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HomeMy WebLinkAbout020-1078-40-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER roaNr ADDRESS Yg.4 KZ Z-A 131 Fey', ~SUBDIVISION / CSM# LOT # SECTION. Z Jf T_9N-R_jjW, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 93 iP J INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ~siC •D ALTERNATE BM: r SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION Manufacturer: Liquid Capacity DOd Setback from: Well House /9 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: /L Length i~l Number of trenches .2- Distance & Direction to nearest prop. line: 7 SV i Setback from: well: Allkf House ~J 7 Other ELEVATIONS Building Sewer 9 s ST Inlet; ST outlet Q~ 96 PC inlet PC bottom Pump Off Header/Manifold ?70 Bottom of system f',0 Existing Grade Final grade pIP-0~pO DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: 31~~ INSPECTOR: T%. 3/93:jt LW&TIa rartNWRIPIN s;~P • 29.19.3] FrFI T~,R~I'E ~,sndRIVE County: Safety ety and a Human Relations INSPECTION REPORT Sngs Division ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No--. 193446 Permit Holder's Name: ❑ City ❑ Village [;A Town of: State Plan ID No.: v.. Insp. BM Elev.: LBM es cription: Parcel Tax No.: d , - tc '5 020-1078-40-000 14/1 E ATION DATA A9300111 TANK INFORMATION TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic a Benchmark 160, Dosi ng Aeration Bldg. Sewer 3 , Rgs Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic > >o NA Dt Bottom Dosing NA Header / Man. g 7• U Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade c 0 Manufacturer Demand Model Number GPM TDH Lift Friction Syesatem TDH Ft Forcemain Length Dia. HH Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ` ( DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type 0 r CHAMBER Model Number: System: } 7 N f'~! OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 28.29.19.317B,NE,NW,LOT #1,dRU dRIVE 1o'. Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: EZ17:0ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couNTY STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. C rev on o re lous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRO TY OWNER PROPERTY LOCATION Gtr 41 C All,, S ZY T N, R E (or)!V PROPERTY 7r, S MAILING ADDRESS LOT # , BLOCK # Lt .9 f CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER m .W A -232J* '17 6 II. TYPE OF BUILDING: (Check one) ❑ State Owned V VILLLLAGE : NE ST ROAD ` ❑ Public V11 or 2 Fam. Dwellings of bedrooms PAR L TAX . NUMBER(S) III. BUILDING USE: (if building type is public, check all that apply) 1 ❑ Apt/Condo 20 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. T New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 [A 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 Q 7 ZG z I "Feet ✓ Feet VII. TANK CAPACITY Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank 4011~_ 1 Ej [I I F-1 R Fj 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. Plumber's Name (Print): Plumber's Signature: (No Staff) fMWPRSW No.: Business Phone Number: 10 tuber's A dress (Street, ,State, Code): 36 170 dZ IX. LINTY/D RTMENT U ONLY ❑ Disapproved Sa tary Permit Fee (Includes Groundwater Date Issued issuing ent Sig s) Approved ❑ Owner Given Initial / Sur°her e Fee) Adverse D erm'n tion 7' 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 ; ` f 1. 4A sanitary permit is valid for two (2) years. 2. 'Four-sartitary,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. bnsite sewage systems must be property 'maintained. The septic tank(s) must be pumped by'a licensed " pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the Stat f:Wisconsin, Safety & Buildings Divisioq, 608-266-3816. 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. It. 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. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% 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 3he.county; E) soil test data on a 115 form; and F) all sizing information. t GROUNDWATEh 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 moniforinggro.undwater, grqund Water contamination investigations and establishment 01 standards. . % SBD-6398 (R.11/88) w 1 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 Location of pr perty_,&El/4 &U) 1/4, Section g P . T? - N-R_/j W Township Mailing address Address of site ri`v c subdivision name rK ✓t~C_Lot no. Other homes on property? es ---.t---' No Previous owner of property Total size of parcel - `7 r i Date parcel was created Are all corners and lot lines identifiable? Yes No ~ Is this property being developed for (spec house)? Yes L/~o volume,fZ1 and Page Number _Zit~ 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 TIIE REGIS'T'ER OF DEE 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 he office of the County Register of Deeds as Document No. oand I (we wn the proposed site for the sewage disposal t system) rr I e(we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly Noco~d/nthe office of County Register of deeds as Document qat re o applicant Co-appl cant r Date o S gnature Date of Signature . DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-19N TM14 "Act ac"IMD FOR Rccoro"NO eAT,% QUIT MAN! DEED 1 486452 VOL 961 Pa~N 1.09 REGISTER'S OFI`t CE 1ohn.. J..._.Rauchnat,.•.a1.k,la..Iobn-.M,.-Raucbnsat,.-.amd.- ST.CROIXCo.,V" A9Aer_R--_Ra=hmab._..hips_..wAfe...As..-joint... tenants,_ a bed fix RoM ~ .Qxmntarzs -JUL 291992 attit-elaims u ._..A vid..>1e_._Rl>xemel..And.-PaFrmiCia..A............ ...ond.xife..Ai~uxiYU.?~?,P..:. of 10:15 A. M nutx~.L,kx,.Rzape>~xy_, ...GxAnteaa die following described real estate in ....St.._-CrOi.x conatyr - State of Wisconsin: aaTun" TO - Tax Pared No: . A parcel of land loc :ed in part of the SEk of the NWT of Section 28, T29N, R 9W, Town of Hudson, St. Croix County, ..Wisconsin, described as Lot of Certified Survey Map dated October 30, 1990, recorded July 12, 1991 in Volume 8, Page 2378, Document #4'.1464, in the office of the Register of Deeds for St. Croix County, Wisconsin. This i8 not homestead properties (18) (1111 Dated this :r day of If.9 ?C • . --..........(SEAL) SEAL) a9hq..,7-...Res.uv.)xnQ.t&...a/.k/A..John N. • .~l a..R..-_.Baurhno Rauchnot .............................................................:.......(SEAL) (SEAL) • • ADTRSNTICATION ACKNOWLEDGKIIINT Signature(&) _ STATE OF WISCONSIN j } 5116 c _ . . fff 4? T County. ic-- ate- authent, - -d thb: day of 1g...... ersommy eame before me this &4....day of ~UI ......................e 10.9t- the above named ~QH D. TITLE: MEMBER STATE BAR OF WISCONSIN _ s- `~h`!.(!._ . - . of UOt' - ed * NII antiwris by 1 788.08. Wis slats) to to m. known to be the person ..5.---.-- w ex ted.bi j foregoing instrument and seknowledge the p THIS INSTRUMENT WAS DRAFTED BY 10F, U194C Ul . T Qm?s.. -...A ~ 5e C~ S N e "iltldSOit~..~......... _$T..~ ...1i. .................Coanty, (Signatures may be authenticated or acknowledged. Both esion is perm nt. (If not, state expiration are not necessary.) LTA?.._ date 10.9.9.) •N•aree of persons ekning in •sy a pseib should be type4 or printed below tmir eieneturee. 4~R~'► A "am Nn. i WISCONSIN gatN Sfock No. 13003 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/Bb-Y-ER_ A" ~G~4~titr~I ADDRESS: FIRE NO: LOCATION: d1/4, X1W 1/4, SEC. 2,P T2'9_N-R_' ~g W, TOWN OF: -A~Ao-lt- ST. - CROIX COUNTY_ SUBDIVISION: . ~ ✓dC. ;179LOT NO. - 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 to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating 'condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system-in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. e SIGNED: DATE: da e•' St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N W1 3707 HUMAN RELATIONS (ILHR 83.090) & Chapter 145) LOCATION: SECTION: TOWNSHIPLOT NO.:BLK.NO.: SUBDIVISION NAME: 1/ f AIF N/R/f E (0 2- I COUNTY: OW R'S E: MAILING ADDRESS: USE DATES OBSERVATIONS MADE __[NNO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES RIPTIONS: OLATION TESTS: Residence 3 m New =Replace RATING: S= Site suitable for system U= Site unsuitable for system ONVE1COSOCEISOU1 NTIONMOUND: IN-GROUNCD-PRESSURE: SYSTEM-IN-FILLHOLDICNG TA'NtK: RECOMMENDE SYSTEM:(optionaI Z J ❑U ❑ S ZU E:] J ©Y(/lfL r ~CC If Percolation Tests are NOT required DESIGN RATE: ~ If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST- HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 1 11 1 B- d7z~ Y ` ~t t r /1 /rt Gv B- !s A 3 ' s A ' B- 3 '77 d e / L3 . t/ 'R" 5 w d t ' .n s w B- C/I .2_ 1W. i ~rn > l- z ` s/ V s s . 13- 5d ff f t'3dC 1.3 S 3 S Cv t1, 7 • hr r a+ ~lB 6 B- St SW OO. Co~r~r►r PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. -PERIOD 1 PERIOD 2 P R PER INCH i' P- 7- P_ rppp__ 3 0 ? rr r S PLOT PLAN: Show locations of percolation tests, soil borings and the dirnensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on he plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION fs - E , / 77 kEC t_ rf e w 81y tssrr{ 1P ` r e~ NE3 ° >i J 3 x r~ +y a~ - - - a!'~'i'liro~ .t~cy I, the undersigned, hereby certify that the soil tests reported on this form ere made y me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the test are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: DAVE FOGERTY PLUMBING Z ADDRESS: licensed Perk Tester & Plumber CERTIFICATION NUMBER: PHONE NUMBER (optional): #3233 #3289 erly s r%gag CST SIG TURE: ROBERTS, WISCONSIN 54023 Phone 749-3656 t7g #I - , 14 cAel DISTRIBUTION: Original and one copy to Local Authority, Property Own and Soil T ster. A7% DILHR-SBD-6395 (R. 10/83) OVER - Nk t" IRV ~ a Ft.: 'LUTING Fes" i. I 4 e. i - e it . TO ~ l 4 & > ~ i~ ; f i d J Y I I I I I i ~ H W N I I I ti - ~ a\ C 1 _ V 0 1 ~ ~ ~ dd n .T I I DAVE FOGERTY PLUMBING Licensed Perk Tester & Plumber 03233 #3289 Fogerty Heights Road _ R08ERTS, WISCONSIN 54023 Phone 749-3656 E r c r c f~ I I > ~'de r AND V rFvy 1 I 36 3' i J - s I t c i I DEPART.,t11AENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION L:ABOR AND T PERCOLATION TESTS (115) P.O. BOX 7969 LABO HUMAN RELATIONS MADISON, WI 53707 (ILHR 83.0911) & Chapter 145) ~ LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: OT NO. r LK. NO.: SUBDIVISION NAME: A) 1/ 00 1/ 2-F /T 4 N/R19 E (or y~os0~ csM r ~l s COUNTY: MAILING ADDRESS: ,L/ Ct~/s • S.yD~ ~v s~ CPOi X ]RA UE >3tUEMFL USE 3 6 - 24DATES OBSERVATIONS MADE NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: ROF1 LE DESCRIPTIONS: PERCOLATION G TESTS: 1`lesidence1 3 op 4- ®New ❑Replace p ScS ,~D(O 13 VRK ti >z 2:~ T- RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) Q S L7U ®S ❑U ®S ❑ U ❑ S ©U ❑ S ©U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the Ar- under s. ILHR 83.09(5)(b), indicate: 1574S'S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS H BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED HE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) /V Yoe'/ 5 10C4 &,0 14"-2S' /0 Yle3~3 S/ 1 SbK~r r B- /09 V8 3 *,6 5 10 8 ~ s /o yR 15~ z „ s b Ice / o YR 4/~ O Ig" /0 yR 3/ p/oweD; le-27"/o y f ~2 S ~~rn, r B- Z 10? 9~ ~tp > 10.0 .27-(n4 "10yR 414 St*/, 3cbK,GG°-/o f t,i,.t 5 0f S n„ of r . i 0- o' / %R 313 5/ /a rdE4D - /D 3 4 /o % G k B-3 106 /63,0(0 _X0 >/00 I~~s~,n"ufle;'3G',-/o/o ye S/4 -FS, ofS,~M.uf;, 0-8" /'0 yR 313 5 , P/ods<O; s, f s5 It B- 11 0 103,59*0 1 10 75- YA' s/G fs, 1 f 9 x , /►m f r y D-b'" l S fie 3* S; p/ocaEO ; 8"- /y" 7.5 pe 4~/ S~ B- 5 log DZrB~ ~o !c yR of /P 1 /off", 71S %R f"Z-r is If5R fR PERCOLATION TESTS ° -TEST DEPTH. WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATTER INCH ES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. P I D t P RI D P- 1/00 7.-f/ 3- t411 IS/ 14/ S. PZ 3 - /o / 15//4, S /0 - 61 P_ 1716, / 3, N P- ~I P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. ibe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all bo ' a tgt e t n and percent of land slope. O .1 SYSTEM ELEVATION. to o y 7' -T s 01-0 4~g ✓ V r Z 1.._ _ . l w tN;k 71 14 I : . I ~ I j i ' I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME printl: HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: 655 O'NEIL RD., HUDSON, WIS. 54016 /P 41,v /e Irf / ADDRESS: RTGHT-- CERTIFICATI N NUMBER: PHONE NUMBER (optional): WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. 71/ ~ Z 3006 8/00 DESIGNER de. 110. 00663 CST StG DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. L DILHR-SBD-6395 (R. 10/83) - OVER - 1 I j - I~ t~ u m RI ~ ~ N ro H O' ~ D o ~ N P h o Z ~ o ~ n -a 0 IT, \ N Na / -CA i ~ x i Lq- f "C1 III IIVIV.r%I "mcru t 1 vn avu. P%jnmV%7 111w DIVISION LABOR AND 5~7C P.O. BOX 7969 INDUSTRY, PERCOLATION TESTS (115) MADISON WI 3707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) Z . LOCATION: SECTION: OWNSHIP/MUNICIPALITY: OT NO. LK NO.: SUBDIVISION NAME: tiE 1/ N~ V/ 2P /T2? N/RI? E (or HvDSo~ csH P o r07s o iX S.yD/~ COUNTY: DAUE j3LUEP~)EL 7x~f/NGcpxADDRESS-: _S-r, c,P & USE 3 6 - 2G DATES OBSERVATIONS MADE S: NQ BEDRMS : COMMER IAL DESCRIPTION: ROFILE DESCRIPTIONS: PERCOLATION Residence 2 oe ®New ❑Replace *M//0 /Q J ScS v~ < A,* R,o T- RATING: S= Site suitable for system U= Site unsuitable for system ONVENTI NAL: IMOUND: OUIN-GROUND-PRESSURE: S STEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:loptionall to So U RI S ❑U ®S ❑U ❑ S ©U ❑ S ©U C'a,vvE-uTra a-t L - T,P1FVCA1 If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: =7=7 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS \A BORING TOTAL DEPTH TO GR UNDWATER-INCHES HARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED_ E TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.) F 0-9"10W 1 s pib4e*o; 9„-a6° M , 0ebnS~,imofR; \ B- 1 /Doo /037,5 ?'LU 0,~' 3 C. /0 p " 1.5 > P S/¢ /S" /A- A , V r- In 0-5"i0 Yf s/Z S, dwFO; S e, .S, B. Z 12-0 lo3,2-,? /ZO oti„S~, n„vfr ) 2y''- ~zp"9SY,e S/9 /s, IfsI, nnvfe o- 7, S yR o ,1 P d wED • 7-1p, 7,3 y~r 3/2 a p e a B- 3 0 /03./5 > 18''-30' -7SYk '4/z b/C,,,~ F' 3d"- 1 71.5 Yf< ¢ 5-11j 3M ; 50'-76- z5 PS/G S/ ofs5, e,fA C . B- y 0-8" io yc 3/z S p owe- i 7 yR Y 6 r 14Frg, B- ! l 0 /0 y ! 6 Icy) >//d nr, f k S /6 //0 " 7's Ye `51f /S , I f ,e f R 7. S Y,< 6,V 0wis,0 ; d0 i, - ry 7, S Y/C G B-5 I► S /0373 fr,/ji "-,ts -7:s'. PERCOLATION TESTS EST DEPTH , WATER IN HOLE TEST TIME DR 1 WATER V L-I H RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 3PERI CH P. SD / 4 / 4 /G p- Z 1'yl~e ► 3,3 P- t5 t Y (1 t ¢ 51 P- ~I P- P_ ?b PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hor)-' zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. ' SYSTEM ELEVATION ` U. j ` 1- FF _ Nh ! ! { _ ~ ~ I ! I i I ~ I I r r t? ~ ~ 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and h i e Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief, NAME (print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. / 655 O'NEIL RD., HUDSON, WIS. 54016 1041 /0 IffADDRESS: ROBERT CERTWICATI N NBER: PHONE NUMBER loptionall: UM 3 & ^ /eS WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. yov Z MINN. INMI:2111 &DESIGNER tie. NO. M3 CST SIGN"' /4 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - N Qo N V nnJ c , om~~ o l~ f"=H W CW7 atl ' u°IMOD~w O S' f' oo J In x !4t ~a - tC a V I .00 ,y T I I J ~ I cY N Q N~ o K o K o ~ v ' vl i I ~ rte. 3 7~ ~ J E Parcel 020-1078-40-100 02/04/2005 02:48 PM PAGE 1 OF 1 Alt. Parcel 28.29,19.317B-10 020 - TOWN OF HUDSON Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner * BLUEMEL, DAVID J & PATRICIA A DAVID J & PATRICIA A BLUEMEL 551 DRU DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 551 DRU DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 7.510 Plat: N/A-NOT AVAILABLE SEC 28 T29N R19W PT SE NW BEING LOT 1 OF Block/Condo Bldg: CSM 8/2378 7.51 ACRES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 28-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 961/109 2004 SUMMARY Bill Fair Market Value: Assessed with: 48256 308,400 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 7.510 73,100 165,500 238,600 NO Totals for 2004: General Property 7.510 73,100 165,500 238,6000 Woodland 0.000 0 Totals for 2003: General Property 7.510 73,100 165,500 238,6000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 119 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Parcel 020-1078-40-000 o2/o4/2oo5 02:47 PAGE 1 OF 1 F 1 Alt. Parcel 28.29.19.317B 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner " U S BANK TRST U S BANK TRST RAUCHNOT AGNES R RAUCHNOT AGNES R PO BOX 64142 ST PAUL MN 55164 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description " 777 CROSBY DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 15.440 Plat: N/A-NOT AVAILABLE SEC 28 T29N R19W PT SE NW EXC N 10A & Block/Condo Bldg: EXC P317C & EXC THAT PT TO CSM 8/2378 & EXC PT TO FJ 1513/092 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 28-29N-19W SE NW Notes: Parcel History: Date Doc # Vol/Page Type 05/23/2000 623517 1513/092 FJ 2004 SUMMARY Bill M Fair Market Value: Assessed with: 48255 216,600 Valuations: Last Changed: 06/06/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 15.440 167,600 0 167,600 NO Totals for 2004: General Property 15.440 167,600 0 167,600 Woodland 0.000 0 0 Totals for 2003: General Property 15.440 167,600 0 167,6000 Woodland 0.000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount I Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 020-1078-40-200 02/04/2005 02:48 PM PAGE 1 OF 1 Alt. Parcel 28.29.19.317B-20 020 - TOWN OF HUDSON Current X! ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner " U S BANK TRST U S BANK TRST RAUCHNOT AGNES R RAUCHNOT AGNES R PO BOX 64142 ST PAUL MN 55164 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 28 T29N R19W PT SE NW BEING OUTLOT 1 Block/Condo Bldg: OF CSM 8/2378 1 ACRE Tract(s): (Sec-Twn-Rng 401/4 1601/4) 28-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 05/23/2000 623517 1513/092 FJ 2004 SUMMARY Bill M Fair Market Value: Assessed with: 48257 5,200 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 4,000 0 4,000 NO Totals for 2004: General Property 1.000 4,000 0 4,000 Woodland 0.000 0 0 Totals for 2003: General Property 1.000 4,000 0 4,0000 Woodland 0.000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges 00 Total 0.00 0.00