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AS BUILT SANITARY SYSTEM REPORT
OWNER SQ,~
ADDRESS
SU DIVISION / CSM# n C k cq/~+' LOT
SEPTION_--7 T Z N-R• j✓' Town of rl S o .N,
ST~ CROIX COUNTY, WISCONSIN
a
PLAN VIEW
SHOW E ERY!BHING WITHIN 100 FEET OF SYSTEM
6a~aq~. ~iuc .~0. '
.2txso wm [I
61
~
3I
bp'
c, a
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: ~4 I n ~lK Q o~/l ~/o f ti ld7F /S-
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: GL/ ~ f Liquid Capacity: /0-00
Setback from: Well q/ House y~✓ Other-
Pump: Manufacturer - Model# Size
Float seperation---------- Gallons/cycle:,,-
Alarm Location
I
I
:SOIL ABSORPTION SYSTEM
Width: 5' Length Number of trenches
Distance & Direction to nearest prop. line: 2 j
Setback from: well: House 2 zoo Other
ELEVATIONS
Building Sewer ST Inlet. 7, 4g ST outlet sy
PC inlet PC bottom Pump Off
Header/Manifold /0, Bottom of system 7
Existing Grade Final grade 7,Z-
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
i
c i tg i rtr ie o ~i ust~y7.29.19.1~WIVRyE' S *AWJPS~Sf ERJANE, LO Ir 19
County:
! Labor and ►+rtaman Relations
Safety and Buildings Division INSPECTION REPORT
rmit No.*
I~ GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PeST_ CROIX
171456
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
SAN MILLER HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
Gr] ~ (9\ ; "Ipy 7 020-1168-90-000
TANK INFORMATION ELEVATION DATA A9200221 C~
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 6D,
Dosi
Aeration Bldg. Sewer
Holding St/ Inlet 54
TANK SETBACK INFORMATION St / ~*f Outlet 9G' vsl /
TANK TO P/ L WELL BLDG. Veintake ROAD Dt Inlet
Septic 44 NA Dt Bottom
Dosin NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
M nufa Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Forcemain Length Dia. H Dist. To
SOIL ABSORPTION SYSTEM
BED/TRENCH Width, Len th / No. Of Trenches PIT jNk. Of Pits Inside Dia. Liquid Depth
DIMENSIONS D N 1 N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING nu acturer:
SETBACK
INFORMATION TypeO CHAMBER
CHAMB Mo a Num er:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/ Distribution Pipe(s) f x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length _'k Dia. / Spacing /
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over 0 Depth Over ,t xx Depth Of xx Seeded/ Sodded xx Mulched
9eddTrench Center /19 ` Bed/ Trench Edges /g Sy I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
la. T,9 9
Plan revision required? ❑ Yes ''No
Use other side for additional information. Qoik SBD-6710 (R 05/91) Inspe or's Signat re Cert. No.
ADDITIONAL COMMENTS AND SKETCH
t,
SANITARY PERMIT NUMBER:
D11..HR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
a::a.a° aww~w.v~
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ l 7 1 C4s-h
8% X 11 inches in size. Check if revision to revious 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
Ael- S tJY4 0YW S T -:17, N, R E (or)D
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
4'a i
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
3G w
III. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
6' /
) ❑ State Owned ❑ 5a =NOF: VILLAGE:
air
❑ Public X 1 or 2 Fam. Dwelling- # of bedrooms ~ PAR LTAX NUMB ( )
111. BUILDING USE: (If building type is public, check all that apply)
oZo- 7.0
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. Q 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 Seepage Pit Pressure 430 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./inch) 0. ELEVATION
Sfl 7 Z O g 30 69- S z S gV. 3 4b Feet 3 S Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank O D O Li/ jr 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 Stamps) MP/MPRSW No.: Business Phone Number:
G zr 7 Z
pfikA t b 1.41 1
Plumber Address (Street, City, State, Zip Code):
Q-e s4/ R; c k m J_ S o 7
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing ent Signa o Sta ps)
OR~ Surcharge Fee) Approved ❑ Owner Given initial g19Y5 tG
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6388 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by -the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior 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.
If. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, ~ocaticn of
holding tank(s), septic tank(s) or other treatment tarks; 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)
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
e~~r, ~J ~ ✓
Location of property lA11/4 Section, T~ N-RA
cs'
Township
Mailing address 5Plip)C
u AJ~r~•r:
Address of site r~j tZ"t f
Subdivision name- Lot no..
other homes on property? yes No
Previous owner of property C/
Total size of parcel 3.i) l AC_
Date parcel was created / 2 - - `ly
Are all corners and lot lines identifiable? Jr Yes No
Is this property being developed for (spec house)? Yes No
volume y and Page Number 416 E. 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. 4150 s o e) , 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. 16_0,0
Signature of applicant Co-applicant
C -Z
Date of Signature Date of Signature
'l<_< 'z-, . ~ ~'F9 ~a-^• ; ,r ~a+l~~~. }0...,. sir
11 ~
Crai L.._Fag~.rness, a single _pe-rson...... L
PRO S 1992 ,
P. M
4.5
. d
5s>A.. miller
conveys and warrants to
RETURN TO Reywoo
_d Car i
i
. .
P.O. BOX 229
Hudson, wl 54016
Sk, ..Gr.Qix... Court),
tM lolbwintt described real estate in .
State of Wisconsin: Tax Parcel No..~20-1168-91)..
Lots 17, 18 and 199 Plat of Ranchwood in the Town of
Hudson.
T! t• is not hnntcxtl:u~ prv 1~crt}'.
(is not )
Ex/•,1,t;rnt 7tKt.X, s nontie~: Existing highways, easements and rights of war way of record.
April 102
llut~•li ti V ~Y /~I~
SEAL
Ad -1
tSEA1.►
• Craig L. Faget.n~
. ' -IAl
I"EM~ %,~-4
AUT81iNTICATION ACKNOW LEDGKENT
STATF. OF WISCONSIN
giRnstun (e)
t . C r o i x t .,t,nt, 1
sAICOP da>
authenticated this dad- ~f 19 March 1;rn 2 th,• ,I ove nan
Craip; l,. Fagerness, a 'single
person
riT1.F: NIFNIBER ST-•ITF: BAR OF
t 1 not,
authorized by ,111. h, i r~.t• f. inn',\!• •i, t!tt• 1-r•--M
n r. .nI• fit ui %kit•i.,.
Attorney David J. Estreen Y•<, _
V
• N'
Hudson, Iv I i .
621 2nd St., t
Nr.,
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER X'// l
ADDRESS FIRE NUMBER
CITY/STATE ~r"~ y Y ZIP`
PROPERTY LOCATION: 1/4, SECTION , Tj~c_ N-R Zj`J""0
TOWN OF St. Croix County,
SUBDIVISION 4ti~ W60r;l , LOT NUMBER_~f_.
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.
ca
SIGNED-;
DATE:
St. Croix co. Zoning office
911 4th St.
Hudson, WI 54016
SAFETY&BUILDING
DEPARTWENTOF REPORT ON SOIL BORINGS AND D
N
-I~VDWSTRIVISION
C P.O. BOX 7969
LyJABOR RY, UMAN REL~ITIONS PERCOLATION TESTS (115) MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOHTI '/W V/ SECTIO%T N/ E ( *OWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SU 15 COUNT ! BDIVISION NAME-
#A COER'S/BUYER'S NAME: MAILING ADDRESS:
r ~ D
USE DATES O SERVATIONS MADE
TESTS:
[W,,id,,ce NO. BEDRMS.: COMMERCIAL DESCRIPTION: PRO FI L2EE E SCRIPTIONS: PERCOLATION
❑Replace ~O evt~!4
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
au 1?, ❑u CAS ou CA au ❑u
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: 09 1 r- I Floodplain, indicate Floodplain elevation: 2kII A
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.)
Z '
B- -3 7 7
B- /6 3 / K / 3 rr~S .7. 3 c~/S 3 ~/'Zol S /
B- 57 /3 / y > 3 / c s/ a iris 3 -;Z '/(,(IS 7 %?W L
-tff ~',Rk / 3 , 3 AoOS
PERCOLATION TESTS
9- 7
kNUN&ER DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERT D PER INCH
3
P-_
3 s C 2
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
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 9®. '
I
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L
J
rte,, /~2~ a _ TN
J.,
34' _A7740C17W4P -
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~ ~ ~y. ~ ~ .lily (,./~-"'~'_.-_~l~/',~~`~ _~i l~'ae tX '4iYe?
/ ~
r
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 (print): DAVE FOGERTY PLC I MBING TESTS WERE COMPLETED ON:
R Tester &VPfllulmber lolazm
LiCenSad Perk ADDRESS: #3233 #3289 CERTIFI TION M ER: PHONE NUMBER (optional):
IF arty Heights Road
Phone 749-3656
LDISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
LHR-SBD-6395 (R. 02/82) - OVER -
r._ t
Imo'"TRUCTIONS FOR COMPLETING FORM 115 - SRD - 6395 ~
To be a cornf 1 accurate soil test, your report must include:
1. Complete!, ription;
2. The use tclearly indicate whether this is a I- once or commercial protect;
3 M ~Xi ! Ii',' 3r of bedrooms >r cornmercial use
4. iacement sy ~
5_ irlity rating' A SITE IS SUITe,~--E FOR A fiOLDING TANK ONLY IF ALL.
O ARE RULE f , BASED ON SOIL CONDITIONS;
6. PLEASE u: •!~reviations here for writing profile descriptions and completing the plot plan;
7. MAKE A LE ' diagram ritely locating your test locations. Drawing to scale is preferred, A
se s' uF-ed if d i;
H. M ' e sw,. t..rrk an, elevation reference point are clearly shown, and are permanent;
9. box, dates, names, addresses, flood plain data, percolalion test exernp-
10, flood plain, ration) does apply, place N,A. in the e box;
11. your currew ass Nnd your , fication number;
12. N" i distribute as recuired. ALL °"3IL TESTS MUST BE FIE. ) WITH THE
'ITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
' ".~a, ° v -d Textures Other Symbols
BR Bedrock
cols J"} SS - Sandstone
gr- 3„} LS Limesto
Ht - High G ;
- C d - Pereolat
- n S -rid _ yell
- ~ Building
Is .~ul j Greater Than
< _ I .,s Than
L Brt .:vn
81
Si! Gv
" Y
Loam R
-oarn mot s
- -lay w! -
Sic - C ay fff _ ; int
r
cc c
Ins - mm
ni - - d
HVVL-l-.,~
~~^xtures Sul *
disposal BM -
VRP - vertic
T ;
or [ r ~y redu >t
it for ,ny
.
Nam.-
r
,-1 ~ f%
, -w ,
~r~i ' _y ft'- d .3 _ ~ i f ry,~ ~ ^s, Sn ~ dy ~ t ~ ~ S n akn~ ~ y
as, .t=a ro Fi ^:l's~~' ,i.~:. ?e:r-,w ;3-s.&5~•~.•A_E`=a, i ~'~c. :.;j ~+.8888i +Tj
i,
}
S,
1
4
y
NUMBER
RV 1 6 6 7
RIVER VALLEY ABSTRACT & TITLE, INC.
ST. CROIX COUNTY, WISCONSIN
Lots 17, 18 and 19, Plat of Ranchwood in the Town of Hudson.
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REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1
04/26/93 08:33 REQUESTS FOR INSPECTION WORK SHEETS FOR: 4/26/93 AREA: JT
Activity: A9200221 4/26/93 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 07.29.19.1047,SW,NW, WINDLOFF LANE, LOT 19
Parcel: 020-1168-90-000 Occ: Use:
Description: 171456
Applicant: SAM MILLER Phone:
Owner: SAM MILLER Phone:
Contractor: STROHBEEN, DOUG Phone:
Inspection Request Information.....
Requestor: STROHBEEN, DOUG Phone:
Req Time: 14:04 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION