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AS BUILT SANITARY SYSTEM REPORT
OWNER Vwli W~ro ~ ~ .$A~ ✓ /TO rr ~ D Ze
ADDRESS Zt- Z frL. -
SUBDIVISION / CSM#,~ LOT
SECTION. T 2 ?N-R /y Town ofrc
1
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4,X2y, ~r~v~ u~Ay
We-
371 y', C
3,21
. ~0 Cttt f o 6~ ~~+e.lC
CTrgAp 12 x (.p' 3g'
I
g.111, T6 f INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this-form.
Provide 2 dimensions to center of septic tank manhole cover.
t,
1,
BENCHMARK: ~m-P err ~ /ofi/ .",pa.. e►'~ S~ Carnar ~ ~ /0~.C7D
ALTERNATE BM: 77
SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION
Manufacturer: (Jg-%s a-~ Liquid Capacity: 110019gad ,
Setback from: Well_A'~-l_ House 'a Z Other SF ce,No,a~ f/a4
Pump: Manufacturer Model# Size
Float seperation/4 Gallons/cycle:--~-
Alarm Location
.:SOIL ABSORPTION SYSTEM
Width: I Z' Length 60 ' Number of trenches
Distance & Direction to nearest prop. line: 39 7c Se K1 ~ti /e'f /%N~
Setback from: well: House__247_ Other
I
I
ELEVATIONS
Building Sewer ST Inlet; q 03 ST outlet q, Sa
PC inlet PC bottom- Pump Off
Header/Manifold -~s Bottom of system
Existing Grade Sr Final grade
it/Of~ i Lu ~o ga /a a. t~ a Sy
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: Z
INSPECTOR:
3/93:jt
• 4 •
L jPXp. t VP§,gAuJr~ • 29.19.13~RIVAT ga-2Qt At E ~YS QQS~ 3 TEM WAXON L I NE
County:
s Labor and Human Relations INSPECTION REPORT
~Wety a 11d Buildings Division ST. O
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
186532
Permit Holder's Name: ❑ City ❑ Village ki Town of: State Plan ID No.:
[HUDSON
C T BM lev.:~ty~1~ Insp. BM Elev.: BM Description: Parcel Tax No.:
~•W l60`c' ~e QcS fQ 020-1029-90-120
TANK INFORMATION ELEVATION DATA A9200417 Uqksp
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ( Benchmark 5 Z, .66 l
Z
Aeration Bldg. Sewer U ems(
Holding St/jIF Inlet n J ~~y
TANK SETBACK INFORMATION St/)E Outlet
TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet
rl
Septic NA Dt Botto
Dosi NA Header f4ellr;l. ?7
Aeration NA Dist. Pipe y y 5, 5 '
Holding Bot. System Z
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand -60Ps'7'
Model Number GPM
TDH Lift Friction System DH Ft
oss Head
Forcemain Length Dia. Dist. To wen
SOIL ABSORPTION SYSTEM
BED/TRENCH Width 0' Lengt No. Of Trenches PIT Inside Dia. Liquid Depth
DIMENSIONS 1a IMEN I N
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu er:
SETBACK
INFORMATION Type 0 ne,> / CHAMBER Model Number:
System: AQ, 61 S, <1? 9"0 OR UNIT
DISTRIBUTION SYSTEM
Header abd I Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length S Dia. ~ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over J Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /T h Center Bed /Tfe"ch-E-dges Topsoil E] Yes No E] Yes F] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 16.29.19.1366AA--220,NW,SE, LOT 3, WAXON LANE
2'~. ter.
"-Plan revision"requiedf Yes No
Use other side for additional information. ~p ~9 g 9
SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: , k ?
1
1
a
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE/I~TSA ERMIT#
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~b" 'f` 5C~
8%X 11 inches in size. eck1 revision previo sapplication
-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
• 116 ~---/1 4cti(' a I'I NUJ %4 E S G T , N, R E (o W
PROPERTY OWNER'S AILING ADDRESS_ LOT # BLOCK #
C 7-N FN
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
141 o r 5 /6 fe G, J% Zo S
I-] I
11. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) State.Owned O VILLAGE : Sort
❑ Public El 1 or 2 Fam. Dwelling-# of bedrooms 3 R EL TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) 20 _ --L 0
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
50 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
i
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
130 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 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVAThON
4I S-0 -7 i o ZD Feet 9s, Zs Feet
VII. TANK CAPACITY Site
in alIons Total of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 000 LA) a: sE ~
Lift Pump Tank/Si hon Chamber RF1 EFFF~] El I El
VIII. RESPONSIBILITY STATEMENT
1, 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:
1) J It /af Sffd~iG GA 2 f7 3.~ 33
Plumber's ddress (Street, City, State, Zip Code):
tiG t' l Z N r't tv [ G 7 j'j1 y (f t `7 / l
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination
/
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly PI b-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanita"r~r permit is valid for two (2) years. '
2. 'Your sarfttary 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 bya 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.
11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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.
p 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
required by the county; E) soil test data on, a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
STC-100
This application form is to be completed in full and signed by
the owner(s) of the property being developed. Any inadequacies
will only result in delays of the permit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), thenta second form should be retained and completed when
the property` is sold and submitted to this office with the
appropriate deed recording.
Owner of property _lley`to n ItXOs~
Location of property,~kW l/4 S .6 1/4, Section 1 TAN-R l W
Township so s-.
Mailing address S4/9 Gay T
4,~t
Address of site L~~ x o ►N.
Subdivision name G s, ter 6-z o G Lot no.
other homes on property? Yes No
•
Previous owner of property _ S f_,.C~o i v Co k K~ u
Total size of parcel
Date parcel -was created cro; ~ocUt~
Are all corners and lot lines identifiable? ,k yes No
Is this property being developed for (spec house)?,"e_Yes No
Volume 3G " nd.Page' Number S/ 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.a 1-5-?/ , 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. a 59~$)
r •
i 'Ll'r 7 Y\
Signature of applicant to-applicant
1 ,
Date of Signature Date of Signature
per
191 81 Hiller-Davis Co.. Minneapolis, Linn.
WARRANTY DEED (Former Statutory Form). B~OBTA
VV-W
Form Na f W.
259581
drnturP.'~ anus by et. Croix County Public Welfaiv DepartMat
i grantor of ~•~*ou County, Wisconsin, Iuteby convey and warrant to
Vernon. vspp, ;and Irene Wazon, husband and wife as joint
~F tgnants aki pet tn7n is common
fra ee , o?• at. Croix County, ,
WiaconWn, for the aunt, ofOr i pollar and other good and valuable consideration
i the following tract of lant$ its et. Croix CoKnty, State of Triseonsin:
' The vest i1#i=half Q) of the Southeast Quarter (8B})
of Section'..8lxteen. 16), Township TWOUty-nine (29)0
North of o4tmRe Nineteen (19) vest, excepting the
railroad right-of-way of the Chicago, of. paul,~
Vinneapolts cad omabs Railway company and excepting
a conveyance of lands to St. Croix County for highway
purposes as shown in Volume "336" Deeds, page 65 in
the office of the Register of Deeds for St. Croix
County', and subject to an easement to the Wisconsin
Telephone Company an shown in Volume "898" Deeds,
page 3719 ih the office of the Register of Deeds
for at, Croix County.
REGISTERS OFFICE
- ST. CROIX CO., W16. '
Recd for Record this--3Dth.
day of_5VRtembQC_A.D.19.59
at- :OLL__---A., M.
/ Registe&eeds
I
I
In Slitnrsu 1111llpreaf, The said grantor ha s hereunto set big hand and ,eul this
28th day of September .4. 1)..19 59.
SIGNED AND SEALED IN PRESENCE OF
j St. x Corot Publ WeADept.:
Kenneth H. Hays By:
4 SE.1L i
Lr 8 Bri b Direr or
81lon Marlette
' ~SEi]L)
i
j j ~ftt#e of isco~s~,
. as.
St. Croix County
Personally came before me, this 28th day of September
i
.4. D. 1959 , the above named St. Croix COtiOt Public Welfare Department
By Summer S. Bright, Director
i
to me known to be the Person . who executed the foregoing i,nstrtA eryt a *eknowledsed the same.
This imstriiimeat drafted Ay
lceaaeth It. •syes,' Attomwy • _
at Law, Hudson, Wisooaoia.
Notary Public, o at 4~ CJ;tU County, Wis.
My commission expires J. D. 19 ~
T•
1 irpewrtte Name under each Signature'
1. .~.~y... %pt V.
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER !w✓ no.1 W L)eor►
ADDRESS 5_"Al Gtr -r/-- 4-FIRE NUMBER Sy9
CITY/STATE Aiccd'' soA_ (.t/ Z ZIP_ - S~D~G
PROPERTY LOCATION: V 1/4, S F-1/4, SECTION /4 T a~N-R / W
TOWN OF g" So 1 , St. Croix County,
SUBDIVISION C. Q //P LOT NUMBER_:~_.
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, 1918. 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.
SIGNED: i , x'~ ~ru7'>L Li "y~__
DATE :
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LA60R AND P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707
(1) & Chapter 145.046)
SHI NICIPALITY: OT NO.rM.NW Sk D
N 1/4 L 1/ 79 N/Ri9 8(04V 3Zo~s>;d csr
COUNTY: 'N ' V1
. ► CPOI Sao RA9 -T/4 q.. /4 o
USE DATES OBSERVATIONS MADE
NO. BEDPJVK: OMMERCIAL DESCRIPTION: PROFILE E)ESCRWrtONS: ER
RINfResidence Nk OjNew ❑Replace 404/ ~ /9
:~U,~s OIP~ 4 S$ ~t4*~. 2 - t3oitK►lgQ~ li
RATING: S- Site suitable for system U- She arteuitsble for system 5 t $ ' SArT Rk
IN-FIL L O~L~D~G A K: RECOMoNVENDiSYS~ SYSTEM: (optional)
f U s. ❑u ❑0 MIURE -
rMsot
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: CLAi.- ` Floodplain, indicate Floodplain elevation: NN
t' C` 'T PROFILE DESCRIPTIONS
BORING CHARACTER TOTAL TO R UP gd§S L COLOR, WITH THICKNESS TEXTURE, AND DEPTH
NUMBER ELEVATION
TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
.0 ER%jEQ EST, HIGHEST B- 1 S g`?, a b n~or.►~ > 7+? ~ ~r5 ~~"$QN L 4~$ SfL,te CoL N:3~~QRNCS~f ~R
116 ~ON /Z ~~~LL ZIa + S es r~fA ~S
B- 3 x,91 44:57 0 > •9Z c c 2~" "NQ S S CS
B 4 1,-6,06 99. s 6 v e '9.06 12" uTs 20' L A 2A R41111 C b "N34uC'S~
B- /6'' Stob 5s" „cSi4l,
e-
PERCOLATION TESTS
TEST DEPTH WATER IN L ' TES TIME DROP IN WXTER LEVEL-INCHES FIXTE MINUTES
NUMBER INCHES AFTER SWELLIN INTERVAL-MIN. PER) H
P. f 6 O 1
Z b o 99.6 0 3 > t
P.
P. 3 -u o►~e 9.50 > > <
P. I
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil area. Indicate scale or dists6ca. 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' 46.00
.
14 I I
i ;
/ ~ 1. Y i I ,
:
gp - 1'N
2'
_L ATE"
B,I _I B-3 j
5000
01
L
N G
+ Z t
1. ! _ ~QhK1N~7+~Rlli' ~Rd1U tP6-
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 Cade, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME( print : j TESTS WERE COMPLETED ON:
~flr l `a.0 av S< R! ~t~d~~JE YlP, C. `
ADD 5 A CERTIFICATI N NUMBER: PHONES/ NUMBER (optional):
SI TURF:
N: Or iginal and one copy to Local Authority, Property Owner and Soil Tester.
-6395 IR. 021821 - OVER -
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