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AS BUILT SANITARY SYSTEM REPORT
OWNER /o L~uho U 'rd l 4T CgGy'
ZpNI VG O fi 1C`
ADDRESS S ,rev?~ /o
SUBDIVISION / CSM~ ~j/u,,,b~ gal lls• LOT ~ yam,
SECTION 97 T d2? N-R_/~W, Town of
4
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
W
16'
~aG D
7Us "l=l~
SU
~ I
~I
~l
s
a
aINDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~olGu~s7`r~.E.r/ Liquid Capacity: J;21Q d
Setback from: Well 'V_House Other
Pump: Manufacturer Ze-c AXr_i,. Model#!FF- Size 3
Float seperation Gallons/cycle: 145~.2
Alarm Location IY~~S
-.SOIL ABSORPTION SYSTEM
Width: Length 7S Number of trenches o2
Distance & Direction to nearest prop. line: mss'
Setback from: well: 160 House. Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: LICENSE NUMBER:
INSPECTOR:,
3 / 9 3 : j t
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO P RMIT) Sanitary Permit No-:
GENERAL INFORMATION /,/a'
1(6 - P mi o r' El City Village 9 Town of: State Plan o.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
16L) /U j, tL. j,'
t y ~s J %Ij TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /J
Dosing 7N✓ t s - €~G? z1 r 86
Aeration Bldg. Sewer
Holding St/Ht Inlet 11,12, 97•_%r~'
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. AirI tntaoke ROAD Dt Inlet c'
rl /1.~. ~'•.6
Septic NA Dt Bottom
9~,f
Dosi ng NA Header/Man. 4 14 qg,:
Aeration NA Dist. Pipe,
Holding Bot. System , '9 ~l
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Ala~ Demand
Model Number qg ~b GPM
TDH Lift G It Lriction.,7L+ System TDH 1j,~ Ft
oss mead
Forcemain Length /)O Dia. S11 Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S ~2_ DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type 0 loz J / CHAMBER Model Number:
System:?/~.-; ~ 'BOO ' ' /00' A1d.4 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 Dth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed / Trench Center /Trench Edges Topsoil El Yes F] No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION : HIUDSON, 27.29 19W , ND' NE, ORIOLE LAN .
Ali
Plan revision required? ❑ Yes '1~fKlo
Use other side for additional information. Cer
SBD-6710 (R 05/91) Date EK; Tt___Signature t No
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 8112 x 11 inches in size. L - v0 l
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs
❑ Chec revision to previous application
(Privacy Law, s. 15.04 (1) (m)).
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Propert Owner Name Property Location
t~ LY A& 1/4 Zj 1/4, S 7 T q , N, R jQ E (or W
Property Owner's Mailing Address Lot Number Block Number
.3 a S?" /_f
City, State Zip Code Phone Number Subdivision Name or CSM Number
. TYPE F BUILDING: (check one) ❑ State Owned [3 Cit( Nearest Road
❑ vil age
Public 1 or 2 Family Dwelling - No. of bedrooms Town of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
11-
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs
4 ❑ Church/School 8 ❑ Mobile Home Park
5 ❑ Hotel/ Motel 9 ❑ Office/ Factory
IV. TYPE OF PERMIT: (Check only one box on line A. Check box o,
v
A) 1. s4New 2. ❑ Replacement 3. ❑ Replacement of an
------System System Tank Only- 1g System
B) ❑ A Sanitary Permit was previously issued. Permit Numb
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution
11 ❑ Seepage Bed 21 ❑ Mound ling Tank
12 RLSeepage Trench 22 ❑ In-Ground Pressure rrivy
13 ❑ Seepage Pit ilt Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. 1'er_- 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
4!; eLd -7,5-d r e Feo...3 G Feet
VII. TANK Ca
in gallo city Total # of Prefab. Site Fiber- Plastic Exper
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App.
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank 1 R ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber Q 7`e ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: o Stamps) pa-
Zee PRSW No.: Business Phone Number: 10, 3
Plumber's Address (Street, City, State, Zip C de):
I'd 70 _7ca 7"74-
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing A ent Signature (No St
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination /4 J
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.
11. 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 sep _ic, 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 cou,ity. 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 sakes; 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.
w e fi t l~U
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Y
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i
PAC F GF
PUMP CHAMBER CROSS SECTION AKJG SPECIFICAT10kJ5
VEUT CAP
11"C.I. VEkIT PIPE
T WEATHERPROOF APPROVED LOCKIAIG
JUIJCTIOW BOX MAIJHOLE COVER
- 25' FROM DOOR,
WIMDOW OR FRESH 12"MIN.
AIR INTAKE
GRADE I
I `1" MIKI.
I ,
18" 11 AI.
COWDUIT _
18"MIN.
~ 111
IKILET PROVIDE
AIRTIGHT SEAL
A I ICI
I
I I I
I I I ALARM
a I II.
I I
*APPROVED I 0w
c JOINTS WITH I
ELEV. FT. APPROVED PIPE
3' ONTO PUMP
~ OFF
D SOLID SOIL
CONCRETE BLOCK
RISER EXIT PERMITTED OWLy IF TAKIK MANUFACTURER HAS SUCH APPROVAL
SEPTIC f SPEC. IFICATIOUS
DOSE
TANKS MANUFACTURER: &,'d4Je--13 7-C-vA-1 IJUMBER OF DOSES' 41 PER DAy
TAWK SIZE: GALLOWS DOSE VOLUME
ALARM MANUFACTURER: U2 41-m v. INCLUDING 15ACKFLOW: l~-3 GALLONS
MODEL IJUMBEK: OG CAPACITIES: A= a/"31LJC14ESOR y46- GALLOWS
SWITCH TSP[: 1 c "
B INCHES OR -71 GALLONS
PUMP MANUFACTURER: zdeZZ e v G = G 91MCHES OR
.L~9- GALLOWS
MODEL HUMBER: q
D= 4Z INCHES OR --dGALLONS
SWITCH TYPE: MOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE, RATE KM GPM ,~~INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE,p.~~ FEET
+ MIKIIMUM NETWORK SUPPLY PRESSURE . , , , , , . , , . , fi'b' FEET
♦ 20 FEET OF FORCE MAIN X 2124' --pFxFRICTION FACTOR..'?' ;77 FEET
TOTAL 0SMAMIC HEAD = FEET
IIJTERMAL DIMEIJSIOMS OF TAWK: LEM&TH_Z'1 ;WIDTH ` ;LIQUID DEPTH
i
j SIGNJED:~~n LICEMSE KIUMBER:-_&ZfjL??.2 DATE:
' ~ • ~ACG~. 6 6
HEAD CAPACITY CURVE 3 7/8 6 1/4 of
MODEL "98"
30 4 5/8
8
25-
3 3 5/8
= 6 20 m
0 x'1.11 O l
a
15-
3/16
4- 4
Z8.o
0 10
1 1/2-11 1/2 NPT
2
5
0
U.S. GALLONS 10 20 30 40 50 60 70 80
LITERS
80 160 240
0 FLOW PER MINUTE
TOTAL DYNAMIC HEAWFLOW PER MINUTE
EFFLUENT AND DEWATERING
CAPACITY 12
HEAD UNITS/MIN
FEET METERS GALS LTRS
5 1.52 72 273
10 3.05 61 231
31
15 4.57 45 170
20 6.10 25 95 r•. 3 5/16
Lock Valve 23'
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Electrical alternators, for duplex systems, are available and • Mercury float switches are available for controlling single and
supplied with an alarm. three phase systems.
• Mechanical alternators, for duplex systems, are available with or • Double piggyback mercury float switches are available for
without alarm switches. variable level long cycle controls.
SELECTION GUIDE
Standard all models - Weiht 39 lbs. H.P. 1. Integral float operated 2 pole mechanical switch, no external control required.
2. Single piggyback mercury float switch or double piggyback mercury, float
98 Series Control Selection switch. Refer to FM0477.
Model Volts-Ph Mode Amps Simplex Duplex 3. Mechanical alternator 10-0072 or 10-0075.
M98 115 1 Auto 9.0 1 or 1 & 7 - 4. See FM0712, for correct model of Electrical Alternator, "E-Pak".
N98 115 1 Non 9.0 2 or 2 & 6 3 or 4 & 5 5. Mercury sensor float switch 10-0225 used as a control activator, specify
D98 230 1 Auto 4.5 1 or 1 & 7 - duplex (3) or (4) float system.
6. Four (4) hole "J-Pak", junction box, for watertight connection or wired-in sim-
E98 230 1 Non 4.5 2 or 2 & 6 Y or 4 & 5 plex or duplex operation, 10-0002.
7. Two (2) hole "J-Pak", for watertight connection or splice.
CAUTION
Fa kdormation on additional Zoeller products refer
to catalog on Combination Starter, FM0514;
Piggyback Mercury Switches, FM0477' Electrical All installation of controls, protection devices and wiring should be done by a quali.
Alternator. FM0486; Mechanical Alternator. fied licensed electrician. All electrical and safety codes should be followed includ.
FM0495; Alarm Package, FMO513; Sump/Sewage Basins, FMp497; and Simplex Control Box, ing the most recent National Electric Code (NEC) and the Occupational Safety and
FMO732 Health Act (OSHA).
RESERVE POWERED DESIGN S 9 Z$ s, 2
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
MAIL TO. P.O. BOX 16347
Louisville, XY 402564W Manufacturers of...
0 SHIP TO. 3280 Old Millers Lane
7ffzz-zz)-F TZ7. Louisvrlh, KY 40216
er aio `41J41/7Y /SUMPS SNrE ARY rr
m..m •.~e _ ,...e
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
St. Croix
Attach complete site plan on paper not less than 8 1/4x) Ictioltd-16' eid Klan must include, but
not limited to vertical and horizontal reference int PARCEL LD. #
po 4r of $tape, scale or
dimensioned, north arrow, and location and distance to Nearest road.
APPLICANT INFORMATION-PLEASE PRI T L INII''ORMAiOplREVIEWED BY DATE
PROPERTY OWNER: PROPERa LOCATION
z. ` 3
Pat Collova GOV;Tti. T NW 1/4 NW 1/4,S 27 T 29 N,R 19 i5 or) W
:
PROPERTY OWNERS MAILING ADDRESS LO ' BLOCK # SUBD. NAME OR CSM #
400 S. Second St. na Humbird Hills
CITY, STATE ZIP CODE P ❑VILLAGE )MOWN NEAREST ROAD
Hudson, WI. 54016 (7- Hudson Oriole Dr.
New Construction Use Ic ] Residential I Number of bedrooms 3 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow 450 and Recommended design loading rate • 7 bed, gpdm2 - 8 trench, gpd/ft2
~w_ . a Fi43 _a 7 x.2 a..:...,i, a.~ ae....w _
n1YborpuOn area iequ:rau bed, v 56Fi_b uan&., a iviaM~o, i~~.ueSjy~. ivaui~iy isle • 7 bed, y~,~2 • ~ UIti, yMur~
AD 2 lu IL_
Recommended infiltration surface elevation(s) 98.51 It (as referred to site plan benchmark)
Additional design/ site considerations alt. area=97.86' system el.
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=nsuitable fors stem ]S ❑u ®S ❑u ®S OU ®S 13U OS 0U [is ®U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bourd3y Roots GPD/ft
Boring # Horizon in. Munsell Ctu. Sz. Cont. Color Gr. Sz. Sh. Bed Tterxft
1 0-11 10yr3/3 none 1 2msbk mfr cs 2f .5 .6
2 11-28 10yr4/3 none sil 2msbk mfr gw if .5 .6
Ground 3 28-84 7.5yr4/6 none cc s Osg ml na na .7 .8
elev.
102.01 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring # i 0-12 10yr3/2 none 1 2msbk mfr 9W 2f .5 .6
lia 2 12-30 10 r4 3 none sil lfsbk mfr if .2 .3
3 30-86 7.5yr4/6 none is Osg mvfr na na .7 .8
Ground
10Ye 6tt
Depth to
limiting
factor
+86"
Remarks:
CST Name.-Please Print Gary L. Steel Phone. 715-246-6200
Address: 1554 200th. Ave., New Richmond, WI. 54017
Signature: Date. CST Number:
12-15-95 cstm 02298
PROPERTY OWNER Pat Collova SOIL DESCRIPTION REPORT Pap- 2 -of 3
PAIMMID. #
Depth Dominant Color Mottles Structure GPD/fi
Boring # Horizon in. Munsell tau. Cont. Color Texture Gr. Sz. Sh. Roots Bed ►TOnch
1 0-12 10yr3/2 none 2msbk mfr cs 2f .5 1 .6
C-3
2 12-28 10yr4/4 none sil 2msbk mfr gw if .5 .6
Ground 3 28-84 7.5yr4/6 none is Osg mvfr na na .7 .8
1
10 .76ft•
Depth to
limiting
+84" _
Remarks:
Boring #
1 0-12 10yr3/2 none 1 2msbkrtflt 2f .5 .6
C4----l 2 12-
28 10yr4/4 none sl 2mgr mvfr gw if .5 .6
3 28-84 7.5yr4/6 none is Osg mvfr na na .7 .8
Grand
elev. '
100.46 it
Depth to
Ming
faCDOr
+84"
Remarks:
Boring #
1 0-14 10yr3/2 none 1 2msbk mfr cs 2f .5 .6
5K 2 14-30 10yr4/3 none sil lfsbk mfr gw if .2 .3
3 30-80 7.5yr4/6 none is Osg mvfr na na .7 .8
Ground
100.86ft.
Depth to
#kng
+8O"
Remarks:
Boring #
Ground
elev. ~
it,
Depth to
limiting
faMr
Remarks:
STEEL'S SOIL SERVICE
Gary L. Steel Pat Collova 1554 200th Ave.
CSTM2298 NW4NW4 S27-T29N-R19w New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246-6200
f lot #42-Humbird Hills
N /
BM.= top of At lot stake @ el. 100'
7z'7G~/✓lrl
lp '
~f
o 6h 36 ~ -Z-07C k~
bm ~x
l ~y
Gary L. Steel
12-15-95
` WlscGr)sln Department of Industry, PRIVATE SEWAGE SYST County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
safety and Buildings Division
sanitary Per itfoN 10
(ATTACH TO PERMIT) .
GENERAL INFORMATION
f: Stat la o.:
Pei 6t I-j, 8tM : BUILDERS, INC. City ❑ Villa o no
CST BM Elev.: Insp. BM Elev.: BM Description: Pa el x No.: V~r TANK INFORMATION T LEVA ATA
TYPE MANUFACTURER CAP I S N HI FS ELEV.
Septic mark
Dosing
Aeration Idg. Se r
Holding St/Ht let
TANK SETBACK INFORMATIO St/ let
vent
ir Itnto a eD
TANK TO P/ L WELL D A
Ar ke
ottom
Septic NA
Dosing Nder /Man.
Aeration Nt. Pipe
Holding . System
PUMP / SIPHON INFORMATIO al Grade
Manufacturer ~e and
'JenA% Model Number GPM
TDH Lift Friction System H Ft
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 DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type Of CHAMBER 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
No
Bed /Trench Center Bed /Trench Edges Topsoil El Yes E] No Yes El
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: hudson.7.29.19W, NE, NE, Lot 42, Oriole Lane
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH .
< I
SANITARY PERMIT NUMBER:
iF
I,
_ r.
z.~ y s p
d
Safety and Buildings Division
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 ~J
than 8112 x 11 inches in size. S4. • See reverse side for instructions for completing this application State Sanitary Per I Number
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
Property Owner Name Property Location
1-d ,"z Q -1/4 Z,- 1/4,S T ;2 f ,N,RE(or
P operty Owner's Mailing Address Lot Number Block Number
1.2 -7 S' JY •2 v Y ;2-
City, State Zip Code Phone Number Subdivis on Name or CSM Number
0 ( ) u it ; r t(/:` ~r P~( G. 2-
II. PE F BUILDING: (check one) ❑ State Owned ❑ Ity Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 1.4 -e-
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
G,?0-~36~-~d
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 tine A. Check box on line B, if applicable)
A) 1. (1 New ❑ 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 P4 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) Jr a Elevation
trt~F6 -7-1-6 75_6 r ~ :,rd's- F ,.v - o Feet ` 5 Feet
TANK Ca aut
VII. in atlons Total # of Prefab. Site Fiber- Exper.
NFORMATION g Gallons Tanks Manufacturer's Name. Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding ank .:144/e ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber El ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (N Stamps) P/ PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
c a- E d,✓ Y
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa tary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
PfApproved Surcharge fee)
❑ Owner Given Initial ~ ~ .~,lrQ
Adverse Determination 7
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 ;n 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.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system- Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 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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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pagel of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05,.Wis. Adm. Code
COUNTY
5T. c'f
orx
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan mat include, but, PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direction and,%, of 6", scaia 4r.
dimensioned, north arrow, and location and distance to nearest road. 4~
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION _ REVIEWED BY DATE
PROPERTY OWNER: S Li9tiD O /d PROPERTY LOCATION
//L.. 04///Ow - GLiA/,~.~! y GOVT. LOT 1/4 NE- 1/4,S z7 T 2-9 N,R E (or) W NAME OR 0
P336 ~wOWNERS MAILING ~ 8 f9iO,v£~i' LyZ BLOCKN AiumB PP H N)_3 04ASE ~
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE [~tSWN NEAREST ROAD
?T~/i~L At N• S5/0/ (Gri) Zz2-5SS5 }f~1~So,.~ olio/E ~~v
New Construction Use [ krAesidenaal / Number of bedrooms J Addition to existing building
[ J Replacement [ J Public or commercial describe
YSa -
Code derived dairy flow r ao gpd Recommended design loading rate bed, gpo1ft2 trench, gPdjft2
trench, 112 Maximum design bading rate bed, gpdAt2trench, gpoln2
Absorption area required kr2 bed, n2 ;402 7-
Recommended infiltration surface elevation(s) s-~ P cA • 3 n (as referred to site plan benchmark)
Additional design / site considerations
Parent materials 4 sq r~ ~P~ Flood plain elevation, if appli6able 414- n
S = Suitable for system IONAI um IN-G D PRESSURE AT-TGRADE
SYSTEM N FILL HOLDING TANK SA, LU=unsuitable for System C~[] U[] U C, U CC'S U i-S" a U [is
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bounds ry Roots GPD/ft
Boring # FHorizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed t nch
0-/3 /10 L 51A If At /W eS /f S G
13 -_:0 /a
Ground -3 D ~
elev.
Depth to This hest site PROV D
limiting r a CO vention septic em
factor
Remarks:
Boring # / D -/o
/ a yie y~Z Sid. 1 7~ S`J~ ~Yr~ 7°~ O S l f ' S ' G
[3 40 2 ~D J~/P y Si 1 A& 'W lie ~ S /7"-
13 -%y /0 y/e d~ _
Ground
elev.
/oaf ft.
Depth to
limiting
facts, i
PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of 3
PARCEL I•D. t 140 7- yZ - / fU,y l3/ i(°v h`///S
Boring # Horizon Depth Dominant Color Moores Texture Structure Consistence Bouclaiy Roots GPD/ft
in. Munsell Qu. Sz. Corr!t. Color Gr. Sz. Sh. Bed mrxh
. y 5
o iZ /aY 2-/2- S'// / f SAI(- s' 2f
Ground 3 W13 160516 elev.
/"I, ff6 ft.
Depth to '
limiting
j~~ E
Remarks:
Boring # op .4~rG
F1 ~ O-~ p Z 2. ~ •S/~ ~ f Ship ~f~ S ~f , S
Z ioy/e I/ a S 17e
S 1 G
20
Ground
elev. 3
/60, /Y It.
i
Depth to
limiting = .
factor i
i
Remarks:
Boring # O-iL / y Z S/ z~S/✓.t f~ S • S
z 12-V /a`e Jdr fie s , S
Ground 7r 5,
,
Sq.
Depth to '
limiting
factoor~~ ~
Remarks:
Boring #
Ground
GL
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Leo-o `
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till
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11 y , • /3S
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER C 0v4LOvq 'E3ui4/JE'2S ,~rL _
o , lvl S 0 3
MAILING ADDRESS 1195 7-15- kE~~-~►'Z A UE • /-l VC,
LSD Dri'ole G, 0., - l ~sa%,' 0
PROPERTY ADDRESS l n♦ 42 Nv.~enu N ~'~c,s 7,4 A 4 1T(o a
(location of septic system) Please obt in from the Planning Dept.
CITY/STATE 140CI SI AJ , e O s 1 ~1
')z
PROPERTY LOCATION 1/4, elX_ 1/4 ection T_ 2_3;'N-R__ZFW
TOWN OF V /h/ ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP , VOLUME , PAGE , LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system 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 ~,xpixation ate. /
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
• 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 - 6o d `i4i N
Location of propertyLl/4,!/F 1/4, Section_? T aQ N-R_lQ W
Township Hud So N Mailing address
Address of site 'e-
Subdivision name rn e~` ae~ i ~~S Z:'" Wo {iLot no. z-
Other homes on property? Yes_ No
Previous owner of property Jy(//K&nn kAAICL CorjQ
Total size of property Kn-T - 01 ,/7
Total size of parcel 14 A
Date parcel was created tlti! •',v awN
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house)? Yes No
Volume !7_1 and Page Number )Il 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. 5 3(., 3 , 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.
~gXgff-atiite of Applicant Co-Applicant
//-/6.Qs
Date of Signature Date of Signature
HERITAGE TITLE CO. Fax : 715-386-1075 Nov 16 '95 11:01 P.01
11{ rau ~esi ■i.~Rtib ros ■acoso4wo *ATA
. v " 1 1111 U
oO(:VM12NT NO. STATE RAT OF WISCONSIN FORK 1-19821 nos
A NTY MISTER'S CCI~sE
536362 Ott
Sr. cRancco., w,
WdforRword
I This Deed, made bctween ..HWmb.t.rd La.nJ, CgrpAT.r7tiAA.,, ~
A. M.lnfiesota..Cor.pQr.aLion.... NOV 1 6 1995
j .
ar■ntoq /0t 06
1 af1~l P C.'.SoLl.ov.a .Huia darts, ' Inc-.....
Grantee. R091daraftecis -
j Witnesseth, That the ss14l t raptor for o valuable consideration....., UJI11 :.n7
,~oovr~s to Gtentec the following described reel Witte in ...~5~ Gr.p,i.X...
Comity. Stele of Wisconsin: Hsritage Title
Lot 42, Humbird Hills Second Addition,
l Town of Hudson, St. Croix County, Wisconsin Tax Parcd No:
l
EM! ER
FEE
This 1 s ..n.4.t........ homestead property,
(isl Is not)
Tosothor with ■ll and atngnter the her•ditaments xPA oppurtononess therounte belonging; r
Humbir
And ....................d..~.J!?d.,Ga.~'tot.at»f.an.....:,,................
n-orroni that the title Is good, indefeasible In fee simple and free and clear of encumbrances except
Easements, restrictions, and Rights-of-way of record, if any
and will warrant and defend the some.
.10..x...
Astcd this 1th......._........ y of November
Humbird Land Corpor ti
...............ISEAL) 8Y.'....:......_,. ...,.....,..................(8EAL) i-:
Austin J. fail n, Its President
ira.r.
ya
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AVTURNTIOATION AS7SNOW'LaDtillt>1!1?
9lgnsture(s) BTATX OF i?VYIl;"NAN h
MINNESOTA es '
Ramsey
t
this ........dor of............. 19...... Personally cane before me this .....Utah _dar of
9.Y.O fter 1995... the above named
•
Austi J•„e
R...... dl...QR+..Pf.Rblf1l:J1L.A.f
Humbi rd Land Corpora.ion
TITLE: MF.UNSR STATR BAR OF WISCONSIN s;.
(If not,
authnrir.Od by 1 706-06. Wis. Stets.)
to me known to he the person w
foregoing instru t Ovid adcn
TNIS 1asTnuMtNT WAIF Dnarrct) eY r,. Land Cor oration
JALIC ,o C LINTY
liy a.l.. ~ ...............e............. A. Bailn
Y
W=ASHINGTON M Notary mmPublic festoe is srmanent >tel! t, s31 2000 ;
r
(91);nwtnrea may be nuthenticated or acknowledged. Both y
are net necessary) Januar x 2000,) S
• date: ................Y ....3j
•N- of P-.. .1g.1- In ♦ar e.oarl.r .h...ld M trprl r, p,1.W b.iew ("T armors.