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HomeMy WebLinkAbout020-1308-30-000 O °vy O °vy o o ao III I i a' o I O I ts I I c I I N I u c a a) a) I I a) N O C Z N C Z LL O LL O CO C 'o N 9 3 m 3 Cl) a) a) z N z a rn E E Ei U) rn a m a m 64 o I o z d c 0 ' r O N ` N o d Z i 0) c 0) c Z cn ~ c (D a) I E c E '2 •a m v .o w c+7 I N Q N O C 0) C7 O O d L L 2 U) L _ c O O O O 2 Q O N Q w Z H Z z m z N z N N > N £ j N c. CL M L p c L (6 W d i O T N i N T ° N cD p G a co a o a a t N H H H c O V F- I- I- c O d m 0 0 0 LL LL X 0 0 0 d LL Z° •N a a a a a a 0) a) }}^yy to U rn Z z p O O N _ ° N O r J O J O E C m C m C n- L N Q a3) Ep N a) Ci7 N N 7 7 co a N co N N c c O r- O CN C a) 4) :3 CO~ L~ M~ O a) U) C 3 a) N LL °O 75 r/ ❑GO O O~ LL c E N a c E c N C - O C O 7 N 0 (D NUJ m 0~ 0 O N -Np f'_TM! N Co O N N E O pp t N E O U • r' O = N O 'n Z N O N 19 Z Cn 0 ~ i' I = I V v~ a; m y a y a at L a g a EL y 0 CL 4) a) 4) r- r A U a j', 0 N V 0 in c0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION LOT LJELL.. SECTION- T AN-R~Z9 W, ?own of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 00 FEET OF SYSTEM y9 ' INDICATE NORTH ARROW nd elevation information on reverse of this form. v eons to center of septic tank manhole cover. w;. d - Od,p BENCHMARK: Ajlp n r 1- G ALTERNATE BM: SEPTIC TANK / -1-21-1-M-72 CH Manufacturer: Gf/,rt~s Liquid Capacity: Setback from: Well >.S'o House io ! Other Pump: Manufacturer Model Size Float seperation Gal s/c e: Alarm Location SOIL ABSORPTION SYSTEM Width: 12- Length Number of trenches ! Distance & Direction to nearest prop. line: ZA/ ? 7.C Setback from: well: > 75,E House Jf Other ELEVATIONS Building Sewer !f'~S ST Inlet: 113 ST outlet: f7.0 PC inlet PC bottom - Pump Off / ~ 3 Z Header/Manifold 3. p2 Bottom of system Pfd eH~ Existing Grade f7,L Final grade 19,;7,0 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: ~jG~- RTY PLUMBING 3/93 : j t DATE: _3171f7 (f.~..~..rr.... .108 PT: Z 11&17 Jos SP:~"-~~..,.. - Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: J.abbr an,4 Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 289356 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: WEBER, PAUL HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1308-30-000 TANK INFORMATION ELEVATION DATA A9700172 TYPE MANUFACTURER CAPACITY STATION B5 HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeratio NA Dist. Pipe Holding Bot. System PUMP / PHON INFORMATION Final Grade ManufaCiturer Demand " ; . y; ivfu^j Number GPM Lift friction System TDH Ft oss H Forcemain Length Di a. Dist. To Well SOIL ABSORPTIOM 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 CHAMBER INFORMATION Type O 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.16.29.19,WEST,SE 914 BENJAMIN LANE LOT 3 Plan revision required? ❑ 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'■L■'■R SANITARY PERMIT APPLICATION BuSafetyreau o oand ff uiBuiidldininggWaterlSystems In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. 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 1/2 x 11 inches in size. • See reverse side for instructions for completing this application state sanitary Permit Number The information you provide may be used by other government agency programs ❑C hec ~a-/ (Privacy Law, s. 15.04 (1) (m)]. revision to k ious application 9/Y B&? apmn L a. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prop Owner Name Property Location a/ 4,elei E'1^ fw 1/4 1/4, S T , N, R A5p E (or Property Owner's Mailing Addres Lot Number [Block Number Ile, 3 tO Cit , State Zip Code Phone Number Su ivision Name or CSM Number ,t ( II. P B ILD NG: (check one) E] State Owned Its Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms r C1 To age own OF 111. -BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo • ~9. 7 • ~5ya ® 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 0 S New 2. E] Replacement 3. E] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an _______yst_e_m _________System Tank Only Existing n System Existing System B) X A Sanitary Permit was previously issued. Permit Number .2j'yZ,4,T Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ 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: Q T1~d~ 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) -Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation a I b1 3 s~ • 7 .7 . Feet Feet VIL TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per. New Existin Gallons Tanks Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank O~ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ E31 El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of a onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No St ps) MPIMPRSW No.: Business Phone Number: 77 _A - u is Address Meet, City, State, Zi e): Z IX. COUNTY/ D ARTMEN USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater n619 Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surchargeree) Adverse Determination ro )-77 LZW4;~ a X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SOD-6398 (R. 05194) 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 y 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 mast 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 El 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 inducts 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. DATE: OAYE FOGO(TY PLLMOM licensed Fwk ester Plumber JOB PT: wFS, va 54023 JOB SP: Phan 749-36556 eft#z 0 cur 1 L_~ r iF3 r r 1 X, f y~ r r J Sc~ / ^ Hof #..3 ,1 ~ ~ goa . ~ f Gi ~ L,•., c 43S~rsHe /oo,~' / r L A ~nr ~i y o f NE LoT Coe~✓e r sop ®.s Qss~ < 9f! ~6 / ~ Y 1 > o = /,coo !rAe. S 7-- ~ ~rtir.~u~r STB~s q~rou~v7~6/> 3c•~~ (-4z IVAU :3TAa :T9 80L -V 8OL* I i WsscroandDepatmetof Industry, SOIL AND SITE EVALUATION REPORT Page of 3 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 J_ • ezl~ 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. rv --~?v APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PR RTY0 ER: PROPERTY LOCATION 6:41 '6 „~/f GOVT. LOT 114 SE 1/4,S T N,R E (o~ 0 ERTY OWN R':S MAILING ADD SS LOT # BLOCK # SUBD. NAME OR 68M # LltJ CITY, STATE ZIP CODE PHONE NUMBER []CITY [3VILLAGE OWN NEAREST ROAD New Construction Use Residential / Number of bedrooms 3 [ J Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow! ® gpd Recommended design loading rate gybed, gpolft2 • $ trench, gpd/ft2 Absorption area required 6 y~? bed, ft2 ~"3 trench, ft2 Maximum design loading rate ._2 bed, gpd/ft2 .~_trench, gpd/ft2 Recommended infiltration surface elevation(s) ~.3.D ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 0S ❑ U OS ❑ U 0S [JU 1Z S ❑ U []S O U ❑ S rA U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Baa>dary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench .5- -66 Ground .3 -/,0/ 'z y- p .7 elev. _ I 10A,G ft. r Depth to limiting factor Remarks: Boring # D -.24 / SA/ Aesff-k S IF S -T Ir./ -27 7-S - Y1Z S als C, AL Ground 7 elev. )is ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address: r~o 12O 2 3 Signature: ate: CST Number: PROPERTY OWNER L!/~~• SOIL DESCRIPTION REPORT Page I of~ PARCEL I.D. # j2d 3d Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft 9 Texture Consistence Botxrlary Roots Bed Trench in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. S <,3., Z _ s G GS sl:rz Ground elev. • ,QQ ft. f Depth to limiting factor > Remarks: Boring # VAZ Ground '3 7• l elev. ,V-fj ft. Depth to limiting factor > /f2. Remarks: Boring # 67 57 Ground 7 S L elev. 9 ft. Depth to limiting factor 7 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: DAVE ARTY IP41JMMG DATE: X 171 f'7 Ut pd~y f °r JOB PT: -T-z 7 ROBEtRS, V ~IN~54423 phone 749-3656 V1 W. Ogy i E~ c ~ S \ ~ Gay I I #.q T ' 1' '1.3 ,?q 4~aFrrfO~+t" 30 /~7c 3 I°~o /p0~ 4-ce si~~ Offu~~ /mop • _ ~E wT ~o~rt/'~ r~r,~~ ~ ~ i 3g' 2 d 7a© d~ S'le e / 4w e OO !I- .2 ~ \ Cg oss~.., r / 6 ,r \ i5b°es~ f I/Y°NNE I = fit " R' V vm _ 4elooL 8GL} . i 1 ~M 1•f U \ o' w ono A i. A N j y y N at o Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: aHuman Relations Safety fety and Buildings Division INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284268 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: WEBER PAUL L HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1308-30-000 TANK INFORMATION ELEVATION DATA AQ?7n n17 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet vent irrIto ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A 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 Forcemain Length Dia. I f 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 Type O CHAMBER Mode 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.16.29.19,WEST,SE 914 BENJAMIN LANE LOT 3 Plan revision required? ❑ 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: ~ta~~ra Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 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 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sannitar ,Pee it Number The information you provide may be used by other government agency programs E] Check if 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 G L. rE' &S2114 s-a 1i4, S 14 T Z N, R lfp E (or Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number ,S y cGlr 227-07a 4 U) It. TYPE F BUILDING: (check one) E] State Owned ❑ 'ty Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 3 ❑ village Town OF fQ C ~j , 14 Ill., BUILDING USE: '(If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo - ,9- p 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. m New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing n -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 410 Holding Tank 12 0 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) jov /,Of-5- ' Elevation 41r.0 16/3 S6-3 . e ,K2 10.3.o" Feet 107.0 r Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex er. New Existing Gallons Tanks Concrete strutted Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank o 3 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ r~ Vlll. RESPONSIBILITY STATE-MENT lJ I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Sign: (No amps) PRSW No.: Business Phone Number: 01 1 Pl ~ uer's Address (Street, City, Sta , Zip Code): ~p~ tr W .~3 IX. COUNT / DEPART NT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing A ent Signature (No amps) Surcharge Fee) XApproved ❑ Owner Given initial ,Qj 3//lam Adverse Determination /o vcv X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) 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 --ransfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systemssmust be properly maintained;,, The septic tank(s) must be pumped by a licensed,pumperwhenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or theState'of Wisconsin, Safety and Buildings Division, 6087266-3815. , 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 11- system is to be installed- . s 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 E 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; vvater 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 11.5 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. r DAVE FOGERTY PLUMBING ucensed Perk Tester & Plumber #3233 #3289 Fo~~yyrr Heights Road ROSEi~t'S, WISCONSIN 54023 Phone 749-3636 Gde~r 47- #3 Y. Y scams ~ ' = 5+b' ~sspwE iQ7.0 ~ X = 3oetx/G O = ova 6";fz. ST; ~Y ~ Z iv3. a - [owER o j /{SE ~ hx~s :510 S- 1 r l 8~~ -~X ~ E S7 ~ - ~ ar ~Z y c 's ~I 6 r /r6.dGE ~,~-rvEwA~/ ~tl~rF; ~t-c ~r.v. ScrsAc,~s' r4CcoaxvrED DATE: ja=7 -fr~2 JOB P?:~ore~,•Lc TU f~, .108 SP: . y~ 1 . i I -TR i low ' 4w Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749-3656 Ilea L. Cv~'~~re P, s//;ode l0 7 Y/~ a~r~~/~ eVB~9Er ~D.17LS' c ti T : ~'odE F0011M PLUMBING DATE: x/)/97 JOB PT: .~48 SP:.r.«..._,,..,....,, ~r MUM .^y.,. ....h r. .,r+....~.n~W.<4a:VPPW►: I~MMSA'4 `PMt1~' r Rid ~,~k..r '.J Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY S o t' Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but 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 I/E4100 E•° 4V A X 0 AJ GOVT. LOT wE r -5C 1/4,S Ko T 2 9 ,N.R.1 q E (or~ PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBO. NAME OR CSM # . 5 9 C,r • IRO. A 3 Pl"S>+NT utEw CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD vDSo.j ewS . SYo /6 (7/5) 96.3'138 HUDSo,J r Y. v 1- f New Construction Use [ Residential / Number of bedrooms 3 40 y [ ] Addition to existing (wilding _ j j Replacement ( ] Public or commercial describe 50 - Code derived daily tow &6 gpd Recommended design loading rate bed, gpd/ft2 • ~ trertch, gpd&2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 77 bed, gpd/ft2 ' a' trench, t Recommended infiltration surface elevation(s) ~5.eP-~~ . 3 It (as referred to site plan benchmark T)e Additional design / site considerations s E e-kt S o S /off w/ o t'o~o ~o X Di'S 7-. Parent material 5-CS F,? Q u t2K k A R 0T- 5 Flood plain elevation, if applicable Al • It S - Suitable for system VENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL W.jlNG '.w( U= Unsuitable fors stem MS ❑ U 2S ❑ U as ❑ U a S ❑ U 21- ❑ U U S C~ SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Modes Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tench ,4 O - / n y/2 2-/i. s 1 2 A" 5 bk /►M R c S 3-F • 5 . ~ 13 ► ~I. 1 g / o we 316 s 1 -F sik .U'-fR s Zf . . S Ground (32- / o yip 3/6 S Y 'e d P S • 7 •0 ft G -y goy, s 49 Depth to limiting factor „ Remarks: Boring # F113, p. 2 /Q ~/,AO SAV- u-Fx C S z ~2 foA 3/4 ~ sl I f s le "s'K4k C.5 zf . y~ • S 132- -3316YX 3/( I s 1, , f4 de s r Ground elev. C I 3" S~ G S S /02 _ 0 ft. Depth to limiting factor Remarks: CST Name:-Please Print RO 8E iZ T' Zt L R I ti T' Phone: 715. 3 84 - ?185 ress: (a 55 p' N e i L 'R. D. t' tl OSo n9 to I. S. S y 01 lv CS r h 2 y $L Signature: J Date: CST Number: PROPERTYOWNER V~t2rJ WA)(01.3 SOIL DESCRIPTION REPORT . Page ? Of PARCEL PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence amcr,3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. B~ rends S -3 /o Yle 316P If slk- ~,-►,7~•e cS 1-F . y . S lie and 2- y /e y 3~~ Y. C) C Depth to j limiting factor ~ } Remarks: Boring # ; 14 P -/3 V LIB as ~3= 2.)- /0 31~f 5XV -FR Cs If Y s ~ L 230 /o ,t° s/~ s ~ ,P S r- • 7 ~ Ground /07 el$ ft. Depth to limiting factor~~i Remarks: Boring # - iaY/ s6.,e nn v~ 05 3f 5 - zo /o 31s / s!~ /1%7~e ~s if Y I. s Ground - 2.X0 ~3 ~S ~z S • 7 nd elev. /O SIP . S. O, S GQ~ i - /07-2- ft. Depth to limiting factor~, I Remarks: Boring # ♦Q } 1 Ground elev.. ft. Depth to limiting factor Remarks: car% 040A10 ACIAn% [3, loo. s y 5 ?F,y TR t.uc.4 l Fuh T Z !02' Jo ' rN A Re N- T3 - B . l'3 5 d 3 t o y. p q H G-►ti T R u cl~ lO y.50 13y 16~. ~ ~ low TReAJc k 10 3. 0 I'ys 107-10 5CAL : = 3.30 /3f} -404 - Pi Ts c.oT 3 ~y ifs - ' Gs 133 I ton~q Q I s lll~ i - X07 • J 7 I i f3 7. yG _ 23D ~ : S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property ?.*ac. 4. cv,P j? Location of property cL4r 1/4 sa 1/4, Section T f N-R___jf W Township-_ (cfp3o l Mailingaddress rz L,e f?o~- / P"& 01 If,, rs--Z W Address of site Subdivision name Lot no. .3 Other homes on property? Yes t/ No Previous owner of property y,rT,y L0,gxso)u Total size of property Total size of parcel yyr Acc6S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes _Z' No Volume /AIS- and Page Number 6141 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":r?ftl , 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. ~s3 Po! Signature of Applicant Co-Applicant 3 of - ? 7 Date of Signature Date of Signature r ~i, !}!s p 6t ~f ~'hRt~z # b.2o- /3d~- 3 STC - 105 SEPTIC TANK MAINTF,NANCE AGIZIA-"N1 ;NT St. Croix County OWNE1b/I3UYF.IRiS~kL L G..E-SEi2 MAILING ADDRESS j 0,4P,, !tel.. G.~~cr ~Y &r~'c '&f& PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE '&DlvA _ t cc~ Syo/! PROPERTY LOCATION ev,"7 1/4, S__ 1/4, Section 'f'_N-RZ~' TOWN OF s~itl~ScxJ ST. CROIX COUNTY, WI SUBDIVISION ?C6WAor t1X 14 LOT NUMBER 3 CERTIFIED SURVEY MAP , VOLUNIE , 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. 11«'e, 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. SIGNM DATF~ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, \\'I 54016 11/93 WARRANTY DEED 553901 - - ~•f Document Number z )T V11 Roc ...J , .:.Yr r) 31 1996 , ' Return Address kd 10:00 A Vi i-" c,, of es... -+t LdAk Ray~au ,;t ck...u Parcel I.D. Number. Vernon Waxon, a/Wa Vernon E. Wazon, and Irene Wawa, a/k/a Irene S. Wauon, Susband and wife, >rusband and wife, as survivorship marital conveys and warrants to Paul I.. Weber and Donna J. Weber. State of Wisconsin: property, the following described real estate in St. Croix County, Lot 3, Pleasant View in the Town of Hudson, St. Croix County, Wisconsin. r This is not homestead property. Exception to warranties: Easements, restrictions and rights-of-way of record, if any. 7 1 s Dated this ~L day of December, 1996. V .Q/~rn,Qn~ W (SEAL) Q (SEAL) Vernon Waxon, a/k/a V on E. Waxon Irene Waxon, a/k/a Irene S. Waxon AUTHENTICATION S TRoANER # 3 Y t Signature(s) Vernon Wazon, a/Wa Vernon E. Waxoo, FEE ` and Irene Wazon, a/Wa Irene S. Wazon, husband and ' wife, authenticated this day of December, 1996. Y i C &U, Kristin Ogland TITLE: MEMBER STATE BAR OF WISCONSIN THIS INSTRUMENT WAS DRAFTED BY: Attorney Kristin Ogland Hudson, WI 54016 41 aw ; r<n Y y ~ s r S ~ ~~~9L r~_- ~ ~ e ~ ` l.. ~l Y 1 of