HomeMy WebLinkAbout020-1145-60-000
-0 0
0
o 3 3 0
h 0v pvy
v
vi pq I', N N
0. 0 0
L L L
N N ~ N
w. ~
h T c~
•O I ~ cEE
N E a a
x L_
Q, X N .
v r a 3
a)
' O ~ a)
o
ao
E. N > o
N O _ C
U
'd Z 'o Z m
c c c
ca a•
3 m - - c m
-
c -
LL c co E LL E
- .0 en CL
O a O e
C:) 0 Q E Q m ?i 9)
a)
U
M
co
d ~ N
Z E
W 0
rn Z o
o O
v E P L
z.° E
C14 (L co (L
0
U
o Z
V~~ O N I N w
~ ` O O
7 c
a) Z C Z
to F- rn 0)
c ~
E E
O N M
_0
N N
N O C N O O
' O a)
tic Z a)
N a (n
n C N i C
• IV 'I, (n L d U L
a
O c c O v
0 _ o a°) Q o 2 Q w
z m z Z F- Z o
o
Cl)
43) V-
O E N
W ` R 0 H li~
3 CD - i C (O 4) (D K
O MO MO
Y/ y L N O N V 2 N O
o G a s v 'c o a m 0
(D o
y_ Y E O cn (n 0) E O O
N 04
ON'fN1 Co n. cn 3: 3: 3: o" z o
0
►i O O O c 0 0 0
•N aao. Naas U
0. C
(mil ig N 0) 0') y = v 0)
o U) _ r- r- o
rV (n J U } rn 0) Z
-co 0 ~ (o co 0 a
0 cu o o E O C) _ U
a
~ c m a O co y c
'0 y N L 'C co N m d
E 0)
(n U) fp N V!
yO,+ O N h C p 'O Y N LO -O C E ^O O C O U N O) O
C) In 3 0) o c c cn v a rn o
co o m 0-
0 E c a N
_°n a 01
E co (o
W UJ = O T M a) r
O- N G) (D Z O a) -O F- C a)
70 I~ N N 'a M 00 a07 E O O B
_ o N o E v
•'V NO Z N Z F- J N O Z N zj (n
O ~ w
r E
V1 d a a
m
3 a L (L w (L
• a m .2 m o c c a, c
raj w E c w 3 c
r A c°~a~ '',OcnL) OyV
I t
w7 -5;!95TI
' Z O lk ,
STC - 104
AS BUILT SANITARY SYSTEM REPORT
G~U~T
OWNER/4 ~ /
ADDRESS
SUBDIVISION / CSM# Ph Ilk y i e-nzJ EST . LOT 7 Z.
~So.7
SECTION I'1 T N-R 11 W, Town of L9
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
.sue- 4 r-TAc4-*.,a dL.A.5
v1lyFia
INDICATE NORTH ARROW
e setback and elevation information on reverse of this form.
ovide 2 dimensions to center of septic tank manhole cover.
50LPaeyo12'S 147- ,vw 7-
BENCHMARK: /O 0 ~ 0
ALTERNATE BM. T d ~Al L-1 to eel; 9G- /l'~ 7~•
,
coves- X3 00
SEPTIC TANK I-pump ER / TION
Manufacturer: Liquid Capacity: le-ov
Setback from: Well House Other
Pump: Manufacturer / Model# -----Size
Float seperation Gallons/cycle:
Alarm Location
l
/NA'Nl~olE GdUgER° Ggf-S /J~Qpjjl~b=Z) W~~Zc ~~4,~iZ1 ~DGIC 5=20 -l~~
SOIL ABSORPTION SYSTEM w 1 ~ c ESL
Width: 5 Length 63 Number of trenches ~'1 v i aLO
Distance & Direction to nearest prop. line: 3 1/
l •L• L•>
Setback from: well: House 3 ~ 'Other
T~.~k' s~%d ~~pi'• ~uaTy S,~a rAr~o~ i'xrsra T.~~lC ? !3i
G SEty ~e !P~ • ~sFn~
ELEVATIONS
?
Building Sewer ST Inlet: ST outlet 7 6
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: PLUMBER ON JOB: Ro13~'i T ~lQ/~!• T~
LICENSE NUMBER: 1WIl 3 3d 7
INSPECTOR: J I GAOL of
3/93:jt
'AS ~3U~LT PLOT or
Z
W.~•L • O
O ~ p w
0 -n L%
-4h
trri v
oo _ o
o ^ n c ~ , / ,o, col
► i •Q
~ I I I 1
I r
o I~ I I ~
w
s
E
ro m m ro~~ ~ d`^
L Z L fi rn b Z 3
t~ Ll
°o c
c y ~ ± r N
R o --1
K ~ y v>, 7D
n ~
a Q1
RI
~p ~ II
4 ~ ~ O
° v
fK
'G
6Q
'T.Okiv-MFr( PartPT1&@#dVd4sttg . 79 _ 19W - CAIN SEWAGEISYS4,Tlawman Rna County:
Labor and Humpn Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitar rmit
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI .
x
s 713M Elev.: BM Descriptio . Parcel Tax No.:
TANK INFORMATION ELEVATION DATA AQ4QQt~G s 2~
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septi ( Benchmark ,D
Dosin
Aeration Bldg. Sewer
Hold, St/,pit Inlet
TANK SETBACK INFORMATION St/Pf Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet ,
Air Intake
Septic NA Dt Bottom
Dosing NA Header-/- o
Aeration Dist. Pipe 98 0,1'
„p/~
Bot. System Y. P3~ P7 / 97.10
PUMP/ SIPHON INFORMATION Final Grade
Man Demand 7•Z3, 9~.7d
koSlr /
Model Number
TDH Lift Fr' Sys
rcemain Length Dia. H Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH width r Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION S 3 DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEAC Manufacturer:
HTNG-
SETBACK CHAMBER
INFORMATION TypeO z f Mo um
`~Q„UNIT
System: m ~ 4,4
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) / x H x Hole Spacing Vent To Air Intake
Length Dia. Length,2, Dia. Spacing 1,3
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over r/ Depth Over l/ ( a xx Depth Of xx Se odded xx Mulched
~lTrench Center Rod-Y Trench Edges 3q - T Z Topsoil_ ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION; Hudson: 7~29,19W, SW, NE, Lot 72, Sherman Roa.
S,lJ /,C! • ~c~"7a-`~ C/l/l~ ~ (1 O~l~i`~ -~'~i~ O~ G~ ~V . ! ~~-r
Plan revision required? ❑ Yes L~ryo
Use other side for additional information./
Date Inspector's Signature Cert, No.
SBD-6710 (R 05/91) ~~Q~
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
sT-, c ~eo~' X
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a 01003
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. N
PROPS TY OWNER PROPERTY LOCATION
_fAT LerVEIe 7y Sw % NE '/4, S TIME N, R 9 E (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # 7,z BLOCK #
& 2, -5 EkM r}-'v
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
u Sow 15$-rol (e 353 70 ?1+k., v i'F-w Es T1TE's
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
~y ) ❑ State Owned P VILLAGE : ~ pSQ.v S7f
El Public Ln 1 or 2 Fam. Dwelling-#of bedrooms - PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
20 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 in line A. Check line B if applicable)
A) 1. El New 2. LJ Replacement 3. ❑ Replacement of 4.E] 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 r❑ seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 tJ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure i 43 ❑ Vault Privy
14 ❑ System-In-Fill Z 7A0-&,U 44e S ~f ~Zf_ x~! O
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
-1150 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 013 ELEVATION
s~ ~oCS d Feet l0 O Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION Manufacturer's Name Con- Steel Plastic
New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank 6 D O /&00 l
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.
Plumber's Name (Print): Plumber's Signature: (No Stamps) 7330? PRSW No.: Business Phone Number:
'~og.T- ihXt'
674 1 T i~~ ?iS ~d~ '
Plumber's Address (Street, City, State, Zip Code):
S S .v-r - ffvOSo~J C~~S S ~'D~
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanity Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature No Stamps)
Approved ❑ Owner Given Initial n Surcharge Fee) l 0
Adverse Determination ✓ . 4° ~
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 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,_.608-266-9815.
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.
Vlll. 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.
i GROUNDWATER SURCHARGE
i'
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)
V, Z H
w li's •r Lo r I.. tee.
ROES
OC (._I w
cam` ~
N r
~1 ~ ~ n d ~ ~ col I I
I I I
1 n O ~ • I~ I I
N °SC~ Q I
I e
- b
w
N C
0 ro 1 d
R 7D O
y
C
d
- INI ~
-6 y e N CO m
N
-zA
W ~S Z Q
Z N ~ o 0
Ln IN.
N •
X N I
70° m S Z4 > a
o
O y
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade rl~llSff_eD /040
-Above Pipe _ 4' Cast Iron '
7o Final Grade Vent Pipe'
Synthetic Covering
Min. 24 Aggregate
Over Pipe
Distribution Tee
Pipe 0 0 0 0 0
69 Aggregate a Perfbroted Pipe Below
Beneolh Pipe
o - Coupling Terminalinq At
syST y 9G •SO v, Bottom Of System
Fresh Air Inlets And Observation Pipe
approved Vent Cap
Minimum 12' Above
Final Grade
/040
. 3(o _ Above Pipe 4" Cast Iron
.
"to Final Grade Vent Pipi
Synthetic Covering
min. 2" Aggregate
Over Pips
Distribution -Too
Pipe , 0 0 0 0 0
4 "Aggregate o Perforated Pipe Below
Beneolh Pipe 0 -Coupling Terminating At
s ysTF,H ~~,•T Bottom Of System
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 3
Labor and Human Relations _ Of
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY •
ST leo/'
X
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Ile. /WS. ATfdc e Z c deer y GOVT. LOT , W 114 1/4,S (7T 2~ N,R /f E (or) W
P~jQ PERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM #
7 ~i 2 S ~1~,~ iP0 • 7 2. /~/1 /P,~ !/ice ~c/ E'S T,4TEs
CITY, STATE 21P CODE PHONE NUMBER ❑CITY ❑VILLAGE OFONVN NEAREST ROM 146k tf opso.o W I • SYoi ~ 1~~5r3~G - SVo uOSo J T
[ j New Construction Use [ Residential / Number of bedrooms Addition to existing building
[replacement [ j Public or commercial describe
Code derived daily flow e gpd Recommended design loading rate bed, gpd/ft2 trench, gpdt t2
Absorption area required bed, 112 563 trench, 112 Maximum design loading rate bed, gpd/ft2 french, gpd/ft2
Recommended infiltration surface elevation(s) 5-A-0- q . 3 ft (as referred to site plan benchmark)
Additional design / site consi tions S 3
Parent -iterial SC 5 5 S D A kOT,q- - 144,,*l .00r& Flood plain elevation, if applicable /V 14. ft
c • LA_ o c i-
S = Suitable for System DONIQ uOUNn IN~GR~OUN❑D U ESSURE AT_ GR~E❑ U SYST IN FILL HOLDING TANK
U=Unsuitable for s stem ll~d S tr7 u B-9 D p U ❑ S
/fall/ 2.0 ' 60,qP1467Zr_P is-""v SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bour>daty ;Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0- /0 yle A, -f 5 13
-L- L
Ground a! -/G A0 YX 31y S~ f 5,6,E i►« Ile- 5 2-f - S
elev.
ft. 6-33 75 yR y/G /s 2,.»,,
Depth to /!C 3 3 -/a -7,5 y/e
limiting
factor u
~~oa
t
Remarks:
Boring # tau 5
io Yee 212_
o,~~ •~t s 3~ N
I Jae
y, N Z 9- ?Y /0 y 3/~/ Y, sd~ .w► ~°.t? s 2'f . y . s
00
131 -y 75 Yoe y 4 /S 69,4-1
,y~ wee _~S Zf ,
Ground r N cc u S 1'6
elev. $2f yy yy /0 y/? 51,11 /.SA< fJ`Fi' Cs PP k-1 P
/b/. 2.0 ft.
OV /Si' E- Si' Ezv
Depth to
limiting l'C 9 /O I D t~/e 7 4 S ~i c, 5 •7
factor „
7100
Remarks:
CST Name._PleasePrint R013&-,e7- -211_134(e4 T Phone: 7j5 _ 3
Address: &5S" 0.114vi'4- ~°D• ff v1~So.~ CtJ/. Syct~G y-~ CST,y 2I/P
Signature: Date: CST Number:
i
~~~'STi%~ (r. f ~f'i(r',v Fi'~ ~D ~E~~ E'ST~/3~ ~•S/~~-s
`f /S T~'~'I ~S iiv CODE' G'o.~r l~ i~ •~T'• Soi /s
lee-
~dY,
PROPERTY OWNER SOIL DESCRIPTION REPORT Page 2- Of 3
PARCEL IA La T Pf}It?/~ (JOE w
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boixxlary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
;f A J0
Co,y,p, C,7- AOf 11,4-7z-,v i~ e;f
S
Ground 14 /o yle 315 7,` she i,,► 6f C s 2. f y . 7
elev.
/o/. L It. $ 3 7 s y~P y/ 15 0"w, 7,P e" es
N
Depth to 1.32-f 413 119 V S/y 5i/ 7F s6K limiting
factor „ i.S w 7'1,vva v5 ltNv of S~ % s s of Sit ,fL
7/d D 1G 3 -/,Z /c y
Remarks:
Boring #
..t v:4ti
..........?;c~8
Ground
elev.
It.
Depth to
limiting
factor
Remarks:
Boring #
-ME
R,
VTPNih.•:C
Ground
elev.
ft.
Depth to
limiting
fablor
r i I i ---L--
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
eon ooon,o ACM b%
- tt~ u1
Pt,~ES
N ~ ,J
J
n
o r
7 30. ° p
v ~ O
• b
- w
ITI
rr) 70
-4-) t) (d I
co Ir
cn r
-may y w m
INI
o Q
z N
N In
I
zT, Ilk
0
0
- O y
i
-57 oEr
s yon
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
b'd
serving the r1
T7- l1 Ty residence located at:
s~ 1/4, 1/4, Sec. /7 , T 2"( N, R W, Town of
Ou flsoUpon 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 to 1'.A3
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacurer (if known) : #j 04EES4EEe, Z
Age of Tank (if known) : 10 y~>4RS
(Signature) (Name) Please Print
(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).
E '
Name ~l ~lbl~1T Signature / MP/MPRS 3307
5/88
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 44 % G E!/~/PT y 3 5~ ~o ^ .5~3 d
MAILING ADDRESS Z Sff S'z/'0/6
w~ 11~
PROPERTY ADDRESS S4.4(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION :!rco 1/4, N 1/4, Section , T If N-R W
TOWN OF N' UP Sol" ST. CROIX COUNTY, WI
SUBDIVISION PAf k V l~:-7w C S t-A-rE 5 LOT NUMBER 72-
CERTIFIED SURVEY MAP , VOLUME , PAGE ; LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
2GCl r % - s
DATE:9 y
St. Croix County Zoning Office
Government,. Center_ . -
1101 Carmichael Road
Hudson, WI 54016 11/93
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 b owner co'
Y ntractor s ec
house), thenia is form should be retained and completed when
the property' s sold and submitted to this office with the
appropriate deed recording.
-
Af'. 14 f'S. A.4T G 9'U~~ 1
~
Owner of property
y
Location of property S4/1/4 N,&71/4, Section 1-7
, T _ N-R W
I
Township UPS OA.:)
Mailing address 7G 2- 5WJ!5;ri4 IfW le J49 III&OJ0A.) 4 / S yplG
Address of site
Subdivision name l' ltxt-Ulizo e5-'ST~T~ S Lot no. 72,
Other homes on property? _yes K No
Previous owner of property
Total size of parcel l~(J r'1 5
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for ~
(spec house)? Yes No
Volume 4`0 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 & 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.
.
OWNER-CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I am the owner(s) (we) (are) of
the property described in this information form,. by virtue of a
warranty deed recorded the of ice of the County Register of
Deeds as Document No. , 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 County Register of deeds as Document
No.
Signature of applicant C applicant
Date of Signature Dat of S ature.
✓ I STA"rF 13AR OF N'1SCONSIi: -FORM 2
I~ 01)C',2MENT NO ~~J I WARRANTY DEED
J THis SNA,:F RE~ERVFU FUR RECORCING DAre
i
360438
SAE'! E. MILLER, a single man REGISTERS OFFICE'
ST. CROIX CO., WIS.
Recd. for Record. this_12th
- day of Oct. A.D. 1979
coat et,- •.nd 'v.+rr.+nS to PATRICK T. and _I`111RIA:.1iIE J. _ 4:~F"`~t .
LEVERTY, husband and wire, as joint tenants- at M
_
RpBtt of Deed]
RETURN TO
the f ilea )rig described real estate in St.. Croix County,
Stale .,f 'x+sconsln:
Tax Key No.
Lot 72, Park View Estates Second Addition to
the Town of Hudson, SUBJECT to recorded
easements, covenants and restrictions.
TRANSFEa
r,~ U
This is not homestead property.
(is) (is not)
Exception to warranties:
Dated this - ` day of_ -October 19 79_.
1
NSA (SEAL) yYJ (f , . (SEAL)
Sam E. Mi11e
(SEAL)
(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated thi stay of STATE OF WISCONSIN
ss.
St. Croix County. 12th
N/A Personally came before me, this _ day of
October the above named
TITi_E 11FS1HER ST.%,rE B R OF WISCONSIN Sam E. Miller
! no"
- -
~t~,nted bV -06.06. Wis. StatS.) -
,n ent was Irifted h, - - -
Hugh F.Gwin, Attorney - - -
Gai Gwin & rtu'agei. ,4 - n, Gilbert, . i to me known to be the person who executed the fore-
30 Second Street going instrument and acknowledged the same.
:iudson, Wisconsin 540-V6;~0~p -
J4 - 4` 1 } Laves F. nderson
V 4k.; Kolar Public St. CrO1X County, Wis.
a~ NIy Commission ~!?~X4CX(EDft7dQSX } E Sa~Il43C
Axxx- expirea--- S_ 11th , i9. 83.j
- 9pt
• cn. .AC= 9AR OF WISCONSIN FORM NO
o(1) p 0ca0 3-0 n
c 3 _o1
1
1 1 c ^
r: z
CD
v o a O ° o (rD o y p M C V N 0
N 3 a m m o N 3 m co m' °
a- -0 or
O
CD (o 0
CD co a) 0 3 a x N C p
O
0 -4 C: CD 6
N N T to 0 (n ~ p C
c (D
CD (o m N C °=r a. m N C a
(D 3 CD
a- a
3
° 0
CD CL
0. ;o QO-
2
z co CO a ~ co
o co n r N
c y cvo co J0 3 M
vvv0
z CSO CO O 'C 000
CS
< C N p N N ~f
o. 7
y0) ca
T
CD (D N w OMf 'NO <p
!D
CD p
p 7
N 3 n) o 3 d y
3 C w
z N y N
o D m z z co z O
> > a
O =r
- i fD W cn
C co N ~7 v cn
N D
.0 iv N O CC N
W (O CL a
a 3 CD = 3
z (D K6 (D
~ N
7 O Z
° (n cn
v a a Q
0
W M W M (ENO
Z
_ A
CL CL ,
O " O z
m
C
z
y y
D O A
w 0 w f
(D
m m o CL m o Aa
a cr o- C:, CL
=r - °
3 m c n
- v c
000 = o a m o a
• (nn ;<'@ N CD N
CD
CL N Si
N ' O y
f N 4
=r n N A
X
O 3 N
n
N p.
S 0 a (0
M N N V
O N ~
:3. 3 tv
cu (o c
9;s o
a d a; (n
A
o o ?e
> > A
fD < V
o 0 0 0 a
C
ya
p i p a b y
i .
' AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP l~ ~►Jsb~ SEC. )7-T2 N, R I W
ADDRESS ST. CROIX COUNTY, WISCONSIN. T
3DIVISION V t c,. LOT_z2_LOT SIZE
PLAN VIEW
-Distances b dimensions to meet requirements of H62.20
SHOO,' EVERYTHING WITHIN 100 FEET OF SYSTEM
j kk
V "'I i
D Z
6 0 ! f s
i
1
ff I ~ i I j j ! r
i
7 ! - !
"TIC TANK S) poG 11MFGR. 1/r/r , s ~-Indicate Nanth A)Ltow
CONCRETE STEEL Sca.2e
NO. of rings on cover, Depth DRY WELL
,,NCHES NO. of - width length area
no. of lined width length j 2 area
depth to top of pipe
-z3EGATE
• RATE ~S AREA REQUIRED 4" / S AREA AS BUILT 2 ;L
,claimer: The inspection of this system by St. Croix County does not imply complete
,•aliance with State Administrative Codes. There are other areas that it is not possible
-,.inspect at this point of construction. St. Croix County assumes no liability for
,,tem operation. However, if failure is noted the County will make every effort to
.'ermine cause of failure.
,.'-ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST*.
- INSPECT
DATEDD~ PLUIMER ON JOB 00 c
LICENSE NUIMER - Z
. tip..
ti
Z
jKREPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM ~
San.itaty Pn.m.i.t/_S"e_
State $PpccJ5~2.~~~
NAME Township St. Cno.ix County i
Location Section _
SEPTIC TANK
Size 06 I~ ga.2.2ons. Numb en ab Compantmentd
i
Distance Fnam: Wett 12% on greaten .6tope ~ it
Bu.itd.ing r it. Wettands ~ .
H.ighwaxen it. t.
DISPOSAL SYSTEM
Distance Fnam: G►e2t -12% on greaten .6tope 6t.
Bu.itd.ing f' it. Wettands Ft.
H.ighwaten St.
FIELD DIMENSIONS:
Width o4 tnen chiz. Depth o6 Aoek betow tite/_,L-in.
Length as each tine 4 & it. Depth o6 rock oven tiZe in.
in.
Numb en o6 tines Depth obiZe bes?ow gnade
Awe_
To.tat Zength o6 t inez it. SZope o6 tneneh Z in pen 100 6t.
Distance between Zines 6t. Depth to bedrock ~ •
w
Tot .e. ~ 9round aten it.
a absonbtian area ~ ;'t2 Depth to 5
Requited area J ~t Tape ob Covek:'PPa.__pen an Straw
PIT DIMENSIONS:
Numb en o pits % GAavet around pits yea no
Outside d.iamet~n it. Depth below .inlet it.
2
Total abs onbt.,#:6W akea -it A
2
Area nequkxed_ rn
41 i -77-
INSPECTED BY TITLE APPROVED ! DATE ] 9
REJECTED DATE 197
1
C'
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TES/TS/
LOCATION: 1/4,&1/4, Section T/c2f/N, RL E (or) W, Township or MuRisipality Gam" /
Lot No., Block No. ff !/.c~`c7~A7`~S q2A%4j- d County .4 42 Subdivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms - Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS ~ Z Y Z' `',2: PERCOLATION TESTS
SOIL MAP SHEET -~E SOIL TYPE~~'~~
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P I Z Il >~r- 3 5
P
0 a,
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
s r 2 4,
R_ 71 /7
71
-V 7 "S
/ 1 / ' H I• , I~ 1 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate n mber of square feet of absorption area
needed for building type and occupancy. C,Ld:Tw Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
+ )2C
z 5
a ~I ,
0
AN,
° t N
t
i
L
4
V5
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 location of test holes are correct
to the best of my knowledge and belief.
Z8
Name (print) Certification N
Address <S
Name of installer if known
CST Signatur
COPY A -LOCAL AUTHORITY
V ~
State and County State Permit
PLR.*.67 o Permit Application County Per i#
x
for Private Domestic Sewage Systems Count
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: Ali:"- '/4 Section 12 , T N, R E (or) W Lot# City
Subdivision Name, / nearest road, lake or landmark Blk# Village
Zj Township H K S o ,~J,
C. TYPE OF OCCU A~!£Y: *Commercial *Industrial *Other (specify) Variance
Single family ~ Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY DU Total gallons No. of tanks
HOLDING TANK CAPACI;FY Total gallons No. of tanks
Prefab concreted oured-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 Total Absorb Area sq. ft.
New ~ Replacement Alternate (Specify)
Seepage Trench: No. of L' 2 Ft. Width ,Q 2Dppth Tile depth (to No. of Tre:nKhes
Seepage Bed: ~gth- Width.~Depth Tile depth (top) D / No. of Lines ~
Seepage Pit: Insi a diameter Liquid Depth No. of Seepage Pits
Percent slope of land Fc Distance from critical slope
WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, 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 t e l C.S.T. # - and other information
obtained from w el R r (owner/bui
MP/MP SW# ! /1- Phone #Z,47- ~ ~ 3 7
Plumber's Signature 41)
Plumber's Address w
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.
e
E
s
d' .
E
ft'., ~n'r-
7 C
y
r
~~rL ~A
E
L
i
i C
3
E
E ;
Do Not Write in Space Below ,FOR COUNTY AND STATE DEPARTMEN USE QNLY
Date of Application Fee Paid: State ' ount ~f C" v e_
Permit Issued (date Issuing Agent Name
Inspection Yes No State Valid* Date Recd
1. county ( i copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 3
2. state (pin copy) 4. plumber (canary copy)