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HomeMy WebLinkAbout020-1020-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552358 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Deshler, Joseph & Kathleen Hudson, Town of 020-1020-80-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 65 14.29.19.94C TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Z. -7 fQZ.7 Alt. B~ ~3L~-~ 3 ° 14 J e")4 F4,_ Aeration Bldg. Sewer Holding SUHt Inlet ~ (o St/Ht Outlet l~ TANK SETBACK INFORMATION 1 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Z•3 S tic Dt Bottom > ~d 440 wxg 1P1: C,4, Dosing J~ / Q I N Header/Man. 7 7:5.3 Aeration !Q7 lJ Dist. Pipe 7-1 5 Z- Holding Tot. System F G 9' . Z Ov' ' PUMP/SIPHON INFORMATION Final Grade + `ISM Go Manufacturer Demand St Cover N A Model Number ~~loa$ Z • Z 160.5 TDH Lift Friction Loss System Head Ft Z.z .3 /6#. Forcemain Dia s . to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width ~ength No. Of Trenches 1 ~ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~f SETBACK SYSTEM TO lO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer, ) INFORMATION CHAMBER OR , / T'7 Type Of System: ^ Z~ / / UNIT a ~.C Model Number: o ~ea~v b jr- DISTRIBUTION SYSTEM 5 C_ Pja e, I& f- / (o = 3 Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Q Pipe(s) \ ` ~J~d •s Length Dia 4 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 TMLAIZhed Bed/Trench Center T✓ Bed/Trench Edges \ Topsoil 'gs 0 No s 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 775 McCutcheon Rd. Hudson, WI 54016 (SE 1/4 NE 1/4 14 T29N R19W) NA Lot 1 Parcel No: 14.29.19.94C 11 n r 1.) Alt BM Description = W e.X..Q, L)& ,UA A o uKe. fj0oc, 614 ~ $ 6k vL 2.) Bldg sewer length = % \ ^0e., to G~e v ~'1 / be, - amount of cover = d r of ~-k.. Plan revision Required? 0 Yes o Use other side for additional information. c••.J C~ (Q Q ` SBD-6710 (R.3/97) Date Insep s Sign Cert. No. CommePC Safety and Buildings Division Coun 20 W. Washington Ave., P.041x ' sc ' Madison, WI 53707-A,62 Pe it Nu her (to be filled in by Co.) Department Com t j'~7 S nitav 11Cation State Transaction Numbed In accordance with s. Comm 8 .21(2), - ' J submission of this form to the appropriate governmental N~~I unit is required prior to ob ermit. Note: Application forms for state-owned POWTS are Project Address (if dill nt than mailing address) submitted to the Department o erce. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1) m , Slats. 1. Application Information - Please Print All Information s4 u1L Property Owner's Name Parcel # Off-/ODD Property Owner's ailing Address Property Location Govt. Lot City , State Ziip• Code Phone Number ~ y, _V,45" %a, Section I ~N; R f /19zirele on T E rW II. ype of Building (check all that apply) Lot # or 2 Family Dwelling -Number of Bedrooms Subdivision Name Block # ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use [CSSM Number 11 >illage of -7 own of III. Type of Permit: (Check e- o A. Complete line B if a plicable) A. ❑ New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner l9 IV. T e of POWTS System/Component/Device:. Check all that apply) on-Pressurized In-Ground ❑ Pressurized In-Ground At-Grade ❑ 24 ' . of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ~ pretreatment Devi plain V. Dis ersal/Treatment Area Information: e r Flow (gpd) Design Soil Application Rate(gpdso Dispersal Area Required (sf) Dispersal Ar a ed tem Elevati n e.1 -e 1/ 7, 10c VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ° New Tanks Existing Tanks c u a U rn ~ r/~ w C7 a. Septic or Holding Tank g S &A(rp l0 OL VIL Responsibility Statement- 1, the undersigned, assu sponsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' at. MP/MPRS Number Business Phone Number RJ Ce~ ZZ Plumber's Address (Street, City, State, Zip Co / Z /Zlo~ ~ 1z; VIII oun epartment Use Only Permit Fee Date Issued Issuing Agent Signature Approved ❑ Disapproved $ ~l 1 QQWnef Given Reason for Denial o WfnTiF=~pa for Disapproval ~'ep irCnr I` ~I 7u dispersal cell must all be serviced / maintained management plan provided by per Plumber. P 2. All setback requirements must be maintained as per applicable code/ordinances. sti~'1 (x/t . P Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size SBD-6398 (R. 02/09) Cover Page Shaun Bird I Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715-246-4516 Date: 518/12 Owner: Joseph Deshler Location: SE1/4 NE1/4 S14 T29 N,R19W 775 McCutcheon Rd Hudson System type: In-ground absorbtion system(conventional) Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-5. Maintanance and Contingency Plan 6. Filter Specifications Sheet 7. Utilization of existing se tank for Signature License number #226 0 PLOT PLAN PROJECT Joseph Deshler ADDRESS 775 McCutcheon Road Hudson Wi 54016 SE 1/4 NE 1/4S 14 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5/18/12 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Bottom of shed siding ASSUME ELEVATION 1001 Filter BEST Filter ❑ OLE *H,R,P, me as Benchmark All piping shall be SDR 30/34, within 1 (of tank, piping shall be Schedule 40. SYSTEM ELEVATION 94.5/94.3 4.5' below qrade McCutcheon Road Existing 3 Bedroom House Well 65' 55' 1320' Property Line ST Valve Huffcutt Filter Tank Old Drainfield Failed 35' Plans Designed Using Conventional Powts 100' Manual Version 2.0 o~ 1~ 40' 55' 15' Scale is 1" = 40' 20' unless otherwise B. * 15' Shed noted 50' S, 15 B-1 30 2-3 X 66 Cells Lent with >3' spacing >6„ Quick4 Standard B-3 5, of Cover eaching Chamber ith 20.0 ft2 of Area 4% Slo e 4 Lon0.2ft^2/Pair of end caPs p 349' Grade at System Elevation 700' B-2 Vents 330' Property Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber To be >1' above grade 10.2ft 2 pair of end plates Finish grade elevation Typical Installation 99.0' Vent Grade Vent 3' 4" 3' X30/34 Septic Tank 5' Long 151 5' S' Long 1 Grade at System Elevation Grade at System Elevation 36" Spacing 5' 2-3' X 66' Cells Same on other end Observation tubeNent 7::::: At end of cell A B 16 chambers per cell System elevations: A-94.5 B__94.3 Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan Option #1. If system fails, determine cause of failure use alternate area and install new Sastall tested replacement area. Install system at a lower elevation, by removing chambers, removing biomat, new system. Option#3. No adequate area is suitable for replacement area, and system elevation cannont be lowered. Install holding tank as last resort. 3. Replace any faili y n9 components as needed. Plumber: Shaun Bird 715-246-4516 St. Croix County Zoning 715-386-4680 Pumper Tom Mondor 715-246-5148 Shaun it 226900 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer J _ Mailing Address? 257 ~L1 LIAe Ll/~ J -1 1 1. Property Address Po (Verification required from Planning & Zoning Department for new construction.) City/State _ T Parcel Identification Number a~iiJ ~p~Q - ~J _Z797) LEGAL DESCRIPTION Property Location SE '/4 , N~ '/a , SeC:, TN R/f W, Town of 1 Subdivision Lot # Certified Survey Map # Volume Page # 7 Warranty Deed # , Volume , Page Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 0 A~~ 71Z_ _7~~NAYORE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) _ z ~~ao 4 v . cn u- _ - ~ LL. a \ a ~ cri 1 [ c ~ 4~~0 ~L - t~ N r - - ~u ~O N N W N Cji 77 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK `L'hi.s is to certify that I ha e inspec ed the septic tank presently serving the S~ Q~ residence located at: Section, T~N, R W, Town of Upon inspection, I certify that I have Y found the tank and baffles to be in good condition, and it appears to be functioning properly. ,ast time serviced:- 1)id flow back occur from absorption system? Yes No (If no, skip next line) Approximate volume or length of time: gallons minutes --apacity: At7o Construction: Prefab Concrete 4 Steel Other Manufacturer: (If known): Abe of T k (If known) 1 (S. ture) (Name) Please print (License Number) Dry to 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: _ Ire 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, W' . Adm. Code (except for inspection opening over outlet baffle). Name Signatur MP/MPRS~62V WisconsinDepartme tofCommerce:', ' SOIL EVALUATION REPORT Page ~of Division of Safety a uilding$ h Comm 85, Wis. Adm. Code ~t`u~~ ~*tG P Couri Attach complete site plan or pater r$- /2 x 11 inches in size. Plan must include, but not limited to; YaertiJ ar~d orizontal reference point (BM), direction and Parcel I.D. percent slope, scale df.,dirntwfisions, north arrow, and location and distance to nearest road. (ja Please print all information. Reviewe Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 5' Zf / Property Owner J Property Location o'SM4:::~ Govt. Lot SE 1/4A/ 1/4 S YT 2 N R E( W Property Owner's Mailfhg Address Lot # Block # Subd. Name or CSM# 67 1-7 t1o 74 CRY State Zip Code Phone Number ❑ City Village Town Nearest Road to ,5`/ol (n, I (7t j) 3&- 6 L ❑ New Construction Use: esidential / Number of bedrooms Code derived design flow rate yJy GPD JZ(Replacement ❑ Publi or commercial - Describe: Parent material Flood Plain elevation if applicable --Zt'-Z ft. General comments and recommendations: C r System Type L System Elevation F 1-1 Boring # ❑ Boring Ground surface elev. ft. Depth to limiting factor In. Pit ' d U ~ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 - 9-30 3 - r o d l~ Boring # ❑ Boring 9 ® R Pit Ground surface elev. O ft. Depth to limiting factor &0 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munselll Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 w~ s' d~12 r Z )2-361- 7 r 3 _ p S S-OY A/1-4 Effluent #1 = SOD > 30 < 220 mg/L and TSS >30 1150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Hams (Please Print) ture CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54 J- /,Yr 715-246-4516 I Property Owner _ Parcel ID # Page 2 of ❑ Boring E Boring # Pit Ground surface elev. ft. Depth to limiting factor U in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 0-18 A "31Z- r 3 - o S Os. 4 f qV, 3 2 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon 7epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 'Eff#2 Effluent #1 = BOD, > 30 < 220 mg1L and TSS >30 < 150 mgll- ' Effluent #2 = BODS < 30 mg/1- and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (RAM) Soil Test Plot Plan Project Name Joseph Deshler Sha ird i Address 775 McCutcheon Rd Hudson Wi 54016 M #226900 Lot Subdivision Dat 5/18/12 SE 1/4 NE 1/4S 14 T 29 N/R19 W Township Hudson Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of Shed Siding System Elevation 94.5/94.3 *HRPSame as Benchmark Existing 3 McCutcheon Road Bedroom House Well 65 55' 1320' Property Line ST Old Drainfield Failed 35' 40' 55' 5' Scale is 1" = 40' 20' unless otherwise B.M.* 15' Shed noted 35' 15' B-1 30' B-3 5' 4% Slope 700' B-2 98.5' 99' 330' Property Line Parcel 020-1020-80-000 07/17/2006 08:13 AM PAGE 1 OF 1 Alt. Parcel 14.29.19.94C 020 - TOWN OF HUDSON Current X11 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - DESHLER, JOSEPH & KATHLEEN A JOSEPH & KATHLEEN A DESHLER 775 MCCUTCHEON RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 775 MCCUTCHEON RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 10.000 Plat: N/A-NOT AVAILABLE SEC 14 T29N R1 9W SE NE W 1/2 OF W 1/2 Block/Condo Bldg: BEING CSM V IV PAGE 967 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type i 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 10.000 117,000 150,000 267,000 NO Totals for 2006: General Property 10.000 117,000 150,000 267,000 Woodland 0.000 0 0 Totals for 2005: General Property 10.000 117,000 150,000 267,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 134 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 w AS BUILT SANITARY SYSTEM REPORT j~ ~k.__._..SEC f '1'Z/ N-R~W OWNI?R.... .S. TOWNSHIP 4tJP>0. ADUIO,SS ST. CROIX COUNTY, WISCONSIN. S U BD I V TS LOT-*- .1 LOT SIZE P IAN VIEW Di.sl.ar►ces and dimensions to meet, requiremeT►ts o.t 1163 _ 0 . EVERYTHING WITH IN 100 1 E'E"1 OF SYSTEM T 5 fi± it . _ F-- I I di a ~e otlth Arrow . SC Lf~' • ~ RKNCIiMARK: (1?ermanent_ reference Point) Describe: ',407- fi& 717P 5;tr46& Nov no 0",U6 E: P©sT f El.evat _ orn of vertical reference point: at site: ~ `;I:P'[' f C TANK. Ma.nufa.cturer ; i Liquid Capacity: Nunliirr Of rings on cover ~an'k'manhole cover elevation: `lank Inlet Elevation: Tank Outlet. Elevation: PUMP CHAMBER. Manufacturer: _ Number of gallons [:dumber of gal. pump set or a cycle gallons; tota r. apac ty of distribution lines gallon: s ze o pump- head; I:;a t l on' per minute horsepower. name of pump arid model number Type of warning device IiOl.Dl NG TANK : Manufacturer Number of gallons Elevation of manhole cover `t'y pe of warning device SE:h:PAE~: PIT SIZE: -mum er o p is ~eet diameter feet liquid deptFi- - - seepage pit inlet pipe-elevation bot:torn of seepage plt e eva feet-. le SE'KPAGE BED SIZE: number of li..nes lei----3_; ~:r .i.le depth I?I-AIACE? TRENCH: width length _ PI?RC0LAT-LON RATE E QU 1T7LT- 630___ IiA'1'I:U PLUMBER ON -J~SI3 _4'liO - P~ - _ - - c Lp~ 1 ~„l~ LICENSE' NUMBER J REPORT Of' INSPECTION - INDIVIDUAL SVWAGL SYSTEM San.('. tar(.(1 Pel( m.i -t --tl 4 State Sep.ti.c _~4 0_ 00% NAMC. Townehi' St. Cna.i-x Countrt _ Location __A k4ec-_-S e,c tion~Loz - -Subd.i.vision SEPTIC TANK Si ze -^_gattoms Numbe.h o6 eompan.tmentz Di 5.tance. ()nom: weBuilding ~L ^12% '51.ape._----- _ Highwaten PUMPING CHAMBER S4 ze. gaIf0n6 Pump ManuKac.tun.e.n Modef Number( HOLDING TANK S"i ze. gaffonA Number a6 Compan.tments P u m p e Ax a n m S y s t e m, D.i sfiance. (nom: Weff, 8u.i.2d.in12% ePape. Highwa.tek ABSORPTION SITE 8 e d-Ij t._~ T ti n c h 04.btancc64om: Wefe 8ui.Pdin _l20 Afo e Il,i ghwa teri' ABSORPTION SITE DIMENSIONS Width o6 tne.n.eh 6t Requi ted area ~ t Length 06 ,e'aeh. fine- _^_6t Depth 06 hock below •ti. e:~ (vr ~Numben 06 Depth o6 hock oven tile. otaP tength o6 ei nen 6t Depth o6 .tite below grade v, r •r r, „ V ~rrlr~rry vr..p.... „rMr. A(z bvtwe.en Pcnea fitloArvpe a~ the"nc.h 77! `1 00 At Totae abAonp,t.i.on area - 7 --6t Type. o6 Coven.: Pape.n. an AO(aw PIT DIMENSIONS Numbef( o6 p-i.t,6 GhaveP anon d n%.t5 yee Oufi,6tide diame_ten. _6t Depth below inlet TotaE abAokpt,Eon atte.a 6t An.ea ~equi.ned _ 6t INSPECTED BY TITLE APPROVED DATE - 1!t REJECTED DATE: I'I4 REASON FOR REJECTION G. ' 3' EH• I O Rev_ 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 8 LOCATION-3. %A_j6%s, Section-Z4,T!;IN,RZIlMor W)~ownship or Municipality Lot No.-, Block No. County T Subdivision Name t A a Owner's%Buyers Name: eS lcl' e AJd D Mailing Address C C. TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS s__,'_ S'/ PERCOLATION TESTS 5-- & SOIL MAP SHEET SR NAME OF SOIL MAP UNIT B;< B 94trAy4 -r PERCOLATION TESTS CoM~ e~ TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE NUM- SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD I PERIOD 2 PERIOD 3 P- / d" e ¢ teorc q /SAO /0 33 3':- 3 P- r2. ~~~yy1e, Q e Bare a2 140 /O 3 3 3 3 3/y -2 P-3 .moo" t it o rC aum 02 O 0 3 P- P- P- f V SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST ,I IF OBSERVED IN INCHES B- 6 of 0/12. P (O Ol 9 tD ~.SI~+ ~y *J.S B- 6 4- h 54 " j S B- 3 e. 7flif 7S a" s s" a _5 B- At 421, 4 y 1, Zvi- a S4, V n B_ .0- If-.n S'A. 12 " Mad S B- PLAN V IEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on th lame I ion and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy cat ( o Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. Ie, ,~~AP" A:v - /YO ~$j_aWg A4 is S v-- Asua~ _L @r 5V a L, 't$ f met of ~'plipc f.+!'i~s ~ _ ` C r af t:rtAk#,_ te K~A, 3 N ;OU a Ua, aid 4. L, - = F/6s _ m 1, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods ified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my wledge and belief. e (pint) ` r L"Nain Certification No.dress " Ol me of installer if known dam CST xgnature r w A - Local Authority R •A « ~L State Permit # PLB 6 7 State and County 9Permit Application County Permi !4: fl. for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: 045? ;f& A5.r71_1 L,e B. LOCATION: '/4 Section T_ N, R_ E (or) W Lot# City Subdivision Name, nearest road, ~l/ake or landmark Blk# Village U7re!'~ /u and A. Township Ntr~Sa/J C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) Variance Single family -x- Duplex No. of Bedrooms 3 No. of Persons D. SEPTIC TANK CAPACITY 100 Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete-- Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate - 44 Total Absorb Area sq. ft. New. ')0( Replacement Alternate (Specify) Seepage Trench: No. of Linea~Ft. Width Depth Tile depth (top)-No. of Trenches Seepage Bed: ~(_Length 4R.< WidthA?_Depth 360 Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope WATER SUPPLY: Private T9 Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: 1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil' Tester, NAME ~~jr",,~//~/j S ~/l,Qfm~~Bp~}r,0-Ag:4) C.S.T. # S - f ~ and other information obtained from (owner/builder). Plumber's Signature MP/MPRSW# 16 C Phone 40 Plumber's Address j 1y y so v. Z ,e,% tYa i G PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. a a 7Q r t • Y- ! t S i 4' +ilC x,17 E i Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT SSE ONLY Date of Application Fees Paid: State Co t D - Permit IssuedAsj~eeed (date) Issuing Agent Nam Inspection YesNo State Valid# Date Recd 1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2- state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 ~~eo1x C y / we sir /V, 7-z9 ,e~9 S~ L~ so hl~ NAf riu No ~ rt ~ V col Nous~ le (fAl 9::: 701P ~ S /00 v Aii f u ~ ~ ':r f J ~ 1 i I ~ f. I ~ J.i r A F... ~ _ ~ , . _,t I VAM NO. 985•A MGM~Cpp.r~® SEC. 14 t4 CERTIFIED SURVEY MAP SEC " CO. MON. SE 1/4- NE 1/4 - SEC. 14 1 T 29 N ! R 19W N BEARINGS REFERENCED I 1 LAN~g• ALONG THE EAST LINE OF ~PNpS i s s 11 ` pLptK~s.M~• P~ CE~ THE NE 1/4 OF SEC. 14 v (ASSUMED N00°-07=09"W) W TAN N EY LANE -4 !v 1 I i~ (TOWN W64 61, 1 S 89R-12'-52"W MCCUTCHEON RQ. 1 320.65' _ _ _ _(TOWN ROAD) CD ~r (L S89°-25'-05"W m NORTH LINE OF THE SE 1/4-NE 1/4 _ _ _ _ O'- S 89°-12'-52"W 987.90' _ _ _ _ _ - .A S89°-25'- 5"W 11.5' _ _ _ ~ F D. 3/4! 1. P. P po 320. 3' o *~aO~~,Ai0481!Ol~t~r~®14 BEING 2.83' W ♦~G0Aicn SOUTH OF -q ~S ,,•6 SET I" I.P. p- GENE C. .a ' a SHAFFER S-1325 at0+, '.F HUDSON Q~y11T~'~ m WIS. D z ~~A Np SU R'J x'01 o ° ''CRPC~ m LEGEND o SM a -V S oo •n •-'•(FiP`r',.- w LO T I ' 0---3/4" IRON PIPE FOUND z w 9.60 ACRES 0---1"X 24" IRON PIPE SET, m _ EAST LINE OF THE WT. 1.68 LBS./LI N. FT. W 1/2 -W 1/2- S E 1 /4 -•N E 1/4 m co - -+r-w-EXISTING FENCE _ N W W U ~ THIS INSTRUMENT WAS o w DRAFTED BY G.C.S. OT INTENDED TO 79-64 °D IE THE WEST LINE 4 IF THE SEI/4-NE 1/4 200' IOC 0 50' lod 200' I C SCALE IN f=EET co I to 1" = 200' N ~ e' N N 89°- 21'- 25' E 14.5' FD. 3/4" I-P. w " E I/4 CC BEING 2.91' SOUTH OF SEC' 14 SET 1" I.P. SOUTH LINE ~0. MON OF THE NE 1/4 %%40 1.~; . Sil`P • K~ PC'f S VOL. PAGE CERTIFIED SURVEY MAPS ST. CROIX COUNTY, WI.