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HomeMy WebLinkAbout020-1036-30-110 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Hudran Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI BISHOP, JOHN X 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 Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift `riction System TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.18.29.19W, NE, NE, Lot 1, Trout Brook Road Plan revision required? ❑ Yes ❑ No Use other side for'additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION accord with ILHR 83.05, Wis. Adm. Code oo (J'SIn ER # TE SANIT AR 461 -Att ach complete plans (to the county copy only) for the system, on paper not less than -jc-{I, 8% X 11 inches in size. Chn to vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S' PR PERTY OWNER PROPERTY LOCATION Ito C- /a ~ /a, S ) 02" , N, R 19 or) W PROPERTY OWNER'S MAILING A DREn LOT # JB 1) e CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER- . Tv7 e IS 160 A4 11`1 Pt II. TYPE OF B 1LDING: (Check One) ❑ State Owned L O VI AGE : S G NEA TROD / ❑ Public ®1 or 2 Fam. Dwelling-#~ of bedrooms ! PARC LTAX NUMBER(S)} Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo CCC... V 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 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. 0 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ® Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 420 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 ''11 REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 1 ~v r¢ Fe 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 structed Septic Tank or Holding Tank V C S Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on th ttached plans. Plum er's Name (Print): Plu =Signature: (No S mps) MP Business Phone Number: / Aq q ~ G( , o~S lI SGP S P u ber's Address (Street, City, S te, Zip CZe ~ U 21 77 v~P IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanita Perm' Fee (Includes Groundwater ssue Issuing gent 1 harge Fee)[ate 0 Approved ❑ Owner Given initial V.,1`]yw' ~L.., 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 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. t' 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399),,to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations September 30, 1994 2226 Rose Street La Crosse WI 54603 WANG EXCAVATING THOMAS WANG W9672 770 AVE RIVER FALLS WI 54022 RE: PLAN S94-41018 FEE RECEIVED: 60.00 BISHOP, JOHN NE,NE,18,29,19E TOWN OF HUDSON COUNTY OF ST CROIX HOLDING TANK The Department has reviewed the above-referenced submittal.. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. i This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, rard Sw Plan Reviewer Section of Private Sewage (608) 785-9348 6380R/ 1 SBD-6423 (R. 01/91) 12 !~4r: le Sum Cab~~~ ~nlooa ~la;~ S94-41018 pv~ doh n lb qi ~ `3upmfeu- A ue S 3F15 a 1!2 3 1 rd e Troufi 8roo~ ola 5 Stem `fie be A nilbne d g, h1. Uent-Tod )a" Zrov% f i P~ ~01.7a l Y 701.7a tra Elev. al Ei's n .fir 7Lo 6e ropcsec3 fink to; 1; i1 0' a o H9 r0, ki~ . '•~~~~I ~a S l ~~D ~d 1'h 416? ~C ~ Ys L4. o A"J UK. a. aMo ~44 Ornaf;v( 116o kar, L-2-1,ao6 a S e pt, c S Poole 141 e S' a ri c S RECEIVED Q ~ SEP 16 1994 SAFETY b BLDGS. DIV. HOLDING TANK CROSS-SEC'T'ION ki 94 41o18 ? tipProved Weather Proof Vent Cap f Junction Box /Approved Locking Manhole Cover 4" C.I. With Warning Label Attached Vent Pipe Minimumo24q" A 00C 5xiSf, RW _,L71Mle }~laih Final Grade 0'?4„ , Minimum cttotte- S'ea1 taut !Approved Joint 18" Minimum Water Tight-O"Seal \ High Water ' 1 Alarm Switch SPECIFICATIONS - ^ _ - - r TANK New X Exi tang Approved Joint Manufacturer: e Pre w/ C.I. Pipe Blind C.I. Tank Size: 1,1~o6 Gallons Extending 30 Plug ALARM Manufacturer: : a xlerfi Onto.Solid Soi` Model Number Switch Type NUMBER OF BEDROOMS: GALLONS PER DAY: 0 a " 9 t . 6 of Bedding Under Tank' Owner's Name: .x 6 g 4, Address: /I ~o~ n ~~y3 iscr pt on: J N ~,~94, sh Municipal ty: County:r , s 9y- 9/0/ a, ~o 3 tan ~ab cu. • X PLUMBER DESIG 39 X b,~.yl6S = aYjS97 Signature: ~T ~xmh -4 C.ou err we; )1 S j 3j&30 Ibs License Num e Date: 5 0 ,A h etio W e.I J411)897, b T,4,K k -to b e S trkgyp.eA 4- Ac korej 00Gj l ~o P(evet4t Vetif i ~hkole ~o beetctei4ed V'a, t) Fx'st' F~.ood loJ; VL E It v. ~ 7 ,y~ o~Se,~ Man ke Ic ~oo er 1 riLHR SBD-6698 (P1b.89) APPLICATION FOR DEVELOPMENT OF'FLOOD PLAIN DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS When the installation of a new, replacement or expanded private sewage disposal system is proposed for a flood plain area, this form must be completed and submitted to the Dep rtment of Industry, Labor & Human Relations along with plans and other necessary data. r Jo / a~ 9 OWNER'S NAME f~? g} DATE ADDRESS O v te>r, r- -a n' ADDRESS OF BUILDING OR LOCATION OF PROPERTY a S ^lU ~ r y N L Y Sep 1~ 7~~ rSl f LEGAL DESCRIPTION A1,6 TOWNSHIP SO VI COUNTY [ r U 6 lIC Is this system new replacement expanded Is area: In regional floodway? yes no not determined In regional fringe flood area? yes no not determined Contiguous to•ground higher than any of the above? yes no What is the established regional flood elevation? Are flood plain maps published and available or determined by the Department of Natural Resources? Le5 Has or will permission be granted for the following: Fill required for building? yes no x Building permit? yes--X- no Sewage disposal system (sanitary permit)? yes no Action taken locally by zl hIvlq G Comments regarding development (zoning administrator, board of appeals, etc.): Favorable Unfavorable Special Recommendations: Sep f4, e '3 11 4 ~9~!/~ 1'7EC7*6-':D 9 SAFETY BLDGS- DIV- I Signatures: County Represents Department of Natural Resources _ 3~- 9~29~94 Department of Industry, Labor & R tion T 11 ' . ry."4 • v-'+.r: r, .e'u.i ~ A Y.- , ~ rv.w~ • 3 J. r.' i. C.~'3~..-.. "h..e..:.3' R2e.~ -_..F y. ( _V 04_W - - Oocirme t No. Triis ~ya.:~ rstiyrv~t tw rsucr,l3rsy ICI HOLDiNG TANK AGREEMEs: 'r A ro*mtnt Dal - G This agrearrient is made batvraan flte REGISTER'S OFFICE - - - - - - - CO., 1 Cot my or Local Govsmmantal Unit - Holding Tank(s) - Owner(s) S1_- CROIX . Recd for Retard .rL W A4unK;pa;i y below) at S E 3! 9 M We acknowledge that application is being made for the installation of (a) holding •M ~j~ tank(s) on the following property, (Provide legal land description:) Reglsfars~ft /V , 09 C's M ~orl A f Rshrrn To - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - f or wall continued use of the existing premises requires that a holding. tank be installed on the property for the purpose of proper containment of sewaya. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. IL 4R 83, Wis. Adm. Code, or Ch. 145• St tats. t~ As an inducement to the County of to issue a sanitary permit for the abnve described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 33, Wis. Adm. Code relating to holding tanks. It the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate P. nuisance as described in ss. 146.13 and 145.14, State- the municipality may enter upon the property and service the tank or cause to have tits tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by a. 66-60, Stats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or oiherwisa so, icing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. i li 3. The owner, except as provided by s. 146.20 (30) (d), Slats , agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service cwntract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch NR 113, Wis. Adm. Code who shalt submit to the municipality and to the county a report in accord with s. ILHR 8118 (4) (a) 2, Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under a. 146.21 (3) (d), Slats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said ce-ification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. i 'I 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreeme, to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) (Print) )Owner(s) Signature(s) Subscribe and sworn to b9fpr*,Me on this date: - S (A/ Municipal Official Name (Print) ( Municipal Official Signature -r- ' Nou~ r ( My commission exp;. e 90A!0V -1 Municipal Official Title Print 70 le rkir ( - SSO.6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. SANITARY PERMIT ro r x COUNTY TRANSFE NEWA UNIFO M PERMIT # (~)DILH ~3 (PLB 67-T) ~ PERMIT RENEWAL DATE: PERMIT TRANSFER DATE. ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I%LNUMBER: y- ~ 3 - r ~ h " 5 JJxx PROPERTY LOCATION: CITY: / VILLAGE: E (or W TOWN O~/ '/a,S R,T 0 ^ N,R ON LO NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE O LAND, AR r, ~ %S~d ~~d73~- - c ' PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: SIGNATURE: NAME: PHONE NUMBER: NAME: /fir ;1 - ADDRESS: PHONE NUMBER: ADDRESS: 6166m;,I ~Dn r►, ~~S/j~ I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUMBE S IGNATURE: ` PREVIOUS PLUMBER'S NAME (IF CHANGED): PLUMBER'S ADDRESS: PREVIOUS PLUMBER'S ADDRESS: M /MPRSW NUMBER: PHONE NUMBER: MP/MPRSW NUMBER PHONE NUMBER: ( ) SIGNAT E OF ISSUING ENT: DATE APPROVED: DISTRIBUTION: Original - County Copy - Bureau of Plumbing G( t J /~J of k~ Copy - Owner Copy -Plumber DILHR-SBD-6399 82) s FILED SEP 11 5 2 91989m. } V rJtul . - %:.f j, /J I CJ I>h~~r 1 A ES O'CONNEU / e9 ster of Deeds St. Croix Co., WI 45~.95S ~ CERTIFIED SURVEY MAP Located in the NE1 /4 of the NE1 /4 of Section 18, T29N, R 19W , Town of Hudson, St. Croix County, Wisconsin. Surveyed for: Robert Bauer 620 Kinnickinnic St. NE Corner Hudson, Wi. 54016 S ction 18 , 19W R - r~ T 2 N NOTE: Part of this / of is within the floodplain and as ~ptERS N 80'3 7g5M6 3`~ 1 surestrctions ~~O~~i 90 oo E•w 196 ` O apply A9ti22 • ~ ~ ~ ~ ~ EXISTING \~00 HO SE a DRIVEWAY \ z c W al o LOT 1 :.m N o \ :v r 3 111,205 Square Feet WI ivN (2.553 acres) ; c a~ •Q To meander line to d p z~ o POWERLINE_; • 'ate D I • ~O B S 89'0746"W 337.91' 6 6~ East line of South line of the NE 1 /4 - NE 1 the NE 1 /4 _UNPL_ATTED L.AN_DS_ 3 \ co in= \ ~ M M O z 1 Bearings referenced to the East line of the " El/4 Corner NEl/4, recorded as Section 18 S0')43' 18"E T29N, R 19W L E G E N D A Section Corner Monument, (ST. Croix Co. cap) i. . lop • 1" Iron pipe found 0 1 "x 24!' Iron pipe weighing 1.68 lbs . .EP 2 $ M19 per lin. foot set. CURVE DATA Radius - 259.65' SCALE IN FEET I"= 100' Central Angle - 12°23'52 O 100 200 300 Length - 56. 18' Chord - S38°57'05"E 56.07' Tangents - S45009101"E S32045'09"E VOLUME 8 PAGE 2158 This instrument drafted by: HGJ 489-1612 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: LtboranAumanRelationS INSPECTION REPORT St. Croix Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATIONNE, NE, Sec. 18, T29-Rl 9, Rustic Rd. 149231 Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.: John Bishop Hudson S91-40689 CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: K6A-1 0 020103630110 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet rl Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Mode Number: System: OR UNIT DISTRIBUTION SYSTEM Header/manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of T xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No F] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. w ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COON Eac: -MEMMMS T~N~RIP -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ check if revislon to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. ~g PROPERTY OWNER PROPERTY LOCATION S Y. S T , N, R E (or J h h b , L yj PROPERTY OWNER'S MAILIN ADDRESS LOT # BLOCK # 9X 0Ai, et vif CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBEfj, m© II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) El State Owned ❑ VILLAGE : 5 v ❑ Public IR 1 or 2 Fam. Dwelling-# of bedrooms J_ PAR EL X NUM R( ) . BUILDING USE: (If building type is public, check all that apply) 4f ~a 3 63 111 16 1 ❑ Apt/Condo 66 V 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 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. CS Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 19 Holding Tank 12 El Seepage Trench 22 El 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) Cj~ ELEVATION I~~~`~IIJI 4 6`®e 0 Feet /0 y d 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 cc~~ structed -7 -13-f Q 1 11 U Septic Tank or Holding Tank e~ dC% 'e-.I- Fri-as 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): Plu r' Signature: (No Symaps) MP/MPRSW No.: Business Phone Number: 3 ► Plu r ?,Address Stre t, City, State, Zi Code)- 0 1 p~ & A ~ f~ !y IX. COUNTY/DEPARTMENT USE ONLY 6 Permit Fee (Includes Groundwater a e ssue Issuing Agent Signeto mpsSurcharge Fee) ❑ Disappa=a Approved Owner A ve X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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 revisi.onsto 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 priot to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) • APPLICATION FOR SANITARY PERMIT 3TC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property 'Oul E1,4612 Location of property --l/4 1/4, Section ~ r T~N-R22--w Township Mailing address yJ LA-,;ay 1) Address of site I u --j LCD /L . Subdivision name Lot number Previous owner of property •~Q`cY t` 1 C~ Total sise of parcel J Date parcel was created Are all corners and lot lines identifiable? on No Is this property being developed for resale (spec house)? Yes No Volume and Page Number f~ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described In this information form, by virtue of a warranty deed o ed 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) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been 1 r rded in the Office 5eC~ <,A of the County,R gister of Deeds, as Document No. Si ature of Owner Signature of Co-Owner (If Applicable) Dat of S nature Date of Signature to SEPTIC TANK MAINTENANCE AGREEMENT rt St. Croix County OWNER/ BUYER ' dp 1~ Q o ROUTE/BOX NUMBER ' k Q - I.A ~Iy o e e Fire Number :3 CITY/STATE ttLjb1 q ZIPS r . PROPERTY LOCATION: k,gEk, Section •,,T N, R__ZLW9 Town of- & A 30 41 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 con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed 's'e'pt'ic tank umber. What you put into the system can affect t e function e septic tank as a treat- ment-stage in the waste disposal system. St. Croix Countyy residents may be eligible to recieve 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 County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or.a licensed pumper veri- Eying that (1) the on-site wastewater disposal system is in proper operating condition and .(2).after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I/WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with y the standards set forth, herein, as set by the Wisconsin Depart- : meat of Natural Resources, Certification form must be completed •d and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED & ~Ij_c DATE p c St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. k ST. CROI X COUNTY 7 y WI S C 0 N S I N Z O N I N G O F F I C E (715) 386-4680 ti= 911 Fourth Street 4== Hudson, WI 54016 0 W N E' R P U M P E R A G R E E M E N T PLEASE BE ADVISED, That un it you axe _W ~,qa J ied, I Witt contxact wit / o c , P~Acll Wisconsin, (Pumpex), box the puxpoze o6 temov,i.ng att-wa to 6xom the .san.itaxy system to be .Located on the pxopexty and 6utuxe home site .Located in St. Cto ix County, Wisconsin, Township o6 being in the 4 ab the 4 a6 Sec. T. N.-R. W. (On mane bu.L.Ly dactibed as 6o.L.Lowd: ) Dated this day a6 C~ 19 ' State o4 Wisconsin) ~ AND County a6 St. Ctoix) •,~PtIW~,~'•••_ Petzonna.LLyappeaxed be6oxe me this t(} day ob the above named f,~~,,_,, VY1 to me known xa_be l le petzon who executed e 6oxegoing tfiztxument and acknowledged the same. ataxy Pu tc, t. Cxatix County, ~-7 My Comm. (.ins penmant) (Exp.ineb) ,I r1, ~4 CA hexeinbe6ane xe6enned to as Pumpex, ocn in e above agxeem t to the extent that I have a contract with Owner as above stated. (.PUMPER ) 4 . PAGE Document No. This space reserved for recording data 473799 HOLDING TANK AGREEMENT Agreement Data REGISTERS OFFICE This agreement is made between the ~~,„A, County or Local Governmental Unit Holding Tank(s) ON~ner(aj ST. CROIX ~~►►~~nn ` 441,` l Rec'd for Record . 1991 (Called Municipality below) I at ~O 30 M We acknowledge that application is being made for the installation of (a) holding /g tank(s) on the following property, (Provide legal land description:) ftegt:t~rt># ee jam' `mow 1~__ __.dc3 a~ 1 Return To or that continued use of the existing premises requires that a holding-tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. As an Inducement to the County of l~6 l to issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in as. 146.13 and 146.14, State. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Slats. 2. Owner agrees to pay all charges and costs incurred by the municipality for Inspection, pumping, hauling or otherwise servicing and maintaining the holding tank In such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall ue collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), State., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a ropy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the cervice c ntract. 4. The owner agrees to contract with a person licensed under Ch NR 113, Wis. Adm. Code who shall submit to the municipality t.nd to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Coe for the servicing on a semiannual basis. In the case of registration under a. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local govern ental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil ab orption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition,, this agreement may be cancelled by executing and recording sal certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of he owner and assignees of the owner. The owner shall sug 'Agreement to the register of deeds and the agreement shall be recorded by t e register of deeds in a manner which will permit the existettagreement to be determined by reference to the property where the holdl g tank is installed. k Owner(s) Name(s) (Print) I Owner(s) Signature(s) ~tJ i _ _ _ Subscrlb and sworn to, #prf~ I' Municipal Official Name (Print) I Municipal Official Signature e.~.. Py • I My commi lon expl, ' !T?1 p r1 t a`1$ie-ri A)e ; uo l/ I ~1 Municipal Official Title (Print) ••••:'...••'••'4~.•, SSO-8123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations. Bureau of Of6mtifng. T ~ . _ ~ . it r J'.~1_ o , o AW- --014 t ot, i # n .10 r v s P1 I , r a t. i74 e le'n., l .r ` y ! I f ~ ~p t Y t HOLDING TANK CROSS-SECTION C r ~deK " Approved Weather Proof Vent Cap Junction Box - Fni9(ntd E~~~~s Approved Locking Manhole Cover 4" c. I. With Warning Label Attached 707, 0 Vent Pipe f/ d 1°la;n Fkv, /Final Grade i !Approved Joint _ w . 18" Minimum Water Tight-•'" Seal High Water ' Alarm Switch SPECIFICATIONS I TANK New _,X Exi #ting Approved Joint Manufacturer: 1a'e w/ C.I Pipe Tank Size: Q~ Blind C.I. Gallons Extending 30 Onto Solid Soi Plug ALARM Manufacturer: -Q „ f Model Number: Switch Type G NUMBER OF BEDROOMS: GALLONS PER DAY: _~D , 3" of Bedding Under Tank Owner's Name: TbL Address: L iscr pt on: "Ala ' nshi Munici al ty: SOP? • tt Coun P'Q 4X LOW, • ~~~r~ SEP 1 03 199w`. LosK PLUMBER/DESIGNER pL~GE ~ E ,Cp ES Signature: 4Lilt License Num e : Date: 810 ~ 17 V 'tc) e SararfeA I- xt~orel Doan. to Prev enf fio1a*il T& 4(l01/11 tai cos ' =0 Volt ~ /VQhhole to be Mood plan 4 -le, J ©r Seat oLover 70-7 , 0 Plb. 69 Carl I.aR Afa-~ 7/~! ~e • APPLICATION FOR DEVELOPMENT OF FLOOD PLAIN r DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS When the installation of a new, replacement or expanded private sewage disposal system is proposed for a flood plain area, this form must be completed and submitted to the Dep rttment of Industry, Labor & Human Relations along with plans and other necessary ala. P OWNER'S NAME _ 611 /Y R o (n DATE ~ J ADDRESS V 'T& e J ' h! / '7 i 5. E ADDRESS OF BUILDING OR LOCATION OF PROPERTY /44-t.5 n n) QJ/'S G~ LEGAL DESCRIPTION 6 Z i~ d0i"oN J TOWNSHIP ~p COUNTY St(_ V D t k Is this system new replacement_ expanded Is area: In regional floodway? yes no _ X not determined In regional ftinge flood area? yes no not determined Contiguous to ground higher than any of the above? yes no What is the established regional flood elevation? -70S Are flood plain maps published and available or determined by the Department of Natural Resources? y Q~h Has or will permission be granted for the following: Fill required for building? yes no \ Building permit? yes no Sewage disposal system (sanitary permit)? yes no Action taken locally by _ Comments regarding development (zoning administrator, board of appeals, etc.): Favorable X Unfavorable lr• Special Recommendations : S~'ILavC LOO Signatures: County Representativ Department of Natural Resources S~~ 1 Department of Industry, Labor & HUIT41.11 • 9 FILED 5 SEP2 91989►- JAMES O'CONNELL Aegisfer of Deeds ~ St 45195 Croix C~0•, WI N CERTIFIED SURVEY MAP Located in the NE I /4 of the NE1 /4 of Section 18, T29N, R 19W, Town of Hudson, St. Croix Cobnty, Wisconsin. Surveyed for: Robert Bauer 620 Kinnickinnic St. NE Corner Hudson, W i . 54016 S~ction 18 N T29N, R 19W ` NOTE: Part of this of is within the floodplain and as W R N e0•32' E 3,' • such, special o a00 E,o i96.79t~i \~j• restrictions P OWE \ N69 A2' G apply -75 2~ i~oc~a ~lon \ PreSe~. ti~o~ 6feu~~a~~5 ~ a9~22• ~ oe ►~cv.o~e ~ •s'. ~ EXISTING O HO SE O -0--R IVEWAY a W al C o LOT 1 m JI \ N In o \ 111,205 Square Feet w~ N (2. 53 acres) ..o F-I \ •,p Q \ 'o To me nder line a D POWERLINE_ ?i Z 6.. S 9'07'46"W 337.91' \ 6 6~ w' East line of South line o the NE 1 /4 - NE 1 /4 the NE 1 /4 UNPLATTED LANDS 3 ` 1 ao " Z Bearings referenced to the East line of the El/4 Corner _';NE1/4, recorded as Section 18 SO`43' 18"E T29N, R 19W L E G E N D