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HomeMy WebLinkAbout020-1174-10-000 ~ ~ o I ~ o 0. 0o is y ~r n c N a ~ I I N O n ~ O t ~ D ~ C d q d 4) rn EZ?5 rn mov o z° € c c. c LL cO m Om Q C O Z yj I 0 O z Z n 64 ~ a m o c v o z Z aoi Z c o N F- (D O N N ~ (D (D • _ O O 0 0) O Z co z Z; m N _ LL 41 N Ql N 72 V x f0 a ~ m C An a) j N N N ) • oaaa ;n a y I co J V = rn rn aNi N r r } 'a Mo CM M O O N M O O m c a Q } to 0 O o V- o w c O o rn 2 w u as o o rn [ F°- c E r N ~ N H C El v. r- b r' O N co ~ N° p yr E R U 04 r- C) r- .w C c `m ~r~w• co a m ° a`r d 0 u c c A ciaa2 I0UU Q Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT &JV ~ ~ ✓ . TOW-NSHIP / y SEC. ~ T ~ N-R~W OWNER J)e_J'Tes, fe, ADDRESS ST. CROIX COUNTY, WISCONSIN CY z.~ SUBDIVISION, i_pr LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYT111HIG WITHIN 100 FEET OF SYSTEM ~C INDICATE NORTH ARROW BENCHMARK: Describe the vertical re'erento point used m ~ cz 5 ~ Elevation of vertical reference pol;v_: Proposed slope at site: SEPTIC TANK: Manufacturer: ~/~57T Liquid Capacity: '4/_ Number of rings used: G~ Tank r-ianhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Rcal : Front,O Side ,0 Rear, 0 l'/U feet .From nearest property line Front,O Side, Rear, 0 ~`I ef feet r 4✓ r Number of feet from: well,;u LW(building: SEE REVERSE SIDE septic tank) (Include this information of the above plot plan)( 2 reference i 9 PUMP CHAMBER Manufacturer: j, Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Len$th:_ Number of Lines: 2_ Area Built:.,,---,2,71 Fill depth to top of pipe: CIe Number of feet from nearest property line: Front, O Side, Rear,0 It Number of feet from well: 2G-'r` 21 Number of feet from building: V A (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box o been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: s Dated: ~j J~ Plumber on job: License Number: 3/84:mj SANITARY PERMIT APPLICATION EA:i1LHR In accord with ILHR 83.05, Wis. Adm. Code COON .tue,~wnww~w~j STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. c i evisi n pr`v.ous 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 r..-o 7"r a ,i CQ '/4S~✓'/a, S C' T a?Q, N, R E (or) LOCK # PROPERTY OWNER'S MAILING ADDRESS LOT # B CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER CITY NEAREST ROAD L:I II. TYPE OF BUILDING: (Check one ❑ State Owned ❑ VILLAGE 'p M'4QWN OF AP' ❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms 15 PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) f.2 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. TYPPEI OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. WE New 2. ❑ Replacement 3. ❑ Replacement of 4. El Reconnection of 5. El Repair of an System System Tank Only Existing System Existing System Z B) ❑ A Sanitary Permit was previously issued. Permit # ~3`~ Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 C& 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 y~ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 5 r ELEVATION 4~" /S' P72 d - 1-3 7400 Feet Feet VII. TANK CAPACITY Site in ailons Total # of Prefab. Fiber- Exper. INFORMATION New F-xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank AcW Lift Pump Tank/Siphon Chamber VIII. 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) P MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 11101 _3 'JILCI IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui Agent Signature (No Stamps) Surcharge Fee) Approved ❑ owner( iven initial -7 1 c_ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: I SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber I INSTRUCTIONS f 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. t' 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'f 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 j 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 farm; and F) all sizing information. i - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 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) S ,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 MADISON WI 53707 State Plan I.D. Number: SE~ , SW,-, Sec .17 , T20-R19 CONVENTIONAL El ALTERATIVE (If assigned) Town of Hudson Lot *(lap PAAR 1!j Holding Tank ❑ In-Ground Pressure El Mound R NA OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: 0S /Po BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. P . LEV.: CST REF. PT. ELEV . / I Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: SEPTIC TANK/ g ,(c /00- ! / G. 96' 7.Of MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: MrCJW f' ~ illc,1)06*0~ 99.191d 6. 9 YES ❑ NO ❑ YES NO BEDDING: +FEAIT DIA.: MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WEL BUILDING: VENT T FRESH C .D' /1 C, 0, ALARM: FEET FROM LINE: / / AIR INLET: ❑ YES NO ❑ YES NO NEAREST My Jj MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO G LONS PER CYCLE' PUMP AND CONTROLS OPERATIONAL: MBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DI - EN FE OM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEARE SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: IAMETER: MATERIALAND MA NG: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue. CONVENTIONAL SYSTE : 9•s~ = 96.60 k=,-, oP -_>y5 WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH / TRENCHES: M IAL: DEPTH: DIMENSIONS f~ s.3 61 ~ 4 P GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABODE ~C9V EJR: ELEV. INLET: ELEV. END: V?1"4 )c S~ y(j~ PIPES: FEET FROM LINE: / AIR INLET: (4 1 97 / 7 7-m_ _ NEAREST MOUND SYSTEM: g,Vs' g.ss' 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 O DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES NO PRESSUR17eEb DISTRIBUTION SYSTEM: BED/T CH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRA TH BELOW PIPE: FILL DEPTH ABOVE COV . TRENCHES: DIME IONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: EL TION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: 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 LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST G~~2 Sketch System on etain in county file for audit. Reverse Side. SIGNAT RE: TITLE: / SBD-6710 (R. 06/88) SANITARY PERMIT C~ COUNTY CODILHR TRANSFER/RENEWAL UNIFORM PERMIT # - (PLB 67-T) <7 PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: 36 I PROPERTY LOCATION: % '/4,S 17 T d d N,R E (or) O a'4_z o LOT NUMBER: BLOCK NUMBER: SUBDIVISIIOON NAME: ROAD, LAKE OR LANDMARK: r C 5 1_1 I PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUMBER'S SIGNATURE: PREVIOUS PLUMBER'S NAME (IF CHANGED): r w, o ec 7t-Y' PILUMBER'S ADDRESS: PREVIOUS PLUMBER'S ADDRESS: MP MPRSW NUMBER: PHONE NUMBER: P R NUMBER: PHONE NUMBER: SIGNATURE OF ISSUING AGENT: DATE APPROVED: DISTRIBUTION: Original - County Copy - Bureau of Plumbing Copy - Owner DILHR-SBD-6399 (R. 5/82) Copy - Plumber DFPART`MENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION "91IS.76` ,7,V4',~7K 17 , T29-R19 L(Ft 93 State Plan I.D. Number: E .7° 2 LJ CONVENTIONAL El ALTERATIVE (If assigned) Town of Hudson 'Zi.d e Pass Rd. ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Delta Construction Co. 206 2nd St.,Hudson, WI 54016 BENCH 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: Jim Boumeester 3034 St. Croix 135434 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 MATE: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NC DYES El NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ 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 ❑ 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 INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: 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: i 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: I ❑ 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: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: R MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS I E] YES ❑ NO COVE ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88)' L TBILHO SANITARY PERMIT APPLICATION CouNTY5f In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ZJ 55~ 8i~ x 11 inches in size. ❑ Cif revision to pr vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY [TNER PROPERTY LOCATION < 0 4S(.0 %a, S 17 TQ Q, N, R E (or) PR OWNER'S MAILING ADD ESS LOT # BLOCK # t~~ 5 O A CI R, ST TE ZIP CODE PHONE NUMBER SUBDI (SI NAME PS NUMBER SaN W IsC, S ) OW la p- II. TYPE OF BUILDING: Check one CITY NE EST ROAD ~~ryry ( ) ❑ State Owned ❑ VILLAGE : r' 1 ❑ Public 01 or 2 Fam. Dwelling-# of bedrooms PAR EL TAX NUMBER() Q 111. BUILDING USE: (If building type is public, check all that apply) /Q a 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 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.E] 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 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION (0115 (ODY .7,-2 < Q ( 1 ~ , 5Q © Feet td0. aFeet 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 Holdin Tank Nbo Lift Pump Tank/Si hon Chamber Vlll. 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: Plumber's Address (Street, City State, Zip Code sc, Cpl IX. COUNTY/DEPARTMENT USE ONLY KDisapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui g Agent Signature (No Stamps) AGiven Initial Surcharge Fee) Adverse Determination l qv 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 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. ti SBD-6398 (8.11/88) v, H a ST C- 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d _ a OWNER/BUYER ROUTE/ BOX NUMBER 2 iV.c~ v T Fire Number CITY/STATE 9~! .S A ZIP PROPERTY LOCATION: , _14, Section , T~6 N, R/!f _W, Town of , St. Croix County, 7 Subdivision Lot number Improper use and maintenance of your septic system could result in I 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 ~ 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. 0 E I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- a 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 " ll ATE < 7 -ell 1 D - 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. 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. ---------------------------(----9---------------------------1--------------------------- Owner of property 2~--G~~=D--~ C10+ Location of property ~ JE1/4 -5 w 1/4, Section , T Z (ZN-R r / W Township Mailing address Address of site / 3:2-- %J r Subdivision name Lot number Previous owner of property f4 Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _ _Yso No Is this property being developed for resale (spec house)? _Yes No Volume 3 and Page Number Y(o~,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 ~yV ded 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 rec rded in the Office of the,County R gis er of Deeds as Document No. 3 Signature E n r Signature of Co-Owner (If Applicable) Date of Signature Date of Signature DQCUMENT NO. STATE BAR OF WISCONSIN FORM 1-19@$ THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 63PAGE41" l • r REGISTER'S OFFICE T 1 Deed made betty n Sr. CROIX Mi W1 B & evee3:dpment, 1n6 Reed for Record . FEB 19 1330 e . it Grantor M u and o onsl;r cirion Co 8:00 A. • Re~Otof deeds Grantee, Witness th, That the said Grantor, for a valuable, Sonsideratlon...... B & H Development, Inc. CrOiX RETURN TO conveys to Grantee the following described real estate in . S... County, State of Wisconsin: Lot 93, Willow Ridge East in the Town of Tax Parcel No: Hudson, St. Croix County, Wisconsin. 'w l; TRAM SF This ...1s..nOt..._....... homestead property. ' (1s) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; B & H Development, Inc. And.......................................................................... - - . I warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except i' easdments,, restrictions and rights-of-way of record, if any. i will warrant and defend the same. i i! ~ II Dated this 15.th................... day of February 1990._.. B & Development, Inc.' by: .........................(SEAL) . . . _ (SEAL) II Donald _E.._ Bjornstad.,..Pres.. ti i i (SEAL) .--4W. (SEAL) William C._Harwell Sec y AUTHENTICATION AGKNOWLED,GMENT Signature(s) STATE OF'WISCONSIN f ,.5 ..c1"01X-- ------=----County. authenticated this ........day of 19...... Personally came before me this ......15:t h ..day of EP_bX. ar.y 19 the above named ! 1 IInnald_.E,...B nrnstad._anci---. --_-.-----.-1~i 11 ism. nt i-ng--- I TITLE: MEMBER STATE BAR OF WISCONSIN l f ~ i~ (If not. authorized by § 706.06, Wis. StatsJ I to me known to be the ersor6 who executed the f ?oregthILUAN f 01df THIS INSTRUMENT WAS DRAFTED BY Notary public Ki sSl _ Lundeen. li~n Ppnto Attorney at Law Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration I are not necessary.) January 31 date; 19 .94 'Names of persons si¢nina in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAIT OF WISCONSIN Wisconsin Leal Blank Co. Inc. FORM No. 1-180 Milwaukee, Wis. I DEPARTMENT OF REPORT ON SOIL BORINGS A ND SAFETY & BUILDINGS 1~NaU$Tf~Y; SOIL BORINGS J /`1 DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 P.O. BOX 76 HUMAN RELATIONS (H63.090) & Chapter 145.045) ! ^~-ATION: SECTInN; IP/, OT NO.: ELK. NO.: S/UB~DIV SION NAM r /T20 N/R f[ (or TOWNSH 015 \1 Q 7~ 1L 7 !rt/ • /1~T/C -3 COUNTY::^ OWNE 'S BUYER'SS N )E: ]MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERC A DESCRIPTION: ITFIROFILE SCR IONS: PERCOL ION/ES TS: ~esidence ,^Vf New ❑Replace Z~ z 9~ RATING: S= Site suitable for system U= Site unsuitable for system CNTIONAL: MOUND: IN- ROUND•a URE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYS EM:(opti al) S ❑UU (IRS EA U aS U ❑S If Percolation Tests 7eN required DES IGN R If any portion of the tested area is in the under 0'a ' .09(te: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING IOTA D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHM4, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVE (SEE ABBRV. ON BACK.) B-/ 33 Z, ,733. i s3' .as'!~~ s- S,08' ,..s B-2- -117 1, 1 46- B- 0 /U~ . Sbl > 70 B-.s a1.17 ' > x,13 ` e/S, . 33 IYA 2,5 ",d//, , o „ , .U,Bs B- 33~ / ) x.33 #Sn T; . X3/3 40~,' .LS PERCOLATION TESTS TEST DEPT WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER JAIGI#-S AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERI002 P R PER INCH P- 41,33 IV 71 7- 3 P_ s y L 3 P- 2, <3 P-_ 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 1 Iyl i ( ~ S 3 . ~ I yy~ 4~<A~N f E I 5 i , 1 3 ~E1pu. , ._._J 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 : 4A~ TESTS WERE C MPLET99D ON: ADDRESS: CERTIFI ION N MBER: PHONE NyM ER(optional): , NA, l S' D3f~~~ 3- ~8-3 CST SIG WTV'R Fe / G DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6595 T a plete and accurate soil test, your report must 'inf Jude: 1, =scription; 2. T1 gust clearly in( care, whether this is a residence or commercial proftt; 3. M rber of bedro commercial use planned; 4, Is s enlacement sy 5. Coml. i)ility ratirn A SITE !TABLE A Ok-5.ING T LY IF ALL OTHE EMS ARE RUJ O'JT BASED S IL COND1 B. PLEA. abbreviation: i here for vv 'tip 1 profile descrons ornpletr the plot plan; 7. M I' "3LE diagram is `-'y locating ur- st location.. Drawing to scale is pr, red. A he used if ri_;I; mark and + tical elevation re rence point are clea wn, and are -manent; )priate boxes as to dates, names, 'ses, flood pl= p'rcolation t, ernp- 19 te; 10 motion (such til-~' "in, elevation) does fly, plat, ~ the 7 ~ iat b 11 . n and place y it address arsd your c tifieation nrfmbe , 12 copies and di ar as rout !d. ALL IL TESTS MUST E FILED KITH THE ~1`HGRITY VVITi- =N DAYS O ET N. ,EVIAI 1SK._ _''IFIED SOIL T` RS So S€ 1 Textures d ° ~mbols st BR Bedrock cob - Cobble 10") SS - Sandstone gr Gravel (under 3") LS Limestone s Sand W Nigh Gr--,.._ Alan.. Cr~,.~ car,rl Percola well Bldg - Building Is - Lo:rmy Sand j - Greater Than sl Sandy Loam < Less Than I Loam Bn Brown sii Silt Loarn Bl - Black si Silt Gy - C y `cl - c.ly Loam Y - [to se' -iH- Clay Loam R - sir' y Clay Loarn mot - p u, s - Y Clay wr' - to s Clay fff . - CC "t mm r , fr P .,«ck d p - pror HWL - High Si I =r:tures sue fc. li-,;_rid 4 fsa}: BM' Bear VRP Verti Point - r . TO TI I 1 3, a m nay rn°tuest l r th rate T- o; • P. B. I:_..... 6 7 PL OT t,, 5 f ~ C -f ~ I ICI ' N A M E De, ►,5. R 411 dN ca N A M E r< -off(. a~ . ~Gr-e1 L o c AT 10 N W I i--i c E N x ~z PLO 0 -1= M A_P A:sm 'N' stJ gob IN 9Rl S+3 lot 73 Cor-Ntr, L-n tom . ti U 60rek11C S a 'o x= PrcWt r • p =f'~or~e f~~ #L1101a S E Coa,.~occ lufi ~ki'C ; Ad j ACetifi ~ul"I, l,~Q 1~S 'A2t rJR~~'P, 1• _~~U//• / /000 0 ~N~~ . I S •5pR~1~ fhPN l~ Fie on Stc. e sy f ~.m S ~ gtl P~ 13 A., w : o d(33 30 37 ' Ba yy, An,,A rA rAk IC l 01 1; a q' FRESEI AI1: IPdLI:Tli AND OIISERVA'1'IC}N PIPE C11%0-S SECTION r Approved Vent Cap Minimum 12" Above Final C>zr7Sl~_ ya" MAI< 4" Cast Iron Above Pipe Vent Pipe To Final Gradr. Marsh Hay Or Synthetic Coveri.ng Min. 2" Aggreg'cll o _ Over Pipe Distribution I F- Tee Pipe Aggregate Per-f.ora ted Pipe Below T 5a a~}~oM . Bencath Pi e Coupling Terminating 910 6 r _ Bo t tom of System a Ql ~ I a ~ r? wi 02 C" w I ° c' dl 41 ` t -74 I /mot, ~ .ew." son r dt ~ ~ A • I ~ Ir. i y ~ • , Ir• •r f ~y t ~ p / r~ yy • • e,.r M 021 - 1 , kv) 1, cr) r~~ r of ti 0 0 - ~ a.1------ _ -tl'- - i"-- ~C P.01 T~:ANSA~_ T I CiN REPORT - DEC-11-89 MOO 11:51 + DATE '=;T~4RT :.EN-DER RX TIME PAGES NOTE ~r l/~-7/r~ v . ~ a - ' I w Ve R.• 6 1 P L `/T A N 1) I-~ O SS ! E C T I ~\I i. NAME e_L.► ~1N _C! .,N n M E i p rvtee s e yL0CATI0N I(U: ~ L I .ENS E, -...3.03Y Al E 219 PLO ' A=6p\ V std Rob iN 5rd 5W lot 73 Corom \ a U 60Re~wks o x= Ph o )es act =P~oNe ~ ALIIO~ p S F Go"r, loft a' 11k331e; WjAQjjt loft, WeIts'ARk -f(A4AeR rh~„ !30ft TKan1 Ste,cr Sj5tfM f'k on Se i e Sy t 'trh _ ? f 'Spc B 16 gy ° R \ bS' 1,3 ~S ~ I III 63 d _ 30l - _ - _ XP3 _ PO 39. ay B lNC~ nn~aKK S~ 10 e A e, FRESH AII: _ NLETS-AND OBSERVATION PIPE _ C SS SECTION .Approved Vent Cap Minimum 12" Above Final Gras~e~__~. I OU,~ 8 4" Cast Iron Above Pipe Vent Pipe To Final Gradc* Marsh Hay Or Synthetic Coveri. ng Min. 2" Aggreg',.1I _ Over Pipe Distributio41- Q Tee pipe I ._1 Aggregate 1 Per-foraLed Pipe Below Bencath Pi e t Coupl.i.ng Terminating P 910.5$ Qao~ 6eP _ • Bottom of System 1