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HomeMy WebLinkAbout020-1045-00-000 ~ o I o ~ I N M C U a `y w ~ I Cb N N h *CA r ~ I I N N a Z c LL o o w c ~ m I a~ o Q v I U I M °I v I ~ H I rn 0 o I ~z Z N y y a m rn lam- w o I O z :!t c o d Z c N ~ ~ c CD o I a•°i R ` M I N CL 7 N N •i C d U L c O co I O Z F- Z _ N co Z M d C r- N (1i C ►~ii O ` O C y CL y H d ~ N L O ~ v D D tL ~ U ~ ~ w 7 U) U) Z •tv ~aaaa a N J V U co co Z ° 0 v w O E m a co C c v •o ~ ~ m ~ a I 'MV d ¢~u) co N fA ~i La L _ 1V w+ O EO O H O E O O 3 N " d LO CD 0 l \ L6 ~ V y N y 16 c N v ~O~.r 0 O N N` Z 2 W M d N C N • O CD- _ :3 0 (0 > O z N Fc- Fes- .E' (n oaf as L: CL rr`wIv 40 CL L 'c c _1 A ciao Ov~ci t 3~n d co~ ° fD a) m ~low ~ O. 0 P O o ~ b O 0 r0tn c N 3 Q Ni • O i J A ? ~ A z 0 i i i O A Vq N N O O q w A dQ b ~ O t, l A Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT V E GCJ TT OWNER ' S I-f U FO'%) SEC. T2t N-R / W `1/~~ S T ,E?5 TOWNSHIP ADDRESS 3 4 D Gay. ~ D A- ST. CROIX COUNTY, WISCONSIN ~"}`V1~.SO~ WIS S4di SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 t~ z~s-~~~►~~ you, ~s,~ A) ICS 6' 1 Lj A.) S - E SE PE)g476- hz- o 7- ~f - v r r T Tv1( r i INDICATE NORTH ARROW 30 iTo M Elf- o F BENCHMARK: Describe the vertical reference point used S/CV,0 r /fs S7104." i Elevation of vertical reference point: 149 0' Proposed slope at site: (,JG L--e S CO ,v C-.t 4.a- Ppo D cvc TS _ n SEPTIC TANK: Manufacturer: Npu IVi Ho,JD Liquid Capacity: ZOd S`~ Number of rings used: /06At` Tank manhole cover elevation: c ~ ~ r Q( ,gyp Tank Inlet Elevation: / 7 35 Tank Outlet Elevation: Number of feet from nearest Road: SFr nt Q Side,O Rear, O S~0 feet to ES Tr ..From nearest property line : Front,OSide,ORear, O 2 7 feet Number of feet from: well building: 13 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE f a a 1 PUMP CHAMBER Manufacturer: Liquid Cap ty: ' Pump Model: Pump/Siphon Man acturer: Pump Size Elevation of inlet: ottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet fro nearest property line: Front, O Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: • 5 Z 3 B~t3~ g Width: 5 Len$th: Number of Lines: Area Built:--2-- depth to top of pipe: V0f1 3 G Fill Wes T Z Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: 5 Number of feet from building: Z / (Include distances on plot plan). SEEPAGE PIT Size: Number of pit Diameter: Liquid depth: ottom of seepage pit elevation: Area Built: Has either a dro ox O or distribution box O been used on any of the above soil absorbtion tems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of in t: Number o eet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: ~ (kd0' ZqInspector: sO.V Dated: Plumber on job: License Number: HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT `.YIS',MASTTti DER &BGRSIGLIC. NO. 3307 NER LIC. NO.•P00669 3/84:mj i A t< e- AAA%jeWc?A.- w iiCt 1 • r s Ce1£ : t =Z 0 . 3 $EORN. W/kTT'ERs If~ME or raeocp S oPr• ` f3oTtoAy IFt*E fIEVr1T,o~° /00.0 © ExfSty~G- wE(I C 4,j DER ' ec k\ J 19 CJUERSisED T sepr ir - Qox ` rt v gap I,.i1.CT Te DRS tri CL: :1 r, ~ X75 W z OEUATtOAJ SPECS a v 5ySTEr1 EIevATioz o Ii TPeme-W S = 93.50 / 0 • TOPS bF 2-711 Pe#eF. D~STRi'(3Utr'o~ P' pes AT nQSEku/rTiva -VENT Eap , f'/, 33 i • Tap S CIF A(I DCSTPjgor,oa Pipes ,~r , DppOSi-(E ~tvEtT~ ENS = 9y. V2 * . o L j Tat-D~- 5.~ at-?-T 7-o F0uA,~0AT/'0"j 9p,13 'T'QENCfti SPEC S II 1 ISr DRpr t3011t, CIOSESTt` TO Nauss ~~EpS 13OTtN TIP~~ucl•, A Tit E N C. fin. n 13 ~S I A t> L TA A! f Ou S L r TrzE~r-G... "C TO REcei0E &FFLLXjT d~~~~ Ro-I~, A Rap „ ARC TOTALLY S^TVP-A-tC 7 . or- wAS Hev 3/it gSQECrr~TE uODE72 SC4*1 ~7•Z~ I~1~~~IS - ~9 yy~E~~t r~ cot~Q2~v w ►+G~ t~i< p ~ ~ Fit L3R t L POP- I i Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT Z g OWNER ~h~~ S 'So E LI 4 r7r-"?5 TOWNSHIP V ~So-J SEC. 19 Ts l N-R / W ADDRESS 3,40 Ny• PD A- ST. CROIX COUNTY, WISCONSIN U J) SO,j , W 1' S S4o~ SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I.IHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM zN s-~~~I~D Maw ~lD I ~N k ' DRYwt (1 C Rvs >t 13~N 1~o-~ D ' s S•FE SEVt~i► TE ~L o 7` ~ ~ ~1.ti ~4 TTrf ~ l.~.a~ t I i INDICATE NORTH ARROW Tao ITO /-i EGYrc' o F BENCHMARK: Describe the vertical reference point used Sw/aCr- /4S S7 Vj.C'1 ✓ ~ I Elevation of vertical reference point: 149 0' Proposed slope at site: - ~a hAac~:ti~4 (,c)Cf KS COA.)"4.0- PP0DLx7'S O~~r SEPTIC TANK: Manufacturer: Npu_~ `QiC(AKoJD Liquid Capacity: 1 t8. fs Number of rings used: /k-*A-)t- Tank manhole cover elevation: a ~v Tank Inlet Elevation: ~ 73/ Tank Outlet Elevation: 0 Numbof 4 feed from nearest Road: Front QSide 0 Rear, O feet west 27 .From nearest property line Front,OSide~Rear, O feet Number of feet from: well building: 13 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE I PUMP CHAMBER • Manufacturer: Liquid Cap ty: ' Plump Model: Pump/Siphon Man acturer: Pump Size Elevation of inlet: ottom of tank elevation: Pump off switch elevation: Gallons per cycle: --Z - Alarm Manufacturer: Alarm Switch Type: Number of feet fro nearest property line: Front, O Side, O Rear, Q Ft._ Number of feet from well: Number of feet from building: (Include distances on plot plan). Q~ts Si 2 e, " SOIL ABSORPTION SYSTEM U~ x Bed: Trench: 3 TJ2eA.) S Width: 5 , Length: 5 Z Number of Lines: Area Built: J Fill depth to top of pipe: Wes I- Number of feet from nearest property line: Front, O Side, O Rear,O Ft ~z _ Number of feet from well: 5 V Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pit Diameter: Liquid depth: ottom of seepage pit elevation: Area Built: i Has either a dro ox O or distribution box O been used on any of the above soil absorbtion tems7 (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of in Front, O Side, O Rear, 0Ft. Number o act from nearest property line: Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: JOE (Sow ' dM Inspector: ~(~l Plumber on job: Dated: License Number: HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT WIS. MASTER PLUMBER LIC. N0.3307 M.P.R.S. MINN. INSTALLER & DESIGNER LIC. NO. WO 3/84:mj II~ i Scl*l£: / r-20, - 3 '$EDRN. wk'TTERS Ifo~E VERT• REF. PT RoTrom ~I~1SE OF I.aocp S!D/~(s - F'IEV~Tro,~= /000~ © l:xr'ST/a~ WE(I C-ujOFI- ZEcInc) - M 11r i8r OVER SiZED ! 2Q 12&0 S&P. septa r. 5 cr-` C NO QISEPS ~ , S y` yo TO ~N~ R P I,iLI T TO DPW ` 'S 1 vi ~RfN IS d Lm CL: 27 c c 061d ATlp,v SPECS z - SYSTEM EIevATro,3 All 'TPE-uc oS = 93.50 0 ' TOPS OF Z7 1g pE12F. DI- STRI'll 0 Tt'D&j P' pES AT WaSePWA O.3 - VEA+T 60,D Ty. 33 • TOP g OF 4N ~D rs1,-r jgor,oA3 pl'pes hT 1 Dppost-IE (oe-tT) l:NL) = gy. z/2 o L • T3~0~- 5~.-~. at-~T Tv Fou~OrtTi•o~ 9,13 r TQ~~~~ S Pic S 1ST- 3)P-0 N61, , C IOS Es'r' TO HaUS E , Fe E DS 13OTL. TIC &NC ti 3 7l2E,UC, w 13 sl'.AtuLTAAJ touS T2ENU-- "G h To 'RE-CEIl9E cFFLcuEaT C»LAI g0' - T Ra c d A a T hTU2 GG.. R ~ T ~1~cy S ATrl' 4 of WASNED 31q' 4g51PCC,ATE uA-10E0- See-' a7Zj I+TEPI/S • 4 yy&64 7x- CO[9Q2FD w ►'tG. TY p A le. Fit QILt L ~DEPARTNIENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION ~~D ~.SO 53 State Plan I. D. Number: NW 4 ,`iV~~ , 97e c. 19, T 2 9 - R.19 (If assigned) ❑ CONVENTIONAL ❑ ALTERATIVE Town of Hudson Hwy. A ❑ Holding Tank ❑ In Ground Pressure El Mound NAM OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Chris Waters 340 Ct . Rd. A. Hudson WI 54016 1/-'/S+E 1 1130 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: Robert Ulbricht 3307 ST. Croix 135395 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: lpROPERTY WELL: BUILDING: I VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: [I 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: PUMP AND CONTROLS. OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH D R. 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 ❑ 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: WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS E:1 YES ❑ NO [11 YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST / Retain in county fill f4udit. Sketch System on Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION I L H R u TY In accord with ILHR 83.05, Wis. Adm. Code coSf~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El 1Jzsion o previo~Q 8% X 11 inches in size. Check if revius 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 e IfA NomN,//Wilk, S T, ~ N, R E (or) W PRO RTY OWNER'S AILING ADDRESS LOT # BLOCK # go _ /toc . CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 9V t~9 So.✓ !CP S 47 El NEAREST ROAD State Owned VILLAGE 14, 11. TYPE OF BUILDING: (Check one) VILLAGE: ❑ Public N 1 or 2 Fam. Dwelling-# of bedrooms - PARCEL TAX NUMBER(S) )b Q apply) ` (l y l 7 7 III. BUILDING USE: (If building type is public, check all that / 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: (Chec my 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) 3 L jNFS r E4 GG~ ` ~C ro / 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 0 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) c GELEVATION 5 Yff S 11JJ D 3' J Feet / 7' s Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Con- Steel Concrete structed glass App. Tanks Tanks / e3-S16- Septic Tank or Holdin Tank 0 Q 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): umber's Sign ture: (No Stamps) MP/MPRSW No.: Business Phone Number: vogepl ZllV!(/~4 3307 41(1S Plumber's Address (Street, City, State, Zip Code): n . O IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) AApproved El Owner Given initial S o d Surcharge Fee) l Adverse Determination X. CONDITIONS OF APPROVALIREASONS 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. ll. 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. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER-SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) Y t s 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 o_f 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 M11-5 ~(14- 74'5 c Location of property /V 1/9 1/9, Section f=, T~N-R_~7 W Township U 0So" i Mailing address 4D 0Y, / ya s~,J ~/S S j o/ Address of site Subdivision name Lot number Previous owner of property A Total size of parcel r GIJ~~ Date parcel was created r12 Are all corners and lot lines identifiable? x Yes No Is_this property being developed for resale (spec house)? Yes o Volume and Page Number - 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 reco ded in the Office of the County Register of Deeds as Document No. ; and that I (We) presently own the proposed site for the sewage disposal system (or 1 (we) have obtained an easement, to run with the above described property, for the e tion of said system, and the same has been duly recorded in the Office I th egist r o as Document No. Signature of wner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature 'I R S 5 ~ ~ ' { lk I. ~fi. r STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER 31-0 CI ~1 FIRE NO. 3 1 CITY/STATE P~Q) ZIP 5 7 ~ ~ CO PROPERTY LOCATION: 1/4/v w 1/4, Section l 7 , T L( N, R_!J W, Town of St. Croix County, Subdivision , 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.Cr unty Zoning Of Min 30 days of the three year expiration date. SI NED DATE V / 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 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOh AND PERCOLATION TESTS (1151 P.O. BOX 7969 HUMAN RELATIONS 1 / MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: *OWNSHIP)IvI0Iq el1&A,6"Y: LOT NO.: BLK. NO.: SUBDIVISION NAME: AJE V/ WV4 19 X? N/R/y E (or u scA.) COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: S+-C2o(X CAP_fS w4Tz~ RS 1,31 o C+ y. P . A- HuPsoa, tj is . syoi Cp USE 3 z DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILEDESCRIPTIONS: 1PERCOLATION TESTS: Residence 3 N ❑New Replace I NOfJ i RATING: S= Site suitable for system U= Site unsuitable for system JCS M E R T (S ' CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U CS ❑U DS ❑U ❑S ©U ❑S ❑U Caa0CA!)T66 ./AL If Percolation Tests are NOT required DESIGN RATE: [Floodplain, If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: C-I ~ indicate Floodplain elevation: Ito- 'PE-WS NOT ~E Qvi p PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) t r IECTiU~ SfiRONfr 5 ` Ae- 4 v . /5 7. - Y. . S 'f//N• iM•4Q• S B- Co• (e3 Ser-PA6-E AT )5 Z wig I ~ N o'f' S OR 3.5 ' 2, 5 ' y,e*y - a. S*AjD A r y,V9y c%ty le," . B- r ' t 1.0 ` Re /3N S /,d ~0,C.-8.a cs B- Z o Z > o -0, 6-9 y 0 - T4,..' O&CA ~s B--3 7 0' 5T36 '7, 6 ' • S ' D,f' Q,~ ~5 I. 0 ' 3a • I S l $ ' Ba C S 3 5 ' op, vE,~ C 6-P. - > > B-y 5' 7-1. 3Y' 7,0 1 7 s. •75'ok eN• IS i.2.S' I3N- Is r0 ~ TjAj CS 6- 2. , S' G /+h i '10,414 w n µ I ' FB- pRoh . Mot+ICS . 4r 7,5 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- P- P- P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SyS'1'E I'1 = SYSTEM ELEVATION 3. S r 3 ~ f 9 r . xpe I r 1' 5t6 so(" y s_T-H 3 I i F i ' I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print : TESTS WERE COMPLETED ON: I I _ C FAQ HOMESITE SEPTIC PLUMBING CO. 7 to L) ADDRESS: 666 G'NF=IL RD., HUDSON, WIS 54016 ROBERT ULBRIGHT CERTIFICATION NUMBER: P/HONE NUMBER (optional): 1 y P z. 3 P16 -001 S INSTALLER & DESIGNER LIC. NO. W663 CST SIGNATURE: kd~ U4M t Cy~~ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. D ILHR-SBD-6395 (R. 10/83) -OVER - ti -RUCTIOP I COMPLETING FORM 115, -6395 0 To, be ~ accurai , your ref: 1, Co pt:ion; 2. Tl U, € clearly indicate whether tl ence or corrrrnercial project; 3, MA: of bedrooms or commercia 4, Is -ement system; r ci bcsxes. A ~ is SUITABLE FOR A't TAI~F~ C)f~LY IF ALL C, is F ? ODU-BA. D O SOIL CONDITION, , t ttiee 3bbi _ ere fur v,vriting profile descriptio-, "no cornpleting the plot plan; 7. L.:GIBLE dia, t ira ely locating your test locations. Drawing t scale is preferred. A °t may tan t, irei ; G ~rrnanent; k S ~3 your b !n ;nci ver kcal elevation rcfar'nce point are ch ar 9. _ all approp , boxes Ait:o dates, narnes, addresses, flood ta, -st exemp- r=r)propriate; 3p - - # ;raat:ic3n {sr ~ : as fl(.) slain, elevationl) does riot apply, place N,A. it) the ~I ropriate, box; 11, S, )n the form ~ lace your'rrent address and your certification number; 12. lea e le(.ible co ies-_a r -4)ute as required. ALL SOIL TESTS MUST BE FILED WITH THE ~ ~G~ OF L AL AUTH013IT`lV-iTI°fl MAYS CAF C'<OMPLETION. IL4 Sv \ 3 , O ABBREVIATIONS OR CE &IEC SOIL. TES-I- ~ 3 p~ Soil Separates and Textures Other Symbols it = Stone (over 10") RR -1 Bedrock W 1 S~'idff WE1) - - - - cob Cobble (3 - 1C#") Sandstone E4 gr - ~rati=e r.rn er nestonr~ veaT. Ref • ~T.: C S7EP5 Sans '50770.~ Et ~cfh Oroerradwtrter s - Coarse Sand ~ 5(006 C.' /0&i' o P .rcolation Ivrte 70 r ea; ZO fs Fi ie S, Bldg ilding .~:NoM 15 > rezater Than 3G , _ »sl Sandy Lam .ss Than I - Loam B a otivn s 1 Silt Loa BI - Black i st - Silt Oy gray cl Clay Lo art ~,Ea~ Y - Yellow ! sca -Sandy2i&a R _ Red . sicl - Silty cif oaR?T Inot - Mottles W/ - ;rvi th sc Sandy C a sic Silty Ci fff - few, fine, faint *c Clay cc cornrnc c:oars<; pt Peat min - Many, : - m Muck ~0 d - distinct p promin,, S HWL Nigh wa, r i, ' J Six general soil t'I re, surfa / j for li Wu :ste (lisp sal BM - Bench Mar / I VRP - Vertical R -lance P int loll J 1'1 SEPT to, gb I i 9/ri16~~ll TO TNjd7Wl'TER: ~ This S~, / - ZO oil test report is the first stela in sec ring a sanitary permit. The cou ty or th3R~~t/t i verifi ation of this soil test in the field rior to permit issuance. A c~j lete set of sI ,ft wrr at sews sybt% and a permit application It be submitted to the a4r~dlar -to local authorn orcTer to obtai )Permit. The sanitary permit must e obtained and posted prior to th start of any construction. i 101AESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WI& 5501 sy~, ROBERT ULBRIGHT 2_ 'tIS. MASTER PLUMBER LIC. NO. 3307 M.P.FL& wE7~~tal~ aN. INSTALLER & DESIGNER LIC. NO. WA Ih y PLO'( PEA d i SYST*cm F tFV,~TI ohs so ' 93. 5'o sic Piz ~ SO \ T;3 J ~ I I ~ I CA ~Q.Sfprrc ,Zao S ,S ~ II Tn~K W ~D VERT Prf • i)T. _ 'BoTTU H ED6£ of SiD1A-N(w - 70 - 2.0 3 Btopm EfoH t UpAC 1 J 01- 10 l~ SePVc FI( 20 09o ` 2090 = BABA-1'+r 8ael:0 6-S s +!OMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT 4 sr 2 yPZ ilS. MASTER PLUMBER LIC. NO. 3307 M.PA& wETPA41P i -4. wsTALLER & DESIGNER LIC. NO. 00W l i Q Q ill V -T\p,ct1t- FOR- v Fresh Air Inlets And Observation Pipe CQ h 0 Approved Vent Cap ` Minimum 12" Above Final Grade F-I'a* L "'s 15`='d 4" Cast Iron 36 Above Pipe Vent "Pipe' 'to Final Grade Synthetic Covering min. 2" Aggregate Over Pipe Distribution 171 PUG Tee Pipe -0, 0 0 0 0 0 Aggregate 0 Perforated Pipe Below Beneath Pipe 0 Coupling Terminating At Bottom Of System 93• sa ~