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HomeMy WebLinkAbout020-1159-00-000 o avi°o I ~°o a U U 0 4 o o °o rn I I N N co N h ) Y N n cc ~ y S? '0 c i c "0 C m C N 2 .NO. L O Z 3 0 Z 1i c E ti _ O a s O 0 3 ENE Fes- a Q c Z N Z N U) i.; O w O O O N W a m d co N F- Z O C (7 O 2 c a0i Z~ o ~ I ~ o N F- ~ ~ I ~ Z v I E r~ N y co LL a N y c O c C~D (D 30 ) 0 g c p o N C Q a°i Z m D Z m D N Z CD a - N = N c d c o a .OL. a'; ° c N d N N d m CD C C a ~ o o G a ~ c co fq N N E Y N N N v av 03 FL l oo am z IL CL CL aaa ;n a I ~ c LO Lo • 7 O N a00 O y O O) O U) J U rn z -o Z ~ z :3 v I O = o ti~ 2 4 N = O m a E a v v ml Q m (D m v N Q O ) is z in c0 Q z m ~ U) ce) to ~ to ) O rn H C H C E CD 0 7 c a [O o n 3 aNi m V O F- ca € a) p rn 0 0 -3 o d c W 7 p N U N ^ W N U N a0+ "O r of N O. CO d N V d W N 9 c (U t!y~', ~ O N :3 LO y N 0 N O O N O N U • ~'~1 O N 2 2 O Z c z = N O Z c z U) O ~ I I eL ~d c 4) m a (L • C. m .2 m c m as c ~`1v o i`a 310 o O v0i o r A U a 0 U- U DEPA*TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING DIVISION LABOR & HUMAN RELATIONS P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MaMUTON.~N~ 537070 pine Dr . State Plan I.D. Number: CC1l LKC 1L It assigned) NE 4 f SE 4, Sec. 20 ,T29T9 ❑ CONVENTIONAL ❑ ALTERATIVE Town of Hudson Lot Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Jim Haut RBox 94 Amer WI 54001 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: P. Sykora III 3212 St. Croix 1353 8 SEPTIC TANK/HOLDING TANK: OVER MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARM PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABOVER PROVIDED, ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: NLOTRESH (DIFFERENCE BETWEEN FEET FROM LINE: PUMP ON AND OFF ❑ YES ❑ NO NSOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N0. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST --1111" Retain in county file for audit. Sketch System on SIGNATURE: TITLE: Reverse Side. SBD-6710 (R. 06/88) DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ` ~~Ra STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than /hJk.Z 8% x 11 inc hes in size. 1-1 visiont pious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWN R PROPERTY LOCATION CL t 10± NE o %&E '/4, s 20 TZ9, N, R /q' E (o W PROPER,TYL OWNER'S2 OA~NG ADDRESS LOT # ~ C BLOCK # N/ A rTYD`, STTA ATT 1., 9~TZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER W 5400 1(-715 M06-2,50 , g GrojLt e.` 4-s II. TYPE OF BUILDING: (Check one) CITY NEA~j~ ST ROAD ❑ State Owned VILLAG NQF: E 14Kj /~►4K dw, rd l~'lhed ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms 5L PAR EL TAX NUMBER( S) 111. BUILDING USE: (If building type is public, check all that apply) f 1 ❑ Apt/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 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. X 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 - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSEED/ (sq. ft.) (Gals/day/sq. ft.) (Min./inch) f~?~~, ELEVATION 50 G 15 GZ T ~ 7 Z ~ 10 19 1 , ZZ Feet 9 7- Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank o Iwo Week Gk, fjr)6A. [R n F1 I [I S Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Busines Plumber's Name (Print): Plumber's Signature: (No Stamps) M MP SW No s Phone Number: p :RZ ~~S sus- Plum is Address (S , City, State, Zip Cod f2bK `7S gad 5~'1 IX. COUNTY/DEPARTMENT USE ONLY L] Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued 9 Agent Signature (No Stamps) Surcharge Fee) Approved El Owner Given Initial 00 Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber I INSTRUCTIONS t. 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the 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 & 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. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/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% 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) +r . • APPLICATION FOR SANITARY PERMIT STC - 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 ~ ] iuV1 IGtN a Location of property 1/4 E /A, Section 20 T_?.2N-R L9 _W Township {:-&-d Soo ^ LL Mailing address SBDC 94 Address of site Ad-U Jc_ C-'A WA S-04 Subdivision name PHe Gv~®vp-p% - S Lot number Previous owner of property RiC~~►~/`Q~ .t~ Total size of parcel. y 9,&- 1 Y /,00 Cr C ice, S. Date parcel was created Ate all corners and lot lines identifiable? an o Is this property being developed for resale (spec house)? _Yes No Volume and Page Number -30/ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUNB 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 Nap, 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, b virtue of a warrant eII¢¢ recorded in the Office of the County Register ofDeeds as Document No. yAl* 0S7- ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of sal system, and the same has been duly recorded in the Office the County a er of Deeds, as Document No. nature of owner Signature of Co-Owner (If Applicable) Do a of 814natu a Date of Signature l i ' L 4 14 - X . 1, f nq h n r Wit, i4- yv s, - ti Man CW *ISO**" f 4 t - 7 to m wow a t ) IC 1 7 CM~ j7 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER L ilM Au42 ROUTE/BOX NUMBER 1% ~j~ oec FIRE NO. ` Z I P $'~00 CITY STATE PROPERTY LOCATION: ME 1/4 S~ 1/4, Section ZD , T 29 N, R /C1 W, Town of 4t4A s-a H , St. Croix County, Subdivision P,,.e hrc)yQ lA~ S, Lot No. 't Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper nce consists of pumping out the septic maintenance tank every three years or sooner, if needed, by a 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 $3000 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification form will be sent approximately 30 days prior to three year expiration. 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED 1 DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 (715) 796-2239 or (715) 425-8363 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, CC DIVISION N P.O. BOX H LABOR UMAN REDLATIONS PERCOLATION TESTS (11J) MADISON W 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/PADTKXXXWY: LOT NO.: BLK. NO.: SUBDIVISION NAME: NE 1/4 SIV4 20 /j29 N/Rl9 1(or)WI Hudson 4 In/a Pine Grove ts. COUNTY: OWNER' MAILING ADDRESS: St. Croix Richard Stout IR.R.#2, Box 340, Hudson Wi. 54016 USE DATES OBSERVATIONS MADE ®Residence NO. BEDRMS.: COMMERCIAL D SCRIPTION: New ❑Replace I R FI 7 lIPTIONS: PERCOLATIO 3 nlh 5h N T STS: rVa RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) O S DU O S OU ❑ S ❑U O S ©U a S EA conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: class 1 l Floodplain, indicate Floodplain elevation: n /a PROFILE DESCRIPTIONS BORING IOTA DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL W H THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 7.25 94.56 none >7.25 .00bn.s.l. 2.17bn.sil. .58bn.l.s. 3.50bn.c.s.&gr. B_ 2 6.92 98.27 none ».92 1.00bl.1. '.42bn.l.s. 5.50 bn.c.s.&gr. B_ 3 6.91 98.29 none >6.91 .92bl.1. 1.08bn.sil. .33bn.s.l. 4.58bn.c.s.&gr. B- 4 7.67 96.89 none >7.67 .83b.1. 2.00bn.sil. .42bn.s.1. 4.42bn.c.s.& . .B- 5 6.83 94.09 none >6.83 1.25bl.1. .75bn.sil. .58bn.l.s. 4.25bn.c.s.&gr. B_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P- P- --jeL-lestgn rate- P- 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 hor, 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 percer of land slope. SYSTEM ELEVATION 94.22 i- I i k i j M f f i _ , , t I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin 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 : TESTS WERE COMPLETED ON: Gary L. Steel 5-6-87 1RESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 988 N. Shore Dr. New Richmond Wi. 54017 22298 CST SIGNA tJ I / Original and one copy to Local Authority, Property Owner and Soil Tester. .,-6395 (R. 02/82) - OVER - J! ST. CROIX COUNTY WISCONSIN ZONING OFFICE I N I N N N N■ rrrri ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 September 18, 1996 Attn: Darlene First Federal Savings Bank - LaCrosse 201 South 2nd Street Hudson, Wisconsin 54016 Re: Septic Inspection for Property Located at 493 Maud Road, Hudson, Wisconsin Dear Darlene: An inspection of the septic system installed to serve the above described residence was conducted on November 15, 1995. This property is located in the NE, of the SE; of Section 20, T29N-R19W, Lot 4 of the Pine Grove Heights subdivision, Town of Hudson, St. Croix County, Wisconsin. At the time of the installation, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions with regard to the above, please do not hesitate in contacting our office. Sincerely, Mary J. enkins Assistant Zoning Administrator pe I I BENCHMARK: Fap ALTERNATE BM: SEPTIC SEPTIC TANK,,/ PUMP CHAMBER / HOLDING TANK INFORMATION . Manufacturer: lc f Liquid Capacity: Setback from: Well /M%Lse Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width:-Z,15- Length tfp Number of trenches-// Distance & Direction to nearest prop. line: /5 Setback from: well: 10 4'1z~`ouseYe!-' Other ELEVATIONS G% Building Sewer. ?ST Inlet. ST outlet .v2 PC inlet PC bottom c~ Pump Off Header/Manifold Bottom of system ~l-y/• Existing Grade 7# g3 Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~Gi m t' S l7c~ k~' ADDRESS :3-.5 ~ v ~fj l ~2t'h CCU SUBDIVISION / CSM# CT/ade- LOT # 42 e SECTION 90 T N-R /y W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITH N 100 FEET OF SYSTEM va /A 41i ~y INDICATE NORTH ARRO Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tangy; manhole cover. Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations ST. CROIX Safety and Buildings Division INSPECTION REPORT `GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village Town o : State PIA o.: HAUPT, JAMES L. CST BM Elev.: Insp. BM Elev.: BM Description: Midsell Parcel Tax No.: /b0: 00,' TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark / p l . , Dosing 5- Aeration Bldg. Sewer 17,3 ' 9a, 9a' H olding St/Ht Inlet 7 66' 9a. G F 1 TANK SETBACK INFORMATION St/ Ht Outlet 'L 99 99, TANKTO P/L WELL BLDG. Aiirlntake ROAD Dt Inlet Septic ?as- i3 NA Dt Bottom Dosing NA Header / Man. g/j Aeration NA Dist. Pipe 91• 71 ' Holding Bot. System gl.yb' 90,76 PUMP/ SIPHON INFORMATION Final Grade 6-39 ' gq pt, ~ r 4n i= Manufacturer Demand ,Fnco P coger q3-6 8 Model Number GPM TDH Lift Friction System TDH 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 /-6, h 0' DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Moe Number: System: Y" /e{ ~o GcOaxa_ 1,4 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 Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges ~51 g` 30- y Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.20.29.19W, NE, SE, Lot 4, Maude Road X A.5/0 p A . . . c.L`,uf1 /;~q `D Plan revision required? ❑ Yes ❑ No - Use other side for additional information. C p d SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division v~■~r.r. SANITARY PERMIT APPLICATION Bureau of Building Water System! 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. C^011 • See reverse side for instructions for completing this application State Sanit rmit Number ~ 74-2 S; The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)). ' State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Na / ropert Location s h't 1/ „ 1/4,S W Tod N, R Property Owner's Mailing Address Lot Number Block Number a f SI`- Ciy I tate Zip Code Phone Number ~S Subdivision rpe or CSM N mber II. TYPE F BU LDING: (check one) E] State Owned 0 Cit~r Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms vows IF cc 9i Cl III. , BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 6'10 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2, ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an System System Tank OnlyExisting System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 1 1,KSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13 ❑ Seepage Pit 43E] Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: qj -7(- 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. Syy~ m I 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ``77 . < Elevation 17 e5d 171) 41-5 P 7, - 7 C 7 G eet Feet VII. TANK Capacity e- Site INFORMATION in gallons Total # of Manufacturers Name Prefab. Con- Fiber- Plastic Exper- New Existin Gallons Tanks Concrete strutted Steel glass App. Tanks Tanks Septic Tank or Holding Tankj / , ❑ ❑ ❑ ❑ ❑ 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. Plu is Name: (Priry>;J~ Plumb nature: (No Stamps) MP/MPRSW No.. Business Phone Number: l / 7 047 er's Address (Street, G , State, Zip Code): F I~A - _R I-;- IXP(;000 / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groun water ate Issue Issuin Agent Signat re (No Stamps) VAppr0ved ❑ Owner Given Initial U Surcharge fee) Adverse Determination -/Y- X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. OS/94) DISTRIBUTION: original to Counly, One copy To: Safety & Buildings Di-,ion, 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 mailintg 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 Fami`y 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, rc-connection, or repair. V. Type of system Check appropriate box depending on system type. Vi. Ak3sorption system information- Provide ali i- ormation requested for numtlers 1 throug' 7 Vli_ Tanv information- rill in the ca;)acity of every new/or existing tank, Iistthe total gallons, r-,J m')er ofta-,ks,and '_~facturer's name., indicate -refah or s °:_c constructed and tank mat~riai_ C n- llete f -)~Jl+~;_rJc, PurTrp/siphon and l ding tanks for this system. Check exper imr?ntal approval only if tanl,s re,,-.9 v e.J e<pe-i ri . !t i' :roduct approval from DI1,HR. Vill Responsibility statement. Installing plumber is to fill in name, license number vvith appre>:,na!e ::r-efi>. 'e.g. rMP, etc.), address and phone number. PlUrnber must sign application form. IX. County / Department Use Only X. County /'Department Use Only. p 'in~ mu nC. .-1[iiCl>j, sewt' ` _ - - •i ,=,5 fin.=t!O`t ~.~c .elf rr;la_on - GROUNDWATER SURCHARGE . fit;! a A,( 41'J ,,.ruded the (re-at`on c,'- cS} f^r a nuns .i11,tcd t)F ' A`hl,=1l can. effect ar-ound,,r;ai- er. _;5_j )ve, "'o -rn, ar.d est Bbw;•'rnoii t of stand a"cis FLU I FLAN PROJECT_ Ja Am e-35 -11,//~,~vf/-ADDRESS .1/4 N/R~W TOWN COLIT `,x MPRS Byron Bird Jr. 3318 DATE - BEDROOM CLASS PERC~_ CONVENTIONAL,2IN-GRO PRESSURE CONVENTIONAL LIFT MOUND, HOLDI TANK SEPTIC TANK SIZE - IFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE - / BED SIZE l~ ><14 . \ Benchmark V.R.P. Assume Elevation 100' 7TT^~ Location of Benchmark p o J,~, forte e.- * H. R. P. 0 Borehole Q Well Scale _ Feet 0 Perc Hole System Elevation Uent 12' Grndp- * TYPAR COVERING 12" 3- 4 6' Q 3' \ I 6 M Sewer Rock l ff VIA;` o .0 yi , DEPARTMENT Of REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969 HUMAN RELATIONS N WI 53707 (H63.09(1) & Chapter 145.045) + LOCATION: SECTION: TOWNS HIP/PJDTNXN!)~Y: LOT NO.: BLK. NO.: SUBDIVISION NAME: NE 1/4 S~ 20 J29 N/W9 (or) W Hudson 4 n/a Pine Grove ts. COUNTY: OWNER'S/ MAILING ADDRESS: St. Croix Richard Stout IR.R.#2, Box 340, Hudson Wi. 54016 USE DATES OBSERVATIONS MADE NO. BEDRMS,: COMMER IAL DESCRIPTION: PRO I E DESCRIPTIONS: PERCOLATION TESTS: ®Residence 3 At RNew ❑Replace 5H6 87 ra/a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ~S ❑U ~S ❑U OS ❑U EIS ®U ❑S DU conventional If Percolation Tests are NOT required DESIGN RATE: [Floodplain, f any portion of the tested area is in the under s.H63.09(5)(b), indicate: class 1 indicate Floodplain elevation: n /a decimal, PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL W H THICKNESS, COLOR, TEXTURE, AND DEPTH UMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 7.25 94.56 none >(7.25 .00bn.s.l. 2.17bn.sil. ,5$btt.ls,,3.50bn.c.s.&gr. B_ 2 6.92 E98.29 none >6.92 1.00bl.1. `.42bn.1.s-..5.50'bn.c.s.&gr:' B- 3 6.91 none >6.91 .92bl.1. 1.08bn.sil. .33bn.s.l. 4.58bn.c.s.&gr. B_ 4 7.67 96.89 none >7.67 .83b.1. 2.00bn.sil. .42bn.s.1. 4.42bn.c.s.& . B- 5 6.83 94.09 none >6.83 1.25bl.1. .75bn.sil. .58bn.l.s. n.c.s.&Rr. B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P- P- P- 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 f -uxf, - 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. SYSTEM ELEVATION 94.22 \y@\i p ( y ~ ~ T i I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin 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): TESTS WERE COMPLETED ON: Gary L. Steel 5-6-87 ¢ ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 988 N. Shore Dr. New Richmond Wi. 54017 222 8 1715-9.46-69.00 CST SIGNA E: _ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. I DILHR-SBD-6395 (R. 02/82) OVER - - e ~ INST"" "'TIONS FOR COMPLETING FORM 115 - S BD - 6395 To ' nl rae sail test, yoUr report must include: 2. n M., ndieate whethe, is is a residence or cornet a 3. I~. or comiT u,,,! planned; 4. rr ; 5. poxes. A SUITABLI CSR A H0LDIf,J T, IF ALL _ED OUT 3 Sol 9 FIONS; 6~ own fees for ruing profil r: ascriptions a 7_ -Urately Ic ng your test locations. Di A red; .ale • point are clearly nent; dates, r a(!, food plain r: .e€np- - C, box; - Ievatian} does riot ,.fit.,.,, dress and your c n required. ALL SC" TESTS FILED VVITH TIME ~ .,UTHORIT' YS OF COMPLETION. e..,. u I A C n ar _R C L_ F.T n. . _ L i s a T acres C r -)Is BR ...-:..rn WL - ;I, fi B m VRP K` n ! i n,~grove ~fQl~h~s X101. S o~4' P lads 8 ~1ona Rage q • S 15 N LAND SURVEYING • HUDSON , WISCONSIN 54016 (715) 366-2007 Name Da-n Sch-neckenberg Address 491 Maud Circle Hudson, WI 54016 Description Lot 3 and 4, Pinegrove Heights Addition to the Town of Hudson, St. Croix County, Wisconsin. N CURVE DATA Curve Radius Central Chord Chord Are No. Length Angle Bearing Length Length 1 - 2 203.00' 46028134" S7502711311E 160.19' 164.67' 2 - 3 60.00' 55031'43" S70055'38.511E 55.90' 58.15' 3 - 5 80.00' 99026'15" N87007'06"E 122.06' 138.84' 3 - 4 80.00' 33007'49" S59043'41.5"E 45.61' 46.26' 4 - 5 80.001 66018126" N70033'1111E 87.50' 92.58' O1 / LEGEND O9 2'' Iron Pipe Found • 1" Iron Pipe Found 0 1" x 24" Iron Pipe Set O v`O PINE O DRIVE 0 4 M ~ I ss ~0 M $ Q fl 02 ~ c Ln LOT 4 LOT 3 u; N '91 - - ' tI1 o 9 8 o N i O CD a O O z 246.00' 390.65' S89001'32"W 636.65' State of Wisconsin ) County of St. Croix ) ss. SCALE OF MAP - I INCH : 100 Feet 131 Allen C. Nyhagen , registered Wisconsin Land Surveyor,do hereby certify that on October 16th 18 91 , 1 surveyed the above described and mapped property according to the official records and that the accompanying map is a correctly dimensioned representation to scale of the boundaries,that all buildings and improvements lie wholly within the boundary lines, and that no encroachments by adjoining owners appear from said survey. Map No. 81-40-191 , F.B. i.. Drawn By . Z-J cwt v l,' is 3. 1 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER To- V't e S L hta c.c,Lo-t MAILING ADDRESS L I 'v,- ~V CcY y L..~ _ 5-41o-0 t h ~~f 4l~ PROPERTY ADDRESS 41;p 5; !0& - J -dz (location o septic system) Please obtain from the Planning Dept. CITY/STATE t .c(Sz>v< D 1, PROPERTY LOCATION 1/4, 6 ru 1/4, Section ,2& T_,-2~N-R_ a ~ W TOWN OF 41' ~ ST. CROIX COUNTY, WI SUBDIVISION ~ha yl2f LOT NUMBER CERTIFIED SURVEY MAP,3`,7LYIo , VOLUME ~ l , 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 t ee expiration date. SIGNED: DATE: 13 btt St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 Location of property 411 1/4 1/4, Section,,T -R W Township Ma' ing address Address of site w subdivision name Lot no. Other homes on property? Yes_ _No Previous owner of property OLO Total size of property Total size of parcel Date parcel was created '7-j~ /e Are all corners and lot lines identifiable? 'Yes No Is this property being developed for (spec house)? _Z-Yes No Volume IL71Z~ and Page Number 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 i h _office of the County Register of Deeds as Document No. J o5~ 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. nature of Appli ant Co-Applicant ) 3 5~ Date of ignature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 449505 9c. 845Pa'JE It',I(ft REGISTER'S OFFICE ST. CROIX CO., WI Recd for Record Richard O. Stout and Janet P. Stout, husband JUL 101989 and wife, and Maud H. Stout, a single person, at 8.00 A conveys and warrants to James L. Haupt, a married man $0441 V ftb Of 011111116 r' RETURN TO Jim Haupt Route 4, Box 94 the following described real estate in St Croix County, I Amery, WI 54001 State of Wisconsin: Tax Parcel No: Lot 4, Pinegrove Heights, Town of Hudson Section 20, Township 29, Range 19W FEB This ]..G npt homestead property. (is) (is not) Exception to Warranties: Dated this 6+-h day of j u 1 y , 1989-. (SEAL) (SEAL) Ma -i- ld 14 Strut by Richard O -Stout R chard 0 Stout J44t:.-~g Power of Attorney (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN / ss s4 -~rro k' X County. authenticated this day of '19 Personally came before me this 6th day of dilly , 19-$2the above named Richard 0. Stout and j*anet P. Smut- ~ 'S TITLE: MEMBER STATE BAR OF WISCONSIN a (If not, to me known to be the person a execu{ad:thA authorized by § 706.06, Wis. Slats.) fore ing instrument and actin ed al'1jq. yw~ THIS INSTRUMENT WAS DRAFTED BY danet P. Stout Ire Notary Public - r County, Wis. (Signatures may be authenticated or acknowledged. Both My Commisa' n is permanent. (If not, state expiration are not necessary.) date: 19 'to Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 7774 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-02M Form No. 2 - 19112 ecJ ~iw~au Qed~®~w JhU.A4L - p rolz7/~a~ MPIRs 3Zt2 vcu,le - ~ !a' ~,`hG j~?v►1 ve g ~EC. F-0b 2 I1 gM ,s. fop of IU S p p4$ S. uJ, CSC ~r to e-J` , ssu.•.e o it _ x1= Bauer .t~l1~~a►3he. 1 of c~o~~ Q.s I 0 39/, 9g~ ~d0 dal s. r7,' 3 C"r ZIS,(ol r propose-A cveu CE> PEGS - 1066 u)eek - S.'T /21K 5Z` V)aSk-S;OA -cat cr t- Ler ok,: -sA-6- 1ce_ s -to w.e*-t C..6tke 390 . mss' Ca`o s s s pc 10'A fZy 2~' 4" The final item required for holding tank submission is a cross-section drawing of the tank (ILHR 83.18 (7) (b) and (d)). Examples #11 and #12 show all necessary details. Notice that the tank manufacturer and volume is shown. The tank must be a state-approved model unless site-constructed. Considerable construction detail is required as specified in ILHR 83.15 (2) and (4) (e). There appears to be a mistaken belief that site-constructed tank details are the responsibility of the concrete contractor. This is wrong. The code sections previously mentioned, because they are a part of the plumbing code, make this the responsibility of the master plumber who signs the sanitary permit. Once the plans are approved, it is up to the master plumber to be certain that the tank is built properly. IV. CONVENTIONAL SYSTEMS Conventional private sewage systems can be beds, trenches or pits. Beds are best suited to fairly level, open sites. Trenches can be used on level sites, but are more likely to be used on sloping areas to avoid excessive excavation and burial depths. Seepage pits are rarely used because they require great depths of suitable soil. Although it isn't required, the CST can make a recommendation as to the system which should be installed. A properly completed 115 will designate the suitable area, thus, making the decision as to system placement. The designer's responsibility is to draw the site plan with the system in that suitable area. Before designing the system, examine the 115 for completeness. Be certain for new construction that a replacement area was tested and shown. Ground and system elevations, not stick readings, and a permanent benchmark must be designated. Is there sufficient information to locate the parcel and the system area? If any of this data is missing or in error, it must be corrected prior to obtaining state approval. The plot plan for conventional systems requires more detail than that for holding tanks. The main objective is to prove that the system will be in the soil tested area preferably with a scale drawing or by dimensions. A popular approach is to show the system superimposed over the actual soil boring locations. Be certain to show the benchmark and define what it actually is. All of the parcel information from the 115 should be incorporated into the system site plan. The building must be shown as well as the building sewer, the septic tank the effluent line to the drainfield. Show the well on existing propert4 well area on new sites, any failed systems, and, finally, any signifir topographical features. It isn't necessary to show every tree, rock SS depression on the site; only those which may affect the private se, system. -12-