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HomeMy WebLinkAbout020-1176-70-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNE ADDRESS ,'u P1 4"~ r ~I , c~v 7' Sr C/0;2 .1- SUBDIVISION / CSM# LOT # J SECTION_j_T2? N-R__ZY_W, Town of ~ /n- ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~zr 2 SCA I< T = 1. ovo' f'~ 0 k INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. s BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~c1 Liquid Capacity: ^~cr Setback from: Well House /t Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length o Number of trenches Distance & Direction to nearest prop. line: ' /.5- Setback from: well: House-,F4 Other ELEVATIONS Building Sewer _01,?. ST Inlet. fy, /a ST outlet ~Z- PC inlet PC bottom Pump Off Header/Manifold 7 Bottom of system rr . 7. Existing Grade''. Final grade %.d DATE OF INSTALLATION: PLUMBER ON JOB: -T LICENSE NUMBER: INSPECTOR: 3/93:jt o ds 5 ~~e Neva n SANITARY PERMIT APPLICATION ~'L" R COUI In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PER # -Attach complete plans (to the county copy only) for the system, on paper not less than (a 7 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. PR,9~P_ERTY OWNER PROPERTY LOCATION Gzf l t r~~ ,aYc :E A I W % 5 S ?s' T.; N, R / E (or PROPERTY OWNER'S MAILING ADD SS LOT # BLOCK # _::F02 X1 I 1 CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR M NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROgD~ ( ) ❑ State Owned VILLAGE : 4OWN OF: ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms 7 PARCEL TAX NUMBER(S) , III. BUILDING USE: (If building type is public, check all that apply) 1 f~ a 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. TYP~ryE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 511 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 M Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION c 7--)G 7,>o 3• X Feet , y Feet CAPACITY VII. TANK Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xistin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holding Tank F1 Q 1 F1 El Lift Pump Tank/Si hon Chamber VIII. 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 Sta ) 1QtP/MPRSW No.: Business Phone Number: P umbers Address (Street, Cify, State, Zip Co )r s' - Wr t/> tr IX. COUNTY/DEPA MENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent SigT amps) Approved El Owner Given Initial Surcharge Fee) , r r Adverse Determination X. CONDITIONS OF APPROVAL/ E`e#]}'SONS FOR DISAPPROVAL: I SBD-6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber sT 1 fi f.y ♦ c ta13 t l.a i tat Aat».A»4a4 l~.a.ka+ a l a al~R. 1. l.d. . . a 4 ♦.f i ! d t A.t»4 i l 1."t'A,4Pl•L,l.a♦»AiE.at c•l fil ll~l l !la ! t t- 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 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. 11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing.plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) AIX i DX1IE FOMlry PLtl11 ONG Limrd,ed ftA Testes PWnbar f Ri I - „ sp `1 n id ROBEI~S. ~~N~IN 54023 phone 749-3656 1/7 T Hof ~ ~ ~ `l ~ , i C,~ x 717 ?I CGS r6m9 . ® - we!( > $Br S T, A,/ (©YHers - ~UVNCI 1 (r1 ~ a vI 4 i i• ~ g { ~ •n sn z - ~ zG en # j f 1 j. . i Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor aril Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: pp City ❑ Village aTown of: State Plan o.: T.W. HOMES-THOMAS & LINDA HA SON X CST BM Elev.: Insp. BM Elev.: BM Description: HUDSON Parcel Tax No.: , Zo /Old a' 's-C Q as o&t A9400303- TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 5,3(1 /4~.~/v r Dosing C/ r i Aeration Bldg. Sewer Holdi St/* Inlet 07 TANK SETBACK INFORMATION St/ W Outlet Vent TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet Septic „C(j f NA Dt Bottom Dosing NA Header! Aeration Dist. Pipe 2~ Holdi Bot. System 9~z 5 ~ PUMP/ SIPHON INFORMATION Final Grade Man Demand Model Number GP TDH Loss System TDH Ft Forcemain I Length Dia. Head Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length / No. Of Trenches PIT _ No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~o~ DIM N I N SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHIN Man urer: SETBACK INFORMATION Type O e.A.) CHAMBE Model Number. System: !E%~ ~lo C~- OR U DISTRIBUTION SYSTEM Header/Manifold / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing (y SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S s Depth Over Depth Over xx Depth Of xx Seeded / Sodded x Bed/ TImMOKenter -~JS Bed /+rw~-Edges V.-`3F`1 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.28.29.19W,NW,SE,LOT 8,ALDRO RO / Plan revision required? ❑ Yes No Use other side for additional information. 41 19 1 SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: _ I I SANITARY PERMIT APPLICATION V'~f7~1 In accord with ILHR 83.05, Wis. Adm. Code coin T STATE SANITARY PER # -Attach complete plans (to the county copy only) for the system, on paper not less than a L j 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. PROPERTY OWNER PROPERTY LOCATION E (or )dV 17 W. L NGd'/a 5'/4, S ..5-S T2 , N, R PROPERTY OW ER'S MAILING ADDRESS LOT # BLOCK # !J CIp. ST &E ZIP CODE PHONE NUMBER SUBDIVISION NAME OR M NUMBER l °v Fu I/s w~ o.) ~ y~ X _Z 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD / State Owned O VILLAGE : N OF: ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) D .ZG _ l7~ _ 7D 1 ❑ Apt/Condo 2 F] Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. Z New 2. ❑ 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 21 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION --v 7~o 710 S:8' Feet 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 F1 F Septic Tank or Holding Tank l C{ Lift Pump Tank/Si hon Chamber El El F] I [I El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu er's Name (Print): Plumber's Signature: (No Stam N11/MPRSW No.: Business Phone Number: / r u _ . 7 ? 6 P mb ' Address (Street, City, State, Z p Co d / ZpO IX. COUNTYIDEPAFrrMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signatur mps) Surcharge Fee) Approved ❑ Owner Given Initial 0 -2 ~ / ' y Adverse Determination X. CONDITIONS OF APPROVAL/ ONS FOR DISAPPROVAL: 4-11 SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety A 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,Saniitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ¢#1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) SANITARY PERMIT APPLICATION w'~'■i r~'i coPr ~lU~ In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than AN ~G7 7 8t% z x 11 inches in size. 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. PRQEERTY OWNER PROPERTY LOCATION S TX- , N, R/ E (or PROPERTY OW R'S MAILING ADDRESS LOT # BLOCK # j r/. TY, S TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR68MilHMBER d; 11. TYPE OF BUILDING: (Check one) 13 CITY NEAREST ROAD n ❑ State Owned VILLAGE dw: !a ❑ Public 01 or 2 Fam. Dwelling-# of bedrooms 23 PAR EL Ax NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 7 a 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. Q New 2.E1 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 430 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 V.P* 72-0 M. d Feet 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 t Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew system shown on the attached plans. Plu is Name (Print): Plumber's Signatures) MP/MPRSW No.: Business Phone Number: Pd isAddress (Stre , Ci , State, Zi Code): o r s Z3 IX. COUNTY/DE AR MENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Si s) 0 A) Surcharge Fee) C pproved ❑ Owner Given Initial 7 V Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 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, 6OB-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new arid/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. , MP, etc.), address and phone number. Plumber mus4 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) Fc~Ea~r PLUMB" / DAME plumber Lkens/d park Tester N3233 No ! u sp ~ 23 ~y so ~ ~ Phone 749-3656 Tw, 41 ; i I 1 l - !Lt~ *Z ,N 3 Q / t i Z E y6 # x s / ivs~ s/s , rt'p, . = we/( t > Soy 's' s' T' /o/ co;- er5 - 4u,w. ST• - ~ ~Oa y'4 / • ~ 3 Ld rv~ - e l v . _ ~ 1 1 Ir/14f j 4000r/H/rL/ . n ~ H MET Im e- r I Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page-of Labor and Human Relations Division `of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION A U/ cs GOVT. LOT vu/ 1/4 S,c- 1/4,SZp T ~ AR ~ E (orev PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUB D. NVE OR CSM s /c O /y1n /f/ r i S ¢ CITY STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEARES ROAD New Construction Use Residential / Number of bedrooms -3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate _bed, gpd/ft2 . ? trench, gpd/ft2 Absorption area required 7z19 bed, ft2 SE'S trench, ft2 Maximum design loading rate bed, gpd/ft2__,,r -_trench, gpd/ft2 Recommended infiltration surface elevation(s) 9 5;-, d ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND 71GIROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK El S U U= Unsuitable O S ❑ U ❑ S O U S U El S U S oil SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bounclay Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerlclt Nrolund elev. ft. Z. Depth to limiting _ factor 3 S~ S S / 4 S - .Y , d y S .7 Remarks: Boring # Ate: w.u 9Ground elev. t V'j_ ft. Z z -3 3 ~rJ / Depth to limiting 3 Z /02 f S © S" _ 1.7 factor Remarks: CST Name: Please Print / Phone: q` r r ~ 3G ~ ~ Address: 6~ ~1 a 3o T~ Signature: Date: CST ber: Z-1 17 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # ' Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ' 3 l ! round elev. ft. < K t~ r S Depth to limiting factor 3 _ o s- S f / Remarks: Boring # ,zK -'Ground elev. Z 6/~ f9~~ft. Depth to limiting _ factor (77,9 E41 Remarks: Boring # Ground r elev. ft. /-s 3 c` w fja vx r + ,s Depth to limiting S m S / _ - ,8 factor Remarks: Boring # Ground ~f { ~a /goo elev. A ft. Depth to limiting factor L Remarks: SBD-8330(8.05/92) f 9233 402 U_ ~Mty ; AORE sm S 023 ~s. M~ INtpne 7+9-3656 ~~y 1 j w , J~~r cS' l93 •`~1 ,t o "V VE \1 , x,26 - - i 1 , XI a 1 / I ado A \ I I r i f ~al~ l = yo X ~ - d = 8jjl~ asl K Lo f IL ro r m -m f X .~1~ = 9G•d'~ ly f le"r, e r~ _ ,00 '89 ' O + 3.EZ.O9.89 N ID I %p c .00 99 0 40 3..£Z .09 SONi I C 0 ! o ° II v I o N vo ~ I I z 10 ti i" I J in I o I ~W a i lz 1 II ? .00'Z4r I I 0 Y 1 i 4 ° 0 I I .8'693 o w~ M o~ m I I NI ° ° 3,EZ.05,B8 N n 2 .00•Z4v I > ' ! M I I I to ! Q ° I f No 160 ° c+1 o " I V) 3,Sf,9E,BB N ~ I I ("m I .Sf'69r I q p I ! p 3,£3.09.89 N ly m° .00'34r Z 1* ! 's S` Lr) 0 10 C cv O ; / N I 3,so.eo ce s mI OL EGr z 63eq 9~' \ ' H I ' ~~p CO O Io I I _ S` N ! / O 3.90.EO 48 s ! j 4 e~ cl.9L'Sr3 I I O ° ~ I N -,00'O£I --~i I 8L S£'OLS .09'493 1 .00'348 209V.L6.68 N (2 d' tw ~ 3 y STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~t ffN# S 1 ' I.J, 4. 5 A, MAILING ADDRESS 2 0 C? S V4 A14T0 12 s r, W PROPERTY ADDRESS S C ei(~'I2 1 ~l S 5 I(A~ez (location of septic system) Please obtain from the Planning Dept. CITY/STATE 12,; t/ Aj E %y PROPERTY LOCATION 1/4, 1/4, Section 0 T N-R W S TOWN OF LS•d~- ST. CROIX COUNTY, WI Alr SUBDIVISION (r G~- ~f i ll S LOT NUMBER CERTIFIED SURVEY MAP , VOLUME PAGE LOT NUMBER d Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiratio date. SIGNED: r/1".1 DATE: Z'l Y g St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 r S T C - 100 U • 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 1 :,A- ZTW, 4me,3 Location of pro erty 1/4 1/4 , Section T~N-R /Z 1 W Township Mailing address a /C Address of site ,e-s 5 191dro d_ Subdivision name _ ZGOCI4.,L di' dl ~S ley Lot no. ~ItitC~SD~ Other homes on property? -Yes No Previous owner of property & Total size of property _ 3 t- Total size of parcel 3 t Date parcel was created - / - Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? Yes _Z No Volume / ~l and Page Number 33:7 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the o fice of the County Register of Deeds as Document No. 5 Z p 8 y 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. _S~- o d y 2-- Signature of Applicant Co-Applicant Date of Signature Date of Signature i von DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA • STATE BAR OF WISCONSIN FORM 2 -1982i 52-0842 , ST. CROIX CO., I Reed for RFCord Len Company Inc' a Wisconsin Cor oration - 11 - . . - - W - I' AUG 3 0 1994 - 4:15 P. at M - - j conveys and warrants to "TW" Homes. Inc.. . I' RegiStefofDeeds RETURN To the following described real estate in St-. Croix County, - - State of Wisconsin: Tax Parcel No Lot 8, Cedar Hills Estates in the Town of Hudson, St. Croix County, Wisconsin. i This is--not--------- homestead property, i(k{: (is not) Exception to warranties: easements, restrictions and rights.:of way of record, if any. Dated this day of ---August - 19.._94. Len Compa , I •----•------.---•----_-----.(SEAL) .Bye - (SEAL) * ..--.Robert--Lenertz,--Pres3dent_---------- (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN SS. County. authenticated this day of_____-•______________ 19 Personally came before me this day of --------------August_._____ 19-__94. the above named * Robert Lenertz TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to.be,itibe,,person who executed the foregoing i ar c powledge the same. THIS INSTRUMENT WAS DRAFTED BY Joseph D. Boles -Attorney at Law y.: River Falls, WI 54022 (715) 425.7281 - - Notar . County, Wis. (Signatures may be authenticated or acknowledged. Both My' Cd~f~il~i . ~ nt. (V not, state expiration are not necessary.) 7 G date 19__/_~) Op ~~~SCC *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 2 - 1982 Milwaukee, Wisconsin ST. CROIX COUNTY WISCONSIN E`er Nampo ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER , 1101 Carmichael Road Hudson, WI 54016-7710 K (715) 386-4680 October 28, 1994 Metropolitan Federal Bank 200 East Chestnut Box 8 Stillwater; Minnesota 55082 ATTN: Sandee Barth RE: Septic Inspection for T.W. Homes Lot 8, Cedar Hills Dear Ms. Barth: An inspection of a septic system for T.W. Homes was conducted on October 28, 1994. This property is located in the NW; of the SE; of Section 28, T29N-R19W, Lot 8, Cedar Hills Estates, Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions with regard to the above, please do not hesitate in contacting our office. in erely, ..y,; 7 James K. Thompson Assistant Zoning Administrator St. Croix County, Wisconsin mz