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HomeMy WebLinkAbout040-1025-95-000 ti 3 o M "V D0 G C~ a I 0 N O N j j j ~ I p O C Z LL. O E a U l6 r it ~ N 'I z = o° I v z (D d 00 co FN- Z a M 0 O Z d v y Z c o ip F- r O) N Z E o ` N N O y N ~ N • N L U) O O O (0 © O N Q z co z 5 ' Z O 41 N c W £ E N m Y 0 `m a `D a R O CD O 06 o m a~ c o o O O O O O N III C G CL S3 C N N N U) U) V) E 0 O U N N N _ C O O O d 0 z O O O •V ' o a a a a ~ 7 0 N N 6~ O N Vl J U > rn rn } Cl) 0) (D w~i O o o oo rn o0 N O O ^7 N N 'O m a) `j~j O d Q a? m U) 7 Q C"i O V1 0 0 Cl) N U) N C ~O '6 E O ~~rr O N v O O O N w (0 O Ci 0) m O E O 0 M 0 o 0 0 0) W C co C ~ N O- ' U 'B O CL N Q- O O N N N O p C N p t: N^ 00 V r.r O O M N= d:2 O N O N lye' C"i o -p F- C m i?5 6t (cp 2 O QOj W O E Z U rrVV y,~ O O F- U O U) z~ .w v ~ °'dt QI ma U a w E "~1 A vaM oU0 y 3 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1-of -3 Lflbor and ,human Relations rfvision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY _ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but / not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # - IA dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL IN REVIEWf&J-1 DATE PROPE TY OWNER: PROPERTY LOCATION L GOVT. LOT ) 1/4 1J 114,S T N,R i(ord PROPERTY OWN R':S MAILING ADDRESS LOT # BLOC # SUBD. NAME OR CSM # ± - C17 /STATE ZIACODE PHONE NUMBER ❑CITY VILLAGE MOWN NEAREST ROAD [ ] New Construction Use D<] Residential / Number of bedrooms ( ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow j f06 gpd Recommended design loading rate _bed, gpd/ft2_jtrench, gpd/ft2 Absorption area required 9_5',9 bed, ft2 ~N-0_ trench, ft2 Maximum design loading rate ed, gpd/0_, ~trench, gpd/ft2 Recommended infiltration surface elevation(s) ya: 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 SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 0S ❑ U ®S ❑ U ❑ S 19U ❑ S O U ❑ S O U ❑ S Nu SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Du. Sz.,Cont. Color Gr. Sz. Sh. Bed Trench j -2-0 A/ 9'r Ground -3-9 IV14 elev sy~y~ rtt 5 I" ~2 Depth to - - limiting factor Remarks: Boring # LL "Z S* Z1_/1Z A~Z ~ yc'S/G a J Ground elev. - - ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address: Signature: Date: CST Number: j C ~ f PROPERTY OWNER-/~~~,r~ L~;,,Fea^~ SOIL DESCRIPTION REPORT Page-;_,,) of PARCEL I.D. # Depth Dominant Color Mottles Texture Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. nt Color Consistence Boundary Roots Gr. Sz. Sh. Bed Tnench Ground elev. Depth to limiting factor Remarks: - i Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) I I I T , I I I it I~ i I ~ ~ I I ~ i I I i I I I i i ~ I . 1-4 r I , i t + b - - - - i ' I I I I I i I I I I I II I I ! I I fi l l vs. tifi /r r-t. i ~ li II I I I 1 ~ i i II 1~ I ~l I i 'I I I I k I T i I I III I i i I I I i I . : . STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS , Jc,~,•~,k~, Zd SUBDIVISION / CSMI LOT & SECTION W, Town of 2-s. 19 . gCo ST. CROIX COUNTY, WISCONSIN PLAN VIEW SH W EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: L42z,-) I ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: I)~ s Liquid Capacity: a. Setback from: Well House_ -Other .3A3 Pump: Manufacturer Model# j j* Size Float seperation Gallons/cycle: f7% Alarm Location -:SOIL ABSORPTION SYSTEM Width: L- Length_ Number of trenches Distance & Direction to nearest prop. line: iIA2 Setback from: well: House__Z~2_ Other ELEVATIONS Building Sewer ST Inlet; ST outlet PC inlet BS7/ PC bottom ~f Pump Of f Header/Manifold Bottom of system 9,21_,9 Existing Grade Final grade DATE OF INSTALLATION- - 7- -C~ PLUMBER ON JOB: LICENSE NUMBER: S INSPECTOR: 3/93:jt I' ~artm~*rTT uYf Mst-r , 8.19.86B Labor and Human Relations PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) sanitary ermit o-: Permit Holder's Name: ❑ City ❑ Village X" Town of: State Plan I o.: CST BM 13M.: , Insp. BM Elev : BM Description: Parcel Tax No.: 7c A-Is / Z," ~ G~ /off • ~ _ TANK INFORMATION ELEVATION DATA A93002781p 07 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ZZ, L2 Benchmark r Ll "Id Dosing G~ Aeration- Bldg. Sewer Holding StlA Inlet 901 TANK SETBACK INFORMATION St/ hk Outlet TANK TO P/ L WELL BLDG. Ai Intake ROAD Dt Inlet j yy P,9 Septic >/LYE r -50f- NA Dt Bottom c 106, ~Z Dosing NA Header k 7, 7 1 ~fl Aeration NA Dist. Pipe Holding Bot. System uT PUMP/ FORMATION MFinal Grade ' 760 Manufacturer / ,?v 6 v r- 3 53' 7, 5lT / `G± , CiR~s k ' Model Number :;e- lvCO 3 /I n1 &6 GPM TDH Lift Friction :/It SystemA# TDH 014t Forcemain I F Length Dia. n ,I Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHI Manufacturer: INFORMATION T CHAM ype O R, -W. F)9-,c i Mo Num er: \ System:(,,,,, beef 114 UNIT I /I DISTRIBUTION SYSTEM Header / Ind Distribution Pipe(s) / x Hole Size x Hole Spacing Ve e Length fo ' Dia. Length -1 Dia. 7 Spacing do SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syste my Depth Over Depth Over xx Depth Of ed / Sodded xx Mulched Topsoil ❑ Yes ❑ No ❑ Yes ❑ No Bed ! h Center Bed / Fr Fr Edges _3?" COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 06.28.19.86B / Plan revision required? ❑ Yes B'No a Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: d I E . SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY S STATES KAYS1021)5ious RY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Ch k application -See reverse side for instructions for completing this application. STATE g hl pplication. PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OWNER PROPERTY LOCATION '/a Vtj t/4, S , N, R E (or) PROPERTY OWN 'S MAILING AD RESS LOT # BLOCK # "Zia CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE : NE ST ROAD ) ❑ Public X 1 or 2 Fam. Dwelling- # of bedrooms AR L T AQX'N: 111. BUILDING USE: (If building type is public, check all that apply) Q 5/U~ /OAS- 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ 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 ~ Seepage Bed 21 E1 Mound 30 El Specify Type 41 El 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 12. 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 ./i ch) ELEVATION Feet Feet 1-1194 01) AL 9ZA VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New listing Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber 5?f~V) F] F1 - VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber' Nam (Print): Plumber's Ign ture. Nostamps) MP/MPRSW No.: Business Phone Number: P u 's Addr (Street, City, State, Zip Code . IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee (Includes Groundwater ate Issued Issuing Ag nt Sl re ( Stam Approved El Owner Given Initial Surcharge Fee) Adverse Det rmin tion X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. . 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 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. ll. 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 cn 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 13'% 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) _3at1fkiC k) w~ yvi /Vii sz-_ Z, 7~8r✓,~/qGJ -zL/ Iwo s9 i' 1J~L r~ /s o~ /mom y~P h~~t ys~ s may, 1 foci C ` o S ACC 1 01'1 p IS ten. ♦ ~f11A. A!r.9111111 °`x?!,4)►101v4pb1 pipe ~.~..ra.. A1N„N 1. YEN Cq YWw•w IZ°AN♦• i' • ♦ h~ of I so 80- 42" Above ?1 4' Cost Use 11 flow Goode. NMI My. r Iqr♦• INi W ir•~ly1k Chuk~• 0 N=~y1K.1N• , Maslow t1p1 / h1 i • A' AIp~1a• • 2.1.l• II•• ' • • `Palwela/ Pop YN•v C644141 1we"SlIal AI ~ ••u1. of i1111w Phu ,.o1t r. D Ar%4.1 rh clt P =OIL FILL' OIMI9LITIO1.1 PILL APPRO'/CG S•INp1CTIC COV[ OF ~GGRE6A1E "`-MATZW I. OK 9" OF STRAI. OR MARa>•. NA.y ELEV. OF/ Y E •~S'b~ ? IOPJs-L~/= NGG tCGNTC 'P IT, OISTR1bUTlou rAm Trj pC AT 4CAlIT jWC.HCS 6CLOW ORiVOWA1, •,-A&DE AIJU AT LENST&O IWCH6t♦ OUT 1.10 MOfIC THAW yZ IuCNCS gCLOW /IWAL GIkgOG l'Wcv~uM pEPT.N.OF EIKAVATIOP FKOM 0KIONAL 6R v~ WILL AC ~ •~...LL.~_ 1 u t H E 5 AHJMVM OEM OF E CAVATION f RO^ ~IGIWAL GRADE WILL be s; INCHI: s SIGWCO: LIC:CIJSC WUMDCJJ: ; 75 ))i • QATC: 9-117 n r ..L. : PAGE OF PUMP CHAMBER CROSS SECTIQJ ARID SPECIFICATIONS VENT CAP 4* C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTIOIJ BOX MANHOLE COVER ~ 25' FRAM DOOR, WIWDOW OR FRESH I2"MIU. I AIR INTAKE GRADE I I 4" MIN. IB" MIAI. COIJDUIT \ INLET PROVIDE I AIRTIGHT SEAL ( III J/ I APPROVED JOINT A I III APPROVED JOIWTS W/C.I. PIPE I III W/C.I. PIPE EXTENDIMO, 3' I II ALARM EXTEUDIWG 3' OMTO SOLID SOIL B i i I ONTO SOLID SOIL I GN C I. I . PUMP ~ ~ OFF D CONCRETE BLOCK RISER EXIT PERMITTED OWLS IF TA1JK MAWUiACTURER HAS SUCH APPROVAL SPEWFI.CATIOUS I:PTIC AND ) OSE TAWKS MAIJUF•ACTU;LER: /~k S IJUMBER OF DOSES: :~z PER DA:i 77, TAWK SIZE: GALLOUS DOSE VOLUME: GALLOIJ& ALARM MANUFACTURER: ~JnC CAPACITIES: A= Z_IIJCHES OR r/3 GALLOWS MODEL 1JUMBER: ~hJ B=a_IIJCAES OR 39 GALLOWS .SWITCH TYPE: C= 7 IIJCHES OR _L.G1 GALLOWS PUMP MANUFACTLIRER: Idl-c 0- IMCHES OR ._z6_ GALLOUS MODEL 1JUMBER: A, D3/Ilyl NOTE. PUMP AND ALARM ARE TO BE DW11CH TYPE: LTL IUSTALLED ON SEPARATE CIRCUITS PUMP DISCHARGE. RATE GPM® /0 ~ VERTICAL, DIFFEREKICE bETWEEU PUMP OFF AND DISTRIBUTION PIPE.. 21' -ig FEET + MINIMUM NETWORK SUPPLY PRESSURE . .IV!✓l. .-175- FE.ET III, j / T,/ - i ♦ FEET OF FORCE MAIN X .___,F/oo FxFRICTIOW FACTOR.. _L- FEET TOTAL 0t3 JAMIC. HEAD = FFEET • ~ifl~nt~,Et. O INTERNAL DIM SIOMe& OF TAUK: LENCPTH ;WIDTH •jLIQUID DEPTH SIGNED: LICEIJSE IJUMBER: DATE: Performance t+ r Curves Pumps METERS FEET - 90 MODEL 3885 25 80 SIZE 3/4" Solids WE1SH .~`1PiS'SjJ ~'S~ 70 9~yg3 X 20 WE10H 60 -WE07H 15 50 40 WEOS.H I 10 30 WE03 20 WE03L 5 10 0 0 0 10 20 30 40 50 60 70 60 90 100 110 120 GPM i i i i 0 10 20 30 m3/h CAPACITY GOU LDS PUMPS, INC. SEW-CA FALLS NEW YOPK 13148 METERS FEET 120 MODEL 3885 35 110 WE15HH SIZE 3/4" Solids 30 100 90 25 80 70 20 60 O WE06HH 50 t- 15 40 10 30 20 5 10 0 0 0 10 20 30 40 50 60 70 80 90 100 110 120 GPM L i i i 0 10 20 30 m3/h CAPACITY 01965 Goulds Pumps, Inc. Effective July, 1985 C3885 Wisconsin Department of Industry, SOIL AND. SITE EVALUATION REPORT Page of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL IN REVIEWED BY DATE PROPS TY OWNER: PROPERTY LOCATION GOVT. LOT 1/4 l) 1/4,S COT N,R )i(or PROPERTY OWN R':S MAILING ADDRESS LOT # BLOC # SUED. NAME OR CSM # CITY TATS ZIP CODE PHONE NUMBER ❑CI VILLAGE (OTOWN NEAREST ROAD [ ] New Construction Use D] Residential / Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow 4~06_ gpd Recommended design loading rate lambed, gpd/ft2--S trench, gpd/ft2 Absorption area required 9-SS bed, ft2 ~mQ trench, ft2 Maximum design loading rate 1-bed, gpd/ft2; g trench, gpd/ft2 Recommended infiltration surface elevation(s) 2.2 ylt It (as referred to site an benchmark) Additional design / site considerations 14' - _ Parent material Flood plain elevation, if applicable 1/4 It 7Uunis able fo r system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK uitable fors stem 9S ❑ U ®S ❑ U ❑ S NU El S ® U ❑ S ®U ❑ S RU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Ground elev. s y~ &Jilft. Depth to _ limiting factor / Remarks: ~,Pize.~l ,C.~.rre Boring # L _ Ground elev. ~Zu ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address: Signature: /Kl / Date: CST Number: PROPERTY OWNER JSOIL DESCRIPTION REPORT Pageof PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BmrclEry Roots GPD/ft in. Munsell Qu. Sz. nt Colo r Gr. Sz. Sh. Bed Trends ~~:iu•:iiw 8~4 Ground elev. ?Y,L ft. Depth to limiting factor Remarks: - i Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor I --t--{--- ' - ~-~-/.drams G2r~-~--- I I i ! IAA) i I I ~I I I I i! 14- 6;~4 T _-L _ i _ I I i i nl I ! ~ ~ I I ~ I I II _ I I r__ ! I I i - , ( - - I ! I -I Lev, - -1 -I ---I I b I ' I i ! I T I i SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Ob mes O C©t~~n,-r ADDRESS: 30 Q1USR,V %-&w ViLIVC- FIRE NO: 30 LOCATION: V3W 1/4, U W 1/4, SEC. 6 T_N-R W, TOWN OF: ST.•CROIX COUNTY SUBDIVISION: LOT NO. tJl- 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. V SIGNED: DATE : S 6 0 Q '3 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 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 Ia 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 MES O k- \Act•. rr-" J C off r-O R.'7 Location of propertyW_W 1/4 MW 1/4, Section G , '72--S N-R-Ll-W Township - -Tizo y Mailing address _ 30S VnusrL V 1 F u) ymA1 t Al vp v o rv W 1 401 G Address of site T4hr- %-S ti A t L i Me., p* A pn,*,Q-? Subdivision name Lot no. N Other homes on property? yes _No Previous owner of property J1~t1'ES lacy b I Total size of parcel 13 .1q Date parcel -was created 'Are all corners and lot lines identifiable? --L-YesNo Is this property being developed for (spec house)? Yes -!J_No Volum-SHE and. Page Number t_ 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._B3 84 (81 , and that I (we) presently own the proposed site for the sewage disposal system 4kr 1 we) bt 'ned n e meet to ru the eve d scribed prope , mr t nst ction of s d sys m, a the ame hl been duly co a in he of Ca o Count Regi er of eeda s Document No. C\\~A11Y~4n ~ ~ . Signature of a plicant Co-applicant I 3 Date of Signature Date of Signature . ~1..e~i::'.YFJ ~s r _ Y>' ~ j t: # n 541 Pd ACS and M. G. Kochsiek, Assistant Secretary, 1 President of First Trust Company of Saint Paul to me known to $ -be the persons who executed the foregoing instrument and ackbow-• ledged the same in their respective capacities as Co-Personal.: Representatives of the Estate of James H. Boyd, Sr., &A/a James Hinds Boyd, Sr., aA/a J. H. Boyd. F y - T may' Notary Public, Ramsey County, !M My commission expires XAAA+.""A&M4-A4A4AAAiAAA&AAAAAAA"x - ? 00NOINr FUNIINOUJER r < ~ -I-11V vutlUo rrl.•4,01A R 10 , W. aAMSEV COUNTY a * Mr rpnirn ss M fronts pn 29:1911 J . =cve*r••.,.•.,r_..••envr`rraaawarrsln/~ri( ` ff ' 16 19 'r go 21 88 o~z 83 r: ~vj z a4 95 } 86 :88 a0 3#L % ` L COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 l,.. 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ST,'CROIX COUNTY GOVERNMENT REPORT NO.S 47751/01 PAGE 1 CENTER REPORT DATE: 8/27/93 1101 CARMICHAEL ROAD DATE RECEIVED: 8/26/93 HUDSON, WI 54016 ATTN: THOMAS C. NELSON OWNER: James & Heten Comfort LOCATIONS 305 Riverview Dr., Hudson COLLECTOR: Jim Thompson DATE COLL.ECTEW B-25-93 TIME COLLECTED: 1:30pm SOLRCE OF SAMIPLE*# Kitchen faucet DATE ANALYZED:8-26-93 TIME ANALYZEDS2:00pm COLIFORM,MFCC: 0 /100 ml INTERPRETATION: Bacteriologically SAFE NITRATE-N: 5 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 ml 12 Nitrate-Nitrogen, m9/L 3Y RECEivEO ;N 'AUG -3 0 119 d' ST CFi4ix C4, WUNN rONI NG OF"6 LAB TECHNICIAN: Pas Gane 9 G~A,. F,\NOEVENbp - ~c'O so WI Approved Lab No # 19 ~ D V Means "LESS THAN" Detectable Level. Approved by: PROFESSIONAL LABORATORY SERVICES SINCE 1952 Ci~ 3 14 9 a3 ST. CROIX COUNTY f tic( WISCONSIN ZONING OFFICE t., ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 SEPTIC INSPECTION / WATER TEST REQUEST FORM Specify desired test(s) & remit appropriate fee with application. outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. O Water (VOC's) $185.00 Irissual eptic $25.00 KWater (Nitrate` & Bacteria) $35.00 inspection) owner. ~I,tr1ES 4 IEMV) C43nf t-, Requested by: 3 Address : 3©S CL1%je4L U1Q_W V3 TL Address: -74) 0 City & State: 43ubgo" , W 1 City & St . c . L Zip Code: - ~1 Zip Code: ,~-/o Telephone N4: (_116) "3056 leAn2y Telephone N4: (_Lij x,86 s-? Property address (Fire NO & Street) : SOT (IkQet1pmw Dp_ Location: NW,NW Sec. , T lq NR 45 W, Town of St. Croix Co., WI. Tax ID NO mk 16arcel ID NO House color:) ) v Realty firm: lfi2 ~,GC Lock Box Combo: ~ ' Water sample tap location: TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF HIS FORM Is the dwelling currently occupied? 0 Yes ❑ No iG~q3 If vacant, date last occupied: q I 3 Septic system installed by Yea ~ Septic tank last serviced by: Dat • Previous Owner's Name(s): Have any of the following been observed? OY ON Slow drainage from house. OY ON Sewage Back-up into dwelling. OY ON Sewage discharge to ground surfa road ditch or body of water. OY ON Slow drainage from the dwelling. OY ON Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. OWNERS SIGNATURE: DATE: 4/93 0Uelf-I r' OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION t IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? OYes ONo Soil series per SCS Soil Survey: sheet # Tyne of soil absorption system: ❑Below grd OAt-Grd ❑Mound Approx. size 'X ❑Gravity ❑Dose OPressurized Ft.' ❑Bed OTrench ❑Dry-Well Molding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: OHouse ❑Well OProp. line OOther Dose tank Setbacks: OHouse OWell ❑Prop. line OOther ❑Locking cover OWarning label OPump/Floats ❑Alarm OElec. wiring Soil Absorption System Setbacks: OHouse OWell ❑Prop. line OOther OPonding: ODischarge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title ST. CROIX COUNTY WISCONSIN ZONING OFFICE r r r r." ST. CR IX COUNTY GOVERNMENT CENTER 1101 Carmichael Road _ - - i 40X Hudson. WI 54016-7710 ' c t+afir , y (715) 386-4680 S',h' W,r3 r---- 1,r . SEPTIC INSPECTION WaTE TPPV REQUEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. Water (VOC's) $200.00 ❑ Septic $125.00 R-Water (Nitrate & Bacteria) $55.00 ❑ Nitrate & Bacteria XWater (Lead Conceentration) $21.00 retest $15.00 Owner : ,7,- &2~aAiT TE Requested by : Address : 3c~6 1 J V/Etit/ VF Address : xx /-E -553 0 Al ZIP :~1 I. ZIP Telephone W: (-7k6-) (5b /t:3 ~a(, Tele one W: ( ) Property address (Fire W & S reet) Location: Sec. , TAN l9 W, T of Realty firm: Lock Box ombo: Co ' ng Date: v~o -iaZS=y S'-ooo oj -17~ l3 TO BE COMPLETED BY PROPERTY OWNER 1 ~GJ -73 *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THI FORMS Water sample tap location: Is the dwelling currently occupied? Yes ❑ No If vacant, date last occupied: Age of septic system: Septic tank last pumped by: Date: Previous Owner's Name(s): Have any of the following been observed? ❑Y Slow drainage from house. ❑Y Sewage Back-up into dwelling. ❑Y Sewage discharge to ground surface or road ditch. ❑Y IN Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. DATE: OWNERS SIGNATU 7 1/94 ST. CROIX COUNTY WISCONSIN ZONING OFFICE """p""' ' - ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 { (715) 386-4680 Fax (715) 386-4686 April 25, 2000 J. Peter Ritten 305 Riverview Drive Hudson, WI 54016 RE: Water Test Results Dear Mr. Ritten: Enclosed are the original water test results from Commercial Testing Labs, Inc which were taken at your property on 04/17/00. If you have any questions regarding this, please call our office at (715) 386-4680. Sincerely, 4;v~- -~I~ Kevin Grabau Zoning Technician Enclosure i COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800-962-5227 FAX - 715-962-4030 Jim Thompson Report Number: 00009078 Page: 1 5t. Croix Zoning Office Sample Number: 00-02147 St. Croix County Gov. Center Report Date: 4/24/00 1101 Carmichael Rd. Date Received: 4/19/00 Hudson WI 54016 Owner: J. Peter Ritten Address: 305 Riverview Dr. Hudson WI 54016 Collector: Kevin Grabau Date Sampled: 4/17/00 Time Sampled: 16:10 ::ample Source: Laundry Room Tap Date Analyzed: 4/19/00 Time Analyzed: 14:00 Caliform,MFCC: 0 /100w1 Interpretation: Bacteriologically SAFE Nitrate-N: 4.6 ppm Above 10 ppm Nitrate--N exceeds the recommended Public Drinking Water, Standard. Lead: 16 uq/L Above 15 ug/L exceeds the Maxi MUM Contaminant Level (MCL) it drinking water systems. Lab Technician Pam Bane WI Approved Lab No. 19 II C Means "LESS THAN" Detectable Level Approved by: C..`I j COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800-962-5227 FAX - 715-962-4030 .Jim Thompson Report Number: 00009078 Page: 1 5t. Croix Zoning Office Sample Number: 00-CE147 St. Croix County Gov. Center Report Date: 4/20/00 1101 Carmichael Rd. Date Received: 4/19/00 Hudson WI 54016 Owner: J. Peter Ritten Address: 305 Riverview Dr,` Hudson WI 54016 Collector: Kevin Grabau Date Sampled: 4/17/00 Time Sampled: 16:10 Sample Source: Laundry Room Tap Date Anal/zed: 4/19/00 Time Analyzsd: 14:00 Coliform,MFCC: 0 /100ml Interpretation: Bacteriologically SAFE Nitrate-N: 4.6 ppn Above 10 ppm Nitrate-N exceeds the recommended Public Drinking Water Standard. Lair Technician: Pam Gane WI Approved Lab No. 19 t Means. "LESS THAN" Detectable Level Approved by:P~