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HomeMy WebLinkAbout020-1040-20-000 I o 2 $ § 0 4 E CO} c2 /2Jk)/ [E rE E 0 0(D CL o o $I)I ) a0r—M R (D -$mac § % f�«0 k\\ko§ = U) , E0C (n r- � $ Z C. c z caC» ` c Ac §aca@a ¥ 2 =o o. 0 % _ .2;a 3: E - ■ aEf ` EKao E 7 /2k$«- » ) C-4 f E w $ E ; z ® k _ § a. m ) z ¥ — U) F- ƒ f E \ � / � k ca § 0 0 7 I z z ` k k E { k . 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E « § k2f- ! $) S _ e & ;=' cam U. � tIEke�f ( / 2 ® Se E© ca � � k §/k\kk)] E < e _ I0�= S- § C k w E ° « k z' § z ® = / / \ CL ED . � § ) ¥ 2 \ § § $ © » & 2 � L a) k ) § % % / a 0mr § } / % 7 k/ z ) g � ., z o $ 2 Its \ j ( § 2 k \ � k 2 2 7 t § / Cl) £ o o a = 7 § § 7 7 } / - m � n a a a t to $ j ) \ k \ p ) a § o � ° ° \ � LL CO $ 2 _ J (D u » m § 2 2 R a / / / § 7 } k - E 0 _ @ $ k k ( B 2 \ k 0 § / Z ) 2 0 2 21 2 4 ® ' CL EL/ « L u (L # E 2 § $ 0 a 3 $ J COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715 - 962 - 3121 800 - 962 - 5227 ST, CROIX ZONING REPORT NO.S 12052/01 PAGE ] 5T. CROIX COUNTY REPORT DATES 10/10/91 COURTHOUSE DATE RECEIVED' 10/08/91 HUDSON, WI 54016 ATTNS THOMAS C. NELSON OWNER: Dr. 'Art�t LOCATION: 353 353 Hatchery Rd., Hudson COLLECTOR S . SOURCE OF SAMPLES Outside faucet COLIFORAii 0 /100 ml INTERPRETATIONS BacteriologicaLLy SAFE NITRATE-NS 6 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 ml Nitrate-Nitrogen, mg/L 96 9 i.LAB TECHNICIAN: Pam Gane p C-3 WI Approved Lab No. 19 V' � ���,WpEV61p�Nl i V g ( Means "LESS THAN" Detectable Level Approved by: �� ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 y , ST. CROIX COUNTY ZONING OFFICE IV 911 4th Street Hudson, WI 54016 715 386-4680- Telephone P (715)386-4680 The St. Croix Co. Zoning Office offers the service of septic and water inspection to Lending Institution, Realty Firms , and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. . Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING--------------------------------FEE:$ 25.00 X (For nitrates and coliform bacteria) WATER TESTING--------------------------------FEE:$175.00 A- (VOC'S) SEPTIC. SYSTEM INSPECTION---------------------FEE:$ 25.00 PROPERTY OWNERS NAME: ' PROPERTY OWNERS ADDRESS-*. d�l'l&LI CITY: Legal Description E 1/4 , -E 1/4 , Sec. , T N-R�W, Town of 1�a1.t1s�7�1' ,Lot No. ,Subdivision FIRE NO. _ LOCK BOX NO. Color of house Realty sign? Firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e. , COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services �/�- C�I�.Phr> Telephone No. L. - REPORT TO BE SENT TO: 21 CLOSING DA Signature: �� 1 � C-Ai ��� �����:0- =^��"^ ����~ ��������"^ ������u ����� `ou,West County Road o2. St.Paul. Minnesota s11x Phone(6`m000-71m FAX(612)o36-71m LABORAT�RY ANALYSIS REPORT NO: 8449 PAGE 1 10/22/91 [�ommercial Testing �-aboratory 514 Main St. Box 526 DATE RECEIVED: 101109/91 � Colfax , WI 54730 COLLECTED BY : CLIENT DELIVERED :;Y : CLIENT SAMPLE TYPE : DRINKING WATER � Attn: Pamela Bane � St. Croix Zoning � abd�5,vn;,. . VT ' 54GI6 SERCO SAMPLE NO: 107661 107671 SAMPLE DESCRIPTION: Kaemmer Kaemmer 37O 353 Hatchery Hatchery ANALYSIS: Rd 114 F,d ________________________________________ ________ ________ Bromodichloromethane, ug/L <0. 2 <0. 2 Br�mofczr�, ug/L <0. 5 <Q.5 Bronome��ane, ug/L (Methyl bromide, % l. 0 �arbo� tetr chloride, ug/L <0. 2 <0. 2 enzen ug/_ ��lorcethane, ug/L chlorzde) 2-ChioroethylvinyI ether, ug/L <0. 4 <0. 4 ���or�form, ug/L <0.5 <0. 5 Chloromethane, ug/L (Methyl chloride) Dibromocnlorometnane, ug/L <O. 4 <0.4 ' 1 ,4-Dichlorobenzene, ug/L <1 .0 (o-Dichlorobenzene) 3-Dichlorobenzene, ug/L (n-Dichlorobenzene> 4-Dichlorot-enzene, ug/L O �7 , 0 (p- hlorob en.zene) � chloroethane, ug/L zv2-Dichloroethan e, ug/L <0. 2 <0.2 (Ethylene dichlori�e> 1v1-Dichloroethene, ug/L <0.2 <0. 2 trA-.ns-1 ,2-Dichloroethene« ug/L <0. 1 �0. 1 1 ,2-Dichloropropane, ug/L <O. 1 <0. 1 cis-1 ,3-Bichloropropenev ug/L <1.5 <1.5 -i�-rans-1 ,3-DichIoropropene, ug/L <0.9 <0.9 Methylene chloride, ug/L {5~0 <5.0 (Dichloromethame) � � < means "not detected at this level ". 1 mg = 1000 mg. - Member � - ���� * N������� ������o� ���������� ��������������� ����� ,m,West County Road cu. St.Paul. Minnesota es,mMv" m,wom6-no FAX(6`2)o36-7,m LABORATORY ANALYSIS REPORT NO: 8449 PAGE 2 10/22/91 SERCQ SAMPLE ND: 107661 107671 SAMPLE DESCRIPTION: Kaemmer Kaemmer 370 353 Hatchery Hatchery ANALySIS: Rd 1143 Rd ________________________________________ ________ ________ 1 , z ,2v2-7etrachIoroethane, ug/L <0.2 <0.2 � , 1 , �-Trichloroethane, ug/L <5. O <5.0 151 ,_-Trichloroethane, ug/L Tric�loroethene, ug/L <0.4 <0.4 Trichlorofluorometha.ne, ug/L (Freon 11 > <0. 7 <0.7 Vinyl chlior.1de, ug/L Tetrachloroethene, ug/L <1. 5_ < 1. 5 Benzene, ug/L <�. O < 1 . 0 Ethylbenzene, Tolu�ne, ug/L < 1 . 0 <1 . 0 This sample 's analytical result are oelow the U. B. EPA 's SDWA Maximum Contaminant level o� I _50/91 for those requested compounds which are alsc on the SDWA MCL list. All analyses were performed using EPA or other accepted meth000logies. Samples that may be of an environmentally hazarcous nature will be returmed to you. Other samples w42l be stored for 30 days from the date of this report , then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval �~o� SERCO Laboratories. Report submitted JJ 4. n d 2e ��r.' Project Manager < means "not detected at this level ". 1 mg = 1000 og. T� l I COMMERCIAL TESTING LABORATORY, INC. 5t4 Maim,Street, P.O. Box 526 Colfax, Wisconsin 54730 715 - 962 = 3121 f 800 - 962 - 5227 't { R ST, CROIX ZONING REPORT NO.S 12049/01 PAGE 1 ST, CROIX COUNTY REPORT DATE! 10/10/91 COURTHOUSE DATE RECEIVEDS 10/08/91 HUDSON, WI 54016 ATTNS THIS C. NELSON OWNERS oKa!emmmer LOCATIONSn COLLECTORS M# Jenkins SOURCE OF SAMPLES Spigot on pressure tank COLIFORM*# 0 /100 at INTERPRETATIONS Bacteriologically SAFE NITRATE-NS 6 pps Above 10 ppe exceeds the recomended Public Drinking Water Standard. Cotiform Bacteria/100 el Nitrate—Nitrogen, eg/L 9 �0 LAB TECHNICIANS Page Gam p 2 C, N WI Approved Lab No. 19 G 9 >� ti .OF,NDEOENpFMr � I V A < Means "LESS THE" Detectable Level Approved byS �� ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 rdC !0- u -A�- 1 a3- Q ST. CROIX COUNTY ZONING OFFICE G�( 911 4th Street ' Hudson, WI 54016 II r l4 /U') Telephone - (715)386-4680 ly, "The St. Croix Co. Zoning Office offers the service of septic and water inspection to Lending Institution, Realty Firms , and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. . Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING--------------------------------FEE:$ 25.00_ (For nitrates and coliform bacteria) WATER TESTING--------------------------------FEE:$175.00 (VOC'S) SEPTIC. SYSTEM INSPECTION---------------------FEE:$ 25.00 PROPERTY OWNERS NAME: DP-,, 6P- -KftSM Meg- PROPERTY OWNERS ADDRESS: D ey CITY: r'LA 'SUt� Legal Descri tion_ JJEE 174, /4 , Sec.�'�, T t2 N-R�,�W, Town of <'c� ,Lot No. ,Subdivision FIRE NO. 31D LOCK BOX NO. Color of house jZEp Realty sign? Firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e. , COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case P lease make proper arrangements with this office to ensure time when entry may be gained. Firm or individual re �J1 m L��Mft' -fL Telephone No. I. REPORT TO BE SENT TO: ey' CLOSING DATE: Signature: i N ~Y O N O N O h ti 0 0 6 h ao Gp 4) N ° ° ~O C M r- m .J L Y -0 X cv o ooo~p ti N a° X m N a o a) C', +r y am C.y C ° T°•y y N m 52 y E 7 C c ~ 0 8y y act C y o Q! 0 7 a C'o 'a N L C C CL O c m E O N `L'am C N' C C C 0)aC m NN (D 'Zi C C O y n > V i °•-y E E c m ~L ~ o Of'c y C d y 3 N O . N ° V - ~ O O N _ CL - d y y ~O C C ~ C c -0 0 3 ' N n a y O N G y E y N Z O'Q N YO N D.-CC O O C O Y y Y O O O 0 C w C C C z Cv ° 3 a~ o m z` c °oY m m° cC c H m o co n LL c-D m O = 0 vi o LL c ' w m _ tm O Q V E O ,O U O- X 'J O L C m am a 3 v o a)'o E 000 aci 3 -0 Co E Q h nL y~ 0 E Q 5~ o m rna m cV m cV W E E U) o o Z a m C041 IL m I I o z a V1 H r aci aci E I E I 'S 9 Y O Y O C L C L O 3 o Q Q o Q Q = z z z z z y y E I _ d E I ~i c ' m E I m E I o 0 a~ w a~ 24 a Cl L'coCL rooa` E a~ Cli y co rm U) E o y rm rm CA > o m E = 3 3 3 a = 3 3 3 a m •N ;aaa aaa co m 0) io3u) o I~Go ° z z AV N m ao 0 m 0 ] j C) 4) 0 CD C p ml c 'O y Q m f- 'C y o m p d Qzfn I(D~ d <zCO 7 0) 7 2 C N C ° L O L O D O O O Q N C c N C C F O O E N y N Z E N y N V Z of y E to m a~ v E co m *4 C5 C%l "a (D co m E co E o co m N o z Z H Y N o z z H O Cd 99 € € € 4) M a a • 'C9 a d L: a a rr'1~i v E c c w E _1 A v a 2 0 p) 0 0 f) V -r - I a o ~ ~o I h N ~ ~ M N d a 0 C N O O ~ m y O O fA 7 La N O 0 00 fD 7 L C O O O N O U0O0 MT N c O O W fn c Co w U d y A v d ; to ~ZZ y y o 3 € d fu m~4C) o >E o-yfn C Z N U c U 12 N [6 L f6 7 Y c g aa~~« U. 3 c o~ m i5 7 OV N EO 4) 0- E Q HwH Oft N N ~ N W E W 0) OO fA Z ~ a m I c o z c w z a~i Z o c z N H Y, 4) G fy E v co N t N O. I, co 'C fD 61 o c 01 s O O O 2 Q c Z H Z o N N Z fn _ d E N a ! m - 2~ y N ° O fy M L G G a E (cpp N N fV U fA Vl fA 70 N a- m N 0 0 0 Z •IV ~ cc a (L a v, IL a) ~i N 6A 6A U) J V O° (D O) z Y fA fA fU I~j 8 O C O m co co _ E a O co C y tU m CO d Q 05 t6 CD 3 0 O 16 H C C) ° t `O v E O r N 7 O lC 9 0) 0- N O Q 41 CO C N ~ N O E O N N Z w '~O CO Ci O y E O y fU 'O C N .0 (D co • C14 2 Y o Z Z H fq O ~ - I c~ a Cad E ` c A Vaal 0Uu t s Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~(Z~ ~ I + f r } TOWNSHIP I1 CdQ50 N SEC. T / N-RjW ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 5K3?' - zerjc_ , 80 All 0 !00 17d o as' d5- a6 ~ • a3' INDICATE NORTH ARROW Top o faUI,)V w BENCHMARK: Describe the vertical reference point used N (,J C,dRNel~ Elevation of vertical reference point: 0U. Proposed slope at site: SEPTIC TANK: Manufacturer: ks Liquid Capacity: 000 Rai Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: 9 .0 Tank Outlet Elevation: 97.~(p Number of feet from nearest Road: Front,® Side,O Rear, O 53 feet .From nearest property line Front ,OSide ,QRear,O QV@F- feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) - - SEE REVERE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevationi Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). 5x 39 Nereie 97 19 FEND . shit a.(, cP 5x 3U OQAM c 47 19 END 97.10 SOIL ABSORPTION SYSTEM I 0a. &Nrn BD 5%34 Bed: -2tATich: J T>`'t oc,h e 5 5k 3 U Width: Length: Number of Lines: Area Built: Fill depth to top of pipe: Q0 6veK Number of feet from nearest property line: Front, O Side, O Rear, Pt ZM-4F Number of feet from well: 5131 Number of feet from building: C~ (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: 1 Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box0 been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: ~ Dated : e u " "'1 1989 8 Plumber on job: License Number: S 3 4U 7 3/84:mj DEPARTi1!ENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION Pb. BOX ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: l~ .11ti BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST FIEF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PU ❑ YES [__1 NO NEAREST 11111- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER PIT INSIDE DIA.: # PITS: DEPTID TRENCHES: MATERIAL: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the'fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW EYES E NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO EDEERTPENCHIBED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST' U P' Sketch System on etain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION a m LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY Sv M, C STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than CJ AN ~RY~ 8% X 11 inches in size. heck if revision 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 A IL OWNER PROPERTY LOCATION Q '/4 '/a, S T N, R E (or) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # kd~- CITY, STATE ZIP CODE PHONE NU,. BER SUBDIVISION AM OR CSM NUMBER ci, r ` x7fv CITY ~ NEAREST O "ff II. \ PE OF BUILDING: (Check one) El State Owned ❑ VILLAGE ❑ Public M 1 or 2 Fam. Dwelling- # of bedrooms PARCEL AX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ls! 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 12E] Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Chec on line A. Check line B if applicable) A) 1. El New Replacement ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 4Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank Trench 22 ❑ In-Ground 42 ❑ Pit Privy Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION - 3C _ c) 43 Feet Feet VII. TANK CAPACITY _ Site Fiber- gallons Total # of Prefab. Exper. glass App INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel Plastic Tanks Tanks structed _tkl -F El 1 -0- Li Septic Tank or Holdin Tank a Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: ~-~1 ►vt L)V"Jo,t..eJ jI TY0 0 7~ V l L~(i Plumber's Add rep (Street, City, fate, Ip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S tary P. it Fee (includes Groundwater [Date Issued Issu' g ent Signature (No Stamps) / Approved F1 Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. ' 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; (Jose 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) INDUS DEP.ARTMLNT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS P.O. BOX 769 (115) HUMAN RELATIONS MADISON, WI 53707 (H63.09(1) & Chapter 145.045) j i LOCATION: T N: TOWNS Z [OT N .:BLK. N SUBDIVISION NAME: /T)%N/R/ I (or) ~ COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: PP ~i 1 I .J~ V""~ ~ ~ ;l i r ~ \ ~ r~ 4. ~'r Ili .mot i ' ..~-I-•. J i USE DATES OBSERVA ONS MADE NO. B DR : COMM R D S R S: STS: Residence PTIO ❑New eplace 44 RATING: S= Site suitable fo system U=Site unsuitable for system ~ NV NTIOOU INS DU IN-GR fEtS ❑U E: [:YITEM ] S QU HE]SG :RECOMMEN FJVI:(optional) If Percolation Tests are NOT required DESIGN RATE: / If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH]. , ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ~ABBRV.ONgBACK.) 0 S~/~ ' r rjr W 7-57 B- $3 ` S33 ✓i S 0 Q., s, B-2 s•,o '~yrs 9 ; . 9Z gys s C Q /,7S S. 1J B-3 6. o / 977S' 3 3 1 lel, g,3 ' SL`,~ ~Q/Zi • S3 t s, n c i n 4 B- B- sh s; 15-,67 5, x (n VJo, 1A . B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SW L ING INTERVAL-MIN. PERIOD 1 PER D 2 PEFLIOD3 PER INCH P_ ( ~3 z 3IV:-" 3L" F 6- 7 P-Z 2 <3 P 7' %V P-. P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 0/ 1 ! U f 4 ALI- C- 014 00, q E P• p,~sy 1}V I'S 4 1 . i i ' r s i , . . I r I, the undersigne , 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. NAM rirlt : TESTS V~E RE COMPLETED ON: ;Lh4G/ Gyl ~p r7 D / ADDRESS: CER IFIC TION NUMBER: PHONE NUM13ER(optional): CST SIGN TU I DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - I - - INDUS DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVIS :-LABOR ANb ( C 5 P.O. BOX 71969 HUMAN RELATIONS PERCOLATION TESTS 1Z 5) MADISON, WI 53707 • (1-163.090) & Chapter 145.045) LOCATION: CVT)qN/R/j T N rLK. N SUBDIViS10N NAME: 4 ~InJ 4 11 l (or)TOWNS IP =m ~ O NER : COUNTYQ:~ 'S BUYER'S NAME: MAILINGADDRE! 4ro-i 4ve 7%mv~ USE DATES OBSERVA ONS MADE NO. B DBMS.: COMM R SCR TIO URF-cIA : TESTS: [~JResidence ❑New /54% eplace, mss' RATING: S- Site suitable fdf system U= Site unsuitable for system NV NT L• MOUND: IN-GROUN ESSUR : S TE -IN-FILL OLDING TANK: RECOMMENDED S~ YSTV:(optional) S ❑U UgS ❑U f~M DU ❑SA~JU ❑S~ll If Percolation Tests are NOT required DESIGN RATE: / I if any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. I H TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ' O 3 S33 it 5-'Q s~ . Srg &r S 3,O • S7 r 9~ w B-2 ~ D 7s S. 6 S S. o r~/ ~asa~fi 01 .8 B NSA Z)Ta~BJIS'~9i✓ ~~/7 f'rhI - J ( /(l 977 ,3 3, ~ V ~ 'SG ~ w B- ' B- • PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES,* NUMBER AFTERSW L ING INTERVAL-MIN. PE p p PER INCH P Z , 67 Z <3 P_ Z 6 M P-. P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION C. s _ vu . 12- - qo, 36 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, NAM rigt : TESTS WIER COMPLETED ON: , AV 1~ 1140 171alril A DRE . / CER IFIC TION NUMBER: PHONE NUMBER (optional): 6W. 9 CST SIGN TU DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - l' P.B.L. 67 PLOT AND CROSS SECTION PROJECT PLUM E NAME t2 r~e NAME IT-m Boumz-eAk L O C A 10 hf<Szp-~l ~A L IC ENS E A E 110 PLOT MAP em IF 6 F04"00dp ~Q I ~ s~ A 2a ~bfrt ~ ~ Cvtt►~R R o ~ ~ I J~,) Ng N Vt~1e ~~nf s0 i JOQ. b U = P0 R.t-fj G NOfi c We~I S ~pIL~~. ~'~pN X' Q~RC ~UIeS 13,.A W cop-It 9)(If A' ^I ~ OPa ~ c--- ~ 3~ o sys~'en~► . i uS t., FRESH AIR INLETS AND 0BSEIN IQN PIPE CROSS SECTION Approved Vent Cap ap) minimum 12" Above Final Grade 4" Cast Iron Above Pip` Vent Pipe To Final Grad Marsh Hay Or Synthetic Covering Min. 2" Aggre Over Pipe Distributio 4-1 Tee Pipe Aggregate Perforated Pipe Below Beneath Pipe Coupling Terminating At QD~ Q~ Bottom of System i DEPA4TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION g j DgI~I; V~l~l„5370b , 19W X- PLACEMENT State Plan I.D. Number: 125 L7 VE IONAL El ALTERATIVE (If assigned) Town of Hudson Lot 1 Hatcher R Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF P IT HOLDER: INSPECTION DATE: Art Kaemmer " Central Ave. Bayport, :'ZIT 5500 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Jim Boumeester 3404 St. Croix 128621 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PU ❑ YES [__1 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: LENGTH: - NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. NO, PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED, SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST I Sketch System on Retain in county file for audit. TITLE Reverse Side. SIGNATURE: : ZONING ADMINISTRATOR SBD-6710 (R. 06/88) THOMAS C. NELSON DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY C, STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ~ ~p revious application 8% x 11 inches in size. ❑ CKeck If revisron to p4-1 -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OW ER PROPERTY LOCATION 5Q X.ST_ %,S ~g T N,R ~ E(or W PROPERTY OWNER'S MAILI G ADDRESS LOT # BLOCK # A , n Iv CITY, STATE ZI~O JPHONprBER SUBDIVISION NAME OR CSM NUMBER ors - ' N 0 CITY VILLAGE S 1 NEARTh Oi A II. OF BUILDING: (Check one) El State Owned Rm AF: ❑ Public M1 or 2 Fam. Dwelling-# of bedrooms -D PAR EL TA NUM ER 111. BUILDING USE: (If building type is public, check all that apply) 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. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in alIons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed ~eptic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage syste on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MP RSW o.: Business Phone Number: 3P~aA '~1' ~ U r. ~1`r I Q~, V~&~A2n_ Plumber's Address (Stre t, City, State, Zip Code): b aka S~ o I r b IX. COUNTY/DEPARTMENT USE ONLY p Disapproved Sanitary~rmit Fee (includes Surcharge Fee) Groundwater Date issued Es u'ng gent Signature (No stamps) Approved El Owner Given initial ~1 A verse rminatio / -°~7- F~ ` X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; . C) complete specifications for pumps and controls; close 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-6396 (R.11/88) APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - L - - - - - - - - - - - - - - - - - - - - Owner of Property el Location of Property c`G(1 Section , T_N-R Township Mailing Address [;/`DC~GC J`~~ Address of Site yeA Subdivision Name L AI :Lot Number Previous Owner of Property e Total Size of Parcel Date Parcel was Created / /ON Z`Y ~ Uj . Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No SE Volum and Page Numbe.L _ 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) CeAt16y that a t statements on tha 6onm cute tAue to the best 06 my (ouA) hnowtedge; that 1 (we) am (aAe) the owneA(s) o6 the pnopenty descAi.bed in this .i.n6onmati,on 6onm, by vi)Ltue 06 a waAnanty deed neconded in the 066ice o6 the County Reg-i,b.teA o6 Deeds as Document No. _ S ' ; and that I (We) pnesentty own the pnoposed site bon the sewage didpos sys em (on I (we) have obtained an easement, to nun with the above dacAbed pnopeAty, bon the constnucti.on o6 said system, and .the same has been duty neconded in the 066ice o6 the County Reg-iateA o6 Deeds, as Document No. ~Ga~~ SIGNATURE OIL OWN R SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED Violation Number Form - S T C - 101 J PRE SANITARY PERMIT ISSUANCE PROCEDURE Location Section Township/Municipality Lot No. Blk. No. Subdivision S~ 141S~ 141 1 0 IR igW . a~: J13 ~r1f , T Procedure prior to sanitary permit issuance where a septic tank must be replaced during winter weather or other health emergency and soil evaluation or other sys- tem evaluation cannot be conducted. 1. Obtain assurance that the property owner is aware of further requirements for a system evaluation. 2. Obtain assurance that owner is aware that if system is found to be failing, it will be their responsibility to replace it with a code complying system. AFFIDAVIT TO BE SIGNED BY PERSON REQUESTING THE SANITARY :PERMIT: I, J ; the undersigned do hereby acknowledge that I am receiving a sanitary permit to j~_~QIJKS without a soil and system evaluation due to inclement weather or health emergency. Furthermore, I acknowledge that a soil and system evaluation will be conducted as weather permits and that if the system is then found to be failing as defined in Section I L H R 83.02 (18), Wisconsin Administrative Code, it will be replaced with one that complies with Chapter I L H R 83 of the Wisconsin Administrative Code. If temporary pumping is to be utilized for maintaining a newly installed septic tank, due to failure of the system, the tank shall be maintained by a licensed pumper in accordance with N R 113, Wisconsin Administrative Code. SIGNED DAT A copy of an affidavit in lieu of EH 115 along with the P:LB 67 must be submitted to the Plumbing Bureau for purposes of fee reimbursement. Age- 7.;~r! Sig to e of pplicant Jt..n.y Date i Subscribed and sworn to'before me STATE OF WISCONSIN This y2- day of Au_ 19 0. SS. COUNTY OF S+- Cecv d Notary u lic, State of Wisconsin My Commission Expires: - 7 - 9 H t T C 0S S r 51:~'TIC TANK MAINTENANCE "'AGItEEMLN'T ' Ho St. Croix County x c~ OWNER BUYER Pi ROUTE/ BOX NUMBER ~ Cr~'OCGL~ Fire Number CITY,/STATE Ica kt lk --ZIP S~~0521 i YROI'Ek1'Y LOCATION jGd, Section /c 1 N, R / W Town; of1,1 f3e~✓ St. Croix County, Subdivision Lot ,number Improper use and maintenance of your septic system could result, in its premature failure to handle wastes. Proper maintenance=cu,-. -silts of pumping out the septic tank every three years-or su;Uner, if needed b a licensed septic tank )umr. What You put °,i n t u _Ile What You Y _ the system can affect the function of the SVI)tic tank as a'treat- ment 'stage in the :waste disposal system. St. Croix County residents oia-y-.be e'li'gible 'tu recuivi! a.gr.4iit'fuC. a maximum` of 60% 'o'f the ycost of replacement „of, ,a fai`~in}; system, which,wab i'n opei ton; ~tior- to July.;1; 197$, St d of accepted this pr'~,Lgr~lm 'in .A`ugu5t of 1980, witlC 'tI,o' u'-L, `1~at RS owners of all new systems'-'a'gree to `keel>. thr systet pro = ilia i n t a i i e d kp , :a y ~ - t ~i• fir r ~:,ti 'S N . „f ~ ,tie. . e property owner, agrees -to" submit :to 5t., Croix Coutity ":7.o1lin•g, a- ~certification form, signed 11 by the -owner and by a maa`ter'plii wlier, -,journeyman plumber, restricted plumber of .n-0licensedpuuiperi~Veri- fyinb that (I) the' on-:site wastewater` disposal 'syste'►n i' in'.,pruper operating condition and (2) after inspection and puuiping (If`;,nec- essax:y), the septic 'tank is less than `l/3 full of sludge and'scum. Certification form will be sent approximately 30 day's prior o" three year expiration. yo I/WE,the undersigned, have read the above requireme:nts:and,,agree N to maintain the - private sewage disposal systen in accordance with the-standards-set forth, herein, as set"by -the Wisconsin Depart- ro ment of Natural Resources. Certification form must1be completed and returned to the; St Croix County. 'Z .oili Office within 36`A-1'ays of the three.year, expiration date. SICNE DATE' ' St. Ctloix C.-)unty Zoning Office P.. 0. f- o x ' 98 Hammor•d, " WI 54015 715-7S 6-223 or 715-425-8363 Sign, date and return to above address.s P B.L. 67 PLOT AND CROSS SECTION PROJEC RLUMRER 'NAME (LK~Q,ti, NAM r\ au tP_ LOCATION pY~ LIC ENS E DATE PL T MAP ~~i~~ N~ Wa~tl~ CnAK.1Q ~ I WTI) f pRP Xr1b L) 1 1a U P-~ ~IU (,~~fl 15 I~p~t~ y0 41 3G~ arRor., T~~ K AIp~,~•., ~ N Alt Tbt~K r HoIJ) uy fw _j As .o ~ t Ge O r 1 I 31 ~ "9 N 1.) Cap ~A+l.'bf J ~~►;lfi; , N~~ - NouSe cc =~~ofo N FRESH A R INLETS AND OBSER A I PIKE CROSS SECTION. Approved Vent Cap Minimum 12" Above Final Grade 4- q Cast rAbove Pipe F"- Vent Pipe To Final Grad Marsh Hay Or Synthetic Covering Min. 2" Aggre Over Pipe Distribution_ Tee Pipe Aggregate Perforated'Pipe Below Beneath Pipe 4_ Coupling Terminating At Bottom of System i DOCUMENT NO. I STATE BAR OF WISCONSIN FORM 5-1982, II PERSONAL REPRESENTATIVE'S DEED 601764 EEDS WALSH YOi- 1420PAGE 566 REGISTER H. D ST. CROIX CO. , WI ii ;I Carol V. Guy and Donald L. Fry RECEIVED FOR RECORD 04-22-1999 9:30 AM aS Co-E brS hf the esLate9of Maudie Lon and Clair V. F'rv PERSOMRI REPRESENTATIV • EXEMPT I CERT COPY FEE: ("Decedent"), COPY ' TRAl15FER FEE: x25.00 for it valuable consideration conveys, without warranty, to RECORDING FEE: 14.00 I Arthur W. Kaenymr PAGES: 3 Grantee, the following described real estate in ~t• CrO]X ...............County. State of Wisconsin (hereinafter called the "Property") : Return to: Law Fi .C. 430 2nd St. Fn, WI 540 See attached legal description. az -reel o: 020-1039--40-000; 60, 0 1040-20-000- 020-1043 30-11• 0 - - - ~I This Personal Representative's Deed is given in full, final and on J~ of the terms of a Land contract dated May 15, 1987 and r=ecorded May 18, 1987 in volume 778, at page 504, as Document No. 425759 in the office of the Register of Deeds :y for St. Croix County, wisconsin. ' • I~ I~ Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal this epresentativyl bqs since acquired. day of F------- 19. 99 Dated i' -Cot- It (SEAL) (SEAL) Donald L Carol V .Y . F'r'y i' AUTHENTICATION ACKKOWZ.RDGM=NT Signature (s) N/A STATE OF FWR.IDA ' . ss. PINF'LT S . County. authenticated this day of 19...... Personally came before me t V. _s day of I! 1o.9..... the above named ~I Caro l V. ii TITLE: MEMBER STATE BAR OF WISCONSIN _ (if not............................................................. /L}I { authorized by D 700.06. Wis. State.) i - . to me known to be the person..1j4--. ' ..who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY At Hu H. GW1i1, (nTAV LAW FIRM, S.C. ~ I 430 Second St..,... Hudson, WI 54016 II . No Public County, (Sigrlaturex may be authenticated or acknowledged. Both My Comaio is permanent. (If not, state expi; tti~on ~j are not necessary.) date: - - - - ~ - - ~ - - - - Syr - - - . . •Nam.s of perso- aianina in any capacity should be typed or printed below= their slanatares. * My CWnmWlon, 000410M Emma April 23.1001 Parcel 020-1040-30-000 01/11/2005 11:12 AM PAGE 1 OF 1 Alt. Parcel 18.29.19.170 020 - TOWN OF HUDSON Current )(I ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): = Current Owner `ANDERSON, LEIF LEIF ANDERSON ANDERSON DANIEL J _ANDERSON DANIE ROUT-BROOK ROOK RD 154016 Di stricts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.500 Plat: N/A-NOT AVAILABLE SEC 18 T29N R1 9W PT NE SE PRT AS IN VOL Block/Condo Bldg: 172 PG 314 ORD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 18-29N-19W NE SE Notes: dy q , I p y Parcel History: ~v ` `10 Date Doc # Vol/Page Type 06/08/2004 765229 2591/233 AFF 05/13/2004 762468 2570/631 PR 01/24/2001 637279 1578/243 07/23/1997 793/281 _ V/D 2004 SUMMARY Bill Fair Market Value: Assessed with: 47915 183,200 Valuations: Last Changed: 06/05/2002 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.500 49,000 92,700 141,700 NO Totals for 2004: General Property 3.500 49,000 92,700 141,700 Woodland 0.000 0 0 Totals for 2003: General Property 3.500 49,000 92,700 141,700 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 762468 U 2 5 7 0 P 631 KATHLEEN H. IIALSH REGISTER OF DEEDS STATE BAR OF WISCONSIN FORM 5 -2000 ST. CROIX CO., WI PERSONAL REPRESENTATIVE'S RECEIVED FOR RECORD Document Number DEED 05/13/2004 09:30AII LEIF ANDERSON, as Personal Representative of the estate of DAVID PERSONAL REPRESENTATIV LAWRENCE ANDERSON ("Decedent"), for a valuable consideration conveys, without warranty, to LIEF ANDERSON, Grantee, the following described real REC FEE : 11.00 estate in ST. CROIX County, State of Wisconsin (the "Property") (if more space is TRANS FEE: needed, please attach addendum): COPY FEE: CC FEE: PAGES; 1 AN UNDIVIDED ONE-HALF INTEREST IN THE FOLLOWING PARCEL: That part of NE 1/4 of SE 1/4 in Section 18, Township 29 North, of Range 19 West described as follows: Beginning at a point on the E and W 1/4 Section line of said Section 18, which point is 114.95 feet W of E 1/4 Section comer of said Section and at the point of intersection of the northerly line of the County Highway; thence S 53 degrees 0 minutes W a distance of 639.4 feet along said right-of-way line; thence N 33 degrees 15 minutes W, 308.5 feet; thence N 59 degrees 52 minutes W, 253.3 feet; and thence E along said E and W 1/4 section Recordin Area line of said Section 18, a distance of 900.4 feet to point of beginning and said - tract contains 3.5 acres. Name and Return Address Attorney Barry C. Lundeen *This Conveyance is exempt from Transfer Fee and Transfer Return pursuant to Ito Second Street Sec. 77.25(11). Hudson WI 54016 Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to i Decedent's death, and all of the estate and interest in the Property which the 020-1040-30-000 Personal Representative has since acquired. Parcel Identification Number (PIN) I Dated this / day of May, 2004. * * derso Personal Representative P nal Representative AUTHENTICATION ACKNOWLEDGMENT Signature(s) Leif Anderson authenticated this day of May STATE OF WISCONSIN ) ,2004--7 D ) ss. ) 7r41-1 - County I *Buty C. LuWm Personally came before me this day of TITLE: MEMBER STATE BAR OF WISCONSIN the above named to me known to be the person who (If not, authorized by § 706.06, Wis. Stats.) executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorneys C. Lundeen Hudson W154016 Notary Public, State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not necessary.) My Commission is permanent. (If not, state expiration date: , *Names of persons signing in any capacity must be typed or printed below their signature. PERSONAL REPRESENTATIVE'S DEED STATE BAR OF WISCONSIN FORM No. 5 -2000 HUDSON `W' PLAT T-29-N • R-20-19= Landowners) See Page 112 For Additional Name ST. JOSEPH 'W' PAGE 44 R20W R19W 400 300 GOLDEN OAKS LN T T B 500 200 OLD HWY 35 Eckert K5 °o Fam LL LP 51 t~u qtr tr 37 0 2 1 m 3 tr tr TS 5 A 17 M n an P tr N fen 21 I 5 9 n6 4 &N JD IDATORS INC. KR RY _ 8~ ' tr r gw . L" ri CASPE DR swot 47 Robert& 'lace To Shop DR tr Jew r35 Won & Jacobs Brigitte i of Items 13 Rod & ' 441 B SB 5 3 Gun etch 8 J e * Furniture 7~~y~ ~ * ci 100 / 3 2 16 3 Housewares HUDSON 4 11r ° ~r 1 greeting Cards ; MALLALIE & LJ g ited On: 1 tr 5, o R&J B, Woodville, W1 54028 54 tr tr Sienna 3 S iz, Co- •2252oration 3 2n( o~ iators.com / W 1 6 r oc nmunity Since 1981 v ' A ,F 10 154 tr DH Z z : 2 SL ' 2 3 o~ R 128 2 4 10 10 LAKE 00 WELL ST Edna 19 ~o C At- 40 R 1 0 CROIX Wood , ' NG INC. MMare $ x l ?o- 4 9 I 'RODUCERS HUDSON 30 28 tr r - J Midwest :E 1946 ,I d~A 10 Const/Dev Of Hodson Q{~1 34 2 JNG BED DONMENT LLP 30 SYSTEMS 94 MT JR TANKS r tr ~ S 2 v, STAGE _j >'RAE i _ RD CEO 2 F / p MAYFR RIB HUDSON `W' DIRECTORY f (Residents - Owner or Renter) ST. JOSEPH 'W' PAGE 45 OLD HWY 35 GOLDEN OAKS LN TROUT BROOK RD Michael IN n - ~ ElO;- - ~ ~ RohertJ- - - IT7LE ■Johnsoa Strand F LS Roy 100 Ewks ° GOLD IN ■ LA Starwoo~dnHart i~ OAKS DR w 1 G IN BRAN- Ranch _2 W I 2u11an1 Q DON DR Woods v Scott GJowe na Ei STARR ■ ■D. MILLER RJ e P K)n ■W Hart- I)- RD Hart land htd■ 8 johllson ■ i G ~q Thomas ■ I ■ ■■6 ■M.doVega t`h`u I■ Neruubbiggr-7■ C RSON DR 1 RK LN Pak Vkw Estates ' "ru IN TOR / 10 ~uler 41 KRATTLEY IN Kra l awe UTCHEON LN LN ■ 9 Do E 1'ly ■ 1 N M ~P 3 O~ ■1 PAS f a 2 60 ■Z Q~2 GREENMILL I 3 PaRick LN p Joe Chdstlaa- ¢ J ]2 8Cn BROOKWOOD } +;I DR J N Y BI Trout A EN HUDSOlJ?F S W-0 ods I~57 WBook oods LN W111ow 35 J MALLAL(E Q Ridge IErot. w Q - ■ ~ - - Illow- - - Mallaco christo• Add 1 er her 9 17 Jenunwu S a atters int .~.b 9t A 1 nes Holden ■15 e"I ■ _ John ■ \ R Roy Ka OR W N R 7_ 160 ■ 14 uP 3 9 r- J/ .19 PP ~ ■tz I ~ 0 ■1 , 0 D O~ 1011,■7 ■&I Q 'Y, S t LAKE ~P ■ ■ Das1d t ~ 6 I ►d Ali ~ untry i 1 Rssings ;00 UU Yt•od ■G ■9■■ CoOUntry ROIX 1011 view 0 ir ■vioal b I III 30 w Z~ w H i ERI A HUDSON Q 2 r, , chard cedar Evj C, crest Pr<ddentlai > U 1, Estate ¢ V 2~ 9 0w Q tl I 0 ~ us: 1 94 - • ry >a6e ~ '07 j Line o+ li I 1 \ ~`p I 1wdd 4 Windsor / Heights / J o I MAYER RD TROY'W' PAGE 13 " v Parcel 020-1032-80-000 01/11/2005 10:59 AM PAGE 1 OF 1 Alt. Parcel 17.29.19.146C 020 - TOWN OF HUDSON Current ❑ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * NORD, LLOYD W & EDITH A TRUST LLOYD W & EDITH A TRUST NORD 958 TROUT BROOK RD HU I~~ HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 958 TROUT BROOK RD SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acr 1.710 Plat: N/A-NOT AVAILABLE SEC 17 T29N R19W SW NW COM W L SEC 17 Block/Condo Bldg: 44~V 1/4 COR TH N 432.3' E 171. TO CEN LN TN RD S23DEG E ALG RD 99.7' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) S11DEG E 100' S16DEG W 70'S41 DEG W 83.6 17-29N-19W FT TH S54DEG W ALG CEN LN SD RD 192.970 POB Notes: Parcel History: Date Doc # Vol/Page Type 09/06/2001 656043 1714/633 QC 07/23/1997 315/214 2004 SUMMARY Bill Fair Market Value: Assessed with: 47846 172,400 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.170 29,200 104,200 133,400 NO Totals for 2004: General Property 1.170 29,200 104,200 133,400 Woodland 0.000 0 0 Totals for 2003: General Property 1.170 29,200 104,200 133,4000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 126 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 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LA&DR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION WD N, uv1g537,[!§ 19W X-REPLACEMENT 'Number: , , 11 > L > (If assigned) Town of Hudson CON NTIONAL ❑ ALTERATIVE Lot 2 Hatcher R Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: OF P MIT HOLDER: INSPECTION DATE: Art Kaemmer ADDRESSCentral Ave. Bayport, MN BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Jim Boumeester 3404 St. Croix 128622 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ONO~ I ~ ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PU ❑ YES [:1 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: INSIDE DIA.: PITS: LIQUID BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER # TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO MBER OF PROPERTY WELL: BUILDING: PERMANENT MARKERS: OBSERVATION WELLS: iARES COMMENTS: ET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO T tch System on Retain in county file for audit. Ske Reverse Side. SIGNATURE: TITLE: Zoning Administrator SBD-6710 (R. 06/88) 'Nelsoll C. Thomas i DIL.HR SANITARY PERMIT APPLICATION COUNTY f In accord with ILHR 83.05, Wis. Adm. Code E STATE NIA ERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ owo z„~,_ 8% X 11 inches in size. heck if revision 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 P 't k S(,)%SF.'/a,S j~ Tc ~ N,R E or PROPERTY OWNER'S MAI ING ADDRESS LOT # BLOCK # ay, I - A a I W y. STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR M NUMBER MkA 004 1'x I INN I Ssooli( M K ) CITY NEAREST A 0 R~, 11. P OF BUILDING: Check one ( ) ❑ State Owned ❑ VILLAGE : 1AIJ sop ❑ Public L~J 1 or 2 Fam. Dwelling-~# of bedrooms ~ AR TAX NUMB (u) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 90 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. VX Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete structed Con- Steel glass Plastic App Tanks Tanks IT\ Se tic Tank or Holding Tank Q' y F-1 E] 1 0- F1 Lift Pump Tank/Si hon Chamber El Ll F] 1 11 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached pla Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Stre t, City, State Zip Code): g S~ Ar sc, IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitarypermit Fee (Includes Groundwater a e ssu is in Agent Signature (No Stamps) Surcharge Fee) pproved ❑ Owner oven initial kcs- ~-02 7-g Adve Q X. CONDITIONS OF APPROVAL/REASONS OR DISAPPROVAL: ~~-~9 SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber II INSTRUCTIONS ` 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually, every 2 to 3 years. 6. If you have questions concerning your-onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. i GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. i, i SBD-6398 (R.11/88) APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property to M Location of Property Section , T_~g~N-R / 9(_ J Township _4L 50ly Mailing Address l~/'~Lr1J Address of Site ~0 ~J r~ ~DtPLI Subdivision Name 1C1/,~y Lot Number Previous Owner of Property (-a i!'e e Q/ Total Size of Parcel 171 acre-5 Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this petty being developed der resale (spec house) ? Yes No Volume and Page Numbe -Zrj~l s recorded with the Register of Deeds. INCLUDE WITH THI 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 (We) eeAti6y that att. ~s-tatement6 on tW 6onm ane tAue to the best o6 my (ouA) hnow.tedge; that 1 (we) am (ane) the owner(s) o6 the pnopenty ducAi.bed in .this in6oAmati.on 6ohm, by vii tue o6 a waAAanty deed neconded in the 066ice o6 the County Regis.ten o6 Deed " Voeument No. and that I (We) pne,6 entty awn the pnopob ed z to bon the sewage df b pos z yss em (on I (we) have obtained an ea.aement, to nun with the above desehibed pnopehty, bon the cone.tAuc ion o6 .6aid by.6tem, and the Game has been duty neconded in the 066ice o6 the County Reg-ia-ten o6 Deeds, ad Uoc ment No. SIGNATURE OIL PWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED l Violation Number Form - S T C - 101 PRE SANITARY PERMIT ISSUANCE PROCEDURE Location SectionTownship/Municipality Lot No. Blk. No. Subdivision Sl,.)~ISL14I O JT,~~ N R 1 W !V Procedure prior to sanitary permit issuance where a septic tank must be replaced during winter weather or other health emergency and soil evaluation or other sys- tem evaluation cannot be conducted. 1. Obtain assurance that the property uw:-r is aware of tufther requirements for a system evaluation. 2. Obtain assurance that owner is aware that if system is found to be failing, it will be their responsibility to replace it with a code complying system. AFFIDAVIT TO BE SIGNED BY PERSON REQUESTING THE SANITARY PERMIT: I, U1 Y\ the undersigned do hereby acknowledge -T- that I am receiving a sanitary permit to 16) h Q, L5 without a soil and system evaluation due to inclement weather of health emergency. Furthermore, I acknowledge that a soil and system evaluation will be conducted as weather permits and that if the system is then found to be failing as defined in Section I L H R 83.02 (18), Wisconsin Administrative Code, it will be replaced with one that complies with Chapter I L H R 83 of the Wisconsin Administrative Code. If temporary pumping is to be utilized for maintaining a newly installed septic tank, due to failure of the system, the tank shall be maintained by a licensed pumper in accordance with N R 113, Wisconsin Administrative Code. SIGNED DAT "7' 7- rr A copy of an affidavit in lieu of EH 115 along with the PLB 67 must be submitted to the Plumbing Bureau for purposes of fee reimbursement. S 'g ture of App icant Date Subscribed and sworn to"before me SPATE OF WISCONSIN ~ This day of 199y . SS. COUNTY OF Notar Publtate of Wisconsin My Commission Expires: J r-i u r S T C - 105, " Sl'sP`1'IC TANK MAIN'1'ENANCE ;1G R I{IsMENT r+o St. Croix County 9 OWNER /BUYER.f ROUTE/BOX NUMBER Fire Number ZIP S~/Da PROPERTY LOCATION: ,-5&" 14, `Section T j ,t, R Town of I~ ~06t1 St. Croix County,,` / Subdivision LO t number Improper use and maintenance of your 'suptic system could result its premature failure to handle wastes. Yropc r maintenance 'cotl`s~t silts of pumping out the, septic tank every three years Yo'r,s,oonbr:; NMI if needed, by a licensed sc1 tic tank _Ium_j er. What you,p'6r 'int6 the system can affect thefunction of the. septic tank `as `a treilC`cf' ment `stage in the waste disposal system. St..•Croix County residents Lila y. l be eliglb e 'to receives a ;gr411t fU a maximum 'of .60% of the cost. of replacement •of; a failin}#". tein y which' was` in ,operation :friar to July, 1, <1978 St 1"Crpi 't~' u[~t f°~, ' accepted this program in :Auf;uf~ of ~ly$0, with` the r6'qu1"' t1C t°i at ~'.wners of. all new-,.s bt'Ents Lk glCee to keep; thclrr.sy8tuius ;prb i'`rly 1 lilt, i.nt`ained r ' The 'property - owner agrees to submit to St. Croix County =7.0 11 "ing a certification form, signed Iby the owner and by a master 'plumber journeyman plumber, restricted plumber or a -licensed pumper veri fyinb that,(I) the on-site wastewater disposal system is"in,prope?r_ operating condition and (2)",after inspection and pumping _(i f.nec- esbsary), the septic 'tank is less than 1/3 full 'of sludge,,and scum. Certification form will be sent approximately` 30 days prior to three year expiration. y 0 • E 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 setby the Wisconsin Depart b ment•of Natural Resources., Certlfic-aton.form must be completed; and returned to the.St. Croix County zotti ffiee within -30 days of the, three year expiration' date. SIGNED DATE St. Ct,oix County Zoning Office P.. O. Uox 98 Hammor d . WI 54015 . 715-7S:6-223 11 or 715-425-8363 Sign, date and return to above address. P.B.L. 67 PLOT AND CROSS SECTION ~PROJECT PLUM E 7 NAME ti 1~jnrmwgr_ NAME iti-. U LOCATION Nh LICENSE a DA E 8 PLOT MAP Z191 it"", N-y Wp)-~l n I a9- N ' p~ j pc~~►~'t ~0~+5' , r N1)1 ' W 11 ;_S flow Y? co 4b Fa ~r -IWNj 10009 d as' do- ~x 1 I~ I nr q p/T jM 1 r11 ' IPJ ! Tb4_ AO\AS t id;N ~a N 9~ As ~ ON Sire ~vQiM~fi)n,~ WA To)" Ak1sau N FRESH AID'. INLETS AND OBSERVATION- PIPE CROSS SECTION.._ Approved Vent Cap Minimum 12" Above Final Grade 4" Cast Iron Above Pipe Vent Pipe To Final Grad Marsh Hay Or Synthetic Covering Min. 2" Aggre Over Pipe 7 111 Distribution <Z- Tee Pipe - 4 Aggregate Perforated Pipe Below Beneath Pipe Coupling Terminating At Bottom of System