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020-1059-60-000
o -p o Y v ° o ° N o 3 0 ry p (s O e» yc > o ~r, C c c 4 0 0 m c -0 =3 e3 c ~ c O a) io b C vcco ccO mw Q) N CIO O N t0 (1) m w 'O X C 0 0 N w N. 0 + om > mmE v ooa) p~ ° a) a) =6 E 0 a- a~ c L Fn .2 C.) M c w i C a a m m L N a-D --p a) a) .p p N't an d y L m p c N a) C CO U C- p C C '0 V O (D N O S N T Q m c C a) U O ami U))0 _ Q) c my N N~ m ~ as m 'N D s- Q N "0 E_ o Y N X c "O C - O' m - C 'O `C m m m d C Z V) L 'O " U o ' 0 E 3 N ~ c p 0. U y E co E y N' N L a_ ry O. O X N .L.+ V N L 7 N a c q C: 0 o m(o ON O~ E N 3 =3 E 0 ~ N -6 N y-0 m C N c 3a, a)°~ a~ a)~~ ma O 'O m 4= ~6 a O p L V U L U 0 0 E c z U° S 0)N c z N N 7 ((0 c 0 2 _m p 0 LL a~m :Nw LL c ~EE~v°v~ t o c 3 X o U, v (p co E mL c m> c E Q mm a E Q 2 wH cO04It c o o ax) CO CO U U co m V CL 0- a) a) N 6i « m C/) O O L L z v E o N N W a co a m N F (n c p i C C7 O Z d c c U m Z d c c a) z to a) Z 2 2? a) a) g a) m N N CL 0) i m Q a CL ~ N N N N ~ N C o a) o • a) N O d U Q O C C Q U O Q 0 2 Q Z m z ° Z I- Z o O Ln Z '3 3 ar N C _ E a) C E Q) O L m p O L t9 O a m N °1 2! w 02$ C C y 3 y C O N 4) w (D a) N a) L Q) L = a) L L 0 p N 'a a L U❑❑ a L~ U N N co U) 0) E U) cn E N E 2 N d: 5 Of FL 5 *i 0 0 0 0 0 0 0 z o of m a a ~c a a a N a 0 c O O 1 00 0 N m o o U rn 0) to U m 00 00 y (D } CO - !7 oo 7- Cl ~ N C) o t-- C) _ E m O O 06 O O 0 co Q (D O m a) N a) Q) "IONA aj$p d Q } .a a) Q } (9 04 O O N C O N C C) 0 4 CQ O- 3 O (D N C 4) N 0 a) O N N O O r Ti (O Z' p 0. d -p~ N N 4 \ L 67 N H m ~n m N C N E E ~I V T 'J LO C m N p O 0 7 00 N 13i 0 - m z' o f w~ cl N p > O O m 0 m N E E U~ ^w y' O N S> (O O NI S I- O N L E L E L . a L L: a N o ; ca c+a rr o~~ 1 A v a l O in o O m V SANITARY PERMIT APPLICATION TUILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY f C ip MEMO STATE SANITARY PER -Attach complete plans (to the county copy only) for the system, on paper not less than 8'r4 X 11 inches in size. U-1 i revision ro 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 -D E A CIA.)D M4 E '/a Sw Ya, S Z-A- T if , N, R ~l E (or W PROPERTY OWNER'S MAILING ADDRESS LOT # / BLOCK # (0 1 . 0 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~so✓ ~/f Syria & y3~ 330 70 l~0/.s~z P~. 87 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned O VILLAGE hl (,p flJ O~N~ s TOWN QF: ❑ Public A1 or 2 Fam. Dwelling-# of bedrooms _ PARCEL TAX NUMBER(S) (00- Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nurs g Home 10 ❑SOutdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ epaiMAR 1 ❑sRestaurant/Bar/Dining 4 El Church/School 8 ❑ Mobile Home Park 12 ❑Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory ST. CROIX 000 , 1 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 M Seepage Trench 22 ❑ in-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 El Vault Privy 14 El System-In-Fill ~4~► Z S tl Re Cl< 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) f 5 EF __L)<VATION 1660 (;-)o Y. 3 17. 5 Feet 9~1. 5 Feet VII. TANK CAPACITY Prefab . Site in allons Total # of Manufacturer's Name Con- Steel Fiber- Plastic Exper. INFORMATION qTanksTanlks n Gallons Tanks Concrete structed glass App. Septic Tan k or Holding Tank Isn 0 N ti DWG/ KI 1:1 11 Lift Pump Tank/Si hon Chamber , A/ El I El 1-1 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) '1 1MPRSW No.: Business Phone Number: 2013,k .F r 3.30 1(7/~; Plumber's Address (Street, City, State, Zip Code): S" 0' nJ~/e- tv I~ID.tJ ~t1/S' sri'd/ IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater jDate Issued Issuing gent Signature (No St ps) Approved ❑ Owner Given Initial _ Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 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 P ISON 153707 State Plan I.D. Number: ..~L11~~ , Soy ,See . 2 2 , T 2 9 - R19 (If assigned) iwn of Hudson U-1 CONVENTIONAL El ALTERATIVE Holding Tank El In-Ground Pressure El Mound ~dland_s_R_d.- L4 _ INSPECTIO D TE: NAME OF PERMIT HO(. DER ADDRESS OF PERMIT HOLDER. Dave & Cindy Mathison 640 Badlands Rd. Hudson WI 5401 BENCH MARK (Permanent reierint)DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. LEY.: CST REF. PT. ELEV.: / .OS '-v o Nameof - Plu mb er----------------- Sanitary Permit Number: MP/MPRSW No.'. County : Robert Ulbricht__ 3307 St. Croix 128698 TNK OUTLET ELEV.- WARNING LABEL LOCKING COVE ..7 SEPTIC TANK/ MANUFACTURER LIOUID CAPACITY TANK INLET ELEV A PROVIDED. PROVIDED-. C-YV~. . .1,- ..r-iC~ (t .,l)G~d "Q'J_ 9~i i'N.3s YES ❑NO ❑YES NO BEDDING: VEtA'f DIA : VENT MATL. HIGH WATER NUMBER OF ROAD. PRO RTY WELL BUILDING: VENT FRESH h~ LINE AIR INI,E C r. ALARM FEET FROM ❑YES NO ✓ ]~4 &-c- ❑ YES NO NEAREST _ DOSING CHAMBER: MANUFACTURER BEDDING- LIQUID CAPACITY: PUMP MODEL PUMP/SIPHON MANUFACTURER: ARVIN OVIDEDG LOCKING OVER ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH FEET FROM LINE: AIR INLET. (DIFFERENCE BETWEEN PUMP ON AND OFF El 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; _ WIDTH: L U&TH:NO. OF DISTR. PIPE SPACING COVER INSIDE DIA.: PITS: LIQUID BED/TRENCH TRENCHES MATERIAL PIT DEPTH DIMENSIONS J 10 c9 T/ GRAVEL DEPTH FILL DEPTH ;EE TR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL NO. I TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER: ETELEV DC~ PIPESLINENLET !f !40 I ✓ FEET MOOUND SYSTEM: Il r '4 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 W LL ❑ YES ❑ NO ❑ YES El NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL SODDED. SEEDED: MULCHED: CENTER: EDGES. L7 O ❑ YES ❑ YES N ❑ YES ❑ NO ❑ NO PRESSURIZED DISTRIBUTION SYSTEM:-------- _ WIDTH LENGIH NO~OF IATERM SPACING GRAVEL. DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. BEDITRENCH 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 SPAGtNG DRILLED CORRECTL V-. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES LJ NO ❑ YES ❑ NO PERMANENT MARKERS. OBSERVATION WELLS: NUMBER OF PROPERTY WELL BUILDING: FR OM COMMENTS: - NEAREST UNE. ❑YES ❑NO ❑YES ❑NO NEAREST-► ~ is • etain in county file for audit. Sketch System on TITLE SIGNAT E' ~ Reverse Side. ~ C&' ) SBD-6710 (R. 06/88) ` 1 d PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/S h Manufact.: Pump Size Elevation of inlet: Bottb of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_, S e_, Rear-Ft. Distance from: Well Building 2 Tpl--va,15 - 5")( (a SOIL ABSORPTION SYSTEM S -'X 70 Bed: Trench: Seepage Pit: I~Q~~Q3 Width: Length Number of Lines: Area Built 17 41, zs TAPPt e TR ENCe-t A.)d -fit. Grade Elev. 5 2 , p Proposed TFinal Grade Elev. E ~cG LpCc~C.Q 2Co Fill depth to top of pipe: /en 3 6 " 710 I'2' No. feet from nearest prop. line:Front , Side)( , Rear Ft. No. feat from well: 7 'No. feet from building 5 7 HOLDING TANK Manufacturer: pacity: . No. of rings used: Elevati of bottom tank: Elevation of inlet: No. feet from near prop. line:Front Side, Rear Ft. No. feet from- ell , building nearest road Alarm Ma facturer: -i' 1 ~1 I ~`1 O~`-t n INSPECTOR: r S I Z l [ / • DATE: PLUMBER ON JOB: LICENSE NUMBE&ALSITE SEPTIC PLUMBING Ga. O'NEIL R- ROBERT ULBRIGNT 6/90 : C i ; nS.', .--mR PLUMBER LIC. N0.3307 M.P.R.S. "~.sALLER DESIGNER LIC. NO. 00663 ' i FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 1144,1~ SD TOWNSHIP ~UdsO~ SECTION T ~ N-R f W ADDRESS 016 ~ADC~wD S O'T. CROIX COUNTY, WISCONSIN S"eevi Gam/ S S yO SUBDIVISION LOT---, LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM P lo 7- 1 r INDICATE NORTH ARROW TD rp ~,Q SiP~Gv~1L~ Cc~ ' BENCHMARK: Elevation and description : c~ P 6,4474,0- /00,6 Alternate benchmark i?E co,u S7~ uc T~l~ 7~ r SEPTIC TANK : Manufacturer: zsx is j Liquid cap. 3600 Rings used: Manhole cover elev: f7,60 Final grade elev: ~Y- 70 Tank inlet elev.: yf Tank outlet elev.: > d0 / No. of feet from nearest road:Front X , Side , Rear Ft. From nearest prop. line:Front Side k Rear Ft. -5 0 No. of feet from: Well 6 D , Building: 13 01 (Include this information in the above plot plan) S-PTiC (2 reference dimensions to septic tank) No?E SEE REVERSE SIDE E 'tv T it-Gv T o c y f I I E S Ito %fi'+~K /N SP ~ c 7 U 3 fez ~s z. RE E-P 66 ~ s 5 CIt FTC ULBRICHT & ASSOCIATES CO. 655 O'Neil Road • Hudson, WI 54016 Reg. Designers of Engineering Systems 715-386-8185 Private Sewage Consultants RECEIVED MAR 1 2 2002 ST. CROIX COUNTY ZONING OFFICE St. Croix County Zoning Dept. Government Center. 1101 Carmichael Rd. Hudson, Wis. 54016 March 8, 2002 I REGARDING: The Dawid & Cindy Mathison property C 640 Badlands Rd. Hudson, Wis. 54016. CERTIFICATION OF POWTS CONDITIONS Report follows: This property consists of 2 seperate duplexes (4 bedrms. each unit), served by 2 sperate POWTS, each installed by this firm. The trench POWTS (1990) serves unit #2 which is proposing a home addition. A POWTS "bed" installed by us (approx.1986) serves unit #1. This is to certify that I have personally verified the soils immediately adjacent to the trench POWTS serving unit #2, and have determined per attached report, that the system is in currently approved soils and may remain intact' it meets all existing codes. This trench POWTS is still in excellent working condition. The highest trEinch only had I" of effluent on day of ins ection - FE?(J.l4, 2002) , the lower tren.cn was dry. Further, both site constructed treatment tanks (each 3000 gals.) excEed all current codes for capacity, with intact modern fiberlass baffles. In addition, we also inspected the condition of the 241x31' POWTS "tod ' . We (let ermined and located its ~dg -~s also. See Soil/site report. This 71OWTS serves unit #1, but lies closer to unit #2 (54' setback). This POWT:i system is also in good working condition, wit~i 1!ss '..Iian 1" of efflu ant ~)resen,it i?i tf ,n 4" c.i. veat/inspection pipe. kIN L e R\ r A The proposed 18' wide home addition for unit # 2 will not violate any current code setbacks, either to the existing tank, or to the edges of the treatment bed. Per stakes set owner, the closest edge of the addition will lie 5' from the tank, and 25' from the bed. The owner and builder shall have the final responsibility to maintain and ensure that these minimum setbacks are respected during construction (i.e. 5' to the tank, and at least 15' to closest edge of the bed). We do not see this being a problOm in meeting any current code setbacks.°- If you have any further concerns or questions, please contact us. Sincerely, Robert Ulbricht MPRS#226375 cc: David & Cindy Mathison I i Wsconsln Department of Commerce 1ffo SOIL EVALUATION REPORT Page / of 2 livision vision o of Safely and Buildings in accordance with Comm 85, Wis. Adm. Code _ Attach complete site plan on paper riot less than 8 112 x 11 Inches in size. Plan must County !7; C~~l y Include, but not limited lo: vertical and horizontal reference point (BM), direction and /S Parcel I.D f _ (00 OWV percent slope, scale or dimensions, north arrow, and location and distance to nearest road. I.D. D 1 D /D S 2 Z. Please print all Infonnaflon. R wed by Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Properly Owner Property Location e 3 Z C/~D/v /y/f ~ Govt.Lot Jr ~ 1/4 5AI1/4 S Z Z T 7 N R Property Owner's Mailing Address (o►) W ~f' Lot # Block # Subd. Name or CSM# yD 131~41,¢.vPS RP • c5/i4f 33o 7 3o 1/0.5 3 z Pj . 7 Cily State Zip Code Phone Number City Village Town ❑ E] Nearest Road ff UDSD~v Cv/• SyD` ~S w 3 6,G• d~ ❑ New Construction Use: W Residential / Number of bedrooms Code derived design flow rate & GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material /oE$S' p (AV SJ ya 64TjWf r~J Flood Plain elevation It applicable N n General comments ~ ~ 1 d~~-- and recommendations: ~'I Sl`/ ,0G- Sys! ~fNt~ /s s~rTL~v N CEIVE4 c© pE • to wev ( ~ l ~ lt1 R 1 2 200 2 Boring # ❑ Boring p2 ' ZONING pFFIC€ V pit Ground surface elev. it. Depth to limiting factor ~2 ° in. Roots Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary In. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 I o-/y /P Y X 2/3 I7c-r4x /W fie kJ .1 f 2.. . 3 , Z W. 21 /O /P Jl Y/4 Z 1-S , 441 C S • S ~ ; S. Z • 77 ~oy~ s s.~ i~shk ~s . z . 3 7 S s. o; s ,e cs A Z s ~oy,~ si s. a . 7 , z Boring ❑ Boring # ❑ ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon bepth Dominant Color Redox Descriptlon Texture Structure Consistence Boundary Roofs GPD/fl' In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. .12011 •Eff#2 Effluent Ni = BODs > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent 02 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (lase Print) Signature CST Number 1-2Address 4 3 7 S Date Evaluation Conducted Telephone Number 3- . l7jpS Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 'xis rrivU- •syS%. - ~7. SaT /BUG . z7-7-f property Owner Parcel ID # Page of Boring # ❑ Boring U pit Ground surface elev. it. Depth to limiting factor In. Soil Application Rafe Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl= In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eft#1 'EtN12 ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rafe Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eft#1 'Eff#2 ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor In. Soil Application ,S Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff2 Rafe In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 Effluent #i = GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD9 < 30 mg/L and TSS < 30 mg/L r The Department of Commerce is an equal opportunity service provider mind employer. If you need assistance to access services or need.material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SAD-0330 (R.6RI0) 1 ~ N ,a o . k oZ • w V~ d` o lol 101 (1) I I I I ~ N, i V I l_. I Ix 1'~ 1 100 . y I ' I I ~j ~`1 ~1 ~ I I I~ _ ~ ~ C1 N III II I / _ I 1 I I ~ / ! ~ I ~ b I s x o, ,o c rh W I I 1 FLO C-" m cp 08 Ilk i ` N V .C a mo I ~°o a 0 ° 0 vq~ a d ea o ° o 2i Y ^L 'm 0 ` c N N O 7 C C N O a N fO w f0 N c0 E .0 E ti CM 00 2 N .p. 'C 00 N m N t y C-4 I o C p N C y :2 0 a = C - C. 0 Z5 m O ; •E y tl f0 N • W N E cu .L W y NAM NL COj co cu ;t CL Cj CCU 3 y N 7 p Y N N U M 'I, ~ w.0 N C T d co o Z o tm° o Z 0 3 C y C -Fo 0) LL C CL'o U. c y E E p e 03•x~ o yam w 3 a ca 3 ~.n'0 co I c -o y c ao E Q mm.2 a E Q 0 N CL v a v v a~ m ~ y I ~ H r E E 0 = 0 ~ ~ ~ € Q E o z rn an d a m N H U) a m I o o zv' ° ~ c V 7 N p N w d 2 a ° ° o c rn c c E Z I c E -o N N O l0 1 O O j y N N O C ~ P V C ~ ~ d a v o c a t L U C 'p Y C C Y U z m D z f- 0 Z 'O O .C O d C N O cD R O O W N y O O d CL CL y OA d O L > to 0" N -O O a~ ` G r O CL U rC ar O. -0 U m N 0 0) :3 U) U) 2 3 a 5 5 3 3 7 a o E 3 0000 =000 z a a a a =aaa p p N ~ I v fn fn y w c) O U) 1 O OOi O co i v rn rn N J U m 0 c >T v f0 CO a~ v o o o m o o .0 E N O m ° \ - O m c m c yam m a} in m a z J) o H N N N$ CD 3 ^l i+ O O CV V1 c ) V! c O RS 9 LL C co m O d O O N C Q y U a 0 0 r G i N f- Ca p a C a N N V 0 o~ c C7 o d 0CO oL aci y M d (U Z COO N H C N • ~ N N p rn O N 0 y N O N E U O O N 2 0 O Z C F ~ Co Z C~ ~ fn v~ d'a a da o y:~ yam ~;a~ E ` 'c c c 3 3 8 A A va inv OfA0 SURVEY MAP FOR DAVID MATHISON N114 COR. SEC.22, 7291V,R19W, Pndicates 1/2" re-bar found. ( COUNTY SURVEYOR'S MONJ 0 Indicates 1" x 24" iron pipe weighing 1.13 lbs. lin./ft. set. i ~r U lF V 89 ° 50'4 6' t 8. 00' f, ~ O U' , p Y 3 0.74 9 ACRES o hi w a to to o DUPL EX DUPLEX H O v, N 3 k o k, ty °O FENCE ~rl~ ili I o O y ~ ~ to 2 ti MONUMENTED NORTH R.O.W. O h N,00 °2940 "W ttq ti N90° 00' 00"W 188.00' 33.09' m W ~ to S LINE SW //4 367.01' S 89 ° 50 4 6 W 259T.04' SW COR. SEC. 22, T29N, R/9 W, BADLANDS ROAD (COUNTY SURVEYOR'S MON.) S 114 COR. SEC. 22, T29N, R19W, (P.K. N41L FOUNDi Description: That certain parcel of land located in the Southeast 114 of the Southwest 114 of Section ?2, T 29 Nr, R 19 W, Town of Hudson, St. Croix County, Wisconsin, more fully descroibed as follows; Commencing at the South 114 corner of said Section ?2, thence S 89 50'46'W (assumed bearing on the South line of the Southwest 114 of said Section 22) a distance of 367.011; thence N 00 029'40'W 33.09' to the POINT OF BEGINNING, of the ` parcel to be herein described; thence N 90000'00"W 188.00' on the monumented North R.O.W. of Badlands Road;. thence N 00029v40-W 173.401; thence N 89050,4611E 188.00'; thence S 000291401,E 173.91' to the POINT OF BEGINNING, containing 0.749 acres, being subject to easements of record. State of Wisconsin) County of Pierce) I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that I have surveyed the above described and mapped property according to official records and that this map and description are are true and correct representation thereof to the best of my knowledge and belief. ST. CROIX COUNT SURVEYOR S Y RFC0 DATE 5- / 8 - 93 ,,,t~µ11tf1ffl~~ `CJG Q ~j~ FLD SURVEY MAY 1993 Or " SCALE / - a o ; ` ~ ,w LAURENCE W. ;URPHY = cY DRAWN L If M ~ m RPHY o 1713 REVISED REGISTERED LAND SURVEYOR ~%RIVER FALLS ft LOCATION 22 -29- 19 RIVER FALLS, WIS. 54022 •.,WISC....•~~~ b4 LANG S COQ NO. 93 - 025 ,,,•~~~~U111~~~,~ 12 QvJ ` P IL t rAq Aft 13 247; 698.61 - - - - - 300 392.46 Wjb 2!"3S- Wf 2710 13 Qe ° zuqb-159 12-3 q z 5 P 225 G o o3~ s b ° M M ~a o~'o°P~~ RDAs , u1D ZS35-y9 ►21 2709 220' 307 i SE 114 -S 114 0/9 ? ~C 12'% , p4)` D 213 's SW 1, 225B a~~~~>> i I95 2701 3f 228 D 225 A 1239/287 . a~ 225 H 1106/96 I()D 253s y9~ ,7 2; Pro 4b ~ 491,34' . 2 i A LOT I C. S. M. VOL~ip, _PG. 2 8 71 ' - 2 F8 E, 288' I I _ 188.00 200-09 IX _ 13 1107/42 { 2 cvo 0 $ ; 4'1 g °o 16x,.14 Il2 - 1106/615 Room w4 N GD fp~b 9 2 6/ 6 1 I waL~:uJ 2250 225 F 225 D 225 228 B 22 ROAD 1 _ 188.00 200.00 100. ' 13M,50,1 11 29' . S 1 /4 COR. - SEC._ 22 - 92f/613~~ 926/61 . y Parcel 020-1059-60-000 01/19/2005 10:13 AM PAGE 7 OF 1 Alt. Parcel M 22.29.19.225F 020 - TOWN OF HUDSON Current IX,I ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * MATHISON, DAVID W & CYNTHIA J DAVID W & CYNTHIA J MATHISON 640 BADLANDS RD HUDSON `HUDSON WI 54016 ~s ~Y SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2611 SCH D OF HUDSON \ 67 ~~Y SP 1700 WITC}~ Legal Description: Acres: 0.760 Plat: N/A-NOT AVAILABLE SEC 22 T29N R1 9W SE SW W 188' OF E 555' Block/Condo Bldg: OF S 207' EXC PT TO TN FOR RD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 22-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 926/612 07/23/1997 818/497 07/23/1997 783/358 2004 SUMMARY Bill M Fair Market Value: Assessed with: 48087 285,400 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.760 27,300 193,500 220,800 NO Totals for 2004: General Property 0.760 27,300 193,500 220,800 Woodland 0.000 0 0 Totals for 2003: General Property 0.760 27,300 172,300 199,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 223 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Parcel 020-1059-30-000 01/19/2005 09:59 AM PAGE 1OF 1 Alt. Parcel 22.29.1 .225C. 25H 020 - TOWN OF HUDSON Current LX ST. CROIX COUNTY, WISCONSIN Creation Date Historical ate Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner "ALWIN, AMY E L 640A BADLANDS RD t,* HUDSON WI 54016 Districts: SC =School SP =Special Property Address(es): " =Primary Type Dist # Description ` 640 BADLANDS_ED SC 2611 SCH D OF HUDSON r / 11, SP 1700 WITC Legal Description: Acres: 5.410 Plat: N/A-NOT AVAILABLE SEC 22 T29N R1 9W W 100' OF S 207' OF E Block/Condo Bldg: 1/2 SE SW EXC PT TO TN FOR RD & INC PARC COM SW 1/4 TH N 90'W 655.OOFT; TH N 00' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) E 207.OFT TO POB;TH N 00' E 732.98FT; TH 22-29N-19W S 89'E 307.OFT; TH SWLY TO A PT 288.OOFT N 90'E OF POB; TH WLY TO POB more Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 926/613 07/23/1997 827/505 07/23/1997 426/554 05/16/1997 559492 1232/387 Jn e 2004 SUMMARY Bill M Fair Market Value: Assessed with: 48084 230,200 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.410 60,500 117,600 178,100 NO Totals for 2004: General Property 5.410 60,500 117,600 178,100 Woodland 0.000 0 0 Totals for 2003: General Property 5.410 60,500 117,600 178,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 001-WATER SPECIAL ASSESSMENT 0.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Parcel 020-1059-40-000 01/19/2005 10:14 AM PAGE 1 OF 1 Alt. Parcel M 22.29.19.225D 020 - TOWN OF HUDSON Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * NISKANEN, CRAIG R & THERESA L CRAIG R & THERESA L NISKANEN 648 BADLANDS RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 648 BADLANDS RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.880 Plat: N/A-NOT AVAILABLE SEC 22 T29N R19W PT SE SW W 200' OF E Block/Condo Bldg: 300' OF S 207' EXC PT TO TN FOR RD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 22-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1027/39 LC 07/23/1997 926/616 07/23/1997 414/327 07/23/1997 339/571 2004 SUMMARY Bill Fair Market Value: Assessed with: 48085 109,000 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.880 23,800 60,500 84,300 NO Totals for 2004: General Property 0.880 23,800 60,500 84,300 Woodland 0.000 0 0 Totals for 2003: General Property 0.880 23,800 60,500 84,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 131 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 001-WATER SPECIAL ASSESSMENT 0.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 x` Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT ESE,.TOWNSHIP~~~ soti 2- / OWNER SEC. T 2 N-R W ADDRESS CROIX COUNTY, WISCONSIN SUBDIVISION LUE LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I'IHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Hof G%~~) ; . I 1< a. Q • bv,;~ ~J I ~ ad j / 1,3 31 ya • ry 3 well INDICATE NORTH ARROW Top Of e!ASr ~2~~►k .DOd~' BENCHMARK: Describe the vertical reference paint used Qfek; cc vG~t,~~) . /d Elevation of vertical reference point. d• 0 " Proposed slope at site: y.Z S, H X , woof- x S• L SEPTIC TANK: Manufacturer: e,X/_s]'~ l Liquid Capacity: le -s . /Vo~y~ 7 700 Number of rings used. Tank manhole cover elevation Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side,O Rear, O V feet .From nearest-property lane Front 10Side ,ORear, 0 (J (3 feet Number of feet from: well 7/dy , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE It t PUMP CHAMBER Manufacture Liquid Capacit Pump Model: Pump/Siphon Ma cturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch eleva n: Ga Rc.per cycle: Alarm Manufact er: Alarm Switch Type: Number feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: ? Trench: Width: Z Length: 3 Number of Lines: Area Built: Fill depth to top of pipe: A4ofY/ 4 a"-1 7/4- , Number of feet from nearest property line: Front, O Side, © Rear,0 Pt. J Number of feet from well: 30 ' Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Diameter: Liquid depth: ottom 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 Manufac urer: Ca a Number of rin ed: Elevation of bottom of tank: Elevatio inlet: ` N er of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: V Plumber on job: License Number • HOMESITE SEPTIC PLUMBING CO. CD Vv f ROBERT UIBRICHT MINN. INSTALLER &B DESIGNER L IC. NO. 00663 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & H,JMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.0 BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ~y~ L"jCONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: (lf ass~9ned) El Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Gary Waltz & Robert Jewell P. 0. Box 36, Hager City, WI 54014 9: 6-gs 3 : 30 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.: SE SW, Section 22, T29N-R19W, Town of Hudson Name of Plumber: IMPIMPRSW No.. Cnunty. Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 69636 SEPTIC TANK/HOLDING TANK: MANUFACTURER'. LIQ^UID CAPACITY KI ET ELE V.. TANK OUTLET ELEV.. PRWARNING LABEL LOCKING COVER ~D O ^ OVIpED: PROVID P YES ❑NO ~~"yy S ❑NO BEDDING: VENT DIA.: VENT ATt JHH WATER NUM BER OF ROAD:(((/~11I~((([jjj n PROPERTY WELL: BUILDING: VENT TO FRESH ARM FEET FROM V ` LINE AIRI ❑YES NO ❑YES ❑NO NEAREST v .!1 DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACI TV PUMP MODE L PUMP: SIPHON MANUE ACTOHEH WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM "E AIR INLET PUMP ON AND OFF) ❑YES ❑NO INEAREST-N SOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of plowing Ncn{ D1nnaFrEH n+A7ERInEANDMARKINC; FORCE or excavation, (If soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDT LENGTH NO OF 1115TH PIPE SPACIN', INOEDI VER INSIDE DIA -PITS LIDUID BED/TRENCH rRENC:HFS rEEtlnL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR PIPE 1115TH PIP n DISTR PIPE MATERIAL H NUMBER Q~ T OPERTY VENT TO FRESH BELOW PIPES ABOVE COVEEl V IN1 f S FEET FRUMNE AIR T: CO, CCU!! Z 2 / 14 NEAREST h C7 MOUND SYSTEM: d, Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAMOFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE E1111MANI NT MnRKEHS o❑YES ❑NO YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL jS'OI1OFD SEE UFD MULCHED CENTER EDGES ❑YES ❑NO ❑YES. ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF LATERAL t1N11,HAV1 PTH BELOW PIPE - FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIERIAL NO UISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.'. ELEV. DIA. ELEV. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING CHILLED CORRECT LV VER MATERIAL PLANSCAL LIFT CORRESPO NDS TO APPROVED ❑YES ❑YES ❑NO COMMENTS: PERMANENT MARKERS'. OBSERVATION WELLS. NUMBER OF PROPE RTV jLL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST - Cf. ~.s0 Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITL i DILHR SBD 6710 (R. 01/82) Wisconsin APPLICATION FOR SANITARY PERMIT ~'LHR ~WA OUNTY (PLB 67) T OF UNIFORM SANITARY PERMIT # vdMneoniienin OEPRRTTEn Z InouSTR4, LROOR C/P 6 MUTRn RELRTIOnS fa IT Z - -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER 70- LING ADDRESS */If T Z A0 6ur El f/ ~o X 3& f~/1 ~rti2 T l ~~-T s D/ PROPERTY LOCATION 21 q v SF 1/4 SW1 /4, S 7 T'Z! N, R / E (or) W TOWN OF: OJ D LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STA E PLAN I.D. NUMBER ,e*t~jOGAwO S ~ v . V t+- _____j TYPE OF BUILDING OR USE SERVED L 4pr. ~ i7apisooms FA« S-1* 1 or 2 Family Number of Bedrooms: A.. D L>15 Le-x U4+, THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair ~fdeplacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Cxl ST//J 6- -1 / ~Q O Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: r~ N0w / S I IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PRROPOSE (Square Feet): YV F;0 ~(D 3/ • 11r3( Private L] Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): HOMESITE SEPTIC PEUMBIN tOnature: ~vIT%MPRSW No.: Phone Number: RT. 3 O'NEIL RD., HUDSON, WIS 54016 33o7 (7/S Plumber's Address: 111,101:111 ULbt(IUHI Name of Designer: WIS. MASTER PLUMBER LIC. NO. 3307 MAR.& COUNTY/ DEPARTMENT USE ONLY Si gnat re of Issuing Agent: Fee: Date: ❑ Disapproved El Owner Given Initial le. dot ~ J A J a Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 ' To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. 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/contractpr,("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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - / MAToiP Owner of Property Location of Property sF--k Section T 2fN - R I W . Township ll~ S6A) Mailing Address /0 I`AL5-7`6A:) R1N~- mod- . P Subdivision Name Lot Number • ' , Previous Owner of Property nA l ~~Ltl ? Total Size of Parcel Date Parcel was Created ) Are all corners and lot lines identifiable? Yes X No Is this property being developed for resale (spec house) ? Yes ` No Volume 7 3 and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. arranty Deed 2. Land Contract 3.• Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. • PROPERTY OWNER CERTIFICATION I (We) eeAti.6y that a.tt 6tatement4 on thiA 6onm cute tn.u.e to .the beat o6 my (oun) knowtedge; that I (we) am (one) the ownen(b) o6 the pnopenty debChi.bed in thiA in6o4mati.on 6onm, by v Atu.e o6 a wauanty deed heeonded in the 066ice o6 the County RegiAteA o6 Deeds ab Document No. 3!S 0 7S0 ; and that I (we) p4e6ent.ty own the p4opa&ed 6 to bon the sewage di6po-.&-aT-Aystem (on 1 (we) have obtained an eabement, to h.un with the above deaehi.bed pnopenty, 6oh the con&tn.uction o6 chid system, and the came has been duty teco4ded in the 066.ice o6 the County Reg-ieteh o6 Deede, ab Document No. gttj 2"". j L"'L ~ SIGNA RE OF OWNER SIGNATURE OF CO-O R (IF APPLICABLE) DATE SI NED DATE S GNED flur d ~ .I r! OAF IV- ~ N { Y'S+'•'~X x *460..QI a~ AS`^ I ° f`7 rr T u ~{a 1~'".T li ~ ' r Fah 115 ~e {{~I~,,~ a , 7 ~ 5. A I pi. "iPt.'RR1. F• Y r ~ F ` , ~ '~q•.' ~a.:,del'. ~ ~ r. § ~f >'~Y 7 4 :fit' ~ • ; 11t f. E p~~r ~Yf ~Y 1 1 99 » ~ , K~ - f "Iii" ~7•;R".i 1° ~ ~ "F~ ~ eft R.. _ s s s~~' ' . r H 9 ST C- 105 r H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z f t7 ~y~ Po fl" 7- ~e k7 a]pD OWNER/t1rT= ROUTE/BOX NUMBER 11 ~ (ItP4,WP5 Fire Number CITY/STATE (~t~,s0~ J ZIP PROPERTY LOCATION: SE `f, -Section 22- T N, R W, Town of L) St. Croix County, Subdivision Lot number I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 E z I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- IV 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 DATE St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. a i- y O cn _ g v o (0) (D (D CD M C-Dr En -1 0 :3 3 vr° 0 -7Awi O o ° C w w 3 ? S c° m 3 c (o (o ' X ~ ~MmN CDDafD0)N off' °0 0 ~wp°~c- CL o ~ v- m"CD waN Co O (D v n . ~r om°' 00 °~ww > > g o w of°' ° o 3°c .<Cc'c C l< a- 0 ID) (D w y O- o a c~D 3' (D OD > ) Q.0, C A ~CO v myC Co>ccQOA p ~y► c o = j; n n C G) 0 (D (p O O C L Q j ^ (D pFi C `1l~m p V1 (D ? w y C m O CO) CO) (D w y CO) CO) 5D :e - (D -1 »w--f v a O y (D (D o-' ? (p Z aon 3(~D(DCD~a a »w=.om M Q.g -r ? w 0 a C n~ ((DD y v (D (nyww G m ~Og CDC oa~((DD°s m m 0 (CC - -1 D O ti w w vi m a n w = o CL (a CD E: (A C Co o (o D 1 =1 wC ~~Nti m 'ao c cro E g w G) wow cD c.C aw 0 m age aaaaCO° c G) m' n c (p N (D 3 a° oQ a c 0 0. CD CD C 0. C CD - (D 0 co - 1 0 Z! W 1 DE 'MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, 1 G DIVISION P.O. BOX 76 LABOR ANb PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (1-163.0911) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/P*U#0 I+TY: LOT NO.:BLK. NO.: SUBDIVISION NAME: SE" '4 22- /T ZIN/R /I E (01 v C>.S0 ,3 c. 3 '71 d vQfs.3a- . d07 CO N Y: OWNER'S *tl`eEF S NAME: ILING ADDRESS: C p L A! VVIZ!AJ'41~ S • 5yoi G G7-2 D. fox 3lv # ~~P 0 w l USE AIM& DATES OBSERVATIONS MADE NO.BEDR TION: PROFILE DESCRIPTIONS: ER OLATION,TESTS: 2 d s N I Residences ❑ New Repla a ice' i~ / 160 j A -A" jt , 117 RATING: S= Site suitabl r system' iMabte for asst- m ~ - rONVENTIONAL: MIWIT-72S -1: STEM-IILLH~~G .RE,,, MERE/or~M:(opti on S ❑ U U 00- _'W If Percolation Tests are NO r ui IGN R :rnrx If any portion of the tested area is in the under s.H63.09(5)(b), indicat w I Floodplain, indicate Floodplain elevation: AVOW ARRAS Of t i PROFILE DESCRIPTIONS j/V ~Drcf mAL. Fr. BORING TOTAL DEPTH GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBS VED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) F I. 1 , , .D• . 17• csh Ac7Ev , t% ; , rx• B- / 7 17l y fo .3 ' Olive- aq r~ w 1Jd+ t - 3 c r- ox- 4 . Aso fr . 14 - i r .1; 7' le f , . S ' No. S / a LED ce QED B- Z ? 7. yy Z f.,, .5'e.4. es 3. CS W/ Al MO i+L4- C l rr C J, 7_5 q~ 1.o 8 f. II Top Sol I, . 9i' S/.) o ' Z~. t1, 5 B3 ' //•D~' 7 ~s' O Cf 3•0 ' L3 AV ED 540D r 'u • 90 790 • . B- iIAJ CS . 0-1 &A$. Sit S •o 2F W 2 .06#4 .004*'A" 14 E/OC,ACC-*" rys- EM, i T r B-Sp [ CC1A N b 1 ' Qe /pc c o~ Lif+ Ttoa To OSC AUR11,4* - ALOC4 tree fYEo crew s. PERCOLATION TESTS 1410011 A 800 ' 'ri:M is TAB K TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES PMBER INCHES AFTER SWELLING- I INTERVAL-MIN. PERIOD 1 PERIOD2 PER D PER INCH NU _ *.3 2. P- r P_ !o G•3 P-. 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. ~O of / D ♦ _ n ~1 A 7 SYSTEM ELEVATION 7 E E I ~ c ~ s } )fir E E ~ f I 3 ~ t ~ j ~ 1 ~ ~ ~ s i ~ € 3 ~ 333 I ~ 1 3 I I I I;,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. 2 -a S ADDRESS: 110. 3 YNEIL R9., I AUDSON, WIS. 54016 ROBERT ULBRICHT CEOj~-© k t NUMBER: PMI NN. INSTALLER & DESIGNER LIC. NO.00663 CSS''T f~ 1 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Test DILHR-SBD-6395 (R. 02/82) - OVER - ! 1 4 INSTRUCTIONS FOR COMPLETING FORM 115 - SBA - 6395 To be.a c to an(! accurate soil test, your report must include,: 1 . Compi€:te scription; 2. The use s^ i, or - clearly indicate whether this is a r sii or commercial project; 3. MAXIMUM number of bedrooms or commercial use plarim,1; 4. Is this a new or ~..1 -nent systern; 5. Complete thr rating boxes. A SITE fS SUITABLE FOR A HOCDING TANK ONLY-IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON-SOIL CONDI'TIONS;. 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. "1AKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A iy be used if desired; r renchmark and verti(..l elevation reference point are.clearly sl,~pwn, mare permanent; :<< ri<ate boxes as "_s, names, addresses, flood plain data, percolation test exemp- ~n ach as flood !Ievation) does -,)ply, rAce N.A. in the ap ate box;- , I 1 . i d pace your cxai lot ess and your c:aion number; 12. copies and distr'& as re(juired. ALL AL TESTS MUST BE FILED WITH THE AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIAT _ FOR CERTIFIED SOIL TESTERS Sail Separates d Textures 0 Symbols r'4 St - `Stop. r 1011) B.R - -ock coin C" 1011) SS Jelone G r 3") LS - Lnr,ustone 's - S HGW Groundwater CS Pn~t~ 'ation Rate not"'! S ; B,ng I~. L Sand ~.rter Than Loam _ ~ - I is Than Bn L: own BI Black GV. Gs.a,y, ci aaQ1 Y - 'fow scl - 'kiy Loam R - r sic I Loam mot sc Flay w/ v °is stc. - fff - f -v, fine, fai "c - cc; -ton, cc p` mm - ,r, r,,"Jiui n~ - d - d :inct p prominent HWL High water h soil textures surface wa' ! waste disposal BM - Bench Mark VRP Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior, to pernnit. issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must. be obtained and posted prior to the start of any construction. L_ i REPORT ON SOIL SoRINGS PERCOLATION TEST5 IIS 6741~y 141,41- 7-7- - ~Pr Poor PLAM PRosE t•. D. DA rE fl v • IL ~.~5_ HOMESITE TESTING CO. R • 3, O'NEIL ROAD BOB UlVj?jL'. AUUSON, WIS.,,.- 54016 C57- SS5 02 yfz PROPOSED HovsE moor LIE 2,T Fr o,, Mot£ F;QOM ALi- TEST ^ee. }S, PRo POSED weLL M v6r we ,50 FT OrQ Mp~QF Ffem ALL TEST ~jiPEi9S, • = l3Ace1*E PiT,f O = EX/sra(r WELL X = AnQL. 10collONf = yq,VP gilelPE0 o,Q S~odEL l3o~tES #Oe;z . f3M (orl'GAL ,PEf6,Pt~vc6 PoiaT T'°P ~~r' ?'~"%f ~ co, &,,,V(Z /PJ~Qn. 0000,t /L~o~✓ . ' LEGEND el"Ard1v OA var. &J & /00-0 c ZIMi + 8 2U,u i r- Z 0 vee r. Y5 wEST co or Gi.v E ~ Gas O Q o So ~ o Bs a 3d -i R ?Z -60 ZS 7 of . WA sys~~~ nor GiNE .2y ')(3r /34P ?o I J 14/Pelf aF• R, - f3- ~s S cA'E f ",3 0 /PEQI>/,pEPD: -tom A0 rff . a/":: 70~ saz- 70 lie IYvLG ~ze--4 Vf~ tr?Pt4 wrs T 0 7' N 0 p I I ~ .9 s I I I I 1 --r r~i I i IIVN V -W tyl ~ 3 j O w ~ f X11 144 V a o o ca ' v ~Il '0 O SysTE.y v j ~u Fresh Air Inlets And Observation Pipe I~ ~ h 00 ~ _Approved Vent Cap ~ Minimum 12" Above Final Grade 76 - 0 FT, 4't Cast Iron Above Pipe Vent Pipe 'To Final Grade HOMESITE SEPTIC PLUMBING CO. RT. 3 O'NEIL RD., HUDSON: WIS. 54016 Marsh Hay Or Synthetic Covering ROBERT ULBRICHT WIS. MASTER PLUMBER LIC, NO. 3307 M.P.R.S, Min. 2" Aggregate MINN. INSTALLER & DESIGNER LIC. NO. 00663 vy Over Pipe Distribution Tee Pipe 0 0 0 0 0 CP Aggregate 0 Perforated Pipe Below Beneath Pi e pf ~ p 0 Coupling Terminating At h~ ,f•D%L Bottom Of System 70+ I-es~' h St. Croix County Zoning Dept. -s- Government Center 1101 Carmichael Rd. Hudson, Wis. 54016 March 8, 2002 REGARDING: The Da*id & Cindy Mathison property C 640 Badlands Rd. Hudson, Wis. 54016. CERTIFICATION OF POWTS CONDITIONS Report follows: This property consists of 2 seperate duplexes (4 bedrms. each unit), served by 2 sperate POWTS, each installed by this firm. The trench POWTS (1990) serves unit #2 which is proposing a home addition. A POWTS "bed" installed by us (approx.1986) serves unit #1. This is to certify that I have personally verified the soils immediately adjacent to the trench POWTS serving unit #2, and have determined per attached report, that the system is in currently approved soils and may remain intact;, it meets all existing codes. This trench POWTS is still in excellent working condition. The highest trench only had 1" of effluent on day of inspection (Feb.14,2002), the lower trench was dry. Further, both site constructed treatment tanks (each 3000 gals.) exceed all current codes for capacity, with intact modern fiberlass baffles. In addition, we also inspected the condition of the 241x3.4' POWTS "tod". We det; ermined and located its ?dg-:!s also. See Soil/site report. This 73OWTS serves unit #1, but lies closer_ to unit #.2 (54, setback). This POWTS system is also in good working condition, wit?i 1!ss :•han 1" of effluent f_>resenut iTi Ur,!? 4" c. i . ve;it/inspection pipe. 0 R I C--)' N A L h The proposed 181 wide home addition for unit # 2 will not violate any current code setbacks, either to the existing tank, or to the edges of the treatment bed. Per stakes set owner, the closest edge of the addition will lie 5' from the tank, and 25' from the bed. The owner and builder shall have the final responsibility to maintain and ensure that these minimum setbacks are respected during construction (i.e. 5' to the tank, and at least 15' to closest edge of the bed). We do not see this being a problem in meeting any current code setbacks.' If you have any further concerns or questions, please contact us. Sincerely, Robert Ulbricht MPRS#226375 cc: David & Cindy Mathison D 7X4 sysr- L ~tisf-¢~~- Itiya rMsconsin Department of Commerce ;A41 SOIL EVALUATION REPORT Page / of Z gvision of Safely Safety and nd Buildings n in accordance with Comm 85, Wis. Adm. Code _ Attach complete site plan on paper riot less than 8 112 x I I Inches In size. Plan must County !T; C~Q~ hrclude, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance (o nearest road. Parcel I.D. Please print all Informa(ion. Reviewed by Date Personal information you provide may he used for secondary purposes,(Pdvecy Law, s. 1 04 (1) (m)). Properly owner d Prop rly Location G " /'57 ~ Govt.' of 7 ~ 1/4 s~ 2? 1/4 S22" T N R Cc (or) W Properly Owner's Mailing Address of # Block # Subd. Name or CSM# (ey0 13.9O4, vPS ,Pfd esAf 33073a Oo/.532- P, . 9 7 City Stale Zip Code Pho a Number i L vD~ON S Village t] Town Nearest Road (_J New Constructlon Use: Residential / Number of bedrooms Code derived design flow rate (esb GPD Replacement ~ Public or commercial - Describe: Parent material 14,ess p Q(J~-W~ rA Flood Plain elevation If applicable General comments X-~- and recommendations: ys/ .~-t~r /s s~ •T~l~ itJ c~~~ y(~ Boring # Boring ~Z • > 111 rrr III spit Ground surface elev. if. Depth to limiting factor 1z 0 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roofs GPDW In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •E1101 •EH#2 / o -/I/ /oYR 2,13 f f4X sm fie ~W .1 f i . 3 2 • Zy /o /P Sic 2 t-S,C 4*1 e S /0W.5/ s.L /ieshk 25 , . z . 3 75 s. o;s . ,e cs .7 A z Boring # r~--1 Boring u Pit Ground surface elev. n• Depth to limiting factor In. _ Soil Appllcnll^n Rnle 11^rh^n hnppt hnminnnl t;nkn p,,u texture SUUCtUre_ Consistence _Boundary Roots GpDnp In. Munsell Gr. Sz. Sh. 'Eft#1 'Ef f#2 Effluent Ni = BODY > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent 02 = BODs < 30 mg/L and TSS < 30 mg& CST Name (Please Print) Signature ~ CST Number a ~7l3R ~•C z Address zee 3 7 S _ Dale Evaluation Conducted Telephone Number Private Sewage Consultants 655 O'Neil Rd. ~ Hudson, Wis. 54016 06 axis rrivG•- sySr T',~~~ - 119 ST- A/t-e Z? o. I ~J v~ v~ Cn o IS r Z • w lol w I too T I I I I I; ~ 1 N QPYavc h1 W ~C e ~ I I b; p a =0 wa~~ p z N m ~ b - , v i P ~ 1 ' FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 1141 TOWNSHIP SECTION s2 Z T 2~ N-R_ZIF_W y(fV pht-d ~ ADDRESS 0516 et-t--42 S ST. CROIX COUNTY, WISCONSIN U SD-,~ ~46 2~ S S yam SUBDIVISION LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f., INDICATE NORTH ARROW -rot rF- e fiR siL'GveLK c ~ BENCHMARK: Elevation and description: ceg 100,6 Alternate benchmark _ i TE c o.v STS v c TAO 70 SEPTIC TANK: Manufacturer: --xis iN 6- Liquid cap. 3000 d r Rings used: Manhole cover elev: Final grade elev: f5F- 74 Tank inlet elev.: ~S Tank outlet elev.: r No. of feet from nearest road:Front X , Side , Rear Ft. d O From nearest prop. line:Front , Side , Rear Ft. > 'go / No. of feet from: Well Building: 13 (Include this information in the above plot plan) 5"71C 4A~~ (2 reference dimensions to septic tank) ND%E SEE REVERSE SIDE c IFS o -~i o %~~K Sao Fc T p i3rtf c ~S - Z Fi's E-A 6:-4 /f s S Q G es' i r PUMP CHAMBER Manufacturer: ZZLiquid Capacity: Pump Model: Pump/S h Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: ~77 Switch Type: Location Distance f om nearest prop. line: Front_, S e_, Rear-Ft. Distance from: Well Building 5_ " JC Cp~ SOIL ABSORPTION SYSTEM VX 70 Bed: Trench: Seepage Pit: -43 '~Q~" Width: Length Number of Lines: Area Built 7~/, zS APP" TRCacPi, / O 9o tilS~ ~ -9*"t. Grade Elev. 5 2- o Proposed Final Grade Elev. Fill depth to top of pipe: 3 co " 116 `F2- No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from well: 8 7 'No. feet from building s HOLDING TANK Manufacturer: pacity: No. of rings used: Elevati of bottom tank: Elevation of inlet: No. feet/ from near prop. line:Front , Side , Rear Ft. No. feet from* ell , building , nearest road Alarm Ma facturer: Ifs INSPECTOR: DATE: O~ I2 L " ~O PLUMBER ON JOB: LICENSE NUMBS ITE SEPTIC PLUMBING CO. ROBERT ULBRIGHT j py~, y~,R'31'ER PLUMBER LIC. NO. 3307 M.P.R.S. 6/90:C ~f;I r; I~ *;TALLER & GESIGNER L1C. NO, 00663 /~~J rJ yGsJ &.417' /O f 1 Y 1 , , I I n y ~ I I I c t 1 ~ ~ O ~ I~ h I C I S C> \ ! In, ICI ` ~ L_ I t- I ~ 1" I ~i ~ ~ v V 1 awl ~ ~ ~ I ~ o i to s -c 0 > / L o • 7 -ra -O (p Ntz e~ N ° ° c m rn ry IV Z) N ti; m Zrn ~ N i W L'v 16 o o rnLl _u R Q z. o o rr, W r~' m cmi~ i x ul L) 9* IT, r G La r- n N C) 65 ~ z o~ y~o o ~ ~ p `W w~~ DEPAKTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING DIVISION 1 LABOR & HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION P .P. BOX 7969 ISQNT}~I 53707 State Plan I.D. Number: 5 W y4 , S 2C . 22 , T 29 -R19 (If assigned) of Hudson CONVENTIONAL El AL7ATI VE 1 R Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIO D T Dave Cindy Mathison 640 Badlands Rd. Hudson I 5401 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELE ~ ,OS Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 128 98 SEPTIC TANK/ r cc~e MANUFACTURER: LIQUID CAPACI Y: TANK INLET ELEV.: TANK OUTLET ELEV.:- WARNING LABEL LOCKING COVE / PROVIDED: PROVIDED: O C O 9~ . 7 , 3s' YES ❑ NO ❑YES NO BEDDING: IA.: VENT MATL.: HIGH WATER ME OF ROAD: PRO RTY WELL: BUILDING: VENT FRESH C. C O, ALARM: FEET FROM ` LIN? AIR IN ET: ❑YES NO ~Gy)f n!l11Q ❑YES NO NEAREST-~ /TA DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING L %BEL L CKING OVER PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO RESH GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING: AIR INLET: (DIFFERENCE BETWEEN FEET FROM LINE: PUMP ON AND OFF ❑ YES ❑ NO NEAREST -10" LENGTH: DIAMETER: MATERIAL AND MARKING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM WIDTH: L NO. OF DISTR. PIPE SPACING: YNU.U151R IDE DIA.: ~WLL7 PS: LIQUID BED/TRENCH , TRENCHES: DEPTH: DIMENSIONS j 'fQ GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: jL PROPERTY BVNT TO FRESH BELOW PIPES: ABOVE COVER: ELEV ET: ELED: , q0 pVC, LINE: AIR IT: & I `6 MOUND S YSTEM: I . 9.s " ~o-t Crn154 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: RENCH WIDTH: LENGTH: TNO.OF RENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: BEDITDIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: F O.ESSTR. DDISATR ELEVATION AND . PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: I15 butL~ h f ❑YES ❑NO ❑YES ❑/NO INEAREST1 5.7 E n a. 90.7, gl,sv` C"C et in county file for audit. Sketch System on Reverse Side. sIGNAr E: TITLE SBD-6710 (R. 06/88) Givl SANITARY PERMIT APPLICATION TOiLHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY ST, C~eOt STATE S~TARY PERMIJ.~ -Attach complete plans (to the county copy only) for the system, on paper not less than (/(er(7}Q(/ 8% x 11 inches in size. ❑ c(eck l4 vision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. ' PROPERTY OWNER PROPERTY LOCATION DWE- 3 C%A)9 MItf4 1'5-0 Ad' ,C- '/4'/4,SZZ TN,R ~ E(or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # U &fp G ,v CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~~o.J w/S ~'yoiG coyd~~ cs-t 330? 0 00/.s~2 P~. 87 s 11. TYPE OF BUILDING: (Check one) El NEAREST ROAD State Owned ~ ❑ viLU4GE : [TV Q~jt~ 10 JOWN OF: ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms --PARCEL AX UMBER ) io- IL (M - (0 Ill. BUILDING USE: (If building type is public, check Z11 that apply) Oa 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 4.0 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 El Seepage Bed 21 ❑ Mound 30 El Specify Type 41 El Holdin9Tank 12 M Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill Z 41,E f ~'1 4~L 5*t )`l( 67 / 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) g S ' EL 600 1660 -)O S. 3 17. 5, Feet X9.11.55 Feet VII. TANK CAPACITY Prefab. Site Fiber- Exper. INFORMATION in New Exi gallons stin Total Gallons # of Tanks Manufacturer's Name concrete Con- Steel glass Plastic App structed Tanks Tanks Se tic Tank or Holding Tank N o 6dA.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) IOWMPRSW No. Business Phone Number: Ro13 T- W-AMI?A7- 330 Plumber's Address (Street, City, State, Zip Code): 57Z.5' /W. _5_1916 D' ~:C« f>1a~ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary vermin Fee tincludes Groundwater Date Issued Issuing gent Signatur ((No S Surcharge Fee) Approved ❑ Owner Given 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 i INSTRUCTIONS r , 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, Ei08-266-3815- To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. ll. Type of building being served. Check only one and complete # of bedrooms if 1 or2 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) L MUMS ^y .y`M. H NY~FMNMw.w.a ••.-•+..-...'.n-r-T`M.rw+..«~-i,w..w.MIM-NYw-wwww.....•. ••w.w.•w..w«= ,Ole `./.=.riswwX.1.~«r..wrwrwr lpr.f east SAS first of Sawtb 207 feet of SUSA ~ e f b at ~alatta; b ~bways, easements and rights atwayr -0 Is it." f't •--'-•-.w« ~ ._..w ......w • JP Y..... X1 1! R 4 t_--r---- .CYAt!►ia_.J.... thiaoa........ WAM 4W Its Ysm~ Ir r. w Lwa t~ M 1r 1~~ ..r-.. tiw aw~~ ~Si.-..+w........ lllssssssffi~ -w«.. • ...w... d..p,... • ........-.N. .w.M-w«. . r.N ^i • 4' i ~ O Oct„ mz O ~l 1~ 0 v J z_ v, w `i 5357~w aap~c_7 Z I~ V Q~j ==W IU d\ f~ IC- O M W ww •r C3 cr V ~ I ' I Q 2 Cn LLI Q Z F ~ w . o I \9 41 ILK J ~p II 4 0 ~ ? I V I~► J w 1 f l ~ ~ a I F W a, 3 w ~ `C S y~ ` ~ OJT I a 0 a IC3 40 - \t, AL W ~ 2 1-- 3 0~ I o: I I h I o cn W y j I ~b I 1 D k •1 ~ 1 vt 2 P' oc a cu , f~ ~ ~ ~ I ? 1 ` I W I Oe N Icu Iii V I I p(~ I I , i .I O I ' I 1 I i I V I 1 , I fl ICI a~ ly o Js613 ~'~ynlsN I s • t 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 :~)"t -Cl- tip/ "A 7A /sf Location of property S 1/9 SGt/ 1/4, Section Z , T L~ N-R-~fW Township Mailing address 5,- l c Address of site Subdivision name Lot number ` Previous owner of property Total size of parcel a,~rer Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes No Volume Rand Page Number L6? 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 BEAL 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. L6y O/ & ; 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 of the County Register of Deeds, as Document No. OV ~ 4 Signature of Owner Sign *a of Co-Owner ( pplicable) 7U Date of Signature Dat Signature I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUST 1 Y, CC DIVISION LABOR P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707 % (ILHR 83.0911) & Chapter 145) LOCATION: SE 1 N: OWNSHIP/ OT NO.: BLK. NO.: SUBDIVISION NAME: SE 1 '5rd 1/4 12- /T 19N/R if E co ifvAR-fe lJ cSrj 135,07130 !io/ S 3 2 . • g C.CY: OWNER S RULER'S NAME: MAILING AD R SS: Poi K _-'bAuf -kCi o,11y MA-► iSO-) G go 73~o~•~ti s P-& . 4U'0_('0_) Gvis s~aiO USE 6 to y DATES OBSERVATIONS MADE NO DRMS.: N: PROFILE DESCRIPTIONS: 1PENCOLATION STS: Residence ! ❑New Replace PIT, {j SE~1, s1 o ~vpt.L=X '{~.ES ~ D>`~ SC.S °J ,~v1°,fG~ fI'RDT RATING: S= Site suitable for system U= Site unsuitable for system , ONVENTIONAL: MOUND: IN-GROUND-PRESSOR : SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) 't 60 lc-c ~~~ow Spy lATE , f R] s ❑u EIS au ES au Ds ®u ❑ s ©u s E f'-_ iU S/o 6 ee S PiGt t PoeFt•C-1c'L of o/O A,6~Iut fv DESIGN RATE: / f7i S YS If Percolation Tests are NOT required If any portion of the tested area is in the / nl under s. ILHR 83.0915)(b), indicate: ( I SS Floodplain, indicate Floodplain elevation: t►~ i PROFILE DESCRIPTIONS BORING TOTAL PTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIG HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ,2. o ' o,t4Nr'c 81e. S p I -SN . S . S • ak. S r, B- p ` I. 96, S. S' %IfA) CS W /iuct&I SiJd- 1961FETS J OF gipAy i' M 0-H LED l B- r ! f.~' /3!,( SW /,o' D~ .v• .2 O' T.,, Sr~. Z B-2' y D 13-0 o ~o > b f!O TAN cs w F ~atCu iuE 't3 0 C6CET S N! oP 94,e4 y S. ~i~ro ttcE m B_ B.3 lo10 r ~(1 , > 9. ' 1•S ' IF. S, 2, p a, - a. !!L 0 -17 1 n.) CS w ~'xtr ,ac ~ t EI o o or f 144y S" B- No'116: IORE* o,j o oc v o a K- S EF Dior I mo. PERCOLATION TESTS o l EST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD RI PER INCH 10 P • flt7 Z It 1! 16 s 2__ P_ 2'Z4a S-3 rv! P S S ' P- P_ r J`l 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. L Ow.-4 716-_N 4%, = ~f 7 So ~ V N SYSTEM ELEVATION _ flr Tit0,E.uc%~- To%F _ ?IN roT_. CIA 11 Rd S10* L 14 r' T~?~tiv~' - ~T •m . t "'CZ '"T LOT g .S Df ~ t i T i fr0 M i. _ y i ACCE c ~u o o ~'k-T n ter- is I~ AJ4 :)BE 4:) -lit JA 11~_ Of 04 TA - Di h r, ~~2 ;D i i j T v S _ -r o a / lvF12e_S0 T" 4.),PlG 1'T 4)t le Dr- . b C4L S 47-v.p71 T/'o•J I, the undersigned, hereby certify that the soil tests reported Qn 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 HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: C,' Z 655 ()'NEI1 go.. HUDSON. WIS. 54016 SCpr, 2 ADDRESS: ROBEFIT ULBRIGHT CERTIFICATION NUMBER: P O E NUMBER optional): R PLUMBER LIC. 140.3307 M.P.R.S 1 y ~L slip - ! s NU. 0W_ MINN. INSTALLER & DESIGNER CST SIGNATURE: 41 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R, 10/83) - OVER - ce • r \ 1~ t0 d N 0.h 9 IL h (U ca Z h zw r ~p • -j S2 cm, C C3 C 1 U~ ~ 1 111 k Q VS0 U_3 ° z a 2 z Q. 4 h~ o QN~w o c`\ tT! .~l ~ y N N w lu o W r F 4. U W e ~ S ` W n~ io I l~ ~ 4 0 6 C) a.l W eo , I ~ Z vhi ~ n°, Iw ~ Io I I. 7 ~ ~ ~ x W' 1 Ip I -a ; W I a ~ M • 1 ~ ~I~i ' \ t~l IWI v d- II- I iii Imo; X31 ICI i of °(p s i p 1 1 1N Xi INI 0 3 ' I e or N ~ in Z Fresh Air Inlets And Observation Pipe N, 9i C)--Approved Vent Cap Minimum 12".Above Final Grade ~LC-- M0fAdA Ot" 4" Cast iron kjY Above Pipe Vent Pipe' -to Final Grade kill' . Synthetic Covering r; Min. 2" Aggregate Over Pipe Distribution if Tee I Pipe 0 0 0 0 0 Aggregate o Perfbrated Pipe Below V,. Beneath Plpe 0 Coupling Terminating At Bottom Of System Z- C v Fresh Air Inlets And Observation Pipe 00 Q•-- Approved Vent Cap Minimum 12" Above 4 Final Grade 4" Cast Iron 1/2- Above Pipe 'to Final Grade Vent Pipe' tc . Synthetic Covering Mina 2" Aggregate Over Pipe Distribution Tee i p • Pipe 0 0 0 0 0 Pi Beneath e Pipe 0 Perforated Pipe Below 0 Coupling Terminating At t' Bottom Of System STC - 105 ' SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ~ ~ /tea ~Ifl ~,J/ fv.✓ _ - C ✓ ~ OWNER/$WUk.R a~ G ~ a ROUTE/BOX NUMBER "~o S FIRE NO. CITY/STATE ' ' " p50'Al ZIP s y61 PROPERTY LOCATION: 1/9 S~ 1/9, Section L 2 , T L/ N, R r w, Town of C7 y , St. Croix County, Subdivision , t No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists 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 sepCic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED X2 DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 59015 (715) 796-2239 or (715) 925-8363 Sign, Date, and Return to above address Adwhk -ANOm SMoNNI•-39 3210.09 Need t99Q-V9"IL 'X3 0998-be9-91L 'HcI NO 9NOUV'OOl ONY 9NOI9N3WIG '93ZI9 too" IM 'uln pvg - U wtin$ 19 uIrW 0% ~ IW kaIBA Ot WNW/b0iVWUINO0 -IVI72BWW07 1HVI I • k IIWV=I-I.Linw • IVI.03093Z! :310N 1NV'.LNOaWI N9193<3 VNI.L=I'VNCI LSEIMC 1 W -----n II 11 11 11 11 II 11 11 11 11 - 11 11 „ z II Q r 11 o 11 a 11 11 11 11 . 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