HomeMy WebLinkAbout020-1189-40-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER/5 ,_'h' A~,je w e e
ADDRESS Ct~yo
l
~a.-~~~ c.~ lam, r 1
SUBDIVISION / CSM# LOT # o~
SECTIONT ZV N-R l
Z.L , Town of
l'ry
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
HOW EVERYTHING WITHIN 100 FEET OF SYSTEM
M
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J^VYAT/
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tot
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form-
Provide 2 dimensions to center of septic tank manhole cover-
1
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BENCHMARK : , SGr~r~ C S / /
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~j, ~dWesr Liquid Capacity: ~~6 U
Setback from: Well ~S"~Q House_ Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: J.~ Length 7 Number of trenches 3
Distance & Direction to nearest prop. line:
Setback from: well: House~I Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
~-T
PLUMBER ON JOB:
LICENSE NUMBER: INSPECTOR:
3/93:jt
L Labor and Human i Relations ~r 4*?VASh 9F D??Y§?N County: Safety and Buildings Division INSPECTION REPORT
(ATTACH TO PERMIT) sanitary ermit o.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village 1kTown of: State Plan o.:
ev.. Insp. BM Elev.: BM CDescription: 1~/,e ~s Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9400056 G Z/ 7 9
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ///7,-0116-{C_.-.-? r o 2 Benchmark
Dosing
Ay, oZ 1U, / '
Aeration Bldg. Sewer ` ~
Holding St/'Inlet Z y'~ , 6/
TANK SETBACK INFORMATION St/ ICE Outlet S d;' g(o,/~
TANK TO P/ L WELL BLDG. VVe stake ROAD Dt Inlet
NA Dt Bottom
Septic >-570
Dosin NA Headers-- 9-57 x.309
Aeration Dist. Pipe 3,1 a0 Ile Z-19- 91, r
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grad
d^ Y t
g<
Man turer Demand f1r
Model Number
TDH Lift Frictio
Forc main Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Widths v Lengtfi / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 13 1 DIMEN I
LEA Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM
INFORMATION Type O 1774-v 1 , , h 3 CHAMBER umber:
System: c..yt~(Q. OR
DISTRIBUTION SYSTEM
Header/Manifold + . Distribution Pipe(s) x x Hole Spacing vent To Aj~ Intake
Length Dia- Length _(&Z Dia. Spacing I-
SOIL COVER x Pressure Systems Only xx Mound O7At- Grade Systems y
Depth Over „ Depth Over , xx Depth Of xx S ed / Sodded xx Mulched
E] f}ed /Trench Center ~p Z Bed /Trench Edges V - o E] Topsoil Ye s ❑ N Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 28.29.19.1190,SE,NE,ALDRO ROAD
ONO
Plan reisidr r>' equi'L No /
Use other side for additional informs 'on.
SBD-6710( 05/91) Date Inspeto.r s S' aur /I Cert No.
--~--r~.% ~QCv _ ~Z7 ICJ ^ ~ : f l-A ~.a ,cC ' Q~ ~ ,fir . ~2 ~C~ ~ ~(i'=~'✓-~ ~,o ~.~r~,c..~-, , _ atJ-~~(.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
e
d2 lf~.P ~¢~~s" k`- ,'fir -3`~" ~_~r¢ ✓-+~°ea
SANITARY PERMIT APPLICATION
V~LR In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~1 57-
STATE SANITARY PE IT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ~ ~X08
8tr~ x 11 inches in size. L<heck 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 4+ '/a,S f Tc?? N,R E(or ,2 jo~ a e- _5Z PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
7 1? Xa/"I-aV at cc/*,
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
~f(a.s.rr w c adav /Y'.`/s 7-
_0 111. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE : Qf~ dy,o
❑ Public [U1 or 2 Fam. Dwelling~# of bedrooms PAPq TOWN OF: RCEL TAX NUMBER(S) G°
III. BUILDING USE: (If building type is public, check all that apply) r~o~~- l 8Q ._yd
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 120 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.E] 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 420 Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) o ® ELEVATION
QQd Xo/DI- f2' Feet dr Feet
VII. TANK CAPACITY Site in altons Total # of Prefab. Fiber- Exper.
INFORMATION New tsttn Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App structed
Tanks Tanks P d~G 17- F1 1-1 F]
/9400 ( Septic Tank or Holding Tank 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 (Print): Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Co e):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing Ag t nature (N tsAps) -
Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination J
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
SANITARY PERMIT APPLICATION
COUNTY ' I~'el`r■Ir,. In accord with ILHR 83.05, Wis. Adm. Code
MIT #
STATE SANITARY PE[ -Attach complete plans (to the county copy only) for the system, on paper not less than BQ
8% X 11 inches in size. heck 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
S 2f T.1 C7 , N, R /Pr E (or)6
BLOCK # ' PROPERTY OWNER'S MAILING ADDRESS R/ LOT #
.3 ^rl-ovG/~rel p- 12
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~adsr rv W ' ,S /G C cd*v ff,,/S --7-
0 TYPE OF BUILDING: (Check one) CITY / NEAREST ROAD
11 State Owned R TOWN OF: I TILLAGE : ouo-~.!/ 4 dVo
❑ Public Fill 1 or 2 Fam. Dwelling-## of bedrooms -y- PARCEL TAX NUMBERO f _
III. BUILDING USE: (If building type is public, check all that apply) o p a_ -yd
1 ❑ ApVC4ondo
2 ❑ Assebly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Cam ground 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. N New 2. ❑ Replacement 3. ❑ Replacement of 4: ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ® Seepage Trench 22 ❑ In-Ground 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) v ELEVATION
46w 161d d 44 a 8- lp-' Feet V~+ 57 Feet
VII. TANK CAPACITY Site in altons 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 Holdin Tank 7'
Lift Pump Tank/Si hon Chamber El D El I [1 1:1
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) VMPAPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
r_6_77 141?_e1#f
IX. CO /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater [ate ssue suing Ag t ature ( t Surcharge Fee) Approved ❑ Owner Given
Initial Adverse Determination
X. COND TIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
y SBD-6398(8.08/93) DISTRIBUTION Original t Safety & to County, One Copy ! To: Buildings Division, Owner, Plumber '
, xn Vn'6'4 s~4''F y'4.*3~. 4 t 1 t1.4 1 'i 4 4~1"k I* 4V4, l+1, 1-1*i'4'4 4~4 }its. ip
a
INSTRUCTIONS
f ~ w
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, 60,B-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
repai r.
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 muss: 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)
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.
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.
I SBD-6398 (R.11/88) ^ AI
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SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code C(OK
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than O
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.
r~ PROPERTY LOCATION iZty
PROPERTY OWNER (3 j
S.1 T,- , N, R / E (or
PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK #
7f.3 A le -41'e
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned ❑ VILLAGE ~ ~4_~
❑ Public ®1 or 2 Fam. Dwelling-#~ of bedrooms ~ ARCEL TAX NUMBER(S) G~
Ill. BUILDING USE: (If building type is public, check all that apply). - /V
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 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. VSI-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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Od 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
d o~ Q .cJ- 9-Z- o Feet 9j'r ~a 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 old FK- El FT _L2
_9~-1 Fj F-1 L:]~ ET
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
PRSW No.: Business Phone Number:
Plumber's Name (Print): Plumber's Signature: (No Stamps)
7.gr I (
oil/. a c r- - ?/.S f of
Plumber's Address (Street, City., State, Zip Code :
i
Id ;7,d -5-,d 0 Z20-_jVd A4,; 016e
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sry Permit Fee (Includes Groundwater ate Issued Issuing Ag t Sign o mps
/ ,
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination l// r-
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite seWELge 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'/s 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 (8.11/88)
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page/ of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
- COUNTY '75rr Can Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 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
P ERTY OWN R: PROPERTY LOCATION
BIQ OV) Ems. GOVT. LOT S,LZ 1/4 t4C 1/4,SZ2(T 7-9 N,R 1~ E (or) W
PROPERTY 0 NER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR1,CjSM #
d C,t Q-C-Lc 7- C E 4vv2 N ► LLS ESQ jQTQ 3
CITY TATE ZIP COD PHONE NUMBER ❑CITY ❑VIL E OWN NEAREST ROAD
Xv d~>rJ W1 cv 6) `/vbSow eru ' wlk-
~Q New Construction Use kj Residential / Number of bedrooms 3 [ J Addition to existing building
j J Replacement [ J Public or commercial describe
Code derived daily flow gpd Recommended design loading rate 0.4 bed, gpd/ft2 O'4 trench, gpd/ft2
Absorption area required / J 'Z5 - bed, ft2 OD trench, ft2 Maximum design loading rate gibed, gpd/ft2 (3.6 trench, gpd/ft2
Recommended infiltration surface elevation(s) oN PA4e 3 o R 3 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 IN-GROUND PRESSURE AT-GRADE SY TEM IN FILL HOLDING T K
U = Unsuitable fors stem [XS ❑ U KS ❑ U L~St: S ❑ U S ❑ U ~S ❑ U ❑ S U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bouinday Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
iaYk 3 Z SL c r Z O q 0.S
< SL r 1 O.S~
0413
Ground Bz 14-S1 6 r24 4 s rh r ell C f 0.7 O
4 elev.
$ ~~-11~ ~o re s 4 s n, 1 6.7 l
Depth to
limiting
? facto
F-F I I
I
Remarks:
Boring #
a Z. S f1i c r fill 'Q 0 4 0.5
?N,
Z rA
/6 >~4 3 S L n4 C 16\14 4-1 Ground
i Z3- 4$ 4 S d r►, r wt c 1 Q.7 O
elev. 6\1A S 5 r 1 1 .S O
c.19 ft.
Depth to
limiting
factor
lD*00
Remarks:
CST Name: Please Print \QWNSD^j Phone:
Address: tN U +~SD •.1 f'SGatJ51 N ~t0
Signature: Date: i 2 94 CST Number: ~4g4
I- ~
PROPERTY-OWNER iJl~l HAAUEU- SOIL DESCRIPTION REPORT Page? of
- PARCEL I.D. # LaT 67- CEM k 6.(1 a:5
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
n;:rik 4? Q
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER &
MAILING ADDRESS 7 V Y zi r Le y C i`y' c i -e
PROPERTY ADDRESS 7G 4 aD
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION S'am' 114,A ~ 1/4, Section T__gg _N-RZO'_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION Z-', 7- LOT NUMBER _e~2
CERTIFIED SURVEY MAP , VOLUME PAGE S-q LOT NUMBER.~- Z
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.
l/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 expiration date. 1
SIGNED: .LG c,~ y~7it'L~~~kt'
DATE:
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 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 aW 'Ayelir la-e-l/
r
Location of propertySt 1/4e!~&E 1/4, Section T 2 f N-R~W
Township imbeds s~ Mailing address ' 9.3 441A ep-
l~K..tsu.v ,.s ; 3 yD'r.G'
Address of site
Subdivision name Lot no.
Other homes on property? Yes_kg~ No
Previous owner of property ~A~,
Total size of property r 7 C e
Total size of parcel y--7,6
Date parcel was created ,oelv /2 Zd -IZE2
Are all corners and lot lines identifiable? Yes PC No
Is this property being developed for (spec house) ? Yes W No
Volume '7y' and Page Number,'FY6w 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 office of the County Register of
Deeds as Document No. , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signature of Applicant Co-Applicant
Date of Signature Date of Signature
y DOCUMEN I NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING oArA
` STA'r E BAR OF WISCONSIN FORM 2-1982
wry REC9~r s G:',1 01-4:1CE
432050
1J6naW's ST. cRow, CO., WI
- Recd for Vocord
J. Francis Larsen, F.A. Larsen, F. Iola Millin McDiarmid, Nov. 10, 1987
Jean" M. Stewart, L G. Millin, Jay Taylors Lael V. Taylor 10:45 A M
Schneider.,- Burt F, Taylor,. Eleanor•.Hatch..Zurn,. Lois
Hatch,,Dorothy Hatc o e is h as*
conveys and warrants to edar Hills-Develop -
T en t., Inc. a Register of Deeds
Wisconsin corporation
i RETURN TO
the following described real estate in ...........`t. CYOix County, !
i State of Wiscsnsin:
Tax Parcel No
The NJ of the NJ of the SEI of Section 28-29-19, except the South 106 feet of the East 565
ifeet thereof, and except a parcel of land located in the NEI of the SEI of Section 28,
;.T29N, R19W, Town of Hudson, St. Croix County, Wisconsin, described as follms: Commencing
at the El Corner of said Section 28; thence S8903714611W (asslmed bearing referenced to the
monlmented East-West } Section line of said Section 28, bearing assumed S99e3714611W)
23.781 along said East-West line to the point of beginning; thence continuing S89e37146"W
'1301.481 along said line to the West line of said NEI of the SEJ; thence S 000314411W
661.631 along said West line; thence N8903414811E 761.971; thence N 0005112"W 100.001;
thence N8903414811E 535.401; thence N 003013818 560.561 along the Westerly right-of-way
'line of U.S. Highway 1112" to the point of beginning.
NEI of Section 28-29-19, except that parcel described as Lot 1 of a C.S.M. recorded in
Vol. 3 of C.S.M.1s, page 862 as Doc. No. 359579 and except that,parcel described in Vol.
583, page 527 as conveyed to the State of Wisconsin.
This deed is given in full satisfaction of a land contract recorded in Volume 743, pages
185-186, Document No. 413179 in the office of the Register of Deeds for St. Croix County,
Wisconsin, as assigned.
*Personal Representative of the estate of Howard Hatch, by Harry J. Stewart, their
attorney in fact.
is not En
This
homestead property. ~ ZL. q
(j@k (is not)
Exception to warranties: easements, protective covenants or restrictions Efrec~ord1, if
any. No warranties are made hereunder as to the interest of the estate of Howard Hatch.
This deed conveys as to said decedent all of his estete and interest in the property**
Dated this November 87
- day of 19...
**which he had immediately prior to his death ,
and all of the estate and interest in the 1,>LV^a
(SEAL)
property which his Personal Re resentative
P Harty J. SiiteWart1; as At"to>:n~p 3"n
has since acquired. .Fact-.for the.-above.-named gYikbr5-
r`- tsrAL>
J
• #
AUTHENTICATION Q
ACHNOWLEDGM T.,,•,
Signature(s) STATE OF WISCONSIN
SS.
St. Croix
County.
L~1'
authenticated this day oL .........................119 Personally came before me this J--........... of
November 19.8 the above named
Harry J. Stewart
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not
authorized by § 706.06, Wis. State.)
to me known to be the person who executed the
foreg i gstrume It an owledge the same.
THIS INSTRUMENT WAS DRAFTED BY - /L J
Lois A. Murray, HEYWOOD, CARI & MURRAY
P.O.•_BOx-229,_-Hudson,. WI 54016 .
Notary Public - ---------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date:
kn
*Names of persons signinz in any capacity should be typed or printed below their si8natc.rea.
WARRANTT DEED . STATE BAR OF WISCONSIN Wi.-nsin Leg.] lilnnk C... Inr.
FORM tjo. 2- 1982 Ji~i.cAnkcr. Wis.