HomeMy WebLinkAbout020-1134-70-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 563874 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Szumilas, Jeffrey Hudson, Town of 020-1134-70-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Towrimange/Map No:
G 20.29.19.657
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic GS+~ / J Benchmark
x;6~-cfn /llOD 19Z - /63.8 I13~
_j J Alt. BM ll
CJ; e 3.5 3zo r1.1 L' 14 r" 011 /6z
o /t ]a 5Z-5 _j Bldg. Sewer
G• I
Holding St/Ht Inlet I
TANK SETBACK INFORMATION St/Ht Outlet
97• L
TANK TO P/L WELL BLDG. ent t it Inta a ROAD 3 Zo ` ~ g? 7,5
S6 eD
c 146 46 ' 13 - m 3 Z.0 o 4-37 4 7, J
ti -
ae&m9 / Header/Man. /1• Zb 92 .
A3 tL%.) 69 rr Aeration Dist. Pipe / 20 94 • co
i 9Z .57
Holding Bot. System / Z • Z 9/. (s
~ .z 9I.5
Final Grade S•~
PUMP/SIPHON INFORMATION
Manufacturer GPln~land St Cover' 1.7/ I47Z.1/
Model Numb 7
T Lift Friction Loss System H TDH Ft J~ 6 7•~ ~0 z 2
Forcemain eng Dia. Dist. to Well , J e av ~ / ~ !4 -7 G, Z
SOIL ABSORPTION YSTEM V (J
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 S~ z al PeL&ff~7 \
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactures 1 I ~~I
INFORMATION ~,,/~J CHAMBER OR `ice . T
Typ QOA Jte 'D"'_'v S~ ( ) I I UNIT Model Number: n ds
DISTRIBUTION SYSTEM 4 /`J Z I e~
Header/Manifold / ~ Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) ~ (.~C.s1 e S
LDia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over I, Depth Over xx Depth f xx Seeded/ dded xx Mul ed
Bed/Trench Center Bed/Trench Edges \ Topsoil Yes Z No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 420 Northview Pass Hudson,, WI 54016 (NE 1/4 NW 1/4 20 T29NI_R119W) Willow Ridge 2nd Add Lot 48 Parcel No: 20.29.19.657
1.) Alt BM Description = r,• 114& 4 be_LS %
2.) Bldg sewer length = d I,
-amount of cover= " 4v_"
I w.. Oo
P
Plan revision Required? 7N Yes ] No Use other side for additional information. rjj~1
J
Date Insepc s Signat Cert. No.
SBD-6710 (R.3/97)
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County
Safety and Buildings Division St. Croix
201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
P$ Madison, Wl 53707-7162
Sanitary PQnit Application C State Transaction Number
In accordance with SPS 383.21(2 s. !Ifflubmission of this form to the appropriate gov ental um fl r 6)IA
is required prior to obtaining pplrcation farms for state-owned POWTS a milted to IUAddress (if d ffactit than mailing address)
the Department of Safety i -W Servi oval information you provide may be used for s a~
purposes in accordance with v , s. 15. I m Stars. S ` a Wne
I. Application Information - Please Print All Information o d~
Property Owner's Name qo, Parcel #
Jeff Szumilas 020-1134-70-000
Property Owner's Mailing Address Property Location
420 Northview Pass Govt. Lot
city, state Zip Code Phone Number NW _ _NW /4, section 20
(circle one)
Hudso 54016 715 386-0510 T 29 N; R 19 E or w
H. T e of Building (check all that apply) \ Lot #
1 or 2 Family Dwelling - Number of Bedrooms 4 48 Subdivision Name
Block # Willow Ridge
2`~ addition
D Public/Commercial - Describe Use Na
D City of
D State owned - Describe Use CSM Number D Village of
Na p own of Hudson
III. Type of Permit: (Check o bovvu4i#e A. Complete line B if applicable)
A. D New System
eplacement System ~ ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
I
NumbgX
B- ❑ Permit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New List Previous 6 7 and Date Issued
Before Expiration Owner 1~ c^ 2,
IV. Type of POWTS System/ComponentlDevice: (Check all that apply) z
i
Non-Pressurized In-Ground D Pressurized In-Ground D At-Grade D Mound > in. of sui le soil Mound= 24 in. of~suitablc soil
❑ Holding Tank D Other Dispersal Component e
V. Dis rsal/Treatment Area Informatio : 42 Infiltrator "Q4 Plus" Standard c 4 endca s, Pot Lok PL-525 effluent filter
Design Flow (gpd) j Design Soil Application Ratftdf) Dispersal Area Required (sf) Dispersal Area Propose y3will '
600 Gpd ✓ 0.70 Gpd/Sq. Ft. 857.15 sq. ft. 860.40 Sq. Ft. 91.50
VL Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units $
New Tanks Existing Tanks w c $
U 0) m cn C7 A,
Septic or Holding Tank W320-MR 1,000 1,320 1 & 1 Wieser Conc/Wieser Conc. X
Dosing Chamber
VII. Responsibility Statement- I, the and ned, sssu a responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's ignature MP/MPRS Number Business Phone Number
James K. Thom son MPRS 30021 715 248-7767
Plumber's Address (Street, City, State, Zip Cod
340 Pa lson Lake Lane Osceola, WI 54020
VI oun /De artment Use Only
Approved ❑ Disapproved Permit Fee Date ssued Asuimg Agent atw )
❑ Owner Given Reason for Denial /,-I 1 3 IX. Conditions of Approval/Reasons for Disapproval
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LG~t1~'~►~
SYSTEM OWNER: Y(3
1. Septic tank, effluent filter and
dispersal cell must be-a uked l malntelr -49 C~ / w A rr
as per management plan provided by plumber, y►-t L" cf G
All setback requirements must be maintained
as per applicable flans for the system and submit to the County only on paper not less than a in x 11 inches in sine
SBD-6398 (R- 11/11)
Conventional PQWTS Index & Tilte Sheet
Project Name: Szumilas 4 bedroom Replacement Conventional POWTS
Owners Name: Jeff Szumilas
Owner's actress: 420 Northview Pass, Hudson, WI 54016
Site address: Same
Project Location:
Subdivision: Lot 48, Plat of Willow Ridge 2nd addition
Legal Description: NW 1/4 NW y4, Sec. 20, T.29N., R. 19W., Tn. of Hudson, St. Croix Co., WI.
Parcel ID 020-1134-70-000
Page 1 Index and Title Sheet
Page 2 Site Plan
Page 3 Dispersal Cell Sizing Calcualtions
Page 4 System Cross Section
Page 5 System Management Plan
Page 6 Filter Specifications
Page 7 Septic/Filter Tank Cross Section
Page 8 Parcel map
Page 9 Septic Tank Maintenance Agreement
Page 10 Certification for Utilization of existing septic tank
Page 11 Waranty Deed
Attachments: Soil Evaluaiton Report
Mater PI ber Restrt ted Service: James K. Thompson, Dept. of Comm. Credential #30021
Signature: Date: l02
Page I Of 11
Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01101)
■ So,/ei/a/ua~o~/o; E
Proposu4 d;s pcrsa/c~//. TwQ (z~ e: S/D
f,^cncl Ls ~ 3 `x 8G' w/ tl L~rwEv~- ~e 3-Ai
ro- "P/usc.(`.nbcra &A"
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A f~udson, r.~/. SYo/6
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SZUMMILAS DISPERSAL CELL SIZING CALCULATIONS
1. (4 bedrooms)(100 gallons estimated flowx l .5 design factor) = 600.00 Gpd dessig n
2. Mltrative capacity of native soil = 0.7 gp ft. ft.
3. Absorption area required: 857.15 sg. ft.
4. Absorption area as proposed:, 860.40 sq_ft. 42 chambers total)
Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4 Plus" end cap = 5.10 sq.ft. EISA
857.15 sq. ft. - (4 endcaps)(5.10) = 836.75 sq. ft.
836.75 sq. ft./20.00 = 41.84 chambers required
Number of trenches: 2 aA 21 chambers per trench
Trench width: 2.83'
Trench length: 86.00'
Trench spacing: 9.00' on center
Total system area w/ 9' center spacing: 12.00'x 86.00'
Pg. 3 of 11
1
Soil Absorption System Cross Section
r
97,70
k4" Schedule 40 Final Grade
VC Vent Pipe
ith Vent Cap ft
Leaching
Chamber ~50 ft
System Elevation
3.0 ft Z!,-e ft
Soil Absorption System Plan View
ft
3. ft
(P,Q ft Vent Or Observation Pipe Leaching Trench 1
Chambers
4" Dia.
Trench 2 Header
Leaching Chamber Specifications
turer And Model,
FEISARain
.0 sq ft per chamber Soil Application Rate 0.7 gpd/sq ft
ow T Soil Applicati
on Rate EISA Chambers
2 rows of
chambers each.
Page of
Conventional Septic System Management Plan
Pursuant to SPS 383.54, Wis. Adm. Code
General
The conventional septic system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall be maintained
in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system
maintenance and maintenance reporting shall be complied with.
Septic Tank
Septic tank servicing mechanics comply with SPS 383.54(1)(e). Septic tank to be located within 150' of service pad, with
bottom of tank to be5 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be
assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in
the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR
113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are
not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be
needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to
ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank
that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be
serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water
tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of
service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater
than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank.
No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank
abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS
component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If
such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings
Division.
Soil Absorption Cell
Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should
be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for
vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface
within and above the system and will promote frost penetration during cold weather months. Cold weather installations
(October-March) dictate that the system be heavily mulched for frost protection.
Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not
exceed maximum design flow specified in the permit for the installation.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the
owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring.
Effluent flow shall be alternated between dispersal cells on a two-year schedule by use of diversion valve. Effluent to
be diverted from new cell to old Drainfield at 3 year anniversary of new system installation. Old drainfield to be utilized for
a I year period. Effluent dispersal to be alternated between systems on a two year rotating basis thereafter.
Contingency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil
absorption cell to bring the system into proper operating condition.
Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715)
248-7767 or the St. Croix County Zoning Department at (715) 386-4680.
Pg. 5 of 11
Filters
PL-525 EFFLUENT FILTER (
Polylok, Inc is pleased to add its
new commercial filter to its existing
line of quality effluent filters. The
PL-525 is rated for over 10,000 GPD Alarm
(gallons per day) making it one of accessibility Accepts PVC
the largest commercial filters in its extension handle
class. It has 525 linear feet of 1/16"
filtration slots. Like the Polylok
PL-122, the new Polylok PL-525 has
an automatic shut off ball installed 525 linear feet
with every filter. When the filter is of 1/16"
removed for cleaning, the ball will filtration slots Rated for over
float up and temporarily shut off 10,000 GPD
the system so the effluent won't
leave the tank. No other filter on
the market can make that claim! Accepts 4" & 6°-
SCHD. 40 Pipe
PL-525 Maintenance:
The PL-525 Effluent Filter should
operate efficiently for several years
under normal conditions before
requiring cleaning. It is recom-
mended that the filter be cleaned
every time the tank is pumped or
at least every three years. If the
installed filter contains an optional
alarm, the owner will be notified
by an alarm when the filter needs
servicing. Servicing should be Gas deflector
done by a certified septic tank Automatic shut-off
pumper or installer. ball when filter
is removed
1. Locate the outlet of the U.S. Patent No# 6,015,488
septic tank. 5,871,640
2. Remove tank cover and pump
tank if necessary. PL-525 Installation: 1. Locate the outlet of the
3. Do not use plumbing when septic tank.
filter is removed. Ideal for residential and com- 2. Remove the tank cover and
4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary.
5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the
tank. Make sure all solids fall 4' or 6 outlet pipe. If the
filter is not centered under the
back into septic tank, access opening use a Polylok
6. Insert the filter cartridge back Extend & Lok or piece of pipe
into the housing making sure to center filter.
the filter is properly aligned and 4. Insert the PL-525 filter into
completely inserted. its housing.
7, Replace septic tank cover. 5. Replace the septic tank cover.
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O m EwT8 CDnCAE TE DRAWN BY: SME SCALE: 1/4"=1'-0" PRE-POUR:
T, - SEPTIC MANUAL REV. N0. 2
WY 10 MAIDEN ROCK, WI 54750 DATE: JANUARY 2012 DATE:. 3/6 12 POST-POUR:
° REVISED JAN. 2012 00-325-8456
FILE: W320-61R
2338
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations
At!&n* pan not less than 8% x 11 inches in size. Plan must County St. Croix
innot horizontal reference point (BM), direction and
peorth Wow, and location and distance to nearest mad~C: Parcel I.D.
L',,,, 020-1134-70-000
nt all information. ~ vi By Dete
e used for secondary purposes (Privacy Law, s. 15.04 &Q. T V/ ( 3
Property Owner P Location
Jeff Szumilas Govt. L or r~NW 1/4 NW 1/4 S 20 T 29 N R 19 W
Property Owner's Mailing Address Lot # oe # Subd. Name or CSM#
420 North View Pass 48 4 Willow Ridge 2Nd Addition
City State Zip Code Phone Number _ I City I Village 16 Town Nearest Road
Hudson i WI 54016 (715) 386-0510 Hudson 42 North View Pass
New Construction Use: a Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
oM Replacement I Public or commercial - Describe:
Parent material Glacial Outwash Flood plain elevation, if applicable Na
General comments
and recommendations: Site suitable for conventional POWTS dispersal cell with 0.7 gpd/sq.ft./day loading rate. Recommended
infiltrative surface elevation = 91.50'.
( 7 i Boring # J Boring
16 Pit Ground Surface elev. 97.68 ft. Depth to limiting factor >1 1in. Sail Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD
in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. "Eff#1 fW2
1 0-21 1Oyr3/2 none sl fill 2mpl mfi aw 2fm1c 0.0 0.0
2 21-40 1Oyr4/4 none sil 2msbk mvfr cvv 2fm1c 0.6 0.8
3 40-56 1Oyr4/6 none Is Osg ml cw 1vf,f 0.7 1.6
4 56- 11> 1 Oyr4/6 none s Osg ml - - 0.7 1.6
❑ Boring # Boring
Pit Ground Surface elev. 97.53 ft. Depth to limiting factor >115" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0-8 1Oyr3/3 none sl 2fgr dsh cs 2mf 0.6 1.0
2 8-19 1 Oyr4/4 none sl 2msbk mfr cs 1 fm 0.6 1.0
3 19-31 10yr4/6 none Is Osg ml cw 1 vf,f 0.7 1.6
4 31-48 1Oyr4/6 none s Osg ml gw - 0.7 1.6
5 48-115 10yr5/4 none s Osg ml - - 0.7 1.6
' Effluent #1 = BOD? 30 < 220 mg/L nd TSS ?30 < ' 50 mg/L effluent #2 = BOD s 3O mg/L and TSS <30 mgA_
CST Name (Please Print) Signatu CST Number
James K. Thompson 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, W154020 7/25/2013 715-248-7767
Property Owner Jeff Szumilas Parcel ID # 020-1134-70-000 Page 2 of 3
3 ] Boring # I Boring
F
01 Pit Ground Surface elev. 96.13 ft. Depth to limiting factor > 104" in.
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Sbucture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-16 10yr3/3 none I 2fgr mvfr cs 2fmc 0.6 0.8
2 16-35 10yr3/2 none sil 2msbk mvfr cs 2fmc 0.6 0.8
3 36-43 1 Oyr4/4 none si 2msbk mvfr cw 2f,1 me 0.6 1.0
4 43-56 7.5yr4/6 none is Osg ml 9w 1vf,f 0.7 1.6
5 56-104 1Oyr4/6 none s NO ml - - 0.7 1.6
Boring # Boring
J Pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture shiclure Consistence Boundary Roots GPD/fe
in. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ Boring # J Boring
J Pit Ground Surface elev. ft. Depth to limiting factor in. Soli Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. *Eff#1 *Eff#2
' Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = SODS <_30 mg/L and TSS <30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-31 S 1 or TTY 608-264-8777.
SBD-8330 (R07/00) A.C.F. Sol & Ste Evaluations
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ST CROIX COUNTY
LOCATED IN THE SE 1/4 OF SEC 18,'THE SOUTH 1/2-OF THE SW 144 OF StC 1
AND THE NW 1 /4 0F:~~SEC. 20 ALL IN T. 29 N., R. 19 W.
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ST. CROIX COUNTY
SEPTIC TANK. MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Jeffery Szumilas
54016
420 Norihvlew Pass Hudson, WI
Address
Mailing
Property Address Same
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Number 020-1134-70-000
LEGAL DESCRIPTION
Property Location NW 1/4 , NW 1/a , Sec. 20 , T 29 N R 19 W, Town of Hudson
Subdivision Plat: Willow ridge 2nd Addition , Lot # 4$
Certified Survey Map # Na , Volume Na , Page # Na
Warranty Deed # 493124 (before 2007)Volume 986 , Page #541
Spec house 13yesEho Lot lines identifiable ®yes[]no
SYSTEM MAINTENANCE AND OWNER CERTFICATION
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 pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of 00 m
o s /13/ 13
S T OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 04/12)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 420 Northview Pass, Hudson, WI located
at: NW y4, NW '/4, Section 20 , Town 29 N, Range 19 W,
Town of Hudson , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service July 24, 2013
Did flow back occur from absorption system? Yes No X
(if no, skip next line.)
Approximate volume or length of time: Na gallons Na minutes
Tank Capacity: 1.000 gallon
Construction: Prefab Concrete X Steel Other
Manufacturer (if known): Wieser Concrete
ge o Tank (if known): 35 years - Installed 1978
Permit umber (if known) 774
James K. Thompson
icensed Plumber Si attire) (Print Name)
MARS MFRS #30021
(Title) (License Number) MP/MPRS
August 9, 2013
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
P~
I II IIII II
rrI DOCUMENT T 140. 11 uxreor ~wtrv _ne_e _n II rHls srwcc F~ row aecn woinr. oArA II
II
II r. r o i~ STATE BAR OF WISCONSIN FORM 2-198211
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the fuflr ..ingg dcncribed real estate in St -...Croix
Ii State of Wisconsin:
•rax rarcol NO: ...........II
Lot 48, Willow Ridge 2nd Addition in the Town of
II Hudson, St. Croix County, Wisconsin
n
I1 it
FRAN SO
I I II
i
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This As
homestead property.
(is) (is not) I)
Exception to warranties:
Dated this day of December L,?
1.th
j r
(SEAL) /•=,t.. . (SEAL)
r JOS _.H. M' ~AX/1~7ACHER I.
2- : - A L
EBORAH A. i
-
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
- St. Croix ss.
County.
~I authenticated this day of------- 19---- Personally came before me this .._...day of
December_............... 19..._x? the above named
- 3oGeph -M,._A=nacher and
Deborah --A- Axinrxcher
_ iI aiT'LE• tIEZiBER STATE BAR OF WI CUPISIN
it
II (if not -
authorized by § 706.0E, Wis. StatsJ - - - g I
T5. Y o me known to be the person . who executed the
P.OGM ` oregoi instrym~It and acknowledge the same.
THIS INSTRUMENT WAR r-FTED BYNC3TARY PUBLIC--__
4_ Aff
Ij
s ER D BEVE.RS 11
- - -
- Notary Public St....Cr;07.X County, Wis.
(Signatures 1"ay be authenticated or ackii,rwledded. .Moth idly CU111tiliss1o11 'S pernlanent. (Ir -not, StflCe expiration
i are not necessary.) date: .._....Ja - rnicaxy 14_.. 1996
~I •Nnmes o4 p-.. signing in any capacity should be tyl-i or ,aimed below their signatures. - II/, / 4-//
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AS BUILT SANITARY SYSTEM REPORT
OWNER-305& -OW A,-W,4ch9 Xlf TOWNSHIP u 3 so u
SECTION X7/0 T a~N-'R_,~ 2 W/~
ADDRESS Va0 A/oRTf/ Vita.., Ss ST. CROIX COUNTY, WISCONSIN
t7 SaN SYo/~
SUBDIVISION w~<LOt ~i/)~~r LOT ~ LOT SIZE AIA
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/V orF ~l /jSc~lroT/vc~ ~~c.~ i h~~
MtE T i/ II~Y~ /,J~~TM /(E C~ U R~/1/~/V TS L: S
JENTS ~s s"
I~
S
I
Rle~ Ef¢
Sc d C'/!/fv~/.v~ ro SDI 3S
I
~v?«f X~ -QRA~~I~iElo
1
~ ~x /ST/N<o ~~N< rIM►V(K r %nO of /~~NrI~~,C
I
i to
/ INDICATE NORTH ARROW
(„)ClL ~ SC Lc
BENCHMARK: Elevation and des ipti : /v~ aF Sri~N~ /l ~sJ,dxc- ~v✓~.~'
~ /ov. ov
Alternate benchmark I'VA
SEPTIC TANK: Manufacturer ZX/5-, /A/c. TA.voquid cap.
Rings used: Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front , Side Rear Ft.
From nearest prop. line:Front , Side , Rear Ft.
No. of feet from: Well , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
66
a ' ~s
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front-, Side_, Rear_Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEJ(
~a• Sv ,
Bed: Trench: Seepage Pit:
a x Width: Length 5~Number of Lines: > Area Built S~fv 5
Exist. Grade Elev. /c~0 A✓~ , Proposed Final Grade Elev.
Fill depth to top of pipe: /7Vee.
No. feet from nearest prop. line:Front , Side Rear Ft. !0~
No. feet from well : :~aS~- No. feet from building lr 3
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE:114 Z" ~2 /1-:? PLUMBER ON JOB : ,
LICENSE NUMBER : IId[ S 3,~
6/90:cj
~►IS1 i artr> str~0.29.19.6~~ 'JG' e4 VS TH VIEW
Labor and Human Relations -County:
Safety and Buildings Division INSPECTION REPORT ST- CROTX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Pernfit Holder°'s Name: ❑ City ❑ Village EkTown of: State Plan I R0290
ID No.:
-CsTin ev.: Insp. BM Elev.: BM Description: P
o.:
/ol~, c
TANK INFORMATION ELEVATION DATA A9200369 D 2
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing-
Aeration Bldg. Sewer - ea
Holding St/Ht Inlet d ,/2
TANK SETBACK INFORMATION St/ I ;W Outlet 3.Z'
5
TANK TO P/ L WELL BLDG. Ventte ROAD Dt Inlet
Air Intake
Septic 'd NA Dt Bottom
Dosing NA Header /-MaaL-- 4d
Aeration NA Dist. Pipe z. 9
Holding Bot. System
92.61
PUMP/ SIPHON INFORMATION Final Grade Z
Man acturer Demand
Model Number GPM
TDH Lift Friction stem TDH Ft
oss
Forcemain Length Dia. Dist. To`
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length , No. Of Trenches PIT o. Inside Dia. Liquid Depth
DIMENSION
CX1 D (MEN
;IONS
SYSTEM TO `P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O r,,.n V. CHAMBER Mo Number.
System: (03 >/GO OR UNIT
DISTRIBUTION SYSTEM
Header /A4afti4e4d- Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. I Length _Z7 Dia. -4 Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded T Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil El Yes ❑ No ❑ Yes [I No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 20.29.19.657,NE,NW,LOT 48, NORTH VIEW PASS -
_ l ur GAF;
,r / W V_ v
o y Slr -"moot
4 75 'ti
/LL, . f CL~aC`* Eel l J
`i Plan revision required? ❑ Yes
Use other side for additional information. 20 9Z
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CO
STATE SANITA ER IT
-Attaph complete plans (to the county copy only) for the system, on paper not less than a
8% x 11 inches in size. 1:1 /
ChACk revision to 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
r ~3oQ y alt %a /l& %a, S ao T N, R /R E (ol6p
PROPERTY OWNER' MAILING ADDRESS LOT # BLOCK #
393jo i/JG~wvaO VV 1`//4
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Ei4to~ou /YIA) ~S o?3 6L,~iLLocv
II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE NEA-R}ST ROAD ~
4014 Q~: /4 10 Sanl /Vr~/f1 GV ~i4s5
❑ Public )NJ 1 or 2 Fam. Dwelling- # of bedrooms NUMBER( S) -.1 %C_EL TAX III. BUILDING USE: (If building type is public, check all that apply) U /3 y 190
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 80 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.E1 New 2AReplacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ 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 300 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 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) A 93. yp - E A
SG SsQ~r 5 ~0 Sq Fr 99.9o Feet ooVGet
VII. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank mac-, /000 / IVA
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plum Sig ture: (No Sta ps MP/MPRSW No.: Business Phone Number:
&03 d. ~~.Ps 3395 ~iS 38' -a~So
Plumber's Address (Street, City, State, Zip Code): 7 A9 :5 o L,r1 S 4/0
IX. C UNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing A nt signal No Sta s)
Approved El Owner Given initial
5011k ;410 Surcharge Fee) / O O
Adverse Determination O
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 renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by tlne permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (S13D 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.
II. 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.
Vlll. 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-loo
This application form is to be completed in full and signed the octinez(;;) of tile property being developed. Any inadequacies
well only result in delays of the
permit
issuance. ths
development be intended for resale byowner/contrachtor C
d spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with
appropriate-deed-recording-._-__-----_ the
Owner of property
c~eti
Location of property ~1
/4 l/4 r Section T~N-R ! ~l W
Township
Hailing address
7 / I l I~GJO ~.t/ vU' Gl C t
Address of site
~ y S
Subdivision name----- I t4 t~
Lot no.
Other homes on property? Yes
y ✓ No
Previous owner of property
A Ile of j Total size of parcel
Date parcel was created 17,
Are all corners and lot lines identifiable?
- V1, Yes No
Is this property being developed for (spec house)?__Yes
/ __&o
volumes ~y and Page Number L? as recorded. with the Re
of Deeds. ~ gister
'Lilt
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARIUVITY DEED which includes a DOCUMENT NWiDER, VOLUME AND PAGE.
NUMBER & THE SEAL or THE REGISTCR OF DEEDS.
certified surve In addition, a
y, 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 (wc) certify that all statements on this form are true to the
best of my (our) knowledge that Y (we) am the property described in this information form, bthe owner( y virtue sof oa
warranty deed recorded in th ffice of
Deeds as Document No.?
CJ the County Register of
own the proposed site for the sewage di p salt system) orr I e(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. > 7
Z
ignature of a scant
• o-apps
`D i
Date of i a ure -Date o s gnature
t
HIM Ago"
a~
---&A AMMIJ As
r
1Mi 6111"b s:L. cmix ago".
of Willow Ridgt Second Addition, Township of
(Town of Hudson)
k~
yr
Ski t f - n+^
list &mak- Is JIL
Iffiff f •y a so ,
1r..ry i ~rir~w.~+rlrmr ~ -
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amiss* N/A -d"Of OUTE OF 00 0
iw,
'Ile
ST. CROIX .
V4 7RV-,.
ls~i~~r
V
show J ffre a.
§21p-yiq. husband And Age
Or p. Attorney
;
9h a,
~ t 10/1Nknown baft-, wra
f
Ivock"00.000pt UP meow
a it
ba~~gM~MtMflMr~rMiM4/M~M11rIi11~MF
t* OWN-woo
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the ( )--rEAN ,~~C/~s9CNf2 residence located at:
-Ali. 1/4,_&k/ 1/4, Sec. 90 T_2LN, R__Zy W, Town of
Z/2/ Ozv Upon Inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced -2 /s, fTy~
Did flow back occur from absorption system? Yes_I/No (if no, skip.
next line)
Approximate volume or length of time: gallons minutes
Capacity: .11)pq
Construction: Prefab Concrete Steel Other
Manufacurer (if known) :
Age of Tank (if known):
txllr~
(Signatu (Name) lease int
(Title) (License Number)
/ofo2o/ 9~
(Da td
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR-83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name !~-?9,T /lnTNf T,, Signature -Mix/MPRS 3.?00
5/88
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ,D~
ADDRESS: 4S7!~ FIRE NO:
LOCATION: d_1/4, ~(,(J 1/4, SEC.~_T 2 N-R1~W,
TOWN OF:_ ST. CROIX COUNTY
SUBDIVISION: IV ~~LOT NO.~
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.
114
SIGNED:
DATE : l9 vZ -Z
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
! Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page t of
!ate and Human Relatio&
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
C
rQO ~ x
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PROPERTY PROPERTY LOCATION
SWNER-
a~ l`IXih~c~E GOVT. LOT 1/4~((,J 1/4,SZOT Z9 N,R E(or)W
PROPERTY OOWNER':SM~ ILING AD`D~ESS /4S5 L T # BLOCK # SU$0. NAME CSM # ,f
4Zd No ,-rH 1r, ~ I~JILL0L+ r~4f Z~.t~
CITY, STAIR, ZIP CODE PHONE NUMBER ❑CITY ❑VItt~~.AAGE OWN NEAREST ROAD,
b~~ LJ r ~.qa J~ ( ) ~/u bs C. T. 1
[ ] New Construction Use P6 Residential/ Number of bedrooms ( ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system 0 VENTIONAL MOUND IN ROUND PRESSURE A GRADE SY TEM IN FILL HOLDING T K
U= Unsuitable fors stem S❑ U OS ❑ U KS ❑ U S❑ U S❑ U ❑ S LI SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Barclay Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trerxtl
- S L 1 rh rf'r C Z 0~9 O.5
-9 It 16 YR 9/'z
Ground g /3~' /6 YQ4 3 "5 f~. 1 r /h C / C~,Z 0.3
elev.p
4/A- 5 M L ,,^1 14
Depth to g. 7A A. ~ \1 4 4 ~ r~ ~ i D
limiting
fact r
> JJ,~7
Remarks:
Boring # lD Z p(l C Z .4 O.S
z ti 4 -9p 7-5 -1A Z o SL Z 0. o
29 a 11YA 4 z 5, L 1 At Al ,P)
Ground n L ~'t • L 0, 0,3
elev. ft. 8 Z4n o A 4 4 5,
Depth to 4 16Y441&
limiting
factor
~ {d•SO
Remarks:
CST Name:-Please Print Phone: g6`0 &b
q~v~ JoN>J~N
Address:
14 U 56N W ) Date: CST Number: c
Signature: 92 ~O4
PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of
r
PARCEL I.D. #
Boring # Hodion Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
L.tia`acisLxvv
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring # 1A YR -z S1- d f Q Z 0,4 '6
. J*J
O.~
ye i r e Z
3 s a
(3-4 i Ground
.sr Z/6 s~L /46K~ /h-F) z zd.3
elev. t SIL / aloK rh C- Z 0.3
-77 M:~ 0-77 10-7
Depth to
limiting
factor
l 6,x"5
Remarks:
Boring #
~2.\Lvti4.i3
j
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
hk
~~htinS.htii'•..7•:u4
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
1'A4>< 30¢3
1
~ I
ae IO Ib .
" rdN1~ 10~ ~1_d~J 4T IOW 1 ,
`S
t
ScPrIL SLUT
N+Dy-L -rAW1,,
Coil c!~
i
t
i
NDR~-u ~I Ew ~A~S
PLB 67
PLOT & CRO SECTION PLANS
ZAPPA BROS EXCAVATING INC
/t/oTE = At35~ePTiol/ A-,cA To gr Lur o, IovF_ 6,1 q'& PLUM ING UNIT
To- /yJtET /~JA,: . O~PTH ~GL~N~ •CE~tIf vrs .
ga
'i55-E
I- le GP ~r/vvr,vr OG /QG.~E~.9~E A P CT
f3L-/V6A'Ti4 O,STiQ'z/~GT/cv✓ rl5f X
~
~ q EO CE .v7' S T~
I
s~~3 L`~/(Law i G£
15r1 N - 'e '
I
/J~~ E~Fti ~N r I ,
r~o L i ~ T F s ol)
L-I AJ C '
~QoGf.~ox I I Sr x ~ou.vrY
Ei, sTiN
~cPTc
~ n~X I S Tin/G
' G jc /STill/C D,?,4iN xl-/,E,u
C~A~AG~ 1 0
eg',e E ivc~ 1~T
E
'To
R~'44 NO
SCALE
s
FRESH AIR INLET AND OBSERVATION PIPE
APPROVED VENT CAP
MAXIMUM 12',
ABOVE FINAL GRADE
4' CAST IRON VENT PIPE
MAXIMUM OF 42' ABOVE
PIPE TO FINAL GRADE
SIGNED:
MARSH HAY OR SYNTHETIC COVERING LICENSE: XilOS
MINIMUM 2" AGGREGATE DATE: /
OVER PIPE
DISTRIBUTION PIPE TEE
SOIL TESTING BY:
Jr- J v 11A.) 5p'62
ELEVATION BED AGGREGATE •
BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW
TESTIS • COUPLING TERMINATING II
, o' FT. AT BOTTOM OF SYSTEM
I
I.
I
REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1
10/1,9%92 14:21' REQUESTS FOR INSPECTION WORK SHEETS FOR: 10/20/92 AREA: JT
Activity: A9200369 10/20/92 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 20.29.19.657,NE,NW,LOT 48, NORTH VIEW PASS
Parcel: 020-1134-70-000 Occ: Use:
Description: 180290
Applicant: AXMACHER, JOSEPH & DEBORAH Phone:
Owner: AXMACHER, JOSEPH & DEBORAH Phone:
Contractor: STAHNKE, MARK E. Phone: 715-386-2850
Inspection Request Information.....
Requestor: ZAPPA BROS. Phone:
Req Time: 13:10 Comments: 1;30
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
I
AS BUILT SANITARY SYSTEM REPORT
OWNER r ` r l I r- r TOWNSHIP SEC.; o T ,2- f N, R_`' W
P.O. ADDRESS w; ST. CROIX COUNTY., WISCONSIN
LOT SIZE t CC1
SUBDIVISION— , r . LO
T(4
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100FEET OF SYSTEM
c.
F
s ' j s l ~ c, ~G
% np ~cnMn..'
U [
Apt,
- . o
;/,v Grp f v;e1~ S
SEPTIC` TANK(S) 1'6CG MFGR.r CONCRETE STEEL
NO. o7 rings on cover Depth y DRY WELL
TRENCHES No. of width engt area
BED no. o- lines wi tFi i'- length--1,2- area
{ dept to top of pipe -7'
AGGREGATE
PERK RATE r' AREA REQUIRED AREA AS BUILT C 1
a
DISCLAIMER: The inspection of this system by St, Croix County does not imply
j complete compliance with State Administrative Codes. There are other areas
that it is not possible to inspect at this point of construction. St. Croix
County assumes no liability for system operation. However, if failure is
noted the County will make every effort to determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH STEM.
INSPECTOR
DATED PLUMBER ON JOB
LICENSE #
REPORT OF ITISPEMON--I71DIVIDUAL SEWAGE DISPOSAL SYSTEM
Sanitary Permit
r State Septic
"A= T6IIISHIP
• ~ t. Croix County
SRP'TIC TA'?1: 4""r (J
Size ~ ^ gallons. `
umber of Compartments ~
Distance From: Well f, ft. 12% or greater slope 1.
Building ft. Wetlands
- Dishwater ft.
DISPOSAL SYST:4 Tile Field or Seepage Pit(s)
Distance From:' 'Tell _ ft. 12% or greater slope ~ft
Building -J, f t. Wetlands f1!1-
FIELD HiFhwater Y ft,
Total length of lines ft. Number of lines ; Length of
each line ft. Distance between lines ft. Width of the
trench. ~ft. Total absorption area sq. ft. Depth
of rock below tile Dr-pth of rock over tile in.. Cover
-Dver..rock, Depth of tile below grade min. Slope of
r
trench - in per 100 ft. Depth to Bedrock ft. Depth to
ground water eft.
PITS -
Number of wits Ou E! iameter ft. Depth below inlet
ft. Gravel around j es no. Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
O
%j c~ quare feet of see afl t r 'required -
Insnected'-b*~y: Title:.
Approved ...Date 197
Rejected Date 197.
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
{
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
' ~ADISON, P.O. BOX 309
WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS /
LOCATION: &t, Section69f-' , Tit- N, R /2E (or) W, Township or Municipality
Lot No: , Block No. /Z #01- / 4r a `Q County / Ci-G' I,Y
Subdivision Names
Owner's Name:/ /71 Z,24, 4// mo-
Mailing Address: `s'ue i~ `~-11 3
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MA~jDE: SOIL BORINGS PER ATIO TE TS
SOIL MAP SHEET , .2 - SOI L TYPE N TS
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 AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P- 7A/
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
17
B-
L/ 1-2 j r 1 r lb S
j -72
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate number of quare feet of abs rpt' area
needed for building type and occupancy. } ic~attele
or distances. Give horizontal and vertical reference points. Indicate slope.
i
u
~N
rp
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 location of test holes are correct
to the best of my knowledge and belief.
r
Name (print) 7" ey I My .v 5 Certification No. 3
5
Address k, j IV
Name of installer if known
CST Signature
COPY A -LOCAL AUTHORITY
ML r
State and County State Permit
Per v~
PLB67 Permit Application County
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:
SA ~/A r'l IL_ L R r)oxz~-z-
B. LOCATION: 'N VJ '/4 Section e2 6 , T2_~_ N, R-1-1 E (or) W Lot# City
Subdivision t Name, , ne road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Co mercial *Industrial *Other (specify) *Variance
Single family ✓ Duplex No. of Bedrooms 3 No. of Persons
D. TYPE OF APPLIAN~ Dishwasher v YES NO Food Waste Grinder L-YES NO # of Bathrooms
Automatic Washer /1 YES NO Other (specify)
E. SEPTIC TANK CAPACITY /0 60 Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks /
New Installation Addition Replacement - Prefab Concrete x
*Poured in Place Steel Other (specify)
F. EFFLNT DISPOSAL SYSTEM: Percolation Rate 1) j 9 2) . S 3) S Total Absorb Area / sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _
Seepage Bed: Length Width Depth Tile Depth No. of Lines Z
Seepage Pit: Inside diameter Liquid Deptll 4 Tile Size
Percent slope of land ~ '75Fa Distance from critical slope
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 I~ IC R D \AJ /4
®hJ_I M S C.S.T. # - 17 13 and other information
obtained from 4,*1 ! l ;+r (owner/builder). _
Plumber's Signature MP/MPRSW# 111 H 5 9 3 2- Phone 47 31 3
Plumber's Address N" < < o
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
¢ H62.20, including well).
L t/ G
F~ y r r z a~~ 'v
~ y
a
"ha~q Be/lo R DEPARTMENT US 0 I
JFees P ' tate Count Date
Issuing Agent Name
Data Roc'd
er (green cop dN OF HEALTH. P.O. BOX 309. MADISON. WI 53701
ST. CROIX COUNTY ZONING OFFICE
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
Telephone - (715)386-4680
The St. Croix County Zoning Office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion 9-t this form I& essential aQ that tba property can be
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received..
0
WATER TESTING-----------------------------FEE: $ 35.00 (For nitrates and coliform bacteria)
WATER TESTING FEE: $185.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION FEE: . $25.00
(Determines if system is properly functioning at.time of
inspection) /J
PROPERTY OWNER'S NAME:eJ~-/~---N l.Lbry~ ~if7~xrt Ct C~e~
PROP. ADDRESS: e CITY Legal Description dr. 1/4 of the X1/4 of Section , TAN-Rd:
`
Town of Lot Number 19 Subdivision: tu;&.) 1777
FIRE NUMBER LOCK OX NUMBER o20 - 1/ 3 4
Color of houseo1eao.,yb,-«,_ Realty sign by house?A/d_If so, list fi~lrn /
PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOR,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER .TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
Telephone Number /I al
/P ode wao
REPORT TO BE SENT TO: r-1 & C.,04 m. )4X-i4_aje.,- 373(.
~'i4- 4 .S a
CLOSING ATE:
Signature
Ple,* APE
/
COMMERCIAL TESTING LABORATORY, INC.
,$4 NraiM' Street, P.O. Box 526
Colfax, Wisconsin 54730
C:ck
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030
ST. CR01X ZONING REPORT NO.I 3'3341/01 PAGE 1
ST. CROIX COUNTY REPORT DATEI 12/07/92
COMTHOUSE DATE RECEIVED'* 12/02/92
HUDSON, WI 54016
ATTNI THOMAS C. NELSON
iJ I
OWNERI oseph Deborah Axmacheir
LOCATIOW 420 o son
COLLECTOR* M. Jenkins
DATE COLLECTED! 11-30-92
TIME COLLECTED: 2.00pm
SOURCE OF SAM(PLEI Kitchen faucet
DATE ANALYZEDII2-02-92
TIME ANALYZEDI2i00pm
COLIFORMI 0 /100 ML
INTERPRETATIONI Bacteriologically SAFE
NITRATE-NI 3 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 ml
Nitrate-Nitrogen, mg/L
/QF ~l
w 0~ CFi~~O
LAB TECHNICIANa Pam Gane Cpl, Nry
.of,NDEOFNpFHr F
~pp WI Approved Lab No. 19 Fig
4A f Means "LESS THAN" Detectable Level Approved by:
PROFESSIONAL LABORATORY SERVICES SINCE 1952