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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Sfi C dal fl
u
ADDRESS S
~ WL syd~s'
SUBDIVISION / CSM# LOT #
SECTION~_T N-R___ZfW, Town of t~.C1 0,
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF S STEM
as
b
b
alf
INDICATE NORTH RROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
J
BENCHMARK: fn t1 ~Q
• f. « 6,bvK•
ALTERNATE BM:
2 g
SEPTIC TANK FORMATION
Manufacturer: - WtAA1An Liquid Capacity:
WDL
Setback from: Well H6=e Other
Pump: Manufacturer _N/A Model# Size
Float seperation Gallons/cycle:
Alarm Location N/11.
SOIL ABSORPTION SYSTEM
e LkAe, S
Width: /p Length C~5 Number of des
Distance & Direction to nearest prop. line: - Sow
Setback from: well House o- Other
ELEVATIONS
Building Sewer ST Inlet; Q$, _ ST outlet
PC inlet ! , PC bottom Pump Off
Header/Manifold 15,3 Bottom of system 76,7
Existing Grade 16 647 Final grade 6-0
DATE OF INSTALLATION: (9 -
PLUMBER ON JOB:
LICENSE NUMBER: 15G3
INSPECTOR:
3/93:jt
i~'s;. ~Jart Tv44t~ st5~ • 29.19W, ffisATE SEWXGE SY, ay 12 County:
Labor and Human Relations INSPECTION REPORT
Safer' Buildings Division
' (ATTACH TO PERMIT) Sanitary Permit No.: ST_ CRQTX
GENERAL INFORMATION 208973
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
8 Tir.HWAY lHudson
S BM Qe Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9400096
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic lS Benchmark - ioo
Jv
Dosing
Aeration Bldg. Sewer
<
Holding St/Ht Inlet 1,17
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom 1
Dosing NA Header / Man. c1 9 i y
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Hea
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Lengtp, 7 No. Of Tre s PIT No. Of Pits Inside Dia. Liquid Depth
t Q "1
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER ' Model Number:
f IV System: Q X06 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 a Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
x,
a?
Bed /Trench Center ~ t( Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) ~f L
U
LOCATION: Hudson.22.29.19W, NE, NE, Lot 1, Highway 12
tr
Plan revision required? ❑ Yes ❑ No 1 n
Use other side for additional information. 6 ( yr
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
V• jL, jj COUNTY
In accord with ILHR 83.05, Wis. Adm. Code f 6~ 'r
of
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 0101913
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.
PROPE TY OWNER PROPERTY LOCATION
•G1^0 % `o /V t/a S ~A TaN,R / or)W
PROPERTY OWNER'S MAILING ADDRESS/ LOT # BLOCK #
P50 D._Ull~ f. .
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM U BE
y~ao i s C. gy m- P 02 e/ b
II. TYPE OF BUILDING: Check one CITY : EAREST ROAD
( ) State Owned
❑ VILLAGE : ~5 0~ 4 ~ y
'Q TOWN OF:
w
XPublic ❑ 1 or 2 Fam. Dwelling- # of bedrooms - PARCEL TAX NUMBER( S)
Ill. BUILDING USE: (If building type is public, check all that apply) ~t /6-97 QO
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 Other: Specify 50 "'010&
IV. TYYPEj OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ~I New 2. El Replacement 3. F] Replacement of 4. F-1 Reconnection of 5.0 Repair of an
l 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 220 In-Ground & ❑ 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.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Y6 7
1214>16 W,7 7 Feet Feet
CAPACITY
VII. TANK Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xistin Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank f! g b5 -ql+ F] F1 E] ~=D F-1
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (PP49, Plumber's Signa re: o Stamps) •MP/MPRSW No.: Business Phone Number:
ca) u r. C-F V-50 , CX62~
r 15 s- d yG 5%3
Plumber's Address (Street, City, Statt& Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanit ry Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature o Stamps)
Approved E-1 Owner Given Initial )OSurcharge Fee) q.;q `cj~
Adverse Determination
1 14,
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.o8/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 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 Sanhary 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, 606-266-3815.
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 i 1 or 2 Family Dwelling.
Ill. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement; reconnection, or
repair.
V.. Type of system. Check appropriate box depending on system type.
VI.- Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
- - - - - - -
SBD-6398 (R.11/88)
FORM NO. 98SA
1lc~xi«cros.•®
Stock No. 26273
CERTIFIED SURVEY MAP
LOCATED IN THE NW1/4 OF THE NE1 /4 AND IN THE NE1 /4
OF THE NE1 /4 OF SECTION 22, T29N, R19W TOWN OF HUDSON,
ST CROIX COUNTY, WISCONSIN
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER St. Croix County Highway Department
ROUTE/BOX NUMBER 1 1 5O nayi s _ Street FIRE NO. to CITY/STATE Hammond, WI ZIP 54015
PROPERTY LOCATION: NE 1/4 eL E/4, Section 22 , T29 N, R 19 W,
Town of Hudson , St. Croix County,
Subdivision CSM vol. 9, P.2490 , Lot No. 1
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 S oix County Zoning Office within
30 days of the three year expiration date.
SIGN
DATE
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
(715) 796-2239 or (715) 425-8363
Sign, Date, and Return to above address
l
S T C - 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 St. Croix County Highway Department
Location of property NE 1/4_1/4, Section 22 T 29 N-R 19 W
Township Hudson Mailing address N S O -Zo..~ ~ .
Address of site(,(,b E A Ash , W j S*- V,
Subdivision name GSM Vo. 9f P.2490 Lot no. 1
Other homes on property? Yes X No
Previous owner of property nay;d waldroff ~oS)
Total size of property 20 Acres
Total size of parcel
Date parcel was created February 11, 1993
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for ('spec house) ? Yes X No
Volume 993 and Page Number 52 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A W ANTY•:DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
MIR-BER 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 recorded in the office of the County Register of
Deeds as Document No. 494A74 , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Siqnatur _fpl' nt Co-Applicant
04 It 1, S
Date of Signature Date of Signature
li DOCUMENT NO. T.I. SPACE RESERVED FOR RECORDING DATA III
WARRANTY DEED
STATE BAR OF WISCONSIN FORM 2-1982
II
49497-4
i -----=vo__ R GiST-ER'S OFFICE
ST. CROIX CO., WI
DaWaldroff -a/k/a_ David _ J.-_ Waldr_ off-and--Julie---- F' r~ f.~r lPr,rcrd
_ -Waldroff,., husband _ and . wife -
FEB 1 1 1993
05
- P
M
4:
conveys and warrants to ..DeP?aZtZ)ent-- o
~I
r I Crr-dS
RETURN TO
the following described real estate int • CT'OlX County,
-
State of Wisconsin:
Tax Parcel No-
A parcel of land located in the NW1/4 of the NE1/4 and in the NE1/4 of the NE1/4
of Section 22, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin, more
particularly described as follows: Lot 1 of Certified Survey Map recorded in Vol. 9,
Page 2490, Doc. No. 484314, on June 5, 1992 in the St. Croix County Register of
Deeds office. (Parcel was previously described as the N112 of the NE1/4 lying
South of Railroad right-of-way, except Lot 1 of Certified Survey Map recorded in
Vol. 3, Page 621; Section 22-29-19).
This Deed is given in fulfillment of that certain Land Contract dated June 18, 1992,
recorded June 19, 1992 in the Office of the Register of Deeds for St. Croix
County in Vol. 955, Page 588, Doc. No. 484863.
A-4
This ....15 _JaOt------------- homestead property.
(is) (is not)
Exception to warranties: easements, restrictions and rights-of-way of record, if any.
.I
Dated this -------------1-11b------------•----------- day of -------February------- - ----------------------------19-9-3.--•
(SEAL) (SEAL)
David Waldroff a/k/a David J. Julie Waldroff
--Wdldroff----------------------------
-------------(SEAL) (SEAL)
i
*
AUTHENTICATION ACKNOWLEDGMENT
Signature (sSTATE OF WISCONSIN
SS.
S ry~
t.__CT'OlX----•• ---------County.
authenticated this __..day of 19 Personally came before me this I ± ___day of
February___ 119.93__- the above named II
Da_v__id Waldroff a/k/a_ David J.__ Waldroffl Is
* -Julie adrof'f
- - -W l------------------------------------------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
-b---'
authorized y 706.06, Wis. Stats.) to me known to be the person s_-___-._._, wii6_b1%4ted• the
fore g instrument and a novel R• i~ieme:l
THIS INSTRUMENT WAS DRAFTED BY
CA
Kristin Ogland , .
A
Attoe a Iaw o ~t~~~'
a~
k
---------------•-----------Notary Public 7 ;
(Signatures may be authenticated or acknowledged. Both My Commission is permanei t' not, Utg yra-W 11
'
tforr
are not necessary.) s
date:
'Names of - - ~~F
persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
April 26, 1994 2226 Rose Street
La Crosse WI 54603
POWER, CALVIN JR
1969 - 185 AVE
NEW RICHMOND WI 54017
RE: PLAN S94-40235 FEE RECEIVED: 110.00
ST CROIX CTY HIGHWAY DEPT
NE,NE,22,29,19W
TOWN OF HUDSON COUNTY OF ST CROIX
NON-PRESSURIZED IN-GROUND SYSTEM
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.
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,
erard Swim
Plan Reviewer
Section of Private Sewage
(608) 785-9348
3545R/ 1
SRD-6423 (R. 61 /9I )
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Safety and Buildings Division
Labor and Human Relations REVIEW APPLICATION Bureau of Building water Systems
Hayward Office La Crosse Office Madison Office Shawano Office Waukesha Office
209 W 1st Street 2226 Rose Street 201 E. WashingtonPve. 1053A E. Green Bay Street 401 Pilot Court, Suite C
Rt 8, Box 8072 LaCrosse, WI 54603 P.O. Box 7969 v P.O. Box 434 Waukesha, WI 53188
Hayward, WI 54843 Phone (608) 785-9334 Madison, WI 53707 Shawano, WI 54166 Phone (414) 548-8606
Phone (715) 6344804 Fax (608) 785-9330 Phone (608) 267-5119 Phone (715) 524-3626 Fax (414) 548-8614
Fax (715) 634-5150 Fax (608) 267-0592 Fax (715) 524-3633
INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this
form together with fees and plans/information. Your submittal must be received at least one working day prior to the appointment at the office
where your review was scheduled. Please call any of the listed offices if you need help filling out the form or hav yon whAn "2'a"080 submit. PLEASE PRINT VERY CLEARLY.
A sample of a completed form is on the reverse side for your reference. ri G2 V 5
1. APPOINTMENT INFORMATION -if ou have scheduled an appointment, fill in the information requested below to save time:
Appointment Date Re wer Name Plan Identification yumber
41
=;e `er Swl Vn, 591 - S~Da 35
2. PROJECT INFORMATION If this review is a revision or extension to your existing
plan identification number, provide that number here: ~I
Project Name
ri" ❑ City ❑ Village Town Of: County
f. tr C u,
Project Location
GOVT. LOT 14 F 1/4,S T a N ,R / Aft) yy Tt U 0,516 Y~ .s~~ r o x
3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED
System Type (check one): System Type I (include new and existing tanks)
Up To 1,500 gallon septic tank $110.00
A ❑ At-Grade 1,501-2,500 gallon septic tank $120.00
H ❑ Holding Tank 2,501 - 5,000 gallon septic tank $160.00
M Mound 5,001-9,000 gallon septic tank $200.00
N Non-pressurized In-Ground(conventional) 9,001-15,000 gallon septic tank $300.00
P Pressurized In-Ground Over 15,000 gallon septic tank $ 500.00
0 ❑ Other: Up To 1,000 gallon dose chamber $ 70.00
1,001 - 2,000 gallon dose chamber $ 80.00
Building Type (check one): 2,001 - 4,000 gallon dose chamber $100.00
4,001 - 8;000 gallon dose chamber $120.00
D ❑ Dwelling, 1 or 2 Family 8,001 -12,000 gallon dose chamber $140.00
P X Public Building Over 12,000 gallon dose chamber $160.00
S ❑ State-Owned Building Up To 5,000 gallon holding tank $ 60.00
5,001 -10,000 gallon holding tank $100.00
Code Derived Daily Flow_gpd Over 10,000 gallon holding tank $150.00
❑ Check If Replacing Existing System Experimental System (additional one time fee) $ 300.00
Revisions To Approved Plan 2 $ 60.00
Petition For Variance: Setback $100.00
❑ PetitionFor~VEp Site Evaluation $225.00
Plumbing $225.00
APR 2 0 1994 Revision $ 75.00
❑ Groundwater Monitoring Groundwater Monitoring - Per Site $ 60.00
(other than a proposed subdivision)
❑ Site Evaluation in Lieu o
Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 60.00
Subtotal:
Priority Review: Enter same amount as Subtotal:
MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee:
5. SUBMITTING PARTY INFORMATION
Telephone No. (include area code & extension) Co ny Name Contact Person
( 71S) ~L V6 -S/ S P6 Wtr ri .~•tic. ~o~.~ a r~s,..,
No. & Street Address Or P.O. Box City, To n or V' age, tate, Zip Code
A)o
9 9 °
and Gvl 7
Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers.
2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals.
NOTE:. Fees are pursuant to Wis. Ad m. Code, Chapter ILHR 2, and are subject to change annually.
SBD4748 (R. 03/93) OVER ~41111..
Wisconsin Department Relations Industry,
L$por and Human Relati SOIL AND SITE EVALUATION REPORT Page
/ Of .3
Division of Safety & Buildings in accord with ILHR833.05, Wis. Adm. Code 4 0 2 3 5 COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but S-t C r`0 t x
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
St (2 r-6 , 1 W4 GOVT. LOT Ne- 1/4 No 1/4,S ;2 IT N.R 'for) W
PROPERTY OWNER':S MAILING ADDRESS LOT BLOCK # SUED. NAME OR CSM #
Sm,Co( ~196
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY OVI LAGE ®I' OWN EAREST ROAD
L 5 i~o~s (pis) a "
rCode ew Construction Use (j Residential / Number of bedrooms [ ] Addition to existing building
eplacement ~ Public or commercial describe LA
derived daily flow~Q_ gpd Recommended design oading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 7 bed, gpd/ft2 19 trench, gpd/ft2
Recommended infiltration surface elevation(s) ) ft (as referred to site plan benchmark)
Additional design / site considerations /✓on..
Parent material O .L& La 111A Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-_9ROUND PRESSURE AT-GRAD SYSTEM IN FILL HOLDING ~~T++NK
U= Unsuitable fors stem S❑ U S0 U S❑ U 11 S U E3 S MU ❑ S 21U
SOIL DESCRIPTION REPORT P/ A 59
Boring # Horizon Depth Dominant Color Mottles Structure G PD/ft
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trertch
'12 p y►t 5i)< Sr a.
6 io 115% l I rr► bk i'>7fr; is
/ s
Ground 3 -yr D R. n1¢d 5 D S nt / G W • 7
elev.
/~`jft. l -9frO A Q S D C.
5 ~n I , 7 8
Depth to
limiting
factor
Remarks:
Boring #
a63 /a k y17
r m S M/ Ground c w
/ l~ft -96 IC S ~ 0 67 '
Depth to
limiting
factor
>
Remarks:
CST Name:-Please Print
O WQ. ~ Phone: 715-
Address: * q _5-W 17
Signature: Date: CST Number:
PROPERTYOWNER pkshwm SOIL DESCRIPTION REPORT Page o? of 3
PARCEL I.D. #
Depth Dominant Color Motbes Texture Structure Consistence Bw-day Roots ' GPDIltr
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 C) -Q Q / r 3
Is d 5.l l bJ; cw ,S
Ground. 3 a 7 3~ R 1-117
elev.
Zoo, A 36-47 5 8 sf s 1 6 ,
Depth to y7. 9d R g s rrt / D T • f1
limiting
factor
> 96
Remarks:
Boring # k 2 , Y , S
~ l~-.Z5 v !I s, l mS~ s ~
S m~ Gw o ,7
M C.
3 as 39
Ground
elev. M-70 /D R S Z7 /00-s ft.
Depth to
limiting
factor
7 90
Remarks:
Boring #
4, ~n5ik Min 5
L ~.-C %J
~ 3 / f1 to 49 M rv ~ G 4j
Ground 6
elev. 27
Depth to
limiting
factor
90
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
_S611 "f S fie G`~U a.l,u~w~w^^ Po-cc~a 3 t-3
9 4 4 0 2
~ J
A 0, a,1,7cX Ilia
4
PI-c P a 5 ¢ ~
Ile
aw~5
s Ali, 4 l~
0
o °
0
iio ' /o a 7'
*IVY
"94 402'
Plb. # 60
1/78
PROJECT DETAIL DATA SHEET
NAME OF BUSINESS r o Ca 4 Le ~w`~"w~ e w` 1
LEGAL DESCRIPTION fj/f=
OWNER Gro - MAILING ADDRESS //SO .~a.ucs 5f
n 17dmm Gc%ZIP .6 6 /S
, CoJu r - o w z vrs ADDRESS q~ 9 / ~5 1~ we.
PLUMBER tR-DESTG1,ZR
/1 ora J ,c, , LJ.rZ I P 5 yo I
TELEPHONE NUMBER 7/5 -,;1 ~C( - S/'S
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed. Please consult Section H 62.20.
Existing building New building _VAddition
( ) Apartments and condominiums . . . . Number of bedrooms
( ) Assembly hall . . . . . . . . . Seating capacity
( ) Bar . . . . . . . . . . . . . . Seating capacity # of meals served
( ) Bowling alley . . . . . . . . . Number of lanes ( ) With bar
( ) Campground and camping resorts . . . Number of sewerea sites
Number of unsewered sites
Total number of sites
( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons
Catchbasin ( ) Day and night Number of persons
. Number
( ) Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons
( ) Dance hall ( ) With kitchen Number of persons
. Number of persons
( ) Dining hall . . . . . . . . . . . . Number of meals served daily
( ) Dog kennels . . . . . . . . . . . . Number of enclosures
( ) Drive-in restaurant . . . . . . . . Inside seating capacity
Car-service Number of car spaces
( ) Dump station . . . . . . . . . . . . Number of dump stations
Employees ( total of all shifts) . . Number of employees la
( Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2 persons per unit
Number of units with 4 persons per unit
( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff
Number of office personnel
Number of patients
( ) Mobile home parks . . . . . . . Number of sites
( ) Nursing homes . . . . . . . . . Number of beds
( ) Parks . . . . . . . . . . . . Number of persons ( ) Toilets ( ) Showers
( ) Restaurant . . . . . . . . . . . . . Seating capacity
( ) Dishwasher and/or disposal?
Retail store ( ) 24-Hour service
Schools , , . Total number of customers
. Number of classrooms __FT Meals ( ) Showers
( ) Self service laundry Total number of machines
( ) Service station . . . . . . . . . . Number of cars served daily
( ) Swimming pool bathhouse . . . . . . Number of persons
( ) OTHER . . . (Specify) . . . . . . .
COMPLETE OTHER SIDE
2. Indicate whether the following facilities are present.
Floor drain yes no Number of drains
Food waste grinder yes no
Dishwasher yes, no
Automatic clothes washer es no Number of clothes washers 11/
3. Septic tank capacity C/390~
Holding tank capacity W ,
Septic or holding tank manufacturer ( Jk) D ~
4. total square feet width of trenches
length of trenches depth
number of trenches
SEEPAGE BEDS: total square feet _ /7 width is
length of beds depth 3.77
total square feet outside diameter
depth below inlet
total depth from top to bottom of pit
Signature of person completing form: FOR DEPARTMENTAL USE ONLY
-Dip
Address 9 50V-R.
Telephone Number 71 o2`r~G_ ~-J~/~3.5
Date
II
i
Sy4 40235
• j~
j I I N00.37'15"E
I 1 308.26'
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PAGE OF
r
CrUSS Sec~IO0 O~ SyS~er+-~
xii
Fresh Air Inlets And Observatlon Pipe
J Approved V64(i Cap ! A` ".w ~o «
Minlmwn 12" Above
Final Grade
20- 42" Above Pipe Caetf,lrpn
To Final Grade Vent Pipe
4
Marsh May Or Synthetic Covering
Ytn. 2" Aparepale `1ti' Q
Over Pipe t~
01atribullon -Tae 0~~ GO
Pipe -1 9 o 0 0 o 441•
Aggregate
!
Beneath each Pipe o Perforated Q Pipe Below ~v
o -Coupllne Terminating A
Baltotn Of Syalem
Pru(~ose~ ~1~~~ `9rcJ(
SOIL FILL
DISTRIBUTIO}.I PIPE
APPROVED $tf►JIHETIC COVER
cam, - e ° "-'-M I1Tf R1^t- OR 9" OF STRAW
OF MCYREGMa OR 1JARSN NA`J
(o' OF J2 -2t/2 AGGREGATE
tLEV. OFW-.7 FEET
3 ) --3
DI8TR15'JTIOIJ PIPE TU BE AT LEAST _ IIJC,HES BELOW ORir iQAL GRADE
AQU AT LEASTZO IIJCHES BUT I,10 MORE THAIJ H2 IAICNES BELOW FINAL GRADE
MIXIMUM WN OF EXCAVATImw, Rom ORI& NAI 6KADR WILL BE IIJCHES
IAII41MUM W " of EACAVATIOM FROM 01KI61WAL GRAPE WILL BE -L INCHES
L1C.EUSE DUMBER: ~
a DAT E : L ` l3 / /
P/C)I- 0 a ys'- AA!F
• / l ~ Gv~y ~y~-. u~c~S are
~a~r~s s~, mat 1
11.56
~1(c~ m mcs-r mil/ s y d/ S94 4(,?
A 15e,~
Sca-Qe. J ~ o,
6 ,~,.~►J~6caral~-,.a..
.6,W)g pate
0?0
y 9t X sC~? aoo ,
+ -7,50 ~-I rte-
~zs
go
rw~sw ~S 63
r
70
t7 Q ! S 6.5e Llf-
9 s-
PRIVATE SEWAGE SYS•I-EM-
Conditiona ly
AFr
DE!'i. OF INDUSTRY, LAor6R & as~iS tl 1
OIVISIOINI F SAFETY A
4
SEE CO
1
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,
LABOR AND BOX 7969
PERCOLATION TESTS (115 DIVISION
HUMAN RELATIONS (H63.09(1) & Chapter 145.045) MADISON, WI 53707
LOCATION: SECTION:p r TOWNSHIP/
~LITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
HE ' !%4 22 /T29 N/Ptgx ~ (or) W Hudson
COUNTY: OWNER'S B AME: n/a n/a n/a
MAILING ADDRESS:
St. Croix Dave Waldroff 398 River Rd. Hudson, iii. 54016
USE
NO. BEDRMS : COMMER IAL DESCRIPTION: DATES OBSERVATIONS MADE
❑Residence n/g trk garage New ❑Replace PROFILE DES RIPTIONS: ER CATION TESTS:
6-2-92 6-2-92
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL. MOUND• IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
S OU 1 Fyls ou x S 11 ❑ S r-xU ❑ S DU conventional
rufn Percolation Tests are NOT required DESIGN RATE:
de r s.H63.09(5)(b), indicate: If any portion of the tested area is in the
n/a Floodplain, indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS
4,111iij;re 58 PEA.
BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL
Vii I 1 11 THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 84 101.52 none >84 -13-, 10yr2/2, L.; 13-28, 10yr4/4, sil.;
8-32 7.5 4/4 l.s.• 32-84 V >m514 co .s.
B- 2 96 101.62 none for -12, 10yr2/2, L.; 12-25, 10yr4/4, sil;-
25-30, 7.5yr4/4, l.s.; 30-96, 10yr5/4, co.s.
B_ 3 86 101.79 none X86 0-12, 10yr2 2, L., 1 -2 , 10yr , si
24-30, 7.5yr4/4, l.s.; 30-86, 10yr5/4, co.s.
B_ 4 84 101.55 none X84 0-13, 10yr2/2, L.; 13-24, 10yr4/4, sil;-
24-28 7.5 r4 4 l.s.• 28-84 1 5 4 c s
B- 5 86 101.12 none >86 0_12, 10yr2/2L L.; 12-28, 10yr4/4, sil.-
B-
decial' PERCOLATION TESTS
NUMBER I EPTH . AFWATE TERSWELOLING INTERVAL~MIN. PERIOD t DROP IN WATERER ODE2 EL-INCHESP R PER INCH
RATE MINUTES
P- 3.50 none 3 6 6 6 <3
p_ 3. 0 none 3 6 6 6 <3
p- none 6 6 <3
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.
SYSTEM ELEVATION 98.02
-
00,
Vs
V~S
3
w E
=3
t . ,
I, the undersigned, hereby certify that the soil tests rep r n this for evade in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and th ion of )t e 1,i s ~rrect best of my knowledge and belief.
NAME (printl: '°f1bbb"<I C`
TESTS WERE COMPLETED ON:
Gary L. Steel
-2- 2
CD ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200tb Ave, New Richmo 2298 5-2,46-6200
s CST S AT
ell
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
Tc - coinplet° and accurate soil test, your report must include:
1. C iption;
2. st clearly im.- icate whether t`ds is a residence or commercial project;
3, M/ 'i ber of bedroorns or comm planned;
4. Is this a or t vlacement system; .
Coral:" 1, tability rating boxes. A SITS iS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHEII .,,;I -MS ARE RULED OUT BASED ON SOIL CONDITIONS;
6, PLEASE use the abbreviations shovvn here for writing profile descriptions and completing the plot plan;
7. N KE A LEGIBLE diagram accurately locating your test locations. Dvd ving to scale is preferred. A
T sheet may h used it desired;
8. Mr sure your b<,-chi-iark and vertical elevation reference nt are c Nn, and are permanent;
9. Complete all apI c, e ~)xes as to dates, names, addi td plain ?rcolation test exemp-
tion, if appropriate;
70. If the inforrnation (s :h as 8004, elevation) does t ly p"~'ce N.k in the appropriate box;
11. Sign the form ari ' ' osrr Ct. dress and your c ,rt. 1 lumber;
12. Make legible cop',- ~ distri' U ~ required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORI- Y','VITHIN 30 t YS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
S id Textures Other Symbols
st 5 td„~ BR - E- Brock
col: Cr=,) S`u tone
gr _ Gi 6 r 3") LS - L
"s S> HGI+V - ri
i .
Rer.^ - in
cs C:
r Ied s
fs B: dg
Is t
5I <
P-
s 1 .
l BI
si Gy -
cl am y
I-Oalc R
r mot
fff
=:;c
tat ruin
d
p pr
I
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VRP V
TO THE OWNER:
litary r0cUest
T; l T 15
r'ate
t; , to
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er
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Z Co z
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rn d ° cu
d G w U C
H
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Z > - O N FN- H H = 3 U
= o 0 o a s z
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a _ m
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= rn 73 rn
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