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HomeMy WebLinkAbout020-1333-60-000 / V ST. CROIX COUNTY ZONING DEPARTMENT 5 6 AS BUILT SANITARY REPORT Owner SAW M 1 l L J- tL r 7 Address '7y 'Y 4ca/LC. ,FRr a 20 i City/State gu p sou wl sY cc~©t co FICE ING 1 Z0 mjWGOF Legal Description: Lot I Bock - Subdivision/CSM # eAD L4ND3 «Aiiz) '/4'S E '/4 &S( Sec. :Z,2, T Z.9N-Rjjff, Town ofw vL-se k PIN # ©z 13 3 3 - `o SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: 9000C' r Tank manufacturer W G (S E A-- Size ST/PC / Setback from: House lc/ Well Sq P/L 'moo Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: 7-R F NC H Width Length 4 d , Number of Trenches 'Z Setback from: House ems. Well T z' P/L y° ' Vent to fresh air intake / e. z ELEVATIONS: Description of benchmark 2 "62 UC- Gs n(Lo~ ' L / A4f' Elevation Qo, o(n Description of alternate benchmark s I c 4 o K k Ac k 2~ Cr_ k ~ Y~ Elevation 17,-7Z Building Sewer ST/HT Inletl-gO = 9G-Is' ST Outlet'7,1 z PC Inlet 7 PC Bottom Header/Manifold` a-e' s S' t Top of ST/PC Manhole Cover Z. 9 ~J kJ16 N y cS" ! 4Ot✓ Distribution Lines "~`~'p4 .5; < `I ,0 ( ) Bottom of System ( ) 16 ' ( ) 11 , I -Z-' ( ) Final Grade ( ) 41 ]e 0 SS ) ( ) Date of installation 3-/ / epermit nu ber Z!910 State plan number Plumber's signature License number Date Inspector od f~n' Complete plot plan NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. L D g~LAN r VIE ♦1 . r i !t T 44 NI SELL ,~RA6E Iq L 7-~\k At j4-rL 14 2tF A ~y' ~g xsz 0 4s 4 t3. 1M, t,. Pvc. IS 1: /00,W 10 INDICATE NORTH ARROW 1 ~ 1• 4-1 AS. 41 'f - 3K 1 60 Q J il.l v ' to i '1 th' o (eve ~ v i `O a l y o y L 0b CO 1 s Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT 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)]. Zqq M/ Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.: W 111115 hs01V - CST BM Elev.: sp. BM Elev.: BM Description: Sa►++` ,cs Parcel Tax No.: 1;7 `0~ 7e v-f L" PJL i e Z- c-sTs OZO-/333-(oD-ooa TANK INFORMATION ELEVATION DATA 7004-10 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Sep is pip Benchm rk 3~$ .103• loo Dosing k~, 8/1/( ` ~i-O$r 9T 77 Aeration Bldg. Sewer 7.` ~j(~•r~ Holding (2Y P* Inlet 760' 96 -2,5- TANK SETBACK INFORMATION <2>4% Outlet ?go,, gs-wr" TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake e tic tzc;r c/o NA Dt Bottom Dosing NA Header / Man. RS•?~ °•98 93dS 9Z!! Aeration NA Dist. Pipe ~O•~ 1. 89 Wm` 193.17* Holding Bot. System r'"' /•R'L 4P-cf f PUMP/ SIPHON INFORMATION Final Grade $'.Z 9Sro5' Manufacturer Demand ST. litkole, 6 c✓ ~•l2.- 97-73 Model Num er GPM TDH Lift Friction Sys TDH Ft Head Forcemain Length Dia. Dist. To eIl SOIL ABSORPTION SYSTEM BED TREN Width S+ Length GD / No. Of Trenches PIT No. Of Pits Inside Dia. quid Depth DIMENSIONS 2 DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI anu r: SETBACK CHA ER INFORMATION Type O 60" -l OR U de Num er: System DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) ~ x Hole Size Jx Hent To Air Intake Len9th ?s•~J - Dia Len9th 0/ Dia. tr Spacing / SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx De th Of ed Fx Mulched Bed /Trench Center Bed % Tre es i ❑ Yes ❑ No ❑ Yes E] No / COMMENTS: (Include code discrepancies, persons present, etc..) ~~tf V/.1o ~Rd S PMiric~( at"141"4111~ It's w0ja 0-k 40P d& 4~i:4 daL u .yvr(l a rvcuilfic,k ~z„ . 6V ( 4;-~-~ G2(ef/a,K Plan revision required? ❑ Yes ® No c2l't JJ 1-7 ~5~ Use other side for additional information. F fV/-~, SBD-6710 (R.3/97) Date Inspector's Signature e-CeRN o. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 0,91949/ f we~( Im-ov~ ,ov5G NO{ Suc t~ ND ~ 86~. S _ i 13M00. pl~vrw,~- slit ~torir.~~_u.~, Ena 4o vG du, ~rtrW So Sr~s+~w. does naZ", need ~„t, p c~a ~ br✓-ti_ ~o7Nw i~ M = ° o , 0 o~ -N 00011-- t I z p~ryy g I y V a I M z ~ Z I i ~ I o I W ti e I w ~ m 00 W ~ i (O d L I• ~ Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page 1 of 3 division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code 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 St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # da0-/075-60 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 Richard Stout Govt. Lot SE 1/4 NW 1/4,s 27 T29 N,R1 9 %(or) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 1353 Awatukee Trail 16 Badlands Prairie City State Zip Code Phone Number ❑ City ❑ Village ki Town Nearest Road Hudson WI 4016 (715 )549-5631 Hudson State Hwy 12 ® New Construction Use: H Residential / Number of bedrooms 3 - 4 Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow 60C) gpd Recommended design loading rate 7 bed, gpd/ft2---8-trench, gpd/112 Absorption area required 8 58 bed, ft2~ rench, ft2 ~.,Maximum design loading rate • 7 bed, gpd/ft2 • 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations;, Q T! q1 a ~LUT li~~lr Parent material Glacial deposit Flood plain elevation, if applicable It S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holdinn~u U = Unsuitable for system ® S ❑ U ~ S ❑ U Rl S❑ U 0 S ❑ U ❑ S 0 U ❑ S 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 1 1 0-1 10yr4/4 none is gr vfr cS if .7 .8 2 .14-85 10yr4/6 none s sg l cs .7 .8 Ground le" t=Z^ Y1f~d Depth to limiting factor 85 in. Remarks: Boring # 1 0-1 10 r4/4 none is r vfr s if .7 .8 2 2 14-SO 10yr4/ none s sg 1 s - .7 .8 Ground elev. Depth to limiting factor 9D_-in. Remarks: CST~~Name / (Please Print) / Signature o ~ Telephone No. !Ni l~l . a $G /1 1~ A!"1 gel/ r im-~✓!~C ! S -.3 F,." Address Date CST Number •PROPERTYOWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3 I 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 1 -18 10yr4/4 none is ogr mvfr cs if .7 -.8 2 118-9) 10yr4/6 none ms osg ml cs .7 '.8 Ground elev. Depth to limiting factor , 94_in. Remarks: Boring # 1 0-2 10 r4/4 none is o r mvfr cs if .7 ;.8 4 2 26-89 10yr4/ none ms osg ml cs .7 ;.8 Ground elev. Depth to limiting factor 8 9 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD1ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 0-4 1 0yr4/4 none is ogr mvfr cs 1 f .7 ' . 8 5 2 48-()6 10yr4/51 none ms osg ml cs .7 '.8 Ground elev. 9~~y Depth to limiting fa6tgr bb in. Remarks: Boring # Ground elev. ft. • Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) i s ai ~o7r J°5 3 i 0 Q GN e_ 3 G ` ~I 13~ a Y 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_ 5-{ M IW I LL-4rL Location of property 1/4Al w 1/4, Section Z '7 , T_7~tIN-R 19 e7D Township ka Q ,-n N Mailing address a cX'4 /5 1 !1 ~ M w 1 .~'~f+D lG Address of site 7 5/ y W / L kcf4 p Subdivision name Z i4 S) L A N 0 g ~ Q Aj P- 14 Lot no. Other homes on property? Yes)( No Previous owner of property f~- ( e_ µ A R D ~ 'To tJ-T- Total size of property z, S 2 it 4C- Total size of parcel Z 14 s.. Date parcel was created / b - 3 - cl "7 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? AC Yes No Volume 1 tog and Page Number ,3 V Z_ 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. 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. 5~~--cam' y3 4 ~B qn"ture o Applicant Co-Applicant Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER .S AAA YK t LLV(L_ MAEUNG ADDRESS F... Q&44 /5) PROPERTY ADDRESS 7 yy W 1Z Fi2.FA RS A (location of septic system) Please obtain from the Planning Dept. CITY/STATE 40 " 0 Q A-01 z_ yp PROPERTY LOCATION 5 E 1/4, N W 1/4, Section 'L -7, T=N-R W TOWN OF ~V V QRS 0 ST. CROIX COUNTY, WI SUBDIVISION 13 AD f- A N D R b ~CZ l 1`. LOT NUMBER (<o CERTIFIED SURVEY MAP C41 0 1 V, VOLUME (10 , PAGE q , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: 1. U (p -7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ST. CROIX COUNTY WISCONSIN ZONING OFFICE n n x n n- ► ST. CROIX COUNTY GOVERNMENT CENTER n~rs4 1101 Carmichael Road - Hudson, WI 54016-7710 - (715) 386-4680 June 3, 1998 Home Realty Attn: Dave Anderson Hudson, WI 54016 RE: Septic Inspection for Sam Miller located at 744 Wilfred Road, Lot 16 of Badlands Prairie, Town of Hudson, St. Croix County, Wisconsin Dear Mr. Anderson: A septic inspection of the above referenced property was conducted on February 9, 1998. This property is located in the SEY4 of the NW'/4 of Section 27, T29N-R19W, Lot 16 of Badlands Prairie, Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions regarding this, please contact our office at (715) 386-4680. Sincerely, Rod Eslinger Assistant Zoning Administrator /sm ^:;E^ Safety and Buildings Division rr.•■~r■r. SANITARY PERMIT APPLICATION Bureau of Building Water System! t 201 E_ Washington Ave. In accord with ILHR 83,0,5,1941Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county opy,only) fo06,w~sy~tem, on aper not less County • than 8 112 x 11 inches in size.`` t • See reverse side for instructions for c4rri`1eting this'afllcation State Sanitary Permit Number The information you provide may be used by other ►nrr tr JAG og,4m S heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 74 ~ Rd State Plan I.D. Number 1. APPLICATION INFORMATION - PL R INT ~►E1L INFORMATION Pro erty Owner Name Property Location ~A SE1/4AIU) 1/4,S 2'7 T ZR ,N,RE(orl'w Property 0 vner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number SO lJ 1.clio/(. (3 > x'740 A ::Pk l 11IE: II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road ❑ Village Public 14 1 or 2 Family Dwelling No. of bedroom Town of Ui~SO K ( R40 P D III. BUILDIN SE: (If building type is public, check all that apply) Parcel Tax Number(s) ^ ozo _ ! 3 3,1 - (Do of 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. ❑ 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 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 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) 91-01 Elevation 7 S 0 q 2.210 Feet 'q(##? Feet VII. TANK Caallo in aclts Total # of Prefab. Site Fiber- Exper. INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete stCo - Steel glass Plastic App cted Tanks Tanks Septic Tank or Holding Tank 10~ 0 ( Cj~ ❑ ❑ ❑ ❑ ❑ 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 mps) MP/MP SW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): nn so YO if C. 9 , IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) .Approved ❑ Owner Given Initial Surcharge Fee) L' Z. (p, q g Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SSD-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 may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Cede 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 subm tted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed- 11 . Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 111. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line 13 if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE ° 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Division r.~■`~r• SANITARY PERMIT APPLICATION Bureau of Building Water System: 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. < - (2, r03- I • See reverse side for instructions for completing this application State Sanitary Permit Number atop/ The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property 1/4 S 2'7 T Z9 , N, R /4 E (or) y Owner's Mailing Address Lot Number Block Number Propert IMIg Cit , State Zip Code Phone Number Subdivision Name or CSM Number RA121.E c )P30 N W f S 4 /Co ( > z7 RADLA140,S II. TYPE F BUILDING: (check one) ❑ State Owned o ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Town OF R vO.SoK 1Q) (LFQF- A RD III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo Z4 - 3 3 3 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. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an /System System Tank OnlyExisting System ---------Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12eepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13U 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 S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Y-5-0 -5-0 !S,40 3 j"2. Feet a3, (a Feet VII. TANK Capacity Total # of Prefab. Site INFORMATION in Tanks Manufacturer's Name Concrete Con- Fiber- Plastic Exper. Steel glass App. New Existin Gallons strutted Tanks Tanks Septic Tank or Holding Tank X OOG I,U ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: No Stam s) MP/MPRSW No.: Business Phone Number: MI kE S L t_ P S-v3Sdo 38 - 4- -L..,. Plumber's Address (Street, City, State, Zip Code): /070 9- 0 ID H v 0-10 ht W I 1(0 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa 1 ary Permit Fee (includes Groundwater Date Issued Issuing ent Si re (N amps Surcharge Fee) RA/pproved ❑ Owner Given Initial Z/?o 5 d6 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD: 6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms if b 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 isto fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. 566438 STATE BAR OF WISCONSIN FORM 2 - 1982 WA 5NTY DEED _ , DOCUMENT NO. VOL Y.68 PACE' RE91VER~'S p~OFFICK gi charri n qj-n„+ f?Tr sti~~~epRl~"ri WI i OCT 0 S 1997 conveys and warrants to Ram F M i l l P -r 2:00 -q 0.j~ Re star of Deeds THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in Ri- rrni x County, State of Wisconsin: /r 3 W3 I it Lots 16 and 44, Plat of Badlands Prairie, Town of Hudson, St. Croix County, Wisconsin. I PARCEL IDENTIFICATION NUMBER j~ f) T ~EPZ .i ~I II it l I is not ~i This homestead property. (is) (is not) Exception to warranties: easements, restrictions, rights-of-way and covenants of record. ii Dated this lst day of October A.D., 19 97 . (SEAL) (SEAL) Richard O. Stout „ ! (SEAL) (SEAL) ,i i~ i i ~I AUTHENTICATION ACKNOWLEDGMENT State of Wisconsin, II Signature(s) ss. St. Croix County.