HomeMy WebLinkAbout161-1092-40-000ning and Zoning St. Croix County_Ptlan Tuesday,Awaust28,200-7at8:52:35AAf
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Detail Sanitary Information
Computer #: 161-1092-40-100 Sub/Plat: St. Croix Station Section: 13
Parcel #., 13.29.20.728A Lot: 4 TNIRNG: T29N R20Wrt
Municipality: Village of North Hudson CSM: 1/4 1/4: NE 1/4 NW 1/4
Owner: Gilbert, John 305 Station Lane Hudson, Wl 54016
State Permit: 18795 Issued: 09/14/1981 POWTS Dispersal: Non -Pressurized In -ground Permit: New
County Permit- 177 Installed- 09/17/1981 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund:
POWTS Pretreatment: NA
Plumber QthqLEI�_ �uire�ffleT�§ Additional Notes Mgp.Q�Qw�ed
Issuer/inspector As Built
Harold Barber Y . es Zappa, Gary Anthony Zappa installation - std/ 3 BR system - file $0.00
with 1993 permit
Harold Barber Y e s
Owner: Gilbert, John 305 Station Lane Hudson, WI 54016 Dispersal: State Permit: 193511 Issued: 07/1211993 POWTS Non -Pressurized In -ground Permit: Replacement
County Permit: 0 Installed: 08/13/1993 POWTS Detail: Bed - Seepage Bedrooms: 3 WI Fund:
POWTS Pretreatment: NA
N n t os:-
Issuer/Inspector As Built
Tom Nelson Yes
Jim Thompson Yes
, ` -
Scheduled E9MP Date Purned
_
8/13/1996 8/26/2003
8/26/2006 4/2412006
4/24/2009
Plumber Other Reguifernents
jL,
Bourneester, Jim
1st Notification 2nd Notification 3rd. Notification
Additional Notes Money Owed
re -used existing 1000 gal. septic tank and installed $0.00
a valve to alternate between new 18' x 50' bed and
older bed. file 1981 permit with replacement
Parcel #: 161-1092-40-100 01/09/2006 10:38 AM
PAGE 1 OF I
Alt. Parcel #: 13.29.20.728A 161 - VILLAGE OF NORTH HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address:
GARY & KATHRYN MORTENSON
305 STATION LA N
HUDSON WI 54016
Districts: SC = School SP = Special
Type Dist # Description
SC 2611 SCH D OF HUDSON
SID 1700 WITC
Legal Description: Acres:
ST CROIX STATION LOT 4 ALSO PT OF LOT 5
COM WLY COR LOT 4;TH N 51 DEG E 40.76'
POB;TH N 31 DEG W 43.67';TH N 51 DEG E
41.32';TH N 37 DEG W 9.57';TH N 52 DEG E
38.29';TH S 37 DEG E 24.65'; TH S 51 DEG
W 120.53'POB
Owner(s): 0 = Current Owner, C = Current Co-owner
0 - MORTENSON, GARY & KATHRYN
Property Address(es): Primary
* 305 STATION LN N
0.000 Plat: 04/38-ST CROIX STATION 1977
Block/Condo Bldg:
Tracts): (Sec-Twn-Rng 40 1/4 160 1/4)
13-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
08/14/2001 656650 1719/156 WD
11/10/1999 613603 1469/501 WD
1 2005 SUMMARY Bill #: Fair Market Value: Assessed with:
108562 517,500
Valuations: Last Changed: 05/20/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 120,000 386,400 506,400 NO
Totals for 2005: General Property 0.000 120,000 386,400 506,400
Woodland 0.000 0 0
Totals for 2004: General Property 0.000 75,000 298,000 373,000
Woodland 0.000 0 0
Lottery Credit: claim Count: 1 Certification Date: Batch #: 519
Specials: Category Amount
User Special Code
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
STC - 104
AS BUILT SANITARY SYSTEM REPORT
I
OWNER
ADDRESS- 3K Lfir�e
SUBDIVISION CSM#
-R W Town of
SECTION-.� -T al N I
ST. CROIX COUNTY, WISCONSIN
LOT #
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK.•
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING -TANK INFORMATION
Manu f acturer : Li i :
� Y
k4l
Setback from: Well . �01 House d
Other
Pump: Manufacturer Model # � Size
Float se eration Gallons/cycle.w--�
P
Alarm Location
1,;SOIL ABSORPTION SYSTEM
Width: Length Number o f trenches
Distance & Direction to nearest 1 ine :
prop.
Setback from: well: C7 VV House 55'
other
\AN
ELEVATIONS
Building Sewer ST Inlet; `� V 5 ST outlet9�.S()
PO inlet -�� PO bottom Pump Off
Header/Manifold 9 S?. k# ,) Bottom of system [�
ExistingGraded Final grade
DATE OF INSTALLATION. il5
PLUMBER ON JOB : I" �:Vt�
LICENSE NUMBER:
INSPECTOR:
3/93 : jt
I
sUM *a A e rHU"QNr, 12 * 2 9,w 2 0
OM4At E 4*4&V� 4MV
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION
Permit Holder's Name: o city E:1 Village � Town of:
insp- BM Elev.: f
A
BM D scription:
000 V I
Lei I OA IMU.-
I
'10-A
A �d' It Uj
. 0wo
I_j_W__
Gan
TANK INFORMATION
ELEVATION DATA
A 9 3 0 0 16 8
TYPE
MANUFACTURER
CAPACITY
STATION BS
HI FS
ELEV.
Septic
x t
Benchmark
7
Dos'
L/
Aeration
Bldg. Sewer
Holding
St 4W Inlet
vy
-v—v)
TANK SETBACK INFORMATION
st/�w Outlet
TANK TO
P 1 L
WELL
BLDG.
ventto
Air Intake
ROAD
Dt Inlet
Septic
NA
Dt Bottom
Dosin
NA
HeaderkMan,
Aeration
NA I
Dist. Pipe
S 7.
Holding`,,
Bot. System
PUMP SIPHON INFORMATION
Final Grade
Manufacturer
Demand
01
74
ZVI
Model Number
GPM
TDH
I Lift
I Friction
SYstem
TDH Ft
L
Head
Forcemain
Length
Dia.
Dist. To Well
SOIL ABSORPTION SYSTEM
DISTRIBUTION SYSTEM
A IC 1.4 Distribution P1 ok)i .01 x Hole Size x Hole Spacing vent To Air Intake
Header I
Length _42 Dia-
J_
V Ile 'Ar
Length ,OTO Dia- 4/
I ,
Spacing
SOIL COVER
x Pressure Systems Only
xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center
Bed /Trench Edges
Topsoil 0 Yes El No El Yes [I No
COMMENTS: (include code discrepancies, persons present, etc.)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
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
1,
�'/4 ZI
IL A�Ab
i LOT
COUNTY
STATE SANITARY PERMIT #
❑Ch/eck if revision o previous application
STATE PLAN I.D. NUMBER
T N I R �Cj E (or
. ( �
D0n0U0'rV OWNERS MAILING ADDRESS BLOCK fi &
Z� ZIP CODE PHONE NUMBER
111. TYPE OF BUILDING: (Check one) ❑ State Owned
E] _52 Public 01 or2Fam.Dwelling—#of bedrooms - )
111111. BUILDING USE: (if building type is public, check all that apply)
1 F-1 Ant/Condo
2 El Assembly Hall 6 0 Medical Facility/Nursing Home
3 0 campground 7 0 merchandise: Sales/Repairs
4 El Church/School 8 11 Mobile Home Park
50 Hotel/Motel 9 0 Office/Factory
_426 j\; tj
SUBDIVISION NAME OR CSM NUMBER
CITY NEAREST ROAD
,VILLAGE:
%,
M TOWN 0L
PARCEL TAX NUMBER(S)
10 ❑Outdoor Recreational Facility
11 El Restaurant/Bar/Dining
12 ❑Service Station/Car Wash
130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑New 2. Replacement 3. ❑F-1 Replacement of 4. ElReconnection of
System System Tank Only Existing System
B) El A Sanitary Permit was previously issued. Permit # Date Issued
EWWNEEEENEAMNNM�
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution
11 12 Seepage Bed
12 tr Seepage Trench
13 ❑Seepage Pit
140 System -In -Fill
Pressurized Distribution
21 ❑Mound
22 F1 In -Ground
Pressure
Experimental
30 EJ Specify Type
V11. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE
GALLONS DAY
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.)
1-7 0 0
Vill. TANK CAPACITY
in gallons Total # of Manufacturer's Name
INFORMATION —New lExisting Gallons Tanks
Tanks I Tanks
5.E] Repair of an
Existing System
Other
41 ❑Holding Tank
42 ❑Pit Privy
43 ❑Vault Privy
5. PERC. RATE 6,. SYSTEM ELEV. 7. FINAL GRADE
(Min./inch) LEVATION
(j, * 8(�eet
Feet
Prefap. Site Fiber- Exper.
ConcrOte Con- I Steel glass Plastic App. structed
Septic Tank or Holding Tank
Lift Eump 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 Signatvrer (No Stamps) MP/MPRSW No.: Business Phone Number:
_ ,,,
Plumber' dress (Street, City, 'Sta4e Zip de):
1]C07COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (includes Groundwater Datelssued Issuing Age to Stamps,
[:] Approved Owner Given Initial Surcharge Fee)
Adverse Determination I
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
INSTRUCT IONS
1. A sanitary permit is valid for two-('2) years.
i
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 8399 to b } e
,submitted to the county prior to installation.
5. O.nsite sewage systems must be properly maintained. The septic tanks must um ed b` a lid n t} be p p y esed
puFnper.;whenever, necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage .system, contact your I0ca1 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.
II. Type of building being, served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling.
III.. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one 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.
Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
9
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 tank{s}, septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B} horizontal and vertical elevation reference points;
C} complete -specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
.-performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
`-required by the county; E} soil test data on a 115 form; and F} all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations, and establishment of standards.
SBD-6398 (R.11/88)
S T C - 100
This application form is to be completed in full and signed by
the owner(s) of the property being developed, Any inadequacies
will only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
----------------------- I ---------------------------------------------------
Owner of property
Location of property 1/4SU 1/4, Section T N-R,- W
(A
1lqi�? o
pia il-ing address 0
Address of site -Jr) 1� - A-); efxjx0_
Subdivision name
t�(- - _(flz Z) I X Lot no.
Other homes on property? --yes V' No
Previous owner of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? _ Yes No
Volurne4,1_/�7 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 AJ14D PAGF
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. _�_,0
ancl that I we presently
own the Proposed site f-06r, the sewage disposal, system or I (we)
obtained an easement, to run the above Cescribed 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.
na",,ire of applicant e5e!b- ant
.0
i na
Date o Signature
_Daf.-__of 'Signature
COCUMENT NO. STATE BAR OF WISCONSIN FORM 1-19$2 THIS SPACE RESERVED sOR RECOROINa OATH
WARRANTY DEED -
38070 C a
'7 ACE 46�
�MrIes
s Deed made bets _ _ �rbe.rt - T.- Koch ! ,7x' ...........
and E .' G. . Larsen
., Grantor,
andiohn .C. . Gilbert_ a,r''k/sL__Johm.Gilb.ext. and ................
Nancy L. Gilbert, husband and wife, as
. . ... ...........................
joint tenants . ................ .... ---
._.................. ...------ .-, Grantee,
Witnesseth, That the sad Grantor, for a valuable consideration.
..............
conveys to G: rantee the following described real estate in . , .. _ 5t.1. _ . Cro iX...........
County, State of W isconsizi
Lot 41, St. Croix Station in the Village of North
Hudson, Wi scone; in
RE ST '5 Ip FICE
5T.s"-''" rC Wi.
Rey:' d. r , 0hr 6 t h
: Jain. A , 83
dcy
at 0: QQ _
ftag"It'r Q4 ®wOds
acruRN TO
Tax Parcel No: ---- -------------------- ------
This Deed is given in performance of a Land Contract dated December 10, 1980
and recorded December 11, 1980 in the Office of the Register of Deeds for
St. Croix County, Wisconsin in Volume 622, Pages 391-392, Document #368263.
This .. ....... )...I1Qt_-_-. _otead property.
Together with all and sirg-ala4r the hereditamenta and appurtenances thereunto belonging;
And - Norbert. T._-.Kochz. Jr.- _ and__Charles--L.. G. --Larson ....._...---------- ................... ---------
warrants that the title is good, nuiefeasible in fee simple and free and clear of encumbrances except easements
of record and the covenants set out in the Declaration recorded in the Office
of the Register of Deeds for St. Croix County, Wisconsin, in Volume S6S, Pages
and warrant and defend the one.
-r December 82
Dated this .....--- day of - ------ .., 19._._..._.
__.... (SEAL) SEAL)
_..--- �.---- .._. ---...
NO ERT T." -�
. KOC H , JR
• ... ------ ......
) ,
..`
(SEAL) �...... -, `r'.�
C11ARLE S E . G . LARSON
AUTHENTICATION
Signatures) ------ - -- -------..-------_--_-_-- ------ ---- -----
authenticated this __.___--day of__-_.__------------------- 19------
*--------------------------------- ---------------------------------- .......
TITLE- MEMBER STATE BAR OF WISCONSIN
(If not, -------------------- -- ----------------.._..--------- ---
authorized by § 706.06, �ii :s Stats.)
THIS I"J iTRUMENT• WAS C%AF E_ D BY
_. HEYWOOD, CA.Ft..I - & - !� -
F. O. o7i ng
Ifudsanr. Wl..54016............. ..-------_-----
( Signatures may be authentleAt..ed or acknowledged. Both
are not necessary.)
ACKNOWLEDGMENT
STATE OF Wisconsin
f
St • Croix Country.
Personally came before m+= this .__- ---- ---_day of
---------------Dec-ein ex-----_---.., 1').82--.- the above named
..-------------------
-----------
Larson and as St. Croix --Station
..
......-•----.................................................... _---.---- .. :--
-- ---------------------r-=--- ` -- '- -
to me known to be the person � --------- who e+Sikeuted e
foregoing ' iiment and ck�awlede the • sarri
-�
IL
*------------- �,. � ------T 7 •-----------
NotarY public _t_* CrolxCot nty, 1.3 •
My Commission is permanent. l i f not, state expiration
date: -- ------`--_-------------........
•Names of persons wigning in as:5-s.;iart:7 should be typed or Wrin" below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wkeon-in Leval Blank Co. Ine.
FORM No. 1 -- 1982 Milwaukee, Wis.
(z')
`� ���� jam/ -� ��: y����F���.;-�m_ ._
�471SION:
4-
t
ra
nanY o 1 C S Y c*e Ur
0 1" er-
A. r Q
v;astec
matTi7e f ailure tc
pre
117 0
t t1le, I C e v c_1 r y t1l
inkping OU
'hat
b,
4
sept-ic tank pumper
V
ensed
tank a -Furp-tjon S
the Sys.,,-em can afect th A- I-P
L.- A 0
a 1 S Y's
vie wast, dis 0s tr P
t
I. -age
to
c idtabe
if
-A. rj er a n
Ct,,onty resens ny gi,).Lttwthicl,
t cosr. of replacenent
e r---
3- C) 81 4. st ix t Y a
_J u I Y -1 e -L"
(_:�rai. t' n prior tc t- I w,,,
e n. t
ugust 0+_ 1980 f wit!, t requirem
VI
T) r a in ill
to
vstem keep their S,
*-102 W agre
syster
•e t1- ioto igsubd iby to e the Stroyix
4. Tn.crees m .bCm0a1s"lI- teY-JW
thowner and
cfmsnd
a C e
plumber or
c. -y m a- n plumber,, restricted
t
Isposa
stewater d*• -7
0
the on -site wa
t 1 4*. nd
Lng con .2 a f t e 1 •nes, p e c 1-.&� - J
r t J dition and Z
c tank is less thcin 1,13 f Of
ell S a ry Sep
"JAPInl- n er, e. s,,:,
PU ;j I
.11 1 L *11 be sent approl".
-1 'ertif ication f 0M W1
I and s c u
IJ C�I 0
30 37 three year exp.Lration�*
above. recluirements 01 -A
�iave read the
:�Cc, �4
-L-da
lsposalL 'sy
private sewage d' -set by t h e, W 1:�- co s a. n N,
herein as
h c,
completed and returnec;�
ci r i'i
4 11
of
cer within. 3o days
?Ian
Ing
G 14 E D oie.
DATE:
-_,UjIty f
W
116
Page of
Wisconsin 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
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.
APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION
PROPERTY OAUER.
"I G _14
PRr)Pc:o'rv, PWIqER':S ILING ADDA
CI , STATE ZIP C DE PHONE NJjE
COUNTY
PARCEL I.D. #
REVIEWED BY DATE
PROPERTY I QCATION
Gon LOT ! 5f 1/4 1/4,S T c N,R E (or)(fW)
LOT/# BLOCK # I SUB ME OR GSM #
0 i I
[:](fIT�Y BLOCK
DOWN NEAREST qRA'D
New Construction Use Residential I Number of bedrooms Addition to existing building
Replacement Public or commercial describe
Code derived dal flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required %/,7 bed, ft2 trench, ft2
Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) lg;. ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN -GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U =Unsuitable fors stem EIS E1U �Els Ou El S 0 U El S 0 U 0 S 0 U El S 0 U
Boring #
Ground
lev.'.,
IS ' ft.
Depth to
limiting
fgor o
MOM
Ground
5mv;
/.IL4�ft-
Depth to
limiting
ft
SOIL DESCRIPTION REPORT
Horizon
Depth
in.
Dominant Color
Munsell
Motes
Qu.• Sz. Cont Color
Texture
Structure
Gr. Sz. Sh.
Consistence
l3wictry
Roots GPD/ft2-
Bed Trench
A71
1
,
" 'A 1
-7 Ypi
Remarks:
iI
AI
1A
Remarks:
CST Name: —Please Prin Phone:
Address:
/10 /70
Signature, Data: CST Number:
3
711i
*Aff I r
PARCEL. I.D.
Page, of
Ground
%lev.
Depth to
limiting
tor
.00>no
Remarks: -
Boring #
Ground
elev.
ft� tt
Depth to
liftfing
factor
Boring #
G round
elev.
ft.
Depth to
Imiting
factor
-Boring #
Ground
elev.
� ft
Depth to
limiting
factor
Remarks:
S9D-8330(R-05/92)
14
0
tve
67 P T A IN.) 1 1, 0 S S S E C
L 0
L I"
0 J E (_1 11 LU
i1-)i1zn'L 1 7 T t
M N A M E
L IC ENS E--
L 0 A 10 NJ
I.) A T E
ID
loc)-o
r
71-
as
0
.30f
Af.
FE-Sfl All), 1UL&'TS AOD 013SERVATIOt'l Pf.;?8
c1 1% 0 '"S `)'ACTION
Approved Vent Cap
Minimum 12" Ahove
90' �o
4 Cast Iron
Above Pij�e' Vent Pipo
To Final Gradc
Marsh Hay Or Synthetic Covcr,*�Ilg,
Min. 211 Ag(jrc(.j%11-
Over 'Pipe
Di s tr ibu tionl%_ T e e
Pipe
Aggregate
-,ncath Pi4: Ir! i *.:� r " i . �', ' r.
pe ('-'o u p n I T
notl-0111 cf
4
AS BUILT SANITARY SYSTEM REPORT
I -IF OWNER T2qN-P2(-'W
IU&4
ADDRESS�,_,T. CROIX COUNTY, WISCONSIN.
KV /_1 flo
:>6 AJ S,
SUBDIVISION w �- �,� LOT LOT SIZE
Jr'-/22ZZ,0
PLAN VIEW
Distances and dimensions to meet requirements of H63
BENCHMARK: (Permanent reference Point) Describe: k�'L' 'T< g
Oil- IN 049 1 I
Elevation of vertical reference point: Slope at site:
Liquid Capacity:
III
SEPTIC TANK: Manufacturer :w--:g,-(--K�,C-9-,S
7
Number of rings on cover Tank manhole cover elex anon:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons —l- capacity__
Number of gal. pump set fora
a cycle gallons,head-
distribution lines gallon: size of pump
gallon per minute horsepower brand name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Ty of warning device
SEEPAGE --Number of pits feet iameter
E E PIT SIZE:
feet liquid depth seepage pit inlet pipe -elevation
bottom of seepage pit elevation . feet.,tile depth
SEEPAGE BED SIZE: number of lines 17 width. j;3 1 length
SEEPAGE TRENCH: width I eng th
PERCOLATION RATE A AREA REQUIRED AREA S BUILT4ZL3 p
DATED
INSPECTOR a ---
PLUMBER ON JOB�,��_�1`_
LICENSE NUMBER
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit
State Septic 19P�Itqqv
A M E _/ OP D or TOWNSHIP jVel St. Croix County 001i LOOM I
.00ATION Section Lot # Subdivision S7,
�EPTIC TANK
Size gallons Number of compartments---L
)istance from: Well Building �"�Z 12% slope
—
Highwater
'LIMPING CHAMBER
Size gallons Pump Manufacturer
Size
Pumper)istance from:
ABSORPTION SITE
Bed
gallons
Well
Highwater
Number of Compartments
Alarm System
Building
Trench
')istance from: Well
Highwater-
'r S Z " 'LT i's Ir ^ 'ki el
Model Number
12% slope
Building 12% slope
Width of trench
4
f t
Required
area
47
f t
Length of each line
ft
Depth of
rock below
tile
in.
Jj
tile
in.
Number of lines
Depth of
rock over
16
Total length of lines,
ft
Depth of
tile below
grade
in.
Distance between lines.
ft
Slope of
trench
in. per 100
ft
LA
Total absortption area
ft
Type of
Cover:
i,IT DIMENSIONS
Number of pits
Gravel around
pits
yes_
no
Outside diameter
ft
Depth below
inlet
ft
Total absorption I area
ft
Area required r
ft
I.NSPECTED BY
TITLE
DATE
198
-APPROVED
?EJECTED
DATE
198
I�EASON FOR REJECTION
a
PLB 67 State and County
Permit Application
for Private Domestic Sewage Systems
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
State Permit #
County Per i #
County
A. OWNER OF PROPERTY Mailing Address:
o +4Aj Co i L 6 j--rT 2-� 1 Z
B. LOCATION: -5 '/4Ya, Section �Z , T N, R ;�ZO E (or) W Lot# _City
Subdivision Name, nearest road, lake or landmark Blk# Village CGA)
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family _);w Duplex No. of Bedrooms _ No. of Persons
D. SEPTIC TANK CAPACITY QnQ Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured -in -Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify)
E EFFLUENT DISPOSAL SYSTEM: Percolation Rate. _— -Total Absorb Area Lam, -lam--- sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth jtop) No. of Trenches
Seepage Bed: Length ,' Width ' Depth Tilt depth (top) �•�. � No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope
WATER SUPPLY: Private 2S Joint 0 Community 0 Municipal ❑ �....
Owners name as I isted on E H 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.2+0,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME4 C.S.T. # and other information
obtained from (owner/builder .
Plumber "s Signature MP/MPRSW# �'� Phone #---
Plumber's Address
PLAN VIEW: Provide sketch below of sy/stch.
lude direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on tIndicate or dimension location of all wells on the property or neighbors
property. If well has not bd please indicate.
v oTloNl �
fgkK.
98Zo`
0
0
6F-0
a
0 00 0 ---
We,
Do Not Write in Space Below - FOR COUNT �NDATE,D�PARTMENT SE �1�j
LY
Fees Paid: Stag Count D to`
Date of Application Y
Alp,-
Permit Issued a (date) _ c.'� Issuing Agent Nam •
Inspection Yes No State Valid# Date Rec'd
1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 7/1/78
EH115Rev. 9/78,
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION Y4,Section NZ- Municipality
Lot NO. f' _ ,Block No. er County Y--
Subdivision Name
s Name: =y_0 �n
rowrier*
Mailing Address:_Z'"-T t P, Q V-v vie'-_ lov% 3
TYPE OF OCCUPANCY: Residence t`�_No. of Bedrooms -COMMERCIAL
EFFLUENT -DISPOSAL SYSTEM: NEW I .�REPLACEMENT ALTERNATE SYSTEM _OT ER
DATES OBSERVATIONS MADE: SOIL BORINGS ]Ze�Q PERCOLATION TESTS Ilel
SOIL MAP SHEET '�/ 7 z
NAME OF SOIL MAP UNIT
PERCOLATION TESTS , 14,Lj i= 6 qv-cl
TEST
HOURS
WATER IN
TEST TIME
DROP IN WATER LEVEL, INCHES
RATE
NUM-
DEPTH
CHARACTER OF SOIL
SINCE HOLE
HOLE AFTER
INTERVAL
MIN/IN
2
3
BER
INCHES
THICKNESS IN INCHES
1ST WETTEDI
SWELLING
IN MINUTES
PERIOD 1
PERIOD
PERIOD
P_
P_
'Tv S-r
L�g
i if I?—
P_
P_
P_
f.
OWN
SOIL BORING TESTS
TEST
NUMBER
TOTAL DEPTH
INCHES
DEPTH TO GROUNDWATER, INCHES
CHARACTER OF SO t,THICKNESS, CO-IGR--
TEXTURE, MOTTLING AND 1DEPTH TO BEDT(OCK
IF OBSERVED IN INCHES
OBSERVED
ESTIMATED HIGHEST
B-
k'
J cm q
13-
7M 3
B-
AJ
B_
c
a
)q TL.1-0 -s-ct v.1,rj CkJ I? r 0. Cori
B-
Z) Ole% 0—o'
r
L B-
7 51: 77�
T s