HomeMy WebLinkAbout020-1084-50-000
/ rsi ~ ertrtreffttlt'rR~st~y9.29.19.3 ~IVATF ~ ~}S~~y LOT 3 County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
180305
Permit Holder's Name: ❑ City ❑ Village EkTown of: State Plan
ID No.:
CST BM E e Insp. BM Elev.: BM Description: Parcel Tax No.:
a
020-1084-50-000
TANK INFORMATION ELEVATION DATA A9200386
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic rC zSjJ . Benchmark
Aeration Bldg. Sewer /Z
Holding St/ t Inlet
TANK SETBACK INFORMATION St Outlet 5 '~'~L I
Verit
TANK TO P/ L WELL BLDG. Aiinta to ke ROAD Dt Inlet
rl
Septic ) 2!%. Ce NA Dt Bottom
Dosi raw NA / s 5 r
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade nit)
Manufacturer Demand q 213
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width / Length r o. Of Trenches PIT Of Pits Inside Dia. Liquid Depth
DIMENSIONS S DI N 1 N
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Man-o€aQrre`
INFORMATION Type O 7f
`i , CHAMBER Model Number:
System: iec ~D ' 52 OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes E] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 29.29.19.337D,SE,SW,GLENNA DR. LOT 3
64 ' Y[ a 7~i~CJ00 ~{j Gig liy i2G~ 6 c . Cl~ ~Y1 - Y7 ~ .
C/ ~~c.r y S C' ert.. t 1,
x~~~--~~ -
Plan revision required? ❑ Yes No
Use other side for additional information. 69
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
r
ADDITIONAL COMMENTS AND SKETCH '
or, SANITARY PERMIT NUMBER: ,
r /6 ,
elf~w =/ZS Z`~=
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170,1 SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code Co
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 2~~
8% x 11 inches in size. ❑ c revs ion to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER / PROPERTY LOCATION
wta 5,!~ S,,/S L T Z 4', N, R ! 4' (or)
PROPE OWNER'S MAILING ADDRESS LOT # t6iL6&#
'711 61 clki n a r
CITY, STATE IP CODE PHONE NUMBER SUBDIVISION NAME ORS M NUMBER
Gr~1 6,es, a4 a /leee5
IL TYPE OF BUILDING: (Check one) State Owned ❑ VITM NEAREST ROAD
VILLAGE ~
❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER() Ca
III. BUILDING USE: (If building type is public, check all that apply) QoZO ~G~_
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 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 M 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) T / yd/, 75/ LEV TION
T2
5p O 75 3 5rz. ~c Feet 7 Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New )Existing Gallons Tanks Manufacturer's Name ncret Con- Steel glass Plastic A
strutted pp•
Septic Tank or Holdin Tank Tanks Tanks 2G0 / ~g p,~ EN I n- F] -7 1 F1
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No mpg) MP/MPRSW No.: Business Phone Number:
6 to r 3 Z 77 Z 3z1Plumber' Address (Street, City, State, Zip Code):
/ SY 76 /k ae Gc1 t W CcJls Q -7-7
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater e u Issuing Agent Signature (No Stamps)
%Approved ❑ Owner Given initial / 7 Su rcharge Fes)
Adverse Determination 0 U
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,sanitacy 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. `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 inst$(led_ - r
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.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the, county, E) soil test data on a 115 form; and F) all sizing information. _
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
APPLICATION FOR SANITARY PERMIT
BTC-100
7hls application form is to be completed In full and signed by the ovnst(s) of
the property being developed. Any Inadequacies will only tesult In delayS of
the permit Issuance. -Should this development be intended tot tesala by
owner/conttactoco(spec house)# then a second form should be retained and
completed when the property is sold and submitted to this office vlth the
approptlate deed recording.
Owner of property
Location of property x_114 5,+i/it Bectlon a ~ T •R~V
Township Melling address /'Pnn~ 17,E
Address of alto
lubdlvlslon na"_ r/eS1c19,4L1A-e ele-i •
Lot number 3
Previous owner of pcopetty S•-Cae
Total size of parcel
Date parcel vas created
Are ail cornets and lot lines Identifiable? Y_Yes _ No
Is this property being developed for resale Caper house)? as x 0
volume and Page Number r L` as recorded with the Register of Deeds.
- - r - - - - - r r - - - - - - - r - - - - - - - - - - - - r r r r - • r-r r - - - - - - r - -
INCLUDE WITH TH18 APPLICATION THS FOLLOWINCt
A WARRANTY DRID which Includes a DOCUNKHT NUMBIR, VOLUM2 AND PAot NUMfaR, and
the BRAL Or THR R90I8TRR OF DERDR, In addition, a certified survey, if
avaliable, would be helpful so as to avoid delays of the reviewing process. It
the deed description references to a Ceitlfled Survey Nap, the Cettllled Survey 11
Nap shall also be required.
PROPERTY OWNER CERTIFICATION
t(Ve) c.ttify that all statements on this form are true to the best of my (our)
knovledgel that I (we) am (ate) the owner(s) of the property described In
this Intotmatlon form, by virtue of a warranty deed recorded In the office e1
the county Register of Deeds as Document No. '/&7 Z r'p j and that 1 (vat
presently own the proposed site for the savage disposal system (at 1 (Val have
obtained an easement, to run with the above described property, lot the
construction of sold system, and the same has been duly recorded In the Ollie,
of the county Regls r of Deeds, as Document No. 1
.
I
jo_~, e-oe~
f ature of owner 1 nature I Co-Owner (If Applicable
Oats of Signature Date of Signature
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SEPTIC TANK MAINTENANCE AGREEMENT Ct
~St. Croix County
OWNER/ BUYER W
0
ROUTE/BOX NUMBER ' '7/1 '61elAk. A/ Fire Number
C
CITY/STATE ZIP
`Y
PROPERTY LOCATION:_ PSA, Section -~qFT ZS N, R_W,
Town of St. Croix County,
Cr
Subdivision 0041es~ a/ pl Lot number 7
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Prover maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed's'e t'ic tank pumper. What you put into
the system can affect t e .unction o, the-septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents may be eligible to recieve 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 .sys't'ems agree to keep their system properly
maintained.
The property owner agrees to-submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater 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
three year expiration.
H
I/WE, the undersigned have read the above requirements and agree o
to maintain the private sewage disposal system in accordance with 9
the standards set forth, herein, as set by the Wisconsin Depart- a•
ment of Natural Resources. Certification form must be completed d
and returned to the St. Croix County Zoning Office ithin 30 days
of the three year expiration date. ~
SIGNED /
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDI
INDUSTRY, , DIVISI
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7!
HUMAN RELATIONS
N W153.
(ILHR 83.0911) A Chapter 145)
LOCATION: SECTION:-- /MUN OT NO.: BLK. NO.: SUBD NA :
.SE sw y l 9 /Tn N/R/7 E (o MW ff U 0so Aj 3 4a-e s
COUNTY: F MAILIN ADDRESS: *5 j3 ST e,49 /1( To~+~ KATHY E pA1ZD 277&2_ - 7,~ . S /Z.
USE wt' - d d y6 : 4-/2- - 7'27 , ~ZZ3 DATES OBSERVATIONS MADE
NO. BEDR 0 R A RI TION:
Residence 3 of IV New ❑Replace Mj}~ 3 ie,~
~ 3 •r'y,Pr~ 13, /gyp
RATING: S- Site suitable for system U- Site unsuitable for system
ONVEN I1 NAL: MOUND IN-GROUND-PRESSURE: S STEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
~s []U ® S ❑U 0 S au ❑ S Qu ❑ S Ku Co,vv£,uTio.~.► e- 7-,ee-,v eXes
w o
If Percolation Tests are NOT required DESIGN RATE: If an
C/~s s any portion of the tested area is in the
I_ I under s. ILHR 83.09(5)Ib►, indicate: Floodplain, indicate Floodplain elevation: 1'w`G-
wi~_Irkx EST Sv'A'j 3& F~ q"fAoS!- PROFILE DESCRIPTIONS S-C$' 6
c o~o,r oNs = /3 0911A
4007-
BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COL , TEXTURE, AND DEPT
NUMBER DEPTH IN. ELEVATION UBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 9C1~ 97 yy' ?-to > ! V Zy„_ y~ 7
B- Z /ZO ~1.~. y0 I ~ /1.0 s. ; s: , /2 -t V 0,40
"
o~.
B_ 3 /~0 ?moo > /z o ° ~''$~k S , . z f/
S4 6_4 i 3 G " oe C5 > dR 36'/20
B_ I C S 6 - 115 B- / O l~70~ Ito > /00 O.._~" /3/ . s,/ ~o"D,--ZA 20"
,
7y Ito
0'_& - IYIA- - Si' 6 Dr-&J . Sr'/ 04 Sli 2 y
PERCOLATION TESTS OP• !S 4 //O'•T~,~ UC-S
TEST DEPTH , WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RA MIND S
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. p I D I PERIOD PER INCH
P-
P- 2- T; Z YJ
PP.- 3 !L0
P_
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distano$. Describe what are the It,
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 pore
of land slope.
SYSTEM ELEVATION. 92 y
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piste '
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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 Wisconsi
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 : - HOPdESI. TESTS WERE COMPLETED ON:
TE SEPTIC PLUMBING CO.
655 O'NEIL RD.. HUDSON, WIS. 54019 lkf"eec 13 / /
ADDFIESS: ROBERT ULBRIGHT CERTIFICATION NUMBER: P N NUMB Rlo tional)
WM MAMR PLUMBER LIC. NO. 3307 VA.& 1 Y'P2 ,Q ~p S
:a CST SICij~AT RLf~ 2
DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester.
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TIMM EXCAVATING SHEET NO. ` OF Z-
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY leo-`e'v ✓ ' H` -"'DATE -'Zo - ~Z
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE I-800-225.8380
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TIMM EXCAVATING JoB 'Zl
- Route 1 Box 192 SHEET NO. OF
WILSON, WISCONSIN 54027 CALCULATED BY L v ~i r+ DATE 1 ° ~S2
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED SY DATE
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-8DD-2256380
REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1
63/01/93 09:14 REQUESTS FOR INSPECTION WORK SHEETS FOR: 3/ 1/93 AREA: JT
Activity: A9200386 3/ 1/93 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 29.29.19.337D,SE,SW,GLENNA DR. LOT 3
Parcel: 020-1084-50-000 Occ: Use:
Description: 180305
Applicant: BERARD, JON W & KATHLEEN T Phone:
Owner: BERARD, JON W & KATHLEEN T Phone:
Contractor: TIMM, ROGER Phone: 772-3214
Inspection Request Information.....
Requestor: TIMM, ROGER Phone:
Req Time: (}9 :93 Comments : ?tffj
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
PPrcel 020-1084-50-000 02102/2005 09:15 AM
PAGE 1OF1
Alt. Parcel 29.29.19.337D 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
*
JON W & KATHLEEN T BERARD BERARD, JON W & KATHLEEN T
711 GLENNA DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 711 GLENNA DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.163 Plat: N/A-NOT AVAILABLE
SEC 29 T29N R19W PT SE SW LOT 3 CSM Block/Condo Bldg:
4/903
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-29N-19W SE SW
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 886/189
2004 SUMMARY Bill Fair Market Value: Assessed with:
48304 335,600
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.163 21,600 238,000 259,600 NO
Totals for 2004:
General Property 1.163 21,600 238,000 259,600
Woodland 0.000 0 0
Totals for 2003:
General Property 1.163 21,600 238,000 259,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 216
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
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & B
INDUSTRY, LABOKANDPERCOLATION TESTS (115) MADISON,
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
[L05_'CATION: SECTION: TOWNSHIP/ OT NO. BLK. NO.: SUBDIVISION NAME:
V4.54) Y4 y /T n N/RI E (o ► W f U 1a10
COUNTY: MAILING ADDRESS:
L 7' C,P 4 /k/ J'0#0 6 'hT N Y '5E I? ~7! 2- 7(D 2
USE wr - - 17 OA* d O,~E l0/2 - "27-,F-2-2-3 DATES OBSERVATIONS MADE
NO. BEDRMS.: (;OMMER IAL DESCRIPTION: DESCRIPTIONS- 1PERCOLATI
Residence INew ❑Replace 741111- 9 3 13 AtpGl,, 13, RATING: S= Site suitable for system U- Site unsuitable for system
ONVENTIONAL: MOUND: ,t IN-GROUNaPRESSURE: SYSTEM-I(N~-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional)
Ms ❑u ~S ❑U QS ❑U ❑S ❑S ~U cOtiv~,rJjio.•r L - TiP~v
/.v •~o X A. ~ S T/t~' ~r
lation Test
s are NOT required DESIGN RATE: If an
s, y portion of the tested area is in the
s. ILHR 8
Fu"=_r_c0_
3.0915)Ib), indicate: Floodplain, indicate Floodplain elevation:
0A1'
0 TEST
C Svv~y~ 3~ e F) g"if'oSr' PROFILE DESCRIPTIONS SCS Co /3 ()X 'AAR01-
v,vpiTiO,uS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED E HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 17 y'f' 2v > lCO -7 -may s~ 2y„_ 7 5
B- Z 1-0 ;-10 5
Ae- d- /fF .2 40'_ 0A
20
B_ C S j 6-A
IA4- A0
D6 •',f -~y Si/ i3 g- OR ~,1f ~ '-/Q /C
B- Q /40.70, to > ~00
1-0 cS j R ''-/oo
B- ro 9 7y' TAN
~So //tl _ O'' iY10- S./ 6 " /O" Dr.&J . S,J ~6, - Zy" o.P. S,Y
PERCOLATION TESTS eS j fR • i 3q> //O'" Teti UC;S
TEST DEPTH WATER IN HOLE 1"EST TIME DR I WATER LEVEL-INCHES RAT MINUTES
NUMBER INCHES' AFTERSWELLING INTERVAL-MIN. P I D 1 P I PER INCH
P_ / < 2 r IV,
P_L _:L _Z
P-
P_
P_
_P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION. G--k T ofE~ e,& e,/,
' 9 z - Yv '
~ t
1 4,
1 ~ 10-7 -
r
N
-
. ,.I t t
I, the undersign 'hirob "'ty h he soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, ata recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME lprint):- y TESTS WERE COMPLETED ON:
ADDRESS: - c6f C) F_= r'LQ4( Oti WIS_54016 A~~~ /3
R(),T ULBRIGHT CERTIFICATION NUMBER: 1PIN~$NUM78FI(o tional):
MAMR FL kl-BER LC. N0.3307 M.P.R.& 2 1/002- S
u D-00663- CST SIAT~ &26 CIA;~_
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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Form- S T C - 104
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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. 2 i T Z I~ N-RAW
ADDRESS 07~~ C /Pr1.~ ,lJr. ST. CROIX COUNTY, WISCONSIN
SUBDIVISION e°Sl`_ ~i ~5 LOT 3 LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
IV
BENCHMARK: Describe the vertical reference point used of c',. ,,f G zo/ -~2
Elevation of vertical reference point: /6b Proposed slope at site: 4E
SEPTIC TANK: Manufacturer: G~it° ✓ Liquid Capacity: 1,160
Number of rings used: b Tank manhole cover elevation:
Tank Inlet.Elevation: Tank Outlet Elevation:
I,I
Number of feet from nearest- Road.: Front,O Si.de,O Rear, O feet
- From `nearest- property line c Front 10Side ,ORear, O lez~ feet
Number of feet from: well , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
E
PUMP CHAMBER
Manufacturer: /V 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:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench-
Width: Length: Number of Lines: 3 Area Built: EG:
Fill depth to top of pipe: z-'~' :l'-/
F_
Number of feet from nearest property line: Front, Side, Q Rear,0 Ft. /
'
Number of feet from well: '5'2-
I
Number of feet from building: 2
(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 or distribution box been used on any of the above soil
O
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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: 7
License Number: 3 L 2z
3/84:mj
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ST. CROIX COUNTY
WISCONSIN
`L ZONING OFFICE
r r r N • _ Nails ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Please specify desired test(s) & remit appropriate fee with
application. Outside water lines are often turned off during
winter months, making access to the home necessary. Please make
arrangements with this office to insure that entry can be gained.
❑ Water (VOC's) $185.00 ❑ Septic $50.00
Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria
retest $15.00
Owner: Requested by: 11~ ya z
Address: 1 D r - _ Address: S a~ ,~4
kJ w z ZIP t71 ZIP
Telephone N°: (-)IS) Telephone N4: ( )
C~ 4 r • Sw.
Property address (Fire N° & Street) : -711
Location: Sec. S , T-j--el R~ W, Town of 4,,JSo„.
Realty firm: Lock Box Combo: Closing Date:
TO BE COMPLETED BY PROPERTY OWNER
PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Water sample tap location:
Is the dwelling currently occupied? Yes ❑ No
If vacant, date last occupied: -
Age of septic system: _t1_4,(_.
Septic tank last pumped by: Date:
Previous Owner's Name(s): -
Have any of the following been observed?
❑Y RN Slow drainage from house.
❑Y lei Sewage Back-up into dwelling. ra rf~♦
❑Y PN Sewage discharge to ground surface o Toad P40
rz:~
❑Y KN Foul odors. hAR 3
t 1 1994
Other comments relative to system operation:.,.'. sT~
I certify that the above information is complete a q
best of my knowledge.
OWNERS SIGNATURE DATE : 3 ,oellly `C
1/94
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
IN
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? OYes ONo
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: OBelow grd ❑At-Grd ❑Mound
Approx. size 'X OGravity ❑Dose OPressurized
Ft.2 OBed OTrench ❑Dry Well
❑Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other OUnknown
Septic tank
Setbacks: OHouse ❑We11 ❑Prop. line OOther
Dose tank
Setbacks: OHouse OWell ❑Prop. line ❑Other
❑Locking cover OWarning label ❑Pump/Floats
OAlarm ❑Elec. wiring
Soil Absorption System
Setbacks: ❑House []We 11 ❑Prop. line ❑Other
OPonding: ❑Discharge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
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Inspector
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Voucher #
COUNTY OF ST. CROIX
State of Wisconsin
Check N
TO: Jon Berard
Vendor #
Address 711 Glenna Drive
Hudson, WI 54016
(Complete for vendors without numbers)
Account Name Zoning Fees
Description R6:fund for Water Test
Invoice H
Fund Dept Acct Obi Amt
100 00 45190 000 •45,00
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TOTAL x 4 5, 0 0
Filed -19-
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
r r r VON ONE ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
June 3, 1994
Mr. Jon Berard
117 Glenna Drive
Hudson, WI 54016
Dear Mr. Berard:
We are refunding your monies of $45.00 for a water test that you
canceled. Enclosed is the check.
If you have any questions please feel free to contact our office.
Sincerely,
2ackie Stohlberg
Secretary
Enclosure
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