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e AS BUILT SANITARY SYSTEM REPORT.`
R c5. ' r ll , TOWNSHIP SEC./ 7 T.211N. R L q j .
.O. ADDRESS o , ST. CROIX COUNTY, WISCONSIN.
.~BDIVISION a k-,,.~ LOT 4 KLOT SIZE 1 .
PLAN VIEW
-Distances b dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
0 0"
Z ° u
I di, a e o th A r
SC L - 0 --i
RTIC TANK(S) 0"MFGR. t-t-c CONCRETE &"~SSTEEL
ON of rings. on cover 2 Depth ij DRY WELL
tl:NCHES NO. of width length area
no. of lines ~9_ width length area1 ~L-
depth to top of pipe S r' .
GREGATE
RATE, AREA REQUIRED (y AREA AS BUILT 4' 2
isclaimer: The inspection of this system by St. Croix County does not imply complete 1
o7ppliance with State Administrative Codes. There are other areas that it is not possible
C inspect at this point of construction. St. Croix County assumes no liability for
stem operation. However, if failure is noted the County will make every effort to
ekermine cause of failure.
GASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST
'-INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER - 2-
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitaty Permit
State Septic
NAME Township St. Croix Countc,
Location_ Section Lot #Subdivibion
SEPTIC TANK
Size 16,6 gattonb Numbet os compattment.a
Di4tance Stom: Wett Buitdin
9 ~ 0 l2$ btope
Highwatet '
PUMPING CHAMBER
Size gatton4 --..Pump ManuJactutet Made. Number
HOLDING TANK
Size gattonz. Numbers o6 Compattmentd
Pumper Atatm System
Distance Sum: Wett Building 12% stope_
Highwaatex
ABSORPTION SITE
Bed Ttench
Distance Strom: Wett Building ~13V 12$ tope
Highwatet=
ABSORPTION SITE DIMENSIONS
Width o j ttench 1 ~ St Requited axea
Length o6 each tine St Depth o6 to ck b etow tite / in
Numbet o6 ti-nez Depth a Lock oven tine rt
v
atat .Length o6 eti,nee St Depth o6 tite b etaw gtade_~,;~_~ n
iztance between tines ~ St Slope os ttench ~ in. pet 100 6t
Total abbotption axea St Type aS Covet: Paper x ttaw
PIT DIMENSIONS
Number o6 pits Gnavet around pits yes no
Outside diametet St Depth betow intet
Totat abbotption area St
Atea teq uit( „ ~ St
10484
REPORT ON INSPECTION OF SANITARY PERMIT #
(1' e a ddr s of Permit Holder Person/Persons at Site (2 )Date of Inspection
Time of Inspection
ame, es l ense No. ot in a Ong lumber ~j
3 I STALLA N CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BEN ermanen reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
(7)DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO
;
8 HOLDING TANK: Manufacturer o gallons
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? YES ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ N0; Wired? ❑ YES ❑ NO;
Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO
(13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO
DILHR-SBD-6095 N.0 /80
E 115 Rev. 9/78
+3 11
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
. WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701 d
of
co ~ L
LOCATION:/y )_%A!61a, Section T2j N,R p or Municipality
LL//pp Coal (or6Township or Municipality
Lot No.7 9 Block No. County
ivision' Name
Subdivision'
Owner's/Buyers Name: ro
Mailing Address: 7Toi,_4 9-rook Rif o
TYPE OF OCCUPANCY Residence No. of Bedrooms -3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW -REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS o2,8-jE0 PERCOLATION TESTS 9--2-0'_&0
6
SOIL MAP SHEET JY NAME OF SOIL MAP UNIT Jo'd- 03 14 /0,qAA,
PERCOLATION TESTS
WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
TEST DEPTH CHARACTER OF SOIL t
NUM- INCHES THICKNESS IN INCHES HOLE AFTER INTERVAL MIN/IN
BER SWELLING IN MINUTES PERIOD I PERIOD 2 PERIOD 3
P- Q re P- A~Qre
4
3 41" e z.
yo -3
P-
P_
P-
P
-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES Q A/ e B- Z $i e 7 a « r. " rr
B- sr e- H a< u~ <S n 4 pN.
B_ dsr ? sr "I-S: Al 4, V a n 0s, p S
B- b " O 7 G .a - I/ J
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy 0O Z71 Indicate scale or distances.
Give horizontal and vertical eference points. Indicate slope. S(A e 4-k-_ ~
we.
,G(lQ SCAM - _1,91ue es _ . s., , ,u_c~• 9 c l dl
J
E
130 r-c 9
t
b yea y o, p
e
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t ~ f
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Peril Ir~~„
Z n - r -
/l M C ` l3 = 9. S ~y s dew, ~ _ s
_
PLB'67 State and County State Permit #
Permit Application County Permit #
for Private Domestic Sewage Systems County
I
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address: 1:1 ol /11111 tI e1 14uW 5, , G'~r s
B. LOCATION: 7 Section 47, T ' N, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY L 0 0 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT ,OISPOSAL SYSTEM: Percolation Rate ~2 Total Absorb Area sq. ft.
New r/ Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Cje~pth Tile dept (top j No. of Trenches
Seepage Bed: _L,"-Length idth~Depth Tile depth (top No. of Lines
Seepage Pit: InSid~ydiameter Liquid Depth No. of Seepage Pits
Percent slope of land . /A Distance from critical slope
WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tes~jer, L
NAME /✓n n /~5 ~r~ S [ 6-"; j f'/7 C.S.T. # and other information
obtained from -5 a -A 4
!
Plumber's Signature 2 j
MP MPRSW# r a 3 '--Phone #,1
Plumber's Address oQ t: 4j-' A/ A
PLAN V I EW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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S/-2-~ SJIST:
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 3
s/ADDRESS
~~S S poi CP
SUBDIVISION / CSMJ LOT r~
SECTION T~N-R W, Town of_
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Cap ~Lovvec~--
' ZL S~ ~Q~.,vs ~ co f1-C l7i O /~¢-T-< ovs
C-1) 6,4- S o,~ cY l3 / icAe-,~
Ulbricht & Associates
A L Private Sewage Consultants
ORIGIN H 665 O'Neil Rd.
Hudson, Wis. 54016
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
`r
1
BENCHMARK: v J,Q 17 , = l O e)-.Q
ALTERNATE BM:
U <r ~~I mac`- -7("
SEPTIC TANK / PUMP CKA-M- -E LT-HAi.BENG
N crW TA -'e ,
Manufacturer: Cl7S L2~~~-- Liquid Capacity:
Setback from: Well House > 35 ' Other Capacity:
Setback
Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length T Number of trenches 3
" -ID
Distance & Direction to nearest prop. line:
t r
Setback from: well: I-W House ~s Other
old 7,~,k Cz-51W`
dt-2 7 6C-T l ~P, Z O
ELEVATIONS
E~ ~S Ti,v 6--- 2
Building Sewer ST Inlet: ST outlet:
PC inlet / PC bottom Pump Off
Header/Manifold / Bottom of system
J 7.6
Existing Grade -~f Final grade
DATE OF INSTALLATION:~ T
PLUMBER ON JOB: 1-3013
LICENSE NUMBER: 33 0?
.INSPECTOR: A. ~l`l/VS
3/93:jt
ID T I
IOEGL-
yy j3~D~i~rS y~
j3M i8 p SP.cvZ~
~D~ o f SrDi.v G-
c~/C v, = /00 •O' y
Ags0~1a~e8 o S,T,
U►btkbt a Conaultsnt~ f
P~yvate Sewa~ ys c
655 0Ne11
Nndson, 54018 ~vs
O
Ne w
g~ gig
3 z1 v /0
ST'. 1
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31/
• Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Count
Labor and Human Relations INSPECTION REPORT bT. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitn6loyv.:
WIEMERSLACE, PAUL & SHIELA f-1 r~ slag cage Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: ilJll v Parcel bf~8q-'1143-20-000
/ /00 r s'
TANK INFORMATION ELEVATION DATA A9700367
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic
0 Benchmark ,g6 00 , o
?04-k Op
/zz~ eew 6&4
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 5 !t
Vent
irito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Ar
Septic go, r S NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand dz-,Vt'U S- /Qlp,~ '
Model Number GPM
TDH Lift Friction System TDH Ft ( g' C)2,
bss Forcemain
I 1 Len th Dld. H Dist. To Well ~ A 0 13 7, ?ZV 9-7• t q
9 10.1-r
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Mode Number:
System: Pte` ~0 5 /o~ 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 a Bed /Trench Edges -~U 4 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LO TION: HUDSON 17.29.19.741,SW,NE 4,92 9kRMAN LANE LOT A
-9,0,9.3, Piz_ _~1E~Q1.._ 9/03 -/0.5 40.06 - 3 • v o
lo,ag'_ ,320,17 " 1. 0 7
c - 9), 7 o`
Plan revision required? ❑ Yes ETNo
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspect"s Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
Wisconsin 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 ST. C4 X
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
a 9 16 50
The information you provide maybe used by other government agenc programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)). :i State Plan I.D. (Vumber
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N
Propert VA ner Name Property Location
t E (o W
UL !1, E 5&) 1/4 NF_ 1/4, 5 17 T N, R PG
Property Own is Mailin A dress G Lot Number Block Number
Z-. iy>~-N rv z
City, State Zip Code Pho Number Subdivision Name or CSM Number
40pSo.a LJ1 sy bl 49 1(3 63 Z3 l~j w ~'S T TES
II. T PE F BUILDING: (check one) ❑ State Owned !t Nearest Road
r5 ElVowI ge I+V
Public P-lor 2 Family Dwelling - No. of bedrooms J n OF 511146&%1f ti
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
a9. / g. 74 oz. o" 03 • a 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. ❑ New 2. placement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System System Tank Only______________ Existing 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 2-5-eepage Trench 22 ❑ In-Ground Pressure r 42 ❑ Pit Privy
13 ❑ Seepage Pit '0. 3 "X 41t 43 ❑ Vault Privy
14 ❑ System-In-Fill `L
VI. ABSORPTION SYSTEM INFORMATION: f/,p' `vr 5-.0
. 7. Final Grade
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System ~Fe
Re uire (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min /in h) rjp•LS Ell*v~ti r)
IS
IJ ~3 q N .$'p Y Fee
t TANK Capacity
VII. NFORMATION in gallonTotal # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New Existin Gallons Tanks concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank 00 100 1860, Z waz-.s 2 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 1V.QGt7 El ❑ ❑ ❑ 13
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) /MPRSW No.: Business Phone Number:
Ro lsE2r u1s kc'mT- 3307 ?LS 3X 'c:?/,3C_>
Plumber's Ac dress (Street, City?State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
[Approved ❑ Owner Given Initial Surcharge Fee) 610 qw
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
1_
INSTRUCTIONS 1
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, 608-266-3151.
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.
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.
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 th s 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 Flans 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 peeformance'curve; pump mode[ and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) 1-oil test data on a 115 form; an ),.,#II sizing information.
- GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) fora 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.
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
d ~I Minimum 12' Above
1,40
lT t►, Final Grade
' C a sl Ir an
_ 4
3 (a4 Above Pip. Vent 4'Ipe'
tt 1s Final Grade
Synlhelk Cowring
Min. 2' Aggregate
Over Pipe r
0 Dlelrlsution - Tee
I Pipe o 0 0 0
60 a Aggregate b Perlbreled Pipe Below
J Beneath Pips
S y/ STZE~y -"ice QQ`~~~ C Bottom 01 S.ysleee
~ 3 ~ ~ ae QV
\~G ~0 ),M tiJlbricht & Associates
O ~aGO G~p~1 P~ ` e consu►tants
~ Q G VF; gt private Sewa9
665 p.Ne{I Rd. 0
3 '3 6~
O Q~~ ~S• ~~~~5 JC M~~S' Hudso ~ ~ 540
114 ;;%Aresh Air Inlets And Obserrolton Pipe
off-
h ~ Qtl~~a O~o266
11~~ Approved Vent Cap
r n
n Minimum 12' Above
~W II Final Grade
F► is ~+~D G~r9-f>
j T R i_' O C N- '
_ d' Cost Iron
Above Pip.
fr'
~ V\ '"1o Final Grade Vent '
Synlhetic Covering
tU Min. 2 Aggregole
Over Pipe
Distribution - Tee
pipe 0 0 0 0 0
R " Aggregate
0 o P.rfbraled Pipe Below .
8eneolh Pipe u -Coupling Terminating At
Bollom 01 s,rslsm
25
Fresh Air Inlets And Observation Pipe
O Approved Vent Cop
:z M
q r► Minimum 12' Above
C I~/ Final Grode
v
ll l) TR EN c 1--F- T3. 0
~ NY' ~ E ~~M S y(o
N ~y
361
!57 30
- ~ ~ rG ipoo
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0 i
- Door.
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f3 z
131
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qty. 3 0
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION Page of 3
Labor and Human Relations
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and S7• C1014
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
()-2-0-11y3-2-0
APPLICANT. INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location ~1
a Govt. Lot ;5 IV 1/4lVf 1/4,S ~7 T2G N,R If E (or)(9
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
2- s ~ ~ /-N • v~Ew ~s
Ci n State Zip Code Phon Number Nearest Road
h vDSo~ Sy01Co (1 l5 i3 a •63 ❑ City ❑ Village Town Sif~AW9,v Lti
❑ New Construction Use: LTResidential / Number of bedrooms Addition to existing building
[replacement ❑ Public or commercial - Describe: /VO
Code derived daily flow 7h^y gpd Q Recommended design loading rate bed, gpd/ftz ' a trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate" bed, gpd/fl2_ _trench, gpd/ft2
Recommended infiltration surface elevation(s) 5-,eg- ~ ft (as referred to site plan benchmark)
Additional design/site considerations p
Parent material 1,0e5'5 Lf )P OVA- .511WP 00ralie Flood plain elevation, if applicable _ ft
S = Suitable for system Conventional Mound In-Grround Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system Eg 1:1 U I~ S 1:1 U 15 ❑ U El's, ❑ U ❑ S ❑ U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
l oil ioy 3/ Z- / y cs :.s
z Y• z / s~ 1f 51 k 0197 -Cs I-F . . 5
Ground - L, S GG ~C Cf . 7 , .
elev.
Depth to
limiting
factor
~70
Remarks:
Boring #
I - /D 3 SSG ~fs!>i~ n~+i' S 2, Z 3
Ground s S ' 7 • CJ
elev.
Depth to
limiting
7 factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
ZoSee.T- ZQt-3 i cc~ - Its • 386 ' 9/ S 5
Address late CST Number
CQ55 b f' ~O • v g ct:o 8
PROPERTY OWNER ~~E~CR SAS SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
3 2-1
0-/L- /0 2- Z,,~ sti,~ ~f cs 3
Z -34 ma 313 /f rti /w fR c t ~f . z 3
Ground f,~JJ
00
elev.
g3. ~o ft. S O
92
1 0924
Depth to
limiting
factor ;
Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles tructure GPD/ft2
Textur Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev. -
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
• t /
~ s
Nv f3~~~H5 y~o
y,
361
30
_ I /Op0
ell,
O
' i L pooh'
~y
f3 2 •
. ~u
16 5
gb y,• ~ ~
vevr
sysrt
jq.3 0
3
1
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/33 93,/0
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank rese
serving the ~4 4'~ 4 s4,e%1/} Glj/E~yE ,f~ p ntly
q
le ~fFS residence located
S~ 1/9,--x_1/9, Sec. T bt:
UI~.SO,*J N R--°Town of
Upon Inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears
to be
functioning properly.
Last time serviced ?
Did flow back occur from absorption system? Yes No
(if no, skip
Approximate volume or length of time: next line)
__.____gallon s -Minutes
Capacity: ~tv Q
Construction: Prefab concrete
steel t h e n
Manufacurer ( if known) : 0 iz~`s'E7- .
Age of Tank (if known):/i/~~x Zp I~
z-:: X ow
gnature) (Name) Please Print
Ulbriaht & Asc a Consultants ~ ~ 6
(Title)
is!i5 0'Ne11 Rd.
Hpdaan'WIS 54018 (License Number )
(Date)
Form to be completed by licensed lumber
or-Licensed Disposer-(NR 113 Wisconsin Admin(s.145.6, Wis
t trati ve Code)nsin Statutes)
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding
condition, I certify that the tank to the best eofs my gknow edge will
conform to the requirements of ILHR-83, Wis. Adm. Code
inspection opening over outlet baffle). (except for
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name ;t>'8r / ?//,b'QIG4% Signature ~3 6
NP/HPRS 3
8 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 /q4u/ S #1'6FiZ-"+
Location of property S 1/4 I-T 1/4, Section /7 IT Z/ N-R W
Township #yPSO141/ Mailing address
?F2- 511Xa:-? fv • fi`l~f~S o l.V~ S . ~S'Y o Co
Address of site CQ"l-t-
Subdivision name P
49&V,I-7-t' G~ST~f-TES' Lot no.
Other homes on property? Yes L-No
Previous owner of property 511f1, /////E)t
Total size of property 2.0 'F /Fetes
Total size of parcel X2.0 f 4-&Xl S
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes No
Volume 62-7 and Page Number 31f 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. .37U i V (~v , 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.
jf e of ApplicanCo-Applic nt
Si.gnatu e Date Signa re
• s , •
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
O R
MAILING ADDRESS fdp 2- /01
PROPERTY ADDRESS d-
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 1/4, Section f , T -2-f N-R l W
TOWN OF 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 canaffect 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: g "
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
• UTAENT NO. STATE BAR OF WISCONSIN - FORM 2
WARRANTY DEED
70 "
627 PAGE'
3 I V 1L~6 TWO SPACE RESERVED FOR RECOPpMO DATA
VOL ar I
SAM E. MILLER, a single man, REGISTERS OFFICE
ST. CROIX CO., WIS.
Rec& for Record m 3rd
pril A.D. jq_81
cciveysandwarrants to PAUL D. WIEMERSLAGE and Lo'
SHEILA J. WIEMERSLAGE, husband and wife, as 0 P. ioint tenants, for and in considerat i_on of
the sum of $77,000.00,
s ~ oe o..a.
s'.
l To
K _
County,
h the following described real estate in St. Croix
Ii State of Wisconsin:
N Tax Key No.
Lot 48, Park View Estates Second Addition
to the Town of Hudson, SITBJECT to recorded
g~ easements, covenants and restrictions.
f
.ANSM
s ,oa
FM
This _i s nOthomestead prooerty.
(is) (is not)
Exception to warranties:
X
n Dated this day of March 19 81
I
a
a
(SEAL) (SEAL)
Sam E. Miller
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGEMENT
Signatures authenticated this day of STATE 4.F WWAX NSIN
tg St. Croix County.
Personally came belim ffw, this /day of
"
March 191"
TITLE: MEMBER STATE BAR OF WISCONSIN
i the above .rl~aied ' • . '
(if not,
by § 708.08, Wis. Stats.) Sam E. Miller ;
This instrument was drafted by -
Hugh F. Gwin, Attorney
Gwin. Gilbert, Gwin & Mudge ~c
430 Second Street '
HrT~sOn~ Wisconsin 5401( to me known to be the person _whoexecuted th~
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