 Ll 11,36 /3-5 JCS. fC1� /3 I / 0= %/© 0 • 1-5 IN S 7' �� � � �' � (.: � � �V o ram- %� E/o `�' 7-11-13 1,E-- leiv e, 4 I /. Ir 1-7 o 0'uz) sy 7 0 -roli a/c j6,: i I/if 7-1 at) HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD.. HUDSON, WIS. 54016 ROBERT LILBRIGHT C57W 2 N16. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. f,trNfl. )JALLER & DESIGNER LiC.',40. 00663 lf'yp Ole r/-1 eo"o 4 3 of 3