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HomeMy WebLinkAbout020-1145-90-000 ° ~ ° ~° I ~ o o, i a o a i ° N 'r 0~ I ~ ~ I °' ~ ~ c I c I c ~ 4 o ~ I o ~ I ~ I I o I I N o I I ~ I I a I I A I I ~ ^~ € I I h o~ I I ~ ayi ~ I I Z ayi I I z° ~ I ~ z I LL O N IL O ~' I ~ a I ~ I 3 M a M ~ Z y ~ tl! I I ~ Z !_' Oo !' G z .- ~~~ € d a m I € d I a m I I I o I c C9 o Z~ c I c ~ d' o ~ I E u ~ o I d Z rn F- ~ ~ aci m a ~ ~ I I U ~ m N N O N ~ ~ O ~ W y ~ = N d ~ I I • ~ °~ ` a~ ~ o o c a ~ ~ I a ~ Q Z Z I Z c Z y = m N y m I E z E o E I 3 w 3 ~ m d ~ p c ~ as - d I ' a~ I m - a ~o ~. d N d O m .. ~ a r y d N x ~ fd N c ~n O 0 ~ d ~ G G a N .n t ~ O G G a ~ a~ O m N a ~ ~ rmr rNr r~r ~ E °-~ I rmr rmr rmr 3 ~ ~ °-~ ~ o I ~ooo 3~3~0 I Zo • N ~ ~aaa I oaaa ~ ~, ~ ~~ ~ I O O O y y = 0 0 y y ~ d1 J U ~' ~ ~ ~ ~ ~' > N N •c } o M _ I I a Z o N O ) O N 0 D N O ~ ~ N ~ - ~ ~, I € ~ ° °' a ~ I ns i s m I v d ¢ r i I tt v °-' n Q n ~ O° O ~~~' r N C y y C ~ ~Y O ~ o~ ~ O ' ~ ~ 'e I 2 m ~ M O c°'id°p°p I c ' V ~ 01 ~ ~ ~ ~ C ~ l6 fA ' ~ O ~~ m ~ N ~ N U~ -O N N l0 y f~ O ~ N M 4y ~ O : y U 'O p ~ O y Y ~ a' (O ~ ~ 7 ~ m O O~ O y N ~ U • N o ~ 2 p~ ~ ~ v y Z ~ S Y M o Z ~ Y g cA 0 ~ = I = I U ~" C~ ~ ib ~' ~ =~ ~ € a I = ~ I ~ a I "'" y o ~ ~ a~ I m a w • ti at °~ . m . o R~ as ~ c 3~ 'o I d c g o 3 ' I I ~1 A c~a~ ov~c~ 0 , v~c~ ~~ ST. CROIX COUNTY ZONING OFFICE J~f \~ 911 4th Street d~, ~S Hudson, WI 54016 ~~ Telephone - (715)386-4680 J 02~- i/~~-io~-~ v The St. Croix Co. Zoning Office offers the service of septic and water inspection to Lending Institution, Realty Firms, and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING--------------------------------FEE:$ 25.00 (For nitrates and coliform bacteria) - WATER TESTING--------------------------------FEE:$175.00~ (VOC'S) SEPTIC SYSTEM INSPECTION---------------------FEE:$ 25.00 PROPE~tTY OWNERS NAME: ~l~i,s L {'o d.~ {~J~~ ti Jam) 1C 1~ ~fl i ~T,~ /~ PROPERTY OWNERS ADDRESS: ~lf! ~ S}~,nm9~~ CITY: Legal Desc~rpt'on 1/4, 1/4, Sec. , T N- W Town of µ; L~,l! ~~/ _ , Lot: No. ~~ ~ ,Subdivision a ~ `~ u.~~~~ f S FIRE NO . _____ ~1~ LOCK BOX NO. Color of house ~~~~ Realty sign? ~ Firm: ' PLEASE INCLUDE, IF AT 1~LL POSSIBLE, A MAP, i.e., COPY OF PLAT f BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. z 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. Firm or individua Telephone No. REPORT TO BE SENT requesting. services: ._ y 4~ a ~_~--~ .~ , ~ c ~ . , -c~ ~v ~ ~ u - /'Z vt Cl ~ U d~s~ /N y ~ 7<L.f (/-~ CLOSING DATE: Signature: SERCO Laboratories 1931 West County Fbad C2. St. Paul. Minnesota 551 t3 Phone (812) 636-7173 FAX (812) 63&7178 LABORATORY ANALYSIS REPORT NO: 4359 PAGE 1 12/18/91 Commercial Testing Laboratory 514 Main St. Box 526 DATE RECEIVED: 12/12/91 Colfax, WI 54730 COLLECTED IiY CLIENT DELIVERED SY CLIENT SAMPLE TYPE . WATER Attn: Pamela Gane SERCO SAMPLE NO: St. Croix Zoning ..H.ud~Qn, .., 41Z ..5.4:Q16 . 133531 SAMPLE DESCRIPTION: Kla- Witter 1220 ANALYSIS: Bromodichloromethane, ug/L Bromoform, ug/L Bromomethane, ug/L (Methyl bromide} Carbon tetrachloride, ugfL Chlorobenzene, ug/L <0.2 <0. S X1.0 <U.2 {1.0 Chloroethane, ugfL (Ethyl chloride) <C7.4 2-Chloroethylvinyl ether, ug/L <0.4 Chloroform, ug/L ~(),5 Chloromethane, ug/L iMethyl chloride) <0.b Dibromochloromethane, ug/L 10.4 1,2-Dichlorobenzene, ugfL X1.4 (o-Dichlorobenzene) 1,3-Dichlorobenzene, uglL ~l.t) fm-Dichlorobenzene) 1,4-Dichlorobenzene, ugfL X1.0 tp-Dichlorobenzene) 1,1-Dichloroethane, ug/L X0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride} i,1-Dichloroethene, ug/L x;0.2 trans-l,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 cis-1,3-Dichloropropene, uglL C1.5 trans-l,3-Dichloropropene, ug/L C0.9 Methylene chloride, ug/L <5.0 tDichloromethane) { means "not detected at this level". 1 mg = 1004 ug. r ., SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (812) 636-7173 FAX (812)638-7178 LABORATORY ANALYSIS REPORT N0: 9359 PAGE 2 1'?118/91 SERCO SAMPLE NO: 133531 SAMPLE s7ESCRIPTION: Kla- Witter 122a ANALYSIS: ------- ------------------------------- 1,1,2,2-Tetrachloroethane, ug/L -- -------- <0.2 1,1,1-Trichloroethane, ug/L ~5.q 1,1,2-Trichloroethane, uglL {q.i Trichloroethene, ug/L q,4 Trichlorofluoromethane, ug/L (Freon 111 q.fi Vinyl chloride, ug1L ~l.q Tetrachloroethene, ug/L <i.5 Benzene, ug/L ~i~q Ethylbenzene, ug/L ~1.U ToI uene, ctg/L .~ 1. q ~; L/aisi This sample's analytical results are -~-~, below the U.S. EPA's SDWA Maximum Contaminant level of ~O/91 for those requested compounds which are also on the SDWA MCL list. AlI analyses were performed using EPA or other accepted methodologies. Samples that may be of an environmentally hazardous nature will be returned to you. Other samples will be stared far 3q days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, ~~~~ ~;,~~z~ Diane J. nderson Project Manager ~ means "not detected at this level". 1 mg = 104f) ug. . i • AS BUILT SANITARY SYSTEM REPOP.T ~,;. ADDEESS ~, , , TO~dNSHIP !~ u~~ pfi SEC. 7 T~N, R~W ' , ST. CROIX COUNTY, WISCONSIN. DIVISION 1-d r~~~ ~ n ~ vy , LOT 7~ LOT SIZE . " - ' PLAN VIEW .Distances b dimensions to meet requirements of H62.20 - __ _ _ __ ~nuw ~:v~:xzTxiNG WI THIN 100 FEET OF .SYSTEM --~ +~--~-- IG- ~ - . , ~ I ~ ~ i ~ _ ~~. ' ~ , ' ~~ i ~ ' ~ ~ a t -- ., ~ i ~ ~ i ' II ; ~ , f ~ ~ 1 I ~ I ~ f i ~ + } - --~-t-- ~, `~ .~ ~ ~' Ind~.ca~e Naic~h Ahn.aw' .:''TIC TAIv'K(S) U~"~ ,~`MFGR. lid/ ~, ~y. CO.~CRETE ~ STEEL Sca.~e ,~ N0. or rings on cover Depth DRY WELL • ;.:'ACHES N0. of --- width length .area no. of lines` width__~_~_ length /- 7~ area_~ ~ ~ ~ _ ' depth to top of pipe 2 ~ ---~•-~ r~EGATE ~:.:: RATE ~ AREA REQUIRED C ~ S~ AREA- AS BUILT t; 1 ~ ~tciaimer: The inspection of this system by St. Croix County does not imply complete a~pliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for ~te~n operation. However, if failure is noted the County will make every effort to _'~en~ine cause of failure. =ASES A'~D OILS SHOULD NOT BE :DISPOSED THROUGH :'HIS SYSTE.*i. • • •'' . • ., ~ 'INSPECTOR ,,~r- ~• DATED ~ PLU;tBER ON JOB ~ ~>~'Z~~-~ LICENSE NUMBER `' - y - REPORT 017 ITS1rCTIO_ -INDIVIDUAL SL. 11GE DISPOSAL SYSTEM Sanitary Permit . / - d State Septic _ ; ti. TOWNSHIP , ,,,c• -----"-St.• St. Croix County SF?'TIC TAn.K . Size / 00 0 gallons . `umber of Compartments / . Distance From: Well 5^5,`, ft. 12% or greater slope ---ft • . Building ft. Wetlands ft liighwater ft. DISPOSAL SYSTE:r X Tile Field or Seepage Pit(s) Distance From: Well ✓ � ft. 12% or greater slope -- ft Building, 3 0 ft. Wetlands " f.-, FIELD . 1;ig;hwater -- f t. • . Total length of lines 41 2, ft. Number of lines Length of each line 140 ft. Distance between lines (00 ft. Width of the trench f;L. ft. Total absorption area G q sq. ft. Depth Yof rock below tile �. in. D,e th of rock over , p tile fin. Cover role over .rock , Depth of tile below grade A/ in. Slope of 5 t trench 7.. in . r 100 ft. Depth to Bedrock ft. Depth to • ground water —ft. PITS • Number of pits 0 tsid diameter ft. Depth below inlet ft. Gravel a-r df pi : - yes no. .Total absorption area sq. ft. • Square feet of se age trench bottom area required /e f.!) • square feet of s epage pi ea equired - Inspected by. Title: . • Approved J` ,. Date 6j 1972. Rejected , Date 197 . • • • EH 115 - WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES 9\ )?A/ ity I. . '\)DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH -11„ �'--I/ P.O. BOX 309 Q' ',:� MADISON,WISCONSIN 53701 Q`�cF��F g19 `� ' REPORT ON SOIL BORINGS AND PERCOLATION TESTS tom_ ` �?. 1 LOCATION: l� '/4, ' o� �_ �/4,Section �,Tom`/N, R /��(or) W,Township or �+e�a� /`f�� d ��� e` � ';,4��4`� i`' eftLot No. 96 , Block No. , phi,Ii I.'I e ,c= 6-�S -H- 6-s County '�' t '\ z Jt, Subdivision Name > Owner's Name: .f9//77/ I V///t /' `n 4 /`Mailing Address: 4,-d �C/L t uel Lc$6_ TYPE OF OCCUPANCY: Residence '"------ No. of Bedrooms 3 Other EFFLUENT DISPOSAL SYSTEM: NEW _---- ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS ,--F— - " -J PERCOLATION TESTS •- 2 `7 — 7 `J SOIL MAP SHEET J-4 SO I L TYPE44J3 • /O•)t7 .&_---1,z:7 PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- -gib„ $G;z;" Te- OH1/4AP / y(iv --)' 6 /5 P z - ' ' " '/ // / /00 j � ' SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) $ z /air :C '7Z 4G "V`_s; G '1:S, z // 772 " l- " / -: G e '/-s ( 77 " // > 72-" (, "74..c• G A "1.5.• B .5✓ .z „ _ // ' 7Z" e,"f.S l! / " 6 72 „ // > 72_„ ' "/•s Gf ''s PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indi to number of square feet of absorption area needed for building type and occupancy. &/.e.,— II/ C. / BQ1?/ 1,`9,/,-/N6 .) Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. !IiIIIIIUL;ii!IIIHL!illla , 6111.111111L11111111N11111111111111111111111111111111E11111IMEMMIll 1111111111■ 1gli .1 lielditaill,LIN !IIiIPI!I1iNi!IIIiA!i!!H iiiiiiii um ■ ■■ ■ ■ • iuu u urn immisimmomm. •• IBM IIIIIMMESSE111111111111P1 if ii II L 43. "Ks I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct to the best of my knowledge and belief./ �, Name (print) i 7' N . - ertification No. ,9er Address Y,P.,A/ _ .2- "'" Aa. ,oftle'50.] / ,J(2 Name of installer if known CST Signature ,,,,,a--, COPY A— LOCAL AUTHORITY Plb `67 rr- ,•.0.4M-1tolitAa. State and County State Permit # G © '-' Vg?sit Permit Application County Permi for Private Domestic Sewage Systems County e, *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: /4 ( // 4r (- ;-( cif soy �,✓r 9 B. LOCATION: // '/4 g(�'/4, Section / 7 , T,21 N, R i i E (or) W Lot# 7 City Subdivision Name, nearest road, lake or landmark Blk# Village P /( l�� ivr-' Township f{tci5on C. TYPE OF OCCUPA)CY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms ) No. of Persons D. TYPE OF APPLIANCES: Dishwasher t./YES NO Food Waste Grinder '-'ES NO # of Bathrooms - . Automatic Washer L- YES NO Other (specify) E. SEPTIC TANK CAPACITY / 0 6562 Total gallons No. of tanks c *Holding tank capacity r' Total gallons No. of tanks New Installation Addition Replacement Prefab Concrete L' ( *Poured in Place Steel Other (specify) F. EFFLUENTS DISPOSAL SYSTEM: Percolation Rate 1) . ' 2) • 5 3) ; 5 Total Absorb Area C L' Y sq. ft. New ✓ Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_ Seepage Bed: Length 4-2-Width J ..'--- Depth r Depth7-�- Tile v No. of Lines 3- Seepage Pit: Inside diameter Liquid Depth Tile Size 4-- Percent slope of land 7 76 Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, aand that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, (rQ 5' r,' '( NAME h 5 C.S.T. # r,- 'f b' and other information obtained from f c fri, /V( ( a ti (owner/build _ Plumber's Signature 0 "�c f v-, MP/MPRSW# !� S t-3 .-Phone # ;11- ?'2-3 PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). I - ;� 1t fI1, ' � � — i � � f i {� !1 7 `t l 1 l � 1 .i I E F , j 1. i . l 1 7Ii _ -I- . j_ �1 _ i _. �_. _ _ 1___ _ r 3 _ _.I__ __ j I I I .r_ ,i .._1 m I _ - _. _ ..... -___, _-__:...__ E 3_.. - ......, , _ .._..._ r I I t ! E Do Not Write in Space B low - FOR DEPARTMENT USE ONLY cs- Date of Application -, _..3/2 7 Fees Paid: State /O,O() Con c-•- --— Da Permit Issued/ (date) - 3/ 77 Issuing Agent Namp�� , e, I. . f Inspection Yes No Valid# Date Rec'd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 3/1/75 ~Wiscons~ Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division 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 ^ Tgtwn of: Klawitter Bruce Hudson Township CST BM Elev.: r Insp. BM Elev.: BM Description: tom? . ~ l ~ / ~ au ~v',~~ - C 5 t /~tM, ~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ Lr~ cam- ~ Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic ~~ -(- ~~ / ~„` .-.~ NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION Manufac r Demand Model Number PN TDH Lift , ___ ~ _ tem TDH Ft Forcem4ain Length Dia. Dist. el SOIL ~SQ$,PTION SYSTEM (j c,~;~n,,.,.~, ELEVATIDN DATA County: St. Croix Sanitary Permit No.: 353290 State Plan ID No.: ~~' Parcel Tax No.: 020-1145-90-000 STATION BS HI FS ELEV. Benchmark ~~ ~`L? p-~ , Alt. BM 4.2~ cr , ~~ Bldg. Sewer 5 _ St/Ht Inlet ~~ ~ ~ ll St / Ht Outlet Dt Inlet Dt Bottom Header /Man. RY•s'6 ~ Dist. Pipe ~w '~''; ~ ,~j,1 N 4•z 2 .o ' Bot. System ,~~, [ ~ .~''~ g r•~Q Final Grade ~j~, g0 St cover .4.x.r s .C cc c ~:. `~wtG ~-.. .$~GB / NCH Width 1 Length No. f T nches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 1 N ,3 S} ~ DIMEN I N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Man~~y~t+ur~: b ' S~ ~~ SETBACK ~ INFORMATION Type O ' ~ ~~ t ~~~ r ~~ CHAMBER o e Num er System: vU • > ~ ~ OR UNIT ac.t DISTRIBUTION SYSTEM ~ ~ Header J Manifold ~ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. ~ Length "~'--Dia. `~ ~ ~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ~~ Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched t,., Bed /Trench Center 1 "r Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No _s.~ COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: `~ /~~/~ Inspection #2: ~ /- Location: 967 Sherman Drive, Hud on WI 54016~SE1/4 NE1/4 17 T29N~R19W) - 17.29.19.768 Parkview Estates -Lot 75 1.) Alt BM Description = ~a-~a st~~~ ~a-~-~~~ °"'' ate. re"~ti~- S~~) 2.) Bldg sewer length = ~ ~Z ~ ~_ -amount of cover = ~ $ " -~-~ ~~ ~~~ Plan revision required? ^ Yes ~No Use other side for additional information. o`I Z~ ~ n~s~. ~ ( ~ SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: -, ~ , ~~ _ , ._ .. `~ I f ~.~ ~ : ,? ~ M V ' Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue ~SC~nS~n P O Box 7302 Department of Commerce In accord with Comm 83.05, Madison, WI 53707-7302 ~~~~ Attach complete plans (to the county copy only) for the , on pap ,r notiess~, County ~j r than 8 v2 x 11 inches insize. /[~ -~G u,~ See reverse side for instructions for completing this a p tion ~~~~9+~~ ~ ~5tate Sanitary Permit Number 1.C) ,/~,~e ~ .i ~~~. /Q Personal information you provide may be used for secondary purposes - f '~ ~R. , } Check if revision to previous application [Privacy Law, s. 15.04 (t) (m)]. ~>T Cgp~X``t`~'/ ate Plan LD. Number I. APPLICATI N INF RMATt N -PLEASE PRINT ION ,~~~ Prop,~rty Owner Name ~~ ` ~' ~ f~ tia y i S T~9' N R j~E(or~N c~ cc. e ' , , , Propert Owner's Mailing Address ~rN b Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number II. P F 6 ILDING: (check one) ^ State Owned ^ !t Nearest Road Public ~ 1 or 2 Famil Dwellin - No. of bedrooms ~ ^ Village Town OF u ~ ` Sfi a l~ia .b III.- BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~~" U O ~ 11 ys ©d~ ~ X 7 q 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_____________ Tank Only______________ ExistinQSystem ________ Existin~System 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 Tank 12 ®Seepage Trench 22 ^ In-Ground Pressure ~ /I 42 ^ Pit Privy 13 ^Seepage Pit , S2G~ 43 Vault Privy 14 ^ System-In-Fill ,~ ~~~~~~.$- G~ a -~b~t~'S g VI. ABSORPTION SYSTEM INFORMATION: --"- 1.Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. S~em Elev. 7. Final Grade ~/ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation SQ ~~ " / Feet f$ ~ d Feet S~~ ~'~~ ~ pL <Q - VII. TANK INFORMATION Ca aat in alto s Total # of Manufacturer s Name Prefab. Site l s Fiber- Plastic Exper. N i E i Gallons Tanks concrete tee glass App ew x st n strutted Tanks Tanks Septic Tank or Holding Tank h J~,'~S' G ~ ^ ^ ^ ^ ^ 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) P PRSW No.: Business Phone Number: ~,~ r``,~,~ Sc ~ rev ~ ~ ~1?Irr4 ~lS- 38G- 31~ l Plumber's Address (Street, City, State, Zip Code): ~ 4~v16' ~ 5'c o IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issui g Agent Signature (No Stamps) ~Approved ^ Owner Given Initial Surcharge fee) ~~S ~ ~-lL-o'D ~- Adverse Determination INSTRUCTIONS 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 licen"sed 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 tobeinstalfed: 11. Type of building being served. Check only one and complete # of bedrooms if t or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. 1V. Type of permit. Check only one on line A. Complete {ine 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 (e.g. MP, etc.), address and phone number. PlumbeFmust si.grrapplication form. IX. County /Department Use (0nly~.; .._ , 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) all 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. ,~ . a .. a . _. ~ _ _ . ~: ., .. ,, .~- S~a~'~ l ~`,-`7'a v .a~ /~V pat:d S~G6 ~~o~ ~~~~ ..ST~Uy / ~x ~tC { ~G x ~~ m Z ~. F n a- d` M1 '~a `~ .,- °~~ ,Fs~ ~lu~s~,d ~,Jr •~~~~ .. •• Wisconsin Department of Commerce Division of Safety and Buildings Bureau of Integrated Services SOIL AND SITE EVALUATION in accordance with Comm 83.09, Wis. Adm. Code 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. APPLICANT INFORMATION -Please print linformation:~ Personal information you provide maybe used for seconds urpo cis (Privacy:.aw, s. 15.04 (1) (m)). Property Owner Property Location Page ~ of r~T ~ ~Y~ ~1~X arcel LD. # , OZ~ ' / (~-(S -~0 -~ ew wed by ~~a u ~.. -- DD ~A( Date ~[~ e~~ I 1 - 12 - Ofl t^ 1 ~ ~ ,;~ ° Govt. Lot ~~ 1/4~F 1/4,S J ] T Property Owner's Mailing Address ? ' ~ Lot # Block# Subd. Name or CSM# ,N,R) G/ E (or~ ~ ~ z ~l~ ~ ~- .~ .. 5~ - a ~ k- ~ ,~ w .~ ~. City r State Zip Code;Phone Numpe ~ .'t~,Y ^ Ci(y ^ Village ~ Town Nearest Road ,~ vc,1 S~> r~ I ~ -.. r ^ New Construction Use: Residential /Number of a rooms 3 Addition to existing building Replacement ~ Public or commercial -Describe: Code derived daily flow 11 ~ gpd _ Recommended design loading rate ~~bed, gpd/fit ~ ~ trench, gpd/ft2 Absorption area required?J~,~~bed, ft2 SCE trench, ft2 Maximum design loading rate _r ~__-bed, 9Pd/ft2 ~ if trench, 9Pd/ft~ Recommended infiltration surface elevation(s) ~U ~ ~~ ft (as referred to site plan benchmark) Additional design/site considerations Y1 d V~.Q Parent material ~I y-~-W ~-S (r~ Flood plain elevation, if applicable ~ f ~~ ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank u = unsuitable for system ~ s ^ U ®s ^ U s ^ u ®s ^ u ^ s ®u ^ s .(~ U SOIL DESCRIPTION REPORT Boring # 1 Ground el~~ Depth to limiting factor .~.~.in. Boring # Ground elev. ~~. Depth to limiting Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/fit in. Munsell Qu. Sz. Cont. Color Gr. Sz, Sh. ry Bed ,Trench l -~ lU r'. Z ~ rncn,b f~~-- ~ u~ ~,~ ~ -~r. rl~ r -- S 5 ~ ~ ;~~ `L" ' , ~•~( Rz.Y Remarks: cry IO~r z - s L 1~~~~ ~~ c tu-~ ~~ ;,~ I v r -- S 1 ~. 5 ~ ~ ~ 8~ ~~ racror in. Remarks: CST ..Nnnam/Ie (Please Print) /~ ture > / Telephone No. Y~ l~ ~~ r ~%% ~i" !j 71,5. ~Y7 ~ `~'C~ CJ ~' Address Date CST Number - 7~ U l~~- i1r~lY ~ J ~L/ ~V\1r ~ [N ~ ,1 L~ V 7 , ~ L -(i r l ~ / I ZS3.3 o q PROPERTY OWNER ~ f (~c~ ~ ~`~`"~ ~ SOIL DESCRIPTION REPORT PARCEL I.D.# Boring # Ground elm ~~ft'" Depth to limiting factor j~..{lin. Boring # Ground elev. ft. Depth to limiting factor in. Boring # Page ~ of ~ ., Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound R ots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ary o Bed ,Trench ~" S D Remarks: Remarks: Horizon Depth Dominant Color Mottles T tu Structure C nsistence Bounda Roots GPD/f12 in, Munsell Qu. Sz. Cont. Color re ex Gr. Sz. Sh. o ry Bed ,Trench Ground elev. ft. Depth to limiting factor in. Boring # Ground elev. ft. Depth to limiting factor. Remarks: 'n' Remarks: SBD-8330 (R.9/98) PAGE 3 OF~ NAME ~) UW i -~-h-? r LOT# LEGAL DESCRIPTIONS E '/4A,~14 S) 7 TZc/,N R J~{ E (or)® SCALE: I"= gf'U ~ ~ BM I ELEVATION f W ~ V BM I DESCRIPTION -~ui ~ ~ ~ lJ ~ ~ 13v,~',e./cPJ /~ BM 2 ELEVATION ~lj • `~ 5 BM 2 DESCRIPTION ~~ off-' Sep ~'t ,~hk Gn ai- h~ ~o SYSTEM ELEVATION ~D. 5 ALTERNATE ELEVATION Gl o ~ CONTOUR ELEVATION l~-C3 /~A- r ~• O Ohl V Q3 t 8l ° Z %v~ ~~ ~5~ nv old Sys~^ ~'~ ~ ~~ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~~ c -~ Mailing Address %~e 7 S~e ~ ~d,cJ Property Address Sa ~.Z -~ (Verification required from Planning Departtneat for new construction) City/State ~~. ~ ~ ~ r Parcel Identification Number C~'v2 ~ ^ /l Y s- ~~ oo ~ LEGAL DESCRIPTION Property Location ~ %,~ '/., Sec. _ / 7 . T ~~ N R ~W, Town of f'Sl~ ~l.~o~~/ Subdivision ~ ~ h' ?/~ ~ z cJ Lot # `. Certified Sarvey Map # Volume .Page # Warranty Deed # 3s' 7 8` ~i,~ Volumc ~ f'~' .Page # ~ G _~ Spec house O yes ®-no Lot Imes identifiable (~ yes ^ no SYSTEM-II~AT~'~NANCE . .~aseandmaiateaa~eofyoars~iosy~~oouldresaltiuitspc~maturefas~nretohandlewutes.Propcrmaiaoeaanoe oozJSists of pumping oat the septic taalc every S~ y~ ~ if headed a Iieensed can affoct tiee won of tha by . pumpeG What you put into the system septic taaic-as a h+atmeat stage is See waste disposalsysbem. The. properiy~ owner agroes to snbmit'to St Cknoc Zoning Dot a certification form, signed by the owner and ~y a 'P]~y~aP rest<ic~edplu~mbcr or a lioeasedPumpu ve~~riag $~t (I) 6u oa-site was~vaterdisposal system is is pmpec operating condition and/or (~) after inspection and pumpiag.(~y)~ ~ septic.taalcis less .than 1/3full of sludge. ~. ~ mod havcrcad tha above rrquircme~ and agc+ce m maintain ttee private sewage disposal system with the standards set fcnSe, luxeiq'as set 6y the Dcpartmemt of Commerce and Sra Department of Natural Resouc+ces; State of Wisconsin.. Certificafioa ~~ that 3^~x ut'~ ~~ has boea maiaffiiaod must be complexod and rehaaod to the St (~+oix.County Zoning Office within 30 da f the.three y/eFar expir~ati///o/Jn/J~date. GNATURE OF APPI.IC~tINT / / a d DATE OWNER. CERTI~'ICAITON I (we) certify that all statements on this form are tnu to the best of my (our) lmowledge. I (we) am (are) the ownu(a) of the ~ describod above,/by~virtue of a warranty decd recordod in .Register of Deeds Office. ~: ~ ~ l //diaa TUBE OF APPi;ICAN'T DATE ss«««s Any information that is mis-represeatcdmay result is the sanitarypetmit being t~cvoked by toe Zoning Department. «s«sss ss Include with this application: a stamped warranty doed from the Register of Deeds oflice a copy of the certified survey map if reference is made in the warranty deed ' ~ t ooct~lT ~. - 5~~ _ 263 .35'7893 von {~~~~ SAM 8. MILLER, a single man soavega~ a~nd warrants to BRUCS A. RLAWITTER an DAWN 8. lCLAWITTER, husban an tv a as o nt tenants KCMl,pOnyrrB ,rit tfTATR t~ oI+ stt_t+aai nas atAC[ a[s[av[o tae ateoaaipn oASe t{K3i5TEfiS OPfiC~ ST. C.~Qp( CO., W~. Recd. for Raoa[I iNs 28LIi Aoy o~ ~ I1.l1,',j9!~~ ~` ~_~77s--'~ f1n -- - w..~ .r-v..~~ - arrta~rt ro the following described real estate is County,. , ' State of Wiacoaaia: ~~ Tat Kq ~To: Lot 73, Park View Estates, Second Addition to the Town of Hudson, StTBJECT to recorded easements, covenants and restrictions TR:4IVSPE$ `*~ .,. , . - ,, This ; a nnt~ homestead property. (is) (is not) Exception to warranties: ~ Domed this 28th ~ ~ June 1974 I , (SEAL) ~S^eS~~'. " ~ r 'e'J .-(SEAL) .,. NfA SA!! E. MILL N/A (SEAL) (SEAL) `~: , ~ AUTHENTICATION ACKNOMlE06NENT ~~ARi6naturea authenticated this any of STATE OF WISCONSitI .~ t9 St. Croix Cobnfy. sa. Personally came befoee me, this 28th: dray of NyL71 _ 1979 the above named TTFLE: MEIMBER STATE BAF, OF WISCONSIN Sam E. Miller (N ~. sutlwrized by $ 706.06. Wis. Slats.) This instrument was drafted by ~„ Hugh F. Gwin, Attorney . ^' , ,~ GWIN, GILBER'~ b GAIN _ !\E t ~ • ~f•~~' • - vt~me known to be the person.- who executed the fon- $udsonC .btiseonsin 54010 ~•~ ~ ~ ~•` n Y~°'~ iat}~ea a>,d~ekno~edQ`d t e same. (Signstnres may be authenticated n aeknowle~eA. ~$d~t~~~ ~~,~ ~~'d !` ~T>~1'iCD are not necessary.} r~, 4, •~ary Public.--S-t_. Ci'Clif Coasty, Wis, 9 ~ ~ f ~~ ~` V ~~Commiaaioa is permanent. (if 1L ate expiration - ~s'4 ur..rtay^~,. 'ate: _ $~e- W.ts . 19jL~,j eARR AriTY D6aD-Y[ATx aAR Ot wIlCONSIN. tOE4 KO. t-1l7T ~0~ ~~ ~ ~~ - 9~ ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (7 i 5) 386-4680 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 ^ Water (Nitrate & Bacteria) $35.00 (Visual inspection) Owner • C nl ~ I,t) ~ P ~'" Requested b .- Address: 2~^ Address: City & State: ,~~ C i-~ ~ S - , Zip Code: Zip Code: _- Telephone N°: (~~~~_~~~' _ Telephone °: ( ) Property address (Fire NQ & Street] : ~e r Q ~ 7 s Location: ',, ;, Sec., T~~N, R~~W, Town of S.t. Croix Co., WI. Tax ID N4 Parcel TD N¢ ~ House color: Realty firm: `""~ L ck Bo~Con~ibo~©-~y Water sample tap location: ~, ,~Fau P.~~- o~ S, d~ Y TO BE COMPLETED BY PROPERTY OWNER ~co ~~- t~laGr *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM Is the dwelling currently occupied? ^ Yes ^ No If vacant, .date last occupied: Septic system installed_by: Year: Septic tank last serviced by: Date: Previous Owner's Name(s): Have any of the following been observed? ^Y slow drainage from house. ^Y Sewage Back-up into dwelling. ^Y Sewage discharge to ground surface, road ditch or body of water. ^Y ~'t~l Slow drainage from the dwelling. ^Y Y~N Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. ' ~-- OWNERS SIGNATURE: DATE:~(~ oZ5"~,3 OWNERS DRAWING OF HOUSE & SEPTIC-SYSTEM LOCATION 4 I~ TO BE COMPLETED BY INSPECTION AGENCY System design &/or Soil series per SCS sheet # Type of soil absorption system: ^Below grd ^At-Grd ^Mound Approx. size.. 'X ^Gravty ^Dose ^Pressurized Ft.2 ^Bed ^Trench ^Dry-Well ^Holding Tank OOutfall pipe DESERVED DEFICIENCIES COther ^Unknown Septic tank - Setbacks: ^House ^Well ^Prop. line ^Other Dose tank Setbacks: ^House ~ ^We11 ^Prop. 'Line ^Other ^Locking~cover OWarriing label- ^Pump/Floats " ^Alarm ^Elec. wiring Soil Absorption-System - ~- Setbacks:._~House _~Well ^Prop. line OOther ^Pondng: ^Discharge: General comments: permit on file? ^Yes ^No Soil Survey: SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 34156 PAGE 1 of 3 11/12/93 St. Croix County Zoning DATE COLLECTED: 10/29/93 1101 Carmichael DATE RECEIVED: 11/01/93 Hudson, WI 54016 COLLECTED BY CLIENT DELIVERED BY CLIENT SAMPLE TYPE WELL WATER Attn: Mary J. Jenkins CLIENT'S ID: Klawitt SERCO SAMPLE NO: 142733 SAMPLE DESCRIPTION: Klawitt Sample of ANALYSIS: 10/29/93 ---------------------------------------- -------- Benzene, ug/L <1.0 Bromobenzene, ug/L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 Dibromochloromethane, ug/L <0.4 1,2-Dibromo-3-chloropropane, ug/L <1.2 1,2-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. 4~ n MEMBER SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 551 t3 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 34156 PAGE 2 of 3 11/12/93 SERCO SAMPLE NO: 142733 SAMPLE DESCRIPTION: Klawitt Sample of ANALYSIS: 10/29/93 ---------------------------------------- -------- 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) <0.5 1,1-Dichloroethane, ugjL <0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-l,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-l,3-Dichloropropene, ug/L <0.9 Ethylbenzene, uc~/L <1.0 Hexachlorobutadiene, ug/L <0.3 Isopropylbenzene, ug/L, (Cumene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isoprop~7ltoluene) Meth1~lene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L <1.0 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ugjL <0.1 Tetrachloroethane, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichlorobenzene, ug/L <0.2 1,2,4-Trichlorobenzene, ug/L <0.2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. :,: . ~ ~_, moo. MEMBER SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 34156 11/12/93 SERCO SAMPLE NO: 142733 SAMPLE DESCRIPTION: Klawitt Sample of ANALYSIS: ----------------------- ------------- - 10/29/93 - 1,1,2-Trichloroethane, -- - ug/L ------- <0.1 Trichloroethene, ug/L <0.4 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <1.0 1,3,5-Trimethylbenzene, u (Mesitylene) Vinyl chloride, ug/L Total Xylene, ug/L This sample's analytical SDWA Maximum Contaminant compounds which are also PAGE 3 of 3 g/L <1.0 <1.0 <1.0 x^14 ir~ 2193 results are / ~-~oz-below the U.S. EPA's level 0 30/91 for those requested on the SDWA MCL List. The analytical results in this report pertain only to the items tested. All analyses were performed using EPA or state approved methodologies. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 dais from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, ~~~~~ Ohl-~~~ Diane J. Anderson Project Manager < means "not detected at this level". 1 mg = 1000 ug. ~,,., MEMBER