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with ltH de, PARCELI.D•#
r~nent of Industry in accord but _ C p
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
!O
OWNER C 4aia RECEIVED
ADDRESS I (o G , 7-r '
(X)UN rY F,.
' NVtNGOF'Fr-E
SUBDIVISION / CSM#'LOT^'{ .
SECTION ;Z q T 99 N-R W, Town of H
ST. CROIX COUNTY, WISCONSIN 29• Z j' y3~
PLAN VIEW
C.a. SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
10
8 /.-77/
-2. 3s'
3,a7'
owl
/o 7, 143
I 8.357
9 a2~
a
/33
Ilel~9~ I
b
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
x
/Qd cn '
BENCHMARK: 47 t, 30 4 .,,A/,
ALTERNATE BM: o_v y A ,v,.• Py+ 9 3,271
Y 1,
SEPTIC TANK / PUMP CHAMBER / H8 91NC W 4F INFORMATION
Manufacturer: LO-w J,4, / L-J-a .A L, Liquid Capacity: /00 0 Soo
Setback from: Well y go'~' House 9-1N t other
Pump: Manufacturer Model# 9 8 Size !a NP,
er
Float seperation fo,S,ti~. Gallons/cycle: iq6
Alarm Location 4A."~
SOIL ABSORPTION SYSTEM
Width: o~ 8 Length 45 +
Number of t_~-`:r-c
0
Distance & Direction to nearest prop. line: a ~q ~1
Setback from: well: 133 House l q 5 Other
ELEVATIONS
Building Sewer q-15-,c(o ST Inlet: yy,/y ST outlet: q 5. 9
PC inlet 3 PC bottom 9 4, 1( Pump Off Ct ;t
joo,?(+
Header/Manifold Bottom of system_ /oo,/
Existing Grade qq, j Final grade i o a, Y 3
DATE OF INSTALLATION: 9'~8 9 7
PLUMBER ON JOB: LI) ~
LICENSE NUMBER: o17'7'710
INSPECTOR: I
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL. INFORMATION 299042
Permit Holder's Name: ❑ City ❑ Villag Town of: State Plan ID No.:
FORD, STEVEN HAMMOND 9 _
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
//mil), GC? lG~ , GJ Sp , ~~E Q 4- - 018-1064-40-0009 &g
TANK INFORMATION ELEVATION DATA A9700359
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / Gild Benchmark 3~ 93, ~7
Dosing rl 1~60 10.
Aeratio Bldg. Sewer Off/
Holding St/ I~f Inlet g5~/
TANK TBACK INFORMATIONO St/ I#f Outlet f/o' 93.0
vent to '
TANKTO P/L WELL BLDG. Airlntake ROAD Dt Inlet A, 0 3513
Septic w, V5, C~) NA Dt Bottom d
Dosing NA Man. 7,aS~~ t~• -7
Aeration NA Dist. Pipe
Holding Bot. System q/~ ,
PU ` P / SIPHON INFORMATION Final Grade
Manufacturer Ora Ieme nd
Model Number `t`( p r' d-f` r
TDH Lift ,~D Lriction,rjO Systerr. TDH Ft
oss Head
Length/7,5'1 Dia. " Dist. To Well
Forcemai n
1 2_
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S DIMEN I
SETBACK SYSTEM TO P / L BLDG WELL LA E / STREAM LEA G Ma etvr
INFORMATION TypeO At,, ~ CHA Mo
System: /
/rl~a , d >/Gave 3 a _12-70 NIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Piip~pe//(~~s) x Hole Size, x Hole Spacing Vent To Air Intake
Length Dia- Length . Dia. Spacing L+ I lkl~
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 ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HAMMOND 29.29.17.437,NW,NE 1665 COUNTY ROAD TT /
sd7'~9~/D~, Co
/97
a,., a C
Planrevision squired? [:1 Yes No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
ing ion
SANITARY PERMIT APPLICATION 20Safety and
1 E. Wasshinghington A Ave.
• `~$CO ~ 201 E. W
ve.
ns~n In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County h _
~
than 8 X112 x 11 inches in size. J
• See reverse side for instructions for completing this application State Sanitary Pe mit Number
ON
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
1'_,rV E 09 W01/4 AIE 1/4,S ;Z9 T;2.9 ,N,R/7A.)W
Property Ow er's Mailing Address Lot Number
Gty RD ck Number
O 7'7" o
Cit ,State Zip Code Phone Number Subdivision Name or CSM Number
A h'1 o h t~ ~ Syo ' S' ( >
II. TYPE F BUILDING: (check one) ❑ State Owned o ity Nearest Road
Public 1 or 2 Family Dwelling - No: of bedrooms 3 E] Tolwn OF 14A in yn ° h P C~ r T-
111. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment /Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. KNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
______System ________Sysfem_____________Tank Only Existing System _____ExlstingSystem
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 2(Mound 30 ❑ Specify Type 411-] Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Al ~D Required (sq_ ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) Elevation
/I P S f ly pts- / D 10 0 Feet to 2t 1Y,3 Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex per.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic APp
Tanks Tanks struaed
Septic Tank or Holding Tank /Cop 10".01 0 ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 1000 8Od AAAL-i- ® ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/MNo.: 11Business Phone-Number.
LX')O- fie)` Nee,k Vj, Pe LZ m3;L-1-0 A 7414- ~ a-2,
Plumber's Ac dress (Street, City, State, Zip Code):
9107 14 w to s A o b
IX. COUNTY/ EPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued I
ignature (No StampsL
XApproved ❑ ,mot Surcharge Fee)
Owner Given Initial l7~
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
It. Type of building being served. Check-only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
SAFETY & BUILDINGS DIVISION
201 E. Washington Avenue
P.O. Box 7969
1 isconsin Madison, Wisconsin 53707
Department of Commerce Tommy G. Thompson, Governor
William J. McCoshen, Secretary
August 29, 1997
ULBRICHT & ASSOCIATES
ROBERT ULBRICHT
655 O'NEILL ROAD
HUDSON WI 54016
RE: PLAN S97-02811 FEE RECEIVED: 180.00
FORD, STEVE / PAUL
NW, NE, 29, 29,17W
TOWN OF HAMMOND COUNTY OF ST CROIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters Comm 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter Comm 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
S' erely,
times Quinlan
Plan Reviewer
Section of Private Sewage
(608) 266-3937
5860R/ 1
SBD-5524 (R.07/96)
ULBRICHT & ASSOCIATES CO.
655 O'Neil Road • Hudson, WI 54016 Reg. Designers of Engineering Systems
715-386-8185 Private Sewage Consultants
PROJECT INDEX
DILHR Plan I.D. # S97-02811 Date Aug. 29, 1997
Owner Paul & Steve-Ford (Father/son) Phone 715-796-2607
Address 1554 Co. Rd. TT Hammond, Wis. 540
Legal Description A 40 acre parce. Tax Parcel # 018-1064-40
NW,NE, Sec.29, T29N, R17W
Town of Hammond County St. Croix
C.S.T. Robert Heise CSTM04005 Installer
Local Authority/ Supervision
St. Croix Cty. Zoning Dept.
PROJECT DESCRIPTION
A 3 bedroom home is being brought onto the 40 acres.
New construction. Estimated daily wasteflow: 450 gals.
Soils are permiable (.4/.5 GPD/Ft2) but seasonally
saturated at 36". A long narrow mound system, curved as
needed, using 12" of sand fill is proposed.
S 9~ 8 x RECEIVED
AUG 2 9 1997
P•0 -tonally SAFETY & BLDGS. DIV.
Cond ,I
APP Itoy-ED ,oo~ ocojv
TMENt of r
r f 1V1S10N Of SpFETY Raw IL
'n AND _ U p RICIIf
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I; ORRESPONDENCE Q • L ~ HUDSON W
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Pg.1 PLOT PLAN VIEWS
Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS
Pg.3 PIPE LATERAL LAYOUT
Pg.4 DOSING CHAMBER CROSS SECTION
Pg.5 PUMP PERFORMANCE SPECS
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G I.o FT. . S FT • Tap °F 1 .1 /1 2- IArERA IS /60.7,57
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-TOTAL I VOI DxE Of
PERFoRArED PIPE. DETAi L ,
NOIEs locATEU ox
GA ' 90-rroM 5NAli BE
1- VARiAf3LE y e CR0NI1%/ 5PACeD..
Y DIST"Nce
p 3 r r H0 Di K~ T r- R ~N .
LATERAL
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X ~uch~s FoRcE MM0
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PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS P,44E of S_
-VEWT CAP
`"C.I. VEMT PIPE WEATHER PROOF APPROVED LOCKIfJ&
JUUCTIOU BOX MAMHOLE COVER
25' FROM DOOR, W/ pj~~(~t1Jp(f 1A13EI
WIUDOW OR FRESH 12"M11l.
AIR IMTAKE
~~/1flE 1-/0 Al GRADE I 'i"MIAI. /t
I - Ib^Mlu.
I COIJDUIT
/ 7
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PROVIDE
_ _ I _
~~~jjr- IIJLET - AIRTIGHT SEAL I III
IpE I III APPROVED JOIMTS
APPROVED JOIIJT A III b~~ I II W/C.I. PIPE
1,J/C.-J. PIPE l~n~ I III ALARM EXTEAIDIMG 3'
ZXTEMDING 3 ~0 Q I II ONTO SOLID SOIL
01JT0 SOLID SOIL B
OIJ
•I I
ql'0 c
ELEV. FT.-- PUMP OFF v,6- 3 ,fAPV
OtppIA6 I BLOCK SnNI~W
RISER EXIT PERMITTED OUL9 IF TAIJK MAMUFACTURER HAS SUCH APPROVAL
SEPTIC E SPEGIF(CAT IQK S
DOSE wp-t!KS CpuCt f,-- 6 NUMBER OF DOSES: PER DAH
TAMKS MAMUFACT URER• II'L
TAMK SIZE: O Da i `t ' GALLOMS DOSE VOLUME LQ 4
~Q VEL h~>q~M INICLUDIAIG SACKFLOW: " O GALLONS
ALARM MAIJUFACTURER: //j/,
MODEL MLIMBER: ~ V p~ CAPACITIES: A= If-(e IAICNES OR CALLOUS
GALLONS
SWITCH TYPE: ~ `ep RCOrY f-t 0A t~ g = rn~" IIJCHES OR t,
PUMP MAMUFACTURER' Zo'S ' C= IMCNES OR ~~GALLONS
MODEL NUMBER: • D= INCHES OR GALLONS
SWITCH TYPE: ?wyMcr- Flo#TT- MOTE: PUMP AMD ALARM ARE TO BE
MI INSTALLED OM SEPARATE CIRCUITS
IJIMUM DISCHARGE RATE 3 d GPM -I'A,~k S~>~GS
/ FEET ,___.V__•___~_
VERTICAL DIFFERENCE BETWEEAI PUMP OFF AND DISTRIBUTION PIPE.. 4
-4- MIUIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . 2 5 FEET EAC, (A, k a~ J{
+ «0 FEET OF FORCE MAIM Y, ~F/ooFT.FRICTIOM FACTOR.. Z'S FEET t-goA 20• S
is,
TOTAL 09MAMIC. HEAD = FEET
RVUA.Iv Sy " 3 ~
INTER"AL DIME"SIOMS OF TAMK: LEKIGTH ;WIDTH ;LIQUID DEPTH
A
HEAD CAPACITY CURVE 3 7/8a .1/
4
3 MODEL 93
o 4 5/9
e
2 4
L I 3 5/B
20
a ~O + +
15
4 4 3/16
~ B
• f-
10
2 1 1/2-11 1/2 NPT
5
0
U.S. GALLONS 10 20 30 40 50 BO 70 e0
LITERS
eD 160 240
0 FLOW PER MINUTE
TOTAL DYNAMIC HEAWLOW PEA 111INTE
EFFLUENT AND DEWATENNO
CAPACI7Y 12
HEAD UNITS/MIN •
FEET METERS ( LS LMS
r b 1.52 72. P73
1 10 3.05 of 291 I
Ib 1.57 IS 170
20 6.10 25 95 3 5/16
Look Valve
c •
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Electrical alternators, for duplex systems, are available and e
supplied with an alarm. Mercury float switches are available for controlling single and
three phase systems.
Mechanical alternators, for duplex systems, are available with or IS D
ouble piggyback mercury float switches are available for
:without. alarm switches. ~
variable level long cycle controls.
i,
SELECTION GUIDE
Standard all models -Weight 39 Ibs, - +/s H.P. Inlepralfloat operated 2pole mechanical switch, no external control required.
98 Sorlea _ 2. Single piggyback mercury float switch or double plagyback mercury. float
Control Selection switch. Refer to FM0477.
Model Vphs-Ph Mode Amps Simplex Du lox 3. Mechanical alternator 10-0072 or 10-0073,
M98 115 1 Auto 9.0 1 or 1 a 7 - 4. Soo FM0712, for Correct model of Electrical Aflemalor, "E-Pak".
1 1 0 ; 5. Mercury sensor float switch 10.0225:uebd as a control activator pecify
N98 1_ Non ___qL I- D98 230 1 Auto 4.5 1 or 1 _ . duplex (3) or (4) float system- I I
E98 230 1 Non 4,5 .2%244L 8. Fcur {q hole "d-Pak", )unction box, for con
3 or 4 8 5/dDht connection or wired-in sim
-Plsx or duplex operation, 10.0002.
7. TWO (2) hob "J•Pak", lot watertight connection or and-
Wisconsin
and Hum nrtmoe t of sdustry, SOIL AND SITE EVALUATION REPORT Page ~ of
Labor Division-of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY '
-Attach complete site plan on paper not less than 8 1/2 x i stze4.W ?hest include, but
PARCEL,I.D. #
not limited to vertical and horizontal reference point (B ctio ar~/o of slQpe,`~cale or
dimensioned, north arrow, and location and distance rest r
APPLICANT INFORMATION-PLEASE PRIN r IN PRMATIR REVIEWED BY DATE
° LOCATION
PROPERTY OWNER: S7 CF?R_%
Z N,R / 7 Jr) W
v d )V 0 1/4~E 1/4,S 29 T
COUN?v VT_
PMAILING ADDRESS ~Lvfflffi ~OFBLOCK # SUBD. NAME OR CSM #
CITY, STATE ZIP CODE PHONE N ❑VILLAGE WOW r AREST ROAD
b~J New Construction Use V] Residential / Number of bedrooms [ J Addition to existing building
j J Replacement [ J Public or commercial describe
Code derived daily flow !~/-50 gpd Recommended design loading rate r 3 bed, gpd1ft2,Y trench, gpd/ft2
Absorption area required bed, ft2l1n25- trench, ft2 Maximum design loading rate I j bed, gpd/ft2 .s trench, gpd/ft2
Recommended infiltration surface elevation(s) /do ft (as referred to site plan benchmark)
Additional design / site considerations d-A ' dM in ;SY AWUkhok alVe a ib ~feLm
Parent material Flood plain a evation, if applicable, .Vft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ❑ S O U ®S ❑ U ❑ S O U ❑ S O U ❑ S EqU ❑ S ~U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tench
gk~
v- l 10a 3/a 51 I 2 f sbk P_ C s 3 f S b
'%u
4
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Ground 3 -y3 5 ii foy~jz AS, 1 T .S
elev
A13-64Mwe :518 L4,0 /y) 172 N-P We
q(7 C
Depth to
limiting
factor „
Remarks:
Boring # S, Z f A Fie C S 3f to
12-5 02 I s/ s / m s,6
3 se s/ s I C . sb k r~~ ~ •
1 Ground
elev -H b 1 7C y Z. 8 S' / A'1 ~i .3
eft. s. ' 5 /)z ec rVe . Z
Depth to .
limiting I OF s 0-
factor -
3(0 L4- W c CC /1
Remarks: C
CST Name:-Please Print Phone:, 5 - 6981- .23
Address: 3® Sr AeQDPICA ✓e tvesG. SY7S`
Signa Date: CST Number:
?/i d 0 s
PROPERTY OWNERS Al 21~z~// SOIL DESCRIPTION REPORT Page 7 of /
` PARCEL I.D. # 04- /Olo~ 7e ,
Boring # Horizon Depth Dominant Color Mottles -Texture Structure Consistence Bourd3y Roots GPD/ft .
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
'Res 73T'.5 '201
Ida
Ground 3 S 2 'y/~ / rn S~ik ~K s l ..S , fv
elm ft Y►'I'i
Depth to .5~ -40 ,S sf8 c ) S p M m
limiting
c D w
Remarks:
Boring #
mil}}
Ground
elev.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
a
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
Depth to
limiting
factor
Remarks:
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER J `fie ye ►1 e-) rcl
MAILING ADDRESS I SS`s/ Co k l)- T T
%j
PROPERTY ADDRESS G C 1'1f TT l P
1 (location of septic system) Please obtain from the Planning Dept.
CITY/STATE He, v.n m p n c1! , W Z
PROPERTY LOCATION ti w 1/4, 1/4, Section a c1 T a N-R / W
TOWN OF 1- a m m D h ~ , ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained. +
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
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 DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year ex . Lion date.
SIGNED
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8 T C - 100
+ r
This application form is to be completed in full and signed by the
-owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property ~Sf~e vin Fo f-a
Location of property k) 1/4 nJE 1/4, Section ol T a N-R_j_~2_W
-~~vh►+^or~ Mailingaddress CAD. 7-7-
Township Address of site /&L S 7' 1 11 7- 7- `
Subdivision name iU 0 NE Lot no.
Other homes on property? Yes___,~-,- No
Previous owner of property ?a L"_ ( H• r o lz Lam,
Total size of property /a 6crr{5
Total size of parcel D
Date parcel was created i S- 1'
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house) ? Yes - A- No
Volume 4-!f and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. S'Coa and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
nature of Applicant Co-Applicant
5-'7
Date of Signature Date of Siqnature
ATE. "t iF~ ~I~CU~v59iv I'LiR+vf 1982
- o17
CROIXCMVA
fju1: 15: 3991,
,.r
r ."e ro nt b ,vd
1 r r d Deeds J
r
I
k,
i