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SANITARY PERMIT APPLICATION couN
01LHR In accord with ILHR 83.05, Wis. Adm. Code
Ezz rz~~
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than / `qGD
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
'/4 '/4, S L? T , N, R /P E (or
PROPERTY OVQNER'S MAILING ADDRESS LOT # BLOCK #
R 4<-
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
OtA_ AA 94 A r-- A.
II. TYPE OF BUILDING: (Check one) CITY - NEAREST ROAD
❑ State Owned VILLAGE : Gd- ff
1&j i 1 or 2 Fam. Dwelling-# of bedrooms TAX NUMB
❑ Public
111. BUILDING USE: (If building type is public, check all that apply) d ai~ - ~l S~ ^ ~4
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 80 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. [N 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 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
Feet i '2SFeet
.0 Q 77• _75'
'FaIr 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 structed
Se tic Tank or Holding Tank
F1 I F-1 El-
Lift Pump Tank/Si hon Chamber
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) /MPRSW No.: Businesses Phone Number:
rQlYt Q~P ~p~~
Plumber's Address (Street, City, State, Zip Code):
A, `~Y l G
IX. C LINTY/DEPARTM T USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing m nt Sign re No Sta
Approved ❑ Owner Given initial
Adve a Determination Surcharge Fee)
0010-
X. CONDITIONS OF APPROVAL/REASONS F 6R DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER~d " y TOWNSHIP
SECTION T a, N-R W
ADDRESS. ST. CROIX COUNTY, WISCONSIN
SUBDIVISION Y ~ LOT LOT SIZE yt V
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
P/' !t A
.44
r ti~~l
~5~
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: 4 IS
Alternate benchmark s_.
SEPTIC TANK: Manufacturer: Liquid Ca
Rings used:.;. Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front , Side Rear Ft.
From nearest prop. line:Front Side , Rear Ft. a
No. of feet from: Well " -,"Building:'
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
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:-_Trench: Seepage Pit:
Width: Length Q' Number of Lines:_.;2' Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: 16-1a "
No. feet from nearest prop. line:Front__y , Side , Rear Ft.7 47'
tp ar;at
No. feet from well:{-'No. feet from building",!5"
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 : -Izza / PLUMBER ON JOB :f$~ds..
LICENSE NUMBER: rs.--
6/90:cj
A
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
• LABOR & HIJMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
CP4DISSIE WI -g-57 2 9 , 19W Sta s fined) I.D. Number:
Town of Hudson CONVENTIONAL ❑ ALTERATIVE (if Fox Valley - Lot # FLI Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: [ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
VA,
BENCH MA (Permanent re.f(erence point) DESCRIBE IF DIFFERENT FROM PLAN: / ! ` / • REF. LFrV. r CST REF. PT. EL
f'ci Q CAS t21">~ y~C~ n J aG. . Q_ (J /l. ( z' 0/, / r d 7 O
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
SEPTIC TANK/HOLDING TA : = o . S5 6
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: T OUTLET ARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
Gc S~ Co's / z6ZI` 98, sZ AXES-❑ NO ❑ YES
BEDDING: DIA.: VENT MATL.: HIGH WATE NUMBER OF ROAD: PROPERTY WE BUILDING: VENT TO FRESH
' II II ALARM: FEET FROM LINE: I AIR IN ET:
❑ YES O `t ❑ YES NEAREST DSO
DOSING CHAMBER:
MANUFACTURER: BEDDING: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: BER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEE LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: ETER: 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 SYSTEAf- Lo pJ - 4-6 ~
BED/TRENCH WIDTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
t t TRENCHES: f MATERIAL: PIT DEPTH,
DIMENSIONS ~ (.01 1 - 7~ " -
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PI E DISTR. PIPE~y1 RIAL: N ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
LINE: / r AIR INLET:
BELOW PIPES'rl ABOVE COVER: ELEV. INLET: ELEV. END: z"// PIPES: FEET FROM
- 'I 6 r 52
tI~ ~ NEAREST ~✓lo. 01 01
MOUND SYSTEM:
Mound site plowed perpendicular 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.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
COMMENTS' PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM
❑ YES El NO [:1 YE~S❑ NO NEAREST
Sketch System on etain in county file for audit.
Reverse Side. SIGNAT RE: TITLE:
SBD-6710(R.06/88) mss.- Zoning Administrator
I-M
APPLICATION FOR SANITARY P$RM1T
STC - 100
i
This application forut is to be completed in full and signed by the owner(s) of cite
prupurty being developed. Any inadequacies will only result in delays of the permit
lssuatice. 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
suld and submitted to this office with the appropria;e deed recording.,
- - - - - - - - - - - T - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Wcat luu . of Property 5C„ z, Section 23 T 2' N - R W
TuwuShip Adj, et'l
1U I I lug Address _
Subdivision Name LeX /5aM?y
Luc Number
Previous Owner of Property rM /per ~il~r/~ Za
Tucul Size of Parcel C12 ae,-es
UaLe Parcel was Created
Are all corners and lot lines identifiable?~ Yes No
1b LhLs property being developed for resale (apac huuae) ? X _ Yes Na
Vulutlle and Page Number .'S as recorded with the Register of Deedu
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
J. Other recordings filed with the Register of Deeds Office
It, addltion, a certified survey, if available, would be helpful so as to avoid delays
6►1 Lite reviewing process. If the deed description references to a Certified Survey
map, cite the Certified Survey Map.shall also be required.
PROPERTV OWNER CERTIFICATION
I (We) ceAti.6y ttJt&t aet 6taatementa on .tUA. 60nm ant .true to the but o6 myua )
l:uuwY~tdge; that I (we) am (ane) the ownen(a) o6 the pnopen,ty de6cA bed in ti
ut6u-,unati.un 6onm, by viAtue o6 a wa"anty deed necoaded in the.066ice o6 the
Cuu11 t y Reg-i 6 ten o6 Uee,4 ab Document No. G ~0 and that I (we)
p4e.6entty own .the. pnopoaed cite On the sewage poa eyatem (on I (we) have
ubtai ned an eaa emen.t, to nun with the above dee en i.bed pnopenty, bon .the
eu►ti.tnucti.on o6 aai.d syo.te►n, and .the came has been duty neeond'd in the 066.ice
u6 the County Regiz ten o6 Deeda, as Document No.
i ,Loy
S1GNn'1uKE OF OWNER SiCNATu" o 'U-OWNER (IF APPLiCAULE)
DATE S1GN1•a)
Un'i'E S1GNL•'D
^--APR 26 '91 14 35 RIV VAL ABSTRACT 3867664AAAAAAAA P.2i2
on -P, 'DOCUMENT NO. STATE EAR OF WISCONSIN FORM 1..w 19$a ' T11111 arAcs RxseRVeo roR ReaoaalNG DATA
WARRANTY DHED
468608 VOL 899 PAVE 552
,E:
This Deed, made between ..9...4`?~rs REGISTERCR01'?CS CO., OFFIWI
Frank LaPlant A.................................... ts in , and each in s„own ST.
.
Xigbt.................................................................................................... Reed for Recar
' Grantor, Af R 2 4111;0~J 1
and....... Randa].1.,...t.b 1; *A
at 10:45 A. M
Grantee, negisfer of Deeds
WitneSS6th, That the said Grantor, for a valuable consideration......
. . . . I I . . . 1. 1 I I
r$4?? nrruRN ra ~~d~c~c~i Lca~rltSS+~
conveys to Grantee the fallowing described zeal estate in
.tr.r..... "261 So.
.ZrtQ •
County, State of Wisconsin :
sC,l"Q~s.-n
cr~2 y0
Lot 8, Flat of Fox Valley, Town of Hudson, St. Cro*
County, Wisconsin Tax Parcel No:
This homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And.......~lOIIld3~.C...MS.a1zd,Fraxlk La]lt
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same.
Dated this ............27;th day of 4Y.............................................., 29
................................................................(SEAL) ....................................................................(SEAL)
. (SEAL) (SEAL)
"
i
' AUT 0 A09NOWY.ODGMENT
Signature(s) STATE OF TMOOMM MI A
ea.
• 71 t?~j.~,AIA.................Caunty,
authenticated this ........day of 19...... Personally came before me this 7:f.....day of
Jay 19.. 9.. the above named
No n C. d LaPlante
n
"t:~ ..?~n . cc~m??a}l ra . 4'.a: _ _i ,his
TITLE: MENEER STATE BAR OF WISCONSIN cxm-
(If not,
authorized by 706.06, Wis. Stets.)
to me known to be the parson ..@1 who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY ,
Joha & Ica_y_ , In _
..Waoc'ibtu-~', hlN 55 BARRY ptaw UM - - - G' r'.Cs.......,•l,~~.'.,.......
----,G00D4M-G6t1 T-Y Notary Public ..........................................County. Wis.
(Signatures may be au h d~r~dri My Commission is permanent. (Ti not, state expjr Lion
are not necessary.)
date. -7:/3 19..
•Namee of persons signite in any espaeity should be typed or printed below their siffnaturos.
z
CA
ST C- 105 r
9
H
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z
0
9
OWNER/BUYER M
ROUTE/BOX NUMBER z0y 'f & Fire Number
CITY/STATE ~°~S 'I. I P 0/6
PROPERTY LOCATION: , S 4, Section__23 T 2y N, R_/? W,
Town of ~pSvtJ St. Croix County,
number
g
SubdivisionX L u t
f
I
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 licensed septic tank pumper. What you put into
I
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new 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 veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- hn
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED
f,- G I
DATE
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION '*P.O. BOX 7969
-LABOR
REANDLATIONS PERCOLATION TESTS (115) MADISON WI 3707
HUMAN
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHI /*t!t ICTP~ 71 : LOT NO.:BLK. NO.: SUBDIVISION NAME:
'/5c WNER'~TUE W/RAM E (o W IU' SONG ADDRESS: 8 'P0 lLeY
COUNTY: O
S-r CedIx p 1'eIcK~88E 13 7 M 'STIZZ
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence uhl New ❑Replace Zk/q9o J( 199 0 enot Sobs G, S8 SOI S &IL ouRK►.IAQIJ~
RATING: S= Site suitable for system U= Site unsuitable for system
O V NTIONAL: MO~1ND: IN-GUND-P URE: SYSTEM-IN-FILLHOLDING TP~JVK: RECOMMENDED SYSTEM:(optiop~l)
S ❑U ❑u
rL~L,NI'~J` S U Es ❑U ~S a krjT) b ~ A1 &t'
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: CLIQss I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH-M ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 ~~.~7 X0.7 dN > I 67 ~r"'BcL:s t6'6aaS,~9'$c.I~CAb~~» 9Z~8~,,cs,FG~e~co
B- 2 o~.Zf > 9.SQ) _410 84-C.-TS I1"ge"&
B- .S 96.3 > 9.~~ %"'fRLCTS 14- S~ 04 kdS
B- o 7 > ~.o / ~$LL-tS 33~~ 4 MS-~GI~ ,~GS4
B- $.0 SI > 5.611 Z"gLcts 2 ANSI Sc 4~`~aU CS~jC~,
B-
PERCOLATION TESTS
bt
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 40010S AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- I 59S oWE 1160:7e, 3 > 2 ? -Z P- Z 4 0 *11E 1 1.2h > > > <
P_ 2. t o c go r) 7 2-
P_
P_ h i w►
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. I
SYSTEM ELEVATION q 4,7S ' lAt
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Tit ANN.
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47/
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LoT LIN
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-70
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40
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print : TESTS WERE COMPLETED ON:
N~~~ ` ~~}-1NSo>t,1 ,o~ sa>~ EY tn14 Ir/<.
1jP4E Z$ t996
ADDRESS: CERTIFICATIO NUMBER: PHONE NUMBER (optional):
VZ s>vcowL 14Ufls4 U
CST SI TURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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