HomeMy WebLinkAbout020-1002-50-020 (4) J �,tiy County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
G p In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
*,♦s Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
G [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
$� Hudson, WI 54016 -7710
(715)386 -4680 Fax (715)386 -4686
Attach complete plans for the system on paper not less than 8 -112 x JJJpches in size.
County Sanitary Permit # ❑ 'cation
S 3/ RECEIVE I
I. Application Information - Please Print all Information Location:
Property Owner Name ^7
SEP 0 4 2008 E 1/4 -
E 1/4, Sec /
C 4 �� 2- N, ' R E (o
Property Owner's Wiling Address ST. CROIX COUNTY Lot Number Block Number
D o ZONI OF FICE
City, State Zip Code Phone Numer Subdivision Name or CSM Number
�s o S� t (6 Ire,011
11 Type of Building: (check one) amity ❑ Village XTown of
❑ 1 or 2 Family Dwelling - No. of Bedrooms: [n
13 Public /Commercial (describe use): 14 J A.S6
❑ State -owned Nearest Road
II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 1G. U 0A XS h - /c_-
Parcel Tax umber(s)
A)
1�'Repair 2. ❑ Reconnection ❑Non- plumbing 4. ❑ Rejuvenation 4;, 3 0 f o'z-8 - ?I5 = 000
Sanitation >zo - f OQ( - 1 0 — dOd
B) Permit Number Date Issued
fate Sanitary Permit was previously issued 0 / 70
IV. Type of POWT System: (Check all that apply)
Non - pressurized In- ground (�(Jl ❑ Mound a 24 in. suitable soil ❑ Mound <_ 24 in. suitable soil ❑ Mound A +0
❑ Sand Filter / ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
Pressurized In- ground - ❑ Holding Tank ❑ Single Pass ❑ Other
At -grade Aerobic Treatment Unit ❑ Recirculating
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil AiTplication Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals. /day /sq.ft.) (Min.Anch) Elevation
np 45ov fb -SZS .o?
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks f�
/? ❑ ❑ ❑ ❑
5D / ❑ ❑ ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair / reconnenction /rejuvenation/installation of non - plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non - plumbing sanitation system.
Plumber's Name (print) Plumber's Signature (no stamps): MP /MPRS No. Business Phone Number
= fin._ �A `L 0 o -It4.( ZZ3-v �, 17 /1_ _ wZgZS
Plumber's Address (Street, City, State, Zip Code)
o� o , �- �� K �'� ° I
III. Coun!1 Use Only
Disapproved Sanitary Permit Fe, ate I ued Issuing ent Signal No stamps)
LY Owner Given Initial Adverse � 1 /1 Determination `
IX. Conditions of Approval /Reasons for Disapproval:
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained _ r
as per management plan provided by plumber.
All setback requirements must be maintained ,fiJ L2 `7
as per applicable code /ordinances.
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buye
Mailing Address
Property Address " 4 < 6 L� �✓ 1����/
(Verification required from Planning & Zoning Department for new construction.)
X 30 — / 0 Z's '-Fri -:wnho
City /State Gj Gr��T�,4 /Parcel Identification Number 0 zo too I _ t o _ gQ v
LEGAL DESCRIPTION
Property Location '/4 , '/,, Sec. 7 T N R�own of �(A 50 yt
Subdivision Plat: TkQ y T R oa f; �(� Lot # Zd .
Certified Survey Map # 4 3 � y y , Volume Page # � $'
Warranty Deed # ( 3 � 3 Y (before 2007)Volume s7 Z, Page # 3
Spec house�yes Lot lines identifiableA�y no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(l) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) the on -site
wastewater disposal system is in proper operating condition and /or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
I /we certify that all statements on this form are true to the best of my /our knowledge. I /we am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms ,
1` SIGNATURE �OFAP DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving the
D6 144 �,,� residence locat at:
If- 1 /4, ly E 1 /4, Section �, Town Range / 7 , Town
Of NOSSO N , St. Croix County Wisconsin. Upon
inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be functioning properly.
Most recent date of service q N1 O `8
Did flow back occur from absorption system? Yes No-X--
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Capacity: 1OW -1260 "ate A4--
Construction: Prefab Concrete L-"' Steel Other
Manufacturer (if known): ( A4,�
Age of Tank (if known): /7 7F
/m "Z6�� /;1'
(Licensed Plumber Signature) (Print Name)
mtop s z - z- C'0
(Title) (License Number) MP /MPRS
gI3)os
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes)
or licensed disposer (NR 113 Wisconsin Administrative Code)
'VOL 1572 PAGE 581
I>66346
STATE BAR OF WISCONSIN FORM 2 -1999
REGISTER OF DEEDS
Document Number 'WARRANTY DEED ST. CROIX CO-, WI
RECEIVED FOR RECORD
This Deed, made between Teresa M. Clancy and Gera N. 01 -05 -2001 4:45 PM
B utler, wife and husband
— WARRANTY DEED
EXEMPT V
CERT COPY FEE:
Grantor, and Donald K. Harkcom and Mary Kay Harkcom, husband COPY FEE:
and wife TRANSFER FEE: 749.70
RECORDING FEE: 12.00
PAGES: 2
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix _ County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Name and Return A�Qress
See Attached Exhibit A m OCC
S.�
030 - 1028 -95 -000 & 020 - 1001 -10 -000
Parcel Identification Number (PIN)
This is homestead propert3.
(is) NXOO
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of December 2000
�*Teres a M. Clanc --
s
—' « Gerald N. ut —
s
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) �M ' )ss.
4/
. y fg County ) �
authenticated this _ � ( day of — Personally came before me this � aY of
December 1 2000 the above named
BARRON Teresa M. Clancy and Gerald N. Butler, wife and husb —
EAqWWIbVWWqMVqM E - - -
u TITL E: MEMBER S to me known to be the person(s) who executed the foregoing
(If not, instrument and acknowledged the same.
authorized by § 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY + —
Attorney Kristine Ogland Notary u tic, State of Wisconsin
Hud K 54016 My Commission is permanent. (If n t, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
IrTOVmatbn Professionals Company, ForW du Lac, WI
' Names of persons signing in any capacity must be typed or printed below their signature. aoo ess.zozi
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 1999
. -. lVQI. �J7?PAfE505
Exhibit "A"
(� 3 c�P qqv
Lot 201 of Certified Survey Ma d December 27, 2000, in Volume
14, pag 016,s Document No N
635909 ocated in the W of the NE
and the of the NE of Section , 9N, R19W, Town of St. Joseph,
St. Croix County, Wisconsin, being part of Lot 20 of Certified Surve
Map filed in Volume 1, page 92, as Document Nom.
325982 in the St.
Croix County Register of Deeds.
A do z 63h444
CA CERTIFIED SURVEY MAP
Located in the NW 1 /4 of the NE /4 and the SW '/4 of the NE'/4 o�Section 7, T29N,
R19W, Town of St. Joseph, St. Croix County, Wisconsin, being part of Lot 20 of
Certified Survey Map filed in Volume I, Page 92 as Document No. 325982 in the St.
Croix County Register of Deeds. That part of the SW %4 oftheNE 1 /4 is located in the
Town of Hudson, St. Croix-County, Wisconsin.
OWNER /ADDRES,V
TERESA CLANCY
1083 GOLDEN OAKS ROAD NE CORNER SECTION 7,
HUDSON, W1. 54016 T29N,R18W, ST, JOS EPH, e
(1' IRON PIPE FOUND) g
BMRINGS REFERENCED TO Tl}L
NORTHEASTERLY OF LOT SCALE IN FEET I
HIi 150
C}:R'l1F}I:D SURVEY MAP IN VOL. I, I'AGI-,
92, PREVIOUSLY RECORDED AS AND 0' 75' 150 3 00'
ASSUMED TO 131?AR S27 00 o
S 8B• 55' 30' W 2065.47
NOTE: PARCEL "A" IS
DESCRIBED IN VOL 1572, PG. a� >t '� ro NOTE: THIS CF.RTIFIF.D SURVEY
379 ST. CROIX COUNTY crA a MAP IS INTENDED TO REPLACE
REGISTER OF DEEDS. a \0\ ' THAT CERTIFIED SURVEY MAP
^S
g ' OT FILED IN VOI_ 1, PAGE 92 IN THE
AN ) ST. CROIX COUNTY REGISTER OF
G - � { G DEEDS. PARCEL "A" WAS SOLD
OF �51� � TO AN ADJOINING OWNER AND
r 0F ��� �N 0 0 n THIS MAP REPRFSF.NTS nIAT
Scale 1 �� 150 Oi? o 2 �0 �5 \`'� � 0 -p PORTION OF THE ORIGINAL LOT
R O ,�a ►►� ' s
�� � TIIAT IS REMAIN[NCi.
`b. <�, o ALSO, THIS MAP SUPERSEDES
PREVIOUS NE LINE OF THAT CERTIFIED
LOT 20, C.S.M VOL. 1. SURVEY MAP FILED
N 9 a y1 • ° o,y \`'� PAGE 92. / IN VOLUME 14,
!c (P ,& / PAGE 4016 IN THE
ST. CROIX COUNTY
REGISTER OF
Cb \ 1'i O DEEDS.
1' MION PIPE FOUND 0 lev
\ 1.91' S01 4711 "E FROM !
COMPUTED POSTTION `-
LOT 209 lv LEGEND
206,836 SQUARE FEET
O ( 4.748 ACRES) ` �P- SECTION CORNER
MONUMENT (AS NOTED)
NW114 -NE111-4 ��' P 1" IRON PIPE FOUND
O I X 24' IRON PIPE
WEIGHING 1.68 LBS. / LIN.
88
I 1" IRON PIPE FOUND FT. SET.
VO
1 83! FROM
CO 0
1 COMPUTED POSITION
NOTE: TI IIS MAP IS A
�
DWELL /
R1iSURVEYOFAN SWI 14 - NE1 14 CURtT""V'0nh1TI0N
UR VE 1
EXISTING PARCEL. � N / � RADIUS- 539.95'
TOWN AND COUN'T'Y
APPROVALS ARE NOT I 3 / DE.L TA- 25°28'(X)"
REQUI11ED. b CHORll- 238.(2'
Q
}�'" S44
�► ° / ,'a A/S" ARC- 239.99'
Q / ' �',.••" TAN. IN- 531°52'2( "1V
:' J EPH W. * TAN. O(TI- S57°2('20"W
I 0 092 ° G ANB RG CURVI: 2
I �'� / W ?'HMOND RADIUS- 636.11'
i WI ) DELTA- DF43,18"
Men"
� WQM 0 ° o
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.r
Va, .� S
in � La L"
W ► lt'
GNU ~�' -at°iW
CERTIFIED SUR VEY MAP
Located in the NW' /4 of the NE' /4 and the SW '/4 of the NE' /. of Section 7, T29N,
R19W, Town of St. Joseph, St. Croix County, Wisconsin, being part of Lot 20 of
Certified Survey Map filed in Volume 1, Page 92 as Document No. 325982 in the St.
Croix County Register of Deeds. That part of the SW '/4 of the NE 1 /4 is located in the
Town of Hudson, St. Croix County, Wisconsin.
DESCRIPTION:
A parcel of land located in the NW '/4 of the NE %t and the SW '/4 of the NE '/4 of Section
7, T29N, R19W, St. Croix County, Wisconsin, being part of Lot 20 of Certified Survey
Map filed in Volume 1, Page 92 as Document No. 325982 in the St. Croix County
Register of Deeds, further described as follows:
Commencing at the NE Corner of said Section 7; thence S03 °39'50 'W 330.46'; thence
S88 55'30 'W 2065.47'; thence S27°5 1'00 "E 490.54' to the former Northerly comer of
Lot 20 of Certified Survey Map in Volume 1, Page 92; thence continuing S27°5 1'00 "E
247.96' to the formerly Easterly most corner of said Lot 20; thence S3 1`52'20"W 63.81'
to the point of beginning; thence continuing S3 1 °52'20 "W 393.40'; thence
Southwesterly 239.99' along the arc of 539.95' radius curve concave to the Northwest
whose chord bears S44 °36'20 "W 238.02'; thence S57'20'20 'W 50.92'; thence NO2'
09'40 "W 242.26'; thence Northwesterly 318.87' along the arc of a 636.11' radius curve
concave to the Southwest whose chord bears N16°31' 19 "W 315.55'; thence N59'
07'00 "E 451.07'; thence S27 51'00 "E 277.21' to the point of beginning, containing
206,836 square feet ( 4.748 Acres ) more or less and being subject to any easements,
restrictions and covenants of record.
SURVEYOR'S CERTIFICATE
I, Joseph W. Grranberg, Registered Wisconsin Land Surveyor, hereby certify that by the
direction of the owner, Teresa Clancy, I have surveyed the lands shown hereon in
accordance with official records, Chapter 236.34 of the Wisconsin Statutes, the Town of
St. Joseph Subdivision Ordinance, the Town of Hudson Subdivision Ordinance and the
St. Croix County Subdivision Ordinance and that this map and description are a true and
correct representation thereof.
GENERAL NOTICE STATEMENT The parcel shown on this map is subject to State, County
and Township laws, rules and regulations ( i.e., wetlands, minimum lot size, access to parcel, etc.)
Before purchasing or developing any parcel contact the St. Croix County Zon' Office and the
appropriate Town Board(s) for advice.
THIS INSTRUMENT DRAFTED BY: JOSEPH W. GRANBERG.
DATED THIS 6 DAY OF JANUARY, 2001. �� G D S /,y
SE H W.
O f G AN ERG
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N RICHMOND
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PREPARED BY:
GRANBERG SURVEYING
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Parcel #: 020- 1001- 10-000 05/18/2005 10:33 AM
PAGE 1 OF 1
Alt. Parcel #: 07.29.19.1 K 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* HARKCOM, DONALD K & MARY KAY
DONALD K & MARY KAY HARKCOM
1083 GOLDEN OAKS DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1083 GOLDEN OAKS DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.710 Plat: 1200 -CSM 14/4018
SEC 07 T29N R19W PT SW NE SLY 250 FT MOL Block/Condo Bldg: LOT 201
OF LOT 20 AS SHOWN ON CSM 1/92 PART OF
THIS CSM IS IN TOWN ST JOSEPH Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
030 - 1028 -95 (108A) NKA PT OF LOT 201 CSM 07- 29N -19W SW NE
14/4018
Notes: Parcel History:
Date Doc # Vol /Page Type
01/05/2001 636346 1572/584 WD
07/23/1997 940/112
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.710 53,300 188,100 241,400 NO
Totals for 2005:
General Property 0.710 53,300 188,100 241,400
Woodland 0.000 0 0
Totals for 2004:
General Property 0.710 53,300 188,100 241,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 119
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel #: 030 - 1028 -95 -100 05/18/2005 10:58 AM
PAGE 1 OF 1
Alt. Parcel #: 07.29.19.108A -10 030 - TOWN OF SAINT JOSEPH
Current �X' ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): ` = Current Owner
* HARKCOM, DONALD K & MARY KAY
DONALD K & MARY KAY HARKCOM
1083 GOLDEN OAKS DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description " 1083 GOLDEN OAKS DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 3.920 Plat: 1200 -CSM 14/4018
SEC 7 T29N R1 9W PT SW NE NLY PT LOT 20 Block/Condo Bldg: LOT 201
OF CSM 1/92 ALSO SURVEYED AS LOT 201 OF
CSM 14/4016 NKA LOT 201 OF CSM 14/4018 Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
PART OF THIS CSM IS IN THE TOWN HUDSON 07- 29N -19W SW NE
020 - 1001 -10(1 K) EXC AS DESC 1572/579
Notes: Parcel History:
Date Doc # Vol /Page Type
01/05/2001 636346 1572/584 WD
01/02/2001 636344 1572/579 WD
07/23/1997 940/112
2004 SUMMARY Bill M Fair Market Value: Assessed with:
4965 71,600
Valuations Last Changed: 07/07/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.920 70,400 0 70,400 NO
Totals for 2004:
General Property 3.920 70,400 0 70,400
Woodland 0.000 0 0
Totals for 2003:
General Property 3.920 41,400 0 41,400
Woodland 0.000 0 0
Lottery Credit Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
=0
NORTH EAST CORNER SECTION 70
T 29 N R 19 W
CURVE DATA TABLE
3
Curve -2 R = 539.95' O
Central Angle = 25028' SCALE
Chord = S44 0 36 1 20 1 1V 238.02' 200 0 100 200
Tangent Bearing = SS7 "W
M
Curve 3 -4 R = 636.11 TRUE N
Central Angle = 28'43 BEARING POINT OF BEGINN S 88 o 55 30 W
Chord = N16 0 31 1 20 "1V 31S.SS' 20 47'
Tangent Bearing = : ;30 °53'W S 27 51' E
490.54'
2� o
2 2 O 6 • �6 N r',a
LEGEND - 21
SECTION CORNER NIO ff:
iM1� - r . y 9 ° off N NW 1/4 - N E I
120
O 1" X 24" IRON PIPE WEIGHING �� 104 °21'40
1.68# /LINEAL FOOT. 1 EASTERLY RIGHT- F-
33. LI E 20 A . *
5.07 ACRES
33
3 5 6
��/�
�0% e CO d !I� - — I ; w ry` �r NORTHERLY R IGH
oat►, +�\ e°" \ OF-WAY LINE
FRANCIS HA
1 �
U�a ` p 19 °21'40"
• ry I
= . Z 19
S -882
RIVER FALL4, G:° I 167 16'
1
W1s r {� SW 1/4- NE 1/4
F .•' °i .j o N � /
%10048866 m
3 6 A W 50.92'
00 30' S 57 20" W
SURVEYED FOR: K. B. Pries ter
619 2nd Street, Hudson, Wisconsin 54016
DESCRIPTION
Aparc — e - 1 -- of land located in the W1 /2 of the NE1 /4 of Section 7, T29N, R19W, Town:
of St. Joseph and Hudson, St. Croix County, Wisconsin described as follows:
Commencing at the NE corner of said Section 7; thence S3"39 "W (true bearing)
330.46'; thence S88 0 55 1 30 11 W 2065.47 thence S27 ° 51 1 E 490.54' to the point of
beginning;, thence S27 247.96 thence S31 0 52 1 20 11 W 457.21' along the Norther]
right -of -way line of an existing town road; thence Southwesterly along said
right -of -way line 240.00' on a 539.95' radius curve concave Northwesterly whose
chord bears S44 0 36 1 20 11 W 238.02 thence S57 0 20 1 20 11 W 50.92' along said Northerly
right -of -way line; thence N2 "W 242.26' along the Easterly right -of -way ling
of another existing town road; thence Northerly along said Easterly right -of-
way line 318.88' on a 636.11' radius curve concave Westerly whose chord bears
N16 0 31 1 20 "W 315.55 thence N59 506.25' to the point of beginning.
AS BUILT SANITARY SYSTEM REPORT
A
TOWNSHIP SEC.
....• s ,, , ,,...
ST. CRO X - COUNTY w WISCONSIN ,
1
' LOT LOT SIDE
PLAN VIEW
� d a 49 6 4imemi to meet requirements o H62.20
W ti
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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Width length....; are
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A Pp
(� AREA
UIR AS' BUILT
e�flat #hap+cion of this system by St. Croix County ;does not imply complete
r eter Administrative Codes. There are other areas that it is, not possible
this port of construction. St. Croix County assumes no liability far
+an4 a;io Howoyer, if failure is noted the County Will make every effar to
o. fai�ur�
AHOwQ LS SRO NOT BE DISPOSED THROUGH THIS SYSTEM.
4 ^ d
`INSPECTOR
WV 4
'
/ PLUMBER ON 30B
]F1111R.iFFln 15 I Y
}
LICENSE NUMBER
Z _ _ REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
Sanitary Pehmit-
1
State Septic
NAME � � � � � Township
St. Croix County
Location -4 o4 /'� %, Section 7 VA, R 11
SEPTIC TANK
Size 01S 5 gattonz. Numbers a6 Compartments
Distance From: Glee it. 12% of greater ztope 6t
Building it. Wettandb ix.
Highwaten it.
DISPOSAL SYSTEM
Distance From: Wett ' it. 12% of greater ztope li iz.
Buitd.Lng it. W ettand.6 Ft.
Highwater it.
FIELD DIMENSIONS:
Width o f trench y 'j it. Depth o f tack b e.Cow tite —42-- .
F Length of each tine T - it. Depth of Aoch oven tine � i n.
Number: o6 tines :� Depth of tine below g
s
Totat .length o6 tined Sto pe o6 trench kn peh 100 it.
Distance between tines t- Depth to bedrock
Totat ab.eorbtion area <� ;; f bt Depth to gtoundwatet fit.
2
Requited area it
PIT DIMENSIONS:
Number o6 pigs Gravet around pit.6 yea no
Outside diameters it. Depth betow inlet it.
Totat abz o&b,tio ax a it . A
J, 3: Atea %equi � �t � rn
INSPECTED BY TITL
APPROVED �/ , - )ATE / 197.
REJECTED DATE 197"
01 1.15
4 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
' DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
k P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: SW y, NE %, Section , T N, R 1 E (or) W, Township or Municipality Hudson
Lot No. 20 Block No. Trout Brook Hills County Ste rni
Subdivision Name
Owner's Name: David Plank
Mailing Address: RR 2, Hudson, Wisconsin 54601
TYPE OF OCCUPANCY: Residence X No. of Bedrooms 4 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT X
DATES OBSERVATIONS MADE: SOIL BORINGS Sept. 27, 1978 PERCOLATION TESTS Sept 28, 1978
SOIL MAP SHEET St. Croix Co. Interim SOIL TYPE Onamia loam
report BSA- 2FF -58
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM— INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
P_ 3" dk bn Ts 1, 18" bn sl,
1 36 15" s 26 no 10 2 1/4 2 1/2 2 1/4 4
1P_ 8" dk bn Ts 1, 20" bn sl,
2 42 14" s 26 no 10 2 7/8 3 2 3/4 4
6 dk bn Ts 1, 20" bn sl,
3 36 1 10" s 26 no 10 1 1/ 1 8
SOIL BORING TESTS
TEST TOTAL DEPT b UNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES. �j B VED TIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B _ 1 72 `� '� 72 3" dk bn Ts 1 18" b sl 51" s S
2 78 ii I bn Ts 1, 20" bn sl 50" s
3 72 72 6 dk bn Ts 1 20" bn sl. 46
4 78 . n A 7$ 7" dk bn Ts 1 10 bn 61 "
_ 5 72 none 72 12" dk bn Ts 1 12" bn sl 48" s S
6 72 L 72 10" dk bn Ts 1 18" bn sl 44"
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. 660 sq. ft. trench, 820 sq. ft. bed Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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State and County State Permit #
Permit Application Count y Pe it
1 for Private Domestic Sewage Systems Count
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. R OF PROPERT Mailing Address:
`!���
B. LOCATION: '/4 '/4, Section _, T Af R .0 E (or) W Lot# City
Subdivis' n Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCU Commercial ndustrial *Other (specify) *Variance
Single family � � Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: ishwasher YES NO Food Waste Grinder YES _NO # of Bathrooms
Automatic Washer ES NQ Other (specify)
E. SEPTIC TANK CAPACITY Total gallons No. of tanks
*Holding tank capacity To No. of tanks
New Installation Addition lacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F oe
F. EFFLUENT DISPOSA�LJS -STEM: Percolation Rate 1) 2) 3) Total Absorb Area sq. ft.
New Addition A- Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length Width Depth Tile Depth 4 ,C> No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certified SoiwTester, p�
NAME 3 C.S.T. # — and other information
obtained from (owner /builder). �y
Plumber's Signatur / PRSW# r Phone - 0 1 0 geD
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).