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#COMMERCIAL TESTING LABORATORY, INC. ICI 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715- 962 -3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ST, CROIX COUNTY GOVERNMENT REPORT N00. 43404/01 PAGE 1 CENTER REPORT DATE: 6/22/93 1101 CARMICHAEL ROAD RATE RECEIVED. 6/18/93 HUDSONr WI 54016 ATTN** THOMAS C. NELSON OWNER** Ernie Zappa, Jr. LOCATION** 316 Edgeaood Dr., Hudson COLLECTOR** M. Jenkins DATE COLLECTED: 6 -16 -93 TIME COLLECTED: 2**15pm SOURCE OF SAMPLE*# Outside faucet DATE ANALYZED : 6-18 -93 TIME ANALYZED:1i.00am COLIFORM** 0 /100 mL INTERPRETATION'# Bacteriologically SAFE NITRATE -N** t 1 ppm Above 10 ppm exceeds the recommended PubLic Drinking Water Standard. Coliform Bacteria /100 ml Nitrate - Nitrogen mg/L 1 2 o 01 LAB TECHNICIAN: Pam Gane OF.NDEVfNpE r H WI Approved Lab No. 19 Z< A C Means "LESS THAN" Detectable Level Approved by** i 4 PROFESSIONAL LABORATORY SERVICES SINCE 1952 � � ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386 -4680 Ot� SEPTIC INSPECTION / WATER TEST REQUEST FORM Specify desired test(s) & remit appropriate fee with application. (� Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. ❑ Water (VOC's) $185.00 ❑ Septic $25.00 ,X Water (Nitrate & Bacteria) $35.00 (Visual inspection) Owner: , c z, jxf Requested by: /Pe' W6 • � 4v A &n .k Address: e .tv Address: `T .D ✓.` City & State: I I ri"A , City & St. JVctD So Al, Zip Code: a f << Zip Code: Sa Telephone N°: ( 6 4 7 & Telephone N ( yflS j .3 Lu Rk # '7 /5" 3 8l - a 3 j _ S �,to R, - 77/y o Property address (Fire N & Street) : &Af e Location: ;,;, Sec. 7 , T 2. N, R U Town of S St. Croix Co., WI. Tax ID N l arcel /ID 4 3 -4 Q @ House color: Br�(� Realty firm: N rnn L oxVombo: Water sample tap location: Ejtj TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Is the dwelling currently occupied? Yes 0 No If vacant P date last occupied: s Septic syst installed by: Year Septic tank last serviced by: Date: Previous Owner's Name(s): Have any of the following been observed? 12 1 ❑Y ON Slow drainage from house. ❑Y ON Sewage Back -up into dwelling. ❑Y ON Sewage discharge to ground surface road ditch or body of water. ❑Y ON Slow drainage from the dwelling. ❑Y ON Foul odors. 5� 0 cP �p� pFF� f 'n Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. � OWNERS SIGNATUR9ti - UG14r4 - DATE: I OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION NN — TO BE COMPLETED BY INSPECTION NCY System design & /or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system Q�elow grd ❑At - Grd ❑Mound Approx. size 'X ❑Gravity ❑Dose ❑Pressurized Ft. ❑Bed ❑Trench ❑Dry Well Molding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other (dnknown Septic tank „, Setbacks: ❑House ❑Well -- ❑Prop . line Q'.,)k ]Other Dose tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover ❑Warning label ❑Pump /Floats ❑Alarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House ❑Well - ❑Prop. lin ❑Othe ❑Ponding: w, ) ❑Discharge: General comments INSPECTORS SKETCH OF SYSTEM LOCATION N Inspectors J r , Title 0 m o o f § (D � § g 0 / ) �.. T.. CD CD � r O _ \ z « r a z o_ o o. c 7 ° • / (a ° I p I § ° E go ) *4 I E g K) , , g » 2 £ 0 [ B a ƒ O - § � N ro E; ] 2 w 0 < %� ) ) } ) _/ f 0 § \ l fA ■ M a Cn \ / G F Ca F CD 7 / § ¢ ) m / ¢ k CD o OF 3 q § CL e $ / o o 0 , m. � ® § \ i ® ( \ K O ee CDo. / 2 2 L $ \ k E �. a / � 9 § 0 0 0\ 0 0 0 E C', / M. { ) )) / f { (A k ( E / 7 q G 7 CD 0 / R § K \ E E 3 E cn § I ; \ z � / \ o \ . \ g S n 7 � o 2 m / % D § kN / kN C ( \ E E FL 2 \ 2 / ■ CA k § § § 7 E # § 9 0 Z / * (D m C co CL 3 o l / $ o o FF z » / m 7 z ! � �f � �% '� ; fƒ2 � fk n = a § 0 e § , a o § n � ; -{ z % z % o = o k \$ &{ � )/ � i $ C � f = 0 $ E k-j qb ƒ ƒ / \ C m /o »o kCL §i �2 SxC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS 3 1 & 3 7 7 /f vf�So^� G� /S • S� � � SUBDIVISION / CSM# ,00y ST'�s LOT # 3 3 SECTION 7 T Z ? N -R l W, Town r ST. CROIX COUNTY, WISCONSIN ��� O ZO 00 p PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM,_ N J / AV -5 464 O /oo lij�� INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic- tank manhole cover- ORIGINAL BENCHMARK: ALTERNATE BM: -o 4f e iV C 1, e 5 Do " /,90, 26 611 Sl7 N6" SEPTIC TANK / PUMP CHAMBER / HOLDING. -TANK INFORMATION '� ?S Manufacturer: tV Liquid Capacity: Setback from: We11 /SQ House Other �y GAT L Pump: Manufacturer Model# /� Size/ Float seperation • Gallons /cycle: -A Alarm Location c7yl' C 7 CD . :SOIL ABSORPTION SYSTEM Width: Length 7 $ Number of trenches Distance & Direction to nearest ro line: 2 - Z P . P- Setback from: well: Sy House ( ;P 40 Other e C T I � lL ELEVATIONS Building Sewer ST Inlet: ST outlet. PC inlet 93 • 0 PC bottom 7 9' 5 4 Pump Off icg o 70 Rea Bottom of system s�Q�2 OI --- Existing Grade Final grade DATE OF INSTALLATION: yyJJ --yy�� PLUMBER ON JOB: Roll ?� �( / / ✓/� Gyl LICENSE NUMBER: INSPECTOR• 3/93:jt s • 1 ' /45 RVI'Z, 7 ` o pz-o � I �� /,( , / / 1 :7 - Ulbrl ht & Ass ates Pr(v a Sewage onsultants 655 'Nell Rd. Hud n, Wis. 5 018 y� r 7 to 19,0 i J 1 I I ► 7I��w � Ir s I of Z� . 5y' � 03 4 � 2 - Tai f� .3 , i� a= = T1) . 0 �,v Pro it- 00 a Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: ,safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)( 384205 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: L ukas, Mark Hudson Township CST BM Elev.: Insp. BM Elev.: BM scription: Parcel Tax No.: 020 - 1164 -00 -000 TANK INFORMATION ELEVATI N DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Id U U Benchmark 0 �0 v Dosing t lt. BM ation Bldg. Sewer - Holdi (5/ Ht Inlet CJ�_ ?2, Q TANK SETBACK INFORMATION fit) Ht Outlet Z. d TANKTO P/L WELL LDG. Ventto ROAD Dt Inlet S / f f Z,'(0: / SO 3 Air Intake Septic 7S"D + � I 7- NA Dt Bottom Y 40 p O Z 20 . . Z Di NA Header / Man. 7. L Q L 1- g `.� ; Zing on Dist. Pipe Bot. System g , 6 PUMP/ SIPHON INFORMATION e Final Grade 9 , Manufacturer 9�' Demand t over Model Number Z j GPM r s r ` Friction System TDH Zp t TDH Lift , - L , I f Forcemain Length Dia. Z r' Dist. To Well J , .Z 0 Z l0 SOIL ABSORPTION SYSTEM /° C� Z L BED THE Width r Length mo No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth 1 E N x. IM N LEACHING Ma a r r. SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREA HAMBE INFORMATION Type Of Z Z _51/ Mo Number: System: p f Z DISTRIBUTION SYSTEM Header / Mani of Distribution Pipe(s) 9 �� x Hole Size 7 x _ Hole Spacing Vent To Air Intake Length Dia._ Length GZ,S Dia. �[� Spacin SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over x [xxSeeded /Sodded xx Mulched enter Bed / Trench Edges soil es ❑ No ❑ Yes [3 No fnMMFy�S Inclu ade cr an r s ent ection #l: /� /O� Inspection #2: Lo'CiYtibri''31Ti Eag�ewoo�� rive, u(flon,'' Waif (l�f�' 1/4 1/4 7 T29N R19V) - 072919963 Edgewood Estates -Lot 33 J > o ( teu�✓ ir,ev o� ✓c'��w cr P (4", 4 1.) Alt BM Description= p r / 2.) Bldg sewer length= �J � S �1�. +o Per f1 wn1e1 S AS- 4,0 - amount of cover = Qrcc,( P 3,) 4i,,,..k s luwc p up ec�' . G f L ��o /, 6, ,1W 3 a� � `9 eg; s� a! / A 4 ;e / orb fi�4i►� D - ' 7/Z(o/ Plan revision required? ❑ Yes 0 No Use other side for additional informhtion. B SBD -6710 (R.3t97) Oat Inspectors ature Cert No. .- Wa,4 4joA rv ^k,wj r'Jn `t k a� (r- sPrL�q� C� 3 9 a Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ST G/PD�. v �• N iscgmsin Madison, WI '53707 - 7162 Site Address 31& 506 Department of Commerce /,�vD O 4�/. Sel. Sanitary Permit Applieatio Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal info 1 4Z Q� may be used for secondary Privac Law, ❑ Check if Revision I. Application Information - Please Print All Information �0 State Plan I.D. Number Property Owner's Name Parcel Number 1 LU�i4S �fFR rn k MAY 7.Qf11 ZD• /liY cat .�' .fib Property Owner's Mailing Address ST CFOIX Property Location 3 t0u?ITv ZONNVGOFFNCE NW tX AIWIA S ` T 2 'f N, R u City, State Zip Code Number Lot Number Block Number �Lo ff VJ9 _# o,J Cv/ S • S S ubdiv i sion o� � , 33 3 �d ision Name amber S49 15 00V ' ES7 -r,&. -s II. Type of Building (check all that apply) 3 ❑City X 1 or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public /Commercial - Describe Use ownship u Vv� OA_-3 ❑ State Owned t / Nearest Road R Z 3 K (ail. TS III. Type of Permit: (Check only one box online A (numbering scheme for internal use). Complete line B if applicable) A. 1 ❑ New I 2 )(Replacement System 3 ❑ Replacement of 6 ❑ Addition to — o For County use System Tank Only Existing System B • ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44)d Non - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Dis ersal/Treatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals. /DayslSq.Ft.) (Min./Inch) / t•• 0 �` Elevation y�a 315 3 .7 �(. .� / r3• o' 9y to VI. Tank qTank Capacity in Total Number Manufacturer Prefab Site Steel Fiber P lastic Gallons Gallons of Tanks Concrete Constructed Glass ew Existing nks Tanks ,p Septic or Ho Dosing Chamr 75O 1 - 7 SO �, �• l/ VII. Responsibility Statement I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature UP/MPRS Number Business Phone Number VOSERT' Wil?141 as co 3 ? 7/S • 3 0 • 8ljOS Plumber's Address (Street, City, State, Zip Code) k 4P 55 Xv 0 / R IL PLO h�v PSo s ,) W Y,01 4e VIII. Count /De artment Use On X Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signa (No Stamps) Surcharge Fee) - ❑ Owner Given Initial Adverse DeterminationS� IX. Conditions of A for Disapproval � (, (�.9.Q!!,a(� vwu.L- 5 - (]t �'•�+�A.i �"�^ - 1 04 PAI 1 �1 OWA 0 . �t Attach complete plans (to the Connty o*) for the system on paper not less than 81/= s 11 es In size SBDy6398 (R. 05101) 717 S DoT 55'C,41E ; / -2 D e. D /l�T /O�vS f,o'f- Dl ., ql, 5 T, 93,a� �- I f 1 - - - -- ; 0,� I� ,r 4. (1p 95,0' � r ✓ Z ...�- of -T A L tP 5q t i, 4► /o 0, o o : 33 �I - 0 6 8 i Z� sTo r o,D 13 j e ion-- l 30' 2- 0 I � KBRICHT & ASSOCIATES CO. y Q55 O'Neii Road • Hudson, WI 54016 Reg. Designers of Engineering Systems 715- 386 -8185 Private Sewage Consultants PROJECT INDEX Plan I .D. # Date w' y :2g. .6 Owner M I GU� ��li /� S i . �� NN�� e -Phone 3 • I1'1�C Address .3/(, �!�(�- � j d0 f� o �/t ° )4d- Legal Description Town of op's6 County s/ X C.S.T 0 2 Z(,e 3 7 S' Installer U 7 Local Authority/ Supervisio 1 2;(/ / d 51' � /'X Cif /` - PROJECT DESCRIPTION - ORIGINAL cc.,rrsri &- 3 e lS . �- 7.5 GIFT l" 7_1t1V a ( � ' CA S Tim �`� S� �� . ( UlbdCht �.0 s0 Gl7i e`St�J' CD•(� Ct,l Lp . a / Privaef I*we OOR�l1lii�flE� 655 O'Ne8 i • Hudson, Wis- 54010 IS Pg.1 PLOT PLAN VIEWS Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS (REVERSE SIDE DETAILS INSPECTION PIPES & FABRIC /TOP FILL DETAILS) Pg.3 PIPE LATERAL LAYOUT (REVERSE SIDE SHOWS DETAILS OF LATERAL CLEAN OUTS) Pg.4 DOSING CHAMBER CROSS SECTION & SPECS. Pg.5 PUMP PERFORMANCE SPECS (REVERSE SIDE SHOWS PUMP DETAILS) Pg.6.OPERATION, MAINTENANCE REQUIREMENTS (REVERSE SIDE SHOWS �_�.� - - .��.- �.��.. ...... .. �. ... ...... .. ...... �� .... T1•T/TIt T.TTl1LT TTTkTT,ITTT' T!% o �y o tn SIN o�f[�[ N FN VIA w n ' Zl �i PAS ;17 I S, C-, LvT ✓ .5 : / -2 D v n � /- �tJrtT /OrvS Ef 1 1 I Ise oT I I 6e 9 O' I "� �l 5 y5T - I - X4te4 S) t3s y3, o ' ' --- Z� rkP � 5q ohs jAJ Q l Ltit I 1 -r P {� 30' 2- a i 7 '0 A& Usti c APP �D T .4/d R JR/ . 2 �. 1// M 125 Cfo SS SEc �o,) © TrpEw�s T � Z�Si 6- l� ►��, c� j�Ac � r)/ ,,S�pE-w;,v�,� �� � L 3 'x G '�. " � o,v c� �''' l ► IV 54 * V1OA00j!!%P c �fcir�/ SCG 7 A1 0 I ff ! An observation pipe may serve as a combination observation/vent pipe providing it terminates in the same manner as required for vent pipes. See Figure 6. Vent cap � Return bend . /Cap 12" nil". 12" min. Final grade. ; Aggregate istrilrution lateral 3 e t o' yp. a '& q... \System elevation Figure 6— Vent and combination observation/vent pipes Leaching chamber tops are at or below the -original grade. Leaching chambers are placed directly on the bottom of the distribution cell. The locations of leaching chambers are in accordance with Table 3 of this manual. Observation pipes are installed in the distribution cells and are provided with a means of anchoring to prevent them from being lifted up. Observation pipes extend from the infiltrative surface for stone aggregate systems or from the inside of leaching chambers to a point at or above finish grade. The portion of the observation pipe below the distribution pipe for stone aggregate systems is slotted while the portion above the distribution pipe is solid wall. Observation pipes for leaching chamber systems are attached to the chambers in accordance with the chamber manufacturer's printed instructions, extend from a distance >_ 4inches above the infiltrative surface through the top of the leaching chamber up to or above finish grade and terminate with a removable watertight cap. All observation piping has a nominal pipe size of 4 inches. See Figure 5. I f Water tight cap V min. dia. Th Repair couplings Slot F min. . Infiltrative surface Water Closet Collar " Bar (318 mitt. dia.) PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS P /fyE 6 p > /O - f o Gvi vDotd, -Dooe 7 p vc- -VEMT CAP I PIP i VENT PIPE WEATHER PROOF APPROVED LOCKING Q'f JUNCTION BOX MANHOLE OVER 1 2�MIU. I w� lu,t�(N�o(� IA/3El 1"17 GRADE I 4" MIIJ. � IB" MIN. / CONDUIT 3.0 _--- - - - - -_ � IE v�+r�� � ti yp' � g INLET PROVIDE _. -_._r- - - - - - - -- AIRTIGHT SEAL I I V I I I APPROVED JOINT A INy I Ii� APPROVED JOINTS w/ PIPE I N M I I I � EXT[Mt)[IJG 3' 01 ( I I ( ALARM EXTENDIMG 3' OMTO SOLID SOIL B -) I I it ON�� LI OIL sr,,4 . qo P / 3 ( �0 19 i i OIJ vo /01 Q q o c 3 ELEV. �I� / FT. 1 J " Z/.iE 3 mil I PUMP -� OFF BLOCK ( c At V f io A) j �r uG RISER EXIT PERMITTED OUL IF TANK MANUFACTUR6.R HAS SUCH 'APPROVAL SEPTIC E SPEGIFICATIOAJS DOSE ��(f(^,{ IJLIMBER OF DOSES: PER DAS TANKS MAIJUFACTUR.ER: TAAIK SIZE: �SC> GALLONS DOSE VOLUME 39 / ALARM MAUUFACTURER: LEv 41A" ( INCLUDING BACKFLOW: GALLONS MODEL 0 NUM E : �� ' G ' C APACITIES: A= CNES ✓� B R �IN R GALLONS 0 z SWITCH TYPE: B = INCHES OR 37 5 GALLONS PUMP MANUFACTURER: C= = ,L INCHES OR 1 GALLONS MODEL NUMBER: /3+ If P CIS v ' D= � INCHES OR 2 �'�' � GALLONS SWITCH TYPE: _pi w Ucr NOTE: PUMP AMD ALARM ARE TO BE 77 MINIMUM DISCHARGE RATE� GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. I �' ( FEET -rAOF L SPIELS y� - MINIMUM NETWORK SUPPLY PRESSURE // . , , , .. . FEET EACG� ZZ.S FEET OF FORCE MAIN X /�� � F /ooFT.FRICTION FACTOR. !� FEE = TOTAL DYNAMIC HEAD = * 'L3 FEET INTERNAL DIMENSIONS OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH A UO ID U 0 / U,G, E- felf 2 z S F' . pv Fo Nei l 36.E l / TO AST (30 � J J ZOELLER EFFLUENT PUMP MODEL' 98 8 I ' IIEAb CAPACITY MODEL r�g1)CUIiVE �s— r TI I Js le— 0 —+ + le— 11 1 3/m e 1 1/2 -11 1A NPr �!. aLLoNS 10 --- 40 _ so so Io so so 1 FLOW PEq MINUT E • 210 • f of ll( DVNAyq HrM•rl°W too fur W t f ' frrlurlrt u�o orw�rrwN° �� tA►Atllt 1>f . �_ YNIIe/M�lr ! Iv fit! lrrye 11 ! 0� 1! /7! t or l »I or ri e° s Wck v&% J 5/10 CONSULT FACTORY FO 0 Elsclrlcel atlenletors, for duplex ey01er110, ere ev:dlable a p SPECIAL APPLICATIONS $owed wAh an elerm M • Mercury noel awhches are avaAable lot c �. 11ce1 eMs oche Idr duplex a ele three Ilse onlro11in' e wAhoul Maim hvllchee. v me, ere evelleble wllh a e �' eyelems, 9 Ingle and Double pbgybeck mercury noel Switches are avellable lot varlable level long cycle controls. Blendard all Models. W N series ei hl 30Ibe. - /1ll. 1, InlegretMoalo e ELECT1oNOUIDE Model Control 9eleejlon !. stn to i Pertled 2 pole r erJcat ewhch, no eelerndeonbol legldred. t y h_ f! ! Ph; M�od_e 4:7 o P o0rbeek mercury rl°a1 switch a double Pf;oyb ewheh. 141er b fM0111. °eN mer°ury. aoN ulo .. Du let �. Meehenky ppE --- -..I m— 1. ass F ?, la oorr/cl �y4 t N 2JO _ 0 !. Mercury eemfo Ib.l �� M Eleclrlcal Akanela, ! r e i °� (0) a (q #O•1 •y lerte IooZ20 „Md y • eomrd .etivaa ,peetlp ! a 1 1 a 1 hple "j Pak", IuneM°ri d N eonnecdon or wlred•in eMn• p! fell • J• ►e1< ". la welerMelN eara......n epNa. tAr„ p„ y�� M4r MedIRM ►elw b wite4 � �, 11°11► E binr,M � Mrintla- /lln�u... _. . rM061/7 •r ._ . _ _ •..._� _ PAGE 6 REVERSE SIDE OWNER's MAINTAINCE OF SEPTIC SYSTEM POWTS (landowner) is reponsible for proper operation and maintenance of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of this system. The owner is required by code to submit all necessary maintenance /inspection reports to the controlling authorities. SPECIFIC CONTACT 'AGENTS s{, j�KJ /X 1'�` , �O * Governmental authority/ inspectors: o/ ,���5 * Licensed installer, responsible for providing an operation/ maintenance "Users" manual: ,Vo I3" * Licensed service / inspection agent other than installer: * Electrician, for pump, electric controls, wiring units: (� 6 . "' 733 IMPORTANT OWNER MAINTENANCE REQUIREMENTS 1. Winter traffic (sledding, shoveking, etc.) across the area shall not be permitted, or frost can /will penetrate into the cell, freezing up the system. Discontinuos use in the winter (a vacaction trip, resul tin in no water us e) e) can also lead to freeze ups. 2. Water conservation needs to be exercised! Or system can be hydrolically overloaded and destroyed. This system was designed for a maximum wastewater flow of 4150 gals. daily. 3. POWTS are not designed to accomodate wastes from a garbage disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. 4. If a power outage occurs, or a pump fails, it may result in a temporary overload of effluent being pumped into the cell, which may adversely impact the cell (leakage). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts. Consult your installer immediately for advice. 5. Neglect of the vegetative cover (the cells insulation & erosion preventive) can lead to failure. Compaction or heavy t he traffic also can destroy system. It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER � ER A SYSTEM!! Ef fluent the system beneath IS NOT sufficient alone t0 maintain a grass cover. 6. Periodic inspections by the owner, or his aaentG. is r �� 13 V ye s ; M�4 ��,� S J av f ���� Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code X 1 C 41 D Q � Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County C -Tj include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. D /G [� Cep • OC9O percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Z� ' Please print all information sewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).,��� Property Owner /-- �n Property Location /� ) & C— gw+ J Govt. Lot NW 1/4 !V W1/4 S I T 2 -1 N R Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 3 /Lv �f> 10002) l�,f'. 33 f 3 SP&6 e51 City State Zip Code Phone Numb r ❑ City [j Village Town Nearest Road ffvUS W/, 5 W16 ( WS ) 3SI6 • y6sG /fv�soA 4XVa ",0- DAP. ❑ New Construction Use:,1 Residential / Number of bedrooms Code derived design flow rate GPD X Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments �, STiN 6— SY S % . / / Cf /�(� S) /S and recommendations: .SOS 1 d Sig T7� -PAL ls' /'t Fvx �e Zr�e . Ow c 0e4e . /� �r r :e �,. e�„ -►'� � C /� - /3 s • 113�� ��l/ /c�� rc.�.( �DiVlr• O/�GG /LJ ilia ,tt F 71 Boring # ❑Boring ��. ft ? D SE,¢So,vAllt' - 5 'i4-Tui1�t� pit Ground surface elev. . Depth to limiting factor J in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I 'Eff#1 'Eff#2 1 4 /PY/f 31 5'C 2 -441 i �n C G/ 2 , S • 9 z- 3o io y� S / s Cry 30 IV 2 - • 5 3 lh //f' Ike i 3 /' s 5 wW/ZL, 51d eVWA— Boring # ❑ Boring 7 ` s�iis�il/i�lY s�rGGr+Cj . ❑ Pit Ground surface elev. J ft. Depth to limiting factor j in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 d• /© re 2- 3 S L Z�s6k z Z? /D 3 j /fS n- y►�X C / 2 -7.35 /o .> �'. D dt as - ? �• Z S•� 75 31 C Z� 1oyle C` z Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L. CST Name (Please Print) Signature CST Number o 6k r zl/,6 G41T 2203 - 75 Address Date Ev luation Conducted Telephone Number S•3 ; Uibricht & Associates Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 1 Property Z Parcel ID # Page 2- of P Y Owner " Q Boring # ❑ Boring pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 0 �/3 5L 2- I sAe "W 3 Y • io cZ 6z M oTS /O 2-- � --- rie 4 s YI-f y16 Boring # ❑ Boring ( 7o Pit Ground surface elev. " ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 49 /oYle3 /3 — Gs 1,mshe b �, w 2f • 7 �• Z �V • /V /o /P y` z- 5 /,►t, cs .7 z FYI Boring # ❑ Boring ❑ pit Ground surface elev. O ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture 1 Structure Consistence Boundary Roots GPD /ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 D 3l LS 1,w .7 /. Z G / ,t C -7 /.2- 3 ' Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SBD- 8330I(R.6100) 2 � 3 Property Owner � • � Parcel ID # Page of ® Boring # E] Boring ❑ pit Ground surface elev. ! ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft In. Munseli Qu. Sz. Con Color Gr. Sz. Sh. 'Eff#1 "Eff#2 - i 2 /0 Yle A i 4 - 2 .Z- /o ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fl In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 ❑ Boring # ❑ Boring Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SBD -9330 (R.6100) , s Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4 1/4 S T N R E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village ❑ Town Nearest Road ❑ New Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments and recommendations: F] Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I •Eff#2 Boring # Boring ❑ ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 F Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg /L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Address Date Evaluation Conducted Telephone Number P-EDs 47— 5C,41-;/ s ysr 9 s- o' s'� q, 67p I � i of p 0 Top I g� 1 2 z i l oo r p a(o 50 �, t �ou� 30' % ST CROIX COUN'I•Y SEPTIC 'TANK M AINTENANCE AGREEMENT AND -- OWNERSHIP CERTIFICATION FORM Owner /Buyer Mel< Z I/ e1 s Mailing Address J Property Address (Verification required from Planning Department for new construction) #V' City /State Parcel Identification Number LEGAL DESCRIPTION I' Property Location (V O '/4, IV U) 1/,, Sec. - , T if N -R W, Town of V L S O"J Subdivision ������ t�$T�f -T�$ Lot # 3 3 3 Certified Survey Map # Page # Warranty Deed # (�° 7 7 2 - - Volume _ 16 3 1 - ,Page # 413 Spec house ❑ yes ❑ no Lot lines identifiable yes ❑ no SYST MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed putifper verifying that (l) 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 die 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 staling that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the tht yea expi tion date. SIGNATU E O - APPLICA DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) 9m (are) the owner(s) of the prUty ribed o ve, virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is nris- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with tills application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 183)jFA;,E 432 STATE BAR OF WISCONSIN FORM I - 1999 64447'2 WARRANTY DEED KATHLEEN H. WALSH Document Number REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Ernest L. Zappa, Jr, and RECEIVED FOR RECORD Betty J. Zappa, husband and wife 05 -03 -2001 9:00 AM Grantor, WARRANTY DEED and Mark J. Lukas and Jennifer A. Polk, both EXPIPT R single persons as tenants in common CERT COPY FEE: WPY FEE: TRANSFER FEE: 590.70 Grantee. REC9RDING FEE: 10.00 Grantor, for a valuable consideration, conveys to Grantee the following PAGES: I described real estate in St. Croix County, State of Wisconsin (the "Property ") (if more space is needed, please attach addendum): Lots 33 and 34, Plat of Edgewood Estates, Town of Hudson. Recording Area Name and Return Address 020 - 1164 -00 -000 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This is homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Roadways, Easements, and Restrictions of Record. Dated this 30th day of April 2001 . ` `Ernest L. Z- W-1/ r ' "Betty J. Z pah AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) Signature(s) ) ss. St. Croix County. ) authenticated this day of Personally came before me this 30th day of April 2001 the above named Ernest L. Zappa. Jr. and TITLE: MEMBER STATE BAR OF WISCONSIN Betty J. Zappa (If not, to me known to be the person s who executed authorized by §706.06, Wis. Stats.) Kay V. Palm the tp r oing in t ent d a knowledged the same. THIS MSTRUMENT WAS DRAFTED BY Notary Public • K V alm Michael H. Forecki, Attorney State. of Wi sconstwtary Public, State of Wisconsin Eau Claire, Wisconsin My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are nor necessary.) December 12 WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1 -1999 *Names of persons signing in any capacity must be typed or printed below their signature. -'--- ZlpFonn^ by RE Fonn$Net, LLC 18025 FIR— Ml* Ra d. 0"M "M Township Micrrgw 48038, (800) 383.9805 Pr Altarney M3hxel H F—ki 1830 B,e ., Avq Eau CWa W154701 - 462] Phone:(]15)835 - 3029 F— (n5)r354112 06683901.Ur �55y S i �° � �• � � s ue . � ` � , � w 71.00 a r Q �° w •O O ° • +I s .. r• i 1 - o + a -� rt 0 1 M / r too r i Oa1.`M►.. 0 R m S its• o �O • " 1 • 41 � 1 ° s'111 I `'•, 1. 4 4' 41 1!•47 2441.14' . TO � � per. E 1 / 4' COw11tR !!44W � � . `� /1 a•41•w� :s7.u• r ROAD AI O '41 "w 271.74' + IC ••'' � s .M � !i �+ j ' o z �e40_ l 0 211sr r a — LSEL �i_N_ !4.553' sso.o0' 1 41 -w 214.sa' 9s iBU - ROAD M O —1 _ 1 '41- 214.7=' " 3'45.± x 1 scow + w � (+ w � w ,; � •• z � N �I M O OI �a1 ss•41 -w 1TaZi rr d-4,OT _ 0 o w 0 .. s - fir CA ° C y + II w► a L�- w e 1� ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN E ISTING SEPTIC TANK N d to 449L. W - - J*C41WIF &2 P& ��- This is to certify that I have inspected th eptic tank presently serving the � /E - residence located at: — 1/4, tiAl 1/4, Sec. , T Z � N, R / W, Town of # VPs 0-j ,_ Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced A -1 y;2, fl / Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete " Steel Other Manufacurer (if known) : 4J 14ESEi e cw6t t ee-- YJ Age of Tank (if known) : I tIll.2ox • (Signature) me) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name _ -OB E'kT U I b2 IC(7 — Sig n ature ��MI/MPRS 5/88 Ulbricht & Associates Private Sewage Consultants 655 O'Neil Rd. A uudson, Wis. 54016 Parcel #: 020 - 1164 -00 -000 12/13/2004 04:52 PM PAGE 1 OF 1 Alt. Parcel #: 7.29.19.963.964 020 - 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 * LUKAS, MARK J MARK J LUKAS POLK JENNIFER A POLK JENNIFER A 316 EDGEWOOD DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 316 EDGEWOOD DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.050 Plat: 1929 - EDGEWOOD ESTATES SEC 7 T29N R19W EDGEWOOD ESTATES LOTS 33 Block/Condo Bldg: LOT 33 & 34 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 07- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 05/03/2001 644472 1631/432 WD 07/23/1997 723/318 2004 SUMMARY Bill M Fair Market Value: Assessed with: 49030 226,100 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.050 32,800 142,100 174,900 NO Totals for 2004: General Property 1.050 32,800 142,100 174,900 Woodland 0.000 0 0 Totals for 2003: General Property 1.050 32,800 142,100 174,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 211 Specials: User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 f Form -STC -104 AS BUILT SANITARY SYSTEM REPORT OWNER 15 1� mlL TOWNSHIP SEC. _ _ T,. N -R Z�2 W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM y r-� r � - INDICATE NORTH ARROW BENCHMARK: Describeaddomwertical reference point used ply ic�z.5 ,! /Ar�ctx� ��,rcat, Elevation of vertic point: i0z) Proposed slope at site: /-0 • ti PUMP CHAMBER i' . Manufacturer: 1 ( Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size :. Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Pt. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: V Trench: Width: Lengkh: 4T. Number of Lines: Area Built Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, Number of feet from well: z Number of feet from building: l� (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box. 'been used on any of the above soil absorbtion s y terns? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING! LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 79219 ` BUREAU OF PLUMBING MADISON, KI 53707 KXCONVENTIONAL ❑ALTERNATIVE State Plan iDD. Number: (If assigned) E] Holding Tank El In-Ground Pressure 1:1 Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: B & H Develo ment R. R. 2 Hudson WI 54016 1l� g6 /_ 6) BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN'. REF. PT. ELEV.: CST REF. PT. ELEV. - SW�WT - N Sec. 7 T29N -R19 W Town of Hudson, of #34 d ewo d Name of Plumber: MP /MPRSW No Counly Sanitary Permit Number: Roger Timm 3224 St. Croix 69669 _ SEPTIC TANK /HOLDING TANK: MANUFACTURER: + LIQUID CAPACITY. TANK INLET ELEV TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER C� PROVIDED PROVIDED: Q)_ / �" S lI. OYES ONO DYES 5mo BEDDING: VENT DIA. VENT MATT HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING VENT TO FRESH ALARM LINE AIR INLET'. FEET FROM _.5-- / -) ❑ YES NO DYES NO I NEAREST �- `4� c DOSING CHAMBER: MANUFACTURER BEDDING. 1-101-111 CAPACITY J PUMI MODEL j PU1,1P,1IPR0N MANUE ACT11EtEH WARNING LABEL LOCKING COVER PROVIDED'. PROVIDED: ❑YES ❑NO DYES ❑NO ❑YES ❑NO GALLONS PER CYCLE: J PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL J BIJILDING J VENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LI NE AIR INLET. PUMP ON AND OFF) DYES 1:1 NO NEAREST 0 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I f Nl,Tll J IIIAMI TEIt MATERIAL AND MARKING or excavation, (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue,) MAIN CONVENTIONAL SYSTEM: `F�� WIDTH'. LENGTH NO OF D PIPE SPACINI, COVER J INIIDL DIA -PITS LIQUID "BED /T1i ENC" 1 TRENCHES // MAT EHIAL: PIT DEPTH DIMENSIE151S.. a -- R V LDE FILL D ' UIS1 Ft PIPF DIS7H PIPE DISTR PIPE MATERIAL NO DIS t NUMBER OF - PROPERTY WELL. BUILDING: V NT TO FRESH BELOW PIPES ABQVE COVER EI EV INLFF EL V END PIPES LINE AIR INLET FEET FROM (c t - 1 1 4 .7Z I� . G c� 2 7 2 `1 NEAREST---•• �S �� j J 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- 1:1 YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER I TEXTURI PE HMANI NT MAHKF HS OIfS EHVATION WE TITS ❑YES ❑NO DYES ONO ' DEPTH OVER TRENCH BED DEPTH OVER TRENCH 11111 DEPTH OF TOPSOIL SODUF U SEE UFL MULCHED CENTER EDGES ❑YES. L1 NO Y ES ONO DY 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH No. OF LATERAL SPACING GHAVEL DEPTH BELOW PIPF 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'. D ISTR I BUT ION II11FORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ONO DY ES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS'. FEET N BERRUOMF L NE: WELL: BUILDING: q I El YES t ❑ NO ❑ YES ❑ NO NEAREST I 0 (1 !i �i trt Aii (6 Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TI E. DILHR SBD 6710 (R. 01/82) .: -1 -— unsconsin APPLICATION FOR SANITARY PERMIT � (PLB 67) C OUNTY �OEPRRTmEnT OF UNIFORM SANITARY PERMIT # r InouSTRV,LR801 6MUTRn RELRTIOnS &Z 9 — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /2x 11 inches in size. —See reverse side for instructions for completing this application, PLEASE PRINT PROPERTY OWNER MAILING ADDRESS 4 A/ / zzel a PROPERTY LOCATION r CITS': 1 /4 /4,S 7 , T- N, R (or)O TOWN O • We iiZ l lT7 LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER 3S< ?� TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: 3 ❑Public (Specify): THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity U Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: e d IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity 41 Z11 Lift Pump Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of P_ umber (Print): Signature: MP /VI $$ICLNo.: Phone Number: `7e 3Wd 4P 4 Plumber's. dress: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved �� 6-D q � y0 n El Owner Given Initial jj 5 A ppro Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber r t INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property �� PV C LO #3MFN - IfJ G Location of Property SU3_ PO 1 4, Section _2 _____ T "! N - R Township &dsorj io Mailing Address f T, V Subdivision Name 2i. xg --- V Lot Number ,3 • 3 Previous Owner of Property AtI / Total Size of Parcel Q�`L Date Parcel was Created Are all corners and lot lines identifiable? No Is this property being developed for resale (spec house) ? Yes X No Volume 1 70 s and Page Number T' 6Z as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Deed Z. Land Contract 3.• Other recordings filed with the Register of Deeds Office 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 Certified Survey Ma shall also be Ma the the e y p r q P• -------------------------------------------- PROPERTV OWNER CERTIFICATION 1 (We) eeAti6y that att axatementa on thin 4on.m an.e tAue to the b eat o4 my (oun) know2.e.dge; that 1 (we) am (ahe ) the owner l a) o6 the pnopeh ty dea eh i,bed in thiA in6o4mation 6onm, by vi tue o4 a wwL&anty deed neeonded in the 0 44ic e o4 the County RegiAten os Deeda ab Document No. 3ff7& ; and that I (we) pneaentty own the proposed zi bon the sewage poz ayatem (on 1 (we) have obtained an eaeement, to r w.,. - ; above deaeni,bed pnopenty, bon the conat.u.cti.on o6 aai,d A ana tiame has been duly neeohded in the Oj4ice o6 the County Regl . 1 6 0 , ^ument No. 3997E ) /1 A e ty if St. Croix Ir feby certify th�f this werva" 1. a full, lrue'add dcrred coPY.,OQ§6z40VAW* an file 6f 46*d in My o#iq%, qnd has tree. 66*at4d by dtfes: 1.t..,.:S ptember 18 • in 85 James O'Connell anNS Car" Register of ` Deputy I a 9 ST C- 105 r `F a SEPTIC TANK MAINTENANCE AGREEMENT h St. Croix County z r Y OWNER /BUYER D_CV w _ c� ROUTE /BOX NUMBER �T• z Fire Number E f j CITY /STATE VC1C.0 �Vi• _ ZIP ',j�/C1 14 PROPERTY LOCATION: S W 0*1_ 1 4, Sectio T N, R Town of //V0/50A) St . Croix County, � _ f ' f } Subdivision Q0 5� -I- Lot number .33 -3 7/ 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. If k St. Croix.County residents m_ y be eligible to receive a grant for j: 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 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 - by 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. SIGNED DATE / ✓ a St. Croix County Zoning Office P.O. Box 98• Hammond, WI 54015 715 - 796 -2239 or 715- 425 -8363 Sign, date and return to above address. ° LO) r n s � s r -1 ? fA N N 03 0 j v cn w CD ? ID 7 cD `� O O0 Q p C p 0 w N > c�aN m�o�v�� F 0 CD awe i ::C N� � r �o3n, o� °��w o (D •» C o w o C 7 7 . m = o w G zQ w .. N m w w 41 30 W N o a (D < m N :N ca Q p (D c p _D c - cD _• G) w A d tD pi .' (D �p 7 ? fA C 0 CD w CD Z w =0) r. � p C $ a N ( (� m ?� D -� N CO) a D .. =0 ' war: 'T > > CA ac 0� m C m CD 0 o CD N CD up, aw ( A n O.Ca ..ID w Qw = °, ..o u, o �_�� a wow CD 9v�' ° ' c DTI S ao f 0 ap�i p Cl a a o m Q 0 f a= N ��� N �c � n (A 0 �'(°a pN`���° 7 CL p a c( w 2 m m c cD S ,� a c 3 0 ? C D 0 0 F� a � OL o 3 CD w o -� Z F. T • I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, . DIVISION C P.O. BOX 7969 LABOR AND HUMAN RELATI H63.019(1) TESTS (115) MADISON, WI 53707 H63.09(1) Bt Chapter 145.045) LOCATION: SECTION: OT N. K. NO.: SUBDIVISION NAME: SW 1 � �'� Z9 N�R /9 �lo 14Uts 33 3 . — CU,F-\4 & CSTA + ES COUNTY: :. ' , &6 I A �� YssL4 836 STGeplx sm. NotTu flue W, DATES OBSERVATIONS MADE O TS: ArResldence �AI(C N • �• ONew. OR eplace. ° �� Ui6usT Z9 dIS&< - *PT Z S e- P4 49 Sts, c � : � s$ 3, .W ET RATING: la Stitt pi14e far system U- She unsuitable for system r ONVIENTI im P LL OLDI G ANK: RECOMMENDED SYSTEM:(optio 1 9. .- U. S ❑U ❑S ❑S Loti V1<�T'loNAL E b If Pereolatioto Tests we NOT required DESIGN RATE: If any portion of the tested area is in the A � under e.fI61.00(5)(b), itust�et� �CJaSS Floodplain, indicate Floodpla elevation /Y, A PROFILE DESCRIPTIONS BORING r A 1 THICKNESS. OLOR, EXTURE, AND DEPTH NU lm w RLEVAfION eFFIV1110 TO BEDRqqK IF OBSERVED EE ABBRV. ON BACK.) ��� ::►. 0-1.1 B- ►l �. /- .z GwS, Z- 2.9 N CL / lO1.� ► . NaNE /x•10 z.g - 3•S @RNSL 3 /A / meof S G-k 12., © -/ SL / 0 -2.0 s 5,L 2.a s.0 N L B- Z 12.0 /07.1 /IJoN 1C 00 S .Qa- �T .O n.ee/ 5 54 B- 3 /or3' �o2'.25� IYo�.v>r 5io -3o' d -os &� 3- O.3 SeNR jS -33 5a.,e L BL[_ o.s- /• 3 gem S r C /.3 -/•8 a L 4 /bib' /a1:4Z' BONE '>/ ' /. M6 S S{ 6R 3.s- /b•0, r•rds 041 4ILL /. / -2.2 U L 2.2 -2.4. S4mb.L B- 4 5 /4�.a /olo. b' NoIN t 7/0 Ao 2. L• /o. o 'S w 6 e PERCOLATION TESTS EST MJMIEit I I t AL -Mile. RAPER M INU TES P. 06 / A 4 17. P• 3 5.6 bjjI 4b &akIL 7 , P. E I 0 . . "LOT PLAN: throw IoO joss of permletion tests, soil borings and the dinwmions of suitable soil area. Indicts scale or distances. Describe what are the horn :ontM end vertibel 0m tion i0mmosoe points and show "Ir loction on the plat plan. Show the surface elevation at all borings and the direction and perch+ of land slope. SYSTEM 1 p i 1 W • w ;S /S r Lri-r ! 34 I f i .. __. _ i i ! IAaMet .... • • to wig AVILO I'=4& 7. L 161C 1 etiG o0 1 JOB �47 �✓ 6C�l�P /�iO ROHL & TIMM EXCAVATING SHEET NO. OF 310 Arch Street p y HUDSON, WIS. 54016 CALCULATED BY M DATE (715) 386 -8664 Q ' / CHECKED BY DATE_ SCALE .......... ........ . . .... b $ ri\ `A ! 1 ..... . ........ w !`a , j i N V. I PRODUCT 204.1 ees Inc., Groton, Mm. 01471. JOB KOHL & TIMM EXCAVATING SHEET NO. � OF 310 Arch Street _ • HUDSON, WIS. 54016 CALCULATED BY �'� ��•"�`" DATE �� L 60 (715) 386 -8664 mn � CHECKED BY DATE_ SCALE � -- JD_3, y� eav � rt . . .......... ....... ... . ... ......................... . ......... ............... ............. ............ .......... PRODUCT 2041 Inc., Groton, Mass. 01471.