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020-1081-90-000
Zappa Brothers Inc. 715 Sixth St. N.,Hudson,WI 54016-1074 Office: 715-386-2850 Fax: 715-386-0323 Email:zappabrothers@sbcglobal.net June 4, 2014 RECEIVED JUN 0Q 6)1L` Ryan Yarrington ST,CROIX COUNTY St. Croix County Planning and Zoning COMMUNITY DEVELOPMENT 1101 Carmichael Road Hudson, WI 54016 RE: Faith Community Church Expansion Project, 777 Carmichael Road Section 29, Township 29, Range 19W Town of Hudson, Parcel Tax No. 020-1081-50, and 020-1081-60) Hudson, WI. Faith Community Church is proposing to expand its existing facility, the church building addition would consist mainly of expanding and adding gathering and office areas, the worship area would remain unchanged. Based on current DSPS data for estimating wastewater flows, basically the wastewater loads would not change, due to the worship area not changing in size, which is the major component in calculating wastewater loads (flows) , in terms of the seating capacity of the church during peak wastewater flow days (I.E. Sunday worship) . The existing POWTS (see attached inspection report) is functioning properly at this time and is in excellent condition. It is our opinion that the existing POWTS should service the expanded church facility adequately. The Faith Community Church is also willing to perform twelve month monitoring for risk of producing high strength wastewater. Ryan, if you are in agreement with this letter, would you please give notice to Brian Wert, building inspector for the Town of Hudson, that a St. Croix County Sanitary Permit is not required, or changing the existing POWTS. Any questions Ryan please call me, thank you for all your help in this matter. Sincerely Gary iappa�� MPRS 222373 State of Wisconsin MPCA 1171 State of Minnesota a 20 - /O'S r - 916- oC76 XT Z1, 9. 33 I Zappa Brothers Inc. 715 Sixth St No.,Hudson,W154016-1074 Office: 715-386-2850 Fax: 715-386-0323 E-Mail: zappabrothers @sbcglobal.net cctvE® June 4,2014 TO: Ryan Yarrington �. G St. Croix Planning and Zoning p9ta1 1101 Carmichael Road SUN Hudson, WI 54016 ST CRopEVE ppMENT JOMM�Ni�' RE: Faith Community Church Commercial POWTS (Private On-Site Sewage) System Inspection LOCATION: 777 Carmichael Road, Hudson, WI DATE OF INSPECTION: April 17, 2013 INSPECTION PERFORMED BY: Gary Zappa, Zappa Brothers, Inc. DATE OF ORIGINAL INSTALLATION: July 23, 1992 The following was observed: 1. Building Sewer - 4" PVC SCHELUDE 40 2 . Septic Tank A. Size: 2,500 Gallons B. Type of Construction: Pre-cast Concrete C. Structural Condition: Excellent D. Condition of Baffles: Excellent E. Level of Scum and Sludge Prior to Pumping: Normal F. Horizontal Setback Parameters: 1. From Church: 6 L.F. 2 . From Well: 330 L.F. 3. From North Property Line: 202 L.F. 4. From South Property Line: > 400 L.F. 5. From East Property Line: 135 L.F. 6. From West Property Line: 242 L.F. 8. Cover over Tank: 4.00 Ft. 3. POWTS Treatment Component (dispersal system) : A. Type: Trenches B. Size: 4 - Trenches, 93 L.F. each C. Condition of Soil below Dispersal Trenches: 1. Dry, Trace to No Discoloration 2 . Trace to No Clogged Soil, Biomat appears Normal D. Filter Material: Aggregate E. Observed Level of Effluent at Time of Inspection: East Trench None, Middle East Trench None, Middle West Trench None, West Trench None F. Horizontal Setback Parameters: 1. From Curch: 31 L.F. 2. From Well: 350 L.F. Page 1 of 2 Y Zappa Brothers Inc. 715 Sixth St.No.,Hudson,W154016-1074 Office: 715-386-2850 Fax: 715-386-0323 E-Mail:zappabrothers @sbcglobal.net 3. (continued) 3. From North Property Line: 99 L.F. 4 . From South Property Line: > 400 L.F. S. From East Property Line: 135 L.F. 6. from West Property Line: 212 L.F. 7 . Cover over Dispersal Trenches: 2.83 V.F. FINAL CONCLUSION: *The POWTS (private on-site sewage system) is functioning properly at the time of inspection. The POWTS was built to service a church with a 1,464 gallon waste load per day. NOTE #1: The existing system under current Wisconsin Dept. of DSPS Chapters Comm. 83, does not fully comply. However, the system was constructed to Wisconsin Dept. of Commerce Standards at the time of Construction. Existing systems are allowed under Comm. 83.03(2) Retroactivity (a) . *Estimated Useful Life Remaining: 60% NOTE #2: Estimated Useful Life is based on the Church having a maximum waste load of 1,464 gallons per day or less. NOTE #3: Estimated Useful Life is an opinion representing our Professional Judgment. No Warranty is expressed or implied. Sincerely, Gary Zappa Zappa Brothers, Inc. MFRS 222373 State of Wisconsin MPCA 1171 State of Minnesota Page 2 of 2 s a o a) o ~ 00 a~ o° w C c c i a) in P.., U) C •E CT N t N O C 3 CD CL u GN) -C N N a m ° a>; ELF mc) 3 Q co O C.) O N a) U O ~j L N A "O C -,t Q O 14 r N a' a) (1) -o U) m~O O 3 E E: 0) fn L E C 0 D O O co a) _ L 0 C -O i O O O C; L 0 O m 3= ° Cm r (6 E LO C cc E E ( cr o a~ Nw N n a 3 U d o a N Q) E C N N L C Z N -O 3 j 0-0 N V N N O) a, 0 LL p C U LL O LL C N 3 C= N d C U c ~ .coELO. 3 mo°oyoar°o d dUoa ~`\J d Srimo I-M0-2x a 3 Q) rn E Z E z 0 0 v o T o N F- (n (L co V CO. co O Z d c m z d C o E Q 70 l ) o F~ I" O O) N O_ ~I./J N O CL ai N O 1 d L L N N c-0 O ~ c c O (3 ~ o 0 O N N N l~V\ Z co z Z F- Z Z O 4 4 O '0 0 4) V C E 16 E cu ca ~l O o a in a m ni 0 a d al E CO FN- H c m H H H O I m x'000 n N 0 0 0 ZOf ~3lN c a a a a a a CL m m O cn = oo w m m cO J U rn rn rn w _0 E cr \ } N M N N O T ` U O O 0 0 (D fl- r- 00 N 44 (0 O N V O O C< r` O O E 6) O O O • ~ G7 4/ } O '6 ~ Q Q) (BOO ~ Iw L d W ~ O 00 I~ N C N C 6 O c O C C E lA U') m y? OR M o L O-e N y N fl O O a CL Q. Co Co m O O .t O O O) N O O O) C C m L'i Q) O N 'O -0 N L L O ^I O N 'p N O O O (D • N of a) (o (o N om m ! N E E U T- N 0) U- ;C /t C y a) a L CL :3 ` a w a w s a y 0 a' Y c y E i c c 0 c C `~1 A c~ a 0 in c~ 0 ii 0 Parcel 020-1081-50-000 05/17/2005 08:44 AM PAGE 1 OF 1 Alt. Parcel 29.29.19.331 E 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner * FAITH COMMUNITY CHURCH, OF HUDSON INC OF HUDSON INC FAITH COMMUNITY CHURCH 777 CARMICHAEL RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE SEC 29 T29N R19W NW NW S 208.7 FT OF N Block/Condo Bldg: 926.8FT OF W 417.4 FT CHURCH BUILDING/PARKING LOT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 29-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 876/562 07/23/1997 869/159 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/24/1995 Description Class Acres Land Improve Total State Reason OTHER X4 2.000 0 0 0 NO Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 020-1081-90-000 02/02/2005 08:49 AM „ PAGE 1 OF 1 Alt. Parcel 29.29.19.3311 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner FAITH COMMUNITY CHURCH, OF HUDSON INC OF HUDSON INC FAITH COMMUNITY CHURCH 777 CARMICHAEL RD HUDSON WI 54016-7702 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 777 CARMICHAEL RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 5.100 Plat: N/A-NOT AVAILABLE SEC 29 T29N R19W NW NW COM 926.8'S OF Block/Condo Bldg: NW COR SEC 29;TH S 926.8'POB;TH S 89 DEG E 417.4;TH N 88 DEG E 160';TH S 0 DEG W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 387.4';TH S 89 DEG W 577';TH N 394.4' 29-29N-19W POB VOLLEYBALL AREA, PROPERTY Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 877/287 2004 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/24/1995 Description Class Acres Land Improve Total State Reason OTHER X4 5.100 0 0 0 NO Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNERiTfl TOWNSHIP f~,nsay SECTION-_ ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT..LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM , ikST R0 o~?T~ 4~,ur ~SC~ ~o•4L ScPriC ~Ii~tJK ' S/ p✓c 303 / 5ZA-,Z?I.IAJ ~o~ iJcvcES, • . o ' . • V ~ N-rs /00'3'~Oos~o CNaQtN . Pe. fy a ~ - - - - - - - i ~F. gds. g IT. fucNlYl ►tPK - ~ t t . Opal 4aV: jA)& or /Qt7, oc~' r ; • '•'s fXis irt~ cc (f 11~r.ri t c WA--4 ~,o • INDI ATE NORTH ARROW 0 BENCHMARK: Elevation and description: Alternate benchmark F.f We EGv, g4.~ ~g• ° g~~•93' SEPTIC TANK: Manufacturer: Liquid Cap. RSoy C. 4z- Rings used: J_Hanhole cover elev:/o=_Final grade elev: /oS Tank inlet elev.:-/0o-3S` Tank outlet elev.: /oo. No. of feet from nearest road:Front , Side ✓ 9 Rear Ft.~ ca nearest prop. line:FrontSide Rear Ft. /5/0 ' J~ No. feet from: Well Building: r-S' ~2' '-0 nc e this information in the above plot plan) rence dimensions to septic tank) T SEE REVERSE SIDE n Cr F. r jv'i ' I PUMP CHAMBER Manufacturer: • r Liquid-Capacity: Pump Model: Pump/Siphon Manufact.: Elevation of inlet: Pump Size 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: V 9~. eepage Pits Width: Length 93 Number of Lines:_L..,_Area Built /<~-,nS4~T Exist. Grade Elev..? Proposed Final Grade Elev.J 9Q.9sFill depth to to you. S~ IV: vegi No. feet from nearest prop. line:Front No. feet from well: So' Side, Rear ✓Ft. Noe feet from building HOLDING TANK Manufacturers Capacity: No. of rings useds~_Elevation of bottom tank: Elevation of inlet: No. feet from nearest drop. line.Front_, Side No* feet from: Well Rear`Pt. building , nearest road Alarm Manufacturer: INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: ~ PiP 3.3 ss 6/90:cj c, IQCAT199: HUD$ON 9.29.19.3 PRI~AW N EI~V CAE MICHAEL RD. isconsin epartment o Industry, SYSTEM County: Labor and Hkiman uildi Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitar mmv , GENERAL INFORMATION 171629 1--7S 60 Permit Holder's Name: ❑ City ❑ Village [Town of: Sta Plan ID No.: FAITH COMMUNITY CHURCH, OF HUD OHUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: PDD, 00 ~~'s~'►~ 6,5 1 020-1081-50-000 TANK INFORMATION ELEVATION DATA A9200289 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dos' Aeration Bldg. Sewer Holding St/O Inlet TANK SETBACK INFORMATION St/~K Outlet Vent irIto ntake ROAD Dt Inlet TANKTO P/L WELL BLDG. A Air Septic ti Slj `c >,2oD 7.5 NA Dt Bottom Dosing NA Header/-Map Aerat* NA Dist. Pipe Holding Bot. System Z- PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand &Cp C9-rS. rn'..'Ad[c Corer Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Ti riches 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: OR UNIT DISTRIBUTION SYSTEM Header I-Wmrrrfefd Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length ~ Dia JL Length Dia. Spacing ~l 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 -/Trench Center 2j --~4) Bed-/Trench Edges Cp - Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 7=f T-Z e3 T q Q s sue. Plan revision required? ❑ Yes No Use other side for additional information. Ta 2L_,Z SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: } SANITARY PERMIT APPLICATION -90ILHR In accord with ILHR 83.05, Wis. Adm. Code CouNTY ST ITARY ;PE MI -Attach complete plans (to the county copy only) for the system, on paper not less than M 8% x 11 inches in size. h k lf re~ic~ r )application -See reverse side for instructions for completing this application. ~Z STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. f PROPERTY OWNER PROPERTY LOCATION ti 1,/'/4 /,/'/4, S T 911 , N, R E (or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned O VILLAGE ~ " ja WIN w: 4~9 Public ❑ 1 or 2 Fam. Dwelling-#of bedrooms- ,t o -/oorP- J-0 III. BUILDING USE: (If building type is public, check all that apply) cal e, 0 2 v - eO 1 ❑ Apt/Condo 1 6 2 -,/0d ;y 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 8 ❑ Mobile Home Park 120 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. S 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 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: i = 3s dt.=99 S'S 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 (s q. ft.) (Gals/day/sq. ft.) (Min./inch) =ys",ro0 ELEVATION ) 6.2 =/00- 3S- = Z goFeet - S Feet VII. TANK CAPACITY Site ' in alIons 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 Holdin Tank - Lift Pump TanWSi hon Chamber F-1 F] __E1 0 1 LJ F1 VIII. 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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Z4 TN& s G . ,?.3o 0 /S .7dpe "_s'o Plumber's Address (Street, City, State, Zip Code): 4:00- 4, IX. COUNTY/DEPARTMENT USE ONLY Disapproved tary Permit Fee (Includes Groundwater Date Issued Issuing A ent Sig S Approved El Owner Given Initial f~ lnn~ surcharge Fee) Adverse Determination W 08 06 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. 1 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 (SEiD 63911) 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. 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, dravrn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatn^ent tanks; building sewers, wells; water mairs/water service; streams and lakes; pump or siphon tanks; distribution boxes; scil absorption systems; rep"Ecemert system a,, eas, and the location of the building served; B) horizontal and vertical elevation referen+,<a point::.;; C) complete specifications for pumps and controls; dose vc.<luimu; elevation differences; fri(,t:on foss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption :,ystem if required by the county; E) soil test data on a 115 form; and F) all sizing information r, GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The ni-)nies cco!i .:cited through these surcharges are used for FInonltoring grcv.j -rdvvater, ground- water contamination investigations and establishment of stand it=;,:•. SBD-6398 (8.11/88) 17, • ~ s r ~o kA y M ~ ~ ~ v1 ~ y o - y T Z d~ o~ ~ ~ ~ ~ g Z 3 o ~ c w r r Ilk I W$~ , t i~ O LAb o rw S4 •O O' / Z n' p~0~ tS'~ G'~j V A ip" 10, 00 'Po O O C tVS1TE SEW GE SYSTEM J/i. 'h ~vnd natt t, kA y R v e.D APto DEPARTMEN INDUSTRY, LABOR A BUILU GS RELATIONS DIVI5EON O AF 2 ~ ~ SEE CDR S C I^ y a c 0 .0 00 I ~ I ' ' y I I ~ ~ I y c ~ i i 41 o o I ' ' L o 41 a ' I i ' T b ^ N I i n. y~ k I i ; I 5//0 IN N , 54 I y I , 1 Milo. ` O ~yo e,VVRV^~v^' o V 'A Ath g v c N pN E SEWAGE SYSTEM Conjitionatty r Aw%Pm v "so r T E INDUSTRY, LABOR AND HIrT1DAS tD~-'.ARTlv7EN ISION OF A UDl ' , ~ ~ now SEE COP-9 E g N 4.1 M a. ~ O y -a Q 1 LA o Ilk. M r o N~ 0 (P~4 4 TA ~ o ~ Z ~ ~ u 1 O n Z L 1 - h Q k 1 0 0 N ~ M ell Q 0 o g 3-4 \ h s -c o w Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pa / of 3 LaWr and Human Relations - Division of Shfety & Elui~ lings in accord with ILHR 83.05, Wis. Adm. Code 0 sT ch°orK Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D.4 dimensioned, north §rrQw, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION ~f}/7f f GD.~f~1 vui Ty G141RCX GOVT. LOT NAI 114114,S 2-q T N,R E (o Wo PROPERTY OWNER':$ MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSI~ If 1(2 s y 41 1011,e 7- 4F ' C7 /Ia4CS CITY, STATE ZIP CODE PHONE NUMBER OCITY (]VILLAGE [9TOWN NEAREST ROAD CITY, Ds~ti ~/S „sy0/Co ( 7/5) 32(o - //07D vDSo.~ c/t.PMicA~rL Rf.~ VI New Constructiop Use [ ] Residential / Number of bedrooms [ I Addition to existing buildipg L I Replacement I>1 Public or commercial describe - Code derived daily flaw gpd Recommended design loading rate / bed, gpd/ft2 - ? trench, gpd/ft2 Absorption area required bed, ft2 trench, tt2 Maximum design loading rate , bed, gpd/ft2 - 120 trench, gpd/ft2 Recommended infiltropn surface elevation(s) SSE P~ 3 it (as referred to site plan benchmark) Additional design / si oonsiderations -U-SE d 1,y 42,ee p U K 0,, slip/,eu T1cx4.J Parent material 6' 14CI' 4L- a4 T7al4Sh -S4--'A-57 Flood plain elevation, if applicable ft $ =Suitable for SySt8ri1 CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem 0S ❑ U l~ S O U] S❑ U 8 S ❑ U S ❑ U ❑ S EI U sG5 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 tends /0 Ye 7-/ 2- y4e 1m7;e_ < z _S /Oy/2 31y / f shy ~-5 Ground elev: I J 9 ft. 3 y. /ors 7/7 ~5- c Depth to C y1 120 ~D t 5~ r----- G, n►►:Q i , limiting factor > /1D LLL KrI Remarks: C /iD~i'Zl~,✓s %v 7.5 fl ~'E /0 OS, 5 7,e'lt7-1FI ETA Boring # G'3 0 /o y/e 5/6 ,,,,,,t ~ ~ ~ • S' Ground - elev. C 2 0-/ Depth to i limiting his fie t site APPROVE ,facto/r - for ptic Remarks:. HOMESITE SEPTIC PLUMBING CO. CST Name:-Please Print 665 e4elt RD.,110BBEIN, WIS. 50116 ROBERT ULBRIGHT Phone. 00 S Address: PAS, MASI 01 KUMBLM . 033 . ?`?NN. rw TALLER & DESIGNER LIC. NO, 00663 1 Signature: Date: S _ y2 CST Number: PROPERTY OWNER SOIL DESCHii- f10N REPORT PARCEL L0. y Page a of ' G~. UR~V • Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistenca Bour>da~y Roots GPD/ft _ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer + k 3 ~{t 0-8 /oyie 2/z , , ~s • s Ground is - JO H I , , 5,6 /Y►'tfiie 2S f -S e9stt. C o-//S /o y% s~~ - JC p 5c ,h►~R. p Depth to I limiting factor a Remarks: Boring # O yA 4r nnv~2 CS 2f I'S ye IIAM ~~-i ~15 Ground yie f • Shy I . S lev. 11103 e- 66 ft.z /Oa 4 S rkr ,e M+Q c s Depth to C - ~[5 /0 y~ S~ _ a~ q~'! , $ Mn J~- .-r ~ i cQ limiting - factor r I ~.rJ Remarks: Boring # Ground l1- /OYX y elev. IPA 16 2.4 2w, ft. C G-/,o /010 MA Depth to - limiting t°Iso - Remarks: Boring # Ground - i elev. Depth to - limiting r factor L T i _ r Remarks: 07 ~o w i I ~ ~ <TI f o N -o I UI I , kA I i n I I II III rn o I C I I I I i I I I I l j ka\ I I i t I I ~ C ~ i I I I I! i ~ ~ ~ ~ I I I I ~n 1 i ~ ~ I °l ~ i I i I I I I I i I I i,~~JJi I Its I 1 ~ d III .f, l l I ' I I ! I rn ~ - - = °Q I ~ i ~ (ki III Ijl~ 1~1=K j 11 IIiN iiW i';~ yJa I;i I~I ' I II ~ s~o I j III III II , rS -V Qv t L~ SEPTIC TANK NAINTENANCE AGREEMENT St. Croix County OWNER/BUYER F aO; # /n ~d FIRE NO: ADDRESS: LOCATION: No 1/4, tVk 1/4, SEC.__Ag__T --2q N-R_Lq_W, TOWN OF: ST. CROIX COUNTY SUBDIVISION: LOT NO. result Improper use and maintene n~oe handle rwastes septic system Propercould me ntenance in its premature failur three years or consists of pumping out the septic tank every 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 receives grant to tem which help with the cost of the replacement of St Croix County accepted was in operation prior to July 1, owners the requr irement p properly this program in August of e 10, to 1 keep the system of all new systems gre 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 e n DNt the standards set forth, herein, as set by the Wiscon. Certification form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE : ( Y r St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 STC - loo , This application form is to be completed in full and signed b the owner(s) of the property being developed. Any inadequacies will only result in delays of the issuance. tis development be intended for resale bytowner/contr chtor,l(shec 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 Location of property_ j~1/4 Ntj1/4, Section 2q~ T-99_N-R-LY_W Township c Nailing address Address of site Subdivision name Lot no. Other homes on property? yes No Previous owner of property a IF Total size of parcel 3, ass A. Date parcel was created Are all corners and lot lines identifiable? ✓ ,Yes No Is this property being developed for (spec house)?_____Yes _J/No volume-176 and Page Number Ste? as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: - A WARRANTY DEED which includes a DOCUMENT NUHDER, VOLUME AND PAGE. NUMBER & THE SEAL or THE REGISTC.R OF DEEDS. certified serve 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(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am the property described in this information form, bthe owner( y virtue sof oa warranty deed recorded in the office of the county Register of Deeds as Document No. own the proposed site for Elie sewage di posalt system) orr I e(we) obtained an easement, to run the above described for the construction of said system, and the same hasopbeen,duly recorded in the office of County Register of deeds as Document No. ign t e of ap~li.cant Co-applicant Date of Signature wave of signature pocuMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 460969 ,,~k "1D~P[~~►~ REGISTER'S OFFICE Richard John Zezza and Sandra L. Zezza ST. CROIX CO., WI sband an nd w...i f... e Rec'd for Record ....hu - • ------------------------------------------------------------------U U L 3 11990 at conveys and warrants to Faith-..Community -Church...of 1ius3'5=1a..Wl.sconz.1n...Inc............... tUptsNr of Cs,ds 12:10 P. M RETURN TO C-------..._--...--.-..-....-......_.---... St - - ro...... l.X County, the following described real estate in . State of Wisconsin: Tax Parcel No: Part of the NWk of the NWT of Section 29, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin, described as follows: Commencing at the NW corner of said Section 29; thence South on the centerline of the Town Road, 926.8 feet to the POINT OF BEGINNING; thence S89'431E 417.4 feet; thence N 88'471E 160.0 feet; thence S 0'02'W 387.4 feet; thence S 89• 10'W 577.0 feet; thence North on the centerline of the Town Road 394.4 feet to the Point of Beginning. This ..-....is homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. 007 Dated this .........16,. day of July---------------- 19...9.0.. jZLGG (SEAL) (SEAL) v Richard John Zezza Sandra L. Ze za (SEAL) (SEAL) + AUTHENTICATION ACKNOWLEDGMENT Signature(s) Richard John Zezza, STATE OF WISCONSIN Sandra L. Zezza ss. -County. authentioted thi da_y_of---`TU1yn; 19 9~ Personally came before me this _ ..day of * 46 1 19__-•---- the abora named Kristin-- Oglan-- Lundeen - TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland..Lundeen « Attorney at Law Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: + 19.........) eNamas of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. V-n 9._-_ logo Monpnpeoahmertof industry. !iiUILUtJt-txlrIlvtxrtLr Vnr a0or and human Relations '0 lot (Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) rJadrson, :.r :3: C' Page = . curt'04A .u J six avAk. oAra Cu"O+two wrvao covt+s AAnlrr yA Ea,4 KOetrAaeact P9.7 u b /,I Z it i C C 7, AS OWN cm arArE bit eocear sntLOAt»aoeowa IOCAICH acrsar toNMEMIA1uraClAlffY tAxeAK0.lAAith • BORfT4G I C l bra CS4l LOT BLOCK SUBDIVISION XNEW _ nEet Aet B- Houton Depth Dominant Color Mottles Structure Llmning Faclord Loaanq UPD,sq n. In Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Boundary Depth Trench Bad Elcv - °.;1 r ; _ Houton Depth Dominant Color Mottles Structure Unsung Factor/ LoAdiog.GPO'" n. B In. Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Boundar Depth, Trench Bed Elev 3 • r /V /I B - I Horton Depth Dominant Color Mottles Structure Llrrtlting Factor/ LoadingGPO sa n. In. Munsetl u. St. Cont. Color Texture Gr. St. Sh. Consistence Rootf Bounds Deprn Trenen Bed /j 4 Elev - } Z B - I Horton Depth Dominant Color Mottles 'Structure Llmlting Faetod LoaongGPDsq. R. In. Munsell u. St. Cont. Color Texture Gr. S:. Sh. Consistence Roots Bounds Depth Trento e.a AJ111 A/ Elev - l i d X i' 211~_I'L~ _ZL ~111 b-1 4 j, "12 -AL 12 Al X l B, Horton Depth Dominant Color Mottles Structure Umlling Fac1oN LoaangGPDso. h. In. Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Boundar oepth Trench Bed i AL -3y Elev 2", A' 1 ~vz _N '7L~ Ct 4/4 27 Additional Remarks: RECOMMENDED SYSTEM TYPE: Other Site Features: Systcm Elcmion CST . Signaa Date Signed Telephone No. c'CSTa - CST Name (Print) City Stella Zip N64 77 I Al~et„ fr< t ~G/l / Q~'7 /U- SC,}/G~t5 ~6J ~(/9n aq f'afr, ~C~ V / r r / / /w r d' ",ALofr" ~ I I ~ r I i i I ~ X onsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 + r and HJman Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but I.D. t not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or FREVIEWED f/PO/ dimensioned, north arrow, and location and distance to nearest road. DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION PROPERTY OWNER: PROPERTY LOCATION 9 io CD.~fi''1 lJ.u/ 7y G/iU/PG~ GOVT. LOT N/,l/ 1101V 1/4,S 2/ T -7 N,R /9 E (o PROPERTY OWNERS MAILI G ADDRESS; LOT # FK#J!UBD. NAME OR CSM # /0 z y , P,1 ,eT of s' d Ass CITY, STATE ZIP CODE PHONE NUMBER (]CITY OVILLAGE [MOWN ]NEAR ERO D L Rf~ f v vSoti w/S .5 V O/ ( 715) 326 - yo 7o v Ds oA C.4041,, CA.4& (A New Construction Use [ J Residential / Number of bedrooms [ j Addition to existing building j 1 Replacement [>rJ Public or commercial describe_ 111&y 9Pd Recommended design loading rate / bed, gpd/0' trench, gpd/ft2 Code derived daily flew Absorption area required bed, ft2 If30 trench, ft2 Maximum design loading rate / bed, gpd/ft2 _ trench, gpd/ft2 Recommended infltralion surface elevation(s) SSE ft (as referred to site plan benchmark) Additional design/ site considerations 1.2,,66 10 I?O X Di S Ti ~~3v T/O~1 Parent material %'`FL OU?GV'fS`t - 5~9~'OS Flood plain elevation, if applicable ft $ _ Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSUREJ AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for system OD S C3 U 0 S ❑ U KI S❑ U ® S ❑ U Z1 S❑ U D S Sl U yGs SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Gu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch 40, /0 0 2V -1 '1~ 1-15 ,..r< E - i y ~o y/Z 3/~/ / f, shy rn~~C' 5 2"'' Ground l~ 3 /0,v y/y off, Shy ",e2 .2 elev. /4 YX y~7 9g• 7~ ft. ~z 3y- /20 C Depth to limiting factor L C „ ~o~''• zo,~s %v ,g// 7-5 ttE /a aSE. - Remarks: Boring # a- ~P IL9 2-12- 0,5 r; f, Shy ~h► ~,p e ev nd C O-/ lD t~ S/ S M,~ 7L ft. 2 ' r.. r>~ c C Depth to T% limiting C r. c a Q 1-5 W. factor q /1d Remarks: - s Co. 'lull CST Name:-Please Print Phone: oc> ROBERT ULBRIGHT Address: # ,NAI rNS CALLER & DESIGNER LIC. NO. 00663 Signature: Gv Date: ~S _~2 CST Number: yIPZ.. PROPERTY OWNER ~,yy~,lT y SOIL DESCRIPTION REPORT 1 PARCEL I.D. # G~ uRGG~~ Page . 1 Boring # Horizon Depth Dominant Color Mottles Structure } in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Bound ry Roots GPD/ft Bed Trench 212 S / f s6,~ 2-4 S :vw E - s Ground '5-3 Ja elev. - I Sb,~ ~,1 fe q es f 1. //5 /0 Depth to V limiting factor v Remarks: Boring # .s 0-/a /0,//z .2 F Ground z(A /o elev. to 3. Ga ft. -3(0 C5 i l/s /o y2 S/ Depth to liming tact J' Remarks: Boring # - 5- r / f 54k Ground l1- / SOY A y S d k P/~ G S 141M elev. V t, 162.42- ft. l l~ 4 ~ e...----~' A+'1, Nh s i i c 6-% ~DY~ S s a Depth to limiting fac X 50 Remarks: Boring # Ground elev. ft.Depth to limiting factor r Remarks: SBD-8330(R.05/92) /~O. GOT G•iidC' m O o N y n j I ~1 a I a -44 - - • ~`1 - kA I I I , I I ~ I,. I ht 11 1 ' I I I ° 1 ~ , 1, 1 m T oc~ ~'1 G, 1 I I I C I I ~ W tr ~1 l,~ I ! ' I III i ~ C. Z I 1~ 1 ka" I I I I _ °@---- ~ ' ~ I ~ III I ( ~ 1 I I I iN i,I yRO I i I lil I I S/opt ~ ' I I I I 'YI I , I I ' III I z • ► U-1 - ~d~ G o col C T7ZI ~ Q I m m c rn re m m t,N N ~ a Y 6 0 CO 'Is K, 315 ,f .C IN N R fom CP N W p v e a L Vl Z n VIE N ' AS BUILT SANITARY SYSTEM REPORT -11 TOWNSHIP IflPD S-O SE •,A 9 T2N-R/9W OWNER. C A Q ADDRESS gfe ST. CROIX COUNTY, WISCONSIN. N, WLS- _~t'oC ~o LOT SIZE ~ SUBDIVISION LOT PLAN VIEW Sold g q D Distances and dimensions to meet requirements of H63 EM-THING WITHIN 100 FEET OF SYSTEM N ~ n di a e o th Arrow ' I SC L : T P ~ - ~ BENCHMARK: (Permanent reference Point) Describe: ' site: Elevation of vertical reference point: Slope at - - SEPTIC TANK: Manufacturer : f 1, S --s Liquid Capacity: f z o 0 Tank manhole cover elevation: Number of rings Elcover evation Tank Outlet Elevation: k InletEl: Tan PUMP CHAMBER tota capacity o Manufacturer: _ of gall gallons; Number of gal. pump set or a cyc e Number of gallons head; distribution lines gallon: size oT pump ran name ea pump gallon per minute horsepower ~ E- of and model number ' Type of warning device Number of gallons HOLDING TANK: Manufacturer Elevation of manhel-P cover Type of warning device um er o pets SEEPAE PIT SIZE: sNU- feet liquid dept eet iameter eepage pit in et pipe-elevation depth 3 Z bottom of seepage pit e evation th / feet. SEEPAGE BED SIZE: number of lines wi -length SEEPAGE TRENCH:. width -AMA REQUIRED RE AS BUILT PERCOLATION RATE INSPECTOR PLUMBER ON J B __~C DATED LICENSE NUMBER :pC REPORT OF -INSPECTION - INDIVIDUAL SLWAGL SYSTEM Saved. tahit Pvhrni t State. Septic, /V4 N A A1 St. Cn.oi.x County ~~1 f d f r r► (t a Y, S e c ~ o L L a t Sit b di vt s d. on tit I'7 IC TANK Si `gattone Numbeh o6 compa.n.tmen-tA~_~_!_ - Vi-e.tanee Ahom: Well to Bu.itdt.ng 12% .5k-ope. _ Highwateh PUMPING CHAMBER e~c-_- Size gatton6 Pump ManuAdctuheh- Modet Numb HOLDING TANK Si; ga fone Numbeh o6 Compahtmente PU Irlp n Atanm S yb tem D i h t a e e h a ma,..:a.~{1 a w? t: . „B.cxd k d~ n g_ 1•,2, 0• e Q. o p e_ Highwateh ABSORPTION SITE S v T r e n c h tape. lding_ -12% D~ ti trtvi r v chum: Well. Building Hd_ghwate.h~ A6SORPTION SITE DIMENSIONS WA. dth o6 theneh I fit Re.q ud.h.e d anew _ -__bt Len,,q th 06 each tine. ~h At Depth o A' hock be.Eow .td Pe_1 .2.._, _d n Depth o h.oeh oven tife d.n 3 Totak tevcgth o6 tine,5 1ss --tit Depth o6 tile- below gna.de~~ I.n D.i e tanee between fine.6 K~ -6t Stope o6 tne.ne.h__ Ln. peh 100 V Totoe..ab6ohption ane-a_q Q D _ At Type oA Cove,h: Papvh oh s thaw ' Pit DIMENSIONS N(I rot) vh r,~ Pit's Ghavee oho► • ;?A,tS ye15 - nu 0ut6ide dd.ame.teh At Depth below inlet To toil' abso Lpt.ton ahea At Ah v a he.qui. ed At INSPECTED BV TITLE. GZ/"---------- - , v- APPROVED DATE_ ~L"=<------ 19 8 RI TI (1 [ i. D GATE 198 I:I AtiON I OIZ R[ 1ECTION 1 4{ AO-- Y ~ Q t State and County State Permit PLB 67 Permit Application County Permit # o • C/~CY X for Private Domestic Sewage Systems County S t *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Z~z2ff- /0.3 B. LOCATION: N '/4, Section a, T2 N, R~ E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township Huy SON C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY fLOy Total gallons No. of tanks / HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete x Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement x Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate A2 2- Total Absorb Area sq. ft. New Replacement X Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width p Depth Tile depth (top)--No. of Trenches Seepage Bed: X Length 3S Width --!Y -Depth D--Tile depth (top) 32 No. of Lines u Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land g d10 Distance from critical slope NONE &4X/ 5 TS WATER SUPPLY: Private 9 Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: 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 xpoh F Z0401f/ c 4 T C.S.T. # .5 .S OZ / 0Zand other information obtained from soi/ T--5'7Z-R (owner/builder). n - A96 2850 Plumber's Signature P/MPRSW# Phone #713 Plumber's Address -A- M /VO Uv GU/ PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. ` l . AP ,w _a E 91 ` C n y f/'O'L) cur 3 9 E m Ye- AA out z 00 0 0 _w j2- zu Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY / Date of Application Cn-e5 V ,F1 Fees Pai StateC 021 ate ' 2Z Permit Issued /~iejeeted (date) - - Issuing Agent Nameunt Inspection Yes~_No State Valid* Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON; WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 J EH 115 Rev. 9/73 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 aw ~w 29 iy 9 ,yvvso~ ~o~ I LOCATION: Section ,T_N,R E (or) W, Townshi or Municipality S C~O pf 6 Lot No. ,Block No. County _ --Subdivision Name Owner's/Buyers Name: 4 ~E GviS C MI614 PL /Y• 131VE15-~O-) Mailing Address: TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT X ALTERNATE SYSTEM - OTHECR DATES OBSERVATIONS MADE: SOIL BORINGS JAY 15 48 PERCOLATION TESTS 41"'1 SOIL MAP SHEET ~765 (06 NAME OF SOIL MAP UNIT 1342IM4.4tA9 PERCOLATION TESTS TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE MUM- DEPTH CHARACTER SOIL SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- I ~4L To 710 l)DA11 R < 67 . P- 36 d9 950 a / ~ 13 0 ° F 47 Go,0 AEEP so " DEEP IL BORING TESTS SO DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEST TOTAL DEPTH TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- ?Z NONE 72- 7`'/3.1;-G .SG VVIAJ-SIL, 0-6-BA) . cS B- No,V.- > /6"&4Y. .SL Sc. o" L& L-4N CV B- B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the loc tion and square feet of suitable areas. ZV SQ { {QiQ Indicate scale or distances. Indicate number of square feet of absorption area needed for building type and occupancy & Give horizontal and vertical reference points. Indicate slope. Y 19AW A Af - fo~P ~'P't~NFiEaE'D 3 !IS' ` o` yg~ o B2 ?J~,i- j SST Aiof t 2 ' P tN 'Al lg Ef .vallll?'# fe4142 ~Pos Ti f--;r /940A4__ ,FsoA/? DrtC~i C,t?d~tcJ~/ (,vcsc> /.A) 6'_ ~ I / /3 %4PE"•v 4ZO6- 1()04A t 4l' V l APO" ~ I, the undersigend, 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. LL (print) Certification No. 3 r 0Z y402_ Name ~n L' Address IC T 3 o'~V El ` ~o- ~7 V yzoA.) 4,iS -Name of installer if known .04"4: AA0 oS /,V NO P-7% /Z-00So- ' 4~/S ~ Copy A -Local Authority CST Signature .71 A i P1,~G~9,UtirEw. ~'~~ArE•vc~T S~SI~tiI AlbieA 110DSoA ; Fok %1/Gl r9~E'V ZEZ Z~9- ~ .~^yoX ~r M s c2 t plop J~QjiGAL O f ~,lo E ° /o' Mt/i~acJ~t f,Po~wO~d of o.P^i~~aco d~0a 3 r / Op ~ lloo y~/ . s~Pf~~ 42 A!E er Mm llcewce PO qt,~~/EVE row o~ 134 41~ Xj5PAI~ 7E 2,Z h Niz v • Well o/4 13e.D 13,A.A4 . ~s C A") 4 fl y .(0 .Pi,.?.ttc,~ 1 1V0/t L ~,PApG ovc~Q !~'~o ,Pxi?v/.4E GvTti~/y 6f~ mom Af. . , , . ----•----'--r_t---------err-.. - i A T THUDS-ON T29N*-R-20- SCE PAGE 89 _ Ernst ' L;. ECkCrt' Lind- /4.d SO ..TR ~ ~ ~~Cp .4 (.SfQf'C' o au u F. 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N ~ iiiii • R 3 99 liu: uu t- n•,•ra ~ 0 2 v" ts1 s h y y kCi7a J .fo • . 6.7 C l^ v~ e M a a s. s 0 b y ~e O ~ i's:t:::.. vi 1 i' :.:iii?iii': ~ii':•i ~ii':i' '..:iii:.........:iii~:.:.:. v,'• 5. Q! J• /46 e - \ r1 /a O ucfr R cu- a .P N n Herds o a bQ~r .,ot `ii:;. • rii:~;~ ~is••i€si` -:~.'i`:ii ::`.'.ii's'~'..:'.`iiii` / a t e n ~r CO / s ns f / 0 4 .E'... ........i . L o unfry Hud- hos iiii Fzn- 2G 7BRDJ 7 9+ Ile v eao C 6B . p n I asl • F .T9 k m. 0 n 9 4 b . ii'siii;: iE F ii S:r:~A:VL Qtfo 0 RAFT.. /yar h ii C 0 r K a l h s C 9. s y ,z O f/• r ii!i R OGe a tCt / e / / rn /a e W Le • a h e L u n .so s y 9 iii Li//ian •H. /5~/v,i~ et¢/ ,v~/ //i9sta W zs 6 n ieaman z /s 2 i...... Bo 9z o /9~,poc,Efoid /7a/oP~,b/sylirc SEE PAGE 13 u`1. Crox o,~rty Wis iPev /979 R. 20 /9 W. i 66 N R (Joins sheet 58 k LL Ax 5 p O L~ or- c 00 ~ r 07: -fqaww -IN Mlt. yl L~t :::777~~~ _ a~VB~ 1 r.. .j" 1. r f p K- 1w~'~Yr ~ F ~i 'Yil r Y. Y r k~ - PIA K F a ? ~ ~S t sf,H a 1 0 8 a Y h - s PIA {E p (Joins sheet 74) 1 300 000 FEET O L e+ I so 0 O C r 7 W O cn = O Z C fNO N °C . I• c) y N v~ O CD C n O s~ CD O fD y N ICI c° n n uJ N 0 off., 9 (C) co y ^ O Q 01 01 CD 'co N .04 O C W N O CD CA) N O 1 ~ C fD 7 Q / SI 3 -4 1 0 C 0 cn D a U m CD CD CL -u co 0 y Ic 3 coo rn d 10 m \ ~ `y o o 0 0 r. OD CL 0 1 a= 3°'a CL T T"a T o i N ~-3 0 ~vv~ m COJ m c{D! o N O Iy c '3 eo _ °v 0 N O a m a z D a O c CL m M "I m ) . CD t~1 • C 7. C N CD W N O d 3 3 Z --I co o c° A Z CD C s v n A S CZ W M N tN0 < a Z G 7 Z c'o y I m a v 1 _ p x 3 Q.. O L~n3 ` N fD N co -n v C S 0) 7 CD V O o0 O C=) -4 ID C O . D) S 3 ~ ~ N C 'fDCD y mm ~ y f fi N N 0. O F ~ F' 7 O 1 n y C.) A mr, X o N _ =r CD CL o O aro CD O ° o CD Y t n N O C M 0 m o o m ro v Z 3 \ 3 - ~ 0 a~ U) m o=i N o c) o • = CD CD CO (D Z NO W W O N C Q fia N d N 'n W ~-0 0- cr CD 0 N4, o p V IT" CD CD - CD 7 6 6 ~i O . 3 -4 O N V O O C d ~ (7 ~ D ~ a v r+1. (m (n Q 3 C: =r rn a) "IftA CD o o ;o o N co A N O co s c a a v v o 3 N N N O 0 cr v o N m m o CD Q N cr 2) a N N C) z 0 Z W O Z 0 ? o O o D o CD Cl) m "NA • tol rn ° m CD CD CL `6 A Z CND c CL z C Z PO W m o G Z 0 3 A CD a A N COD YkO V nO 7 D 3 O =r V 3 O CD C1 CD N C V C S ~2 Ci C 7 O? N :r N T W W 3 O CCDD O Q' C O .0 - 3 C) a, 10 =r O Cn c < N 00 CD CND N Rim O N S7 7 :1 O * O - S O A COON = p N0 - CD7 O S O. CD 4t3 Qf c V ? T -At t rnX N CO O ? W CD a ti r d 0(o 0(D O (FD 3 N 3 CL CD N j o b N de O v 0 0 V 8ZT/8£S L66T/£Z/LO :Azo Eg Z d0 Z 3OVd Wd 6Z:b0 90OZie«90 000-0V-ZBOVOZO IGDJBd Parcel 020-108240-000 05/13/2005 04:29 PM PAGE 1 OF 2 Alt. Parcel 29.29.19.332B 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner " FAITH COMMUNITY CHURCH, OF HUDSON INC OF HUDSON INC FAITH COMMUNITY CHURCH 777 CARMICHAEL RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 771 CARMICHAEL RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 4.080 Plat: N/A-NOT AVAILABLE SEC 29 T29N R19W SW NW COM NW COR SEC 29 Block/Condo Bldg: TH S 1320 FT TO POB TH E 755'S 250'W 755' TO CEN LN TN RD TH N 250' TO POB & Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) EXC P332J 29-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 10/03/2000 631020 1547/567 WD 07/23/1997 1012/506 WD 07/23/1997 731/56 07/23/1997 718/553 more 2004 SUMMARY Bill Fair Market Value: Assessed with: 48288 256,600 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.080 52,500 146,000 198,500 NO Totals for 2004: General Property 4.080 52,500 146,000 198,500 Woodland 0.000 0 0 Totals for 2003: General Property 4.080 52,500 146,000 198,5000 Woodland 0.000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch 145 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 i Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Ap~ ( 1Ulll/ ~G' TOWNSHIP 1/ UD ! D SEC. T Z~ N-R W ADDRESS A~, 3 3~6 ST. CROIX COUNTY, WISCONSIN CAiPM~ ,~F~ UDC o A) WA S SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Po/E 4 • , f~Ev~}riD,v ~ ~ (3E~ 1 c~ d 5'!0 0 Gorr" ya.~s L __J A ` s I # ( '7^. /00 f r. 3&' V . r +1 t/4ri"aa s 73,g 10 r = X3.6 y ~AVAJ OOM S var. ~ Pf• of ~5 (3~p~ r.a~, s G r~ T is TIIp S4EI=L - //oea. PE•11AP,,SEr'~EXT TO pawEre X0/7 Vi' `y. palms To ~F'SAR 'S Zf1~l • 100 04 X00.0 l`T. G~(Evr}Tio~S ~ Sj~~ ~ ~1 c 69,vEPS OF A-5 fl. VE SE~0 c ~~1~ ~iE'S E"X4e T4y ~y FRoM CEti TER o,~ ~ o ~ . INDICATE NORTH ARROW Fog r/f AJk dra c y. TOP/ of 60"48 fA_ 5TEP s/// BENCHMARK: Describe the vertical reference point used ~00AI vd0~ Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK:, Manufacturer: Liquid Capacity: Number of rings used:1116A e_ Tank manhole cover elevation. /~P• ' ya , Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,© Side 0 Rear, O > lJ d feet From nearest property line Front, 0Side ,ORear, 0 > 10-D feet Number of feet from: well 55 building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) Op 1wV1?R4r gTDI t PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: mp/Siphon Manu urer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elev on: lons per cycle: Alarm Manufac rer: Alarm Swi h Type: Number f feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed : X Trench: 2 f Width: 2--l Length: 3G Number of Lines: y Area Built: Fill depth to top of pipe: 11,74 X/,/`+ U", Number of feet from nearest property line: Front, O Side, O Rear,O Ft. Number. of feet from well; 70 , Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: umber of pits: meter: Liquid depth: om 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: C ty: Number of rings used: Elevation o tom of tank: Elevation o et: Nu er of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated • SE/af Z 0 Plumber on job: H0I4ESITE SEPTIC PLUMBING CO. • ROBERT ULBRICHT 4016 License Number : WIS. MASTER P MR- INSTALLER & DESIGNER LIC. N0.00663 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS 'LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 I. BUREAU OF PLUMBING MADISON, WI 53707 State Plan I.D. Number: ❑ CONVENTIONAL ❑ ALTERNATIVE (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound 06 NAME PERMIT HOLDE ADDRI~"/ F PERMIT HOLD R: ` INSPECTION DAAE: 101 J _9j BENCH MAA'RK~ (Permanent ference point) DESCRI E DIFFERENT FROM PLAN. REF. PT. ELEV.: I CST REF. PT. ELEV. S W Name of ben MP/MPRSW No.. County Sanitary Permit Number: SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: ` TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER ^ PROVIDED: PROVIDED: /y YES ❑NO ❑YES ❑NO 9 BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD PROPERTY WELL: BUILDING: VENTTOFRESH ALARM: FEET FROM LINE: ~ AIR/I~T. YES ❑NO sOC ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO AN N OTRESH GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. IVEIR (DIFFERENCE BETWEEN FEET FROM LINE PUMP ON AND OFF) ❑YES ❑NO NEAREST IN - SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing r,T i JDIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH. NO. OF DISTR. PIPE SPACING. COVER INSIDE CIA. #PITS: LIQUID BED/TRENCH 1 TRENC / ~GFERIAL' PIT DEPTH. DIMENSIONS J ~j GRAVEL DEPTH FILL DEPTH JDISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N TR. NUMBER OF PROPERTY WELL BUILDING: VENTTO FRESH y{L BELOW PIPES ABOVE COVER EL LET ELE . END._ FEET FROM L1NE~0 AIR `//Fw W//~ JJ6 NEAREST--s MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO ❑ OBSERVATION WELLS SOIL COVER TEXTURE PERMANENT MARKERS: YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED: MULCHED: CENTER. EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO ELEV. ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: D:STR. PIPE Bs' DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: : ELEV DIA ELEV. : PIPES. ELEVATION AND DISTRI BUi ION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS: ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF L O ERTY WELL: BUILDING: FEET FROM ❑YES ❑NO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. T E: TITLE DILHR SBD 6710 (R. 01/82) c unsconsin APPLICATION FOR SANITARY PERMIT ILHR (PLB 67) COUNTY UNIFORM SANITARY PERMIT # -,-ffRT771E R OF rlsTR4,LBOR 6 Humpn RELRTIons ,-r/ 12, -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS Qvi1N) ,80X 3f S 11vDSdA? 4OiS. PROPERTY LOCATION SW 1/4PUAA, S Z , T# N, R E (or W L NEAREST ROAD, r-AlItE OR STATE PLAN I.D. NUMBER C h~'--- TYPE OF BUILDING OR USE SERVED 00?0 - l~ 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): THIS PERMIT IS FOR A: 1❑. New System ❑ Tank Replacement ❑ Repair X~ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank J System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity ~L Lift Pump Tank/Siphon Chamber Holding Tank capacity tv/f IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPO ED (Square Feet): Y ~ZV 20 N 2 X Ly , Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: jW/MPRSW No.: Phone Number: HOMESITE SEPTIC PLUMBING CO. ! 3 30 (715') Plumber's ti r I 'ROBERT ULBRICHT Name of Designer: VA& MASTER PLUMB&R LIC. NO. 3307 MARS. COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ~~yy/ ❑ Owner Given Initial y(f~ 14-do --Ay Approved Adverse Determination Reason for Disapproval': Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. 1 APPLICATION FOR SANITARY PERMIT ST C- 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/contract,Q]C,("spec house"), then a second form should be retained and completed when the property is sold and qubmitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property 14 AGcl 3, Section, T 'Z N - R W Township Mailing Address 0-3 , 9&Qx Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE'FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In additign, 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 the Certified Survey Map shall also be required. PROPERTy OWNER CERTIFICATION I (We) ceAtijy that aU atatement6 on this 6o4m ate t.ue to the but o6 my (auA) k.now.eedge; .that I (we) am (ane:). the owneA16 ) of the pnopenty deacA bed in -tW injanmaz%an Janm, by vvc:tue oj a wa4vcanty deed n cad in the 0jjice of the County Regi6 tee. o j Deed6 a5 Document No. 33 3 ; and that I (we) p to entty opm the pno poz ed A to bon the sewage dizpkat s ys tem (on I (we) have obtained an easement, to /tun with the above duc4ibed pnopenty, bon the con6t xuc ion a6 6aid 6y.6tem, and the same h" been duty hecon.ded in the 06jice o6 -,ateA o Deed6, as Document No. thReg Z) . SIGNATtr OF E SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED ,p sa„7~ >a ' T$r ~ x yt x •'1 ~ y , ~P~Y~ ~ AMY: ~t e t a T ~ f rl~ i' K< 4 Y _ si t. ' • x 1* Y 61TT , ?UAL -s ,,19 v y~i tt `--'S ax r Y { h # r Tice ayMt one Y - ~.r S. 4 a Mo a rt~tl ~ ~ ~ tY H G ' H 9 ST C- 105 H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County c7 9 H OWNER/BUYER - u < fe'V_;6_ ROUTE/BOX NUMBER Fire Number CITY/ STATE L( alt-e. • Z IP sw a 5w 1 t , PROPERTY LOCATION: Section T N , R W, Town of~ St. Croix County, Subdivision Lot number Improper use dnd 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 put into. the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-cite 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 z I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- 'v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Of ce within 3 days of the three year expiration date. ; SIGNED DATE St. Croix County Zoning Office P.O. Box 98, Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY Y, ~ DIVISION LABOR AND PERCOLATION TESTS (115) MADISON W 7969 HUMAN REL!.ATIONS (H63.090) & Chapter 145.045) LOCATION: 1v - SECTION: JTOWNSHIP LOT NO.: BLK. NO.: SUBDIVISION Sw NAME: 1/ ;1 /T s.9 N/R / E (o /yvo so~ COU TY: OWNER'S NAME: MAILING ADDRESS: 5*1 D So.J co i •~o/ .v~'" 0~•//ice 6-- 1,~I?7- 3 ~o x 395 J~' USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES R TION ATION TESTS: KResidence ❑New Replace If-2, RATING: S= Site suitable for system U= Site unsuitable for system 13 (J/C h" ev C Y 5,'~ '~S CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: rYSTEIVI-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) Zel o $ ❑u S ❑u $ ❑U ❑ $ Qu ❑ $ ©u awv6o% /.~ev z 'x 3 If Percolation Tests are NOT required DESIG RATE: T I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: eDAAll f ~ Floodplain, indicate Floodplain elevation: is i~LO %N L-C iMA[- Fr. PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN: CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST.IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- I 9•.l I .0 S- , /.'f'i! 0.4 M .O S' f3N • IoA"+ Sol J 1> G 8a 33r Q'v. IOdH 7.~0~~•r.9u ~Uaj a A" i B-2 ~V,/•~/ L B-3 B- B- B- iN PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER _ AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- 310' ' 4.)A 7,6 A Die,4iu_4- P- 41^ T 9,;7-46'- P- 2, cZ P P- G 2-- 4 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. /30'/ -T O-M /d ?i~• 73- f7 /3~ pojoCk PWA& SYSTEM ELEVATION / T _ i t?F A7s W r ilk f Pr. P Y( Si 5 L , 13 JL ~ 01 : Pee- t E N ~gv 77 176 OV e test 3 ;cdn I - - 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): HOMESITE TESTING C-0. ) TESTS WERE COMPLETED ON: "ATE APPROVED SITE EVALUATIONS (PERC TESTS / f-- ADDRESS: MINNESOTA LICENSE NO. 00663 CERT ICATION NUMBER: PHONE NUMBER (optional): WISCONSIN LICENSE 140.55-02482 55--o L VLf ; 11 W1 5016 ~ CST SIGNATURE ISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. ILHR-SBD-6395 (R. 02/82) -OVER - INSTRUCTIONS FOR COMPLETING; FORM 115 - SBD - 6395 , To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL. CONDITIONS; 5. PLEASE r' s the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE _IBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sl.:y be used if desired; S. Makes, _ e enchmark and vertical elevation reference point are clearly shown, and are permanent; 0. Complet.~ ~ropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, i' e; 10, If (~rch as flood p elevation) does not apply, place N.A. in the appropriate box; 11. S`_- 1 lilt ce your cur ,,,]dress and your certification number; 12. Make I, lies and distri`ut:- as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Se! and Textures Other Symbols st - e ne (over 10") Bid - Bedrock cols Cobble (3 - 10") SS - Sandstone gr - avel (under 3") LS - Limestoi >s HC''' - High C cs - Sand P, Percy coed s 1 'i 1 Sand Well f, r,:nd B! B-" Is , ny Sand > Grea Than sI dy Loam < Less Than 'I - Lc.,m Bn Brown s i I Silt Loam BI Black si Silt. Gy Gray cl - C' Loam Y Yellow y Clay Loam R - Red C:ay Loarn not Mottles - dy Clay v,/ - will) sic - y Clay f1f few, nt Pt onm NP m c crt - C('*-, lr~rn - Mt:k d disti =a -prom. • • _ - High Six gc- >tures for liqu ;,oral W - Beni- VRP - Vert R, TO THE OWNER: a: is the first step in sec ,4 sanitary permit. The county 5" i nc nt may re,lur st i ~ini7 of )il test in the fii - r~.r,,.,mrt i_s,' uance. is for th- }t -nit applicat -I t 10 0 or ~r ~a p errnit musrr t,., pt) ted I:i ;t, - /or • ~5!(~DD51' IA PLE3 0 UST' • ~-a--- ~ 5 ( RAF PT r 5' I G wEll . o titi ~ fu~uQE ~ r P~p~'(• t W P/ - i5Half G r Li r Q o 1*111'•U 6- Flo /y w /y S i y, T zyN, ,Pi y ~c1 HOME SITE SEPTIC PLUMBING CO. A/FD RT. 3 OWEIL RD., NU_DSOri. WI 51016 till t RT Iii CHT, WIS. MASTER PLUMUR LiC. NO. 3307 M.P.R.S. L jC,A0C- MINN. INSTALLER & DESIGNER UC. N0.00663 Fresh Air Inlets And Observation Pipe SOIL TESTI►ag By MOMESITE TESi.'NG CO. Approved Vent Cap RT-3, t:,uii . HUDSON, WIS. x;4016 Minimum 12" Above Final Grade r-7- MA$jMVJLA fl _ 4 Cast Iron "Y Z Above Pipe k bt~ -~ES~ i o Final Grade Vent Pipe E P~ s Marsh Hay Or Synthetic Covering ~d Min. 2" Aggregate Over Pipe Distribution Tee pipe 0 0 0 0 0 7 Fr " Aggregate v Perforated Pipe Below 2 • ~ Beneoth Pipe 0 Coupling Terminating At Bottom Of System Parcel 020-1081-90-000 05/13/2005 04:34 PM PAGE 1 OF 1 Alt. Parcel 29.29.19.3311 020 - TOWN OF HUDSON Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): = Current Owner " FAITH COMMUNITY CHURCH, OF HUDSON INC OF HUDSON INC FAITH COMMUNITY CHURCH 777 CARMICHAEL RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description " 777 CARMICHAEL RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 5.100 Plat: N/A-NOT AVAILABLE SEC 29 T29N R19W NW NW COM 926.8'S OF Block/Condo Bldg: NW COR SEC 29;TH S 926.8'POB;TH S 89 DEG E 417.4';TH N 88 DEG E 160';TH S 0 DEG W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 387.4;TH S 89 DEG W 577';TH N 394.4' 29-29N-19W POB VOLLEYBALL AREA, PROPERTY Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 877/287 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/24/1995 Description Class Acres Land Improve Total State Reason OTHER X4 5.100 0 0 0 NO Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 00 Woodland 0.000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 020-1081-60-000 05/17/2005 08:44 AM PAGE 1 OF 1 Alt. Parcel M 29.29.19.331 F 020 - TOWN OF HUDSON Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * FAITH COMMUNITY CHURCH, OF HUDSON INC OF HUDSON INC FAITH COMMUNITY CHURCH 777 CARMICHAEL RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.270 Plat: N/A-NOT AVAILABLE SEC 29 T29N R19W NW NW S 133 FT OF N Block/Condo Bldg: 718.1 FT OF W 417.4 FT CHURCH BUILDING/PARKING LOT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 29-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 876/562 07/23/1997 869/159 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/24/1995 Description Class Acres Land Improve Total State Reason OTHER X4 1.270 0 0 0 NO Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 00 Woodland 0.000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 020-1082-40-000 02r02/2005 08:42 AM PAGE 1 OF 1 Alt. Parcel 29.29.19.3328 020 - TOWN OF HUDSON ST. CROIX COUNTY, WISCONSIN Current ' X' Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * FAITH COMMUNITY CHURCH, OF HUDSON INC OF HUDSON INC FAITH COMMUNITY CHURCH 777 CARMICHAEL RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 771 CARMICHAEL RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 4.080 Plat: N/A-NOT AVAILABLE SEC 29 T29N R19W SW NW COM NW COR SEC 29 Block/Condo Bldg: TH S 1320 FT TO POB TH E 755'S 250'W 755' TO CEN LN TN RD TH N 250' TO POB & Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) EXC P332J 29-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 10/03/2000 631020 1547/567 WD 07/23/1997 1012/506 WD 07/23/1997 731/56 07/23/1997 718/553 more 2004 SUMMARY Bill Fair Market Value: Assessed with: 48288 256,600 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.080 52,500 146,000 198,500 NO Totals for 2004: General Property 4.080 52,500 146,000 198,500 Woodland 0.000 0 0 Totals for 2003: General Property 4.080 52,500 146,000 198,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch 145 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00