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Parcel #: 020-1144-00-000 12/06/2005 09:28 AM
PAGE 1 OF 1
` Alt.Parcel M 17.29.19.749 020-TOWN OF HUDSON
Current X ST.CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner
O-RAMSAY, MICHAEL R L&MOLLY
E
I�
MICHAEL R L&MOLLY E RAMSAY
459 MCCUTCHEON LA
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description '459 MCCUTCHEON LN
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.110 Plat: 2276-PARK VIEW ESTATES 2ND ADD
SEC 17 T29N R19W PARK VIEW ESTATES 2ND Block/Condo Bldg: LOT 56
ADD LOT 56
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 1170/396 WD
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.110 69,700 197,200 266,900 NO 05
Totals for 2005:
General Property 2.110 69,700 197,200 266,900
Woodland 0.000 0 0
Totals for 2004:
General Property 2.110 36,600 179,600 216,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 113
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP l j r SEC. T N-R_Z
ADDRESS (� ��� ST. CROIX COUNTY, WISCONSIN
SUBDIVISION C 111G OT 1�C LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Oft
�.
xv
'988 \y v
,?a 1v'
new /cr
// L?ey101�yG"� �jaGQi° Oc`
y
Et-
ARROINDICATE NORTH W
Lc T �E' u� �'��rErn
StzGt 7/��iv OW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: C/���� Liquid Capacity: �4d
Number of rings used: 7 / Tank manhole cover elevation:
CTank Inlet Elevation:�5`/ Tank Outlet Elevation: 3•z Y
U �
umber of feet from nearest Road: Front 10 Side,O Rear, O feet
- From nearest- property line . ' Front,OSide,ORear,O feet
Number of feet from: well -;- 57-0 , building: -, 25 �
C (Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
. or
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, O Side, O Rear,0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: 4 Length: /3rZ Number of Lines:_1_ Area Built: elSS—
Fill depth to top of pipe: 410
Number of feet from nearest property line: Front, O Side, O Rear, Pt . y° ,
Number of feet from well:
Number of feet from building: ,? 8
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: 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•
Dated: Plumber on job:
License Number: 1d 9
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUNIAIV RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
SGl%,N0%,S1 7,T29N-R19W KXCONVENTIONAL ❑ALTERNATIVE SltatePlanI.D.Number. ^�assignedi
Town a{ Hud�san ❑Holding Tank F-1 In-Ground Pressure El mound
Lai 56 PanfzView EZtazU
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE'.
GoAq Paut6an 459 McCcrtch.ean Lane, HudSan, W1 54016 Q- S-
BENCH MARK(Permanent reference p-11 DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF.PT,ELEV.
Name of Plumber. MP/MPH SW No.. Coumy Sanitary Permit Number:
David B- Pa end 32 89 St. C uix 112 833
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV.: IWARNINGLABEL
6111 LOCKING COVER
J�'� / P O�V°ED: PROVIDED
��• / �� DYES : NO OYES NO
BEDDING VENT DIA. VENT MAT L.. HIGH WATER NUMBER OF ROAD: / PROPERTY WELL. BUILDING. VENT TO FRESH
CI C ALARM FEET FROM — ` LINE: AIR INLET
DYES ONO / ❑YES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER BE DOING LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO EYES E NO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL JBUILDING JVENTTOFRESH
(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 LENGTH JOIAMITER MATERIAL AND MARKING
or excavation. (if soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH INO OF DISTH.PIPE SPACING COVER INSIDE UTA 'PITS LIQUID
BED/TRENCH THE Es MA AL PIT DEPTH
DIMENSIONS J
GRAVEL DEPTH FILL DEPTH DISTH PIP' DISTH PIPF. DISTR.PIPE MATERIAL. NO TR NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES f� ABOVE OVER ELFV INLF 1 ELEV END �� PIP FEET FROM LINE: AIR INLET.
2 NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES NO
SOIL COVER TEXTURE PERMANENT MAHKEHS OBSERVATION WELLS
1:1 YES 1:1 NO 1:1 YES ONO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BE) DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
DYES ONO ❑YES ❑NO OYES 1 N
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LEN(iTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTH DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEV ELFV DIA ELEV, PIPES DIA:
ELEVATION AND
DISTRIBUTION HOLE SIZE HOLE SPACING DRILL E D CORRECTLY COVERMAT
INFORMATION ERIAL VERTICAL LIF T CORRESPONDS TO APPROVED
PLANS
❑YES ONO ❑YES NO
COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS: NUMBER OF PROPERTY WELL'. BUILDING.
FEET FROM LINE:
1-1 YES 1:1 NO El YES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE.
Zoning Admt.ni6tAatan
DILHR SBD 6710 (R.01/82)
SANITARY PERMIT APPLICATION COUN Y
DILHR In accord with ILHR 83.05,Wis.Adm.Code ck
SANITARY PERMIT#
8x3.3
-Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION r�
1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE 1:1 YES Lxl NO
PROPERTY OWNER PROPERTY LOCATION
Cej '/4 '/4, S 7 T , N, R E (or
OPER OWNE S MAILING ADDRESS LOT NUMBER BLOCK NUMBER DIV ION NAME
n
CITY STA E ZIP CODE PHONE NUMBER 77 CITY NEAREST ROAD,LAK OR LANDM RK
D ILLAGE: f
zw= OR
II. TYPE OF BUILDING OR USE SERVED: a(�- - d O- 11W-e0-to 10
Number of Bedrooms if 1 or 2 Family. OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. dew b.L Replacement c. El Replacement of d. El Reconnection of e.El Repair of an
1. a. 01�
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The Y 9 Ownership stem is shared b more than one owner/building.. Attach Common Ownershi Agreement to County Copy.
Y
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a. 216onventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION; (Check one)
1. a. El Seepage Bed b. Seepage Trench c. ❑See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
Q ,Z, 0 Feet C Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank D e t-t 0 Lift Pump Tank/Siphon Chamber ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
PI tuber's Name(Print): ��� Pjer5ginature:(No Stamps) MPRSW No.: Business Phone Number:
-� $- 7Y
Pl dr ( reet, Na ur s
VIII. 901L TEST INFIORMATION
Certified Soil Tester(CST)Name CST#
'7 G
CST's ADDRESS(Stye ,City,State,Zip Code) Phone Number:
2 &/
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial ��1 Surcharge Fee /
Adverse Determination �`' 00 O�� /U RGOPV, jh
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
I
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMJT
APPLICATION '
TO THE APPLICANT:
1. This 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. ATl7evisions to this permit must.be,approved.py the permit issuing authority. A new permit may be needed
if tTiere is a change in your•building'plans, system location, estimated wastewater flow (number of bed- -
rooms, etc:), depth of system, or-type of system;
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. Private $evvege-systems.must�e properly maintained: The-septic-tankt s) should•ba$_Umped by a ljcensed tt`
purnp.er whenever necessary, usually every 2 to Tyears;
6. If you have questions concerning your private sewage system, contactyour local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide: the legal description where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for a//septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 81/2 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; dosing or pumping chambers; 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. -
GROUNDWATER SURCHARGE
On May 4, 1984; 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection lain(. This change in statutes was the
result of over 2 years of steady negotiation and public delaabb The.•groundwater bill Ground at�f
included the creation of surcharges (fees) for a number of regulated practices which Wfsco irt'S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried f'E.'asure.'
is used in your building is returned to kh�groundwater through your soil absorption o
system or the disposal site used by you olding tank pumper.
o
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- " t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
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 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 ,��/�
Location of property __7�/ 1/4, Section �, T�N-R��W
4 Township /`emu/)_YQA1
Mailing address ,5 ic �ieT��FotJ .�/f�rt/E.
Address of site
v
Subdivision name ,/�i�.e.� ��i,E�y /�S'TJ¢7-�S _�Ec�o.✓� e�-/o�/
Lot number
Previous owner of property '1%¢xp!
i
Total size of parcel
IDate parcel was created
Are all corners and lot lines identifiable? _Yes No
IIs this property being developed for resale (spec house)? Yes No
Volume 59 and Page Number to 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
Ithis information form, by virtue of a warranty deed recorded in the Office of
- - the County Register of Deeds as Document No. It. 33 and that I (We)
r presently own the proposed site for the sewage disposal system (or I (we) have
I 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
{- Hof the oun A Deeds, as Document No W"'f ) .
Signatur of Owner Signatu of Co-Owner (If Applicable)
ZZ lqo '60 ,
dek 17, 19, C-V
Date of Signature Date of Sig ature'
I
w?
s '
4 5 '
OAT
TK
�, � .•dry '4A
..
* �r
wA }F + K
�'r �'� !�' � C��'~ ♦�. 'may .•�
V
d -. e
yi3
vy a+
�y p Tk ,
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ll&jCord
ROUTE/BOX NUMBER 7GAC, LQ/?L FIRE N0.
CITY/STATE &dson �0*7,y/,.*7 ZIP
PROPERTY LOCATION: /4, Section 7 -, Tj2f_N, R�[�W,
Town of 404�Sa� / [ , St. Croix County,
Subdivision Ark U11LW S74TCS , Lot No. S-L—.
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.Croix County Zoning Office within
30 days of the three year expiration date.
SIGNED
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DEPARTMEN i OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
INDUSTRY. _ _ —
PERCO TESTS 115 P.O. BOX 7969
i_AR(1F. -^-''D ( ) MADISON,WI 53707
(ILHR 83.09(17& Chapter 145)
T01tiN HIP' UNICIPALITY -- LOT NO BLK NO SUBDIVISION NAME:
sw 1/a N_E►/ai ,�, /T �=�N/R I�'E I — — �v�so�, S 6�-- �_
"LINTY OWNEP' YER'S NAME: MAILING ADDRESS: L(Scj MC C-,) e� LI�yUF
DATES OBSERVATIONS MADE
USE
PROFILE DESCRIPTIONS: R LATIONTESTS:
i -- — NO.BEDRMS.7Q S
ERCIAL DESCRIPTION: (� zr
—� ]N ev Replace Q),B� 83 7-ZGAU J/-
Re,"jence 3 /�
RATING: S=Site suitable for system U=Site unsuitable for system ——_--
+:;ONVENTM AL: MOUND: IN-GROUND PRESSURr�jTn_T ILLDING TANK:RECOMMENDED SYSTEM:(optional)
I k�,S u ®s auT �s au u ❑s ®u
-- DES IGN RATE: If any portion of the tested area is in the
(I1 Percolation Tests are NOT required Gl�f�S 2 N a
n oer s ILHR 8309(5)(b),indicate: - Floodplain, indicate Floodplain elevation:
_--__-
c��g ) - PROFILE DESCRIPTIONS F OBSERVED (SEE ABBRV.ON BACK
H rW. OBSERVED EST.HIGHEST TO BEDROCK _ EXTURE. AND DEPTh
GORING TOTAL D PATH TO GROUNDWATER IN'f3M£�S CHARACTER OF SOIL WITH THICKNESS, COLOR T
�Z
ELEVATION - -—�
NUMBER DEPT ,_'v Ott B►1 S) ►S O.8'ens) cl.Vl3n L;
Is- 1 q� V 4 6_p' KN6k1� 7 9. Z'
C51 ott$hSITs ; o-vans l ; 7.g•r3n /xQ S 8 6� —1
B- 2 14•y ` 46 , S ' Yvo>ti� > 9. y'
-- r C'.t ' nkBh S TS ; 09 '8nS1 g. l ' V-,-,r) Px CS
E -- I!S. S •_Z,tZBh ISTS ; 1.6'Qh \S j •3r �>7S ;3•a �hh7•�` S
Z IG Om L 'rS f 2— 7, 1�Y1 S 1 V. S /t�r)) L d- D k S
i
B g Lj �. ? ' l-.:,o>U ?'Y ' 14•n' Bn ,K a i s -- - — — — —
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD 2 P R PER INCH
3/ 3/
P. 1 S O 1v 3 a� 6
P_ Z S N /j
. 3 Z 8 Z 96.6,
P- 3L S Iv• A . 3 3 3
1
P V = L C OL Z CCU Chi \S U� t S _.
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 'aEwe%a BI,BZ,B3 — q 0 r t'�-,S8 `�uZ1L1`}'ARDT S
SYSTEM ELEVATION
1 wee i_
? 8►t1 rtZ- t
--- _ �>`�1 T• I tiav SC - - - ._ e�tlj Z, l.1\!JA Iry 6_
_. SIsoTC tah�z St'j� LACIY`7L'� lD0♦ S, 9
S-Z S'*Lv,of 'TT'E tvp 'dbtAJft
? ` __ _, _ K l S1�N o f'T14 @ Sa.o V-N E��e)D
y r�f'r
lip oil
)tl
ti c. ILt"EDN
! "'• .Z Pte- v f^ z !�2c'` r I A.
' B Flo
cR�HILL u1c,c,
J 'IP L
y F,L� Ito t -w j o - r
' Sw ''
°r
M-t+.►rJ`S'�►►V -moo' _ __ _
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S IAiaES �jc C�L�)wG Z o°jo 'rC 5� S^�E I r,_ S Q J 1t� ll
the lers, ned hereby certify that the soil tests reported'on this form were made by one in accord with the procedures and methods specified in the Wisconsin
a;imu Stwe Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief
- --- ----- jTESTS WERE COMPETED ON:
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�T CEH I IFICAT10N NUBER. PHONE NUMBLRI.
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t ��swo�zL,. wt Syo�J 5�6 its-alts- o�6Y
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DISTRIBUTit)N Or :i 16' w d one copy to Local Authority,Pioperty Owner nd So: re"er
UI 1�4-_61_:-6395 iR 10/83) -OVER-
• � � . ILT SANITARY SYSTEM REPORT
41 Al l ( I � 0 r , TOWNSHIP I 1j u¢1 S��, SEC. T.2-IN$ R Ll
.0. ADDRESS , ST. CROIX COUNTY, WISCONSIN.
;,r S u 11
'BDIVISION r o � c./ LOT C LOT SIZE
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
�fit ' • •
G u5P
Grip • .
:'TIC TANKS) IMFGR. ��l ^ � !''' CONCRE E " STEEL
N0. of rings on cover Depth �� _ DRY WELL
INCHES NO. of width length area
no. of lines 2- width length= area
depth to top of pipe
3REGATE
a RATE , AREA REQUIRED ( 5� AREA AS BUILT i , Z
:claimer: The inspection of this system by St. Croix County does not imply complete %
pliance with State Administrative Codes. There are other areas that it is not possible/
inspect at this point of construction. St. Croix County assumes no liability for
Item operation. However, if failure is noted the County will make every effort to
`ermine cause of failure.
BASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
I LI
`'INSPECTOR ,,}
DATED / PLUMBER ON JOB
LICENSE NUMBER
REPORT Or ITISPECTI01I--114DIVIDUAL SM•IAGE DISPOSAI, SYSTE11
Sanitary Permit
• • r State Septic n n -
.,A IE TOZ•JIISHIP
t. Croi;; County
SEPTIC TA'1I: /� /
Size gallons . ,umber of Compartments -
Distance Front: Well !.�..__.ft, 12% or greater slope --f1.
Building ' ft. Wetlands f:
11ighwater �ft.
DISYASAL SYST -11 Nile Field or Seepage Pit(s)
Distance From: Well ft. 12% .or greater slope —ft
Building; ft. Wetlands f z
FIELD 1-Up iwater ft. ,
Total length of lines ft. Number of lines r� Length of
each line ft. Distance between lines 40' ft. Width of the
trench / ft. Total absorption area ��• sq. ft. Depth
10ver.f rock below tile �in. Dp-pth of rock over tile min.. Cover
Irock. Depth of tile below grade 4n. Slope of
e trench -in Ter FOO ft. Depth to Bedrock ft. Depth to
g.,round water �,.•_£t.
PITS
Number of pits utside diameter ft. Depth below inlet
ft. Grav rid pit : _-__yes no. .Total absorption area
sq. ft. -
Square feet of seepage trench bottom area required
Oquare feet o see age i area required
,� c'
Inspected b Title:. -
Approved - Date G 197 .
Rejected Date 197
115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICE'.
DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEA k�1`�,
. . t P.O. BOX 309 Q CGS . ao
MADISON,WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TES11, _' @ ��e`,6
'°LOCATION: C'/a,Section 17—,T2JN, R"E (or) W,Township or Municipality
Lot No.,Z6 Block No. �r County
�� �
Subdivision Name �� ;�-,-:, ;`•��9
Owner's Name:
Mailing Address: —�-t �. 42 &1
TYPE OF OCCUPANCY: Residence No.of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW —ADDITION
DATES OBSERVATIONS MADE: SOIL BORINGS 3 — 77 P RCOLATION TESTS
SOIL MAP SHEET S9 SOIL TYPE 0 h,* Z_' '.'''�"
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
SINCE HOLE HOLE AFTER INTERVAL
NUM- INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
BER
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF (OBSERVED)
11
B ;1 7 :Z ' 7 7 2 ) b w
, . 7 44
2 72L
B
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PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square fget ofsuitable areas. Indicate number square feet of abso area
needed for building type and occupancy. L, n� scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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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 location of test holes are correct
to the best of my knowledge and belief. � )
Name (print) G A e't"z=1—w/�'- Certification No. 0
Address—
Name of installer if known
CST Signature
COPY A—LOCAL AUTHORITY
Plb 67 State and County State Permit #
"r Permit Application County Pe rrpity#�T
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OFPROPERTY Mailing Address:
/ /
B. LOCATION: = '/4 ../4, Section T,2-IN, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
19,r Township s a
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family —L�� Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste GrinderL,4-ES NO # of Bathrooms
Automatic Washer ,5 YES NO Other (specify)
E. SEPTIC TANK CAPACITY f lib i; Total gallons No. of tanks
*Holding tank capacity' / Total gallons No. of tanks /
New Installation V Addition Replacement_ Prefab Concrete l/
*Poured in Place Steel Other (specify)
F. EFFLUEN , DISPOSAL SYSTEM: Percolation Rate 1) , 2)i�3) , y Total Absorb Area sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet i h Tile Depth No. oTrenches
Seepage Bed: Length_A 1 idth Depth= Tile Depth 2 No. of Lines d
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land 2 7" Distance from critical slope z 7
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, an that 1 ave sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester l(CA 14
NAME " C.S.T. and other, information
obtained from -Z 41 e N (owner/builder 2
Plumber's Signature MP/MPRSW# !� � y-1 3 Z Phone #2f7— 3 1
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space B to OR DEPARTMENT USE ONLY
Date of Application 3 Fees Paid: State /C O C unt Date
Permit Issued/R.Airied (date) /,j/J j Issuing Agent Name
Inspection Yes 4---No Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 3/1/75