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020-1000-60-000
� / ¥ ? E _ \ 0 \ / � � ) � � ) � § e � # § : $ f % ) CL U. \ 00 \ /i ; Of « w \ \ ! k B 0: k k k tm { z E CD ; c @ § J c k 7 2 � \ U) I � .. m G ) % ) � M k � � \ o 0 a ® g E » U) § £ ) � / § § § \ 2 0 U) ' k b } § { ] 0 _ ° ~ § k o J G 2 ) \ § % < g R � , _ _ $ z m , � ■ d § � ° � f 7 0 7 2 Ems _ § / \ \ / / \ 0 ( } / k § _ $ 2 £ e § o o f J / o ) / } k \ — a £ ; a » a o 2 . 4) § / k IL / k J Parcel #: 020-1000-60-000 03/31/2005 03:03 PM PAGE 1 OF 1 Alt. Parcel#: 07.29.19.1 F 020-TOWN OF HUDSON Current I X_ ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner *SPERRY,JAY P&CAROLYN L JAY P&CAROLYN L SPERRY 1080 GOLDEN OAKS HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description * 1080 GOLDEN OAKS SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 5.500 Plat: N/A-NOT AVAILABLE SEC 07 T29N R19W SW NE COM E1/4 COR SEC Block/Condo Bldg: 7 TH W ON S LN NE1/4 2165.89FT TO POB W 454.41'TH N 525.2FT TH E 459.91 FT TH S Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 525.31 FT TO POB A/K/A#17 07-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 12/15/2003 749161 2474/421 WD 10131/2003 745360 2447/118 TI 07/23/1997 728/39 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 47579 475,200 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.500 81,800 285,800 367,600 NO Totals for 2004: General Property 5.500 81,800 285,800 367,600 Woodland 0.000 0 0 Totals for 2003: General Property 5.500 81,800 285,800 367,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 124 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 001-WATER SPECIAL ASSESSMENT 0.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 f PUMP CHAMBER ` Manufacturer: Liquid Capac Pump Model: Pump/Siphon Man cturer: Pump Size Elevation of inlet: ottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet om nearest property line: Front, O Side, O Rear,Q Ft. Number of feet from well: j Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: 737 Number of Lines: Area Built: Fill depth to top of pipe: 30 4 Z II Number of feet from nearest property line: Front, O Side, O Rear,O Pt .— r Number of feet from well: �� 3 Number of feet from building: /d 5 (Include distancee.0 on plot plan). r SEEPAGE PIT Size: %. Number of pits: Diam . Liquid depth: Bottom of seepage t elevation: Area Built: Has either a drop box O or di ib on box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Ca city: Number of ngs used: Elevation of bo om of tank: Eleva on of inlet: Number of feet from nearest property line: Front, O e, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Q Dated: V ✓ 7- 07 7 Plumber on job: License Number: HOMESITE SEPTIC PLUMBING 00. RT. 3 O'NEIL RD.;HUDSON, MS.54016 ROBERT ULBRICHT 1nS.::,-ASfR PLUMBER LIC.NO.3307 MAU 3/84:mj �N STALLER&DESIGNER LIC.NO I10%4 Form - STC - 104 r AS BUILT SANITARY SYSTEM REPORT OWNER 1` / TOWNSHIP fq V r�OS&O SEC. / T 1l N-R p W ADDRESS fii�dyT A/I ST. CROIX COUNTY, WISCONSIN �f • � �{uDSo,J �uiS .s�o�� SUBDIVISION 1A0 7 1!?1e00je LOT �7 LOT SIZE Z � S PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM tJE�� D 4040 s� qq IM � .s • 3Y �� ia2 � P111 0 5'915 �F To / S r x �, .P 5 S 4 - INDICATE NORTH ARROW ao X Der► �-N 9�sQ ,"r TD BENCHMARK: Describe the vertical reference point used POST . Elevation of vertical reference point: /00 10 Proposed slope at site: 7 /0 SEPTIC TANK: Manufacturer: /� Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,©Side,O Rear, O 0 feet From nearest property line : Front,Q Side 0 Rear,0 Oaj6_k 300 feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) PUMP CHAMBER Manufacturer: Liquid Capac Pump Model: Pump/Siphon Man cturer: Pump Size Elevation of inlet: ottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet om nearest property line: Front, O Side, O Rear,Q Ft. Numberof feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Len$th: 7_S7 Number of Lines: AZ�- Area Built: � I 4.2, Fill depth to top of pipe: 3 d Number of feet from nearest property line: Front, O Side, O Rear,O Dt * 30v r Number of feet from well: e� 3 Number of feet from building: S (Include distance,�p. on plot plan). , SEEPAGE PIT Size:_.. �� Number of pits: Diam Liquid depth: ",-. - Bottom of seepage t elevation: Area Built: Has either a drop box O or di ib on box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Ca city: i Number of ngs used: Elevation of bo om of tank: Elevat&6n of inlet: Number of feet from nearest property line: Front, O e, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: (�r Plumber on job: License Number: HOMESITE SEPTIC PLUMBING CO. RT.3 O'NEIL RD.,HUDSON:WI&54016 ROBERT ULBRICHT V!�.;�}►STf R PLUMBER LIC.NO.3307 KPU 3/84:mj : INSTALLER&DESIGNER LIC.NO.DOW i Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT i i L d 1 l 1�. � V OSO� �ry l N-R ` W OWNER / TOWNSHIP SEC. / T ADDRESS A/!l' ST. CROIX COUNTY, WISCONSIN �f .� �{vOso,� �iS •sf�'!v SUBDIVISION 7iPd�7 LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I.HR 83 i SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM D 41140 s� !,V of v/,�p 5',K'75 S�rTf'yEv T�S //rG-!� �/E�• X951 � Q ,..s/fTE'.,,t !'/ElJ • G/0,yes r TO tfo°s � r - -- --- -- - -- - - -- -� - SAS f4�Q5 ,,ei�PST- Gin '40 &Cv INDICATE NORTH ARROW ao x Der, �N • 9�-s� �itv• _ �.Yy' ' �i � fe Csl— ,v,"T 7'a BENCHMARK: Describe the vertical reference P oint used SSE L POST. � 0� j Elevation of vertical reference point: /QQ ,O Proposed slope at site: 7 Po SEPTIC TANK: Manufacturer: 'OzEle�r Liquid Capacity: X00 0 vim` I Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,©Side,O Rear, (D a'OL'c-k 30 0 feet From nearest property line Front,©Side,0Rear,O wek 301) feet Number of feet from: well _, building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) nnra nrnrrnnry nTTle DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.B,PX 796% BUREAU OF PLUMBING MADISON,WI 53707 SW'k,NE�4,S7,T29N—R19W CONVENTIONAL ❑ALTERNATIVE (Ifassgned)D.Number: Town of Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 17 Trout Brook Hills NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: Ken Kreye Route 1, Box 4, Hudson, WI 54016 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 92495 SEPTIC TANK/HOLDING TANK: MANUFACTURE LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER f��y� ,�/� PRO IDED: PROVIDED: boa ,5/ �V� o"p ES ❑NO DYES &NO BEDDING: VENT DIA.: VENT MATL.: HIGH WA ER NUMBER OF ROAD: PROPERTY WELL: BUI LDING. VENT TO FRESH � T ALARM: FEET FROM LINE: r7 AIR INLET ❑YES �O C-r- DYES DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO ❑YES ❑NO ❑YES ONO GALLONS PER CYCLE: PUMPANDCONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING.IV NTTOFRESH (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 LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: JNO.OF IDISTR PIPE SPACING. COVER JINSIDE CIA. UPITS LIQUID BED/TRENCH R 17b TREN ES / MATERIAL: PIT DEPTH DIMENSIONS J /V/^ GRAVEL OEPTH FILL DEPTH DISTR.N DISTR.PIPE DISTR.PIPE MATERIAL: NO IS R. NUMBER OF PROPERTY WELL BUILDING. V NT TO FRESH BELOW p if ABOV COVER: EL ;I T 1 / .�' PIPE FEET FROM LINE rjIR�IN L ET. 99pp/✓({�I Y`I NEAREST O.y.R-Jf /(J.7�hJ1 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: PERMANENT MARKERS OBSERVATION WELLS DYES ONO DYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER. EDGES. DYES ❑NO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE, FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR,PIPE MANIFOLD MATERIAL. NO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND ELEV.: ELEV.: DIA.. ELEV.: PIPES DIA.. DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS DYES 0 N I DYES 1:1 NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY W FEET FROM uNE: I 0 ❑YES El NO OYES 1:1 NO NEAREST 0 '0 to 83 -�9 Jt. aO lV. 8C) Sketch System on ---- Retain in county file for audit. Reverse Side. SIGNATU TITLE. DILHR SBD 6710(R.01/82) Zoning Administrator 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 3 years; '6'. If you have'questions concerning your private sewage syste,:i, 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: Property owner's name and mailing address. Provide the legal description where the system is to be installed; ll. 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; ill. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; I`/. 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; V'lll. 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'/z 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 ccmmon!y known as the groundwater protection law. This change in statutes was the result of ove- 2 years of steady negotiation and public debate. The groundwater bill tzraundjrt ter included the creation of surcharges (fees) for a number of regulated practices which Wiscort'Ws can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried T @a stlC@ 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. T' rnonies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural R soa;rce . These fur's are used for monitoring ground- t ater, groundwater contamination in�estigafi ns and establishment of standards. Glround'Ma'e�, ii'S worth protecting. SED-6398(R.03/86) SANITARY PERMIT APPLICATION COUNTY�-�►�� 7 DILHR In accord with ILHR 83.05,Wis.Adm.Code 57T- •�-• STATE SANITARY PERMIT# J —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 NO PROPERTY OWNER PROPERTY LOCATION <stAl kREy� 5 P % A)Ar,%, S 7 T�'�, N, R if E(or(o PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME R,e/ ReX f+upSa✓ ��S . /7 T,Pour13 Oa,< CITY,STATE ZIP CODE PHONE NU 3 P2_3 v PSOA NEAR 1'e`D. � Ej TOWN OF: II. TYPE OF BUILDING OR USE SERVED: fi SUti Number of Bedrooms if 1 or 2 Family '� OR ❑ Public(Specify):) �02�— /D�®u ���� 111. 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 inspectedand 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 Tan k V. ABSORPTION SYSTEM INFORMATION: (Check one) 1- 41AAt �5 57 �( r 1. a. El seepage Bed b. Seepage Trench c. El See a e Pit 7 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 t Z 73.-0 O 1015- Feet KPrivate ❑Joint ❑ Public VI. TANK CAPACITY Site in ga ons Total ##of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New xisting Gallons Tanks Concrete glass App. Tanks Tanks structed El Septic Tank or Holding Tank 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) MPi MPRSW No.: Business Phone Number: BY-7_ ,qtAjef,C4F 3-307 PI u ber's Address(Street,City,State,Zip ode): Name of Designer: U-T= 3 D I+�t(L z)l�So�l/ �v/S'- Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial 4 A �rcharge Fee ,Q Adverse Determination / V U 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 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. TD be complete and accurate this sanitary permit application must include: L Property owners name and mailing address. Provide the legal description where the system is to be installed; li. Type of building or use served: If public is checked, indicate .type of use (i e. 10 unit apartment, 30 seat restaurant, etc.). Fil•. in number of bedrooms if building is a one or two family dwelling; II'. 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'/z 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 Groundy ater — included the creation of surcharges (fees) for a number cf regulated practices which wiscor4in's can effect groundwater. The surcharge took effect on ,July 1, 1984. All of the water that buried freastlPB is used in your building is returned t^ the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. a Ti,e nnonios c gilt,ted through these surcharges are cred ted to the groundwater fund adminis- tered by ?he Department of Natural R--sources. These funds are used for monitoring ground- t v.ater, groundwater contamination in;estigatinns and establishment of standards Groundwate.,, it's worth protecting. 4-3D-6398 fH.03/86) DILHR SANITARY PERMIT APPLICATION COUNTY - .�,.. In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# -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 I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO PROPERTY OWNER PROPERTY LOCATION '/4 %, S T N, R E (or)W. PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE-®R-L-NDMA-RK 10 TOWN O VILLAGE: , t 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. ❑ 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. ❑ seepage Bed b. ❑seepage Trench c. ❑ seepage 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 ❑ Public VI. TANK CAPACITY Site in gallons Total ##of Manufacturer's Name Prefab. Fiber- Plastic p INFORMATION New xisting Gallons Tanks Concrete glass App. Tanks T u urer Con- Steel A Tanks structed Septic Tank or Holding Tank ❑ ❑ ❑ 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) MP/MPRSW No.: Business Phone Number: Plumber's Address(Street,City,State,Zip Code): Name of Designer: i VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) ElApproved El Owner Given Initial Surcharge Fee Adverse Determination 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 HOMESITE SEPTIC PLUMBU CO. RT. 3 O NEIL RD.,HUDSON,MS.54016 APPLICATION FOR SANITARY PERMIT ROBERT ULBRICHT WIS, MASTER PLUMBER LIC.NO. 33D7 M.P.R.S 1MINN. INKAtLER&DESIGNER LIC.NO 00663 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 56-) ; , Section 7 , TZN-R �y W Township Mailing Address j�/,5--��C- _6412_3 Address of Site S Ldso h T1Atf .�Ol Subdivision Name T2QUT �j�op,� << S, Lot Number Previous Owner of Property Total Size of Parcel •o���ES Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes _K_ No Volume Z" 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTy OWNER CERTIFICATION I (We) ceAti6y that att statements on this jotcm atce ttcue to the best o6 my (oun) know.s?edge; that 1 (we) am (a4e) the ownetc(s) o6 the pttopehty deb c tibed in this .in6oAmati,on 6oACm, by viAtue o6 a wa Aanty deed necotcded in the 04jice o6 the County Registe> o4 Deeds as Document No. '/O'? U-1 3 ; and that I (We) pttesentty own the ptco pod ed site 6otc the sewage dLs poa s .6 em• (otc I (we) have obtained an easement, to tool with the above deschibed ptcopehty, 6o,% the con6ttcucti,on of said system, and the same has been duty uco tded in the 046ice o� the County Register of Deeds, as Document No. ) . S ATURE OF/'OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) . ) , DATE SIGNED DATE SIGNED j r� ���'"•�w xi k P +<• xis., # - �q ,y t'v ."cY f ? 5 ! I j 4-' Al' PR .• '��ayr:R° f1a i2kiu K t .� ! � .Jy� ,'may► �' '� ih ' N.� ... Y�.e� .-l.., •,.4M. wi'Pr}f �,ri- i v e�, .P u 5� .. 4 5 e yp 1 3 i r ' � H z cn H 9 STC - 105 r 9 > H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a � H OWNER/BUYER ROUTE/BOX NUMBER/Ot Fire Number CITY STATE �' ZIP � PROPERTY LOCATION:S0 k, JU y 14, Section '7 , T d / N, R W, Town of /S7r/1,,5'f�� , St . Croix County , • r Subdivision,7,Z , Lot number I Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists 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 treat- ment stage in the waste disposal system. St . Croix. County residents m_ y be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , 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. 0 E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- b ment 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 . SIGNE DATE St . Croix County Zoning Office HOMESITE SEPTIC PLUMBING CO. RT. 3 O'NEIL RD.,HUDSON;MS.54016 P.O. Box 984. ROBERT ULBRfCHT Hammond, WI 54015 WIS.MASTER PLUMDER LIC.NO. 3301 MARA 715-796-2239 or 715-425-8363 ':'SINN. ;NSIALLER&DESIGNER UC.N0.00663 Sign,, date and return to above address . Y INSTRUCTIONS FOR COMPLETING FORM 115 - SBIJ- 6395 To be a complete and accurate sail test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a rJesidence or cornmercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A 81TE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SQIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale; is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate boxes as to dates,names,addresses,flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation)does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12= Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS Soil Separates and Textures Other Symbols st Stone (over 10") BR - Bedrock cob Cobble (3- 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater cs - Coarse Sand Perc, - Percolation Rate coed s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is - Loamy Sand > - Greater Than sl --- Sandy Loam < - Less Than *I -- Loam Bn -- Brown *sit Silt Loam BI Black si - Silt Gy Gray cl - Clay Loam Y _... Yellow scl - Sandy Clay Loam R - Red wl - Silty Clay Loam mot - Mottles sc - Sandy Clay wi - with sic Silty Clay fff .._ few,fine,faint *C -_ Clay cc -- common, coarse Pt Peat mm - Many, medium m - Muck d - distinct p -- prominent HWL - High water level, Six general soil textures surface water for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction, D�PAI`.TMENT OF D- `� kRO RT ON SOIL BORINGS AND SAFETY& BUILDINGS INDt1STRY, C DIVISION LABOR AND oC FCF, , RCOLATION TESTS (115) MADISON WBOX I 3707 HUMAN RELAfi S � ��/j (H63.09(1)& Chapter 145.045) LOCATION: TIO N TOWNSHIP UNICIPALITY: OT NO.:BLK Ngr SUBDIVISION NAME:-'_ -V- 6 COUNTY: O BUYER'S MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DES RIPTION: (PROFILE DESCRIPTIONS: PER OLAT ON E STS: Residence I ❑Replace 4L RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: M LIND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM: ®s ❑u s ❑u SEA ❑s .Zu ❑s ®u �.� If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the Z under s.H63.09(5)(b),indicate: C i 5 S Floodplain,indicate Floodplain elevation: 1 0 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) I B- / 0. -7 cis �, o ... E �' 8•-7 ' BJ /� : �/ 'J 'eET-1s B- ZE! S "/o�. B- g " �.¢. / 8• / moo.-7 ,�� /"��/. 6" ,Q� B- „ A,� C—=C---T ¢ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PER PER INCH P- P-_ P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION SCA LE 1° = 40' AR i 3] KDE.PJTi .51_ITABLB. ABEA 379 C At d- r _ 7. 2 ,4 tN f { SEE ATTACH D PHOTO F R A PR. X ._....... ._ _. — ITE LOATI 1 I i ' tt V. R.E P TOP � 1 RO N P 1 E _ A S S�U_„M. D 1� 0 ' SEC.7 _ _ i�✓ I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): CST SIGNATURE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — Z c ` < Z P1 •,� �, ty`7 Z �•, � a .�4si �imk�i t ijrA Ar K. 0 rn x s a s a .• # M' `f.r i'L t �, rj,+. T+ "'ir' ,`Lt'A .• W •R• j � �• a �' .t`i UD ;�� � d.. �. .i y.: GN+,�tai +yy�. �y N �• $$[ � -- Oil m 1j ,� y; � z " •� &,.�y� ,fir ;; Y~ e�.. 8` Co mm off . 3 N x . T , o e :q" *•' � 3M M' �z N r �► yp z,., sb , � 9 D cs oo (Jens sheet 50) Sk2 Vs 0 1 Mile 3000. 2000 .1000 5 000 Feet � N Z Scale 1:15 840 LA- LoT 36A Ile, 3.32 ACRES pa���,r." i� -?r T = 15 w { - ► Al N S w �. ' / O o o /, f Qo F' o�` 65oG cc 6' L07 365 ; 2.12 ACRES ` 4 EXc_j-rP c L�:)gDWAY EASEMENT` i `o _� PQB POB z / 459.91 -- - ' dI ' i 106.88 N 84" 26 E f 336.03--`-- 4 V r f' LOT 17 ' 5.50 ACRES W O _ v eu ° rn o c� Lo 454 .4.1 CENTER OF SECTION .7 'Df.PA ENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS IN TRY, DIVISION LABOR AND P.O. BOX 7969 HUMEAN REL'AT10NS PERCOLATION TESTS (115) MADISON,WI 53707 (H63.090)&Chapter 146.045) LOCATION: SE 1 N: TOWNSHIP UNLCIPALITY: OT NO.:BLK.N SUBDIVISION NAME: '/ '4 /TRH R��E(o W .�,• 5 0 -7 /'� -,���T �,QO� � COUNTY: OWNER BU R'S AME: MAI LI AD, R SS: U DATES OBSERVATIONS MADE N0.BEDR CO M RIPTIO ® R / TS: RResidenca New ❑ / - RATING:S-Site suitable for system U=Site,unsuitable for system CONVENTIONAL: IN-GROUND-PRESSURE: S S EM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) PSEM IMOUND:SDU �S []U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the Iutoer s.H63.09(5)(b),indicate: C.c,.L S S Z Floodplain,indicate Floodplain elevation: i✓ o PROFILE DESCRIPTIONS BORING TOTAL DE&H TO QRQUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH BER DEPTH IN. ELEVATION SERVED EST.HIG H TO BEDROCK IF OBSERVED SEE ABBRV.ON BACK.) a: B- �( -,t PERCOLATION TESTS EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEV L-N HES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. D PER INCH P. P- i P_ P 'LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances.Describe what are the hori- ontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent )f land slope. ySTEM ELEVATION o SCALE I = 40 g 2 y &ACA 1= pI T C b C 9 5 +, P 2 q to.. %N b r EE ATT C H 0 R.H 'f. OT -, R Al PQQX. / ITE L0 ATI -N V. R.P. IRON P1 E X SEC.? I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin - Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NJAME.(print): TESTS WERE COkIPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): CST SIGNATURE: 1)WRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. 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' �� 4 tom. • � '� • v - r� 0� uj Nc cc— SLY 35G rn z ry 2.12 A"RES Cj Cj N L� �`j EASEMENT y E'OB PoB 459.9!N 8 9° 26'E V C : t � . 4. # f LOT 17 i 5.50 ACRE W i 0 _ � O tr ! Z t"J f � 1 4F4 .41' , CENTER OF t SEr"n ON 12. ( ST47 S �4PPPov,�p i000 �ssQ . SEPTiC 7". �ROPos�a Well ~ e1om TfiNK /DD ",O.A4 HOMESITE SEPTIC PLUMBU CQ �"— roeemGhES die RT.3 UWL RD.,HUDSON,M&54016 ROBERT ULBRINT MASTER PLUMBER LIC.NO.3307 M.P.R& NS'TALLER&DESIGNER LIC.No.006" y, �y Q 100 0 M f • T' Jr 7.5 - � Z � N�F,P,tE,trS P&A- Sail T�STi ✓tej- e�f. p�..P p v Fresh Air Inlets And Observation Pipe _ /Oao J 0 — Approved Vent Cap Minimum 12" Above Final Grade fi:urs,r/EO �'e*Aar— �j Nrs-NE s T 36 � 'r'o „ TfA A3614 -- . Above Pipe 4 Cast Iron Vent Pipe AWU NEA7 To Final Grade yp'fPC /owl r&,,vrAv-, Marsh Hay Or Synthetic Covering /0 - Min. 2" Aggregate Over Pipe Distribution Tee ! ` ! Pipe r-0 -00 0 0 ��� SOiL I'Fsj' (a " Aggregate O Perforated Pipe Below Beneath Pipe o Coupling Terminating At Bottom Of System