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HomeMy WebLinkAbout020-1221-20-000 s STC - 104 AS BUILT SANITARY SYSTEM REPORT r OWNER ADDRESS k3e Gv7 St/ /G SUBDIVISION / CSM# I LOT # SECTION / 7 T2-!? N-R Zcl W, Town of A~rX4 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r' sCa (e 30' e~ 14/I'ri•t7~ f/~~ f.r h 4,51 I INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ^ f ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 4. -e S Liquid Capacity:_-r, ~ l•S. Setback from: Well p House /6 Other Pump: Manufacturer Model# S'? Size Float seperation Gal ns/cycle: 2 ya Alarm Location SOIL ABSORPTION SYSTEM Width: / Z- Length ` z- Number of trenches Distance & Direction to nearest prop. line: Setback from: well House Other ELEVATIONS Building Sewer ~'f~ > ST Inlet. 9cr s~ ST outlet -I PC inlet 93. PC bottom ~'9 C Pump Off D.D Header/Manifold Bottom of system /00,z/ Existing Grade I& Y. 3 Final grade ~03 f DATE OF INSTALLATION: 4 ztrz PLUMBER ON JOB: LICENSE NUMBER: X4-1 INSPECTOR:- 3 / 9 3 j t : F Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM county-ST. Labor and Human Relations INSPECTION REPORT CROIX ` Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 218964 Permit H 'Aer' 6Q- RUCTION C] City Village IR Town of: State Plan ID No.: DEL 6 HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /Go- 62) /Ud, a a-s' ot A9400352 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic RCS (:~We Benchmark S9 Dosing Aeration Bldg. Sewer 9sl9S/ Holdin St/ Inlet 7 , So2~ ANK3ETBACK INFORMATION St/ Outlet 13.3,V" ~ -gib f Vent TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet Ar 13, ~W ~U, P/ / Septic Sp' 17 r- NA Dt Bottom Q, ('W/ Dosing ~Sd' NA Header /D/ 7 r Aeration NA Dist. Pipe ~,ss ( /d/, 0 Holding Bot. System T __2 V~ d, 3S PUMP '/SIPHON INFORMATION Final Grade S87 /o , 07~ Manufacturer Demand T e Model Number A4GPM Yl~ /CI-4 7S TDH Liftl t),O~ 1 Friction System TDH Ip,s ' Ft I Loss Head Forcemain Length Dia. o? Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length, / No. Of Trenches PIT Inside Dia. Liquid Depth DIMENSIONS ~ DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu SETBACK CHAMBER r~ INFORMATION Type O L (,3 b i I Mo Q um er: .~1 System: Cor,~;tJ OR UNIT qS DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing 1LIaAir Intake Length CJ Dia. Length Oca? i Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade ems Only Depth Over f? It Depth Over u r xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center w~/~ ! M Bed /Trench Edges Y)- 3W 1 Topsoil. ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.17~./29~.18W,SE,,NE,LOT 124,J NSON LANE/W RT ROAD Plan revision required? ❑ Yes 2-60- Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's ignature Cert. No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: i i SANITARY PERMIT APPLICATION C9tTjY V'~Lf1~1 In accord with ILHR 83.05, Wis. Adm. Code OF. STATE SANITARY ~ERM1# -Attach complete plans (to the county copy only) for the system, on paper not less than (~Oj t/[/~ 8% x 11 inches in size. ❑ Check if r&ision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE OW ER PROPERTY LOCATION f' S T,,~ , N, R ,P E (or PROPERTY OWNER'S MAILPJG ADDRESS LOT # BLOCK # 2 Q /.2 CITY STA E ZIP CODE PHONE NUMBER SUBDI ISION NAME OR CSM NUMBER Afk vi Pf--' s7'a 14 II. TYPE OF BUILDING: (Check one) CITY / NEAREST ROAD ❑ State Owned VILLAGE : t~G(fOH - ❑ Public [Z 1 or 2 Fam. Dwelling-# of bedrooms -3 PARCEL TAX NUMBER() Lw III. BUILDING USE: (If building type is public, check all that apply) ;2.4 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 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. V New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # :2.2 Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 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) ELEVATION ySIp 720 7 Z a 6 3 Oo. 41' Feet o. 8 Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Se tic Tank or Holding Tank Dd0 ©ma twe'e Lift Pump Tank/Si hon Chamber 4jew otva / l C S El L1 I L-1 1:1 Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew ge system shown on the attached plans. PI ber's Name (Print): Plumber's Signature: (No Stamps MP/MPRSW No.: Business Phone Number: 3G s~ Jt*f 31 f 7 1/ 19" vi v rr umber's Addre (Street, City, -State, Zi ode): 0 30 IX. CO NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater a e Issued Issuing A nt Sig ure (No tamps) Approved El Owner Given Initial Surcharge Fee) Adverse Determination ~~Q{` / ~d/ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(8.08/93) 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, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) DAVE FNEM PLUMBING Plumber Uosnsed03i~k233T #3289 E N . IN 940 ~ROt M ph no 7"14 r LBO i faA If I i l~ m ScaX~ i A a , ASS y„,~ /oa. o X - Ud- /off ~nrN .T 74 ti'W 93, s, T /did I I ~ 12X,/o ` l2~~Ni/N•u~ f~f ler~"r. /r.<<o~~ ✓~r!' 7" • - _ J O 1 i ` I i 'I M a +O Q~ r 3t 0 CL > i&w I~ ` SAVE FOGERTY PLUMMNG PAGE F Licemed kTe ~t*r r CHAMBER CROSS SEC T ICIIJ AMD SPECIFICATIONS ROSEW NNI IRoad 4023 Phone 749-3656 VC JT CAP `1~~C.Z. VE!~1T PIPE WEATHERPROOF APPROVED LOCKIAIG ' FRO.^1 DOOR, JUMCTIOIJ BOX MANHOLE COVER Z5 ±'s WIMDOW OR FRESH IZ"MIU. AIR IAITAKE GRADE I I ti" MIN. COIJDUIT 18"MIU. 11~ IM ET PROVIDE AIRTIGHT SEAL I * * A I ICI I III I I I ALARM B I II I I C *APPROVED I I OM JOINTS WITH I ELEV. FT. APPROVED PIPE 3' ONTO PUMP OFF D SOLID SOIL ` COKICKETE BLOCK RISER EXIT PERMITTED OIJLy IF TAUK MAUUFACTURER HAS SUCH APPROVAL SEPTIC E SPEC.IFI.CATIOUS DOSE TAWKS MAUUFACTURER: al/y_kl IJLMBER OF DOSES: \ 2 PER DAy TAMK SIZE: _Z' gog GALLOMS DOSE VOLUME( 5 ALARM MAMUFACTURER: L✓~ ~!~f~-~ INCLUDING 6ACKFLOW: 2 8-1 GALLONS P Y) MODEL IJUMBER: / /.wea I CAPACITIES: A= z S INCHES OR ! 5_0_ GALLOU5 ~I SWITCH TYPE: A14 ef B . INCHES OR GALLOIJS i PUMP MAMUFACTURFR: CIMCHES OR _12-Y GALLONS IIII MODEL MUMBER: #57-7 D-- INCHES OP. "R GALLONS SWITCH TYPE: _ MOTE: PUMP AMD ALARM ARE TO BE MIMI MUM DISCHARGE RATE ?10 GPM INSTALLED OM SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEM PUMP OFF AMD DISTRIBUTION PIPE.. FEET + Mlu'MUM KiETWORK SUPPLY PRESSURE . , , . . " , . FEET + FEET OF FORCE MAIN X l' 3 F/oortFRICTION FACTOR..- FEET TOTAL D9 JAMIC HEAD = FEET IMTERMAL. DIME.WSIONC OF TAUK: LE.IJGTH ;WIDTH ?Cl) ;LIQUID DEPTH S3 SIGUED: LICEMSE MUM E : ~ R ~ nATc Q W HEAP/ W U. W ~ 115 CAPACITY 2105 CURVE 30 700 95 28 90 26 85 EFFLUENT 24 80MODEL p 75 MODEL 189 PLUMBING and W ,65 DAVE FOGERTY DEWATER/NG ~ 7° Licensed Perk Tester & Plumber 20 s5 #3233 #3299 Fp~~~y Hei is Road a 0~_ NSI $4023 R091 t9 so KTS~ ~ _ p ss 16 ~hAne 7•3f1f3 Fa- 50 _ODEL O 163 MODEL F 14 45 188 12 40_ 35 10 MODEL 30 MODEL 137,139 - 185 SEWAGE and 6 25 DEWATERING 6 20- i MODEL MODEL 161 4 15 7 10 ! w 2 MODEL W W 5 53, 55, a 57,59 0 i GALLONS 10 20 30 40 50 60 70 80. 1 90 100 110 24 80 LITERS 0 80 160 240 320 400 75 22 FLOW PER MINUTE 70 20 - tg 60_ MODEL p 295 W 55 = 16 V 50 Q 14 45 MODEL Z 294 } p. 12 40- - J MODEL A 35 293 0 ,o ~ MODEL F- 30 284 i 8 j 25 - - - I( MODEL 6 20- 282 t 4 15 F 10 MODEL OL. ll Oi 2 5 267,268 0 3280 Old Millers Lane GALLONS 10 20 30 40 50 60 70 80 90 100 110 120 X130 140 150 160 170 180 190 P.O. Box 16347 ..I Louisville, Kentucky 40216 LITERS 0 8,0 160 240 320 400 480 560 640 720 (502) 778-2731 CFLOW PER MINUTE PLWIAB~NG DM I HARM 1 Lionged Pork Tester member 5~ i ROfIE I~~TS, yVIr Phase 749.3656 r I , I i ' I , i I i G I 4 i I wr"nrlow f,"11 I i I ND 6 i K = eorrr9 j I3 ~ j i c 'tak NLV ~ o r N ~t ✓S i I I X q X Ll `X +f°3 Sb ~ ~ _ ---ter-- ~ S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER'tf;'- I!, r✓ ~rY ADDRESS FIRE NUMBER- CITY/STATE ZIP S T O b PROPERTY LOCATION: A/ 1/4, SECTION, T_:±! -IN -R.. -.(-!a-w TOWN OF , St. Croix County, SUBDIVISION' 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 a licensed septic tank pumper. What you put into the system can affect the function of the septic.tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 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 septi has been maintained must be completed and returned to the St. Cr ix Co. Tani g officer within J~ 30 days of the three year expirati~ date r / SIGNED: DATE:- '22 17- St. Croix co. Zoning Office, 911 4th St. Hudson, WI 54016 •r GWIN & WERTHEIMER, S.C. HUGH H. GWIN The Groin Building 715-386-9510 ROBERT A. WERTHEIMER 430 SECOND STREET FAX: 715-386.6456 HUGH F. GWIN P.O. BOX 106 Of COUNSEL HUDSON. WISCONSIN 54016 May 10, 1994 Mr. Virgil Fedorinko HAND DELIVERED Delta Construction Co. 206 Second St. Hudson, WI 54016 Re: Lots 120 and 125, Parkview Estates Fifth Addition Dear Virgil: I previously had written you a letter on May 6, 1994 indicating that the Werts were giving you permission to build on dots 115 and 129. It appears that I had the wrong lot numbers in that letter. The lot numbers that you want to build. on, I have been in are lots 120 and 125. Accordingly, I am amending the lots listed in my letter of May 6, 1994 to read lots 120 and 125. I am copying all of the same parties on this letter to whom I had previously sent copies of the previous letter. If any of the people receiving this have any questions, please contact me. Very truly yours, GWIN & ERTHE I R S.C. Hug z Gwin HHG/en cc: Darrel and Beverly Wert Tom Nelson, Zoning Administrator Attorney Barry Lundeen Jim Henry, Edina Realty Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of y~ Labor ansi Human Relations Division ofSafety & 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 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 PROP RTY OWNER: PROPERTY LOCATION GOVT. LOT S~ 1/4 N5-- 1/4,S /7 T,,;~ ,N,RZa E (o4v PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUB NAME OR CSM # r ©G f - s CITY STATE ZIP CODE PHONE NUMBER ❑CI ❑VILLAGE ❑fOWN NEAREST ROAD c~fo+a w.L s' ~ /(o (r' ~l) //Glv S'en .sv, New Construction Use [ A Residential / Number of bedrooms 3 [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow 11-5-0 gpd Recommended design loading rate .gybed, gpd/ft2_trench, gpd/ft2 Absorption area required ?~o bed, ft2 5- 35- trench, ft2 Maximum design loading rate -7 bed, gpd/ft2 . trench, gpd/ft2 Recommended infiltration surface elevation(s) /ov, ft (as referred to sitg plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem OS ❑ U ❑ S O U 2 S ❑ U 0S ❑ U ❑ S m U ❑ S JZI U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouaxby Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 7 /o - 3 c 3 C S6 E' nA r Q S 2 O „G Ground 'z 7 -Zp e- c/ 3 6k -(r s 1 , s elev. Depth to _yv 16 - 3- S ®s , 7 limiting factor LI I Remarks: Boring # 4 /1 3 < e, 4 < +vt 7'r G V i Ground elev. 3 •k4 ft. /1/ I Depth to -3 _g - s - $ 6 r limiting factor Remarks: CST Name:-Please Print n Phone: cV 7 r Address: o /3d 2p T-~ 116 a Signature: Date: CST Number: -°y ~ a S Z?3 PROPERTY OWNER SOIL DESCRIPTION REPORT Page a of I PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/f1 ; in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends 3 %ik '57- C O O Ground elev. /aft. L yt o _ C / c a6/~ ~r cs ,S~" Depth to limiting factor 3 _ S- L S o Remarks: Boring # 3// A 4r 4 -V Z P%, Ground elev. Z //-3 lo - Depth to limiting 3 - s - - y S - factor c~ - • 8 Remarks: 3 5k Boring # . /d® &2 Z _ y C 3 c Ground elev. ion eft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) . S T C - loo 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), thenta 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 C-~ f~ C c~~/ST ~r ry n/ Location of property Allr- 1/4 )E,1/4, Section 11 , T N-R W Township OW i Mailing address AlAeti,W 5- m I Address of site S i Subdivision name I Z ~f Lot no. other homes on property? --k-/yes No Previous owner of property 1L Total size of parcel Date parcel was created t Are all corners and lot lines identifiable? V Yes No Is this property being developed for (spec house)? Yes V No Volume 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. 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. , 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. Signatu a of applicant Co-applicant Date of signature Date of Signature i SPEED MESSAGE ro . FROM ` C!ra x~ C e>ci S~n~J )ieVl PSP "h,~. .~S~v~ ~A~ZS, 4dOl~ ILA a SUBJECT L l C) H crjv, a DATE r V` In O 1~ d cl c1 (.t F~ EJ- l4 t CL 9 ,44A'~ - ~,4 ka-~- ( vc~ MQ- opy-f-pc-+ wt vv\~,,v- r\- k~ lie- -&,tpplD&eA 4c, 1Z0 Q4 e vu~- Y\uv-116-e-v-,- WD cA ~'e ~O C%(Cp ~f 1/~C~ , Vim. Q ksl !Q~~[ ~-C~ ~1n. C.~CC' c 11~ 6,t.~ lr` f 'Qo As 'DCxV` r l ,j v- CCJ~ - ~ov-c_ C~C~ - c~rre v ev e-ve r~J ~ivkc i Ulm ~t Inn, 1 1 ~ SIGNED WilSWId01188 • Cerbonless • MADE IN USA ORIGINAL 44-900 Duplicate Wisconsin 132partment of Industry, PRIVATE SEWAGE SYSTEM County: Laborand Hwman 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 Plan ID No.: DELTA CONSTRUCTION Q CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing 100 OF Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent i,ito ntake R D Dt Inlet TANKTO P/L WELL BLDG. A ir Septic NA Dt Botto Dosing N Heade an. Aeration A Dis ipe Holding t. System PUMP / SIPHON INFORMATION Final Grade Manufacturer DemM Model Number TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To W SOIL ABSORPTION SYSTEM BED/TRENCH Width Length o. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manu acturer: SETBACK INFORMATION TypeO CHAMBER model Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distributio ipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Len Dia. Spacing SOIL COVER x ressure Systems Only xx Mound Or At-Grade Systems Only Depth Over pth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center led /Trench Edges Topsoil ❑ Yes E] No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.17.29.20W, SE, NE, Lot 124, Jensen Lane 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: SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COSf STATE SANITA Y PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than QQ 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. PROP TY OWNER PROPERTY LOCATION t/4 S Tit , N, R p E (orkip iry A_t 7Z. AE 'ge PR PER WNER'S MAILING ADDR SS LOT # BLOCK # CI TATE ZIP CODE PHONE NUMBER SUBDIV ON NAME OR SOMyd0WITIER .-v !u/ 1 II. TYPE OF BUILDING: (Check one TM NEAREST ROAD ) State Owned VILLAGE : ❑ Public Z 1 or 2 Fam. Dwelling- # of bedrooms AL PAR ELTAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) ,I)LO ^ .2- 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 90 Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. V New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 0 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP: AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION S~ 7.W I VW 7W .43 .7 JET: ,P Feet d®i /Feet VII. TANK CAPACITY Site in alIons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank d El M i 1:1 Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se ,4ge system shown on the attached plans. PI ber's Name (Print): Plumber's Signature: (No UP/MPRSW No.: Business Phone Number: 0 Z.-If 15 . d, 9 36s~ Iu is Address (Str , Ci , state, Z' ode): W 01- 1X. COUNTY/DE R MENT USE ONLY p Disapproved Sani ary Permit Fee (Includes Groundwater ate Issued Is uing Agent Signat a (No Stamps Approved El Owner Given Initial Adverse Determination Surcharge Fee) 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"maintain+ed. 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, 603-266-3815. 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 arid/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 tURCHAROE 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, grpoq • water contamination investigations and establishment of standards. SBD-6398 (R.11188) nlet I I 1 -7 I ~ jz33 7K~ 3`s^~ " I X } i4 cu~ ~~-ivf a l f~ 1*3 i G/-~k k E- js ' s 4 = aSSa c /mv. v X 6a r ~ "N~r j Gw o 1 Ge~i rte- , Gc('vGrt i I Wisconsin tepartment of Industry, SOIL AND SITE EVALUATION REPORT Page _J_ of 2 Labor and `Oumaif 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 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 PROPCMTv OW R: / PROPERTY LOCATION GOVT. LOT 1/4 ~c1/4,S/7TH N,R.20 E(or652 PR ERTY OWNER-:S MBLING DDRESS LOT'#/ BLOCK # SU . NAME OR CSM # / CITY, STATE, ZIP CODE PHONE NUMBER CITY ❑VILLAGE OWN NEAREST ROAD [/J New -Construction Use [/J Residential PNumber of. bedrooms 3 [ J. Addition to-existing building ] Replacement [ ] Public or commercial describe Code derived daily flow 0' jely gpd Recommended design loading rate, 7 bed, gpd/0 ..Y trench, gpd/ft2 Absorption area required Y'o bed, ft2 Z& trench, ft2 Maximum design loading rate . ~ bed, gpd/ft2 . F trench, gpd/ft2 Recommended infiltration surface elevation(s) f ` ft (as referred to site plan benchmark) xv, Additional design / site considerations .lo ` of- or Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem mS ❑U ❑S mU 0S ❑U ❑S 0U ❑S OU ❑S OU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.Y Bed Trends Z 2 ~I . 7 G .2 /Yt f GIB M Ground elev. ft. 2 S !it c ~.J . 7 Depth to limiting factor 3 ~m 3 Sr rlc i • > 's ~ Remarks: Z cs fA 1104It Boring # 7 0 .t o A _Z Ground elev. Z o s ~n . p lg ft. Depth to _ limiting factor 4'k 10 Remarks: h CST Name:-Please Print Phone: , 36 7' s G 0- 467. 7410 Address: ~ r r w.~ 13 Signature: Date: CST Number: f ~ 3Z3 PROPERTYOWNERrl7`~/ SOIL DESCRIPTION REPORT jPagt.,- of 1. PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends Ground elev. Depth to limiting y factor 7 S 2 S c . 0 . o S m j k~ 7. l Remarks: 3 6 1. Boring # y O -.ZO a c l .2 t ~k wv tr C s . S Ground - elev. Z r f o /,O£.x ft. Depth to limiting p factor 7- Remarks: Boring # IN C C G ev awl- Ground elev. 2-- y,~~r 1T f t. ~o Depth to limiting 3 y s .8 factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) ` NSS ~2y N~Z33 #32~~ ~ E yy WIrg O23 36 / o Phone 7 ~l 9~f'y 1 SS I i J i i f 4/ P i i ' i 6/ ~ -max x ~ ~ Y aE i II SCQ ~ r~ = S0 d = sm, , 7-Op r,,& ,.r /OD.O 4eAAer t tSN Mr X = 6~r~'rys It v 1fL /x 740 *3x = fs • eoPNer T°'NNc( 3 X 7`'' he Y X = d v r'~ 41(f ASA. t I~ - ~ 3 x f.o ~c f X ° /8 ~ i ~ I~ ' z DAVE FOGERTY PLUMBING Licensed Perk Tester 6 Plumber #3233 63289 Fogerty Heights Road ROBERTS, WISCONSIN 54023 Phone 749-3656 i y'-I or f "Al rd,r I. 6( f 3~ I I 3' SANITARY PERMIT APPLICATION - cot~~ ~~I~n■i In accord with ILHR 83.05, Wis. Adm. Code STATE SANITA Y PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than i 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. PROP TY OWNER PROPERTY LOCATION j / 11 ( rd,rf'1• ' ,/4 '/4,S~ T.,-2 N,R1o E(ordV PROPER WNER'S MAILING ADDR SS LOT # BLOCK # _ o, CITY, STATE ZIP CODE PHONE NUMBER SUBDIV6%ON NAME OR-6 M-NUVISER II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD ( ❑ State Owned VILLAGE ❑ Public 0 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCELTAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply). 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 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. ❑ New 2. ❑-Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 © Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 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) ELEVATION -115P *W ~.?D 7 -;-r, d Feet CL 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 Septic Tank or Holdin Tank / / Fla t F1 El 171 1 D Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. PI ber's Name (Print): Plumber's Signature: (No Stain &4P/MPRSW No.: Business Phone Number/: lumb~ar's Address (Street, Ci , State, Ziode): IX. COUNTY/DE AR MENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) f r r Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber r t . . I o r I. , , , t a , > r - } . r r r , r t r , 4 , r 5 % 4 ♦ { Y'r a t.*~' 9 y l:{.,,?.{,.+r{}1x9•f ~1'~~'{4i'4 ~#'~t'1~4~4'~~I t'E~ ~~{~1Rlilt4 !'4f sf; a t s t, .t... s a s. c 5 t s 1.~!l t o 9i'lS'1'•1 ? S''1 45 i..}. ! 1 1t: 3 1 i} 1 1 t i - 6 t i t i 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, con Y g y tact 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. 111. Building use. If building type is Public, check all appropriate boxes that apply. Ih 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 b the • E) soil test data on a 115 form; an by ) and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (8.11/88) GWIN & WERTHEMR, S.C. HUGH H. GWIN The Gwin Building • y _i t '3 715-3W9510 Flut:715-90e-e4N ROBERT A. WERTHEIMER 430 SECOND STREET HUGH F. GWIN P.O. BOX 100 HUDSON. WISCONSIN 54016• OF COMM December 28, 19944 k Tom Nalsor.4-,.; ryy St. Croix County Zoning Administrator 1101 Carmichael Rd. Hudson, WI 54016 Rea Lot 124, Park View Estates Fifth Addition Dear Tom : Pursuant to my letters of May 6, 1994 and May 10, 1994 wherein I indicated I would inform the Zoning Office of the buyers of said lot so their names can be put on the septic permit, please be advised that the buyers of Lot 124, Park View Estates Fifth Addition are Mark Frederick and Judy McElroy. Very tr ly yours, GWIN W TH M , S.C. r ~ H gh Gwin HliG f en ~l~ ~