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HomeMy WebLinkAbout020-1036-30-120 N ~ O O° N O N O 603. Oi N CD o op 0. O O O CD L(D I N C o E O aL O~ O•y m c 0 M Z O L U co QO O O O(n C ay O m= U N 0 a= t., p»cOn 7 y N 3 00 CD OD a) 0 (D 04 CD . 8 m o - m0 - L o~ -0 o oL vw 3 c a ~ C a~ a~m3 _ o0) CD me a~L fn o.ca) w O E 0 y y y X c (D (DE E ayio ° 3 E (D 0 0 L) (D ooh 0 o m a a Lc o` -0"0 ~o o as y ODC(D (D m m o C- c o ~.0 o E~ Z C C'. `o 0 0.5 E z tm z x o YQppp -ov) C) En 0)2 LL C ~'O ~.a) R LL C O mN LL C mO V` a o c ao O D U a) N O O O N co m N N y- C O - 0 0 - y O a 0 O yet c 3 0 O 3 ~ aa w 0_M_v c S '0m m y r 'O a) y a) 3a)~ Cw I Q C C a O X O O H - L E y Q E Q m off N m N m 3 ° a v a~ aD d rn w z E E E Z d m a0 N W d co a m a co F- z co O O Z ! c v c v w w d z v o o CD o tAH~ E a E c E M Cl) 'D GO) CD O y (D c (D CL CL N a' N LD a) 0)1 0 U c 2 co m Q z co z m z z z° m z N z Z co 0 E c aci aci E c N A E N (D m E a~i tO m E N Co Nt A R a o y R y m a u2 C co O) d a) O y d y d N N O° ° O G a Q E. m D o a E v 1 3 O O a o f N Z M> y r Nr Nr N a >I o o r m N N _7 a o m N > o N c O O O m z 1 3 3 3 a _ 16 3 it m Z o •~N1 X aaa. y I=aaa =aaa m p p 0 U) J U Y T rn O O O y Y O O) y Z O } O } N M0 a) m O) m 0 0 a) 0 0 CD 0 E c y o o = E o > > 0 9 0 5 m y c a m y c m y c a a 0) a~ •0 0) V 0) m `ice • p d Q Yin io w ti o_ Q u~ 1 Nm v _d Q ~n m Q !I °iS to y °a y y y w ~ CO y = y C N ((Q°~pJ 0 0 y O O C C -06 0 0 CD C C E CY) 0 :3 O M In 0 y C V d co" N C a G. y a C. C a O r V (o ~ c a°i M 0 E E 0 y E E c CD I O O fM0 y ~ r O A L L O L L d O d N v o~ «m 0 Z c c r m r~~ Cl) .yd. _ • N co 0 0 o (n m o m m o m E E m o w E E o O O r_ N O Z Z Pi fn m 0 Z '7 m 0 Z W ~7 m etl I I I C ~ U E€ E d E 44) L L: L: L: CL a a IL IL IL • a m m rrww a, ~1 A 0 at 0 U)o 0 NV iv STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER IbIU Ws) ( KO-\i ADDRESS I KOIi {jKtJC~ C>Y~ SUBDIVISION / CSM# LOT # SECTION__L6__T_a_? N-R,d_W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM N0' 1111 ow 1INQ Bet) Vi00 9° 1 PL, p Cl~. 4 Vol \ a & Ppw m CA6; N V N A T INDI E NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. . n BENCHMARK: I Pe ?T Lev ~ 10 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ee~S Liquid Capacity: soo qo~ Setback from: WellK)ol 1 N House Other ~Pump: Manufacturer Zodler, Model#Size Float seperation Gallons/cycle: D5- f a Alarm Location H oUS e Q SOIL ABSORPTION SYSTEM Width: Length _Number of trenches Distance & Direction to nearest prop. line: Setback from: well:NOT I N House VU' Other ELEVATIONS }~eAae e CoUeR 160 S8 _100,88 Building Sewer ST Inlet; 17.3(o ST outlet ~.O 9$•7$ PC inlet 97.0 o~ PC bottom 13. 3(10 Pump Off w 5c) 50 I 0(j:-Z5- )0o-jSHeader/Manifold Bottom of system 9.83 Existing Grade 101, ~6 Final grade 103.0b DATE OF INSTALLATION: 5)3)79 PLUMBER ON JOB: 6~.~/1~.A1k LICENSE NUMBER: ~voq INSPECTOR: 3/93:jt I sAs , art ,4 4&%t • 29.19W, PRIVATE SEWAGE SAffl t Brook oG- I un y: Labor and Hutnan Relations INSPECTION REPORT Safet,Y and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) sanitary ermitNo.: Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9400086 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO 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 Friction Syestem TDH Ft Forcemain Length Dia. M 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 INFORMATION Type O CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.18.29.19W, NE, NE, Lot 3, Trout Brook Road Plan revision required? ❑ Yes ❑ No I _T71 I 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 COUNTY =:71011L~HRO .3f C SSLkNITARY POT-9 :i-IT # -Attach complete plans (to the county copy only) for the system, on paper not less than IO 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. PROPER OWNER PROPERTY LOCATION N Wt I K -f° N X N S T-~ , N, R E (or) PROP RTY OWNER'S M ILING ADD-RM LOT # 3 BLOCK # NA 2 14 r CITY, TATE ZIP CODE PHONE BER SUBDIVISION NAME OR CSM NUMBER kt0SbN ►1'r- Sys 0 j II. TYPE OF BUILDING: (Check one CITY NE EST CAD( p ❑ State Owned ❑ VILLAGE: F U D v IJ 0 L 8 Qb D r OA D ❑ Public eK 1 or 2 Fam. Dwelling- # of bedrooms PRA R EL NUM ( 111. BUILDING USE: (If building type is public, check all that apply) OaO /o 0' a0 1 ❑ Apt/Condo 1 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 50 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. Lam, New 2.E] Replacement 3.E1 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 Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 130 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.) (G ay/sq. ft.) (Min./inch) ELEVATION 163 3 0(~) (000 . 11 . S 4. Feet l a J~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 Holdin Tank Q 1 Lift Pump Tank/Si hon Chamber, 8 0 a We t rv El El El I El El 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) MP/MPRSW No.: Business Phone Number: ~N dour, 3YOY r.~ 3806)0 Plumber's Address (Street, City, State, Zip Code). 16-16 W4 S vbsaN W,Yc 5 ~a1 ~ IX. COUNTY/D ARTMENT USE ONLY ❑ Disapproved SanitaryPer d Fee (Includes Groundwater Date Issued Issuing Agent Signature (NO Stamps) Approved ❑ Owner Given Initial T f x surcharge Fee) Adverse Det rmination / U J X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 14/KaL CeJ-(_~ k V'4-1 - SBD-6398 (formerly Plb-67) (R. 11/88) 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. 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. u 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; close 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) PLO AC o N ~o v -N..A M J I r'^ T mgt M N 10 now R o a'pp I C E N S E- o_ 3y() y I PLO I' M A h 4 b/TeTGNn~~ Arty g3~ O _ 3y o o~ ~ I W~SA~~en. P4 n,J~ L~P7.-~1;. • _ a~, ql j a°~ OU c ~Vf,h M ~ 01 PN ~oS a l.. SY~c) . P-k ~4V i0o.0 I 1 S4 p~ , PIMP K-- SyS~e m . w. i 2 S0~ 'PRur•. St~~l~ Sy r I . i FRESH All: lPdL[:'1S_AND OBSERVATION PIR1; C1,0sS -SECTION _ - 1 Approved Vent Cap Minimum 12" Abovc Ei na1 ,ra I 4" Cast Iron Above Pipe Vent Pipe To Final Grade- Marsh Ilay Or Synthetic Covcr Min. 2" Aggr.ccJ'Iol over Pipe - Tee DistribuL•ion _I Pipe Aggregate Pc.rfora I:ed Pipe felon, Q i)encath Pipe --Coup).i.ng Ter.minat:i.nq T ~,a3 ~~f~~. - L+._ Bottom. of System. • 1 L - ,l PRIVATE SEWAGE SYSTEMS - II PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP Y.C.I. VE4JT PIPE - WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER ZS' FROM OooR, IYMIU. WiNCOW OR FRESH AIR INTAKE I GRADE I y"MIM. r I IB"MIU. COAIDUIT IB"MIN. \ ~h PROVIDE I INLE T AIRTIGHT SEAL I III I I ~ I APPROVED .:OIAITS ~ APPROVED JOINT/ A I I I i W/C.I. PIPE w/C.'I. PIPE I II ALARM EXTENDING 3' EXTENDING 3' I II ONTO SOLID SOIL ONTO SOLID SOIL B I I ON C ELEV. FT. PUMP-~ OFF r 0 CONCRETE BLOCK - RISER EXIT PERM11TED GNL'J IF TAUK MANUFACTURER HAS SUCH APPROVAL SEPTIC SPEC.IFICATIOPIS E DOSE ~t r~S TANKS MANUFACTURER: NUMBER OF DOSES: _PER DAy TANK :•!ZE: 8~o GALLONS DOSE VOLUME I Ia- 1) GALLONS ALARM MANUFACTURER' INCLUDING SACKFLOW: MODEL NUMBER' IV CAPACITIES: A= INCHES OR S7~1' GALLONS SWITCH TYPE' Na B= INCHES OR ~J GALLOUS PUMP MANUFACTURER: C = 'NCHES 7R ='+A_I.OMS MODEL NUMBER: 0=_INCHES CR GALLONS SWITCH TYPE: MOTE: PUMP AND ALARM ARE TO BE INSTALLED ON SEPARATE CIRCUITS MINIMUM DISCHARGE RATE -48 GPIA (1 VERTICAL DIFFEREAICE 5ETWEEAI PUMP OFF ANO DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY PRE7SQQSURE . . . . . . . . . . 2.5 FEET + FEET OF FORCE MAIN X Ja F ooFLFRICTIOU FACTOR.. FEET TOTAL DYNAMIC HEAD = ? FEET I II y',. MITERUAL DIMENSIONS OF TAUK: LENGTH g~ ;WIDTH .11.-;LIQUID OEPTH 'E I`J ~ 7 l,,l 1"•_ 34 U`r OAT E. 51GK;E0: Qni=RzL LICENSE UUMB=R. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of Labor_aM Human Relations :Division of Sfifety & 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 S71 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 UOAJ OWNER~O rr PROPERTYLOCjION .Ir ~•t. GOVT. LOT ~ 114 NG~ 1/4,S T Z`~I N,R PROPE,IRTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # (1 ) CITY, ST TE ZIP CODE PHONE NUMBER []CITY VI GE MOWN NEAREST ROAD rrxb4 [ ] New Construction Use Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 3,0 y gpd Recommended design loading rate bed, gpd/ft2 , trench, gpd/ft2 Absorption area required bed, ft2 SDw trench, ft2 Maximum design loading rate bed, gpd/ft2 , ` trench, gpd/ft2 Recommended infiltration surface elevation(s) _j ft eferred to site plan benchmark) Additional design / site co siderations r~,iz~ S Parent material m 141 ve, /-3 4-7 ar ° Cow, Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL §UND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem S ❑ U ® S ❑ U MS ❑ U as ❑ U ❑ S oil ❑ S MU 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. Bed Trench hW61 .7 Ground Zn-y1 / y s d~,r~/ G to elev . AWY ft. Depth to limiting factor Remarks: Boring # ! S 4Y Ground I o02 P' &C ft. Depth to limiting f~y y 6 ~N R Remarks: ' 3 S Y; C~►io,•+i d~ : Zu•-. CST Name:-Please Print ` Phone: 3 Address: /O~a ~ ~ ~ ~G►'s©a~i fi✓ , .SyO~,~ Dat CST Number: Signature: Ilk (2tz 4_9 PROPERTY OWNER SOIL DESCRIPTION REPORT Page a ofT PARCEL I.D. # Boring # Horizon Depth MuDominantnsell Color Qu. SzMottles Cont. Color Texture Structure Consistence Boundary Roots GPD/ft . Gr. Sz. Sh. Bed Trends IY .1 Ile. G round y y n Sb~k., r,J S elev Depth to limiting ff ct~s..,. Remarks: Boring # O- y !7' Z L 1u- S ~Sb~iw y r,~ S Ile S yJ, we ~S yvl✓~ G - S H / elev. y~ G ~5 d,~d'^ ✓ _ S /bd Zft. Depth to limiting `fa Remarks: Boring # , s a- o e 7-s de r , 3 z/- 4S Ground elev. ~ t. Depth to limiting fa r,, ot le Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Per c0,-~,~ Cc/ A,l o = ~~c P.fS;~rs ti z- s o S~ ` g~ gti ~ ~ D o ~ v` Ole 3y ~r pop Zs Ceti... 0 1 1 1 t V' Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of Labor and H man Relations Division o"tSaety 8 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 P PERTY OWNER IJ PROPERTY LOCATION 0A) Notrj h~ GOVT. LOTNJ~ 114Nr 1/4,S6T Z~ N,R /9 PROPERTY OWNERS MAILING ADDRESS LOT # B K # SUBD. N1 R CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY I GE t9rOWN NEAREST ROAD [ ] New Construction Use Residential / Number of bedrooms Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow 3,0 c, gpd Recommended design loading rate S bed, gpd/ft2 , trench, gpd/ft2 Absorption area required d!6>O bed, ft2 SDU trench, ft2 Maximum design loading rate _S bed, gpdm2 C trench, gpd/ft2 Recommended infiltration surface elevation(s) 3 ft - feferred to site plan benchmark) Additional design / site co siderations fb + v '64k, le, e, S ye. 1-5 S"7 ar Cow. Flood plain elevation, if applicable L ft Parent material m l N S = Suitable for system CONVENTIONAL UND I I~~IGROUND PRESSURE AT-GRADE T SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem S❑ U S❑ U e9 S❑ U as ❑ U Os 2 U ❑ S ~qU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends Ground 3 /Z- `/I C ~ S ~~w, la^✓ t~/ C bJ elev ft. Depth to limiting facto Remarks: Boring # 0-6 P L S /56~~. h~✓ G S C Z Z G ZL 3j S s6~~ y~~ ~w r S 72 j41 j/ 3 ~Oy Ground elev. s"/,~' yi ! ~S SM y~ ✓ ?Y r L jQ ft. Depth to limiting facto[. , r[ ,,t►! / , gill c Remarks: 3 C S idl 4 C4raws . Gj h~. it 5 CST Name:-Please Print Phone: L'/? 3 1 ress: /070 ~l~ S`t/V !~G/~~ li✓ ~ . ss~0~,~ J Signature: Dew CST Number: ~O 109 1W7 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. ff < , , ,Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer Y/f R I. Ground 3 y yY 5~~~ +rIG' r , J S G elev. i Depth to limiting j factor Remarks: Boring # / 2X ~.~'M1 Cw 1v~ cw - s , Ground elev. Depth to limiting \ fa Remarks: Boring # 10)~e 31? Ground ` 3 ZI' y ~S IS r- - S L e1e/~1.L1rt• Depth to limiting fac Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) A P.~ l"-!cultih~~% Cc o =c /tog p.f s;ks Z S S9' Py) ' ,gZ 2 S y h9 ~s s W STC-105 SEPTIC TANK MAINTENANCE AGREEMENT A• St. Croix County OWNER/BUYER 1q&).kL_b ~ ~OC.L<O MAILING ADDRESS `I l0 ~i~,,,ti~,E,Q- • - P / PROPERTY ADDRESS R IlOtc V1 , (location of septic system) Please obtain from the Planning Dept. CITY/STATE A-'W6 to toy NOGb PROPERTY LOCATION N-~; 1/4, A JC 1/4, Section T Lq N-R / W TOWN OF ST. CROIX COUNTY, `VI SUBDIVISION LOT NUMBER _ CERTIFIED SURVEY MAP~ ,VOLUME Y-,PAGE Q, 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 "Coning Officer within 30 days of the three y r expiation d t . Wk, SIGNED: DATE: 0 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed b 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 ox-) 4-'A Location of property /1/4 AjV 1/4, Section t~ T L~N-R W Township Mailing address ~p Address of site felt subdivision name Lot no. Other homes on property? es Previous owner of property Total size of parcel L.47 Date parcel was created 11--/1,0/ Are all corners and lot lines identifiable? Yes _--------No Is this property being developed for (spec house)? Yes &No Volume and Page Number_ of Deeds. J as recorded with the Register INCLUDE WITH THIS APPLICATION THE FOLLOWING: _ A WARRANTY DEED which includes a DOCUMENT NUMBER & THE SEAL OF THE N~~~ VOLUME AND PAGE certified THE, REGISTER OF DEEDS. In addition, a 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) the property described in this information form, by virtue( sof of warranty deed recorded in the office of the Count Deeds as Document No. Y Re i own the - q l ~ ~ 5 3 , and that I (we) g ster of proposed site for the sewage disposal systemorr Ie(we) obtained an easement, to run the above described Doc for the construction of said system, and the same has been duly recorded in the office of County Register of deeds property, No'------- S~ as Document Signature of applicant Co-appl cant Date of Signature _ Dat oe f Signature"" DOCUMENT NO. i WARRANTY DEED THIS srwcs Ruenveo FOR ReeoteotNa owrw • V a• 479153 :!STATE QAR OF WISCONSIN FORM 2 -1982' II 11 I i 034wE 51's REGISTER" UffICE l Ruby.•L-.---Bauer••and••Jane--C.-•--Roryi-ck-,---tenants-------• • CRO x cc) in common-,---Grantors,--•- Recd for Record 1 i9 FEB 1 N 92 Q conveys and warrants to f_and ._.Patrx.gia... 4:05 P. rA S... Wblkof.f... husbanr3__and_..wife_..as._.s.urviv.orshi_p.__...._ ate, 0 Mari-ta.l--Pxoper.t-y,_..Grant.ees-,....................... Pegister of Deeds I i . the following described real estate in ...__..St. CroiX County, State of Wisconsin: I Tax Parcel No:.............................. A parcel of land located in the NE4 of the NE4 of Section 18, T29N, R19W, Town of Hudson, described as Lot 3 of Certified Survey Map dated November 25, 1991, recorded December 20, 1991 in Volume 9, Page 2431, j Document Number 477031, in the office of the Register of Deeds for St. Croix County, Wisconsin. Together with a non-exclusive 66 foot wide easement for ingress and II egress, from Trout Brook Road, across Lot 2, and to the northeasterly li line of Lot 3, as located and described by said Certified Survey Map. i I, I: S COJ~ I: I' FEE i I This is...not...... homestead property. (is) (is not) i Exception to warranties: Easements, covenants, and restrictions of record, if any. Dated this day of December _ 19.97 i Y I .....(SEAL) ' (SEAL) . . • ..Bauer. - --.......-(SEAL) 1 (SEAL) .t - Jane C. Rorvick AUTHENTICATION ACKNOWLEDGMENT Rub L. Signature(s) Bauer dnd STATE OF WISCONSIN x Jane C. Rorvick ss, ------.County. authenticated this day of December 19 -91 Personal) came before me this ____-____-___--day of - 19 the above named ' .Th_oma_a._A..._.Qahle.............................. ITLE: MEMBER STATE BAR OF WISCONSIN - (If not, authorized by § 706.06. Wis. slats.) - - . to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY - . Thoma_s._A_._.Dahla...... Hudson, WI Notary Public . County. Nis. (Signatures may be authenticated or acknowledged. Both My Comnns,lon is permanent. (If not, state expiration are not necessary.) date: 19 ) •Namn of oer n signing in any capacity sh,,uld be tyl-I or printr.l b,,I,.w tnrir FiRnau-- STATF BAR of WISCONSIN H.L Rlaaf E FORM No. 2 - - I Stock No. 13002 `~~e oG3 G yti` ~45~ ~b ~r.~~ oh ~5 ~ 5 ~ o III l~ ~3 ~z3 szs ~ ~ y 36 'o 0 o ~ ; °o I 3 0 M C c ao a 0 y I Y 7 I m r4 2p aEc O G N V 4.~ Ol N 3 y 0 0 Co - C-4 CD r- LO >1 +d.. .C 'O pL N~ 0 0) C .C ° C r m ~ Y .y I Y~ .x a I a 4) Ea-° i O) VyJ L a m C_ O U - a) '0 C CL a) CL N U O m E -OD Lc aa) o a c Z rn cmi z x E O U. C o lp N O m u7 tm ` OO _ O O CCO V' CO mo 0) CIO (n 00 m E Q H umicE E Q m off N m aQi I a I ~ N 0) W r E E Z o 0 it .9 v 2 z r z a m a m c t9 I ~ I O Z -V v V~ r i N O d zq c 2 y O N H r! y ° y Z E E Cl) J~ 7 N N 7 cc (D D C C L a t O I C ~~pp o O O O Q Q O N Q w Q = Z Z Z co z _ 6 N Z ° aci c ° m E N _ y a y c cc ° G C a a L y d ami o° r r o rG rG ra No N~ Zr>> IIV33 n v333 n m ov X000 X000 Z° •N =aaa =aaa y IL a o l o aN of CY, N N N J V Y W O) O Y 0 0 a) r } O r $m~ EjZ 8 m - 0 m O o w 0 r O O r 'O 7 O O 4 E ~ m y O N m N ayi m N GO 'a d Q U) co Q (n m m U, 0 y V! ,an,ti,, O N O O j O C C y C 0 C C E M r a a s a m a a a m o CO) of ~ c E E u) E E m a~i co l Cl.y O C lO L L LO O O a) ICI d N 'O 0 CD (D O N 0) w O~~° r:5 C N • , N co D! m O y E E m o y E E v O o r 2 m r o Z 9 m r o Z N In r\ i# Y E E E m IL • o m v y a d a E d o d o r 1 0U)0 _w 1 A loo a t 1:8;50 4 c~C/fc~ 2iY C cv FILED DEC 2 01991 NNELL JAMES 0 CO Register of Deeds.c t 477031 St.cmtx Co.,wi?-~'~ C ERT I EF- I EO S UR V E Y MCI R Located in t the / of the NE1 /4 of Section 18, T29N, R 19W, Town \ of Hudson, St. Croix County, Wisconsin. 1 \ EA CIE I IIZGJEL ~LLB_ L•7NPLATTED LANDS NE COR. N 89007'46"E 1302.08' SEC. 18 ( N 89° 04' 50 "E ) W 41 Bearings referenced to CD ;i LINE TABLE the East line of the NE1/4 m NI of Section 18, assumed ZI LINE BEARING DISTANCE S00*43'18"E 0 *0 Q1 1 S 35'49'46"W 41.13 Q O J~ 2 S 01'31'00"E 57,05 3 S 72'50'37"E 169.46 (D 4 N 72'50'37"W 181.66 N 5 S 04'44'10"W 51.57 D~ DEC, w ST. CROIX CC:iiiN'I / QI / / O C 0NIK~HF,~JSIVF: F41< S P1ANNINC: AND L.- 1,39,6.,947 Square Feet 66' Easement v v (32:.070 Ac.) o f~ n 16-' o s-1 10 q6 • N 3 Floodplain elevation contour 5 X according to Hudson topographic / Cy O:. CU .i maps.. 61 eg" J O n N 4 0 44'10 OF GRAVEL ~y si 51 57' S 85'15'49 DRIV t7J' • 294.99' SEITIC \ ~1 O G{ vEIITX ® SHED O 3 \ E 1/4 COR. 3 Vol `r\• SEC. 18 704 I pi o ~ 107, 624 Sq-Ft ,3% • O . (2.47 Q1 NOTE: Lot 3 Z "o A K ICJ j . ' CABIN contains 1.05 21 CA81N ~ / O. acres of net project 8_1,07 ZI \ area above the 704 N 7S. 3 WEL r o" V o C'S .M. 2'4 ~ry I _ 2158 floodplain elevation 71, W ' contour. Approximate 7!5'. ' Y setback line Q, \ S 89007'46"W 803.75' °i>( LEGEND Ul PLA T T ED -L.gNDa) -10- Section Corner Monument, Berntsen cap. Surveyed for: Don Wolkoff • 1'' Iron pipe found. 2233 University Av. 420 0 1 "x24" Iron pipe weighing 1, 68 lbs Suite St ; Paul, , Mn per lin, foot set. Owner: Robert Bauer Building setback line. 620 Kinnickinnic Hudson, Wi, ( R) Previously recorded information. SCALE IN FEET I" = 200' 0' 50' 100' 200' 400 600' This instrument drafte.d by: JWG VOLUME 9 PAGE 21131 4911896 FORM - STC -/104 AS BUILT SANITARY SYSTEM REPORT OWNER_ Bob BA LAP- '(Z. TOWNSHIP [ALA SUN SECTION _T )9 N-R 19 w ADDRESS !►20 V bRppK u-0 t ST.,rC~ ROIX COUNTY, WISCONSIN sr C&, m a-n o c~o~- cSf~t Z~f 31 SUBDIVISION- NA LOTNALOT SIZE UA PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 73' ~4~ / Pump G~pyh~ 6 I E CC 4 3d , a f ,31 1 I x y~ T~" INDICATE NORTO"ROW BENCHMARK:Elevation and description: fUp o fyu0C0)UFO N w Gewp- Alternate benchmark II~ll SEPTIC TANK: Manufacturer: W'C-0(s Liquid Cap. Poo aAl Rings used: I Manhole cover elev:9 &:15Final grade elev: 16 0 Tank inlet elev.: 1~,7 2 Tank outlet elev.: 15-7,5 No. of feet from nearest road:Front_, Side Rear. Ft. From nearest prop. line:Front Side , Rear Ft. w(F. No. of feet from: Well 53 1 , Building: W (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER 1 1 Manufacturer: W~ S Liquid Capacity: 00 A~ Pump Model:-3'-7 Pump/Siphon Manufact.: ~A Pump Size Elevation of inlet: Is.y Bottom of tank elevation Pump on elev.:13,71 Pump off elev.: L.85Gallons/cycle: Alarm: Man.: (-ey-C ) AIAK,YY\Switch Type: - Location I~j NOI,~~ Distance from nearest prop. line: Front_, Side_, Rear-Ft. GUe~ Distance from: Well a Building V1 Sl.oT- 106 3-a0 9eDak- Ivo. 31 Fib 10("(7 SOIL ABSORPTION SYSTEM 1Q / 3.913 Bed: Trench: Seepage Pit: Width: -Length L'U Number of Lines:_J_Area Built -)0 o Exist. Grade Elev. (011 Proposed Final Grade Elev. 0I•U6 Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side , /Rear Ft. (,)\K-K, )Wft No. feet from well: No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front Side Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE: PLUMBER ON JOB:. LICENSE NUMBER: 30V 6/90:cj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON WI 53707 .State Plan I.D. Number: NE, N , 18 , 2 9 , 19W X ' CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Hudson. Trout Brook Rd ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Rub Bauer 620 Kinnickinnic Hudson WI 54016 s 6u BENCH ARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.. CST REF. PT. EL a Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Jim Boumeester 3404 St. Croix 149035 SEPTIC TANK/ ' • 4,&,5' MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEr. ' TANK OUTLE WARNING LABEL LOCKING COV R PROVIDED PROVIDED: `rl 'OC7 , G7JC1r $ I/~fES -1 NO E] YES 0 BEDDING: VENT DIA.: 7ATL.: HIGH WATER UM ER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LIN / r / AIR INL T: ❑ YES [:1 NO ❑ YES ;4A NEAREST `J 3 DOSING CHAMBER: 3 o 1,C ' r> = al ' g ' •5 ( C7 , ' _ ,w, ov M'ANUF1A~C(T~UEE BEDDING: LIQU~I)D C{A}PACITY: PUMP MODEL: PUMP/ ANUFACTUR R: WARNIN LABEL LOCKING COVER E] YES a;-1106 b GU S 7 6 PROVIDED:--- PROVIDED: e y- C~ YES NO OPERATI -1 NOONAL: NEARESTNUMBER OF WELL' BUILDING: VENT TO FRESH GALLONS PER CYC PUMP ON AND OFF LE 3 f ' PUMP AND CONTROLS (DIFFERENCE BETWEEN fI- fi FEET FROM LINE: f AIR IN T: / SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: I DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN 40 the soil is dry enough to continue.) a y f P✓Ci CONVENTIONAL SYSTEM: o {rm = z ' BED/TRENCH WIDTH: LEN NO. OF DIS R. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N (f. D TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: y ABO OV ERr ELEV. INLET: ELEV. END: r t/ PIPES: FEET FROM LINE: AIR INLET: yr~ l 6r (Jd, ~~C/ NEAREST~~ MOUND SYSTEM z. Mound site plo perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: iAREST-_ MBER OF PROPERTY WELL: BUILDING: ET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO fx.s I it-Z' , a_~ Sketch System on Retai n county file for audit. Reverse Side. SIGNATUR TITLE: 51 SBD-6710(R. 06/88) Zoning Administrator DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY -..~...,...a.~.~..,~„e, j . STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than iy90 3 -s 8'f 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. PER PROPERTY OCATION _ftl Y. MTr_ %a, S T , N, R 17 E (orli ['PAROPEATY (O~WNEP MAILING DfIESS LOT # BLOCK # CITY, TATE ZIP CODE PHONE N MBER SUBDIVISION NAME OR CSM NUMBER bS0 >v SG S 6 I A II. TYPE OF BUILDING: Check one CITY NEA ST ROAD ( ) State Owned ❑ VILLAGE NN OF. 0 401 _j Rcs~ ~Koo'~ ❑ Public 1K 1 or 2 Fam. Dwelling- # of bedrooms J_ A EL TAX NUMBER( S) 111. BUILDING USE: (If building type is public, check all that apply) 14 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) 11-1 New 2. N Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # _ Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill 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 i REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) LEV TION 1 3 a OS 3 0 J 9,. Feet 6L eet VII. TANK CAPACITY - Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank t 1 aoC e S Lift Pump Tank/Si hon Chamber $ 0 I 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) MP/MPRSW No.: Business Phone Number: Try ou e e /S 38 - d Plumber's Address (Str"t, City, State, Zip ode): IX. UN /DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee (includes Groundwater Date Issued Issuing ent Sign re (No Sta ps Approved El owner Given Initial ,n,`\Surcharge Fee) Adverse Det rmin lion fAr 000 OU 7 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber s r 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 property 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: i. 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 systerns; 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 -`~rformapce. curve; pump model and pump manufacturer; D) cross section of the soil, absorption system if =,Auired 12y. 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 S T C - 400. 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 develoment be intended for I P resale by owner/contractor, ("spec,.; then a second form should house") 'be retained and completed when the property is sold and submitted to this office with the~appropriate'deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property A- . _ ,c ✓/G_ / Location of Property Section , TZN~B i9 W Township ) S o rl/ Mailing Address 1f0 -2110 V/C « ~r rzi~ C /74~ 10 A4. Address of Site "C-/ xf F ' ~ Z Subdivision Name Lot Number Previous Owner of Property /IOE72/~ l q Xjl Total Size of Parcel Date Parcel was Crested Are all corners and lot lines identifiable? Yes IVO No Is this property being developed for resale (spec house) ? Yes /V o No Volume and Page Number as recorded with,the Register of Deeds. l r INCLUDE WITH THIS APPLICATION THE FOLLOWING: i 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) cVW6y that a t btatementb on this orcm cute true to the but 06 my (ouAc) know.Cedge; that I (we) am (ah.e) the owneh (.6) o6 the pnopeAty des cA i.bed in th.i a in6oAmation 6onm, by vi4tue o6 a wa Aanty deed keconded in the 066.ice o6 the County Reg.ibteh o6 Veeds" Document N2pozat own the ptopoded .6 to bon the .sewage 6ye`em_ (o dI (we)Iha(Weku ve)obtained an eahement, to nun with the above dedcti,bed pnopeAty, bon the constnucti.on 06 said dytem, and the .dame haz been duty tecokded in the 066.ice o6 the County Reg.iz teA o6 Deeds, as Document No. - , ) SIGNAT OED OWNER SIG ATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED 00- NO. 596 V F!'ATt MR 17r vot l r'r ejllyt'PACE sfl z 357781 REGiST ' Aubr 1. Bauer and Sane C. Rorvick. also krtnrn ss ST. CRC I C. 0mr, also known as Js1fa Bauer t3orYi~k Rw*d. for " individually seed as joint- tacmts..r.• Y, i flauar and Jane C. wit-It, . raQ _ d y of._~ e ~ ' Ilan-claims to t1►rtollowbtg described teal estate in St. rn1 x County, tats of Miscoasis anvsw ro r c' Tan Ney No. The Northeast Quarter of the Northeast Quarter (NEk NE%)'of Section Eighteen (13), Township Twenty-nine (29) North, Range Nineteen (19) W St. • ut _ Tbiu_ ' ~.w Est bomest"d vesputp. ~ r= (is) (is sat) Dated this ++i1 .c2 day of rem- - 19 M w _ SEAL RubX L - il~ 6- t7k k AIITNlNTtCATION ACKNOWLEGM11111 rive of STATE OF WISCONSIN s Sgnstares'euthesticsted 610 Personally came before me, tthis~ the above sumd TrrLE: 'MEMBER STATE BAR OF WISCONSIN Ruby L. Bauer (if sot. Jane C. Rorvick eadm ris d by 9706.06. Wis. Stets.) _ This isstlems~tt Wes drafted by to me known to be the person.Ite "Muted d sw* , G' Willi= J Redosevieh going instrument and acknowledged thsstns. Attornoy at taw e..,rnin 5 16 N~cfsert: Wi (StSigsatutes stay be aatbenticated or acknowledged. Both Notary Public I x!.04'"-"r. as sot wMessry) My commission is permalteat. (K tats M-9 MMI a=:.,e date: ~+w s1 tOR1L'tto. s-lKV ct„ait pa" - sew too _ r 90$ 40 Wbcousin Go" At St. C-hi:- t hereby t~ ?'t i n -hru6AW M r true and corr, t#,xu►e~nt ~n and of recc , c and him 'bIat ~LOp~arc~ t . Aiw, October 15 19 90 James O'Connell deputy DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX HUM N RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 (1-163.090) & Chapter 145.045) LOCA~T'IO SECT ON: PTOWN HIP MUNICIPALITY: O; O.:BLKC O.: SU D V ON NAME: '/4q/4 19 /T N/R / 91P(or l1 /A1/ it//' / `(uqTY~rGI OWER'S BUYER'S E: MA~NIG ADDR SS:/ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER DESCRIPTION: ~y~ PROF C ONS: O TESTS: Residence ❑New f0heplace 3 qv r- RATING: S= Site suitable for system U= Site unsuitable for system ou MOUND: 0 S WU IN-GROUNDS~STS -I®UL QSG NK: RECO1MDSY~~ optioPal) COY \lJ(Q~/7SS TIONAL: UU SS SNA LEU tf Percolation Tests are NOT required DESIGN RJE: l If any portion of the tested area is in the under s.H63.09(5)(b), indicate: i Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHIk, ELEVATION OBSERVED EST. EST H TO BEDROCK IF OBSERVE (SEE ABBRV. ON BACK,) B- / `per d~ S.'~L'Uri S S~7 Ci~G S f •/!t<,i.._ , 77, B- ~7-S, 2,339,, s y>s,3,-C s U Dy o ' Y1 91 s 5!7s c-3' > 7 B- B / t / /j»d fy- S'• /rs//err it lr1' .e.^ a,lt,,~ Bcff~ B- Ao-A,'n -o PERCOLATION TESTS TEST DEPTH ' WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INGM*S AFTERSWELLING INTERVAL-MIN. PERIOD P RI D PER INCH P- /v z' Z- G ! l P. P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. ~o~ SYSTEM ELEVATION i _ I ~Py (a <<%, AN &.-A 10 $ / °f••ct Pas } i i tLnn e~ sir ; • i E i LZ E ' I I i a 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print. -7 TESTS 11V RE OMPLETED ON: i 413 CT t` ADD G CERTIF CA/'I Iy,NUMBER: JP~L l - . / CS SIGNA C `i DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County i y OWNER R A (J~ 3 ,C i~ 7C C E /-V> A AJC C td,C, ✓i ' ROUTE/BOX NUMBER FIRE NO. CITY/STATE G/ ZIP PROPERTY LOCATION: 41& 1/4 -VC 1/4, Section T N, R i ~ W, Town of /z Z2 St. Croix County, C o. ~=e Subdivision Lot N 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 $3000 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification form will be sent approximately 30 days prior to three year expiration. 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED ` DATE / CID St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address E N A M EeA, f 3>,L(. 2. _ ..~1 AM L 0 CAT 10- I C E N S 1.) A C-__ PL.0 MA - • W e ~ ~ S At.e ~i'pn"~~eti ~A _ loo k-t fftrx s lc P%/-~ ~ GJe~I i s ~•~a~'1-~~ ~s ~ ' I '0j GO- nR 6 ~e. SO it PSI Q Cnb~r~ i 0-O 0 177 .4 icxi J'h N fry ~~a~o~iP, 5•~ L. d' Us2.Q f~ks ~ r 12 * } 'E<lstih~ Cr~i,, • ~ I~ s~ce I f ~CN~e ~~1•~ ~ Cr ►•,e r_ j j 16 FRESH Ain ItJLE'i'S~AND OBSERVkriot PI.B>; CROSS SECTION ..Approved Vent Cap • Minimum 12" Above 7 7, Final Ur de___.__~.__ ` c~~r SAX ~ 4" Cast Iron Above Pipe- Vent Pipe To Final Grade r. Marsh Ilay Or Synthetic Coveri tig Min. 2" Aggre,1i'm~ Over Pipe ~Y Distribution : Tee Pipe I _........_.I _l Aggregate rer-forated Pipe Below Ilencath Pipe Coupl.i.ng Terminating ng T ~~c Bottom of System State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION PNtW(T,k SEWAGE PLAN APPROVAL 01tive or Division Codes and Appiir:at:ion 201 East Wa h i ng t on Avenue P.O. box 14613 Madison, Win onvin 53101 HUMESI.TL SEPTIC: Owner: UUN WULKOi F 655 U'NLIL ROAD 'x'2:33 UNTVERSIIY AVENUE SUITE 4'0) HUDSON WE 54016 ST. PAUL MN 55114 RE: Plan Num r: S91-01894 Date Approved: August 16, 1911 Gallon, Per ay: 300 Date Receivod: August 14, 911 j Project. Name: WOLKCIET, DON RINIDENCt location: NL,NL,18,29,19W Town of HUDSON County: Sl CROIX the plumbing plant, and spvLification4 for this pr"jvit have been reviewed for compliance with appllc,able cndp rvquircrnents_ this approval is biased on Chapter 145, Wisconsin Statutes and the Wiscon%in ladminih,trdtivv Cade. The plans are stamped 'conditionally approved'. Thin appruval 14 ront.ingent. upon compliance with any stipulations shown on the plane. All items that are noted must be corrected. All permits required by the city, village, township err cnunty shall be obtained prior to con,truction. the licensed plumber responsible for this installation, shall keep one scat. of plans with the departrmenl_' s approvol stamp at the construction site. The installer %hall ntily the appropriate inspector when inspections can be made, this approval will expire two year:, from the dalP approved or if a sanitary permit is obtained, it will expire the day the initial %anitary permit expires. The Section of Private Sewage has reviewed these plan for private sewage system code requirements only. These plans have not been reviewed for the code requirementq sett forth in 'section 11_HR 82 for general plumbing or in Chaplers 50.64 of the Wisconsin Administrative code, This approval iq for the following components only: RE PLACEMENT PETITION RE:PLACEME:N1 MOUND SB06*3 (IT 0818) - - - - - - - - - - - - s State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION I HOW-S111. SEPTIC Paq( 2 1..nquir-1es concorniriq thi aOOr(1VaI (liay h(> Ilkide by a11'1N14 (608) ?66 t3~!30. aincPreIy, r N f.TH SiIEMKE Sec ion of Pr iwite ,,ewage Division of Safety and buildings PPP016/0009n/12 c : DON WOLKOf f Pr ivatF? 5ewo9c, ("on"IlRdnl „County _ UW.-5`aWMI} Plumbing Cow u l l (int Owner Plumber E.nvi ronmenta l Health I SBD-6423 (R. 08/88) I SAFETY & BUILDINGS DIVISION 201 E. Washington Avenue P.O. Bog 7969 Madison, Wisconsin 53707 State of Wisconsin Department of Industry, Labor and Human Relations August 16, 1991 DON WOLKOFF 2233 UNIVERSITY AVENUE SUITE 420 MINNEAPOLIS MN 55114 Petition No. 591-01899-P Dear Mr. Wolkoff: Re: Don Wolkoff - Residence Private Sewage System NE,NE,18,29,19W Town of Hudson, St. Croix County, WI Your petition for a variance to section ILHR 83.18 (3)(b), Wisconsin Administrative Code, has been reviewed. The rule being petitioned requires that there be at least 2 feet of freeboard between the top of the service manhole of a holding tank and the regional flood elevation. i The variance requested was to allow a watertight manhole cover to terminate i. less than 2 feet above flood elevation, The following comments were made in the petition analysis: 1. In reviewing the petition, it was noted that the request was similar to other petitions accepted by this departreient under petition numbers S89-03286, S90-02591 and S90-00874. 2. Based on the precedent established by the previous petitions, this petition for variance is being processed as perr,itted by Wisconsin Statute Section 101.02 (6)(9). Departmental Action: Approved. SBD 6928 i R. 01/01 SAFETY & BUILDINGS DIVISION 201 E. Washington Avenue P.O. Bog 7969 Madison, Wisconsin 53707 State of Wisconsin Department of Industry, Labor and Human Relations Don Wolkoff Page 2 August 16, 1991 This approval is granted with the understanding that all of the petitioner`s. statements and any conditions of approval cited above will be carried out. n Prepared by: h Sti eM e P1 an xaminer Private Sewage) Section (608) 266-8231 Departmental Signature: Dater I c veyer, rc ec Director, Office of Divisio6 Cddes and Application KS:594WPP3 Enc. cc: Leroy Jansky, Private Sewage Consultant - District 6, Chippewa Falls Thomas Nelson, Zoning Administrator - St. Croix County I S B D 6928 (R. 01/81) FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~Dw ~OGif'6/cjC TOWNSHIP ~fl~DfOw SECTION 100 T 2-f N-R 9 W Cs~/M ADDRESS tfwv ° v ~"~s ss."0/6' ST. CROIX COUNTY, WISCONSIN .cc_ zz33 Z/•viUSiTy fIUE S~iE yZO ST Phu ~.yN. S'S/~ y SUBDIVISION_ ~ s,`I S6 0 P ftiDiN I,OT_ / _LOT SIZE GI Z 7vr3~ VIEW LET 3 CS'nt a a~3 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM o 7 rrItc t INDICATE NORTH ARROW BENCHMARK:Elevation and description: SvR7O 2 S 461 ~O Alternate benchmark SEPTIC TANK:Manufacturer: • Liquid Cap. Rings used:_Manhole cover elev: Final a elev: Tank inlet elev.: Tank outlet eve: No. of feet from nearest road: ntSide Rear. Ft. From nearest prop. line: ont SideRear F No. of feet from: 1 Building Qa { fir. (Include thi nformation in the above plot la (2 refere a dimensions to septic tank) SEE REVERSE SIDE , U /i> E ,a PUMP CHAMBER Manufacturer: Li Capacity: Pump Model: Pump/Siphon nufact.: Pump Size_ Elevation of inlet: ttom of tank3elevation Pump on elev.: Pump ff elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nea est prop. line: Front, Side, Rear Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: Length Number of Lines: Built Exist. Grade Elev. Proposed F Grade Elev. Fill depth to top of pipe: No. feet from nearest p line:Front , Side , Rear Ft. No. feet from we ._No. feet from building HOLDING T K ToT,f L ; 2 day Manufacturer: GIN Q CO 2-) Capacity: ~ Jam' ;r4,0eS No. of rings used: 2- "Elevation of bottom tank: ~7 C, ~ Is r -7 60. 3 6, Elevation of inlet: $0. No. feet from nearest propo line:Front Side so, ear Ft. No. feet from: Well y57 buildingnearest road 8 Alarm Manufacturer: 1 TP/ O ~~-1EIl ,CAS ~U~l~J ed - INSPECTOR:_ Tt M T~O~r~S4i✓ DATE : PLUMBER ON JOB: ~ LICENSE NUMBER: 3 36 7 ~•°e-5 6/90:cj ' Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Lafet and Human Relations INSPECTION REPORT St. Croix Safety andBuildings Division ~A A 2H9T~ IP~RM Sanitary Permit 5 GENERAL INFORMATION NE, NE, Se , T~To~ut Brook R 149245 Permit Holder's Name: ❑ City C] Village [.k Town of: State Plan ID No.: Rub Bauer Hudson S91-01899 CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: v^v 5 156A TANK INFORMATION ELEVATI N DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Sepiic Benchmark p7 3,GPJC Dos' A On dg. Sewer S', 7q! Y3 Holding l - a G~ St/ Ht Inlet y TANK SETBACK INFORMATION St/ Ht Outlet yb+ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom 96sing A Header / Man. Aeration NA Dist. Pipe Holding 5_01 3,. ' `tom 1 5? Bot. System PUMP/ SIPHON INFORMATION Final Grade ~ Manufacturer Demand ,F 07.4 113' Q(, 495- eNumber GPM TDH Lift Friction System oss Fi Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN DIMENSIONS LEACHING Manufacturer: tDIS, S BACK SYSTEM TO P / L B WELL LAKE /STREAM INFORMATION Type o CHAMBER Moo eINN ber System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake g Dia. Length Dia. Spacing SOIL COVER x Pressur tems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx ched Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No Yes ❑ No COMMENTS: (Include code discrepancies, perso resent, etc.) A KA Plan revision required? ❑ Yes M-No Use other side for additional information. m SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: • ' > ~3vy~R - 'voN rva~~aFic lift- Ly9- 3 Soa SANITARY PERMIT APPLICATION =:7.EDq1&LnHR couNTY In accord with ILi-IR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ! 8% x 11 inches in size. ❑ heck ii!onYtO pous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. $ g/ - O! f PROPERTY OWNER R f1~ y PROPERTY LOCATION ptuw~ AJ t/aS j~ T21,N,R E(o W PROPERTY O ER'S MAILING ADDRESS LOT # BLOCK # Ct ~ ~ iv.~i 1 Gf' e~✓N i G C` ICY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER vpso•✓ Wf. 5 yotG 3~ .3 t C-S,~•l II. TYPE OF BUILDING: (Check one) ❑ State Owned Ell VILLLLAGE : NE EST ROAD if uV ~a 7-,ft v r 1a.,4001C / - 2- A TOWN OF: ❑ Public R1 or 2 Fam. Dwelling-# of bedrooms _ AR TARGN MBER() L_ d ~ Z0~ D 363 00 O III. BUILDING USE: (If building type is public, check all that apply) ! Z 7 ✓ 1 I CO~s~O~C~ .jf 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 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. 14 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 ❑ 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 od REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 3 Ifit/ • . 14. / v'• /T I A , Xl' f+ - Feet N4- 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 woldin Tank 200V Z GvlES£7~ Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT 1, 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) /MPRSW No.: Business Phone Number: r2o aR 7- -i lh v t*e i4 ' 3 3 a 7 765 314; ` J61(? S Plumber's Address (Street, City, State, Zip Code): 6 SS d 1W &i L IX. COUNTY/DEPARTMENT USE ONLY Disapproved S itary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (N~ta, S charge Fee) WApproved ❑ Owner Given InitialAdverse D t rmination 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 th-.y 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/RenewalForm (SEED 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 systEIm. 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'h 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; (Jose 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) c.n m cn N zp~ \ °D C clo I OO i 4 7o jt, 4 ~ WE-5 S tai h ' va h r 1 ~ ~ o u r 10 JS ~ w► i to I-N o oo ~ o Qrh 1 ~ ~ 3 ~ ~ ~ r GN c l c D m 0 Tlt) c~ i p ~ -1 ~ Ry, rl O \ a 0 ~ 0 4 s Lr C 70 State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION PRIVATE SEWAGE PLAN APPROVAL Office of Division Codes and Application 201 East Washington Avenue P.O. Box 7969 Madison, Wisconsin 53707 I HOMESITE SEPTIC Owner: DON WOLKOFF 655 O'NEIL ROAD 2233 UNIVERSITY AVENUE SUITE 420 HUDSON WI 54016 ST. PAUL MN 55114 RE: Plan Number: S91-01899 Date Approved: August 16, 1991 Gallons Per Day: 300 Date Received: August 14, 1991 Project Name: WOLKOFF, DON - RESIDENCE Location: NE,NE,18,29,19W Town of HUDSON County: ST CROIX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - REPLACEMENT PETITION - REPLACEMENT MOUND SBD-6423 (R. 08/88) State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION HOMESITE SEPTIC Page 2 Inquiries concerning this approval may be made by calling (608) 266-8230. Sincerely, 4 N ETH STIEMKE Sec ion of Private Sewage Division of Safety and Buildings PPP016/0009n/12 cc: DON WOLKOFF -Private Sewage Consultant -County _UW-SSWMP -Plumbing Consultant Owner Plumber Environmental Health SBD-6423 (R. 08/88) SAFETY & BUILDINGS DIVISION 201 E. Washington Avenue P.O. Bog 7969 Madison, Wisconsin 53707 State of Wisconsin Department of Industry, Labor and Human Relations August 16, 1991 DON WOLKOFF 2233 UNIVERSITY AVENUE SUITE 420 MINNEAPOLIS MN 55114 Petition No. S91-01899-P Dear Mr. Wolkoff: Re: Don Wolkoff - Residence Private Sewage System NE,NE,18,29,19W Town of Hudson, St. Croix County, WI Your petition for a variance to section ILHR 83.13 (8)(b), Wisconsin Administrative Code, has been reviewed. The rule being petitioned requires that there be at least 2 feet of freeboard between the top of FtheJservice, Inaphole pf i holding tank and the_.reg1pnal _flobd,elevetion. w x..w m. The variance requested was to allow a watertight manhole cover to terminate less than 2 feet above flood elevation. The following comments were made in the petition analysis: 1. In reviewing the petition, it was noted that the request was similar to other petitions accepted by this department under petition numbers S89-03286, 590-02591 and S90-00074. 2. Based on the precedent established by the previous petitions, this petition for variance is being processed as permitted by Wisconsin Statute Section 101.02 (6)(g). i Departmental Action: Approved. i i S B 0 6928 (R. 01/91 SAFETY & BUILDINGS DIVISION 201 E. Washington Avenue P.O. Box 7969 Madison, Wisconsin 53707 k State of Wisconsin Department of Industry, Labor and Human Relations Don Wolkoff Page 2 August 16, 1991 f This approval is granted with the understanding that all of the petitioner's statements and any conditions of approval cited above will be carried out. Prepared by: Kthrffilth St! era. e Plan Examiner Private Sewage, Section (608) 266-823 Departmental Signature. Date. I is ar , eyer, -c ec ~ ! Director, Office of DivisjroW Codes and Application w KS: 594WPP3` , . Enc. cc: Leroy Jansky, Private Sewage Consultant - District 6, Chippewa Falls Thorlas Nelson, Zoning Administrator - St. Croix County SBD 6928 (R. 0"1) VOL 911 PAGE t%1 Document No. This space reserved for recording data X2330 HOLDING TANK AGREEMENT Agreement Date This agreement is made between the - _ REGISTERS OFFICE County or Local Governmental Unit I Holding Tank(s) Owner(s) ST. CROIX CO, /~v~So~. Tocu.,uS ~r I oN~fG D /LI, lv o ~ ko~~= I f Rec'd for Record (Called Municipality below) I A U G 0 a 1991 We acknowledge that application is being made for the installation of (a) holding at 9:00 A~ tank(s) on the following property, (Provide legal land description:) j Regtaterof Dew 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. 7-- As an inducement to the County of Y 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 ss. 146.13 and 146.14, Stats. 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, Stats. 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 be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Stats., 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 contract 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 shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Stats., 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 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 the owner and assignees of the owner. The owner shall submit the agreement 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 wh a the holding tank is installed. - er(s) Name(s) (Prinnt)~ I Owner ig to s f`Qa..p - - - Subscr' el and sworn to bef a me on this at I ~ AV4 ■ MARY ELLEp MOVVELL Municipal Official Name (Print) I Municipal Official Signature mum bdijFWRN o ry Public Vft tsios I ~j My com ~ 4111111111, Municipal Official Title (Print) I SBD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry. Labor and Human Relations, Bureau of Plumbing. Cj • n ~y 4W v a~ STC-105 ` 3C ` X1,7'. 4.4 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ~v~~jg t4 ;P+v/3 A R/BUYER ©AV t fJ 01,)L-0 ROUTE/BOX NUMBER .Fire Number CITY/STATE ZIP --VI PROPERTY LOCATION: N6 k, N,~ k, Section T a! N A 'l fw1 . Town ofOS~.~ , St. Croix County, ~ Subdivision e_f , 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 septic tank pumper. What you pat into the system can affect the function of the septic tank as a treat- ment 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, I 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying 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. 0 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 Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Off:Lpe within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office "f P.O. Box 98i Hammond, WI 54015 +I 715-796-2239 or 715-425-8363 j Sign, date and return to above address. o • APPLICATION FOR SANITARY PERMIT 9TC-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 picrnit issuance. -Should this development be intended for resale by owner/contcactot,(spec houaa)i then a second form should be totalned and completed when the property 1s sold and submitted to this office with the appropriate deed recording. Owntt of property d4J Location of property N-AL11+ yl Sectlon . `0 Township CoZO ~,v ' Mailing address ~ C ~fvDso S' , s' y40 /6 Address of site Srbd lvls lcn name (f.Y M END /V 6 • Lot number t / Previous owner of property ' Total 5136 of paccel 2'0 1- Oate paccel was created Ago all cocnsts and lot lines Identifiable? Y- on •,~N0 11 this property being developed tot resale (*spec house)?- of .~,.M0 Volume %5 and Page Humbsr6? _ as recorded with the Reglstet of Deeds. • r - - r - - - w r r r • r - r r • r r r - - - - - - INCLUDE WITH THIS APPLICATIOH Till FOLLOWINCI A WARRANTT DRID which Includes a DOCUHYHT HUHBQRr VOL.U)i1t AND PAO[ RUNegR, and the 82kL Of Till R8018THR OF DEEDS. In addition, a certlfled survey, It avallable, would be helpful so as to avoid delays of the tevleving process. it the deed description references to a Csitlflsd survey Map# the Csttlfled Survey Hap shall also be required. PROPERTY OWNER CERTI►ICATIOH i(ve) certify that all statements on this term are true to the beat of my (our) Rnovledgej that I (we) am (ate) the owner(s) of the property described In this Information form, by virtue of a warrant deed recorded In the office of the County Register of Deeds as Document Ho. -302.5'0/. j and that I (we) Presently own the proposed site for the aewago disposal system (cc I (we) have obtalned an easement, to run with the above described property, for the construction of sold system$ and the soma has been duly recorded in the office 94 th ynty polls c of Deedss an Document Ho. sign uce f owner 6lgnatute Co-0 6t (11 1►ppllcabte) Orll- 0-4to- of 8 1gnat t6 Date Signature QUIT OI.AIM DROD DOCUMENT NO. STATE OF WISCONSIN - FORM 18 THIS *PACK Rtra6RVKD POR OXCORDINO DATA 3021 Ft f:"Gr'~Tl-`1::~, C7Fr~1C:L Doris C. Engdahl and Recrd for !'nc , J this .15th THIS INDENTURE, Made by day ofQctober._ -i'.O.1~~_ 70~ Ruby L. Bauer David Hope grantor_$.-., of De cl< quit-claims to _.Tone...CA.._D~u~'?~,....Aor nl~d.~hl.. nd...911-~?Y....~+.... deputy RETURN TO s.... J 1Mt..M.1? 1Rtm...W t11..Ei?~ght _ o GWin.,Fetzner.0Richards and Survivorship Skox grantee..,$ Him.- acmrsRrnernw.nwmmm raOU/it~,-WfsEOasie, for the sum of One Dollar and Other Good and Valuable Consideration , Dollars i the following tract of land in_......... St........ C.._._.._..roix_.. County, State of Wisconsin: • I The Northeast Quarter of the Northeast Quarter (NPI NEI) ~ of Section Eighteen (18), Township Twenty-nine (29) North, 1.. Range Nineteen (19) West. j~ ,g In Witness Whereof, the said grantor_S_ ha Ve-. hereunto set.their hand S_. and realS.__ this-_..-5 _ day of.. ...........October ........A. D., 19...70.. SIGNED AND SEALED IN PRESENCE OF ..............-.._.._...--........-.__.._._....(SEAL) n Dis C. E d a h_l _ (SEAL) Ruby L. B, .....................(SEAL) B rbara 1A1 ftm~ma at>t - -(SIiAL) Marcella Olson - , State of Wisconsin, - St. Croix ss. County. Personally came before me, this ....14th- day of..... ....October I ' I ,I 70 Ruby L. Bauer A. D., 19....... the within named i, to me known to be the person.... ,xi'te foregoing instrument and acknowl ged the Same. j •'~c ON as THIS INSTRUMENT WAS DRAFTEp•OY i ,e_. I' Marcella Olson , T -S Ardell W. Skow -C' N104 Attorney at Law .4otary Public, ..........aS..a._. County Wis_ _h-- y commission (expires) OM ..a r 11_25 197.1 - - - P (Section 39.51 (1) of the Wiac BjiFutb pprovidta thit truments to be recorded shall have plainly printed or typewritten thereon I the names of the granters, gran vltaessp(ttnd notary. on 59.513 similarly require that the Dame of the person who, or guvem- mental agency w61eh, drafted LI be ted, ty pewritten, stamped or written thereon in a 1egihle manner.) ►,ta, TIM OF VIWoXNX wleconsln Legnl Blank Comnany Tf..,. T ~Y11mo•.Ir.,.. Urlu rr.,h otivda 1 STATE OF MINNESOTA) ) ss COUNTY) Pe sonally came before me,Ahii~ day.pf October, 1970, the within named Doris C. Engdahl, to roe kpq~rxrthe per8on who executed the. ng instrument and acknowledged the @ "F Notary h t .T'•;^• g~~:r .l Y.: a a~ Seal ..,'end, nk..r~yy,• ; k yMiw it ' 4~. CK! ra^ . t i. .y .'t.,`J•'ylh I, err R 1 } ' .4 7 ` , 4 YV ~ I i• _ If ~ ~ ,A s::t ,yy~yt ~ d