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020-1183-80-000
o ° a�3i o CD a 0 O � I d °o 0. ° w g e ca ov L CD a)-C ry m c v a� E m c -0 2 m n a> 0 D O a) V E c 3$ (D 7 N E C 02-0 U - CD a3 >.E 3-0 E w c o v C C y C C i O m E m O E N d• aa00a)O p a) An = z° a� = z m C yM m m L y LL O O Y LL 0 cc o N c 3 m•€ 3 E °C> d O C O w� ° m L) a Q v°i!i�5w�w c I > Z y Z E rn w E U) = p = O O O` Z `m m ° Nw am am N I— Z �Opp g O Z C U C V =O O W O d 'z a 4' Z 4' v Z U) I- ! c E E M v Cl) a� c m ° m ° a a� c LD (D a� •N �' U) r °_ m t ° N a a O in z° mz OQ zmz 0 N Z _m m •• d � N d N _ (D y > 4f }}yy \l M C d O CL m O O p N a 1 o E rn IL n F Lo 000 000 - Z • a a a *Iva _ a a a �, l CL co ao 3 O N O ro O ° co 00 N U) V ur rn Z N = o o 4) d U o o m D ° Q 0 ° m rn ° a� I N 'O QI Z fn fa 'y •O d Q >- N cc J f7 N C /y) I q- O O E O 2 C Lo rn d m � O C a) C C qOj d N C C V d 00 C C N \ y a0 H O v, € m of ° m v v c w ° cc :; ° E r N O CN O O 0 0 0 0 U N O y 0 0 m • O N 2 m O Z 'n Z Z CA m 0 Z Z F- O E Cd E m E a CL CL y� • eo a d .� m c m m c tt`I�v c :°. 0 3 `.3 o L I� J ,r►' # ply — Form - S T C - 104 ,� AS BUILT SANITARY SYSTEM REPORT OWNER YG� �-�1 TOWNSHIP / '522 SEC. _-,-V T -#@O-N-R W ADDRESS A ,15,,,, ) ST. CROIX COUNTY, WISCONSIN SUBDIVISION dode /T LOT / LOT SIZE 2 V- a(,.res PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 I W j i 1q' L13 y� ! � /Ud r p G INDICATE NORTH ARROW i BENCHMARK: Describe the vertical reference point used Sim e '61s, Tl✓ 1"S- Elevation of vertical reference point: 1��• Proposed slope at site: -i SEPTIC TANK: Manufacturer: 1)440& Liquid Capacity: zow? Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Sideo Rear, O feet From nearest- property line Front 10 Side,O Rear,O feet Number of feet from: well �'7 building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER y Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: I 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: ,X Trench: Width: j Len the 3 Number of Lines: Area Built: 4L/'-5- Fill depth to top of pipe: �� yam?'' Number of feet from nearest property line: Front, Side, O Rear Pt . o2 Number of feet from well: 6-0 Number of feet from building: �7 (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, Q Ft. 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: 3/84:mj t DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR ° SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION PI,O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 T T CONVENTIONAL ❑ALTERNATIVE IS,,,,Plan LD.Number NE�,SE�,S28,729N-R19U1 XQ (if assigned) Town ob Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 18 Pine Gnove Hei his 1.6t NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: 12 -S- 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: Witham Schumaketr 6382 St. Cnoix 1112684 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LAS L LOCKING COVER P OVIDED. PROVIDED. Ln-0 l(Ja •� �0�• o� YES ONO OYES NO BEDDING. VENT DIA VENT MAT L. 1"EIYES NUMBER OF ROAD PROPERTY WELL. BUILDING. (VENT TO FRESH ,�( (�. /^ ALARM. FEET FROM 7.S—( L��Q AIR ITT❑YES NO l 1. NO NEAREST / / DOSING CHAMBER: MANUFACTURER 7ING'. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ES ONO A ❑YES FIND ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CON.T S P ATIO AL. NUMBER OF PR OPER TV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YE ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER 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. NO.OF DISTR.PIPE SPACING COVER INSIDE DIA -PITS JLIOUIII BED/TRENCH TRENCHES MA RIAL' PIT DEPTH DIMENSIONS (7 �( GRAVEL DEPTH FILL DEPTH �ISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL OTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FHESH BELOW PIPES ABOV COVER. LEV.INLET ELEV ENO�j rn� PIPES LINE AIRRIII T1 EET FROM r 0%O( �Jf)r7� oc �25 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 ITEXTURE PERMANENT MARKERS OBSERVATION WE ITS OYES ED NO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL iSODDED SEEDED MULCHED CENTER EDGES. DYES 1:1 NO DYES ONO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE M NO OISTH DISTR.PIPE DISTHIBUTION PIPE MATERIAL&MAHKING ELEV.. ELEV.. DIA. ELEV. PIPES DIAELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY OVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE C1 cal ❑YES ❑NO ❑YES ❑NO NEAREST 4Z O e �O / OAS \ J yJ 7 Sketch System on Retain in county file for audit. Reverse Side. — SIGNATU TITLE DILHRSBD6710(R.01/82) Zoning Adminiztiraton � SANITARY PERMIT APPLICATION COUN' Y DILL-IR In accord with ILHR 83.05,Wis.Adm.Code I S STATE SANITARY PERMIT## —4ttach complete plans(to the county copy only) or the system,on paper not less than / y) Y P P STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. �j 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FORT VIARIANCE ❑YES L�4 NO PROPERTY OWNER PROPERTY LOCATION '/4 S/G '/4, S Q' Tat , N, R E (o PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME t CITY,STATE ZIP CODE PHONE NUMBER CITY WEAAEST ROAD,LAKE OR LANDMARK it S Ll�. Jt^yGv��G, ❑ VILLAGE: II. TYPE OF BUILDING OR USE SERVED: 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. Z�New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System J/ Existing System 2. A Sanitary Permit was previously issued. Permit## 1 01006 �1� Date Issued ^ 13 "R& 3. An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2) 1. a. Conventional 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. MSee a e Bed b. ❑Seepage Trench c. ❑Seepacie 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): l S f 64• Feet X.Brivate ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank x— D ❑ 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. Plumber's Name(Print): Plumber's Signature:(No Stamps) /MPRSW No.: Business Phone Number: Zj i ff'a cti a*--,kw 2 / 21 Plumber's Address(Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## CT's ADDR (St et,City,State,Zip Code) Phone Number: ja IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee Groundwater ate Issuing Agent Signature(No Stam s) is Approved ❑ Owner Given Initial ' u char e Fee pp. Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: q SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION f 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. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there 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 sewage systems must be properly maintained. The septic tank(s) should be, pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your 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 all 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 8'/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 law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground included the creation of surcharges (fees) for a number of regulated practices which Wisco il�`S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried rea sur8 is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. a 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) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, C DIVISION BOX 796 'LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 9 HUMAN RELATIONS (H63.090)& Chapter 145.045) MATION. SECTION:T y p TO NSHt UNICIPALITY: OT NO.: LK.NO.: Sf BDIVISION NA/ E: i� �/ �/ 1rg N�RO E (or J��S(i /g 1-iNEbI�p1tl !`r C.-M S� COUNTY: WNER'S UY R'S NAME: MAILING ADDRESS: MA&4C- 12(, Z d <-,T SOry �1 USE DATES OBSERVATIONS MADE NOS COMMERCIAL RIO I TS: /q(Replace a4 g f �� AfelC T RATING:8--Site suitable for system U=Site unsuitable for system 7� r ONV—EN oM zV ❑� IN S �U WS []I C7 s .RECO�OMN VL wrIb M�(olpttona`rl) If Percolation Tests are NOT re wired DESIGN RATE: q I If any portion of the tested area is in the '/� under s.1163.0915)(b),indicate: L JA Jam, Floodplain, indicate Floodplain elevation: 'wV A 'lju v ,-. PROFILE DESCRIPTIONS BORING TOTAL P H T R UN ATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER EP'TFi ELEVATION ____OBSERVED EST. TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) A� g"$CLTS 9"$QNSL ' oO'&N MS Z7" gQNcs ?C." 9Q"M5 � rJ�. B- 2- 1167 /6z-4-(- c< y//6 7 3c,'8_r L. B- 3 111.4Z f c W MoT A°o) tT 3-'N,C c S ro"8c LYS 14'Be�,SL. 31-tr 4,v M-'FS 2% A tt,r R btrr B- ` /b 7S 04 •9�1 >�� 7 S b 15 LTIRRN M -FS 3c" 16#"CSVCI>Q o% .-7 S owl t !::T L �TS S^i&RN SL Se9�CTIgRu� 12��$R�v CS-44* B- PERCOLATION TESTS T DD��RR��H WATER IN HOLE TEST TIME D W V -1 S RAT MINUTES NUMBER lS AFTERS ELLING INTERVAL-MIN. PEA10D I PERIOD 2 PER INCH P- ( 1.9S 1> ? �'? < P- z Flo /4S 1 P- /oS L t3 P r P=---- A PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or dist ces. Describe what are the hors zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all bo.ngs and the direction and percent of land slope. SYSTEM ELEVATION /00.7 s Gal P f ALYLQNA rE, S,TF._,.. 91 29' La. �9 �VAC.AAj TN ( �acr l x'40' Cz' DoT ) 1 _ y i ---_. $Ew_HmAk - NW cak ok NsIP Qac A41, C C t Pc.LI5 644-r -roil of 9k) cav: /00.06 I,the undersigned, hereby certify that the soil tests reported on this form were m e by me in accord with the procedurgs and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are corre to the best of my knowledge and belief. NAME(print)` TESTS WERE COMPLETED ON: 44r? ay ol�N �^a Al f�UK,<E1 ,���'���/N� //V t. h.�k1( 19f�8 ADDRESS: CERTIFICATION NUMBER: P ONE NI/MBER(oplional): A f�� ..���/ t X401 � CST SI ATURE: DISTRIBUTION: Otillur:d and one copy to Local Authority,P,operty Owner and Soil 7estei, DILHR-SBD-6395 (R.02182) -OVER -- , I � I ` Q � �J y3 , a , -5 3 5` <r 4� re d 00, a �r x t DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS ,LABOR 8i HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 ' BUREAU OF PLUMBING MADISON,WI 63707 29 CONVENTIONAL 29CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number. Town of Hudson ED Holding Tank ❑ In-Ground Pressure El Mound (It eeslpned) Lot 18 Pinegrove Heights 1st Addition NAME OF PERMIT HOLDER! ADDRESS OF PERMIT HOLDER INSPECTION DATE: Daniel L. Bracht 126 2nd Street, Hudson, WI 54016 Nki BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PTIEV. Name of Plumber: MP/MPRSW No County. nary Permit Numbe L Gordon A. Sromberg 5861 St. Croix 106061 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. W COVER PROVIDEDDED DYES ❑NO DYES ONO BEDDING: VENT DIA.: VENT MATT HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING: (VENT TO FRESH ALARM FEET FROM LINE. AIR INLET. OYES ONO I I [:]YES ONO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING'. LIQUID CAPACITY PUMP MODEL JIUMP,SIPHON MANUI ACTIIHEH WARN ING LABEL LOCKING COVER PROVIDED. PROVIDED. ❑YES ❑NO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF <PHOPERTV WELL JBUILDING V (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ONO NEAREST' SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing Nt,TI+ UInME TEH IMATI HIAL AND MARKING, or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) I MAIN CONVENTIONAL SYSTEM: _ WIDTH. LENGTH NO.OF UIS TR PIPE SPACINI, COVER INSIDE CIA -PITS LIQUID BED/TRENCH THE NCHES MATEHIAL'. PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH IDIIS I HPIPE DISTH PIPE DISTR.PIPE MATERIAL NO DISTH NUMBER OF FROPERTV WELL. BUILDING: VENT TO FRESH BE LOW PIPES ABOVE COVER E EV INLEI ELEV.END PIPES FEET FROM .LINE AIR INLET. NEAREST----1► 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. DYES NO SOIL COVER ITEXTURE PEHMnNENtMnHKE[IS OBSERVATIQNwELLs _ ❑YES ❑NO OYES_ ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH RE1I DEPTH OF TOPSOIL SODDED 1611 DEC MULCHED CENTER EDGES ❑YES, 1:1 NO ❑YES ONO [—]YES E1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO.OF LATERAL SPACING IGHAVELOEPTHHELOVVPIPf- FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES "DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE JMANIIOLDMATEHIAL DISTR PIPE DISTHIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV. CIA ELEV. ['70—DISTH IPES DIA ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING; CHILLED cnHHEC7 L Y COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS OYES 0 N ❑YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF LINE O ERTY WELL. BUILDING: FEET FR DYES El NO OYES ❑NO NEARESTOM Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE'. DILHR SBD 6710 (R.01/82) Zoning Administrator SANITARY PERMIT APPLICATION °O� C Dl�C =0q1L In accord with ILHR 83.05,Wis.Adm. Code STATE SANITARY PERMIT# /oho —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 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES X NO PROPERTY OWNER PROPERTY LOCATION Itt;l=C. C T DC%SC %, S 1() Tc1 , N, R 17 E(or) PRO�PERTYO�W1N,E�R'S MAILING LOT NUMBER BLOCK NUMBER SUBDIVISION`e N1ME rsr A CI''Y,STATE e3 ZIP CODE PHONE NUMBER CITY NEARE ROAD,LAKE R LANDMARKI i� W Sg0i S` 'bSL VILLAGE: DOaWi II. TYPE OF BUILDING OR USE SERVED:, Number of Bedrooms if 1 or 2 Family -3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. � New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an 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 System is shared by more than one owner/building. Attach Common Ownership Agreement to County-Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. ®Conventional 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. Dd 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): PROPOS�ED(Square Feet): 3 (a )�j L 1� 0 �. Feet [9 Private El joint ❑ Public VI. TANK CAPACITY Site in gallons 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 an OO I L r - I; ❑ 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. Plumber's Name(Print): P tier's Signature: No Stamps) P PRSW No.: Business Phone Number: 2 i.5' X66-866 Y Plumber's Address(Street,City,State,Zio Code): V Name of Designer: F+ 0, l eg Vlll. SOIL TEST INFORMATION Cert'fied Soil Tester(CST)Name CST# I A-t2U _ o ti+St;n1 -3v� CST's ADDRESS(Street,City,State,Zip Code) Phone Number: o-) a"—°' �Dsd� (�° S 16 386 �!o 0 IX. COUNTY/DEPARTMENT USE ONLY �( ❑ Disapproved SUitary Permit Fee Groundwater ate Issui Agent Signature(No Stam ) 5 Approved ❑ Owner Given Initial S ch�arlge Fee Adverse Determination 2U X. COMM TS/REASONS FOR DISAPPROVAL: �� SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT, APPLICATION y 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. All revisions to this permit must be approved by the hermit issuing authority. A new permit may be needed if there 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 sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your 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: 1. 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; 111. 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 all 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 8',6 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 law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground 9da included the creation of surcharges (fees) for a number of regulated practices which Wiscor in* a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasutw is used in your building is returned to the groundwater through your soil absorption :, o system or the disposal site used by your holding tank pumper. ! a 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) APPLICATION FOR SANITARY PERMIT STC - 100 This application fora► is to be completed in full and signed by the owner(s) of the. pruput•ty being developed. Any ie►adequacies will only result in delays of the permit isstua►tce. Should this development be intended for resale by owner/contractgr, ("spec house") , .then a second form should be retained and completed when the property is 5uld and submitted to this office with the appropriate deed recording., owner of Property Lucat Lou of Property li))- It _2)E- k, Section Q y . T N - Ro7o-J W Tuwuship M.►11 Lng Address Subdivision Name 7 Lot Number Previous Owner of Property Tucal Size of Parcel 1. •L Z- OL�_,_,7 ' DJLU Parcel was Created 0 Are all corners and lot lines ident liable? Ll Yes No lb tl►lb property being developed for resale (spec house) 7 you No Vulutuu and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 1. Land ,Contract . 3. Other recordings filed with the Register of Deeds Office !t► addition, a certified survey, if available, would be helpful so as to avoid delays ,I cite reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Nap shall also be required. ` I - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - i PROPERTY OWNER CERTIFICATION 1 (Wc,) ceAti6y that aU e.tatemente on tUA 604m ane true to .the beat o6 my (uuA) It►uuwtvAge; th.a.t 1 (we) am (ace) the owneA(a) o6 .the oapenty debCAi.bed in tU16 016u.,unati.un 6aun, by viAtue o6 a wannan.ty deed Aeeonded in the 066ice o6 .the Cuu►ity Reg-i.a•teA o6 Deeds as Document No. 1135 g 3 and that I (we) p4e,6e►l.txy own .the.p upoded d.c.te bon .the sewage PO-6 bya,tem tun I (we) lows ubtained an eabemen.t, to Au.n with the above des cA i.bed pa.upeA ty, bon ,tile cu►vstnuctiun o6 eai.d 6y.6ten, and .the same has been duty keco4ded in the 066.ice u6 .tile County Regie•ten 06 Deed6, as Document No. ) . ci,� � zsaie— — SIGNATURE OF OWNER SIGNATURE OF CU-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNI:U L_ ..DOCUMENT NO. ST -E BAR OF WISCONSIN FORM 2-1982 "S SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 4350583 !Vol SOGWA REGISTE R'S OFFICE RICHARD 0. STOUT JANET P. STOUT and ST. CROIX CO., WI MAUD H. STOUT Recd for Record MAR 28 1988 conveys and warrants to A d/b/a of 8:45 A M BRACHT CONSTRUCTION CU Register of Deeds RETURN TO Richard 0. Stout Route 2 Box 340 the following described real estate in St. Croix County, Hudson W i . 54016 State of Wisconsin: Lot 1 , Pinegrove Heights First Addition in Tax Parcel No: the Town of Hudson located in the Northeast Quarter of the Southeast Quarter of Section 20, Township 29 North, Range 19 West. r a3 This is not homestead property. (is) (is not) Exception to Warranties: Dated this 24th day of March ' 1988 (SEAL) (SEAL) Richard 0. Stout Janet P. Stout LY (SEAL) • Maud H. Stout by Richard 0. Stout, Power of Atty. AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. St. Croix County. authenticated this day of , 19 Personally came before me this 24th day of March 1988 the above named Richard 0. Stout and Janet P. Stout TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the persons who executed the authorized by§706.06,Wis.Stats.) foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout Notary Pub ��' _ roix County,Wis. (Signatures may be authenticated or acknowledged. Both My Comm alitent.' (If not, state a lion are not necessary.) r ' ) date: 4 , 19 *Names of persons signing in any capacity should be typed or printed below their signatures. NTF 2280 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms,P.O.Box 1075,Green Bay,WI 54305-1075. Form No.2—1882 . Y STC � lU i r 1 r-. Y ' r•1 SEPTIC. TANK MAINTENA CE ACKEEMENT o Sc , Croix suety � Y NEk/BUYER � � Olin-Lt',��-(j•�-c.��rF--- --•— m UTE/BOX NUMBER—4(9&) !�. �2�..� Fire Nun►her TY/STATE �o�� ..� =�r.� c Z11' OPEKTY LOCATION :rL1G�, / �;, Suction �qo N . Town of SL . Crutx Cuuncy , Subdivision I i.uc uumber�/�.• . _Vie, , 1 proper use, and maintenance of your Septic: bystetu could result in I a premature failure to handle wastes . Proper maintenance cot► - bcs ut pumping out the septic tank every Lhl"Ve yvars ur buuurr , I needed , by a licensed septic tank 2umpur . WIIJL you puc inL .j e sybtcm can affect the function of- c4ie srpcic tack as a tre.,c - nc static in the waste disposal system. Croix County residents !ay be eligible to receive a gral►c lur maximum of 60X of this cost of replacement of a falling system , !ch wdu in operation ....... 192&—. St . Croix Cuuncy .cepted this program in August• of 1980, with Lite requirement that hers of all new systems agree to keep their systems properly intained. - — is prupurLy owner agrees to subuilc to St . Croix Cuukity 'Lading a rtification fora, signed by thu owner and by u auacer 1) 1umbeI— . urneyman plumber , restricted plumber or a licensed pumper veri - y.ing that (1) the on-jaito wastewater disposal ayscem is in proper perdcing condition and (2) after inapectiun and puwpit►g ( it nec - asdry) , the septic 'tank is less than 1/3 full ut sludge and scuu►. ercificacion form will be sent approximately 30 days priur to hree year expiration . o /WE, the undersigned , have read the above requirements and agree N o maintain the private sewage disposal system in accordance with he standards set forth, herein, as set by the Wisconsin Depart- Dv ent of Natural Resources . Certification form must be completed nd returned to the St . ' Croix County Zoning Offkre within 30 days f the three year expiration date . SIGNED DATE —/ 2- - t . Croix County Zoning Office . 0 . Box 98. ammond , WI 54015 ,15-796-2239 or 715-425-8363 ign , date and return to abovu address . s S00 049 40"E w Lot DEDICATED .TO. THE PUBLIC • V I S 000 49'40"E 350.98' v Irn Im co � 3 I I N N c m -+' I �r Im 1 LA A te+ ILA 10 W CO t4 I �Dlc O? N N o ~ in 1< -1 rn IN 1� is 1 �o ' N 00° 52' 50"W 300.00' SOO° 52' 50" E 351.17' co �t' t N o • s 0) CD w ' IO r O A w D n u W °> -4 f o M to U N O 0 N� m o u V ti ij (n Oi cni — _ .� s �' -n m m nN 0_h 10 N -n 1 V 4 • N D l 1 N. ! S2 A o [' :t l0 30 , s• i� 49. < � �> 29e 2�• � z .'.;�;. ., Sb 91N 0 :. 0 G) o i L u :' 0 v . ' — cx) O 0. n u ;u-4 N 0 N o 213 - © �• S00° 8.28"E �'258.59`-- S 0 0 58'28" E 3.00 295. 0 ® I .. W M A U D -ROAD '-�: . • .� \\, O ,.rn. .• .. rya T9. W•,...-:; 295.00' Z,• N00° 58'28"W-�•- 275.10 4 �' N00°58' O'CD LA ul CA 1 O W m i BOO , f f I W O A U1 Ull m n�v' O O n y m N W m m Q o . to m O.N • V 8 m N N W m N 00°05' 24"W ;%•': :f '41" E 247. 35' Q.� 0 295.40 _. S02° i2 . 1. Z ' <-4 < N r m W O v 1 m 70 ° W m O N T z A < CD °0 N N o N W •��' (D �� tip m �; y 51 �. ti O A (n — LA (!1 �, Ln O xl s m O �1 0 N -+ A, • S 00° 58' 43" E 736. 06' ::' " EAST LINE OF THE SE 1/4 ' 1.,.•. .. µmg i x % a air,�ty�a� �..:„t aty ,'y .a: 1' � � is'X �&�;.5��f r Y� id.F✓ ��f��� J I r f•F ,,�,r'I SX,t'.�' �k v���' t � ?�${,. '� , � �k�i�. y w°y.'.r � ������f f; !9" a"�•a� �'. �° ��' •t `^F � _ a ly � '' ,• 4 d t .M 6 R"s 'yx ro,,x.X'rt �} �; d ° !!: s"ri" � G e nk*,�T,3 S fr ri c t ..r •y; ..+.r ,-a, v ?'". f - yto n R h 1 anc • r F` IN} ,+"A `t'"^fie 5 +�Z X ..; w a^Y, �':j- ', t'��g'fit' fi°' S!` , , I1^6F * `E.r +a1 S .,t r•f n:,t r t Y°p �� #� N `'; .� '' .� # r x4 FS 1 1 d i'Y xi =Ag r4 v' ��s a w4xv 'i"' .'' I �II'Ift " a. ,'?"� 7 �',a°- ,? ac.St`z 9t •;� Ili, 11 fir, III it I ill fit 11 1 I if J1 vi (spa s }ky j c: N /lp s �0� ar�y r fi �K irrw 3 Ft It ..n x a 6 >� F. 5 M1 ry / N If r. / N / N / a .. ?. W } 12-6 4-3 5-6 9-6 10-3 42=0 = 1001 50. FT. y BEDROOM *`I DINING O 0 x KITCHEN ',, n { t a mk " -:-JF v'x k t° y a y #2 ';': BE DROOM*3 LIVING ROOM o a _ 1 `§t t >," y A s � � 1 F,',. � 1..: 1 x � .. 'F`�•a Y%'S Fed ":-'�yy.t7�J C r x' 2,. 4 SNE3t �- �k :x xr, / �r i z; X fib• Ar; Xx :a , t 3� r•.. a '' 5:,° G�..,e tIlk { T •�+1M1 r k 13 6 8 6 r 20 0 6n .r7 - , � a auw v '¢ R� 'mss � a-�'''��&,�+ a.'�p ,� �i ,• r •XFt, i ! a"�� i•1 r i . K Y"t t V RC Y i kA r Ir a w .TM aRiq falldarilly show atww ' "3 N C. < x contain optional of aupyaam featlwaa � , ,' t:TtlaJ w pWl M for daalpn r�NfaflOp 110! P.O.Box 37,Stratford,WI 54484,Phone 715/687-3133 for oonatnlctlal puryoeaa. Am . !<'FV; �.- � �. _ : :.. •a � "n.� � -t. u r SEb'SY2,.en• ^'i�� �.�'„.is'# �3 � 'r'.,�'��x , `;`Lasting Value Based on Honest Craftsmanship" $ ".v`�rfru"�.�t tugs��1�A i i""t• '! . �"�.� _ ,�,' is 3„',��7`f^�gr'ah '3S,t.,y4 r:^� ,.•a y�"s � �`i 7 - DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDI,ISTRY DIVISION ; LAEfOR AND PERCOLATION TESTS (115) MADISON W 7969 HUMAN RELATIONS ` (1-163.090)&Chapter 145.045) L A., "s T NSH UNICIPALITY: NO. LK.NQ: S SDIVIS ON NA�M E: sT N9- 1/4 G �/ Tz4 N/V E(or uasA [OT I�,NE�e Nan / COUNTY: OWNER'S NAM : MAILINGAD ESS: S-r C�olk S �� /26_z ,& ST USE DATES OBSERVATIONS MADE NO.BE : COMMERCIAL DESCRIPTION: STS: I.QdResidence �� ZNew ❑Replace 7&eIL /9�� 4PkIL 9 /9%e. 'AILS ��K C� S$ So trs $K2- Q.rhfA��T - RATING:S-Site suitable for system U-Site unsuitable for system S,d- Swrrkif rM ONVE QA_ .IMOUND:� a� IN �� S ��L Q�GRU .RECO��Mti VrT�E,M�(o�ptionaf) I If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: CLIdSs r Floodplain,indicate Floodplain elevation: AM 1Sfc,P-r PROFILE DESCRIPTIONS BORING TOTAL ATER-INCH S A ACTER O SOIL WITH THICKNESS.COLOR, TEXTURE,AND DEPTH NUMBER DEPTH ELEVATION B R TO BEDROCK IF OBSERVED SEE ABBRV.ON BACK.) B- ( 17 104.5$ �t 9./7 W<S 9'944SL 36'&N MS Z7"BQ.�CS 36~T IOR1. -ls B- Z 11,67 /OZ.4� r4wv 9 >//-67 30$Ls DTs ,, 21:,k m Z1'9e,41. cr$e►�M-F's 5Ss'2rti$lees� �� B- 11-47- / S, 40N I: ? //.4 7- &-f CL bict- tak W PA MoT Atbt)*rT I , 13.'1414 & ' /o"BLLTS A'Bw44. WC-1`94N M- 201 RN Git 2&C B- /6.-K 104 -9-7 IE� >16.7 S f C06 "C &N M -Ipr. 30~$,eN CStG>e B- S /�7 /o%,? 7<S -S^9RivSL. Std CT&I MS 5e�&N CS�(4 B- PERCOLATION TESTS T '-DEATH I WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I I AFTERS ELLING INTERVAL-MIN. PER INCH P- I .7 0 Z < P- Z ,it, P- X05. Z 3 P- P LE4 AT 1 Oha A T P- P- PLOT PLAN: Show locations of percoli ition tests, soil borings and the dimensions of suitable soil areas. Indicate scale or dist ces. Describe what are the hori zontal and vertical elevation reference Foints and show their location on the plot plan. Show the surface elevation at all bo Mgt;and the direction and percent of land slope. SYSTEM ELE"T : I ( � ,S ,._ . -17- I l i ALTr:2NAT'E STE F Lon /9 (V4c-4N>) TN =40• , � Y , Al fa . ti 9a• $Ew.h+r�,.�,K- NW CokPIdR Nsp eac Pad LQSS I C OF 9,00 c aefv c /60-00 I,the undersigned, hereby certify that the soil tests reported on this form were m e by me in accord with the procedurls and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are corre to the best of my knowledge and belief. NAME(print): n c' TESTS WERE COMPLETED ON: 1140 Y JOLIA(SaN US�(J Ju�vFr/NC, / c krL 9 /486 ADDRESS: ERTIFICATION NUMBER: P ONE NUMBER(optional): .107 S�CQN S— 1./��sv �, 4 , 3 4T%4 �86. 400 CST S ATURE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Testur. DILHR-SBD-6395 (R.02/82) -OVER - 1 ' Edina Realty INC. Hudson Office 700 Second St., Hudson, Wisconsin 54016 • (715) 386-8236/Twin Cities 436-7072 Ot6#jL-e'- Dr4(J L 43 2roc t4-r {J `lq SE '/y S a0 -Ta 9 u R )i U) y'w cp 'TANS W« 4LL T � L� 3 JD` P• AST. \fit PL\ N W Corrw►� M N S P a o,c P)Vj P�aUL:. L--L(;-u 100.06 N ERdealty REALTORS®, MLS 5g6 I (4- c?g fAbORPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DUSTAY, DIVISION AND PERCOLATION TESTS 1115 P° BOx 7969 MAN RELATIONS 1 MADISON,WI 53707 1 , (H63,09(1)&Chapter 145.045) LOCATION SECTION: rr T NSHI UNICIPALITY: OT NO..BLK.NO.: Sj�BDIVISIO NA E: T21 N/R�9 L for 0-bi /8 f ,n/eCaepW �nl$ /S"� COUNTY: 4 WNE OUT M S NA : Sr Coo Ik &4 C_Wr ZN 4 5T USE DATES OBSERVATIONS MADE B 1COMMERCIAL DESCRIP1 �Residence New ❑Replace tAi\ (PROFILE DESCRIPTIONS: PERCOLATION TESTF.__1 A AelL $ 19$� p APtelo9 /9E�C SOILS DOOV� C7 S$ So'" fk Kz- 1.CfjA1k T RATING:S-Site suitable for system U-Site unsuitable for system S',8_ S-krrk LM ONV Q�: I ❑� IN S ❑u ou ❑�G�1�1K:RECO�to N V*Wrl6)yAx(optional) If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. 63.095)(b),indicate: Floodplain,indicate Floodplain elevation: Y A PROFILE DESCRIPTIONS BORING TOTAL ATE •INCH CHARACTER SOIL WITH THICKNESS.COLOR,TEXTURE,AND DEPTH NUMBER ELEVATION B TO BEDROCK IF OBSERVED SEE ABBRV.ON BACK.) B_ rlJ t s W<S 9"$QNSL 360&14 MS Z^7"BQ,4M 97 36~CZBRNNrs it B- /61.46 r4om Le >//47 3�'"$c.5�'r5 24'$�►v MS 44'ge,�c•MS d d+t U'r*rd>#lN e'4* B. rt'$I,t,15 21�8E'rJSL 36~Gr$QrJM-FS S��RA$RCS'� /I.4 Z S, NON I: '�'//.4 Z cow ry MaT Albt>rls �314, , 8_ 4 .75' 04 .9-7 >/6.7 S I-S N M -s. Zd- $tee,CS G le B' B3 /a L 7$«TS S^I&RNSL. 18 L-r&,j Ms _7e'&,v Cs-t4R B_ PERCOLATION TESTS p�R�H WATER IN HOLE TEST TIME RATE MINUTES NUMBER S AFTERSWELLING INTERVAL-MIN. PER INCH P- Z /D o icS.f *> Z 1 Z < P- O ros• Z 1 < P- P- PLOT PLAN: Show locations of percol itlon to rings and the dimensions of suitable soil areas. Indicate scale or dis ces.Describe what are the horn zontal and vertical.elevation reference ants and show the location on the plot plan. Show the surface elevation at all bo ngs and the direction and percent of land slope. SYSTEM ELEVATION i I , ` AD(Lb4ATE S'TF tN 'ScALC 1740- �Lar 19 ' I "LIP. PAL Ld6516 C1. �la�^ TbP oP 180x, Ec4v; i00.o0 `—�_... — I,the undersigned,hereby certify that the soil tests reported on this form were m e by me in accord with the procedurls and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are corre to the best of my knowledge and belief. NAME(print): ` TESTS WERE COMPLETED ON: 1�A2 Y JCK1NSdN T�USGu JuQ1/EY/144 IAJ APkIL I 1999 ADDRE S: CERTIFICATION NUMBER: - NUMBER(optional): 07 Si-Ce-NN - 1. U�sv 1 4 3 A�4 1PI-LONE n& 4o%o FEVISF-D �uNfr2TS, E��t20AAfD /S �YsOF! CSTS ATURE: 10 Acr_omO�.14TE klo(g c DISTRIBUTION:Oriyrnal and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 IR.02/82) -OVER - VOL 1498PAGE 510 a, EXISTING SEPTIC 62p3�2 SYSTEM AFFIDAV 'T' KATHLEEN H. WALSH Document Number REGISTER OF DEEDS ST. CRDIX CO., WI Name & Return Address RECEIVED FOR RECORD Richard C Kahl r 494 Lassie Circle 03-30-2000 8:00 AM Hudson WI 54016 AFFIDAVIT EXEMPT D CERT COPY FEE: 020-1183-80-000 20 .29. 19 . 1 COPY FEE: 2.00 TRANSFER Computer I .D. Number Parcel I .D. Number RECORD NGFFEE: 10.00 PAGES: 1 The existing septic system which serves the dwelling being added on to must be verified by an acceptable soil report or be inspected by a licensed soil tester for compliance with high groundwater and/or bedrock separation requirements as set forth in s. COMM Chapter 83.10 (2) WI. Adm. Code. The results of that inspection must be made available to this office. If the existing septic system meets these minimum requirements, and is properly functioning, an addition may be added to the dwelling without updating that system. This addition must not, however, encroach upon the required septic system setbacks as set forth in s. COMM 83.10 (1) . Property Owner(s) Richard C. Kahler Property Mailing Address: 494 Lassie Circle Hudson WI 54016 Property Legal Description: Lot # 18 CSM/Subdivision Pine Grove Heights NE Y4,�SE%, Sec. 20 , T 2_9-N-R__J.2_W, Town of Hudson Comments: The existing septic system was sized and installed for a three bedroom dwelling. The building remodeling project will involve adding a bedroom and an office in the lower level of the structure. The addition of a bedroom is considered an increase in wastewater load to the septic system and as such may result in septic system to be undersized for the structure being served. The office does not contain a closet and as such is not considered a bedroom. The septic system was inspected by Gary Steele (ID#222353) on 3-9-98 and appeared to be functioning properly and baffles were in-place on the septic tank. I, as the owner of the above described property, hereby affirm that the septic system serving this dwelling meets the above referenced state private sewage system codes. I realize that this remodeling project may cause the existing septic system to become undersized for the dwelling being served, and I will make this information available to any future parties interested in purchasing this property. Signed-g ,�p Notary Public Subscribed and 3 /z 9 O O __ 1+�+ rn to before me on this date: Date. / �r�rt;tllJt�e. �bZq o20 D Zoning Deportment ' � - p� -M co&ission expires: Approval: Date: March 20,2000 TO WHOM IT MAY CONCERN: Due to unforeseeable circumstances, the following address, 496 Lassie Circle has been changed to 494 Lassie Circle,Hudson,Wisconsin. The address change originated within the St.Croix County Planning Department,not with the homeowner. Please do not charge the homeowner for any expenses relative to switching the address. If you have any questions regarding the address correction, please contact Renee Potter at 386-4671. We are sorry for the inconvenience. Thank you for your cooperation. Sincerely, Renee Potter Mapping Technician St.Croix County Planning Department RP/jk MAR-15-00 WED 12:38 PM NEW MECH INC FAX N0. 651 642 5591 P. 03 win i� 6113th Ave So • Ho ns,Minnesota �i3+43 • 612)935-3556 7 ' Q3N�199b Gary Steel 1554 20(1[h St, New Richmand W 54017 KkFpMT aF WATER ANALYSIS tAb#: 3"r CUr iebarakory mMeb knew analoCAI te3UIt$,determined on a=Mple takPn by CLIENT an awmigm irom tho ruliowinp lowoon_ 404 tsssle Circle HUdwonjAll Wiform Bactclia �1/10Q ml Nitrates Nihngen 3.95 mpA Lead t4bt The MAJ1111 at these tasks irldirAe tto this well is Ixndudna Your mat moats the stdarda fnr TM repan jr.does not Mclu a�1rd"s Q Lwad other canc�ain rits,(Unlase as sNe `�trY dterny i cr Clinic,Inc. will r�ur:oiB�� W11f wG►ty1r YAY� BOillSw� t.b"ftrUllimi assmy„o MAR-15-00 WED 12;39 PM NEW MECH INC FAX N0, 651 642 5591 P. 04 EXISTING PRIVATE SFWAGE SYSTEM = ,, E INSp ir_TION REPORT owner's name City—MCI am PMVw"K aw"Los aloe(A Cosysq E/W Type of accupilley J _ - Dste Rf irrsv 100 wilding currerstly ooaupled? Y N Parma frlforrnation available? Y N a Soil ►apart an tits with aaUM"? Y N Q t:t Ua ervi YC3 v[] ®/ck•uPs Y N© Fmezx-ups Y❑ N❑ baepsSa Slew drairuge Fpul tsdvts r__Y(� N❑ other Date of last m oxic rank scrvic 9- Other comtnuuS_— •-- Date: Ovynds civs�nsre- �11SIt�,]uSDlt[t1QII elOw a At grade ,,,nd Type of ptivws seuaee SYMMS! pressuta 8 Dozed tnt -Bed ?tench OtDs:r Howe tank Privy �eil gysldin� t line 17eatmaPl tank yeituek Camolistrsce: L..� rp°I� Surface rater other wall Buildlr6 tat Ilse posing sank SeMck oomPliersat: J Surface; uip,Ter QthCr L���JJ tell 8uildine ��LsM1 SAS setback eomolianeC ppol SurRec •++stet Other Isirsplpin orfter(sl, Ttlras tia nN10as 1rtWPra���t19COtraOqs aryyaG?'P�@'m���lla�'LeWs.I.SOiflxmll• P+✓i ids MAR-15-00 WED-12;39 PM NEW MECH INC FAX N0, 651 642 5591 P, 05 _. _� �cw.nnnGSt Cundi ' e ` • size; Gallons Treaaecnt lIP1w- pFLLAetional pNrck roPlactme"t Warning label Bafilos: Mae— (3acplao6 fl Locking dcwct C� ti(,rnhole co ny C N ltlfllurt'ton: rzllons drrjcc p Warne isbd Holding Mok: Size= []UPlaoe f.oekiAQ I►tanhide oOrftr� Alwrn # oasl: O Y G �" la lion: 0 Y p y �/� Gallons p label (,losing took: Sixa: _ • OReplace 13 LoekiAg device Q W Arnitt Manhole K Al unctiond: ❑Y Q N mp focttgnal: 0 Y D InRlrrouort: OY f] r Square fetal Total area- _� es SAS' punding depth; Ins:h jrches System dopth belrnr zMdg: -J - Ven�obiefvgti011 pjpt% functional- •�Y n seepage, Or surface discharge. ❑ Y ❑N. pOtenlial revilcama[IS ama availablc4 0 11 N GIoRBi2% r_t foRnad; R _ e t d Rec tia dati s h Ccrti to o a I Shclimt:r Tkle inspeMion Vise bal6ed upon a surfACO giv.. Aical. of Slid syst ern. ar�d did not 1 �,nalYeis• AeCoGd,ingiy, e'iu!re it tl3e v, any �dvabinq or ctbemica this it�sptzets�" inwi mtst nor diev�+Vr��e bYtntior► Of pDSB i}ai]ity of ?,j Edon def}�rarlCnnt O��arantit'C tiha t:iuued t Thi t � r5ot 1n dr7Y th:La sysre«l. Tnspe+ctor5 S gzlatute� } LID T7 rT l Ln- c c r -� - y> i L—� [mil ;71 FNJ r - - rJ U T� ,y i 0 'd 1699 M I99 'ON XH ON I H03W M3N Wd LE 21 a3M 00-9 I-MVW MAR-15-00 WED 12:38 PM NEW MECH INC FAX N0. 651 642 5591 P, 02 F-F-I - c 7 _ _ C--D TT-.�._� I ITF[Tv �. rJ� c^ J r� i •.. T ......................._... �. SL Fri r/,� 1 G C1 erns- F77 r h ~ 9. i v rn CZ C-J m c i �, � \` � � � , �� � d .-� O �� �N 1 .-� �- �- �- -. � � � � � � �' r C� '�- � 1 '1 � ..