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HomeMy WebLinkAbout020-1037-80-000 Q o w ° o ° h ~ o 0 0. 0 E x C _0 C O U O C N o C 3 m y a 0 o E 3 a a~ U = 3 Q 33YU o 'CL (D c w w°• c i o~°oc ° ° ) Ca U 0) N m- 0)C C C E O O -p X ° U N O 2 O y M o r a cn -o N m C Co N ' o) ca N (0 O 3 I- (6 C 'O N - LL C N 7 N - C o o Na NYa 3 EP 23 0) Z .j O d U) co E F S °0 4) U co ~ I N Z 4i O Z ~ 'N m ° cli a m i o z N d z v 2n E Y tU • c L C iE5 O o ° a a o = z z N E CF 0) 0 w 0 o 4') N CL u = c o aL n ° c 2A N N m ° 3 3 3 5 c O O O • rv a a a (o o ua~ a z N 7 p V) N fA J U rn rn } I T O (D N 00 ~O O C) O L3 N 'p w N .21) O O 023 y C C p .O ° O C O ° C [ CC W LO 30 O C E 'L 7 C LO O O [ O ti C p o 06 H- • N E y O 2 W O Z ~ w L i a Q. d 2 d 4w L C C _1 A 0 a 0 2'n V ENAR GfAENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS NDUST~Y, DIVISION LAFjOR AND P.O. BOX HU AN RELATIONS PERCOLATION TESTS (11J) MADISON WI 53707 S%Tt~ 4PP.-Ius- 972- 7_,eour 8^W 12z9 t1LHR 83.09(1) & Chapter 145) //UDIa r~ Gvls S~{Q! ~ LOCATION: SE~ON: TOWNSHIP OT NO.:BLK NO.: SUBDIVISION NAME: 5e / /T27N/R/E(or,W f/(i ofae'j COUNTY: MAILING ADDRESS: ~f• C,~D%~' TO1~~J ? L UGi%/`c ~SS/;u J'v/iET v-e . ST• v ~ii:t.,,~ SS/0 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRI TION: I DESCRIPTIONS: S ROFI LE Residence ❑New /Replace L Ue KIT S I ''v ft 00 0 RATING: S= Site suitable for system U= Site unsuitable for system f' / ONVENTIINAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:loptional) E] S ou a S ou o S CCU El S ou a S au ,419ydF $1PI4.)6- T',Vl(-s If Percolation Tests are NOT required DESIGN RATE: I O Q / If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HE TO BEDROCK IF OSSERVED (SEE ABBRV. ON BACK.) B- B- d T tiSS'~t - S E No T E' B- B_ B- B- B- PERCOLATION TESTS } TEST DEPTH WATER IN HOLE TEST TIME DR I WA ER LEVEL-INCHES RATE MINUTES F NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER INCH P- P_ P- P- D li/ Y~ z< /t1J / GD P- GOO GU 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. It-907- J 1 P 1_0T Prr,9 /J ? U E IP S .5-EE- t_ /j/D7~ AGI- ,0i vT5 ©f- e l/S7-4c~(r yrPAD€ ~1Gr-flSS . TN SrffGL GpT &Law 45 ct vE IeS Tf'c~-vs i'd'G~ ,J Nd ,MOU•v,R SyST&---1 Ooe /w -G,eD v,vr> SipT/`c S yST:c~I ~S ~I~6 GJ iQL> ~ G).J C~/ r~D d ~.I.pp~ A491,06- TE S 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): COMPLETED HOMESITE SEPTIC PLUMBING CO. TESTS WERE QN: ~ O 655 miL Rb.. HUDSON, WIS. 54016 ADDRESS: ROgERTULBRIGHT CERTIFIC~A/TpION NUMBER: PHONE NUMBER (optional): . MASTER PLUMBER LIC. NO, 3307 M.P.R.S. 2 Al ,:f Z- 116^Sopa .0l~S HINN. INSTALLS & DESIGNER LIC- No, MW CST SIGNATUR DISTRIBUTION: Original and one copy to Local AuihoritY. Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - ra S k ? 2 r' t ell Gl.- ~aJ Vi a g~ o r Y ~M otu I Q- w M ~ , .J ~ 1 Q y ~t~ ~ O 4 k (L_ I, w, t~ ~ ~ IiAs-!R QF MEP R N SOIL BORINGS AND SAFETY BUILORCI .►Vl7U.,.I~Y' DI10N LA80 NO PERCOLATION TESTS (115 P.O.84*8 MUMAI )RELATIQNS l MADISON Wji4,3701 ~.'7- .y~,AA, JSr ' g?2_ 76ur Q, oe /2p (ILHR 83.0911) & Chapter 145) If UD,Ia,ti Gulf' .S~{4! N: TOWNSHIP/AMGkAL1Tc OTNO.:BLK.NO.: SUBDIVII NAME: 52z N/RAE (or) W f/o o'ra'j QUNT ;f : MAILING ADDRESS: ~9Q~ y TtSS~;cJ Ax-e DATES RVATIQNS MADE BE COMM€R IAL DES R1PT10N: NesirWricq ON1'VV Replace /mar 5t! 111',%cC G v r ~,3T S ! `'uI O4 L~ 4.01 RATING: $ita suitable for system Um Site unsuitable for system ONV M ZONAL: M-GROILL OLDING TANNDED SYSTEM:(optional) NND S DUT ❑ S [A ❑ S DU 0 S ❑loop II Per col stion Teats are NOT required DESIGN RATE: it any portion of the tested area is in the f unoer s. I4HR,83.09(51(b), indicate: Floodplain, indicate Floodplain elevation: / Q z ri PROFILE DESCRIPTIONS IiiORING TOTAL P H O R UNDWATER INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND QEPTH NUMBER DEP 4IM, ELEVATION B ER -OS D H TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) 4 ~3• 1?pc°i~c~(rS o ~U..'.I.S'rt l~ t` No T E r L_~'o cJ 13• PERCOLATION TESTS '`ESr DEPTH yUAT'ER IN HOLE TEST TIME DROP IN WATER _ V_Fr H fi`-~.a... ;q {`yjjNtFl ~4'C'JU#.fl EFi IN F•iES AFTER SWELLING INTERVAL-MIN. j4~ t p ~Efi INCf+ N. D 0 GG/ +t.OT PLAN: Show locations of percolation tests, soil borings and the aimensions of suitable soil areas. Indicate scale or distances. Describe whet are the hors. ct 7tal anc Vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings arsd the direction and percent sl~~op. a' 15110 SYSTEM ELMITION r j' NaT '44'e- ,0i1uT 5 0,,4- z X13'; /4J 6- t LL•- Z-eP 7 dome)( . j~/ "l 4 Lo ~v tev~`T/a-c.~, ~J CCi-ta VE IP$ ~tTf' s fr 9 i rJZ~ ,tJ ' . ' ' L • SYS 7 6 le 0 U_4,) '0 ` S~->E-., ! Sll~d 4.y/ Gl. t 7 c'~D D ~.t pGli/~G`, r i Oto undmignecl, hereby gerti(y that the soil tests reported on this loan were made by me in accord with the procedures and methods specified in the Wist:p+vsin walinistratiVe Code, and thaat the data recorded and the location of the tests are correct to the best of my knowledge and beliaf. E I. HS t, IIE SEPTIC PLUMIING CO TESTS yrERE COMPLETED N: ~ ~ a AL. HUDSON, WIS. 54016 Z ~ ' - AIL _ . _ - _ HES> RODERTULBRIGHT CERTIFICCA/TION NUMBER: PHONE NUMBERItptwa:;p: wls• YASTEA P4UMiBER UC. NO.3307 M.P.R.S• I/T^Sop(:p MINK, (PiSTAi.LE ~ . CST SIGNAL ad':r•fHIhUTIC,IN Original and one copy to Loc.11 Authority, Property Ovvnri and Soil Tester. i 40 -rJ -M D 0 LIN ft 't O L 18 -/'Pox , sc, u zo r c r r -tl ~r I N 70 Lot N I a v ~ p o I . s M 1 p O I \N M D tl( c 7 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_JOtt/V LUCiI(~ ESSTOWNSHIP ~{VDSD~J SECTION 19 T 2 ( N-R ( ( W ADDRESS &14 T01"CI ST. CROIX COUNTY, WISCONSIN T 11 /~'1 ti's CIO S SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I S.& E eLOT Pi1^ 11) IN- 77~0\ C ffLlO INDICATE NORTH ARROW 700. 2-9 " s'TE~L 1 a D~~l1C2v BENCHMARK:Elevation and description: p Alternate benchmark 70 tits r To SAE/ NOS , SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: Manhole cover elev: Fir4&l grade elev: ` Tank inlet elev.: Tank outle elev.: j~ No. of feet from nearest road:F nt Side Rear Ft. 4 y From nearest prop. line:Frorit , Side , Rear Ft. No. of feet from: Wel Building: Include this in rmation in the above lot ( P plan) (2 reference d' ensions to septic nk) SEE REVERSE S1 f •~y ~~n0f,/~ ',La 01,2 .5 V9 00'6ldV of `75'01aV a-7115-1er l X0:06/9 s i~, o ky :2 aGKfIH SSNSDI'I 1 . v q I k Y, : gor No M UCT :HIM ~o S d ~-,.oy~ w : xos~~asxl of W ~ b`7b~ ~ tl ~`7 :.1a.1ng0e3nuPH MIRTY peoi sa.zeau ' butpTTnq ' TTaM :MOO; 4903 'ON CJ / • 43 .zeal ePTS ' OI 4uo.z3 : auT T • doid 4saleau MOO 3 4aa3 -ON X :49TuT 3o uoT4enaTS : Xueq mo44oq 3o uoT4enaT9 Z : pasn sbuT.z 30 • ox I : A4Toedeo 5.._Z :7 <7CI 0 : a9an4oe3nuvK XKYZ 9KIa'IOH o O 1 -2 V S-Yn'-,,1 z f buTpTTnq mo.z3 g993 • oN : TTaM mtO 4999 • oN • 4d .zeal OPTS ' 4UOad : auT T • do.zd gsaape m<o z3 -.9a3 • oN :adtd 3 doq o4 g4dap TTT3 • naTg OPPJD TeuT3 pasodo.za • naTg OPRAD • 4STXa ~4TTng Reav : sauTZ 3o aagmtnx 11-4bug t : g4PTM :4Ta abeda :looszs :peg HRISAS K0IwH0S9Y Zlos TPTTnH TTaM • o.z3 9oue4STU •43 199H '-OPTS '-4uo.zd :euTT •doid -.s eau MOa,3 9DUe4sTQ uoT4PDOq : adAy g04TMS • UPK : Ma9TY :OTOAO/suOTTe0 :•naTg 3o drama :•naTg uo dmna uoT4enaT9 Xue4 30 ~409 :49TUT 3o uoT4enaTg ezTS darns •400 ueyl uogdTS/darns :TepoK darns :A4TOede ptnbTZ :.za.zngovjnuPH 2i'agKVH3 d nd b VO Q C Z o~ O ~ 11 m b r= . rp ca ~~l ~ 0 "1 fi .n ~ ~ • ~ as I . C Z d Q a m z o r- r , z h 0 p 3 Ll y ~ y n o ~ 0 14 )L V lil o ~ ~ r ~ I o O o %S. o , ^ n, -n O o ° h l D ~ ~ ~ N tt Vi LA t6 a O I~. r o r L x _ p S o sN y Z 1 J ti Y w S 7 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER JO H-n1 LUc.01c ESSLr&~ TOWNSHIP ~ UDSO/J SECTION 19 T 21 N-R r W ADDRESS ST. CROIX COUNTY, WISCONSIN T, PA SUBDIVISION--- LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM S.e E e LoT pLit N il,\ 1 77~ C f fEP rY A*r 1 \ Y w 9 1~ INDICATE NORTH ARROW -OCR - 2-9 54E /(1CLv ETC-- 1 BENCHMARK: Elevation and description: 70 = ti / % ?'a 5-/ / ~t44 X rids r Alternate benchmark 600 - SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: Manhole cover elev: Fi .,'grade elev: ` Tank inlet elev.: Tank outle elev.: No. of feet from nearest road:F nt , Side , Rear Ft. k ° From nearest prop. line:FrraA , Side , Rear Ft. No. of feet from: Wel , Building: (Include this in rmation in the above plot plan) (2 reference d' ensions to septic tank) SEE REVERSE S` DE ' ~l n~o~~, Yr7 ~ ✓ Cl O C7 f ~ c'I err / y~ ~ ~ ~ ~ } , L ~ • x -?I/ o,/ s~ O/,, 2 gLt-Js -7,P/C77 -9101vdv o_L 731,01,-V S in o~ 4/o y ryply ---(QO Y/ 47[/~in Co:06/9 s o ;-y HasHnN asmaoi'I -1 '7 p . j I YL ' gor No uagxn Id Z ~N gSYa ~o S d ~-~oy~ w : xosoadsNi :19lnqoe3nueH ntaeTY of W V7!/ C7/ peo.i 4s9aeau buTpTTnq TTOM :moa3 gaa3 -ON j '4d .zea11 ' OPTS ' 0j:4uoa3:auTT •doad gsaaeau moaj 49aj -ON X :49TUT go uoT4enOTg i : xue,4 ato~,4oq Jo uot4enaTg Z : pasn sbuTa 30 • oN : A4Toedeo > .rL ;7(7(70 ~/d : aaan4oe3nuvH 000-C 7V~Lo_L ~ J ~ s ~ ?IKYS 9KICI'IOH 0 41 -7 _)Y .3 'S-Y(-Y4 r1 buTpTTnq moaj gaaj ON Zdo:4lo4 490J -ON •43 aeag ' apTS ! ~.uoa3:auTT •doad 4s499j *ON : adTd 3 gdap TTTd i •naTS apeao T9uTd pasodoad •naTg apeao •4sTxg 4TTng eaay :sauTZ 3o aagacnN qMbuaZ :IMpTM :4Td abeda :gouaas :peg HaLLSAS KOIWHosgY 'IIOS ZTDTTna TTOM • 013 9oue4sTo 4d_19811 '-OPTS '-4uoad :auTT •doad qs eau MOIJ aoue49TU : • uey~ : at.zeT~+ uoT4ROOq : ad~TS Zdui aTo~Co/suoT Teo : nd : • naTa uo du[nd uoT4enaTa xue4 9o aTuT 90 uoT49n9Tg a zTS dmnd : •~.os upw uot,(dTTS/dmnd :Tapox dtund :A4Toeds pTnbTZ :aaan~ag3nuey~ RaGHYHO cnmci y o ' ris C ill o o~ Q r Q~ rn ti~~ ~ qQ m -1 ~ a ~ ~ ~ I o G c -4 ~ z -4 4z$ G1 r I, ~ ~ Q /_gy a nr L /%,C~ a 4 ~ rn ~ ° p v o M f Q Y f+ ~ ~ rr, L ~ R. \LA C ~I C -IN o ~ o 0 0 1 r v Lm -IZZ Z ~ Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St, Croix Safety and 6uildings Division Sanitar (ATTACH TO PERMIT) Permit No.: y GENERAL INFORMATION SE%,NE% Sec. 18 T29-R19,Nord-Lane 149095 Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: John & Luc. Esslin er Hudson s90-02370 CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing • Aeration Bldg. Sewer [Holding ~5&),-4,ie. (2mc P /W. -21 "pO */Ht Inlet 37 & 99-9,3 TANK SETBACK INFORMATION St/ Ht Outlet Ventto TANK TO P / L WELL BLDG. Air Intake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding _16' Bot. System ~,►y PUMP/ SIPHON INFORMATION Final Grade f Manu er Demand sEx ,o 9~.O Model Number GPM TDH Lift Friction stem TDH Ft 7"i• Forcemain Length Dia. Dis . o Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Mode Number: System: 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 ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Q . _5~ r p !)r/C 1 ,S rat 01 Plan revision required? ❑ Yes :G Use other side for additional informQ 1> SBD-6710 (R 05191) ae Inspector's Signature Cert. No. 7c!ILH SANITARY PERMIT APPLICATION Cou11NTYCQO` R In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than /h. 4 ~ _ 8% x 11 inches in size. 1:1 it ZV-n to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER -7 0 1. APPLICANT INFORMATION -PLEASE PRINT PLi, INFORM ON. 155?0- C9 23 PROPERTY OWNER ROPERTY LOCATION Auz& '/.NE %a, S T LC / , N, R E (or) W 7p`f N GUG ~SS~/N(ri PROPERTY OWNER'S MAILING ADDRESS OT # BLOCK # RU 7 u / 47- oq-vf- RhAr OF C,?o 11je4,:F SITY;ST~(1. L ( ZIP 1 17 PHONE NUMBER C ~ SUBDIV~ ON NAME OR CSM NUMBER Nti ES~ 11. TYPE OF BUILDING: (Check one) ccOO LL JJ El VILLAGE : #V State Owned VILLA LLAGE • ES GN ❑ Public X 1 or 2 Fam. Dwelling-# of bedrooms / PAR ELT iQNUiBQER ) r ~ ~ r 111. BUILDING USE: (If building type is public, check all that apply) In 01 ti 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.E1 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 ❑ 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 12. 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 X1 /(~A 1014- Feet Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Expen INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed r Holdin Tank ZQGO L bar N &%Z-rf Z- El I El El 1 El Vlll. 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 Signat re: (No Stamps) IA!'/MPRSW No.: Business Phone Number: /Z . Zl hRll eA 7- 330 it S 4 41? Plumber's Addres0 1reet, te, Zip C de): UP J 1,4.~ 'S , 9 IX. COUNTY/DEPARTMENT USE ONLY V Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui g Agent Signa No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adv rse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary-Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. 'the lseptic 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 cn 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 13% 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) a m 4 CJ ~ O~jd- "D ?b p ~ ~ ~ rn h NJ T3 00 -TJ fly PO Z d Q ZZ Z h C ~70 p \ U ~T N -r , ~ a/ a ~ ~o w I cz~l m ~~y rn 3 100 o n ~ cr, a 6 94 N Ir 1~1r w 0 sI ~ O G? ~s D M x p do R D ! Pri N -L x o v Sr 11 4 z fem. ~ V . P a :s c J ZO h s H W in oo ~ J t" lz N C o v cz 4J Y W L` N w v N M 0. L L E O z > • i~ -1 HZ 4J N V Z~ W Q 0 10 O ro O V) 4- r- U W N 4J CO a O d' b a s C c to 03 LL a a ~C 41 V 6-4 = x I-- N O ILA LL. ix m T^ Q Q \ H W O QC Q W V W CIO -j qJq `J , C b N ZI I Z C'~ I. U O v° ~ , 2 J V L. IV m aa ~t > 2- ~tb oWo 3 w a3~ W O c et J v L. o t V1 41 L 443- 43 OAt V-1 CIO 'r- ui •E N ~ o G V W l . CL J r U Z UI O 41 Z 0 G Qf o J c~ aLic vac c 4) 4) O a ,C J m o. C "a rn > > t" u4-3 4) 0 QJF-V G. NJO V1 ILHR 83.08(2) PROJECT INDEF. SHEET Owner Address Site Location ~PPiFOX - % ~ ff ~ii~PCe~ SE riy NE iy Srz 1~ T 2~j,v , /mil 4> , %a W~ o f/vvs©,~ s T'• CAA K cc 0'. T y Project Description oti E a~~.~~, 7 ~1Q,[J~~~ 5 ~9 fD.d~L 1 ~fU~IE `1,xs 0/0 G>e~Ss o o s y s r .-r G,g r e~ o.Po .era rO.vDE.~-r.V~U RV ST• CXOt ~41~,vT 2enw,') Lip T _ P l zo P os ~ v s s ~ w~ s w~t~v~o l~ co ry GO.u V Je ' ,q Glass sell G-~T • . ~ pig T S ,P • ~O z, D Cl0 OO - ~ic°D D~ ~D LD ~,v G-- ?%t-.v lrs ~i~° ~ 7~.2 O.c~ c y © ~I~/6~~,~~ rye df sl's T~~I • Page 1.1 Plot Plan & SYSTEM Plan View p Page 2. Cross Secti of ~o LDi,c~ D- 7~t a try 0- %P fi PLUMBER: WZ,eA+ HOMESITE SEP7 UDSO SO NN~IIWIS 5040016 s05 at4EIL RO•. HU poeEW7 ULBRIGHT 3V11A•P•R•S Date : _ MASTER PrUM6ER GNENR LIC. NO. 006M TALLER & GESI - . MINN Signature: t State of Wisconsin \ Department of Industry, Labor and Human Relations PRIVATE SEWAGE PLAN APPROVAL SAFETY & BUILDINGS DIVISION f Office of Division Codes and Application 201 East Washington Avenue P.O. Box 7969 Madison, Wisconsin 53707 HOMESITE SEPTIC PLUMBING COMPANY Owner: JOHN & LUCILLE ESSLINGER ROBERT ULBRIGHT 655 O'NEIL ROAD 1894 JULIET AVENUE HUDSON, WI 54016 ST. PAUL, MN 55105 RE: Plan Number: S90-02370 Date Approved: September 1, 1990 Gallons Per Day: 150 Date Received: August 28, 1990 Project Name: ESSLINGER, JOHN & LUCILLE Location: SE,NE,18,29,19W Town of HUDSON County: ST CROIX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - REPLACEMENT HOLDING TANK i Inquirie concerning th s approval may be made by calling (608) 266-2889. Sinc e P ER E. PAGEL Section of Private Sewage Division of Safety and Buildings PPP013/0009n/ 4 cc: JOHN & LUCILLE ESSLINGER -Private Sewage Consultant -County _UW-SSWMP -Plumbing Consultant Owner Plumber Environmental Health SBD-6423 (R. 08/88) HOLDING TANK SERVICING CONTRACT .t Contract Date This contract is made between the Holding Tank Owner(s) Name(s) and I Pumper's Name J`©tjN FSS L. t"6 E dam-. I -(R( c u N'T4~ 1J T (.c71~1 G-Lt 6(t,L!_ GCSLl1JGEP,- I We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) Ste-' T Alvp SO 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of ~T 4~01 ' 1 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owher agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality j and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Owner's Signature(s) ~ rp (-~J S5 L 1 M G I 1 Subscribed and sworn to before me on this date: U.GI LLEE F_ SS Lt. :•,a:. GREGORY A. PRICE " . N0TARY UBLt - : "ININILS A ( QUNT1' Pumper's Name (Print) I Pumper's Signature ub is poop Popp My commission expires: Pumper' egistration Number O SBD-7574 (N. 11/95) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. P lb. 89 ' APPLICATION FOR DEVELOPMENT OF FLOOD PLAIN Department of Health and Social Services j When the installation of a new, replacement or expanded private sewage disposal system is proposed for a flood plain area, this form must be completed and submitted to the Division of Health along with plans and other necessary data. OWNER'S NAM ~0~ ~S SL / •N GCE / 3 _ DATE ~!lv~ 20 I `1 Sd ADDRESS f 7 2.. i(10A1? /I Al - lJ f7,j0.✓ /S S" yd/ ADDRESS OF BUILDING OR LOCATION OF PROPERTY sue- j LEGAL DESCRIPTION S'am' XV IVF,T!f 5AC T 24, v r w i 1 i TOWNSHIP O,~Oi✓ COUNTY Y expanded is this system new replacement A I Is area: In regional floodway? yes no not determined In regional fringe flood area? yes no not determined Contiguous to ground higher than any of the above? yes no X_ What is the established regional flood elevation? 7d Z- (7 t Are flood plain maps published and available or determined by the Department of Natural Resources? K9 I Has or will permission be granted for the following: Fill required for building? yes no X I Building permit? yes no _X i Sewage disposal system (sanitary permit)? yes no Action taken locally by ST "jX y Comments regarding development (zoning administrator, board of appeals, etc.): Favorable Unfavorable Special Recommendations: i Signatures: ° County Representative XJ/' Department of Natural Res urces C/ 1113 I Division of Health ..e; . t. ^'n ..vrv...ropnNr. :.o- .a . ...........+ivaa..se.r+ws-•.~.u .........w.w...--.• w...r. i STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~N ~SSL/ ~G~/~ G ROUTE/BOX NUMBER ! 71-- tiOfgU N FIRE NO. ` CITY/STATE SC~~ e'o S ZIP PROPERTY LOCATION: 1/9, Section / , T l~ N, R-If-W, Town of ffv 'p-ro ' , St. Croix County, Subdivision /y , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 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 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 form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the S "`1cUUnLy ce within 30 days of the three year expiration date Id1 7~A,~,rA4V' SIGNED DATE Qa St. Croix County Zoning Office P.O. Box 98 I Hammond, WI 59015 (715) 796-2239 or (715) 925-8363 Sic:r: "ate, and Return to above address APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed in full and signed by the ovner(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 secon should owner/contractor,(apec ho)# then a thls office with the completed when the property is s appropriate deed recording. _ t, 3A 7 X Owner of property Location of property S 1/4 C 1/4, Section T_±f N-R 1( V psi Township Mailing address I Address of site Subdivision name Lot number previous owner of property Total size of parcel Date parcel was created Ace all cornets and lot lines identifiable? _ on No Is this property being developed for resale (spec house)? Yes No Volume and Page Number 3 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PACE NUMBER, and the REAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(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 Information form, by virtue of a warrant dead recorded in the Office of the County Register of Deeds as Document No. ; 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, lot the construction of geld system, and the same has been duly recorded in the Office of the County "4*Ler,~ of Deeds. as Document No. 1 . $ig at a of Owner Signature of Co-owner f 1►pplicable) Date o Sign tune Date of 91g ture