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HomeMy WebLinkAbout030-1015-70-000 a m 0 69 a) a� Q 4 o 0 H co cc r j CL u O N Ali C = ,C O i m .�'_n M N w a) x Eo- O O W O a '<Y O O E L O � m5 p. U [r E O C O N -U,)'V N U p M U 'O O y.-. O 'p M X N p p c z E c Z Opeo () 7 ca p N 3 c6 C C to LL 00 0 a LL p0 .N a) p 0) L d c U L I 16 M 0 M CL N cc y rn E E NN z '= °o = ° LL € L E o L () ate) N d c-, w !' a m a m I I O z d c c 3 N 3 N a1 Z g L C OL C rn c E c E N a) 3 N a) 3 N (D '� N N N a) N a) O O O Z [0 Z Z [0 Z �N } M Cl) ld J L 10 J 0I d Q N Q w N `"oll'' 4) 42 0 ooaL ° 0 0 0 0 0 0 0 o '',_ aaa aaa a 0 � }}yy V1 J V o rn rn N 1 0 O p .0 CN LO C14 "Wft- a N rn rn Z co 0 Q S2 0 0 0 •� N O O O •� 7 N N N m G d 'fl N N rn 'a m Q z .- Z ° O 3 N° ° — L Z5 N O 'p c Lo ~p LO c) O LO° c ° ° o ii ai O o o o N N y E N N N N N 42 M m a U n O m Y c 3 dn N N _O O C � O Y u> N 'O a)d N U O teN C 3 O E v L N CO N O z N 2 H CO 0) 0 z N Z Z (.0 SO cc ~ :L w E :: € V _ L € a € a dt a , L m rrww c ..3 c CL —1 A U a � ,! 0 U) O vii U .,OMMERCIAL TESTING LABORATORY, INC. 514 Maim Street, P.O. Box 526 C$Ifax, Wisconsin 54730 715 - 962 - 3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ST. CROIX ZONING REPORT NO.: 32934/01 PAGE 1 ST. CROIX COUNTY REPORT DATE! 11/27/92 COURTHOUSE DATE RECEIVED: 11/24/92 HUDSON, WI 54016 ATTNS THOMAS C. NELSON OWNERS hilUip + Virki Block �r LOCATION. 522 River Rd., Hudson COLLECTOR: M. Jenkins DATE COLLECTED* 11-23-92 TIME COLLECTED, 14'45pe SOURCE OF SAMPLES Outside faucet DATE ANALYZEDSII-24-92 TIME ANALYZEDS2S00pm COLIFORMS 0 /100 mt INTERPRETATION: Bacteriologically SAFE NITRATE-NS 4 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. CoLiform Bacteria/100 ml Nitrate-Nitrogen, mg/L LAB TECHNICIANS Pam Gane �E•\NDEVENDENr• WI Approved Lab No, 14 SA { Means "LESS THAN" Detectable Level Approved by'. ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 . ST. CROIX COUNTY ZONING OFFICE St. Croix County Courthouse 911 4th Street 1 Hudson, WI 54016 e ` f Telephone - (715)386-4680 The St. Croix County Zoning Office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion pt this form ja essential I?4 that t1lg property can 12e- located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail , along with form to the above address. Testing will be done as soon as possible after fee and form are received.. ----------------FEE• $ 35 00 WATER TESTING------------ . (For nitrates and coliform bacteria) WATER TESTING FEE: $185.00 (For VOC'S) SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00 (Determines if system is properly functioning at .:time of PROPERTYpOWNER'S NAME: I y t UUC PROP. ADDRESS: CITY_ 4-60(S W-\ Legal Description 1/4 of the 1/4 of Section AZ T z N-R[? Town of Lot Number Subdivision: FIRE NUMBER LOCK BOX NUMBER 030- I6/ 5-76-00 Color of house Realty sign by house? If so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A HAP,i.e,COPY OF PLAT HOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SI1EET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER .TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. ' I Firm or individual requesting services: ftM D r 1 a H1�1��SOh Telephone Number - ly REPORT TO BE SENT TO: i ` Lk- 0 ` .1 WTQ : t h o v- CLOSING DATE: k\-3b-1A- .\ Signature�(��'h� .y�nck. Town Hall ra +,o�G4� T,m� 2 Ave 46 132nd 1 YT, Porch Luke Rd. ' 130th Ave . Pine Valley ov (— Tr. Lamar La F W uct F � Ave. tzerh e E Ave 125th Ave. A\ ¢ $ Pine Tr. 90 a White Cds9 Oak ka rn Wmsn Rd. et3 La. Rod O ak 45. z Bluebird Or AL7palousa ¢ m ` Coun g N d F v �q ❑ Rive pd N Pond t a xr' m °q 2 T oui 3 B:o°k Tr G r �C O e I 'fit ,� ��U4 he* _ o Oaks Rd s Goldo arch an p a. Lill/e Fo//s MnetRa. Q Pond �• a) Park la. Town Hall cCuLtaaheon I Q° O�l � McCutcheon Rd Nord 1.MhNe Rd. Spudine Minnie Rd. 2 t Green MOI La. GON r^ Qs• 9roo 2 Becky Cu o Holden U.ir kwood Dr. % m @� Ridge paor look ® 3 . S Audubory Aud ubon CL a•a z. �° I C1 si 1.Vnaeyvfewa. -g N W V 12 4 f 2.Wort Rd. yC 3.V191—Ridge I 4.Trout Brook La. °¢ _'9 _JCL ' IL 5.Aspen Vlew Cr. 1 2 2° �Praide La .. i Hutton Hdl Rd o wagonwh J Maud F Ca Court do/ d \�^,d r z t Fos Jacobs La. C dn9 g` ie a 2 Lassie Or UU r 3 Jacobs Ladder ohm x everse Side r `9 �� Badlands Rd. udson and h Hudson cc =3� O DN°` °°� a Hudson Township ity Map y Deer Haven Dr. 9' R. D w o Rd. coda, La.ci JG. LenerLp Brakko Dr. Meadow Eton 9 l/ z S'31 m ya9° Ban Tara D,. N U � / N TN�O e 8 ^ o m J e J Carmichao—•.J l RA.+( �. Nigh \ W \\U( River View Dr. — — t„ 31* ? Luna�� m DoerwaodDr. O E To Tavp 4 P r;.Q .s Valley view A?F ye. j Red Brick Rd. Ff U`r;t �. .,• .. i{ Coulee � a ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST.CROIX COUNTY COURTHOUSE x ,J 911 FOURTH STREET • HUDSON,WI 54016 = 1 - (715)386-4680 November 23, 1992 Tracy Jenkinson MidAmerica Bank/Hudson P.O. Box 71 Hudson, WI 54016 Dear Ms. Jenkinson: An inspection of the septic system on the property of Phillip & Vicki Block, located at 522 River Rd. , Hudson, WI was conducted on Nov. 23 , 1992. At the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon as we receive them back from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Sipcerely, Mary J. Jenkins Assistant Zoning Administrator cj EPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS ABOR&,,HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION .0.60X«7965., BUREAU OF PLUMBING MADISON?WI 53707 r (CONVENTIONAL ❑ALTERNATIVE Sate Plan I.D.Number: ❑Alding Tank ❑ In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HO ER: INSPECTION DATE: / 0 BENCH MARK(Pe anent reference point)DESCRIBE IF DIFFERENT FROM PLAN: If REF.PT.ELEV.: CST REF.PT.ELEV.. Na of umbe MP/ PRSW No.: , County: Sanitary Permit Number: SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV. WARNING LABEL LOCKING COVER ( f/ PROVIDED: PROVIDED: W 0 © O q� 9'1' 7 ❑YES ❑NO ❑YES ❑NO BEDDING: V : VENT MAT L.: HIGH WATMN. ; ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: e LINE: 9 . DYES ONO C ( ❑YE DOSING CHAMBER: MANUFACTURER BEDDING: OU ID CAP I7V. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: EYES ❑N EYES : NO OYES ONO ENT GALLONS PER CYCLE: //�//f/AND CONTROLS OPERATIONAL. ";' PROPERTY WELL BUILDING.IV R NLO�RESH (DIFFERENCE BETWEEN uNE PUMP ON AND OFF) DYES El NO SOIL ABSORPTION SYSTE .Chec a soil moistur at the depth of plowing ���I� LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,cons ruction shall cease until ss the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH. LENGTH. NRO OF DISTR.PIPE SPACING: COVER ?INSIDE LIQUID T ENCH ES. MATERIAL ^ DEPTH: GRAVEL DEP H FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DIST T PROPERTY RTV WELL. BUIL�G:JVIENTTO FRESH BELOW PIPES ABOVE COVER ELEV.INLET ELEV.END. PIPES. " �� e 5 LINE; ��� � AIR INLET. (pt 5e+, �9-97 89 97 t�VC !O/JIIJ MOUND SYSTEM: Mound site plowed perpendicular to slope Check t text e f the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: moun syste make certain that it ON REVERSE SIDE.SHOW ELEVA- me s the cr' aria r medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER. TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS. VI ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCHBED DEPTH OVER TREN /BED DEPTH TOPSOIL: SODDED SEEDED-. MULCHED: CENTER EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF L TERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER. TREN iES: MANIFOLD PUMP M NIF LD DISTR PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV.. ELEV. A. ELEV. PIPES. HOLE SIZE HOLE SPACING GRILL D C RFIECTLV. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: YES ❑YES ❑NO ❑NO COMMENTS: PERMANEN MARKERS: OBSERVATION WELLS: PROPERTY WELL: BUILDING: LINE: YES ❑NO ❑YES ❑ P�� W ,1.a1 11.9 Iz .q� ra(I. gg h (p .� 2, �� CQ..,a 10l• '08 yr� � S.fG I"L q°n Idl "�9 �g 57. 87. 97 Sketch System on 7 ?� Retai in ounty file for audit. Reverse Side. S TITLE. DILHR SBD 6710 (R.01/82) DEPARTMENT OF APPLICATION SAFETY&BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABO£'A.ND ` PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON,WI 53707 1 Attach plans for the system on paper not less than 8%x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed,sealed and dated by the designer. If designed by a Master Plumber,the date,signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. Prop ner: Mailing Add ss: 1-11; ,11"a 16 b) a, ; z. s Prol5erty Locati n: City,Village r ownship: County: '/a ( /aS 44 /T NCR - (or) W _ 1 . Lot Number: Blk No.: Subdivision Name: Barest Roa ,Lake or Landmark: State Plan I.D.Number: _ (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALL ON (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED(Square feet): ❑ New Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): 5 71 Private ❑ Joint ❑ Public I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. A =22M Name of mber: Signature: MP/ PRSW .: I Phone Number: Plumber's Addre : Name of Designer: RA 4 a i COUNTY/DEPARTMENT USE ONLY igna re of Issui Fee: �� Date: Sanitary Permit Number: S&4e&�2 1 y� APPROVED 2 aJ DISAPPROVED (1 son for Disapproval: Alternate course(s)of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County,Canary-Bureau of Plumbing,Pink-Owner,Goldenrod-Plumber DILHR-SBD-6398(N.03/81) AS BUILT SANITARY SYSTEM REPORT U OWNER �,, "� �(°, TOWNSHIP SEC .)T f*-R,*W ADDRESS 12A Z M �& &h ST. CROIX COUNTY, WISCONSIN . SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 THING WITHIN 100 FEET OF SYSTEM V y r , Irdipatte o th Arrow ' i SC L _ BENCHMARK: (Permanent reference Point) Describe-� 9 S�W411C S lib �i Elevation of vertical reference point: 0-p ' Slope at site :--7% SEPTIC TANK: Manufacturer: o ( Liquid Capacity : Number of rings on cover Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of pump set or a cyc a gallons ; total capacity of distribu n lines gallon: size pump head; gallon er minute horsepower ran name of pump and el number -s— Type of warning device HOLDING TANK: nufacturer Number of gallons Elevati of manhole cover Type of wa ing device SEEPAGE PIT ZE: Number o pits feet diameter feet 1 uid dlept seepage pit inlet pipe-elevation bottom of seepage p�3 eva on feet . SEEPAGE BED SIZE: number of lines width length36`tile depth-!Zef SEEPAGE TRENCH: width _ length PERCOLATION RATE .S" AREA REQU D ,& aCz RE BUILT INSPECTOR DATED PLUMBER ON JOB LICENSE NUMBER t 0 10 t� o d .. O O n " O c 3 - O f c °.: ° o c co CD > > O cD ° O O � ... A n ►. CD m X O N 3 O O N n CD n N lW N O �►i A c O S O O =r •° m m - ? rn 4 I0C � m v ° 7C o 0 o CP cn N 3 N N CA a S N N 00 0 cn Z i a m cn Z N D a D CD c N O W 0 0 °° 3 ° co coo a I- c` c\ a N O O = I 0 C .�,• O O C 0\0 0\D c li y Z co y r N O 4 j ° N N �. 3 O^'. Z CS 0 0 <o �1 O CEO O �:2 •H -1 ° !�i C 3 w co co ; ca co co - D v v v o Q v o o I CR m y cD N CD r d 3 m W Q 3 rr Q ``I 1 z Z CCDD o D C CD o O D a ° v O CL 5 3 N� CD ° m N co CA (D v co � c N 11 N CD (D ° o a �. CD 3 3 o cn o \. cn ° z c I � c?' n a A Z 3 v G) 0 cn m M W M m z z CL 3 'o CL ;w ZC m O N CD ? c00ia, S � Q m (A CD Q arc m 3: n CD c 1 v c CD ooCD o — ° 1 m — x N °- o C. 1 3 o a o ii o N C N 2) N 0 1 3 ` �a 7 m °-o 0 d 0 CD �_ 0 o g ° = y ~ ° p mn co nx.v co o v o v m o 0 d• 1'�— ID ti v o 1 a S m CD 0 a f in O v CD p i. 0 0 CL ; �.. 'Parcel #: 030-1015-70-000 04/07/2005 08:32 AM PAGE 1 OF 1 Alt. Parcel#: 04.29.19.65C 030-TOWN OF SAINT JOSEPH Current [k ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner * PHILLIP H &VICKI BLOCK BLOCK, PHILLIP H&VICKI 522 RIVER RD HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *522 RIVER RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE SEC 4 T29N R19W SE NW LOT 1 CSM 2/534 Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 04-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 4828 203,700 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.000 99,900 100,500 200,400 NO Totals for 2004: General Property 5.000 99,900 100,500 200,400 Woodland 0.000 0 0 Totals for 2003: General Property 5.000 58,600 75,000 133,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 211 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& DINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING + MADISON,WI 53707 SE-, NA, S4,T29N—R19W )MCONVENTIONAL Repair ❑ALTERNATIVE State Planl.D.Number: (lf assigned) Town of St. Joseph ❑Holding Tank ❑ In-Ground Pressure ❑Mound River Road NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Phillip Block Route 2, Hudson, WI 54016 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No Coumy: Sanitary Permit Number: Gary L. Steel i3254 St. Croix 99106 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO OYES ONO BEDDING: VENT DIA.: I VENT MATL.: HIGH WATER EAREI;MER ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. ET E,R O LINE: AIR INLET: OYES ONO ❑YES ONO T' DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO ❑YES ❑NO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBEROF 'PROPERTY WELL. BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES 1:1 NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENCrH DIAMETER MATERIAL AND MARKING FORCE or excavation. (if soil can be rolled into a wire,construction shall cease until the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: ei sat WIDTH. LENGTH-. TRENCHES DISTR.PIPE SPACING. COVER JINSIDE DIA.. #PITS LIQUID TRENCHES. MATERIAL: PIT DEPTH. GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER. ELEV.INLET.ELEV.END: PIPES FEET FROM LINE: AIR INLET: NEAREST--- 00 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES 1:1 NO SOIL COVER ITEXTURE PERMANENT MARKERS JOBSERVATION WELLS ❑YES 1:1 NO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED-. MULCHED: CENTER-. EDGES-. [11 YES ❑NO DYES ONO ❑YES 0 N PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: 13EOI TI VNCeH', TRENCHES: `r MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.: ELEV.. CIA.-. ELEV.: PIPES. DIA.: ELEVATION ANN OISTR Ill HOLE SIZE- HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED 'iNF"�,R�lATI(�N PLANS. DYES ❑NO OYES El No COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER ROPERTY WELL: BUILDING: FEET FROINE: ❑YES ❑NO [:]YES ❑NO INEARVESI:::� Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: Loning Administrator DILHR SBD 6710 (R.01/82) INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT . APPLICATION TO THE APPLICANT: i 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 210 3 years;\ 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owners name and mailing address. Provide the legal description where the system is to be installed; Il. Type of building or use served: If public is checked, indicate type of use (i.e: 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair, IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/ x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. ---------------------------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground edb — included the creation of surcharges (fees) for a number of regulated practices which Wisco [IT`5 can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Tea Surel e is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. c The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) i SANITARY PERMIT APPLICATION COUNTY Zt DILHR In accord with ILHR 83.05,Wis.Adm. Code St. Croix ST A E SANITARY PERMIT# 916) —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION �j 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES 115..1 NO PROPERTY OWNER PROPERTY LOCATION Phillip Block SE '/4NW 1/4, S4 T 2 , N, R (or)W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER TLOCK NUMBER SUBDIVISION NAME R.R.##2 n/a n/a n/a CITY,STATE ZIP CODE PHONE NUMBER 1= CITY NEAREST ROAD,LAKE OR LANDMARK Hudson, Wi./ 54016 n/a E] VILLAGE: St, Joseph River Road II. TYPE OF BUILDING OR USE SERVED: 030— /j/6 Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ❑ New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.® Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. JL1 Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. ❑seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): n/a Feet ❑Private ❑Joint El Public VI. TANK CAPACITY Site Fiber- Exper. in allons Total #of Prefab. INFORMATION New xisting Gallons Tanks Manufacturer's Name Plastic Concrete strructed Steel glass ti App Tanks Tanks Septic Tank or Holding Tank 1000 1 Weeks Lift Pump Tank/Siphon Chamber _=4A ❑ ❑ ❑ L El ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's S' ture:(No Stmps) 0 MP/MPRSW No.: Business Phone Number: Gary L. Steel l—/l�J/ 3254 (715-240-62W Plumber's Address(Street,City,State,Zip Cod Name of Designer: 988 N. Shore Dr. , New Richmond Wi. 59017 VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# CST's AD S(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY F-1 Disapproved Sanitary Permit Fee Groundwater ate Issuin Agent Signature(No Stamps) 19 Approved ❑ Owner Given Initial charge Fee Adverse Determination �� X. C//OMMENTS//1REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber NwY� 5� � � R 19 � OP � 00 IC S rs-F� V,5 Y� �- � - 3a � g� APPLICATION FOR SANITARY PERMIT S T C - 100 his application form is to be completed in full and signed by the owner(s) of the roperty 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 t-he property is sold and submitted to this office with the appropriate deed recording. Owner of Property Phillip Block Location of Property SE 1% NW It, Section 4 , T 29 N-R 19 W Township St. Joseph Nailing Address R.R.#2 Hudson, Wi. 54016 Address of Site Subdivision Name Lot Number n/a - Previous Owner of Property Wm. J. Paul Total Size of Parcel 10 acres Date Parcel was Created 1_20_78 Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Yes X_ No volume 568 and Page Number 397 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: I A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- - I ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I We) cvLti6y that aff s•tatement6 on .thus Oran ane tAue to the but o6 my (ouh) hnautedge; that I (we) am (ahe) .the owneA(s� o6 the pnopWy dezmi.bed in .this .in6olmati.on 6o4m, by viAtue o6 a waAvcanty deed kecokded in the 066.ice 06 the Coumty RegiA ten o6 Deedh ah Document No. 346209 ; and that I (We) phesen.tty aun 1- pnoposed site 6ok the sewage diApo,5aZ s ys em (oh I (we) have obtained an ea.aemcnt, to nun with the above deAchi•bed pnopehty, bon the cons•tAuct.ion o6 said s ys.t"t and the same hae been duty necohded to the 066.iee o6 the County Reg•is.teh o6 V tech, ab Ooement No. ) , SIGNATURE Of /yy ER/*� SIGNATURE OF CO-OWNER (IF APPLICABLE) L___ Ak� —,A . SIGNED DATE SIGNED 4Pp` x{ 40. 44 1 44 " -,--Av4,,, H z .. H rn ' ST C - 105 r a I H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a H OWNER/BUYER Phillip Rlork � ROUTE/BOX NUMBER R, .R#2 Fire Number CITY/STATE Hhdson, Wi _ 54016 ZIP PROPERTY LOCATION: SE k,NW 4, Section T29 N , R19 W, Town of St. Joseph St . Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists of pumping out the septic tank every three years or sooner , if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix. County residents m_ y be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1 , 1978 . St . Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St . Croix County Zoning a certification form, signed by the owner and by a master plumber , journeyman plumber , restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration . 0 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- �0 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 . SIGNEDAr-__ 41- 7V- Z. V.s�e_'. DATE 9-30-87 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 . u 5Ri 1 a Al '' DEPARTMENT OF REPORT ON SOIL BORINGS AND _ S B ; oN INDUSTRY, 440 LABOR AND PERCOLATION TESTS (115) �. W. 09 +iLN,IA'N„RELATIONS i LOCATION: SECTION: TOWNSHIP/ LOT NO.:BLK NO.: S ISION ME: COUNTY: OWN R'S BUYER'S NAME: MAILIN ADDRESS: S • CrvI` �It e l� �0 ' I�_Kj USE DATES OBSERVATION9 MADE NO.BEDRMS : DESCRIPTIONS: /A TESTS: esidence COMMERCIAL DESCRIPTION: ❑ �� I/ New epl//ace. I RATING:S=Site suitable for system U=Site unsuitable for system �- ' g CO®�TI❑� . �.❑U IN G®S ❑U RE: SYSDTEM-I®ILL r[:]S OLDI gU TANK:RECOMMENDED�� SYSTEM:(optional) If Percolation Tests are NOT required DESIGN RITE:JSYSTEM ELEV. If any portion of the lot is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED +EST,. HEST TO BEDROCK IF OBSERVED (SEE ABBRV.O/N BACK.) / B- f l�` f •�/ / � ll /#7 11,8 � 0 n C 0�� O Af B- I y �loft� 7 " /.Z r .2 Y" �/> C ICO., ti ,trd.(S or B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH *�3 P- P- P- _ PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION t'9 if T .1/ �►`, y M � . — �f .�. ., .�Li .Gl � 1 –ff lei �...: __ _.�__. ;._ �. r�?rs _. �N ° v �pYER" + P �q/5 E 5 ... _.._ , . .. t ..... .��.... .. .. 'Was Ae all, � . S c I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): o CS C IGTURE a DISTRIBUTION:Original-Local Authority,2nd page-Bureau of Plumbing,3rd page-Property Owner,4th page-Soil Tester. DI LHR-SBD-6395 IN.03/81) IA �. � � ,: . _. �. , .� .� ,s ._ �, _. i _ . _, <:, o i t 1 � � ,j �. ;. ..... ... ' . .. ___ s ,. _ _ , � — i .. { .. 9 � a ' � } _. ....... _ � . 8 , ... ..... _ _ ._ �.. i 4 , :. ...�. ...,...,i i� .. ..�. .. _ � � t i . t "3 ro 44, z � I I i