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Home My WebLink About020-1270-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 561018 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Andrews, Charles & Deborah Hudson, Town of 020-1270-40-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: /A I Gbrt' 21.29.19.1336 TANK INFORMATION ELEVATION DATA /d3 j l' yo TYPE MANUFACTURER 5 CAPACITY STATION B 1 1, ' FS / ELEV. r Septic W k-44--, Benchmark 6,66 1A D T N64v ► e-5.~, Z.5 Alt. BB~f Q .Ae Bldg. Sewer LA. ~n .5 r 1:5~j i 1 Holding St/Ht Inlet 1 TANK SETBACK INFORMATION St/Ht Outlet ~•a ~S TANK TO P/L WELL ~LD Vent to r Intake ROAD Dt,,r . 7n l~/~ Septic 1664& ~17 56 -74, 7. q-1 16 Desift Header/Man. 3Za 5 Sd 3 7 Sa Aeration Dist. Pipe . -6 9 9. 3 6.6 2.3 Holding Bot. System S. p 7'$ • cv. b 10/7.71 PUMP/SIPHON INFORMATION Final Grade 3 s- cl 8 Manufacturer Demand St Co r PM ~ Jr.`9 d Model Number Jac. Y. 7.9 TDH Lift Friction Loss System Head TDH Ft ,r t p V ~1 3.64 q9, Forcemain T_Zngth Di Dist. to Well lyf,~17_23 SOIL ABSORPTION SYSTEM 1*1::r-z1z-*Ae locaw BEDITRENCH Width Length No. Of Trenches PIT DIM SONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 V10 L ► l Ev~.Cj 4 \ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer P-,- INFORMATION CHAMBER OR ^ P-j / Type Of System: I Z' 1 W6 T Model NCu~m'ber: ~ Co,t,d~~rO l.. c~1~ DISTRIBUTION SYSTEM L = j4L Header/Manifold Distribution ix Hole Size x Hole Spacing Vent to Air Intake y / Pipe(s) S J Length / Dia Length Di._ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/ ded xx Mu ed Bed/Trench Center 5 Bed/Trench Edges Topsoil _ N No - Yes o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 838 Harbor View Road Hudson, WI 54016 (NW 1/4 NE 1/4 21 T29N R1 9W) Jacob's Landing 3rd Addition Lot Parcel No: 21.29.19.1336 1.) Alt BM Description 2.) Bldg sewer length - -amount of cover = 1 _ Plan revision Required? 0 Yes No Use other side for additional informain -7 'rn S BD-6710 (R.3/97) Date sep is Signat Cert. No. County I Safety and Buildings Division St. Croix ' 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) $p Madison, WI 53707-7162 ;P fate Transaction Number ~:~`rriit Application In accordance with SPS 3 (2), Wis - 49e, submission of this form to the appropriate governmental unit' a is required prior to obtair sari it. Note: Application forms for state-owned POWTS are submitted to P%ject Address (if different than mailing address) the Department of Safetsionat Personal information you provide may be used for secondary purpos in accordance e Privac Law, s. 15,04(1 m , Stats. Same L A tication Information - Please Print All Information Property Owner's Name Parcel # Chuck & Deborah Andrews 020-1270-40-000 Property Owner's Mailing Address Property Location (.1336) 838 Harbor View Road Govt. Lot City, State Zip Code Phone Number Sw Y<, NW Section 21 (circle one) Hudso WI 54016 (715 381-1283 T 29 N; R 19 E or W II. Y4e of Building (check all that apply) ~y Lot # 1 or 2 Family Dwelling -Number of Bedrooms r4/\(S~ 43 Subdivision Name Block # Jacob's Landing Yd addition El Public/Commercial -Describe Use Na ❑ City of El State Owned -Describe Use CSM Number ❑ Village of Na wr.wn of Hudson III. Type of Permit: (Check on x on line A. Complete line B if applicable) A. ❑ New System 0-1f.-placement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Num r and ate Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New 112151111 4 Before Expiration Owner IV. Type of POWTS System/Component/Device: (Check all that apply) Pon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) Q Pretreatment Device (explain)- /U Z "/0 V. Dispersal/Treatment Area Information: 42 Infiltrator "Q4 Plus" Standard chambers & 4 endca s Baer ML3-916 effluent filter Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf ) Dispersal Area Propose s C/ f y D 600 Gpd 0.70 Gpd/Sq. Ft. 857.15 sq. ft. 860.40 Sq. Ft. ~j D V, VI. Tank Info Capacity in Total __Tof Manufacturer Gallons Gallons Units New Tanks Existing Tanks U 35 X Septic or Holding Tank W320-MR 1,000 1,320 1 & 1 Wieser Conc/Wieser Conc. F Dosing Chamber VII. Responsibility Statement- I, the and igned, ass me responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Signature MP/MPRS Number Business Phone Number James K. Thompson 5-- - MPRS 30021 (715) 248-7767 Plumber's Address (Street, City, State, Zip Code 340 Paulson Lake Lane, Osceola, WI 54020 VI oun /De artment Use Only Permit Fee Date Issued Issuin A t S. attire r) ❑ Disapproved Qb I ❑ Owner Given Reason for Denial $ y / ' i 0 201 IX. C9 "g? 8 ovaUReasons for Disapproval 03 1. Septic tank, effluent filter and n p d U~~ dispersal cell must be serviced / maintained W" as per management plan provided by plumber. U4-,e ~ 2. All setback requirements must be maintained _ ttac to comp ete plans for the system and sub it to the Co ty ouly en p> C to less than 8 V2 x 11 I Ashes/inn sues ~ Glc~c G (Xp <(j//I ,G"o Q1fC~- ~ ~ ~I~p~'~ ~ / l y ~ • SBU4M (Rh 1/11) tv, e%i Proposed 01,3/e./s--/a//.7wo~i6-146Ae.5a4 5ca/e:/=~flp• 3'x f6 "Y 1/ 4v's 5&i7 eva/cca bra &Y T~n EX%s~g 9~adc ~Ie►` 960 96.70 , 63 A l/ TSTO SId1°¢~'~"~6`a` 838,s~~6►~rd,'~~o! `'mow" P~~' ~ _ Lod s~3, s cobs 7:~Y4'7'R 9974 ♦ - - ;nG c~ SrJY{nW~'l Sep .2/1 .94 - i -/J - - T .o ff f~ cr,, S te- Crt;x (IDA 1 ~10 ! ~c(#os0 -/z70 -VO Pg. ~Pfc 1_'1 30- - ~ ~ ! - ~o f o: A,op~v,Y, /oCaE;v>7 0{ ~isfi ~ ~ ~ 1- vn,lut ~!B X 36'al!'s~.~CL//. /`~aLade - - :5 ce ele~l =977.3 ~ 1 3 d 3 e{{~/CcRn b /i nl Peop0statJ;e &e-er"C.. os_o~ i /u~Sao-wtR scP6'cX /Lel&-K C-/id 4.6-60,OOf`rl,_nAd/e CoJe-/'=/I339.4,~- /naF 0 4,6 ';®G = log. -<40 ,,~j.Di ! ~ x1 1 i i - diousC. Ede%-// X18• U ! a'`•V I- ~CJ.%v~Cr1Ge ~ C,plFG!'G~L G.~fo? Clspka.L~ ~X;s~i~ Wcl/ J NI Ve war PY X38 bvr- (~iF~J ,Qd. ~G. 2 a{' ll Conventional POWTS Index & Tilte Sheet Project Name: Andrews 4 bedroom Replacement Conventional POWTS Owners Name: Chuck & Deborah Andrews Owner's adress: 838 Harbor View Road, Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 43, Plat of Jacobs Lance 3rd addition Legal Description: SWI/4 NWI/4, Sec. 21, T.29N., R. 19W., Tn. of Hudson, St. Croix Co., WI. Parcel ID 020-127040-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcuaitions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Septic/Filter Tank Cross Section Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of existing septic tank Page 11 Waranty Deed Attachments: Soil Evaluaiton Report Mater Plumbe estri ted Service: James K. Thompson, Dept. of Comm. Cre 1 #30021 Signature: ~r Date; ,2 C)~ Page 1 Of 11 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01/01) Tp of /o~6:6aecl.c%~ = 9-518. V proposed cl,~Pvsa./G./~ 7wo (Z~ tic.+~l~ts ~ 5ca./~: ~ s~~ eha.,zdsi3,af'-fi~ic~.. ~-..r„~'-~<ro~6!'ur , ~ ~ • ~c~% eva./ccs~bn by 76~~.sa„ Su~Fi,ce t,/eo = 9B.o'e 99.0.' , / So:/e✓a/ua o»~O,'E5Y7 ®~,~,d~ 70 --63 6"C-4 ■ _ . qzo ` _ -5.6 at/ e 9B.o' - - _ - - C /es,P~ E~e6orr L,,¢~ weeuzs Err✓,=/~~p ~'a!%ouj - - --srd,4e Ar o- 838f~~~rdc~~d. c ld 1 "I• ~fi - - SYo/6 9y7d'A ;nc ccs Skv)xj 5-Z 2/,2X'7R ~ ~v • / ~100.0r l u~sT~►t3 I J/V~IC,/."TA(C7;2 47-70-~O-MO ~ I /%a5 " 3o s 5! earn 6 /int i ~ ~ ~ P/o~ooscr.~cd:es~r '(m„c. EXis~i.~ ~ a.P cc~: es~ ~Gyo, ' ~/~~o-n~Q sc~o{,yF../~6~ ~-5tp~•'c.. ~c'. C/c~G.~-Eoao~`r~'1~.,,h.~/e 4a I 1. • ,41f_. 6 M. Tod of aE Su). CoYnei-4 j, c'r~-~s6• 1 F/e✓, ; Cortevc~[ caPfo.7 E,ri~zli.t cvcll--/ aspka.L~ B3B bar' l~iP.cJ P~. 2 o /i ANDREWS DISPERSAL CELL SIZING CALCULATIONS 1. (4 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 600.00 Gnd design flow 2. Infiltrative capacity of native soil = 0.7 g d~/sq. ft. 3. Absorption area required: 857.15 sq. ft. 4. Absorption area as proposed: 860.40 sq. ft. (42 chambers total) Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4 Plus" end cap = 5.10 sq.ft. EISA 857.15 sq. ft. - (4 endcaps)(5.10) = 836.75 sq. ft. 836.75 sq. ft./20.00 = 41.84 chambers required Number of trenches: 2 (a, 21 chambers per trench Trench width: 2.83' Trench length: 86.00' Trench spacing: 9.00' on center Total system area w/ 9' center spacing: 12.00'x 86.00' Pg. 3 of 11 Soil Absorption System Cross Section /03.5r ' ft k4" 40 Final Grade pe 99 n p Leaching J B.D' Chamber 990' ft System Elevation 1.63 ft 6.W ft Soil Absorption System Plan View 8G. c0 ft .Z.93 'ft { (".60, ft Vent Or Observation Pipe Leaching Trench 1 Chambers 4" Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model--,-,v~~'/`~/a ~014<S EISA Rating .Q s q per chamber Soil Application Rate 0•70 gpd/sq ft (u! 6Vgpd Design Flow = 0.70 Soil Application Rate + -~z6•O EISA = S/~ Chambers 2 rows of chambers each. Page of DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, . DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969 HUMAN RELATIONS s abet' (ILHR 83.09(1) & Chapter 145) OWN HIP/1411JANC{AAI !;F* A OT NO. LK NO.. SU DIVIS ON NM SW~/NtN ~4 z- %Tz9N/R/QE(o W /4ubsaN W1 IL43 I -iAco$SLM9rNG ILI NU ADOM LS COUNTY: WN , Srcpb)x 'S-4m MI'Lk a' ('T &zCW' &A6 N)L)w6v USE DATES OBSERVATIONS MADE NO. DESCRIPTION: _ TESTS] OLATION Residence D(New ❑Replace MA~~ 1 I ~QI u za K 58 r<~ - k.N_~tt~AT mss.. RATING: Sa Site suitable for system U- Site unsuitable for system Salts Sib- Swrr*r NVENTION O IMi9 E'r I o s UuL ❑ SGL~]J~ TANK:1RECOMMENDED YSTEM Ri J ElV : J au IN 93S ❑U AJ O)JA •(opt~i) OUND: If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the r under s, ILHR 83.0915)(b), indicate: C4A 5S ' Floodplain, indicate Ffoodplain elevation: ^ ` Y A PROFILE DESCRIPTIONS BORING TOTAL ELEVATION T R UNDWA ER-IN HE CHARACTER SOil- WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH OBS RV T. HIGUgST___ TO BEDROCK IF OBSERVED SEE AB~RV. ON BACK.) 7'& 'S 04 M S1 B- Z ,p /o3.z,~ n/oN~E ? ~-68 14" t. ' Q M516"Um, s 40 N,MS >9.05 " tc l7`+~0 161 ANcs,f6; 67"8 ~Si NOW B- ~v.0o It>l. ~9 Iff >/l3.66 6"141.-m x-7790., t 7 ` 8eNCS'~K 41,M B`5 ias•14 > 9.00 ~z"Bt~TS "g sc. B3'$eH pis B- bcf- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER V -I HE RATE MINUTES NUMBER RI1CM46 AFTERS WELLING INTERVAL-MIN. PER INCH P_ , ►0 Nawr 16S. > > Z > 43 P- .10 1 zo > Z > > < P- O fir > > 410- > 2 < Id ap P- P- EWAA Io AT P- Q, PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Ind)cevLscaror distances. Describe what are the hod zontal and vertical elevation reference points and show their location on the plot plan. Show the surfacq)!tevatio gall borings and the direction end percen- of land slope. i ' SYSTEM ELEVATION IOQ• 0 g r 11 f 1 , I I l 1 I ! ! 4- 1 LL- t -4- tN f flpz- i 1 ; ~ f l r -I i i 1 ~ 4 I ' ! ! f ! 4 J9 - - r 4 - ' ,I - ! ! Lot I, the undersigned, hereby certify that the soil tests reported on this form Vrere made by me in accord with the procedures and m s.~cffied in the Wisconsin 7 Administrative Code, and that the data recorded and the location of the testa are correct to the best of m( knowledge and ~-P Z~ AM rint : T S7 WERE COMPLETED ON: dQ Ey J4NasaN JaNNSWV ' (.AVCMA M Xtr- J 20 1991 AOD S: CERTIFICA 1 NUMBER: P S9- NUMBER(optional): 0• f ax 1 u& soN 1 S4ol b 34r6N 4oao ' ATURE: 00 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHRSBD-6395 (R. 10/83) - OVER - ` Conventional Septic System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with SPS 383.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two-year schedule by use of diversion valve. Effluent to be diverted from new cell to old Drainfield at 4 year anniversary of new system installation. Old drainfield to be utilized for a 1 year period. Effluent dispersal to be alternated between systems on a two year rotating basis thereafter. Contin encyPlan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the Polk County Zoning Department at (715) 485-9279. Pg. 5 of 11 .PR ~sfj~, GRAVITY ~a FILTRATION 1 ~ 1 A4. ~''..BgT. 200$ ~ ~H Low Pressure/Gravity Filtration Order # Model # Description List Price EFB-ML3-916 ML3-916 Residential Effluent Filter 170.8 See Catalog Section (4) for Effluent Filter Alarm Switch! LOW PRESSURE/GRAVITY FILTRATION MODEL: ML3-916 & ML3-932 DESCRIPTION: The ML3-916 and ML3-932 are gravity fed, natural flow filters designed to be placed in line with standard single home residential and commercial application septic treatment systems. Both filter models aid in the operation and longevity of Advanced Treatment Units, pump tanks, and drain fields alike by removing solids and semisolids from the progressive waste stream in order to reduce particulate and organic overloading of the downstream treatment components. It's unique use of a large "Quiet Zone" to reduce flow velocity and high filtration inlet flow area help to reduce the opportunity for many solids to be forced through the filtration steps and beyond. 1 i # FEATURES AND APPLICATIONS ■ Gas and high velocity vertical flow diverter plates. - Two velocity reducing "Quiet Zones". - Three distinct levels of sequential filtration. ■ High Level/maintenance alarm receptacles. ■ Cartridge easy maintenance access and alignment handle. ■ One optional 3/4" support pipe to reduce stress on the outlet pipe. ■ Single Home Residential. ■ Multi-Home Cluster Systems. Pre-filtration for ATU'S. - Small and large business septic applications. FILTER SIZEING'IN GALLONS PER DAY ■ Large and small scale industrial septic applications. Model Application <300 300-600 >600 CBODS CBOD5 CSODS ML3-916 Residential 2750 2000 1500 INSTALLATION AND OPERATION The MI-3-916 and ML3-932 are each to be assembled with standard ABS/PVC plastic ML3-932 Commercial 2750 1875 1500 glues to septic tank Outlet pipes or adapter of standard 4-inch Schedule 40 PVC. - /Industrial - Each filter is to be assembled such that the filter cartridge can be removed for regularly scheduled maintenance cleaning as dictated by the system's design. An optional 3/4 inch schedule 40 PVC pipe can also be assembled into the lower support SPECIFICATIONS receptacle to reduce the moment stress otherwise placed on the outlet pipes from the weight of such filters. ML3-916 ML3-932 The ML3-916 and ML3-932 both received clarified effluent from the clear zone of a septic tank by way of the lower inlet of the filter case. Clarified effluent enters the Primary Filtration Size (in) 3/161h 1201h "Quiet Zone" where dense solids reduce in velocity and fall back into the septic tank. Remaining solids that make their way into the filters undergo three progressively finer Secondary Filtration Size (in) 1/8th 1261h filtration steps before entering to yet another small "Quiet Zone" to allow denser solos Tertiary Filtration Size (in) 1/16'h 1/32nd again to "slough" back into the tank during rest periods. This design is aimed to ensure that only solids smaller than the tertiary filtration step can continue on to tree Total Weir Length (ft) 236.49 248.93 next steps of the treatment process. Settling Area (in2) 527.63 555.40 Outlet Size 4" SCH 40 4 SCH 40 Materials PP/ABS/PVC PP/ABS/PVC Revised 2.15-11 6-11 D z N N D m a z 58" AS REQD N D I 4" ~ D C 50" cn 48" z m m p Ir ;:u O O m UP 47" 4" CAS - - Q 4 LL 0 m II II m II II m < 3,. 51 I < I II 0 m j m IIII II > UP 45" L _ = J ~ 4" CAS n I w I I 4g" o 0 N r- N J m m O C p m n K D m N z i I ~r D I N m D r n n c: Z< D r0 r- Z Z 0 -I m0~ x D °c m m m C-) z ° _ z Z D ?Z c: co ~m XX D G7 ~ mo Wo ZmDO ODN m C z n o p D ~Np N o O C o ~ GD ~ zm r Z - p p 0 ;G 0 c (A -4 m A> v>M n W U) > MOO m>0 - 0.. <U N O z G7 \ 0 ;v z (!1 C = --1 C M Z Ln m p ~N zz s N z ~zm n I 'm 'm Wmm°o~.. w f7 N D o m D ~ D ID 0 ' A n G z O W p p m co m rN~ W vj (n ° o p Q ' - o v D 0 -Nip n (n o n Npm Dr W(.;0~ -q I o D Z cam, z \ mDm NO N < A m D -n `t y c) W Z irz r0 n z v v O H X c >%o W0 N O m rn r v°r °x --I z X >1 m O m n U) j m mm 0 p m O Q z a: Lo > ;o X C O t~ z Z r O m n r L1 DH m m r m I m I \"D W320-MR 101ESER COnCAETE DRAWN BY: SME SREV. 1/NO 2-0" PRE-POUR: SEPTIC MANUAL DATE: JANUARY 2012 DATE:. 3/6/12 POST-POUR: z W3716 US HWY 10 MAIDEN ROCK, WI 54750 REVISED JAN. 2012 800-325-8456 FILE: W320-MR po.~~~// ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 8,36 //,-,e...) eoa-d located at: S5 J '/4, 4) 1/4, Section ,21 , Town-,z.~? N, Range/~;'_W, Town of St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.2, and it (thee) appear(s) to be functioning properly. Most recent date of inspection or service. 26,12 Did flow back occur from absorption system? Yes No 4--- (if no, skip next line.) Approximate volume or length of time: -A gallons minutes Tank Capacity: ~d Construction: Prefab Concrete Steel Other Manufacturer (if known): [.L.); e Jell- concrt"Olze Aa Tank (if known): xz Srnit n mber (if known) /51~~ a .S censed Plumber Signature) (Print Name) (Title) (License Number) v41)16 Q. 7~z ate) Form to be completed by licensed plumber (Dept of Commerce Chapter and s. 14 .06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/7 r _,c 17 1,0S lvfailing Address 63,e l v,,ec,J ez/, Property Address Sa.,,,ie (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number owe-/~70-f~-4~D .sue, cJl. S~ ~ LEGAL DESCRIPTION Property Location Sw '/a , /;I AJ t/4 Sec. z! , T N R_~9 W, Town of hj Ldkc Subdivision Plat: _::7-ej_c_4b S, Lot Al V3 . Certified Survey Map # nq , Volume , Page # Warranty Deed # (before 2007)Volume Page # 3 Spec house 0 yoggiTa6 Lot lines identifiable &-fe's 0w SYSTEtII MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that ( I ) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &t "Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we ant/are the owner(s) ot'the properly described above, by virtue of a warranty deed recorded in Register of Deeds Office. Nurnberof'bedrooms ~:~hApej 71 - Ll 43 SIGNATURE OF APPLICANT(S) DATE "`Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey nr,;p it reference is made in the warranty deed. (REV. 09/0) lo,, /'9 PONDING EASEMENT S B9. 10 ' S6' W LANE _ N 09'10'560E 247.41' ro < B3•i1'ZZ-E ryd* ry~ \ ~ ~ r X77 .7 i ' / _ . ry+lb / Nn1 ~ ~ II 45 hryn7-~/ •ry0/ \ 40 130, 099 SQ. FT . m 907 SO. FT 2.987 AC ) N 2.018 AC. ) / 2 \ p s7s. a 04, 1/7 / e i 44 135, 565 SQ. FT . ( 3 . 112 AC. i O9 1 PONDING n~O EASEMENT / Q ol C) i, F % ~'0 •OJ ar L u/ r / • i " 43 165,269 SQ. FT. ~O (3.794 AC.) 2 S Q %04. 42 122,386 SQ. FT ( 2.809 AC.) + 2 i I .2 , 0 ' ,3.E 1 I N ? 254 .22 • S\ r W N i gA 90 3 3 6• 362 ,q 5 ° 64. ~g~ I f f \ o I i 0 0 0 \ 2'9 gg I Z &,I I 75. .:^^•w WARRAM-TY DEED =2,3i n__1,I1 al? :,1SCn_M111 FORM :sue. Vol. 4,1%PME4 R ISTER'S OFFICE _ _ r • n8eE'g for R£^!31`x'? _ 2 i99] at 10.50 A. M cunv }a and warrants. eo iur'~ L?_S, AW.mp and Debora-1 L :111 bans3 cY)(it~ _Sr f e 5mr i vorsnip d .atiw.tt.~~ -m3?' r3rngs f wh - ftsgissE~of Oe~rls - t1w following described real estate in .51- -Croix. ounty, State of Wisconsin: Tax Parcel No: .To t 43, Jacobs Landing Third Additiort iri the Town of Hudson This + S. nQ s homestead Property. (is) (ia not:) Vxc(iptian tt. warranties: easements, restrictions and rif7hts-of-way of zecovd, If any rented this 19_ dny of Au gu s l; _ I9 91 _ ,am E.. Mil er _ ISF'ALI (SEAL.) AUTHENTICATION ACKNOWLEDGMENT Signature 12) :;TATE QF WISCONSIN i ss. r. autt..,,.,i..,tted this __.._._.day eI' Parsonslic enure before tile this .-__._da of n u t t• 19_91. the above namc,l . TITLI '_1llitliBER sTATE BAR OF WiSC-0NSi \ - - (If not. _ . Y r ` . authorized by a 706.06Wis. Stnts.) ~ d the t,E t?, n,r }:n.:svn to 'bq the It.^r<op ~ p i 'lc 1 tEtr r tlx(1 in~irui It~`lt.~ sc ge it c K q• 11 Tc S INSTRUMF-NT WAS ORAFIED PY •iJ .tom., t r tom, :rt ..%2 1 :y:`i• - r- t~ r i y , vgL~C c~ yr: may lie . cr.ti s •rt, or scRnra .i,.. ~k P'_ -•r r' /ji .c.. c a;It'r. c tr. •trd~r.t. T.Tr,f ~~`•(I j'•1t`;jl' tr_ not i '_c,r l 'Vam• ,I P'e?n n„ _.¢nln¢ in nny nl'1. •t i. ; .s a-: I. ^h ;r )Cr WAtt."NTY DLF.D s-rATr, nAn OP h ISC ON%,\ - - - ` o Foub. No. 2 I 1+ v-a:s4 V ( v } t FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER -f~- r►n Vln'~~- TOWNSHIP u ~~QN SECTION 21 T 7-1? N-R Q ADDRESS ST. CROIX COUNTY, WISCONSIN }1 s~ ~ W~ s `i U A L SUBDIVISION :5&cob4 ~anQ1k~ LOT y3 LOT SIZE 3.79H XL PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Lot ZS S~5}~wE1.= 1004° kale fly _ ~O \ a g.N~. 1 I~t 1~ r ATNWto, Lot 7-4 i = roti' L6+ 7- q F- f a 77' J G 6 i HoYS', Y 'r 3 2- i D P 4th INDICATE NORTH ARROW BENCHMARK.Elevation and Gescrlption: ) `I'rV Alternate benchmark j; SEPTIC TANK:Manufacturer: Liquid Cap. 1000 I Rings used: z Manhole covar elev: Final grade elev:Z, Tank inlet elev.: 2.q J Tank outlet elev.: ? . z No. of feet from nearest road:Front X , Side , Rear Ft.1,5 From nearest prop. line:Fr,)nt , Side, Rear Ft. 7 7 No. of feet from: Well So Building: Z (Include this information -1.n the above plot plan) 1-, (2 reference dimensions to septic tank) 2g'' SEE REVERSE SIDE 5 ~r~ t ~ I PUMP CHAMBER Manufacturer: //A y ~ Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front-, Side, Rear-Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed Trench: ° Seepage Pit: Width: Length 3 Number of Lines: 3 Area Built ((8' S,~f Exist. Grade Elev. Proposed Final Grade Elev. ff y Fill depth to top of pipe: ' 2 No. feet from nearest prop. line:Front Side , Rear Ft.4oT-~ No. feet from well: 12s No. feet from building -7r7 HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE: PLUMBER ON JOB: ~ r,~L LICENSE NUMBER: 6/90:cj DEV TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING ' LABOR & HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICDIVISION ATION P.O. BOX 7969 MADISON WI 53707 State Plan I.D. Number: SW 4 , NW 4 ,Sec . 21, T 2 9 - R19 9/ONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Hudson, Lot j 43 Rd I Holding Tank El In-Ground Pressure El mound H NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE sam Miller Box 282, Hudson WI 7 0 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. E S REF. PT. EV.: 14 a r 111 5,4 af, ZA Wh Lk MP/MPRSW ; ~-0- ~Y N Poc, e. Name of Plumber: cr: County: Sanitary Permit Number: 2 St. Cr x 148992 en SEPTIC TANK/HOLDING T K:- .2~ S MANUFACTURER: LIQUID CAPACITY: TANK INLET A EV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: e. l G Jtrl //O. o 71NE: S ❑ NO ❑ YES BEDDING: DIA.: V449-MATL.: HIGH WATER NUMBER OF ROAD: OPERTY WELL: BUILDING: VENT TO RESH lQ C• v . ALARM: A.1 I FEET FROM / f AIR INL ❑ YES O ❑ YES 0 NEAREST-~ DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: NO I- I ❑ YES ❑ NO ❑ YES ❑ NO GALLON CYCLE: PUMP AND CONTROLS OPERATIONAL: UMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN F OM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEARES SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BEDITRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID i TRENCHES: , MA~EBIAI PIT DEPTH: DIMENSIONS )7 36 GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. 11-S-TR-1 OF PROPERTY WELL: BUILDING:- VENT TO FRESH BELOW PIPES- ABOVE QQIER: ELEV. INLET ELEV. END: f I n PIPES: FEET FROM LINE: Of AIR INLET: V 7C/ / 91 we IV~-. NEAREST--00. (_P0 o, 77 ~OJ MOUND SYSTE - / ' Mound site plowed perpen icular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. / 2,9/ SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ~~oaOJ ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: $ g3 CENTER: EDGES: . 2,11 ❑ YES El NO [__1 YES E] NO E_] YES ❑ NO .9 PRESSURIZED DISTRIBUTION SYSTEM: t a o. X3 WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: ~1. 1.5- DIMENSIONS 7 MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: / y ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST T , g.83 ~ _ .y P Q may,; ~Af 12- /64 76- Ulm, fain in county file for audit. Sketch System on Reverse Side. SIGN URE: TITLE: SBD-6710 (R. 06/88) ' ' SANITARY PERMIT APPLICATION A*A9 IIHR o ~ ~ 3 In accord with ILHR 83.05, Wis. Adm. Code COUN, STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than / ~ f1gQ~ 8% x 11 inches in size. ❑ Check if revision 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 5111" 1011- 4 ER k_,1 lt/'/a, S 7_,1 T 7- N, R 17 E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Se,r ":r- Z$Z -113 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER c<</~ti Wz S-oq /0 3y6 z 7 G ?.e,c o 6 s L i n II. TYPE OF BUILDING: (Check one) El State Owned ❑ CI VILLAGE : NEAREST ROAD / 10 2o rr Ha/6o✓ ,aeuJ ~~1' ❑ Public [21 or 2 Fam. Dwelling--# of bedrooms..?-- PAR ELTA NU BER( ) Ill. BUILDING USE: (If building type is public, check all that apply) 3 3 1 ❑ Apt/Condo 20 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. El Replacement 3. El Replacement of 4. El Reconnection of 5. El 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 M Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 4/So 6/s, ? 4,72- 4-3 /00. y0 Feet /03.7 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Se tic Tank or Holdin Tank X 00 AL s 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 Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. C TY/DEPARTMENT USE ONLY ❑ Disapproved San' ry Permit Fee (Includes Surcharge Fee) Groundwater rffa e ssue issuing A nt Signature (No Stam9dV Approved El Owner Given Initial Adverse Determination ` X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Ptb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SB 7 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 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 !ranks 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; close 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) So-m n'1~ ►14~. fe.ce, s Javr_-s`ue'. Dr'ry a.- cy ati,tE1. = loo. Kc' sal 114' lo' " ~3 2 /,/off; AT Ai-to BpitS Clack 4•~, A- p~rc s F a 5 'L wl c P% r r- 9 2 p oa ?a O eJ o L v I' A 0 ~ P Lof Z s ~ 0 r -B_y pgA A P i , 1 0 4t C1• s 100-0, e , O 0 u n Lot 2 y ~ J- a Y f / llce S a. ~ , ~y'x3z` 'p L ' 1 r DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, , 1 DIVISION P.O. BOX 7969 ' AND RELATIONS , PERCOLATION TESTS (115) MADISON WI 53707 HUMAN ff'' (ILHR 83.090) & Chapter 145) LOCATION: SECT4 TOWN HIP/A.41~F~ LOT NO.:BLK. NO.: SU DIVISION NAME- Jdco~Lb~~r~16 A~m Wrltn~ZI /Tz9N/R/9E(o W / u&Sd W, 1 4.3 S COUNTY: OWNER'S MAILING ADDRES ,sr ceb).x 'Am /Yf II-La, &a USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: ~PR FI I IONS: PERCOLATION TESTS: Residence Uq - KNew ❑Replace MAeCN 9 / MOCW ZQ RATING: S= Site suitable for system U= Site unsuitable for system S l J~ 1 Y MIS TElU 's ❑u INGni J PaURE:S EM-IN❑-FILLH❑SGUTAN J~:RECe0NVCVT/b7Ti1A:(opt9al /IS ' DEIf Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: IqA PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH=. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 12,17 /06 ~sZ p nl > .1 `1 V$t5 C?s N S X37 Q /hS~GQ B- Z ,p /o3.Z3 ►JoN~ > n7 .D~ I1"8cLTS 14"Bow L 2olej /h.S i6~8 Cs44 4 B- .O8 /04.17 0 >9.05 " 1-C-M /7**Re Sc i6°AaNCS14e 47_eI?Nh5-~4,,e, B- 4 ,mo lm.,4 45#06 >/v.oo /d"eit-TS z-7"eQN L 77 ` 8RHcsdG 4 JB- S 9. los-S4 " > 9.60 rz-& -rs /3A8e.,4,SL 83'4N A75 i6I, B- ~T PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER MOOMM AFTERSWELLING INTERVAL-MIN. PERI D 1 PERIOD 2 P R PER INCH P- 1 S.10 No /6S-s > > Z > z 43 P- 2 "BO t za > 2 > > > 2 < P- 3.80 r-LmLr 2C7 >Z P- P - I A A-r v- P- pp,,~ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Ind;cate-sca1'e'or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surfs-L&evatio tall borings and the direction and percent of land slope. Z SYSTEM ELEVATION 166'46 g 1 q _ E + ; 444 1 3 t i t t ~l .-fit--- . E r E E <A ctJ d K Ito_ AT n1 6k ¢ I E k E ~ 64 ~O e { _ s Lo-c z~ 1, the undersigned, hereby certify that the soil tests reported on this form WeFe made by me in accord with the procedures and me hods cified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of mt knowledge and belief` y L43 NAME rint : TESTS WERE COMPLETED ON: dQVEY ~D1JNSon, JaNNScN S( QVEWAA P°1xfca 20 1991 ADD~ SS: CERTIFICA I N NUMBER: PHONE NUMBER (optional): t'0 1 vdsong i S4o16 CST S ATURE: I 00 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - r 26a. S 313.14' / \ _ S 23.28'23 m 4g •4g•29,w SEY o D~ 23.E 261 - - N 23.28.235i~9 00 ~ r 'J ,n I 4.\ v d` S to v d~ Ln 2 o cn 6+ c+ rv vs c ~ 9~ ~ ~ O N F J .ct r: SO UI NO •~tJ,tV~n ~ m i ' X92 I ~ , ~Gl '3. \20 /f J O~ I S Sv~5~5W.19 X90 i U! AS _ I NSAS j / i d \ a' (T / ti9O • O A9 p , 6 • ~JO t I. ti ~o m 50 420 / ~cG N /A c dt j . A9 / V' ~ / ~yi~ X00/ m~NN 2 tro 9 . APPLICATIOH FOR SANITARY PERMIT 9TC-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 parmIt issuance. -Should this development be intended lot resale by owner/contractoc,(spec house), then a second form should be tetalned and 1 completed when the property is sold and submitted to this office with the appropriate deed recording. Ownst of property SQ-,►r, 197"11'gir- Location of property SGtJ 1/4 IV~JJ1/4, Section Z T -R V Township _ Lx.,Sov& Melling address _Avy '7_ex---- Mates@ of site 60e- e-/3 r. 1vbdivlston name X44 eo b I n~ 7 Lot number 3 Previous owner of property Total also of parcel 7fV S Date parcel was created 3- 2 Z. - 88 Are all corners and lot lines identlflablet __X an xo is this property being developed for resale (spec house)T.x as No Volume $ S and Page Number V4 Z- -r_ as recorded with the Register of Deeds. -------•---------•---ww--------------------- ft ft INCLUDS WITH THIS APPLICATION THE FOLLOWINCs A WARRANTY DIND which Includes a DOCUMRNT NVNBRR, VOLUNK AND PAGE NUMBIR, and the REAL OF THE REGISTER OF DEEDS. In addition, a certifled survey, it available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Ceitifled Survey Nap, the Certified Survey Map shall also be required. - PROPERTY OWNER CERTIFICATION f(ve) certify that all statements on this form are true to the best of my (out) knowledge that I (we) am (are) the owner(s) of the property described in this Info cmatlon form, by virtue of a warranty deed recorded In the office of the County Register of Deeds as Document No. , .3391/:z - s and that I (we) Presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the conetcuctlon of sold system, and the same has been duly recorded In the office of the County Regis r of Deeds, as Document No. _5e3--r-4 ~AL,- signature of owner Signature of Co-Owner (11 Applicable) Date of Signature Date of Signature I - ~ u If ncocupartlt NO WARRANTY DEED loo's srA t ttstr.vu. rot tr..r.aU.po UA.A STATF: IIAlt OF WISCONSIN FORM 2-1982 '43041.7 W REGISTER'S OFFICE X17 its. SQJPnE ININJIlitill' ST. CROIX CO., WI Recd for Record Virginia M. Ilanson, a single woman MIAR 2.2'999 « 8: 00~! - A 0M c..mr.< awl u.lrant, In Sam E. Miller. a single mall • tlb~MlM ~1 Ds~1 ~ the fall•.w•ine dra•1 ihrd real estute in St. Croix C•nl.a), Stall! Sir Witicon!'ill: Tax Parcel No:... West Half (W'j) of Lite Southwest Quarter (SW'14) ill Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except Chat part South of Lite public highway and except Lots 5, 6, 7, and 8 of Certified Survey Map n Vol. 6, Page 1747, Doc. No. 419479. That part of the West Half (W%) of the Northwest Quarter (NW'r) of Section Twenty-one (21). 'township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lylaig South of Lite right of way of the Chicago, St. Paul, Mlnneapolf:, and Ihnaha Railway Companv. •tRAN st 0 0 • $ q 111 FFF Thix is not hnllu'.Ir:i.l prnperl;:. tusk 1 is pilot) E:xrrp•inn l.• aurranliesr easem•_nts of record and pro►ective covenants and restrictions of record, if any. . oZ ~ S e Ihilyd this .L•i~ ..f ♦ ( 1!1 88 1 ~ F.:\ 1.1 rJL~~~t~I-~C-aJ~//•~lwr-~ '-f/ 1 ~ l:.\ 1. i Virginia M. Hanson ICE:\1.► EAI.1 AUTHENTICATION ACKNOWLEDUMENT Signature(s) STATE: OF WISCONSIN 1 INS. 1 authenticated this day of 19 I'Sr-onulk rnmr before rise this dad of m~'►'4 t- 19 88 the adore nann•.I Virginia M. Ilanson TITLE: MEMBElt STATE: IIAlt OF WISCONSIN I It not. authorized by 706.001• Wis, slat..4.) In air Lnown Its Le the t.cr:on lcho.•s.•rulyd the foreviiin trunu•ul :nqJ a0lnow•IedRe the :•:rlnl•. T•. S MSTRUMCNT WAS DRAr'TCO nY V'. Lols.•A. Murray, JteyWOOr1,• Cart b Murray/t~.. P.U.''sox 229. Iludswn. W1• • 54016 So '}y fkjl . M .ola•• ut111•' P \ 1'nuntc. \\'i•. (Siennturra may he nulhenticaled nr m•koonrir.leed. lball \I• 1''• •11.10 'Vol) If nnl. xt:.t.• r': 1• ration nre lint neersaury.) 1!1 1 •Nsmrs nr p.rso,mi rltnint its toy rsrnriq •1...•,•.11. 1". i.-ni••11 w •1.•., . WARRANTT DI:LD STA'IP. AAR OF V61S1.11\• W N.••. ..va 1•inl 1'uv • Felotm IJs 2._ 1... 6' ~•e SEPTIC TANK MAINTENANCE AGREEIIENT r, St. Croix County - w n OWNER/BUYER $a, /'Y1 o • 7 ROUTE/BOX NUMBER '''vx # Z Z-- Fire Number d ~ T r Ve _ CITY/ STATE //si er /S ZIP o PROPERTY LOCATION:%. ]66LA Section Z T Z IN, R.! iD Town of l~~r.Soi-► St. Croix County, Subdivision S ~obS 2ah• Lot numberS(.1r• 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 licens'ed' 's'e trp is tank pumper. What, you the system can affect the :unction of the aeptie tank as a treat- ment-stage in the waste disposal system. St. Croix County residents•MaX be eligible to recieve a grant for a maximum of 60% of the cost.of replacement of a failing system, whc was in operation prior to~July 1, 1978. St. Croix County accepted this program in August of 1980, with the r Pequirement that system owners of all 'new s yst•ems_ agree to keep their p heir maintained. The property owner agrees to submit to St. Croix County Zoning a mater lumber , ion form signed by the owner and by a p certificat journeyman plumber, restricted plumber or..a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper nec- operating condition and •(2)•after inspection and pumping less than 1/3 essary), the septic~~iikbe is Certification form three year expiration. y 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Certification a and returned to the of the three year expiration. date. SIGNED VIL DATE _ St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. . A ,'-c' v" u N.. 10 er- 00-4 Psi a • ' 3- LAO P ~e o F^ % V, Is + r* 4 I s W r4p h ~ • 1 ; p n •n ~ ~ fix cr ` P I ~ o y Ps- -d Ell r r ~ -D ~vs ';ooooooo vs, .o w s 'd T p r w ^~a