HomeMy WebLinkAbout020-1303-20-000
STC - 104 O~ .10
AS BUILT SANITARY SYSTEM REPORT
RECEIVED
OWNER
ADDRESS 7&6 ~~g6
ST CROIX
/ Y Gc SGD~ J `q COUNTY
S'Y6t~' 20NIN!NGOF
OFFICE 1,
SUBDIVISION / CSM#~ LOT #
SECTION T N-R W, Town
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
'0y e
po
a
v
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK. ~n e c~ S ll
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: /V, 'do -es.7`,e v-,J Liquid Capacity: l;:z d d
Setback from: Well p~ House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Jr- Length ?.5_ Number of trenches -
Distance & Direction to nearest prop. line: 34
Setback from: well: /BD House_,9,~' 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:
3/93:jt
Wisconsin 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.:
P~rq}i~,iinldar,,~~iillffCC~~~1UamboUG ❑ City ❑ Village R Town of: State Plan I No.:
LLUUi1wLL77l1ii I 7~
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: a, I /'-J' C ~ rrt Cl. C ~CC' ~ f G-i
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic e~ ~~.GasC ~G, Benchmark /S lee
Dosing 6/.35/
Aeration Bldg. Sewer
H 061 g St/IK Inlet 95
TANK SETBACK INFORMATION St/ Outlet 77
Ventto
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet f
Septic ! l r KaG~ ~A NA Dt Bottom /
h~~cs
9d S6
Dosing NA Header4h&n- 11,90 /0. 75?
Aeration NA Dist. Pipe 3(0~ 01
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model um er GPM
TDH Lift Lriction Ye DH Ft
For, ain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT N. Pits Inside Dia. Li uid Depth
DIMENSIONS S -7 a DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING f urer:
SETBACK
INFORMATION Type O CHAMBER del Number:
OR UNIT
System: {fc
/174
DISTRIBUTION SYSTEM
Header/Manifold e, Distribution Pipe(s) ev x Hole Size x Hole Spacing Vent To Air Intake
i
Length / Dia. Length ~ Dia. _~L Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade ems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Hudson.27.29.19W, SE, NE, Lo 37, Oriole Lane
r F
V rr
C~
Plan revision required? ❑ Yes E3-N6
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No
SANITARY PERMIT APPLICATION
e:'~~~r■In In accord with ILHR 83.05, Wis. Adm. Code COUNTY
A S-5 76.
RY PERMIT #
STATE N41P
-Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
Gov I'r L u'vD/3&-e6-- .SE % Ali& S 27 T 2- N, R % E (o W
PROPERTY OWNER's MAILING ADDRESS LOT # BLOCK #
Cons Go tom. 37
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
,uo /v9.S'o.~ Gill Syo~~ 7/~` ~G"o3 vn/3 l,P~o /fi 6/S D/'~~l Gv ,
II. TYPE OF BUILDING: /(Check one CITY NEAREST ROAD
) El State Owned L~ E3 VI LAGE : t4 UP_rC 3
aWN OF.
RCEL TAX NUMBER(S)
❑ Public 21 or 2 Fam. Dwelling-# of bedrooms PA
Ili. BUILDING USE: (If building type is public, check all that apply) !rJ ZQ - 3Q - Zd
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 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 in line A. Check line B if applicable)
A) 1. P New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 2- -rp eN61,e-S
VI. ABSORPTION SYSTEM INFORMATION: - I/• J,'O
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
('000 REQUIRED'(sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 4 ELEVATION
.S~ S O 90 Feet ?4' O 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 strutted
Se tic Tank or Holding Tank 12.0 /100 / wE37pN FjPr F]
F-1 R F-1 F1 I El F-1
Lift Pump Tank/Si hon Chamber
I J_ I
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. 94
Plumber's Name (Print): Plumber's Signature: (No Stamps) P MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. LINTY/DEPARTMENT USE ONLY
❑ Disapproved SaVary Permit Fee (Includes Groundwater Date Issued Issuing A nt ' n lure it Sta s)
arge Fee)
Approved ❑ Owner Given Initial
Adverse Determination Ml~ ~Zxz
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) 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 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 every2 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.
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 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 forma
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.
GRAUNOWATER 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)
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Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12".Above
Final Grade
~ ~.5, ~/P~~~" •
9/ S~o
7j 4" Cost Iron
2.. Above Pipe Vent 'Pipe'
'to Final Grade
Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution Tee
Pipe FO-0-0 0 0
ri Aggregate 20]1 Pertbroled Pipe Below
Beneath Pipe Coupling Terminating At
Bottom Of System
8
/_0W 7rE.,v cam.
Fresh Air Inlets And Observation Pipe
Approved Vent Cop
Minimum 12" Above
Final Grade 73.V
Above Pipe _ 4" Cast Iron
-to Final Grade Vent Pipe'
Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution-'' Tee
Pipe 0 0 0 0 0 ,
(p " Aggregate o Perforated Pipe Below
Beneath Pipe •
0 Coupling Terminating At
sYS 2---~
ky. Bottom Of System
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page /of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05 Wis. Adm. Code
517F- 76 9,RI44~` t~vl~S~v COUNTY 5 c
T Leo ~
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
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. 02a 3403 -0
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION C
P01l6- J, V fia,!ET LU.v1~/~ (r GOVT. LOT S5 1/4 ~E1/4,S 27T L9 N,R /7 E ( W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
//S
G l 5 o tom 37 H0Mf31PV
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE WN NEAREST ROAD
NO , I~vDSoll) 4-j/, sy0/~i (7/5) IN -033 vDSo,~ 141V F~ic-i .P~l .
[ ew Construction Use [residential /Number of b6drooms [ J Addition to existing building
[ J Replacement [ J Public or commercial describe
Code derived daily flow &0a gpd Recommended design loading rate bed, gpd1ft2 trench, gpd/R2
Absorption area required _ bed, ft2 7C ✓ y trench, 112 Maximum design loading rate bed, gpd/ft2 trench, gpo1ft2
Recommended infiltration surface elevation(s) 5,eC_ P4 -3 ft (as referred to site plan benchmark)
Additional design / site considerations WS'AE7'_ 7_R EN el&,e S wW 414a
Parent material SCS' 64 Sa4r 4-ow' Flood plain elevation, if applicable ft SYSTEM IN S = Unstable for System CON-i8 Pr 7797 UN ❑ D U ESSURE AT-GBADE
-S 11 U Q-a- ❑ U L ❑ S HOLDING TAW
U =Unsuitable fors stem BS 1:1 ❑ U U S ❑ U M
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botnday Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
/ 0-/0 idyr? 313 fsh~ AwF CS 34 , 5 .4
Z /o-/,? lo ye S/Y S/ zfS •Wvf-e CS 2+ . S ,
Ground /Dyie S/~ ~S O S
elev.
9/L ft.
Depth to i
limiting
factor,
Remarks:
Boring #
7 Z i2 io 3l s ?ter sly Cs z-F , s
3 -V io s/ CS o s aP~ ,
Ground
elev.
`7 /c O L ft.
Depth to
limiting
factor
7
Remarks:
CST Name:-Please Print Ut 19 k1 IBC k'r► Phone: 3S6
Address: C S` ' 1 C 1" /1 S G S r14 ~ yd Z_
Signature: L[ „n~O~ I s (jOl Date: j~ CST Number:
I
o~ ~,pl E"IE N?'
Alec A- - Zt' S E 5 r'tt~5
'~ES-r~t~ 3 ,4PP~ac~t<o
10-~ t- ~y .
PROPERTYOWNER ~,~u.~Df3E1e G` SOIL DESCRIPTION REPORT Page? of 3
UM (IeD ! y lIIS
PARCEL I.D.# LUT 3-7 _
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxiary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rench
-2 io 3 S 2f Sh K c , s, G
Ground 3 /D S~l~ S S p[ 7 '
elev.
Z ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
A
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
ij~~ St. Croix County
OWNER/BUYER Od V' Ja'dd L unL~.~J
MAILING ADDRESS S-/ N, 1/~als6b zVi'i
PROPERTY ADDRESS 76 of /A Zs we.. z~~a Gt//, 5zl a/ &
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE /y/1/61i,
PROPERTY LOCATION 1/4, /V.C_ 1/4, Section 27 W
TOWN OF 11yO1S0AJ ST. CROIX COUNTY, WI
SUBDIVISION /Jir /7/ //S LOT NUMBER ,3,7 317
CERTIFIED SURVEY MAP , VOLUME PAGE 57~' , 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 expiration ate.
SIGNED: X0 t2mtl~
DATE: 16 b C91 19 0
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
.4' 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 40U ~U/1OG22'
Location of property ;i 1/4 XIC, 1/4, Sect on 27 ,T_Zy N-R W
Township Mailing address/S'
Address of site L,¢it,~Q, Sd E/0/
Subdivision name Aln ,f7f/, /~S Lot no.
other homes on property? Yes X' No
Previous owner of property AoMk /7i/s ZAWd Z d,
Total size of property 46 9 oelz
Total size of parcel !!ry Out,
Date parcel was created 10d 1994
Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for (spec house) ? Yes __y No
Volume 1/36_ and Page Number J-60 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. 5-32-911 , 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.
S' Z 9//
Signat of jAp .ic nt C -Applicant
Z o eT / ~ ~ S 9s
Date of Signature Date of Sig ature
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DOCUMENT NO. 3TATS BAR CF WISCONSIN FORli 1-IOBf TM~• ~ ATA '
WARRANTY DEED '~~~--~=n;~r--.
_ i
3 f~a ror F.~,~
~ This Deed, made between
A i
Humbi-rd.-Lams .Corpo,°a•~i pn, _-d. Mi-Rnescta_.l:Arpor-a_t_ion-_._..._.. tjtj V 3 ~9
Grantor,
and.--Douglas._D.•.-Lundberg- and--JanY-t--M,•--~,uadbera._.husband... 4s 9;,30 A.^,~
and rt~fe I ~y~j l
Witnesseth, That the said Grantor, for a valaable conetderation__.._. 01 D
• RaTV11M TO
eon Pys to Grantee the following described real estate in .St.a...G.~'-O.1X
County, State of Wisconsin: ~v
' 0 G r-r(
Lot 37, Humbi rd Hills Second Addition,
Town of Hudson, St. Croix County, Wisconsin. Ta: Parer! xo:,~.._
F~
Thie ...._.i•s•-not ~ p~p~tl
(b) (fa not)
Together with sll sad dngu)ar the hereditament! and appnrtenaaeee thereanto belonging;
And •
' warrants that the title L good, indeteasibie in tee simple and tree and clear of eneambrancea e:eept
Easements, restrictions, and rights-of-rtay of record, if any .
' snd will warrant and defend the same.
Dated this .-----•---15th day ot ......-...._.._....Asigslst._._..--.----.. 19.95---•
Humbi rd Land Cor oration
~A4.(Gr~TK._ (SEAL) i
Austin J. Bai ion, Its President
.....................................................................(SEAL) ...----....._......__.........._............................(SEAL)
AUTHHN?IOA?ION AOENOWLllDQMaN?
Signatnre(a) STATE OP ~{Ol!{ '~i •
MINNESOTA a.
..................................................w..._..... Ramsey .
' _ ---__._....---------_Coanly.
authenticated thin ........day oL__.__.---.---.°-•_°., 10...... Peraonallt came betore me this 15th day of
August
..............r.., 1~ .95. the above named
Austi nom. ~-Bai 11 on President of
Humbi ~~-i:•and-~o~'-oratfiori
TITLE: MEMBER STATE BAR OT WISCONSIN
(It not,
rt
aatho zed by ; 706.06, WIs. 8bta.) ~ m! known b b! tIN person
' f hsatrameat sad ) e~p~
• TMr! INlTRUM[NT WA! DRAR[D !Y rf~V L A• BAIL ON
,NOTARY ESOTA
Humbi rd Land Cor oration NATO-MIN
• ..............................P......._.._..............._.............. ~ Paul A. Bai l ion WASHI N C N7Y
s -
~ rnt~lte b~as~bti~l i<an~.~........~~T. E '
alto:..
(S!gnatnrea may M aathentkated or acknowledged. Both Ny Camaebisioe d permaaent. [t ao stab ezyirstioa e
; sn not necessary.) .lanuary. 31 7iIf~.20Qq •
. ~ •x... ~ s«•o•..k.us r..•r e.a.dq~ .k.•u b. U•.e n~rst.d b.le~ tl•.tr .k..~.....
"R wsRaANVV assa sTets lout o>r wrRCOHatx wa~•.r• t,.s.t lr..r ca r.a
roar x. ~ - ua rNwwt«. WY.
Wisi'bnsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
` itabor 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 ❑ Town of: State PI
LUNDBERG, DOUG & JANET X
CST BM Elev.: Insp. BM Elev.: BM Description: Hudson Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sew
Holding St/ Ht
TANK SETBACK INFORMATION St/ H O et
Vent
irito ntake ROAD le
TANKTO P/L WELL BLDG. A
Ar 0,0- VVIC
Septic NA 'NklMottom
Dosing %NA ader/ _JF
Aeration A Dist. Pi
Holding System
PUMP/ SIPHON INFORMATION Grade
Manufacturer emand
Model Number VVV G
TDH Lift
I Loss Friction System Fi TDH t Ilk Is
Forcemai n Length Dia. Dist. To A
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length . O n PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS o DIMENSIONS
SYSTEM TO P BLDG ELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O 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
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Hudson.27.29.19W, SE, NE, Lot 37, Farm Road
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
SANITARY PERMIT NUMBER:
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a:. Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building water systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. 6/ C 1
• 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 ❑ 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 PropertLocation
Gc. !ti d Etta 1/4, S ii?7 TOW , N, R/f E(or)ff
Property O ner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
( )
II. TYPE F BUILDING: (check one) E] State Owned ❑ It~ Nearest Road ti.,
vil /e
age
Public 1 or 2 Family Dwelling - No. of bedrooms - Town OF lyl
111. BUILDING USE: (If building type is public, check all that apply) cel Tax Number(s)
6a0-~3o~-mod
1 ❑ Apartment/ Condo Q 1^
2 ❑ Assembly Hall 6 ❑ Medical Facility/ rs ome 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Mercha"Fa 1 ❑ Restaurant/Bar/Dining
4 ❑ Church / School 8 ❑ Mobile 12 ❑ Service Station / Car Wash
5 ❑ Hotel / Motel 9 ❑ Office / 13 ❑ Other: specify
)
IV. TYPE OF PERMIT: (Check only one box on lin C x , if e
connection of 5, ❑ Repair of an
A) 1. [,New 2. E] Replacement 3. ❑ Rele ~bl
System
_-----System --------System - Tank ly- -Existing System Existi
B) ❑ A Sanitary Permit was pr io su it ber Date Issued
V. TYPE OF SYSTEM: (C ck nl
Non-Pressurized Distributio Pres " d Dis n Experimental Other
11 ❑ Seepage Bed 21 0 30 ❑ Specify Type 41 ❑ Holding Tank
120 Seepage Trench - ro d Pr a 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFOR ATION:
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) /,g, 5' E evation
~~0 c ~d`" D Sa Feet j/G Feet
VII. ITANK NFORMATION i Can alloaclt s Total # of Prefab. Site Fiber- Exper.
g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
1. 1
Tanks Tanks
r
Septic Tank or Holding Tank C~/esr`tt~d ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
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)A>, `jr,rC,,,t Plumber's Signature: (No Sta s) P PRSW No.: Business Phone Number:
P umber's Address (Street, City, State, Zip Co e):
ea '1-45-
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Id ss ng Agent Signature (No Stamps)
Surcharge Fee) /
Approved Owner Given Initial P
d
Adverse Determination /in
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SSD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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INSTRUCTIONS Y'
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 applicatimust include:
1. Property owner's name and mailing address. Providg t al description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check nl one and cQxnp e f bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, all a ropriate t an- ply.
IV. Type of permit. Check only one on line A. tof per or tank replacement, reconnection, or repair.
V. Type of system. Check appropriate en sy ype.
VI. Absorption system information. Provi I for a n rE uested r n ers 1 through 7.
VII. Tank information. Fill in the capacity of e e /or e ng t e gIons, number of tanks and
manufacturer's name, indicate prefab or site cte a to m ial. to f9o a// septic, pump/siphon and
holding tanks for this system. Check experime ov< if r eiv rimeAtal product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fi in not lic mwith o ate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign applicati rm.
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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Wumnsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis.:Adm. Code
T Glfol X
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan pw incId09, but EL I.D. t
not limited to vertical and horizontal reference point (BM), direction and % of sb fPOC-1.
dimensioned, north arrow, and location and distance to nearest road. A
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: D PROPERTY LOCATION
d L 7-3 GOVT. LOT $C 1/4 //e-1/4,S 2 7 T 29 N,R /Jf E (or) W
PROPERTY OWNERS MAILING ADDRESS ~ip,~>~? LOT # BLOCK • SUBD. NAME OR CSM /
334 *o.lem.FWrs ST C 0 37 Aji UMRi RDV H NIEARESTROADs~
CITY, STATE LIP CODE PHONE NUMBER []CITY []VILLAGE W
AV1- 11N• 5'5/0/ IG~► 2Z2-5SS5 }}upSo,J f~i// fita°M )LIOP -
New Construction Use [ krAesidential I Number of bedrooms 3 [ ] Addition I xistingbuilding
) Replacement Public or commercial desaibe
Code derived daily lbw boa gpd Recommended design loading rate bed, gpd/ft2 - f trench, gpd&l
Absorption area required /V"/) bed, ft2 -73-0 Wench, 112 Maximum design loading rate bed, gpd/tl2 `,P trench, gpdAt2
3
S~ y W(as ,gyp referred to site ego plan benchmark
Recommended infiltration surface elevation(s) It
V D/6-?W1,By n .1.11
Additional design / site considerations *Sf_ ~f u 405 oSla
Parent material SAS /3 ~~'eli /f IPP 7- _Flood plain elevation, if appli6able 414- h
S = SUltable for system CONV~O MOUN IN-GROUND PRESSURE AT-GRADE SYSTEM IN ALL HOLDING TANK
U = Unsuitable for system BS ~ ❑ U [9.S- ❑ U ~ ❑ U ~O U $
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in Munseil Qu. Sz. Cont: Color Gr. Sz. Sh. Bed tertcit
a s 3A_ s/ f s6.r e s 3f , s
Z - ) z 7, s ye ~/y sly
Ground 3 2' J(o 7 5 yid' y~~ S S . 7
elev.
//lle , 3 Z ft.
Depth to
~ 8
V '
limiting s
factor ~
Remarks:
Boring # p_ 9 7 S )lle 3/L S~ 17f 5A't n,~-fie S
S~ fS~,t` ~S /f S
El y' - 161f 7,5 1//,f 313 Im-yeA ~S /PC. S
AF 7S-yle 3/3 elev.nd -yG 7 SYie y/G a s . o(-Q - s
/Ot, 7 ft.
Depth to
limiting
~
factor
7
Remarks: S-~ NaT~ ~l ld
FAddress:6(5.T Name:-Please Print ? & B E R 1` Zf LC1P i' C k Phone:
0sNt I L 'P~ • 4UP.SO.J ~/s nature:
Date: CST Number:
/5r - ~ 141
N ~T~ ~
PROPERTY OWNER SOIL DESCRIPTION REPORT page?of
PARCEL I.D. # z-e t 3 -7 ffv~l,~i;Pv /f.,//s
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bo rxl3y Roots GPD/ft
In. Munsell Qu. Sz. Color Gr. Sz. Sh. Bed nnch
3 r d--lf 7,5 yte 2/z S 1 f Y/~ lwfle S& F, s ,6
L, #-Y) 7 5-V4 y/ ,s/ 2 f sie ds IT 'S
Ground ?S ye
elev.
7,S y.P y~ - S G, S
Depth to i
limiting
factor
}
Remarks:
Boring # 17cS/~,~ S Z~ ,S -6
:.y... z zo 2 S Y~ 313 s/ Z fsb,~ f~ ~s If
,s
-3 O's-5
Ground
elev.
2- 11.
l
Depth to
limiting
factor
Remarks:
Boring #
/Ic
JX3 2150 3/3
Ground D
elev. ,,S S 3 -Co
/a 7 7 it. y
Depth to '
limiting
factor
7 i
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Remarks:
Boring #
i
Ground
elev.
ft.
Depth to
limiting
facto
Remarks:
con 0-213^10 ncm~%
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-g 66.00
LOT 39 a o
3.68 ACRES ~
60,279 SQ.FT. o .l .lLV JIJ -,\Ir-y MAP
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:RES. ; i 116,990 SO. FT. p i
SQ. FT. I o
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