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384205 020-1164-00-000
Wisconsin Department of commerce PRIVATE SEWAGE SYSTEM safety and stAidings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personai information you provlce, may be used for secondary Purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: ❑ City ❑ Village Town of: Lukas, Bark Hudson Township CST BM Elev : insp. BM Elev : BM f�escription: C� TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing i t Fation Hoding TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. vent to Airintake ROAD Septic 7S 01 ?5 2 Z NA Dosing NA Aeration Holding ..-.— ■^ar ■ur^n&A A r1llk1 r'V'v r- J J1rr 1v■. ■■%I v■•■rir�..v.. f,`, Manufacturer Demand I[ ✓ �nt� Model Number 75--GPM TDH Lift ? `) Friction System ETDH2,0,?ft HeadForcemain Length ; Dia. ZV Dist. f[j,< County' St. Croix ��'�' Sanitary Permit No 384205 State Plan ID No Parcel Tax No 020-1164-00-000 ELEVATION DATA STATION B5 HI FS ELEV. Benchmark y �Q Alt. B 1 Bldg. Sewer S! Ht Inlet a f Z, 6 Q 9 Ht Outlet Dt Inlet Jr I l2.. q0 i I 5-0 Z. 3 Dt BottomY I'0� O Z . i0 . _ 2- Header/Man. Dist. Pipe L ie 7. Bot. System R / �S Final Grade D t Cover ,ce r,t(� s . . d 9 �. SUIT- AIIS3UKF' I IUtm , r a a r_1VI ro C L BED TREN ii ` Width Length � o' Z Z rr i ` No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth iME1+1 1 N ii•s' SYSTEM TO P! L '7 - DIME 1 N Ma a r r: BLDG WELL LAKEISTREAM LEACHING SETBACK H Mbbol Number: INFORMATION Type Z Z i -� System: DISTRIBUTION SYSTEM HeaderlMani oid DistributionPipe(s) , x Hole Size x Hoe Spacing Vent To Air intake Length Dia _ Length IZ��a Dia- Ilik Spacing ,2 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over ❑ No ❑Yes ❑ No xx Depth Of =Ieededll�dded xx MulchedBed /Trench Center Bed! Trench Edges Tnpso�l f }ection #1: /�/ Inspection 42: .� 1 o&R`nQMM��FFy[�TSS' (Inciucge6ade djjc',feanc i, e4r59L1s�[�5?�� N� ` 1/4 7 T29N R19W) - 072919963 Edoewood Estates 0I1: w Fil woo of . on, 11 I (> -Lot 33 = t1 I I � > � ° eo"rs' �ev G�✓r'Jet✓a� f P( [r 1.) Alt BNI Description 2.) Bldg sewer length = / s� �� per f I b-)4er S GU-/Ac1// -amount of cover = a S i Pdrec.� 3) 4k k4 lvert pu., ped ,m 6/7- -plo'%/ k.eed{ed 4 ;e pwYsu�,i'ai,� 4r- 7'/Z(CI Plan revision required? []Yes ONO j Use other side for additional information. Date Inspector's ature Cert No SBD-6710 (R.3197) - I.�! 0.,E [ ✓ 4,1A S ►roc n rtrv�q r w�'D s;� �,�C ( ' � QCk c 1-5�1 "� /MMERC|AL TESTING LABORATORY, INC. 14 Main Street. P.O. Box �1-' ,3m|hux.Wisconsin 5473O 715-962 3121 800 982 5227 FAX '715'982 4030 ST, CGOIX COUNTY GOuERNITS- CENTER 1lO1 CARMICHAEL RGAI HUISJN, WI 54016 ITrY! rH0MAS C^ NELSON' Coiiform @actaria/100 m` Nitrate -Nitrogen, mg/L CYW 1,64 lgio� REPORT NQ.: 43404/01 REPQir :ATE! 6/22/93 DATE RECEIVED! 6/18/93 ~ OWNER: Ewe Zanpa, Y. LOCATION: 316 Edgewwod Dr., Hudson C[LL[CTQR| M. Jom.lns DATE COLLECTED: 6-16-0 TIME COLLECTED! 2:15pm SOURCE OF SAMPL[| Gutside faucet JATE ANA070:6-18-93 TIME ANHLYZE11:11;o0am C8LlFOF11 O /100 m( INTERFIETAlIONz 8arterio/nwca/|v SAFE NITRATE-N| ' 1 ppm Above 10 ppm eKeeds the recommended Pubiic Drinking *a+e. Standard. LAD TECHNICIAN: p*m Gap* WI Approved Lab P. ` < Means "LESS THAN" Det*c+abie Me; Approved b'� PROFESSIONAL LABORATORY SERVICES SINCE 1Q53 ZXTA�� ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET a HUDSON, WI 54016 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. ❑ Water (VOC's) XWater (Nitrate & Bacteria) $185.00 ❑ Septic $25.00 $35.00 (Visual inspection) Owner: _ ,, e Z, ti _TA'Requested by: /)e-+re 1,',Im-n. Address • - e u Address • /` p0e�s+",eul City & State: City & St. _CS6A , •,i 'Zip Code; n tL41 l zip Cade, ;_Ve Telephone N-: (�Sr) '� - 9 -.{�L Telephone W: ( �7)5� ti F R k # ,y/s_ 3 F& — -q 3 V% S � Ice) Property address (Fire N° & Street) - Location: ;, ;, Sec. % , T ; � N, R_/9_LW, Town of 41V J-5o St. Croix Co., WI.� Tax ID N4�j,�1- --Varcel ID House color: &t1J r Realty firm: L cK Box Can,bo: Water sample tap location: TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Is the dwelling currently occupied? If vacant, date last occupied: Septic system installed by: Septic tank last serviced by: Previous Owner's Name(s): Have any of ❑Y ❑N ❑Y ON ❑Y ❑N ❑Y ON ❑Y ON Xyes ❑ No the following been observed? Slow drainage from house. Sewage Back-up into dwelling. Sewage discharge to ground surface road ditch or body of water. rn Slow drainage from the dwelling. -� Foul odors. Other comments relative to system operation: I certify that the above best of my knowledge. OWNERS Year: Date: information is complete and true to the SIGNATURES arc- `� r DATE: �. OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION f IN _ TO BE COMPLETED BY INSPECTION AF,NCY, J \ System design &/or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet #_ Type of soil absorption system: Velow grd ❑At-Grd ❑Mound Approx. size `X ❑Gravity ❑Dose ❑Pressurized Ft.Z ❑Bed ❑Trench []DryWell Molding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other Bdnknown Septic tank Setbacks: ❑House,, ❑Well Y ❑Prop. line _.���=-E]Other Dose tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover OWarning label ❑Pump/Floats ❑Alarm ❑Elec. wiring SoilAbsorption System �, Setbacks: ❑House ❑Well - ❑Prop. line C,❑Other ❑Ponding: - ; , c ❑Discharge: General comments: 0 INSPECTORS SKETCH OF SYSTEM LOCATION .fir. _ Inspector Title f S:C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER IkWK LU, � S �� �vf %�.C.L, 1DOA 5t'1X- - ADDRESS 3161 f 7�'�S� Gf,/.S • �5�ci' CP 377 SUBDIVISION / CSM# %�� sT�TL;c-S LOT 3 3 t3 SECTION 7 T "Z f N-R / W, Town r 17 ✓Z�)J C ST. CROIX COUNTY, WISCONSIN /"//,) O 2-0 • /ECG 0o ` dG PLIM4 VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM oU 7, . fix, INDICATE I4ORTFI ARR" Provide setback and elevation information on revorse of this form. Provide 2 dimensions to center of septic tack manh,-Ae cover. X ORIGINAL =- 10P- a BENCHMARK: r ALTERNATE BM: 7-019 0f 4�?iV 4a -e �I d /b = boo • -z _ SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer:tc11c`5e"'0 Liquid Capacity: 750 Setback from: We117/SQ House Other �y GaT L Pump: Manufacturer Zoeh1e1_f Model # Size/d Float seperation g ! « Gallons/cycle: /5-0 '� �4 c� Alarm Location %2`7 Ul( ? e 1-e C7j 1 • C SOIL ABSORPTION SYSTEM Width: 3 Length 7 $ Number of trenches Distance & Direction to nearest prop. line:y 2 2I ' Setback from: well: sy House> 6�'40 Other t 54W /'i'c T WVZL = /4.4. Z S ELEVATIONS Building Sewer ST Inlet: ST outlet PC inlet 83 • o PC bottom 757,50 Pump Off Sd 41eadertHan±fUtd Bottom of system ��� 0 7 -- Existing Grade Final grade lQ.vt/ DATE OF INSTALLATION: 2 I I PLUMBER ON JOB: �Dl3 /• /�%� ic/q LICENSE NUMBER: 3 INSPECTOR: 3/93:jt 0 /45 , RVI'Z, 7— f1 Vlbri ht 8 Asso.4i l PIN a Sewage ewal onsuttant! '55 'Neil Rd. Hud n, Wis. 5 018 i f .7np 5' W ct � co te FAIN, Fr rf , NlDL�� A 1 Safety and Buildings Division County ST per. /t 1pi�sconsin 201 W. Washington Ave., P.O. Box 7162 Madison, Wl 53707 — 7162 Site Address 31& 5,P6- ivo-oP Department of Commerce // ? d to/. S�la/G- unitary Permit Applieatio Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal info rtt>r you�mY �42OS ❑Check if Revision may be used for second ses Privacylaw, I. Application Information — Please Print All Information RFCFIvFn State Plan I.D. Number Property Owner's Name �GU,��s s awe �R �, KMAY ' " Parcel Number zo //Gy a� °��,jt.01' 2Q01 Property Owner's Mailing Address ST GRCXX 31 (e FP&& Lo o o jv J7 CP ZONNG FFtCE +� Property Location G 440 AIWIA; 7 Z` /l �,A S T N R jr- City, State Zip Code Num"ry., (% S CA) �/ S / 3 3 f 3 Block Number S yDl Y Subdivision Name gtt-I,t:,,,t,.r IL Type of Building (check all that apply) 3 ❑City X I or 2 Family Dwelling -- Number of Bedrooms — ❑Village ❑ Public/Commercial - Describe Use ;Township rL' T u O.s o D ❑ State Owned t 9. Ts - Nearest Road Lit. )type of Permit: (Check only one box on Iine A (numbering scheme for internal use). Complete line B if applicable) A' 1 ❑New 2�Replacement System 3 ❑ Replacement o�f6 Addition ro For Cotmty useS stem Tank Onl tin S stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44,1 Non -Pressurized In -Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In -Ground 41 ❑ Bolding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 44 ❑ Recirculating 30 ❑ Other V. Dis ersaUTreatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade b yo Required Proposed Rate (Gals./DayslSq.Ft.) (Min./inch) / s ©"�` Elevation 9 315 3-77 . 7 0.2 )" o �� VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septie ar Holding Tank /OMv �ESc/e .f7(2Q basing Chamber -750 .-7 Sa I I r z k VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature 4+'IPIMPRS Number Business Phone Number i�ot3gzl` T,�/6RicGiT ZZ a 315 715' - 3 �G • ftIRs Plumber's Address (Street, City, State, Zip Code) 4p.ss o' Aze ; ,L RP. 11v.PS©,j S y©/ 6 VIII. Count /De artment Use OnI Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signa (No Stamps) Surcharge Fee) PA ❑ Owner Given Initial Adverse � �J r � �� Determination J IX. Conditions of ApprovaUReasons for Disapproval t7 �t„�. 6� G �' «•ti. c- - CCI - , tom► fit-,. C Lp Amplete plans (to the Coonq oply) far the system on paper nol less then Sfl2 s 11 inchn In else SBD-6398 (R. 05101) ULBRICHT & ASSOCIATES CO. W O'Neil Road - Hudson, WI 54016 715-386-8185 Reg. Designers of Engineering Systems Privafs Sewage Coosuffants PROJECT INDEX Plan I.D. # d-------_ Owner Address Address 316e 41 Legal Description Town of C.S.T. AD, Zr1J1/'C47 Local Authority/ Supervisio � {J% x C �► PROJECT DESCRIPTIONtiCT- Alle %24. #0pse l) Date PfV 2g• .d / —. Phone 3-77- 57q!57^ County Sf X Installer �De�% �z6/ / ORIGINAL 1pgm "," sySre-", ° y 750 600 (y, Ulbdcht AssooiaN• Sewage Con�ultentg • V� �LT /� Prtvaro N411 Rd- Hu 0,, Wis. 54010 �,� / 4,.5,,t & llfplp� . „� Nonce � # 4"I0,; "x IS z _ 6 Pg.1 PLOT PLAN VIEWS Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS (REVERSE SIDE DETAILS INSPECTION PIPES & FABRIC/TOP FILL DETAILS) Pg.3 PIPE LATERAL LAYOUT (REVERSE SIDE SHOWS DETAILS OF LATERAL CLEAN OUTS) Pg.4 DOSING CHAMBER CROSS SECTION & SPECS. Pg.5 PUMP PERFORMANCE SPECS (REVERSE SIDE SHOWS PUMP DETAILS) , Pg.6.OPERATION, MAINTENANCE REQUIREMENTS (REVERSE SIDE SHOWS SITE & SPECIFIC PROJECT DETAILED INFORMATIONrUNIQUE TO LOCALE AND GOVERNMENTAL UNIT AREA) The attached plans and specifications are based on the following approved manuals: "Mound Component Manual For Private Onsite Wastewater Treatment Systems " (Version 2.0 SBD-10691-P(N.01/01) and "Pressure Distribution Component Manual For Private Onsite Wastewater Treatment Systems" (version2.0) SBD-10706-P(NO1/01). --:1 S�Z7--/ _ ��oS -v.-' �S!n7 ��1�1s `7.P�� ��dol✓ ON I ( , 8') x, � SYP''vd'dl Z') -L z 1 �Z1> /iV� PEDS 47` I S, E . L-0T S cor2N-� SC,4/E: / O 42", = yiP,4D A2 1 o/l!%tT/ows i�L-�t 1 Leo Eol l ! v 5 �3 ° -TOP VIP ' ��.SirU �. ` 1 0 A 13 co /0 1 30' i 22- C',flc u GhTEV o-45 cJj !� i Sf�INGL �J'' 1N3jg6e 7-1o� e-4P R141 Iff 1 � APPAW vE,0 T c,�V //V IWI EC7/o,o IP/A-e �-L. F�;v�s�E4 99 0 CF'o SS SEC T10,Aj W5/AU 6- /NG 7(C,4 7--0,�s it Yl*& cAP c r >r' 'S�v��vi v .i° ,1wDt5L 3 ")C G ',�2 " o,v w fA l 7 , I Y sQ Fr rfidP�'ov�p cam, iJclrt/ tLti- Sec ro,'o.v .� h►PP�ov�I� vEv T c410 Iff sc�. 40 9�PAf�L f �L i OVER: See Reverse Side for Vent/ Observation Pipe Details. An observation pipe may serve as a combination observation/vent pipe providing it terminates in the same manner as required for vent pipes. See Figure 6. - Vent cap ` Return he • Lap 17, 12" min., 12" min. Final grade, Aggregate\ � Isnibutlen lateral i :`. a"' ?':a'.. a tip•'fi'fir i:'c arasrr NP• '-system elevation Figure 6— Vent and combination observation/vent pipes Leaching chamber tops are at or below the original grade. Leaching chambers are placed directly on the bottom of the distribution cell. The locations of leaching chambers are in accordance with Table 3 of this manual. Observation pipes are installed in the distribution cells and are provided with a means of anchoring to prevent them from being lifted up. Observation pipes extend from the infiltrative surface for stone aggregate systems or from the inside of leaching chambers to a point at or above finish grade. The portion of the observation pipe below the distribution pipe for stone aggregate ' systems is slotted while the portion above the distribution pipe is solid wall. Observation pipes for leaching chamber systems are attached to the chambers in accordance with the chamber manufacturer's printed 'instructions, extend from a distance z 4inches above the infiltrative surface through the top of the leaching chamber up to or above finish grade and terminate with a removable watertight cap. All observation piping has a nominal pipe size of 4 inches. See Figure 5. ' 6" Water light cap Top of 1' min. dla. �� leaching Repair couplings chamber Slat Infiltrative surface \� H 611 I1" "lilt, Water Closet Collar Har(3/a" mim di a.) Figure 5 - Observation pipes Vent pipes, if installed, connect to the upper half of the gravity flow distribution laterals and extend up to at least 12 inches above finish grade. Vent pipes terminate with the vent opening facing downward by the ineans of a vent cap or fittings. Vent caps inust allow a free flow of air between the distribution lateral and the atmosphere. All vent pipes has a nominal pipe size of 4 inches. PUMP CHAMBER CROSS SECTIOM AND SPECIFICATIOUS p,¢ E g OF S VELDT PIPE I / 3.0 f IE UArr �, 8yo, IULET APPROVED JOINT/ IJ/ PIPE ZATEMI)MIG 3' ONTO SOLID SOIL 564.40 Poc 0 ELEV.9I� FT. VEUT CAP Pi PE 7 /D fO W/NOOCeJ, 17cb/e %�/,P /,v 1i}if� j I1'MIU. WEATHER PROOF JUMCTIOM BOX GRADE V PROVIDE AIRTIGHT SEAL 3.3 /yo,/ PUMP 1 APPROYED LOCKIM& MAIJHOLE COVER 4' MIM. i APPROVED JOANTS �II W/ PIPE ALARM EXTEMDIIJG 3' ONTO SOLID SOIL ou OFF 40 k �,J BLOLK RISER EXIT PERMiTfED okii-4 IF TAUR MAIJUFACTURER HAS SUCH 'APPROVAL �[ SEPTIC E SPEGIFICATIDIUS DOSE C /G- TAMKS MAk1UFACTURER: (DUMBER OF DOSES: PER DAS TAWK 51ZE : �S� GALLOWS DOSE VOLUME 39 % o ALARM MAIJUFACTURER: Lever �� � IMCLUDIMC, BACKFLOW: GALLONS MODEL �' L ' // 30V DUMBER: CAPACITIES: A=IMCHES OR GALLONS 2. 37�J 5WITC14 TYPE: B= INCHESOR GALLONS PUMP MAMUFACTURER: ZO� C= IUCHES OR �5© GALLONS MODEL AIUMBER:_ /`i+ IT,E, �l5 U' IL� '�GALL000G SWITCH TYPE: Pr e QACK7 D=INGHESOlt DOTE: PUMP AMD ALARM ARE TO BE GROAT MIMIMUM DISCHARGE RATE GPh1 INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFEREIJCE BETWEEkJ PUMP OFF Ak1D DISTRIBUTIOkJ PIPE.. IS. I FEET -rAA* SPECS -f- MiMIMUM PIETWORK SUPPLY PRESSSUKE✓,. . . . . .. . . . . FEETOeS y� Q �4MW + 2_Z5 FEET OF FORCE MAIM X 63 ■ FTlooFLFRICTIOM FACTOR..' " � FEET` (}S /({, %5' 1 — TOTAL DyUAMIC HEAD �Als. = I � �"3 FEET Rwtfo IUTERMAL DIME►JStOMS OF TAQK: LEM&TH ;WIDTH ;LIQUID DEPTH A 11,9 / 0 UO / U.y t- f014� 1, Le F TO 91S i � 60 VtX7 iCct-0- l i ff �E-A .wt.L 2zs F, � JI 4>06 17, 0 3 60 - SEPTIC TANK, per Comm.83.44 (2) (c) shall be equipped With an outlet attached approved filter device (Zabel fliter). Tank shall have an approved above ground locking manhole cover for regular (every 12 months or less) inspection & servicing by a licensdd service pumper. .0 ZOELLER EFFLUENT PUMP MODEL-98 1/2 NPI FLOW PER Milmu1E fe14 erM4/a NtNHInW 11d Mir W1r rrnuruf aro er..�trwMe IAIAs 11 etAtl1[ 11r1emin ,let MRrIg l It 1t7o Pro 31i Nrto re is CONSULT FACTOnY FOP SPECIAL APPLICATIONS q*PEleci►k e► allelna1o11, Ior cWplex eyslems, are available end A4#d ed whh an elerm. • Mercury Moat ewhches are avahable Ior conlro �.*1ecl+arlW& a "Chet. kd Ifu '@x eyelems, ale available whh or a pee Phase syslems, Ongle and Harm hvAches' cue Piggyback marc variable Iavel r"y Iloal ewechas an avallable for �W rycN controls. has 911ndsld ell models - Weight JY The M e•rl.. /. H.P. Med• Ain Cenhel a•leellon .lee --AWL at �—� ON Del ELF e l �LQttiL EN /ie 1 1' 1:t oar l i r _ I. McWrMl1••e►Mb+Mw bt.f rartMAbeP&Aee• Ir ly qMM IAtFLI NmeNwp�tic„�y4"i,t I. •rywPod alloC11014GWOE /..e icn. Wewbk m.rcu .,E aeel iNad, er `h' 1° •q•m.l eawof Floret so rAbe77, Pliara•ek m•refaY. flow E. M•ch•fdcolVfe"14401le001Eof 10-0014 ' 1. ee• /LMr IE, hx owr8DW nfed•1 of EIea41c•I Aeerrreler .P.k, e. duple �Nw.a By.,., 10 .ni 02ta y . •Mlrfd •cavYp � r9 �',l�l) fore "1 Pdi ", MM,eac,f Amr, lq 'Po* r. wa �R eM�•tlen, to eap7. N eOnn•caon a wAr[d In IIk py hole `4fol ; kr *� d t000' All lube.11w if r°^l, Mdrd•• CA` flan N:M Aw..l M.diN MrM.eN �RM.41� c w 64 "s I%, 1• daw ►o • F�+E• IKMf M 14 .y d le•HAe, !Ir FI[t) .M the (•wY�Mwd For unusuAl condolons a reRssrve ERVI~ 0WEpED DESIGN Y *Vlneered info 1118 dea n ig of o�ery Zoeller pump. / Min IQ•vv4 dOXIbill ir � ,���L ��� .N•/I/�7+ - lanrl.,AY 10756-OJp 1 NIP rk ) a d0 . go,, tart Ma4Wtcfura►i M.. . tal�f�: xr snare � -- _ rsor1118 2?Jr .. Mfj,502) nr.,tszr ,Quwalr/QeyArfiaW PAGE 6 REVERSE SIDE OWNER's MAINTAINCE OF SEPTIC SYSTEM POWTS (landowner) is reponsible for proper operation and maintenance of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of this system. The owner is required by code to submit all necessary maintenance/inspection reports to the controlling authorities. SPECIFIC CONTACT AGENTS * Governmental authority/ inspectors: 3 o/ * Licensed installer, responsible for providing an operation/ maintenance "Users" manual: 3 * Licensed service / inspection agent other than installer: 7R/ " 6l y 5Z, * Electrician, for pump, electric controls, wiring units: 7-Z-�i0K.eAE' c5/,2c. 6 . fps- 733C, IMPORTANT OWNER MAINTENANCE REQUIREMENTS 1. Winter traffic (sledding, shoveling, etc.) across the area shall not be permitted, or frost can/will penetrate into the cell, freezing up the system. Discontinuos use in the winter (a vacaction trip, resulting in no water use) can also lead to freeze ups. 2. Water conservation needs to be exercised! or system can be hydrolically overloaded and destroyed. This system was designed for a maximum wastewater flow of //C n gals. daily. 3. POWTS are not designed to accomodate wastes from a garbage disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. 4. If a power outage occurs, or a pump fails, it may result in a temporary overload of effluent being pumped into the cell, which may adversely impact the cell (leakhge). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts. Consult your installer immediately for advice. S. Neglect of the vegetative cover (the cells insulation & erosion preventive) can lead to failure. Compaction or heavy traffic also can destroy t he system. It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER A SYSTEM!! Effluent in the system beneath IS NOT sufficient alone t0 maintain a grass cover. 6. Periodic inspections by the owner, or his agents, is necessary. Inspection pipes and ports have been incorporated Into the system: on the mound basal area (effluent level inspection pipes), cleanout terminals on the pressurized laterals, at each tip - for flushing and cleaning the laterals out. The filter system in the tanks (via a locked above ground cover/manhole). only a licensed properly qualibied person should be performing this work which involves health & severe safety risks. Evidence of effluent ponding in the system's treatment cell shall also be regularly inspected. B . � U yes ,F M�� ��,�� s ? J E,v,✓%��-� ,�a�1�-, `� Wisconsin Deparlrnent of Commerce SOIL EVALUATION REPORT Page / of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan most County-j7 include, but not limited to vertical and horizontal reference point (BM), direction and Parcel I.D. © jGr L�, (j© Q(' percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Zo - Please print all information. sewed by Dale Personal information you provide may be used for secondary purposes (Privacy Caw, s. IS.Oa (1) {m)}. '�%a. Property Owner L �/� Property Location , / ) '] �J C/ GR C„ N/ C � / p11 J `" Govt. Lot N(Nt 1/4 N (Ni/4 S + T 2-1 N R >/ / E (o V1 Property Owner's Mailing Address Lol # Block # Sub& Name or CSM# 3/ (n 6f wooD -2e, 33 + 3 �DGEcvo�a ES %I`7� City State Zip Code Phone Numb r >t fvOsO k/, s yo�� 7is 3� yG ❑City ❑ Village� Town Nearest Road ( ) �f vds wvm�- D ❑ New Construction Use:,® Residential / Number of bedrooms ✓3 Code derived design flow rate GPD P1 Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments 9j(I'5T-1 [) (,- Sy $' % . � / and recommendations: s�7 �10 n 5-""/r,- 1'7L- ejV,00% GcfT /ti%,frT Fr>k 4e e7v r;Y ogG. / ' Boring # L] Boring � �- J `r 7 I KI pit Ground surface elev, fl. Depth to limiting factor J in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft= E%#1 'Eff#2 / a-G /o yx 3/i sG 2.,t, ile "%e175e 'fw z f s 9 Z G'30 /0 sc N 30 2, SY G 3 /7' S ,e A of ' � ion lilt Boring # ❑Boring ti 3.3 sE,4so u���Y s1-7-a-,C {A4 . ❑ Pit Ground surface elev. I ft. Depth to limiting factor 3 in. C-;l n ar .: 10-711 Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDlflz Eff#1 'Eff#2 a /o YX 2 3 S L zfsbk f cw zf s 9 27.35 eo "k a, S. D, d o as -F S % ?S 31 C z �Q ire jS USA of nrl ,�j' y t> �oY/2 1` z tnruent 81 = UVus > 3u < "U mg/L ano I55 >30 < 150 mg/L Etnuent 02 = BODs < 30 mg/L and TSS < 30 mg1L CST Name (Please Print) 1 Signature CST Number 303 &-it T' Zt'/,61Pi GG, T' 2z (.e3 "7 5 Address Date •Ev� luation Conducted Telephone Number JL zz � ?lS 3arclo -S115:1S Ir VIVIII.III u i..a.ay......�� Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 ORIGINAL jL Property Owner e . ;74pfParcel ID # 131 Boring # ❑�Boring ki a 4 q l d Pit Ground surface elev. 1 ft. Depth to limiting factor in. Page Z of / Soil Anoliration Raie Horizon Depth In. Dominant Color Munsell Redox Description flu. Sz. Cont. Color Texture Structure I Gr. Sz. Sh. Consistence Boundary Roots GPD/ffa 'Eft#1 `Eff#2 p-� /0Yf 2-/j 5& z,,., 5W " CS s - 9 3 io cz Me-rs �lGL /star -0>-/, /0Yle z- �- 5 Yl? yl G Boring # ❑ Boring e } Flo 1 / pit Ground surface elev. ' �O ft. Depth to limiting factor In. Snit Anolication Rate Horizon Depth I In. Dominant Color Munsell Redox Description Our. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDltt, 'Eff#1 'Eff#2 o-� 16W3/3 -- Z-s /,Mshe 4W b,"rR w 27F- .7 % 2 1— 6 - /O /' es -- 7 4 Z lo slt ,,�e�. -Y. X Boring # ❑ Boring n Pit Ground surface elev. tJ ft. Depth to limiting factor g in. Cnil Annliratien Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont, Coin Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/W 'Eff#1 'Eff#2 lov 2- 0 7• S G -e- C � l Z Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mglL ' Effluent 42 = BOD, < 30 n-WL and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. seaaa�olrt.6iao1 Property Owner I `�P& Parcel ID # El r Boring # J & n p;l Ground surface elev, it. Depth to limiting factor �`� in Page of 1 Soil Annliralinn Rate Horizon Depth I In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fl' 'Eff#1 'Eff#2 © /0 rl? 3/3 L S 11M 5-k 1* k -T . 7 / 2-- /o S S.di/ Z Boring Boring # ❑ n pit Ground surface elev. It. Depth to limiting factor in. Soil Anoliration Rate Horizon Depth In. Dominant Color Munsell Redox Description ou. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fl' 'Eff#1 Eff#2 Boring I I Boring # (around surface elev. ff. Depth to limiting factor In. SaV Application Rate I ❑ Pit e Horizon Depth in. Dominant Color Munsell Redox Description Du. Sz. Cont. Color Texture Structure Gr, Sz, Sh. Consistence Boundary Roots GPDltF Elf#1 'Eff#2 ' Effluent #1 = BODS > 30 < 220 mgrL and TSS >30 < 150 ri ' Effluent #2 = BODY < 30 mg/L and TSS < 30 mgA- The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. S13"130 (R "o) Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited W vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and localion and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). Sroperty Owner Property Location GovL Lot 1/4 1/4 S T N R E (or) W Iroperty Owner's Mailing Address Lot # Block # Subd. Name or CSM# ;ity State Zip Code Phone Number []city ❑ Village ❑ Town Nearest Road ❑ New Construction Use: ❑ Residential / Number of bedrooms ❑ Replacement ❑ Public or commercial -Describe: Parent material General comments and recommendations: Code derived design flow rate Flood Plain elevation if applicable GPD ❑ Boring # ❑ Boring ❑ pit Ground surface elev. IL Depth to limiting factor in. Soll Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/►t7 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDW •Eff#t •Eff#2 - tntuent 91 = M)US > aU < zzU m91L ano i ss eau < t 5u M91L tniuent uz = BUDs < 30 mg/L and TSS < 30 mVL CST Name (Please Print) Signature CST Number Address Date Evaluation Conducted Telephone Number ' �PSe&v0®D PIP.'a-Q—y- 7- 5, C= . LOT e-ore"i e-, 9� ' V /54 cFfrz�e- P175 E�lOrtT IONS T 93,a QI,d6aN� Post— �n� 7, - r A 1 20 ►'�R� � I I �4y 2 '1 ,- - � Lz FA r 12' �g'X3& �o,�pI;ANT ia� S'a� S•I' CROIX COUNTY SEPTIC 'TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer. /t 01< Z U e,Q 5 ' JE•tl v�' �O/� Mailing Address 3 Property Address City/State (Verification required from Planning Department for new construction) �QSo,,1 Parcel Identification Number LEGAL DESCRIPTION� Property Location NO '/,, �� +/�, Sec. , T N-R I W, Town of V DS'a.J Subdivision (5 p6i542,00Z CF5;7_ 7-2_ES , Lot # 33 3 Certified Survey Maly # , age # Warranty Deed # & 7 7 L Volume 1631 Page # Spec house ❑ yes CI no Lot lines identiftableXyes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic lank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The properly owner agrees to submit to St. Croix Zoning DeNrtment a certification form, signed by the owner and by a master plumber, journeyman plumber, testricled plumber or a licensed purifiper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 Adaysof�V he thr yea expi tion date. SIGNATU - APPL A DATE OWNER CERTIFICATION ' I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the ownet(s) of Athertojr"tydribed ove, virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE ****** Any information that is mis-representedmay result in the sanitary permit being revoked by the Zoning Department.""" •� Include with this appflcallon: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed EDGtD ESTATES A MMAL SUBDIVISN�N LOCATED IN THE SE V4 OF THE NE I A OF SECTION 12, T2814, MOO, AND IN THE SW V4 OF THE NWV4 OF SK � NE CORNER a TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN SECTION 12 WO ! T 29N . R 20 w O UNfLATTED LAND! E 764.37' w « NORTH LIME Of THE SW —NW N!a°O!'18"E 1133.13' 31 t t aa.0d� i4o�` _ —14l M' — 74.3« a.er"�l se 11 I� 167-.W �I _'ilV4. W �� �. A r 9, tea of ro 1$ ° $ 23 i"� 24 29 *� w = �i 30 »l 10 34 11 35 !at 0!'47'W r u !ai a!' 7'w« I r aa! '1•-w '! • w !aa°t 1.241 "w f ° �I °0s•47-w tf �, r� 1 i•183.841 iaa 1111i-w �I —i1;sue — , io1.:4• �+ ^ < « 1 Ir! « r• 1 « p I « �O I 100061 aas 1 r10-w 22 $I ; 25 pl I« 28 al s p �w 31 �I IS ; °1--1 i 1` 104.00, ° M M � �w 17 • "- ub i I�I # V + �w I wl IV�« • J : "w ° .w +J » saa i •1o"w ;.1 sat 11• -w I �� _ o. e 8 •� ' °� 171.fa' I +� °� laa.ia• 1 « + I . 033 :: I 36 « 21 I ' �0 26 '•I Iio 27 O� °; W 32 �� �•.' • :be 1 aso00, �� Iw y�9 wl •« y O� I • ti3e — « \ d 's T.aa� �1a_aa• — i444o' —1 a9.a6• Iw tQo^off _ i ` _- 17rE,. 1! - aaa 11'10-e 320.72' '15 M D D 60001 t'ia"IM 314.73' -- llffl°t t'10"1M ai .t37.� 111�a— ioi:bdr4 le?, i1S0� t'i�3b— idToo' 110.�'— — �a. wl = o�• -too, I 9 I Io 1 sa•4 '� S, � �' I � $ °�1 g o to a 1 ly �,'• I `Nb. 68 67 I I. 66 65 64 �� : 0 i 43 42 41 40 I• °1 '20 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN E ISTING SEPTIC TANK This is to certify that I have inspected th eptic tank presently serving theIQN/E „ _ residence located at: _/VU/ 1/4, ti%t% 1/4, Sec. 7 T 2-d7N, R /7 W, Towne of I! V,910^-) Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced �� D / Did flow back occur from absorption system? Yes No /4(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: /4 "6�a, Construction: Prefab Concrete X Steel Other Manuf_acurer ( i f known) : &11ES&i 4e—w6e,t7Q- Age of Tank ( if known) : ff'/o//��' • lfrl (Signature) (Title) (Date) ) Please Print (License Number) Form to he 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 certify that the tank to the best of my knowledge will conform to the requirements of ILHR--83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name_ -�aB ee—T- �t (bR rC 0e Signature /MPRS 2Z�3-2S MmFI 5 / 8 8 Ultxicht & Associates Private Sewage Consultants 655 O'Neil Rd. 14odson, Wis. 54016 e Form -STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER _TOWNSHIP &/S�f SEC. T..L_N-R_Z 2 W ADDRESS � Ike ST. CROIX COUNTY, WISCONSIN SUBDIVISION Q !I LOT j LOT SIZE PLAN VIEW 3 r Cv Gcksa� Distances and dimensions to meet requirements of I-IRR 83 I�. SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ✓e,�- F � 1 n f actl 1 �• t INDICATE NORTH ARROW BENCHMARK: Describ ertical reference point used do a)-, S ✓i� i , �� ,�,t Elevation of vertic rence point: /D, Proposed slope at site: i0 ca SEPTIC TANK: Manufacturer: &-JteSX/S C�.f? Liquid Capacity: j0-O(J 4g.[ Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front10 Side � Rear, O � S c> feet From nearest property line : Front,0 Side ,3Rear, O feet Number of feet from: wellbuilding: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE A 1 PUMP CHAMBER Manufacturer: �' Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Pump Size . Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 kit. Number of feet from well Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: `', Trench: Width: a y Leng'fh:8 Number of Lines: Y Area Built: I/5z Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,®Pt.,rcu� Number of feet from well: 7 ;5' -A Number of feet from building: '7y (Include distances on plot plan). SEEPAGE PIT Size: A�(j Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box Q'been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: I r Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front; O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Dated: Inspec• Plumber on job:ta�iv License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P•0- BOX 7969 BUREAU OF PLUMBING MADISON, Al 53707 $$.CONVENTIONAL l' ALTERNATIVE I S..tePI, I1 D Number II' nssrq�Pr1! ❑ Holding Tank Lr In -Ground Pressure _ Mound NAME OF PERMIT HOLDER Ar _ 1r1F+F 55 OF PERM.' � r I� I°a SPE CT ON DATE B & H Develo went R. R. 2 Hudson: WI 54016 -IS 6 v%�� 36_ BE. NCH MARK IP�,Ir,a,,.•„I rl lerrnce F+ci�ll DE$CRIHE IF LIFFERENT FROM PLAN '1 %REF PT. ELEV CST HEr PT ELEV SW3- NWT Sec. 7 T29N-R19W Town of Hudson, at�k34 �d ewo d N., F..�r�nr, 1""3'224' M'N S•+ N��' }.'I, ,dry RP.mI� NumL•P, Ro er Timm St. Croix 69669 SEPTIC TANK/HOLDING TANK: _ MANUF ACTJR F.H • L la',no CAPA c 11 TANK I•n I.1 I L F ��% ELEV S �� lAfan lrt,l LFT ELEV fllliALABEL ,("IDID LOCKING COVER PROVIDED It <.2 C L- �` �Y %%• �y RYES ❑NO YES _-�iVO BEDDING ':£VT DIA VENT V' I , :;u-EH NUMBER OF ROAD-�Fa�..I�cERTY L'_ HAIL DINT, VENT TO FRESM EYES G/ CV FEET FROM 75"" /, C� IWE AIR INLFT NO 1 YES LK Nd NEAREST DOSING CHAMBER: MnNIIF ACT JRER BEOUING LIZ7UIF) LnPAt:IIY ✓t.^-ar ^,tour[: I-J"';'�u�r ,., I,.. � WARNING LABEL LOCKING COWER ❑YES ONO GALLONS PER CYCLE_ [11,10 Ah.D eONT142L1 )PE RATI[i rA _ (DIFFERENCE BETWEEN _ _ PUMP ON AND OFF) ,1—YES LINO SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE aI excavation. (If soil can be rolled Into a wire, canstruct.on shall cease until MAIN the sail is dry enough to continue.) r^r1MVG1UTIr1PdAI CVSTVU, PROVIDED RROVIDED OYES ONO AYES r11\10 NUMBER OF PNI,FN*r VELL 11'.1,D' :ENT TOFB FEET FROM NE =1R INLET NEAREST�Ir .. .,..+. I;IA"-1E tE Lr '.tATI HH]L ANi)MAHKIN(, BED/TRENCH '1%1[:TI LEN NTH ., I,`,'++ Pl rse ',•I.; 1 :•. ,^.\II.i ICI'. -F1". L Ut,10 DIMENSIONS vi �f 4 PIT PIT FF T., Iv 41,'FL DE-r+ - LICE J£PTH 151 ![ P I I. T.: Ir�'1 GISTR PIPE MATEHIA, [ NUMBER CiF PHOPE F;Iy WELL HUILDING 'J v7 TO FRESH HE n -, f H',:vF CovE:[ E 1iz C I v INE I I E t/V f NI E1111 ', L FEET FROM NEAREST—�- LINF �� �S !3t?i AIR INLET mVUENU JT A I Cm: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systt�ms to make certain that it } ON REVERSE SIDE. SHOW ELEVA- meets the Criteria for medium sand. TIONS MEASURED, DYES No SOIL COVER 1Ex1,,I+! :,nr IUSSERVATIIINwtLI, I._YES �� NO ❑YES ONO €7EPTH OVER TRF%CE+HEO JLIEPTIII,vl H THENi:�+ H.-'' ]IOUIC"FE) CENTER FDGF$ YES [-N0 OYES LNO DYES ENO PRESSURIZED DISTRIBUTION SYSTEM: ,11:, T,+ LL NE, T11 NO C OF LA I H AI $PA[IN H•:,tL IJf Pit+HE ;ir.1 o1F; FILL DEPTH ABOVE OVFR BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PL, MP rJANIr rII :; LISTR PIPE 'MAN IF(;Ln MA1; i+IAI Nil f)I T11 LISTR PIPE ; II$THISUI ION PIPE MATERIAL & MARKING EI E': ELEV D I A ELEV �IP£S I:IA ELEVATION AND T.� DISTRIBUTION INFORMATION IIIIA F S1ZE HIrI E SPACINI, I I;1I 1 11„ „10 F:" , YLH VATEHIAL VERTICAL LIFT ! IiRRESPONOS To APPRQvt IJ PLANS _ _,YES NO ❑YES NO COMMENTS: PF RMANENT MARKEHSI nesFRvnnoN wEus !NUMBER OF PROPERTY WELL BUILDING (FEET FROM LINE i L YESt NO DYES NO NEAREST j it, i I t r z Sketch System an �J < Retain in county file for audit- Reverse Side. �/ �� (( UU — SIf;NATURk .....� '"�.-'. TIrL F D I L H R S B D 6710 IR.01i82) w+sconsin APPLICATION FOR SANITARY PERMIT �,DILHR (PLB67) �r oc. r cararrnl me R+`3 T rxv. i. A.'o" L. "'n "o FIE, PIT lolls OUNTY UNIFORM SANITARY PERMIT ,# 6 y416 ? —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x 11 inches in size. —See reverse side for instructions for comDletina this application. PLEASE PRINT PROPERTY OWNER / 1 MAILING ADDRESS PROPERTY LOCATION CTT'r: - 1l4 �� ��"1f4, S T�1�, N, R /j (or TOWN OF-> 74V'1L"— er?J LOT NUS/MBER NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER JBLOCK TYPE OF BUILDING OR USE SERVED X1 or 2 Family Number of Bedrooms. ❑ Public (Specify): THIS PERMIT IS FOR A; s New System ❑ Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy _. Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench !J Seepage Pit ❑ Holding Tank System -In -Fill Lj In -Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issueo 'J An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total Gallons #of Tanks Prefab. Concrete Site Constructed Steei Fiberglass Plastic / d Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ! in -Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private I Joint ❑ Public the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Vame of Plumber (Print): Signature: MP/MPT3 iw No.: Phone Number: ez LJ'x 'lumber's dress: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Pr Fee: J/©,( Date: Approved �. Disapproved L Owner Given Initial Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILEIR-SBD-6398 (R. 5182) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation, Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT STC- 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequavies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property J p 1 I )Ey t C-o t3 m Fiu T _rn1 G Location of Property _W It. Section 2 T i2 9 N - R 1 Township �WsolJ1 Mailing Address fT, 2�� Subdivision Name ao-w"d 5STf}4-LS Lot Number 9.3 w 3'/ Previous Owner of Property Total Size of Parcel M fi Date Parcel was Created .41, gxz Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house) ? Yes X No Volume !C and Page Number y'0 / as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2..,,pr Land Contract 3.- Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. -------------------------------------------- PROPERTV OWNER CERTIFICATION I We) ceAti.6 y .that att statements is on .this 6ojun ane tAue .to .the beet o 6 my (oun ) knowledge; that I (we) am (anel the otunen(a) o6 .the ptopehty desen,ibed .in this ,in6o4mati.on 6oxm, by vihtue o6 a waAhanty deed te.conded .in .the 066.ice o6 the County RegiA teh o6 Deeds as Document No. 3YF71; and that I (we) paesentty own the p.4oposed a.i', 6o)L the sewage dt4poz aya.tem (on I (we) have obtained an easement, to r • w- -0,e above described ptopenty, bon the conatnucti.on o6 said f a.na Same has been duty )Lecon.ded .in .the 066ice o6 .the County Regf. {a, iument No. 3997J5V ) L26= d -w� SIG URE DAT SIGP SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED r 1 STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT f St. Croix County OWNER/BUYER ROUTE/BOX NUMBER iCT. Fire Number CITY/STATE 'Cl ,rv01. ZIP„_.,5-qo � PROPERTY LOCATION: Skj 3%, M43_'it, Section___T 029 N, R r2 0 Town of 146 dni St. Croix County, Subdivision 0XV4 SS4rt<, Lot' number M-3V ?- improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists 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 treat - ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, €; which was in operation prior to July 1, 1978. St. Croix County k? 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 veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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 Depart- ment 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. SIGNED % DATE / y✓ C� St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715--796-2239 or 715-425--8363 Sign, date and return to above address. .11 z En H a r r a H H O z d a H t�] H O z Ch x H b Eummemkon DILHR urrm MCA SANITARY PERMIT County GROUNDWATER SURCHARGE Sanitary permit No. On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com- monly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. Signature of Issuing Agent Groundwater Fee: Date: e. - 7 DILNR SBO-7289 IN. 051941 01 Apr, DFPARTMENT OF INDUSTRY, - REPORT ON SOIL BORINGS AND INDUSTRY, LABOR AND PERCOLATION TESTS (115) HUMAN RELATIONS �H83.09111 & Chapter 148.001 SAFETY & BUILDINGS DIVISION P.O. BOX 7969 MADISON, WI 53707 � 1 o. _leaELOCATION: �t W1OU� GSTa � �S COUNTY STC�to17C `FN YLL4PMQfJT' :. 836 src-taw ST.Nam NUfts-otJ wl S•AOI(. �R..idenee UN KrMERCIAL DESCRIPTION: ` Y . A • f�Naw (�Raplaoe. ^6ibtl'T z�•••i Sm••SaePT If Percolmmo Taste we WT t1lgDkad DESIGN RATE: II any portion o1 the tasted arts is in the ♦� undwr adf63 M5)(b1. hld%M [C.t1S5 Floodptain, indicate Floodplain elevation: /Y • A w-_ PROFILE DESCRIPTIONS BSA1TUIIALRLEVATIf,M Drffl CHARACTERi NCOLOR.TEXTURE, AND DEPTH R K IF OBSERVED (SEE A BRV.ON BACK.) B- I //l /O1.(�1 NwE //.10' o-l.l I /.r- .z tWSr - Z-S CL 7.5 - 3-S &m"SL 3•S. /A 1 meal S w G4L IOT.(3 oNK S L / 0-7.o S S,L z.e- s.a N SL S.6-17.0 needs w A B.3 /a•3 ro2,zs /Ya•�►z `���.� 0-08► L o.g-z.S kNSt L xs-3.3 Se.,e L 3.3-/0.3.r..�l S �6R g.4 koNE '�-/0.00' 0-os LC o.'C-1.3 ftkNStC la -/•a at- I S StGR 3•s• /n.e. r•eo1S B-S /C1i:Ci. /pys.56' a/.I LL /•/-Z•Z L 2-2-7.4 Seats z.L• io.a S t ► be PERCOLATION TESTS WA _ dS1. .F. ..l r• -r 1 !'/-L.:.1LJ1�7-4.11.1.5=���l.I a ll:l'i a'. C•7•L� ��:IL1.7•. f��f���a.:i i•� f�f� �.. �r•� ' "LOT PLAN: Sh Mr leewtim - 61. pera0latl0n teau, 1011 borings wed the dimmsiorn of suluMe wil west. Indicate scale or distances. Describe what are the horn :otmN and vwrtlae# wlatw,tlott nlwwtta 0-11 wed show their IOCwtic on the plot plan. Show dw surfaca elevation at alt bodrtpe end the direction end percent at land 810pw. BY8TEM ___....._... _ ....5... �w OIETINEIJTIONt tlri/Mrl fatd om ism to Low Authority. property Owns and Boll Taster, 0 2 D 2 O b m r m m r n m x C7 G m -4 m r z c � O m < m v m i `I v v o m m ROHL & TIMM EXCAVATING 310 Arch Street • HUDSON, WIS. 54016 } • (725) 386-8664 JOB 'Ile/Q1r2 SHEET NO. CALCULATED BY rt'6 �� ��-�"�`� DATE yl/y��` -dS CHECKED BY DATE _ ��Z"2 SCALE PROW 2%1 ees, Inc.. &-ft. Wa 01471