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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ::iT • CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
MILLER# SAM X
CST BM Elev.: Insp. BM Elev.: s BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA 7 3 1
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic III Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/~R Inlet 93,x'
TANK SETBACK INFORMATION St/ffi Outlet B 5(r 99,
TANK TO P/ L WELL BLDG. vent to ROAD Dt Inlet ,
Air Intake
Septic >S / ~g NA Dt Bottom
Dosing NA Header/ % 7,13 O, 03' 1,
Aeration NA Dist. Pipe 041'4
i
Hold' Bot. System
PUMP/ SIPHON INFORMATION Final Grade 9,5107"
Demand i` c-', r 7 G , 7S .
Manufacturer
Model Number M
TDH Lift Ion System TDH Ft
COSS FHead
n Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
a D1 i No. Of Trenches P No. Of Pits Inside Dia. Liquid Depth
BED /TRENCH Width r length
DIMENSIONS MEN I N
LEACHI Manu a
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM
CHA
INFORMATION Type O tie,.- 3 ~ OR UM ER Mo a Num
System: -Lre a('s o?$~,
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) „ / x Hole Size x Hole Spa r Intake
Length Dia. Length _L Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or A ade Systems Only
Depth Over Depth Over „ xx Depth Of- xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges 06 Topsoil ❑ Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION : HUDSON.12.2 9.19W , SW, NW, LOT 4 2 . TANNEY LANE
Yn 61: 7 . .t e w Q'> ~I/`rc~ S hn
C m / ~u
3) t' ~ A0<:C, d GY I /ll itx~'1. //!i~/1 ~Yl C1 xJ c~ E cS/
Plan revision required? ❑ Yes B-No
Use other side for additional information.
D-6710 (R 05/91) , D to inspector's Signature Curt No
6-4-6 .
l c1 L`/1,~6 C"-6 CL ~ "V 0-~r. CcGc l dU--,/ ~d~~
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
a Attach complete plans (to the county copy only) for the system, on paper not less County_
than 8 1/2 x 11 inches in size. --7/- 0 Z011~
a See reverse side for instructions for completing this application State Sanitary Permit Number
a5~ X73
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
L L (;1/4 1 4, S Z T o2 , N, R /f'E (o~
Property Owner's Mailing Address Lot Number Block Number
Z~ Z
City, State W Zip Code d (hone ; um~~ber Subdivision Name or CSM Number
vso
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Nearest Road
❑ VllItyage L04 N~
Public 25 1 or 2 Family Dwelling - No. of bedrooms Town OF -3 ly III. BUILDING USE: (If buildingtype is public, check all that apply) Parcel Tax Number(s)
1❑ Apartment/ Condo O -L C J ) Z"' o
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. P New 2. E3 Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] 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 eepage 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 S. Perc. Rate 6. System elev. 7. Final Grade
Ll ~O Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) `d°l• 3 Af Elevation'4,2F
(pOQ 9O,'1 l3feet Feet
VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
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:
/ S d3~a, -5 vlG- g, rllll9Z
Plumber's Address (Street, City, State, Zip Code): _
A;11L / 1~/~vPSoN 5" ~!0
E
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary ermit Fee (Includes Groundwater F e Issued Issuing Agent Si nat re (No Stamps
Approved ( Surcharge Fee) 7 / J
❑ Owner Given Initial ~J
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal ar j 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-631)9) 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 i censed 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.
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 or system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7-
V11. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for ~dl septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experime -tal product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than _8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wiscr-isin Department of Industry, SOIL AND SITE EVALUATION REPORT Page i of 3
Labor. and Human Relations
:division ctSafety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Si C,pp~x
Attach complete site plan on paper not less tha hes in size. Plan must include, but PARCEL I.D. #
not limited to vertical and horizontal refere ~ ) c and % of slope, scale or
dimensioned, north arrow, and location s e to ne
APPLICANT INFORMATION-PL RI ff A t FO ON REVIEWED BY DATE
<<
PROPERTY OWNER: PROPERTY LOCATION Q
"51~~(h 1 LL [ `j5 GOVT. LOT 'W 1/4 t4w 1/4,S l Z T 19 N,R 17 E (or) W
PROPERTY OWN S MAILIN DDR y L T # BLOCK# SUBD. NAME OR CSM #
TAivriCy k,d4e
iQdv~ ~l~o~K cl 4C_1_ ~
CITY, TATE ZI ZCWQWxjil(AMR ❑CITY (]Vl j4GE OWN NEAREST ROAD /
j> flSdT+ 7 S ) 44 G ~A u A3s `4N
New Construction Use [DQ Residential / rooms NNtiz [ J Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate O ~ bed, gpd/ft2-7trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 0.7 bed, gpd/ft26.g trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations E At U'AT 10 > 46Nt Fob LAT A Av6VA L
Parent material Flood plain elevation, if applicable ft
S = Suitable for system 0 VENTIONAL M UND IN-GROUND PRESSURE AT RADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable for s stem S❑ U S O U WS ❑ U RS ❑ U S❑ U [3 S Nil
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trendl
-6 rhi"r C's 0A
4v4 I f~"
$ S)Z 1 rhsbk m es 1 O.Z d•3
Ground ~i r9'l w 4 S 09 r M1 O%
elev.
&O ft.
Depth to
limiting
f t or _
Remarks:
Boring # C o,4 S
w: 4:. d-2a /ayre3 7 L n,sby; m
112' 8 -s~ /a~J~ 4 3 S Z s bk n~~~- w 1 o.z.3
tg _7r b~/,e 3 S,L / m s6 M_ff C S 0.2 0.3
Ground
elev. 93 1-122 by 4 4 S
94'2- ft.
Depth to
limiting
factor
to,l
Remarks:
CST Name:-Please Print Phone: 46a6
~QV Y ~NNSc,~,
Address: I b ~ 91 U 4ga~
Date: 7 2? 9~ CST Number:
Signat
PROPERTY OWNER -69MM1LLO SOIL DESCRIPTION REPORT Page? Q
PARCEL I.D. # 1-4z-
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence 8axx~ry Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Twich
b-]7 /a~i~23 9 m sbK rn r GS J 0~4 0.5'
]7 34
14 A 4 S1 L. 1 sbk vV~ c5 14 0.1 o.3
10yk
Ground DZ -1]$' /6 k4 L4
r rn J
elev 7 0-%
gz Fsb ft.
Depth to
limiting
Remarks:
Boring #
A -C lb`~ ,~►sb rn~~ es l o .9 :0.5'
Ground::. p S ]1 /b~ R S Q r
elev.
w
Depth to
limiting
7 ctor
Remarks:
Boring #
$24 S,L I M 5'6K m cs
6,77
24- /d 24 4 S r rn Ground
elev.
93A ft.
Depth to
limiting
5 ctor 5
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
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r4otI ~
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
G
OWNER/BUYER 5,4
MAILING ADDRESS 4
PROPERTY ADDRESS &I /tae
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE /~f V b,5 O h f CA-1 I
PROPERTY LOCATION S 1/4, NCt.,1114, Section T__!21_N-R_1
TOWN OF I-' y ST. CROIX COUNTY, WI
SUBDIVISION TAN 9f IZ LOT NUMBER 4/ Z..
CERTIFIED SURVEY MAP S,3 _114 L, VOLUME ,PAGE -6
, 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.
[/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: - 3 l
St. Croix County Zoning Office
Government Center
1101 Carmichael Road 11/93
Hudson, WI 54016
r S T C - loo
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 SftM
Location of property SW 1/41/4, Section Z,T-R
Township 1-4 U i) SO" Mailing address BOX 40~ Z
HcJ ~D5 0 N w[ S q01,4
Address of site /(p eokoo ly Bid
subdivision name ~~e►~~~ elbjC~f Lot no.
Other homes on property? Yes No
Previous owner of property JRAn/ b-A L L `-I/l~h
Total size of property -Z, Z C
Total size of parcel Z , Z S
Date parcel was created - q 3
Are all corners and lot lines identifiable? ~C Yes No
Is this property being developed for (spec house)? X Yes No
Volume Z031 and Page Number 0~ 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. SO V8 S , 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.
Si ature o Applicant Co-Applicant
Date of Signature Date of Signature
u
ADDITION TO TANNEY RIDGE SPECIAL ADDII
) IN PART OF THE SWIM OF THE NW I /4, IN THE NW 1/4 OF THE SWIM, AND IN PART OF THE NE I/4 OF THE SWIM, ALL IN SE(
119W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN.
OWNER
T•r ILL[. Al-I", a[CTIOM 12 00 . •Ot 292
1•VOSOM, -1
s89'25'46'W 984.21'
- 400.00• 584.21
n
0
Z Z_ N S
.3 -g~~ s~• / o OT 41 LO 40 vi It
1j_1?01TE.
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2.44 ACRES 6 ACRES 3 F
OT ,42 '1* 106.124 10. FT. •006 So. FT. a
' (2
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$ o~ OZO 1312- ~D \ 0 2 0 -13 Z" 3 v o 's
97,esi so. Fr.
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o . $~Z 4,~ 7
LOT 43 Ne3•os00
.13 ACRES o.
,592 so. FT ~ ~~i ~ g ( 1
Vv J ' \ 2e •
W~' < LOT,, 39
' ~6` •WO I ~~i 2.73 ACRES ~F
O`- g 119.890 0
N •
- 300"
i o ~ ~ a j • 9a:.s ~ M 66..00'
; QZp-13(2 4l
- Zo\ N
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20 ACRES /
O~ 67'71 So. FT W
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y'ejt`µ I [L • 929.7 pl N M M
's b bZO-13t Z-oa 'qJ. N
~y ` . LOT 37I0
1Q b• 2 2.25 ACR \ \ /z
p l \ 98.009 so. 1
a 0 4310 ' b~- r/~ig29>• 953 sEsslErSOFFI
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pip . wo
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OA ' 4.8 2 SO. Fr p \9(p `.sC~ ay1l„ 7.1 s Fr. D Ill 36
\ b 2 26 ACRES I 1
A. \ \ 98.601 So. FT. I \6
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L[.iATIOR • .00• ~
.26 ACRES 00 LOT 34
I 1 SO. FT. \ `,'Y' • i 2.61 ACRES
\ \ • °o. 113,9:0 50. FT.
656 6; ® p ~s`b,~. • a 0~'°•`P~~E~QOO~`~ 3 ~ \
40'M \ o J ~ ~ 13 /
P
02p-/310 LOT 20 Dl
4.02 ACRES 0
175.310 SO. FT --n o, LOT 3 7
Af OF ` iT