HomeMy WebLinkAbout008-1039-40-000
C o
O
o C c
0
N
~ I
N i
C
0 (0
C N
C Z
C
7 (6
LL C
O
E ~ Q
U
Co
M
(O LLJ III E
C5 O
OL
Z d d
00 C
y O
C C9 O U_
O Z d -0
U co
.y. O
fn E- y Q) Z
2 E a
o E ci
E V
`o v
• ~l N O O
7 0 U
O
Q Q
O Z Z p
N z
00 III, 0,
M N N
E
CL CO I
M m w O C
(N
Al) OCD T N~ O
° Iq a O C E m
y 0 0 0 z
►yw
CL °
0 o M M (n
N V ~ rn rn ~
Z } rn v
o 0) o
! 0 O O r7 ~ ~ M_
O
y ml d
c En
~ U A
O O y to
00 C - UI C
O R O N 00 ~ 0 O~
i O p H N N C y LL O m 0
y V, V N E
M '6 N N
lvl o a~ 2 N E a
M it M
t2 co M CO 0) o 75 00 Lo
CO y E E U
N ° U') o F~ l'i cn
• °O W S y
~Y C6 a O O
e0 ~
3 EL L: CL
w
r~ E L C C
A v m 2 0 in 0
Parcel 008-1039-40-000 08/24/2007 05:00 PM
PAGE 1 OF 1
Alt. Parcel 13.28.16.199C 008 - TOWN OF EAU GALLE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - HOPP, BRUCE A & CARRIE S
BRUCE A & CARRIE S HOPP
2661 CTY RD N
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 2661 CTY RD N
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 2.100 Plat: N/A-NOT AVAILABLE
SEC 13 T28N R16W 2.1A IN SW SE LOT 1 CSM Block/Condo Bldg:
VOL 2/328
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
13-28N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 984/153 WD
07/23/1997 916/112
07/23/1997 885/192
07/23/1997 879/624
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/19/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.100 22,700 68,700 91,400 NO
Totals for 2007:
General Property 2.100 22,700 68,700 91,400
Woodland 0.000 0 0
Totals for 2006:
General Property 2.100 22,700 68,700 91,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 513
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
,p
OWNER L 0 TOWNSHIP Cala
SECTION I3T N-R,, W . ~~I' Zg• ~lO- q G e'
,--tf
ADDRESS ST. CROIX COUNTY, WISCONSIN
1&)Wj yj Ile or
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
e
yo
oso VA
1~6aG
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: 106,0 60 Hey ~co+
Alternate benchmark II
SEPTIC TANK: Manufacturer: (f~(,1`CS 1~QC~ sf Liquid Cap. Q60
Rings used: Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.: p
No. of feet from nearest road:Front\< , Side , Rear Ft.
s
From nearest prop. line:Front-"&-, Side , Rear Ft._
No. of feet from: Well ,6 d r , Building: 20,
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER ,p
Manuf acturer : $t V f?-06Q S Liquid Capacity: 610 /0
Pump model:CoUld Pump/Siphon Manufact.: 66Q./d Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle
Alarm: Man.: hlro'uy~ Switch Type: Gd' Location
Distance from nearest prop. line: Front, Side_, Rear_Ft.~
-7 7,
Distance from: Well Building
SOIL ABSORPTION SYSTEM
i
Bed: b Trench: Seepage Pit:
Width:_bLength 3 Number of Lines: ~ Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
11
Fill depth to top of pipe:T
No. feet from nearest prop. line:Front Side Rear Ft.
No. feet from well: ?a~O No. feet from building
HOLDING TANK
Manufacturer: Capacity:
1}
I s No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: PLUMBER ON JOB:
LICENSE NUMBER: 3 031
6/90:cj
cA:~pe;trr+tiVf ldu'riy,E 13.28.16.1990, SW SE CO. RD. N County:
Labor arud Human Relations PRIVATE SEV(/AGt SYSTEM
'Safbty and Buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 186548
Permit Holder's Name: ❑ City ❑ Village ❑XTown of: State Plan ID No.:
11 BRUCE I EAU GALLE
CST BM lev.: Insp. BM Elev.: BM escription: Parcel Tax No.: G lt~o G 008-10 -40-000
TANK INFORMATION ELEVATION DATA A9300005 X13
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic CrID/ Benchmark ' 17~~'c~, Cd~~
Dosing
Ae ation Bldg. Sewer
Holding t Inlet
TANK SETBACK INFORMATION St/ Ht Outl c
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet 7J
Air Intake
Septic NA Dt Bottom
Dosing NA F aaiiii* / Man.
Aerati Dist. Pipe 27 2_9
Holding ' Bot. System 96. 95-
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number '-CZ L GPM
TDH Lift 1F~J Lriction, Sy HHead TDH 4
oss t
'1 Di Dist. To Well T
Forcemain Length
16 '
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length. / No. Of Trenches PI No. Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING %anufacturer:
SETBACK CHAMBER
INFORMATION Type O I umber:
System: 5 yam OR UNIT
DISTRIBUTION SYSTEM
di@erelcr'/ Mani f old P Distribution Pipe(s) x Hole size et x Hole ~/Spacing Vent To Air Intake
Length - Dia. 01 I Length's Dia. Spacing 3& I Y`9 I li 7`
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: EAU GALLE 13.28.16.199C,SW,SE, CO. RD. N
~ I
Plan revision required? ❑ Yes 2/No /
Use other side for additional information. S--
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: s
701L R SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couN
STATE SANITARY PER
-Attach complete plans (to the county copy only) for the system, on paper riot less than 1:1 « ~PE
8'f x 11 inches in size. i v sion to Fevicus application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERP OWNER PROPERTY LOCATION
112
pin S &l '/a S
T al~ , N, R A6 E (or
PAP 6
PROPERTY WNE 'S MAILING DRE LOT # BLOCK #
6 V ; h k), 14 1
FaR
PITY, STATE ZIP;C DE* PHON NUMBER SUBDIVISION NAME CS MB
II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE : NEAREST A
[a 4OWN OF:
❑ Public 01 or 2 Fam. Dwellin" of bedrooms PARCEL
TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check Z11 that apply) AD _ S
1 ❑ Apt/Condo (J r
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 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New, 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 P Mound 30 El Specify Type 41 El Holding Tank
12 El Seepage Trench 22 In-Ground 42 ❑ Pit Privy
130 Seepage Pit Pressure 43 ❑ Vault Privy
140 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS ER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
-//50 1 I ~?Sl r l <ZO vc"Feet- d 0 Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic
INFORMATION App
Tanks Tanks structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber,
F1 F] [I I [I I Fj
/
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for ins Ilation of the onsite sewage system shown on the attached plans.
Plu er's Name (Print): P b 's Signatur7rjj4 ps) MR4E RSW No Business Phone Number:
_NAo S W "n 3 5J
Plumber's Ad ess (Street, City, tale, ip C?de):
e 1s 15/o as
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sani ary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signatur
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination tee)
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS .
1. A,sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior tT 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'instailed.
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)
'J
4-1
S
IN,
t195
t
F 7, T,
Zi ,
T ~
LLJ d c+ y v ~
l/~ AGE YSTEM
-v s. \ £ + pplV ATt4s
_ v N
itio ally
Cori
ED
.•1.~ qu@AAN R
1' rS - - - - x - 'arid 0 0~1►nWGS 4
t~ 0u", , 04vI%0% of Af
cap
W
f see cGR~E~ 1
u
I o s ~
~ d
T
SLR ~ •
o q
S.
•r ~
v
J
I
Distribution Pipe Detail For A Four Lateral Network
Alternate Position Of End Cap `
Force Main
P
PVC Force Main
PVC Distribution Pipe
P
S-T
es Equally Spaced
PVC Manifold Pipe
1.; f
X
g0119W
S ~ 11'►a0~
X POD
0~ 1HOUA •S~
- q V15S0~
X of
2 ~
C,0F-B
* Last Hole Shoul Ne o End Ca
* 1 Y P 2 .1.3 Ft.
S "34 Ft.
Inches
Y__JeiI aches
Signed:
n Hole Diameter I ~ Inch
License Number: 3~/ 3 ~ 1
Lateral Diameter 1 Inch(es)
Date: A;
Manifold Diameter 2 inches
Force Main Diameter 2 Inches
Holes Per Pipe
Invert Elevation Of Laterals ~ ~ Ft.
Page - Of -
` Straw, Marsh Hay, Or
`.-Synthetic': Covering
Distribution Pipe
~A Medium Sand 1
611 Topsoil H G
D
_J F
11
GE 3
11 /
l:
T
a
V
1
PH .1 .
Car'1 y SJADO
Y Bed Of - 2 % Force Main Plowed
W'k% 12"
p I,"-na%IAggregate Layer
of 1t1DUS~ Y, Lxoja iLuvws (611 Below Pipe)
• D 0 Ft.
t~• vt~►sia s
E Ft .
ass Section Of A Mound System Using
EN
SEE G® E . 0 A Bed For The Absorption Area F 0.8 Ft.
G , 0 Ft.
A Ft. H Ft.
Signed: B Ft.
License Number: K 10.5 Ft.
L i3q_ Ft.
Date:
L
J Ft.
Alternate Position Ft.
of
Force Main w '2.5•'Ft.
L
71-
j Observation
6 K
01
A -<I
W ----------------------•I Force Main
Oistribution Bed Of ' - 2
Pipe Aggregate
'I
Observation Pipe Permanent Markers
Plan View Of Mound Using A Bed For The Absorption Area
PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VENT CAP
4"C.Z. VENT PIPE APPROVED LOCKf~I
7 WEATHER PROOF
JUNCTION Box MANHOLE COVER W
25' FROM DOOR, rnoil „tsbr
-
r
IZ Mlu.
WINDOW OR FRESH (
AIR INTAKE I
GRADE I 'i"MIN.
I
I 19"MIN.
L
COWDUIT--
19"MIN. \
INLET PP,IVA~C BEw n4+~ldy,PROVIDE I I
con(liti AIRTIGHT SEAL I i I I
I
APPROVED JOINT A I I I I APPROVED JOINTS
I I I W/C.I. PIPE
W/C.I. PIPE a ~pl1! I EXTENDING 3'
EXTENDING 3' NuNp~ R~ I I ALARM ONTO SOLID SOIL
ONTO SOLID SOIL B. DF INDUS' A E'(°( PHU gut $ ( I I
IVtStoK I I ON
C P ND NG . ~ I
E LEV.~ .I(~ FT. SIyE GG~~1E PUMP _ _J
OFF
r
D
CONCRETE BLOCK
g ~ 0 134' APARov,
RISER EXIT PERMITTED Ly F TAWK MANUFACTURER HAS SUCH APPROVAL BEDOINfa
SEPTIC E SPEGIFTCATIOUS
DOSE ~~~lf~~l ~fr'<'""I t NUMBER OF DOSES: 3►& PER OAy
TAWKS MAWUFACTURER'
TANK 51ZE : f_~} n GALLONS DOSE VOLUME /!>tOALARM MANUFACTURER: I ' "1/ , If r7- INCLUDINCa 6ACKFLOW~ Doff ' GALLONS
MODEL NUMBER: CAPACITIES: A= 420 INCHES OR365" ~j '0GALLONS
^ ^ i g = INCHES OR %k GALLOL15
SWITCH TYPE:
PUMP MANUFACTURER: C= INCHES OR.0 GALLOWS
=!02 INCHES ORRZ ZFL_ GALLONS
MODEL NUMBER: D /
SWITCH TYPE' MOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RAT GPM ~INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE DETWEEN PUMP OFF ARID DISTRIBUTION PIPE.. cl« 5 FEET '90 t MINIMUM NETWORK SUPPLY PRESSURE . . . . . . 2.5 FEET
i <12
♦ 06 EET OF FORCE MAIN X F%0 F,FKICTIOM FACTOR.. FEET
TOTAL DYNAMIC HEAD = FEET
INTERNAL DI LWSIONS OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH
J
l iJ ✓L`'~ LICEIJSE HUMBER'.-- DATE: L~
SIGNED:
SOIL AND SITE EVALUATION REPORT
i. DILHR
• l 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 PARCEL 5~ I .D.
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or . #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY mi s rf DATE
..w. ~~nom Soh /S 9~
PROPERTYOINNE ~a e Crow (e.~ PROPERTY LOCATION
r51- yr a a ~Jso GOVT. LOT SLI} 1/4 SE 1/4,S 13 T 2 $ N.R J ~o E
PROPERTY ONNER:'S MA41LING ADDRESS LOT N BLOCK N SUBO. NAME OR CSM #
f bb0 . t I tl,
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD
ooa (~/sr - a« Gal T. H, 11-tJ
[ J New Construction Use ( Residential / Number of bedrooms 3
KI-Replacement ( J Public or commercial describe
Code derived daily flow y50 gpd Recommended design loading rate , bed, gpd/ft2 . 0 trench, gpd/ft2
Absorption area required 37 S bed, ft2 7 s- trench, tit Maximum design loading rate o S bed, gpd$ . trench. gpd/ft2
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations
Parent material (91a. c r ~J `I-. L [ Flood plain elevation, if applicable rV.4 ft
S = Suitable for system CONVEMIONA MOUND MROUNDPR SSURE AT-GRADE SYSTEM NJ FILL HOLDING TANK
U = Unsuitable fors stem O S LNV L'A'S ❑ U ❑ S 0 S aT ❑ S 911 EK O U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. Bed Trend
sbk b
Q- '7,57 YK S r v- 0.S _w
~ S
7-10 o YR3 s/ 1 s 6 k t f , s
Ground 3 to-a~ r y,~:. - s!/ v7t aLJ • s
elev.
ft. 1-I -'4- 7, V P,
s fed s t w. . u , s-
Depth to
limiting
factor
Remark's:
Boring #
f y k/IC
~ 11-►~ I~ y~ ~y - s. ► a w,sbk f~.~r ~ . s 6
Ground
elev. ~3P _
r y S`.
Depth to 31- S (o 'I k
limiting O
factt IrrI
y
Remarks: -
CST Name:-Please Print Z'
v1 - 3a7
514 el 'C A~k 4~ ~z I E)- -7 OVI on
1
Address: S \1-' 5 t3o 9 _
Signature: ~ ~Iz £ ~ °'t'•L ~ Oate: CST Number:
411
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure p~'
in. Munsell GP [ftM
Y>:.. Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence eourxiary Roots
. Bed Trees
n: . CM z
Ground 3 _ [ v y _ s
elev. s 6k r t q- . S
2~-3i 10
Depth to J S" -~U S 3 r' ` a d` Q
s~ a.2 -3
limiting
factor
35"
Remarks:
Boring #
k 8 I~ `/2 `L
Ground 3 1$ - I C3 ~ S v~ r to t S-
elev. -3a ° -4' t A
-23 9rt. sal x,,56 cL,)
o- 3 ►m~a C1
Depth to 5 7 5"V a o9o S I c Alp
m
limiting
factor
a3"
Remarks:
Boring #
Ground
elev.
h.
Depth to
limiting
factor
Remarks:
Boring #
i'
Ground
elev.
ft.
Depth to
limiting j
factor I,
Remarks:
h3- r s -t- ~ ti ~ G s-°
N
I I ~
~ Q
1
L ~ rte. ~ S
r s,
p
-
JQ U_ Rama"
-Sal M_
-12 X,
- n6
I
NPLATTED LANDS I 1
. I C.'
o M TOWN ROAD M.
c -S n 00 C7 A
NORTH CL O
J fD • m 4, L: 1155.41' w o 1359.10' C
O d
7r •--I ---1 -1 C") O •--i Z .1 of NORTH co
mr,
(D CD CD (D 'S s o Z
ct ct 154.29 5..30'
xv
n n n n CD w q0 o O
.
F rn
-
O O a Naj Ln
co 'S (X 'T (n 'S E:J < =r o t CD
C
o S 0 ~ 0+ t< ` (D f7 , C7
r+ O X:
Vf
C1~c 71 a\
X:b (n N + c+ (D -1 c ,
CT (D n (D to -n
N N (T• ~S 1< c+ • Z V) c r,
O co \D N (D (D • V)
-h c (D o - : D
r (D F^ ( - c
(D -h CL a, • ((D N
U'1 r+ w CD tv J• (D • m
4 w CD c1" N O < (n • • O n.
F3 C+ em 2 Z •-h O
o w n a y • p
c- o o m (D ct m • N :E: -h
w r+ O) d CD u v m : N N
40 m W D
N N r e • C) CD
(D 0
_h M (D 0
(D (D (D S M 0) 0- • D o n y O w 0 n
(D (A c-+ CA 0) ~ 40 n v • ~ ~ J
o - Q_ r Z F rn O I• m J.
c rh -h
a
O CD r+ (D fl
n, . r
t~ N O CD C W
~ J. c a -5 0 : D ~
r+ o o < o
r /N~
O' -S O =3 cu ~Z
(D J. J. •Q K
N ~o O n
O" C'f' W O 0) 'S I v
O rr 'it Z ~ o. F \
c O r+ I n v rn
-h N r+ O CD ?
Z _co ((D 1 n a` m 50
M 33
-0)(.0 C7 ct c- o 70
Z CS << a fD' U i rn c _ `
70 0 (D ~ J.
cn mp ` lr-_I O
F f/ -fi
? n(O N a J .
rt O l
O 0+ -h << ' 0 I C~ 1
-h r+ r+ 0
O
_ << (D r+ 11
S - 0
w •--1 O O O o 9
l< -I •"h f. Oo
C N
00. •9j.
217 Z:-, 00, 00. 1 (D
S 05° 15 SO'w ~n o0 0.
C7 = n O
O J. O _h 1
c ILL, J
+ BRG. REF. THE WEST L:NE
c = UNPLATTED EANQ 1
OF THE 5: 1/4. SEC 13,
T 28!1 , R 16'W. ASSUMED
BEARING IfttRTH
HELGES 0 N
ExcAvATI N, Inc.
SEWER AND WATER SPECIALISTS
IIC. NO. MPRS3215
BEN HELGESON
W. 1229 770th Ave. Office (715) 772-3278
Spring Valley, WI 54767 Home (715) 772-3127
May 18, 1992
Dale J. Crowley
First National Bank of Hudson
1660 11th Avenue
Baldwin WI 54002
RE: ESTIMATE TO INSTALL MOUND SEPTIC
SYSTEM ON LAND FORMERLY OWNED
BY LE ROY CAMPBELL IN EAU GALLE
TOWNSHIP, ST CROIX COUNTY
ESTIMATE
Estimate to install a complete mound system
for a three bedroom home on property in
Eau Galle Township formerly owned by
Le Roy Campbell. This price is contingent
on obtaining enough black dirt on property
to cover the mound area.
TOTAL ESTIMATE $7,800.00
Bennie Helgeson
President
BH:cz
NOTE: THE ABOVE PRICE INCLUDES ALL
PLANS AND STATE AND COUNTY
FEES.
43ofing # Horizon Depth Dominant Color Mottles Texture Structure~~ nc,
Boundary Roots
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh.
Bea
6-2 lovj? '3-2 k
nce
8-11 0 9--3
Ground 3 11-~ 10 y `L _ s r;, s 6k r t v S I, c
elev. I
Depth to $ --M -7. s
-Ls- -Y a
limiting I
facts
Remarks: I I 1
Boring #
i 4 /V Y sit C's61C ~ r q ,~F . S:I .
13 12 Yk
3 !X - o %yq ~ v 5 y,, cal t v'~ c c
Ground q 3b
(ow cy ~s' IC~ g c ~ s 6 G~ . c4 . S
, .
Depth to 5 h-<« 7. S V 6-ox S I t. t v p
limiting }
factor
a3=, , I
I
Remark=s: _ £ r
Boring # i
f
I
t
Ground
elev.. ;
Depth to
limiting
factor'
Remarks:
Boring #
U`MWI ,
Ground
elev. t
It i
Depth to
limiting
factor ` -
1
Remarks:
A SUIL. AND SITE EVALUATION REPOR
= DIL HR In accord wit 11R 83.05, Wi Ad . Co e
COUNTY
!Sr . C,~a t y
Attach complete silo plan on paper not less than 8 112 x 11 inches in size. Pian must include. but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCELI.D.
dimensioned, north arrow, and location and distance to nearest road. '
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY on s DATE
' .~'~w. \Y~ow. soh ~•/S
PROPERTYCIAWNE Ua~ t J. Crow (e PROPERTYLOCATION
~5 ~ / V a ~ o ti o~~ ~a►, ~C c~ So v., WVT. LOT S LL) 111 ~ E 114,S /3 T N.R I r'o E JaC
PIRQP R?Y CI ( ~S MAILING ADDRESS LOT R BLOCK I SUED. NAME OR CSM I
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD
es" ooA (7131 4Sy--U6(, « 6,11c- c •r: N 5i ll
New Construction Use ( Residential / Number of bedrooms 3
LOReplacement ( I Public or commercial describe
Code derived daily flow • SO gpd Recommended design loading rate . 5 bed. gpdift_ _-b trench. gpol(t2
Absorption area required 375' bed,112 37S'' trench, lt2 Maximum design loading rate s bed. gpolft2 . ji trench. gpde
Recommended Infiltration surface elevallon(s) It (as referred to site plan benchmark). '
Additional design / site considerations
Parent material Flood plain elevation, N applicable NA • R
S - Suitable for system ~NEMO NGROUNDPR SSUAE AT-GRADE SYSTEM IN FILL HHOLDVG TANK
U s Unsuitable forsystem O S Lail f D"S ❑ U ❑ S ❑ S LR tr C] S 9W L'T U
SOIL DESCRIPTION REPORT '
Boring # Horizo Depth Dominant Color Mottles Texture Structure Consistence Baj*dary Roots GP'i0/ft~
In. Munsell Ou. Sz. ConL Color Gr. Sz. Sh. Bed Tree
0_ 7.6 yR 3- s ' sbk v as ~~F S r<
-/-/0 /0 yR 3 . - 5 sbk & c w t , s
Ground .3 lo--)(, to yx: au) elev. • S ~ ~
~H y 7, S-4 S- Vp c 3st- V S l
Depth to
limiting
factor
Remar{:_~ I I I I I I j
Boring #
CL S
C (A
Ground 3 1 I- I /o I ~ Y~ `Ly - 5 i I a w, Sb I~ h. ~ Ili ~ F, s G
elev.
y l Iu - 5C- Ft cv IuF ,y I,<
s •si 3 P
Depth to 31- ~7 l u J i~ v S r c/ c
limiting
factor31 ~ r I
Remarks:
CST Name:-Please Print pin
t(~ `7 a - 3a~
Address:
Signature: f Data:' ' CST Number:
STC-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), thenta second form should be retained and completed when
the property is sold and submitted to this office with
the
appropriate deed recording.
,_D 0
Owner of property v~u~--~~
Location of property_- 1/4 S C 1/4, Section , T ` N-R S W
Township
Mailing address J(41 (C
Address of site
Subdivision name Lot no.
other homes on property? yes No
1 Lc
Previous owner of property -,nL'
Total size of parcel
Date parcel was created
'Are all corners and lot lines identifiable? Yes No
Is this property tieing developed for (spec house)? Yes ,No
Volume CSI and. Paga Number
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 & 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.fi tY~e ffice of the county Register of
Deeds as Document No. Z Z , 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 county Register of deeds as Document
No.
r
L
211
Signature of a icant Co-applicant -
r
Dat Of Signature Date of Signature
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~Vl.ll .ems Gs} 4'7
ADDRESS FIRE NUMBER
CITY/STATE ~~C)< I!i 1;~1- ZIP_ S ~/L
PROPERTY LOCATION: 5G1/4,,S-F 1/4, SECTION T YN-R_J6 CW)
TOWN OF _ _((.U St. Croix County,
SUBDIVISION , LOT NUMBER
Improper use and maintenance of your septic system could
result in its premature failure to handle wastes. Proper
maintenance 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 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 Co. Zoning officer within
30 days of the three year expiration date.
SIGNED: p
\J 7-
DATE : L1
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Perit-Holder's Name: ❑ City ❑ Village wn of: State Plan ID No.:
r (A.. , _6 4,t_ S • 3 _
CST M Elev.: Insp. M Elev.: BM D cription: Parcel Tax No.:
TANK INFORMATION ELEVATIO DATA ka&~r lo,,kt-
0
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark ~a O OF
Septic 2_6/05W, 77
~ .C0
r tl 74' 7u 1117
Dosing lI ` r f UL & & U I~ h" C ti I J % .4.
Aer Bldg. Sewer U
Holding St/hff Inlet v~ 7r
TANK SETBACK INFORMATION St/fit Outlet 8 33`
TANK TO P/ L WELL BLDG. Vent
Intake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing '>/:f 1-/70 7 1 NA Header/ Man.
Aera. NA Dist. Pipe
Holding Bot. System
PUMP / WO" INFORMATION Final Grade
Manufacturer G~c2,c.~S Demand
Model Number IL- GPM
TDH Lift Lriction Syetem TDH Ft
Forcemain
Length " Dia. Fii Dist. To Well
1 4:2 1 1 ] I
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia.___j Liquid Depth
DIMENSIONS DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header J Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No ❑ Yes E] No
COMMENTS: (Include code discrepancies, p~e!rs~onspresent, etc. _
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signat a Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
e i
77 DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COU
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ 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 WNER PROPERTY LOCATION /
rM C, D Ft) -'IJ'/4~~'/a,S T,N,R ~h E(or W,
PROPER Q NER'S M ILING AD R SS LOT # BLOCK #
CITY STAT , ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
e
II. TYPE OF BUILDING: (Check one) CITY NEAREST R07
❑ State Owned VILLAGE :
❑ Publlc ® 1 or 2 Fam. Dwelling-# of bedrooms _2 PARCELTAX NUMBER( )
Ill. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 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.E1 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 and 30 ❑ Specify Type 41 R 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 (s q. ft. PROPOSED (s q. ft. (Gals/day/sq. ft.) (Min./inch) ELEVATION
i
q~o I I Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber_ Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank eo I El
Lift Pump Tank/Si hon Chamber a? " t'
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plu Signature: (No S mps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
J~j (1) 'tC r~ f t;
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued iss Agent Sign (No Stamps)
Surcharge Fee)
Approved F-1 Owner Given Initial 1" d , if
Adverse Determinationi -7
J
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber
I
4 ~
INSTRUCTIONS
I A sanitary pert-nit is valio for two (2) years.
2. Your sanitary permit may he renewed before the. _-kp;ration date, and at the time of ienewal 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 Bid 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.
i
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11188)
HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Holding Tank Owner(s) Name(s) and I Pumper's Name
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
k
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
z.
with the County of
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
I. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract.
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) I Owner's Signature(s)
Subscribed and sworn to before me on this date:
I .
I
Pumper's Name (Print) Pumper's Signature notary Public
I My commission expires:
Pumper's Registration Number
SBD-7574 (N.11185) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
Document No. This space reserved for recording data
A' HOLDING TANK AGREEMENT
Z
g4-(-X_2V2
eement Date
This agreement is made between the
- - - - - -
County or Local Governmental Unit I Holding Tank(s) Owne-r(s)
Called Municipality below I
We acknowledge that application is being made for the installation of (a) holding
tank(s) on the following property, (Provide legal land description:)
Return To
- - - - - - - - - - - - - - - - - - - - - - - - - - - - -
or that continued use of the existing premises requires that a holding-tank be Installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats.
As an inducement to the County of to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders Issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Slats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
a. 66.60, Slats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
a. 146.20 (3) (d), Slats.. the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit
the existence of the certification to be determined by reference to the property.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement
to be determined by reference to the property where the holding tank is installed.
Owner(s) Name(s) (Print) I Owner(s) Signature(s)
Subscribed and sworn to before me on this date:
I
I
Municipal Official Name (Print) I Municipal Official Signature Notary Public
My commission expi s.
Municipal Official Title (Print) I
SSD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
Violation Number Form - S T C - 101
PRE SANITARY PERMIT ISSUANCE PROCEDURE
Location Section Township/Municipality Lot No. Blk. No. Subdivision
14 I ~T, N.. / R J~ W
Procedure prior to sanitary permit issuance where a septic tank must be replaced
during winter weather or other health emergency and soil evaluation or other sys-
tem evaluation cannot be conducted.
1. Obtain assurance that the property owner is aware of further requirements
for a system evaluation.
2. Obtain assurance that owner is aware that if system is found to be
failing, it will be their responsibility to replace it with a code
complying system.
AFFIDAVIT TO BE SIGNED BY PERSON REQUESTING THE SANITARY PERMIT:
I, the undersigned do treby acknowledge c
that I am receiving a sanitary permit CS
without a soil and system evaluation due to inclement weat r or healt emergency.
Furthermore, I acknowledge that a soil and system evaluation will be conducted
I
as weather permits and that if the system is then found to be failing as defined
in Section I L H R 83.02 (18), Wisconsin Administrative Code, it will be replaced
with one that complies with Chapter I L H R 83 of the Wisconsin Administrative
Code. If temporary pumping is to be utilized for maintaining a newly installed
septic tank, due to failure of the system, the tank shall be maintained by a
licensed pumper in accordance with N R 113, Wisconsin Administrative Code.
SIGNED /1 ' v k
DATE 1A /oil 3
A copy of an affidavit in lieu of EH 115 along with the PLB 67 must be submitted
to the Plumbing Bureau for purposes of fee reimbursement.
Signature o APPica t' a~eL
Subscribed and sworn to"before me
STATE OF WISCONSIN
This day of (~"o 19 /Y _211
SS.
COUNTY OF
Notary Public, St to of Wisconsin
My Commission Expires: 7 Q
ST. CROIX COUNTY
r
uk WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
J 1•, Y~ a
r,~~~ r 911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
May 22, 1992
Division of Safety and Building
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
To whom it may concern:
An onsite investigation of the First National Bank/Hudson property,
located in the SW 1/4 of the SE 1/4 of Sec. 13, T28N-R16W, Town of
Eau Galle, St. Croix County has been conducted. This onsite
revealed suitable soils at a depth f 26" requiring 12" of sand
fill for a mound septic system.
Should you have any questions, please feel free to contact this
office.
in erely,
ames K. Thompson
Zoning Administrator
cj