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HomeMy WebLinkAbout020-1123-20-000 ry o _0 °o I ~ °o• I a p ° ° O ~ of (D (D c c o N Y~ I I rnm o ~ N M 0 d N N I ti N I Ep E. i c) t U y Y m cD~o a I I i ~ U N _ CL € N I N N CL N N 0 oaD a o Z o2 z I o 6 LL o O LL o 3 °o ° c 3 °w I E Q I M ~ M v y C I ~ Z N ~ N I w E E a' v ~ ~ I 'c I z 'O I € ~ I N Z a m a m H I _O I O Z :t C c~ ~ ~ a- 7 N ~ N w N Z O O O O ~ ~ M I 7 N N N 7 ~^/d1 'C m 0) C m N N N N N • d N (~D N N N a O a O -0 c 10 5 Q zmz z°mz N cc z aci m y E c 0 to E ? N N N l~~~11 O i ~ R ~ W CL Q) U) N 15- N N to N N y O y A? o c a .o L o c a - lL N CD fA fA tl) O y N 0 o 0 o z ^d X0 am X00 co •N _ a a a0 a a a y ~a a N U) -1 0 (D CD I O N ~ I j N N d f0 i y Q Y` Q in y O y C Q O E j O U U -~5 C C N (D U j N C L N d U) U) d _ d O O N F- c€ V V E E R d N V a~ ~ w~~ o CO 00 .N°. a) H H ~ L~ r; l ° £ N h O LO O t/J O N L R o N E E R U I Q 0 0 2 r Z N z m U r O Z y r2 U v v~ Y, mCL IL Q u N ate JCL N N N 2 c c a r- a • FORM - STC _ 104 AS BUILT SANITARY SYSTEM REPORT OWNER _ G h y. C ~ (-K 1 V fl AA TOWNSHIP k U 030M SECTION ( T_j~l_N-R_L W ADDRESS __4 (9 ~e u LANQ, ST. CROIX COUNTY, WISCONSIN SUBDIVISION ~AG~e 1~1~01 LOT fv~ LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Well O 3 BeDR UUrn Horne TN 9`/-3'S out 9VAY Sept, o 35' 30 a' By 1 I RUN Vw 1 v-e 17' 7 y,. V O I D 5 y s~e r►~ a(axSJ ~ , 8eD i 10' I ' INDICATE NORTH ARROW BENCHMARK: Elevation and description: loo. (j -NO &Kw P o ~ Hov se Alternate benchmark 1' USIN~j SEPTIC TANK:Manufacturer: O) U N'., Liquid Cap. 106 ~ q p Rings used: Manhole cover elev: Final grade elev: T Tank inlet elev.: Tank outlet elev.: 9$3--( No. of feet from nearest road:Front , Side , Rear Ft. From nearest prop. line:Front , Side , Rear Ft. 15 No. of feet from: Well. H ~ , 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 y.~~S NeAO~~ 9 a.8 9- 9a. 8 9 /00 . L30 SOIL ABSORPTION SYSTEM IWy . ;F-,~~ g, r _ 9 a ~3 I a.q a Bed: Trench: Seepage Pit: Width: a Length a Number of Lines: c Area Built (vQ Exist. Grade Elev. 97, '81 Proposed Final Grade Elev. 9~0 3 / Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side , Rear/ Ft.Qj No. feet from well: a~ No. feet from building 3Q1 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 : 3 I PLUMBER ON JOB : LICENSE NUMBER: 3 4 y 6/90:cj . r, . h V0010? DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING *LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MA jSO W1 53707 ate Plan I.D. Number: NN~4 , ~ E o Sec . 7 T 2 9 - R 19 St assigned) CONVENTIONAL ❑ ALTERATIVE (If Town of Hudson Krattle Lane ❑ Ho ding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMI HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Chuck Chirhart 419 Krattle Lane Hudson -q.11"119 / BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELE r' 4 Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Jim Boumeester 3404 St. Croix 128870 SEPTIC TANK/ MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: vD 1 / 7`• / YES ❑ NO ❑ YES NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER UMBER OF ROAD: PROPERTY' WELL: BUILDING: VENT O FRESH ALARM: FEET FROM LINE: / AIR I T: ❑ YES 0 An~ ❑ YES NO NEAREST "JS -"~jZ R: MANUFACTURER: BE PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: UMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN F ROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAR SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: METER: MATERIALANDMARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue. CONVENTIONAL SYSTE : ;t U~ I~o~~r~in o - 91-77 ' BED/TRENCH WIDTH: L NO. OF DISTR. E SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS /112 1 GRAVEL DEPTH FILL DEPT DISTR. PIPE DISTR. IPE DISTR. 2PIPE WATER IAL: O. IS R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE CO . ELEV. INLET, ELEV. END: K PIPES: FEET FROM LINE: i A IRINLET: r ( G n l41:5 ~ rA - - -1 -7 41? NEAREST e1~ ~ ~ MOUND SYSTEM: 9 G'eb taie. 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 OV VER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER:. ED ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LA SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD AL: NO. DISTR. ~DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: ES: DISTRIBUTION -HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: L LIFT CORRES DS TO INFORMATION APPROVE _WIN ❑ YES ❑ NO - ❑ YES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM ❑ YES ❑ NO ❑ YES ❑ NO NEAREST --111I ot~_; ?,~.e' , ~,~:r,~.r~.., clv,:-u--~ err r~c~ce2d .~~e-, guy'. 1901i~ -tv Sketch System on Retain unty file for audit. Reverse Side. IGNATURE, TITLE: SBD-6710 (R. 06/88) r ff!"OcILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code S1 c,9~) STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /~j / 8'f~ X 11 Inches in SIZ@. Chec if r vis on 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 OWJ~E~ PROPERTY LOCATION 1AC-~_ C AID P C,2)%5E S Ta7, N, R E (or) PROPERTY OWNER'S MAILING ADDRET LOT BLOCK # y~ I RA e Il K _ CITY, STATE 121P CODE r PHONE NUMBER SUBDIVISION NAME TR CS NUMBER y Sc l S air f-) 09.K 171 VILLAGE ' NEAREST ROAD t II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ Public W 1 or 2 Fam. Dwelling~# of bedrooms AR L TAX NUMBE 111. BUILDING USE: (If building type is public, check all that apply) ao s 0 a(S 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 90 Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. El 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 u REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 1 S d 15 72 C q / e l3 Feet 1 Feet CAPACITY VII. TANK in allons Total #of Prefab. Site Fiber- Exper. INFORMATION New i s ksGallons Tanks Manufacturer's Name ref Concrete Con- Steel glass Plastic App Tanks Tan Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber N ~ OIL) i "N fl, F-1 + D M 1 0 0 1 0 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: Im 804M~,~Aejz o-yu - )38(1-2046 Plumber's Address (Street, City, State, Zip Code): oN S IX. C LINTY/DEPARTMENT USE ONLY Groundwater a e ssue issuing A nt Signatu No Stam ❑ Disapproved Sanitary ermit Fee (Includes Surcharge Fee) Approved El Owner Givan Initial Adverse 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 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 septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning'ybur onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 6138-266-3815. 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. It 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 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 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; 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. I SBD-6398 (R.11/88) APPLICATION FOR SANITARY PERMIT 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 Location of property 1/4 ~ 1/4, Section , T ,4~ N-R 15~W Township Z~a 01'5e)1) Mailing address Address of site _ -~x/ V Subdivision name Lot number Ck! c' Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _-Z-Yes No Is this property being developed for resale (spec house)? Yes 0 Volume/ and Page Number 1~ n 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, and 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. ; 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 construction of said system, and the same has been duly recorded in the Office the County Registe f Deeds, as Document No. ✓ ure of own P~F Sign u of Co-Owner (If Applicable) o Date of Signature Date o Sig ature 11;7 11PTqvppj11qMqr t..;,1M." i't4a~~aJic/a y k { _ - I ~ 'tid i1 ;4W. fl``t 011 On ,P................................................................... 4 3. Awi. ae. L x. 1-=~~ atir. P1•~~•.. Y 1 + .aw..ar~.. St.: Croix Coants, i _ d il!w:. Tax Peed Nr .litag1i: R1d~ a rural subdivision located in the Southeast Qwrter N" `3Lge.7. Xaah;P 29 North Range 19 West. Torn of Hudson. fc i S homestead rrcrertY• TMs W (is tot) Mott to warranties: e , dents and restrictions of record. June day of . - . . . . . - . IN" d& 140.6a" SE w (SEAL) AL) ii M~Alltstur......-. ; • 7~~ , (SEAL) C~~C~ (8EA~•1! er a/k/a Hope Yde~tt n t Hope L. iAlZ AIITB>•IfTICATION AC=NOWLXDGKNNT STATE OF WISCONSIN St. Croix ouaty. yt 1' C sttGod"M ab ........day of 10...... Personally came before ate itgr et June , 19 tM: Jerome W: FIcI~YTister and Hope fnft side' . - alk7a Hope .Y : noel tz NcATI i ster ° TIM- MEMBER STATE BAR OF WISCONSIN aMllselfsi ; 706.06. Wb. Stats) to the known to be the person who ss:eeotOdo . . foregoing instrument p the same. t ' ~ TMes INSTRUMENT WAS DRAFTED BY ..Bmdosxvirbi...ALtarney..:at..i.aw.. ~ t. i -.SIO_~t~,_...~{uQBall.. ~i ~Q)-fi.......... Notary k St .y - , - Commhuion is permainTdat. (tfsot, state atsF be authenticated or acknowledged. Both my , . ;•Y 'as1► wry.) date: i 4 eetw/ coif b ow emwft .bound be bDed or prhMe blow their Herturea r ~ -0 °o -00 ov Ooi Oe°a HMV 0 0 o o0 o ~ ~ I Eb c O ~ O w E L O X Vl ~ rn o I ~ Y N m U C O 0_ d N ~ 0 (D m Z O L C z ii o m m ~i o .2 3 Q m v) E Q rn L Cl) Co _M z m w U) E °o` o 'a Z `m a) 4) nHZ n.m am 0 E zv" c L) ' ' N d Z ° 2 o m F- rn rn z c E c -0 v a ch N O N C .1 ci f'n n ' Q N N N N U) N U) a _ a o d Q c -o w N ZmZ zmz 0 v, z E (V m O m CL CL v N O H 'r O c (L 0 0 (L rn FS {yam Fy a in a CO W N O S i S 7 O N = O r,. 0 10 z ~Oaaa aaa a w m J U (a rn CA m r O I M O ~l 2 0 0 m o C O co O J~ O N J a) m m a N 'C d Q? (A d u7 m O) ~ m Y ~ Q ~ in m O O `0 Y T C ~ Y2 C .y 00 C O Y E N co O O 3 CD L U a O O \ N H m U C -O N N v ZO N C M O m O O O = N y a~ rn o £ co (D Z C a°i n r m y O N L N O N O • N I-- 7 O LO m O O O 2 z c m U O Z 5 F- CO c l , ;151 R d a m a U (L L; CL 4-, cc CL 0 r`iv E c c - = m r A 0CL2 l0co0 O U) o U) 0 AS BUILT SANITARY SYSTEM REPORT TOWNSHIP 1-4 ,4 q n SEC._ T ~I IN. R I 0, ,ADDRESS i, ST. CROIX COUNTY, WISCONSIN. "i3JIVISIONEaj,> r LOT :2Z` LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM h14? J, j •~o Iw ~ 1-10 A_ i.. l I di ate o thi A}ro SC !)~I _ -j RTIC TANK(S)r MFGR. CONCRETE STEEL NO. of rings on cover Depth DRY WELL tt.NCHES NO. of width length area no. of lines width= length, areal ' depth to top of pipe G GREGATE RATE AREA REQUIRED AREA AS BUILT C: ,sciaimer: The inspection of this system by St. Croix County does not imply complete o*pliance with State Administrative Codes. There are other areas that it is not possible o inspect at this point of construction. St. Croix County assumes no liability for Stem operation. However, if failure is noted the County will make every effort to . etermine cause of failure. GASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST `'INSPECTOR DATED PLUMBER ON LICENSE NUMBER ,M C,C/ z.Lr G , ` REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM 3 F~ ` SanitaAy Penm.i t State Septic_ DAME . Town's hip St. CAo.ix County. Cocat.ion A! Section Lot # Z.~ Subdivi~ion • ,,EPTIC TANK Size l gatCon4 Numbers oA eompantme.nts ` ')i'stance AAom: •We t Buied.ing 120 6Zope- HighwateA 'UMPING CHAMBER Size, gatfon4 Pump •Manu4aetunet Modet NumbeA (OLDING TANK Size, gattons Numbers o6 CompaAtments Pump's n AtaAm Sy'stem ~istanee 64om: Wett Building 120 stope._ H.i.ghwateA 1BSORPTION SITE Beech ..5 . TAe.neh ')i'stance. 44om~: Weett Building . 12% scope ~ H.LghwateA k8SORPTION SITE DIMENSIONS W.i dth 04 tAe.neh At Requ•iAed aAea tLo -{~t Lenqth o6 e.aeh P..i.n.e. At Depth o6 Aoeh bekow tiXe.-~.n Numbers oA Une.s Depth oA Aoc.k ove.A ti. e 2 in TotaY xe.ngth oA f-ine'sjl~ At Depth o6 ti e betow gnade-j~-/__-c_n 046 Lance between tine's At Shope o6 tAench tin. e.n 100 fit l u 1 .1 ub s U&r.1.(:-(.un aAea ~7 2 6t Type o6 Co ve.A: PapeA o- thaw - 'IT DIMENSIONS NumbeA o6 pits GAavet aAound pit's ye's nu Out'side. d-i_ameteA• At Depth be.Kow tnte.t ~x Total ab'sohptio ahea t AAea nequiAed 5t INSPECTED By TITLE APPROVED DATE 198 nf/ _IFCTED DATE 19 8 ;'LASON FOR REJECTION 13-820 REPOU ON INSPECTION OF SANITARY PERMIT # 9 3 (1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection Time of Inspection ~Ix "a", - Name, ess, cense o. BY Installing plum r 3 INST ATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepa a Bed ❑ Holding Tank ❑ Fill System ermanen re erence oin Describe: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: (7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO 8 HOLDING TANK: Manufacturer o gallons construction ; depth to the cover ft; If septic tank is being used are baffles removed? YES ❑ NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ N0; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material ; Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO (13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO DILHR-SBD-6095 N.05/80 Signature of Inspector: I i~' ~ _ : rt _ ~ ~ _ . , {3 y; ~ is i - m ~ _ ~ „ i L.. t e r ~ . ~ 1 • 7 ~ ~ _ _ ~ I . t. _ ~ i - f. - 1 l ` PLB 6 7 State and County State Permit Permit Application County Permit # It' for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: -!,/417 .1 ly -f C/ ;,o ~ Lv,f B. LOCATION: % Section , T251N, Ry E (or) V Lot# 2-0 City Subdivision Name, nearest road, lake or landmark Blk# Village Township ttjCo:1 C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family to"- Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY C (s4~ Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate- ;--Total Absorb Area sq. ft. New I'*" Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: l/ Length ~WidtK~ Depth ~Tile depth (top) No. of Lines 2- Seepage Pit: Inside d' meter Liquid Depth No. of Seepage Pits Percent slope of Iand G Distance from critical slope WATER SUPPLY: Private _ Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, / - „ NAME c t` ! O l~.a f? 5 7 C.S.T. # ' i [ 5 y%nd other information obtained from ri► + (owner/~ q 2 Plumber's Signature P/MPRSW# / 3L Phone 4. 3 Plumber's Address u- e PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. F r x ~t fir' q N L, o-" S fiu,h v v ~m . oe. a iI>r e 41 ar ~7~ r ` oT. 0 zt Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ON_I~Y Date of Application - Fees Paid: State County & Cj Da Permit Issued/Rejected (date) Issuing Agent Name ~J ' *ion Yes No State Valid# Date Recd (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 ,ink copy) 4, plumber (canary copy) Revised Date 7/1/78 EH 115 Rev. 9/78 , f REPORT ON SOIL BORINGS AND PERCOLATION TESTS'. WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICESy P.O. BOX 309, MADISON, WISCONSIN 53701 F ?e . LOCATION: /a, Section T N,R E (or)©Townsh'sp or Municipality Jld q ~ / S Lot No.az0 , Block No. County u ivlslon Name , ` ,Aj Owner's/Buyers Name: Mailing Address: D oroo [ 'u ` tr v~ TYPE OF OCCUPANCY: Residence X No. of Bedrooms -3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X- REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS-3-07--y-ft/ . PERCOLATION TESTS 3---2C-11 SOIL MAP SHEET '41/ NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE R'UM- DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- &rt oZ d D o? d e2 3 P_~ 't it (I. tl Q 3t 3 P-3 51" It It (t A10 PIP- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES S) , B_ ~ 7 tt tt t• a.7 b Q Y.V. 4?46 11 Awe B- 3 6 r' a- [ t (t K k iS~I SVVSi6V%- 7 h j t[ et SIG N 13- a PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plarl the locat* a d are feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy P/ [ icate scale or distances. Give horizontal and vertical reference points. Indicate sll A10/41. 41_4~' 44e• t ; s E E °1°~.._sk^ S E. 1 s.. .A~~ ld/. __.rs AreA_ m 3 do* ( ~N k e 44 RE ~ i ~ t s tree. /$I~A Arc -S 1~4 5 ~ 3 1, the undersigend, 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 location of test holes are correct to the best of my knowledge and belief. q ` Certification No-sr- Name (print) a Address Name of installer if known CST Signatur v A .;-Local Authority `j t. R ~y w 40 a w J 4.5 V) 'SEPTIC TANK MAINTENANCE AGREEMENT - St. Croix County • >z rr OWNER/ BUYER o ROUTE /BOX NUMBER Fire Number ZIP CITY/STATE PROPERTY LOCATION:.' c5 Section T , R_ZLW, Town of l~Sz, _ St. Croix County, Subdivision Lot number o;~U 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'e t'ic tank um per. What you put into the system can a ect t e unction o. t e-septic tank as a treat- ment-stage in the waste disposal system. St. Croix Count residents-may ,£be eligible to£racfailinggrantefor a maximum of 60% of the cost.o replacement 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 .sys't'em 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. H 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 Depart- ment of Natural Resources, ecaoOffice must withincompleted days and returned to the St. Croix County Zoning of the three year expiration. date , A IGNE o DATE ( I C~ St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. `i _ ...____..f-. I . 0EPAF MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY; DIVISION LARJR AND PERCOLATION TESTS (115) P.O. BOX 7969 3707 HOMA HUi1AAN RELATIONS MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: OWNS 1P/ NICIPALITY: ON t t N d /4 S / /Ta N/R or sel-, ' MAIL G ADDRESS: CO TY: OW 14 ER'S U ER'S NAME e L a1 C c USE -DATES OBS RVA ONS MADE NO.6 DRMS : COMM C A DE R O STS: TION: Residence ❑ New eplace v RATING: S= Site suitable for system U= Site unsuitable for system CQNVENT10NA_. MOUND: ( IN-GROUNcD ESSUR : SYSTEM-IN-FILL OLDI~N`G(T 0K : RECOMMENDED SYSTEM: (optional) I'IVS -EIU ❑ Q J t ~U J EIS C EIJ RU If Percolation Tests are NOT required DESIGN RAA~T If any portion of the tested area is in the under s. ILHR 83.0915)(b), indicate: 3 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUM8ER DEPTH.,~N, ELEVATION OBSERVEp iIGff_EST'_ TO BEDROCK IF OBSERVED (SEPE ABBRV. ON BACK.) B- 3~, Ar . , 7 el w yy onf GGD~ S' Al- > a o$' x,13 . 2 'del w gy o~ ccp~ , 7S-` 4s' Z, s. B-2- 9;V /11. 12, r 1 '/3/ s~ 2, 3 3 ~3n i 2, o tan /S~7 I o$'!3^G 9~' 2 B- 19,33__ r- A, b~ ga. /a L r, B- o s H es 13 1 3~ PERCOLATION TESTS rp-2- DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCHES AFTER LLING INTERVAL-MIN. PERIOD 1 PERIOD 2 3 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 EkMTION 91, a 3 A,: 9A p~ o 1114 s.~ I Z Z= o ti Top a~ Glo~k l i t n3 -I Lt ELF CRs+~ s,~~' AA- 1 41 $ rZ3 ; h,'o,► ~i~ Z L,~>e ah ff.'s Gk, N SSE . ~4, ~ ~t,,o f h 141 'pw-1- s sr r s >,(a~~- it I I 44- lot. S''/ S?'~~^ ~ ~ I ~ , ~'74/~G rv ' ~ Crrtf-I /'/rC~,p~v '/~i~ L11y &-5"7't Cow ' )at1k ;iew, 3 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. ZDE 1: TESTS W EKE MPLETED ON: G a ^ CERTIFICATION NUMBER: PHONE NUMBER (optional): S~ s C✓ f S~f o i 6 ,r 3 9-*' 6 P 3 CST SIGN U DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR•SBD-6395 (R. 10/83) - OVER - _ 67 P' "Ross S'E-C'-[-I(')I\l P. B. L. L OTA N I i R OJ EC T 13, L L!, A ' N n M E~"~ t` l r e e r 2 it L O C T 10 N~ 1 z~ I_ I C E N S A h _ P 0 ~I-M >v Ngt T(, f 5\,' Lo -r 13 (Ak V 1W) ti r f3 to <,R l~sRp I ~ ~~tl Leo CAA~ 40 Sylier. S 8,11 P11 A) W ~eQrcuu M ' p~~~ ~v~~zeE lnre►,c~.,1 3 ~~\~►N~ jlvr~e ~ys~"e'r`• w,ll )In~e ~L !,e l L+ CbIJ ~o ~1.1Qt`~. ~ti~~lY ~UVfIr . _ 1 FRESH AI}: INLETSAND OBSERVATION PI-PE C}:nSS SECTION _ - - 1..~~ Approved Vent Cap Minimum 12" Above Cr)tcoa~ r; Final Gr r~`ra A" Cast Iron Above Pipe, Vent Pipe To Final Gradcr- Marsh Hay Or Synthetic Coveri.lig Min. 2" Agga:eg',►I o _ Over Pipe Distribution lr Tee Pipe I Aggregate Perforated Pipe Below g~,R3 Qa~o~ QQ~13cnoath Pipe Coupling Terminating T Bottom of System