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CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM all e 0 1060 51 1 V Ai ve IJ XSY ~O 30 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: LO hi O 06 0 = Q ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION U 5<- r) 1~ N Manufacturer: Liquid Capacity: (000 1 Setback from: Well b.QQ$- 5U House Other Pump: Manufacturer - Model# Size Float seperation Gallons/cycle Alarm Location :SOIL ABSORPTION SYSTEM Width: C Length S Number of trenches Distance & Direction to nearest prop. line: Q3 Setback from: well: aVe(~ House Other 14 w- pGLP, R I a. 3 F--9 a. 3 Q u~l ~ ~l~e 93 New c ►d ELEVATIONS 97 93 g~.93 Building Sewer ST Inlet.- ST outlet S PC inlet PC bottom Pump Off (Header/Manifold Bottom of system 3 Existing Grade 5 Druz Final grade g G 3 DATE OF INSTALLATION: \ I 1 ~i PLUMBER ON JOB: LICENSE NUMBER: `C y INSPECTOR: 3/93:jt Wisccsnsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor agd Human Relations INSPECTION REPORT ST. CROIX * Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 268630 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: DOHMAN, BILL HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600316 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic Benchmark 166 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet yl,~ TANK SETBACK INFORMATION St/ Ht Outlet 9. TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet rl Septic 5 > NA Dt Bottom Dosing NA Header/ Man. 9.~~" ~Ia•va . Aeration NA Dist. Pipe Q'9 qa, . 99' Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft i oss ead _T Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /a' DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Mode Num er: System: -7 OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.17.29.19W, SE, NE, SHERMAN ROAD , 0/ a- &P y - Plan revision required? ❑ Yes No Use other side for additional information. I qJ SBD-6710(R 05/91) Date Ins ector' ignature Cert No. b ADDITIONAL COMMENTS AND SKETCH s or SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuilBuildinWater ing 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. C, ro • See reverse side for instructions for completing this application State Sanitar Permit Number a;s4.3a The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pr rty o n e ~ VL1/ae1~Y ~ 1/n S T , N, R~ ! E (or) W Pro ertOwner's M fling Address Lot Number Block Number ~G. I~~I Code PhoneANp rer Sub ion Name r CSM Numj2er Cit ; tate Zip (.t)L de II. TYPE F BUILDING: (check one) ❑ State Owned ❑ city Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms p Village _ Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0440 ! / ^~r 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 4~g 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 Re ulrq q. ft.) Pro osed (sq. ft_) (Gals/day/sq. ft.) (Min./' ch) IV 7 ti 14S ( l3 0 Feet (vj Feet VII. TANK Capaaty in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION New Existin Gallons Tanks manufacturer's Name plastic concrete Con- Steel glass App. structed Tanks Tanks Septic Tank or Holding Tank , (V~ O tf v A ❑ ❑ ❑ ❑ 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 Na rint) Plumber's Signat : (No Stamps) MP/MPRSW No.: Business Phone Number: JA .4L.4, 1 Plumber's Address (Str a ,City, State, Zip Code): b U tip r~ n oN i S U IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing A nt :gnat re (No St ps Approved ❑ Owner Given Initial Surcharge Fee) / Adverse Determination $j?4 fte 1 ~ , 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 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 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 on 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 all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),- address and phone number. Plumber must sign application form. IX. County/ Department Use Only. - X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; 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. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the B') I 1 -NkMP tl~ residence located at: C;, N f- 141 Sec. 19 , T c~ 9 N, RA _W, Town of i t U.bS' c rJ , St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good con iti n, and it appears to be functioning properly. Last time serviced' Did flow back occur from absorption system? Yes 2 No (if no, skip next line. Approximate volume or length of ti e: gallons f~ minutes Capacity: (Oot~ j') Construction: Pre lab Concrete Steel Other Manufacturer (if known): Age of Tank (if known): -J) (r Q td i Y'i 2 J R 12 (Si ature) (Name) Please Print (Title) (License Number) ~ 39('~ (Date) Form to be completed by licensed plumber (s. 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). Name > n,ur,~.S~C6L Signature Q N^- ncQ MP/MPRS _0 P. B. PLOTA 1-111 1 \'U P iJ L- I -•13 II-- ~r- _ N A M C 'l ll o mPN _N AM inn 604Mpe~~'Q~ L O A 10 - S Qr`.mAU gip.. I C E N S E ' 3 00_~.. h~ PLO I Rox Bd . o w ~d 1N bed ::fia• 5e~: , eelaw lAyt~ 5y a at. f °te + r4~fi MAX Cove►~ • \a~ ~ ~ ~ ~~G~~l) JZQ >xP S (000 ~ n" 3 8W)ea u m oAP, 8-seep ~ stem of VAlve = B m = :Top Q ~ -l"hReAOW WPI K04 QoaR ~I~v= tuO,O d' Q,~ ~,k 1. of P°►~'t . NA-1: Sd, , : a jp~eNl QS,Wc11S a Oak SY'0, c + N FRESH All'. TtJW rs AWD ODSERVATWtTIRE CRASS SECTION Approved Vent Cap . Minimum 12" Above 11NAI G2AQ.Q I Final Gr~i1G_._ 1 43 4" Cast Iron Above Pipe Ven► Pipe To Final Grade- r••• Wisconsin D.pertnenc of Industry, SOIL AND SITE EVALUATION REPORT Page of LsborA" Fh,man Rslstrons givtsion otsafeey 8 Buildings in accord with ILHR 83.05, Wi . C COUNTY C~0 Attach complete site plan on paper riot less than 81/2 x 11 inches in size. st inclu4 but not limited to vertical and horizontal reference point (BM), direction and % pe, EL I.D. it dimensioned, north arrow, and location and distance to nearest road. s° DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATI*C P ! OW ~1 / ,S/ T N,R E (or) W '6RDn~MO-a - ~ PER P ERTY OWNER :S MAILING ADDRE OCK a OR M s CI ST ZIP CODE PHONE NUMBER QCITY OWN N ST ROAD (I~ [ j New Conshell rt Use,[ Residential / Number of bedrooms ~3 [ J Addition to existing building t [ J Public or commercial describe d Code derived dally flow gpd Recommended design loading rate ~_bed, gpd/ft2 - D trench, gpd* Absorption area required r~ bed, ft2 trench, ft? Maximum design loading rate ~Zbed, gpd/ft2~~trench, gpolft2 Recommended infiltrallon surtaca, eleva (s) ft (as referred to site plan mark) Additional deign / site considerations /'0' (m ka,le 4-o e / x Parent material , Flood plain elevation, if applicable It I JD TAW AT-GRADE SYSTEM SILL a SM~G~ rU . 8" nt CONVENTIONAL MOUND IN-GROUND PRESSURE W) ) ror t~11 1;8M O U RM Q U ~s O U eps a U O S SOIL DESCRIPTION REPORT Bori # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bour by Roots GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ivxh l ~-G` 3 3 s ra loxe 106 AA- qf.-5q S y 9 , o fS C - N NyZ / V,, q Id Ground MOU to i Depth to ImItting fam l lo k r' Remarks: 3 4 Boring # E3 F2-- vw Yl y s 0 I - W'37 N,5-; 1 t, K r CcD W145'S~L'` C~ - NP >of around ovr 5AI ~ 0-13w Depth to limiting yf Od` Remarks: FN&rmn*.-^use Print Phone: -715 1 a~ (Pik Date- CST Number: 'W 341v 7 PROPERIYOWNER SOIL DESCRIPTION REPORT Page?- of3- PARCEL I.D. ! Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed 0emh Ytf- ,3 S G f; 4 S ~ 2r~ talc - S4 l Ground v ✓ y y S yK G~ - N t $ N~ 1 Depth to 5 'M b lirn ing factor , > /jam Remarks: Boring # 0-7 --/0 YX 31-3 2 N o w y~ 51 ZA ,t c~ s } L o-vf- R. 0~i s l - o Ground elev. It. Depth b smiting tot Remarks•T S 10,~ -rof Boring # Ground elev. It. Depth to fagot Remarks: Boring # i i i t Ground elev. ft. Depth to Gmiling Isclor Remarks: SOD-8330(R.05N2) BM ► Doopt p /00, o > Say' I a~ 10 f-I o . g~~l~ P~~~ g © Jot, © Vi A2- Oil r , k t dV M y~r~ i / G#r', fry i I s 1 1 S"I'('- 105 SE TIC: 'LANK MAINT'E'NANCE? AG REE, NENT St. Croix County OWNERAMYER --W_ i I,, I_ r rvl ! - ~~oNn~ - - - MAILING ADDRESS PROPERTY ADDRESS /?7 t'= (location of septic system) Please obtain from the Planning Dept. CITY/STATE #U I scams I,iJ Is e- PROPER'T'Y LOCA'T'ION S la~ 1/4, 1111= 1/4, Section TO«'N OF lytt,'1bgoA~ ST. CROIX COUN'T'Y, %N'I SUBDIVISION I~ U T LOT NUM13F.It 7 3 i CERTIFIEDSURVEY MAP , VOLUME , PAGE , LOT'NUMI3BR i 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. i 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 I, 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 properly 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 /Wc, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, ,Is set I)v the Wisconsin DNR. Cell ificatloll stating that your septic has been maintained must he completed and retunred to the SI CtoiX County, loning Officer within 30 days of the three year expiration date DAIF, X~- 9rv SI Croix Collwy laming, OIlirc t iiivelllln(Anl Centcl 1 101 Callul llael Rwid I I I'l.t I lndson. \":I ),1010 ' 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. Owne r of property Gu 4, L t rC~IK 4--r kg /19#/77 A A) Local ion of property SE 1/4 NF_ 1/4, Section f7 Tag N-R IF W Township yU.bSOY0 Mailing address 951) .5#0Rin,%r RO Address o f site 959 St(~2iti rho A.) Subd i vis ion name PARK u j g t/,j Lot no. '73 Other homes on property? Yes -No Previous owner of property E J Erg EI'T bo To Total size of property a /~~2BS o 1lT K ~laS Total size of parcel Iq /}erg=s Date parcel was created Are all corners and lot lines identifiable? Yes k' No Is this property being developed for (spec house)? Yes No Volume 14S and Page Number 410-5 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRA14TY 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. -?,2q& J~ , and.that I (we) presently own the proposed site for the sewage disposal system or',t (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. S3?~lG~ Signature of Applicant Co-Applicant I):itto of i(rnature Date of Signature A ~3 ~r State Bar of Wiswonsin t•ornl 2 - 1982 WARRANTY DEED DOCUMENT NO. VI 115JnsG 405 U: , ' Everett L. Doxtator and Margaret A. Doxtator , DEC 14 1995 - Tiusband -an~wife;-- - - - - - - - j a 10:15 A. M - _ ; { t4~y conveys and warrants to __--William PDohmai1_ and Ila Rae Dohinan husband and wife THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS ; the following described real estate in St. Croix- County, State of Wisconsin: (Parcel Identification Number) Nr` p Lot 73, Park View Second Addition to Town of Hudson, St. Croix County, Wisconsin. This i3 homestead property. (is) }Dow j Exception to warranties: Easements, restrictions and rights-of-way of record, if any. '1J I ! y ` December 95 Dated this - ~ day of 19 ~i 'I l (SEAL) (SEAL) Everett L. Doxtator Margaret A. Doxtator - iSEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) Everett L. Doxtator, STATE OF WISCONSIN Margaret A. Doxtator ss. n County. authentica ed this day of December , 1995 Ftssonally came before me this day of 19 _ the above named Kristi a 091and - - TITLE: MEMBER STATE BAR OF WISCONSIN (1f not, authorized by §706.06, Wis. StatsJ to sae koow-n to be the person S_ who executed the kwepooW instrument and acknowledge the same. THM INSTRI IllCNT MIAQ na AOTCn Gv Wisconsin Department of Industry, SOIL AND SITE E V A L O R T Pagel of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 8 COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches i Plan but e' not limited to vertical and horizontal reference point (BM), direction o of slope, sca e o PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest ro ~'2 O _70 EVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFOR N ST ~ PROPERTY OWNER: -4 p T , N.M4 0 7 LOT W 1/4,S/7 T .2 9 N,R 1'7 E(`trL ) PROPERTY OWNER':S MAILING ADDRESS K UBD. NAME OR CSM # ,0 Z7 CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE WN NEAREST ROAD UOSD~ 0/5, 500`16, ( //s) 3R6-&7&z- 1511161-ele-1410 [ ] New Construction Use ( Residential I Number of b6drooms 3 Addition to existing building jam]' Replacement Public or commercial describe Code derived daily flow yS0 gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 ' trench, gpd/ft2 Recommended infiltration surface elevation(s) S-"-- - 3 It (as referred to site plan benchmark) Additional design /site considerations G- N~ if' wE-uG~/S S/O/+-e /~dX 1~i~7'• Parent material $GS /ja~P.~Li !~T Flood plain elevation, if applicable / ft S = Suitable for system CCOONWIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM-AN FILL HOLDING TANK U = Unsuitable fors stem LA'S ❑ U ❑ S C~'~J C-S- ❑ U ❑ S SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bourtc~Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. i Bed mrtdi /20 y 313 s/ /-~Sde s 9s 3 y - s o z fS! s~ z lo s/ e s of s , C, Ground ifs S - • 60 elev. S D S d 7: 9Z , ~(o ft. l f Depth to limiting factor Remarks- Boring # ye 3~3 - u~~ / lc 56,~ G~SLj S Y •S 3 r2_l33- 7 s lie y/4 1s Ground L'S D, S G~ic ? '0 ft. Depth to limiting ffacttor~ , > tek-- Remarks: CST Name:-Please Print 0 QE R T- .A L RR i c kT Phone: 71 _ 3 Rr!o 60 /605- Address: & - 7/_ / - t~sT~ 2 y~Z n_i_ MT Nnmhar i PROPERTY OWNER SOX T~1 d~ s SOIL DESCRIPTION REPORT Page 3 of 3 PARCELI.DA 020-11915--7o Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bour>d3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rends z Sao o O y s~ /~`s dsG ~s • y -s Ground 3 ' yj /D ~l2 - ~S S• 7 elev. Lh t 5101 Tq D !///C Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Z Q ,do. GOT L • o N , c z o ~ o 0 7 N p c ~ y aO y w m L Di y ~ ro 75 rt rn try ~ ~ _ v n, v w p o ~M, K,UL Vi\L : •`"l ~ , TOWNSHIP INKS SEC. T N, R W jDRESS ST. CROIY COUNTY, WISCONSIN. II ,iVIS10Nr ~r V , ? LOT_7LOT SIZE . PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM { TIC TANK (S) 0" MFGR. r CONCRETE STEEL NO. of rings on cover ( Depth DRY WELL . NCHES NO. of width length area no. of lines width-j length area-77- depth to top of pipe G 3REGATE X RATE 5 AREA REQUIRED AREA AS BUILT -sclaimer: The inspection of this system by St. Croix County does not imply complete .?liance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for Aem operation. However, if failure is noted the County will make every effort to --ermine cause of failure. .BASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. INSPECTOR j~DATED PLUMBER ON JOB - ~?►'~-c~L~. LICENSE NUMBED Z REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM Sanitary Perm.i --__~/j State Septic -J77 NAME Town.6hip St. Croix County Location o 11,1 4j SectionIJT~N, %L W SEPTIC TANK Size gatton.6. Numbe -job Compa,%tmentz Di,6tanee From: Wett it. 12, an greater Mope bt Bu.itd.ing it. WettandA it. Highwate,% it. DISPOSAL SYSTEM Distance From: Wett b 12% on greater .6 tope it. Buitding it. We.ttand.6 Pt. H.ighwater it. FIELD DIMENSIONS: Width ob trench 2, it. Depth ob %och below t.itef Z_ .in. Length ob each tine L~r! it. Depth ob rock oven tite 'Z- .in. 12- - Number, ob tine6 Depth ob tie below grade LI-in. TO-tat .bength ob .t.ine.5~bt. S.tope ab trench ~ in pen 100 it. iztance between tine.6__L,-_jt. Depth to bedrock b . Tatar ab.6orbt ion area'bt2 Depth to groundwater 1 bt. 2 Required area it PIT DIMENSIONS: Number ob p.itz Gravet around p.it.6 ye.6 no . r Out.6ide diamete&___~ b Depth below inlet it. Totat ab.6orbti o-n a ea i~ bt2. z Area required bt2 rn INSPECTED BY TITLE APPROVED C DATE G~ 197 REJECTED DATE 197 EH 1-15 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH { _ P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATIO '/4, /r '/a, Section _L2, T~27N, R 17 E (or) W, Township or Municipality A 0 k-1- Lot No. _23- Block No. Zoe' U~ ~,t✓ County S L ~"c~ lv~Y ubdivision Name Owner's Name: ,S!I Mailing Address: H t~ c~S o ej "2 -[~I/ S TYPE OF OCCUPANCY: Residence ' t"" No. of Bedrooms 3 Other EFFLUENT DISPOSAL SYSTEM: NEW L_ ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 7 PERCOLATION TESSTS~ SOIL MAP SHEET SOIL TYPE"' PERCOLATION TESTS TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL NUM- INCHES THICKNESS IN INCHES BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN -14 -3 37 41 ~ 3 1 G 1 , S SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B_ / 'o X~ 7 7z 5 f ` s S~ S 2 7z r , 5 B 7Z y $ S -5 7:Z 1 g^- y - 5 L .2 -5 PLAN VIEW (Locate percolation tests,soil bore holes and suitablesoil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number o square feet of absor tl area eeded for building type and occupancy. S olt c` "le or distances. Give horizontal and vertical reference poin s. Indicate slope. 7 7 S t N A-a 0 7 PLB67 State and County State Permit # Permit Application County Per t# T for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # n • A. OWNER OF PROPERTY Mailing Address: -5 ks P1 M 1. 1,L F- P, sox B. LOCATION: Y4 F Section , T N, R- E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village S4 PA IC 1 . C -r&T~ Township J4 UP C. TYPE OF OCCUPANCY: Commercial *In-custrial *Other (specify) *Variance Single family L"" Duplex No. of Bedrooms 3 No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES_NO # of Bathroom Automatic Washer Ll" YES NO Other (specify) E. SEPTIC TANK CAPACITY © Total gallons No. of tanks *Holding tank capac.t Total gallons No. of tanks New installation Addition Replacement _ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) -S 2) 3) Total Absorb Area / sq. ft. New L-"" Addition Replacement *Fill System Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length Width Depth Tile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land tl ` Distance from critical slope Z , I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal . system from the EH-115 prepared by the Certified So'I Tester, NAME 00, C.S.T. # 1 3 and other information obtained from 1 41 (owner/builder). n ` Plumber's Signature P/MPRSW# /~3 L Phone # ?1T- 3,2- 3 j Plumber's Address vh PLAN V EW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). V 1 G 7 No Air ell Ile, ern F*2 0/, .2 -VI PnT '~Lw j- lo~