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Ltt 'ds i ert , ~i ~st~y4. 29.19.1 1l11.~ NNf~71 ggr~1 O 44 CDIA U4ID
Labor and:'human Relations RIVAT~ SE E O TIPM County:
54!ety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
186539
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
A SHANE HUDSON
e Insp. BM Elev.: BM Description: / Parcel Tax No.:
01 1 C -
r C~ 020-1267-10-000
TANK INFORMATION ELEVATION DATA A9200426
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic i Benchmark , (Z '
Dos U. 3-13, C-423'
Aeration Bldg. Sewer
6,60 ' 9J, 07 '
Holding St/ Inlet y
TANK SETBACK INFORMATION St/ Outlet '
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
rl
Septic 11 / 17 / NA Dt Bottom
Do NA Header..G7
It. 70'
Aeration NA Dist. Pipe . 9Z, 8957 77-75
Holding Bot. System , P~ G G/
PUMP/ SIPHON INFORMATION Final Grade
40
Ma acturer Demand Coto S.T• s g w9
Model Number GPM
TDH Lift Friction System T Ft
e
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH width Length No. Of Trenches p o. i e Dia. Liquid Depth 5 `7j
DIMENSIONS .3 DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacture .
SETBACK INFORMATION TypeO ,A%,.L CHAMBER
d Model Number: G7
System: >Mi, Stoll 7~- OR UNIT 93
DISTRIBUTION SYSTEM YSE
Header*%% 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
Bes*/Trench Center w
~ya ed /Trench Edges ` 7 oZ Topsoil El Yes El No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 24.29.19.1311,NW,SW,LOT 14, MCDIARMID DR.
Plan revision required? ❑ Yes
Use other side for additional information. 3 O 2L ZLIEjl 10!~:
L
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: }
0
I
DILHR SANITARY PERMIT APPLICATION `
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
ERs
_ 0
STATE SANITA PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑
8% x 11 inches in size. Ch k r s n re ous 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
J6"_ a,hd )Ga.V40, Z q r yV Ld S '/4, S Q 4 To? F, N, R (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
wmo e W A W
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Woodb~.t YAW 1-55,25 1(4J2 64s-743Z St.w J t
CITY NEAREST ROAD
11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE :
: u d 5 0,t/ Ace
❑ Public IX 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL AX NU BERG /
III. BUILDING USE: (If building type is public, check all that apply) G a d j br) , to 6aQ- 9(41
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
4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. rLZVX New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
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 X 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) 4.1 $ $ 'ELEVATION
4 d 5 8~ 0 Feet q 4 Feet
VII. TANK CAPACITY Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks oncret glass App.
Tanks Tanks structed
U A r Holdin Tank 10001 0 00 v. C.-
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
i
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) rP o.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
1042 v~ sT. Lvy Fall s 7_1-
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sagitary Permit Fee (Includes Groundwater Date 21ssued Issuing Agent Signature (No Stamps)
~ Approved ❑ Owner Given Initial Surcharge Fee)
Do Adverse Determination a
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
i
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 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. Onsife 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 systemls'to be installed.
11. 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 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) soiLt4st data on a 11IMorm; and Ejall informatloft
GROUNDWATER' SURCHARGE J
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 investigation's and establishment of standards:'
SBD-6398 (R.11/88)
APPLICATION FOR SANITARY PERMIT
STC - 100
his application form is to be completed in full and signed by the owner(s) of the
roperty being developed. Any inadequacies will only result in delays of the permit
ssuance. Should this development be intended for resale by owner/contractokt igapec
ouset/), then a second form should be retained and completed when the property
old and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property S HAm Mo VArREtJ ~AR~BPr
Location of Property Section TN-R r W
-township S014
Mailing Address 2-39$ ~MA'G `61A`I -
~Jooas~Q~ N1N ~s(ZS •
Address of Site 8S Mc g n~~ -
Subdivision Name N a•` D G
Lot Number ~
~C; h (-ter RAC F~J~ l.v~ ti Ci
~
Previous owner of Property '--Nam- 0.5
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Yes No
is this property being developed for resale (spec house) ?
Volume and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING-
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 refer-
G nces to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
(w ceAtE.6y that a t statements on this oAm she true to the best o6 my (ouh)
nowt.edge; that i (we) am (ane) the owners1 o6 the pnopenty desc.A bed in this
n60nma.ti.on 60nm, 6'Y VitU¢ 06 a wcvvdnty deed neeonded in the 06 ice o6 the
oun ty Re9.c steA 06 Veedso Voeument No. ; and that 1 (we) pees emUy
:on the p~toposed site 6on the selvage cUspos byss em (on 1 (w¢) hav¢ obtained an
as ement, to /tun with the above des eh ibed pnopeh ty, 6on the eonstAuct on o6 said
ystemp and the same has been duty neeonded to tfte 066.iee o6 the County Reg•i.steA 06
eeds, dA Voeumen.t No. ) .
l I Al
zu~
SIGNATURE Op OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
Ii f2~'1Z _ IIL---~cth
DATE SIGNED DATE SIGNED
DOCUMENT NO. u
~i WARRANTY DEED TI11$ SPACE RCtiLI7VEU FOR RCr:nRl)ING DA7A
II STATE BAR OF WISCONSIN FORM `L -1982 !
482GS4
1 VOL 94SPAGE 51 REGISTER'S OFFICE
ST. CROIX CO., W1
Greenwood Enterprises, Inc., n .Wisconsin Corpor.ati.on, R@C'dfOfReCOfd
I
APR 3 01992
j.
ran.t-Q.r....
i
or 8: 30 A. M
conveys and warrants to ..aad..lCaxen--S.....Zaruba., ;
husband..and..wife.-as.. survivarship..marital..prape .ty-,..-.....
( Register of Deeds
_
jl RETUR TO -Heywood
. PwQ. Box 229
pi f,Q Hu n, 4016
the following described real estate in St.....Groix county, Pt Clot. "
,I State of Wisconsin: ) f
I Tax Parcel No: F 7 1D
I I
i
Lot 14 of the Plat of SunRidge filed in the Office of the Register of Deeds for
St. Croix County, Wisconsin, on September 22, 1989 in Volume 5 of Plats, at Page 71,
as Document 451750.
ij
'I
I~
11 ~I
I~
i.
~I This .....is not...--..... homestead property.
II 00 (is not)
Exception to warranties:
,I II
f
! II
Dated this day of _...-April.. .
19.__. 92
.(SEAL) ` ( / _ ......'t~.~ (SEAL)
..James..Jr..-.Rusch.--President ■ ...Mary -g':..Rusch.,..Secretary/Treasurer
-•--.............................(SEAL) . ' . _ .(SEAL) j~
, it
AUTHENTICATION ACKNOWLEDGMENT II
Signature(s) ifLglps..);, _.1~l1SGlll, PrQS].S1~Itiw-- , STATE OF WISCONSIN
. ss.
ST. CROIX COUNTY County.
. n
authenticate this .__.day f...Ap.zi.l 19..92 Personally came before me this .j ......day of li
A. xi-I 19-92... the above named
i j . .
•-.Walt~r_•IiodynskX• Mar _.•1t.A ltusch _ Secretar ./T e►s~tr•er--
TITLE: MEMBER STATE BAR OF WISCONSIN y .
(If not,
authorized by § 706.06, Wis. Stats.) `r,n.,
to me known to be the
person :•t t~ the
fora vi► instrument and nclcnowlttl Q' ` J v
THIS INSTRUMENT WAS DRAFTED BY L Ltd„ •
_
Heywood & Cari+ B Walter Ilod nsk '
r ,
Grace---N ...Mi ] lel'... . 1... Y
P...Q._-.0__229,._liudson,• WI 54016 St Croix
Notary Public
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not,''st,~,t►Fr e~P -tion
are not necessary.)
date 1 )
'Names of persona signing in any capacity should be typed or printed below their signatures.
ST C- 105 a
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County x
d
a
' H
OWNER/BUYER SHANt WAPMJ .A2vgA
ROUTE/BOX NUMBER $S~ C00.4 ~ mko tj t•0E Fire Number
CITY/STATE NupSoN, W~ zIP _5yc l
PROPERTY LOCATION:~~ ~L, Ste , Section , T? V N, R W,
Town of Hupsor , St. Croix County,
Subdivision SUmfLlv6F , Lot number
improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you pdt into
the system can affe- ct the function of the septic tank are a treat-
ment stage in the waste disposal system.
St. Croix County residents may be eliglble to receive a grant for
a maximum of 60% of the cost of replacement of'n 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 veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
H
three year expiration. o
r
.
1/WE, the undersigned., have read the above requirements and agree to
to maintain the private sewage disposal system in accordance with H
.the standards net forth, herein, as set by the Wisconsin Depart- 'd
ment of. Natural Resources. Certification form most be completed
and returned to the 5t. Croix County %unLnB Offi,Ve within 30 days
of the three year expiration date.
S I C N E D~~, _3uk
DATE ~~l2~hZ
St. Croix County Zoning Office
P.O. Box 98-
Hammond, WI 54015
715-796-2235 or 715-425-8363
Sign, date and return to above address.
IDUS
EPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DUSTRY,, DIVISION
4SOR AND PERCOLATION TESTS (115) P.O. BOX 7969
OMAN RELATIONS \ / MADISON, WI 53707
(H63.090) & Chapter 145.045)
OCATION: SECTION: 0 N MUNICIPALITY: OT NO.: BLK NO.: SUBDIVISION NAME:
yV hl 2 /T21 N/R 1? (or) W1 14 A I 1,1 Al A 916 s
OUNTY: OWNER'S/BUYER'S NAME: MAI IN ADDRESS:
ST,CRDI -S Zar~,.bc, 2398 SumoLc W W004)0.,% h .61
3E DATES OBSERVA IONS MADE
NO.BEDRMS.: COMMER A DESCRIPTION: PROF E TION : EFICOLATION TESTS:
Residence N New ❑Replace
3 - 23 - ~2 3-3~ - 9
ATING: S- Site suitable for system U- Site unsuitable for system
JNNVJEcNTIONAL: MOUND: IN-GROUND- [:]U PRESSURE: SYSTEM-IN-FILLHOLDIINNG TANK: RECOMMENDED SYSTEM: (optional)
ICI J DU ®J OU ®J ~ E]S CKU EIS 2 TYCn~I►t5 S -A g~S
Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
nder s.H63.09(5) (b), indicate: TI C I a6s 2- [Floodplain, indicate Floodplain elevation: N Q
PROFILE DESCRIPTIONS
DRING TOTAL ELEVATION P H TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
UMBER DEPTH IN, OBSERVED ES IGHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
1 q2 ~2.l~ n1bNE ~q2 Q-10' S; 10-/.q Gy13-, 5;l i4-34e,s:1
31 66 In V%111ICI S;sr ~G- A2 Li 01f c-S
I- Z 99 q 2.3 YvOrVE 0-9 L'I 31 I-8a S. U's vA' 113-
5~ 6aS 9 ~8~3c8n-fS
q9 -4 e-600"SL o a 'r 60- 9
0-10 131 5; 1 o-14 6Y G4 Si I /q- 23 f3„57;1 23-le
I-3 rionl£ > 99 13"5I.~,,,-r~,cob` s 42-99 L713,c3
9 91'O qJ .2- YV0roE > 9rio E34ft,I to-4t/o LT C3n Sa t- -32 n 5S; 32-9to
~J ~.r> 89 , c7 WpVv>= ] rl $ G- q I S; 4-I $ tan S 5; I 1 $-32 Qti S+~r32-9`~
LT (3n S
t-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER EV L-INCHES RATE MINUTES
UMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD I P PER INCH
1 0. 3 y
_2 41, w 30 2 2 2 5
0 Nowt, 1
OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
ital 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
land slope.. * ( B8, $
YSTEM ELEVATION *Z 87, o
- TO a
L
19x)
-5
2. G A~ - Wok
l
c PZ ~
INS tN
5jT
#Q ,
.
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
Iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
>ME : TESTS WERE COMPLETED ON:
LlrI P. 14 else -3-S/ -4
)DRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
104& 5 McL%,, $ 7. ►vcr Fall 1,11 s 35/4 'V1 495 os
CST IGNATURE:
STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
LHR-SBD-6395 (R. 02/82) - OVER -
Fresh Air Inlets And Observation Pipe
PL.
Approved Vent Cap y Fo r
Minimum 12" Above ~7J1lzL~1 F __~X~ R u ZAP . UM
Final Grade
20- 42" Above Pipe. _ 4" Cast Iron p MP"=
Vent Pipe
To Final Grade
Synthetic Covering.
Min. 2" Aggregate
Over Pipe
Distribution - Tee
pipe 0 0000
6" Aggregate a 1 1 ~8. 8
Beneath Pipe 2 en
o
LaT 1~
2,163Ac
B M 'T t3
p u
7-c\f fhor, Pc,
# L10. 6
Sc.~ 1''=got
brow, vkP+NRP=~M
X89 ` we ° touo Gn-L S~r-I«~ptil~ ~
i N
5 'C4aput,
t
Nyy (p" Mew (1 f-
4 Psr+ pv 6
2
REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1
03/02/93 09:35 REQUESTS FOR INSPECTION WORK SHEETS FOR: 3/ 2/93 AREA: JT
,'Activity: A9200426 3/ 2/93 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 24.29.19.1311,NW,SW,LOT 14, MCDIAR14ID DR.
Parcel: 020-1267-10-000 Occ: Use:
Description: 186539
Applicant: ZARUBA, SHANE Phone:
Owner: ZARUBA, SHANE Phone:
Contractor: HEISE, CARL P. Phone: (715)425-2175
Inspection Request Information.....
Requestor: HEISE, CARL Phone:
Req Time: 16:03 Comments: ~/;pU
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION