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HomeMy WebLinkAbout020-1369-08-000/* Wisconsin Department of Commerce Safety and Buildings Division C- / PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ^ City ^ Village ^ T n of: McCabe, Thomas Hudson Township CST BM Elev.:- Insp. BM Elev.: BM gescription: _ ~. TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ ~ ~ 6~0 Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septic ~ Jr-p' ZZ f --- NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION Manuf cturer and Model Nu r PM TDH Lift Lriction System TDH Ft Fo main Length Fi oweu SOIL ABSORPTION SYSTEM County: St. Croix Sanitary Permit No.: 3b3883 State Plan ID No.: Parcel Tax No ELEVATION DATA STATION BS HI FS ELEV. Ben~i~n~r~ ' 1v0 •©~ Bldg. Sewer ~ ,(, S- c(g. 3~ ' St / Ht Inlet ~ .$Z~ 9'8. 13 ~ St/Ht Outlet 6,q~ r gaip0 Dt Inlet Dt Sottom -~- Header /Man. • 36 •ro 96.5 9~ , YS• 3a Dist. Pipe g•~ 4•~ ~° ~~ S• zs' Bot. System c ,Z ~ 9~, ~s n~ ~' Z Fin Grade Cn.~E~ 5.82 9• r3 B~ ENCH Width - s Len th , No Of renches p1T No. Of Pits Inside Dia. Liquid Depth DIM N I ~ DIMEN I N SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEAC G M aaurer: INFORMATION Type O n , > , "' ~~ CFiA NIT Mo a Num er: System: ~,p-~r~v . 50 1 ap DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) t~ x Hole Size k Hole Spacing Vent To Air Intake u Length ~GL Dia. ~. ~ Length ~ Dia. ~ Spacing ~ ~ ~ I QD t SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over eye- r,~, Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Cente !# Z Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: fXo/ell /a'o Inspection #2: / / /U'e•~S ~ Location: 688 Old Hopkins Place, Hudson, WI 54016 (NE 1/4 SE 1/4 10 T29N R19W) - Hoplcin's Prairie -Lot 8 ` 1.) Alt BM Description = /v~A 2.) Bldg sewer length = 2,Z. o ' ,~ ~~~ ~~ ~,,, ~ ~ ~" u -amount of cover = w~llbe. o,~ ~~ ~~(c.~-l• F~ (,le.,~'~,pc~°.,~ Io-.k~~ lel-~-ou~ ~t~ .~.~cr-aue ~` . 1,.~ :ll u.Qso ~a- ~' ~~w~ °va~ s yS'I~.,~^ °w~c` off.:-~. c~~ c~.~,.pt,~ s~.l c~~..ri ~.S ~~... a;~5~~~ --(~~~""~'e''. Plan revision required Yes No 1 Z [.~ 2«~ ~ S ~ .~ Use other side for adds ion I info a~ti~o~n~.~~Q,~ , ' Sc.-""""'""""^' ~ Date Inspector's igna ~ren -.~- •~.~s Sa~. r_Cs?t3,~~~Std~- (// 1S1BD-6/710 (Ri3/97)~~ . A l,t 1o u-K~~ '1e-1T l Q:'U Sc.Ylu~+~! Su~ r~2.rS~ sl,~.~,~ e,.M.o.. CJ~+cdR~~ ~.;a~ . l,~ . Page 1 of 1 Kevin Grabau From: Rod Eslinger ~~~: Sent: Friday, January 05, 2001 11:20 ~g8 O` ( ~~` ~S (~ To: Kevin Grabau r.C ~'(~ Subject: lot 8 Hopkin's Prairie Kev, Could you call Majid Entezarian at 386-6997 (h) or 715-262-8052? He's looking to obtain a copy of the septic system design for his property. Supposedly, something wrong with the drain field, it sounds to me that the system may be frozen. Check it out and let me know whazzzzzzzzzzzz uuuuupppppppp!!!!!!!!! l o wt l~~ ~ a~~ Bill Schumaker was the plumber. The permit was originally issued to Tom McCabe and the permit #'fs6~8$3. Subdivision: Hopkin's Prairie, lot 8, NE 1/4, SE 1/4 Sec. 10, T29N-R19W, Town of Hudson. ~3 Thanks. ~~e ~ ~ J ,/ ~J ~~ , f ~~ ~- Rod Eslinger Zoning Specialist St. Croix County Coning 1.101 Ca.rrnic°hael Load Hudson, WI 54016 phone 715-386-4680 fax 715-386-4686 rode@co.saint_-croxwi.u_s ~ S~ ~ ~ ~o~ ~- cam- ~ ~-~-~- ~ ~ ~~'~ ~~ `I~a~-- -~- ~.e, ~:e-w...-~?'~•~-~ oa,~ .t~n,~ a _ Gs~"~. •k-~'~-Q- o~oQ. F'co ~a„~ . ~~~M~`~~ c~1 J ~` ~` ~s ~. ~ _ _ -- ~ ~ _ ~~ s sue- .~*~ ~ ~ ~-""l'"~"~ . . ~~~ ~~ ~' ~,E~` Sr'o ~ Safety and Buildings Division SANITARY PERMI , k~~CATION 201 W. Washington Avenue ~SC~ns~n y , P O Box 7162 Department of Commerce In accord with Co °Q5 WiS. Adm. Code j „Q.~~ ~~G' ~ , Madis WI 53707-7162 U! (/ o ~ --ns~~r~~ - • Attach complete plans (to the county copy only) for ~ yster~,a' r not less County ~ than 8 vi x 11 inches in size. ~/ ~ p.- ~ • See reverse side for instructions for completing th' `plicaitipf~ ,~ , ;,~, `:, ~ 2 ~~ 0 State Sanitary Permit Number ,_~ t, ~~ t ~ u 6 3 ~ 3 Personal information you provide may be used for secondary purpo ~~:. S i C,ROIX ?_., _ ` Check if revision to previous application [Privacy Law, s. 15.04 (1 } (m)]. ,-°`~~ CO{1N'TY ' ,, J~ ~~~ State Plan Review Transaction Number L` APPLI ATION INF RMATION -PLEASE PRIN ~' ~I PropJert~OwnerName ~ /,-''~- G' ~ ~y cation R S T a N E (or A/ T~ a Zia D ! , , , Property Owner's Mailing Address ~ r of Number ~ Block Number `7f ~! ~ ~Y ° dS ~ >r . City State ~ ZiptC-ode Phone Number ( ) Subdivision Name or CSM Number ' ~ ~ f 6 u GS l ~ J~ eL II. YPE F B ING: (check one) ^ State Owned 3 ° !t ° rowan o Nearest Road ,,/ ~~ ~~ ~ Public 1 or 2 Famil Dwellin - No. of bedrooms f Sc~.,r1 o i Y III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) a °? Q '- ! r1 /U ~ ?Q' ~~4 d 1 ^ Apartment /Condo 2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify ~ IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1, ~ New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an ______System ________System _____________ TankOnly______________ Existing System ___ _ ExisttngSystem - B) `~ A Sanitary Permit was previously issued. Permit Number 36 3 ~$ s Date 15sued $"- ZZ- Z~xrU V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 [:Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^ Seepage Pit , , 43 ^ Vault Privy i~l S ( ~-- ~ (~.~p 14 ^ System-In-Fill ~~ o p - k VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade ~~-~ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 9S. 3 Elev ion '~ ~ S ~~ a~ t~'•c,~. S Feet q Feet ~ VII. TANK INFORMATION Ca acct in allots Total # of Manufacturer s Name Prefab. Site l st Fiber- Plastic Exper. N i E i Gallons Tanks concrete ee glass App ew n x st strutted Tank Tanks Septic Tank or Holding Tank ,X QC}C~ / c ' W~ ^ ^ ^ ^ ^ Lift Pump Tank/Siphon Chamber ^ ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No amps) P PRSW No.: Business Phone Number: dll r (~• sz ~ k ~».. ~ a2? 4YQQ / - '~ ~- 3101` Plumber's Address (Street, City, State, Zip Cod ): D a' !~ of e ZJ . IX. COUNTY /DEPARTMENT USE ONLY ~^ Disapproved Sary Permit Fee Oncludes Groundwater ate ssue Issuing Agent Signature (No Stamps) ,Approved ^ Owner Given Initial ~ Surcharge Fee) ~ ~ 6'~ ~~ t Adverse Determination X. CONDITIONS OFAPPROVAL /REASONS FOR DISAPPROVAL: "Ise ~e_ ~y ~, (.i~.~: ~~ s ~ ~ , ~ ~ ~ G~ s~ ~- ,~~~ ~~,-+z --~ ~ ~~~ . SBD-8398 (R.12/99) Original to County, One copy 70: Safety & Buildings Division, Owner, I _ . INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a 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. 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. Onsite sewage systems must be properly maintained. The septic tank(s) .must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check al- appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII: Tank information. Fill in the capacity of every"new/or existing tank, list the total gallons; number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILNR. VIII. Responsibility statement. Installing plumber isto fill in name, license number with appropriate prefix (e:g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains water service; streams and lakes; pump or Siphon tanks; 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; frictior. 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 1 15 form; and F) all sizing information. GROUNDWATER SURCHARGE ._ 1983 Wisconsin Act 410 included the creation of surcharges (fees) fora number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations. and establishment of standards. VY~~~.:U~~si„ ~~pan~iirirn or commerce SAIL AND SITE EVALUATION ~~"~~ ~~~ ~~-~ °' -~ Qivisiort ufSafety antl Buildings '~~'~"'~'~" Bureau of Integrated Services .n accordance w'th s. ILNR 83.09;:1+s. Adm. Co ~~- Z- AttRCd i campleta ate plan on paper nat less than 8 112 x 7 t inches in size. PIBn must f.~u County include, but not limited to: vertical and horizontal reference point {BM)r"dirscfion a~ ~~ ~'~' i ~ , ~/ C Y° ' ~ X peroent slaps, scale or dimensions, north arrow, and lacetion and dEStanc~;ta near®a3 road. Parcnt LD. +- APPLICANT INI=ORMATION - P/sass print all lnform~ peroanal information you provide may be used for sacorsdary purposas (Privacy Property Owr~ar r r`.v'O' FAD ~'~ '~Vaj` s Zf Coe Phone Number >,U l 5 .~ o~% 1 ~ ~ J ..i • - ., ..,. . ~ Reviews by ~, property Location ' , Cxit+il ~to~ , tfa S' t /d, S (Q T .2 ~ ~"'S'~ ~ ~ Subd. Nsme o+ CSMs ~ i ~P,~~~~~~ ^ city ^ vlnaae ' (Town Date n~2.~-..~~i ,N,R ~ ~' E (or~ Z ~rYt' ~~ Road New Construction use: ,~,Resident;al /Number of bedrooms __.~._ Addition to existing building ^ Replacement ^ Public or commerc+el • Describe' Code derived dally flow ,~~ gpd .- Recommended design loading rate ~7 bed, gpd/tt~ ~ g trench, gpd/ft2 Absorptian arse required ~~,./,~.bed, ftz ~ ~`~ trench, ft 2 Maximum design loading rate ~._bed, gpolf~~,~_trancn, gpdJffz Recommended infikration surface elevaGan(s) ft (as referred to site plan benchmark) Additional deelgrr/site oon~deretione ~/ 15.3 ~~/ Parent material t.C,e.c .a ~ b ~ ~'w~3dr Flood plain elevation, if applicable ft S Suitable for system Conventional Mound ln• round Pressure AT• ra a System n F II Fialding an U Unsuitable for system ®S ^ u Qs ^ ~ ~ s ~ u ~ s ^ u ^ S (~U a S [A U 13aring # ~{ { ~a i' u ~ '`'; f~ t, ~h ~. Ground elev. ~i~ft. Depth to limiting 1aat0T ~_in. Baring # p~~~~o_ e t" r ~j ~a. a ?d around QIeV. y~ft. Deptri to limiting factor ~~_ln. Remarks: CST Name {Please Prini) Signature Tolephone No. ~~ _ ~l.'a m sG~~ ~~ pis-~ - ~a~ Address Date f~T Number SAIL DESCRI i M l PTION RE PORT Structure R if ~ Horizon Depth In. Dom.{Want Color Munsell o es l Du. Sz. Cont. Color Texture Car. Sz. fSh. Consistence Boundary oots Bed Trench 1 -~' 6 eP -- a ~ • -- N c~j ~ S ; 3 y - o s m ~ ,~ ~~ q S~ 2 (acrn~ rlra ~~ ~d , c/r ~ 5 ; ° mg, ~, Iri S~ y G-~ ~'' /r j ~ .~ . (p y ~ d ~ .~ ~- ~t~' SOIL, DESCRIPTION REPORT PROPERTY OWNER ~. _.__.__ Paye ~ ot''3~ PARCEt_ La.a Boring # 3 v~. .:~.; ,~, Ground elev. ~ft. Deplr~ to limiting fg-ctor ,.~_in. Baring # 22a , " " ~,. ~~'~ ~~s 'ri ;c' t ~ 1y ; L... ~ . .. Gr>SUnd elev, ft. Depth to iirniting taotor in. Boring n: :'~ ICU;~~~l~ri~v.. Ground elev. ft. Depth to limiting taotor ~,,,in. Boring # ~.; F;B x: ~li~ i;,4 ~4~M-. .:~75~.. t3round el®v. tt. Depth t0 tlmittng fi3CtOC in. Horizon Depth Dominant Color Mottles T t Structure Consist nce noa B Roots ~, z In. MunseH Qu. Sz. Gont. Color ex ure Gr. Sz. Sn. e ou ry f Sed Trenoh ~ ~-- ~s•. m x ~ F s ~ ~ ~- G'aS S ~- -r1 ~- r 7 i ~?S. ~ ~ - ~- Remarks: '-'-"""`~ Remarks: Horton Depth Dominant Color Mottles Zs re t Str~~oture ConsiStar Ce Boundar Roots 'f'~ in. Munsell tiu. Sz. Cont. Color x u Gr. Sz. Sh. ~ y Bsd ,Trench Remarks: I Remarks: SBD•8330 4R• 0~~61 ro,u=~ ~ ~~,~ ~oe~ ~t/~%ys'~.%~ 5 /~ Ta~'RIQEII fi~w,~/ of ~! dro...%<~~',3',Sr~ "'DNS ~~ ~~ ~~ , ~~ f. ~~ t~ I `~ L ~a v h~` ~ ~~ ~` ~ V °~n o, a i Q ~ ~~ v (I a \' n ~ / ~~~ f,, ~c U~" S~` o.c~ 07- ~ ~ % J~ ~~ /r ;, ~~. ~~ ~~~ / E~ . `~SCOf1S%11 ANITARY PEF In accord with I Department of Commerce • Attach complete plans (to the county copy only) for t than 8 vi x 11 inches in size. [- -~ • See reverse side for instructions for completing this~3pF Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1) (m)]. ' Safety and Buildings Division N 201 W. Washington Avenue '' ~'' ,~ • ~ R 5 C de ~~ P O Box 7302 , s. o ~, ,tj~r~i,~~~ Madison, WI 53707-7302 f 1 1, 1 'system, on pape not I~ss_ ` county f,. ~. ' ~r. ~ ~ ~ f; ~ p l X IicdtlOrlw;? ~ t., ~ ~``~~ ~a State Sanitary Permit Number C ] .~~c p NC3 ~JF~1~,~ f"~. ^ Check if revision to previous application / ~,r~, ,-y~` State Plan LD. Number I. APPLICATION INF RMATION -PLEASE PRINT ALt~ `IT Property Owner Name erty Location V~ ~ ~ v4 1i4, S T , N, R l~ E (or) Prope jy Owner's Mailing Address ~ / 7 ! Lot Number__ ~1 Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number II. TY E F B IL ING: (check one) ^ State Owned ~ !t~ Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms ~_ p Vil age town of ud S ~ '~~ III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ^ Apartment/Condo ~ - ~ 2 ^ Assembly Hatl 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/ Repairs. 11 ^ Restaurant/ Bar/ Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify IV. TYPE OF Pf RMIT: (Check only one box on line A. Check box online B, if applicable) A) 1. ~ New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an -_____System________System_____________TankOnl~r______________ Existing System ________ ExistingSystem B) ^ A Sanitary Permit was previously issued. Permit Number ~ Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tan)C 12~Seepage7rench 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^ Seepage Pit ~ f 43 ^ Vault Privy 14 ^ System-In-Fill ~ s x VI. ABSORPTION SYST M INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min_/inch) Q/,,~ Elevation9~!°p /~ ~r'J S7 d ~ ~ ' Feet Feet VII. NFORMATION Ca aclt in gallons Total # of Manufacturer's Name Prefab. ion Fiber- plastic Exper. N E isti Gallons Tanks Concrete Steel glass App. ew x n strutted T nks Tanks Septic Tank or Holding Tank [.C~CJ C T" y ~/ ~, ^ ^ ^ ^ ^ Lift Pump Tank /Siphon Chamber ^ ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) /MPRSW No.: Business Phone Number: ~J~`ll.°a ~ s~~ ~ - ~~~~ ~ ~ s - ~~ -s~2 Plumber's Address (Street; City, State, Zip Co de ): f / ~D ~ C O z`~ ~ ~'Y GcJ . ^ 't` d IX. COUNTY/ DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee f'ndudes Groundwater ate ssue Issuing Agent Signature (NO Stamps) ,Approved ^ Owner Given Initial Surcharge Fee) aa S UD ` Z S-T Z c Adverse Determination - er1a ; -~ X\. CONDI,,T~~I~~ONS OF APP VA~/RE"A~ONS FOR DIS PROVAL: `/ ~.,, ~~~~+ C t>w ~ Vc- ~'~R_ - +-~~y 3 1 -I"~ W~d~ ~- T~ n ~ C~4.1eti/v Inc ~~ Z / ~ J ~ S P.e./ C.6~- `ce c C e ~ Z ~ / 1 o ~n SBD- 6398 (R.11/97) if uis ~ xisu nun: yygmai to county, one copy i o: sarety & uwwiv uivision, owner, vwmcer INSTRUCTIONS `' w ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a 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. 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. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: I. Property ovuner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. I11. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type- VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR: VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix le.g. MP, etc.), address and phone number. Plumber must sign application form. tX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s),septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; 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; and F) atl sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. . ~ :~~~ .. SG u ~ ~ 1 _ y6 .~ ~? o i ~~ ~~ CQ> ~Y 0~~ t ~~~ `~ ~~ • , ~~~ J V b ~ q ~J ~.~e ~ ~o ~v~ ' v~G ~,~ r~ 0 Wis,ohai~.Departmentoflndustry, SOIL AND SITE EVALUATION REPORT L'~bor and Human Relations Division of Safetv & Buildings :_ _____~ ...:.w ~~ ~ .r, ~., .,~ ..~:_ wa..,, n,..~_ Page 1 of 3 111 GIVVV~V .•~Lii ELI Il l VV.V V, •.~J• //Y~~~• vvVV COUNTY Plan must include but er not less than 8 1/2 x 11 inches in size Attach com lan on a lete site St. CROix , p p . p p not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 020-1010-70-000 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION E IEWEDBY DATE ~- 22- PROPERTYOWNER: PROPERTY LOCATION Kernon BAst GOVT. LOT NE 1l4 SE 1/4,S 10 T 29 ,N,R 19 f(or) W PRO~F4I~TY~OV1Rge ,~I~NG ADDRESS LO8 # BLnaK # SUHopkinsR Prarie CITY, STATE ZIP CODE PHONE NUMBER ^CITY ^VILLAGE OWN NEAREST ROAD Hudson, WI. 54016 x/15) 386-7775 Hudson Scott Rd. (~ New Construction Use (x] Residential / Number of bedrooms [ ]Addition to existing building (]Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 94.75 ft (as referred to site plan benchmark) Additional design /site considerations trenches spaced to code 4.00' below grade Parent material outwash Flood plain elevation, if applicable na ft S =Suitable for system CONVENTIONAL ®S ^ U MOUND ®S ^ U IN-GROUND PRESSURE ®S ^ U AT-GRADE ~J S ^ U S~~ssTEM IN FILL L~ S ^ U HOLDING NK ^ S U =Unsuitable fors stem SOIL DESCRIPTION REPORT Boring # .................. ................. .................. 1 !< Ground elev. 99.0 ft. Depth to limiting f+90" Boring # 2 '> Ground elev. 98.0 ft. Depth to limiting factor +an~~ Depth Dominant Color Mottles Texture Structure Consistence BoL~r Roots GPD/ft Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-10 10yr4 3 none 1 2msbk mfr gw 2f .5 ~ .6 2 10-90 5yr4/6 none cos Osg ml na na .7 .8 I Remarks: 1 0-8 10yr4/3 none sl 2mgr mvfr gw 2f .5 ~ .6 2 8-90 5yr4/6 none cos Osg ml ~ -' r~a~-. . 7 .8 ~1 ~ . ' ~ '' ''s ``~ '~ 1. .R;. i ~ ''.~, c~~ ~ o ,. t :.,:, f f :'1 Y Remarks: ~~~~`°~.l , CST Name:--Please Print Ga L. Steel Phone: 715-246-6200 Address: 1554 200th. Av . ew Rich on 17 Signature: ~_~ ~ ~ ~ Date: 11_12-99 CST Number: m02298 PROPERTY OWNER Kernon Bast PARCEL I.D. # 020-1010-70-000 Boring # 3 Ground elev. 96.7 ft. Depth to limiting ~~ f+90 Boring # 4 ................. Ground elev. 95.3 ft. Depth to limiting ~~ f+96 Boring # 5 ~' ................. Ground 9`~1e3 ft. Depth to limiting factor +90" Boring # .................. Ground elev. ft. Depth to limiting factor SOIL DESCRIPTION REPORT Page ?"` of Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxiary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-8 10yr4/3 none sl 2mgr my r gw . 2 8-90 5yr4/6 none cos Osg ml na na .7 .8 ~- q f 9 ~ 3~ ' '~_. ' r Remarks: 1 0-22 10yr3/3 none 1 2msbk mfr yw 2f .5 .6 2 22- 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 44-9 5yr4/6 none cos Osg ml na na .7 .8 ~, ey - Remarks: 1 0-10 10yr3/3 none 1 2msbk mfr c1.w 2f .5 .6 2 10-3 10yr4/4 none sil 2msbk mfr yw if .5 .6 3 36-9 5yr4/6 none cos Osg ml na na .7 .8 a-2 Remarks: Remarks: . ~` STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 1 xernon BAst New Richmond, WI 54017 NE4SE4 S10-T29N-R19W MPRSW-3254 town of Hudson (715) 246-6200 lot #8-Hopkins Prarie -~"-40' to;- -,-,.. --- ------ ~,l~t~ BM „ i'n ~, ~°,~~ GAry L. Steel 11-1$,-99 ' ST CROIX COUNTY SL~I'TIC TANK MAINTflNANCB AGRBEMBNT AND OWNERSHIP CBRTIFICATION FORM owsl~Buy« _ ~~~~- ~~~~~ Mailing Address Property Address Clty/5t~ate _' ~~~i Pltaa#a~ Deps~tmeat for aew coastiuctioa} Panxl Ideatlficatioa Nttmbor a ~ ®- ~ D ~ o - 70 -oa ~ Propafiy Loostioa„~~ y~ ~ y~, Sec. /. 4 .' T ? ~•R 1` w~ Town of ~~ ~sd~ Sttbdiviat~ _n/~-.r ~ :~s~u,,`>~ : ~ Lot # GerftQ+ed Survey Map # • Voltuae . flsge # Rrarr~tty Deed # G ~ ~ ~"3~ . Volmma .,~`~ - Pirge # ~~ Spec a ®y~es ^ na Lot tiaes ~landSabte ~ yee ^. ao ' ~00~m°~~1"~~as7+~emaonZdto~alt3albpne~la~oe~olumdlsw~tee.P,r~apecmaiammaa~e om ss~xx a f~m~c ~q-1~ao ~ ac soaa~ ~'aeadedbq a ~oa~ed Whit yOa pnt imo ffia sy~oem seplb timtcys, a ~ ~ ~e w~esTieponia~. ~'oPerb' ~_ sees to s~mlr tq St t Loaia~ D ti ~ ~' tpa awaer aad ~Y a ~~i'~aP~daitmdtoc . ~p~araTlom~edecd~it~l)Qreaa~ie~~ea~rdi~oaisyrta~ ~} onsadpmmpla~,{I!'peoeiaq+),tb~aiopd~c~taaic~falesst'6aa Il~BtliofsWdga. . ~ ~ d burins lead the shore aad s;see m ms~tla ffia pcfrsee diepesat system ~- die sq~ds iet tb~ be~q •ss at by tbu: at~t~aamaaoe sad the Depsdmemt o!'Natnatt R,esoatoet, Stye of Wisooe~., Oett~atiAa ~ ~ sysoeal bier been snort be wed aod:etumed b the tat. t~+oix • Zoala,~ t>ffioe ~at9rin 30 ~~~~ ~ S'~ ~ T~8 ~ ApPLiC~l1t~T DATE ~~t~~~Q~ ~ ~~~ oattlQr ~ sIi this form are fever to flue bat of mY (onr) laoaledae. I (wa) aai (era) tha o~-n~{:) of ~ by of a deed [oooNad is emitter of Deeda Office. ~/ C~iATt7R$ +l4pPt:IGl1NT Dw~ s«aaaa ~, ~matii~on tint is m~ rapt~eoeatadmsy eeeutt is ttue saaitity.po~m3t bei0g t+evoixd by tie Zo~B Depx:tmeot, +~+"•:. ~' Ineiade filth this ~pQticttioa: a etanWed wartaatlr deed ~ tltie Ot DOOdi OfTfGC a wpy of We certlfued ssnvay asap if refa~ace is made is the vvatnnty decd ' STATE BAR OF WISCONSIN FORM 2 - 1982 WARRANTY DEED DOCUMENT NO. y~i. 51,0 PAGE 33 4 ~ - - - _-KernQn.~L. Bast a11d p9nalda J. $p_e_er-Bast conveys and warrants to __.__... .... ThnmaG MCI'ahP - the following described real estate in St •• Croix County, State of Wisconsin: Lot #8, Plat of Hopkin's Prairie Recorded in Volume 7, Page 88, Document #622749 Section 10, Town of Hudson, St Croix County, Wisconsin This is not homestead property. 622934 KATHLEEN H. WALSH kEGISTEk OF DEEDS ST. CkOIX CO., WI RECEIVED FOR RECORD 05-12-2000 10:50 AM WARRANTY DEED EXEMPT q CERT COPY FEE: COPY FEE: TRANSFER FEE: 144.70 RECORDING FEE: 10.00 RAGES: 1 THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS Kernon Bast 948 Labarge Road Hudson, Wi 54016 Part of #020-1010-70-100 PARCEL IDENTIFICATION NUMBER Excepciontowarranties: Easements; restrictions and rights-of-way of record, if any. ' Dated this 10th day of Ma , A.D.,/f~ 2 0 0 ~~'~`~ ~i~Lw2Gc. ~-11L1~+a~t (SEAL) (SEAL) • Donalda J. Speer-Bast . Kernon .Bast (sEAt) (sEAt) ~ i AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. authenticated this day of , 19 Personally came before me this 10th day- of _ May , f9~,Qhe above named Kernon J. Bast and onalda J. _ • Speer-Bast TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Scats.) to me known to be the person $_who executed the fore>;oinA `U K.~ SE ~/4 OF SECTION l 0, T29N,~~~ fy UNT ~', WI~'CONSIN; EEING L 0 T the ~~ 0o~1~~d ~ IN VOL U1~f.~ 13, 1~'A GE s~rry~y, ce prase ~u r~veye E1 /4 CORNER SEj~4 SECTION 10 Wiscorj; 1318.27' ~ ~~ P0~8 a w F~ d@3Gt'ib~ ~ ARC ~' to M H EENGTH TANGENTS ~ ~ Comm@ i' 193.85' S 89'31'39" E S 4i'S1'31" E a C1JOn$ #1 7' 140..58' S 41'51"31" E N 89'54'38" E ;~~~ N89~31'. a' 189.32' N 89'54'38" E S 43'32'05" E ,~ 97.71' N 89'54'38" E S 66'03'45" E a' ~'~a 6egi~1rlin !- ,. 91.61' S 66'03'45" E 5 43'32'05" E o }" SU1 Q2 , )' 134.18' S 43'32'05" E S 89'34' 16" E r~ '~ ~' ~ Ct1r'Vi)tU~ ?' 187.21' N 89'34'16" W N 43"32'05" W ~ ~ rai G8nt1'tJl `! 3' 141.44' N 89'34'16" W N 54'47'24" W ~ ~ ~ ~ and mac 45.77' N 54'47'24" W N 43'32'05" W d- W t p Curve 1 ~, ~' 135.69' N 43'32'05" W S 89'54'38" W ~ ~ ~' " t0 ~h~ ; ~ ~' 196.14' S 89'54'38'.' W N 41'51'31 " W N 1'tgr"tl'18t}S1 41.14' S 89'54'38" W N 79'58'26" W ~ S6{)~54~5~ ~' 155.00' N 79'58'26" W N 41'51'31" W N '' 138.94' N 41'51'31" W N 89'31'39" W CUrV~-` fi'~ ' 155.00' S 41'51'31 " E S 79'58'26" E ~ ~ ~~•~~ #! VO.L 981, F'C. 91 N89'31'39"W w feet; th+~r 427$.92' ____ 5.9~' N SE1/~, 9 42.99' --------------_ ~ ~ 559.36' ~ L?pscrbed SEPTIC EPTIC y, ~~I~j~Ct tt SITE SITE {~ ~ ~~ ~' N ¢ 2.607 ACRES ~6~`~ ;~ ^~' 1 h 1 13,571 SQ i=T ~~$sy N . o g ~ SF, ~,~ f ' ~ ~' 2.385 ACRES 103,876 SQ FT ~0 ~,`~ ~O~ ~ -.. ~ ~ ~ QOM J~~ pP0 `n ttdd ~# ~ \ ~ ,~ d 4P~~~ s~~o ~^ ~ OwNEF~ S _~ ~ ~ ~ • ~`'~.,~ `rpm, ~ ~ ~ ~~ F,~~~~a ss~A~ x,e' As owner ti~~ ~S~~o I ~ F ~ ~ ~" pint to b ' • . ~ ~s~ `~'`~;~ ~~ ~ . . . ~ ~' ~ this plot, ?~s '~. ~ ~'.~/` ~` X236. t,~ d ~ ~ ~ $9' 16 305.2 ...( ~. I ! r.,.. 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FO ~~.p D .I ~ v ( ~ r~\~'a ' 'Po o~ CMG ~ I ~°cbkv o_ ~ ~ I ~: ~~F~~ `s ~ ~..ai 0+ ~. / ~' 9~ • ~ •~ / S`i ' , ~ s o' 41 s.52' °? ~ S00'25'44"W, 334.0 N00'25'924E 920. 0' ~ ~ I "W 2306.91'_ - _ ~ EAST LINE OF THE NE1 /4 OF THE SE1 /4 I UNPLATTED_ LANDS BEARINGS ARE ---- --- -- -- - EAST -WEST I 10, ASSUMED OWNED_BY_OTHERS cm m~wco,ooc~cucc ~~ ~ a~ ~' ~? \ ~ N (D rOn S 3 (~D - ~ Q C