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` AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP
SECTION T oL9 N-R~
ADDRESS Be y It 2 f Z_ ST. CROIX COUNTY, WISCONSIN
SUBDIVISION?/R~ ~Waiwa_- LOT LOT SIZE Y7 A~
L.t ¢ 3
PLAN VIEW /h
SHOW EVERYTHING ITHIN 100 FEET OF SYSTEM
~r 3
G0r1S v Drava Wa y
wd'"
~e X4 8s ~
~ TAN ~ T~►~
- 10
z e
g..1wdR~ lad 3~ytl~J~o,oo"
90
its
95 ~ Z~
~ ie
i
N
INDICATE NORTH ARROW
BENCHMARK: Elevation and description: lae_J 1 Pt ?,P-- ME C.f w~ Fl. = 7
Alternate benchmark top of µe4s-,ra~ al g'oi~ 1 3 -7 S_
SEPTIC TANK: Manufacturer: l;sue Liquid Cap. ®o sue/
Rings used:3GManhole cover elev: q, !mil Final grade elev: G~
Tank inlet elev.: 12-80 Tank outlet elev.: 3 ~y
No. of feet from nearest, road : Front , S ide.A-, Rear Ft . / 3 o
From nearest prop. line:Front , Side , RearA Ft. 2-S
No. of feet from: Well Building: 2 Y
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
a
I
PUMP CHAMBER
Manufacturer: ILIA 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 *'A,)d,77S - / Trench: Seepage Pit: Width: L_Length SAD Number of Lines: Area Built zo f-77-
Exist. Grade Elev..1in Proposed Final Grade Elev.
Fill depth to top of pipe: 91a
No. feet from nearest prop. line:Front , Side X , Rear Ft.95~
i
No. feet from well: 0 No. feet from building s &
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: ~y
DATE : PLUMBER ON JOB :
LICENSE NUMBER:
6/90:cj
LQCaTXQ*j rtrrVT+jI?j9P lst,? 3 . 29 .19 , N 3 ,TT O$E AG~EM ELVE
County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIX
(ATTACH TO PERMIT) SanitaryPermitNo.:
GENERAL INFORMATION 180299
Pe?mit Holder's Name: ❑ City ❑ Village ❑XTown of: State Plan ID No.: HUDSON W~Rrpe_v*
: Insp. BM Elev.: BM Description: Parcel Tax No.:
` , G7i / G GI , Cr]
TANK INFORMATION ELEVATION DATA A9200379 Id 27
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~k f Benchmark /Dsc~
Do g .Cj /W, Aeration Bldg. Sewer
Holding St / I K Inlet 1-2 X0 9~• ~ '
TANK SETBACK INFORMATION St/ FV Outlet /3//, '
Vent
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Septic /0 > ` Z NA Dt Bottom
Dos' NA Header /
Aeration NA Dist. Pipe Z~ ;
Holding Bot. System J~ J
PUMP/ SIPHON INFORMATION Final d a`ce
Col.
Manu urer Demand "
Ma °
m k: 27,01
[Model Number GPM ) C)s
TDH Lift I Friction stem TDH
Loss Read I
Forcemain Length Did. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length i No. Of Trenches P No. O~P+t~s Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHINManufacturer:
SETBACK
INFORMATION Typeo CHAMBER Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length / Dia. Length -37 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 ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 23.29.19,NW,NE,LOT 4, TRAIL TWELVE _
aGot-^~-~
~ ~z - ~
X11 ti l t. 'i r '
Z
Plan revision required? ❑ Yes ❑-Nt5-_
Use other side for additional information. /d Z~zT 5--['9
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
t
7 DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
a
' STATE IT AIRY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ `Q
8% x 11 inches in size. c f rev, onto 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
u/'/a E '/4,S z3 T~N,R / E(o~
PROPERTY OWNER' MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR M NUMBER
o r. W Z-74 t
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
❑ State Owned O
12 TOWN OF VILLAGE : K IS o 1 /a ; 7,--4/c,
❑ Public V~] 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER( b)
III. BUILDING USE: (If building type is public, check all that apply) D Z O - 1661- 30 _ 00
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43F-]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
~So 7 Z-0 zr o O. G Z S ~ z, DD Feet Sr 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
Tanks Tanks structed
Septic Tank or Hold! n Tank O 0 d iz / S P
Lift Pump Tank/Si hon Chamber
Vlll. 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:
40 o 5t-""4 act 06 /0 5- JK 32 1G2,47) 3 Z 3
Plumbers Address (Street, City, State, Zip Code).
RJ I2Z /tw c~ki d7r~ u/rg 17
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa 'tary Permit Fee (includes Groundwater a e Issued Issuing A nt Sign re (No m
Surcharge Fee)
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. ~L: A:sanita.ry permit is valid for two (2) years. ,
2. Ybur'eanitary permit may be renewed before the expiration date, and at the time of renewal any nevfcriteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
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.
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), thenia 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,,,,
Location of* property-kA/l/4 1/4, Section T_LLN-R l
Township 44~6
Mailing address RsX
Address of site l~ro.~ (l✓~
Subdivision name 7,_I'ad Lot no.A
Other homes on property? yes X No
Previous owner of property
Total size of parcel • f 7 /f1Lia
Date parcel -was created
I
Ares-aki- corners and lot lines identifiable?
! _/-1-_Yes No
Is this property being developed for (spec house)?K Yes No
Volume 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 t e office of the County Register of
Deeds as Document No. 4g/1 f~_ , 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
ignature of applicant Co-applicant
Date of Signature Date of Signature
dYC 7.~9P•+..r(i.:s.•Lr«...
IM 4N110 Y t^1.R>teeli-........... -y
~4 gRr, ~nMlale at wlsesasias `r~:.
A Nrosl of lard located is the 5 of the NO of
seeslea 230 TOWN61p 29 north, Range 19 Hest, Town a:
of §Idaen, as oseriW in the Certified Survey Ta: Past :
MV tiled and recorded in the office of the Register
of *"do for 8t. Croix Cowty, Wisconsin, on July 6, ~
lVM, is Oelw 1 of C.S.N., lase 271, Document
#33+1002, shieb parcel contains 20.48 acres.,
PAD"
This is. not.- homestead property.
"r.' ~N (is not) _
' Together with all and singular the hereditament and appirtenancea thereunto belonging:
And...Reatoa.P.. Stewart and Susie-Jo..Stewart.
warrant that the title is good, indefeasible in fee simple and free and clear of encumbrances except easemsote~~
protective covenants or restrictions of record and existing highways, if any,
sad will warrant and defend the same. '
Dated this . 7th day of April _ . tf.92....
+['`Y
(SEAL)!) T1:~ (SL11.>
Kenton P. Stewart -
"
(SEAL) ~yLC~L-......tB~iAL~.
Susie Jo Stewart
AUTRUNTICATION AC=NOWLEDGURNT
Signature(s) Kenton P. Stewart and T 1TF. OF WISC(1NS1!\
Susie Jo Stewart ) ss.
County.
authenticated, this 7th Ei;t. ,f April ty 92 {',.rslwalic runic before me this ..._..._:aay j
19. the abow named `I
1 j -
~Q John D. -Heywood
TITLE: MEMBER STATF. BAH OF WISt•()N~Iti
(If not,
^uthorized b\. , '70((.06' wl to me known to he the tiorson who exetosid HIf ~
foi,•.rolny; instrimient and acknowledge the same_
THIS 1'4 SrRUA•E'.7 NHS r. '•V;FD E•v -
Heywood b Cari by John D. Heywood
P. 0. Box 229, Hudson Wisconsin 54016
I!a, Prlhlic Coon , Wl{.
V C,"wwi •ion is rmanent. ((f not, state ton
(Sittn.>.t,.ro< may he a~E[,r•nhr,itell or :u•kur,alori~ed. Rlni, ~
are not :ere rry.l
•!.tror, .;f Pi-r.oe: tRF.,:.K n. ar. t>.. 'r v'e h.,•.; .1 tK-- L]1••,i :r.r.: i,l.. •A. ir -iRn+st•.n.
s..~.~. K, _ ° •a~atilt~ilu:,tarE=~ •_s_
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Sn_ rr
ADDRESS (Sox :9 Z $ Z FIRE NUMBER
CI^1Y/STATE 41, Ls o, ZIP -.5- 1
PROPERTY LOCATION : "l/4 ,E_1/4 , SECTION , T,21_N-R
TOWN OF gV_ g ' , St. Croix County,
SUBDIVISION 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 600 of the cost of, replacement of a failing
system, which was in operation prior to July 1, 1978. St. Croix
County accepted this program in August of 1980, with the
requirement that owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or a licensed pumper
verifying that (1) the on-site wastewater disposal system is in
proper operating condition and (2) after inspection and pumping (if
necessary), the septic tank is less than 1/3 full of sludge and
scum.
I/We, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix Co. Zoning officer within
30 days of the three year expiration date.
SIGNED:
DATE:- 7 -Z
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attaph complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but -'5T IX
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: n PROPERTY LOCATION
'J4M MILLCS .iWe:tQT 1JW 1/4 /JF 1/4,SZ3 T Zj AR /9 E(or)W
PROPERTY OQWNER': MAILING A~RESS Ly BLOCK # SU~~JNfAME OR CSM #
CITY STATE ZIP CODE PHONE NUMBER ❑CITY ❑VI~L~+GE OWN NEAREST RRp~AD ,
CITY. STATE
wf s4o1+6 ( ) Nu >'.l L1.S.IJrG,iWAY
New Construction Use Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow '$o gpd Recommended design loading ratek-i bed, gpd/ft2 O ~ trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate Q-_bed, gpd/ft2 0 fLtrench, gpd/ft2
Recommended infiltration surface elevation(s)72.00 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL ~guND 1 -ROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable for system S❑ U Y~1 S❑ US ❑ U ~l S❑ U S ❑ U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
aka:;>:::<;;>•.:
l I IoY L l l'vi t- Q 'Z 0.4 .5
$ ~ 2 " IbY+2 ~ 3 r- S c, f c r o•4 o.S
Ground /oy 5 ~'LIs 1'►t f ~•7 01
elev.
96 eft.
Depth to
limiting
factor
> ig 4Z
Remarks:
Boring # nn
wvr
~'g
{ W
Ground M1j D 6" /bylle S(4 MS Ph _7
elev.
9gI& ft.
Depth to
limiting
factor J
> .2s
Remarks:
CST Name:-Please Print J44 R-v \O14 Phone: -eg6, Q96
Address: o dw
Signature: Date: i~ CST Number
L
L__~ 9 ul
PROPERFYOWNER '&MhlI.CL&R SOIL DESCRIPTION REPORT
Page _ of 3
PARCEL I.D. #
. 43 Nwnf~SZ3 z9-~
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft
Texture Consistence Botx>ary Roots
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
.ti
%t
i2 4J4- S L 09 yh 1 C O
A .S
Ground ~j Bey d w2 S 4' 1'h S ry,~ 1 $
elev.
VA ft.
Depth to
limiting
W or
Remarks:
Boring #
16,Y4 C
/4 C-? 0-4 10-,!~,
~z 79" o P 4 P25 9 rh 1 0,7 0,g
Ground
elev.
C6~ft.
Depth to
limiting
>I Z
Remarks:
Boring # n
ok: O's
/ore 4 4 S~ c t
OA;
h `
Ground /OY+e 4• 0,7 O,g
elev.
C,S$ft.
Depth to
limiting
f ctor
j .~d
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
'D-8330(R.05/92)
r
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C-V I - Z
31 4 m
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MEMO
REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1
10/28/92 10:04 REQUESTS FOR INSPECTION WORK SHEETS FOR: 10/28/92 AREA: JT
Activity: A9200379 10/28/92 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 23.29.19,NW,NE,LOT 4, TRAIL TWELVE
Parcel : ` - - - Occ : Use:
Description: 180299
Applicant: MILLER, SAM Phone:
Owner: MILLER, SAM Phone:
Contractor: STROHBEEN, DOUG Phone:
Inspection Request Information.....
Requestor: STROHBEEN, DOUG Phone:
Req Time: 13:10 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION