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020-1185-40-000
°o C61, I 0 C c c hi a 0 ~ I I o I I N I I N I I 'OS _ r ~ I I ti € 1 C a c E m I N O y Z N C Z~ C Z I m U. c LL CO L O Q w E a I a 3 " C I 4) 0 Z y N I 3 tL E E rn ~FF O 1 = 0 am am N H U) Iapp I C z U o Z~ C I c w V O .N. Q 13 w O I y 4) CL 4) U 4 m I a) N A L a a) m N 1 ~1 y yay ~ I'n o I N N N d C • a~ L 1 coa T o 0 0 4) i O C 0 v Z m z Z c z Q " M 1 c I N 5 w ~o o=° y ~n E a N .y.. N •O N O O O. ` N 2 O, l r 0 1 !mil N y O1 N d v N t 0 p l v c G G a o O G a .0 o N ~ w Nt wr E o 1 U U) r U) U) E a N I CL co ! o O3o iLc t O a~ Z~I y •N oaaa ~CL CL CL = c a I o CY) r- F- 0CD N ova X0) 0) 4) 1 M CD 0 00 m 1/~~, CD 0 O I as ~ I O O j o N o 0 o cca CL co c li O mI N C O y O) N d Q} fn an d ¢}U1 o I 00 ~O Lo 0 C O r 1-yA C O E 0 o co cr ! y 0 y aUi d uao _ O O. O. N € Of C N N W co r1 C C O O C p C y d N O fA t L N p y T. N w O r C~ I . la O N % O et d1 y N y j"D C_ 4 }^~)1 N N j ! y M O N g ppj O y O R U • O N= m 0 Z '7 Y N O Z z 2 v~ m R €a €a a I L: a ea I g 0. 73 0 1 tt`I~v o c c 0 9 o 20 U) 0 E Parcel 020-1185-40-000 01/26i2007 03:43 PM PAGE 1 OF 1 Alt. Parcel 21.29.19.1166 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - BULTHUIS, TERRY L & KRISTIE L TERRY L & KRISTIE L BULTHUIS 558 WAGON WHEEL CT HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 558 WAGONWHEEL CT SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.835 Plat: 2354-PRAIRIE VISTA 1ST ADDITION SEC 21 T29N R19W LOT 8 PRAIRIE VISTA 1ST Block/Condo Bldg: LOT 8 ADDITION TOWN HUDSON Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 04/02/1998 576339 1311/313 WD 07/23/1997 874/517 2006 SUMMARY Bill M Fair Market Value: Assessed with: 162597 303,600 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.835 78,300 211,100 289,400 NO Totals for 2006: General Property 2.835 78,300 211,100 289,400 Woodland 0.000 0 0 Totals for 2005: General Property 2.835 78,300 211,100 289,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 208 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Form -STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP! aY Sa.+ SEC. T Zf N-R W ADDRESS you 2r Z Z.-- ST. CROIX COUNTY, WISCONSIN /7 k A t,V . S yD / G SUBDIVISION r/ LOT LOT SIZE ~lll-" 5 PLAN VIEW Distances and dimensions to meet requirements of Illi,R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ___I Hours I Wall N I ~o r ~ z 441 . -17 o i i W - - - - ~4 3 j 4 _ h i 1(0 - e q ~ v i To of P_ u~ dyes o. w k a s CBvl e T- INDICATE NORTH ARROW PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear Ft. 0 Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: !off ✓awl!t),AA Trench: Width: Length: C. Number of Lines: 7~ Area Built Fill depth to top of pipe: Z Number of feet from nearest property line: Front, Side, © Rear,Ft.O O 's i Number of feet from well: $'!f Number of feet from building: 3 (Include distances on plot plan). SEEPAGE PIT Size: /Uji~ Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: A~ Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: s a ~ ~"DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION M ,g4 State Plan I.D. Number: 07 c.21,T29-R19 (If assigned) ° ,3 e Town of Hudson Lotr-~ CONVENTIONAL ❑ ALTERATIVE Larson Holding Tank ❑ In-Ground Pressure El Mound LJ L NAME OF PERMIT HOLDane ER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Verl n Bano 766 Medow Drive,Hudson, WI BENCH MA K (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: R . PT. E CST RP fame of Plumber: MP/MPRSW No.'. County: Sanitary Permit Number: Douglas Strohbeen 5432 St. Croix 135493 S SEPTIC TANK/HOLDING TANK' 7 ,kk CAXe ( /O./Z• 0" 1 MANUFACTURER o-K- LIQUID CAPACITY: TANK INLET ELIEV- TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER 9,7~3 PROVIDED: PROVIDED: TS~ YES ❑ NO ❑ YES NO ca) 97, BEDDING: VCM1lTDIA.: Vf'h1rTv1ATL.: HIGH WATE NUMBER OF ROAD: PROPERT WELL: BUILDING: VENT TO FRESH C1O, C-°, ALARM' FEET FROM LINE: . AIR INLET:, ❑ YES NO S~ El YES NO NEAREST >2 V7 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARN G LABEL LOCKING OVER ❑ YES -1 NO ❑ YES ❑ NO ❑ YES ❑ NO PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH GALLONS PER CYCLE: FEET FROM LINE: AIR INLET: (DIFFERENCE BETWEEN PUMP ON AND OFF El YES ❑ NO NEAREST LENGTH: DIAMETER: MATERIAL AND MARKING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) , CONVENTIONAL SYSTE 23 Z, d='~~ -S INSIDE DIA.: PITS: LIQUID WIDTH: NO. OF DISTR. PIPE SPACING: COVER DEPTH: BED/TRENCH , TRENCHES: MATERIAL: PIT DIMENSIONS / ~A T GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL N DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH G7_3 BELOW PIPES: ABOV COVER E EV. INLETS ELEV. END: /YL(~ ~7~ FEET FROM LINE: S i -/c¢JS-.r'" PIPES: / AIR INLET: •r ~6. 5 A) NEAREST o. I AIR INLET, / 1p.3 >,;2 / MOUND SYSTEM.' , ` Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARFKERS: OBSERVATION WELLS; ❑ YES ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: D: MULCHE D: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION El YES ❑ NO APPROVED PLANS ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST, 10 'z f l V ;,4 i~ w~CC5tJ CCU' t.~ )7'C..G! r' Q G + << 4. f j K C7. G L'~xcvx~ {vv 60 t in county file for audit. Sketch System on TITLE: Reverse Side. sIGNATU r ~rn SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION CILHR In accord with ILHR 83.05, Wis. Adm. Code COu NNW ST TE SANITARY PERMl1f # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 ~C 8% x 11 inches in size. reels n evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION a as s '/4S ~'/4,S 2 T z ,N,R~ E o PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK # nn CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER h W S D 3tf6 Z7<o~! ✓a I5 II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ) ❑ State Owned VILLAGE S ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms 2L- RCEL ZOWN OF: Ax NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1. ~ New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E] Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 N Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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) ELEVATION N SC17 <P 15- Co of C~ -7 Z_ L M '9 S SD Feet Q19.&0 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank 00 ( W Cl U".*' FYI 0 F1 Lift Pump Tank/Si hon Chamber 1 El . El 1 0 P44; 1-1 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 St~a/Cmpp/ss)) MAP]/ V 1 ,~MP y? RSW No.:,Q Business Phone Number: rYt✓ e :1 C iG ~I .5 y~ ( .Vv 4 G 1 1 V ( ~ ~ _ ( 3 ~ ~ 3 1 3 3 Plumber's Address (streett,, City, State, Zip Code): / IX. C NTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing gent Signature (No S Surcharge Fee) Approved ❑ Owner Given initial Adverse Determination `Z X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber t INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the 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. tre whenever necessary, must be properly maintained. The septic tank(s) -must be pumped by aTtLensed - pumper whe Y. usually every 3 years. 6. If you have questions concerning your onsite sewage system, contact your local-code administrator or fhe___' State of Wisconsin, Safety & 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 in 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 in ##1-7. VII. Tank information Fill in the capacity of every new and/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 pref x (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'/Z 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 !ake,3; 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) DEPART,MI:NTOF' REPORT ON SOIL 186RINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISON W 7969 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SE TION: TOWNSHIP LOT NO.:BLK. NO.: S DIVISION N ME: -rj w!/S~ 1/ ZI Av9 N/Ri(A. W 1 UL~SorJ g - AIkIIL IST-4 COUNTY: OWNER'S: MAILIN ADDRESS: STCeatx 5 M R. ~2ol:n $Paorc Po l~ubsaN ~I USE DATES OBSERVATIONS MADE V Residence BEDRMS.: COMMERCIAL DESCRIPTION: I FI ONS: A I N T Ildl ESTS: Residence LANK OrNew.' ❑Replace Z 9d S 3 96 RATING: S= Site suitable for system U= Site unsuitable for system K G 1/CS 1 1 ~-LVT 131 rQNVENsTI0UONAL: M~yJ.❑u IN-GVflS UND-PRESSURE: SYSTS -IDUN-Fl SGEU .RCQM V&DMT10Aj QLopt all If PPeeerrcolation Tests are NOT required DESI N RATE: W If an I #q y portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: LASS I If Floodplain, indicate Floodplain elevation: QEC. IFIi- PROFILE DESCRIPTIONS BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHji ELEVATION OBSERVED S HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 17 /O/.33 Q >cf.17 /3 @c~~s ~9"BeNLr7 6 rir5 11 UCH SD C G►z B- Z 2s /00.7 ! > .2S " L 11'81Z,41- 1S"&,VN5 z3''RnBa GS~tG,~ '360& ,215 B- Jv33 /0l.17 > /0.33 "$CtTS 26 BR LS 2~"~ CS~fG~2 f4'$aNh1S B- 4 &67 1061-7 i,_, > 10.4 /11&CTS A BRuSC 64',SQNMS462 B- S T-7 S 00'79 oN > 77 u: U eN S, L 40"&>,Q" M-5 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 10=;FES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P PER INCH P- 1 1,50 40N 0110 3 > >Z ~ 4 P- Z s.zc, nb ~0 > Z >Z < P. 3 S.?U OJ or.Zo 3 Z ? > 2 < P- P- ELlVr4~ 0 T A~ P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. the surface elevation at all borings and the direction and pent of land slope. 0 .1(j~ e re~~CC ~n re l ~~l"`~ SYSTEM ELEVATION Q ~.SU 1; g_ / _ LTIrQTI~I>< 011 S v ZI pt) 4(K`lC"0r%A 7_10 4 wa s7` 0 Q a! r -r--, cu A- s~. ~ © P ~3P (N rN J w -A ♦ F It 0 n O ~ om- a c all t co S Ql ~ "Y U~ ~F m P rrr -c P s ,O✓" v.. uhf/ Vol z ~ 00 W N D 1 t! IT1 ~ 11~ ~ vim. DOCUMENT NO. STATE BAR OF WISCONSIN FORM 5-1982 THIS SPACE RESERVED FOR RECORDING DATA PERSONAL REPRESENTATIVE'S DEED 410421 Harry J. Stewart co" WI& as Personal Representative of the estate of >4YSrri Vib 31st John- Aldro_ Myren__I,arsens__a/k/a__John__Aldro__Larsen.__..__..._ March 86 A.D. aI a~k~a_ Aldro Larsen 9:45 A ("Decedent")...___.. 1r for a valuable consideration conveys, without warranty, to __Verlyn E. Benoy i and. Catherine A.__Benoy_.,. as_.husband_ and. wife as. right of marital proPerty__with _ survivorship Grantee, RETU To the following described real estate in St. Croix . .County, State of Wisconsin (hereinafter called the "Property") West Half of the South East Quarter of Section 2111, Township 29, Range 19. Tax Parcel No: I i i, VM 'I Ij i i i I I Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. Dated this 2.$th--------------------------------- day of •Mmlz-h............................................... , 19-_$6... ii II li ------•----•-----------------------------------------•-------.------(SEAL) ~!'4_.... ~'UVw1 (SEAL) • • HarrY_J... Stewart Personal Representative Personal Representative . AUTHENTICATION ACKNOWLEDGK T~ -CQ Signature(s) STATE OF WISCONSIN ~4~, 0 M s T ` a1<-..crRiX................ County. 0..41, n., L..,..1.,.7 LL _r _ i APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed In full and signed by the oWnez(s) of the property being developed. Any Inadequacies will only result In delays of the permit Issuance. -9houl4 this development be intended got tosale by owner/contcactoc,(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 VQ=,r IY n wvio CALS , L dZ Location of pro erty<&-- w 1/4 • C~1/4, Sectlon I T 'R Township r o U ~r ~Jca Maliing address ~4(o R W Z = -5740 t - Address of alto rS_ I e- pi - subdivision name Let~ r IQ- L)i- Lot number $ Previous owner of property =_-A L✓o ✓ ~v. Total also of parcel 3 S acc~ S Date parcel was created - 3 Ace all cornets and lot lines identifiable? _~~Yes No is this property being developed tot resale Cspec house)? as o Volume wand page Number S~as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWINCs A WARRANTY DERD which Includes a DOCUMENT NUMBRR, VOLUMS; AND PAcz NUMSe,R, and the SEAL of THE R20I8TER OP OSEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. It the deed description references to a Cestlfled survey map, the Cectifled 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 (out) knowledge; that I (we) am (are) the owner(s) of the property described In this Intotrnatlon form, by virtue of a warranty deed recorded In the Office of STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County r OWNER/ BUYER Vm✓ AIL o ROUTE /BOX NUMBER-74o .(ga o Fire Plumber o _ 14L- d w CITY/ STATE ZIP Sd / rt PROPERTY LOCATION: \AJ S ~F 34, Section TAN, R-L~ Town of St. Croix County, SubdivisioLot number_ Improper-use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, b a licensed 'se tic taannkk pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to recieve a. grant for a maximum of 60% of the cost.of replacement.of a failing system, whic 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 County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or..a,licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and .(2) after inspection and pumping (if nec- essary), the septic,tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I/WE, the undersigned have read the above requirements and agree o to maintain the private sewage disposal system in accordance with 5 the standards set forth, herein, as set by the Wisconsin Depart- ; ment of Natural Resources. Certification form must be completed b and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE 9d T"'7 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016. 386-4680 Sign, date and return to the above address. Pi- rr, ~I ~ I I I ° i < I t I z _ I I I C% i S t I I f Z I I I ° I -o I I v ( I ~ ° I 1 ° I o s z ~ I ~ l I ~ I m I I I m I I N). I I I, ! W I 1 rn I W rn l ~ 1 I I 1 Y I I 1 I m I I I I r I 1 I l y 1 I I I O I 1 I Cl) l i~ I I I Oll I ~ 7C3 I I I z ~ I I j ~a j p C7 C r -v F; CA o -o v I I j m I I I Z W m 1 .I Z CWO I T N I ~ I m I J z 41 --1 to 0° z~ F -n x < or X z m Z7 `u v m 0 X=O T p ~jC U) {a. fT7 m z 777 A . ~ 15 /~E Cc~ ~~~/~iE,v l S~/S % • . S 7.g-l`~ c. 1-7, 1 STC 10 4 AS BUILT SANITARY SYSTEH REPORT oza-//~S~o OWNER ADDRESS •r 50 U~~ K/ C74'• SUBDIVISION ../--eg?TV /lF LOT ~ SECTION 2- T 2 ~ N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM (Y ~ l s • v . AL INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r r -roe W,~GL e4sl'%v(J- BENCHMARR• ALTERNATE BM: 160 /tt 51221A., 7. 3 f U~~ MmK SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION 9KI'S-P ~ oRt'G.'N/1~. A GviBI ~p . -lezyv F'-aQS' . sManufacturer: So-('. Liquid' Capacity: ~b0Q . •T' , Setback from: well > 31 House Z 9 r Other • Pump: Manufacturer ZOE~/~ Model# ` Size Float se eration P ~ Gallons/cycle: ;C'7 fi~ - Alarm Location 4(b-11 -'.'y . SOIL ABSORPTION SYSTEM Width: 3 Length 1 75 Number of trenches Distance & Direction to nearest prop. line: y~ f O IQ 6c 1114 Setback from: well • 7y House Other - EXIS77 &76 - S: T. r ELEVATIONS D& 7-6i~-T p2•/`'O r Building Sewer NSTLw Inlet. c72.36 ST outlet: f 2 •~0 f r PC inlet PC bottom Pump Off ~l• 20 2* Header/Manifold Bottom of system s'~ 3 ~I Existing Grade Final grade • 3 l DATE OF INSTALLATION: dt- G l PLUMBER ON JOB: ;~O/J~T 7 LICENSE NUMBER: IVIeS 33(0 INSPECTOR: R00 3/93:jt . y Bq -e/ = T°/' Gt9~LL , 100. 6 o S~•4 % # 2 P~ T S 200 ~ . X30 /?CJ~ iv(r- ~,~1~ £W ad Q 17,39 iN 1301 ~N► PIoS o/ / ew 0 tq~fr Q3 r ~ I I Iii I i f3 / I f I I' 1 T'o OJT i gy- /p 'x36 /JUT I. I Ioi /lea I-262o El~~v cNf ~~5 ~`M I SYS/ .V 7l 25- I I /evil i ~,~~,gr~oUs - i8 . ~~•~p) I I r I~, s sT M /2•13 ~7 X I y3-c5G M log ~ ,ci 3,50 I3 ~ ~ G /7.50 Tip` eA S S ~3 UIcr PLOT PJAA,), ~5 AS f3;tl 't a,V ~NS~I Ec T/ov ~ Iff 1 Iii s~ • 9iP.¢~L C17S0 ~ s y~ r~M CIfa SS SEC Tio v of T5E/ o!: ~ W5110 It /I 36- 31,2 A&A UstiT &tP I ff ~z_ ~/N~ S QED sc~. ~0 9iP~~~ f75o ~r w % A6, 1301- PUMP CHAMBER CROSS SECTIOIJ ARID. SPECIFICATIOAIS P1416- of S -VEUT CAP 'i~~ C.I. VEUT PIPE ' . WEATHER PROOF APPROVED LOCKING JUUCTIOU BOX MANHOLE COVER 25' FROM DOOR, WIMDOW OR FRESH 12"MIU. G'/.~/lli~N1N(! /A ~E~ AIR IAITAKE v17-/O v GRADE / i 4'MIAJ. y7 d 77 18 MIIJ. COIJDUIT 5.0 flEv~+n ti a I 11~ IULET PROVIDE AIRTIGHT SEAL I i i ( G I APPROVED JOINT A INh I K I III APPROVED JOINTS 1JiC.I. PIPE O~ M I I I V//C.I. PIPE EXTENDIUG 3' '001' -fv I III ALARM EXTENDING 3' OMTO SOLID SOIL $ 3 B ~ ~ ZJ ~ ~ I I I ONTO SOLID- SOIL I i I ZU c 3~ I I ow .I I ELEV. FT. ii ' I PUMP ,j y OFF 2/SE O,e K ge p pIA) 6- ° - Igs ~1o~f'E s~ OP v!1 f io,J I BLOCK S/l vl~ 61E V lr RIStR EXIT PERMITTED OUL9 IF TAUK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPEUFfCATIOUS DOSE KS TANKS MAWUFACTURER: J ' IJUMBER OFDDOOSES: _PER DAS I TAMK SIZE: GALLOMS DOSE VOLUME S ASS ALARM MANUFACTURER: L"~U1041OM INCLUDIUG BACKFLOW: GALLOUS MODEL DUMBER: CAPACITIES: A= /YS INCHES OR GALLONS SWITCH TYPE: 2 INCHES OR GALLONS PUMP MANUFACTURER: C= INCHES OR GALLONS MODEL UUMBER cC`/ p ,/6WYZ ~y D= /0 INCHES OR Z GALLOUS SWITCH TYPE: W S5 - 4"q-VWJV /-l' MOTE: PUMP AUD ALARM ARE TO BE MIUIMUM DISCHARGE RATE ZS GPM INSTALLED OU SEPARATE CIRCUITS VERTICAL DIFFEREUCE BETWEEN PUMP OFF AUD DISTRIBUTIOU PIPE.: rf? FEET *Aok 5'PtC5 F MII~UIIMMUM UETWORK SUPPLY PRESSURE , . 1->E FEET EAC A_ + FEET OF FORCE MAIM X /'/O FYOFT.FRICTIOUFACTOR.. '3 FEET TOTAL DHUAMIC. HEAD FEET FOVA9J IUTERNAL DIMEIJSIOUS OF TAUK: -LEkIC.TH / -W1hru Vyisca•=sin, Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT Sf- Gvo in GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Z41°11i0 U Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: Steyr, a 9V4_0 ,V% oma Kv✓ Nvc/ o CST BM Ele Insp. BM Elev.: BM Description: Parcel Tax No.: 60 ' ' To O to - l l 8rs'- Vo - 0 0 4 0 141 e, TANK INFORMATION ELEVATION DATA AoJwn7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Z•Z = e o epti C -Ks lt.J'7 06) Benchmpj~ osln 8Do Aeration Bldg. Sewer f.~ Holding St/ Ht Inlet p1 TANK SETBACK INFORMATION St/ Ht Outlet o. 9 0 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake 10.3 ~1•w3 e D .~3 ~ r ?vt NA Dt Bottom t3.9(o Zifi ng Ll>?j~ r NA Header / Man. of Aeration NA Dist. Pipe 7 •r 9y Holding Bot. System 27 B'. g 30l 't PUMP/ SIPHON INFORMATION Final Grade Manufacturer o r- Demand St. r!c AY1 ss- 87.75 Model Number 9~ 25GPM Q le140k s ' 11 gZY7 TDH Lift.65`7Lri oss Head ction 2 System TDH4,$'7t o o~ v ~w ~•$3 Z. 251 Dia. Dist. To Well Forcemain Length Mew h- MR W 3 SOIL ABSORPTION SYSTEM BED / Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 75 DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LE ufacture SETBACK INFORMATION Type O CHAMBER Model Number: Syste-An 7.5 OR UNIT DISTRIBUTION SYSTEM 92 wAi; - Header/Manifold o/0 Zbojal Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length w9sa. Spacing 7 ZJ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx xx S d / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present etc. ✓ In ~1~ ✓ b ors !Z ~r.✓ 7~'a K c4J Z gn u ller M54 A W o- gall l'tin lJ,`ve, go Ali e tl~~i~y Co G~~ 6e- -pse- I'L 16 - CV Plan revision required? ❑ Yes gg No gad Use other side for additional information. ~Z. lz X17 g~ SBD-6710 (R.3/97) Date Inspector' ignature 4A4 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division ST. CROI X . INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)). 299200 WdAMO W STEVE & SUSAN ❑ Liyb ~fiage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: HU v Parcel Tax No.: o0 v.(/) 020-1185-40-000 TANK INFORMATION ELEVATION DATA A9700517 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic K Benchmark 100 W-C ~a 2.28 toz-28 Dosing Aeration Bldg. Sewer Holding St/Ht Inlet qqG qZ TANK SETBACK INFORMATION St/ Ht Outlet C> TANK TO P/ L WELL BLDG. Airi to ROAD Dt Inlet Ar Intake cl ~ Septic S3/ NA Dt Bottom $ .3Z Dosing NA Header/ Man. 7 21V S- 9 Aeration NA Dist. Pipe 7 Holding Bot. System XV3 3 QI PUMP/ SIPHON INFORMATION Final Grade qqj 91.15 'Old Manufacturer Demand ML yS~ C17 ?3 Model Number L<GPM 0,80-," Ord C? 21:2 TDH Lift 57 Friction ~ Systems TDH t To c~/v~ 9S3 ~Z7S Loss Head q'T Forcemain Length 57f Dia. Dist. To Well 173 SOIL ABSORPTION SYSTEM BED RENO Width , Length No. Of PIT N Pits Inside Dia. Liquid epth DIM EMSTMIS 3 ~5 2Trenches DIMENSIONS SETBACK SYSTEM TO / BLDG WELL LAKE / STREAM ACHING Manua r: 1 Tr k-- M~ a Number: INFORMATION Type o CHA ~sl System b" -7 5 / OR UNIT DISTRIBUTION SYSTEM l Zuh~ s ,re_t~C__ A Header/Manifold .qp Distribution Pipe(9 / x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 15 Bia 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 / T _ --Topsoil E] Yes C] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 21.29.19.1166,SW,SE 558 WAGON WHEEL COURT S3 40 % C6 ow Plan revision required? ❑ Yes ❑ No Use other side for additional information. 7 6710 (R.3/97) Date Inspector's Signature Cert. No. bb~ ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Ave sion SANITARY PERMIT APPLICATION 018E Washington Buildings D `*6c nsin 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 5 7' than 81/2 x 11 inches in size. /w • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide maybe used by other government agency rograms E] Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. S State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION V / A- PropertyOwner > Name ' S~Srha Property 5 2-1 T" , N, R /f E (or) Property Owner's Mailin Address Lot Number Block Number SS CT 6VA60A-l 46 City State Zi Code Phone Number Subdivision Name or CSM Number PpA, 3lk o.~ ~1. 0~ ( 1F33 /s r r ICC 11. TYPE BUILDING: (check one) ❑ State Owned ❑ Ity Nearest Road ❑ Village ~sQ Public or 2 Family Dwelling -No. of bedrooms own of fOA~, 44-7 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Chely one box on line A. Check box online B, if applicable) A) 1. ❑ New 2. eplacement 3. E] Replacement of 4. E] Reconnection of 5 Repair of an ------System --------System Tank Only-------------- Existing System _________Exlsting----m B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) & 31. 9 X Q, f • S Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 0-5eepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 21. 2 S~DEu~~~O~ " 43 ❑ Vault Privy 14 ❑ System-In-Fill $ - c-- 3 VI. ABSORPTION SYSTEM INFORMATION: 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 a Elevation 6700 7S0 3.5-0 Feet 7• S Feet VII. TANK Capacity gallons Total # of r Prefab. Site Fiber- Exper. INFORMATION New Existin Gallons Tanks i~=ac~>~ Name Concrete st ucted steel glass Plastic App Tanks Tanks Septic Tank or Holding ank Oa ld'DQ /0000 Z - 404vWt7 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber O 0 t - 40&E5&,$7 ❑ ❑ ❑ ❑ ❑ 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' Signature: (No Stamps) MPRSW No.: Business Phone Number: ~0B>F2 r-- 7*43 R rteT- 330 7~s • 3~G • PAO5 Plumber's Address (Street, City, State, Zip Code): S_5- h/ VZ/'c- IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent ignature (No Stamps) OgApproved ❑ Owner Given Initial Q ~d``oSurcharge Fee) IZ, Adverse Determination I 0 / 0 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained`. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have.questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings D+vision, `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 wnere the system is to be installed. II. Type of building being served. Check only one and comp ete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or,site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2:( 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. ULBRICHT & ASSOCIATES CO. 655 O'Neil Road • Hudson, WI 54016 Reg. Designers of Engineering Systems 715-386-8185 Private Sewage Consultants PROJECT INDEX / c DILHR Plan I.D. # N! _ Date Owner S~C~J-2 SUSII I~ A/)?M4{f4 Y Phone /oo3 3 Address ✓ll'~J ~~~__-v ~~G.~Px C~ ~~~t/~''L- S y~~ Legal Description Gellipi~pi sV, SW, .00 c. Z T 1I Q R 1 g `-J p Town of County 57 CPOt' C.S.T. / -2Yo9 Installer Poaeor Zroliitfjrj, r Local Authority/ Supervision PROJECT DESCRIPTION q~o , ~X, s r~~ sys T, . s 7o?&.e s~- a Yee t+ 6/Z Sys: JA.0 13 ow !5:-1 Ro-r APO Y-q7'0'e~ 77 Pg.l PLOT PLAN VIEWS P9.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS P9.3 PIPE LATERAL LAYOUT Utb~lcht & Assoclstgs Pdvatg 96wagg Consultants P9.4 DOSING CHAMBER CROSS SECTION Hudso" udson,WlNlsls- 84018 P9.5 PUMP PERFORMANCE SPECS 1-ly s 3 3 0 0 \ 13 vE;)Aeo4f Bq -el 7-0/0 ~/gyp. ' ~O0•d ~ 5CA-~~ % w , 3l T'd ,P~ ~ use" zy , P~ TS /000 67OLe ZVI '3o MOM PLe 16 zvee 9111v, to y FIB 4 i5/P/106- f7 39 UIh~ I~ go AIX r, Q3 VA .0" 1 1 fox 9S, so I~ i I I ICI 8 i I I I° I! I f `x~ i vE~% I. I ICI /3tI~ ~ o lol I`~I - - ICI Iii i-z676 s ysr Y z S ErF/v too-(- 1671( I~ I ICI ~ I.I 9'2 '~s ~ I I ~ i J r I I ~c I I 11.70 1.•/3•f7 I Z ~~.za' iol I i o Z 13 /Nr 'L 7R5 f TD/L° TiVEtiC,I S s~ sW- 5-0 e.4 S ysT T. Of s - SyST 1-/-t Of 7-4005 f,3 -SO lll) f3-sv 1ff "z_ F/iv/SEED N A7 y ti - CRo S SE c TIOA) TAE ~s 215/~v 6- l~tJ i L 7e,4 7-Of4~ S 31, Ss~.F+ . 6'a P vv icls'~IJ ~c T/ov ~ Iff F~Ni S QED N PUMP CHAMBER CROSS SECTIOU AND SPECIFICATIONS pi4 E g OF S -VENT CAP 4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUUCTION BOX MAIJHOLE COVER ~t 25' FROM DOOR. to l,, 1AAkc WINDOW OR FRESH 12"MIU. AIR IAITAKE f/1AOt rk b~T~ON GRADE I I 4" MIM. J~o IB"MIAI. COIJDUIT 771,14 60 ~ flEv~+n oti ~ 0 111 INLET PROVIDE i I AIRTIGHT SEAL I I I E I III T y I I I) APPROVED JOINTS APPROVED JOIN A w/C.I. PIPE IN ' ~fvM ( I I I I W/C.I. PIPE EXTENDIUG 3' 0 I II ALARM EXTEUDIMG 3' OWTO SOLID SOIL B ONTO SOLID SOIL 3, 2s I I oti 89.6, c 3 ELEV. FT. PUMP--- OFF uSE J D $S ~ ~1o~PE eF p 'I ~N k 'gE ~I~ lr I BLOCK S/~iVD /t VA J,~€G?9i,; 1G-- RIStR EXIT PE.RMITfED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E 5 //PEGIFItAT10MS DOSE TANKS MAUUFACT OgJr &,-S Lo . {DUMBER OF DOSES: PER DAy URER: 15-6 TAA1K SIZE: 600 fi ~U~ A 01J5 DOSE VOLUME s /"s ALARM MAUUFACTURER: G 1/°~jl~p INCLUDING BACKFLOW: GALLOSIS MODEL !DUMBER: Y Ll'AL"' CAPACITIES: A= s INCHES OR GALLONS SWITCH TYPE: ME-^ -72- INCHES OR GALLONS PUMP MANUFACTURER: C = ! INCHES OR GALLONS MODEL NUMBER: 7 `Z D= /0 INCHES OR Z0 GALLONS SWITCH TYPE: WSVPAQ[`~ 4'Ekao7RY )C/* MOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE ZS GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEU PUMP OFF AND DISTRIBUTION PIPE..FEET "rAA)k SPECS iT- + MINIMUM NETWORK SUPPLY P ESSURE . . . . . . . . . . FEET CAC(A, I Of D} P FEET OF FORCE MAIN X ~L/0 FyOrT.FRICTIOU FACTOR.. '3 FEET t-goA 20. s `iii ~s. = TOTAL DYNAMIC HEAD = 712- FEET FOUAl0 11 INTERNAL DIMEWSIONS OF TAUK: LENGTH _~;WIDTH op g ;LIQUID DEPTH . . gyp/ . HEAD CAPACITY CURVE > 30 MODEL •'80" 1 !i/0 e • 23 o 6 ( s/a 20 ~ • O 1s .ZI 4 1 J/10 B 10 2 . 1 1/2-11 1/2 WT s t` 0 U.S. GALLONS 10 20 JO 40 50 BO 70 80 LITERS e0 160 240 0 FLOW PER MINUTE TOTAL DYNAMIC NEAWLOW Pill LUrNlTE . EFFLUENT ANO OEWATEIYNO NEAR CAPACITY 12 UNITS/MIN • L20 T METERS OAL.{ LTRa v 552 71 213 0.05 el 211 1.551 16 170 S 10 255 0S ~ 5/16 Vslw 2a' CONSULT FACTORY FOR SPECIAL APPLICATIONS • Electrical aderllalors, for duplex systems, are available and a Mercury float switches are available for controlling single and supplied with an alarm. three phase systems. p.. Mechanical alternators, fa duplex systems, are available with or • Double mercury float switches are available for without. alarm s~vttches. piggyback variable level long cycle controls. SELECTION GUIDE Standard all modals - Weleht 391b~. - V. H.P. ~ 2. ekgl~ DOW operated 2 pole rnoMarcal J switch, no external control required. W Series Control Selection Single piggyback mercury Ikul switch or double Pigyback mercury, Boat Model V ho-Ph jModo Am a Sim lox switch. Haler to FM0477. MOO 11S Ou lax 3. Mochanicel alternator 10-0072 or 10-0073. 1 g.0 1 a & - 4. See FM0712, for correct mold of Electrical Alternator, "E•Pak" 3 or 44 3 6. Mercury sensor (teat switch 100715 usid M • control activator pecill' D00 220 1 Auto 4A / or 1 i 7 duplex 19) or (4) float system. 'E90 • 290 1 Non 4.5 2 or.R 3 4 3 or 4 '&G _F !:1~ fie' J Pak", )unctlon bt►x,1or gi' ~_.rtlglM onnedkNL or w4.d.l,..i • I Wisconsin Department of Industry, CVV ►ND~SI / LUATION Labor and Human Relations Page of Division of Safety and Buildings n cordak'f'e*R. IL .09, Wis. Attach complete site plan on paper not less than 6 1/2 nchJQfnisizelt a County include, but not limited to: vertical and horizontal refer nee int (BM~jd percent slope, scale or dimensions, north arrow, and to do and dist~arest ropd Parcel I. D. # * ZONINGOFFtCF O Z O ~l .5./4/0 APPLICANT INFORMATION - Please print all Reviewed by Date Personal information you provide may be used for secondary purposes (Pn Irta• , .)5J04 m)). I / 2 1&,q 2 Property Owner Property Location ST~UF -s /~'N ~OMAA1,~}iSe Govt. Lot SW 1 /4 SE 1/4,S 21 T 2 q N ,R 19 E (oto Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# S,s B 14) f4( )-6, 3 cT- a vrsr'-,f- 1ST •4A0;7-- City State Zip Code Phone Number 1 Nearest Road WA60k; 4w 1- f tjDSo~ Gt> l . Syo/& (7iS) 386' 1F33 ❑ city ug & gJe Town Gr¢~°~o u L.v . ❑ N Construction Use: esidential / Number of bedrooms - Addition to existing building l Replacement - ❑ Public or commercial - Describe: ,~f/~ = /VOT /~~LD~1i'~L°•~-~l~L~~ , Code derived daily flow &6V gpd Recommended design loading rate N~//tl bed, gpd/ft2 ° trench, gpd/fit Absorption area required Nr bed, n2 trench, ft2 Maximum design loading rate ~Abed, gpd/f trench, gpd/112 Recommended infiltration surface elevation(s) .542a P ~k • 3 It (as referred to site plan benchmark) . 1j Additional design/site considerations u•SE la o6~ Parent material `S/L7' I0L3•,5' Od,Gt~ S Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system E Ts- ❑ U e-,§- ❑ u 0 s ❑ U C'S~❑ U ❑ S 0-13-1 ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench I 0.20 /0YR *213 - S6L /fs n"~''/' • 3 2- 20.3 /oYR Vil StL Zfsbst . S . co Ground 3 f 0Y`2 Y`& G S ~iw! fe d5' .7 .8 elev. g • U i o Y~2 5/42 .S D 6~ - 7 ft. Depth to limiting factor . 4rcYtsr1,u&- s ys f. is 460,0 - 444tl YitN :50/ /5 Remarks: Boring # i n•lo /0YA2 2-I3 SiL /f 5.,4k' /hi -fl Z z 202 /0ye- N1/ SQL.. 2f5Ae /S"cs i-f .5 ' .G 3 y3 /o Ye ds cs • 7 •8 Ground /D (_9 .s .S • 7 elev. 7.20 n. Depth to limiting fac r 7 in. Remarks: CST Name (Please Print) Signature Telephone No. 'DOSE gT Zt~[3 R t G 1.t,1r-- ~ 7/57• 3 8Co • ~I BS Address Date CST Number ~/POjI'1/~',r•J~4 ~'ri~ SOIL DESCRIPTION REPORT Z 3 PROPERTY OWNER Page of ~ ~ a z~ - ~~~s• yo PARCEL I.D.I6 T Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Gep/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 a 2~ /oYk V 14- 1w 16, s Zf 2 3 2 • y /4 Y.,? .3/f/ 514- f s6,C Ground 3 1' ye Y/6 ~ L-3- 1~1e .S C ley. /0 yve Depth to limiting y &r in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. n. ' Depth to limiting factor in. Remarks: Boring # Grounj elev. ft. Depth to limiting factor in. Remarks: 13 E;)Ae4f ~~10 . ip 0 • d p 56.4 t e 3l APE' uS~ z9 , Pi'T S 710 /000 ~-,~-P. Gv~•z'~ 5~° / 300 So MOM vf1-t f `Ir?, QS Eq-e 9141Y 15 IP IV 6- 9739 Q3 I I t , I I I ~,e0~-1 I ~ ~ / I I I ~ I I ~~~0 l Z'~~••• I I I I I I ~ 0 I I ~ ~ I I I. I lol 4) 36 'dev o t o l I C I I--- - ICI I~~ I-z SYSr 14 6lo 2,5' 'ofFiv .CHIP- I~ I I I I 97.70 i2 /3 S7 ' I i I 13 rj~.2D I i o 43 3 y~~so svySEs~~ 77- SYS77 Pv* O-V-44105 cI3 -SO . - _ I , ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK 7 This is to certify that I have inspected the septic tank presently serving the 5-1?Vx ~M~i✓~4~~~ residence located at: 54) 1/4, S~ 4, Sec. Z~ T? N R W , 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 ®G 1`' j-7 Did flow back occur from absorption system? Yes" No (if no skip ~p next line) Approximate volume or length of time: Yi gallons minutes Capacity: Construction: Prefab Concrete / Steel Other Manufacurer (if known) : Age of Tank (if known): (Signature) (Name) Please Print ANS 33 0-7 (Title) (License Number) (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baffle). 10 Name Signature 4+"MPRS 330 5/88 I STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS L~j, S `yam ~ J PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE / c PROPERTY LOCATION 5~0 1/4, 5 1~7 1/4, Section T 'L ( N-R W TOWN OF llvfiv , ST. CROIX COUNTY, WI SUBDIVISION 15'7-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: ` Q 7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 STC - 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), thenia 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~s~a 5~"~~ A 11 . Location of, property`f4~) 1/4 S6 1/4, section T 2~ N-R ~l W Township SS Lr~~Gt~-y . Mailing address,, Address of site ~i . Subdivision name Lot no. Other homes on property? Yes_No Previous • owner of property , Total size of parcel 2'e), Date parcel was created Z~Ez Are all corners and lot lines identifiable? Yes No Is this property Oeing developed for (spec house)? Yes No Volume i ? and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & 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 n the o five of the County Register o: Deeds as Document No. W, 04 , C , and that I (we);presently own the proposed site for th sewage disposal system or I (we) obtained an easement, to run the aboZe described property, for «Do"M9IR No. STATB'BAR OW WISCOXIM NO= 1- s.rw ansaraa ws sswmsae a WAgfuwrlF Oil . 4 esa Thhe ]~eea,a ►.tr...._.~t...Ndt~thuc,.. .issue MA J asrL., ..l~3aaraa. L..,tromses><az . aad..~..M...[S>. • . mv- 010- WitDeeAth, 7*0 the said Greater. dw• a .,tumble . eser to on*%e as hftwbg auarm" "a ..tax in .....SL... ~ 4 . Cam*, ilea of WLssIds:, rv 'mss !las~+el No:.. Lot 6, Plat o! trairis vista, First Addition in the ?w 4 , of Andsow, St Croix County, Wisconsin. CC a hom obsed preperi Ti*dbw ~ : ~ (is sat} with all and sh4pd r the hmrditaments and appurtenances thmea de WonenS: I ~M And.: JAU-F.--M ll.. . narmdo that the title is good. iadefeas$le In fee "pie and free and clear ai ansv6rances except sssaments and protective covenants and restrictions of mosrd _ I and w® warrant and defend the sasat. Dated this MIA....................-- 4" of Jmme 1991L._. i - • . ----(SEAL) j r , SAN E. EMLLM ,w -•-..W - ...----------(SEAL) ---...------------------•-------(SEAL) t~ i ♦UTB>i NTICATION ALCZ=OWLBDGMXNT r - STATE OF I ML ~ St. CtmU County. aushmmeafte t5is......_.day of----- 19_.__._ Pwae.aib es before me this 28th _day of Jas! 19..,9Q-. the ahoea named . Sam R. MULIer . . - e ' - - - Tr=: MEMBER STATE BAR OF W - _ - s (i otised-by ; 706.06. Wis. 4f~3`✓O to me ie Am person - Y eseeated the . Q' V • ~ = 7n - in ~d srknnsindvaunrt _ DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION _M41" OJJ~ y1(I 53g e C . 21 ,T29 - R19 State Plan I.D. Number: `~jr CONVENTIONAL El ALTERATIVE (I assigned) Town of Hudson Lots-~ Larson Lane u Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Vert n Bano 766 Medow Drlve,Hudson, WI O; BENCH MARK (Permanent re erence point) DESCRIBE IF DIFFERENT FROM PLAN: tR. E p CST REF. PT. V.: ///V Or Name o Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Douglas Strohbeen 5432 St. Croix 135493 SEPTIC TANK/HOLDING TANK - ,r,, ltde, CAXr in /0, /z9 MANUFACTURER: r~ a LIQUID CAPACITY: TANK INLET OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ,B, r~ 97 917,3 YES ❑ NO ❑ YES NO BEDDING: V[IVTDIA.: HIGH WATER C'I NUMBER OF PROPERT WELL: BUILDING: VENT TO FRESH C ,O, ' / n e TM ALARM: FEET FROM LINE: AIR INS ❑ YES NO ❑ YES NO NEAREST --1111' / ' 1 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: RWARNING OVID DLABEL PROVIDED:OVER ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: I VENT TO AIR INLET FRESH (DIFFERENCE BETWEEN FEET FROM LINE: PUMP ON AND OFF) I ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: T AMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTE Z. 23 ec-,( WIDTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BEDITRENCH , TRENCHES: / MATERIAL: PIT DEPTH: DIMENSIONS tJ to T I' NG VENT TO FRESH GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE O w PIPE ~MA~~ TERIAL N DISTR. NUMBER OF PROPERTY WELL: F(a _ BELOW PIPES: ABOV . COVER: E EV. INLET: ELEV. END: ' //11 •715 PIPES: FEET FROM LINE: p i AIR INLET Y2. NEAREST-♦ MOUND SYSTEM: ' Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: HNOEEJ LLS; ❑ YES ❑ NO ❑ NO DEPTH OVER TRENCH/BED JDEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: CHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES YES ❑ NO PRESSURIZED DIST RIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL N0. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WE NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST ► / . i / A7"- 7 rid .is!Q r INDUST OF" REPORT ON SOIL WRINGS AND SAFETY & BUILDING • INl:1TRY, DIVISIO LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 796 HUMAN RELATIONS N WI 537 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP LOT NO.:BLK. NO.: Sy~DIVISION NAME: W V4-,~, 1/ ZI IT-L9 N/Rn4(o W 1 UpsorJ 8 i~A,RijL VI-5r4 COUNTY: OWNER ADDRESS: ClIZ4 •X S M1 ►LL O, L n [~~pOI,C dSAhI USE DATES OBSERVATIONS MADE NO. B : COMMERCIAL DESCRIPTION: STS: wFlesidence uN K New:. [:]Replace O VIZ 9 Q 5 3 9 6 -S:21.1lt; OOK G S8 r.~Orts - ~/1~` f I1.1U`T RATING: S- Site suitable effoor system U- Site unsuitable for system ( OMSTE1U M0S DU I' OS ❑U SWS IOULH0SGU RECOMMENDED Diul'IUtiAL(opt~E~ If Percolation Tests are NOT required DESI N RATE: I if any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: (~,L/~SS ' loodplain, indicate Floodplain elevation: I F 4A ©'Ec- PROFILE DESCRIPTIONS BORING TOTAL DEPTH T GR UNDWATER-INCHES CHARACTER O SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH4 ELEVATION OBSERVED EST. RUWSf- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 11 my-331 Q X9.1-7 /3'g&.i_71Si9'6t4U76 rir5 ~r' tiC~ So" CS G.z B Z ZS /00.7 NO M Le > 2S r ~ ~i:Be,,C rS"P,aN~S 23''Ra$R GS~G,~ "13R ~IS. B- 10.33 /pl.!? > /U.33 "$ccTS 2t; - Q CS It"Ra$ CSI(Iv- S4 "BR. MS B- 8.61 &-7 > z"eLc7s A @avSL 64",6QNMS46e !Z„~NL~GJZ B- S ?.-7 S 00.79 ON > -7.7 try Z6~~ eN S, o„ear, MS 6- R, PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP WATER LEVEL-INCHES RATE MINUTES NUMBER IBS AFTER SWELLING INTERVAL-MIN. PER INCH P_ 1 1C, 4 N 130 3 > >Z > < P. S. 2 v nb .-70 > > Z < P. S.?U a►1 01.16 3 Z > > 2 < P- P LLIL,1A-rjm,, k1 ktL P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hoi zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and per of land slope. SYSTEM ELEVATION reQ~eCLn fe~raly0t of,'Ls t3 6 5/D9j , `--r Suacr z' i r1 ILHR SANITARY PERMIT APPLICATION _ In accord with ILHR 83.05, Wis. Adm. Code COU r ST TE SANITARY PERM # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 inches in size. revis n evious application -See reverse side for Instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ¢ m 5 %-S E, %,S 2 T -Z,N,R /E(o PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK # e. o/\'~~ Dr', Vq-- 7764 18 1 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 14 Z, 41-sq) r-. W S O/ 3n, Z7loy ra 57et_ II. TYPE OF BUILDING: Check one CITY NEAREST ROAD (Check one) State Owned W TOWN OF: VILLAGE Lar S~ti C~ Q. ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/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 in line A. Check line B if applicable) A) 1. [A New 2. ❑ Replacement 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 # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 H Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 140 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) ELEVATION L/ sc" # s Co ~S ('-7 Z_ M 9S.Sb Feet ` O.&a Feet VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App' Septic Tank or Holding Tank Tanks Tanks _V_ FF11 1-1 F1 00 ( IN n : tc✓ Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing gent Signature (No S Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination N 6 S I 5- X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: Form- STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. Z T ~f N-R W ADDRESS fe le 2 L- ST. CROIX COUNTY, WISCONSIN l~k ~so n W .Z S y9/G SUBDIVISION LOT LOT SIZE a-~~<<r 5 PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM House- 6PCAC4.3 zv'x Q Z' Za k v6 I T Wall N 10 I b~ x Ry' Imo- 3c' u I I - - - o I ~4 d 3 j d 1 110 i B.rk.To of~ P INDICATE NORTH ARROW Ii nn~tn*nrAnv. n ..lt. Fl.., .•erl~nol rnFnrnnnA nnint 11RP_[j 1o1o ~~~ftllJi'M/~Q~~/~ l+D~ra✓IAm✓ • T' • I , PUMP CHAMBER Manufacturer: Liquid.Capacity: Pump Model: Pump/Siphon Manufacturer: , Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear , Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: ion ✓aj;&Aa Trench: Width: _1 _ Length: C. Number of Lines: 3 Area Built: Fill depth to top of pipe: 4/ Z Number of feet from nearest property line: Front, O Side, © Rear,O Pt. Number of feet from well: IrNumber of feet from building: (Include distances on plot plan). i SEEPAGE PIT Size: (l/ Number of pits: Diameter: E Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: