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FORM - STC - X1O4
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP_I&IS,&
27
SECTION :2-/ T -19 N-R_Z7
ADDRESS ~oZ 8 2 ST. CROIX COUNTY, WISCONSIN
SUBDIVISION
_L.~G LOT LOT SIZE .2. ?76
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
.ro, C.0 &Z UkA ~Q
75 I ~,/t1, Ro h
~ ~f H, E.lat
E
rl I Y
Aso
---t 4 s
\oS
o ,5v
Zj
i
k- r g'-4
INDICATE NORTH ARROW
BENCHMARK: Elevation and description: TQe dF I" /ye.10--vrw s1=40.0,I
benchmark Lo
SEPTIC TANK:Manufacturer:Liquid Cap. (Opo:ra,).
Rings used: O Manhole cover elev:ff.0 Final grade elev:
Tank inlet elev.:- I'ZV3 Tank outlet elev.: P-.-
No. of feet from nearest road:Front X, Side , Rear Ft. / 31
From nearest prop. line:Front , Side X, Rear Ft. 7s~
No. of feet from: Tell 7S , Building: I8/
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
t••_
• i
~I
PUMP CHAMBER
Manufacturer:," 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 41 Trench: - Seepage Pit:
Qsf~
Width: ~Length ~ Number of Lines: Area Built 72
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
~z
No. feet from nearest prop. line:Front Side X , Rear Ft.S-/
No. feet from well: /OS- No. feet from building
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: LICENSE NUMBER:
6/90:cj
~ a o
Wisconslrn Department of Industry, PRIVATE SEWAGE SYSTEM Count :
Labor and Human Relations INSPECTION REPORT St. Croix
Safety fety and Buildings Division
ATTACH TO PERMIT) Lot 29 Sanitary Permit No.:
GENERAL :NFORMATIONNiN4,Sja4, ec.21,T29-'R19,Jacobs Ladder 149135
Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.:
Sam Miller Hudson
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/~a.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Doti g s ,l?
Aeration Bldg. Sewer
Holding St/fit Inlet
TANK SETBACK INFORMATION St/ W Outlet 12. g!o'
Vent
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD n~.~--
ir
Septic NA
Do ' NA Header 4Maw..-- ~L 23 96
Aeration NA Dist. Pipe
Holding Bot. System R5's
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand /H4,
GPM
M061 Number
I
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width /8, Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING acturer: INFORMATION Type Of Cc-ruf CHAMBER
. Mode Number:
System: I yIeo OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length -1-V 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
4/0" C+ Bed /Trench Center G Bed /Trench Edges 44Y Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
code discrepancies, persons present, etc.)
COMMENTS: Include,.
f
Gil
5,T,
,
~0" ~ r r ~ y type.
Plan revision required? ❑ Yes 11plo
p
Use other side for additional information. 8'~ 0
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION
T. ILHR 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 ❑Q4.0.3to
arc)
8% x 11 inches in size. hec .f ev revtous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
L APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
Q i l r- IVLil 1/4 S u/ %4, S z T Zf , N, R/ E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
o oz Z.-7
CITY, ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
s WZ _ryrv 31T4 2- 74s9 6 Z-,
11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
State Owned ❑ VILLAGE4~ Cry Jaco L s ! d~
❑ Public ~ 1 or 2 Fam. Dwelling- # of bedrooms 3 PARCEL X NUMBER() d
III. BUILDING USE: (If building type is public, check all that apply) Q Z~ - Z SO - 1 O
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ® 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
130 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
SC) -J ZO Z D Q. z. S 4-3 0 Feet 9 So Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 1000 /
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 mps) MP/MPRSW No.: Business Phone Number:
c„ fro h1oo.~r` z `r7 32 j
Plumbe Address (Street, City, State, Zip Code): 01
* 3 jkujil~ ' cV, I /
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sa ary Permit Fee_lknncludes Groundwater Date Issued Issuing A pm Signat re (No Sul s)
Approved ❑ Owner Given Initial I __(lvb harge Pee) ,Q
Adverse Determination v
`r
46212
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
S T C - 100
This application form is to be completed in full and signed by
the owner(s) of the property being developed. Any inadequacies
will only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property SL,y, /h,` 14 -
Location of, propertyA/A/l/4 59/l/4, Section Z-j, T_~N-R_~fS
Township
h
Mailing address ,8o Y` 2 RZ
Address of site Ta~ed~ Lam 2q
Subdivision name_ Lot no. z y
Other homes on property? yes X No
Previous owner of property /LJ ~/erg so
Total size of parcel 2.810 XLme
Date parcel was created
Are all corners and lot lines identifiable? __,,y Yes No
Is this property being developed for (spec house)? Yes No
Volume SOS and Page Number q4Z., as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. ~3 s 1 / 7 , and that I (we) presently
own the proposed site' for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No. X355//7
Signature of ap'~ icant Co-applicant
Date of Signature Date of Signature
0(?(7.I)06Ifrll NO WARRANTY DEED Ills s►A l a1.9r1oHIr roll aU.r•ab.N•. U•1n
1;TATI: 11,\It OF WISCONSIN F(IItM 2 -1902
43%5417 i.• REGISTER'S OFFICE
~ NL~ ST. CROIX CO., WI
Recd for Record
Virl:Lnla M. Hanson, a single woman
M~ It ~ 2 tae
M 8:00 A M
r1n11r~~ and n.1raill., to Sam E. Miller, a single mall
'L
u• .:on •n
the foll••leliov de.rllhe•1 real estate in St. Cruix
Suits! of wlscomin:
Tax 1•arrel No:
West Half (Wt,) of Lite Southwest Quarter (SW'j.) 411 Section
Twenty-one (21), Township Twenty-ni.ne (29) North. Range Nineteen (19)
West, St. CroLx County. Wisconsin except Litat jtart South of Lite r•ublic
highway and except Lots S, 6, 7, and 8 of Certified Survey Map n Vol. 6,
Page 1747, Doc. No. 419479.
That part of the West Half (Wig) of Lite Northwest ouarter (NWIt) of SecLJon
Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West,
St. Croix County. Wisconsin lying; South of Lite right of way of the
Chicago, St. Paul, Minneapolis, and Omaha Railway Company.
'CKANSF•bh~ O
EEF
This is not IJm11(•11•all 1•rnl.rrl;:.
Yolk Its lint)
Votrrl.'iml t•..rarranlies: easem•.nts of record and pro,-ective covenants and restrictions
of record, if any.
14114d tills I dad of M r ( 1., 1!1 88
V.I rg;lnla M. ilanson
f
i"EA1.1 ISEAI.1
AUTl1ENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
1 ss. K_14!
l \ `k County.
authenticated this day of 19 I'rr-nnaliv rnme before nip this day of
Mpl .L L 111 88 the aloee named
Virginia M. IL.'Inson
TITLE: \IFNIBER STATE ItAlt OF WISCONSIN
(If nest.
authorized by 706.06. Win. Stal.a.) In n1r Ln1•un to hr Ihr pr.T_011 lc ho r%rruled the
famlroill ' trunlenl .11101 .1i"MolO r1014e tile S.11tit'.
T•1 S INSTRUMENT WAS DRArTED nY V'•
l.ois•A. Murray, Heywood,. Cart S Murray ~ILQ17~,.
P.O.' Box 229. Iludsltns Wt... 54016 y
(Sieonturrs may he nut or arklm%vird;md. llall, ?I• •u•ri V,n U `R.>rlllan••gt. i If nnl, slate e:I. ratio•1
lire lint nerrnuu'y') dag,• •ZT IAPI .1
•N&Mn n( Mrw.m Pinning let nosy rp.n.ily •L...,••1 1,. I.•..' • 1, .a-4 I ' •1,••
WARRANTT DUra STA'M OAR OF %%1%('(1V' 114
N•. •.+•n I.inl 1'1a•
YrplM N• t-- l,.J it
r
SEPTIC TANK MAINTENANCE AGREEMENT co
St. Croix County ~
n
OWNER/BUYER o
ROUTE/BOX NUMBE Fire Number d
R f~aX d
CITY/STATE ~r',~~~~-~ ZIP
PROPERTY LOCATION: 6Wk, Section -Z / T2 N, R/Zo
Town of orr St. Croix County,
Subdivision auks l.otiLot number.
Improper use and maintenance of your septic system could result in W
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed' 's'ept'ic tank pumper. What you put into
the system can a ect the .unct on of the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents'•MaZ be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whi.c 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. 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-
to Certification form completed
ment Natural
and returned
of the three year expiration.date.
r
SIGNED~_
DATE -t 1--
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 & BUILDINGS
IN~UST,RY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
(ILHR 83.0911) & Chapter 145)
LOCATION: ' SECTION: TOWNSHIP/ MltffdtefPfrethfil': L.: S~ JBD1NNe i,Aw /4 /4 '2J /T0i N/Rill E (orW Sa-U .:11 L
COUNTY: OWNER'S/BUYER'S NAME: ILING ADD ESS:
6rC,Qb►x 'SdMM ►LL•12 MArR60Tf6RaoK &I ~u&Sdti 1 s40/6
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: I DESCRIPTITION TEESTS:
LYResidence / /N XNew ❑Replace P~' 3/9?/ ON H t/l 15014.'S v 5C5 So) LS uLy /99d
'BrCz- aURkN14&t-f
RATING: S= Site suitable for system U= Site unsuitable for sys e
C~STIaU. MQ_~.❑~ INGXS ROUND-POURESSURE: EM-1OUN-F on~
D
If Percolation Tests are NOT :SIGN RATE: required I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: CLASS Floodplain, indicate Floodplain elevation: A
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH 0 ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 0.2,5 S9.67- o C >1615' 1'2'BLCIS /4"'&4L /4"I& mAs 73' ,R~I✓hs~G~~'Gob
B- 2 9.33 p.Sb N >9,33 c-M 0"84m L ?7'$la1,) JMS44Gt:
B-3 .50 89.SL ND > ~.Sb J L J Nl" 21" R~ 5260K MS-~cole, 0~ f1•`~
Rmh 43 eu 2
B- 4 9 9z 89.'52- 0wc > .9Z W-rs P
N
B- 111s ~ceb4s4
5 ,S~ p.3TS t~oN>f > ~•'S~ T.~.2 $a+~L 2a $RN Z3 R IMS~b(i>e
FB-
PERCOLATION TESTS
TEST DE_ PTrI WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER ffpY~f11~1 AFTERS ELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- ► 3.Z o 89.66 > Z > 2 > <
P_ .10 Now 90 So 3 Z > <
P- 1-15 bmtArt 8q,(.0 74 >z >z >
P-
P_ EVATI Q AT Pike-
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
SQL
of land slope. IA 1>9:
SYSTEM ELEVATION 86.46 _ (
N
4,
Ins
9V. ~ E~cNMA~ I
q
EAS-r
Nc*,'r►a -
AT
3
CORNER
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e~~ lDO _
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E
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l OW Cen
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1
La-r Z.9
I, the undersigned, hereby certify that the soil tests rep is form re made by me in accord with th procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded an p~ g lotion o~tfxge tes{s are correct to the best of my kno edge and belief.
q
NAME (print): 1 TESTS WERE COMPLETED ON:
Novo-Y Imi{50xi 36N Sd>u 5u*y NL ,C _y 3) /p /4/
ADDRES CERTIF CATI04N UMBER: IPLIQNg~ NIJ~ER(optional):
vas, I.J, Spa i L4 S ZZ
CST SI ATURE: \14A
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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- - ---I- - - -J
,~--AOMMERCIAL TES ARATORY, INC.
-514 Main Street, P.O. A
B
Colfax, Wisconsin 54730;:n
715 - 962.3121 -
800 - 962 - 5227
1
ST. CROIX ZONING REPORT NO.: 20815/01 PAGE
ST. CROIX COUNTY REPORT DATE; 4/13/92
COMTHOUSE DATE RECEIVED: 4/09/92
HURON, WI 54016
ATTN: THOMAS C. NELSON ti
r
c~
(qq13~
OWNER: Sam M i t ler
'I LOCATION: 509 Jacobs Ladder Ct., Hudson
COLLECTOR: M. Jenkins
DATE COLLECTED: 4-08-92
r TIME COLLECTED: 10:00am
SOURCE OF SAMPLE: Basement pressure tank
DATE ANALYZED' 4-09-92 .
f.
TIME ANALYZED:2:00pm
COLIFOtM: 0 /100 ml
F INTERPRETATION: Bacteriologically SAFE
NITRATE-N: 3 ppm
Above 10 ppm exceeds the recommended Pub L is
Drinking Water Standard.
Coliform Bacteria/100 mL
Nitrate-Nitrogen, mg/L
0 z m ,
T: o Ln ~ ~
LAB TECHNICIANS Pao Gane N
.~'tlWEVENpEN' 1
WI Approved Lab No. 19 Z
s
~ A
A ( Means "LESS THAN" Detectable Level Approved by.
yA
~aao ® PROFESSIONAL LABORATORY SERVICES SINCE 1952
1. - _ _ _
IF
ST. CROIX COUNTY ZONING OFFICE
St. Croix County Courthouse
911 4th Street
.Hudson, WI 54016
^ U
Telephone - (715)386-4680
W
Yv
The St. Croix County Zoning of f ice of f ers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion 21 this form Ja gssential &Q that _thS property can Ig
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING------- -------------------FEE: $ 35.00 ~3s•`~
(For nitrates and coliform bacteria)
WATER TESTING FEE: $185.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION FEE: . $25.00
(Determines if system is properly functioning at.*time of
inspection)
PROPERTY OWNER'S NAME: 5a.ryx A MCC
PROP. ADDRESS : L 2!Z olos Lc~ •e[ Covf`~' CITY - o
Legal Description 1/4 of the 1/4 of Section c-9_4 , T 2- N-R.~g
Town of #~udtio!n Lot Number Subdivision:
FIRE NUMBER '50 LOCK en • /-z~"1
Color of house L-r gCa-In Realty sign by ouse?__tIf so, list firm: t%4
j2art~ h
PLEASE INCLUDE, IF AT ALL POSSIBLE, A NAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water, line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services: ea 4V
Telephone Number 7~S- - 2 0
REPORT TO BE SENT TO:
CLOSING DATE: IT 71
signature