Loading...
HomeMy WebLinkAbout020-1376-67-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAiIa INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Miller, Sam Hudson Townshi CST BM Elev: Insp. BM ti;lev: Bf, scription: TANK INFORMATION u TYPE MANUFACTURER CAPACITY Septic ~~ C J Dosing Aeration Holding TANK SETBACK INFORMATION - TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~1 ~ ! ~_.. Dosing Aeration Holding PUN~P/SIPHON INFORMATION Manufacturer Demand GPM Model Numbe TDH Lift n Loss System Head TDH Ft Forcemai Length ia. Dist. to well SOIL A ORPTION SYSTE ~(yey,~~„~ RENCH idth ~ Leng ~ No. O/f Trennches DIM .~ (~2.~ ~Q,A,.~ I ~ l ELEVATION DATA County: St. CroiX Sanitary Permit No: 430386 0 State Plan ID No: Parcel Tax No: 020-1376-67-000 Section/Town/Range/Map No: 14.29.19.2328 STATION BS HI FS ELEV. Benchmark 09• r BU •o Alt. BM BIdg.Sewer 2 •~ ~O~O•~3, StIHt Inlet `~ O •~~ StIHt Outlet 8.O O Q ~ Sb' Dt Inlet Dt Bottom HeaderlMar~, ' ~ ~ ~ q, ~~ ~ Dist. Pipe Bot. System Final Gr de ~; s~ 8•~ ~ •8~` St Cove ~ '~ ~ ~ ~• }b ZI DIMENSIONS INo. Of Pits N I i~ SETBACK SYSTEM TO P!L -BLDG WELL LAKE/STREAM LEACHING M fa r~r ~) _ ~ INFORMATION Type Of System: ~ CHA uNET OR t CJ~~ ~ • ,,, ~~ ~/ _.~L_ ~„~..~ Model Number: !t DISTRIBUTION SYSTEM tP ~j~ Header/Manifold (~ ~ie GG Length 7Dia Distribution Pipe( Length Dia Spacing x e x Hole Spacing Vent to Air Intake ~ ~ SOIL COVER x Pressure Systems Onlv xx Mnund Or At-Grade Systems Onty Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedfrrench Center Bed/Trench Edges Topsoil L] Yes `_j No j Yes ', No COMME TS: (In ud c d~ discrepe~ie ,person ~esent, tc. Inspection #1~~~~ Inspection #2: ~-s~-~-!• Location: 930 Fraser Lane~udson, WI 54016 (NW 1/4 SW 1/~9N R19W} Swee' 1.) Alt BM Description = 5. ~. ~IV~`~" ~~~ 2.) Bldg sewer length = qS~^ .~i ~~~~ _ ~-l~^~•^°""1'$ +s"~~., 3> ~~tofcover=~~~~ Clz.c~ (~ yy-~! r` Plan r~idion ~ewred~ Yes No „ - ~'I 4 ~ ~~ Use other side for additional information. _ I ~ __ . ___ _ __. SB -6710 (R.3/97) Date s cJ~-•s 5 5-• ~' i 1 ~~ - ---- - ' _ ~ ~ ~ '~ x=10 Insepc;r'sSignature ~~~..`~ ~~yC~ert~No. ~p,._,/I s~ ~ ~ ~ c.~F~ S Lc~F.~T ~R~4ss t,o7'~"~ 7 ~ rt~ is - s ~ ~E v~ s l o ne ~ E 2 ran r -t' ~' y 30 38'6 i~'u/~e ~t ~ D v-n~ -~ ~ Z Sv 3 ~. ~-~~ 3- R:s~s~(~Z"~ w i W ~, 1, B L ~~g ~- 'ta~ c k4 ,,,,, ; ~ C,o w c~ I ZSO CoAI , ~T' La uJ~ ,~J~Zab a~i ~ I oo ~'1 L T ~,2 `a+ Hovs ~.. e ~ y~ ge~~2 r nti ¢~a,~¢ c •~~f'x 3y~ 30 3 - 3 ~X ~ 3.~ Ti2~N~~FE 3 3 0- c ka~le~3 Td~'a 1 (Q-~f4il~ T2ENCH ' 5 Y std'! E % = 9`;~y,~o, ~/~'y ~ ~. 4 / 9 s mo ti+~o 95 : So , _ l ~. ', t3.5 _. ~ e ~o- >3- ~ ~d ~v BM tef ~ ~I~~, ~~D ~ E1.. ico~oo' - ~'2~SE2_LAN~ 14L,T 13 ~ 't',p ~ Stao-1 ~osT` .- ~i lOo,~l9' (~ o l -__ T~- N K ~ ~- 3 . /1'I. ~.Sg - ~ oo. oa' B. s.,~.~r 3.- S= ~ a ~. y 3 5T It~l~ 7,~y = ~ of . g$ t r.Kt Nm~ 13.1 T - Gi ~• i-f 3, y ~-'r' -~~ l3. o Z ~ 9c. -.~'!- ro..~~ ~ - cj S oa ~~~•~ ~ ~~- 13. So:c~i-~g ~ ~ ~ S. t3$ = I y ~ ~o ~ ca CK ~ ~~~eo~~~s-f$ w ` G ia~c = ~3' `~ to ~ ~ ` Safety and Btvldings Division 201 W. Washington Ave., P.O. Box 7162 County ~- S~ • Up ~}( - ~ ~ c/~ D~S~~ Madison, Wl 53707 - 7162 -Sanitary Permit Number (to be Lllcd in by Co. i De artment of Commerce (608)266-3151 ~ ~ O 3 ~~ Sanitary Permit Application Stag Plan 1°. Number In accord with Comm 83.21 Wis Adm Code •personal information you provide 1 , , . ~, may be used for secondary purposes Privacy Law, s15.04(lxm) i Project Address (if different than mailing add: as) 1. Application lnformatlon -Please Print All lnformatlon 9~o G,p ~ e ~ ~ ' J •• Properly Owner's Name Bloc> > Lot p Parr~l ~ s 5 ` D~,"~N C ~ 7 Property Owner's Mailing Address Property Location ~ ~ ~~ Section 'S '- ~' ~° ~ Ciry, State Zip Code Phone Number ~ '' ~ W ~ ~7 ~ ~~1P ~ 27 ~+~ '~r~ ~(oE V~ T or N; R 11. Type of Building (check all that apply) ~l or 2 Family Dwelling -Number of Bedrooms ~ SSubdivision Name CSM Number ~ ~ ~ ~ a S ^ PublidCotrunereial - Describe.Use I ~" ~ ' S ^ S~~ Owned- Describe Use ^Ciry_^Village~Township of~s°-N z ~ 3 ' ~ - .is ~ 7 ti~ ~~ ill. Type of Permit: (Check only erne boi on 1 ne A. Complete line B (f appl able) 1 p 2y ' / 7 ~ -d'CO ~ Z 2 A. New System ^ Rtplacetnent System ' ^ TreaanmVHohiing Tank Replacement Only ' ^ Other Modification to Existing Systeot i B ^ Permit Reaewal - / Permit RevisiUn~ ^ Change of ^ Permit Transfer to New list Previous Permit Number and Date issued Before Expiration Plumber Owner ', 1V. T e of P0~1'1'S S stem: Check all that a I O ~/L'TiL./' _ on -P essurized !n-Ground ^ Mound > 24 ia. of suitable soil ^ Mound < 24 in. oCsuitable soil ^ At-Grade ^ Single Pass Sand Filter L ~ N r ~ ~ Constructed Wetland ^ Pressurized !n-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirttilatin Synthetic Media Filter ^ Leachin ^ Dri line ^ Gravel-less Pi ^ Other (ex lain) ~'. Dls ersal/I'reatmentAcea lnformatlon p ~ ~ ~} ~-~~ ~TitAb. o )(`, _' ~ Lkxign Flow (gpd) Design Soil Application Ra (g Dispersal Area Required (sf) '. Dispersal Area Proposed (s!) System Elevation l oo' ua q 4 - t~ ~ ~ S1 ~'3'~ ~ b g ~ 40 !Lf ~ ,7 4s, s ~ ~a~ ~' _ ' ~ 1. Tank Info Capxity in Total Number Manufacturer Prefab Site Steel Fiber i ?lasr:,: 1 Gallons Gallons oCUnits Concrete Constructed Glass ~ Ncw $ziming i Tanks Tanks -~ S.~ptic or Holding 7cnk Z.. ~ S W ~ ~ /.. rubi~ Treatmcot Unit D~ain~ Chamber V11. FtesponslbWty Statement- 1, the undersigned, suume responslbWty for lnstallatlon of the POW'rS shown on the attached plans. ' Plumber's Name (Print) Plumber's Signature MP/MPRS Numbs Business }'hone Number IM i k a Ud-` .Da ! I ~ ~ Z z_5'-o 3 ~ / z - Ft(o - l z ~ Ptunibrs's Address (Street, Ciry, State, Zip Code) Io~~ ~~~. ~~D(~ ~.~. ~/ ~~o~ W~ S`fOt~ ~'11L Coun /De artment Use Onl ' .an~~ps1 Approved ^ Disapproved ~~ e ~ t Fee (includes Groundwater Date lssue~ Is tun gent Signature (N ~ ~ g ) i ^ Owner Given Reason for Denial ~- ~Z 1.~, Conditions o SYSTEM 1 Septic tank, effluent fitter and dispersal cell must all be serviced /maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. 3 ~ ~~ ~ ~C ~ c6 cOmpkte plans (to the County only) fo/r the .y.tcm oa paper not Icys rhea 8V2 z 1 ~ ~G o ~.`~;~~ ~ 2004 ,, . . , , r - Inchn ia~it(cS",!~G ~YOFFIC= 7 SBD-6398 (R. 01/03) C-fQ~~~~ ~~ (~ 0.~~ S ~ ~ YV~ 1 ~~FR S lt~F.~T G /2 ~QSS Lo~~'G 7 ~ 3o F/lAsE2 ,D2 /V~ 5~4 /~ ~~.,: is .. -~Tl~ls ~s a ~Ev/s ~oN ~E2Mr'T ~' y~o 3gb ;~~ ~ !'Q~~ ~Za Sv 3 ~ r-~ -~ w O z w 3' 3 ~X ~ 3~ "'ri2~N~hF1= S 30-L kaw.lds/3 TdTG- I ~ ©_ £I~~N T2EldcH systd~ ~~: gySo~,~.~s~ 9s%oo~MiD 9S. So' low I z.sn ~R~ , 5T ,~rZob al ~ 100 ~l l r ~2 w` ~-'t n ~~ I'1 ~~ ~ ~~ .~ a J r, ~ ~~ ~~~` / o t5 B 'L r- Hovs ~... oe 'S ~/~ S~~RT M ~A~/1ri~ E ~q t w i3- BM t•~ of ~I~C, QED ~ 1.. ~ co, oo' ~o-~ ~d ~~~ ALT ~ 11A 't'op ~ Sf~a~ ~ ~osr ~I. - ~oo.~i9 ~ ~o 30 --~~ •~ 4 S~ /'~t 11n 1 L L F(~ S W F.ET 6 2 r~SS LQ7"~"G ? ~3o L~i2'~SE2 ~2~Y~ 5~.~ ~~. j~!'= is ~- rt~fs - s a ~.~ Ui s -oN ~F2 M ~"`~. ~# y30 3~`b ~~~ ~t ~ Q v-n ~ ~ Z a Sv 3 ~ r/ -~' N d z w 3- 3 ~K ~3~ Ti2~N~h~ES 3 ~' ~ ka k.la.r3 Tc+`ra. I ~ D- £f~41~ T2ET/GN sysfd~ ~~= 9 y So',y.~s ~ / 9 s, oo ~ hr,r~ l ~tS; So' Law 12.sv ~At, 5T ~~~b~ w-~ ~ ~i~~~ ~-~t ~~ ~: ~3 ~ ~- C] a ~' -.~\ ' .. 13.5 ~ B 'L ~ ~ i-I O v s ~ ~ ~S y. s~~RT nn '~- (,. v i3-1 ~- $M Ta~'o~ EI~~, ~'ED Ef. - ~oa,oo' e w. i~~~~~E ~~~x 3~~ 30 ~ l E o-~ } J°~ ~ o ~w '~ ~'f2-~SEI~LfII`~E -'' LT ti -tn 't`op ~' Srt~.a-1 ~osT`_ Wisconsin Department of Commerce Division of Safety and Buildings ~- s s -f ~`~ - --~ ~ ~ 2~- ~-.t~~ ~.~ ~Q ~ REPORT 1767 age 1 of 3 A.C.E. Soil & Site Evaluations in nrr•nrrl~nr•n urikh /"nmm RS \A/ic Arun rnrlc County Attach complete site plan on paper not less than 8'/2 x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. 02o-137x-67-o00 Please print all in (~ ~ ~ \ / ~ n iewed By Date Personal information you provide may be used for day ~riba.~ L~taiA'~.'1~a o4 (t) ( )), '~ Property Owner Property Location Sam Miller M AR ~ 6 2 ~vt. Lot NW 1/4 SW 114 S 14 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# P.O. Box 151 Sl""~. C~zO!x COU ' ~ `~ 67 Plat Of Sweet Grass City State Zip Code Vllage / Town Nearest Road Hudson ~ WI 54016 (715) 386-2769 Hudson Frazer Lane rNj ,~.'~/~ rf~ ~~ / / New Construction Use: / Residential /Number of bedrooms 4 Code derived design flow rate Replacement Public or commercial -Describe: Parent material Glacial outwash Flood plain elevation, if applicable General comments and recommendations: Install two trenches at elevations 94.50' & 95.50' using 28 leaching chambers. 600 GPD na ^ Boring # Boring / Pit Ground Surtace elev. 99.20 ft. Depth to limiting factor ' 123° in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-12 10yr32 none sil 2fsbk mfr as 2f,1 m 0.6 0.8 2 12-25 10yr4/3 none sil 2fsbk mfr aw 1fm 0.6 0.8 3 25-52 10yr5/4 none Is 1msbk mvfr cw 1vf 0.7 1.6 4 52-70 7.5yr4/6 none s Osg dl crni - 0.7 1.6 5 70-92 10yr5/6 none cos&gr Osg dl cw+ - 0.7 1.6 6 92-123 10yr6/6 none s Osg dl - - 0.7 1.6 ^ Boring # Boring / Pit Ground Surface elev. 100.55 ft. ~ 128° in. Soii Depth to limiting factor Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2 1 0-10 10yr32 none sil 2isbk mfr as 2f,1 m 0.6 0.8 2 10-16 10yr4/3 none sl 2fsbk mfr aw 1fm 0.6 1.0 3 16-46 10yr5/4 none sil 2fsbk mvfr cwr 1vf 0.6 1.8 4 46-60 7.5yr4/6 f2d 7.5yr5l8 sil 1 msbk d1 cw - 0.7 1.6 5 60-78 10yr5l6 none cos&gr Osg dl cvtr - 0.7 1.6 6 78-128 10yr6/6 none,~_-- s Osg dl - - 0.7 1.6 Inclusion of 1 msbk sil w/ f2d 7.5yr5/8 redox. contrations obsArved at NE comer of pit from 46"0". Redox features located at interface of sil and surrounding Inclusion is ari isolated deposit & is not indicative of groundwater. ' Effluent #1 = BOD ~ 30 <_ 220 mg/L and TS >30 < 150 mg/k" ~* Effluent #2 = BODS< 30 mg/L and TSS <30 mg/L CST Name (Please Print) Sig ture: ~;;' - ~ ." ~ CST Number c. :; James K. Thompson ,, ~__.._.__._. 3602 ~.-L' Address A.C.E. Soil & Site Evaluations ~~'~ Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola. WI 54020 3142004 715-248-7767 Property Owner Sam Miller 1 `'~2.t2~ C ~n~ 2 j Parcel ID # 020-1376-67-000 Page 2 of 3 a Boring # Boring / Pit Ground Surtace elev. 98.51 ft. Depth to limiting factor > 112" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. 5h. *Eff#1 *Eff#2 1 0-6 10yr3/2 none sil 2fsbk mfr as 2f,1m 0.6 0.8 2 6-13 10yr5/4 none sil 2fsbk mfr aw 1fm 0.6 0.8 3 13-21 7.5yr4l6 none gr Is Osg dl cw 1vf 0.7 1.6 4 21-32 7.5yr4/6 none cos&gr Osg dl cw - 0.7 1.6 5 32-50 10yr5/6 none gr s Osg dl cw - 0.7 1.6 6 50-112 10yr6l6 none s Osg dl - - 0.7 1.6 ,v ^ Boring # Boring / Pit Ground Surtace elev. 96.28 ft. Depth to limting factor > 123" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/2 none sil 2fsbk mfr as 2f,1 m 0.6 0.8 2 8-27 10yr5/4 none sil 2fsbk mfr aw 1fm 0.6 0.8 3 27-33 10yr4/6 none Is 1msbk mvfr cvv 1vf 0.7 1.6 4 33-44 7.5yr4/6 none s Osg dl cw - 0.7 1.6 5 440 10yr5/6 none cos&gr Osg dl cw - 0.7 1.6 6 60-123 10yr6/6 none s Osg dl - - 0.7 1.6 ^ Boring # Boring / Pit Ground Surtace elev. 96.14 ft. Depth to limiting factor > 120" 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. *Eff#1 *Eff#2 1 0-14 10yr3/2 none sil 2fsbk mfr as 2f,1 m 0.6 0.8 2 14-40 10yr4/3 none sl 2fsbk mfr aw 1fm 0.6 1.0 3 40-48 10yr5/4 none gr Is 2fsbk mvfr cw 1vf 0.6 1.8 4 48-72 7.5yr4/6 f2d 7.5yr5/8 cos&gr 1 msbk dl cvv - 0.7 1.6 5 72-90 10yr5/6 none gr s Osg dl cw - 0.7 1.6 6 90-120 10yr6/6 none s Osg dl - - 0.7 1.6 inclusion of 1 msbk sil w! f2d 7.Syr5/8 redox. concentrations observed at SE comer of pit from 35"48". Redox features located at interface of sil and surrounding cos. Inclusion is an isolated deposit & is not indicative of groundwater. * Effluent #1 = BOD ~ 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 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. .--- ~:w~ . ~ n i ~,~ ~ sOi~2/Q~~CQ'~IO~'7P~~ ~ E/eda~ioy, /oca.~c d ~Or'o~o. ~. d`~1 v i I~ ~ ~~ ~~ w o , ~h• A~0 ~ qq~ p \p~' ~ 8.2 ~ ~' / ~~~/ i ~~. i i ~~ ~~ ~ ,~ ~ ~ ~ `r/e i ~ ~~'~ P ~ ,~' ~ ,~ ~ ~~a ,~ ~~ 4 / ~ h ' ' ~ / ~A ~~ r ~ I. ', 8~ F~encJ, rNn~IC: T po{'e(cC,fruns~Fi~wtaf, F Asswned a ~e~ ~ ~ 79 ~ 88.~~' w \ A«... b.,~t. ~ Top o~ s~~l ~~~l~ios t P _ 3 0~3 s~3~ ~3 ~ B i oD i~ f ser pec~ ~ ations r ~ `.l ' s.~ s ~~.. ~ i- ~ ~~, ~ o ,~ d ~r ~ ° 9s, s . to cd 76' 4 C-,err~ber 1 u { ~~; w Safety and Buildings Division . County i ~ ~ 201 W. Washington Ave., P.O. Box 7162 ~j l CP~7 ~ c~O~ c~~ Madison, Wl 53707 - 7162 Sanitary Permit Number (to be Called in by Co. ) De artment of Commerce (608) 266-3151 O Sanitary Permit Application state Plan LD. Number In accord with Cotnm 83.21, Wis. Adat. Code; ptrsoaal information you provide may be used for secondary purposes Privacy Law, s15.04(1 Xm) oject Address (if di13'erent than ling address) 1. Applicutioalnformatlon-PleasePrIntAlllnforma on RECEIVED ~ q3o Property Owner's Name Part:el # ~" ~~ /)'7; /~~/ SF~ ~ 2 Property Owner's Mailing Address _ Property Locati ~~-~s / ST. CROIX 000N7Y ~/ (~ ' Section ~~~ City, State Zip C e er . !L ~ T- N; R Eo 11. Ty of Building (check all that apply) ~1 or 2 'ly Dwelling -Number of Bedrooms ~ bvvision Name CSM Numbs r ^ PublidC ial - Describe.lJse ~ ~'~~ ~p•/'ett„S 5 ^ State Owned- scribe Use ^City_^Village~Township of ,.SOt7 A ~ X G s lll. Type of Perml . Check only one boa on line A. Complete line B !f applicable) © O - ~ ~-Q~~ A" ~ New System Replacement System ^ Treatment/Holding Tank Repla t Only ^ Other Modificatiat to Existing System B • ^ Permit Renewal ^ 't Revision ^ Change of ^ Perrnit fer to New Lst Previous Permit Number and Date lssuad Before Expiration Plugtber ,/ Owner;' 1V. T e of POWTS S stem: Check that a l p L rized In-Ground ^ Mound > of sui le soil ^ M 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter Noa Pre ssu ~ ~ ~ ConstnL'icted" Gretland ^ Pressurized !n-Crround linlding Tank ^ P alter ^ Aerobic Treattrtent Unit ^ Rxirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leachin ^ Dri ^ Cuavel-less Pi ^ er (ex lain) V. Dts rsal~i'reatmcat Area lnformatton: ~a .~ ~ ToTlj L / ~-^l 3.7 Design Flow (gpd) Design Soil Applicatio~njRa is Area ~ujued (sB Dis roposed (sf) System Elevation; p ~I 1. b0 ~S ~ T 3 3 1 . 7 Q w Vl. Tank lnfo Capacity io Gallons Total Gallons Numb of U ' Manufacturer . Prefab Concrete Site ~tl~ Cons ed ss Ncw Tankx $xiating Tatil:s ~ Septic or Holding Tank 12 ~ I Aerobic Ttcatmctu Unit D~aing Chamber Yll. 12esponsiblll Statement- 1, the under ed, assume reapoasibW statlatlo th o n the c leas. Plumber's Nana (!'rant) Plum s Sig ne t~ ~ MP/MPRS N s Phone Numbs ~~ ~~On.~II v ~ ~1 / May ZZ Z~~~1=/~/Z.7 Plumber's Addres/s~(Street, City, State, Zip e) ~ ~ ~ l~ t O ~ rl'~t~ •.~'4( ~ ~' e i ~O V11L Coun /De artment Use ~ ,Approved ^ Disapprov ~~' Permit Fee (includes Groundwater Da s !ss ' gent Signature (N S~.antps) ^ Owner Reason for Denial Surcharge Fee) 2~ ~ ~.^ l.~i~ 1.X. Conditions of Appro Eteasons for Disapproval n - - ~ SYSTEM OW F2: 3 ~ X 1~9 .v~,c.V~ ~ 1 Septic t ,effluent filter and ,, . - ~ . n~ ` ~ ~ ~ ~"~'~'~ ~ ~ O~ ""` disper cell must all be serviced t mait~~ined asp anagement plan provided by plumber. 2. All se back requirements must be maintained l 4 n `~ ~,, u '' as per applicable code/ordinances. jam At~ ~- l Z ~~U Attach complete plow (to the County Doty) for the system oa paper not tqs than Sl/2 x I 1 Inches Ia stzc ~ SBD-6398 (R. 01/03) S~ m m i~.~.~~ S w~-~ET G2 ~ s S D T s G 7 ~i3a r2AsF2 D21uE SySt~,,--.~/..~ !! 7o'vPPtzT2~M `~ w a U P zov. 3. ~, ~~ASER ~~x~ _ `~ i~isc ns r Department ~f Commerce SOIL AND SITE EVALUATION ~ Divisiop of'SafeAr and Buildings Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference ,`cTi[eatign and ~ --~. C ~J percent slope, scale or dimensions, north arrow, and loc n q~$el iiistaoce to.fie~cest road. parcel LD. # APPLICANT INFORMATION -Please p~rt all in1~31~f78~oti~ ~\ Revi ed by Date Personal information you provide may be used for secondary puFposes (Privacy Law, s. 15.04 (1) (m)).~'~, G~ ~~L 6 3 Property Owner _ "' ' `~ '1 ~ `Property 4ocation ~rC~Y~' ~-~u~~ ~ Govt. Lot~~ 1/4~~ 1/4,S J~ T Z Gf ,N,R /~ E (or iV Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 135 3 ~ w~-~-v.kee "Tr . CQ~''~ .S i.>,see+ C~ ra SS City State Zip Code Phone Number :~• City ^ Village ~ Town Nearest Road UC~Sbn I `J~IC)i ~"I! -) - j_./vr~~c~,-~ ~ Y`z-o Y_ ~a n -e New Construction Use: ^ Replacement © Residential /Number of bedrooms 3 ~ ~ Addition to existing building ^ Public or commercial -Describe: Code derived daily flow ~= gpd Recommended design loading rate • 7 bed, gpd/ft2 ~ trench, gpd/ft2 Absorption area required ~ ~ ~ bed, ft2 ? ~~_ trench, ft 2~ Z ~ ~OM~ xirrtum de i n loading rate ~_bed, gpd/ft2~~trench, gpd/ft2 Recommended infiltration surface elevations u ~- 9 • -7 o v w-e- ~--~` /•7o ft (a referred to site plan benchmark) r/ Additional design/site considerations r ~ y~w-e r' ~`~ ~d , ~~' ' Parent material U ~r ~uG_ 5 Y1 Flood plain elevation, if applicable ti ~ ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank u = Unsuitable for system [~ s ^ u C~ s ^ u Cis ^ u [~s ^ u ^ s C~ u ^ s ~ u Boring # $I Ground elev. Qf.(d~ ft. Depth to limiting factor _~in. Boring # Ground elev. 95.l~ft. Depth to limiting factor ~h in. CMI i']FSCRIPTIAN REPORT Horizon Depth Dominant Color Mottles Structure t C i d B R ts GPDIft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. s ence ons oun ary oo Bed ,Trench J o--I Z /p --- ' 1 m~ k ~ • Z ~ • 3 3 z9-91 ~ ~ v-~1 I c. s ~ ' - 8 / <i a~' ~ ly1- ~ S L L ' 22. ~/ , Remarks: , 1 o-g 1Z1 f 'I ~5 ~v~ .2 • ~ Z g-zy _..- rn m fit- ~~ - - ~ . ~ 8 ti ' Remarks: :.ST Name (Please Print) S' ature Telephone No. A dress Date CST Number ~ /3 ~-Q ~- ,S'~ 5aw-~-Q/"~ ~ ~~ .s- U z s 5'v~-o ~ ~ S 3 ~G r PROPERTY OWNER ~'~'~~~ SOIL DESCRIPTION REPORT PARCEL I.D.# Boring # 3 Ground elev. ~y. ~ ft. Depth to limiting factor ~~in. Boring # y Ground elev. ?eft. Depth to limiting factor 4`/ in. Boring # S Ground elev. 9/~~tt. Depth to limiting factor ~in. Boring # Ground elev. ft. ~~ ~ Paged ~~ o~ 3 Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench 2 ~o-z ~ 13 - L s I rn ~' L - ~ ' - ~ 3 R r ry 1 --- n~~ ps m ~ cs - .~? ~ - ~ ~- 2 _ c(, 2 Remarks: f ~~8 l~ 5~ I bk ~ ~ f ~~ , 2 Z g-Z- I 3 C.-s ~~ S r c~ --- - 7' ~ 3 U- ~ ~l -m~ ~ ~ -- .~ ~ _ 2 Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench I rs-ro (D -- 5~ ~ I m~bk ~' ~ s K~ . Z~ 3 3 zs-q~ kl~ - m vs cs - . ~ '.8 lJ • b ' Remarks: Depth to Q limiting factor in. Remarks: SBD-8330 (R.9/98) PROPERTY OWNER ~_ ~'~~ ~' SOIL DESCRIPTION REPORT PARCEL,LD.# Boring # Ground elev. 1~t• ~o ft. Depth to limiting factor ~_in. Boring # Ground elev. ~ft. Depth to limiting factor .9~in. Boring # S. Ground elev. C//•~ft. Depth to limiting fa or ~in. Boring # ;~ _. Ground elev. ft. - ~,. Page ~ of Horizon Depth i Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 n. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 2 ~~ 413 - L S I m ~-~~ L - ~ ' • $ 3 q ~y I m.5 os~ m ~ cs - .~ ; g o Remarks: 3 ~- ~ ~~~ ~5 I~Y~I c 5 -- . "7 ~ - S Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench rl-l o I0 - 5~ 1 ~ mobk -F' ~ 5 Y ~ . Z ~ .3 Z u-z / --- ~ ) Yrts -fir Ls -- . ~ ' . 8' 3 zs-9~ ylco -- m v s rs _ . ~ :. 8 Remarks: Depth to Q limiting factor ~n' Remarks: SBD-8330 (R.9/98) k i ~ ~, .. ~, ., r PAGE~OF NAME S`I'o~-~ LOT#~D ~T LEGAL DESCRIPTIONA/~ '/asw'/a,S tY TLy ,N,R tq E (or)j~N~ _ SCALE: I"= ~~~ BM I ELEVATION- BM 1 DESCRIPTION BM 2 ELEVATION- BM 2 DESCRIPTION SYSTEM ELEVATION. ALTERNATE ELEVAT 1C~°' O 1 v~~ o erl YDYC.-~n'~Q IOL~ I/ fr ~ J ri00e ll1 Z• 7 D Gow* r ~~• ~V y IONgO. 7V Low« 5S ~. 7b CONTOUR ELEVATION /t/~W 1 i3a~ G Z ~ • ,,,LPN p`1 ~ ~ ~~ ~ ~ ~ 63 ~ X~ _ p.Z~ ~,n U ' ~ Ser S ificationS B1oD~f fu p~ 4 1 4' Knockout ...a.. FILE INF,ORMigTION SYSTEM SPECIFlCATIONS Owner ~ ~,~ ~ ~ LL~2 Septic Tank Capacity ~.~ S~_ ~'~p ai ^ NA Permit # ~/ X30 ~~JO Septic Tank Manufacturer i, ~~e~ ^ NA /.f-f~~ T~~,alch~ 76' __~ _~ o0 =o 00 00 00 00 00 00 00 ~o 00 °° o° o° ~o 00 =o 00 00 00 0 ~~ ~~ =o 00 oo ~~ ST CROIX COUNTY c-. SEPTIC TANK MAINTENANCE AGREEMENT ~_, . AND OWNERSHIP CERTIFICATION FORM OwnerBuyer .S ~ : ~ ~ ~ ~ ~ ~/ , . Mailing Address ''rte ""~ ~ ~ Property Address O (Verification required from Planning Department for new L City/State . H ~ Aso h ~ t __ Parcel Identification Number p2o -t3~fa-(a~-o~C•~~ LEGAL DESCRIPTION property I-ovation ~'/4,5vJ 'I4, Sec. ~ `~ , T Z`/ N-R~~Town of N yc~s o •~ Subdivision S cJJ m.~ 6 i as ~ -, Lot # _ ~~ . Certified Survey Map # _, Volume '^. T'age # Warranty Deed # ~ ~ ~~ 7'~ ; Volume Z Z g ~ .Page # ~ 7 ~ Spx house ^ yes ^ no Lot lines identifiable ^ yes ^ no SiXSTEM MA,INTTNANCE Improper use and maintenaneeof 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 masterplumber, journeymanplumber, restrictedplumber or a liccnsedpumper verifying that (1) the on-site wasteataterdisposal system is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Deparhnent of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the year ex iration date, ~1 ~ ~`~ i6yio F LICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge . I (we) am (are) the owner(s) of the ropetty described above, virtue of a .warranty deed recorded in Register of Deeds Office. TUBE OF PL DATE , s«#t*. sssss« Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. s• Include with this applIcatlon: a stamped warranty deed from We Register of Deeds office a copy of the certified survey map if reference is made in the warrtwty deed 'I 2284P 676 a STATE BAR OF WISCONSIN FORM 2 - 1998 WARRANTY DEED Document Number This Deed, made between Joartrt L. Wert, _ Grantor. and Sam E. Miller, a single person, __ Grantee. Grantor, for a valuable constderadon. conveys and warrants to Grantee the Sol{owing described real estate in St. CTOlX County, State of Wisconsin: 726876 KATHLEEN H. YALSH REGISTER OF DEEDS ST. CROIX CO., MI RECEIVED FOR RECORD 06/23/2003 09:00AM NARRANTY DEED E%EMuT # REC FEE: 11.00 TRANS FEE: 222.00 COPY FEE: CC FEE: PAGES: 1 4iCC01'dlnQ ". -. ~r Name and Return Adtlreas ii First Federal Capital Bank . t 67 Plat of Sweet Grass Farm e Town of Hudson, St. Croix County, Wisconsin. 020-1376-675-000 Parcel Identification Number l~Nl This 1S nOt homestead property. (is) (is not) Exceptions to warranties: Subject to easements, reservations and restrictions of record. Dated this ~ day of June 2003 (SEAL) _ (SEAL) OADIN L. WERT AUTHENTICATION ACKNOWLEDGMENT (SEAL) $lgnature(s) is State of Wisconsin, lI } ss. St. CroiX_ County JJJ authenUca[ed this day of Personally came before me [his ~ day of June, __, 2003 ,the above named ` Joann L. Wert ,I TITLE: MEMBER STATE BAR OF WISCONSIN to !''. (If not, me kn n to b the person who exew mg authorized by §706.06, Wis. Stats.) ~T~Y inst ent hd cknowledge t s - THIS INSTRUMENT WAS DRAFTED BY •' ~ r -~ Stephen J. Dunlap $"s!;~ ~r~.e l~,p~ -_-~~<3~- yy..~ft Notary Public. State of Wisconsin H1.x~SOn, Wisconsin •,, ^ ~.,• ~, Y' My commission is permanent~,(If not, state expiration date: (Signatures may be authenticated or acknowledgeg, aotft^,lYte' ~~' / ~,~„L,.) necessary.) ••••• _ _ _._ _ _ _ `Names of persons sign4ng in any capadcy must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No. 2 - 1998 Miiwaulcae. Wis. ''. (SEAL) l~ Sim ~~~~ ~-T-~~7 '~; ,4£'OOL Z S~! m N .. I ~~ ~~ #: ~ +N r ~- ~ ~ Q~ a ""I O ~ a O~ ~oZ ~ C ~. ~~ e w ~ ~l• .. ~Z M ~~ by a J ~1 v a •~~, I-' ~ O ~ ~~ ~ ~~ Q y . ~` I~ I }/ / I ~SO'4a L Nr ~~O ~~ ~ a° ~ ~ o° m N a ~ ~ ~00'9d t "' r ~ O ~~ ~ ~ ~~~~ a ~~ N 8~ ai i i i ' .~ I '~ N . - - '~ U` • 'I ' - - • ~.pqL . ~. - ~_~. I ~ ' N --• i ti~ I ~" p t ~ ~ .I • ' -' ,fit ,~~s '~ - -. ~~. N - ,I. ~~ i I ala I o~ N \\\ 3°3 es , + N r n _ < a ~ ~I I~ I m u ~ ~~o\\\ti ~~ O , g CC $ ~i ~Q ~ ~'~~ I I~Im$ ~Z ~$0 > MFti a / r fA ~ ~ 12~~191TI ~ Z ~ ~ /.r^,~, iL ~/ ~ ~ ~1!~_ e~\ ~ '~xi~ aZN