Loading...
HomeMy WebLinkAbout040-1198-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 538860 0 State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, S.15.04 (1)(m)J. Permit Holder's Name: City Village X Township Parcel Tax No:, Mudge, Thomas H. Troy, Town of 040-1198-10-000 CST BM Elev: ( Insp. SM Elev: B Description: SectionlTown/Range/Map No: 13.28.20.904 TANK INFORMATION ELE ATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Leo 4-t uw- u• for 3 cTD. 0 Do ' L 11 Alt. BM CN Aerati Bldg. Sewer Holdi St/Ht Inlet 944 TANK SETBACK INFORMATION SUHt Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / I I Dt Bottom 42, Dosing Header/Man. Aeration Dist. Pifte .O 10,10 I65- 10.00 9r. 35- Holding Bot. System 10.44, jo --10 1o. PUMP/SIPHON INFORMATION v jq-0 Manufacturer Demand St overu Zot GAIJI PM 20i 51 9~~3t Model Number TDH Lift F on Loss System Head TDH Ft Forcemain ngth Dia. ell SOIL ABSORPTION SYSTE bo Cry dt~- O BED/TRENCH Width Le h No. Tren es PIT DI IONS No. Of Pits Inside Liquid Depth DIMENSIONS 3 / &Z SETBACK SYSTEM TO P1L DG WELL LAKE/STREAM LEACHING ManufaEter: INFORMATION -M Type Of Syste t / CHAMBER OR m: J 3 1 42- UNIT Model Number: DISTRIBUTION SYSTEM L•or Header/Mani HeadeDistribution x Hole Size x Hole Spacing :Vent: to Air Intake Pipe(s) Ls LengthDia Spacing r SOIL VER x Pressure Systems Only xx Mound Or At-Grade Systems Only epth 5-P, Depth Over xx Seeded/Sodded ulched Bed/Tter Bed/Trench Edges Topsoil 0 Yes F N[,471 Yes [E] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: C 4/ Inspection #2: -~f---*--- Location: 333 North Cove Rd. Hudson, WI 54016 (Gov't Lot 3 13 T28N R20W) Bomar Heights Lot 8 Parcel No: 13.28.20.904 1.) Alt BM Description = ~•-~0.~,~G.~j1►~ 2.) Bldg sewer length - amount of cover = w~ ` Plan revision Required? Yes <No Use other side for additional information. / Z SBO-6710 (R.3/97) Da Insepctor's Signature Cert. No. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538860 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Mudge, Thomas H. Troy, Town of 040-1198-10-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 13.28.20.904 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth -1 1 DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size Ix Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia 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 Yes R No ~ Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 333 North Cove Rd. Hudson, WI 54016 (Gov't Lot 3 13 T28N R20W) Bomar Heights Lot 8 Parcel No: 13.28.20.904 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes ❑ No Use other side for additional information. Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) DIYiimm CMIW / n 1ld ,WI 5370-71M +~~rPQ~Nemf1Q(1Di1C~(edffi1 coj Sanitary Permit Applic do &MT Numbw In wwr&am 90 s Gem 8321(2., W-m Adm. Co k, boa ofab foam to the M A trait is fe"bd prior to obfmisig a saai*y permit Note: Appiie ioa fmm fw am sebmdted so the Depamment of c ommacm. AeaeW P/D ` C¢d timn atldtess) ~aooordaaCewiitie - i.aw s. 15.oA(lx~.S`his ymp"'~ now be L Ltfermatsoe-fteseft A1<%swo dm Pnope~yow~asN~e . Pmaei# a E~tq uG Pmpatty owners tAddrra 0510 - 9B - /a - as o , O 333 I/a.eT Go E D. PL A ST CR()IX COUNTY GwLLot 3 city, sty zip Code PhoBe FICE - yk Sb/ K Sect /3 u,O so.d 1✓T s 6-YO14 6 si ys- ~a~ 9 (cacieone EL Type of B03ditsg (dteek all that apply) I.ot>i T o?8 > R O >Qa~ P(1ar2FamiyDwdift-NumbcrcfBahnnms y 8 , Name DtssdmU a Block- ~v Di'1gQ /~E/~NrS eity c,( 0 Sbftownd-DescnbcUse CSMNember Tows of / /(O y - BL T"esfPansit: { ea Cempkte Gae B if appli mbb) A* 0 New System Syatcm ❑ T Tank R only ❑ Odw Btadi ioa toEmstmg System (aWlam) O P Rwewal ❑ Pmznitxev sioa ~t cb.= ofPlmober ❑rtrmitTraBStrrtorb;w Listpmvh mpan& Mpbwmd Be owner 53~~~(0= q11 v 2~/ /j rv. TYM efrown syshour-omponesmDeview all &at MptV) PNoa-PYt Is-~rad ❑ Pied In4sxmd ❑ At-C & 0 Maud>24 m_ ofsvmMb soft Mound 24 for ab1 soeT ' " ❑ HoNi%T=k ❑0dwD&peasdC.W o i ) 9 1~~/S f st~~S V. Arai bAwm ttim: Deskm Fbw Desga Soil Apply Rde(gpds€) Disp~at Area Regnned (so b /aoo DisesaiAnaPmposcd oa -4- ✓ I/ p (sk) &YMMEIC'sm ~~a3. 2 ✓ - 9y, s' VL Tank Inlb Capacity is Tout # o£ Gwkm caws thins s = a NewTaats EdsdmTanks o 0 0 m a.v er m at3 a 9 if 7Sd /oa0 /7s0 Z /ES~.c ~o.~c.~r ~ VII. Respoodbilky S eafi- the iuia , a c y far bamboa6os of tiepowTs skews oa the attneied pleas, ilumbe'sNa®a(Prnet) PhumbeesSigmte[e MP!l Number Bn PhowNuwba WM d7 - Plumbe~sAaa~(saa~c~y,Se~r.~pcoaa) me O-W Apra ❑ Disapproved PeamrtPoe 0 0 tie S, ❑ owaw Gw- mRe mfwDe=d S S/ I U ~Q 11 Co aasofAppsUReasaas LRintt ~~~x•~~u-r~i1 57336 ft-C14VXk~~ Utt~ih ~CG>;~n~ce {co wnfy) 40 2 Al t5l ~nan1 ~u - Svc ~an "Twet tirllz.Uhadmimsae SBD-W%(R tIPW) vaSd thm O2fll w N o h i i 1 u (A w a u ~ a 1 -o 4 ?t ( a `r~• ' Tt- 61 x L 7 0 ~ C A v r `t P O a h a ~ ~ ° ~ ~ ,o~ti✓6w~Y ~ ''d w n~ y a a e ~ ma`r' o o, n n R j T ` Z IEJ r\ r\ t, Zl( x x n -Q ° I s: 00 V ' ~t N l~ O _ = h C " H i w`. w IV ti 8 a A c °~1 N~~ e 11 /y N 0 ~C 1 a x~ a Private Onsite Wastewater Treatment System Index and Title Page Project Name: ~i%Orii9S t,OEBaA /~No6~ - y,da, /.>r~Qou~o ~wrs Owner's Name: Owner's Address: 333 /~/oc rsi ~ouE ~o,ro G S/ 07 y.5' - a~i 9 Legal Description: 1VE, _SA/. 13 , ?g,41 , 0?o 4✓. Municipality: Town, Verge, -c-ty of a y County: Sr' Subdivision Name: T's Lot Number: 1_ Block Number: Parcel I.D. Number: Page 1 1/A1,oE x //V&~ ~T[ E -5fyz-e Y Page 2 Lor `'~A.✓ Aol /loss- -SEC s-io,J Page 3 rle- d A~✓~ ~i~FGiF/G.~r/a.✓ S Page 4 ~oa✓r,~ a~1.✓~a `s /wwa,4t f /lo~✓~4GErrE.rr ~t,~.✓ !r it rr Page -5 11 If Page 6 Fig re,e 1 41,41., rE.+iA~ct /,✓Fo Page 7 / ~yA 1 uA j io.✓ ~E/~o~ J - Page 8 CT.oGNME.+~ rs - 150/4 Page 9 Name of Designer: ,Tox-) E~,KE License Number: lyre- o?B/3 5'G Signature: e Date: . 9 -a? 9-// _4A - Designed Ptousuant to the Following POWTS Component Manual and Comm 81-85: In Ground Soil Absomtion Component Manual for POWTS (V r. 2.0) SBD-10705-P (N.01101) ~ c. ~ ~ al a ~ ~ 1 ~ / n n1 ~ C Zl` o n. 1 p I-- IN ~x`I I n a h I a- a NO oA ~ ~ ~ Q T c o~ a n n h ~ . _ T ` ~ H a X X ~ t) H AV >o ~ ~ ~ ~ 1 r N 1 O T ~ O R14 t ti 3 a t tiC N N O N ~ e ~C 1 a x~ a 61" 42" z 84" r N m 3" ITI 46' I 4" co \ as ' -n -1 o-0 I 11 o ` i X D n 40" m D °o °c mD D m OX z -4 <n In ~ A X m m C Z Z p 0 r z z O D O o p A m O DN N D D ~z 0 ~n0 n 0 > 041> ~rm0 M>K: C) DO 00>!' > zm m z z rX Z D Z Or ~ X0 -u o rtn v j=1 D -NV in v OCun Ozm1rr-°z D Z my N~ n m_ ~m ADZ D mOp mDpo0~~ - In -I DD c rr-< O =r~ (7 ANC ,-1~c mzm m.p N O z~ = cn m z pn tnzrl I i:j <r0 moo' aW m~ Or Q D Z m O D- -4 DDS <Jtr~D DAN ~N V/ r m m -It v < 0 o ~ m ao -i In ° m -q O mvNM 000o N m aNO ~ mD Dr o Z 4 N ' m ~ QI ~m~ O p .75 o -u M-4 D mDm mo ~ ~ x m O D r nrD r p ~'rnm O 0 O ~ D r z ~O~ WOE 0' O, y O 20 1 m O Im ~~n v7 D 2 O m N In X ~ 0 Z 0 z O O < A O mr ;D n -1 z x r jo -A U) m Iv m O X Ila in 4 m X m ;u X .ZI r 0 o z c z m .'U 0 m m m m z v7 \ o = WLP750-MR MEIER C®®CIETE scALE:1/4" = 1' REV NO. DATE: rrl r SEPTIC MANUAL DRAWN BrSWT z W3716 US HWYIO. MAIDEN ROCK. WI 54750 DATE: JANUARY 2008 0 V REV. JAN. 2008 800-325-8456 FlIENAP750-MR POWTS OWNEWS MANUAL & MANAGEMENT PLAN paw A/ of . FILE 11164oMlMM SVST131 WECIRCATNM owner - _ ~C Septic Tank Capacity /6,0 7s6 . /7sa gal -D NA Ferirdt # 5 U Septic Tank Manufaeftger ~1iowers rc~.✓ 004 D NA 6 ,V ESE` LonJG.tdr6 OBI PAPA Effluent Filer Manufac ,O~Sr NA rz drorhrhhs Q NA Fffkmft Rker Model DNA blic Facility ihrits - D NA Pump Tank Capacity_ al ur (average) S!G o _ galldev Pcxrgt Tank Manufacturer- 0 NA peak). (Estinmead x 1_51- Goo Pump- Manufacturer D NA galiday Application Rate S Pcmnp Model - 0 NA gwdqy hent/Eflitrerrt (haft Monthly average' - Pretreatment Unit Arm Fats. O i & Qmase [FOG) 530 rih & ❑ Sand/Gravel Rw D Peat fiber 1360derrrical Oxygen Demand (BODY j=o vqO_ D- NA D Mechanical Aeration D Wetland 'weal Susp&*w Solids (m. :150 mg& 0 Didinfac riot, D Otlt~: Pretreated Effluent Oua Monthly average t Coats) O NA mochemicel Oxygen mmmand lmxw sio ROIL AM-Cxaacd tg:a+M1r1 a in-Ground to ed) Total Su vended Solids cm) 530 "a D NA D At-Grade (p Mound raca+ c.OWorm lgeorrret rrn1 91a`.pfr,uZOOmI . 13.l3r- -L- ine D Duran: Mahfrmrrrcn Effluent Particle Size Ya in dia. p NA- otha: - G"de- ~,>Fii 3"~c oraa u~ G ,o y~rEU' DNA otter DNA orhr: DNA 'vakres typical for donwaft waseevaaftr and mWw tank tea. Other: 0 NA Nil SCHWULE Se. rift r semi" fhmvmm y . 77. Inspea c onMm of tares At least am every; 3 rnonth fa) Owdamute 3 y D NA Oveww Pump art contents of tank(s) When cgombbu d sludge and scwn equals aid-(XI of tank volsane D NA D m ul Mal inspect dispersal odls) At least once every: -3.1R YeaK&1 man 3 years) D NA Clew efRaent Iftff At least once every: /Y month(s) DNA - - - D year(s) inapect pump, pump controls & alarm At least once every:. D mahdh(s1 .WNA D year(s) Atnh laterals and pressure test At least once every: 0 mahth s)l1 WrNA year( odcer At least once every;.. 0 0 year(s) ts1 0 NA Other` o NA tNaR11TEMANCE WASTRUCTIONS Inspections of tank and dispetga1 cam dud be made by an individual carrying one of the following c mom or certifications: Maur Plumber; Master Modher Restricted Sewn; POWTS kahec tor. POWTS Mahminer, Septage Servicing Operator. Tank am potions must include a visual inspection of the tank(s) to identify any nussing or broken hardware, identify any cracks or leaks, rinefficros the volurnne of condi ned sludge and sc urn and to check for any back up or pondmg of effluent an the ground surface. The sal cell(s) shag be visually inspected to check the effluent )buns in the observation pupas and to check for any pomling of affluent on the ground surface, The pondng of effluent on the ground surface may kwmte a faging condition and -requires the immediate ttod6 ation of the local regulatory authority. VVhen the combilmd accu ion of sludge and acur t in any tank equals one-third ()r) or more of the tank volume;-tine entire contents of the tank shall be removed by a Saptage Servicing Opera w and disposed of In aamdance with chapter NR 113, wwkx msirn Admirfratrative Code. AN other services, bm*m ing but not bruited to the servicing of effluent fibers. mechanical or pressaaed components. pretremUnent units, and any servicing at intervals of 512 mon8ua, shah be performed by a cw~ POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of concpletion of any service event: tD Fri c~ 3 3 m m m C/1 a ow o ;;v • K m S mac„ A ~i -0 I fl O oO N3ym =M„ 3 ° j s o € <~1 d ro ~'ts x o 1 0=1 e ; ° Tr mAam 25 ff 3 f o m 6 m a m m (p QT l J ~ m _ ad d ~ ~ro Q CL .3 'a ate ~30 9p 0 $3 ^mo a =<CLM L V1 m 0o -Z CL m O m 3 so S ~ r'p _ 0 m p er ' 18 _.v~® 1~+ r m m aR aO.b o /1 - fm tA to _ a ro m fl o a lb $ N ° N o c m A c 0 0 ~ -0 3• n ~0 o m - C p,Q .~i ~ N m a 3 s °~'n :r go ` 7 = ° m 3 m Sm n CL IV -7. n moo" N 77- N x (D 3 3 m n~ O O me - - - a3~x C rt rs to 9A 0 FL 3 '"`gym ~_N N n cL~ Z r,m a.roCSCm;~~9 W 7r G N p^1 M 0 a" -v n on mm m no cng g m G1 co ~rz ! cammo<O 3 Ncn. m= W N C i O ro t m iu m R.. m N m ~ >L C M n o n °o Z ~afa"'ifDg ; {7f 3 lD mom 3 ti ~F ro N O rt xo 0 tq T _ 0 ° °1 ow; a~ m L to ro N Oil cr ~°~.'x 'n N LT c ~ ~ O mn n, OF 0 mff Er zoo n Z Qt 4y m3ohs¢ JOEL 'AM ^v~roro rn r* O -0 ,C L r m 40 g~m< mcm~ / 0 z~co~ Z T p O unj~ m --q ® La m ,0 >0 0 - U w ~ 1 ® W p to ~ n U O ion C~~ U3 C: con -oz A m o Zn+~n r s q A ~ to r =5o °°Z tno~ ~T~fA tttLZttt~~LLL~~~~mmD D m n r-~ ' r aF•ris+zac 1 Gi_S CA rn co 00-7 F_4 i Z3 2261 Wisconsin Departmen f Commerce SOIL EVAAT0 EPORT Page 1 of 3 of Safe and ildin C ` t A.C.E. Soil & Site Evaluations Division ty 9sS [ accordan with Comm 85, W. Adm. ounty Attach complete sit plan on in size. Plan must St. Croix include, but not limit to: ve ee point (BM), direction and percent slope, scale rrow, and location and distance to nearest road. Parcel I. -119 10-000 oft ease print all information. Rev' ed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Thomas & Debra Mudge Govt. Lot NE 44 S 19 S 13 T 28 N R 20 W Property Owner's Mailing Address Lot # Block # Subd. ame or CSM# 333 North Cove Road 8 Plat Of Bomar Heights City State Zip Code Phone Number City I Village ✓f Town Nearest Road Hudson WI 54016 651-246-2219 Troy North Cove Road J New Construction Use: sel Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD ✓01 Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.5 qpd/sq.ft./day loading rate. Proposed system elev.= 94.50'. Boring # -I Boring Pit Ground Surface elev. 98.73 ft. Depth to limiting factor >115" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 1 0-12 10yr3/2 none sil 2fgr dsh gw 2fm,lc 0.6 0.8 2 12-21 10yr4/4 none sl 2fsbk dsh cw lfmc 0.6 1.0 3 21-27 7.5yr4/6 none Is Osg dl cw 1fm 0.7 1.6 4 27-115 10yr4/6 none s Osg dl - - 0.7 1.6 I1 Boring # - Boring W1 Pit Ground Surface elev. 99.26 ft. Depth to limiting factor >123" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots ,E 1 PD/ft*Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-11 10yr3/2 none sil 2fgr dsh gw 2fm,1c 0.6 0.8 2 11-25 10yr4/4 none sl 2fsbk dsh cw lfmc 0.6 1.0 3 25-31 7.5yr4/6 none Is Osg dl cw 1 fm 0.7 1.6 4 31-123 10yr4/6 none s Osg dl - - 0.7 1.6 i l 7 `Effluent #1 = BODS> 30 < 220 mg/L an 4 TSS >30 < 1 mg/L ' Effluent #2 = BODS S30 mg/L and TSS <.30 mg/L CST Name (Please Print) Signatur . CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 9/7/2011 715-248-7767 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 333 kOo4d located at: tj 6- '/4, 5cO '/4, Section 13 j own ,28 N, Range Zy W, Town of 771oy , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service -7L 7/2ool I I Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time:- gallons minutes Tank Capacity: Construction: Prefab oncrete r/--Steel Other Manufacturer (if known): 14;-hl a)06e,-h reCAS-6 Tank (if known): 2 J ,3 permit n mber (if known) _7~ - S rcensed Plumber Signature) (Print Name) ko, (Title) (License Number) WN.1 PRS ` 5 _ . 3 .err (Date, Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Own9~T~ '/'xt~• t~ca( 7714 mw At Mailing Address 3 3;3 ~'Lo r . Csot pap( Property Address a4"' t (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number Dti/O'1/98-/d - ©Cr0 LEGAL DESCRIPTION Property Location ~'/4 , 4~ '/4 , Sec. T 28 N R .24 W, Town of T/'Oy 01 Subdivision Plat:_ _ 130rrt 4,0-W e jq,A& , Lot # . Certified Survey Map # A10- , Volume _/44LPage # Warranty Deed # (before 2007)Volume , Page # Spec house 0}+s' Cho Lot lines identifiable yes Cam' SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Nu er drooms QI/lam Z,~J~/ SIGNAT LICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 09/07) II I l1111111111111111lII I I II I III 8034478 State Bar of Wisconsin Form 3-2003 Tx:4024949 QUIT CLAIM DEED 939961 Document Number Document Name BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between THOMAS H. MUDGE and DEBRA J. MUDGE, 08/10/2011 12:41 PM husband and wife EXEMPT#: 16 ("Grantor," whether one or more), REC FEE: 30.00 and THOMAS H. MUDGE REVOCABLE TRUST DATED JULY 14, 2011 PAGES: 1 ("Grantee," whether one or more). Grantor quit claims to Grantee the following described real estate, together with the Recording Area rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach Name and Return Address addendum): Attorney Barry C. Lundeen 110 Second Street Lot 8, Bomar Heights First Addition to the Town of Troy. P.O. Box 469 Hudson WI 54016 040-1198-10-000 Parcel Identification Number (PIN) This is homestead property. (is) (is not) Dated 2011 lc / 912A~(SEAL) (SEAL) * Thomas H. Mudge *Debra J. Mudge (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) r✓ STATE OF WISCONSIN ) (P authenticated on ) ss. St. Croix COUNTY 0~ * Personally came before me on AQccot C~ / 2011, TITLE: MEMBER STATE BAR OF WISCONSIN the above-named T;,oyy t5 I ~ACige a (If , nlurlc~Q not DQbYG authorized by Wis. Stat. § 706.06) to me known to be the person s) who executed the foregoing instrument and ac no led th ame. THIS INSTRUMENT DRAFTED BY: L- Attorney Barry C. Lundeen Hudson WI 54016 Notary Public, S6/to of Wisconsin My Commission (istoRnap,#ax).(expires: 9~Z~~~ Ot ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 3-2003 * Type name below signatures. 1 of 1 a y ~ ~PA m n M Z CO F u O F O -1_ € s 0 m T m~= fit' RS°g~ ~G) rn 1 z m ~O` 4 tinm 3m ~n €~p P R Om VJ 9~ - F I r m K Z 4a Z ; 1 y r m F m A X SI (n m C) C) x f ~s~~ i, ~i a °Ma T ~ r c ac't'\4U ' pm'U~=~y~~•,8 z ! s Rm. m f fjR ~g p a ~ F`M ~ bO g' 8 . O 1 h n ` z =a S u bD sM:s c - r ~ 6 R C 'o m o ! N ! ~ g- g1go_°o to ~gQ ' ~ 4 _4_ z Ull . - v _ ~ III ~JS h S F I E F I. i ~ ~ s~ I O \M1 O E~ G G y ~ u A - ~ mI F £m m !m m O . Y Y ~i ~I 'Exl nrac rJr;rd rzc..D ~ rrrsa~ ,ncr,. w, <c, ee •wr d ~ } i E E E t County St. Croix PRIVATE SEWAGE SYSTEM SanitaryPermit No: 538846 0 INSPECTION REPORT State Plan ID No: Wisconsin Department of commerce H TO pERMIT) Safety and Building Division (ATTAC 10-000 [Privacy Law, S.15.04 (1)(m)]• Parcel Tax No: 040-1198- RAL INFORM' Township elMap No: GENETION village vide may be used for secondary Purposes C0 904 , -Town Of SectionlTownlRang ,13.28.2 Pro -fro Personal information you permit Holder's Name: BM Description: Mud e, ThOITIas H Insp. BM Elev: ELEV. ELEVATION DATA HI Fs CST BM Elev: BS STATION CAPACITY TANK INFORMATION MANUFACTURER Benchmark TYPE Alt. BM Septic Bldg. Sewer Dosing SUHt Inlet Aeration St/Ht Outlet Holding TION vent to Air intake ROAD Dt Inlet TANK SETBACK INFOW WELL BLDG. Dt Bottom TANK TO PIL Headed, an. Septic Dist. iPe Dosing B . System Aeration r final Grade Holding TION Dem d St Cover PUMPISIPHON INFORM, GPM Manufacturer L TDH Ft 6 Model Number system Head Friction Loss Liquid Depth V TDH Lift Dist. to Well pia. Inside Dia. Forcemain Length S No. of Pits PIT DIMENS Sep ORPTION SYSTEM No of Trenches LEACHING Manufacturer: SOIL ASS Length I AKEISTREAM MBER OR BEDITRENCH Width WELL NIT Model Number: Dosi DIMENSIONS PIL BLDG Vent to Air intake VII. SETBACK SYSTEM TO plum INFORMATION Type of system: x Hole acing Jams x Hole Size plums TION Sy STEM DISTRIBU Distribution Systems Only 340 l gpacing~ Grade Sy xx Mulched HeaderlManifold pipe(s) pia XX Mound Or At- VIII Length pc Seeded/Sodded ENO Ye! . Length- Dias P ssure Syst ms Only Depth of Yes Apl Topsoil SOIL COVER Depth over Inspection #2:~I- BedlTrench Edge IX. Co Depth Over inspection #1:~ parcel No: 13.28.20 BedlTrench Center SYS7 persons present, etc.) 1 St encies, R20W) Bomar Heights Lot 8 di; COMMENTS: (Include code discrep WI 54016 (Gov't Lot 3 13 T28N as 333 North Cove Rd. Hudson, 2. All Location: as i 1,) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes URI, No EID'Ite] Insepctor's Signature inr additional information. ry o c °o, I c °o I M p 603. 03 m o 0 ~ I I o I I 0 N I I N d y I (D I o Cl) ~ I w I I ~ ~ I Z Z N a LL c LL L co O O I Q N I I I M M N N z y z y o c) E E co M0 a m a m 0 o z~ c c :3 d z :!t ° o o rn z m N~ c I c E •o 2? M 1 v L_ N 7 O d C N N C N m ~i N a co a • N cn a a (D 0 Q z° 0 z O z° m z o N z d T V L y O N y E O = y as d ~ Q C N O y n Q ca ~ G d p D D a o h p fn fA ~ p. U VO fA CO) (A a WV m co a N Z 3 N I • ~ a a as y as a s N C C d N N '0 CO M O N M J 7 00 00 p 7 co O U = O) Z = z d' O 0 O t co O O co 'p > O 'O U m c d (j m c co r 'C m ¢ z (n 1 N C co N C O Cl) O f7 O ` E tp Cl) O D 0 d Co ° c - c°i a C) l _ y y-2 c V € O ,6 o LL c M y c LL c M a~ F- c v 0 10 Z 'D ap C to 'p N 1 ` r p 'C 4' O _ N ID - (yam, N co N r ] O 2 O O N 2 N p m U L CO O tp f6 O Q M O Z N H ~L (n Q M O Z 0m 2 z f+ v~ r M dIL ma _ a A IL L a i • t~ d M m m= m= E 'E _1 A ciao 0 0 0U)0 AS BUILT SANITARY SYSTEM REPORT OWNER_,/-- ccY /Vi2TOWNSHIP SEC. _/2TAJN-R;(,GW ADDRESS. A/r,,vF leq- ST. CROIX COUNTY, WISCONSIN. SUBDIVISIONa LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 lnl-EVERYTHING WITHIN 100 FEET OF SYSTEM A+E _ X36' a it O T L4 L i Co G pro rk, _ - - j 1 I di atte Lt ~A row SCALL N I j 1._ BENCHMARK: (Permanent reference Point) Describe:,-) fro/ /~~r o _ Elevation of vertical reference point: Slope at site: SEPTIC TANK: Manufacturer:-,- Liquid Capacity: _1ho o Number of rings on cover : / Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cycle_ gallons; tots capacity o distribution lines gallon: size of pump head; gallon per minute horsepower brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & JHUIV~,AN rELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 E2 CONVENTIONAL El ALTERNATIVE State Plan I.D. Number: El Holding Tank 1:1 In-Ground Pressure ❑ Mound (lf assigned) NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Ahrens, Fred Cove Road,RR# 3, Hudson, WI -~(j_ /(>,'Dag BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEVxf~ CST REF. PT. ELEV.: NE-14 SW4, Sec. 13, T28N-R20W, Lot 8 BoMarHeights,Town of Troy Name of Plumber: MP/MPRSW No. County: Sanitary Permit Nurg4r: Anthony Zappa I38524 St. Croix 38524' SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING OV P O IDED: PROVIDE YES ONO ❑ O BEDDING: VENT DIA.: VENT MAT L.: HIGH WATER NUMBER OF OAD: 1PROPERT1 WELL: BUILDING IVEN-rTOPESH' t ( ALARM FEET FROM LINEj) AIR I L OYES ONO OYES ONO NEAREST fC~~ DOSING CHAMBER: MANUFACTURER. rjF I NGLIOUID CAPACITY PUMP MODELPUMP/SIPHONMANUFACTURERWARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP ANDC NT LS OPERATIONAL- NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) YEf ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at; a dep plowing I Fr" TH DIAMETER JMATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, constr lion sh cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDT - LENGTH. NJDISTRPIPE SPACINGCOyyf_i JINSIDE DIA.#PITSLIQUID BED/TRENCH TRIYCHES MRT RIAU r PIT DEPTH DIMENSIONS G" GRAVEL DEPTH FILL EP DISTR. PIPE DISTR. PIPE DISTR. PfP`E MATERIAL: NO. DI NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIP ABOVE COVER. ELEV. INLET. EL V. END PIPE LIN AI LET:. FEET FROM C 77 f 7L,( -.2L 3 r' NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems, to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES NO SOIL COVER TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS. DYES ONO OYES ONO DEPTH OVER E /BED DEPTH OVER TRENCH/BED DEPTH OF ,OPSOIL. SODDED. SEEDED. MULCHED: CEVR. EDGES. OYES ONO DYES ONO DYES ONO ~fiESSIJIIRIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEVATION AND ELEV.: ELEV.: DIA.. ELEV.. PIPES. DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: OYES ONO OYES ONO COMMENTS: PERMTENT MARKERS: OBSERVATION WELLS: IN UMBER OF PROPERTY WELL: BUILDING: EET FROM LINE: f DYES ONO OYES ONO EAREST Sketch System on Retain in county file for audit. Reverse Side. I SIGNATURE: TITLE: DILHR SBD 6710 (R. 01/82) ~C 1 Parcel 040-1198-10-000 09/29/2006 12:30 PM PAGE 1 OF 1 Alt. Parcel 13.28.20.904 040 - TOWN OF TROY Current FX_' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - MUDGE, THOMAS H & DEBRA J THOMAS H & DEBRA J MUDGE 333 N COVE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 333 N COVE RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 3.200 Plat: 0121-BOMAR HEIGHTS 1ST ADD SEC 13 T28N R20W PT GL 3 BOMAR HEIGHTS Block/Condo Bldg: LOT 08 1ST ADD LOT 8 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 13-28N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07123/1997 879/240 07/2311997 875/507 07/2311997 856/306 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.200 84,700 249,000 333,700 NO Totals for 2006: General Property 3.200 84,700 249,000 333,700 Woodland 0.000 0 0 Totals for 2005: General Property 3.200 84,700 249,000 333,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 123 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOWANb PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8'% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must.be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: ,ce_D A ~PE•~s' C/o .Pob.t'T i9 fps, v iPaC~ . yT3ro,v 4015 Property Location: O City, Village or Townshio: ~y County: - n~Ol - /VF /3W /,s 13 iTI N/Rl E (or C Lot Number: Blk. No:: Subdivision Name: Nearest Road. Lake or Landmark: State Plan I.D. Number: O ~Q +,Q~ nnaE (If assigned) I -VA TYPE OF BUILDING GL /'T Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY fj LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: E7'LC' VAT EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inchPROPOSED Square feet): New El Replacement ED Experimental Seepage Bed ❑ Seepage Pit t j (A /0 X ,y ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Sign MP/MPR8W No.. Phone Number: Plumber's Address: Name of Designer: 722- 116,j 0,9:r- Sr, NoRVk vPSo.~ 6t~j' . COUNTY/DEPARTMENT USE ONLY Signa re of Issuing A ent: Fee: Date: Q~ APPROVED Sanitary Permit Number: / 93 ❑ DISAPPROVED 3 Ssa y Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81) 0~ Ev 1~4 PLB (o7 - - - - - ~ ~ . _ - - MQ'r and 0o fr15 SaTION PIANS vs£p v5gp Nona. aM = N \ ~Mt ® 9R°P~ it cuoov W R£, 1Nf-hE--VT IWrA M')(7o' SEQTiG T/~E~1-yENT y 3f /o ov S E~orc I I + 'p %9 t 1304E ~y ~~~~T~T ~rR RIB vE,~r. ,P~F Pr . a Es y~ n %PE P~f0 n s r- s J~A ~P~~ ~/c U~-Tio,J = /DO,Q fr. FRED AffRENS' Lo f do /M?- 70A %S ~~'o~ J~lJ molx s ~"&NED T,4TE.. Fresh Air Inlets And Observation Pipe Sou, Te5r1P39 Sy HOMESITE TEST NG Co. ~ ~ - Approved Vent Cap RT.3► O'WEiL RCS, HUDSON, WIS. :*4016 Minimum 12° Above Final Grade M~ Above Pipe 4" Cast rr on Vent Pioe DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR &'HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ERCONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: 11 assigned) ❑ Holding Tank El In-Ground Pressure El Mound ( NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE. Fred Ahrens /o Robt. Ahrens,Cove Rd.R 3,Hudso BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: NE SW, Sec. 13, T28N-R20W, Lot 8 BO Mar Heights,Town of T oy Name of Plumber: MP/MPRSW No. County Sanitary Permit Number: Anthony Zappa 1614 St. Croix 38481 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ONO DYES ONO BEDDING: VENT DIA.: VENT MATL.. HIGH WATER NUMBER OF ROAD: [ROPERTY WELL: BUILDING: VENT TO FRESH ALARM FEET FROINE: AIR INLET: OYES ONO DYES ONO INEAREST7=t] D OSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY IV, ELL. BUILDING. VENTT FFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) DYES ONO NEAREST 30 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 7J(, T H DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH. LENGTH. N!E:O F DIST RPIPE SPACINGCOVER PIT INSIUE DIA#PITSJLIQUID BED/TRENCH TCHES MATERIAL: DEPTH: DIMENSIONS BUILDING. VENT TO FRESH GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL BELOW PIPES. ABOVE COV ER. ELEV. INLET. ELEV. END: PIPES. FEET FROM ,LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE: SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES NO SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS. DYES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED = 1 TOPSOIL. SODDED SEEDED- MULCHED. CENTER: EDGES. DYES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS I -T- MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: IND. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEVATION AND ELEV.: ELEV.: DIA.. ELEV.: PIPES. DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: DYES ONO DYES ONO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD6710 (R. 01/82) DEPARTMENT OF APPLICATION SAFETY & BUILDINGS • • INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PL13 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. yob Property Owner: Mailing Address: ~ Cd VE lQ0 rl) /9 -0 o E,t C»SO-cJ ~'1 Property Location: City, Village or Township: County: ll AVAC% 5&)I S ~3 /T2'PN/R 20E (or o 770/ S7`' ~/X Lot Number: Blk No:: Subdivision Name: NeareT7;_j Rd, Lake or Landmark: State Plan I.D. Number: 1,09 1 D ~~T7 CE (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: ~1 or 2 Family *State Approval Required. 3 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY X HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental r5?r Seepage Bed ❑ Seepage Pit 10 1113 (oJ?O 52?. ❑ Alternative (specify) ❑ Seepage Trench ~ Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Sign ture: MP/MPRSW No.: PZS) one Number: 2 14! 31AC-RS- Plumber's Address: Name of Designer. 722-- /Ll owi00'r .S'T • o,QC~i. U So.J 4,~1 COUNTY/DEPARTMENT USE ONLY Signa pre of Issuing Agent: Date: Q APPROVED Sanitary Permit Number: O ❑ DISAPPROVED Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81) Form - S T C 100 Owner of Property F,,,,e 166!'GIZS Location of Property k, Section T -N R W Township Mailing Address Subdivision Name C9'tU Lot Number Previous Owner of Property ICD Total Size of Parcel Z Z Date Parcel Was Created Are all corners identifiable? X_Yes No Include with this application one of the following: .Certified Survey Map .Deed ' .Land Contract, or .Other Vagal Document which describes, the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that 1 (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. ot~'F 1 5 (a.:? ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the some has been duly recorded in the Office of a my R 'star of Deeds, as Document No. SI NATURE OF OWNER SIGNATURE OF CO-0W ER (IF APPI.ICABLEj DATE SIGNED DATE SIGNED Saw 0 :50'W ~ • • yr 8' WALKWAY EASEME \ S~ 7.22' Qv a~ DETAIL w tV4v 6 B 0 4 CIO p R / tico cn Q~' 0~2 ~ . _ O.J.• 9 2.25 ACRES !G TOWN TREASURER 66' 1136'•>0 11TH THE RECORDS 0'9' MENTS AS OF AT OF BOMAR y 0 fla 26• '1 235°34`39" ~ 0p~' \ C~ 09° w 4I J9'5~ p0 ® 41039'05" ,00 _ g1 L M ti b 97 00" A 136.78' 4, -Y S89°20'50'W 144.00' I o ?off 7.00, Q1 ' ZO S 'WALKWAY In i EASEMENT M ~ o Oy W h N ~ 05A O M t60~23.22 ACRES 04 2^~ /143054' .gyp A # 60 $O • ; `Q 3 b - V RECORDED AS 9 ~6' G~. • . c3 N22036'E 90' N22043'40"E 1208' QP t 2 . RECORDED AS A O 6„ ~360~9 N o °W Bdt9' y2\~'L J 20, N 18 57)V 84.80 Q J~' .7. / / 136. 67' ~~dzN 880 33'W A. 1-- - 13775' 100.00 36.6 V4. SECTION '13, S88633 " E POINT BEGINNING -LSO WEST = UNPLATT'ED LANDS CIE OF COVE SOUTH LINE OF GOVERNMENT LOT 3 IX COVE S 1/4 CORNER SECTION 13 T28N, R20W A1~V£,vUM To T0NE DEPgRTMN OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IND~JSTRY„ DIVISION 76 H LA8OR P.O. BOX 6 HUMAN RE AND LATIONS PERCOLATION TESTS (115) MADISON WI 53709 HUMA (H63.0941) & Chapter 145.045) LOCATION: , SECTION: /T Z TOWNSHIP/MUNICIPALITY: OT NO.: BLK. NO.: SU~ODI VISION NAME: %r `/G TS G ~ J3 /1 Ooufl/APeE (or TxQ/I/ COUNTY: OWNER'S BUYER'S NAME: MAILIN ADDRESS: S~ ~/X AtiPENs o , 0AW-1111W1i0 AloT 3, 40 VE/~. 11UPf0A) 4011 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMEFIIAL DESCRIPTION: P OFIL DESCRIPTIONS: 1PERCOLATION TESTS: XResidence 3 A/~ New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system ✓ O ~~~r" ~~O W CONVENTIONAL: MOUND: IN-GROUNDPRESSUR : S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) _ r ,3 S ❑U S El S ❑U ❑ S/7U El $ ®U how. A/fPcv Id" -1 I o c~.eoo~, S If Percolation Tests are NOT required DESIGN RATE: 2~j t~. j' If any portion of the tested area is in the under s.H63.09(51(b), indicate:~QOM Floodplain, indicate Floodplain elevation: ~v PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED S IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- B- B- B- PERCOLATION TESTS TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER D PER INCH P- P- P- o G P-_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 7 /7Z-7#,+7Z_ /j O; is 90 ~o✓~ Q/-- SYSTEM ELEVATION /1rgg_ Exc4y&r/OAv rr. zs--~ f ` E i ~ 0 t € t € E t P E _ F 1 ~!G L©u . i DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ,INDUSTRY, DIVISION LABOR.AN,D PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCAT ON: SECTION: TOWNSHIP/MUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: N? /3 /TVN/R;"E (o TPo 3,ZAa .Mi ~7G 7`S 4l COyNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: A/U~p S t '(mot ,PERU C o ~Po6~2 i f~/f~E~f1 s r vt ~'aP • )'T 3 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DESCRIPTIONS: ER O ATItOyN TESTS: Residence 2 A//L New ❑Replace ala -00 RATING: S= Site suitable for system U= Site unsuitable for system SC! CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) pe,,(JT/O,t1~f Aj 161-1 22-69 Percolation Tests are NOT required DESIGN RATE: FT If an ~n~ any portion of the tested area is in the under s.H63.09(5)(b), indicate: ja- IdYJ`~~C1 R Floodplain, indicate Floodplain elevation: FiEGP PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHE T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / ~a 99ZG 0 0 1 0 kv ,GS .,~',6,v.G5, off' AN 7 CS ' B- Z ~~a ~9-G2, 7', Pt- ~5, 53' 1W-1-5) .so'T4N mss, SS B-3 f o f U , ( 0&~ , d • 7 ' A/-4 • GSA W- LSD • 3 ' ;r4AI 4w-k S[ B- ,0 6.0'74A1 B 110 Do.3~ >,o ar 1411. rAV,16 s 014 RA;, sue, cs . IB- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD I PERIOD 2 PER PER INCH P- il/ kiA, 5C5 so O jE- f C 114 10V P- eGyy < P- ZAd 4K P-. P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the horn zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 8070,m of *P FYe,4110;70AI S4,t Q 1,,t l EX~`}CT ~ 7/,73_`r- l x lc,-cr SYSTEM ELEVATION 112SX2i-,rL ieat- RE /.Z E i i x r 1 I i s x 1 - i 1 I t 1 x E x E i I z . x z x PERCOLATioN TESTS IIS ` RfPORT ON SOIL BORINGS 71 Poor PL.AN PROTECT D. 130MI*~ /-&1(-1,Ts DA rE - y 8 3 HOMEsITE TESTING CO. PT. 3, O'NEIL ROAD BOB ULVRjL~ AU1C SON, WIS.-.- 54016 C5T SS- 02 ye2 PROPOSED moose mosr LIE 2~ Fr. of MOR£ "OM •4L4 TEST her,45, PRo poSE D W L 1L M vyT LIE ,5'0 FT o,~ 1lD~PF F.feAl i tl T£ST ,4,PE • = QAGE'/y~OE PiT f O = EXiSrl V 6- LC~ELG 1(_ Aeve- loew-lovf f1Au,0 f~v9fiPF0 o,Q S~iDIIEL FS r ; yofiz 13M Vr,eri hl. &jFi-RtwcJ- p0jO r 'Pi f '7RE : ~T i,Po u P 7- /(pS' Fr iPai y LEGEND /t-v~rdv o~ dot APE'` f 7-. ELF a ff. P5 571 /11 RgIA(0N f w PREP' S.-A ~ s /ate yU V I j p i Q e <----.~j • ~ o ~ e Zgf ~ GIJaUf7 B _,5771 ,tlq,P~E~ W d o~ED . L 1~ 5 y -~~►l~iUf" fir" ' PLE3 ~7 ff > 4ruF wv ` wS~R~~ PLOT and CROSS SFcTjoN PIANS r ( ( ~v~ y+ct ~b ~ ~ i /oco yeQ Scpf~c L ~ ' J 001 t 3 s- , ,0P I a cpE z 13olP-- y 1'~ iTE:R►jp,-'rte A P- CA, ' ys • 7-rS7FAO f Orb /~s~aQ ~Y nf. 16 VA- rr;:w /00,071 VS e s/. fork . AIED Fresh Air Inlets And Observation Pipe 50iL TF-SrIA,5 13y ROMESITE TES11ING 1--o. Approved `dent Coo RT.43, t°'L' m I2G, HUDSON, WIS. b4016 Minimum IC" Above a Final Grade 4" Cost Iron ~2. Above Pipe