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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Q Q 1 TOWNSHIP UUS G SEC.Q~ T Q/ N-R~W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION S UU LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•1,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3 '&D00rr,
Noble
R
O ro9q~ ~aY` ~Q
o' CA
r)O'
a
lei'
INDICATE NORTH ARROW -
BENCHMARK: Describe the vertical reference point used ~K U N 11~Q
Elevation of vertical reference point: 10 0.C) Proposed slope at site:
vv 1
SEPTIC TANK: Manufacturer: W Q h s Liquid Capacity: ~U U b g141
Number of rings used: Tank manhole cover elevation: Q 3. 13
Tank Inlet Elevation: 101. OS Tank Outlet Elevation: 100.7 5 `
Number of feet from nearest Road: Front,O Side,O Rear, Q 58 feet
-From nearest property line : ' Front,0Side10Rear,0 GIS ~ feet
Number of feet from: well IN , building: 1
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
1
r ,
PUMP CHAMBER
Manufacturer: y Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building: '1
(Include distancgR4?5.Vft plan). HeADQ K '1100.5'1
100 SOIL ABSORPTION SYSTEM tpa3
97 uo 13 o1t~M QVd rmID 9833 118.33
CS ~
Bed: Tre'nY :
Width: I~ Len$th:__~_ Number of Lines: C~ Area Built: I
Fill depth to top of pipe: d~ t~
dll
Number of feet from nearest property line: Front, O Side, O Rear, OFt. 8
Number of feet from well: N p 1K)
Number of feet from building: 50
~
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Q Impactor: n
Dated: n / Plumber on job: License Number: 1 U~1
3/84:mj
:5 W
LOCATION: HUDSON 24.29.19.255A30,NW,'SE, LOT 4, MCDIRMID DR.
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 175676
Permit Holder's Name: ❑ City ❑ Village [XTown of: State Plan ID No.:
ERGER, TODD & EARL, MARCIA HUDSON
CST BM Elev.: Insp BM Elev.: BM Description: Parcel Tax No.:
lei , 6' 1 u M..: n a . f r ~ e r' 020-1066-30-130
TANK INFORMATION ELEVATION DATA A9200335 ZZ1
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
SepticS Benchmark
Do ' 81t~ ` Z33 /d S~P~
Aeration Bldg. Sewer
Holding St/ 0( Inlet
TANK SETBACK INFORMATION St/Outlet 53 1,1,0.6601
Vent
irito ntake ROAD Dt I _
TANK TO P/ L WELL BLDG. A
Septic >la Z 2 /d NA Dt BottQ
96. ~B
Dos' NA Header4Ma4a. 91711
Aeration NA Dist. Pipe .
6,11 " 33
Holding Bot. System 9 , `
PUMP/ SIPHON INFORMATION Final Grade 0,7, e6
Ma cturer Demand ~.a°yer 3,ll~ /v3,3~
Model Number GPM
TDH Lift Friction Syste TDH Ft
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengthyr~ No. Of T enches PIT - o. Inside Dia- Liquid Depth
DIMENSION /z Cw DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING nufacturer:
SETBACK CHAMBER
r.
INFORMATION TypeO t t Z ModerNQ
System: L5c;f S0'(,c~ A_ OR UNIT
DISTRIBUTION SYSTEM
Header 4Men+4ekI_ It I Distribution Pipe(s) , r i x Hole Size x Hole Spacing Vent To Air Intake
Length (o ' Dia. Length 57 Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over 3 7Bed h Ove r xx Depth Of xx Seeded /Sodded x Mulched
Bed /Trench Center Z ' Trench Edges ~Z - Topsoil ❑ es ❑ No ❑ Yes
COMMENTS: (Include code, discrepancies, persons present, etc.)
4- 7
Plan revision required? ❑ Yes
Use other side for additional information. ~a
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
T DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUN~
C e'a 1
STATE SANITARY PERMIT
-Attach camplete plans (to the county copy only) for the system, on paper not less than [/PERM
8% x 11 inches in size. ❑ C ec if revlslasn to pr vious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP Ty OW PROPER ION
Z, 6~gl /1IW 114'/4, S a 11 To? , N, R E (or
e
PROP RTY OWN S MAILING ADDR LOT # BLOCK #
n
L ur~~ NA
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM UMBER
13 CITY II. TYPE OF BUILDING: (Check one) E] State Owned VILLAGE T TOWN OF:
❑ Public 71 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
2 ❑
3 ❑ CamP9round 7 ❑ Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining
12 ❑ Service Station/Car Wash
Mobile Home Park
4 ❑ Church/School 8 ❑
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. XNew 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ 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
1S d /sq. ft.) (Min./i h) ELEVATION
REQUIRED (sq. ft.) PROPOSED (/vim /V~i sq. ft.) (Gall/da
X11 U < 911 Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App
Tanks Tanks structed
e~
Septic Tank or Holdin Tank t o o
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signa e: (No Stamps MP/ RSW No.: Business Phone Number:
w, ~3a~rs -e 0~ 3$-go
Plu is dress (Street, Ity, Stater, Zip Code): /
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing gent Signature No Siam
Approved ❑ Owner Given Initial Surcharge Fee) Z
Adverse Determination /D ewl
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety S Buildings Division, Owner, Plumber
1
INSTRUCTIONS
y
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 the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBO 63991 to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) mustbe 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.
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. Complete for all
septic, pump/siphon and holding tanks for this systE~m. 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 83~ x 11 inches must be submitted to the coun~y. 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; replac:emenl 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)
APPLICATION FOR SANITARY PERMIT
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), then a 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 0 dd 84- r
Location of property 'U W 1/4 5W 1/4, Section Y , T -01 N-R 0 W
051D /Ve l/V St //,(7,
'/y Sr 5 c la.~ ~
Township Z IAO rN~
Mailing address',?
1rul
Address of site 8'-1'7 Mc,
c,r vn ; cl yP ~/ucl5v
Subdivision name 5 Mt~'_
Lot number
Previous owner of property 2[4 k'e
Total size of parcel ~ - 5 C" Cre 5
Date parcel was created Ax v
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house)? Yes No
Volume 740 and Page Number I 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, and
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 recor ed in the Office of
the County Register of Deeds as Document No. !'1,?43 S; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No, ' /
Signature of Owner Signature of Co-Owner (If Applicable)
Date of Signature Date of Signature
~ . "f"Yi~'~ ~55..e;nh~~ 1.. 4 Iii. ~t"`~t
3 Hudson, 5t. uroix k-ounty, Wisconsin (V
to w
3
= NWI/4 CORNER LEGEND ~T
W cc
I- m-mSECT10N 24
U_ oI roo T29N, R19W 1-1/4" round iron bar found
.o NI 000 5/8" round steel bar found WN
Z 01 vN POINT OF BEGINNING round iron pipe fouled oa
-4$J- Aluminum monument found ~N
Wo
o 1":.24" round iron pipe weighing 1.68 Z
SS lbs. per foot set ZUW
!2 cc (A'r
~N c'390 2"x30" round iron pipe weighing 3.65
0" lbs. per foot set"'
I~ 0 °
100 o
II' UTILITY EASEMENT PARAL NEL WITH LOT LINE FEET z; N
C IN SCALE h rn
n 1 1
a a
100 200 400 600 W W
o N 0
o UNPLATTED LANDS °
~l z fog
MWO
r.l 3 s?° LOT 2 , g2
c-N N 39, p°0a 5 6% sue-
W 1 o.. ~6 O
kl M , r` F , ~'l rn. J, 49.- LOT ARIAS
oil , p i ~ Fss -'oe as Lot Sq. Ft. Acres
z o 's 1 87,187 2.008
2 132,775 3.043
" o 2a20 33a9 (P,
LOT I 3 111,475 2.559
b 6 4 105,623 2.425
NI I
o1 I 2 , - - '6' LOT 4 UNPLATTED-LANDS
i h2 2A OWNER B SUBDIVIDER:
°
-'6 00 QQGj F O O)' Z.
0W GREENWOOD ENTERPRISES, INC.
f Oo0 a~\ O O' M 420 6th Straat
°I'L 2 a•~6 \ LOT 3 app HUDSON, WI. 54016
6 p5' o ~ s
--S89°3609"W-__-700.00-_-___-_-__-__
\ S 88° 39' 37"E 403.94'
0 w ( RECORDED S88°04' I ~ SOUTH LINE OF THE NW I/4 -SW 1/4ti,; fib( `.(yUNI %
o ~C E R T I FI - - - - _ _ _ _ I ?3VE pit PL~rwlly~
1 MAPS IN Vol. 1, UNPLATTED_LANIz__-MWG Comuff TIT
N; o Page_288 and in
ge 19 13 SURVEYOR'S CER=CAT
W' o Vol. _7 , _ P a _ I E
N' 0 - I
N SW CORNER I, Harvey G. Jo1►nson, registered Wisconsin Land Surveyor, hereby
v SECTION 24
q1 certify to the best of my professional knowledge, understanding
and belief: That by the direction of Creen~-xDod Enterprises, inc., owner of
°)i the following described lance, I have surveyed, divided and ►napped wart of
U. M1 the NW q of the SW a of Section 24, and also part of the NIA 4 of the SE
CQI and part of the SE of the SE 4 of Section 23 (being also part of Lot 21 of
Valley), all in T291q, R19W, Town of Hudson, 8t. Croix_ County,
the Plztt of FOX
Wisconsin, more particularl;r described as: Commencing at the W corner of
said Section 24; thence S 0°39'24"E (assumed bearing referenced to the mon-
umented West, line of said SW 4) 409.68' along said 'Rest line and also along
the East line of said Plat of rox Valley to the point of beginning; thence S 52139'E
727.18'; thence N 60004'52"E 178.05'; thence S 29°55108"E 66.00'; thence S 28°56'59"E
204.96'; thence S 27°00'08"W 339.75' to the South line of said !*1 4 of the SW 4i thence
S 89°36'09"W 700.00' along said South line, to said West line; thence S 0039'24"E 105.95'
along said West line; thence Northwesterly 202.98' along the Northeasterly right-of-way
line of Will Bradley Drive East on the arc of a 334.557' radium curve concave Southwest-
erly whose chord bears N 18°02'16"W 199.88'; thence N 54034'52"E.72168' to said. West
line; thence N 0039'24"W 770.29' along said West line to the point.of beginningy.con-
taining 498700 snare feet, or 11.449 acres, more or less, and being,-subiect to all ease-
ments of record;
That the attached.;llap is a correct rt:?resentation, to scale, of all the exterior
boundaries of the land surveyed and the subdivision thereof made; and
SHEET 1 Of 2 THIS INSTRUMENT DRAFTED BY J.E.R.
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 7&cid ' L e / {c f'Z
ADDRESS ))''I i r WI c~ hr FIRE NO : 7
LOCATION: N~ 1/4, S 1/4, SEC. T :?9 N-R ref W,
clsv ~L'c S E o.~ ti s f ~jY St ~~i Sc: c 3
TOWN OF:- ST. CROIX COUNTY
SUBDIVISION: LOT NO. 41
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.
SIGNED: ~I.
DATE :
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY al 9"'VI
INDUSTRY, DIVISION
LABOR I HUMAN REULATIONS PERCOLATION TESTS (115) MADISON, 163707 '
(H63.0911) & Chapter 145.046)
03CATION: SECTION: WNSHI UNICIPALITY: OT NO. LK NO.: 01VINION NAME:
N ~ 1/sd/ z4- /T z9N/R f asp 4- ~~p s~ e S.
COUN-rY: N S U NAME: MAILING ADDRESS:
U i) 0t-1 u j(- S- /
USE DATES OBSERVATIONS MADE
SEDRMS.: CO
F Residence / t~ New ❑Replace ¢ -z- /fj
9v L-
4- 2S
RATING: S- She suitable for system U# Site unsultable for system OTC ` SST L7 0 -J r-- r-p~ jZI/ I C-- K/
ONV MIN-_ _ _ -FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
[ZS 0U ❑U , [0 S CCU S U DS U
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.It163.09(51(b), indicate: u : I Floodplain, indicate Floodplain elevation: .
°r-~M*L PROFILE DESCRIPTIONS
R ATE -IN H A A T R OF SOIL WITH THICKNESS. C L R, TEXTURE, N E H
BORING TOTAL ELEVATION q FT
NUMBER PTHIM OBE V D TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B r 7' a3' 7, p.&3' 6L Sri S; /,/7'3,,J .83' K j Ma.o
/D Z . D7 Np/~rir > 3, To C' J w ot
,a,1-7' ;15 L '5,'L TSB 1, z 5' SnJ 5; 4- i a8 ,5".0 L. w b
B- ),vo /pz.07 /s/onlE 7 00
3, r0' SN C S Wll~ C--0 /Z' LEA/ /1?e-D S
5 ~ , U. Z' bL 5,'L 7'5 o, 5 3N 3,1J
L~
B-3 8./7' /DZ. T,,0n!C , • 5', 6, 7 ' 3 J ZV G S w
o. C2,' .6e- S ; 75,1 0„4 S,'L \"/6 e.~ t . 17 ' I3ni M en
B-4- ./7 /Dz,37 Alov a S -7 5'0' c vw ' Z,8 ' DNf 5
' N ,1..; 0.83' 8N M try
TSB 4L S
7, S~
B- ~ I p/,5'"g l'\IOs~~ s, u"",.•,i`~' DD' c_
B-
~oTE' Nc.IMi2 corz_~sPa.ic~s wr
DEGiNV~I_ PERCOLATION TESTS
TEST FELT ~ J/<GE~ ~2-E 1-{o~ES
DEPTH WATER IN HOLE TEST TIME DROP IN WATERP :S A MINUTES
NUMBER t$$OI ES AFTER SWELLING INTERVAL-MIN. PER INCH
P- Z 4-,7 o, o,ve
A
P- 4-
P-
P. -~Vr4T ► brJ
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitab it areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show tfieir location on the plot plan. ow the surface elevation at all borings and the direction and percent
of land slope. I E-C-v 1 Q
SYSTEM ELEVATION or- Gr i t-J ,Fa p 1- OIL Gs ll. 04-. Gr -r a sT
y~ c O P Z rise o i. A T l o.l T E S T
F `
v~ j Fi `J C-'4-Lm\,j /
015'z
00
• / / /
L-40T q
,ti
~ AIPee `
13 ff-t'4 C- H MACK. 14S 4-
IR00"i P ps A-ePAL4xrnnA-T-e-~Y
0 r,1 LOT L /NE &rLav' /400- 00
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 : TESTS WERE COMPLETED ON:
J x M er--S u sc~N 4- z~
ADDRESS: CERTIFICATION NUMBER: PHON NIJMBER(optional):
4Z~ Lof~` S~-, 4vp sov LkA -Z~~ 6157') -S 367
CST SIGNATURE:
DISTRIBUTION: 01igmal anal ono copy to 1,ocal Awhoeely, Prnl>cely 0vvof!1 and Soil Testes.
DILHR-SR1711-6395 (R. 02/82) OVER
C? Q.L. 6 7 P OTA ► ►
i'. N A M E /odd 1.. N..A M ~ r EwA p7
LU T10N (--ICENSE 3,19
1) A" T L
-LC -1. M
too looo~~~ 4
• ~ boo 3 ~ i d,
--EDO
rW~.~1'v. 6 J 2~ r~
Note pdjaCeIO '
u
We 11 'I's T~OV46& pu
S 0 k t fr xari. t c. ~~1
N~~ : RoLX used to 0
FRESH ATI; INLETS AND OBSERVATION PI.BE
_ Clio--3S// SECTION
Approved Vent Cap
Minimum 12" Above
Final .~1aj1
4" Cast Iron
Above Pipe Vent Pipe
To Final Grader
Marsh llay Or Synthetic Covering
Min. 2" Aggr.eg'.1!
Over Pipe ,I-
Distributi.o1 Tee
Pipe ~1 ._........_.I .t
Qu a ~t~ Aggregate Perforated Pipe Celow
Beneath Pipe Coupl.ing Terminating P
\ Bottom of System
REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1
12/15/92 17:36 REQUESTS FOR INSPECTION WORK SHEETS FOR: 12/17/92 AREA: JT
Activity: A9200335 12/17/92 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 24.29.19.255A30,NW,SE, LOT 4, MCDIRMID DR.
..•Pafcel: 020-1066-30-130 Occ: Use:
Description: 175676
Applicant: BERGER, TODD & EARL, MARCIA Phone:
Owner: BERGER, TODD & EARL, MARCIA Phone:
Contractor: BOUMEESTER, JIM Phone: 386-9020
Inspection Request Information.....
Requestor: BOUMEESTER, JIM Phone:
Req Time: 11:12 Comments : 111'36
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION