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AS 1iU1L1 SANITARY SYSTL:M REPURT
L V 1
La ,ham TUWNSHI?
UWNL
ADUN.i:SS ~ S'1. CkU1X CUUNTY, WLSCUNSIN
LU1' --f-t' LUT SIZE
PLAN VIEW
DidtanedS and 4jmen4ione to WUaL ruquirdLW;:llLS ut Hb:i
. l0 1:11YTHING WITHIN lUU FLEA' UN SYSTL:M
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L Ill I d1 a e No th Arrow I
UENGHMARK: (Permanent reference Point) Duacribe. if
Elevation of vertlcaj,.reterence poltiL : s ' --SIUPC aL Situ
SEP'rlC TANK: Manufacturer: LikluId Cap ity llU~v
Number of rings on cover -Tank llialthulu cuvur cluvwLloi►
Tank Inlet Elevation: Tullk UuLIcL E1CVatlurl _ _
PUMP CHAMUER
Manufacturer: NLu4ibcL i t;ullumi
Number of gal. puutp set for u ~ycl~- 6aIlulls , LuLLA l_ Capat' i t y of
diatribution linen -buIlull dizt ur puutp- I~u►J,
gallon per minute huraapuwur braid nau►u of pump
and model number
Type of warninK aia-v-ice -
HOLDING TANK; Manufacturer-- Nwnbc,. ut ballu«:.
Elevation of manhole coverT
Ty e of warnitAg device
:iLLPAEE PIT SIZE: - Number ui pi.t,~ r 1cct didLklL•LUf-
faet, liquid d6pth___` duePaF,e pit 1111Ct pipt--ulevaLlurn
b0CLOM of aeepa~,d pit elyvui iun Lect.
SEEPACE BED SIZE; number of l l►►ua '',V w tdi h 1 U11F t-1k U..!pt ►l
:;L•'i.PAGE TRENCH: width Lcnbtl► _ _ -
PL1i(;ULATIUN; M'1'k %'n p QUIRI D ARLA AS bU1 L'1 j, YY
1NS1'I,-k" Ult 7 % -
UATLL) P1.UM111..k ON 1015
L1CL•:N'l. NUMBLR ''l rfG z2 `'c
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN REtATION3 PRIVATE SEWAGE SYSTEMS ioc DIVISION
P.O. BOX 796 1. BUREAU OF PLUMBING
MADISON, Wil 53707
" CONVENTIONAL DALTERNATIVE • ~O State Plan I.D. Number:
III euipnedl
D Holding Tank D In-Ground Pressure ❑ Mound
NA OF PERMIT HOLDER: ADD SS OF PERMIT HOLDER: INSPECTION DATE:
~ i
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:. J REF. PT. ELEV.: CST REF. PT. ELEV.:
n iE_ 5,F- S-jLr- I) Lo _ TQ q n_.
Na f Plumber: 1 MP/MPRSW No.: County: nitmy rmit Number:
Qiv-L I -tmvrrL)
SEPTIC T K/HOLDING TANK:
MANUFACTURER: - LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNIN LABEL LOCKING OV
IPROV ED: F ID
f r" YES ❑NO 1/44S 1 NO
BEDDING: VENT Dr. e VENT MATL.: HIGH W NUMBER OF ROAD: ROPERTY WELL: BUILDING: VENT TO FRESH
I— .H J LARM: LINE / r AIR NjET:
j A
/f
M
DYES NO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIP MANUFACTURER: WARNING LABEL LOCKINGCOVER
PROVIDED: PROVIDED:
DYES DNO DYES ONO DYES ONO.
GALLONS PER CYCLE: PUMP AN L . IONAL: NUMBER OF PROPERTY WELL aUILDING: V NT O FRE H
(DIFFERENCE BETWEEN FEET FROM LINE. AIR INLET.
PUMP ON AND OFF) DYES' O NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the dept f Owi F CE LENGTH: DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction sh ce a til MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LEN TH: NO OF DISTR. PIPE SPACING: COVER INSIU DIA. *PITS. LIQUID
BED/TRENCH I +v TRENCHES MA L! PIT DEPTH
DIMENSIONS a.
GRAVEL DEPTH FILL DEPTH UI R 1 DITR. PIPE IDISTR. 1 MATERIAL: NO. DIS,T MBE OF WELL: BUILDING: V NT TO FRESH
LINE: A NLET:
BELOW PIPES: AS COr ER: E V. JIPS
I `V,L ELEV. END. C, - PIPES:' FEET FROM
7
. / J ! NEAREST- Ail- -0
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: fppund systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
ets the feria for medium sand. TIONS MEASURED.
DYES ❑NO
OIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS
DYES ONO DYES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/ EP Of 7s' IL SODDED. SEEDED I MULCHED:
CENTER: EDGES: -
DYES DNO OYES ❑NO OYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
CO R:
BED/TRENCH WIDTH LENGTH TRENCHES.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. LL DEPTH ABOVE
DIMENSIONS 16 /1') 1
MANIFOLD UM MANIFOLD DISTR. P AE MANIFOLD MA EHIAL. NO. DISTR UIS R. 1 DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION'AND ELEV. ELEV.. DIA. I'L EV.. PIPES DIA.:
DISTRIBUTION HOLE SIZE HOLE SPACING ORIL CONHE LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS
❑Y ❑NO J ES DYES NO
COMMENTS: PERMANENT MA OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
I r 6 DYES C-]NO DYES DNO NEAREST
l La
Sketch System on 1^~ Retai in my file for audit.
Reverse Side. l~ 0
SIGNA HE. U..... I
1
DILHR SBD 6710 IR. 01/821- r
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AI9D PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
,,Attach plans for the system on paper not less than 8'h x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner: Mail in ddress•
. c / , W '
W Pro arty Location: City, Village or Township: County
t/a t/aS J N/R (Or) i
LotNumber: Blk No.: Subdivjsion Name: Nearest Road, Lake or Landmark: State Plan I. . Number:
!~!T/ (if assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
X1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: `
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): )ZI New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public /lean I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Na Plumber. Sign M ~RSW o.: Phone N)umbe~
Plu er Address: Name of Designer: Z 7J
216
COUNTY/DEPARTMENT USE ONLY
Sig a ure of Iss ing Agent: F 400 Date: APPROVED Sanitary Permit Number:
❑ DISAPPROVED
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
DEPARTMENT OF. REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IINOUSTRY, DIVISION
(LABOR AND PERCOLATION TESTS (115) MADISON WOI 639069
HUMAN RELATIONS
IH63.09(1) & Chapter 145.0451
LOCATION: SECTION: 9111190X=117 - TOWNSHIP/10 [OT NO. BLK. NO.: SUBDIVISION NAME:
NA %010/4 4 /Tz9N/R/9fir)W VDSa /P N Alj M~r~QtrSW 5
COUNTY: OW S NAM : MAILING .
t_E XOnI i:.r. N . 1J y T7 VassaN, I I . 4,0
NN A.-
E DATES OBSERVATIONS MADE
NO, : C MMEACIAL O IPTIONS: A s:
TION TEST
I~Rpldtxsce 3 VNsw ❑Replaca 11 1(
14ATINt3: S- Site suitable for system U- Site unsuitable for system
w0® S I Tiff s • Qu IN'Go s ❑u . Elu HQ s Qu • RECOMMENDED SYSTEM:(opliunal)
If Percolation Tests are NOT required DESIGN RATE: rms
LFloodplam, any portion of the tested area is in the
under s.H63.0915)(b), indicate: 1 indicate Floodplain elevation: rV A,
.
pal RV PROFILE DESCRIPTIONS
BORING TOTAL QLEIH R U ATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER ELEVATION B TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
13L L, f.l'j On S% w trslt~ 0.0)") 5, LS w~6t, I f 6•, CS w~bl~y l.G j
B`I 7,z 9/.0 > 7L' 5.,4:s o.s' »~cs•N z.o
f3L Lr 1•L5 rZ0 SIL 3; Y 3., S. L, 0.7; iZog.,
r t-S w U rZ o. Oil Y t3 n 5. ti, P O IZ nn T o,.-.
a. 4- 1 ~$.7 ONE 7 23 bL L, 5., Z-Z
S1. L, 1.7 j be, 5'L r.~taIL #Goa, I.2~ it DFA LS w,/GAL, 0. Z) ~o0n5w
B. S t$-3 f~naE G}C3y/&z MedS 14141p, 9; BnCS, t/bt 1.70,0.
B-L ~G^~ /`IO C $-3r BLLyr.b~ tog.-,L _/s;R,/.+; 5,, L-6 w Gt, 0.7~ CS w/4 C,LI~Mco5
}
drt o-1; 5,1 CS w led I.L' 9n 4-'S 1.0, B ,Cs & 0.4
L S; Lr O. g'•1 a„ SJ L, z. l) a" S L u,~G a, o. 3 ~ PD., LS . t/c7 R, o.4; 8.~
7-° ~35.'S 1~10Nk > 7'~ MeoS Ga. /,9' e-c-S w/C, 0,t-j5, MW0Sw/Awx 0.
3 .y0.9 NONE > 5.1 PERCOLATION TESTS T" It-or-IL_6 1 ocl~.trICAL To i3 - 2
DEPTH WATER IN HOLE TEST TIME WATER DROP IN V •IN HE RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. B PER INCH
,.P_ NONE 3 -4f~'/f /
P- tj ati F_ -3 ZW 2~ % I
P- Z14 2
P-
P.
1 P-
p'i.OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
ryontal 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
r+,land slope. ki 6T : A,P_EA OF F1P_ST " pE=T .c-~, rMSr 131 l7. GN ISToPNi SEn/
SYSTEM . ELEVATION • 7o tai E3~ N s' `-r-n~'`~ e- y'
1 I
o !Mce- 14
eld
P !
1` 14
C* LZE
N
now I~ OF R. E` T .~1 1 I I I I I O
.
i ST*EL' 1=00 (At
T
L0
Popr
54 112
03 ' I I ' l o i J
I I I! ! I ' ► 1_ 3, 6, • fib' Z
3 I ,
T
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I i I I ca ► `P ! I f-
i I I i
1- the underaigneU, hereby certify that the soil testa reported on Uus form were made b mu u, with the procedures and methods spealieJ in the Wilco in
Administrative Code, and that the data recorded and the location of the tests are correct to Last of my knowledge and belief.
AAMETp~inty. TESTS WERE COMPLETED ON:
<QI)RESS CERTIFICATION NUMBER: PHONk NUM8I Riuptwn.rll.
M) o -
i ;r JGNAT11RE
P;JL r C; L E Voi4T'`I OIV' f'J' ASE 0 pN / t C L.-.O T C o 2.
r r, b lr 0 M P A T L. W I 'rt-t a -
a PIZ 1: v o0vfo `-`r ~STc,P►-t
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER l Ak d 63C. 4 ( to M rv~p~
ADDRESS
14
SUBDIVISION / CSM# 1G~~~YlOL,~S" LOT # I U
SECTION -~(Q T D9 N-R-- 19W, Town of }ALAC)g w
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~'q Se~'L~c lY1pu~o~C UN ~ Nvte: Addeo Sxy~'
1Re"A r 800 A) sef jc.
Se p'r, raN ~ s av ~e MnNlra~e , TaN K fii► uP k~ae S~''I+
&CA43e, 0 da'I fiou o
gRplCabM
~1 ~QD6LbOM .
NOW a, a -
sao
~ o
Akw r ~X► ffiN
SxYa 1
} 18k3
\ RvN
T c
f ` ~ t den
W ADO W `vK_ INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1
BENCHMARK: r
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER
/ HOLDING TANK INFORMATION
Manufacturer: wee
Liquid Capacity:
Q d
Setback from: Well
-3~ House Other 7 )
Pump: Manufacturer
Model#Size
Float se
peration Gallons/cycle:-~
I _
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width:
Length Number of trenches
Distance & Direction to nearest prop, line: S 1
Setback from: well:- House Other
I 1 0'
RON~ 95.CND 9E. SCE I
ELEVATIONS cover, J01.5 s
Building Sewer ~ S"
ST Inlet. ST outlet (p,
PC inlet PC bottom
Pump Off
Header/Manifold Bottom Of system Qlr/ I
! 7- lp U c F~~~e d ~4C b~ 9 y. ~
Existing Grade_ 98 ,9 0 Final T / V 7
grade
DATE OF INSTALLATION: )PLUMBER ON JOB:
Q I'6l~rw~_
LICENSE NUMBER: 31[Oy
INSPECTOR:
3/93:jt
r -
Wiscontin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village aTown of: State PIA WO
PLUMER, PAT & BECKY X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/OU ~ l0 D, -
TANK INFORMATION C/ V ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark a.75
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet Q6' q5'
TANK SETBACK INFORMATION St/ Ht Outlet q(, G 7'
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic d;5 71 NA Dt Bottom
Dosing NA Header/Man. 7.p c.~ ys 6 r'
Aeration NA Dist. Pipe S '
Holding Bot. System L/
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand SU~av~G /645
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING manufacturer:
SETBACK
INFORMATION Type O CHAMBER i Moe Number:
System: r LQ~ /~J 0~¢ 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/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Hudson.26.29.19W, NE, SE, Meadow Drive
i
Plan revision required? ❑ Yes O No
Use other side for additional information. ~,y t 5 (o a
SBD-6710 (R 05/91) Date Inspe or's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
=70IL R SANITAR Y PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than . oZ 70 M
8% x 11 inches in size. '
Check if revision to previous application
-See reverse tide for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
WERTY OWN PROPERTY LOCATION
9i. Plyjmer ~f '/a5£ '/a,S T N,R E(or
PROPERTY OWNER' MAIL ADDRESS LOT # I p BLOCK #
e 0i' o I NA
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION AME CSM NUMBER
a)Z7 1,5,54014 1( -719 I.T91, -4//62 (CIT nOtos
11. TYPE OF BUILDING: Check one) CITY NEAREST ROAD
( State Owned ❑ VILLAGE : N% giA0 ovj
❑ Public "~4' or 2 Fam. Dwelling~# oftiedrooms PAR EL AX NUMB R( )
1111. BUILDING USE: (If building type is public, check all that apply) coo - 11<17 _ 4/6 _ c~Z
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 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (C eck only one in line A. Check line B if applicable)
A) 1.E1 New 2 Replacement 3. ❑ Replacement of 4.0 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 11 13 ❑ Seepage Pit Pressure 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
~00 REQQ C7 J~UIRED (sq. ft.) PROPPOSEED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Q, LEVATION
V J $ 14- 1~7 ( Feet Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New istin Gallons Tanks oncre structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank 0 U
,_J_+_~ Lift Pump Tank/Si hon Chamber I F-1
VIII. RESPONSIBILITY STATEMENT BLS ! N ~ I) - I bU b j A . ) W 00 A)
1, the undersigned, assume responsibility for installati n of the onsite sewage system show on the attached plans.
Plumber's Name (Print): Plumber's Si ture: (No Stamps) MP/MPRSW No.: Business Phone Number:
a i 'b 1A s~-c n 3 1/0-V j l.S ~8C~ Cad 0
Plumber's Address (Street, City, State Zip Code): hh
P1 , IX. LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sani ry Permit Fee (includes Groundwater a e slue Issuing A IDnt S ature (No mps)
pproved El Owner Given Initial Surcharge Fee)
Adverse Determination ` (J 7
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R. 11/88) 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 §anitary 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.
III. 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.
R
SBD-6398 (R.11/88)
P RL. 67 P" P FN' 0 J LCr1_ . ' _.13L 1~.~. I
N A M E ri NAME .J`►r_\ X04,
"L 0 C 10 N1_.._.~ .gig e Any l_ IC ENS Er
~b
f~ - P .0 I M .A_P _
Aio~
/ooo
Da
!ram
N
h1~l~oaw D,~~~~
FRESH A111 100E rS AND ODSERVATIOU 'MIRE
CROSS SECTION
Approved Vent Cap
Minimum 12" Above I
Final 7
4 Cast Iron
Above Pipe ~
Vend Pipe
To Final Grade-
Marsh Hay Or ~Synthetic Coveri-ng i
Min. 2" Aygr.ef.j 11 I
Over Pipe •~rr,~'"- ~
Dist-ributi2 Tee
Pipe
Aggregate G_ Per•r,oraLod Pipe 0a 10 w
Dcncath Pipe ---Coupling Termina(Jng' A
` Bottom. of, System.,
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page j of Z
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1 /2 x 11 inches in size. Plan must include, but .53"
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
ERTY OWN ~ PROPERTY LOCATION Ito, GOVT. LOT IC 1/4 5. 114,S24 T Zt N,R wore)
PROPERTY OWNE MAILIN ADDRE LOT # JBSUBD. A E OR CSM
CI TAT ZIP CODE PHONE NUMBER []CITY VILLAGE Pf0 N NEAREST R AD
- /p ea a a)
[ ] New Construction Use Residential / Number of bedrooms I Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 . 7 trench, gpd/ft2
Absorption area required 2, 15" bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 . trench, gpolft2
Recommended infiltration surface elevation(s) /;Z ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material 4 z 6 `o t vAlr' z., Flood plain elevation, if applicable ft
S = Suitable for system QP1 VENTIONAL MOUND IN-GROUND PRESSURE T-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem 421S❑ U S❑ U faS ❑ U S❑ U ❑ S laU ❑ S QU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourcby Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mr&
v:
Ground 3 ~3• Y 0 l S S~~ yN~ C+^' g
eley.
/'9 yx
Depth to
limiting
factor
Remarks:
Boring # .S
.M
s' col,. S s MrFr C✓ 7
Ground f
elev. , 32` /0 S' >r -S R5 IN
lei I" YX /
/49A ft.
Depth to
limiting
~a
Remarks:
CST Name: ase rint Phone:
Ae 3gg ?02
12 ~.t Get
3~
Address: n 70
Signature: Date: 2 3 f Q5T 0 N yyr.
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # '
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bandwy Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
Ground
elev.
ft.
I
Depth to
limiting
factor
Remarks:
Boring #
m
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
r„ it
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
I?G 2,o
N
C a0
_T4. k
" CST
t lam-.'
q4
140
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the OS 4 LQec~ti, um-e(Z residence located at:
1/9, S 1/41 Sec. ~o T N, RILW, Town of
uaSO~ Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes Nom (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity: boo
Construction: Prefab Concrete Steel Other
Manufacurer (if known): W0 5S
Age of Tank (if, known) : ~z f
J )rti I~6~nrn~~1((Z
(Si tore) (Name) Please Print
ry, a l ) m1 t OWSO 3409
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR-83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name-d" J)M 8a14~ft.S14P Signature ll MP/MPRS
c
5/88
263 ACRES
49 5
1 c
> o'' p0 ~ i it
~z 3• 00 a
~co K) _ - 265 c . t
CRES ?!J cn 38 UO u
a o 9
2 - o \2- 35.
4U
f 9-o\
,00 T66 00 S 76° VI V~22'7
52
9016`
3
l OD M N
~j 2.743 ACRES INCLUDING EASEMENT j-0 20
^
-/2 518 ACRES EXCLUDING EASEMENT 0i 19 O d' 2.002 ACRES
s'O45` V 0i W 0
Z
° M 2.004 ACRES
1
v 01 ti
ti
Z 00
EASEMENT FOR WALKWAY M
AND MAINTENANCE 'IEHICLES ~
~,S . 3 sseo
\2~ 8 0 /8 22 90 ,e , f
N 89-- 56'52"E 640.00'
221.00'
223.50' 195.50
Sseo,s- - ~r------ ----------1------ 577.29'
9,E 62.7
1`I ~ PRIVATE PARK FOR HIGH MEADOWS RESIDENTS AND THEIR GUESTS;
00 TO BE MAINTAINED AND ADMINISTERED BY A HOME OWNERS ASSOC.
'1 ~0
N ESTABL±SHEC BY PROTECTIVE COVENANTS.
ACRES INCLUDING EASEMENT
+CRES EXCLUDING EASEMENT
-00 w OUTLOT
3 562 ACRES
S9 0 o
- O
O
0 9
0
o ~ - 577.29'----
to -r` t
S 89° 56' 52" W 788.75'
to
OD
M
w
m . SCALE IN FEET
0 r~n 100 0 100 200 300
a
o
n -
S , ( Ilia
SI;PIIt "i'AN1 N1AIN'I'I;NAN<`i; St. Croix Coull(y
MAILING Auultt?ss - eo 40A) (IOCat1:L, 01 PROPERTY ADDRESS
(T11'Y/STATE, ~dGGd5Q/CJ ail 5 16
~G' ! 9. N IZ 1 /
PRO1111;RTY LOCATION 1/4, Sect lot]
TOWN ON s.1.. CROIX CM INTY, W1
-
SUBDIVISION 1.0,1 NI,IN1131?I2 18
8
<'1;R'1~1FII;DSURVi:Y N1A1' ~ V0LUN1E1&QPAGI% 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 I, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all thew systems ai;rec to
keep their system properly maintained.
1-he properly ownu agrees to submit to St. Croix Zoning a certification i<0rnh, signed by the owner
and by ;h nhater plunhber, journcynhan plunhher, restricted plumber m a licensed punhper verifyintt that (1)
III(. ()It .Itc waslcwater disposal systenh is in proper operatini, cOmditlml and a11cr Inspection and
punhpint" (11 ncCcssary), the septic tank is less than 1/3 hull of dudgc and sium
1/%Vc, the undersigned have read the above rerluircnhenls and ai~Icc to nuhuhtain the private scwagc
disposal sysicnh in accordance with tike standards set forth, herein, a,, 'WI by tilt. Wisconsin UNIZ
t crIIIik:11 wn "tatini,, that void septic has been nhaintantal III 11-J I,r cninlhlcte,i and It.tIII ned to the tit ( ro",
~muhty Othccr willim tO davs of the thick. vcar cxpil;i1mit d;lh,
S I( i N
I )A I I 1 ~-~I I
<
,nIIII i,nlnlf t it Ilk
n ~Vt'I tllll~'tli ( c it CI
1 1111 t .,iiali, b,1,•I h~~,ul
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 a
Location of property. 1/43 /4, Section O ~ TD9 N-R W
Township k,/jJ_5,oA J Mailing address Za i /k UJ '7)P_
Address of site -7/2 f1 oa2 2r ~ J:s-®AJ J'
Subdivision name ael'o Itj,5 Lot no.
Other homes on property? Yes No
Previous owner of property Rrl ~Q A) l~/YIaA)
Total size of property Q.rj I
Total size of parcel i8
Date parcel was created P) P 1,, 5 1
Are all corners and lot lines identifiable? Yes No /
Is this property being developed for (spec house)? Yes ✓ No
Volume IS and Page Number 578 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 e office of the County Register of
Deeds as Document No. ~37_D9 , 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.
Y39 Il~~
'A~d-PA~ ~ a
Signature f Applicant Co-Applicant
r sic [a IV to
II THIS [PAC[ R[lERV[D FOR R[CORGINO DATA
DOCUMENT NO. i STATE BAR OF WISCONSIN FORM 1-1982, !
WARRANTY DEED
I
----__43129 ---I--_ _--80 -8.5REGISTER'S OFFICE
i ST, CROIX CO., WI
rRIas
n I~eet~al flad eman between and... I Reed for Raaord
Bria
~iusbaiia.ariiiWfnis;Joirit...tenants . Grantor, i~ JU
a._atriclt.:..::pluiner":aricl:::f2e6ecca: I~: _ plilm er ii of 1:00 PM
husban.d.and wife as survivorship marital
!
roQerty..•-•...........-•-.•----.-•---•--• .
Grantee, Repisbr of Oeeds
Witnere@JUJi That the said Grantor, for a aluable consideration......
Brian L allman and Linnea Dallman _
- i
Crox [TURN TO
conveys to Grantee the following described real estate in i
County, State of Wisconsin:
Taz Parcel No:
Lot 18, High Meadows, Town of Hudson, St. Croix County,
Wisconsin. 'I
I
,I
TRAN5FM
$ ,01)
FED ii
i~
`i
it
i
I
This homestead property.
(is) (is not)
Together with all and sin s the heredi ame is and ap irtenanc thereunto belonging;
Brian L. Inman and Lnnea t~. Dallman
And------- . .
he title is good, indefeasible in fee simple and free and clear of encumbrances except
warrants that the,
easements, restrictions and rights-of-way of record, 'I
if any.
and will warrant and defend the same.
t--`-~
Dated is day of June 88....
^1 119. ~ M
(SEAL) \(SEAL)
.Brian... ....Dallman ' ..Linnea.. J Allman..
...(SEAL) ••-•--.(SEAL)
- - -
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
----"""""---""""""-"---"-""-""--""---Y St. Croix _ County.
............da of
authenticated this da of 19 Personally came before me this Y
4ne-------------------------------- 19$8.-" the above named
8rain._~.~ ..naYTmari L3Ylriea "-J................
TITLE: MEMBER STATE BAR OF WISCONSIN Dallman
(If not,
authorized by § 706.06, Wis. Stats.) to me known to be the person ---S........ who executed the
foregoing \J1 ins\tr t and ck o w`leedngee a same.
THIS INSTRUMENT WAS DRAFTED BY (
Attorney at g~.~. Law nd..LUpdeen.--------•----------- Alice J. F eis~lhMOxFLOSCHAUER
Attorney at - -
y St . C`rOi3C- -Notary nt Wis.
- Notary Public - ---C~,,r - Wte-,.~,__}~ Y,
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.gwamoo iration
are not necessary.) date: - - --J-une 11 , 198-9._..)
-
•Names of persons signing in any capacity should he typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leval Blank Co. Ina
FORM Ne. 1 - 1982 Milwauk-_ wi.-