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C O E °o c c c v v O N 3 ui d v°, v a OS)' o r CO o f E n a c c\ V 01 ~ l6 N E E O N Cl) Cpy c0 C (A M C O O H N N w N~ _ H F- C N O O O N = O Z co " I ~ I V •E ~a r`1~1 E c c °.3 _w1 A Ua2 IOau Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations Safety and Buildings Division INSPECTION St. Croix SW, NW, 21, 29,19( TTACH TO REPORT PERMIT Sanitary Permit No-: GENERAL INFORMATION Lot 34, Jacobs Landing - liar or view Rd. 149143 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.: 1327 TANK INFORMATION ELEVATION DATA o !I q / TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic UJi P,5~6OA) Benchmark z-7 ' 42,0 Dosing e) 7, 72 d.13< D Aeration Bldg. Sewer dtJ Holding St/joli inlet 8 79( , r TANK SETBACK INFORMATION St/ W Outlet p 166_ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic ~t NA Dt Bottom Dosi NA Header+Men. ?X Aeration NA Dist. Pipe Z 54 Holding Bot. System 17 16 i < PUMP/ SIPHON INFORMATION Final Grade 72 /02' (01 F 107 ,1W 4C:X1 -3, 3r~ v 0 ' Manufa Demand 5 < Model Number GPM Friction em TDH Ft TDH Lift I Loss ea I Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM 9,sG BED/TRENCH Width Length No. Of , renches No. Of Pits Inside Dia. Liquid Depth go DIMENSIONS G / DIMEN I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEAC G Manufacturer: SETBACK CHAMBER INFORMATION Type Of Ceni/ ,t de Number: System: !~c er! 3S - 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/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) & 6/0 e~ Plan revision required? ❑ Yes ❑ No Use other side for additional information. /Q q SBD-6710 (R 05/91) Date Inspector's Signature Cert No. `a Y FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SD r9 SECTION- ~ T a 9 N-R / 9 W !j ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION -,F, LOT'3*-/LOT SIZE 3 rTL. PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 5r3tt-.~ Et.. q7. so' w a, ► I 3 r IV u a , IOO yo i i (y'F' : 4.~~ o or•~ ~t R ~ t s 5~,~ 1 lo' f- S' W. eer tw"' F~ ho 0, INDICATE NORTH ARR R-' der k 4- _ •7 Z BENCHMARK: Elevation and description: a"' Alternate benchmark SEPTIC TANK: Mani ifacturer: Liquid Cap. o00 Rings used: _Manhole cover elev: g42-Final grade elev: /DZ•~o~p Tank inlet elev.: Tank outlet elev.: r No. of feet from nearest road:Front , Side , RearA_Ft From nearest prop. line:Front , Side , Rear Ft. 572-' r No. of feet from: Well 40 , Building: Z!P (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Z4 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: r,cyu! -Trench: Seepage Pit: r r Width:~Length Number of Lines: Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest line:Front Side r prop. K , Rear Ft ..~S No. feet from well: L 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: ,p LICENSE NUMBER: 6/90:cj ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ° ,sr STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than E] , L 8'f~ X 11 If1Che8 In size. Check irev to toarev ous appilcation -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 Sri. A✓ if/'/a W'/a, S / T3 , N, R E (or ,kn PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # .9o Z L CITY, ST E ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM UMBER s o h l~Js o/~ 9 a« oiKs La - II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE : NEAREST ROADI, L 42WN a - U 4 0 Y1 , I/~.Lv ❑ Public X 1 or 2 Fam. Dwelling- # of bedrooms AR LTAX NUM ERO 0,; 00- ' t2)_ 1 _ c3 111. BUILDING USE: (If building type is public, check all that apply) ' Z 7 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. © New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 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 .G ~ Feet S T ..~b Feet ~d Z.o G? G a s 3 D ~7Zc> 7 VII. TANK CAPACITY Site in ailons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank / /0 00 we r- Lif Pump Tank/Siphon 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: oa., j~? -z- z7 3z3 3 Plumber' Address (Street, City, State, Zip Code): X l2 ` ~.Y IX. C NTY/DEPARTMENT USE ONLY Disapproved S tary Permit Fee (includes Groundwater ate Issued issuing A nt Signature (No Sta s) Surcharge Fee) Approved ❑ Owner Given initial / 60/ c3~d p l d 7 7 Axiverse Determination 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 STC - 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 SQ. aj 49l; //an-,- Location of property_5[v 1/4 Allv1/4, Section 2. / , T_2:-tN-R J162 Township t/sor Mailing address .4/~e A(I," ,o ,1 cvs sYv i~ Address of site Subdivision name Lot no. Other homes on property? yes X No Previous owner of property Total size of parcel 2.1,p.3 plc r3 Date parcel was created ` 866 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)?Yes No Volume OS and Page Number y Z 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. I PROPERTY OWNER CERTIFICATION `I 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._q 3Sy/-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. L-r- 3 S~f ignature of applicant Co-applicant Date of Signatu a Date of Signature SEPTIC TANK MAINTENANCE AGREEIIENT St. Croix County m 011NER/BUYER H* 0 ROUTE/BOX NUMBE Fire Number R Zt' 2--- • ' co C CITY/STATE //s; ZIP 62O/G n PROPERTY LOCATION :',510 k► [_4!_34. Section N' R=dD Town of 11' e kte St. Croix County, SubdivisionZa-coi, Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes.. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licens'ed* 's'ept'ic tank pumper. What you put into the system can affect t e uncC on o. the septic tank as a treat- ment-stage in the waste disposal system. St. Croix County residents•m of be eligible tofrecieve aggrantefor a maximum of 60% of the cost .of sys, whic 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 '~s'tems 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)•a£ter 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- s ment of rto Certification form Officetwithincompleted and returned days and of the three year expiration.date. SIGNED DATE ! St. Croix County Zoning Office 911 4th St. Hudson, WI 54016. 386-4680 Sign, date and return to the above address. ti nc't.'.uti+e III NO WARRANTY DEED r«IS Se,:.E RESERVEn $001 R[GnRU,M,i UAIA STATE BAH OF WISCONSIN F0101 2-1982 43 417 r~( r~:c REGISTER'S OFFICE ST. CROIX CO., WI Virginia M. Hanson, a single woman Recd for Record « 8:00 AD~M tnntr•)~ awl tt.,rrnnts to Sam E. Miller. a single man the foll.,win¢ de•scrihed real estate in St. Croix State of Wmconsin: Tax Parcel No: West Half (WI)) of the Southwest Quarter (SW't,) lit Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of tile t,ublic 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 (1411) of the Northwest Quarter (NW's) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolih and Otnaha Railway Company. TMNSV h~ EEF This is not hon,ral,•ad pn'Ia•rt;:. tillk (is not) Fxrel,,imi t,• warranties: easemr.,nts of record and pro,-ective covenants and restrictions of record, if any. aZ ~ S ~ 14tted this t1;1~ r ( L' ! IN 88 f 4iEA1.t iSEA1.1 • Virginia M. Hanson - (~E:11•I I~EALI AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE: OF WISCONSIN ss. ru .1{ County. I authenticated this day of 19 1'ersanall} came before me this y day of MIA 'L , 19 88 . the above named Virginia M. Hanson TITLE:: MEMBER STATE, BAIT nF WHSCONSIN (If nnt. authorized by § 7001,.0(1, Wis. Slats.) In np• 6nmcn to he the pennn tslr„ eseeuled the fort-Loin, trument :1114 nAllowlcdFe the salve. T„'i INSTRUMENT WAS DRAFTED nV u' Lois_A. Murray,•Neywood, Cari b Murray 11 0.' Box 229, Hudson, WI._ 5401.6 `:nla• Alw jr Pt 4y f ~ • ,'nnnlc, R'i<. (Sirnoture•s may he :wlhenticated or aeknowirdued. Both ~I7 ,'.„Ielin M 1AA: I"It'.I If not, slate een ratin.• nre not necessary.) dal ~Y 19f "Name. nr Mr.nm sietninr h, any rq•ar ity •L•.•I'•I 1•• t)I...I .nL .1 I. rl, •r c.: WARRANTT DECD STATE. DAn OF %ISCNN,,V tt,. ,,,rn 1•*el 1!I:,• VnItm NO 2-- 1-~' L -DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, - DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 N W1 53707 HUMAN RELATIONS - (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHI =/MUN+etPAMY; Ls~T~NO.:BLK.NO.: SU DIVISION AME: 5w 1/Ncal/ 'z/ M9 N/R/9 E (or i .~Aco$s AN)+4G C NTY: OWNER'S E: MAILIN A : 5r6b W s,~M M ILl-Ek -aeY Qaox 1oJOS NvIZO N W; 61 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL RIPTION: I R TESTS: Residence K New ❑Replace ~3 91 ~4 9/ vvl~~ 'So,cs x Saxs RATING: S- Site suitable for system U- Site unsuitable for system . NV NT~N~. M~~.❑~ ING~~ ❑~RE:S TANK: MENDED SYSTEM: (optio,41) DESI RATE: u If Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: LrdsS / Floodplain, indicate Floodplain elevation: A V A ha-VT PROFILE DESCRIPTIONS BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH MV. ELEVATION OBSERVED H Sf- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- I ~67 163 Al t44> 9.67 /00Crs 2 " S►L iS''gajjMS 6?h8 MS ►e B- Z /6-A-L 164b3 Nclac ? 10.4Z 'tL l~~ Q 1 C SO''e MS~GK Sb~ CSiI•G R B- 3 /0.00 /02.65 t(oNls > /nho 31" B- ll .is /03.3 40 ME > 9,1s z,. Lc7s /s" us,c !►,5~'Gk sb'' cs~G~ B- S 9.75 inaz4 No NL 9 7"6cCrs "B N L ~s'Gr8 S,C r~~i'I,~r a~'C"$~tu wt4 47091W 49, B- btC.~ PERCOLATION TESTS TEST WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 1DEPTH AFTERS ELLING INTERVAL-MIN. PERIOD P R INCH P. 6 E a;•so 3 >Z >~t >2 < P- Z .015 oue: 04.00 >Z > > < P_ S•ZC .7a > Z > 2 c P- p_ E YAATi xT Ac- 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 ELEVA -7• fob ~ ~ - , i• i -1--l- t t ins F _41 - .72 CIO. a _73) g~a' I, the undersigned, hereby certif that the soil tests r orted on this form re de by ~n accord with the proc ures and methods specified in the Wisconsin Administrative Code, and that t data recorded and t location of the tests are correct to the best of my knowled and belief. NAME print : TESTS WERE OMPLETED ON: ~,dQV •JONnISr!Sw .~01JNScssj o / M1 AODFISS. ' r` Ot CERTI§I ATIQN NUMBER: P ON N~MBQR (optional): CST SI TURE: DISTRIBUTION. Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - Ne r*A /o-" A y L, 3a a r/ ' S a m M: ll c r a' L-r-o b s Lan "-t 3,q S~ sfi `r►. E 1. = g 7. s o ' s~l~ ~i•~". log 1, ~ amore s (B~~ god) ,LJ /'~d v c K-Ar,:Sf BaTr6r. 97 So ' 4` Z Gao49 w~ l t i ~y~Xav vso' U~ 'Zl'~ O 3 J 'fez • i k-- ► 4' -~rl ZS i 1 I I N° ° P-3 1 A T E ` E E P N A A r c t 7 G --~j p B.M. 2~'pP' .cf SE L°~ ~wra~i le't Z ~ j _ ~ I ! I I i c7 rn I I I co ! X Z I I rn I i i ~ I m !i ! rn ! CA I ~ ! ~ t (,,,t i ~ 1 I W I I I ! I ,Ao, 7C) n II: ~ ! I I ~ Z o I ' I -II rn I ~ ~ I t 0 ° I I I w i ~ i ! CA Y rn c a ! --r Z al ~e i -II I _ 4111 S~ x O 0 o c0 cn o ' 'n 9 * _ M b ~ rn O fri L 4, z rn ~~.(n c ,e ~I a