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Home My WebLink About020-1289-80-000 4 0 °~'O I ~O I 0 60 0 ° 0 o-i 4o y CD h ~ I I e °o I I N O~ I I 0 I I ~ I II I I I I I I ayi N z° z° c LL c LL I _ ¢ I 3 o C L ~ II Z E I ~ E II rn IL m a m N 1- z O O Z c r > c w N z o z c E I c E ~ I N a~ N a~ c N 4) 0 N Q CD a w N (n Q) y y c CD (~D o a°iQ o 4)Q 0 z m z z m z o N co c c E C) 4) 3 E t4 E O N d m m "0 Lo % 12 'm CL M CL M v o D a a` .n o O G a L N E E E v S c'+) v N N N o U) rr NNr =333 EL m I X333 au z • R a a a a a a u, a o 0 (D CD C0 iN J V CD z m rn rn N Q) Cl) O (D 5 0) CD a ~1- N C14 0 0 E •7 M r U 1~ n ml C ca C IL Ln (D M W Q O y Q QI .6 Q z cn Q Z fn co O O U H C U N C r.+ ° N O U N U N E N W CO c d C (D :3 y y c c a~i c o 0 o O c O C Y N N N N C, c v O 00 C ! C «N. ~ - N 7 M M 04 C'4 17 7s z n j C D n p N y M N= v O r V) d _ j~ N ~p 7 N O N O O N"S O U O R U • O N 2 m N 0 Z N z z m N 0 Z N Z Ti (n V d a _ € d I € I a a IL L: a ~ • d d d o m e rw r- o t A 0 a2 I0Uo 0U)0 j• DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY" DIVISION LABOP.AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 5739069 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: T0WNSHIPWb*I-etPAt:4+Y: OT NO.:BLK NO.: SUBDIVISION NAME: /,36- 1,3W 1/ 5! 1/ z& /T29 N/R 0 E (or) W H L) PSoj 3 5 H s-tt- ME,4,zows-jLE- COUNTY: MAILING ADDRESS: !5+C'RO( X GLE.v 4VIVOAJ 72- Cp CouIJ TY `-L)- A3 , U D Soo W I S SV6 USE 3 ^Z2 S DATES OBSERVATIONS MADE NO. BEORMS.: COMM R AL DESCRIPTION: FILE DESCRIPTIONS: PERCOITATION ~ TS: Residence 34op- 4- MN,. Replace 7UA.)E I 15 1151 1 S ' Co 19 I -1 1 5CS C~ 13 L) K~ARtaT 5I RATING: S- Site suitable for system U= Site unsuitable for system rONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optiona a J DU ~ s ou OS ou ❑ s ou R S ou TREti1[kl 5 - ,D is R ZROP 900 If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.0915)(b), indicate: 41- S S T Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED I HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) O/6YR 313 Pl51 ; (n le" lo `/R'>/'/ 5 IM,Sbk n,v~,e; B- I n g /00.20 > 108 1811- tog' /0 Y.e o-r iovk 9/3 Is) P10wA-t ; 8"-1/0" /0jVle Ct P. S. B-Z 110 ~y17i'o X110 2 ' 0-12,110 YP 313 s t prowxSL i I1 3G " /o V 31/1 S) B- q I l S l CJ,33 Io l(S Z.w~ sb~~ ,w.~I' a 3G-115 ~o yR ' O-G /o YR 3/3 Ptowco S; 16 y/2 3/`/ S) 1071e B- / 12-0 ~02.0~ 7120 ~xU; Ig"-I2o"lo R '414, A.-P.5- 0-i2 ' /o YR 3/3 P/owtt' 7T -T, - -2y" 13 YR y 4 S , B- 5 l Z ~6.39li-v > 112- 24A 56,4(_- ),W)f R ; :Zy''- y'01, /o'ye !o Si/ 3f56K r- f I' yS"- 112" /o YR V/U S• B- ~~QC ~(~U~FTTONS PERCOLATION TESTS F EST DEPTH WATER IN HOLE TEST TIME DROP 1 WATER LEVEL-INCHES RATE MINUTES f NUMBER INCHES' AFTER SWELLING INTERVAL-MIN. PERIOD I P RI D PEP INCH P- / (4 O - )tv 30 Z <f Y3 P. 2 17to p y, 2 F I(e Y3 P- 3 r( o 2 P- P _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. Show the surface elevation at all borings and the direction and percent of land slope. H l 64- _T Q E A3 3 d r (-t t'D D LE- 7,-f, 6,4J G LL. - 72. 30 SYSTEM ELEVATION. Lou, 70, 0 1 , SSE - - - - - Y _ O PL 51 L~ _ a I.._.. I-. --.1.-...-.... M_...._ __.I is -Y _ ~ PL 0T' PLAN LOT 3 5 i 1 53 i • I ' I 4 5f / s~ 9 59 ~ I j 1 • d5 p~ (ob 24~ i3.M . 'V\- w vov -F~►~' POST" _ u 5cs~~t / 3~, J n w iii _ fl • r. A -5e AS BUILT SANSTC - ITARY 104 SYSTEM REPORT / OWNER ~~IE4) 120&-71ZT a ADDRESS Ip q' SUBDIVISION / CSM# LOT SECTION .Z( T -Z f N-R_ /9 W, Town of t"14e js _ ST. CROIX COUNTY, WISCONSIN PLAN VIEW a SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM \ w o ~ fit e ~ v INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 91 tv, BENCHMARK: 761? 0.77' Z A- ALTERNATE BM: SEPTIC TANKS/ PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: off, ~md r Setback from: Well House Other t Pump: Manufacturer Model# Size Float seperation Ga yc e. Alarm Loca SOIL ABSORPTION SYSTEM / Width: /Z Length %'a Number of t-rerrchT_s- 2 r Distance & Direction to nearest prop. line: > .5'g Setback from: well: >?BD House >fL Other E~ V TIONS a PC inlet - PC bottom Pump Off Header/Manifold 9.2'3 Bottom of system Existing Grade 970 Final grade ' Fr/, J? e am DATE OF INSTALLATION: 7/Io~f~ PLUMBER ON JOB: 7-y LICENSE NUMBER: INSPECTOR: 3/93:jt S Irv Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village =Town o : State Plan ID No.: 7^TR a T"tT^ !YT:'Y"1 TS.°"£': i°' '-T4Y T PT -.'h y 1, M_ 4.n CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 100 • /010, lLri'p 4~1 fed TANK INFORMATION ELEVATION DATA a nrnn^.nn TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic a~ l Benchmark ~o 2,,53` '2.53 0, Dosing Aeration Bldg. Sewer j,3V' 5, a. 7 Holding St/ Ht Inlet ,o ' la Y, 53 TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic '50 96' / NA Dt Bottom Dnsiu o ray, >C50 aL NA Header/Man. ~5-' Ala 3 Aeration NA Dist. Pipe g, 9~ Holding Bot. System a3' q1.3 I ' PUMP/ SIPHON INFORMATION Final Grade ia•73' 9 •8' ~ " d' Manufacturer Demand z t~a'Lr 79 /°U'~`7 r Model Number GPM TDH Lift Lricti System TDH Ft Forcemain L gth Dia. Head I Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS O DIMENSIONS LEACHING SETBACK manufacturer: SYSTEM TO P / L BLDG WELL LAKE/STREAM CHAMBER INFORMATION Type O Model Number: '200' /S, 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 I I 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.) !_.v nrorr rnT d. !,;0N 2,6 2-1 1 Q'.4 NW T,C,`~ ar 'r' D 'T,7 Mn TT TT, 1+i . tT 9 d d'1a J 6~ 1'i A. • ~s . V1 I ? _ f.. V ck) Plan revision required? ❑ Yes Ef No b Use other side for additional information. / / 96 SBD-6710 (R 05191) Date In ector's Signature Cert. No z L ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION Safety and Buildings Division Bureau of Building Water System: In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. P.O. ox 7969 MadiBson, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit umber The information you provide may be used by other government agency programs 0 ~5O (Privacy Law, s. 15.04 (1) (m)]. ❑ Check it revision to revious application State Plarrl.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location eAdEZ L G X1/4 Lve44, S,z, T~ , N, R E (o~ Property Owner's Mailing Ad ress Lot Numbv Block Number Cit ,State ~ Y Zip Code Phone Number Subdivision Name or CSM Number A?o~ c m 6 (P6 > G2 4ds . TYPE BUILDING: (check one) ❑ State Owned ❑ City Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 3 ❑ village O~ Town OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo .0 .-x _.1D 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 5 ❑ Hotel /Motel 12 ❑ Service Station /Car Wash 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 Re lacement of -System --------System - ❑ p 4. ❑ Reconnection of 5. E] Repair of an Tank Only---------------Existing System Existi ----System B) 0 A Sanitary Permit was previously issued. Permit Number 2Y9 7 3 2 Date Issued d 6 V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 d Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22E] In-Ground Pressure 42E] Pit Privy 13E] 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) Elevation 25-10 o p/ 3 Feet ^ 6 Feet VII. TANK Capacity in gallons Total # of Manufacturer's Name Concrete Site INFORMATION New Gallons Tanks Prefab. Con- Steel Fiber- plastic p- . Tanks Existin struded glass A Appp. Tanks Septic Tank or Holding Tank W Z ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber, ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I4PIume the undersigned, assume responsibility for installation of the site sewage system shown on the attached plans. Name: (Print) Plumber's Signature: (No fIRR/MPRSW No.: Business Phone Number: -36s~ Address (Street, City, State, Zi ode): 30 O .r`l~ oz J IX. COUNTY/ EPARTMEN USE ONLY ❑ Disapproved Sani ary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination } X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS r 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may;be,renewgd 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 seuvage systems must be properly maintained. The septic tank(s) mustbe 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. IL 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 i. 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 seo'.ic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental p oduct 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'dlmensions, 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 testclata on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Batt 410 included the creation of surcharges (fees) fora number of regulated practices which can - effect groundwater. The monies collected through these surcharges are uses) for monitoring groundwater contamination investigations , and establishment of standards. z y~ O N O ~ n "^t y r It t~ ~ o ~r C C F o 9 h 14 Q p O C n ~ Z h d m M o ~ n n o Pt I i i I r ~ µy rr i • i t I •I i AAA Old • 0~ wya~ Z~ aR~ 1 i I W V can, Iw a ~ o y h ~ r Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County' - 'Labor Labor and Human Relations ST. CROIR Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sa n ita ry Pe rm it No.: 9732- PeL D No.: i o ,r's1KNERT & CRYSTAL ❑ City ❑ Village R Town of: State Plan I CST BM Elev.: Insp. BM Elev.: Description: Parcel Tax No.: BM Agsnnl2fi TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction Syestedm TDH Ft Forcemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Model Number: System: 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-26.29.19W, NW, SE, Lot 35 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. -4 Id +a: 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 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. Crol • See reverse side for instructions for completing this application State Sanitary Permit Number as~7~ 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)]. r tate Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pr rt Owne Name Property Location 14 _-1/4, S T a?, N, R E (or) W Property Owner's M fling Ad cif ess Lot Number Block Number o Zf 35 Cit , S ate Zip Cod Phone Number Subdivision Name or CS Number S,1/0/6 /7111,0 A /11,5119A Jo- II. TYPE F BUILDING: (check one) E] State Owned ❑ itage Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms VII Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/CondoO 4Lop 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 online B, if applicable) A) 1. XNew 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 121~jSeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM MATION: . Absorp. Area 4. Loading Rate 5. Perc. Rate 6, s e I V. 7 Final Gracfe5 b 1. Gallons Per Day 2. Ab a 3 Required (sq. ft.) Proposed (sq. ft.) (~G~als/day/sq. ft.) (Min./inch) F+ Eievat`o~1Hp 9• eet YY , 44a Feet 75 0 l ~3 1 .-it Q6 VII. TANK Capacity gallons Total # Of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank $ 00 -k f ❑ ❑ ❑ ❑ ❑ 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. Plumb s Nam (Print) Plumber's Signa : (No Stamps) r P/MPRSFO : Busines -hNul: lea 7 / 8 G -1 dwmkcc~ Plu is ress (Street, ty, State, {Cade): 1 L^~W J lb o tA~jUN W~ SG IX. COUNT Y / DEPARTKI ENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent na amps) Approved ❑ Surcharge Fee) Owner Given Initial L71ZC!,p Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber 'r 4 INSTRUCTIONS t. 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 submi 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. il. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dweliing. 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 SystE~m 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 forma 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. PL 0-1- PI-Aj t-0T *k 3 S i i 59 P\ 13 - So e d 5 q ON PE (b GE to coo -J RX-L P05 T I~ .2 x r 134c,-AoE P.'TS i X pt~c /ocrt-T.o~ ~ I3•t1. Scr'. Sf~EL L ~eNnui'r pye, ELe vnrro,-) - loo, o_ HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRfGHT c 5 r -q l- q~r 2- WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. ►aINK P):,TALLER b DESIGNER LIC. NO. 00663 P.B.L ~~7 PLOTA ►',1,~ RO S S S 1= 'NAME L,~ i- P _ :p NAME 31 L O C A 0 N.- _ 1~t1 Peiti? 0~ LIC ENS E:./-, 309 1.) AT P L 0 T M A_(' 3 Pww el,.e S . Sx l►3 ~ " s' o - . ' gs OK e~ as' rn 7 a a' 40 Ows )DO' "eel Colo oU, 0 Pe S b,+R-u rv<D G. SCE FRL'SII AII: L1JL[:'1'S-ACID OBSERVATIOU Pi.P] CI;nSS SCCTION Apprrove(I Vent Can Minimum 12" Above >>va G(cp,~ Fi nom, 14 9S,c v ' m I(.I, v i ' 411 Cast Iron . Above Pipe vein Pipe To Final Grade INDUSTRY, k LABOR AND PERCOLATION f • TESTS 1,1i'o)MADISON, WI 531w HUMAN RELATIONS (ILHR 83.09111 & Chapter 145) OT NO.:BLK NO.: SI,iDIVISIO A :FIE - NC.- KF21 ONTtetY3s H i(j F ♦ D /Txcl NR19ErlW Huaso) ADDRESS: C C•OUti1.7 ~ ~D• I'I E~v 601Xo") ^22 S DATES OBSERVATIONS MADE IiSNT'e 7S: ~ y4, USE W(5~BEDAR : CO A RIPTION: MN, L: t Replace OUSE 143. 15 1991 JUaE ISM IG QResldencs 3oR, 4 Ni4-, 5c a LIR V-kAPOT 51 s RATING: S- She suitable for system U- Site unsuitable for system u ONVE(NT AL: MOUNpD: IN-GROUNDT'RFSSURE: SYSTEM-IN-FILL OLDING TANK TRE.-scl,,, MENDED LSTEM)RO , A0% OS ❑U ❑U 0S EA ❑S 0U ❑S ~U Dr5 r v r a DESIGN RATE: I If any portion of the tested area is in the Ala- 71 GL FS S Floodplain indicate Floodplain elevation: PROFILE 11 Percolation Tats era NOT required Il under s. ILHR 83.0915)Ibl, indicate: DESCRIPTIONS DURING TOTAL P H 7 Fl UNUWATEFl INCHES TOADC~HOCKOIF OBSER (SEE f SOIL VED THIC NESS ON BACK'EXTOR[, AND DEPtff NUMDEFl DEPTH IN. ELEVATION 85ERVED - Tor, --Q 51 •I (0-le" 10 yR Y/y s IAr, S bk, M v~R ~.~.s. B_ / 108 loo.zp, ?1ti > fo8 O-G' /oyR 3/3 P 1a"- low' r,e /,/Cl r v_$„ /ov e 9/3 5 ) Plo..u~ 8"-I/0, /o ye 4 4P• L I ~`{,7(D 1~j ~ n B' 1 0 I ( 0 d-Ill' l oYR /3 s f P/OW~K ; Il ?G' /0 V 3/f 5 3 I I S 15,33 'ko ? l( S 2- Sbk -f'l' ; G I Is" /a yR Y/G ^,Ad. s B _ o-G "/o yR 3/3 plowca s~ G-IP"/o y/1 31y s, ¢9R 120 /02,08 7120 ufR~ I~'"-110"!o R'4/r~ ^"'~•5' B' o-r2 - /o YK 313 plowev S /2e' - )y" /o 7/-Y 5 r s,/ 3~56k r~ i } E).5 (12- T(G .3t 1 w > I l 2 2 w S6K, -fie /o yk '//6 112" /o YR y/G S. s- /2[ _/e_VA17'O'NS PERCOLATION TESTS :I WAT R V L H RATE MINUTES DEPTH . WATER IN I10LE TEST TIME DRU I PER INCH f NUMBER INCHES AFTER SWELLING INTERVAL•MIN. v RI Qj 4 30 2- P_ G P- 3 9 o Z _ P- P~ f • PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe whet an the horn :ontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at ell borings end the direction and peresni oflandslope. 1-REA3 C-t,_- 5/ 30' MiDDZ-E" 7,eC.ve-4- ".~'2.3 SYSTEM ELEVATION VDU' €A' = 90 o T-_ E- ID Z_ 0 1.. i i I I I 1, the undersigned, hereby certify that the soil tests repmred on this form were made by me in accord with the procedures and methods specified In the wiuonsie - Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief, NAME print : I TESTS WERE COMPLETED ON: /7 1 5 1c N~fr1E51TE5)=P{?Ll~r.pl.U~i81)'GfD----- CERTIFICATION NUMBER: PHONENUMBERIo t~onall ADDRESS: T 6b5 CIVIL RD., HUDSON, WIS. 54016 Zy $ 2 3 8Co - ( _ ROBERT UL3RIGHT _ r S. WSTEii->sC[l(1BER LIC. NO. 3307 M.P.R.S. CST SIGNATUE • I,IINN. INSTALLER d DESIGNER UC. NO. OL 663 f`J f - STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNEWBUYER R 0 sczx AO D UN STAL SUM MAILING ADDRESS - (4(Z) Hd~:[ C. UDSOIJ WT-. 54011 PROPERTY ADDRESS Z~~ 4f ad p/,~/ ' j2 (location of septic system) Please obtain from the Planning Dept. CITY/STATE HQD50r3 , W1500113 PROPERTY LOCATION OW 1/4, Se 1/4, Section T_2,9 N-R___t~_W TOWN OF B O D SOQ ST. CROIX COUNTY, WI SUBDIVISION _ ~A1 G IA M SAD O W S ]U- , LOT NUMBER .__3 CERTIFIED SURVEY MAP 15290 , VOLUME 9, PAGE 24ZO , 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 ye expiration date. SIGNED: v.,&- * DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Fludson, WI 54016 11/93 • R rS- 't`his 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. ---------------------------------------------7--------------------- Owner of property ?.Of,ER.-T # IOb CQ,YSTAL B~Af _ Location of property NVJ 1/4 51E 1/4, Section Z(,0_,`I' 2.9 N-R_ 19 W Township 'AQDS00 Mailing address 10 HOYT 5T,_1 H9PSO1SM Z N h)ead'Oaj2)r Address of site 41164 ft"005 Subdivision name 6L(,q McADoWS :IC Lot no. 35 Other homes on property? Yes No Previous owner of property GI.EWW AWD V YCELLA. w h)(00 Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? ✓ Yes No. Is this property being developed for (spec house)? Yes V_"' No Volume &U and Page Numberlj- 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 i.n the office of the County Register of Deeds as Document No. Si nature of Applicant co/hpo1icant Date of Signature Date of Signature R • Sit NO DATA THIS SIACS FCSE"ED FAR R[CORDI ' DOCUMENT NO. STATE BARWOFARRWISNTYCONSDEEDIN FORM 1-1982 • V. 1053PAGE 5 14- ' REGISTER'S OFFICE ST. CROIx CO., VA This Deed, made between Reed *W RWMJ ! GLENN•.WAXON--AND--VYCELLA M..-WAXON,_-husband _ 4 I 1993 and•- wl f e Grantor, DEC !i F ' M ROBERT M. BEARD__AND__"RYSTAL._G. NELSON,.........., 12:30 P and t n li Ia11tdOMds x 0 It Grantee, Witnesseth, That the said Grantor, for a valuable consideration.. - Ir R[Twm To t. Croix conveys to Grantee the following described real estate in S County, State of Wisconsin: - Tax Parcel No: _ 3 I li 7V a 7 Lot 35, High Meadows III in the Town of Hudson, St. Croix County, Wisconsin. . n M1 Ii ~I . 11 1 It This is-not homestead property. it (is) (is not) l urtenances thereunto belonging; aPP Together with all and Waxon singular and the Vycella hereditamenta M. andW axon Glenn And................... indefeasible in fee simple and free and clear of encumbrances ....except - warrants that the title is good. ;i easements, restrictions and rights-of-way of record, if ally. ~I and will warrant and defend the same. November 19-93 II i Dated this day of ` - (SEAL) - --CiF - - ------•-----------•----(SEAL) 3 *en Vy ells M. W on axon ------------(SEAL) _ i _ (SEAL) ` • !I AIITHgNTICATION ACHNOWL$D(IDdSNT ay of I a Signature(s) Glenn Waxon, Vvicella M. STATE OF WISCONSIN s< I Waxon County. d November 93 . anthenti~ ad this of.-_--------------------•--, 19.----- Personally came before m9-----Y the above named i Kristina 0 land - TITLE: MEMBER STATE BAS OF WISCONSIN k (If not, - authorized by § 706.06, W is. State.) atl to me known to be the person who executed the r I foregoing instrument and acknowledge the same. ! ij I~