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020-1102-40-275
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 579031 GENERAL INFORMATION State Plan ID No: r Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. r V Permit Holder's Name: City Village Township Parcel Tax No: Lis Hoier Trust Nielsen TOWN OF HUDSON 020-1102-40-275 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: ,4i daj wee 34.29.19.408D-30 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~ Benchmark Dosing Alt. BM V g b . 12. ipp Aeration Bldg. Se r Holding St/Ht Inlet TANK SETBACK INFORMATION , 0 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Bader an. Aeration Dist. Pipe J2. r5H.7g 2. Holding Bot. System 13.10 $ 3,78 X Final Grade ' U PUMP/SIPHON INFORMATION Manufacturer De St cover Q M D Q Model Number TDH Lift Friction Loss ystem Head T DH Ft Forcemain Le Dia. Dist. to Well ABSORPTION SYSTEM t BED/TRENCH Width Len th No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. 11-ibuid D th DIMENSIONS g 7 1 60 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of System: n CHAMBER OR , i t>y UNIT Model Number: t l; C UTION SYSTEM v V JV~ ea anifold Distribution x Hole Size x Hole Spacing VT ~ pipe(s) Length Dia Length Dia Spacing I SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded / xx Mulched Bed/Trench Center I Bed/Trench Edges Topsoil Yes ❑ No es ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: I Inspection #2: Location: 659 GILBERT RD SC yro ~n ` (p ~l p r~ f D~C ~N I U _ ~laS / J Vl Ill / 1 1.) Alt BM Description ~ O f °'-i ' ((t ~S ! ►nU P° 2.) Bldg sewer length `'p = ~ V l r 1 V ` X J -amount of cover = ~Y ~s~l IV I~ ~ , ~ I al SS ~uSe,tt p (1-~ ! Q► /~I V.x V J p I~"'~r 1, '~YC~►t~~fi Plan revision Required? ❑ Yes No iJ 1 j F~ s( Use other side for additional informab . ~f I J U SBD-6710 (R.3/97) Date Insepctor's Sig atur Cert. No. RECEIVED County , Safety and Buildings Division Cie f~C 201 W: Washington Ave., P.O. BOX 7162 Sanitary Permit Number to be filled in b Co. s g K JUL 13 2015 c y> a s 1NI.#53707-7162 o ox~ ST. CROIX COUNTY 57763 O Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit Note: Application fors for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m .Stats. 657 I. A lication Information - Please Print All Informati 0- &A--a. Property Owner's Name Parcel # L S N~ 15 e OZo /o-Z a z7~ Property Owner's M ' ing Address Property Location [~J( d3D r z_rN~ Govt Lot ' (v " City, State Zip Code Phone Number ~ p t , p , ~j _ _L"u1L Section r`-7- 7 a r "t C~l 7/5 5-F~ry ! 7 T q N. R circlE oene H. Type of Building (check all that apply) Lot # P` or 2 Family Dwelling - Number of Bedr m 3~ b Subdivision Name Block # ❑ Public/Commercial - Describe Use QCQ ❑ City of qq❑ State Owned - Describe Use 1 CSM Number ❑ Village of _ (r~ ~it GG~, t.a~ / +~{oBC~ Cs Mi M7 Town of I.fOS III. Type of Permit: (Check onl one box on line A. Complete line B if applicable) K4 A' ❑ New System ;Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit. Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner 3 0 IV. Type of POWTS S stem/Com onentfDevice: Check all that a 1 7 Aon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Dispersal Component (explain) ❑ retreatment Device (explain) V. Dis ersal/Treat nt Area Information: Design F ow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed (st) System Elevation 90 -57-d r 7 &4/ 6 7 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units c qq 'o New Tanks Existing Tanks °ar v U h v a U y h w C7 Ci. ~ ~ lay s~ Septic or Holding Tank I 7n A Dosing Chamber G/ ~Acl J~ ! - VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name' Print) 11 Plumber's Signature MP/ie$__ lumber Business Phone Number d Lin !v Z, 7 ~l 1?7~ Plumber's Address treet, City, State, Zip Code) VI oun /De artment Use Only Approved isapproved Permit Fee Date sued Issuing t Signature ven Reason for Denial $ '175-4c> 15 DL Condi "sons for Disapproval 3~ 5 ei utA, ~2 1 rOJ~, ,'1. - LCwX'ti t " t nlt, eMt*ht filter and dispersal cell must all be services (maintalW n as per management plan provided by plumber. Q~( eJ t~dU ~b~''~ 2. c~ r tints must be maintoin8d 1 / as pera ire t deI adirisncss: sly, i„~ . 7 Attach to complete plans for the system and submit to the County only on paper not less than 8 La x 11 inches in seize SBD-6398 (R. 11/11) J I W. &415~ 1 QN W ¢ N4 -a J c oal - ~z I EF M 'Zol 14 77 o u J I ' t CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: L / A J/ Owner's Address: ` 4-W/ is i t D a ( U/ Legal Description: tJ A j,4J y T 7 4 2/ -~®~0 ,J Township: County: s~ Cb~ p CSC Subdivision Name: 7` 96 7 Lot Number: Parcel ID Number. D f/~ tf~ "~7 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing P. Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 -Management Plan Page 7 L L~' A Page 8 -s'2s LLcGkC 4( PLU- C A~t6~z Page 9 Attachments: Soil Test & House Plans Designer/Plumber: ~09 Gn L5- it/ License Number: Signature Date: 7 ~ ~ Phone Number Designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 x. t EF 2 M b I or 2- Family Dwelling In-ground Soil Absorption System (2-cell Conventional) Daily Wastewater Flow (DWF) _ # of bedrooms x 150 gal/day/bedroom = - L 0gal/day Design Loading Rate (DLR) or Soil Application Rate = r gpd/ft2 (per SPS Table 383.44-1, 2, or 3) Required distribution cell area =DWF gal/day + DLR 17 gpd/ft2 =~43_ ft2 # Chambers = Required Distribution cell area ~q ft2 + 20 ft2/ unit EISA Chambers Chamber Manufacturer and Model: //J L 7444,:V~ a LC.(c ft Actual Distribution cell area = Required cell area !C~ (i, U ft2 + 'i 2 S / _ ft/unit EISA End Cap Pair ft2 P ti Cross-Section In-ground Soil Absorption System (2-cell): 4" Schedule 40 PVC vent pipe with vent cap q 12 inches minimum 12 inches minimum Z inches Soil Cover Trench 1 Sys- tem Elevation f 2 inch Chamber Height croft <Z) 0 -aft Trench 2 System ♦ Elevation ft ft Trench Separation Leaching Chamber Width 3j ft to limiting factor Plan View In-ground Soil Absorption System (2 cell 3 Trench 1 ft Modify header/ EEZEEM ft design as Leaching Chambers / Trench 2 needed. 4 inch Header L,t ft with end camps Draw Q for a Vent and for Observation Pipe above. They will be located ft from the end of the cell. Vent pipes shall be Schedule 40 PVC and extend at least 12 inches above finished grade. Observation pipes that extend above finished grade must also be 4 inch Schedule 40 PVC. Page of c 12 z~ r~~ p O E m 'c = C 'O _ m e m co Y1 ,5 3 C w - w E C ml~lk S fl o l LL w LL 7m~jw~~ m3E` C7oc~-o -r "•o LO 'O ?~C d if , O b "~C m'~p~Y ,~mcm a~ FE HL VU~a$c I°wr~ ;t vmar ' 5~ c ~~3nn E w ! WoaV . m C o mpCpw wc W c0 r c, nvi~ $ m 8 o n. Q q 0 ■ ww cm C7 r' a~n @ : c C mffi . o c °p w'cwiii ` ' R 5 C` C b N Y e m f cc O ~ w N ~ y ,y vLOmtf m wp rv•`k'E v`k d zr a. n c m m ` ~t ~I f7 o2 E MD ~wpMEmo N. F CLL7ao~o z~Wa~ wmmc~~y O 01 Q a~m o a o w m~ tL~. ! W E k4~~ _ o a It 1A ao C$ !X .21 r ?"T, p~{qq POWTS OWNER'S MANUAL & M,~NAGEMENT PLAN FILE INFORMATION SYST(M SPECIFICATIONS Owner Sept$ Tank Capacity /©©o al ❑ NA Permit # Septl Tank Manufacturer ❑ NA DESIGN PARAMETERS Efflu(ijnt Filter Manufacturer ' ❑ NA Number of Bedrooms ❑ NA Efflut of Filter Model ~Z ❑ NA Number of Public Facility Units NA Pump' Tank Capacity al ❑ NA Estimated flow (average) 3aa al/da Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) I t f ~O al/da PumpsManufacturer ❑ NA Soil Application Rate al/da /fts PumplIModel ❑ NA Standard Influent/Effluent Quality Monthly average* Pretre tment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sar,ld/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD6) 5220 mg/L ❑ NA ❑ Mei~hanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average rDe, sal Cell(s) ❑ NA Biochemical Oxygen Demand (BODa) 530 mg/L 'around (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA !~rade ❑ Mound Fecal Coliform (geometric mean) 510' cfu/100m1 y Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA ❑ NA Other: ❑ NA ❑ NA *Values t ypical for domestic wastewater and septic tank effluent. ! ❑ NA i MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) I At least once every: '13 ❑ month(s) (Maximum 3 years) ❑ NA I;i year Pump out contents of tank(s) When combined sludge and sd um equals one-third (Y) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ® year(s) an effluent filter At least once every: ! ❑ month(s) ❑ NA ® year(s) pect pump, pump controls & alarm At least once every: ❑ month(s) 3 H ear(s) ❑ NA F h later als and pressure test At least once every: ® 13 year(s) month(s) E3 NA LO ther: At least once every: 13 month(s) ❑ NA ther: ❑ ear(s) ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carryFig one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POV1 S Maintainer; Septage Servicing Operator. Tank inspections must Include a visual Inspection of the tank(s) to identify any miss or broken hardware, identify any cracks or leaks, measure the volume of. combined sludge and scum and to check for any ba(,l up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in I,he observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surf'ce may Indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals ocle-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator ancil disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, Including but not limited to the servicing. of effluent filters, r,l~echan(ca( or pressurized components,, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a ce#ifled POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 da ~s of completion of any service event. GMW (4/01) ~l START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) fo;r the presence of painting products oQdlw~lh)emlcals that may impede the treatment process and/or damage the dispersal cell(s). lif high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltra!~Ive surface. During power outages pump tanks may fill above normal highwater levels. V' hen power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) lOnd may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removi d by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer trb assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or'park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may'jimprove .the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs;'; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasol)n'j; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener'brine. ABANDONMENT When the POWTS fails and/or Is permanently taken out of service the folloH,I'ing steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandonedlpipe openings sealed., • The contents of all tanks and pits shall be removed and properly disp bsed of by 'a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed of their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have bei~n, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilize] for the location of a replacement soil absorption system. The replacement area should be protected from disturbance' nd compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines anci wells. Failure to protect the replacement area will result In the need for a new soil and site evaluation to establish a sui, able replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback andlor soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace fhe failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement'jarea. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area.'; If no replacement area is available a holding tank may be Installed as a last resort to replace the failed POWTS. ❑ . Mound and at-grade soil absorption systems may be reconstructec' In place following removal of the biomat at the Infiltrative surface. Reconstructions of such systems must comply wit,' the rules in effect at that time. < < WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL G,' ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUIII~STANCES AND/OR. MAY RESULT. RESCUE OFOA PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLI~. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MTAINER Name © 5 15- rZ, _N SpJ~ Name E -7 Phone -7 11 Z 73 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGII LATORY AUTHORITY Name o14^-1 Sr„Ay 5'.4Nf4.t+rd Name ; /c~RC E Cou,vfy ?o Ail s4 C` /X Zd~l Phone 7/S Z 73 S` / ( _ 3 Phone 2 73° 7151.39,' 1690 This document was drafted in compliance with chapter Comm 83.2212)(b)(1)(d)&(f) and 83',',,54(1), (2) & (3), Wisconsin Administrative Code. a ,Jechnical Data Sheet Basin" 18" External Effluent Filter .ao-s,b,6a7 Applications General The 18" External Effluent Filter Basin provides an ideal solution External Effluent Filter Basins are composed of an 18" diameter section for retrofitting existing residential septic. systems. External of ribbed PVC pipe with a fiberglass base, and an 8" diameter Biotube® Filter Basins eliminate the need to make costly, and often haa- Effluent Fslter(U.S. Patents No.4439= and 5492635). Orenco Biotube ardous, modifications to existing septic tanks with restrictive ~ tic tank The Biotube cartridge handle for easy access openings or to unusable outlet baffles or tees. p has an removal. The FTB1824 is designed to conneetto 4" diameter schedule 40 PVC pipe, using a 4" diameter grommet on the inlet side, and a 4" diameter Schedule 40 PVC fitting that is solvent welded to the ribbed pipe forthe discharge side. When connecting to 4" diameter3034 Grade ring pipe, order a FIB3034KIT, which contains an 0-ring forthe inlet groin- met; and an adaptsr coupling forthe discharge outlet An 18" diameter insert grade ring insertis supplied, butthe riser and a fiberglass lid should be t e pl «'v' " ordered separately to bring the basin up to grade. { r.'» Handle assembly r Standard Models FTB1B24.0812 Vault 14 FTB3034KIT (for connecting to 4" 3034 pipe) 666 Biotube filter Influent Nomenclature cartridge holes FTB 18 24 08 12 I liter cartridge height 12" (305 mm) standard Fiter dlemeter. B" (203 mm) standard Basin height 24" (610 mm) Standard Benin dtameier 18" (457 mm) standard Notube effluent flier basin Materials of Construction: Filter Basin: Ribbed PVC Pipe Filter Basin Base: Fiberglass Reinforced Polyester Biotube Enclosure: PVC Biotube Cartridge: Polypropylene and Polyethylene Biotube Handle Components: Sch, 40 PVC, Stainless Steel Inlet Grommet: EPDM Rubber Discharge Fitting: PVC Specifications Biotube Mesh Openings: Nominal 1/8" diameter, nominal 30% open area m 2012 Of-on Spsleraso Inc. NTD-Fro.M•7 JIM 1.0, ® 07/12 Page 1 of 1 r -1us Standard Chamber Side and End Views 48" (EFFECTIVE LENGTH) 12" a = I i I ,t Plus All-in-One 1 Encap Front, Side and End Views 14.2" l 13" 8" INVERT 8„ INVE T 5.3" INVERT 33"-~~ w , ,I<.>iic 4 l3lus All-in-tine Periscope OUICK4 PLUS ALL-IN-ONE PERISCOP (360-SWIVEL ) i QUICK4 PLUS 12.7" INVERT 6 ALL-INANE 12 511 911 ENDCAP ti Quick4 Plus Standard Chamber Specifications Size (W x L x H) 34" x 53" x 12" (86 cm x 135 cm x 31 cm) 0,6", 5.3", 8.0",, 12.7" _ Invert Height',, (1.5 cm, 8,4 cm, 18.5 cm, 22,6 cm) Effective Length 48" (122 cm) INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, end plate, wedge and other accessory manufactured by Infiltrator ( "Units"), when installed and operated in a leachfield of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder") against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook, Connecticut within fifteen (15) days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units. (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty INFILTRATOR does not extend to incidental, consequential. special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, _ including loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party. s y s t e t71 3 inc. Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure to maintain the minimum ground covers set forth in the installation instructions; the placement of improper materials into the system containing 6 Business Park Road • P.O. Box 768 the Units; failure of the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation; or any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the Old Saybrook, CT 06475 Y terms set forth in this Limited Warranty. Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any 860.577.7000 • FAX 860.577.7001 o third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this Limited Warranty to apply, the Units must be installed in accordance with all site conditions required by state and local codes; all other applicable laws; and Infiltrator's h€ installation instructions. 800.221.4436 (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the www.infiltratorsystems.com original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty > requirements. Any purchaser of Units should contact Infiltrators Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. nNtrator, Equalizer, Quick4 and Quic1<4 Plus are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour Swivel Connection is a trademark of Infiltrator Systems Inc. © 2009 Infiltrator Systems Inc. Printed in U.S.A. PLUS0510101SI-2 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address)` $1 S l L g T-re-4. R-a located at: _ 5W 1/4, -AJW 1/4, Section Town 2 1 N, Range_l__7_W, Town of WU4-5- e,J , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Z o -It- Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: /dn Construction: Prefab Concrete Steel Other Manufacturer (if known): J,J ~C < 5 ~ tic r?- 'e Age of Tank (if known): /nJ f Prtc ,.A S,F /17 b Permit number if known) - t~ ytr~ (L tensed Plumber Signature) (Print Name) (Title) (License Number) MP/A (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS USTR Y, LABOR AND, DIVISION HUMAN RELATIONS PERCOLATION TESTS (115) P.O. Box 79s9 (ILHR 83.0911) & Chapter 145) MADISON, WI 53707 LONTION: TO OW TINO. ~jT27 pp q Lt.tS ~ 3 N~R E (or UafO/ TY: COUNTY: `f'`f NO.: SU OI 1 MAILSIN 9A R 6,,Me~e7- xb0 - H L) Ar40 4~iS J-V01jr, uSE DATES OBSERVATIONS MADE 4 Residence ERCIAL DESCRIPTION- 4Residence y,~/.. ❑New Replace M~ y iP -lff o A* yffo p2a-//o2 "'/a-Jld , ofv3ia Y~ RATING: S- Site suitable for system U- Site unsuitable for system ScS G ~o T3 R K Gi r CyCj/~C-T t S'O~ L S ONVE 1 AL: MOUND- IN-GROUN EM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:loptiotwl) as au ©s au ©s ❑u as au as au T~~N~,t,~s w, ~~o ox iST2i(3O X0,..7 I If Percolation Tests are NOT required DESIGN RATE: If an portion 2 under s. ILHR 83.0915)(b), indicate: GG 4-SS Z'- I Flood of the tested area is in the dplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS Tv -DE /:-'f 'L.- fl-- j BORING TOTAL R U WATER-INCHES CHARACT O SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION RV ES M-W TO BEDROCK IF OBSERVED EE ABBRV. ON BACK.) • r > 11,5 ' $,u- oft-94. 4A R-4f• S. G- ~ S, OR- j, c S s 4 . B-2- Y-0' ~7. Sy• ~ . ~s' a,~-,y. )s 1.(7 • ate. s ).mss ~ ~~,4.~. O v~l.'t 51 . e4 vR s dle-4a . 5 3 (rR B- 8-3 BD~ zG~ v ' bo' 34 - sy. 13,u.-sr s- ss~ B- PERCOLATION TESTS 141 C S S-17Q*Tvt S DEPTH WATER IN HOLE TEST TIME IN WATER LEVEL-INCHES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PFA100 RAPER INCH P. 'z~ tZ P. Z. 3 P. 4; y- 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- Lontal 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 s:~E ~L o T oOG,} ✓ /PeUzi s F i tN i This-f6st site APPR0V for a ccriven ionai septic systerrL a STC - 105 1 ~ t I . SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER V1 I!E y ~ fC G St j/ ROUTE/BOX NUMBER G FIRE NO. `S. CITY/STATE t+V ZIP yG6 ~O PROPERTY LOCATION: S GlJ 1/9 1/4, Section 3 , T 21 No R W, Town of jyvy`r , St. Croix County, Subdivision "-V. '4 , Lot 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 septic 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.Cro within 30 days of the three year expiration date. GNE y J 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 ry o m °o I o ,r 3 0 m !I O ~ I C N a O ~ g I aai ,y o~aain ~ c'ci a m y > a m'o rn~ m ` 0 mUln rn&Ao~U ova Oo3 in SOU M " N 0 C X N E :e C fN0 f~ a' N O) y fa0 m C 4) r, El) y N E N C L vT)KO°oia u) y~wc°i (D U) m CL Z LO y ('o C n(Aw C > V Y O r O C a c N O U. C 'O V O aj e- (O E N C O O o 0 7 a y a C y N O a0 C ! Q C co U .C O w n O ! Z E N rn c c Z ~ v 4i o 0.0 I Z ~ 'o n m d d rn c chi H can a ° c 0 0 > o Z v i, c o c V, o E d Z 7 4 aai o N H r O ~ a rn y a c. N Cl V31 4)i o o ~v c CL E a (D CD 4) 4"' CD N a o y y o lO N N C C O U) N U v o p O O N Q 4= N N N z z a o C) 0 Z Z o o I c m m - a Q- 3 w CD 'ooa` a h co E c z m 3 3 a~ ~ 'N "LO aaa O N 0 H 0) 0) to J U a m O) } LO M N V O - 0 0 0 0 a LON 0 0 0 0 0 Q O O N N N N N a M O w a N N N N ! j 0 a N o 2 W W (O O In a o ¢ in o C C7 S h \i n O o o c ^Ol o ro; i! co o O E (V IS O- LO n V o 0) c U) o a O o 0 00 0 c) N > 0 C ~ Vi h a N N N N N N O O y z L d 7 n N N N N cy; co to c, Lo *0 6 c! LO 4) (D LO 0 ' o z N N g05 ~'a t, o M 2 I:, Z CL a~ a v 'c c c r A vat oav c Wisconsin Department of Safety and Professional Services Division of Industry Services RECEDE' SOIL EVALUATION REPORT Page I of 2 QN 1 n 2014 in accordance with SPS 383, Wis. Adm. Code 7 County ST. CROIX Attach com e e site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. 020 - 1102 - 40 - 275 percent slop%,-t ~dIiWPNibns, north arrow, and location and distance to nearest road. Please print all information. ~viewed' Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).-L t yt,~ 1 j j ~L Property Owner Property Location LIS H TR NIELSEN Govt. Lot SW 1/4 NW 1/4 S 34 T 29 N R 19 E( r))WW Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1917 Twilight Lane 6 CSM 19-4967 City State Zip Code Phone Number ity ❑ Village ■ Town Nearest Road Hudson, WI 54016 ( 715 ) 388 - 5972 Hudson Gilbert Road Q New Construction UseE] Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD El Replacement ❑ Public or commercial - Describe: Parent material sandy outwash Flood Plain elevation if applicable NA ft, General comments (2) in-ground conventional trenches to be added to the on nal 2 trenches and allowed to and recommendatio s: gi dry. Discussed this with Ryan Yarrington, St. Croix Zoning Technician. One backhoe pit required to extend original soil test. No review fee required. a Boring # 0 Boring 11 pit Ground surface elev. 88.71 ft. Depth to limiting factor 96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-24 10YR2/1 1 2fa&sbk mvfr cs 3vf-co 0.6 0.8 2 24-43 10YR3/3 A 2fsbk mvfr cs 2vf-co 0.6 0,8 3 43-52 1OYR3/6 - scl Ifabk mfi cw lvf-m 0.2 0.3 4 52-96 IOYR3/6 s Os ml 0.7 1.6 Horizon 2 has some gr; cob layer between 2&3; Horizon 3 has 10-15 % gr. Boring # Boring ❑ Q pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30:< 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Si CST Number MARY JO HUPPERT/Hollister's Soil Testing & Desi ® 224832 Address Date Ev, n Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 05 - 30 - 14 715-426-1775 SBD-8330(R07/13) Plot Plan for Site and Soil Evaluation Page 3 of 3 Property owner 'It 5 H Tv, I"=4oft Legal Description .sue V4 o,_ ?H e N w V4 3 (except where noted) "T;!q Ail , w ii W, Tt vjA! F- 4 LLbw . sz e-izcai x Q = Backhoe pit 'T%/ W1 J" 5 North L C>goOAA eL.vVA o~ a~ o ~ToP k g SID q6- ,-7 ® V 0 0 4E-V'%sTiN6. o -,V- dal CA PjLocation: , q+ i s ee-. -,y F R i----~t Q~V 0. ~ ~ QJ M r C ~ ~ 1 J o a rI 1 1 r - ~ q ~ r r V° ( 1 ~ ~ 9 ~ X i j _~1 ~ 1rf iLF ' y~ 1 i 1 i Irr V y.~• 1 O J i M~ K ~ ~0 0 y N r N M tip, m d v 77 =2w kit k of i H o ~ a ~ y Wisconsin Department of Safety and Professional Services Division of Industry Services FCEl1/SOIL EVALUATION REPORT Page 1 of 2 in accordance with SPS 383, Wis. Adm. Code l~N 19 2014 County ST. CROIX Attach come a site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 020 - 1102 - 40 - 275 percent sloMjs lt0WNi6ns, north arrow, and location and distance to nearest road. Please print all information. viewed IJDate Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location LIS H TR NIELSEN Govt. Lot SW 1/4 NW 1/4 S 34 T 29 N R 19 E(or))W ❑ Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1917 Twilight Lane 6 CSM 19-4967 City State Zip Code Phone Number []City ® Village Town Nearest Road Hudson, WI 54016 ( 715) 388 - 5972 Gilbert Road Q New Construction UseE] Residential ! Number of bedrooms 3 Code derived design flow rate 450 GPD El Replacement Public or commercial - Describe: Parent material sandy outwash Flood Plain elevation if applicable }q ft. General comments (2) in-ground conventional trenches to be added to the original 2 trenches and allowed to dry. Discussed this with and recommendations: Ryan Yarrington, St. Croix Zoning Technician. One backhoe pit required to extend original soil test. No review y~ fee required. S>✓ci~~.-~ ~'l G~i,Q'~ ,-.zc~f- l 3 5 5"r - / ~d Z~ ~I 1❑ Boring # a Boring El Pit Ground surface elev. 88.71 ft. Depth to limiting factor 96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-24 10YR2/1 1 2fa&sbk mvfr cs 3vf-co 0.6 0.8 2 24-43 10YR3/3 s1 2fsbk mvfr cs 2vf-co 0.6 0.8 3 43-52 10YR3/6 SO Ifabk mfi cw lvf-m 0.2 0.3 4 52-96 10YR3/6 s Os ml 0.7 1.6 Horizon 2 has some gr; cob layer between 2&3; Horizon 3 has 10-15 % gr. Boring # Boring ❑ D Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30:5 220 mg/L and TSS >30:5 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS 5 30 mg/L CST Name (Please Print) S' CST Number MARY JO HUPPERT/Hollister's Soil Testin & Design o 224832 Address Date Eval n Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 05 - 30 - 14 715-426-1775 SBD-8330 (R07/13) Plot Plan for Site and Soil Evaluation Page 3 of 3 Property Owner .i s H Tr M i ELsz-A I"=4oft Legal Description ---W A oi= --rri c N W 'V4, (c wept where noted) D -7,?aA, w III -T-tvjns c~F- 4u;asoA., ist. e.rsrx = Backhoe Pit 13~ 5 ('QC ,'l, II'Ll S ~J•C'r , North ~r~r~L ~ ac ~Ek.tR-y - W EL.~ H o~s~ \J ED BE©r2ooµ ~QV r 0 Q5 y$ d~ Z-~s~ 3 0 0 ~Xs411J~ CI E:A CA • ~ d h 2 ~ a 1 ~ ~ite,L,Iocation: s T fl • N J~ -see- 2sy z ~ h n c c ti r o o L `c nd, e y 1 3 ~1 Fa. ~ a A m n I~r r 33 ~ $ C Q' y Ilk VII ~ 1 + ~ * \ ~~y4j i y i i A `•p p I 1 \ NI IC I 1~ ~ A a ~ A 1 ~ u i t ; 1 7• r ~ i 0 J. w a l~Oo pwo p~ j~ Z a~ i~ 0093 ~ z i ~ c a~a ~ ry o ~ o I o m O (n H ~ ° I N 0.' ° I I m a N o-a o y -m ° 04y ; ~.yV O) pfd°4) d o N a = a ° ° O `p N J Ct ~I r N E = yr ~ II NOO yN ~ 17) u? m mc~a j(Nr~OycL~ yxo;f0 °._°f0 vi°v ° T N N' a 'O Q y c O C U) (n 7 O NL~ O CLU O c N~ O N U. O U O N N N O O rn 0 0 7 3 N C C y J '_Np co c Q C N U C C U ^ O I , 3 m N 3 Z 4) a a) a CL -6 a m v o ( U) c ~ I o z c $ y '6 m Z :t II 2 C fn F- r L N E E N 4) C. N y N o j VJ a E c c (o to N ( vi O O O O d U L_ .O T-N V V N N c O y m O 0 0 O Q w` N N N Z~Z ZC5a w E ~ (D ° a a W N ` N O G CL a U Q O (O 7 L F- F" 1- Z (o > CL 10 0 0 0 = CL CL IL a C p O O U) N J U ! rn (D ° } V In co N_ V W ~O 0 0 0 0 0 0 0 0 Co 0 0 00 _ O N N N N N 'O I~ M m 0.' O N a N N N N ~II a Q Cn m Oi i O y~y N O O p C LO W C r- cn O N c-°p c f0 U O 4? O N CO r LO r- O C) O; N c a V a o O o 0 o o j> y N c- N N N N N N O C C -0 :!t v r- m M rn C N= 7 n N N N N • r O N o d= Z G N 00 to O (n LO N ^x]i ' o ° ~n E U 04 • O o 2 Z CD Z y F- U) IL at a a • O. y V y c rw a> da II,oU)c r A FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER I//~ ~ w i~ L SE~✓ TOWNSHIP SECTION 37 T. z9 N-R W, `t-DgD ADDRES ~s9 G1'1/5Wl_ R~ ST. CROIX COUNTY, WISCONSIN ~l~OSO~J ~!S SlfOi ~ SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM see- INDICATE NORTH ARROW BENCHMARK:Elevation and description: -y (r i(1o~2 Gdl- Li vSL 96;7'0-M a 06 & OF 80.4419 . s B 477~-.,i 6*1'-0 -J 6- A r IlJ , E Alternate benchmark Cdev,~,Q Or- h`ovs er&- 0, ri0- = r/0 • 7?"_ GUEEK5 40,o Geel e /d-oD S.O~f SEPTIC TANK:Manufacturer: Liquid Cap. / Rings used: 0 Manhole cover elev: PV16 Final grade elev: 10/ -75 Tank inlet elev.: ~O2 'ys Tank outlet elev.: a 2' G y / x ' No. of feet from nearest road:Front , side , Ft.- x, 5 200 From nearest prop. line:Front , Side , Rear Ft. No. of feet from: Well X05 , Building: 2-9 (Include this information in the above plot plan) a (2 reference dimensions to septic tank)' / " . SEE REVERSE SIDE / G/ ✓V v ;r - t ' i PUMP CHAMBER Manufacturer: iquid Capacity: Pump Model: Pump/Si n Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: ump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance om nearest prop. line: Front_, Side, Rear-Ft. Dist ce from: Well Building a, s SOIL ABSORPTION SYSTEM 5 X S-' f a-,-P ` 7/ X S S Bed: Trench: x Seepage Pit: Width: S Length Number of Lines: Area Built a' _ s^ g 3 Exist. Grade Elev. ye v Proposed Final Grade Elev. 96-.o ' cam Fill depth to top of pipe: ~7~) 3 No,~ No. feet from nearest prop. line:Front , Side(P71 Rear Ft. No. feet from well : 4g. o ' No. feet from building HOLDING TANK Manufacturer: Capacit No. of rings used: Elevation of b om tank: Elevation of inlet: No. feet from nearest p . line. nt Side , Rear Ft. No. feet from: We , building , arest road Alarm Manu turer: yy'~ INSPECTOR: DATE. PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj HORAESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT VIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. "NN. INSTALLER & DESIGNER LIC. NO. W663 i 1 9` Z tDo O X11 ~ i ~A 2A o W ~ D ~ m u~ c m R' m 0Yii Q 23 ~c ~70a 0~ p n z y' G Z 50 Z :D E: P:~:* q. 2z FA z Z EO \ a~ CD IN. ~m \ J 0 y L m s o ti N 1 )C j~~ ~ j £as Cpl h S Ln I I X Ll m I ~ mN w ~ ~ ~ a O ~ 0 0 ^t Z~~ ~ ~ X093 ~ Z Z 0 ~ ~Y ~ IM O 101< RD AR F INDUSRY, j INSPECTION REPORT FOR SAFETY & BUILDING a LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISQ`1fVLYl 5 eC.34,TZ9-R19 State Plan I.D. Number: ljjj~v ►j ❑ CONVENTIONAL ❑ ALTERATIVE If assigned) Town of Hudson Gilbert R L 1E] Holding Tank ❑ In-Ground Pressure El Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION . Villy Neilsen 659 Gilbert Rd., Hudson, WI 54016 /0 0 d1~~ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. LEV., CST REF. (PT. EE Name of Plumber: MP/It/IPRSW No.: County. anitary Permit Number: Robert Ulbricht 3307 St. roix 135514 SEPTIC TANK rril! G' MANUFACTURER: LIQUID CAPACITY:, TANK INLET ELEV.: NK OUTLE WARNING LABEL LOCKNG CO R r PR VIDED: PROVIDED. 1;:.eaC~.✓ /Olr, Q , YES ❑NO ❑YES NO BEDDING: DIA.: V2rerr MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING; VENT T FRESH C ,O, If C ,C~. L ALARM: FEET FROM _ LINE: _ y AIR INL T YES ❑ NO CLI G ❑ YES NO NEAREST i I DOSING CHAMBER: MA TURER: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES E] NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NU PROPERTY ;;~zNG: AIR T TO FRESH (DIFFERENCE BETWEEN FEET FROM INLET: PUMP ON AND OFF ❑ YES E] NO NEAREST SOIL ABSORPTION SYSTEM. Check he soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARK - or excavation. (If soil can be rolled a wire, construction shall cease until MAIN the soil is dry enough to continue. CONVENTIONAL SYSTEM' 8' ' f u } c (z, 4ti s WIDTH: NO. OF DI TR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: + M RIAL: PIT DIMENSIONS GRAVEL DEPTH ~ABOVF~ LL DEPTH DISTR. PIPE pISTR. PIPE DISTR. PIPE MATE AL: N I TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: CO VER: ELEV. I LEV y ~E ~ C, PIPES: FEET FROM LINE: f J~ / AIR INLET: ,1.';r^E NEAREST~♦ >t°'a MOUND SYSTEM: Mound site plowed per Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrow 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; NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: S MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: - LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. P MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV. DISTRIBUTION -77~: DIA.: HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION ED PLANS ❑ YES ❑ NO S ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: iAREST MBER OF PROPERTY W L. BUILDING: COMMENTS: ET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO - Q 3.3s _ G8 ~~e v. ~ ~ 1- row. Co~ f? )Ci-w~~~,i:..~~ ~z,.r c~• o~~-S /~~w c o~~a~2 = ^,I-~ 20-112 n in county file for audit. Sketch System on Reverse Side. SIGNAT E: TITLE: SBD-6710 (R. 06/88) / r.-,m DI~LHR SANITARY PERMIT APPLICATION A In accord with ILHR 83.05, Wis. Adm. Code COUNTY 5 7r- o i sC 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 ec if r vis n to pr foua 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 /i y ~//EL 5'~~ S/U '/a Nom'4, S T N, R i~ E (or W PROPERTY OWNER'S MAILING ADDRESS LOT # / BLOCK # & S ~ 6-I'l /ate? I- A U 5- 1 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Ff c~~~ fe.t✓ Lv/s s yc°~~ 3'~ S~ ~_s_M y .3S Li,k e, j)/~ P5 II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD n ( ❑ State Owned Ej VILLAGE : i✓ 1) S c^ C E~ - ❑ Public 0 1 or 2 Fam. Dwelling- # of bedrooms / PARCEL AX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 0 Z C% i/C' - Z71 - vC::, 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 El Offlce/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. R Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 3o ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench . 22 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit 2, Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill CL't_X 512 D Az~, K 3 5 VI. ABSORPTION SYSTEM INFORMATION: y~ C 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 3 Y3 Feet ~l l-~Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber ce.) c e F-1 F1 F1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) -MP/MPRSW No.: Business Phone Number: ,Pt,1567k T- ZiG&pillzi 33' i 7/S 3~/~S Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui Agent Signature (No Stamps) 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 INSTRUCTIONS a - ~ t 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, purnp/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 fi;l 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'/s 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) y.. t a . 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 y p J /V ~ E- s ~ Location of property :2 1/9 1/4, Section , T 2-1 N-R_Z~ W Township Mailing address " 5 l Gi /~cJ2 j-' ~dQ 3 f6 - 3 t~ UPS © "v Address of site j Subdivision name Lot number Previous owner of property Total size of parcel' 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 ?IG and Page Number / Z-1--~as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ; and that I (We) presently own the proposed site for the sewage isposa 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 thheeg yrnk qis' er y}aass Document No. ) . Signature of Owner v_C Signature of Co-Owner (I£--Applicable) 06te of Signature Date of ignature i7 Put M& bebm" ......mint i...ri . M6............ a glWL .~oii e~..i.tii ~ ' ~YBUS ~ x h id .nita.AA..A=wlv0mmhip.A=itma............ ~I 1 . I ' Z~ tba sail fiessMe, !Ie s oaNabls oeasii.. ` GwMP w GMMW Ira fiwbs 498W W and tie 4 ..At-..Croisc_.-•--.•. j a# OWN*. skit at wbunk: ftft of ftathmet Guuter of n tbmt Quarter of Ap p 29 Borth, I%Irjp 19 Nast Tw Pmteei Me: Ya Y l or d as 8oLLOWS Lot 1 of Owtifid Izvlby # led 1lpril 30, 1987 in vb1. or, Ptge 1806 and Lot 1 of OWtiftea ftlwy► M9 filed My 12, 1987 in val. "7", pate 1813. ;J mwtbw Zia and 0*:)Gct bo all a0 mn*s, s+aatu%vkicm and stistriatiarn of s+ra 9 re4, Awluding, but not liadto to, those atsown an ft anrtifiied BUKVW Mrs. ~y SIP Thb Y~rIMI eta, " 2 T"MbW 90 V W NbBdW As b0ndA umb Yd apparte mmm tberwste bbasiar; AmA AcUtcm . w =ft om ` a ~N~~ ply and fm tOd ~IMT Of ~6CIi1Ml~tN pt erNrnts, ao~ amm" and t+a/triati~Ons of I+0 O1 Q<1d, if any `s• aad A weasaft aad dsbwd the Mne. . r Ift... Ds.this dyr of t1111y...._ . ~asnL~ w r►ttorney► in fact tarr►LI ..............tawa • • •vsu>Ir::o♦::oN •o=NOWLSBOURMIs sia••~•aa) sTATII of WISCONSIN ,~»S.~A~7f►. aathwlbalad tW ........dy sC«...• r..119 Pwnuan7 cars Mfft* m•thir..,~~..,.,~,/+ a[ r° 'fix............................. M.A.No aMw wi t :irisi xaiisseisizs~ai►s oi.... lsoorratN (It,ec. r*athor vf'►M.... N. w.. b. 8t. .a. b_.. . _ ......_known.to-...-•... : to m be the Pon= Who 400~-tis ends. - ~ TNN IN/[ W" 0RA/TM Mr • + • ~ ■wM auumAkom oe seksewlsyed. Both MY Commb" is p jjnot s i eeeen~e7.1 dat" e e[ /eUer dMMI[ hl MW MgWtr AMM be k1l w primed hehW their demur". . _ F STC - 105 a SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER V l ` E~ ✓ " 'st^~ ROUTE/BOX NUMBER C~ S Crf 1 t FIRE NO. CITY/STATE H-V Ps 0,%) 0 ZIP y~jL PROPERTY LOCATION: 'S G(J 1/4 1/4, Section 3 , T ~ N, R Owl, Town of .cJ , St. Croix County, Subdivision / v ' , Lot 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 septic 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 arc, !t111!g1V 06W within form must be completed and returned to the St.Cro' 30 days of the three year expiration date. / 7- r 11 G e_` 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 RTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS nUSTRY, DIVISION HUMAN D' PERCOLATION TESTS (115 P.O. BOX 7969 HUMAN RELATIONS \ ) MADISON, WI 53707 3707 (ILHR 83.09(1) & Chapter 145) (e . ~..y AG.Is _ 6A) LOCATION: SE TION: OWNSHIP/l*0f+e+~PxcrrTY: OT NO.•BLK. NO.: SUBDIVISION NAME: N~ y 3y /T 29 N/R i9 E (or H L)0 ro._." I csx► 513f.21P 4vlel COUNTY: MAILING ADDRESS: sf.~,~,~ X V///y & S-f H U oso.J 4-)1s USE DATES OBSERVATIONS MADE NO. B DRMS.: COMMERCIAL DES RI TION: I FILE DESCRIPTIONS: PERCOLATION TESTS Residence ~f,~-• ❑ New Re 0 place I ~1 1 if - I f f o2a--1/o2 1/0 ild Yo'p 13/a SGS G~ T3~R lllK`f ~tRDT- C#E-rel 5`611 -5 RATING: S= Site suitable for system U= V unsuitable for system ONVENTI NAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) OS ❑U ©S ❑U ©S ❑U ❑S DU ❑S OU TeE'•JC,jaS 4rl Dto a o1C - is rR i !3 v Tro...7 If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the 2 under s. ILHR 83.0915)(b), indicate: CUSS --17- Il Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS Tv -Daz1: -r¢L fI- • BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HES? TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) HIG B- / d•O, 76.16 I,$ T,u-5y. is 1,5 - oR.9..) 4- s.. ~R S, OR- a,CS 3 6- F- - B. Z. d t `/7. %y • 7 Q- r • 1 S B..) - sy. 15 l 1.0 ' 13.a - s 1. LS ' ~a as f,,,,s ,,vLrr 51 R Ge vle IS o dR-A.~ , c S 3 (rR B- B-3 v ~ lro' 9-)-Sy. S , ~s- ~,r.45A' Yr. s- 5.5 N B- B- PERCOLATION TESTS ho C S ST)e-0,4 5 TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. -PERIOD I PERIOD 2 PE PER INCH P- • 'Z a Z 3 P. , Z P- Z 4 Y-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. Gd Tjerc, e,& = 9 3, o SYSTEM ELEVATION. i APPROVEU for a c rlvenJunal septic system. - - 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print TESTS WERE COMPLETED ON: I'OMESITf SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, VAS. 54016 M'f y Z P I if ! 0 ADDRESS: ROBERT UL0ATW CERTIFICATION NUMBER: PHONE NUMBER (optional): `~:+IS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. ~ y f 7 Z_ 13 S>6 -Q /OS XtIviki. INSTALLER & UtSIGNER tie. W). 00668 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10183) - OVER - O ` ~ o a L \ M2 J Q H L~ ~ U ~ J UCH :3 cc 0 Leo ~ k ~ Z J M Z IV 4 N n'~ M Y J I °G 6 V 1'~ rl ` _I I i 4.. r O J ac - N \ Ell N pr cl "t ; jA V. v ~ v 3 3 ISION 4Ht-ctT«dlIV A uF REPORT ON SOIL BORINGS AND D INDUSTRY, DIVISION IN LABOR AND P.O. BOX 7969 HUMAN AELATIONS! PERCOLATION TESTS (115) MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) . Zy A ca,:; LOCATION: SE fJ OWNSHIP/ft1'TY: OT N0.' LK. NQ: SUBDIVISI N NAME: 6&) 1/ mv.) 3~. /T 2-9 N/R y9 E (or H vkfo.✓ I cs~I 11SPl ' Nl-eI6 iu COUNTY: MAILING ADDRESS: sf •L/e0/ x //y IvIkZ- St ~t/ (o 57 lp G,113EiP7- )eD - Hi U V SO 'Id ~CJ,s Sy4,41,'o US DATES OBSERVATIONS MADE NO. : COMM IAL DESCRIPTION: TESTS: 790TT=15SCRIPTIONS: PERCOLATION OoResidence y,~ • ❑ New wReplace RATING: S- Site suitable for system U- Site unsuitable for system ✓`Cs ?10 R LI ~1 feDT - C>yETt & S'd S ONVENTI NAL: MOUND: IN-GROUND PRESSURE: YSTEM-IN FILL OLDING TANK: RECOMMENDED SYSTEM:loptional) OS ❑U ©S ❑U ©S ❑U ❑S RU ❑S oU TRF•uGklS 401 SRO 01< " iSTf2i(iV D.J If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under i• ILHR 83.09(5)(b), indicate: C1,*SS _-I:- Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS Tv 'D67C%-y4T1 ft- -BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION RVED EST-MUH-TST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / o C/Ci •!(p qtr-- s - OR C S G- g.Z o/ 77. Tv, 7 ~,~-r •'ls" R.~-3y. 15 11,0 Qa- s 1.3'S' 51 1.0 CSR- Ge0je S are-oa S (rR - /,o' 3N-Sy. g- 3 11-0 76, 2.1 g- e- PERCOLATION TESTS /a r-5 STRA7* 5 TEST DEPTH, WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RA MINUTES NUMBER INCHES AFT RSWELLING INTERVAL-MIN. - PERIOD t PER INCH P. .Z'' 3 P. P- 3-3 Z 4- Y-3 P- P- ?LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings snd the direction and percent Aland slope. ff/'G-k 7,,0e,) = f~7!D Law T~PE..uc-Lt, = 93. D ' SYSTEM ELEVATION I S fL 0 T TH ` his'-fesf s"ta AP OVEU for a ccrivcn ionaf septic sy5#em 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. .DAME (print : TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. A1,4 ~ Z ~ if l ~ 655 O'NEIL RD., HUDSON, WIS. 54016 ADDRESS: - ROBEPITULOOGAT- CERTIFICATION NUMBER: PHONE NUMBER (optional): WIS. MASTER PLUMBER LIC. NO. M07 M.P.R.S. x y e Z Co -JO/40S MI CST SIGNAT DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. .)ILHR-SBDb395 IR. 10/83) - OVER - i H ~ce 0 O n $ u x S Oac 0 1 ~ ~ k ~ Z ` M 2N N O 1( M j ~ n- • p J v DTI P 4. t11 - O V J a ~ J UN --------0 - w J 3$ cl \ 3 3 vet Fresh Air Inlets And Observation Pipe Approved Vent Cap - F Minimum 12° Above Final Grade •sh'~v ~iP•g~~ . t. 4" Cast Iron 3U Above Pipe 'Vent 'Pipe' -to Final Grade r Synthetic Covering Min. 2" Aggregate 4 Over Pipe Distribution Tee Pipe 0 0 0 0 0 , Aggregate 0 Perfbrated Pie Below V Beneath Pipe Coupling Terminating At 0 I Bottom Of System . TES sy, . SI S 200,/ ,j HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WAS. 54016 ` ROBERT ULBm"T ~J w;S. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. WIM4. INSTALLER & DESIGNER LIC. NO. 00663 K V Fresh Air Inlets And Observation Pipe ~ h 0 C:~ - Approved Vent Cap Minimum 12" Above Final Grade ~;v~•5~-~ 4" Cost Iron "Above Pipe Vent Pipe 'to Final Grade } Synthetic Covering Min. 2" Aggregate Over Pipe Distribution + s4A Tee ~i pipe 0 0 0 0 0 , " Aggregate o Perforated Pipe Below Beneath Pipe t 0 Coupling Terminating At Bottom Of System s srE~ 3, p i ^t ~ Z ~ ►~h ~ Nm r N ~ N \ O^ _ 161 m~ G ~ r 0 N rn , i ice. O y C ~ I I N t, C ~ I I ~ ~ C n ' ~ I o~ ~ ~ z c ~ to w ~ ~ Np C ~ C Z~ N~ r 37 R n -19 13 c ax 98 0 0 0, 0 ~ ~ ~n N y r ~ C State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION GENERAL PLUMBING PLAN APPROVAL Bureau of Plumbing r 201 East-Washington Avenue P.O. Box 7969 Madison, Wisconsin 553707 HOMESITE SEPTIC PLUMBING CO. Owner: VILLEY NIELSEN 655 O'NEIL ROAD 659 GILBERT RD HUDSON, WI 54016 HUDSON, WI 54016 RE: Plan Number G90-40490 Date Approved: august 16,--1990 Date Received: August 14, 1990 Project Name: NIELSEN, VILLEY - 2 SERVICE Location: 659 GILBERT ROAD PRIVATE SEWAGE SYSTEM Town of HUDSON County: ST CROIX Fees Received: 80.00 Fees Required: 32.00 ( 48.00 Refund forthcoming) The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. Q All items required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. C~ This approval will expire two years from the date approved. If construction. has not commenced before the expiration date, new plan approval must be obtained. The Bureau of Plumbing has reviewed these plans for plumbing code requirements only. This approval is for the following elements only: I - PRIVATE INTERCEPTOR MAIN SEWER - SANITARY NOTE: - NOTE This approval for private interceptor main only. , Inquiries concerning this approval may be made by calling (608) 266-8075. Sincerely, DONALD M. OREMUS Bureau of Plumbing Safety and Buildings Division PGPO11/0011w/31 cc. VILLEY NIELSEh X Plumbing Consultant SBD-6423 (R. 08188) tc 0 o, y \ - cB x 0. J J S ` •0••1 IIII~~ V) i ~c z to 0 N nn 4e 14 0 pq oyi 1 .Q I 1 p U. o AL ~M '1~ c 1 I ~I M Y 1 1 1 1 I Y ~X u ul h , x' ~ • of ! ! 1 s, l J,L `10 40 O 1n Wr N - r tU "O 00 ID 3 . P yp h wit j I ,pn.µ~ MSa/,eJ YT e r~.«qi `.4 ~ . yrl .r'~T•h{. 's~ I ~.i1gTy1^g ryy 1 4. ~ * r~~~~ .Ib a.1F'~} N T ' .y + y r W ~ r- V ~ i "n \ u'M f{,~: ti ~ r ~ !,y t/~:'' ~ 4 t vy. ~S Jp 1 S m~ . r " Two Na Of l • t!? O: under separate oowr, Please find the followlnp; and , ❑''Three sea pf plans and*tL}, '1 One set of Specifications In 04 amount of S ' MAKE ALL CHECtCR DeveDLI= V^. Written bw:__ / t Z o im r CS) ~ ~ m o ~ Q I Z -4 °r. ~o 03 b O y L m a m O ^ err ~ '8 v R\ SqS C o~, _ G rt- i 144 c ~rn a o~ e J ~ ~ y y a1 ~ n 41 ` ~ ~ Z ~Z G 425130 FILED ~ A 98-1 C> ~ N this instrument drafted by Douglas Zahler job no. 86-49 JAMS Of GON~IiLt N ( :1E r~+ Of W0~ co C n rn z o m tr W. O 64 GMh comity, 'may '00 -13 = 0 -5 W 3 + UD W Z T~ n rn GILBERT ROAD d 0 1 11o+ wc~t line of the N o rn --I C 70 336.851 324.38' r" rn rN00°0811411W 324.38' W I w ° 3 I w w -a ° I o ° m z I ~ C)° C/) I I ° C--) I n 331 3 11 Ln M I I C) = o m O p z 1-1 c o s c v+ 9 C O (A /D W I rt C O C ~ ~ F CT N 7 r • ° rn -n I rn rn I NC U3 to Ln I:3 o I O 1 to O o to 1 - 10) I 4- rnI rn 1 rt F ° co Irt o o O - I N O 1 0. Cn - I r f ° i a l CD s I V,", >F r I r o 1 N I I m I- c 1 0 IS IM O M 1 Im Cn IM I a (ti IM O I a l CD {R O~ 1 Z 1 ~ O I C. I~ I ~o I ~i ~ CO I C Cn I I Cn Ln I m O M IC rn I L_L/ I D O c vOT(/~ N G7 i~ i I co 1-0 x N O rn co CT N O) N ~ 1- F I< 4F _ Cn z I 4- I CA V W I O C-) - W O W N N I O - O I V o 0 o -J5 S S;GN ~ 1• Z v F.. a CO 0 o fr cn w cn w rn - I rn -I 0 CD c, 01 C., fla -n ~ I m N ro rn I v v o 1 n a rn a 1 n E I• O 1 1 p I CIO N n. -3 -Ff -hr I r-• C7 rt rt 1 01 O g Cp I I N Z CD. C) 01 n I (n Cx) n a s o I I my r r- c c c io a I I rn v v m rn -1 zpyi~vsLu:t'~~ v YD N PvjJ~ ~ D - rt ~r 324.38' S00°08'14"E APPROVED unplatted lands owned by platter bearings referenced to the west line PR 2 2 of the NWT assumed to bear N00°0811411W. Volume 7 Page 1806 ST. CROIX COUNTY COMPREHENSIVE PARKS PLANNiNO AND ZON1140 COMMITTIJ I 4-4--92-0-9- CERTIFIED SURVEY MAP LOCATED IN THE SW1/4 OF THE NW1/4 OF SECTION 34, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN U N P L A T T E D L A N D S W LINE OF NW1/4 _ - - - - - - - - 20°06'35"E 2644.94' 1 w GILBERT ROAD_ w S0°06' 35"W 336.85' w N w S0°06'35"W 336.82' w z H n N C=7 N W zH~ g rbro g ~z H t1i O W 7d ;o OO G Z n oaon ~ ~wz ZH ~ C y ~7~ HQ y~ G W A N 1J+ ao a cy W N N• 00 oho cno~a cn Idlc C) o P. 0 w Iw o ~ i+ H + lolrir o rT I o v, Ln Q' v r 1-n In 11 v I H cn n - ow tyro w0 wo I I- g ly O w rt r r rti H. H W O 41 INI^d r 0 1 °o 00 7o 09 x 0~0 o o to . I - lT7 , I~ - - w w °w .r` ONO ONO 101H1`n a I~_ a a .o w 1oI;S N H N z 0 ON 0 ~ k-n 1 0~ n m ~9~a F w a. c n ^y n ON 1-n co I+ 1+ - - tri W - 0 A r• co - N I9 `o ~ o 0 0 ~ w I r~ v+ o o d rn v ~ IH - r o o .1-1 x IH o N0°06'35"E 336.40' 1° ~ . 286.96' 49.42' F- 110 r. I X- o r ASSUMED BEARINGS REFERENCED w N o o TO THE WEST LINE OF THE .o N W1/4 OF SECTION-34, WHICH C:) tn BEARS S0°06'35"W r a r-7 1 = : ~ mo .o o u' H H > 100 i > N F-3 cn C tT1 . lTl :S W A I+ ~i N ` 9KH o 1+ r o o ftj I- W N .`X\ m a 0 0 Z Fl OI d O cam. ~o ,Lp0 000Z mZ IVO ~ ~ - N ZG)LT1 y N - - - >E tip _ ~+q HttjtO~V) o C ~ y1 N C) H O w r 01010 z o H o Lil no % . ' d~M EDIE LANE_ w o co ' > N k-n ~I~IF-' Ln r z x _ _ _ ~4 C7 W 0 N l7 u) W.. 1t 1+ l~nl0 t✓ trJ z 4-1 07 F-' 1"Y R'• loo N Iw I\~ 101~H o ti I 1 19 °0 N0006'35"E 335.91' loly - 161.17' 174.74' FILED Izl~ 1 I U N P L A T T E D LANDS 8 JUN22'1989~- 2 - - - - - I JAMES aCONNELL Register of Deeds VOLUME 8 PAGE 2117 Crt Q + F AqorOXi1Y1Q-f~t_ Y'eQ7~~r S /O 1 yes ~ 7RECEIVED 0 ~ ( N 1 5 2004 0i O Z `ST. CROIX COUNTY rn NO 0 I _ ZONING OFFICE NC O Z o ~ f7 p ^ A N m m N p '*t w m n C7 TI ~CDm x x m O c0 00 v a m Oo > w' N N a c c c g M BEARINGS ARE REFERENCED TO THE z rm o= z z n r^ v v z v m WEST LINE OF THE NW1 /4 OF SECTION v O 0 a V) Z O 0 a 34, ASSUMED TO BEAR N00'0717 E O CO m O C p d7 m e z rn m m m%N LO c ~ 0o ~m ZOE O o 0 ~ ~z v r~l* v z -ci A c~Z ~E x a r z N mZ~ 00mozmoz Z mi~c~ N zz 40 m'~-_ > 0 =5m Z =amz~nOti00 > > Fn 0 -n om II- i~S~: Xm~ m Nn0(1) m ppp Zr~* m o m z 8= SMALL TRACTS Z a &I F m Z _ z a, aZ Na>a Z:3 f/) ~o ~ czi ~ (NO-06'35"E 2644.94') o°v~mmr <00> 0 -0 c a ° O ~ z A r^ N00'07'17"E 2644.80' V) o > -+m cc!i g GILBERT ROAD ~Z wEST LINE OF m~ m z m m z - Np A CD m v 5a SO'06'35"W THE NW1/4 m (n -4 Q rn d- -r w - Zrn /lk NOO*07'17E 66f26 1-a 282.09 6 313.17 ' - 1983.54' > r 1 1, mi 0.6'f 282.06' ~,,L X00 313.17' ~ ¢ O CD 0 b n OD •YsiJ'ff5'35"vl~~m'.. 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