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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER SAA, AAI LI-f J,14 N UJAXoh
ADDRESS,3aK Z$ Z.
Ilk l ~e5 ►a u.1
SUBDIVISION / CSM# X6 NI 1„ANF LOT #
SECTION 1 (O T a I N-R /I , Town ofVvu -5 o h
ST. CROIX COUNTY, WISCONSIN
PLAN' VIEW
\ SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
((~70
V`
WVFWAY
Nou
W~~~ 29.'kSOi
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i
10
s 1
S O'
t~ A~-fa-v~-~a f~faa /2 i(Go'
`SS N INDICATE NORTH ARROW
I~• yh . Top e ~ ~ Pte,
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
i
1
+ i
BENCHMARK: T0 lO o, o o /
ALTERNATE BM: 76f Hz.-s.-
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: (000
Setback from: Well 9 House Other
Pump: Manufacturer - Model# Size
Float seperation - Gallons/cycle:.-
Alarm Location,-
.
SOIL ABSORPTION SYSTEM
Width: 11 Length y O Number of trenches .
Distance & Direction to nearest prop. line: 27 T° .Soky'L,
Setback from: well: -16 House Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: Sz
INSPECTOR:
3/93:jt
LOCATION: HUDSON 16.29.19.136A,NW,SE, LOT 1, WAXON LANE c
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor-and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
186531
ermit Holder's Name: ❑❑i6 Cit Village ETTown of: State Plan ID No.:
MILLER, SAM ~6 N
CST BM Elev.: Insp. BM Elev.: BM Description: l Parcel Tab%-1029-90-100
/O , vv 1,-)Z), 61d &,-s- 7
TANK INFORMATION ELEVATION DATA'/ Z,03 TYPE MANUFACTURER CAPACITY STATION BS --*W FS ELEV.
F~ a74
Septic Benchmark
D g 1-z,76 40/1 /0/,50"
Aeration Bldg. Sewer
Holding St/ K Inle
TANK SETBACK INFORMATION St /,K
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet -
Air Intake
Septic NA Dt Bottom
Dosi NA Header lVen. - "
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade s } 22 ~L/
Manufactur Demand
Model Number GPM
TDH Lift Friction System Ft
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
RED/TRENCH Width i Length No. Of Tre ches PIT No. Of Pits Inside Dia. Liquid Depth
/1? DIME N
DIMENSION
S 1
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI Manufacturer:
SETBACK
INFORMATION Type Of CHAMBER a Num er:
System:A6er~ A OR UNIT
DISTRIBUTION SYSTEM
Header /15Wo field- . Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length ~ Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over „ Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed t.I Center Bed /I&ez=4.Edges Topsoil [I Yes ❑ No E] Yes El No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 16.29.19~136A,NW,SE, LOT 1, WAXON LANE
aJ l&•
L~ ~7 1,4~ J F C <Y-1-0
lo~
Plan revision required? ❑ Yes ®'NO r
Use other side for additional information.-. S ~`3 f
SBD-6710 (R 05/91) ~at~//s~~ Inspector's Signatur Cert . No.
ADDITIONAL COMMENTS AND SKETCH i
SANITARY PERMIT NUMBER:
ILHR SANITARY PERMIT APPLICATION
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. c ec if ~iEztlollous 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 /
SR ~.i ~ l~i& or MO 1/4 y4, S N, R E (or W
PROPERRTY OWNER'S MAILING ADDRESS BLOCK #
CITY, ST TE ZIP CODE PHONE NUMBER SUB (VISION NAME OR CSM NUMBER
s`
s v~J vl 91P ) 3 3 9 C- , 5. r- 2 d,
11. TYPE OF BUILDING: Check one) CITY NEAREST ROAD
( State Owned M
M TOWN VILLAGE : Y af5 m Wa- O N L0. K
❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms 3 'PARCEL TAX NUMBE ( )
III. BUILDING USE: (If building type is public, check all that apply) d 2-0 _ /O Z 9 160
1 ❑ Apt/Condo 1
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 1120 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. M New 2. ❑ Replacement 3.E1 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 El Mound 300 Specify Type 41 El Holding Tank,
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
1140 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
5 a ZO -72-0 0,(p 2 ~ 7.SZSeet 99, SOFeet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank X 0 C G(J a. i s d 7F F] -7- F1 I D __JJ
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:
C V-0
00 -2 A o ~ " ~ (.2 -17) 3
Plumber's Addre;(Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signatur (No Stamps)
Surcharge Fee) (nom
Approved ❑ Owner Given initial
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. s h&ur-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 (SED 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:
r.
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.
11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
Ill. 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, 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
(equired 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.
L
SBD-6398 (R.11/88)
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INDUSTRY D~PARTMtNT.OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS c DIVISION P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS
3.09(1) & Chapter 145.045)
LO ATI , :5' SECTION: W NS UDSONICIPALITY: LOT NO.:BLK. NO.: SUBODI~VaI ~t~NQNA~E~I
COUNTY/ E / NER'S T BU Zg R NSRi 1 NAME: E I,
MA LIN AD R SS: JP* Cko I x W A sq 9 CT N "4Utsuq I.W,
USE DATES OBSERVATIONS MADE
NO. BE : COMMERCIAL DESCRIPTIOJ__~7 - I ESCRIPTIONS: 1PERMATION ~E/STS:
(Residence uNK New ❑Replace v(,~ 4Le /7 9 <
~-0It,S 601; +~iE Sotr_g . BicC-e - ~uf2,LNA11bT'
RATING: Ss Site suitable for system U- Site unsuitable for system p - DAKer4
p(IV_EN I[JAL: MOUND: IN-GROIJNS ❑u S s -1NEI-FILL O~LDING TANK: RECOMMENDED SYSTEM:loptional)
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: Cr_•4SS I Floodplain, indicate Floodplain elevation: N A
bb'~'T PROFILE DESCRIPTIONS
BORING AL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHT29F ELEVATION -OBSERVED H TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- ~.S~S 99 •-1'S o E ? SFS `kLL-rs L zz"$eN 20"r:~Beti S~6>Q~<t,b 2 $le CS46 *
B- Z AZ 01,00 Neva >71,g2 /6' $Cl Z9 BeA/S,L S"9ttzvS141Z S6„ r3e,4C<4&Z
B- 3 9.00 q 9 ,q 5 NoNC > 9.06 /6 'ec c Ts 4S" ge i'A 7 "R M S$c etc L 46~&-v CS+6
B- Z5 /VdN~ % g,zt /4'/$LLTS -Z8..$PN SQL S. I~eN SY 4~ sD~~e~ICS>z
B- 'S p.9;3 g9:Ss`~ IVanIL~' ? /0,~3 t7~r t:~TS z7~Se.,S,L 2~~Qe$an/StC~Q/n84NCS•162
B-
G~ PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP WATER LEVEL-INCHES RATE MINUTES
NUMBER 4L S AFTERSWELLING INTERVAL-MIN. PERIOD 1 P I PER INCH
P_ 1 k'S 99,96 3 '>1 Z < ~
P- Z .6 S I'j.t4 1,96 3 > Z >'k
P- .6 9,90 >Z >Z <3
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* ~S.aS
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IF: 7-1111
~,T-u L~N~ of LoT ~
P1 Ai4
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 date recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME print): ` TESTS WERE COMPLETED ON:
.4Q r JOtJ Sa N cN ~~~v.t Y f NC, G ~c~UST / / 9ZS~+
ADDRESS: CERTIFICATION NUMBERTp'? HONE NUMBER (optional):
q01 SacAN►~ ST OU-b SoN Sq t 3A <S ~-40-6 0
CST SIGN TUBE:
Q: Original and one copy to Local Authority, Property Owner and Soil Tester.
I~ 395 (R. 02/82) - OVER -
STC-100
i
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 pormit 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 _ Z&r N o # WA eon
Location of, property4[,)1/4 S75414, Section T-7
Township f ef~ e el
Mailing address G_4=
Address of site Subdivision name Cs "'1 Zf S 20 Lot no.
other homes on property? _yes= No
Previous owner of property Sfi Coo Co U~
Total size of parcel -7--- o~G c.
Date parcel -was created S- et 30 / S 9
Are all corners and lot lines identifiable? --4-yes No
Is this property being developed for (spec house)?„Yes No
Volume S62-and. Page Number 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 ~s 5 Sg , 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
Z-6 9Ss .
S gnature of applicant Co~app nt
Date of Signature
Date of signature-
FF
WARRANTY DEED (Former 8tatatorr Form). •800BTA pp//~~ l'.~".; Miller•Davl. Co., Minneapolis, Eton.
2 5 9 5 8 - - Form Na . W.
• a* *nblrnturp, ~ &a& by at. Croix County Publ to Weifar» Department
grantor " of 01401Z' County, W14conslnn, hemby c'onvey' and warrant to ,
r, Veraon• #app,•iaad Irene Mason, husband and fife as joint
' tanants aka aunt la com~oa
;a ~ratee , at. Croix County,
1risconsin, for the sum of ftii pollar and other good and valuable consideration
i the follo)uing tract of lanct ivy St. Croix Coltnty, State of Wisconsin:
The West toil-half Q) of the Southeast Quarter (SBJ)
i of SeetiO>n'.11Ixteen. 16), Township Twenty-nine (ab)
j North of,'Psage Nineteen (19) Best, excepting the
railroad'vIght-of-way of the Chicago, ST. Paul,,
Minneapolis and Onaha Railway Company and excepting
a conveyance of lands to St. Croix County for highway
purposes as shown in Volume "386" Deeds, page 65 in
the office of the Register of Deeds for St. Croix
County', and subject to an easement to the Wisconsin
Telephone Coapany as shown In Volume "89511 Deeds,
page 3719 In the office of the Register of Deeds
for St. Croix County.
REGISTERS OFFICE
ST. CROIX Co.. WIG. '
Recd for Record this _3Qth
day of-S-vRt=hQr_A.D. 19.59
t
Y at_ %M-----A., M.
Registe ~~veds
I
t
In 811iftwas Whermf, The said grantor ha s hereunto set his hand and seal this
} 28th day of September ✓1. D..Z9 59.
SIGNED AND SEALED IN PRESENCE OF
St. x Count Publ Be~a'ri~Dep~.•
Kenneth Be Hive S?';r1l.I
q r 8 Hri h Dirac or
1111{ ~ f~ , ' , (SI:'.•IL)
Len Marlette
j
' (SEr1 L)
i OWe of iommin,
8s. ~
St. Croix County
Personally came before me, this 28th day of September
.9. D. 1950 , the above named St. Croix County Pablie Welfare Department
By Stoner S. Bright, Director
J to me known to be the person who executed the forejoing inetiume a 4eknotuledged the same.
This lustrtllmeat drafted Ay
Lmeth M., Mayes,' :Attorney •
at Lai, Nudes,, Wiseoasia. Q
Notary Public, el 8t S2 C ` County, Wis.
Jlty commission expires y 'Q' , , ✓l. D. 18
"I ol
•TVprwrire Name undir Mh Sion4lurr '
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER_ Ve-f i1 o h GfJ ,von
ADDRESS' S~9 cfy /r} FIRE NUMBER S"5~5
CITY/STATE W Z ZIP
PROPERTY LOCATION : N01/4 , 5~ 1/4 , SECTION 14 T:!L5 N-R_ZJ_L1~)
TOWN OF Hud5oh , St. Croix County,
SUBDIVISION C• s M ys z oS~ , LOT NUMBER I
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 pate.
SIGNED:_j
DATE : Ile 72-
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016