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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER / `j~K✓
ADDRESS z "-Z P.;-'-
SUBDIVISION / CSM# ~zf4Z~za t1S PC z// T LOT # Z
SECTION, /-_T L 9 N-R /Town of
40? 40? 62.0
ST. CROIX COUNTY, WISCONSIN
ertk /o l; -tQ- PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1 ham- ~e° -yl
- I ~r~
yo ~u
c ice.- n•-t - _ r
;A0
K-10 -)4
o
b
INDICATE NORTH ARROW
}
1
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
y
BENCHMARK: _Top 04 ~o.. Bowl-st /ef
ALTERNATE BM: 146 -tv~oc
SEPTIC TANK / PUMP CHAMBER / HOLDING-.TANK INFORMATION
Manufacturer: Liquid Capacity: 1J,60
Setback from: Well House Other I* A/&, A
Pump: Manufacturer Model# Size
Float seperation - Gallons/cycle:--
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Its Length V o Number of trenches
Distance & Direction to nearest prop. line: / b► Ld &-it-
Setback from: well: r House / 2.0 Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet- PC bottom - Pump Off -
Header/Manifold Bottom of system
Existing Grade Final grade d K,
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: INSPECTOR:
3/93:jt
L
WQ4,;94artr> u IQ istry4.29.19.4~ WACyerr &G~SYS?EUEDDIE County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CRCIIX
1 (ATTACH TO PERMIT) Sanitar i o..
GENERAL INFORMATION 18655 1
Permit Holder's Name: [I City E] Village ❑kTOwn of: Stat Ian ID No.:
a e5 HUDSON 70 Ec1e-4,8 rf_0~
T BM E ev.: Insp. BM Elev.: / BM Description: Parcel Tax No.:
J /'d,(/J 020-1102-40-120
TANK INFORMATION ELEVATION DATA A9300008~ &
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic
Benchmark G 3(, `~1
Dosing- 125.
Aeration Bldg. Sewer
Holding St//tsf Inlet S
TANK SETBACK INFORMATION St/Hoout
Vent
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet 1
Air
Septic >/J,) 7, NA Dt Bottom
Dosing NA Headed ~ J(~ 7 23
Aeration Dist. Pipe / " 8s
Holding Bot. System
97,
PUMP/ SIPHON INFORMATION Final Grade
M a n u facfu Demand
Model Number GPM
TDH Lift Friction Sys fiDH
Forcemain Length Dia. H Dist.Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length / No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5`EJ DIMENSIM
SYSTEM TO P/L BLDG WELL LAKE/STREAM ACHING Manufacturer:
SETBACK
/'l ~ Model Nu er:
INFORMATION Type O , CHAMBER
System - /v Gfl, OR UNIT
DISTRIBUTION SYSTEM
Headers. 48'd Distribution Pipe(s)/ „ x Hole Size e
Length
12- Dia. Length Dia. Spacing CO
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over /Q Depth Over ! xx Depth Of xx -Seeded/ Sodded xx Mulched
Bed / ncfi Center (U `-3 Bed /T.F@iqe Edges ' , 37 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 34.29.19.408B20,SW,NW, LOT 2,rEDDIE LANE S
Plan revision required? ❑ Yes 2'90
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
II
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNly
~ a.wmr..s
STATE SANITARY RMIT#
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 )
8% x 11 inches in size.
e ffi 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
:Z ~ GW1a W14, S 3 S~ T 2 N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
o zflZ- Z
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
cSM .F 104 2 / 17
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) ❑ State Owned 0 VILLAGE . s C 14Z
-a 112 1= (IF: .111
)1 42`1'
❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S) C
III. BUILDING USE: (If building type is public, check all that appl y7 Z _ - Z
1 ❑ Apt/Condo v
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. LC 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 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 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
S 7 Z D Z a O. /a Z 141,4 4G1 3 Feet 9 f S 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 I -T7 L1 1 71 11
Septic Tank or Hold in Tank f X00
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 S mps MP/MPRSW No.: Business Phone Number:
o K S1'.o ~C!.J ~~7 s 321
r umbe 's Address (Street, City, State,, Zip Code): / 7
, , I A,2- A/ F I;v fi ( G 4 G,j W 14-i i 6-
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sar)i~ary Permit Fee (includes Groundwater Date ssu Issuing gent Si atu a (No St
Approved ❑ Owner Given Initial -LDfG® Surcharge Fee)
,c[i Adverse Determination ~G r . X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD46398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safetys Buildings Division, Owner, Plumber
r
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary, permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed. . - el 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.
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 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)
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.
owner of property
Location of property-,2ZVl/4 /VW 1/4, Section _;r 45/, T _Z-7 N-R 19
Township //ee/so
Mailing address
Address of site gg0f eQS4P (/ot $ ?4G9117
Subdivision name G/c✓✓y: Lot no.
Other homes on property? yes)( No
Previous owner of property ar•~ 411 a
Total size of parcel • o /
Date parcel -was created 1 ' Zo - Q
'Are all corners and lot lines identifiable? - ,x Yes No
Is this property being developed for (spec house)?,Yes No
Volume_ and Page Number .3 Z 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 in the office of the county Register of
Deeds as Document No. /7 So b9' , 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. I
Signature of pplicant Co-applicant
ZS -~I
Date of Signature Date of Signature
rliliOiG IA1~1'f NIy A _ 1 nwtr a'w11 + „ t
WAMW "a
t R~ 9
Pirst National Bank of Hudson, a United
.
tatea'' 9a nkingororat on
s JAM
...Sam E. Miller a._.sin 1
e
conveys and warrant to - s
person. a ,
. . s
R[t RN
v T4
.
St. CrtsiX--
the foliowins deseribed real state in . ...County,
" ' State of Wiaoonda:
Tai Parcel No: -4
Lots 4, 12, 13, 14, 15, 16, and 17, Plat of Cherry Hill in the
Town of Hudson, St. Croix County, Wisconsin.
<i Part of the SWk of NWT of Section 34, Towrship 29 North, Range >x
West, St. Croix County, Wisco
y ap filed June 27, 1989 in Vol. "8",.
i~ age 2117 Doc. No. 449209.
Out o s ~Md , t o erry 11 in the Town of Hudson,.
t St. Croix , Wisconsin.
s, o
PEB
This 1A nor........ homestead property.
(is) (is not)
. „ Exception to warranties: easements, restrictions and rigYas-of-way 4
k of record, if any. '
Dated this day of inuary 1992
F s Na io B k of Hudson, by4
(SEAL) (SEAL)
t;~10fL vIC.E- ~Rla'a)AESVr
(SEAL) (SEAL)
AOTBSNTICATION ACSNOW LBDOMNNT
gllttatnro(a) STATE OF WISCONSIN
County.
authenticated this ....._.day of......... 19 ersonal~y came before
me t} is .......day ol
anuary 19.` the above namea
_
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, -
11411writed by 4 706.06. Nis. Stuts.) s
to me known to he the person who executed tbv
A ego' R inntrnm nit a•kno t6i, sine.
ge
'tHle INai7FlJME#JT y11'tib'f DRATTED t, M.
„Krishna land I,un Seen ~11.re Joy o .Top Cdisors
Attorney,at Law St. C j y.
Notary Public
z.
($irtlatures may be authenticated, or acknowledged, Both My C•ommis,cion is permanSh*(
are not necessary.) Ju 1 :r 12
date:
` .60asi ra saMiss'Ift rtas eapaeity should be tyi-i or pnntedhduw tb+lr •itnat-ir"
- ~ Nsrtrsulsir
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER.Bacon /l9.'14s-
ADDRESS Z;-L. FIRE NUMBER
CITY/STATE f Gels e z zip
PROPERTY LOCAATION : S4cl 1/4,1/4 , SECTION,
TOWN OF,~ri~~YSo.-c , St. Croix County,
SUBDIVISION 4'✓/!i A(r J/ , 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 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.
-yyl
SIGNED• ' t
S
DATE:
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
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
Si ceo/h
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL 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 DATE
PROPERTY OWNER! PROPERTY LOCATION
SR/tt M LLCM GOVT. LOT SLA) 1/4 of W/4,S~ T Z N,R / T E (or} W
ASS LOT # BLOCK # SUED. NAME OR CSM #
PROPERTY OWNER': MAILING ADDP
Y.@®c~ Root< KoAA Z CSM Pc, 2/l-7
CITY, STATE ZIP CODE PHONE NUMBER OCITY ❑VIL GE OWN NEAREST ROAD
p Sv W c ) I
New Construction Use [ Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow S 6 gpd Recommended design loading rate (3.7 bed, gpd$ OS trench, gpd/ft2
Absorption area required 6Sb bed, ft2 S6S trench, ft2 Maximum design loading rate D 77 bed, gpd$ O ,1K trench, gpd1ft2
Recommended infiltration surface elevation(s) 3 ft (as referred to site plan benchmark)
- 96
Additional design / site considerations
Parent material Flood plain elevation, if applicable It
S =Suitable for system c0 VENTIONAL MO ND IN- ROUND PRESSURE AT GRADE V$ TEM IN FILL HOLDING K
U = Unsuitable fors stem S ❑ U S ❑ U &S ❑ U "S El U S ❑ U ❑ S
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bw-dary Roots GPD/ft
Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
k . Z Q -4
4 16Y{; 3 2 5L lrl,, C. r n, C
4i A
Ground g 3~ 4Z' /o Yr2 A7`~ 4. l O
elev. MS G / O? O r6
q'9.6Sft. Z' `j~lnY~2 ~ ~
Depth to g /d 6 Y k 4 4 0.7 O.~S
limiting
factor
~.7 5
Remarks:
Boring #
jo VRI ^4 C,
nil d `O.S
°-Z6 Q k 4 _ S~ 0. sn
W
Yie 4 C, ors 0
Ground
4' A Q,? •b ~S
elev. 2- / O Y
M
Depth to
limiting
forte
I
T71- I I
Remarks:
CST Name:-Please Print Phone:
~laR ~v J~x Ns~N
Address: 4 U it~S6 1'j
w
Signature: Date: ///-Z-?L977- CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground A 4 SL aLj~ 0.4 O.S
elev.
/o3.rfft. `Z iJ9 >a~/oe 4 A MS f 0.7 0Ni
Depth to
limiting A Remarks:
Boring # _
R Q ~3 IOY~ 3 S L c r 1'►,~r C Z 4 0
NMI
Y? 3 L c r r, ~r C O.~ d .S
Ground 8-6„ 16M, 4 4 S L (D,~ K r), G 0.9 0.5
elev. -67` Y4 414 MS 0,7 `0
Depth to
limiting
factor
Remarks:
Boring #
/0y9 14 M6
fi .<M;
Ground
elev.
Depth to
limiting
factor
> 7.Sa
Remarks:
Boring #
ai{
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
" ~N W Cat~~~2 Loti' `L
r
cr'
Q'
CLL4A7i6n = /66.06'-
/ 41
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