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AS BUILT SANITARY SYSTEM REPORT
OWNER-`-7 TOWNSHIP
W
SECTION -2 2 T_-21 N-R1,f7
ADDRESS ,Pw~' ST. CROIX COUNTY, WISCONSIN
LAS`
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
aff
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I yo
az' > ! _
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S a /Y 30
t E /..c✓ ~ Li~~-mil >n y7L
' 93.7
N l ~ ~ •61 < GfiCGL6 '2 9 "'7 -1' A~-GO .V C i
INDICATE NORTH ARROW _
BENCHIMARK:Elevation and //description:
Alternate benchmark A0e
SEPTIC TANK: Manuf acturer : allzle Liquid Cap. 14000
Rings used: Manhole cover elev:Final grade elev:/6n_ O
3 2
Tank inlet elev.: Tank outlet elev.
No. of feet from nearest road:Front , Side, Rear Ft. '219'f
From nearest prop. line:Front , Side , Rear Ft.
No. of feet from: Well Building: yo / L --a
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
1
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 SYSTEM
Bed: Trench: Seepage Pit:
Width: Length Number of Lines:-2-Area Built D
Exist. Grade Elev. 9~. Proposed Final Grade Elev.
Fill depth to top of pipe: -3[2-
No. feet from nearest prop. line:Front Side , Rear Ft.
No. feet from well: > >o No. feet from building ~a r
HOLDING TANK 1/I
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: -7/f -Z PLUMBER ON JOB:
LICENSE NUMBER: X
6/90:cj
ANDS RD. LOCATXQX[ 'epVVA +QNi.A3,g 29.19.225R~ ATE ~EWAGE SYSTEM County:
Labor and Human Relations r INSPECTION REPORT ST. CROIX
Safety ana Buildings Division
1 (ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 171470
Permit Holder's Name: ❑ City ❑ VillagK ❑ Town of: State Plan ID No.:
H ~TDSON
TRK4 E ev.: Insp BM Elev.: BM Description: Parcel Tax No.:
020-1059-40-000
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Ltk Benchmark r' 2,
Dosing
Aeration Bldg. Sewer
Holding Stl-kf Inlet
TANK SETBACK INFORMATION St/ VV Outlet q7,3 P
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ycs (/d NA Dt Bottom
Dosing NA Header / Man. q 7
Aeration NA Dist. Pipe
Holding Bot. System , Gq~+
PUMP/ SIPHON INFORMATION Final Grade ,
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Len d No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Model Number:
System: /5-4 Y y o~-O 70 OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold 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 /Trench Center Bed /Trench Edges Topsoil ❑ Yes N ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) to 41,04,1,~
10 01ilaO
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
Y x
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ' f .
:
e
- s
SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMI
-Attach complete plans (to the county copy only) for the system, on paper not less than S NI Y R
8f~ x 11 inches in size. ❑ cMack~f vision 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
~Y4,S,Z2- T N R E(or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
4.4,t syp/A I( 3 6 O iNup- -
1111. TYPE OF BUILDI~For G' (Check one) ❑ State Owned CI AGE : N REST OAD
❑ Public 2 Fam. Dwelling of bedrooms 3 LL PARCEL Ax M R( Aire.
III. BUILDING USE: (If building type is public, check all that apply) /0 3 9 _Y0
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
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. L7 Replacement 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 L'I Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
d2e Q 2O 20 3 • S 3• Feet . 3 Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
structed
Tanks Tanks 14
Septic Tank or Holdin Tank t. gm I _51W_ K
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT A?C~.r !t a < < Im
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
iber's Name (Print): u : No Stamps MP/MPRSW No.: Business Phone Number:
4 r4
ar's Address (Street, Ofty, Stat p Code):
in 110 F Zo b/0,r 5, &WX o?-3
IX. COUNTY/DEPARTMENT U ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater (ate Issued Iss ing Agent Signatur Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
C .Q
Adverse Determination (7 (Q
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. You"r 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'tie property m'aint'alned. The septic tank(s) must be pumped ty a Iiri'nsed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code adM?nilstristor'oP-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 insta fed.
II. 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 Cbrnp ete 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. j
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-fgrrn; and F) all sizing information::
- - - - - - - - - - - - - - - - - - - - - - - - - - - - -
GRbttNOWATEIR -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-
wate( cantarnination investigations ~arid establishment of standards.
SBD-6398 (R.11/88)
APPLICATION FOR BANITAAT PERMIT
• 9 T C - 100
This application form to to be Complntad In full and signed by the ovntr(s) of
the property being developed. luny Inadoquacles will only result In delays of
flit pttrnit issuance. -Should this development be lntended tot m eats by
ovnar/contractot,(spae houa-e), then a sacond Larm should be retalned and
completed when the ptopezty Is mold and submitted to t h I a a L L I c a with the
appropriate decd rteordlnq.
Ovnlc of property zz-
Location of pcop sty 1/4 1/fs section T x•R~V -Of /A Tovnshlp . , i V'~ /y
Hailing addte ■ f-
w
Address of site
Subdivision nawa___ /,R'ti •
Lot number
Ptevlous owner at property'./7~a tram '
T o t a l m i s t of p a r c e l _ Lif/j~cJ-zr~
e Date parcel was created 42F;7
Are all cornets and lot 11nsa Identifiable? /,-"Yes }I0 .
Is this property being developed Lor resale (apec house)?- yes l~ No
YoIup" yt~ and page Humber 3„- as tecorded ulth the Register oL Deeds.
--------9-------------------§-7./
INCLUDE WITH THIS APPLICATION T1111 POLLOVIHCI
vAAt1ANTI DIiD which Includas a DOCUHRHT 11UHOIR, VOLUHZ AHD PAOt NUNaIR, and
the 8¢AL OP Tilt. R1WISTRR OF DRRDD. In addition, a certILIad survey, If
Available, would be helpful so as to avoid delays of the reviewing process. it
the deed desctlptlon references to a CettlLled Bucvey Hap, the Certified Survey
Hap shall also be required.
PROPERTY O1nlll CSRTIPICATIOH -
I(ve) certify that ell statements on this form are true to the best of my out
kmovledgtl that I (we) am (are) the owner(s) of
this the propeenrty deecrlbrd In
s Inlotmatlon Iorm, by virtue of a uerrank~i
the county aeglstst of beetle ae Document lira ` , loq da in the olflca °f
Ptesently own the proposed alto for rho newage die atl and that j (vet (or I obtalncd an easement, . to run with Ilia above d a a c c
I b a d property,(w10r hay
conat vctlo oI s 1 n em, and the same has been duly recorded In the 0 1 1 1 C a
°I Coy y as l to of Dsadm, as Document Ho.
al a ute of veer 8ignstuts-oL Co-owner (IL Applicable)
Date oI signatuts Data of Signature
~cN ieyE.~
fff
WARRANTY DEED (Former Btatotoq /Pees). STATIC OP WINiONStN MI ler-Davis Co.. Minneapolis, Mnn.
280611
Inbesdamr, Made by .Agrold He llolbreadt and Carol •albrandt,
ri~b~od sad , wits
grantors , of St. Croix 10ou>R.Ey, Wtsoo>,ddnl heitiby donvey and warrant to
John H. Boyer or Donna M. HdAr, -1►uiband and, wife
'grantees , ot- at. Cro1! County,
Wisconsin, for the sum of Three Hundred TWenty-live ($325.00) Dollars
the follozaind trait of land in St. Croix County, State of Wisconsin:
R 100 feet of E 300 feet of S 207 feet of SSj of SR~
I ,
of Section 22-29-19
Mr-GISTERS Or r iC;tit
ST. CROIX CO., WIS.
Recd for Record this_?`?t},
day of D.19(2`
j- ln_ n(-)-- A M.
Of eds
i
i
" i
In 18tfarss 1Mllersnf,The said grantor ham hereunto set their hands and sceiA thi;
26th day of Tuns .4. D. 9651,~2L
SIGNED AND SEALED IN PRESENCE OF ~ F
C
Harold R. a brandt 17
Donna JClRyanel La
{s~:'.11
Carol Walbrandt
l
Doris Grubb ° -
ISE,1L )
Wide of Ifteanght,
s8.
St. Croix County
Personally came before me, this .._R6th-_ ,day_ of._.Juao _
.9. D. 1965 , the above named Harold R. llalbrandt and Carol Aalbrandt, husband and wife
to me known t the persons who executed the foregoing instrument and acknowledged the sonic.
aLn
~OTA%,
p = Notary Public St. Croix
c County, Wis.
' oornmieston res /U _ o ~o , .4. A 19
9Af•• ••'e. '1f3r e.>tpi
•~a,N.ap W ;q c *Typewrite Name under ewh Signature,
WVULU
PAfj
:F9 r 4 c -
WARRANTY DEED (Former Statutory Form). STATE OF WISCONSIN Miller-Davis Co., Minnrat,nlis, Minn.
Form No. 8 W.
251190
ibis Nbenfure, made by Ronald 0. Scott and Irene - Scott,
hasbano and wife, '
grantors of St. Croix County, Wisconsin, hereby convey and warrant to
John H. Hoyer and Donna M. Hoyer, husband and wife, joint tenants,
grantee Aof St. Croix County,
coinonsi . or the sum, of One Dollar 01.00) and other good and valuable
the fo~wtno t~rac-ifof land in St. Croix County, State of Wisconsin.
The West One-Half (Wk) of the South 207 feet of the East 200 feet
of the East Half of the Southeast Quarter of the Southwest
Quarter of Section 22, T 29 N, R 19 W.
ST.
1ul _A. 1a. t . ~
y ui
..rc'd for i: (la
. ~ y....._......._...
` ~ r f
fit Witness ?M4ereof,.Th,e said 6r(itl1ors haVeltcrrnnto s,t their L,nr(l S ttttrt ;ru/~ 11th.
(/SIGNED AND SEALED IN PRESENCE
OF Ronald --i -=t ~ -
A/c
- William~T~~ieas---------
- -----------lrene __~co_tt_ _
G _ar1 Humh
- -
s
s
Wate of Wisconsin,
ss.
St. Croix County
g
Personally came before me, this 3 day of June
.4. D. 19 57 , the above named Ronald 0. Scott and Irene Scott, husband and
wife,
i to me known to be the person s'who.executed the foregoinf instrument and acknowledged the same.
` Kenneth H. Haves
St. Croix
r`' Notpa•~j Publio, County, Wis,
- Jfy d%nmiakon expires Aug- 20 , .4. A 19 60
*Typewrite Nome under each Signature
571
339 F"`571
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER D 14~ blz/~
ROUTE/BOX NUMBER l FIRE NO.
CITY/STATE ZIP ~ 41
PROPERTY LOCATION: 1/4 1/4, Section Tg2_N, R W,
Town of , St. Croix County,
Subdivision , 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 for a MAXIMUM of
$3000 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
systems properly maintained.
The property owner agrees to submit to 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 form 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 Department of Natural Resources. Certification
form must be completed and returned to the St.Cr_oix County Zo ing fice within
30 days of the three year expiration date. 1
SIGNED
DATE '
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
'INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: OWNS P/m4wc-fP•Rt4-T1e: LOT NO.:BLK. NO.: SUBDIVISION NAME:
- /4 w t/4 Z z /T,z N/R E (o u sry~ _
COUNTY, OWNER'S/ MAILING ADDRESS;
USE ONE DATES OBSERVA IONS MADE
NO. BEDRMS.: OMMER AL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
[aResidence ` ❑New t' Replace G A-,~
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
IDS 0U 1[21S 0U E3s❑u ❑S2U ❑s~~ /~XyoI/__/
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate Floodplain, indicate Floodplain elevation:
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.)
B nt c ~l
B-
N c
B-
B
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER INCH
P.
M C }
P-
P- Z N . 19,0' S
P_ F
P- 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 9-. 7 '
h~
r r
2' o der: ,
4
N u
- l Corr ors ~ w//
Ilk
~ r F
,o/ 1i
i
I
I
1 E
.
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 PLUMBING TESTS WERE COMPLETED ON:
Lilcannad Park Tester & Plumber 2 .I 9 Z.
ADDRESS: #3233 #3289 CERTIF ATIO NUMBER: PHONE NUMBER (optional):
Fogerty Heights Road
KUt$tK
Phone 749.3656 CST SIG ATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester,
DILHR-SBD-6395 (R. 10/83) - OVER -
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REPrf131 ' HUDSON ST. CROIX COUNTY ZONING PAGE 1
06/25132 14:16 REQUESTS FOR INSPECTION WORK SHEETS FOR: 6/29/92 AREA: MJ
i~Activity: A9200235 6/29/92 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 22.29.19.225D,SE,SW,BADLANDS RD.
Parcel: 020-1059-40-000 Occ: Use:
Description: 171470
Applicant: HOYER, JOHN H Phone:
Owner: HOYER, JOHN H Phone:
Contractor: FOGERTY, DAVID Phone: 715-749-3656
Inspection Request Information.....
Requestor: DAVE FOGERTY Phone:
Req Time: 15:06 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION `
Inspection History.....
Item: 00012 FINAL INSPECTION