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HomeMy WebLinkAbout020-1095-20-000 > tn cz (D t3 §/ M(D CD oc (D U.) cc z m 2 r E 0 'a < c) 1 z E �j w i 0 ■ Cl) 04 CL R Z 0 z U 4) z 4) 0 0 Z3 0 z co z c V- C*41 (D 0 ca cr- 0 c LO.0 .2 CL 0 E /� 5 E 5 0 0 0 z IL CL CL CL 0 U) co co co co Z f \ / 2 LO CD 0 a E cc co (D 0 C5 0 'D = co 4) 04 co c 0- >- C0 cc g A E CO :3 0) CD CD C� CO 0 a r- 0) o C;) m o o 04 U�, 0) a 0 (D Co 00 C14 E E C, m 0 z 0 cv) 12 ■ cn C9 ed � % I IL L L: 0. r r E 0 0 0 IL Form - S T C - 104 • `A AS BUILT SANITARY SYSTEM REPORT ► U � OWNER 4u* ��� TOWNSHIP �7 D� SEC. T 14-R W ADDRESS PKI NWy, tJ ST. CROIX COUNTY, WISCONSIN i 44U OsaAJ SUBDIVISION LOT SIZE 2 O S PLAN VIEW Distances and dimensions to meet requirements of I•IHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM l i INDICATE NORTH ARROW - I I -TOP . OF ;?E-Ag- 57W6-S- DO d BENCHMARK: Describe the vertical reference point used sL,A(3 Elevation of vertical reference point: f� 0' � Proposed slope at site: d Cv4��JE'S CO j SEPTIC TANK: Manufacturer: 40A)640 - Liquid Capacity: �OIJ'a Number of rings used: + Tank manhole cover elevation: c7- s , Tank Inlet Elevation: �l' Tank Outlet Elevation: a 0 ..4 Number Qf feet from nearest Road: Fr 07)Side0 Rear, �V �00 feet 4 Q V Fns /0 From nearest property line Front,OSide,©Rear,O feet. / 1 Number of feet from: well �� , building: 7 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE a PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufactur Pump Size Elevation of inlet: Bo m of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet fro nearest property line: Front, OSide, O Rear,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM R Q Bed: �\Y Trench: � L 1?3 ' 1 � Width: I�" Length: c7 3 Number of Lines: Area Built: Fill depth to top of pipe: w�sT a Number of feet from nearest property line: Front, O Side, ® Rear,O Ft . Number of feet from well: SQ Number of feet from building: �0 I (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: iameter: Liquid depth: Bott seepage pit elevation: Area Built: Has either a drop b or distribution box O been used on any of the above soil absorbtion sy s? (Check one) . HOLDING K Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inle Number of f t from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: �'• NElso� V Inspector: Dated: Plumber on job: -� 1 License Number: v ' 74 X�AJ T 3/84:mj A4 iQ� 33 / DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR$E HUMAN RELATIONS DIVISION P,O.'BOX 7969 PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING MADISON',WI 53707 NWT, NEk, S33,T29N—R19W 1:1 CONVENTIONAL 1:1 ALTERNATIVE State Plan E.D.Nurnber. (If assigned) Town of Hudson ❑Holding Tank E:1 In-Ground Pressure 1:1 Mound HWY N 100 - 3' 30 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Dick & Louise Weiher Route 1, HWY N, Hudson, WI 54016 (o _ )-7_ c3 13 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV.- Name of Plumber: JMPIMPRSW No Cnunty Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 112669 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ONO BEDDING: VENT DIA.. VENT MATL HIGH WATER NUMB ROAD. PROPERTY WELL. BUILDING. (VENT TO FRESH ALARM LINE AIR INLET. III DYES ONO ❑YES 1:1 NO 1NEAREST===L0J - DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PIMP MODEL jPUMP,SIPH1N MANUI ACilIRE11 WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ONO OYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER CIF PHOPEHTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) OYES ONO NEAREST —0 SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing tIr ,TH JDIAMF TE R+ IMATF F41AL 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 L NO OF DISTR PIPE SPACIN(, COVER IN511)E.DIA IPI TS LIQUID BED/TRENCH THEN / / 1 A T L I A L RIT DEPTH. DIMENSIONS �a 53 CG RAVEL DEPTH FILL DEPTH UIS7 H.PIPE DISTR PIPE DISTR PIPE MATERIAL NO DISTR NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES ABOVVEE�CO VER EE EV INLf,2t E V/�NDQ c, PIPES FEET FRAM LINE 9� / AIR INLET. G / G �f/ o� V��7 Z / NEAREST-1. / !v U /cXS f MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM 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 ONO SOIL COVER TEXTURE PEHMANINiMARKEHS OIiSEHVATIONWELLS _ YES ❑NO DYES 1:1 NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEE UED MULCHED CENTER EDGES OYES. El NO ❑YES ONO DYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING IGHAVI L DEPTH HE LOW PIPF FILL DEPTH ABOVE COVER BED{TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE JMANIIOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV.. DIA. ELEV. PIPES DIA ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORHECiLV COVER MAT EHIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION, PLANS ❑YES ONO 1:1 YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBERDI= PROPERTY WELL. BUILDING: FEET FROM LIN NEAREST E: - J OYES ❑NO YES NO I0 'SL� Sketch System on in In cou ty file for audit. Reverse Side. SI UR E. TITLE. DILHR SBD6710 (R.01/82) Wining Administrator 77 SANITARY PERMIT APPLICATION COON Y _ ffl&HR In accord with ILHR 83.05,Wis.Adm.Code S STATE SANITARY PERMIT# 1a q —Attach complete plans(to the county copy only)for the system,on paper not less than STAT LA��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. �1VARIANCE ❑YES NO PROPERTY OWN R ll � , PROPERTY LOCATION - W �- _w i ZoIt#r AF� � w'/aAJE/a, S .3-j TZ N, R � E(q )W P P RTY OWNER'S MAILING ADDRESS LOT N BER BLOCK NUMBER SUBDIVISION NAME l�fl( A/ I O GAS C TY,STATE � ZIP CODE PHONE NUMBER CITY n NEAREST ROAD, RK apfo^/ ✓"/ r tl /(p El VILLAGE: (7 .✓ 1.t9 ty II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLIC�AfTjION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ❑ New b.JL�1 Replacement c. El Replacementof d.El Reconnection of e.El 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) lL 'X J Z 1. a. X Seepage Bed b. ❑seepage Trench c. ❑ Seep 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): —1 LP (5 'Z X S3 /S p, g Feet Private ❑Joint ❑ Public VI. TANK CAPACITY in allons Total #of Prefab. Site Fiber- Exper. I INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdina Tank My Li i on Chamber Lj ❑ 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 Si nature:(No Stamps) A4R[MPRSW No.: Business Phone Number: ROB",- U116A(CAT 3207 7/,7 34 �l�S Plumber's Address(Street,City,State,Zip Cod , •/� Name of Designer: VIII. SOIL TEST INFORMATION Certified S it Tester(CST)Name CST# � 't • ULA IR I Cti T' CST's ADD�iE�SS(07 eft City,State,Zip Code) Phone Number: IX. CUCOUNTY/DEPARTMENT USE ONLY V ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Surcharge Fee MApproved ❑ Owner Given Initial r �� Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: vuj� Val 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 t 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 systeT; 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; Vlll. 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% 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 At�C included the creation of surcharges (fees) for a number of regulated practices which Wisco can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried T @3StC? a 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. G 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) ®ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code Sf Cry r STATE SANITARY PERMIT## —Attach complete plans(to the county copy only)for the system,on paper not less than STATE LAN I.D.NUMBER 8%x 11 inches in size. X/ —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO PROPERTY OWN 9R p PROPERTY LOCATION q !cam NW'/a/V� a, S 3!� T2/ , N, RI9 E (o W PR PERTY O ER'S MAILING ADDRESS LOT DUMBER BLOCK NUMBER SUBDIVISION NAME CITY, UI STATE� /,�v ZIP CODE PHONE NUMBER Cl fTL / V`PO� NEAR ROAD, 151016 O ❑ VILLAGE: YJ II. TYPE OF BUILDING OR USE SERVED: 3 AW,-_- Q a 0 Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#KReplacement#1. Check##2,3 or 4,if applicable) 1. a. ❑ New b. ❑ Replacement c. 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. ❑ seepage Bed b. ❑seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Feet ❑Private ❑Joint El 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 Holdin Tank ❑ ❑ Lift Pum Tank/Si hon Chamber ❑ ❑ El 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) MP/MPRSW No.: Business Phone Number: A08a 7- Z(GB)e/CA .33 a 7 1 Plumber's Address(Stre t,City,State,Zip Code: Name of Designer: 6 5S D fvE%/ VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## L T�- i CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S nitary Permit Fee Groundwater ate Issuing Agent Signature(No tamps) Approved F-1 Owner Given Initial Surcharge Fee Adverse Determination �ZC) �`�'� /v 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 INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT. 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. 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 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. Prcaerty owners name and mailing address. Provide the legal description where the system is to be j 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 v 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 informaticn 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 ii 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 comp)-ete 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 farm. ------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 #e[ included the creation of surcharges (fees) for a number of regulated practices which Wiscor*h.6. can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure 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. o - The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funcs are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(8.03/86) Violation Number Form - PRE SANITARY PERMIT ISSUANCE PROCEDURE Location Section Township/Municipality Lot No. Blk. No. Subdivision 13 3 I T 9 N f R/? W l �i.L SdYj I oc Pr edure prior to sanitary P ermit issuance where a septic tank mus t be replaced during winter weather or other health emergency and soil evaluation or other sys- tem evaluation cannot be conducted. 1. Obtain assurance that the property owner is aware of further requirements for a system evaluation. 2. Obtain assurance that owner is aware that if system is found to be failing, it will be their responsibility to replace it with a code complying system. AFFIDAVIT TO BE SIGNED BY PERSON REQUESTING THE SANITARY PERMIT: I, I� C��ec 5� /"l• �t �C r , the undersigned do hereby acknowledge that I am receiving a sanitary permit to without a soil and system evaluation due to inclement weather or health emergency. Furthermore, I acknowledge that a soil and system evaluation will be conducted as weather permits and that if the system is then found to be failing as defined in Section I L H R 83.02 (18) , Wisconsin Administrative Code, it will be replaced with one that complies with Chapter I L H R 83 of the Wisconsin Administrative Code. If temporary pumping is to be utilized for maintaining a newly installed septic tank, due to failure of the system, the tank shall be maintained by a licensed pumper in accordance with N R 113, Wisconsin Administrative Code. SIGNED DATE 40R�_u A copy of an affidavit in lieu of EH 115 along with the PLB 67 must be submitted to the Plumbing Bureau for purposes of fee reimbursement. Si nature of Applicant Date Subscribed and sworn to" before me STATE OF WISCONSIN This day of 2Cv 19 �J SS. COUNTY OF Notary Public, State of Wisconsin My Commission Expires: L,�� :. I I T APPLICATION FOR SANITARY PERMIT STC - 100 I 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 propertyl L�U.:�l t� -K ��� f Location of property Q 1/4 1/4, Section 3 -3 , T of [ N-R 1 / W Township r Sci"Y� Mailing address (o v W << 4-LA o f Cp Address of site C, 5 Subdivision name Lot number Previous owner of property l�A/ / ��SU� Total size of parcel C-y /`-- Date parcel was created iC1 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes No Volume and Page Number as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ---------------------------------------------------------7--------------------- 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 warrant deed recorded in the Office of the County Register of Deeds as Document No. k )--6 7 3.73 ; 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 tAie County�Register of Deeds, as Document No. ) . Y�l Signature of Owner Signature of Co-Owner (If Applicable) Date 0 Signature Date of Signature DOCUMENT NO. WARRANTY DEED STATE OF WISCONSIN—FORM 9 267373 THIS SPACE RESERVED FOR RECORDING DATA THIS INDENTURE,Made by John E. Hanson and REGISTERS uFFIC=r Ruth Hanson, his wife_a_nd_in i her own behalf, ST. CROIX CO Wi8' -------- __-- —_— ---- --- __ ec'd for Record ths 28th l I day of_.Ngxemmber_A.D.19,61 grantor s of_Hennepin____County,XVAtNKft hereby conveys and wa rants ' to Richard. L. Weiher and Louise M Weeiher, husband an _t00------A, M. wife as oint — — _ RH St r o Devd1 ------- — ZIiIHSt7tH grantee s— RETURN TO of — RF1it1Sey . ' _-- --___ County,% to0H W for the sum of _0ns:_D91larfi-_j-�1.44"nd__other__g4_aaId__v-aluabl e_cons id- - - the following tract of land in St._CroiX__ _County,State of Wisconsin; Part of the North one-half (N?) of Section Thirty-three (33), Township Twenty-nine (29) North, Range Nineteen (19) West, described as follows: A tract of 20 acres of land exclusive of highways bounded on the North by Interstate Highway 94, on the South by County Trunk Highway "N", on the West by a line parallel with and a distance of 1869.6 feet West of the East line of the Northeast (quarter of said section) and on the East by a line that is parallel with and a distance of 1224.3 feet West of said East line of said Northeast Cuarter; being a strip of land 645.3 feet in width. Together with ..^n easement for an cc<„es rose ov3r a strip of land one rcd J.n width, the itr 11nes of °iJt cino sT r aponth-re the tlim- othebove cesrribdarel rreettho Southlinc o” lntor-tate Li hway r)4 thence Ea';terlr along t!,- South line of said Tnterctatc high- • 94 to a 7olnt t"ru rn— WtC i4-• .._'1V .i'r'on!? t.;'i'r, 1.1 n-, o" ill, °uscment aret. rlor.� Cnwlt; T nnl; }>> .t.�,��y "U" au conveyed to the _Ltt:te, of llisconsln; thenr , �,outl„ r�^tcrl_.' to oirt t';o ro(.',- 'o,ith o the :outs lc •1 i.n of Int- "•tats Lir-, - ')4; trJI1C� :�011thE°rh �f .l 1'x_rt l } f 9 ^r £. QUa%hurl �, .. n !_. O_ v -]d <.[� �Oi^i�'lil are:, end ` estl n 7on 4- nix l rca r i I ^al_' rni �;orrt} n� t °,�uth boi)nr'.ar„ or' stria at sw nr, ever ar ] o.,- nd ,.-• if rods in vi_utli ,,-Ytendinl� from the Srnttl: rnd and on^-ht:l-f oi' ',.hc bc>tr• e.t.riu i -t to l?i-«r,l7a•, 111311. J � r • �'� I �of � �I F --�- � ,; ---- t I } } a M II j IN WITNESS 1VIIEREOF,titc card grantor ha Y ' -_hereunto set their lr— hand —?__and seal 3 _ this 6th—_—_ November 61 day of ,A. D., 19 ) ZZAND SEALED IN PRESENCE OF ;' �!`r/t" ��c'�+t J (SEAL) John"i;._Hans on _ / John D. iley Qc - (�. zt. (SEAL) V_ -°f-� ��—•-�•� Rut}; iI nsor. Anno P. Ander,_on (SEAL) (SEAL) STATE OF WISCONSIN, 1 St. Croix. --County. 555. Personally came before me, this _ . . 6th _ (lay of. - .November _,A. D., 19 61 the above named _ John E. lianson and Huth Hanson, his wife and in her own behalf, to me known to be the person S who executed the foregoing igstruitfen5,and acknowledged the s e• I ' NOTARY __John D. -Heywo._ ----- {I I sni. ; •, St. Croix This instrument drafted by Notary Public________ County,Wis. JQh _r,Heywoo?d,Attorney_-et-Law,liudson�. Wis: My Commission4?QjW (Is)_Perma_nent. (Soetion 59.51 (1) of the Wisconsin Statute&provides that all instruments to be recorded shall have plainly printed or typewritten thereon the nemea of the grantors, grantees,witnesses and notary). n( WARRANTY DEED—STATE OF WISCONSIN, FORM NO, 9 9QQK 3�,�„ �'A�f 67 M.C.aILLRR CO..aILW.Uttr STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER t d /to ih.l .Se (,tit 4?A`1 ROUTE/BOX NUMBER lU I ild d e4ee FIRE NO. CITY/STATE_ __ 41,_A S cf\, • t S ZIP J5 461,4 PROPERTY LOCATION: A 1/4 1/4, Section 33, T N, R_LT_W, Town of 44 St. Croix County, Subdivision , Lot No. --- Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30' days of the three year expiration date. SIGNED 4_1 DATE �J St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street` Hudson,, WI: 54016 (715) 3`86-9680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY`, DIVISION L MADISON,WI 533707 707 LABOR AND PERCOLATION TESTS (115) � PS � P.O. BOX HUMAN RELATIONS O HUMAN & Chapter 145.045) LOCATION: SECTION TOWNSHIP/MbMTCTP'A tTY: LOT NO.:BLK.NO.: SUBDIVISION NAME: aw �� �� 33 /T 29 H/R� E(or H v0So &J a'n T_ o -.zo ACLes COUNTY: OWN R S , S ME: MAIL A D SS: 5f. o X - 944 Hwy. N N vOSO co 1.5 y-f O/ Co USE DATES OBSERVATIONS MADE NO.a DBMS.: CO M R A D SCRI VT 10N: PR LE TONS: PEFFCCLATIO19 TESTS: Wesidence ❑ I New Replace (c -17- ' RATING:S-Site suitable for system U-Site unsuitable for system S C3 U R ►�q Rt�T' �'r1~E APT /� ONVENT NAL: MOUND: IN-GROUND PRESS :rYSTEM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) O S ❑U 0 S ®U ©S DU ©S E]U ❑S DU e0 U U SN T 10 a EKGE'SS tp S If Percolation Tests are NOT required DESIGN RATE: j. � I If any portion of the tested area is in the under s,H63.09(5)(b),indicate: GLA-S S LFloodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN ELEVATION OBSERVED EST. GHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) .o' 9- 9 0& ,�� /.s' $a. rouprEF s z.o OR VERI es i2 . o ' A/ v11ie 'cS DO 120 2, p B- ✓ 7 U �T. 7/ 1-to 7, (� 3Z i S 3N.Tvv vac S� 2 .5 ©,Q v au' S B- B- B- SvkfACE '54t/' PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PERIOD 3 PER INCH P- Z- P. P-. RET PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope.SYSTEM ELEVATION �� � (o``� T- P, I R o � _T__ a t,k v E F P T.. -- — l l a P'E U E R s er PLO T fl GAO s r E � t I i i I i a 1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specifiV in the Wisconsin Administrative Code,and that the data recorded and the location of the test§are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. _ '.7_ Q v 655 O'NEIL RD.,HUDSON,WIS.54016 4 Q ADDRESS: ROBERTULBRIGHT CERTIFICATION NUMBER: PHON NUMB (optional): MASTER PLUMBER LIC.NO.3307 M.P,R.S. '6 MINN,INSTALLER&DESIGNER CST SIGNATURE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. " i DILHR-SBD-6395 (R.02/82) -OVER -- 1 �Ry�'gf�TEp oic PLOT PL•A,J oueftowl��j EXiST��� c Y-- 73•M� 400 RAU,uE 13c y. $P tot �J I vk�;oa or _ / c--tR y57 y Pis �2 poc�2 ► s�A4 _/0�• 0 d Q -- OLD ,./-`"' PRyWeil a �— r G-17-8� 3° cc►�T Nome �R °F y / CIE VAT;oNS CIF Ore SGPn� Sepric Thuk caj,4rSer uP°"' �'' rater 92- owueRS G-I!o'�7, ,% ouT�EF � 91 •�a ef Q+'SERS) Ar/iT • � 13 Fuv = 92.37 Sep�Pt T. CON&tI4t CO N Sep 1tv - 17- 91 /00 B� UERT. ►� - . REF. pr- (00 $2 , To? O `— I It I R x C I eV A POO y I, x P3 ( , B w 3 1 131 - 1�9 O6v i P PO POS er, s ysT� �.O Pie Oy. PO . -- F_ N, HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD.,HUDSON,WIS.54018 ROBERT ULPRIGHT +nS.MASTER PLUMBER LIC.N0.3307 M.P.R.S. INSTALLER&DESIGNER LIC.NO.00663 ' O v E� � �C o E W s� o � o � 9 J -n- vFresh Air Inlets And Observation Pipe 'CQ h Approved Vent Cap Minimum 12" Above Final Grade Joe d _ 4" Cast Iron Above Pipe Vent =Pipe' -to Final Grade Mugsh-ttay-Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution .Tee Pipe _} 0 0 0 0 0 Aggregate o Perforated Pipe Below Beneath Pipe Coupling Terminating At 0 P 9 9 Bottom Of System J DAYj'Jj&'tEp ore PLOT Sewell— oueftowl-4 Exisr�r� _ 'I3•NI' ' .,,lam #a+o RAviiF Std' . SPw�- Hof .` y , ,o� fie. rip 6 pooiQ � r Ni AgAmo&AVO S CAM*o is 9A A b C 3 pQM i G-17-88 Sc'o.6 2 O Uk rt F R 30 cEareR �� MoHE Sao OLD StPIn�- FIFVAT,oNS aF ' T/INk^ ;Tee, SePTic TA�fK caMopsev u-poa , OWNERS o'1l0-�7, ►ester= 92- ou t�T - YZ •00 T / co10FR ('71of RI$ERS) i / Q Ar yS° �o$ = 92.37 gEMJ lovO SeFt�•t T. zdk Af-� (�i-17-e? ;'' /p f /Y Orr- � ' 1 B goo —4" REF. fir. yo, I Top of 11 'RAN + s ► I vo B3 = PIK �7 ' PI�oPoSec� SYSTEM F3 . SS � oR alow cry Ro . � • onyLigt,TEP a,o PLOT SEw�R— fF_V.kTrAN t 'l5 c r SaAR, `/0f)• ' 14B�MidbFlEt7 � 17 � I'• Scams l "=z o i �p WE tfF-R cF►�Tf� s� NIKE 2)vo P :. DAD 5ZPI'r<- cc(fvAT;eNS eF T+JN -- ST 1� SerT;< T�Uk i /A)LET- = 9 �4� CpvEP� _ ��•/�- � of 13�pf Svwat. n / pew i000 Ste : a J 3E�u = '12.37 SFpric T. ° { cpp4w x L f� iNSfAAev LAYE(I l f£S /0 C<- 17- K? Efts T OF got j T`IPl d 3/q ` T. P UEPT• r. 1 PEF. Pr 132 top of Rap I f It[)AT'OA 3 . B 3 ' �7 HpMESITE SEPTIC PL11N W1S y4Op18 655 O'NEIL RD.,H o BAS R S aoaEM M p' WIS MASTER PL fMS�NLIC. MINK.INSTALLS t� 340 Q s 13 v/L7•.— ,pip°� r S�'3. - /I-, r�C—2— o R RC) i