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020-1166-40-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division 1 INSPECTION REPORT Sanitary Permit No: 420487 0 GENERAL INFORMATION (ATTACH TO PERMIT) state Plan ID No. Persona'information you provide may be used for secondary purposes[Privacy Law.s.15.04(1)(m)1 /�" Permit Holder's Name City Village X Township Parcel Tax No'. Vogt, Bob Hudson Township 020-1166-40-100 CST BM Elev Ins BM Elev BM Description: i •i --/ I tr, - ► Qua- S TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r4e7) 1 Crt,-- Benchmark n_ wet' Q5� ^q•� Dosing I ref t. Alt.BM�4� 0 "� l Aeration w v`��1�� Bldg.Sewer '•- > _._.____------1:-=---H___.____ -0,...V //// Holding SVHt Inlet • f�'+i) SUHIOutlet 1 TANK SETBACK INFORMATION 8.5D 951/S TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic t Sb/ 1 to �_ Dt Bottom I IS. 5 f Header/Man. 1_ .!� �� 1.3 4 gy. 31 Aeration ) Dis t au.... 14 ' �,.r� ql-Lfi Holding Bot. System l0.2• r 43•KS Final Grade PUMP/SIPHON INFORMATION Cioa.IC O CA.L,Q Q J Manutact r Demand St Cover **it) q (� PM (1• ZS- Model Numbe z ,N gas 4s-.oi TDH Lift lion Loss System Head TDH Ft (.6"4441-4J For ain Length Di . Dist.to Well , tl Li LA, >v412-44C9 SOIL ABSORPTION SYSTEM(I Ski„,,L...s a& • -�k Width r Lengt I No Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIM • •'S 3 13•K. ...) 2) SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Maryltackr@ - 540, 4 ,.Al INFORMATION 11 TypeOf System CHAMBER OR . N f-tt`` CAPT J• ••, , � —�( UNIT Model Number. •12 DISTRIBUTION $16O andpld wS • DisLoa x Hole Size x Hole Spacing Vent to Air Intake r P-Leng • ` L Spa SOI COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx SeedediSodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes - No Yes t No t COMMENTS: (Include code discrepencies,persons present,etc.) Inspection #i:i 4.(22 20,3 Inspection#2: T1 7 1' ` Location: 447 Brookwood Drive Hudson,WI 54016(NW 1/4 SE 1/4 17 7229N R19 Parkview Estates Lot 108 Parcel No: 1�1.7.29.19.P1025 1.)Alt BM Description =4 *2. MO.. C+ER�J t C'��� GIr• T ^ (� 2.)Bldg sewer length= 7 ��}-t /_ (� Oa.t o • f�►►^"^�.e► Ip�ath,O •�x�L ' -amount ofcover= �'^� b�/W �xn F. . f� •2 n+G n.—to.7 .�. t,.% c tiZ (� S . Plan revision Required? Ye No -/"l S-W Use other side for additional information. ?,eL)I A..1,AA^.. UM SBD-6710(R.3197) l�/ lA1ibiQ 50._ r .,r_ -fit,, rSafety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 .J:TCYd er yC ` ISCOnSIn Madison, WI 53707- 7162 Site Addreu Department of Commerce i i0 -Z-1-0 ti 3k/iz- 51:1440_ Sanitary Permit App ' '`LC Sanitary Pmmit 'tin la accord with Comm 83.21,Wis. Adm.Cods,personal(ago ldvr/a D ❑ Check if Revision may be used kr secondary purposes Privacy Lw,s15.04(l)(m) L Application Information-Please Print All Information Saes Plan I.D.SEP 2 3 2002 _. Property Owner's Name Parcel Number /7-29./10'/ 3). 6 � r- ST CROiX COUNT', X� (J ZONING O.,7 CE 020 - �I k -41O -/QD Property Owner's Mailing /Prrope� moron / !7 �rrn a,.aloo� Or C sc ` u:S /2 T aci N.R /5e City.Slue I Zip Code Phone Number Lot Number Block Number Subdivision Name CSM Number Ali& 041 A)i. S'Y�ld .SYO4- 1is-,P:i- ,F'73, f¢vv(ilr•cul ,F 7 IL Type of BuWdang(check all that apply) OCnty 0 1 or 2 Family Dwelling-Number of Bedrooms 0 Public/Commercial-Describe Use CIe �'oge • 0 State Owned , , --L+•tsttT - 51-d n I Rnshad�L�d far c/ (2) 3 X93• -kiwi.. c t .. )CjO S I4eaowJeye,a//Lieaci 40Y III.'type of Permit: (Cheek only one box on line A(numbering scheme for Internal use). Complete line B if applicable) —' A. 1 0 New 2' m Replaceeot System 3 0 Replacement of i 6 ❑ Addition to For County we System Tank 014 1 Existing System B. 0 Check if Sanitary Permit Peeviwsly Issued 1 Permit Number Date haled IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) .E L a(J 4-(co & •4(4-, 44 Non-Pressurized In-Ground 210 Mound 47 0 Sand Filter 50 0 Constructed Wetland 22 0 Pressurized In-Ground 41 0 Holding Tank 48 0 Single Pus 51 0 Drip Line 45 0 At-Grade 46 0 Aerobic Treatment Unit 49 0 Recirculating 30❑Other V.Dispenslf r,atment Area Information: 3er 6 e✓s- -f.rx-ud et v1 i /,.5'AIALLJ/mode y Design Plow(gpd) Dispersal Area I Dispersal Area Son Application Percolation Rate VSystem Elevation Final Grade Required Proposed Rate(Gahs./Days/SG.Ft.) (Min.:Inch) Elevation GOd �'�7 a 3 I , 7 ,c/a— 9y. �O Yq oa VI.Tank Info Capacity in Toni 1 Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass - Nw Fsados Tanks Tanis SFtic a Nddn 9/e Tank . !a?Dp J ! v. CS eY X ' Doting Clamber VII.Responsibuity Statement- I,tie undersigned,assume responsibility for of the POWI'Sshown on the attached plans. Plumber's Name(Print) Plumber's Signaturep RS Number Buskins Phone Number aJ/Y<<'a sws ScLt u.s,a ir 4J../.L' �441...✓�— o?a 7 41+1J 7lS'•38G•-9/2 e Plumber's Address(Street.City.Sate.Zip Code) /424d sc.o - fed f/ so4 iJ,. S'yA/Z.. _VIII.County/Department Use Only Approved ❑ Disapproved Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) Surcharge Fee) 0 D Owner Given Initial Adverse Determination I -/ Z2-5>---- ©OP. Z' IX.Conditions of Approval/Reasons for Dina prove! • ....4(.. 64 p.at ;4.4.4.402. -- C's I-(. --... L .ai-L_ e.1.,..4d q► ass i set l�.r _ _ti 1f- n ,i J iC skis re:41 ' s t'10 'n4=p`„Ll (`( C v)fqr a .S Sieve.than II a acZ t -eta.. & cQ , SBD-6398 (R. 05/01) Y i A b T e7' /44' U< eed c� Te. �f� le 6.4- �4'/04i f/sa sc i v 4 C e 1 1° C1� 7 '(i / AWL iiteJ5 (eke ty fog r1 1 Sw,the g „s TT./ b1- 'At 33 s4-, Oar. 9q.10 � i�� 99D 9//�/dam Ia,e Pi— i6$ /h'c4J EsT 7au� /a� h'ua ,rJ / oa `f'c Ply C c J e- .2efi /'s4 t•k e A/ee SH,,'ta eUcY44.44.iFfessib/e a 3.t"SnYT^'"c1rcS I o I dpMr eta Sys+, .,L-. 91. ile) Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ( of 3 Division of Safety and Buildings In accordance with Comm 85.Nos. Aden. Code - Attach mmplab site plan on paper not less than 8 1/2 x 11 Inches b►slze.elan wet - hawks,but not limited to:vertical and horizontal reference pant(BM).direlUmiDd.. :.J Ca"ty - "'• . I.D. percent slope,scale or dimensions,north arrow,and location and distance 10 nearest road. 9••:fo-0-r--3Mieaseprintallinformation. r 1 y 200 R. . by /�!1/ �nri Date Perron.information you provide may be used for secondary purposes(fiery Law.s.15.04(1)(m)). / \ 0S) 10 .2I 74)2 Properly Owner Property Location 4i 'p / 1/4 S/7-T Z.q N R /q E(o0 s7 Mai reels' { Lot# Block ii S ...Name or GSM* 1 f PrtM�erty q efT lad lain)abc4 0 t' /05 /Gc1 eA'ew Es4r/es City f/�[// State Zip Code Phone Number ❑City ❑V"tie ®Town Nearest Road (fdl so n RA)) I S I/o/b I ( 767 3156'-6 b'73 'c/Son i Br,k mooed Dr. (J New Carsbuctlon Use:CR Residential/Number of bedrooms y- S Code derived design flow rate 606:C' 7 -0 GPD Er Replacement -El Public or commercial-Desaibe: Parent material DCJTW 4 S h Flood Plain elevation If applicable --674- it. General convnents and recommendations: Sys/€• 1 e-/ev. 9y 6d .Rnrinn# El Boring / LS Pit Ground surface elev. 97 3O ft. Depth to limiting factor >/S in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDnt= in. Munsel Ou.Sz. Cant Color Gr.Sz.Sh. 'OW 'Effe2 d-/L /oyc,3/Z - S, •/ „Zia.. pry'.- c 16' ,S- ,ff" Z /z-34 /2> f/f - s/ .. - , (s _ • / . 6 3 ... -S /oyi1 — rrzs os� In / - _ / 2 4f9I.KI/ C'/9 I. Z acging e p Boring pit Ground surface elev. Wiry ft. Depth to limiting factor /e'd at Sod Application Rate Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsefl Ou.Sz. Cont.Color Gr.Sz.Sh. ''Eifel 'Effe2 11-/y /oy/.YZ S,/ G9malf /f'!t/ C S l✓-( , 5 , x z /,1z3v 4,,//y - 3.e/ Zfit jfl , e 5 - . . 3 39 g ,dr-Y/(, — ms a D xi - x.z •Effluent e1=BOD;>30<220 mg/L and TSS>30<150 mg/L 'Effluent e2=GOD,<30 mg/L and TSS<30 mg/L CST (Please Print) Si re CST Number Ai � S�ln.,,.tta.k,a� es-.�3a 9 Tess ate Evaluation Conducted Telephone Number Z .s7 __ s4-7/ w/. s s--/-oz 7/s--,ey7-,' ri Property Owner 1�`'c/ / p Parcel ID# Page Z of 3 leg Boring# ® Pit / ,0U ft. Depth to limiting factor /L/ in.Ground ;urtace elev. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDRt2 In. Munsell Qu.Si. Cont.Color Gr.Si.Sh. 'Eff#1 'Eff#2 I o -/t� /ay/3/z — 3, 1 ;,.,c. �� is /i( s Z /y.ys yoy„/Y _ 5,sc_/ z ,. be /n/- ct - ' 7/ . y 3 y5-/1' /e/f)/Gn _ /V.s OS) to i — , ?- /Z Boring# ❑ Boring 0 Pit Grounds ,rface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure I Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Si. Cont Color Gr.Sz.Sh. t 'Eff#1 'Eff#2 Boring# ❑ Boring ❑ Pit Ground surface elev. ft Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft2 in. Munsell Qu.Sz. Cont.Color Gr. Sz. Sh. 'Eff#1 'Eff#2 • •Effluent#1 =BOD5>30<220 m9&and TSS>30< 150 mg/L 'Effluent#2=BOD5<30 mg/L and TSS<30 mgA. 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 60R-266-315,1 orTfY 608-264-8777. • r.rr. . sflnmottrmaof. • • • •\'••.. . • PAGE / OF 3 NAME Lfo -- LOT#/#8' LEGAL DESCRIPTION IA �4.S T ,N.R Flor)W SCALE: 1"= 17 U ' BM I ELEVATION /Do. 0 BM I DESCRIPTION cI / �✓ t BM 2 ELEVATION 7q 70 BM2 DESCRIPTION Ao a -1 / ! ✓ — — — SYSTEM ELEVATION �� Er 0 ALTERNATE ELEVATION /t"/� CONTOUR ELEVATION 9S fa - tYgo 51 cif() 4Z % 51 SIGNATURE DATE rg o • . Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soli Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.8/99). Table 1: System Design Specifications Sanitary Permit Number 420 Number of Bedrooms `f' Design Flow - Peak (gpd) Lop Estimated Flow -AverageSgpd) Lf-CO Septic Tank Capacity (gal) I , Soil Absorption Component Size (f1) 'g�un Type of Wastewater bomestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component 1 Soil Ab tion Component Design Flow - Peak (gpd) ) 2 g 933 odi Maximum Influent Particle Size (in) I U 1/8 Maximum BODE (mg/9 _ 220 Maximum TSS (mg/L) • 150 Table 3: Maintenance Schedule Septic Tank Inspect and/or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component i Inspect once every 3 years Sectic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stets. The contents of the septic tank she be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the se•tic tank and outlet filter shall be assessed at least once every 3 years by inspection. Th= out et Tilts, shall be cleaned as necessary to ensure proper operation. The filter cartridge shou d not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Pier, for a Sect'c Ta-, aro So: Ansorpt,on Component filter Is equipped with an alarm, the filter shall be serviced if the alarm is activated •.)ntinuously. • Intermittent filter alarms may Indicate surge flows or an Impending continuous alarm. The septic tank shall have its contents removed when tha volume of scum and sludge In the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next seance needs to be performed to maintain less than maximum scum and sludge accumulation In the tank, Manhole risers, acosaa risers and covers enouid be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure n-uit be replaced. Exposed acoeas openings greater than 8-In011ea in diameter shall be secured oy an effective iocking device to prevent accidental or unauthorized entry Into the tank. No one should enter a septic or other treatment or holding tank for any reason without being In full compliance with OSHA standards for ent'aring a confined space. The atmosphere within the septic ar other b'sattnent of holding tank may contain lethal potsa, and rescue of a parson from the Intsrler of the tank may hi NflWit or Impossible. Tank abandonment shad be in accordance with Comm 83.33, Was. Adm. Code when the tank Is no longer used as a POWTB component. doll Absorptjpp CornnanenM The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are showr in Table 2. The longevity of a soil absorption component depends greatly on proper Ana timely maintenance, and system use with.n or below the limits of reliable operation. Good water conservation practices by all occupants and Ova installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soli absorption component's operation must be assessed by inspection at least once every three years. The Inspection shall Inciude recording the levels of ponding, if any, :n the observation pipes, and a visual Inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be Identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic arounc or over the soil absorption component should be avoided particularly during winter months, The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or Impossible to repair until weather conditions Improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil end dispersal co, which may lead to more Intense, and earlier, organic clogging of the soil, 2 Management Tian fora Sceptic Tank and Soli Absorption Component Plantings of deep-rooted trees area shrubs directly over of within ten het of the component should be avoided since root Intrusion into the component may obstruct wastewater flow. Contingency Plan In the event of system failure, a new system Could be installed in an alternate ares. With the Installation of a diviner valve,the existing system could also be reused after a period of three to four years. It Is the property owners responsibility to maintain the arternate arse free from any planting of trees, shrubs, etc. In use of failure of the original system, the alternate area will be needed. if any trees, shrubs, etc. have been planted on the alternate area, they will have to be removed at propeny owners owes. If alternate tires Is destroyed,there are other stteredvs systems that can be used, in which, could result in added expense to the property owner. Any tank abandonment shall be dons In accordance with Wino. Code 113.33. My Questions regarding this code, please contact your local?wing Office or contact the Installing plumber. • .�.oN1Nq ›Cyrs . (1IS)3 " y b% 0 Scalr"ba. . 6411/4*—It. ?\.Nbnrr,le\su (115) Sit V" 31 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Rots e r> U.rt Mailing Address 4/y7 AffdeIni,/ax/ 1 v ••dam Property Address _ �a (Verification required from Planning Department for new consntutlon) City/State f‘‘,d.<,4 N u' Parcel Identification Number j,EGAL_DESCRI1LTION Property Location ,i/a '/., 5-f, 1/4, Sec. /T , T P29 N-R /i/W, Town of j1/4-ciSs-ii Q d , Lot # CdF . Subdivision / V //// Certified Survey Map $ , Volume Page # Warranty Deed # g( s3 9 , Volume ? i1 • Page # 5-3 Spec house ❑ yes - no Lot lines identifiable, yes ❑ no MilifibilgALNIESAICE Improper use imd maintenance of your septic system could result in its premature failure to handle wastes.Proper maintenance consist/of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you putsystem can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to subunit to St. Croix Zoning Departme nt a certification form, signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(I)the on-site wastewater disposal system is in proper operating condition and/or(2) after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree 4.4) maintain the private sewage disposal system with the standards set forth, herein,as set by the Department of Commerce and the Department of Natural Resources,State of WisconsO�Certificationth stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning days of the three year expiration date. f 3�/Je7 SIGNATURE OF 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 property described above,by virtue of a warranty deed recorded in Register of Deeds Office. DATE S1ONA 0 APPLICANT •••••• Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. •• Include with this application: a stamped warranty deed from the Register of Dee Is the warranty deed a copy of the certified survey map if OCQC:UMENT NO WARRANTY CEED r"'e •••LI •{el•veo roe •IC01,01N0 DATA STATE BAR OF WiSCONSIN FORM 2—LWl 419539 eao+c J60,4639 RE•ISTUS OFF10E ST. CAOD( co, W IS. Stewart J. Nelson and Theresa L. Nelson, Reed. Record this 20th husband and wife as joint tenants, day 01 Nov. A.D. 19 tl6 at 3:4 5 P AL conveys and warrants to .LtQber.k .. QCJ.t, /1 husbard..end..wife.,...s.urvivorship. marital..praperty C3 se of Dawdle tha following de•cr.bed real estate in St. CrOiX County, State of Wiseons.n: Tax Parcel No: Lot 108 Parkview Estates Fourth Addition in own of Hudson, St. Croix County, :•'isconsin. $ 3 ye o0 FEE This is homestead property. (is) (is not) Exception to warranties: Subject to easements, reservations and restrictions of record. Dated this .�.. . .Yh -.. day of _ November , lg 86 . _ _ (SEAL) . (SEAL) • • . STEWART...J... NELSON . (SEAL) A. 41,PAwy^1.. .(SEAL) • THERESA. L.. NELSON . _. . .. I Ste` IS 14 W auu.W ... I I— • ■ i , ' I �` I 101 y p iirretree 9E 30 I y 1R1 ia'iaw s IIYI6'I4"W 00- - - O - - ''-N mere246.00' ~'•' z0 t 4.)417 246<C • BROOKWOOD se9'15 I1 W ./ 293.28r - r 243.00r 156.00' -- - --I t` ; F i I ,`_ ♦s 107 '� i$ 108 g 109 1.210 g I— LOT ACRES ACRESen 52697 SO.FT. 46.651 SOFT. j )74 46.795 SOFT. N. 9 / ♦ 8 `�p� 7� E • N891151I44E 243.00 ♦ 0* � 1 -bo N N . ist o untYR � 8 -- Croix CO 156.od I. teris`_...) 8----- �. •�b SOW. CO' NR., J. • I Tangent Tangent *' g Bearing Bearing 0"E S9'48110"E 0 • M. 102"E 536.23130"E NI1042134"W - - '14"E N89.15114"E N65°21146"W • - ---- - - - - - - - - -1 u '40"E N71'50106"E N89°I5I4 E Z6118 NO'06'30"E N17°21122"W I 135"E N45'10140"E '30"w 544'57140"E . H '27"E 40 , I '01 0111WW "112L 129"W RUCCH 4, 12711 JAIIIIS E.'35"E S0'06"30"W 7 t'35"E N45'10140"E 4 A '15 8"E 344'S 7140"E �i�0 :..�v`' sU )'S 8"E _'MN�, 123"" 1451111 H UDsON, VI 105„w ,131"E 135"E 30.06130"W k . ( ctl , P ( (. 10 --/ 161,1/1 jrAte14/ - 11L6"-K} Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT K • OWNER 5 , I ) TOWNSHIP g( Soy 1 SEC. / 7 T 2-9 N-R/�/ gi ADDRESS �ki e5„ y ST. CROIX COUNTY, WISCONSIN w, s . SUBDIVISION//K (/,44_,Jr51,tasff LOT 4/OS LOT SIZE /02 /9e e. /S PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM At?,-00 ✓¢ - — — — — — A So �► lot limit G 3 211' uo .5 2 K S : �• Ij $7 / 17 31— s4 l I� < t" INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Ita� ?e NE La.tncf Elevation of vertical reference point : 100. 0 Proposed slope at site: - 2 % S E SEPTIC TANK: Manufacturer: ()Jc•, SQf Liquid Capacity: I0009a \ Number of rings used: 0 Tank manhole cover elevation: 1 5-. q 0 Tank Inlet Elevation: 9y (A Tank Outlet Elevation: 9y• 4,0 Number of feet from nearest Road: Front ,®Side O Rear, O / z 5f feet From nearest property line : Front,O Side,©Rear,O 7 7 feet Number of feet from: well (p(p , building:/25E4;,1441 20 a,Je,trtobA ,D,,,,r 56-4y,6., (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: '�'/ Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,O Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: j1( X 3 Trench:Width: Of Length: _ Number of Lines: Area Built : 6, 451F . Fill depth to top of pipe: 1 Z" Number of feet from nearest property line: Front, O Side, Rear,O Ft .7O Number of feet from well: 9 7 ' l ` Number of feet from building: SO (Include distances on plot plan). SEEPAGE PIT 1 Size: /L Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one) . HOLDING TANK Manufacturer: it' 4 Capacity: ' Number of rings used: Elevation of bottom of tank: Elevation of inlet : Number of feet from nearest property line: Front, O Side, O Rear, (2)Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: n / Dated: Plumber on job: GY/� ✓"�s�'Ge [�' 2 License Number: //- / 11 7 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS LABOR&'HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,wr 53707 b ii ONVENTIONAL ❑ALTERNATIVE SIR.Nan10 Number III omon.EI ❑Holding Tank ❑In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER INSPECTION DATE Sam MiJ2ela RR# 1, Box 282, Hudbon, WI 2 A /-f5 J,30 BENCH MARK IP.Hn.1Rntr.hr.nc.pool/DESCRIBE IF DIFFERENT FROM PLAN REF PT ELEV CST REF PT ELEV NE SW,Sec. 17,T29N-R19U1,Lo.tf+108,Pa>tkV.iew E4.t.IV,Town ob Hudoon Nam.Oh Plumber MPIMPRSW No Counp Selo.r.,Perms Number Douglas S.t&ohbeen 5432 St. Cto..x 58879 SEPTIC TANK/HOLDING TANK: 'MANUFACTURER 1���/'.�,E� LIQUID CAPACITY�� I TANK INLET ELEV TAN 01. ETELEV 'WARNING LABEL LOCKING COVER /✓ Nv� �O V V I /1 ✓ I/ 9 i/� . D PROVIDED G' E YMllf 7 • r 7 YES ❑NO OYES O BEDDING VENT DIA VENT MATL HIGH RAT R N - DF ROAD PROPERTY WELL BUILDING VENT OFRESH �}�--�,// ( ALARMFEET FROM LIN�J / / �J AIR INLET DYES CSO l/T{// I ❑YES ❑NO NEAREST �.a2 6 / 7 CO(( // DOSING CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED PROVIDED OYES ONO ❑Y ❑NO SR GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NI OF PROPERTY BUILDING VENTT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE 41RINLET PUMP ON AND OFF) EYES ENO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH IAME TER MATE IAL DMARKING or excavatIon. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH LENGTH NO OF DISTR PIPE SPACING COVE - INSIDE ERA SPITS LIQUID BED/TRENCH NOOFTRENCHES MAT FIT DEPTH DIMENSIONS is .F3(o G. RAVEL DEPTH FILL DEPTH UI TH PIPF DISTR PIPE 1015TR.PIPE MATERIAL NO OISTR RRE PROPERTY WELL BUILDING V NT TO FRESH BELOW PIPES FA-COVER ELEV INLET tEL V EN PIPES LINE 9, `� AIR INLET FEET PROM 61- 1.Z 9(a`f I�J /� 27Z7 3 NEARCBT I► �G� / 7 Jo MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. n� OYES ENO SOILCOVER JTExTURE PERMANENT MARKERS OBSERVATION WELLS ' EYES ONO EYES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH.BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES OYES ONO OYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TNO OF RENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL NO DISTR DISTR PIPE ElISTRIRIITION PIPE MATERIAL&MARKING ELEV Elf DIA ELEV PIPES OM ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS YES ONO OYES ONO COMMENTS: PERMANENT MA IIKER OBSERVATION WELLS. NUMBER OF PRLIOPERTY WELL BUILDING. 3 S2 FEET FROM - OYES ONO ❑YES ONO NEAREST - el / - G� Sket System on n� J� ?• I/ ain in county file for audit. Reverse Side. L'f a —1 I1 SIGNATURE R TITLE DILHR SBD 6710(R.01/82) ��" CC �� i""� " 't_c: ,' D I L H R APPLICATION FOR SANITARY PERMIT p, oOf� COUNTY 11 i� Tr.,cr,T OF (PLB 67) UNIFORM SANITARY PERMIT# ell w-,dosTrn.cne &tM-IfTYYlr1ELPTPOnS� �e ^7 9 —Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS J A ni IC I k PL 0 4e f Eel 2n -2---- PROPERTY LOCATION CITY: 44 u `so r, IVE1/451./1/4, S /7 , T2f, N, R fi ! (or� T : LOT NUMBER BLOCK NUMBER SUBDIVISION NAME 'NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D.NUMBER /erg -Zr V.awEsttt. 4- Brr tl4re4 Tar: TYPE OF BUILDING OR USE SERVED 36 1 or 2 Family Number of Bedrooms: 3 Li Public (Specify): THIS PERMIT IS FOR A: Q New System ❑ Tank Replacement ❑ Repair Li Replacement Soil Absorption System ❑ Revision ❑ Privy • Alternate System Li Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepaye Bed ❑ Seepage Trench LI Seepage Pit ❑ Holdiny Tank LJ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issuea . ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity /c'O ) / x Lift Pump Tank/Siphon Chamber ,/ Holding Tank capacity Manufacturer: { t/Q.11 . IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure ,�f Total *of Prefab. Site /•{..J� Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): C 3 Co I 5 (v =/ g' Xrfrivate ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signs ure: „ MP/MPRSW N� Pi Number: D0 cyia S 5 fp0 6ee,1 f ..0. P-7£eT fi 3 33 Plumber's Address: Name of Designer: I A i e cv /l r r✓ h rr 0 n 4 l c/; 5 /h;ka✓ 4f -%osta- /( COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date. ❑ Dippprowd Jialt4t let /n� {'//�► $ " p�/ ❑ Owner Given Initial v o U /.{.a/ �/� �Q O / _ kf Approved Adwrs Determination Reason for Disapproval: t/ Alternate course(s)of Action Available: DILH RSB0.6398 (A.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 • . To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system,circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis.Adm. Code will be applicable. 10. A new permit will be needed if there is a change in,estimated wastewater flow, (number of bedrooms,etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan,drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances,distances between beds if appropriate, tank locations, effluent line from tanks) to system, building sewer and vent observation pipes). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit.Private sewage systems must be properly maintained.Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years.If you have questions concerning your system,contact your local code administrator or the Bureau of Plumbing,DILHR,State of Wisconsin. • • APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house") , then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property Slit PO rh i 1 (v Location of Property ,1E It S4) lb, Section / 7 , T 2,7 N - R /9 ` w, Township 4tu ,`Sn Yl n Mailing Address RQ * I 1 X Z� Z_ Nu y Sot W S S '/nis Subdivision Name 2a f k V:L.uJ S.T4s Lot Number 7Pr / 0 u Previous Owner of Property a (lc.) Lot v-r Total Size of Parcel I. 20 Date Parcel was Created 3// /g" y Are all corners and lot lines identifiable? � Yes No Is this property being developed for resale (spec house) ? X Yes No Volume and Page Number / 2__ as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERLY OWNER CERTIFICATION I (We) een.ti(y that al atatementa on th.i,a ate thue to the beat o6 my (out) knoweedge; .tLat I (we) am late 1 the owner(a ) 06 the pnopenty de4cnibed in thin .n6onma.tLon ionm, by viAtue o6 a wantanty deed recorded in the 066.tee o6 the County Regtaa et o6 Jeeda as Document No. ag31/5 Z ; and that I (we) pneaent.ty awn the pnopoaed ante bon the aewage di.apoact. ayatem (on I (we) have obtained an Eaaemen't, to nun with the above deaen.ibed pnvpenty, lion the conatnueti.on o6 aaid ayatem, and the Game has been duty neeonded in the O66.iee a6 the County Reg.i.aten o6 Deeda, as Document No. 39 3,95-2— ) . "`- 2 JL SIGNATURE 01 0 ER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED 7 . . y . .: .. • • 3U1YZTOA'3 CLATIT CATL I. Amos Z.Rossi,Registered Wt.sa.ta Lied Surveyor. hereby comity to the had of my po.4o.sieeal knowledge. aMMrstsedtry lad bolts[: T1aa 2 hare mar,eyod. divd.d and rnapp.d Park View Estates:yoartb Addition. loomed is N.NEII4 sa the 3W 1/4 and the N'114 of tb. SZI/4 of S.erto, I7. T2174, h l9W. Tows of Nadsen. 3t. Croix Comity, W i.eoesia That I have made sack surv.y. land divialoo sad plat by lbs aissctbe of Anal E. Wert and Doverly A. Wert. swami*el said lead. d..crllr.d as fellows: Gassoaelag us Om t1/4 corner of said hoed*. 17;tb..so 309'L`.•)4"W (usam.d b.aalago ret.sensed to the ut-- _. - •EAST WEST 1/4 3actfoa U..vd 3.ctioa 17, b.safaR..sased 3$122'0$W)(14100.1114114 as 309.21140"W e.that Carta-4 Stormy Ly r000mded ha Y.lam. I.Dag. l34). 1332.91'along sold EAST-WEST 1/4 Sed h ges eat theme 01'01'70"W 237.Ti to the poled et b.µa►a;;thane.WWS240"x 412.00':chaos* • N0'116'30"Z 212.001to the Southerly rigbto/-way Ua..4 Cr...NM Lase:thaws. 7139'524e 64.00'along said rrffg�ltN+sy limo; then. S.PO4')0"W 251.00';thence 579'26 i2"yi 194.35';them..Sl9'iS'14"W re 236.741;the *717337'O3"W 142.171;times. _ 3l'r1S'1d'7 334.30';thence wrov30"E 104.001;Ammo 34 nc Y15'14"W 314.00"1 thee N094...1130"Z 1511.00';the.**Dl9'13'14"W 66.01'1 the...$O'06'30"V 316.43';there . SN'13'l4'W 131.00.;them.NO.37'51"A 54.1$';Ma.el,519'22'0'e"w 14t.30';tb.ass 30'06•030'7 204.40';theme NOl13'I4-x 130.00':them.30'01'30"W 312.57';thane. 1419"13'14"L IS0.00';-theme Smalme.tarly 66.23'along the amt.et a 313.30'radios carve madam Nertheaei,rly whose chord Doers 3.30250"E 64t17';them.7419'13'14"t 57.O1'tMemo Southeasterly134.54'salon;lb.aro of a 317.00'radl.*carve caeca.** NwrtM..cc..rriiy�wt.em chord bear.324 03'O2"C 131.5l';thanes lit 23'30^• 14).14': j tbe.m.Irtr36no"t 160.96';term MVP 15'14"tw.o0';them .,30 06'3Y-W 101.00'; tbeac.16?30'307 269.14';shoos*Seue ..st.rly%.11'alma t •are ata 217.30' r.diwasatw.wa w ay.Nortlea .dwhom,y w .sherd booze 371'03 t6"C 95.101 thanes mar!saws rte.00';thence Nortb.asterly 91.21'also;the aro'of a 300.33'radio. w.s.awt•Nortbwelerly worms sherd bear,N1r32'40"L 90.3S'1 theirs.North- masterly 91.44'*long the ars of a 309.00"radio*crows concave Northoostnrly whose chard hear*2f0'37'2P'7 91.09';shwas N0•04'30"t 150.00':thaws.N09'1S'14 e. 471.0511 thence N(104'30"t 134.56'to the point of begin/Ping. ' That snide pot 1•a cared remme tatfo.of ell the extorter beeedexies,4 tM land Arrayed magi the.abdivla4ea thereat made, tad Thus I haw folly eempUN with the provisioe.of Chapter 236 of the 7f t.eeesla gummed. the$.bdlvtde.and Toeing Regol.tl.ne of 3t. Croix County, the:'ow.of Had...tl.bd4rt.laa OrdLr.c.. end the City of Hideo.3.bdivlelee sad Ylety.erg Or41- .ancs"la.arv.7Aeg.Moldiag sad mapp/a;the.am.. Dated this. Its Ant of M .lt , 1914 R viowl 131k der of April. 1914.us '� es t. tech - .3. 137d Jdltq I. * 421 tamed Street {t Rod.... W I.ee..le 54016 this COUNTY TREASURER'S CtLTITICATL 1d ea / y DTATZ OT WlSCON3:N) , T. GROIN COUNTY ) I. Mary 3...Livermore, being duty.l.ct.d, qualified and aa.ieg Iroa.ur.r of St. Crete County, de b.reby certify that lb.ra.ordo in my offlc.Omer co suroMam.d tax sales and au oupeld ta..s.r .p.cial muds as of /.4.-3,-d{_ alfsothtg the latch ladwd.d la the Plat of Park Vl.w Estate. Fourth AddtIoa. .S-9-1! l�M� ,4..e.a.rr.:✓ Dote Tr.rvers/ ZOND4G CO1iLI'T'e et R r5OLUTION TM.plat 1•her.by apprev.d by the St. Croix County Compr.lu.ear. Parks, Tanning and Zodne Commin.n. , • Date C.deaf 311151_ _ _._- Oaa. AdanW air•tor 1. :wee a1. a 1,et ,.. . ram-,7tt_-alas._. 31 : ln.e.,- IaMaRR • i5rt? y '' _ J soh*ii Nut ( � ,.... r �rf is _ ,. }.• t•C4.^_ . .. . .:7 .J:tP. , • . : Pi'Y.'1:.•ti, r 17. {:11 • • PARK V1E�W ESTATES FOURTH ADDITION r SAL 9.J6CIVIS CN 1..CC.ATW.IN THE ww a prNY6-S£►se SECT1CN IT, T29N1, R19W, i CNN CF HUDSON. ST. CROX COUNTY, WISCC•'VSIN • CERTIFICATE OF TOWN TREAS>iRSA I STATZ OF 71SCCKTD4)as . ET. C3O1Z COI N T T ) I, Beverly A. 3oba..n.be{eg tb•duly elected, qualiflasFaad acting Town Treasurer I of the Town of:godson, do h. H.. o.»t!p that in sccordaaea rpoorda la ray office there u.DO Unpaid terse.or Wpasdal •s...•smeata as of - r7. ? /Y —maa.y land laa►ad.d la the Plea of Dark Vlow Eetat.e Fourth Addition. B�rly. aim . owe Treasurer 1 . • TOW:' BOARD AZ-SOLUTION RESOLVED. that the Plat of Park View E.tat.. Fourth Addition In th.Town of Hodson, Darrel E. Wert and Bits A. Wert, nweer•, is hereby approved by the Tows tl.etrd, i Y. .'� �L`.fe Approved own rman� ij l�! d fr / I C Signed awe t.,titrm.n d♦;'ter.bv !.-tity teat the for.Soint 1s a copy of.. r.•ulutlon adopted by eh. Town I board et tit*Town of Hudawt. I r, : v ! /.. ' • . /, .',' .a....., D•t. i Town Clerk I 1 OWNERS.CERTIFICATE OF DEDICATION A.owner', we hereby c.rittl!y�that we caused tea land described on this Plat to b• surv.yvd, di-.:d.d, mapped tad dadiested a• rep ree.nted on this Plat. W a elsu certify that :Sit Plat is required by S. 236.10 or 3. 23n.12 to be submitted to the following for I appro.nl or ob;action: D•partm•at of Dsvulogm.at Department of Industry. Labor and Human Relations, I Town of Had.oe. City of Hedeon and St. Croix County. W.T!v_SS the hand nod .eat of said owns.this_/— t day of _X. 7. /%.c' In pra.snce cL r� t /1../ )it I :: h 30 y.. arrel set �1 f Beverly A. Ware. . STATE OF WISCONSIN ) ST. CROIX COUNTY ) SS Personally cam•befers me this day of // -. / • •• the above narmei Darrel E. Wert end Beverly A. Wert, to ins anewn to be the par.cns who executed tbe foregoing instrument aad acknowledged the 'Arno, �NotarY Public .' .., rf. Wi•conssinMyeommis.lon expire• L /f9//, Mary t/ &y^^41.ch, `rotary Public CERTIFICATE OF TOWN CLERK • - STATE OF WISCONSIN) )SS ST. CROIX COUNTY ) I. Rita:bra., being the duly appolnt.d, qualified tad acting Town Clerk of the room of:r••dson, do h.r.bj cavity that copie of this Plat were forwarded as required by .. 236.12 on the fJ- day of 1934, and that within the 20•day limit .et by .• 236.12 O) (no obj•cti rot to the plat have bo.n flied) fall ot.jet::nos to•'., •:at h.ays be...met). Dite Alt Horne, Town Clerk I JAMES E. RUSCH 1 SURVEYING & MAPPING HUDSON, WISCONSIN n4,3 INITItL.i '.NT InAFTEO St 4 :tire fe...4�xt1 . r,'.,Q,.... t • .. t 9f et ':.'tf I . -. .kr.yet` Jr C ::'? S`1' J ,� ,. 9 STC - 105 cr 9 y SEPTIC TANK MAINTENANCE AGREEMENT p St . Croix County z e7 OWNER/BUYER VIA . I cLii ROUTE/BOX NUMBER(` p e_# / 3 o)C Z 2' 2_ Fire Number /{/i— CITY/STATE µ'-cQ 50 ►1 (.A}, • ZIP / I, PROPERTY LOCATION : 1V , sIU , Section / 7 , T 1 N , R a Town of l�u- 5n ►i , St . Croix County , Subdivision Ake k , Lot number /0 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 may 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 r• the standards set forth, herein , as set by the Wisconsin Depart- ro went of Natural Resources . Certification form must be completed and returned to. the St . Croix County Zoning Office within 30 days of the three year expiration date . SIGNED' . DATE ' O 17 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 . . x , £I � � } Z a / [ ', � 2 ? IIQI § C % 227 v \ } / § // 7 } ® Q - E j }COCO � _ 7. , _ � � ? �o_ o0. on • , cao _ g , � ir _� � \ 33C - CDEn � � W ® � oCD 0 0CDCDOD w tN = z � \ S � & J � II , oO tEk / } c { {& � � 7 = ! k � � cn Vk • � / \ _. —, AM 311/Mb. — mom & E ; 2V ± o / kk � f/ 00j @ k � D / \ acr3 § C y § , � OD z l# � ) 0) cn § 0 ° f3 O z II , � , EAk } w ; ■ & ; o gx § m � a t d CD ° 7 © 0 _ m 33 air 5 —ca) CD n , , , � � � CL = C) CO m \ g } C \ 0a (D = f0 -, � � n C N ` oo g ' 77 /J > -4 ® { k - kQ & E ( SI \ 73E (nCCC C) O \ ! CD—. 0 E ¥ @ �O. � � 7/ 3 \ ° ° ik@ WC3 ) ( \ 0 § 2 E ° R kfE ;3. A ) / \ o � J 2� � � 2 \ \ / CD 0' IN ' � � � � i ii , a | - , 2 E , c : �f� ., DEPARTMENT OF _ REPORT ON SO ,4011011471 ... • i r t 1 c '`x' ND SAFETY& BUILDINGS INDUSTRY, ON .LABOR NDATIONS PERCOLATI Ii 1 T . 1 ; MADISON W 5DIVIP.O. BOX 3 69 (H63.09111 7 :pter Ot5) � LOCATION: SECTION: TOWNS IP/ - OT .1. 'BLK.NO.: S BDIVISION NAME /it '/�/ /7 /T.29N/R/99to� //w. s, �- '' 1/,.s7 — �',hsE !/e.,fiAlx Ir. COUNTY: OWNER'S/BUYER'S NAME: MAFLIN a • a:-ESS: ci. c. A filfr, M l/a.- 7rtoK . ' l sad i X`s, f'/e/ b USE DATES OBSERVATIONS MADE NO,BEDRMS,: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Pile esidence3 vAl AINew ❑Replace /0.4- Of /Q-2-erL/ RATING:S-Site suitable for system Um,Site unsuitable for system Po, {/ CONVENTIONAL: MOUND: IN-GROUND•PRESSUR YST M-IN-FILL OLDlNG TANK:RECOMMENDED SYSTE:loptiogall/�/���.� 51 S ❑U ®.S ❑U .S ❑U I ES ®U ❑S QU edataies•• Ori.► Ad (/ If Percolation Tests are NOT required DESIGN�/RATE: If any portion of the tested area is in the / under s.H63.0915)Ib1,indicate: Floodplain,indicate Floodplain elevation: A PROFeV_E DESCRIPTIONS a BORING TOTAL/ DEPTH TO gROUNDWATERIM0IIES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTHS g. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- / 7.f' 99ro' Aug_ 7 7• S1 /A8is/) /oB.t s; .s1n is g.8,6►I cs4-9r. B- 2. 7.S ' 7g 7' %L 7 7. s' . d'B/s/, , 9 /3n 5/ . 18,/ /s, so et., cc Vv. B-3 751 91 4 ' A4 — 7 7•S' . (g/s1, /. Sg,, Sj Sr Bn CSF1r. B- Y 7S" int' um-- 7 74 ' . 7 8/3 t /,o 8n s, a. 3 Onls, 3.SA cs*p.. B- f 7.S" 9(3' /14.4 4..-- ? 75 ' . 98/s/ AA B.n s/, .S' e #, Cs �1r. B- PERCOLATION TESTS TEST DEPTH* WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER MleM66 AFTER SWELLING INTERVAL-MIN. pER?OD PER/ D2 PE lOD3 PER INCH P- 11"o' o, .2 ( 6 `3 P- 3 Y./ ' 4/0 2 (p G, 6 L-3 P- P- P PLOT PLAN: 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 slope. SYSTEM ELEVATION 9 £f 7 • Le C. c,as 1 i I //////-,drwk wood Or, /,/ ...,,/// / ..r :Ada- Q 0 /t9, tr's ) g ' I . ter.i /Q4f.. ,4,-,• - /- A. 7Zc /v E. L o¢ .cor,usr ' 0Ac rep eF A i'.6t / s c- IP i ' AI{cc.r,a1 . Ei. =...{ r.-- - _ l ' ! I tN %K- 1►e —)1 a7 6ora-s Cf c%L.e) ar oa- -I_ _ - qt. o Pis c rest. Boeyok, . j ) lie. - - ye' :'-t'' _kJ//tea °lo Slq/t A. i i . i . . . i- I_. . 1 ; - 1 i_ 1 i I -_1. . 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 the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: D444142 / dra4/41C.1 Jo- 3-8PY ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): /// A i 1 a 4 r d 0 /`. A M's, 5144 /51'? 21=30- (I/ CST TUR ^ , • ///r, t DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD.6395 IR.02/82) -OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 •..! To be a complete and accurate soil test,your report nwst.include: 1. Complete legal description; 2. The use section moist clearlyfiri21icate whether this is a residence or commercial project; • 3 MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; - 5. Complete the suitahitity rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE•.RULED OUT BASED ON SOIL CONDITIONS; . d. PLEASE use the abbreviations shown liii it for writing profile desr-i iptions and completing the plot plan; 1. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A .ettaletevsheet may he ysedtif desired' . H. \1. - sure your benchmark and vertical elevation lute!once point are clearly shown,and are permanent; 9. comp ere all ante oprc+te boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate 10. If the rotor mat on Loch as flood plain,elevation)does nor apply, place N.A. in the appropriate box; 11. Sign the form aria place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. . ' • ' is - s,' i : 1 r • ABBREVIATIONS FOR CERTIFIED SOIL TESTERS • - ,, , '. • Soil Separates and Textures Other Symbols F • s st Barrio, move' 10-I BR - Bedrock coh ya acile 13 - 10-I SS Sandstone ,I, G-.isr-I (under 3'') LS -- Limestone - Said HGW - High Groundwater ' c, Coarse Send Pier(' - Percolation Rate • - e . rued s - Medium Sand IW - Well . . , • fs Fine Sand Bldg Budding I--ran, Send • � Greater Than c, Le-s !non '' ; .an, Bo Biutvri Lriani B: Lit.u'k Sit ti'y Gary. •cl Clay Loam Y Yr ante. ;r ' Sandy Clay Loam R - Rffd . s•r1 Silty Clay Loin rural - Mdtlle; _ Su-oily Clay w, - c,ilh ryr , s, Pic, Sliv Clay s.- III - let'' firre,-feint -- _ - . . _.. - _ _ __,.. . '<' Cl;ry cr nrnierel coa-sc: • 'R • pt P,•,rt turn \'.ra y, owderru ' ' r N:lut 4: --'•• d it :...ni.t p -. prrnr-1-in'nt H�;'I_ - High c,sdei level, S.v q,neral soil tq> mines Sin I,Io' water for I:quiel Wtnir il,trxrsal PM,1 - Boric (''.irk • V'CP Vitae Reference Point • 1 . .w, .. . .-. • • , •fir ' t ' r •.r . r , ���• • , TO THE OWNER: ~ This sail lest report is the. List f.trp in 3erwir>(1 a sanitai y permit. The county or the Department may request 0•:i Li.iti.e. of this soil test in the Grail leloi to permit issuance. A complete set of plans for the private ccvirn: system and a permit applicatein roust be submitted to the appropriate local authority in order to . $ n �. hfam a pen n(t. The sanital.y pvn nrt muss be uiila� r�J i and posted p'nor to the start of any const�c[ion.,, _ 'y • • q 'A '/ 1'7 L - ar` \ --x- 'k;_ _ . - m \ `' I. - - j 0 - ..- I' i 0 - � N \ _ 1 r^ CK d vvi K x y r< 0 0 ti o-J +-o . N. c *4- rii 1-1-1 q \‘\ : Iz6i r- •.1i. v1 ri1 c , t, -4- ' ,„-.I4,L) ,ii. o O o 0 _ _ 0 T- d J 0 O 1 2 J- Z d Q v" Q 1 \ of Cr �, v V1 ^� i= _y � 2 vr d A 1 - c - - , iz . r- O I -t ; G 4 r O all J Q' . I cif s. d J 1} kit 'p < V _a b 0Vv � Q 1 At JQ =c I, ...;._ JM N, a _7H 1 C + V N N ` H i X I ' —A- .1\ _. M - i v /1/ . N 41 a k t9' N :4- I I v. V d i 3 d I I ti. i� � I ` i -IN M a.. J J H • STC - 105 a SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z v a �} , OWNER/BUYER 51-¢ uaaf 1 t1 c ROUTE/BOX NUMBER IQ S ae,1 Fire Number CITY/STATE 144-(C.s W , c , -f--, 'LIP Syc7 ( (� PROPERTY LOCATION : N E k, S.civ k, Section ( 1 , T'21 N , R / 1 W. Town of 1.1u.LSA , St . Croix County , Subdivision��� k V , g , Lot number iba 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 may 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 . Ho I/WE, the undersigned , have read the above requirements and agree y to maintain the private sewage disposal system in accordance with r, the standards set forth , herein , as set by the Wisconsin Depart- ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Office within 30 days of the three year expiration date . SIGNED DATE 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 . APPLICATION FOR SANITARY PERMIT • S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house") , then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property �� a � r NQ /c J Location of Property(� /YE k SILL) 1, Section / 7 , T 7 N - R /9 W Township N L«` S n v\ Mailing Address jC 5 �( e $ 1 G N �� Ste ► ,`. W , S . S yo 1 c,, Subdivision Name PO L K V ( C ; . ) E S 1-cd <C Lot Number to A Previous Owner of Property ) ,r a.. Total Size of Parcel (.O -) Date Parcel was Created S /a 2 15.' Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Yee K No Volume 7 / 7 and Page Number / 7 7 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. • PROPERTY OWNER CERTIFICATION I (we) cen.ti.6y that at,t statements on this 6onm fire .tn.ue to .the best o6 my (oun) hnowttedge; that I (we) am lane) .the owneM6 ) 06 .the pnopen.ty desctLbed .in th.iA £n6onmation 6onm, by v.ittue o6 a wattanty deed necoaded £n the 066.ice 06 .the County Regi teh o6 Deeds as Document No. c/c, 3sc y 3 ; and .that I (we) pnesentty own the proposed site bon. ,the sewage dcsposat system (on I (we) have obtained an easement, to nun with the above described pnopently, bon the constnucti.on o6 said system, and the same has been duty neconded .in the 066.i.ce 06 the County Rega.sten 06 Deeds, as Document No. VC 3 yt-1 3 I . SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED