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HomeMy WebLinkAbout020-1326-50-000 -0 a o ° o N ° r~ p 0 °U3, 00 oq o 0 o ~ I I `V (D I I N U N L ~ C O N ~ N O N C N Z c Z LL co c E LL O 0 a v n 0- > Q co N Q I I co O M O V z z N O E E Z oo o a I! £ i £ Z L a a m a m j c o v O z Z ? c c U~~ O N N 4) O Z V C c ° c (D E E '2 -O 0) v rn co ` '-°O N a O N O- O VJIUl N O 3 Q) :3 CD (D C N N N L' L N L L O c C = _ U O Q O Q O Q c= io Z 1- Z z H Z N z OO ~ d d 0) A5 1 - ` _ m _ N CL 1 (0 (D co N N c y d c 0 0 c o C e a o o O G n. o c~ m co ~ U) U) H c0 ~ f N _O Lo H O ) w N ~~yy 0 0 0 a 3 0 0 z •i X 0 0 O X 0 0 O • ►v a a a a a a 0 0 tq J U S z 2 rn 0) 0) rn z M~l j CO ? N O O N > -0 > E E o c, E o co v E c0 ^ m m d m N 0 (D ^ N Q m N N "21 2 ,~j • c o Q z o c Q>- r) m o 00 ❑ m e v w c 'a 04 c c ° O d rn 3! ONO ° to c co d °w a ° 0) f CO O O N N O C I" m N O O N U) C O O 7 co iC ~ O N a n F- N w~ L '=V! N° 0 N E o ° 0 N o E m 0 • O S j N O N L9 Z N O N Z ate,. (n r r\ I = = I V ~ d Ea I Ea ° yaw Lai, 0 CL 7j; 4) C O m v O in ci 1 A 0 as STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SA YV\ (V'k k L, L- 1 (L._ ADDRESS_ U-) SUBDIVISION / CSM# LOT # 6 SECTION T ?'7 N-R Town oft (c f' ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHI.,G,.,WITHIN 100 FEET OF SYSTEM GL ~p?E: fps o~ 7- zY-97 l 6AeR~~ WELD (w c c N o ' r " Y T T ss To 0"1- -a A)a"T pd 1'6 C7, Lou LT5/Z /VA i i I V ©k 1CAU e Soc rE'sf - INDICATE NORTH ARROW ~oaN ~Erl hi ^~DN D Provide setback and elevation information onse o this form. Provide 2 dimensions to center of septic tank manho e cover. ALTERNATE I3M: - Q SEPTIC TANK' PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:` lv F I Liquid Capacity: I Setback from: Well er House S Other ?c, a `~71 Pump: Manufacturer :Model# Size Float seperation_ Gallons/cycle: - Alarm Location SOIL ABSORPTION SYSTEM Width:, J /Len th g Cam, Number of trenches Z.. Distance & Direction to nearest prop, line: or, T<> c~J~ ~ ¢ Setback from: well: 7 S ' House Other ?k I ITS ELEVATIONS Building Sewer ST Inlet:• T$ outlet: 9 ,jo PC inlet J PC bottom Pump Off Header/Manifold Bottom of system )Z,00:7 j 00 Existing Grade 'l . S ' Final grade 7 f 9 -7. GATE OF INSTALLATION: PLUMBER ON JOB: h(- ✓ D LICENSE NUMBER' i~C2 INSPECTOR: 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division ST. CROI X INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanita289*5V.: Personal information p you provice may be used for secondary purposes [Privacy I!, s.15.04 (1)(m)). PILLS der sJ~larpe. (A~rS@jyillage Town of: State Plan ID No.: CST BM Elev.: SAM Insp. BM E ev.: 77 cription: Parcel o&2(5o.:13 26-50-000 TANK INFORMATION ELEVATION DATA A9700270 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/,~ff Inlet-~' TANK SETBACK INFORMATION St/ I,-Y( Outlet Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System /~"ate o ' PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 6. Model Number GPM TDH Lift Friction System TDH Ft oss Fmead Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Typeo CHAMBER Model Numer: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake 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 El Yes E] No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.12.29.19,SW,NW 824 MOON BEAM WEST LOT 68 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division r~~~~■~Ifn' SANITARY PERMIT APPLICATION BureauofBuildingWaterSystems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches insize- _ C/'o j • See reverse side for instructions for completing this application State Sanitary Permit Number ~T4_ The information you provide may be used by other government agency programs Check if revision to previous application IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ~14 W_ Foe_ S(,v1/4 U) 1/4,S l Z T Z.9 ,N,R/ E(or W Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or C5M Number Ho O5 J t4 Ul r fQ l ( ) Z *7&17 -Tip N( ff >e U Z 11. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms C] Town VillageOF V l7 SO 00111 Vb( R III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 / S d 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. Ip( New 2. ❑ Replacement 3. Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an 7_-System System Tank OnlyExisting System Existing System 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Df 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 L r Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) F Elevation 1 $ (o '5 cos - --r Feet Feet VII. TANK Capacity gallons Total # Of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete con- steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank [2 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) P lumber's Signature: (No Stamp MP/MPRSW No.: Business Phone Number: T Mj _ C i► f \ .pd N E i, t- Z Plumber's Address (Street, City, State, Zip Code): 1010 vKt'£rc_. A(c)(CFE 01 1-1) A- fl 14 Id D~ UJI IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Ag nt Sign ture (No amps Approved E] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: S110-6398 (R. 05/94) 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 maybe 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, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. If. 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 13 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. lop, W F L t o E'tlaF I,~ ? ire r 1 173 1 J r " / 4 d x 4\ i / f i ell, x O VI W j (a 'N o "x N '44 LN . a I M I I a t I I w { a Q a t~ F-- t CL . I W Q ' I i I i♦" Al) a m ~ J 11: ~ ~ ~ I h i > I ie I Nil Vi a Visconsir) Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor a z Relations '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 11 inches in size. Plan must include, but 4: m I not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION MK-be GOVT. LOT 5W 1/4 /JLjl/4,S /2. T Z9 N,R /q E (or) W PROPERTY OWNER':S MAILING ADDRESS L TT # BLOCK # SUBD. NAME OR CSM # G1 Y CITY, STATE ZIP CODE PHONE NUMBER []CITY ❑V LLAGE MOWN NEAREST RO D [p~J New Construction Use [o j Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd$ 01 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 0_7 bed, gpd$ 0.8 trench, gpd/ft2 Recommended infiltration surface elevation(s) TSr~lt~1EEA) 9(.0 AKA 3-0 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system C NVENTIONAL M UND IN-GROUND PRESSURE AT-GRADE SY TEM IN FILL HOLDING K U= Unsuitable fors stem S ❑ U S❑ U La S❑ U KS El U I~S ❑ U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bourtary Roots GPD/ft Boring # Horizon in. Munsell Cu. Sz. Cont Color Gr. Sz. Sh. Bed Trench o.s - - S L Yh b K r S I n, LA_ $ r7-21 1,6YA sz 1 m-s 6 t 1 - 64 0. Ground 6/-4S- k4li - Si L b ~r CL3 -Z .3 v. FS" ft. $ S /tit W O. to B -/3 VA 4/4 C~ r,, r M - 4. 16-S limiting factor >11-Dg Remarks: Boring # A - l~Y~2~ S L rhr C S Z 4` O S' Z . $ IA-2-2 3 r; - SL 6< /-V o.~ -3/ i ~ 4 1A 1 bK f~ v~~ s - o.z 03 Ground Weth $3 6/_ f n,►W 16.7 U.~C ft to 8 -13 / m r rh - 0.7 le 124 limiting factor Remarks: CST Name:-Please Print 4 P, s \ 14NSc4r4 Phone: Address: Q 86x u Q SV W Signature: Date: S 4 CST Number: PROPERTY OWNER /'//LL £4 SOIL DESCRIPTION REPORT Page Z-of . PARCEL I.D. 4 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 0 1 - Ground elev. ft Depth to limiting factor Remarks: Boring # a: A 0-16 16 Yoe 2 SL n7 SbK Mh rr S o 4 lo"! 3 , $ -2Z Ip - SL rn Sb n,~'r S 1 0.416 -S Ground 2Z"3r; Di' 4 L rh bK %S - 6a a3 elev. 8 3K-2 10Y 4 /DD •2 ft. Depth to limiting factor > /D 4Z Remarks: Boring # Ground T -rN t AA D4 is C t?, elev. P ► L IrIG t T ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) -Ao y~y V D P 2 ~ m N \ d 0 i 311 ++=3110b,SZ.90S • ~ 8L'8L£ L - 0~ I N 04 (A b N 8 ;8I I a p , 1 + I ` .00 00, f / N N T- N co $ 'U + \ ~9~, ' K~ ~ N N T ~C i Ir- W po a, 3 T 1L7 , W 21'£56 M„60,80.OON N z ►/IMN 3N1 !O ►/IMS 3N1 dO 3NI-I 1SV3 aaF UNPLAiiED =ANDS va as 1z ra IV1,313 I" Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: f aboeandHuman Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division ` (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284302 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1326-50-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM INFORMATION TypeO CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake 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 ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.12.29.19,NW,SW MOON BEAM WEST LOT 68 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. r~ ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: and ff BuiluildinWateing Water Systems v?I~~ir■r~ SANITARY PERMIT APPLICATION Bureasafetyu o o ri 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. , • See reverse side for instructions for completing this application State Sanitary Permit Number 2 Yy,3©a The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location q S"+/jr1 6 N 0)1 /4 S 4() 1/4, S 1 Z T Z 9 , N, R / E (o Property Owper's Mailing Address Lot Number Block Number MC~ __j Cityy,, State Zip Code Phone Number Subdivision Name or CSM Number l'Fc) ~i .~l titJl ScfUl~n (18(e) 7-7(49 TAKAtE.Y 2\Dto II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms Towan OF PL) III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) O z~ - f 3 ZCo - So 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. Y9 New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting System Existing System 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 [4 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 ~SQ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation S_o3 (00C • g 79 (o Feet V/,0 Feet TANK Capacity . Fiber- Plastic Exper. VII. FORMATION in gallonTotal # of Manufacturers Name Prefab. Steel New Existin Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank /000 ) wE /S E t2 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. 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/MPRSW No.: Business Phone Number: m M-f D in wru-, -Z To N, NIP Z_ Plumber's Address (Street, City, State, Zip Code): d 0 E f1 So ttI W l O l IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa tary Permit Fee (includes Groundwater ate Issued ilssuingA nt Signa re (No St ps Surcharge Fee) d ❑ Owner Given Initial -A j Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings 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 concerningyour onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one 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- V11. 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. e ~ ~}G~NQs. 11 T~ x ©2C- I'32G,-So U / lyoef-H LoT Z-/,yE LoT v a$XSD 3,v~ Ilk a ~ v ~~l q0 4, ~~o o loop tee ~ ~ . ~ VT` S~ 'yam \ l' B-y / X10 c~ \ ~2 ~ 31M C ~a~ 1' Ll I c7 fi i I O u i rV p I _ M I ~ I I N -o I m I ~ I ~ I r I Ri I "A o. I I 'v m LI I Z 41. u I Z I I I m - N Or -tz w ~ -11) rr 1' 1 -c o Z o Fn ~0 0 i ~ O z rt -P - Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of s Labor and Human Relations pivision of Safety Buildings in accord with ILHR 83.05, Wil"54 COUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.,,~v Must include, but ` not limited to vertical and horizontal reference point (BM), direction and °/j sf(ope tear PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMAT t rRE1AJIEWED BY DATE PROPERTY OWNER: -,PRO J:RfY LOCATION Sam Miller GOVT. LOT 114 fi/4,S 12 T 29 N,R 19 E (or) W PROPERTY OWNER':S MAILING ADDRESS t BLOCK # SQBD. NAME OR CSM Trout Brook Rd. -2nd Addn to Tanne Rid e CITY, STATE ZIP CODE PHONE NUMBER ❑ fTYe_,aIELAGE.4gOWN NEAREST ROAD Hudson Wi. 54016 ( ) Hudson Tanne Lane [ ] New Construction Use[ ] Residential / Number of bedrooms Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate Oij_bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate Q.-' bed, gpd/ft2 ®,S trench, gpd/ft2 Recommended infiltration surface elevation(s) - - - - - ft (as referred to site plan benchmark) Additional design/ site considerations Soil evaluation done for plat approval. Parent material Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING T K U= Unsuitable fors stem 14S O U 0S ❑ U loS ❑ U WS ❑ U S❑ U ❑ S ITTII SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bairdary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tretxct 1234 16',/e4 4 5, L ,M 5b4~ m~'r s z Ground 4 3 S r m 0- g elev ~,1 ft Depth to limiting fact r Remarks: Boring # 6 i 67Z 6.R o.5 ~z ~ayR 4 4 5 m rho s 10,14 Ground AIM elev. 193 /n r m / %Lj~ It. Depth to limiting yf~t-~ Remarks: CST Name:-PleaHarve G. Johnson Phone: 386-4080 Address: p O. Bo 91 Signature: Date: Oct. 96 CST Number: 3484 PROPERTY OWNER SOIL DESCRIPTION REPORT Page? of. PARCELI.D.# 6% Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence 7Bwxiay Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ranch 1,3 A m ,S l7 yR 4 4 rn she- m ,p. Z 3 Ground 4/4 S L- f M, (,J Q elev. <96b ft. -134 /byre 413 10. Depth to limiting factor Remarks: Boring # A 6-19 16-W,31 ~ - / M,s Y, rn ew 11~n I m A4 m"G c bo - Ground -8-, j 1 d'l.2 4 4 - S L I m~ W_ d .4 $elev 6/-IZ4 1D`/Q4 3 S FYI ~.7 D. Depth to limiting factor Remarks: Boring # _ 0-14 /byQ3 Z t, mSICK mJr e-75 1 6. QS 16yk4 3 S,Z srok prnli~ cs r d.2 4,3 a~ Ground /DyO,4 ~ " ni 0.7 6% I COL ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: con oooni~ nSioo~ M P `a ~ o s 1 CL V'o i i j \~h i~ d / -Z rg~ S T C - )0 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 S'AM 11141_~IL- Location of property_&~2 l/4 S tJ 1/4, Section TN-R / W Township /-{VDS o Mailing address c>X #Z~Z= a.Se(N:_ Address of site 1'24 A1o0,1 g FX1n WFS7 Subdivision name V/►/65e A l p!oE Lot no. 699 Other homes on property? Yes No Previous owner of property ?P(AlbAte- S //V.4N Total size of property 3 . / 7 A e- Total size of parcel 517 L_ Date parcel was created -7 - / - 93 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? X _`'es No Volume 10.2 1 and Page Number Y C -C- as recorded with 1A a Register of Deeds. INCLUDE WITH THIS APPLICATION '"T`E FOLLOWING: A WARRANTY DEED which includes a DOCUMENT LUMBER, 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-0 qT S'.S- and that I (we) presently own the proposed site for the sewagf- disposal system or I (we) obtained an easement, to run the abov described property, for the construction of said system, and the -me has been duly recorded in the office of the County Register of Deeds as Document No. So ygss 0 k( ature of Applicant Co-Applicant Date of Signature D-'.e of Siqnature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT SL Croix County OWNER/BUYER S_/4/r /YI l C MAILING ADDRESS $D XZ ~Z PROPERTY ADDRESS R Z f~- A100 H k F6r W>=ST- (location of septic system) Please obtain from the Planning Dept. CTTY/STATE H 0 L> S<* Uj ~ SV d /E PROPERTY LOCATION 1/4,_s 1/4, Section / Z-- T 2- 9 N-R TOWN OF NVbSO M , ST. CROIX COUNTY, WI SUBDIVISION T/WAI, ~ Duo , LOT NUMBER j6t_ CERTIFIED SURVEY MAP SS-/ 6 3-S-. VOLUME (o PAGE 7-S- , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: y~ j S = q7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 i I • ~ - DOCUMENT NO. STATE BA F WISCON$I ORJd 1-19112 *"1s .1.. •tst"vto ,o" ateo~eo1"a owrw ' ARRANTY D D 504855. r_i 103ipmE456 _ ' r._CISTrR'S OF1CF This Deed, made between i Randall W. Synan and Patricia E. Synan, t Co"%~ mc'd rw Record ........husband...and..w fe t ! 10. SEP 45 T 1993 and Sa~..E....M 1-:er:._...... s:in le...Persori....... at - A:'M Q n, %V -4 aseft . (;mates. Witdesseth, That the said Grantor, f r a valuable consideration...... r,. Ran all W. Synan and Patr~cia E. Synan . i conveys to Grantee the following described real estate in St . Croix R1T°"" To County, State of Wisconsin: y Tai Pared :ale:..« 1 " The SE1/4 of NE1/4 of Section 11; the SWl/4 of NWl/4, the N1/2 < of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of NW1/4 except the East 74 feet thereof, all in Section 12; all in Y, Tovnship 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. FF,F: ~l AND Fn A ' A parcel of land located in part of the NE1/4 of SE1/4 of Secti 11, Tovnship 29 North, Range 19 West, Torn of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1/4 corner of said Section 11; thence S89 30100"W, along the North line of the SE1/4 of said Section, 1212.32 feet to the point ' of '.eginning; thence continuing S89 30100"W, along said North line, 66.00 feet; thence S00 28103"E, 500.00 feet; thence N89 30100"E, along the North line of Certified Survey Map filed in Vol. "30, Page 722, 38.08 feet; thence N00 11'33"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. This ..........1.41 ..IAQ.t homestead property. (ice) (is not) Together with all gad singular the hereditaments and appurtenances tuereunto belonging; And..... )3l?aaa],1...R:...$Y.Ha>l.. and,_Patr-ilia.. E ~...Synan warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. Dated this ..C.~........................... day of Jkug.ust...................................... . it..91. Gt~Hcr ......(SEAL) ~QiFl~,t4.E.A/`'~~LGel~ .........................(SEAL) ' Randall W. Synan Patricia S. Synan " (SEAL) (SEAL) ~ n AUTHENTICATION ACKNOWLEDGMENT i I A Signature(s) STATE OF WISCONSIN ii z St. Croix ».Coaat7. i1 j authenticated this ........day of..... « 19 7 came before ate ........day of August 919 the above aamed Rands 11- w.~'SYnan , ~PaE__r i a A TITLE: MEMBER STATE BAR OF WISCONSIN S nan ...i_c_- « .0~► (If not. » . authorized by 708.06. Wis. Stator.) to we known to - be the Pew . .2..... AYM16 ~4~1e i ncnof 3- o d L1 c > > 3 ~1. 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