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040-1213-70-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 578975 0 State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Markowskl':%Tom Troy, Town of 040-1213-70-000 CST BM Elev: Insp. BM Elev: BM Description: p~ ^ Tat b - Section/Town/Range/Map No: I/ U 011'- 08.28.19.1023 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION y~ BS HI FS ELEV. .J , Septic x` Benchmark b 1 76 lob .7 M11) Alt. BM Bldg. Sewer • Eili ~t/L St/Ht Inlet TANK SETBACK I FORMATION St/Ht Outlet 30 97. -V, TANK TO / WELL BLDG. ent Air Intake ROAD Dt Inlet Septic > S~ ~ ~ 2 7 Dt Bottom 97, 7~ B.'F7 cr7. 0 ` 7/ 9~ 3 J qa i Header/Man. S Aeration / Dist. Pipe J Holding Bot. System PUMP/SIPHON INFORMATION Final Grade (6 /4f 5 Manufacturer Demand St ver GPM a f'. Z ' ~r3 .5 Icy Model Number a ~•9b 47• Z TDH Lift Friction Loss System Head H Ft Forcemain Length Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION / Type ?o System:/ CHAMBER OR a X4W 27 UNIT Model Number; ,Cj,~vQwT7o DISTRIBUTION SYSTEM , r >3 Header/Manifold Distribution x Hole Size x Hole spacing << Pipe(s) ` ` Ven~toAirLlnta~ Length Dia_ Length Dia ~Spacing ~ A SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over «-'t r Center ~ 1XX Depth of xx Seeded/Sodded xx Mulched Bed/Trench Edges ` Topsoil es ~ No tes .ray o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 445 Brick Circle Hudson, WI 54016 (SE 1/4 NW 114 8 T28N R1 9W) Red Brick Add Lot 11 Parcel No: 08.28.19.1023 1.) Alt BM Description = ( 1_ f r 1b4ic- a 'l%_ 2.) Bldg sewer length - amount of cover Plan revision Required? Fv Yes - No Use other side for additional information. F SBD-6710 (R.3/97) Date Insepctor' ignatur Cert. No. _ ``~,arrnv ~ County Ces Division Saint Croix 8 O~ b tr 1400 E Washington Ave P JUN 0 4 2015 M 7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-7162 C 74!9'9 75 °ST Cf~C~IX COUNTY J aPermit Application State Transact' n Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit" is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to - the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) purposes in accordance with the Privacy Law, s. 15.04(l )(m), Stats. ~ T~ /1~,~ 1. Application Infor - Please Print All Information /w( Property Owner's Nam / Parcel # Torn M rkowski 040-1213-70-000 ~ t ((JJ Property Owner's Mailing Address Property Location 445 Brick Circle Govt. Lot City. State Zip Code Phone Number SE '/4, NW '/4, Section 8 Hudson , WI 54016 715-338-6807 (circle one) T28N R 19Eo 11. Type of Building (check all that apply) El I or 2 Family Dwelling - Number of Bedroo s 1 I Subdivision Name Red Brick Add ❑ Public/Commercial - Describe Use 4 Block # El City of ❑ State Owned -Describe Use /r CSM Number ❑ Village of 1 tS~- C ~Q I~►_!I! ~l 5 EZ G~J'S 2 ® Town of Troy III.-Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ®Other Modification to Existing System (explain) s, e r- F /er 4211cd%, B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number nd ate K 01 Befo re Expiration Plumber Owner 128683 10/13/1989 IV. Tay e-of POWTS System/Component/Device: Check all that aPP1 p ~ Y) Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil 1 - ❑ Mound < 24 in. Of suitable soil 1 0 ~m" y'Tank - Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Dispersal Area Re uire 450 Rate 643q (s~ Dispersal Area Prop ed (sf) S stem Elevation 0.7 (gpdsf) 650SQ~ 95,00 VI. Tank Info Capacity in _ Gallons Total # of o o anufacturer p U Ci Y Gallons Units - New Tanks Existing Tanks a. U v~ ~ v: u:. c7 a: d ` 52 0 Septic or Holding Tank 1200 1 Weeks ® ❑ ❑ ❑ ❑ Dosing Chamber - I ED] VII. Responsibility Statement- 1, the undersigned, assume responsi 'lity for i tallation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumb ur MP/MPRS Number Business Phone Number Michael B Rodewald 931384 715-425-6200 Plumber's Address (Street, City, State, Zip Code) - 285 County Road SS River Falls WI 54022 VIII. ount /De artment Use Only - M'Approved ~ d Permit Fee Date ssue G Issuing nt Signatur iven Reason for Denial $ cb ( /5 o4 ' .-.rr. IX. Condi 1 - lips, of ;Disapproval 3J1I l~,Cw tic anlt~ Tit OWAL(, dliorn<-4I citt.ri9uaf all `servt~es I malntainecl ills pit ifi*,WVwr*W plan provided by plumber. 4.4 Q q~ 0+,4yu~~,h, ' . - "Sefba K i~Flterst be maintairfed;, J its per silpilk cede / ordinances. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size S13D-6398 (R03/14) Plot Plan Page,2 of 7 Property Owner omits ~.~10 /1/lxor,sXl I"=40ft Legal DFSCriptton 1 oT I RyaRlcKb~rno N (except where noted) -';E '114 of rHC NW1IL4, she, 2, TzgN, RIgw ! T-ow,-1 of- = Backhoe pit f} G~~s -Mty{ ST, c Ra~x cbLkmzr , vJ tseOm-s a,j • Z. 0/0 North 8 btbrmp M ,6 rdkj&f~ ElfI ~ v~ '✓'J( 0 -~ZO~G ~~rt FiLTOz ~ V)kuLT ~5w p~;pf'DS~D~ bd ~ +'`~l FItT69 Be AbDE O P O o . 71` -5Y$M OK EL 40 bibls~iN 6 f1By `~.oa pp~}d~}d1=dr© Site Location: i ~T g KE.b 8101 Rg. Y'}I L SlTa cc,", F~ CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: j AOMA6 6,K f ,0 01 A. AAKKo WSK 1 Owner's Name: ( 5AA46 Owner's Address: Lj~f 5 .3PJ0,K CF2 Ccc 0 LW SON11 Ws `-519 nil Legal Description: _LOT 11.1 I-~Eb ERIC A-pDr"r1W 5F_,/4 C*-ME NIOX Sg,-Z$.AJO PI4W Township: TROY County: ST CRO I X Subdivision Name: Lot Number: Parcel ID Number: 17q0_1Zi3-70-000 ```~~u~t1111uptgtEi~i~~ Page 1 Index and title 0Page 2 Plot Plan Page 3 System Sizing & Cross-Section MARY JID 'i C Page 4 Filter Specs HUPPERT Page 5 Maintenance Information D 1859 Page 6 Management Plan .RIVER FALLS,, a Page 7 St. Croix Cty Septic Tank Maintenance Form W+••'•• Page 8 Warranty Deed - pN FILE Page 9 CSM or Plat - ©,v F►i.:& Attachments: Soil Test,& ~q S13 Li I LT Designer/ lumber: MAU a -Nuroerr License Number: 18 9-66 7 Date: O6 - Ol - ;Z6 16-- Phone Number .-4! 7i~ z(o - 17 75 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P fi?. Page 1 Plot Plan Page ,2 of '7 Property Owner 1 " 4~ fl, Legal Description LOT/,, ~R~cK ~tbzrnonl, (exr-ept where noted) s~'ly or- THe NWT L s&e. 2 . -rZ$ N },z jr w,j T-OW.-i of: 'Q = Backhoe pit ~Y~ ST. C.RblX n ~.N-~-'(~ l~ tSP I ~ E w1 • ~ Z, ~/d ~"G'~~S North 3 ~ $fDRnD M ~ 00 FILTER PO (vp W V,tuLT7D /FttD€D W~5'Yl~~ PRO~OSrED /d1.6~1 FICT69 P=t-VZ-5Wf' "lsrIN 6 ,I, DT,? Lid Site Location: SITS -a ICK SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page- of! Project Name: -Aos • ~np~ 4 / V I n ~ sx J ~60 25 No. of Cells Per Cell 3 ft Cell Width Total No Of Cell Length 50 sq ft EISA Per Cell l 5 ft Cell Spacing lp`~Z~~ sq it Total EISA Manufacturer Model Laylri Length EISA Ratio Z EZ1203H-5ft 5.0. infiltrator 25.0 EZ1203H-10ft 100 50.0 Gravelless Leaching Unit Manufacturer: ZN~I~?Rfr1"bR Gravelless Leaching Unit Model: 2.)Z6,3f /Qr 61 ZO 3H' S06 Typical Cross Section Finished Grade ft Observation Pipe with approved cap or vent • : Soil Backfiil Geotextile Fabric it Infiltrative Surface 12 in it 9L.50- ft Limiting Factor ZJ6 in Slotted and Anchored Vent! Observation Pipe with Cap rr■r■■•■■rrrr■■■a.ras~iiii■r.■r■.r.rr.r.■r■r■ru rr..■rr.■r■r■■■■r.■■■. Plumber esigne ignature:' License J g~ Db? ate: ~lO Ot 2415 SEEM o © 0 0 111110111 1811111 II III ~ U O O to 1.- u N O N U N n W V fD C O CD C Lq u ' cY U O N u cli N th O O r co C6 L, ch I~ U LO Cli OJ N I~®1 co U ..n.. ~s...~ co lemewmi D c0 ~p CO U N 06 CO W O u U IY Q C/3 w a Y J O CO m NONNI N U a ii~~ 114lulii'lliliii IIIiIII~V / co GAO L O Eli- CIO cn rrl / , ~ ~ (n oo U3 co O 2 X C'4 CO L, LLI F- ~ - CL ~Z U V-o~o u C) a~ C.0w 1~i Q Z ED Lq Lq U J ~ cfl d W W ~ I~ LL 4 Z Lo LD 04 lYd~' P/ D 2MaJ~ O Q m uJ- LL Z \~~0\\\ yJh-w0Q Q OLCM0UO O / N~,O bWSK r off' H W w Y ~ o - a w W Z °c-, =Zo Q. Q~-p0op Qom' Z~Z0~Z 0 W H 1-~~ co U O O O O Q On -4 D: v E o c..) M U C+j O ' M J co O W OO M n > O U co U M U -O NM OOH OO ~M CI ~Co N ~ J d. N LO O ti ' r CO N O U LO e- ~ r 01 N u CD o Z W v O CO U ~ = W ¢ cn U)X zoo CO W 2 otS H J d M C:j U U Z Of LIJ0 _ ¢O ~Cn U ~d W Z co z cn J N Q j ~ U,) 0 a ~ uj U? a W N Z ® U~ F-~ J_ W Q Z O J O O 2 Q Zw JLL- W M aU)_ Q > Lo I Q crCL~ Z Z W Q NF-WCl) J pp L? F- . 0 LO CL CL 0 (6 F - w Y W U d O U CL g U) Z -J E Q' . = Q N N y LLj NL6 W U m Z 0 77 O~~Z=zo~z 0 1 W F-- Q ~ F- d d C) Q O Q U O ~a ~d OQ r-, Cl) V N E O r CD J cli CA Mu W M m E w N O C.) M U J E O CV M M U G O O LCD C') C7 of Lo u u -(6 u N E Ln O ti r Cp N O E Lo r ~ r O N CO F- O Z W U cf) D Q Z U I- Ur UJ ~X Z co CD 2 otS H U W Z m o U Q J O J _ m U' ui _ z z N Cn J O CL > Cn~ 2N Oa_ a w Z L , ® ~LL Q Fw-cN ~Z W ZI- O J 0 02 Z _ !¢-W Q LO i , ~i C4 . -J co C) Z~Z ~a~ LC) NF- WC~Jm -~QQO~tn CL CL 2 0 co Feb.26.2013 01:22 PM St. Croix County Plan/Zoning 715.386-4686 FILE INFORMATION POWYS OWNER'S MANUAL & MANAGEMENT PLAN Page -:~Eof-7- Owner 'r f+U,A _5 ~b D1 SYSTEM SPECIFICATIONS r' WSK 1 Septic Tank Capacity Z al 13 NA Permit - ~~d Septic Tank manufacturer ~ 0 NA DESIGN PARAMETERS Effluent Filter Manufacturer Number of Bedrooms O NA ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Unite ANA Pump Tank Capacity ~ ~ NA Estimated flow (average) /00 al/day Pump Tank Manufacturer 0 NA Design flow (peak), (Estimated x 1.61 S al/da Pump Manufacturer Soll Application Rata 0 NA Standard influent/Effluent Qusl al/d' Pump Model )Q NA by Monthly average Pretreatment Unit Fate, Oil A Grease (FOG) S90 mg/L ~(d NA 13 Biochemical Send/Gravel Filter ❑ Peat Fitter oxygen Demand (BODa) 5220 mg/L Q NA ❑ Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average DFsper Sol C3 Disinfection 4 Others Biochen'nioal Oxygen Demand (8006) 530 mg/L fn-Ground (gravity) G )n-around !pressurized) Total Suspended Solids (TSS) S30 mg/L ti NA O At Grade Fecal Conform (geometric mean) 410' cfu/100ml Mound D grip-Lino ❑ Other: Maximum Effluent Particle Size Ys in die. la NA other: Other: 0 NA ❑ NA Other: "Values typical for domestic: wastewater and septic tank effluent. ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE SeMce Event Inspect condition of tank(s) Service Frequency At least once every: -;z U month(s) Purnp out contents of tankls) ear s) (Nlaxtmum S years) O NA When combined sludge and scum equals one third (4) of tank volume ❑ NA lnspsot dispersal oeil(s) At keel once every: ❑ e a (Maximum 3 years) DNA Clean effluent filter At least once every: e 4 moon` '(a) Inspect pump, pump controls & alarm O NA At least once every: DO earth(s) NA Flush laterals and pressure teat At least once every: 0 mono it(s) ANA Other. ear Slnl ffiCN GNP At !seat once every: mon '(s) gNA Other: MAINTENANCE INSTRUCTIONS tInspections of tanks and dispersal cells shall be made by an Individual carrying one of the following licenses or eartificatlonet Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS MaintolnOG Septage Servicing Tank InapeCtions must Inolude a visual inspection of the tankls) to Identify any missing or broken hardware, identify any cracks or looks, measure the volume of combined sludge and scum end to check for any back up or round Operator, surface. dispersal cell(s) shall be visually inspected to Cheek the effluent levels in the observation n pipes TMand tt to ocheck for any pon of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requiresdthe Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third ) more of the tank volume, ente Contents of the tank shall be removed by a 98M99 Servicing Operator and disposed of i accordance with chaptertNR 118, Wisconsin Administrative Code. All other services, Including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servloing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulktory authority within 10 days of completion of any service event. Feb=26.2013 01:22 PM St. Croix County Plan/Zoning 715.386-4686 START UP AND OPERATION page -k of , For now construction, prior to use of the POWTS check treatment tank(s) for the presence of p,kM,g products or other chamloole that may impede the treatment process and/or damage the dispersal cell(a). If high oonoentratione are deteoted have the contents of the tank(s) removed by a septage servioIns operator prior to use, System start up shall not occur when soil conditions are frozen at the Infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When discharged to the dispersal cell(a) in one large dose, overloading the cell(s) and may result In the herb backup or surface di w1e be effluent. To avoid this situation have the contents of the pump tank removed by a Septage Samlaing Operator prior to res oring power to the effluent pump or contact a Plumber or POWTS Malntalner to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 16 feet down elope of any mound or at grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; clgawte butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; harbloides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS falls and/or Is permanently taken out of service the following steps shall be taken to Insure that the system in properly and safely abandoned incompliance with chapter Comm 83.33, Wisconsin Administrative Code; a All piping to tanks and pits shall be disconnected and the abandoned ph* openings sealed. a The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. a After pumping, all tanks and p"ita shall be excavated and removed or their covers removed and the void space filled with sail, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS faits and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system; 0 A suitable replacement area has been evaluated and may be utilized for the location of a replacement sail absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area Is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be Installed as a last resort to replace the failed POWTS. 0 The acts has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and alte revaluation must be performed to locate a suitable replacement area. If no replacement area Is available a holding tank may be Installed as a lost resort to replace the failed POWTS. Q Mound and at-grade soil absorption systems may be reconstructed in place following removal of the blomat at the infiltrative surface. Reconstructions of such systems must comply with the rules In effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TRLgTMI;NT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS _ ~1VEKTEkZ- -M BE, W51 A-11,Eb nl D sv~rr W ~1 A is POWTS INSTALLER POWTS MAINTAINER Name AAlrrl 6 E Cdr Name EWA Phone - yA5- IoZob Phone /5 qZS-- 6 Zo ?S SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REQUUITORY AUTHORITY Name b~,~ l ~ C 5EK 111a None 57: lX GlJ/.l✓(IT Phone ,Y7t5- yzs_ jots Phone i ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the =&f A4 /V-40"h W-S residence located at: S 1/4, N 1/4, Section, Town_,_N, Range W, Town of T a , St. Croix County Wisconsin. Upon inspection, certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service S /7d Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known): Q 2 k S Age of Tank (if known): X11 Sf4 //e /9$ icensed Plumber Signature) (Print Name) f n0~6 5 *IWW (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) • Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OM = f -6 M MR Row TOWNSHIP fk'o 8EC. T 7 9 R-R q N ADOQt88 7~9 F sZ' (J ST. CROIX CODUTY, WISCONSIN 1-lkdso►~ SDSDIrISI0l1 ~ d 9 2 t. r.~LOr LOT SIZE PLAN VIEW Distamees sad dimensions to meet requirements of ILHR 83 SHOW EVERYlULNG WITHIN 100 FEET OF SYSTEM I NKCATZ NORTH AR#OW MIf7lfA1M<t Describe the vertical reference point used --Lea 6 ~ a-nl 1-7"'( 91"stlom of Vertical reference point: V ` Proposed slope at site= SWIG TA M# Nanuraeturer t ti✓4 e ~ S to quJ d Capacity: 1 -~GV Number of rings used: Tank mnnthute cover elevation: Tank inlet Elevationt-1271-;L Tank Outi-_t. W.ovstion: Number of feet from nears i. r^nd: Front, ."tL-: O Rssr, O R feet -From nenrest•ptapu. ; i.1no : Front. J.Jr, Rear, J feet 0 pr 8'~r- la go 1 6EPARTUENT REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS LABOR AND PERCOLATION TESTS BOX 7 n9 HUMAN RELATIONS (115/} P.O. BOX MADISON, WI 53707 3707 I A I 1 TO HIP ,UNICIPALITY: T NO. SLK NO.: !WBDIXISION NAME: i N v ir_ _ d in . Irl I at i4 i4 V of l'INtor r O. - 1~FD Pif COUNTY: WN R' U A E: q R fir) A ME r 01--a 1K I E I IND, a DATES OBSERVATIONS MADE i FResidence ' a v f XNew ❑Rsplace S@~~s t 6 74 S-t6S &0 RATING. S- Site suitable for syste n Um Site unn ultable for system Q l C rJ U KI'~ AtQ~~ O V ~Y MIDI J. C~Y J C~0 31 V N-FILL 0 Of JG ANK: RECpry1 VNNTIS /S(IQllnpti~nall If Percolation Tests are NOT required DESIGN RATE: under s.H63,i19S511b1, indicate: C If any portion of the tested area is in the <+e~ ' Floodolain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH T UNDWATER-INCHES NUMBER DEPTH". ELEVATION SSE V CHA AC S IL WITH NICKNESS, COLOR, TEXTURE, AND DEPTH TO BEDROCK IF OBSERVED ISEE ABBRV. ON RACK.) :1 9 ~S > 7.0 ~'&sc-rs ra &,M-5 ra'~e„Sat e gg'g~re MS -Z -2- > 9.00 %"&SCTS 31"SaAMS ra'"ea~Src,R ~rsrla<~s SS $QNMS~r432 B' 3 d - /do > $.S6 o8«TS 7',BaNS~ ra"$aroMSq''$P,r.~54GP. 7r"LrI~RN1MS B- 7.4Z 4 l~lo r > 7, 4 Z 8"91-L- 5 C 7Z''Cr$/?rv MS~E~I? B- 9.5k 99.9 o 5 9.S$ rz''>3cLTj z~'BarJCS ~~'•[T$MS B- PERCOLATION TESTS hM1MBER DEPTH WATER IN FTERSWELLING INTERVAL-MIN. D I WATER L V L-IN HE RATE MINUTES P- C~ S PER INCH P- z g.o0 a.o 3 > 2 ~ 3 P- V4T-lo PLOT PLAN: 'Show locations of percolation rests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori. tomal and vertical elevation reference points and shQkv their location On the plot plan. Show the surfaor elevation at a0 borings arid the direction and percent of land slope, A borings ELEVATION g3.oo 'rs,P F,tvr $ a:>rc>a M A2 k- Slnf CokNtR s a ~ aF $wER I~eEsTa Cowcee rir E<i r = 100.0 V I r i tn~ h \~~~R2q ZG' 4 \ Ql f ~ io ~ r~ L Lrj ~ ° N f TN hz o o SGALC 8 ' ! = 30 - z 69 •~Qa~ Lcs< ~ 1 w~c a N ~ 2 %a QEv15azp /c~ia~g - ~ktMaRy SYSTtrM '2 CNAN1.~p w~~ !O Ak:rE-jATEr 00-esa .t YJGC Vck,&. 4, 1, the undersigned, hereby certify that the soy tests reported on this form were made by me in aamr(i with the Pro edures 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 COMPLF7 ED UN' 144V-fljX JayNSa 104 J0RVaY11K, Ma 13 /98® ,ADDR S CERTIFICATION NUMBERS PH NE NUMRERIopliunall, + ! 4a7 SECONa '~-r ~caDS~ti S4G1( 34@4 ~,E, 4 E a& ,7 MCSTS AjT RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, - ` OILHR-SRO-6395 fl:. 0218") Ovt It l Wisconsin Department of Safety and Professional Services Division of Industry Services SOIL EVALUATION REPORT Page I of 2 in accordance with SPS 383, Wis. Adm. Code County ST. CROIX Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 0 - 1213 - 70 - 000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). .G Property Owner Property Location THOMAS G. & JODI A. MARKOWSKI Govt. Lot SE 1/4 N 1/4 8 T 28 N R 19 E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 445 Brick Circle 11 Red Brick Addition City State Zip Code Phone Number ity [:]Village own Nearest Road Hudson, WI 54016 71 386 7995 ( Brick Circle New Construction UseE] Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement 0 Public or commercial - Describe: Parent material sandy Flood Plain elevation if applicable NA ft_ General comments Conventional In-ground Trenches 0.7 loading rate and recommendations: t I 0 Additional boring required to verfiy soils for 3 ft. separation. ~e a Boring # 0 Boring a Pit Ground surface elev. 101.60 ft. Depth to limiting factor 120 in. L, rG --)Per- eA Soil A li ion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-9 10YR2/2 - sl 1 f-msbk mvfr cs 2vf-m 0.6 0.8 2 9-13 10YR3/3 - sil lfabk mfr cs I of-m 0.4c 0.6 3 13-23 7.5YR3/4 s&gr Osg dl cs lvf-m 0.7 1.6 4 23-38 10YR4/4 cos Os dl cs 2vf-m 0.7 1.6 5 38-102 10YR4/4 s Osg dl gw 0.7 1.6 6 102-120 10YR4/4 cos Osg dl 0.7 1.6 Xllbl ❑ Bori ng# Boring ~Zpit Ground surfa ft. Depth 44 ting actor in. oil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 - * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) CST Number -Mary Jo Hu ert Hollister's Soil Testing & Design) re 224832 Address Date Eva on Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 05- 30- 2015 715-426-1775 SBD-8330 (807/13) Mot Plan Page 2 of ; p- Property Owner T arms /~/1oc~rsK/ I"= 40ft I.egacl D 'cripizon 1vT it Rb R,~ a~rnoN,` (except where xo►tag ---`-041 4F Ttf NWI1k4, ssn. 2TZSN,R)QW i lbWAJ of: L'7 = .t aci*oe pk V;_ ST. CRa~ ~uti-~-yLV~ tsrak ~,~,y x.00 A c<&-,5 North BtDRU /A Our To be AtovD w/Sync, -A Z PROPRS~ED d/,(,0 FINER 66 ttDqD , . /f q p a~4~ -DIYERTbR ~ O Site .Location 4~ mac. 61TE - geuxc ' etECt-E PC ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~lif ~iq'/ke cJ S~/ f Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State 1164361".1 Parcel Identification Number Q f4Q /02 /3 - 7Q - 4G LEGAL DESCRIPTION Property Location SG'' 1/4 , y 1/4 , Sec. , T N R~W, Town of Subdivision Plat: n%, , Lot # . Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume Z ' Page # V77 4~AP Spec house ❑ yes ❑ no Lot lines identifiable (yes ❑ no STEM MAINTENANCE AND OWNER CERTIFICATION 1 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 pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number If bedrooms SI A F APPLIC WTS) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) c ~ ° I a O a 0. 0 ~ i 0 N C i i. c II' ~ I ° 3 N o ° a Z io c -o U. c a °c ~I 3 m Z y rn E z . o NN o lL L Z £ 'D (D (D co 00 ~ a m 0 c C7 o m o z CD Z d' ° o to F- a) z E 72 m N O N Na U o O Q z° m z :o N z ~I E CN I a c o c m'! CO W d C N O G O a . m ~hv~ a°i °v v) U) U) E ",l*\ J ,n O O O a Z •~.t ~aaa a o li N o N co 00 o fA J V_ rn rn z Z;5 Z-15 1 1 _0 ~l U o o s no v m d I m N C7) N HIV m d 4-0 io ~ o E O co O m 04 C~ u N C C CJ -0 N Oi 0 3 = v° -0 N N w i a~ m M° m ry\] (0 Q) C) Cy > co °3 ° E E ,c o • yam' o o o H co ' o z N F°- H in r l xt v ~ E d a a a a w CL *2 r 41 0 ~1 A 0CL OU-AC) • 7 Form-STC- 104 AS BUt.LT SANITARY SYSTEM rEPORT OWNSR t ill ~ lR R~ w TOWNSHIP k'o SEC. T 7 g N-R_ ADDRSIS 76 S-t ST. G1t0IX COUNTY, VISCONSIN H Asa ~ SUBDIVISION LOr I LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHW 83 SHOW EVERY )'11ING WITHIN 100 FEET OF SYSTEM 0 J a ISO INDICATE NORTH ARROW r? i SENCNM UI Describe the vertienl reference roint used tDp G; 'Refi't Elevation of vertical reference potnt: fU U _ Proposed elope at site: BBFPIC TANK: Manufacturer: 1•✓eE 1,1 ;uld Capacity: l vo Number of rings used: Tank wnhute cover elevation: l d~ , ~ZS Tank Inlet Elevation: q 7e2% Tank OuLl.- . L.l ovation: Number of feet from nearr i. r"nd: Front,w S U:^,O Rear. O .2 q feet r .From ncnrest•pro;Pc.i. i.lue : Ironc,~ ...1!Jc,0Rear,0 ~S feet f PUMP CHAMBER Manufacturer: Liquid Capacity: • pump Model: Pump/Siphon Manufacturer: pump size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, OSide, ORear,0 Ft.__,__,,,. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: c Width• Length: Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, ©'S`ide, O Rear, OTt.~ Number of feet from well: Number of feet from building: (Include distances on.plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depths _ Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft._._.__ Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Plumber on job: ~k Dated! -;L 1ti1 i~ L G ~f 1~1. License Number: 3/84tsj C 4 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: SE4,NW4,Sec. 8,T28-1.9W ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Troy ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound N MI ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Tom Markowski 709 8th S N Hudson, I 54016 `U zQS f~ 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: Joe Stan 6 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKNG 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: AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PUMP El YES [__1 NO NEAREST 00, 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. 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: 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: 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 --11111' Retain in county file for audit. Sketch System on Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) L °°-SANITARY PERMIT APPLICATION ~01LHR In accord with ILHR 83.05, Wis. Adm. Code couN . &&9 L-Ick STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / Q 2 8% X 11 inches in size. Chec 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 TOM Q/,(awsl~I S4 %a0u%,S ~ T 4,N,R J .E-or)-W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ob1 t0 s~ N ) I - CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 0 : j CITY NEAREST ROAD II. TYPE OF BUILDING: (Check one) State Owned VILLAGE 13 ~,c ~o G ❑ Public El 1 or 2 Fam. D elling-~# of bedrooms ~ PARCEL TAX NU BER( 111. BUILDING USE: (If building type is public, check all that apply) - _ j _ CU 2 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4.E] Reconnection of 5.E] Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 H 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 L-15-0 4419 t6 Cl , ~I 3 9 Feet 1 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tan Tanks structed 1 Q Q I [I _S4 F1 Septic Tank or Holdin Tank l G b ° Q S Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumb 's Signature: NO Stamps) M"MPRSW No.: Business Phone Number: Jo e- ~'t4 1/4 G `~G 66 j 6,t Plumber's Address (Street, Ci tate, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) J)[ Approved ❑ Owner Given Initial i Q O Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: f4t ' SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber a 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; welts; 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) r I 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. Ownet of property re,M Re-'-A`V. r k" Location of property L--' _I/4 N 1/4, Section , TN-R Township Mailing address A4clr6 ~0 1"'-/1"5 Address of site 5-4- ~e - Subdivision name f k 4dd Lot number Previous owner of property Q le 07 t4/4."e- s e-Total size of parcel % Date parcel was created Are all corners and lot lines identifiable? Yes No .Is this property being developed for resale (spec house)? as ti No Volume and Page Number V7 ? as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document KQ. m) a 4, A t 1 Signature -01-Owner Sl nature of Co-Owner (If Applicable) Date of Signature Dat of ignature 09 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER __I G Y►7 ~~/G h G w S ROUTE/BOX NUMBER FIRE NO. CITY/STATE 1A,T ZIP PROPERTY LOCATION: St 1/4 N V 1/4, Section , T_J?_N, R__j W, Town of t fo y , St. Croix County, Subdivision ~e )1'1(k 11 Lot No. Improper use and maintenance of your septic system could result in its p failure to handle wastes. Proper maintenance consists of pumping out t' tank every three years or sooner, if needed, by a LICENSED SEPTIC TA' What you put into the system can affect the function of the septic treatment stage in the waste disposal system. St. Croix County Residents NAY be eligible to receive a grant fo $3000 of the cost of replacement of a failing system, which we prior to July 1, 1978. St. Croix County accepted this progr 1980, with the requirement that owners of ALL NEW SYSTEMS agr systems properly maintained. The property owner agrees to submit to St. Croix County Zor form, signed by the owner and by a master plumber, restricted plumber or a licensed pumper verifying t wastewater disposal system is in proper operating cor inspection and pumping (if necessary), the septic tank sludge and scum. Certification form will be sent appro three year expiration. I/WE, the undersigned, have read the above require the private sewage disposal system in accordance v herein, as set by the Wisconsin Department of Nat form must be completed and returned to the St.Cr 30 days of the three year expiration date. SIGNET' DATF St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above add ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State f~u~S ea fit`f Parcel Identification Number 0 fO -ARE 13 " 70 4d d LEGAL DESCRIPTION Property Location.SGT 1/4 1/4 , Sec. y , T N R_ W, Town of ~rd1 Subdivision Plat: e 2 "Cr/ Jt R n"', , Lot # . Certified Survey Map # , Volume , Page # Warranty Deed # 7 (before 2007)Volume 00 ( 2 Page # 77 ' Spec house ❑ yes ❑ no Lot lines identifiable 1yes ❑ no SMAINTENANCE AND OWNER CERTIFICATION 1 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 pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number f bedrooms SI A F APPLIC T S) DATE * * *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) INDUSTI`.AENTOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR ADD PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS 1 / MADISON, WI 53707 09(1) & Chapter 145.045) LOCA _ N:~ SECTION: AA *!--re, WN HIP UNICIPALITY: OT NO.: BLK. NO.: BDI ISION NAVE: l= P R~_I for SICK 1~wTI COUNTY: OWNER' UY R' NAME: MAILING ADDRESS: ST CeUA Tnfe~ AAQ>t6L St^ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: MAJ DESCRIPTIONS: jPERCOLATIOi97_EST_S_: Residence UN~ I 4k New ❑Replace 50-,L5 6 7 Sofas ►gL)k HAkl~T' RATING: S- Site suitable for system U_= Site unsuitable for system ro-U.M.~1TIONAL: IMO p: ~U IN G S a~ E: SYSTEM 1~U L SG ANK: RECOMMENDED IVTI (okital) 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: CUq ' Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHW ELEVATION OBSERVED EST. 141 HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- :1 g .6S 7.O $~$CS~-t-S i8 $Pt,MS /6 ~~eNS~be ~{9$I~( (~I~ B- 7 4.00 ) 9.00 1"91,SCTS S')" $ie,►MS /4'BftN`3tL~~ 47~S~la~l~s ~S $eNMS~r~12 B- 3 ~6Sb !Va ~~•S6 o8uT57"$a„5~~~"'gRtfMS'Cr,~QnIS~~>~ 7/rLTYSR+vV)'1~ B- 7.4Z .O No L > 7, 4Z 8'$L~ QrAL -l2''Ci $erv MS~G)e B- ' C~. Sk 9 9.9 © 4• S ifZ''$1_L'T•S 2`7' Bterq CS 74 "&r ekt! MS B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER Ii*e*$ES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH P_ z .00 /01.0 3 > ? > > 2 < 3 P- 0 00,2' 3 > Z > Z < 3 D- 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- ~ontal and vertical elevation reference points and shoyv their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. - r Foal, SYSTEM ELEVATION g3,oo I P 8 ENCU M a~ k- 5'N C0kN£►2 1 AAa ELi r - 100.06 • ~ ~ sca L ~ Ev15~p A_ Lcsr ~ 1 ~ w~<< oN - 2 a -Z/-( ` ~etMARy SYSTLrM Cf4ANd,t~'6 i o du-EQNa-~Ir ,oatEa y,cc )A_ksp> I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the pro edures 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): J TESTS WERE COMPLFI ED ON: 1441IZ_rf=X JGHNSaN ~US~NSc~RVS~INC, _ Ma>< ~3 /9~8 ADDRESS: CERTIFICATION NUMBER' ~a7 SEco~ya ~ fJc~ash~ ~r S407C 34e~ PH~N~E~NUMBER (opt iunal) 4o84 ~Q I~7 CST SI ATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SRn-66395 W. m/n1l Ovt It ✓e ~t Taws ~'~?,{?Gw SIB J~e d 13 F~,dGR g 3 ~RA4Jr~ • ~R yr_ a ~ S~ _ s, V'' ~~~e,oc o"o G4.(4 i P fin' ~ r i i y ~ r t} V 10K, r f g•N --s v ' _ j re r- Parcel 040-1213-70-000 02i12i2007 04:37 PM PAGE 1 OF 1 Alt. Parcel M 08.28.19.1023 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - MARKOWSKI, THOMAS G & JODI A THOMAS G & JODI A MARKOWSKI 445 BRICK CIR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 445 BRICK CIR SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.010 Plat: 2365-RED BRICK ADDITION SEC 8 T28N R1 9W LOT 11 RED BRICK Block/Condo Bldg: LOT 11 ADDITION Tract(s): (Sec-Twn-Rng 401/4 1601/4) 08-28N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 812/477 2007 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/22/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.010 50,800 270,200 321,000 NO Totals for 2007: General Property 2.010 50,800 270,200 321,000 Woodland 0.000 0 0 Totals for 2006: General Property 2.010 50,800 270,200 321,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 112 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00