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FIL ED m "o13 )984 CERTIFIED SURVEY MAP e Located in the NW 1 /4 of the NE 1 /4 of Section 16, T29N, R 19W, Town of Hudson-, St. Croix County, Wisconsin LEGEND 1 .1 COUNTY SECTIONCORNER MONUMENT Surveyed for: Wesley & Marge Fern O WEIGH1ING 365~BS./LIN.FT.SET Rt. 1 ALL OTHER LOT CORNERS STAKED Hudson, WI 54016 W ITH I "X 24" 1 RON PIPE e 3/4 ROUND IRON BAR FOUND CBUIIi'~! PIPE W N Z r Iv I-3 ~ 1.68 BS./LNFT. SHETG o O a 1, ~0e. 7D6 -/5 C+ r, O (D CD UN-_ ATTED LANDS fp N.~y O to W N Z GQ W O` O McDONALD LAN WEST LINE of THE NW I/4-NE I/4 1-•.O b V W \ _ 21'36'E 310_00 - - f f-+~D C` ~ n b O N L%) W Z r m Z M A j7, I r 27TOOT---I 0'V rV1 11-. 00 -'O a, H 1011 ~ C ~ O 0 - 4 m < 0 I. _•1 I U) I 3T ~ ~ ~J 00 -J 1 (D e h e+ O 0 v N N 1-+ 0 (1) 0 v i lit I i I t c OQ O Cr w W~ n -n m ° O (D ~ W W -.1 Iv lr Z S r+ (D e+ Gl, z m m p IN 10 I 1~ i --O-I-I I OD H ,3 O O O W 4 Z Icy I I~ I eo o 0 0 0 W m_ z°o° i m' W ~8 ~Zi A A i A et I I N I p I O ~ N. I D I- I m j~ Ln~ O Al I < 1 CO 1-+ O y O O UC2 'd Z Z N W n n I I~ N~ O ~1 W 0 a O O p PI O CD J I ro= i N r- lJ1 O A - W W ~1 .p . J 1-r R' K K - - - - - W U., F" cD (D OQ i \ aq 0 0 to IC j W y 1Z C y `~~s9ro 1Z (D y 10 1.6 I-1 PS I 4r 'z 0 O H X 1-4 Q to 4' S9/y \ iD 10 rn Cr CA Q+ Cr I~ fD ~r O Iw O Ip oowrn 0 O ~Z I~ b W GQ H e~ et P (A N 0o N -'0 C+ P, 1 I~ O I- W O 'D u1 0 .i ;V im Ir ID' i -~I .v to O 10 M a. 1cn I I Z W NNW N I-+ H ID Ito W I I NO°17'12 W i OJ O O` N Fn 0 0 (D p' j O O1 ~O n I I y 436.00 -4 CD v~ aD L11 w o P>v 1-r Ln 0 .fl.owop,m w p 00W O x Iz to IN O N A P, In 0 W (D N /A 1P 11-1 0 lr o_ to m N I H (n W 0 0 0 GHQ 14--1 I o 8 WOO r r4 i $ I 1 O O _FD Ig 40' N0017'12!' W I n I-• O O 4-. <n _ 436.00 12 F.C(1 coo lI 140 I ~ 0 -4 N NN W (D td y A i r r- 0 H U11 I I C $ r^ 8 O^ J N W G fv o 0 0 O N 1 I m I < b g a >?+(D N~~ GQ /fir I I° - ~ ~ ~ I oc. I b b APPROVED I° io iT 1 C IN 133' Ig 4360 1 ~~~t I(A 355.00 61.00 JUL 2 3 1984 ;<< g -N0°1712 W 469.00-~ I EAST LINE OF THE NW I/4-NE I O O' O z 0 ~ 0 St. CRO1X CS Iv A m I IZ r_V dARKRKB F IANNiN m COMPREHEN p ~ I I 1 COI 1 G y SCALE IN FEET `4 AND ZO 0 m J11 OMMITTEE z I I~ IA t= 0 -200' 400' 600' 0 I I A im ICn ASSUMED BEARINGS REFERENCED TO THE EAST LINE OF THE I I p ID NE 1/4, BEARING N0012'49"W j~ Vol. 5 Page 1447 E I/4 CORN N0012149" W NE CORNER SECTION 16 1320.50_- l / T29MR19W EAST LINE OF THE NE 1/4-~ THIS INSTRUMENT DRAFTED HY A-f11t~ lc 483-494 a 3 y ~;F T •Id r .gym ~ ~1°'8i: 'ry .x ,J,-:. ,'.2 •RF ( ~./fryd ~ '-a,~y`;~ ,y i^, S1„[ ,.JxR,a. I P FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER r~'" TOWNSHIP=;,s SECTION16, T-i2~? N-R_L~~~W ADDRESS',T ST. CROIX COUNTY, WISCONSIN SUBDIVISION _LOT_I_LOT SIZE PLANLWITHIN VJ W _ SHOW EVERYTHI10 FEET OF SYSTEM t j ('4 r I a.~Y 3L pA. v~ ~ Its i l r 3& r / rr ~ W ~l r Ito 'o• /F ~9- _ INDICATE NORTH ARROW :Elevation and description: Ind - ~,a : ~•„Jn"~.t~, rb = /oa 60 = l.~ a BENCHMARK Alternate benchmark SEPTIC TANK:Manufacturer: La ~ sc,,,e- Liquid Cap. f • e cover elev:Final grade elev: `y- 4-~ ` Rings used.4"Jn l Tank inlet elev.:_I0-~)6 Tank outlet elev.: l No. of feet from nearest road:Front , Side , Rear ~C Ft. 1%S From nearest prop. 1 ine : Front , Side _X , Rear---Ft. 130 5-2- (Include No. of feet from: Well '4ZO' , Building: ~ this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE I . • A i PUMP CHANBER Manufacturer:-J/A 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:~~A',,dTrench: Seepage Pit: Width: Length 3G Number of Lines:_.t__Area Built 7:T'' Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe:- Z No. feet from nearest prop. line:Front , Sided Rear _Ft. Q No. feet from well:_44..r_No. feet from building SZ_ HOLDING TANK Manufacturer: Al n 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 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & allMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION IS 1'9267c. State Plan I.D. Number: 116,T29-R19 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Hudson 4~~ 1 MCCutchon Rd. ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam Miller Box 282, Hudson WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.:/ T REF. PT. E Vl O Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: ,Doug Strohbeen 5432 St. CxDix 128863 ASEPTIC TANK/ /O-so' MANUFACTURER: LIQUID CAPACITY: TANK INLET TANK OUTLE i PROVI V.: WARNING LABEL LOCKING COYFR~' DED: PROVIDED: >Q~p,~ D.S 20-06 YES ❑ NO ❑ YES NO O~ BEDDING: kC-Ni DIA.: VENT MATL.: HIGH WATE NUMBER OF ROAD: PROPERT WELL: BUILDING VENT T RESH I! p . % ,/H c •v ALARM: FEET FROM r-- LINE: ! r IN T: fir'" ❑ YES NO 7 Gam ❑ YES NO NEAREST AIR All DOSING (CHAMBER: MANUFACTURER: D CAPACITY: P L: PUMP/SIPHON MANUFACTURER: WARNING LABEL PROVIDED:OVER ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA NUMBER OF PROPERTY WELL: BUILDING: VENT LE FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO 'MAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENG DIAMETER: 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 SYSTEM: 90' e , Il`. ° Z- FO' WIDTH: LEN NO. OF DISTR. PIPE SPACING: ]NO.PEI OVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH / TRENCHES: ATERIAL: PIT DIMENSIONS ~j 3 l0 A-111- GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. P E MF~TERIAL: TRNUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PI S: ABOVE COVERELEV. INLET: ES y0 S: FEET FROM LINE: , AIR INLET: (Q ` a g7, g7,~J ~e~la4~C VCS NEAREST >7ar J~c~ > 9Q MOUND SYSTE ' 13, 3 S' 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 TREN NCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATE SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MA LD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND : DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER AL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST R tain in county file for audit. Sketch System on Reverse Side. SIGN TUBE: TITLE: SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION 1LHR In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY PERM # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 4j 8% x 11 inches in size. h f revis n to previous pplication -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 . X11:1A. Y4 E Y4, S T--.)-,F, N, R E old PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER o G !o y 7 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE : Ct~.S© ~ L ❑ Public 'Ad 1 or 2 Fam. Dwellingsof bedrooms E2 4OWN OF: 10AZ ~ AR TAX M R ( ) III. BUILDING USE: (If building type is public, check all that apply) J 7. / 8 1 ❑ Apt/Condo / 2 El Assembly Hall 6 Medical Facility/Nursing Home 10 El Outdoor Recreational Facility ❑ 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 12 ❑ Service Station/Car Wash 4 ❑ Church/School 8 ❑ Mobile Home Park 50 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 4.0 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 In 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 ~sb /S ( 67-72- L 3 ?S, Sw Feet $ 8.94 Feet CAPACITY VII. TANK Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank Oo Se/ - -X-+- 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 Stamps) MAP/jMPRSW No.: Business Phone Number: Plumbe 's Address (Street, City, State, Zip Code): Fw i S IX. COUNTY/DEPARTMENT USE ONLY If I ❑ Disapproved Sanitary Permit Fee (includes Groundwater [ate ssue Issuing A nt Sio Sta ps) Approved F-1 owner Given Initial Surcharge Fee) 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 ~ 'fir 'A.♦ INSTRUCTIONS i 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 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. 111. 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 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 stiff 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) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 7969 ON WI 3707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOW HIP/MtiN~GA4LL~Y: OT NO.:BLK NO.: SUBDIVISION NA E: A/ vi 1/4 g N '/a /T29 N/RAE (o W ua CS 11; C 19 COIJNTY: OWNER'S BUYER'S NAME: MA IN AD R S: C_ MADE USE DATES OBSERVATIONS NO. BEDRMS.: COMM R A DESCRIPTION: PROFILE A 4I N STS: Residence to 8fNew OReplace T ! 9d uc-r ~4 /99 6 BLS v- SO /LS ' ~kCz ll~~K.uAk AT RATING: S= Site suitable for system U- Site unsuitable for system CO,NVENTIONAL: MIN-GROUNDF~n E:S ST M-1❑uLHasGTA K:RECQ~VIOtiY1ENSYSTEM: ►duACptiofiyl~c1 ~~JJ If Percolation Tests are NOT required DESIGN RATE: l• 1 If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: CL ass 1 Floodplain, indicate Floodplain elevation: IVA (7-r PROFILE DESCRIPTIONS BORING -TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHS ELEVATION OBSERVED S HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i0" ZSLTS I S W&L 4il 1 Qu'~►SiG4 B I O.AZ- 82.69 Owl y 14.42 r"Z°80i "aecs~6f- B- IJ-7 B- {).00 96.S o > /U.UV Z' LTS ~S-4. tiIM ~4 a iP cvf6 9 B-d 9.4Z v o ~ >9.4Z '~sc~ " ~ ""~g~QN~►s~fG+~ 3"$p..r3~S B- S g.o$ 5 B4 d e ~9 og s 20g; SITS 1 '84 s, c 1,Y#= B- PERCOLATION TESTS TEST DEP WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 14S AFTERS WELLING INTERVAL-MIN. p PERIOD PER INCH 14 Z -('o > >Z > P- -1. t'. i P. Z- S . No wa4c 9050 11 > > > < P- 3 i -AO 7 - o > 2 > > < P- rY110 C P- All 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 8S 5O ,,,cNM_ a P o~ Tbu T I T ' ( pTZ N 1~ f p t V (~,VT OF Ex t'~ 1 d tat 4A P` I_~= t i I i -t--i 1 S ~To Ca>J~ 45+~ ^4 Y 1, 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: Z4 /996. A DRESS: CERTIFICATION NUMBER: PH NE NUMBER (optional): 3Z ~ ca- d~ a 5fr t~,~>a 5-~ ro ► s 3 CST SI TURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - IV, /o7, /'ham 5'00. co u q Pole. Bo.f n ~i 3o x yo' ~ P P ~ o ii i c~'ryo' i 0 Y 2D V/ 0 R3 M, Tcr' ®F kou5t. 'A ~aclh (a'f%or. E~Y' 100.00 Yeti ' ~ ~ ?pi i yy ~ , t z j { h i ~'1 r 12S Tv Cw.'FmI I~ n ~ t ~ ~f A i ~s I So /y1~ ~/c ~L C• S, rll. 1/0.~ S" PG /yy7 Gof *Y' / ~y s7~,,► sss.sa' - Tb pT Rom Sd boa 1 4 1 i0/ ~ 1,0 O. Q T3 a i~ S ga. - k ►,.Da-) 67. 5, ~ ' ~ ~ 1 1 !I I I . O I I •C ~ ; 1I I z I ~ ~ 1 II ~ rn II ~ ~ 1 I 1 n rn it I!~ ~ rri O S o 1 ~ i~ ~ II 1 l ~ 1 ~ I 1, 1 t*t I 1 I m ( I ~ I I~ 11 , W I a? 1 02 C,_t I ~ 1 1 I rn I 1 l I r I I I I ~ I I f I a I 1 ! ~ I 1 i I n ; -D ~ I 1 j I Z i i n 1 r I I I I I i m !I j m a !I I z C I m e t~ ~ I 10. I m ,W, I ti4 S~ X p -Ar C)" -40 o E{. ~ ;7~ o x --t m 0 r rn 0 ~o n 0 M v sDEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: N[J 4 , NE 4, Sec. 16, T29 -R19 El CONVENTIONAL El ALTERATIVE (It assigned) Town of Hudson Lot Holding Tank ❑ In-Ground Pressure ❑ Mound rr.11f-n'hPr)n Rd NAM F PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: S ~ 'Rc)x 22, Hiiiisnn, WT BEN MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Dnii~z Strohlbeen 5432 St. Croix 1128801 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING. VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: PU MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: MP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: El YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) I ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: 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 SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER PIT INSIDE DIA.: # PITS: DEPTID TRENCHES: MATERIAL: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST 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: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: iAREST MBER OF PROPERTY WELL: BUILDING: COMMENTS: ET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO Sk etch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION ~1LHR In accord with ILHR 83.05, Wis. Adm. Code Cou STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 ~8tf x 11 inches in size. &rOr,,/o 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 A" /t ✓ a N&4, S ~j T N, R I E (o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ff4~~ wz _I all. 381c. Z o c. S_ I'll, z ~o~ s a 1 II. TYPE OF BUILDING: (Check one) CITY ~r NEAREST ROAD d ❑ State Owned VILLAGE' 4~.~~ L~tt,'f~t.~i fLOh ,CO~►'✓ ❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms-3 'PRARNERTAXNUMBER(S) III. BUILDING USE: (If building type is public, check T11 that apply) 12 C, J 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 40 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 4.0 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 ~v G / ~ 40`/ 0.7 Z 149 Feet 99.70 Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank X We S G l _~,___T Ej I F1 Ej 1 0 1 F-1 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 Stamps) MP/MPRSW No.: Business Phone Number: Plumbe Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuin Agent Signature (No Stamps) Approved El Owner Given Initial / s":~ Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: pZ SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber INSTRUCTIONS Y t ' t 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 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 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. SBD-6398 (R.11/88) APPLICATION FOR SANITARY PERMIT i- 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 All//all/ 02 W Location of property ~1/4 ' ~1/4, Section 6 • TN R Township nu'A"? Mailing address jaox Q Z- Address of site /Yl=~c~7F~g--emu Subdivision name C S- 07 3q S-d Z Lot number Previous owner of property Gam/~•~/7 Total size of parcel z S© ~5 Date parcel was created Are all corners and lot lines identifiable? K Yes No Is this property being developed for resale (spec house)? , Yes No Volume IMP and Page Number SQ 7 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. /f 3 a~~ 414 ; 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 dui' recorded in the Office of the County Register of Deeds, as Document No. 41 ~ 1 Signature of Owner Signature of Co-Owner (If Applicable) /v - I -10 Date of Signature Date of Signature A.. .WIG "APR ..iu.ay......«w«.NA •....w.•... and waeealNs N «lirs...ILtllot .a..a1a81~a..paraca..N 9143 •...•N•..N. M.M...•..aN...N• - f .Y•NN.W •N.w..w. .««..N•N•.......... . .«..N..•N..••«..NN.«.««Y «..N.« S .....•.....N...«. w s .......w......w»....N............ «....N Nw.i«.w..•«w«.w.w...... ••.N..•..•..•............................................ ' 1181111N M W.......•. wYN..~../M.•.NwM•N.......... N...................................... . w....N ««•Nw .w«..« • dsIllfiMd eltl#N y w w.... ..C.OSIIt~ t 3 TM Pwsd lM eMNOt verter of the Mostheest Qnerter of Section 169 Toraship 29 ' I"tSt.' Cross Coaaty. ` visconsin alcsrr Lots 1 !hro ti. ~s ` 4 r l~ttw~ 11~ !sled July 239 1984 is Vol. "S", PsBe 1447u8. Doo6 41 c. . •oo. .'"193! s 3034 poet to dm Declaratlea of h+otect:ty* COVORS tte dated Februsi 13 1983 ` r,sdy, ~tM o!lios of dre.Deiister of Deeds an lrbree" 18. 1983 is Vol. 706. la8e,'Me. ■0. 39!808. a Wect to an-exclusive easssimats of Mont for uss of the 66 loot road first *y 3•4f the 'MW Me rationed Certified 8arrey Map. i to tM "tattitiaa 161100 A6100iiieot betwen do State of iiironeia el In';~nr d Yeslep lara dated 8epteaber 139 1979s ssoorded P04 ss 3i. 9 1979 7!"!a'Vol.` "601".da PW 639. Doc. No. 360128 for the aeiateaeaos of-3 Aeass'"letwe!~t1r BY k o! 8s k o! 8eatioa 9-29.19 sad Dii k of a k of 1hZ9-19.` j. Z.+. beamed N». l•MYi.Y N •i'~ . tjd~ 9 ' ~~r fr.m'~> N w . dq of ...................(BRAL) ~ts•~! ~w~ ~osys.ZLeias.Man- ^«L~ . if •N MMAL) lesa..........(S=AL) SOL* • s~ Fern ADT]EXXVICATION AO=NOWL,DOXXXT ~(eI .w...»....... STAT11: OF WISCONSIN llMly Mle »...-..d.r .~..........N...«........, lS...... ST&SI ...................ceuetr. , Pe*oonally eons btfen aN thi... ...d.r of ..'.....-..w........•-..»..» ~~«1ern.slkla.tilts llgr, ti.. z' T"' 31MM M BTAM rose W wISMICSIN MdWIW to I" known tt► M the x t wmm s........ who mfty d ; 41 r•, THIS ""WRIMQ"T wAs DNA"" By 9. t ~ A tM N1M. ; a]... w..... . • ( ....................p... N CeoMY, is-- ~ "t f•) atLllelltk~etei K reknewtea~++l . Ibth Kp N011-Cy nmmi~.atn Public hi... St... CxD~ Lf,~ itlon ; !IY dates W •w•r14~ tAwN M br.d .r nrlM•,l Wow tirlr sltreaurrr. - NNW STATIC sA/t Ot ~VIfICONgItY Von" H. ems. lpf wl...wsh L.nl UMM Cw Iw ,.fir Raw % ~ . N SEPTIC TANK MAINTENANCE AGREEMENT I-A St. Croix County OWNER/ BUYER ~w M~ Iyl % j' _ p Z ' .Number , V ROUTE /BOX NUMBER q z_-1 Fire o CITY/ STATE Hd3 wit ' wl-- ZIP .5- ~ PROPERTY LOCATION:~Section lo_, T_aJLN, R W Town of klid<an St. Croix County, Subdivision G - S ~'I 31 So Z Lot number Improper use and maintenance of your eptic system could maintenanceresult in con- its premature failure to handle wastes.- Proper sists of pumping out the septic tank every three years or sooner, if needed, by a lic'ens'ed 's'ept'ic tank pumper. What you put into the system can affect t - unct on og the septic tank as a treat- staga in the waste disposal system. went County residents-ma 'be eligible to recieve a grant for St. Croix f the cost.of replacement of a failing system a maximum of 607. o 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 '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 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- W ment of Natural Resources, Certification form must be completed •d and returned to the St. Croix County Zoning Office within 30 days of the three year expiration-date. p SIGNED DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. I SAFETY & UUILDIMG. !":•?'1.1,~Ti±Y; R3;d 0 R T 11 "1 S`'k.3 '~,.731~II 1( . .a DIVISIOrJ s .~:tcr),. AT.UPERCOLATION, ~Y TP.U. !:()Y. 7063. ttrs'~~1Fi HL•l.AT!i:: MAOISON,1l,il53JQt (lLva. tJ~1j:R,Citapter 14b 0?1Fi?; t r .71 l tOrl,-- ~`r _ t f .(:~1 OWWS►~t!/ 7UNIE iHAi I f Y OT !'U 11t PJo SUBUI VISION P N C' ~1 :ivr~~ /I' 14 R 9 E Irrt t t.~.1TY: _ i1hj:.ifl YER S h. t1E: PAA LIN=G AIrE fl1_.... L4 DA 1'l OCt ;E Rv11TtONS MADE y-~- - t fl f r.t) 15 . Cnhi1^Aa Ri:~AL Ut Rlf TfONi F' LL t' .i':ii1P'f tb !$i L.A~TGN-f t:.TS: _!R .sulcnt e _ ~l1 rrrl3wr TXIN DRe I tce ~ _ 7/ 11A1'ItJG• S_j Sit, stutahf.i for system Ua Sim unsuitable for system r_>Aw KoTA d~'Ef•Il1iJN .r ~,:Ot t,.') IN-GF201j;J[3►~11E:>:ltFitr'•: r§7E`yl•1N•fll.l IOl CNidf, T Vh fZECrJ`AMENbtU SYSTEht:(o;,uunaq _ ?IS 0_U [AS L~U CAS ElU rMS C]U. CTS :c ,l~ rt n Tess ire Jo r r_•'`tired OES1c,N R.\ rr ul in., tr. l , If racy c!n,non .tt.d 6r Ca IS yr the rn c Hb3.0t)(5)(h), enehrate: M~ A_- Ftoocfptarn, u,dreate Flooalvlaue el Yit.on 'TFEiE A,~ - PROFILE DESCRIPTIONS;` !Ii:U-FFING TOTAL - P F l~~R Uh?YlATEH INCHES CHAFIltCTE.9 Q SOIL WITH THICK.NT. S, C0LOF1, TEXiUFE, AND DEPIH I,.A,t~tR OEP1H lis, =LF:V~>'i'IOiJ __QBSERVED _ ~S~,w~H N TO BEDROCK IF OBSERVED ISEE AS )F2V, ON BACK.) ! t k g cY 13 L. L; 00 IS,J S l- w-i A- 7. o c~ (3 n/ C S w G 9.00' 9'6.77 J~lort rx 9'• DO'. p , /.4U~.$L' Ll 's•~0~ OK. 13 n/ LS W G-r2.~ B :':o' LT i~_ ~ ,o3•~a r~/G,i_ ¢v. I,o~'~L L~-i.¢C1' D~.. e'3,•/ ~;t--~ ~o,z.d' ep s../ L Wz Cis P-1 61801 e_Cs k~~ 5.c v•50 3L L' 10.90 [-;~,,j 5 L WI&Ra; x.30' 8n4 C4 //i0,71 It1G;V'S 149, /0, SC. 8 °•9 ' p^! :(-i 8.4 'C~5wle t- . 'L r3- A_GIMr;tr PERCOLATION TESTS FEET k TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L V I: IN .fiES ftA fE MitluuS Lll_~"U'E 0=0 2S A1'rERS1'rkLLING INTERVAL-MtN. P --d" -fj (ci em INCH lIELIM 2.(P t N IJ E 7 L c 9• _ . 9 f r: 2 c: 3 a~. !*LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable saill areas. Indicate scale or distaoces. Describe w):at re the hori- intral and vertical atrvation reference points and show their location on the plot plan. Show, the surface elevation at all borings and the daaetlon sad percent r,! Iondslops. YSTEM • ELEVATION . U r _ l > Ot fi fTB~F: r ! t -i-. .i+ , ~ .t t , ~ r..,.i 20, to r t t , t •UfA1 ~t.e•a.•a Kes A •t sill f ~^r• :.i- -I 'r "o r -r .gee a ij i t I ' r) t! 1 + t .~d J c I I C'. d•~ a 4:ci t C.•~ir.. f . _ a . 1 t i-. t r rte'; ``ry! ,r -'(slut _ .I f ~ .~~.r.l~. ~ i i f ~ 1 .t. ..l•Si~1..L~..~. t ~ 4) ~~j6 N~~aaG m ~14~ro.rRt I$ To P o f I, the umlersigned, hereby certify that the soil tests reported on this form were n►'ada m1e ~nPttL'tor6lJith~W rolt.0~Wras an m jdwd api ~V• repo'eDW* W cif6 in the 0ttwonsin `,drninistrative Code, and that the date recorded and the location of the tests are oor the bal;t of my knowledge and belief. ~~AtbtE (print : per TESTSM(ERE COAiPETED ON: [KO-DR ESS: - ERT(FICATION NUMBER: PHONE NUMB En (optional): L i?Aj 51: AGV-.r OIV+f` ZA) s-$a/~,~ 9'"6$ /S 3$6-4O$O s a r h CST SIGNATURE: fMSTRI$UTION: r k'7 p: ig.nef +,nr, nn opy to t rr•wt Auth 7rity prop'.er tY OWr►er aMi Seri Tes:ar k I~ -QVIr'r? ~ .r... ~.,a . y '..i~ s~ NoPfi'h 300.00 Milo S /L Saw, M C•S A,%. 39 So Z `-1 W19- I. 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