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HomeMy WebLinkAbout161-1092-40-100 D p °va p °60) M C1 I 4 O O ti. `S N ~ N c n C o U) N i w c s N N N x U h Y x m +y co o 00 n :S M v3= v - Q III a> 'a I c I CL c3 I ° 3 E m o CL m w o w CO c m W m E m c:'E a~ a~ - a~- C Z a C Z co .N Co p ~p N M 7 co N o -p ti C° C U. O -O N > 7 > Q Q 3 E Q~ m o U 3 Cl) M CL z W y N Z 3: 1 ° O O O 0) d m d m M W F Z C O C C9 U O z d' 'c w w I aUi 2 d' c c z M F- cm m CI- E Cl) 0) i O N 7 (D O O N N cc a) co N N CL N N Z N O N C • O N (n -C O fV ~ ~ a I ~ Z O O m O o N Q O o Q w z m z zco z a c a~i m E N - o E m E w I X O. w d N C O G) Q N A) m L y O .8 d E a O D a E E CJ C a co F- y N ° ~1 in v p H H FN- o o ~ ~ ~ 0- m° IL `a O O O N LO O O O z N a a a 3 a a a Mlr a ' hi M M y o y o m O N J U -O N rn m y0. 'NO ~2 } 7 a c) O 2 N M 0 C) 0 N N r N f- GO E N 0 _ C> = J O O .O CO O O 3 ~ a O N N C(~ N O m st r+ o N N w~ co 4) O = (n = A 7 w O O S j u N C LO N C li +r t Cl) O M C E O cD O C) 0 O " O N z L o a a L N o a - N 0 r \ yr I~ O N m Co ° cn U) E m a) N N v _p ~ O O C m m S N O C O i;5 ~ii N N Li O O O c!) tR 'O 'O N to 0 O Z F- D co V N _m n O° ° M ° N E E a v • L U z m 2 C7 o z H v m m a a m fat nl yaw La a F) '2 d u, c o 3 o E` c t on A 0 a 2 O in v 0 v) v Parcel 161-1092-40-100 01/09/2006 10:38 AM PAGE 1 OF 1 Alt. Parcel 13.29.20.728A 161 - VILLAGE OF NORTH HUDSON 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 - MORTENSON, GARY & KATHRYN GARY & KATHRYN MORTENSON 305 STATION LA N HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 305 STATION LN N SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.000 Plat: 04/38-ST CROIX STATION 1977 ST CROIX STATION LOT 4 ALSO PT OF LOT 5 Block/Condo Bldg: COM WLY COR LOT 4;TH N 51 DEG E 40.76' POB;TH N 31 DEG W 43.67';TH N 51 DEG E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 41.32';TH N 37 DEG W 9.57';TH N 52 DEG E 13-29N-20W 38.29;TH S 37 DEG E 24.65; TH S 51 DEG W 120.53'POB Notes: Parcel History: Date Doc # Vol/Page Type 08/14/2001 656650 1719/156 WD 11/10/1999 613603 1469/501 WD 2005 SUMMARY Bill Fair Market Value: Assessed with: 108562 517,500 Valuations: Last Changed: 05120/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 120,000 386,400 506,400 NO Totals for 2005: General Property 0.000 120,000 386,400 506,400 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 75,000 298,000 373,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 519 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 . STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 6U 1.3J C'~a U I h P F'. ADDRESS 305 9r-41, 0 r-) ANA' 'yj # ~f SUBDIVISION / CSM# LOT t~ SECTION~T 31 N-R W, Town of 1~- ~J ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~v n~ 55; _ 901 6u11 ~u,,,Vni~ey ° i _ r~i~~d a7~ I f I~~s(~ Qer,~ S4i's tl' !3' INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: -,M S 2( 1 Dlj f1 (2,~ 0~ ~ C fil L ~ 1 I, ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 0 Liqui PC4g--ty: Uve~ Setback from: Well SO' House ~a' Other Pump: Manufacturer Model# 1 Size Float seperation Gallons/cycle: Alarm Location ;SOIL ABSORPTION SYSTEM Width: Length S-0 Number of trenches Distance & Direction to nearest prop. line: v' Setback from: well: O1QV House 55 Other 13.,11 ~v N Vr, 14 Z N - 9S. s v 00 0-PW Qu ( 01 d 9SLLEVATIONS Building Sewer ST Inlet; 5 r~ ST outlet. r S S y C g Y PC inlet PC bottom 'Pump Off IhT,P r? i ~NU Header/Manifold 8'7•~ 9 $7.9 Bottom of system 8L Sb 5 a r~e Existing Grade Final grade 91.U DATE OF INSTALLATION: PLUMBER ON JOB: r- I 0 UI PNX P f (Z LICENSE NUMBER: y u INSPECTOR: 3/93:jt LG,If+`&TsTr Nl aAeR My-, 12.29.20 `~A~E i& It County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitar rmit GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI . ev,- Insp. BM Elev.: BM Description: Parcel Tax No.: W file; 161-4092 491000- TANK INFORMATION ELEVATION DATA A9300168 f TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark t lit Dos' %5 . ~.•4 IJZ~. S r Aeration Bldg. Sewer Holding St 14W Inlet TANK SETBACK INFORMATION St/ outlet , 9(5 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic ~ r 3~ ~ NA Dt Bottom Dosin NA Header ftM_er r. Aeration NA Dist. Pipe 6, l ~ Holding Bot. System 7, a PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Mo el Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. H Dist: To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length / No. Of renches PIT No. Of Pits inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEASING Manufacturer: SETBACK CHAMB Model Number: INFORMATION TypeO System: OR UNIT DISTRIBUTION SYSTEM Header/ MaRi#eld-. Distribution Pipe (s)/ x Hole Size x Hole Spacing Vent To Air Intake Spacing Length FDia. A- Length 60- Dia. -4-/ 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 [j No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION : N HUDSON.12.29.20 LOT 4 (FATION LANE) 4,02 cv~/ kS) Plan revision required? ❑ Yeses. Pw Use other side for additional information. , SBD 67 0 05/9 Date Inspector's Signat a Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t =EMI SANITARY PERMIT APPLICATION LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El 8% x 11 inches in size. check ifrevision o 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 L en- 61-)ILOr4- C4(- L, SE X. .50J Y., S /-2 T a?, N, R as E (or PROPERTY OWNER'S MAILING ADDRESS LOT # O > L,4 4/e A/ BLOCK CITY, TAE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1y1UZL6AJ1 Z-~Z ~J (21-6 ;)e 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ~I ( ) State owned 11VILLAGE : ❑ u , J 'v Public 2 1 or 2 Fam. Dwelling-# of bedrooms-3 PARCEL TAX . NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) r 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. ❑ 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 ❑ 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.. 15. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROP( ED (AREA ft.) (Gals/day/sq. ft.) (Mindhch) LEVATION US 6 r b C loo d 8(,-s Feet 4 0:eet VII. TANK CAPACITY Site INFORMATION in allons Total # of Manufacturer's Prefa Fiber- Exper. New istin Gallons Tanks Name oncr t Con- Steel glass Plastic App Tanks Tanks. structed Septic Tank or Holdin Tank _Si: L. vi . 4~ j - El El E] 1:1 1 0 Li 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 Signet (No Stamps) MP/IP RSW No.: Business Phone Number: 71 >w a u y0y Plumber' IT dress (Street, City, Stale,, ZiA, I p ode): ' 1\ ~ r~ _S 01P ti~s0r_ r _ Q01 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Age i t Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination 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 renevral 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 (S 3D 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. i- 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: l_ Property owner's name and mailing address.-Provide the legal description and parcel tax lumber(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 Famil / 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 gallon 3, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. G'omplete 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 main:,/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) 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 property 1/45U' 1/4, Section N-R Mailing address 0A--/ L P11,1250~ O Address of site ~r~~,~~~` ✓ro Subdivision name Lot no. Other homes on property? yes No Previous owner of property _f Q111e" Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No volume and Page Number as recorded, with the Register of Deeds. I 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. FR-;t& 6 , and that I (we) own the proposed site for the sewage disposal systemorr Ie(we) obtained an easement, to run the above described the construction of said system, and the same has been duly o recorded in the office of County Register of deeds as Document No. S' nature of app scant •o- ant Date o SignAture Date of S gnature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1988 THIS SPAC[ Rp[RYto FOR R[CORDINO OATA WARRANTY DEED 382426 L ?AGE T Ns Deed, made bet.em Norbert T. Koch, Jr. REC4SMRS OFRCE and arles E. G. Larson ST. CT"`, Co., Wii, 6th ~ Rex d. f-- Jan.; this _ Grantor, day of 19 M3 andJohn_C..-Gilbe.rt---a/k/aL.John. Gilbert. and...... Nancy L. Gilbert>. husband and wife as at 10.00 Pr1. point tenants; 414 Grantee, R~phlgr of Dlod[ Witnesseth, That the said Grantor, for a valuable consideration..-... $.20,000.00 conveys to Grantee the following desmbed real estate in St....CxQi?5........... R[TURN TO County, State of Wisconsin: Lot t. CRoix Station in the Village of North Hudson, Wisconsin Tat Parcel No:................................... Ibis Deed is given in performance of a Land Contract dated December 10, 1980 and recorded December 11, 1980 in the Office of the Register of Deeds for St. Croix County, Wisconsin in Volume 622, Pages 391-392, Document #368263. n, ^T^ t,yV JS } cr~ 0• d D t a ~'EE This .is..not---...- homestead property. Together with all and sirg7lar the hereditaments and appurtenances thereunto belonging; And- .._...-and--C7?arles... G., Larson warrants T,---Koch Jr. that the title is good, - - ndefeasible in fee simple and _I; free and clear of encumbrances except easements of record and the covenants set out in the Declaration recorded in the Office of the Register of Deeds for St. Croix County, Wisconsin, in Volume 56S, Pages an 1 69 grant and defend the same. i.r Dated this _ - day of December - 19_. 82.. - - - - (SEAL) SEAL) - T1 ERT T. KOCH, JRy - - -(SEAL) CHARLES E. G. LARSON AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF Wisconsin g9. St. Croix . ................County. authenticated this day of__-_____________________ 19...... Personally came before me this . day of .__------Dec,embeS_---------_, 13.82-... the above named NQTt2ext_-~-•--KS1~a--17x_... alkd ' - - Chaxles..h_. Lrson _h(-.!?ch- , TITLE: MEMBER STATE B_AE OF WISCONSIN Larson- and. as. St.--Croix _St~tion........ (If not, - - - authorized by § 706.06. Wlis. Stats.) to me known to be the person G.__ who e'fulcuted~Fle foregoing ' ment and ackpowledge the.sarrf~, ~ - THIS INSTRUMENT WAS CpaFTgD BY ~ JJi HEYWOOD, CARI -URRAY -•P.0. X.229'--------- a erry E. Pirius - . T r Hudson, , W1_.S4Q16___---- Notary Public-._'_ CroixColult ~j- . J ---(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration are not necessary.) r _ date: - - ONamen of persons signing in any -a.-Ty sMmld be typed or Printed bebw their eignaturm WARRANTT DEED STATE BAR OF WISCONSIN IBlank Co. Inc. FORM No. I-1981 Miilwaukukeee, Wis. N ,,J t. G A J S F, 1/ 4, 4, EC r V ~Ac nj~ S O}Y ST. CPOIX COUNTY ~V SION: NO. 1 pe use and I+'ic;-_:i'1tf: n~7.?1G'E' of yc;uT se3~?t1C SYSt+ t7tzl(d TJX liiclti.Y{' failure to it e-l <afltPc. r ol,''_v L t T t a j` L C: )G.T ij `t 1 out the septic-' e c.I ever,' of ecied, ty a licensed septic: tank pu.m er Wha - v cu ' nto the system can affect the function of the septic tank as e_, iC?'; ent state in the waste disposal system. County residents may be eligible to receive a grant to 7 th( post of the replacement of a failing system, which G r ti-o rrior to July 1, 1978. St Croix County accepted m ;:ugx st of 1980, with the requirement that owners ~z.L =,,stems agree to keep their system properly .t¢-r-.~,. y ; v,er agrees to submit to the St. Croix County c.r'-,:_ ication form, signed by the owner and by a master jour,neynan plumber, restricted plumber or a licensed that (1) the on-site wastewater disposal system rt proper operating condition and (2) after inspection and necessary), the septic tank is -less than 1/3 full of sludge and scum. Certification from will be sent appraa `_matel, 30 i ty-z pr for to- three year expiration. ndersi.gned have read the above requirements and agree private sewage disposal system-in accordance with ,7 -d: f t forth, herein, as set by the Wisconsin DNR. form must be completed and returned to the Sta. r:ing Officer within 30 days of the three year SIGNED: DATE, C,..,,81}~r '~;or1ing Office Wisconsin nd Department bons Industry, SOIL AND SITE EVALUATION REPORT La . Labor and Human n Relations Page -Z Of Division of Safety 8 Buildings in accord with ILHR 83.05, Allis. Adm. Code COUNTY t~iv^u Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S/ not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY 0 PROPERTY LQCATION (J ( GOVT. LOT t 5 f 1/457 b) 1/4,S f ~C T R N,R a E (or& coT P~ PV{)WNER':S ILING ADD r A L T BLOCK# SUB ME OR CSM # I b 1j 2 A► 1 u P - R( l S o U :C -M I- GVr S~R~ jai _ CI STATE III O DE (HON; N KM []CITY ILLA E ❑fOWN NEAREST I? AID 0 t4 k' "d so y' O t ( ] New Construction Use P4 Residential / Number of bedrooms 3 [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived dairy flow =4-~ gpd Recommended design loading rate bed, gpd/ft2 - 4 trench, gpolft2 Absorption area required OCR bed, ft2 ;N0 trench, ft2 Mahamum design loading rate ~ bed, gpd$ , C trench, gpolft2 Recommended 14 ation surface elevation(s). S It (as referred to site plan benchmark) Additional design /site considerations Pargrht rgaterial Flood plain elevation, ffapplicable / ft ' e for system T CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK uitablefor s stem ❑S ❑U ❑S ❑U ❑S ❑U [IS ❑U ❑S ❑U ❑S ❑U SOIL DESCRIPTION REPORT Bor Horizon Depth Dominant Color Mottles Texture Structure Consistence Botnd3y Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mncth <v -4Z2 /sib/ U- A5 We 2- 7 ra y G S sue ' m Ground 1 Ley Depth to limiting ~f Remarks: Boring # ©'=fps 6 2 / / 2 zj v~ S G Ground 3°=831, ] S yhe y F 1 ~ 24L Depth to limiting 2 2 7c ~ Remarks: CST Name:-Please Prin Phone: Address: /'L Signature- Date: CST Number: 3 >1/y7 v v.~ a.vvnlr 1IVI`I nCrVt1 Page,~L of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft ' La",_ in. Munsell Qu. Sz. Cont. Color Consistence Boundary Roots Y/Z a Be -tr la dE n, Y r S' Z ' Ground elev. , Depth to limiting ~f.a;tDr a Remarks: Boring # -w Ground elev. ft. Depth to limiting factor Remarks: Boring # 13 Ground elev. ft Depth to limiting factor Remarks: LLJ .Boring # 13 Ground elev. ft. Depth to limiting factor LI Remarks: SBD-8330(R.05/92) - ~g9~ 3 v~ 3 8 3 5 off' $ 31 J 4 -Va~- CL L--~-& d 1-1 3 E wllr"~ Gj~// wYll,' > Sro' Ft-v.,, B m LtOAI v^ lv' xf L. 01 13 L -U M131 JEC sv-~' I AN L 0 CA T I 0 1 . ~ . L I C ENS E....__ C.___ PLO -I~ N A_P ~.1n. of -f TN,5P4- Pi <N~ TApt ~CL- 100.0 S«~-e O LJ.f) I as N Cad jP ~e~J' ICJ Wells A4 F;,P-Tk,, xS~ Be o ~a I ► Cx-p, Pull R~~ U~lye I I ~D/ZUUh~ - d I r /rJ~ 8~ S-' w Q ~Klf ~1 NG Q i 1000 r4). r'p ~1 e~ I F ESH i111'. 1PdLT,',r i AND OBSERVA'P10V P1.9t _ CROP`S SECTION Approvek:~ Vent Cap Minimum 12" Above 11►~ D I (~P PQ' Final ga Sb 4" Cast Iron Above Pi Vent Pipe To Final. Grade. _ Marsh Hay Or Synthetic Cover,'.ng' Min. ,2" Aggrey'ofill Over Pipe Distribution Tee Pipe 8~,SU Aggregate rerf.oraLed il.a^e 'it: lr..• (3~ or, llcncath Pipe C:oupli.n;~ Teaminatir:~ T A.._ _ ._.w Bot f,om C f System, 4 AS BUILT SANITARY SYSTEM REPORT OWNER 6 R~ ~'D SEC.I2 V_qN-Q0W ADDRESS A &E &T. CROIX COUNTY, WISCONSIN. v~A.)S SUBDIVISION b'~Q9yp~/ LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 14 TA ~YTHING WITHIN 100 FEET OF SYSTEM a _ J- F- F V Jfj4 Cp B • /a a m I di a e. ~o~thjArrow I _T' SC L i S BENCHMARK: (Permanent reference Point) Describe: 0'" 't100 N$11- _/N 0.49 Elevation of vertical reference point: Slope at site: I SEPTIC TANK: Manufacturer:_WtP1Srg_S Liquid Capacity: IMC) Number of rings on cover : Tank manhole cover ele ation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cyc a gallons; total capacity of- distribution lines gallon: size o pump head; gallon per minute horsepower ran name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: Number o pits feet diameter feet liquid dept seepage pit inlet pipe-elevation bottom of seepage pit elevation feet. ,r SEEPAGE BED SIZE: number of lines-wi width IS length_?_' tile depth SEEPAGE TRENCH: width length PERCOLATION RATE A RE UIRED /n/~ RE S BUILT c~ INSPECTOR DATED PLUMBER ON JOB LICENSE NUMBER REPORT OF.INSPECTION - INDIVIDUAL SEWAGE SYSTEM f Sanitary Permit State Septic *1V0f- 4AME V /7 l TOWNSHIP &uZUQAf St. Croix County .OCATIONWSt SAJ SectionAX-01,ot # Subdivision ST, SEPTIC TANK Size gallons Number of compartments r )istance from: Well v Building L Z 12% slope Highwater 'UMPING CHAMBER Size gallons Pump Manufacturer Model Number IOLDING TANK Size gallons Number of Compartments Pumper Alarm System )istance from: Well Building 12% slope Highwater ABSORPTION SITE Bed Trench !)istance from: Well Building 12% slope Highwater :''iBSORPTION SITE DIMENSIONS Z~oWidth of trench 4/ ft Required area ft. Length of each line o~ ft Depth of rock below tile in. `Number of lines I Depth of rock over tile 12-1 in. (6 Total length of lines 90 ft Depth of tile below grade in. ,5), Distance between lines ft Slope of trench in. per 100 ft. Total absortption area o2 ft Type of Cover: PIT DIMENSIONS Number of pits Gravel around pits yes no Outside diameter ft Depth below inlet ft Total absorption area ft -1 Area required ft INSPECTED BY TITLE ~j APPROVED DATE AZ 198 REJECTED DATE 198 REASON FOR REJECTION L a P 1 State Permit LB 6 7 State and County Permit Application County Per i # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: I L &ErT 2312- B. LOCATION: E '/4.5Section , T N, R90 E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village /yp f9~vGSO 54. e ko ix _5'~XTLD) I /AX '~L9 t"f 4~jr/E Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) Variance Single family ~4 Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY I EY10 Total gallons No. of tanks I HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete 7<1_ Poured-in-Place Steel Fiberglass Other (specify) New Installation ;!!S, _Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New- X-Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depthltop) No. of Trenches Seepage Bed:- -Length -5- Width 4Z' Depth Tile depth (top) n No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope WATER SUPPLY: Private 25 Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, NAME C.S.T. # ~o and other information obtained from (owner/builder . _ / Plumber's Signature MP/MPRSW# 5`" Phone # - Sd Plumber's Address PLAN VIEW: Provide sketch below of system 6 clude direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the s tch. Indicate or dimension location of all wells on the property or neighbors property. If well has not b drilled please indicate. a D _ O o L~ U~ F Zo q `4 V, N m N~ L~~ E -A - s r V-- 0 AZ E a gF-;, C) moo 6 o c' " K T P%P~ Do Not Write in Space Below FOR COUNT ND PARTMENT SE ONLY Date of Application 9141-J;;Y Fees Paid: Stat County e~-d Date Permit Issued a (date) Issuing Agent Nam Inspection Yes No State Valid# Date Recd 1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 ` f H 15 Rev. 9/78 ' REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: S t '/o,a VJ%, Section %Z ,TZI N,R?O V (or)(Z wor Municipality Lot No., Block No. S"a4 [©Y1 County C $ x u wlslon ame Owrier' Buvws Name: VN <2 4 1 Mailing Address: Z -31Z v► KCA, A4 1 TYPE OF OCCUPANCY: Residence - No. of Bedrooms 3 COMMERCIAL EFFLUENT•DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OT ER DATES OBSERVATIONS MADE: SOIL BORINGS :Z& PERCOLATION TESTS _7ZO/Aff/ 7 d SOIL MAP SHEET / NAME OF SOIL MAP UNIT u ~ 6 a~ oa;w~ / Sa- PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P-/ Q - S/ 7 S ZP Z I P-3 3" tC~ _ 3 S S it Js_ P- ! P-Ell i h --T-1 P- LZI r~ SOIL BORING TESTS z rva TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WIT PM_ ICKNESS, C O NUMBER INCHES TEXTURE, MOTTLING AND / H TO BE CK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES c-, B- -78 ~t !fir 'C. 7 8 r, liS C~ gk B- Z 34 o 141 s SL ° s G~ B- 3 -76 7-4 ova 8 'I S S SG r B- Z oh 7 8 Z q6 'S SL 3~ " Sc [ l R rot., " S t rcxo B_ Z 7 Z_ PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the pia the loftpn and square feet of.suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy ~S Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. / 0 rct s 1 ~ MZ •@ C! Y IC> % .4) fN) E x .oo r A t _.4 r i 1 1 1, the undersigend, hereby certify that the so tes 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 location of test holes are correct to the best of my knowledge and belief. Name (print) A 1 yCr M4 Certification No. y Address )08 WG( y1,U4_ Sf v cj ~o y-; f . y c')t <a ,Name of installer if known n n CST Signature ` C Copy A -Local Authority r vliu) Lca- 4+ -Fl A) cp I* ~ i t