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HomeMy WebLinkAbout020-1221-40-000R c a ~; h bq ~ a O~ C ti O O h O M Y C '~ •,.,i N .~ ~l O O ~ w ~~ ~ O ~ I ~I `Mri ~° A ' 'O C ~LLj~j I,~, C 7 I ~ U ~ V b, O. N ~ tq ~. ~ ~ ~~- O ~ ~ ~ O Z ~ ~ ~ °' w a m '~~z ~I c U' N O Z ~ ~ N C ~ ~ ~ `~ O E '~ m Z d' ~ rn t N~•-j; li ~ 'O Y N U I: N I' y `p ~II> a m i I z° ~ z N C ~~ ~ .. N i lE w ~ R d ! d m !' a N d ~ ~ i!,`r°oca ;; '~aaa a ' o _ Si W ~ O ~ ~' j O O ~ N N ~ N N ~ ~ r N ~ a ~ o m m ~~ rn ~ r 00 p l ~ ~ N C Q ~ C i 'd O .N-- O ~ '. 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"" <a N O N -p ~ O ~ O V a rn ' O) ' ~ 0 0 {1 N f6 Q Z ii> I s m Q N ~ N C ~ O ~ C ~ ~ O O ~ ~ ~ ~ a N N E N c o ~ a~ ~_ rn l m ~ ~ 3 ~ ~ ~ r- ~ ~ y ° ° ~ ° ~ ~ ~ z N z z din ~~o d ~, a a~' a , ~ ~ c 7 i 3 ~ O V1 V ~ °o I ~ °~ I ~, I C O (0 N F- C I N y ~ ~ N I O C E~ I L I .~ w a> ~ I ~ti rn a~i ~ I ~ ~ c D ~ C CO p i O Z -O ~p C ~ ~ ~ E O X N f0 Q ~ I ~ I .~ i O ` o ~ N O L ~ Q Q ~ I I } I j ~ ~ i ~ aNi z~, 4 >- </~ I i O ~ ~ y ,~ a I ~ ~ o I ~ N '00 H a N o E I r ~ Z I I I~ ,~isconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION . (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Garcia, Theodore Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: ~ i TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ .1~, cr ; v` Z~p i Dosing n~ t ~Z~ r Aeration Holding TANK SETBACK INFORMATION TANK TO P_ /~. ,,,, WELL BLDG. ~ Vent to Air Intake ROAD Septic J ~ I ~..7 ~ ~ ~ _ Dosing Aeration Holding "~'"' PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss Syst ead TDH t Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 488004 0 State Plan ID No: Parcel Tax No: 020-1221-40-000 Section/Town/Range/Map No: 17.29.19.1225 STATION BS HI FS ELEV. Benchmark 3•b~S /a3.0~ /4~ Alt. BM F. iJu. ~ 3. ~b ~~ r `~ Bldg. Sewer ~~ ~ r SUHt Inlet 0 , St/Ht Outlet ~r3b 9~r 7~ 6i~ln~let r ea.~ C(~ ~ ~,~' ~N~ ~,ez, ~yr~c~ Header/Man. ~ ~ ~' y3 ~ ~, Dist. Pipe • 3~ ~3 .~ 8 Bot. System /6.5 yz •S~ Final Grade 5. 3D , 7 d O St Cover ~, ` l 3 r~~ c~c~ ~ ~ u ~J` C7v~ ~•lo~ y~~ ~{ •..., BED/TRENCH DIMENSIONS Width ` ~ Leng,th/ ~~ ''i'`~' No. Of Tren s ~ ,rte _~_ „h PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth i'' SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: ~~ ~'~,~ 'fa l p .1-rhb-z ~'(c~4'~"L. Ty/pe' Of Systema c ~ ~ ~ ~ ~) r ~.,7 ~ ~ ^ UNIT Model Number: ~~; i DISTRIBUTION SYSTEM ~.,~` ! 1 Prr Imo.. ~~~ HeaderlManifold ~ t~ Length ZT Dia ~~ Distribution F~pe(s) ~ ~ Length Dia ~ Spacing x Hole $i\ze \ x Hole acing Vent to Air Ir)take ~~~ r t .r.s cnu ~nvFla v Drn~mrro Cvc4cmc Clnly vv Mnunrt nr ~4.(~ratlP SVGtPMS L7TIV 3r ~~,.... e~..~ Depth Over / Depth Over xx Depth of xx SeededlS dded xx Mulched Bed/Trench Center 5 7iZ Bed/Trench Edges ` Topsoil ` , Yes ' No Yes ' No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / /_ Location: 930 Wert Road Hudson, WI 4016 (NE 1/4 SW 1/4 17 T29N R19W) Park View Estates V/Lot 126 1.) Alt BM Description = ~ ~ ~`- ~Jt~~ E~ l,,,O i) 2.) Bldg sewer length = ~~ ~ ~ ~ ~'i +~- -amount of cover = /~ ~ n ~---~ -- ~ Plan revision Required? ~) Yes No ~ ~ ~ I ~~~~!~ Use other side for additional information. ~ ____~~~~ Date SBD-6710 (R.3/97) Inspection #2: ! /_ Parcel No: 17.29.19.1225 / - G, ~ - "'~~ ~ ~._ Cert. No. ty uildings Division ~t-nh' 201 W. as on A ?162 $t. Croix ~SCO~~,~, M ~~ 5 errnit Number (to be filled in by Co. ) ~ ~~ ( 2 351 " '" a De artment of Commerce ,A~ ~, ,~ ~ Sanitary Permit Apph a o ~ ~ ~~~ State an LD. Number ~a In accord with Comm 83.21, Wis. Adm. Code, personal ' u provide SA P i l CR S7 proje Address (if different than mailing address) aw, r vacy may be used for secondary purposes ) . OIX CU L Application Information -Please Print All Information nFFI CE 930 err Road Property Owner's Name ~ Parcel #: Lot # Block # Th(~ciore & Melissa Garcia o20-1221.40-00o tot 126 Property Owner's Mailing Address Property Location 930 Wert Road NE '/., SW '~., section 17 City, State Zip Code Phone Number T 29 N; R 19 W / + ZZJ ~ Hudson, WI 54016 (715) 381-9690 lll... ly) (check all that ap e of Buildin II Ty p g . p ~ ~ ^Xl or 2 Family Dwelling -Number of Bedrooms 4 X ~ 5~'~ ~ Subdivision Name CSM Number U i D ib ^ P bli lC l Parkview Estates V addition escr omtnecc a e u c - se / ^ State Owned -Describe Use ~ ~)~' (,..C,L 5 ~ ~ ~"~ ~ t ~ ("~ ~ ~ ^City_^ Village ^XTowttsbip of Hlldsori III. Type of Permit: (Check onl n line A. Complete line B if applicable) A' ^ New System XReplacement S ^ TreatmenUHolding Tank Replacement Only ^ Other Modification to Existing System B• ^ Pecmit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New Z ~'"l o~{ ~' N > bar' / ~ C~ ~ ued Befae Expiration Plumber Owner ~ ~ ~ L ~ _ Q IV. of POWTS fain: (Check all that a Four (4) trenches, 11 "Quick 4" chambers each 3'X44', 44 chain t ^ XNon -Pressurized In-Cxnund ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Siagle Pass Sand Fines ^ Constructed Wettand ^ Pressutized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirt~trlating Sand Filter ^ Recirculating Synthetic Media Finer hin e ^ Gravel-less Pipe ^ Other (explain) V. DIS rsaUTreatment Area Informati : 44 Infiltrator "Quick 4" hambers at 19.1 sq. ft. EISA/chamber + .end =864.00 . ft. EISA Design Flow (gpd) Design Soil Application Rate( ispetsal Area Required (st~ Dispersal Area Proposed (sfJ System Elevation 00' ~ 93 fi EISA 0o s / t164 15 ft ~ 857 7 R ~ . , . q sq , . gpd sq. 6()D gpd / 0. . VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic allons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks septic ~ xoldi~ Tank 261 1,000 1,2,61 1 & 1 Weeks Conc. & Wieser Conc. X W/ Pol lok P1-525 effluent filter Aerobic Treatment Unit r ( ,[1.,~ (~ u.~~.~ Dosing Chamber VII. Responsibility State ant- I, the reigned Dine ncib or installation of the POWTS shown on the attached plans. Plumber's Nam (Print) lumber's ignature MPlMPRS Number Business Phone Number James K. Thompson ~---- MPRS #30021 (715) 248-7767 Plumber's Address (Street, city, State, code) 340 Paulson Lake Lane, sceola, WI 54020 V1TI. Corm /De artment Use Onl ~/ ~ ^ Sarritary Permit Fee (includes Date Issued Issuing SignaWre o v ~S Groundwater Surcharge Fee) ~ van Reason for Denial 3~ . Od ~S ~ 1 Z ~S' YSTEM OW NEK: rovaUReasons for Disapproval ~ _ - - 1 7~-/ 1 Septic tank, effluent filter 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. Attach rnmplete puns (to the c:ouaty owy) mr toe system on paper nos Mesa wan aii~ : i a uocues .n scrti --_ ~ _ ~ ~Pa~ 9~0 ~~ ~~ ~~C $Z~ ~ ~~ ~~ EXi~fft syr~.., •. eliv _ ~3,sS' -~ i~ 0 rnS~<c ~i'o~ ~p /tc4 ,~,~~~ elegy:. ioo.eo.' / ~' l~wll• n ~alUc Ai 6. .8-nt. ~ ToP of',~.,N~a^+ Qf b cc; ld; ~~° Scv~~ ~ __ Elec!' a idi1.~8; ~ EXisr: i~dq ~ oQ wrcSFi ConCxtC i i q I q 0 ~a~-Q I ~~ S ~~ ~U Sl 6ed rr o•~,~ I ~i S; !/O_vt/D Decd o~ Poo/ Y -~---- .I 5 cci(e ~ /'-= s/O' ~ 5oi/Qd4/ua-ion ~0. t b y ~.-~ e~P~ I j/ Jos • So// ei/alKa~~~o;~-6 y (3. UC6i; c kt U/.z 703 . 47. So •con~u.r f~i-aPosad dtspvrG./cal~. v'a~c~(y){rcrtc~gt Q t 3'X d!• ~ `~/ll~ic,(! ~/ cl+a•n6crs p~~ F; /6~?:, Z,`b 5/q~~fh.roK ~.'-- ~- ` 19.0 ' S yStLi71 ~ r O m - e.Xi'S-b'~ y we l/ C~~~ -___ ~ ,~ ~ ~Po~ 5 ~a/e: ~ ~= s~0 -~',TI~ e,,,~o~ I ~/ 7/aS ~~~~ SpruL {~st5 (~ UCb<<ckt (i/,Z7~o3 ~ 8z ~ ~ ~~ • Eyi~S~ n~ ~ rode e%da.~'~- a .h ~ ~ ~_ -~- - - E}'iS+Elnac3 SysEe.n '. \ o . 3 else. 93,.sS' ~ (~ropose~ dtsp~erraPcal~, Fo.c~(~)fr~ncti~,s ~~ ~ Q t 3'X ~/f ' '~/ll~cicX-~/ cha~lw~s~i ~NeI./Y(ar,t~: To~ooF'J.T. _ cN-` ~- ~iz..cd (yycla.~btrs ~I~ 15..11• ~ ~alvc ASE. ~e.~t.: Top a-E b cci 1d; n Scar ~ __ , _ s:r, ~ p, ly le,(~ ~ .. EJe~=ivo.~B; ~ ~- Pi=ssseFC/a~E` ~98.to' E7tis~nr~~gu,7~~o~ F,•lEc~:,. u~raSerCO~C~cfC 2,2+5/q~~-throK I`' -- •.,, , 19.0 ' Stpbc6ay><' systc~l ~recC i ~ q I ~ 0 ~4~ i ~~S~~~U 47L cz~~~Ge ~'~l 4~E o~~X/5~.~~J Gc7CJ/ pool C~~ ........ 1958 Wisconsin Department~Commerce ~ r SOIL EVALUATIO`! page 1 of 3 Division of Safety and Buildings ;,, arrrmtanrp wire r CA~. L~~e A.C.E. Soil & Sfte Evaluations - _ _ __ Cou. Attach complete site plan on paper not less than 8'~ x 11 inches in si . 8M { f i Plan must .~~~ ti ~ ' St. robr ), erence po nt ( re include, but not limited to: vertical and horizorda rec on arld ; g d Pa D percent slope, scale or dimemsions, north arrow, and location and dis oa . to n~ . . 020- 21 0-000 .f Please print all information. ~G~x GGF 1 y Dat Personal information you provide may ba used ~r secondary WRY (~~Y , s. 15~ 1~~G OF /~ Z Z bs Property Ovmer Location Theodore 8~ Melissa Garcia Govt. Lot NE 1/4 W 1!4 1'1 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or Slt~ 930 Wert Road 126 Parkview Estates IV City State Zip Code Phone Number JJ City J Ytlage ~ Town Nearest Road Hudson { Wl 54016 (715) 381-9690 Hudson 930 Wert Road New Construction l1se: ~ Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement ~ Public or commercial -Describe: Parent material Glacial outwash Fkrod plain elevation, if applicable na General comments and recommendations: Site suitable for conventional POWTS. Install four trenches at 92.75' using 11 Infiltrator "Quick 4" chambers (44 total). Baring # Boring Pit Ground surface elev. 98.62 it. Depth to limiting factor > 114" in. Soil Application Rafe Horizon Depth Domir~nt Color Redox DescriQtion Texture Structure Consistence Boundary Roots GP D/ft~ in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. •EfF#1 `Eff#2 1 0-6 10yr313 none si fill na na aw 2vf,f na na 2 6..24 10yr3/2 none sil 2fsbk mvrr cw 1vf 0.6 0.8 3 24-48 10yr5/4 none sit 2fsbk mvfr aw - 0.6 0.8 4 48-52 10yr4/6 none Is 0 sg ml cw - 0.7 1.6 5 52-114 10yr5l6 none s ~ 0 sg ml - - 0.7 1.6 r- 1' Boring # J Boring .~ Pit Ground Surface elev. 97.70 ft. Depth to limiting factor > 109" in. Sal Application Rate Horizon Depth Dominant Cobr Redox Descriptiai Texture Structure Consistence Boundary Roots GP D/ff= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2 1 0-12 10yr3/3 none sl fill na na aw 2vf,f na na 2 12.21 10yr312 none sil 2fsbk mvfr cw 1vf 0.6 0.8 3 21-39 10yr514 none sil 2fsbk mvfr aw - 0.6 0.8 4 39-45 10yr4l6 none Is 0 sg ml cvv - 0.7 1.6 5 45-109 10yr5/6 none s 0 t l ml - - 0.7 1.6 rr Z ' b 'Effluent #1 = BOD 5' 30 < 220 mg/L and SS >30 < 150 " E nt #2 = 80D < 30 mg/L and TSS < 30 mg/L CST Name (Pl~se Print) 'nature: CST Number James K. Thompson s--~ 3602 Address A.C.E. Sal 8 Site Evaluations - Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, 154020 11 /172005 715-248-7767 Property Owner Theodore ~ Melissa Garcia Parcel ID # 020-1221-40-000 / Page 2 of 3 ^ $ ;;~ Boring Boring # ~ Pit Grind Surface elev. 97.27 ft. Depth to limiting factor > 105" in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Descrq~fion Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots *Eff#1 'Eff#2 1 0-19 10yr3/2 none sil 2fsbk mvfr cs 2f,1 m 0.6 0.8 2 19-44 10yr5/4 none sii Zisbk mvfr cw 1vf,f 0.6 0.8 3 44-49 10yr4l6 none Is Osg mfr cw - 0.7 1.6 4 49-105 10yr5/46 none Is Osg ml aw - 0.7 1.6 ,~ ~- rl ~ ~~ , ^ Boring # ~ Boring Pft Ground Surtace elev. ft. Depth to limiting factor in. Soii Application Rate Horizon Depth in. Dominant Cobr Munsell Redox Descr~6on Qu. Sz. Cont. Cobr Texture Structure Gr. Sz. Sh. Consistence iBoundary Roots 'Eff#1 *Eff#2 ^ Boring # :- ~ Boring .J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Applicatiari Raie Horizon Depth in. Dominant Color Munsell Redox Desa~tion Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots 'Eff#1 'Eff#2 • Effluent #1 = BOD ~ 30 < 720 mglL and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mgtl 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. ~\ ~\` ~ r' ~'~~.- ~ ~^I ' 9~0 ~~ ~~~ _ 49. SO~Conz~oa/ ~~' ~~ .`~~~` Spruc. f1'tt5 a .~, E)'iS~J~ Sys.., •. ~ a3 e1cv.. 3.~s' ~ ~ ^ ~N c.fi/Y~ar~: T ~o of J. T ~ ~ 8' -- ~ ~ r'ns~ec E:r'oq ! .9.ssunreJ ~~ ; ~ - Q bk ld~~~jSt~~ ~ -_ ,, .` EXisrln~;ctb~aP, ' ~~ wreser nG+t~t z.~,5/yue~i'hro~cq~'-- ..,_ X9.0' ScQbcf~y~{' sys~c,~1 ~recC ~ ` q i q 'a. D ~a~{ ~ ~~s~nU o ~ ~ ,6cd rctJm ~ c s; d~ to m I~t o eXi'S~'~g c,~7c!/ pool Scn/e: / "= si0 ~.Tl~ e..yo3or~ I // 7/~ • 50;1 erJa./ka~cn,,o; ~ 6 y (~ U Cbr; c fit l~fz 7~°..3 • ~ri~5~ir~x ~ra~e eledo-~"'or ~~. 30~.~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/)tee ~2o C~crr'e ~ ~e ~,'ssa ~orc;g Mailing Address 43o cc~e,•t Q~P f~c~(,~yy, cc.~! StjD/~ Property Address .~~.~ (Verification required from Planning & Zoning Department for new construction.) CitylState Parcel Identification Number ~~' ~2~' `/a' c~ LEGAL DESCRIPTION ' / Property Location ~'fa , Sc.J t/a ,Sec. ~, T .Z9 N R /q W, Town of !~'~~~~ Subdivision ~G~/'~J%~ ~-SS~~4°l~lu!`dr~ _ _, Lot # /z~ Certified Survey Map # ~a ,Volume na ,Page # !1a Warranty Deed # ~~~ ~ Z ,Volume ( 2 ~ ,Page # c~-- 2i Spec house yes nom Lot lines identifiable ~~ SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) 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. Uwe, the undersigned have read the above requirerrents and agree to 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 Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. N~um-ber of bedrooms ~ ~/ c~~ s./ 7~'~iCZ, // l / ~l Gl~ SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08!05) Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.O1/O1). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stets. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should 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 filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should 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 must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mgfL BODS, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effiuent flow shall be alternated between dispersal cells on a two-year schedule by use of a diversion valve. Valve to be switched diverting effluent from dispersal cell currently in use to resting cell on a two-year cycle coinciding with septic tank inspection and maintenance. Contin¢encv Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system irno proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 24&T767 or the St Croix County Zoning Department at (? 15) 386-4680. ,. r~ -~ ~~~~}_ ~~~ 1 ~ a I I i i I ~~ ~ I i ~ 1 i ~ ;` p ,, ~ C n ~ n _ r C T. ~ m ~ __~--- l_ p ~...... ~ ___ ~••!-• D m ^..r... Z :: i o o ® ~ ~..A ~ n C7 ^...... ~" , `~ _ ~ ...~ Z £ \r1w.. x ^/~~~. ~~~ _ ~~~~. _ ~ c ~'~^. a : Y . ~ r ^Or , CND •z~~ m ^-~ ~~~ „~ ~ ,. a . `'-' £~ ~~wr _ _ ~~~; ~ _ ~ _ Z ~., a ~ ~ r ~ p 7 = D r ~ ... ;~ ~ f'1 A 7 > _~ D . ~ ~ nG 'T~ C A n ~z T A J 7 c 5'7863-2 5TATE BAR OF W{SCONSIN FORM 2 - 1982 WARRANTt~Y DEED DOCUMENT NO. s'1L ~~/~_~~i~F'~~~ Peter Scott Vanasse and Tierney Lynn Vanasse. husband and wife come s and warrants to _ T~ieodore R. Garcia and Melissa B. Garcia. husband and wife as survivorship marital property the following deuribed real estate in St. CtOIX County, State of Wisconsin: io°~~ REGISTER'S QFFiCE sT. cROlx co., wi r,,e~~ E,a ,.,-„d MAY ~ e 1998 8:00 Any{ -~~.~~....-4s; cJ.~..l.~ R.~t.t6..r o..d. 1NIS SPACE RESERVED FOR RECORDING DATA t; MME AND RETURN ADDRESS 0~1"121-40 PARCEL IDENTIFICAT10Y NUMBER Lot 126, Park View Estates Fifth Addition in the Town of Hudson. St. Croix County, Wisconsin. TRANSFER ~ Sv ?~ EE This ~ homestead progeny. Gs) ~4RNK~ Exception to warranties: E~ernen~, restrictions and rights-of-way of record. Dated this ~ ~~ 7 day of AQril , A.D., 1 (SEAL) (SEAL) AUTHENTICATION signature(s) Peter Scott Vanasse and Tierr. w Lyrm Vanasse, husband and wife authenticated this ~~ 'day of AAriI 19 9$ Y ,~. ~c----' Kristina Ouland TITLE: MEh1BER STATE BAR OF Wl~!'ONSIN (If not, authorized by §706.06, Wis. StatsJ THIS INSTRUMENT WAS ORAfTED BY Attorney Kristina Oaland Hudson, WI Sd016 (Signatures may be authenticated or acknowledged. Both are not necessary.} ACKNOWLEDGMENT State of Wisconsin, ss. County. (SEAL) Personal{y came before me this day of 19 ,the above named to me known to be the person who executed the foregoing instrument and acknowledge the same. No[ary Public, County, µ'is. My commission is permanent. (If not, state expiration date: l4 .) 84 ~ ~ ~ Yp~ ~ `, 1 3b~ ~~ p ~ ' N tip a a ~ ~ ~ . J~;tly~ .33~ 0'~ 243.00' W ~.'I ~ 160 ~ i ~ , ~ o 0 • S S ~ ~ .~~ ~ 66187 Sq . Ft . I o o ~9, ~,~'; f (1 .520 Ac.~ I z ~ u ~I ~ ~F~ ~~~~ I v A 1 i ~~ ~o, \ ° ~ al ~ ~ ~ ` i / 128 ` ~ v°~ 53179 Sq. Ft. \ ~` - ~ - ~ ~ (1,221 Ac,) ~ ~ ,~ ~ ~ Q ra tp / ~~ , ~ -~{ 6 6 lt/ / 'Y s 12' I I _ I s. ~ / titim I NI •~ / ~ I ~ , .~ // 126 125 I ~° a ~. l~ .i 3 ~ Q m 15 ~ S 89 09 27'N v a~O 63022 Sq. Ft. , o I COI '~ I'( 2 / ~~ (1,44? Ac.) o," I w~ ~ II •~ m ~~ ed u ~3 o' ~~ U ~ ~~o m tr~ m~,~ N~ ti WW ~~ C .~ ~+ ~ u w o V 2' ~ `t' "' ° 47961 Sq . Ft y ~ v I / 618fl3 Sq, Ft. y y (1, 101 Ac.) c o i~ ~ (1.419 Ac.) I °~ ° I I ~ i i N Z i I W i i I ~ ~ I I ---582.01--= ~12_ _ i - ~' b • I -,z<- _~, - - - - - ~- - -~~s _ao - - . -s~7.3tT BB. o / // L= - i~2.54~ 205.41 ~ 85 ` -- 162.50 I 6 6' 206. 63~ I 11 88 I 87 ~ ~; ~~ 1 ~' OI WILLOW RIDGE _EAST ~ ~~ VOl_. 5. PAGE 34 !• ,` ARTlNENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY 8 BUILDING ;sOR,& HUMAN RELATIONS DIVISION f.0. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MAD SON W 53707 State Plan I.D. Number: NE ,. , ~W 4 i S ec . 17 , T29 -R19 n CONVENTIONAL ^ ALTERATIVE (Ifass~9nea) Town of Hudson, L~ 121 _Tanenr~ Tana Holding Tank ^ In-Ground Pressure ^ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: Sam Miller Box 208, Hudson, WI 54016 J/o7~9D BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. EL i ~ . ~ . ~ ~ Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Doug Strohbeen 135462 St. C 135462 CC~TI!`TAWIC/ .!/ .n! 1 n._. ~ ~ n ~h? ni/' //' 'f9~/ /. _s'l MANUFACTURER: LIQUID CAPACITY: ., TANK INLET EL .: TANK OUTL LEV.: WARNING LABEL LOCKING COV~q ~! QC~ 4.J ~ ! /O/.57 / /D /. D9 PROVIDED: YES NO PROVIDED: CJ ~, ^ YES NO BEDDING: Y6MT~IA.: yEOL~MATL.: HIGH WATER UMBER OF ROAp: PROPERTY WELL: BUILDING: VENT TO FRESH C.O • ,y CD, ALARM: FEET FROM ^~ LINE: / ( r ~ ~ AIR IN Tj ^ YES NO ^ YES NO NEAREST ~• O 4S DOSING CHAMBER: MANUFACTURER: BEDDING: APACITY: PUMP MODEL: P/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ^ NO ^ YES ^ NO ^ YES ^ NO GALL NS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER O PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM INLET: PUMP ON AND OFF ^ YES ^ NO NEAREST ~~ SOIt ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (It soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.--~ CONVENTIONAL SYSTEM[ Q. ti % ~v~t_cr,n eL/ p~_ = `1`1. (~F / BED/TRENCH DIMENSIONS WIDTH: / ~ L ~ ~ / OF TRENCHES: DISTR. PIPE SPACING: ~ r COVER MATERIAL: T PIT INSIDE DIA.: q PITS: LIQUID DEPTH: GRAVEL DEPTH BELO PIPES: II FILL DEPTH A~OV~E COV ~ : .3 DISTR. PIPE ELEV. INLE ~ ~ ~~ DISTR. IPE ELEV. END: / ~ DISTR. PIPE MA RVpL: ~ • ~r~. ~j/ Irt- ^27 NO. D STR. PIPES: ~ NUMBER OF FEET FROM NEAREST-r PROPERTY LINE: / ~f WELL: ~ BUILDING: / NT TO FR SH AIR INLET: / "" ~r~ MVUNDSYSLEM' ,Zp' ,3t( Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ^ YES ^ is the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER E= PERMANENT MARKERS: OBSERVATION WELLS: ^ YES ^ NO ^ YES ^ NO DEPT VER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: S ED: SEEDED: MULCHED: - C ER: EDGES: ^ ^ NO ^ YES ^ NO ^ YES ^ NO PRESSURIZED DISTRIBU TION SYSTEM: BEDlTRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELO FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE ERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ^ YES ^ NO ^ YES ^ NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF i NEPERTY WELL: BUILDING: ^ YES ^ NO ^ YES ^ NO NEAREST~-11 Sketch System on Reverse Side. SBD-6710 (R. 06/88) Oot 18 ~:; 12r20p Benjamin Marian ` 715-386-2231 p.l J" A!FJ'ar I ! I r i j i ~~!' \'t iR nlx,rKl~ napartrlnrnaroarllnorce SAIL EVALUATION REPORT r'b]rn j ._ d ...- `3 '*'.vlstM of ;iaratp Md [gpldinge ' , • In eocadamr. wlm ~anm a5, WIE, Pr!r~. r'/a,'n •-- ~ ° ~Q, 'I Akwrh gmnraelo Nte rilnnM ~~ro++n.+r bue n.nn A S/7 w +1 ..•~. Melsr PUi,..m~ J ._..------ - --~-- r ..9..7tnotSm'Ldlo'+eni~4l~Mnr.-.'.-,r.{;I.lcrunoop~iniir~.1~].d~raalonar:r! ~P;r:~ :. 71prfw. It sfbp0, GG7b ardllnNnibrl! rl0ftt+E+row, xrxlkXwl~bl:and dls111nce 41ncwe9teond. ~~` _ fuv;nwnA Iw Ik~ls -': °a~s~= arirtr sG :.~rnd~:::u:. I } tunmM} N..•b.+n~lipa )w! nrpvHf mny M rird rPr ~.~ma~y pula'fa R :v..ry lrrw, ~. 13.M {' 1!'~'tl. ( ..~ 1 _ _ _ ~.L____.._ .._...-.~- ~._...-....f I'roporly rT+TOr .~•.•.-•• 1'r:.xrty Lnu+nf+r A I 7J~=1~ il'r~~G1 }}-' I r,:n I M '1~. ~ra!;'~I1rr. c /7 T Z~ N a ~~1 s mi w I I'nxxuM, ;/wl:;,fro rA~iMq atlaeary,,~, ~~.,.•„ tt.ol v ~' e!acli rt 3uhd, Mntia nr CSMa? ~~ <i 9 i7 crt7Fl~'7'. Kf~ _ ~1~~ _ ? a-~- pG YY ~ Y r $tala Gp r.mo un~i - ~ Q (:ily L, 1A111{I~ ~ TOwn NcAretl RGYf I ~! ;;~r,;.'.' ~~ I Zvi ~ ~ 7~ii,1 f %%; ~ iv:.! ~ C.i9]~_ ,]~U~~,s'P.a1 _ _I ~~ ,, ~ " ~` Iu,~ ...,~w.+;.w..vr Vaa'lAl rw:lluwriy0rl Nrxrger al tlauroarm: Colo alm+ed un5iyn :iow rain ~p~~~,',,~~_ Vr IF 41 R.~tRoamoro L1 px+blk'«ecmmerd~t-a~:.ut~e: „S,J/57~. -~t.?~S_..fJ~~'F,~(I~Q... ,~-r!~ !_~~/~_`~~!-•~ r+~/OrttmManal_,%~E?3--Gi%'f/~,n.__S ~.V!/Y...__ ~ FIDOd Ploln ar~lroam 11 9pplirxdlln !`.1,~__..,___.,.,_.a.~l «fa•lapl D]fRrblltR dl~`i4l.'¢~jL,, . - A,E'~/1 •rEK'r~la /S .SJffJ}6!~ ~rd,~ ~.t.r /:J ~_ 5Ys'r~t+ is /N Ca,?E• ~t~dGi~T sa;~S .~ ~'~4ti1 $t~ G, ~r S,u n4c7- ~D/i' /G~" -ii',~L w~%.4 /4. 1;3~G1.-. Y:~.-{-L" ,ri'~-, r .r ~+6 I~ i~tahrt h N ~ ~ r}~(j. ~~ y+L .I i.. & ICI Ql~mdwlrtam ebv. ~~+ '' n. Cbplh m l'v.uw~e fn~r~ r 6 6_ ia. ~ a e.,.u:..:... li,... iariixon ulpOt ~_ ~_C:,_, txdttglartl `Mllrlsel~ rirxrmrOasRip>fbn ~ Texhae ~ Sauduro Contisla3oe~ °iwmdrlrV ~:cSz Cant.Cda~s ~C 4~.'~•sh, ..-- ---{ R~ ~ ~~ r...~ ?RUi T EIO~ ~01 y R /ra yet ~ -,--_... ~_•s,/ 21 •-~' ~P,_~ ~v. ~F ~ i_~' li/ 3 ~- ~-' ~ i-'-i ~ ~. U!f-~U1.~-l!~ _ irr y.~ ~r~~,l I.' _I. _'"ur s . -... ~~_~_~~~---'fir- ~. t,~+~ I ,.~' r %}:~- ~ti , ~ fir . S r ,c'' . , ~~ '` ~ _' ~ ~ } f ~ } I - _... - --- ~~~ t I L --___I nnrtl„ -- ^ {goring cJ / '7Q }~"~ ~.~_...~ ~ ~;, vanda,"foa,;~!~•.._~_~-l_'_~_.-r oaPmtonrnml,cr?-r . ,": _T~ r~w:t~rnra:s:~i,..~~ I it:ti!T ~__.~ .~ I ubrNrunt color ._ „-,_.~_ _~Julscll .f i° '' is ~~ RedoK R1,~1:1ipuorl ; t..~,.h,•c t stlutum ~ c.~rtsistoncb eound.,y du. Si Cont. r..c~r 4 ,~] Gr. Sn 5it. ~ ~ Q. ~,~ ~~%"'a - '~~c. ~ rmas S - aPLf _ f •EltJil 1_"~R ~"'~~ 1 -' - S R _ L _ ~..., ro ~ -- s o, r- ' E13uan1 At = BOD ~ 3a Y 3Z0 In~L arld TSu ~3U e 1 W rnPll " ETAnlrq 7rJ ~ tlgGi, ~ :1V rt1~1. Or10 I SP ~ ~7V m~grL aT IVatla,t'tea3a ~,1~nt3E~ r r~1b~~c~7 sls,l,;dur. ~.~~ ~S Addro~+s ~ ~ j ~.. ' O ~ j,, aG~ Qate EvaluaNar Carder Tooeptwrw Num6or Sla1_E rn.~G-- U7.4LI ~'~ l~,s . 5y'7G~ ~~_27~ ~3 7/5 • 770 • ~ yy~ sp~~-~ .~Qr~ ~c~~r~,cs~ dr~c.~ r dF• ~'xsr:~G- r.~.v,~ is •- c~ov~ a ~2 E~Tip .4 2,,~ Ca~*~o T•4~~c ~~~ c~er~.t..-- fl' ~,,.ml ~~,~ (~•'-~r~ ~s R~4v/~e~ .4~,+y~rr-- -r~.• ~; ~•rr,d s7 s rLc.A. ~~op..~~~. ~,. •c~ `~ ~~~'~`i I ~~-~e. r/ /~ ~•~~4 0 Tg~vK 4~ a r, vv ~'~ ~!~-~ ~G Olr~.v~ej ~1-~S o /371 A•J~ '~ i. Rf ~ s. J'~_t' ~~~f ~ l/~e~ ~~•~ C1,iS S/iU~ (~ x /'Cif'd~/Yr-qtr ~".wlr~ ~.1C>~%l~ ke.~ .. 11'/~%r,'1(!!i,•V~f. ~r fM ~ 7:..,f.- ~'P.~.x..S /-ll ~OIV',~.. ~~ yr' y l~~ / ~! ~:~ '~O~l4D 6eNng N ~~ Haim t7 ~ p ' ~ '~J ~~.wt Crrurxrsuri:eroWw,.~~~ _. {1. DonlhtolimiGnnfaaor ~ J~ t~, .; ~° r ~f ~~, ' Ftartmn Aoptl't m. O~I9 ~~ 'Janinlnl Gobr rvrunsnu ~aYQ_z! ff l'^.,. Rednx De:criDlia~ I +;eu. „z ~urN. a,a~-e-~ ~~+,~,4~.r'~c~ Taxlurc l SIL SU~iRuo 3,~„t~ (:c ndntmce CrdxWay -~ ~.~~ ~ cS ,-±~ ~ e..., i >t~J y ~~ ~ . G~~ !i~'t.~~ r , ~- H - ,pw,~ ~~.-# --~---~ r -~~-1------f --_-- f--~. ~.. __~ 1 ~ w;;ra ax ~-~ tjminEi ~~ l..l Pit Ground srnLxo okv. ~.... It_ rmnrr, t~ urwn;r,.. r~ e.. WVt~ ~ ' ~np,~ ~ ~:rwrd.,...r r,u M{mceR n..w,_.,, nw....ri.~w~T ____.~-_.. .-__du. sz. Corn. C,ttr~ To.~...~. f _ ~ t;e. w.rar^'+ C~at~vnn.nf ~ m I Gr .Sz, SN. ~ Rmts Gp I r'FJf01 Gcn Rale (~ 9~ ~ -r. I ' - - - f I I ~~ ~I ~ ~~ ~ _ ~...-•~I ~ar~A ._I ~~ Gmund sea4sr ~twv,_______._ h. Deetlr rn G.Jew`rnetr,. J r_ Haimn t)apth t barntrya+t f:atar >'tudax DefcrlpMrn. Tornure 3tniauro t6ks[onra 8axrddry R00~ aP OYff n. Munaap Ou. Sx_ Cant Cda Gr- Si 9h. •Eftii 'EIFA2 I.J t'trxnxJ 8 ~ ~~~ - ^ Pil CrOUnd stntapa Clm. ft. {bplh to Aa~itirg 6rdor ____ tn. t-loetam Coplh tJornNtint Rgdrnt Aw Edit aaAan Rain 1~xM~ Strudura Catststartca 1lcurWory RoOl= aPO/re ,,,_, tn. Afixrsell Ou. 9Y- .(blot Gr. SZ. SA 'E1fNt 'Etft/L ' >=ttttronl xt : SQi], ~ 90 _<7dl nxyR, and 7$$ >~ry < i Stl rnp'l ' C(R~an A'2~= Bt]b~ <',.0 rngll and TSS ~ Jp trglL The Gcpartmcut a('(:amnteree ix nn equol opportunity scrvisc provider and employer. If you need osxistanse tc aeacxs ser~ici+s or treed material iu an nlitrnnte farma4 pkaxt contnci t1x depaMmCnl at 4pR•246-3151 or 77Y bt)R•264.8777. sOPV7ww.+Rar p. 1 « ~ ~ R "---..._.. ------ /~~') \r - ti ~ ~ t ~~ `~- •~ E I {11 ~I t +h ' t y ~ ~/ ` ~ ~ ~ i ~ ~.. ' , ~ ~ { ~ { + ~•~ ` ~~ ~ ~ # + ~ t; j •---_ _• • ~r- ~ ' ~ r ~ ~ L7' s ~ { ` Q' ' ; v ~ , ~ 111 «, t^C r ~ ~C 1 r, ~ i i d ~+ L\ 1 ~ r <~ ~'~ t '~ t Y "..~ ~ l ~~e, ~v 3 ~ v.) ~ ~~ g " t _ III ~.. ~l e .C7 ~µ `~ .~"~~ ~h ~ ~-l_• S .J t "4 J i, ~_ 1 ~ ,' s - ~ ~ Q ~ ~ ~ ~ ~ ~~ ~ ff ~" w ~'; ~ i ~ ti _~ >~ `3 ~~ +~ t ; . ti .__-_., .~ ~ i ~ . ~. ~~ i s ., r .., `r wi ~• ~~a. _ .. .. ~- ~ Form - S T C - 104 . AS `BUILT SAN ~ ' ITARY,.SYSTEM REPORT OWNER ~~., /1'I; (Iuy TOWNSHIP ~--c.r~ ~,.,v, SEC. ~_ T ~~( N-R~ ~ -r`---- ~~: xis'. - ' ,. ,.4 '- ADDRESS ~r,X~~.,gZ ST. CROIX COUNTY, WISCONSIN ~.,~' ~-c~..d~S o v~ ~ -~- s`/~ ~ ~ SUBDIVISION ~Q/ ~ U iF.w ~~`'~~c~(~. LOT I ~-CP ~ LOT SIZE ~~0.3 H" C crs 26U~-~ PLAN VIEW D~/,r,~ /~ ~`7 ! ~ ~---1 ~-- Distances and dimensions to meet requirements of IrI.I~R 83~ lV~~l"' SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I ~'~ Q `T~~-'~'1 ~~~ (.cJ e.vT 1Zoa L' ' k~. '` $~~.ToP o~ ' , , ~_= ~,:; ~,° '~ "ra~~ . ~t a..d '~ ~ ,' ~- ~ ~.: I ~. r7 D ~ R '. Sw-t~ '~ , ~ 't ~ ~~ ~ _ ' ~ x ,. ' ~ I Q~ .111 F~'~ ~ I ~ ~ `~'' :!: ps ( , ~ ~, ~ ~ i i ~ 1 - ~' _ - . ~, "' ~- ~ • t~' ~s •~ fl ~Z ~, i ., ~; ~~. i ~ S,. ~;r b s Gcvas~ ~b s. Zy'xs~' 3 ' So ,r' „a,,, N . :.~{ ~ ~~ y~_ INDICATE NORTH ARROW _:,~ a ' BENCHMARK: Describe the vertical reference point used'~e ,~~,~ n ~ ~ ~d~~ ~ - t ' ~~rL a 1~ Elevation of vertical reference oint: 0. ~ P ~ O ~C Proposed slope at site: S% , ~=-=_ _ SONITORY PERMIT ePPI_ICOTIAN ~' 1~' ,. i~1~IR - - -- - - - .-- ----- - - -- ,- -- - - - - - - - in accord with ILHR 83.05, Wis. Adm. Code _~..o.,~,.....,,.,,..,,~,,,e. couN STATE SANITARY PERM # -Attach complete plans (to the county copy only) for the system, on paper not less than ~^(~~ ~ 8'f2 x 11 inehes•in size. ^ ~~ . C If revision to previous application See reverse Side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ~ ~' ~'/a '/a, S TAR' , N, R / 9 E o W PROPERT ER'~ MAILING ADDRESS LOT # BLOCK # ' Y ~~ CITY, STA TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER n wc~ oi.. S O/ g Z r i' ~S~G ~ .., 11. TYPE OF BUILDING: Check one CITY ~ NEAREST ROAD ( ) State OWned VILLAGE ~ ~ S l D 50 /1 ac.-- ^Public 1or2Fam.Dwelling-¢~ofbedrooms~ ARCELTAXNUMBER() III. BUILDING USE: (If building type is public, check all that apply) Z Z S. ; 1 ^ ApUCondo' 2 ^ Assembly Hall li ^ Medical Facility/Nursing Home 10 ^ `Outdoor Recreational Facility 3 ^ Campground • 7 ^` Merchandise: Sales/Repairs 11 '^ RestauranUBar/Dining 4 ^ Church/School 8 ^ Mobile Home Park 12 ^ Service Station/Car. Wash 5 ^ Hotel/Motel 9 ^ Office/Factory- - 13 ^"Other: Specify N. TYPE OF..PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~, New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an System System Tank Only Existing System Existing System B) ^ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distr)bution Experimental Other 11 ~, Seepage Bed 21 ^ Mound 30 ^ Specify Type ~ 41 ^ Holding Tank 12 ^ Seepage Trench 22 ^ in-Ground 42 ^ Pit Privy 13 ^ Seepage Pit Pressure - 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7: FINAL GRADE ELEVATION D (sq. ft.) (Gals/day/sq. ft.) (Min./inch) REQUIRED (sq. ft.) PROPOS E ~ ~/ " N 7 ~~ ~ / ~0 7 - O, '7 7.~ ~ ~ 7• Feet O Z.$ Feet VII. TANK CAPACITY in allons Total # of ' Prefab. Site S l Fiber- Pl ti Exper. INFORMATION ~ - New istin Gallons Tanks Manufacturer s Name oncrete Con- tee -glass as c App' Tanks Tanks structed Se tic Tank or Holdin Tank ~ ~~ m ~ Qi1~ Lift Pum Tank/Si hon 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) MP/M PRSW No.: Business Phone Number: ,I r Plumber' Address (Street, City, State, Zip Code): ``// ~ L h1 r TO UC. COUNTY/DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (Includes Groundwater a ~ Issuing Agent Signature {No Stamps) Approved ^ Owner Given Initial /~~ Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly PIl~7) (R. 11/88) DISTRIBUTION: Original to County. One Copy To: Safety 8 Buildings Division, Owner, Plumber SAS :~~~~E ~ ~ ~.4. y spa ~, ~~v. = .99.00 ~ ~`"``" ~~ ~....._. ~ L ,~y rZ,~`~ " " _ ~~. ~ - Tar c s (TRSt ~'rta»~ SS, 9 0'~ 5 cap- (a- I/~ ~ _ - o ' S J V'1 wa~~ ~~ ~. SI ~ \ ~ s~ n~ ~i o \° 2 I h r ~" S~ Q~L k-~$-„ A y8 ' ' °- - 3 ~ ~ ~ 3~ E yS~ {9` , 3~% R I ~ , i I~ j ~ ~ ~ ~E ~ `~ . \~ ~ o a `~ti ~ ti ~` 20 A n ~earaSL k(e~..sc A ~ 3Srxs.vr ~St'xy9~ ab a M -~-~_ t \~ .: ~~ ~d A r B.Mr ToP cF r~~E. P.~~t. Env. =loo. o' ~~~~ Seca'" h- /~ ~" ~ i ~+c Zo G. Y d ~ (Mo Say/a DEPA'RTJVIENT OF INQUSTF~Y, ' L~BOR AND HUMAN GiELATIONS REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION ~~ PERCOLATION TESTS (115) MADISON; W 53707 (ILHR 83.09(1) & Chanter 1451 L CATION: N~ ~/ SW 4 E TION: I'1 /T29 N/R 15 lore TOWNSHIP/IN~AF TY: ~ os ~` OT NO.:BLK. NO.: S BDIVISION NAME: >.~ /2C ~A C LINTY: ~'TC~4 t ~ SAM -~~'~2 o~ MAILIN ADD~~RppSS: i'~ - ~ ~~ I ~W S ~ ~~G a,r` ZakOr~Y.. t~~o~ b A ~ uh ~ w vaacnvsi ~ wrvs mAUt NO. BEDRMS.: COMM R AL S RI TIQN: A S S: Residence , `js~ ~ New ^Replace +~li~ c ~PRIC. ~ , /9g0 ~ 9 9D RATIN AIC.S ~. t ~~ "SOIC$ L~ lJ' ~'St G: S= Sita suita6la fer svstam i ~. cirn ~ stile i,... c ,P {C t.ILI ~PdT CONY NT~~. M~~~a~ INGILS,7J ~~RE:S~~1 I~~LH~JGLsiJU.RE~O..fVFtw~lb+.lgLoptL-,aE,~ If Percolation Tests are NOT required DESIGN RATE: J If any portion of the tested area is in the ~ / under s. ILHR 83.0915)lbl, indicate: C(,dsS ) Floodplain, indicate Floodplain elevation: /~/ p[~~'y. PROFILE DESCRIPTIONS BORING TOTAL ELEVATION PTH T GR UN DWATER•INCHES CHARACTER OF SOIL WITH THICKNESS COLOR TEXTURE ANO DEPTH NUMBER DEPTHZfi. OBSERVED , , , TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.1 a-) ~.°~~ ~02.~0 ~o >6.4~- ,2'8~s~ts ,Z,,$aN MS Il'L Ah S~ 6~r3pNcs~~~ 36~~$eNr 6- ~ ' .~~ ,oZ •7 / r~ / ~~ 12~8LSL~~~'/8~N ("t.J ~Zrh" ~ x / 7 "~~l! ~'1C~~ ~rtuG+~ 6- 3 ~,z~ /03,/0 C~.ZS 's''~cS~~s i4"$Q,., ~ 4'~c.rl~~~, ~~ 2'$~„ /~i •~ S B- '~ ~.b~ ,•oq,~l f7"$~sL?S 2D"BQ~Sc ~~E?N ~is~ 99~.~u~'- 1'1S r.•~e 6- p£~~ PERCOLATION TESTS EST NUMBER DEPTH WATER IN HOLE AFTER SWELLIN TEST TIME DR I WA ER L V L•IN H S RATE MINUTES G INTER VAL•MIN. p I t P RI p R PER INCH P. f P- Z 3 •oo 3.30 o ~OZ•~U /~ .J4 3 ~ > Z >~ ~ z > ~ ? 2 ~ Z ~ 3 G P• 3•~o io3aa 3 > Z > ~ > 2 c3 P- P • E 1 N ';tG.. P- LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ~ntal 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 f land slope. SYSTEM ELEVATION. ~g.~0 ,~ ~. ~ ~~ . N '~', ~ n i :i ~ ~-- ---- -, I o I ~'_ `' I z i = ~ _~ i lI I I I Q; O I I R' ~ ~ ~ I I I I ~ N ~ I I I n 'l7 O h I I j m I ~ ~ ~ ~ z° I ~ o I ~ I ~ ~ ~ I ~ rn I j ~. j I I I I I ~' i j I O G! vrn ~ ~ I I ~ ~ I I ~ 1 j ~ I I ~ I -`{ ? : ! I 'v m I I I I O ~ ! z i I 1 z I I o v ~ ~ t ~ I I I 1 ~• m i I I I I ,Ps z f I ~ D ~ ~ . W i "~ i - Z ~ ~, m .., ~ z ~'. ~x J ~..- O O ~ I T OQ ~~ W x ~ ~~J -i V-+J v ~c z z ~ ~ ~ ~ ~ ~ O ~ :a ~' 'v -v m ~ -_ 2 ~~ nom. -~ ~ ~W w ~~ w .~ W ~ W I rn ~~ W ~` -a'Y m _ ~ 0 r m ~ m 0 ~~~~~~~ ,r S.T C - 105 ~, -. SEPTIC TANK MAINTENANCE AGREEPiENT "' `~'~' ~' St. Croix County ~ '`' OWNER/BUYER ~~ ~ j~,'//~ ROUTE/BOX NUMBER~~''~'Z~'~ ~ Fire tdumber ~' '~ CITY/ GTATE~~~~,;,: 'G/ ~ .. ~ ZIP ~~~ PROPERTY LOCATION:~~_~~,~Gl~~, Section ~ ~ •,• T ~'f N, R~' . :.~~, Town of~ St. Croix Count.y,~'~; .,~u Subdivision~L~Q,,~ .~7~~, Lot number Improper use and maintenance of your septic system could result~in its premature failure to handle wastes. Proper maintenance.con- sists of pumping out the septic tank .every tree years or sooner , if needed, by a licens'e~d "se tYc 't'ank' um er.~ What you put into the system can affect t e" .unction o, t e •septic :tank as a treat- went-stage in-the waste disposal system. St. Croix County residents'~m~ be eligible to recieve a grant for a maximum of 60% of the cost.of replacement.of a failing system, whic~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 s't'ems .agree to keep their system properly maintained. ` The property owner agrees to submit to St. Croix County Zoning a certification form,. signed'by the owner and by a mater 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. I/WE, the undersigned have read the above .requirements and agree to maintain the private sewage disposal system in accordance with. -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 ~~?:~•~ 1,c, DATE '~ ~ l y ' y~~ St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 °~r 386-4680 Sign, date and return to the above address. ~~ ~~ ,`~` APPLICATION FOR SANITARY PBRMIT 8TC-100 Thl• application Eorm is to be completed In Eull and signed by the orrnettsl of the property being developed. Any inadequacies V111 only res ult in delays of the permit la~uance. Should this development be intended for te~ale by ovnec/eonttactos,(spac housel, then a second Eorm should. be tttalned and completed when the property is sold and submitted to this office vlth the appcoptlate deed cecordlnq. ------------------------------- -------------------------------- ------------- --- Ovnec of property ~~2..~,~ ~l~ ~ Locstlon of psopesty ~ ~' 1/~ ~~~; 111 1/~, 8actlon T~1-R~ ~5 " / ~ i9 T1 Towns h l p ,, .-+ --~- Mallln9 addcess /'g~~!_ Z- ~ - 1lddseas of site ,''Tay,, ~-~= ~~ _ •ubdlvlaion Haas ~~.- Ic U' ~.•~ •~-~T~-~ . - Lot nus~bat _L,~ pcevlova owner of pcopetty , ~a ~ .a. ~ ~ ~ /`+ - Total slsa of parcel 1 • `~` `~'~ ~ c Q/ 5 ~ • _-~ , Oata parcel vas created / /- ~ ~ ~ ~- J1ta all corners and lot lines identlEiablat Yes ! o is this ptopeety belny developed Eor resale (rpee house)?~,~Yes No Volnwe ~ 5 hand Page Numbat 7~ as recorded with the Register of Ceeda. INCLUDE VITH THIS APPLICATION T{lE FOLLOWINCt A YJIIIRJWTY OEtO which includes a DOCUNTZNT NUMB{LR, VOLUKIi AIiD PAOii 11U?tBiiR, and the 9E11L Ot THE R8QI8TER Ot DEEDS. In addition, a eestlEled survey, iE available, could be helpful ao as to avoid delays of the sevlewlnq process. IE the deed deacslptlon references to a CastlEled Survey Hap, the Cestlfled Survey Map shall also be required. ---------------------------- PROpBRTY OVNBR CSRTIPICIITION i(Ye) certify that all statements on this Eosm era tsue to the best of wy (out) knovledge~ that t (we{ am (atel the owner(s) of the pcopetty descclbed In this In[ocmatlon Eorm, by virtue of a watsanxy deed recorded !n the OEtlee of the County Register vE Oeeds as Document No. a9 7'Z ~ 7 ) and that i (Ve) presently own -the proposed alts for the sewage disposal system (ot I (vet have obtained en easement, .to tun with the above described property, Eot the construction of said system, and the same has been duly zecorded in the OEEIce J ~~~ .{ .~ s f . t !~< O • .. ~~; s,~ sMef ~ 5 ~°~; ; . .•~ ~ °~'~.r sox s~ ... •'ant..~,: point. ant ~~ats...i ~ ~.[i~<... ~ °f se ~~'~r ~~•~ ..... .••'•... ••... •.• •....• ... •..... .. .~.. •. .. •.... •.... ... •• ••~••~~••' ~ ~ ~ ,~1 'Y. •• •...•. '••. •'. w ~.. .. •. ..• ..•~.. •. •....,...•. •..••,, •..'.,••...... •.... ... '~ f~?. °t WLoenstA: eitats in ....gt~ ....... ........... ..... . .. .. 430 ~ WIN & ~~. -~-"" _F .Croy • ... co 1.x n - f .. S t ...... .Coup L.______•~~-_W'~~et ~: . tY. ~~ 54q;`., ~~:facated in the Tait ~"~ ~'; Northwest Paste No: „ ~; >~ ~rJ,;,; ~). .the Southwest Quarter ~f. ........._....,.,,.,..~..;,. ~. r~°uath~st Quar Quarter. of the the SOUtheast >_~; ter of Sou ~., . r fi> ~a-f #, SO~th~es the Sou}~w,ast theast Quarter .t?it~st t s?tlarter Quarter ~?"~A'ty~"Af.ne 't29~~~r (NEB of (~~ °~ sW~r) a (rte ~ of SW~t),~ ~. '~ ~''~4ed ) North, _~~r} of &ection the Nor~...r ~` ~~: ~'~~;a' `~, fohlo~s: ~9e .Nineteen ~ Se~"enteeA ~ r ;At .~, off. X71 thence CO~ncing at fI9) West ~~ 9 ~#3"~ 2 93t .t~A~ N89 53'20" (t ee East Quarter ' ( ~ ~ v° 9 ~6S:. ~ .feet= thence SO OS 20«W bearing) 1332.90) f -: t souk, fut,ls ~ `~ e8s NO 41 W 827.1734.97 feet: the feetY ~v''~. ~;~ . ~gi~Ag~ ~rlS~) ~~ ~d j theACe Fasterl 32 feet j the n; e nce NO • ~~- $ectjon 17 3006 feet°n9 the worth line 36 40"W -.. ~ , FTC Ls ' `'`'~ g~ . ~/ ire or less to the f the ~~ I8c 19?p~`'~~ aisfaction of that Point of ~: 1973 ~• 2~9 ~."~ch 11 origi~l La • r`ecor~d ~-~ :mod .ats corrected in 70 in Vol. 459 Contract dated F ' Tb~s-.tt~a~ 3 x.973 in Vol. 5a Land Cantract~ge 458, 4,., ~ 05, page 606, Docated Nove~r..~4 P't. from .-~ ,~ T~4; a transfer fee ant NO• 31965p~ ` ~ ' = t~l ~1.~~~- ~atea Pursuant ,_.?~ ,.~, tarty. §77.25 (10) . to Wis. Status T 'r • r~, '~ Acted d~ ~~. ~•Q /~ ;~' • ".... .. ... d+~' of .... . .. .... .......... .... ... ... .. ...(3EAL~ .. ~ ....~~~.. .........`...laa.~... ................. .......... _ ..... ...... ........ .... • ... Edna G•. Smith .... .... .... .... (SEAL) ,'Y .. .. • ..... •(SEALi •• ... .,. ', - ~ .. ... ... ...... .. • ... .. .. ........ .............. .. . (SEAL) x~ ... -».......... KNOWLg a „'~~ .-.... ~1-th.. .. ... STATE p D Ci 1!~ 8 N T ante iri • .. .. ... 8 WISCONSIN •• ... ». .. 18~~ •.. ....... .. ... u• • •~u4h .. .. Perwnall ' . .. ....County. ~: . . .. . ...... .... . TJTI;,E; ' F" • w'i^~....... ..... ..... ... ....... ... , Y ~+ane bstore ene th .. NEYBE ...................... - .. .............. .... .... • "" daY of $ sTATg BA .................... •........ 18.....~. (!t ++ot, R OF WISCpN3IH......... a~borisb•by f'~OE.OQ,..~iis. ... .... ...... ...~%.i1~ • .... • ~ ~ve aaA,ed • Sta .... .. .. ... THIf INf~ ............... ............ '......... .. .... .. •.. ...... .. 11UMtN7 t0 me i(noa .....• -• WAS ORAF7[O BY tote A t0 ~ the person ••_.•. ....... .... Coir.~ inf "Eill$x1..F.,.... t and •• .... ~t[4~,g,,•. ~ trurnen +cknowl .... ° ex~uted ~~ U & the .....P,~-A,...~q#. ~L 06 ........GWIN e. ate the Earn (st ....... Huas .... ~n•lnre+ .. ................... are ~+y be auri,enti~,-_~Onr...HiI,....54016 ' ... ......... +w! ........... ...... heeeu..... ..---- ..._ ._ .... ~~ii_~i SANITARY PERMIT APPLICATION ' In accord with ILHR B3.05, Wis. Adm. Code • Attach complete plans (to the county copy only) for the system, on paper not less than$ v2 x t 1 inches in size. • See reverse side for instructions for completing this application The information you provide may be used by other govern rme~ntya~g~eancy programs (Privacy Law, s. 15.04 (1) (m)]. _ (` ~~./ ~ ~I Safety and Buildings Division Bureau of Building Water Systen 201 E. Washington Ave. P.O. Box 7969 Madison, WI 53707-7969 County StateSanitar permit Number ~~r~~r ^ Chec-k St revision to previous application State Plan LD. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFO RMATION Prop y Owner Name Property Location ~/a tra S ~~ T 2~ , N, R~ E (or , Property Owner's Mailing Address Lot Number Block Number Zoo City, State _ Zip Code Phone Number Sub ision Name or CS Number II. TYPE OF BUILDING: (check one) ^ State Owned ~ qty Nearest Road ' Public 1 or 2 Famil Dwellin - No. of bedrooms ~_ Town OF ~°-~ ~ apply) Parcel Tax Number(s) III. BUILDING USE: (If building type is pubhc, check all that p Z ~ ~ ~ 1aa5 4 1 ^ Apartment /Condo ' 7. 2 ^ Assembly Hall 6 ^ Medical Facility /Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/BarJDining 4 ^ Church !School 8 ^ Mobile Home Park 12 ^ Service Station J 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 _ S ~r(Repair of a _____System_____-__System_-_`___,_____TankOnly_____________ _xistingSyste _____ExistingSy em B) ^ A Sanitary Permit was previously issued. Permit Number f1J (J v Date Is ed V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11~ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^ Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^ Seepage Pit 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Etev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/daylsq. ft.) (Min.Jinch) Elevation Lf , y Feet . Z 1 Feet VII. TANK INFORMATION Ca acit in allons g Total # of Manufacturer s Name Prefab. site Con- Steel Fiber- Plastic Exper. Gallons Tanks Concrete glass App New Existin strutted Tanks Tanks Septic Tank or Holding Tank /(~~ /~ 1 v !~7 ~ ^ ^ ^ ^ ^ Lift Pump Tank /Siphon Chamber ^ ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the and rsigned, assume responsibility for i all ion of the onsite sewage system shown on the attached plans. Plumber's N e: (Print) Plumb s to : (No Stamps) MP/ M PRSW No.: Business Phone Number: ~ / ~ (O 71 '~~ re reet, City, State, Zip Code): Plumber's A ~ IX. COUNTY /DEPARTMENT USE ONL ^ Disapproved Sanitary Permit Fee (IndudesGroundwater ate Issue Issuing Agent Signature (No St pproved ^ Owner Given Initial (~' Surcharge Fee) J j ~ „~ /lJ c c J -7~//~ . / ~- Adverse Determination . . X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD-6398 (x. OS/94) DISiRI8UT10N: Original to Gourd y, One copy To: Sotety & BuilJing~ Diva.ion, Owner, PlumOrr 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 S. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by 2. licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions,concerning your onsite sewage system, contact your local code ad,ni nisi: ator or the State of Wisconsin, Safety and"Buildings Division, 608-266-3815. . To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. ~ - ' ' If. Type of building being served. Check only one and complete # of bedrooms if ? or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. Vf_ 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. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 1 1 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, locationof holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mainslwater 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 1 15 form; and F) a!I 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. STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS Q~~ ~ Q,f~ ~ ~s~ ~~1 ~ ~ PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITYISTATE ~.-.~ (~ ~~r~ l~ , PROPERTY LOCATION ~ 114, S i.J 1/4, Section ~, T 2c( N-R (~ W TOWN OF I'I udder ~ ST. CROIX COUNTY, WI ~ r SUBDIVISION ~ t) ~ t., _~~ S ~ ~'~ LOT NUMBER ~ Zoo CERTIFIED SURVEY MAP ,VOLUME ,PAGE ,LOT NUMBER Improper use and maintenance of 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. UWe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standazds set forth, here' ,asset by the Wisconsin DNR. Certification stating that your septic has been maintained must be pleted and returned to the St. Croix County Zoning Officer within 30 days of the three yeaz ~j pirate date. DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 .. ,} ' Wisconsin Department of Industry, SOIL AND SITE EVALUATION Latio~ and Human Relations Page ~ of ,~ Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and ~ 5--~ , percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # oao-~ a ~U~ APPLICANT INFORMATION -Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location ~-~- ~ ,r V ~ ~r ~ Govt. Lot 5fY 1!4 5 ~.J 1/4,S ~ "~ T aC~ ,N,R ~ / E (o 'W Property Owner's Mlailing Adt-dress Lot # Block# Subd. Nam`e`or CSM# C. 3 ~ t,..f--/ Q. Y` 'T ~`~ n P~... ~ ~ oZ (p ~ Qr ~ V 1 Q ~.J '~` ~ G ~ . ~'t't^ City State Zip Code Phone Number Nearest Road ` ~ j G~^ f, ^ Ciry p^ Village) 1 [~ Town 1 'TL~fr 117 Y\ tn~-`.- ~tf~j,aa `/~~J~.~q -..).~o~~ I.JR..St {uY'~~ 1'"~IT~sQ~+'~ W~.`r~ ^ New Construction Use: Residential / Number of bedrooms 3 Addition to existing building ^ Replacement ^ Public or commercial -Describe: -- Code derived daily flow 50 gpd Recommended design loading rate _~bed, gpd/ft2 ~ ~ trench, gpd/ft2 Absorption area required fo N 3 bed, ft2 .S_~_trench, ft2 Maximum design loading rate ~ 7 bed, gpdJfi~ g trench, gpd/fl2 Recommended infiltration surtace elevation(s) ~ 3 . y e1 ft (as referred to site plan benchmark} Additional design/site considerations Parent material q I `i e : ~ I ~ J+~~ ~"~ S ~-~ Flood plain elevation, if applicable 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 Boring # Ground elev. 9~1ft. Depth to limiting factor gin. Boring # r^ Ground elev. ft. s Depth to limiting factor in. SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles T t Structure nsi ten C unda B R ots GPDfft2 in. Munsell Qu. Sz. Cont. Color ex ure Gr. Sz. Sh. o s ce o ry o Bed ,Trench 1 -~ d~ R 3~ -------~ ~ a~ k r a~ , s~~ 3 q- 41 '~ (~ t~ ~ ------~ 5 G !.. Q1 w~ 5 ~ k ~~ r r^~ G w F , y , , S y l- ~11o v `( (2 `~ I3 -~-----~ 5 ~- c~ v~ ~.~ ~ ~. r~ ~= r-' G, ~`' , S Remarks: '. ~,, ,~ . _ l ~ t . ~ ~ 1-~.5~.. ~~ v ~, .i., ~°x sj~4 - ~~ ' ,~ J• ! , ~ '~ ~ f', `; S' / '~~ ' `..~s+~ Remarks: CST Name (Please Print) Signature Address ~' S ~''at,r 'T J'am', v" : ~c> Date (~ -3b- Telephone No. ~~5-a~ 8 - CST Number `~'D ! 1 oa PROPERTY OWNER .PARCEL LD.# Boring # ' Ground elev. ~ n. Depth to limiting factor in. SOIL DESCRIPTION REPORT .s, Page of Horizon Depth Dominant Color Mottles Texture ' Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed .Trench Remarks: Boring i Ground elev. ft. Depth to limiting factor in. i Boring # Ground elev. ft. Depth to limiting 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 factor 'n' Remarks: Boring Ground elev. ft. Depth to , limiting factor in. Remarks: SBDW-8330 (R. 08/95) ~ ( I I \ `r r~ ---""""'FFF ,g `; ^ G~~ C I I ~ ~ I 1 . I ~ I ~ i t° I , ~ • P K Ill . _ ~.__ ~ ---- , ~. __ ~ - ~- ~ _ -- .I ' , _ _ ~~ ~_~ - I ., _ ' I i I _ i ~ I i ~ _._.. _,_ _..... _... ` _ r.. ~ ~~ __ ~ - y. ___ __..._ N ~ I ,~ - ~ _ -_ _ ~~ _-~ -- -- ---l . - ~ f ~ _ - _ __ _._.j __ t ~ __._._~ ____,___ __- t r__;. , ~ ~ _,_.~ _ _ -- . __ . ~ _ ~. __ _ J _ • - , ~ __ ~~` ~bo~y_-__ j ~ I ~~ 4 1 ~ ~ 8 < _ i { -- - .__ __ ~ ~ ~ a ~ ~ - _+- --- ------~ ---r - - o .. -- _.. _ ' ~ ---- ~~ ~ q i ~ ; . - ~ _ ,._ . ____~ --.- t-----t--: !_ i } t--~---- ~ ' - _ __ ,._._ -- __.___ ~ ,_ _ .._._...---t -.-__ , . .~ i__ 1 ____ ~ QQ, ~ ~ . _D______r.D~ _ ._- .._ ~ A ~ ~ ~ ~ ~ ~ i ' ~ ~ -----~- 1 11 ; ~___ ~G^~~1.--_ f..~ 4 - - _ j ._ ~ _ ~ ~ - -- ~ _ I _. _,___I _~ ~_ _ ,.__.. ~.,..}.__...._.~.._. r~o ,. __ , I --1 _..-t _.~_ _ , 1 r ~ , ~ { ~ ~ r -~-- ..... -~~ _ .1 -, ~.~ ,-~ _~ _~_, .__- _ ~-__;~ __~ i ~ _-- ._. G i -- I .._.~ ! - ~ 1 __.~ .. I .~. , i - ~ . .~ - -~ , . ~ ~ I I i ~~ A `~' 1 1 • /~ / r N r ~ - t ~ ~ ! f t ~` O ~ ~ d ~ ~ 1 `. 7 ~ '~ ~ ~ i C. ~ ~~ ~ / I ' ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the '~ ~r IJQ~~, residence located at : ~~_/, ~_/~ Sec . ~_, T~_N, R~_W, Town of u~~ st . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good c ition, and it appears to be functioning properly. Last time serviced ~~ ~ cjcj Did flow back occur from absorption system? Yes,'( No (if no, skip next line. Approximate volume or length of time: ~p gallons ~_ minutes Capacity: __)~Q~ Construction: Prefab Concrete ~( Steel Other ...Manufacturer (if known) Age of Tank (if known) : ~ q (Signa ure (Ti le) ~~i 7 (Date) _-~ r5 Or~~ (Name Plea Print ~o~~ ~o (License Number) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) , Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis_ Adm. Code (except or inspection opening over outlet b fl ). Name Signature MP/MFRS sTC-soo 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 Location of property~_1/4 S „~ 1/4, Section ~, T~N-R~_W Township~~c~,~ Mailingddress~'~,~~/~' j~ Address of site ~ Subdivision name ~ Lot no./~~ other homes on property? Yes_~_No Previous owner of property ,,q Total size of property /; ~/.~¢,~ Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ~_No Volume ~!~~ and Page Number ~ljS as recorded with the Register of Deeds. INCLIIDE AITH THIS APPLICATION THE FOLLOAING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. ~-~~~% and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. `~natur~e of Applicant Co-Applicant /!/~ Date of Sig ature Date of signature M ~~ r' ~ , - r ~v ~/C~ •. -. __ ..... ..........._ ...,...... ~....,~r•:~}.^aw..,a::.w~ur a: •7!M[6'41!'rslT' ,j(tir i111"~:Sl~~1~ilk• DOG':i~.IENT NO. 506546 BTAT)C SA1t O>r w3B00N81N lOlilt ~ ~ tw~l •n~n woes essaavw -w saeoawNe w~~ w~n~m o~ This Deed. acad. bot~raa :.4N1l. Ex..~i}l~r~,• a. ~iagle.,p~rso sad-.PlRI!li:..$541~~. V~ii~i~}, riid, ?i~iiieai, L~iiio. Vana~~ia ~,~~~ .s3te._u..ntzxixa~c>t~~x.,~>c>tit><~..i~><~s~~c~x ...................................... ......................r .. ................................................-................y Witnesseth. Th.t w a.ia o:.ate~, t~ a a ooeaidoratioa...... aea..r.1o mraat.. ib.-11no~wis ir..eeibN t..~.~fa 1~ •..~L.a.C?~oii .............. cr.-v. eta at ~Piaeonob: REGtST~R'S,OFRC~ 51: CftQDI trQ:l1~ Aso'd 1br Rwoord ., OCT :4 1993 ~ 8:00. A'f~ AysM d bases asruaw ,o Lot 126 >'ark Yfex ><state litth Addition in the ?otin of Huds,~p~ ~; -.~~.,.~- 3_ ~ _ . Thi....~l. ~~.. h«..aes.d ,:~. _~ c~ ~~.. Toptias with all aad M ti+o and appnrtenaneoo thereaato balondias: ~-~-•----------~ E...... !=l..a.~~le pesson ....... ..... warrants tJ~at tln tkL b pod. iaddwbla b !oo oi~plo sad tree and ekar of enemabraacw esespt eny liens os eacnebraatces created by the act or default of the Grantees. and wW warraad and dotoal the Dome. Dated th4 ........~~ ~ ......................... d~ ot .....---.lSepte~ber.---•--................................... 1f... 93. `~ .....................................................................(SEAL) \,A~~ s~..-.--.-........~.................._..(sEAL1 8aa t. hiller .................................................... . (REAL) wo:>ts>~::a~s><ox aatbonfde- d this ._......'q of .......................~ 1l..---- ........................................................•--•------.. (SEAL) ~os>KOwLSaa>tc>fir: ar~TS or wzscaxsix ~ ST.-.CHOIX..._.°-......_..lbnnt7. i ao. ` I'eesoaalfy came baforo ma tbir .. ~_~ _.....dq d ._....-~Xigl~ . ................ lf. 93.. tao a>taw aanod sa. t. K~iler. s single person r _ T _ ___ r - = ~ -fl ~ . ~ P ~~ ., . ~ ~ ~. _ -~. .. _ , w.- _ ~ M•H • r•f•r•r•~ N IIN Ewt~ llN { .r rw.7~ ~ ~0 «~u.. 11, ...w~ , • ~ ~ •N N'7 T"IN i • (;~~ ee I I I ~ R• r N ` ~ ~ - 4 ~ , I I I Cl >1c ~ ~ ~ I I 1 ~ ~ , I to I ~- ~ -~ . i ~ ~ ~~ I 1!1~.._ _ 1 N ~~ I ~~ Iwh 1 ~ ~'w/ ~~ ,r 1~ ~~, I ( I~~ n ° >r U - ~ I '~. ~ "~ f .~taJ. W E 1 ~ { {~ i ----s -r-._.__.S QAQ.r_ _ • ~ 1 p ~9AQ w ---- ~~ i ~ - - •w woo a o -' - r- rt I _.. -_-_..- ._- I ~ I „~ -~'~..fia -"- --+ 10.00' 1 N ~ { ~ 1 liso a•~o"wl ~ ~~IO r 1 `w I 1 1 1~ ' I I M ~ 1 r -1 I I I ~\ __._ ~ 1 to ~ 1 • ~ I• . -._.. _, ..... _.- ,i i ~ . 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I Z o N ~ ~ ~ C~D ~ ~ ~ ~ ~ N A Z I N C I y C '~ ~1 >: N d I d A~ 7 I .. Z -I m mo I a`D I a1D ~ Z I r: ~ ° ° ~: cn ~ o H o y ~ CoC Z ~ I ~ C N ~ ~ ~ I A W O. N, i~ I ~ a I a I w a ~ I a ~ I ' I ~ ~ c I m c I ~ o a I o a I y y d y fD d I I I I L I ~ R, ~C I I I n N I N A I I I A I o I o b :° I ro I ro ro o I o 0 I c~ ~ ~., ~ ° ° ~' I o i. I o ~- I i ' ~ r a JqV 26 '04 01=31PM CF~KIRLES SCI-WAB ST. pq ~ ~r ~ r( ,l I ~ 1 r P.2/4 Mllmar7DepsAlantdCalarns SOIL EVALUATION REPORT Pa9. ~ d 3 drYwldsrfMpaflYl~degf i7 aaooidae7~er~Can7mO5.71Y1e. Mm. bode ~M •C~/~ /YIm1- aoe~lw sb ~ a popar mlless *+on ~ 7!2 x.11 Ydiw bfb. fM/~ ews7 Uldu0e.6Weotd~i~d~raNirala+Oho~4onIM7~~oe~0o~+t~9.~~11~"~ Pala pnaecdope. soM tdle~nele~+. nwf7~ o.e... enA WOroo ~dti~e~7e noen<if geed. Pfffas~ plot alt Mlbfw7aQmr. ~ ~ t~ rw.wr nfewren. f++pwM:.+I rwli..w~7Ae.rP-ra1L~. e.77Lr 171f+01• /~` ~ Lonfa7 Z' / ~ ~E ~+ si/~ C/ A" OorL ld ^''G 1M S W S n T N R 9 ~ caw p~p~y ~~~D . Ldi B)arJ~~ '~rbd. try 93 O yiS 3~1. 9G _ • bOlAw/ 41/ S'YD/G ~ iIS 71fiO • olo ~//t~DSofJ a ~~ Cf~iE"RT ~~ Q N.weoeruaen u..:Q4 R~etleridlNUnAwd6ebaees caeseerlyddasipn rae GO'b- --~-F1pD f0~pdcwwfl ^ weicsmw.ne~ea~•prs„iac SYSTerf ~J~S 1p~. / g~ryws'~S- fratlRlw~ar LOESS OV>ti_S/~AlDY ao.a Pl.rir.rafanll ~' - • ~ . ~ ev~'w~F81.. - ~ A~r:l 7f'srFD /s sup Big /~~P ~4.v i;~7 - ~iAvuva ~ovta6~r+os/! L. P o.cd-'r-~. ~~••.. 3 - fX Isr• s!'•s`rB" is ~N eeAi:' Belie [.,i.~T so:ts ~ ~•+F~ • LEi>r ~..~T~teT ~-• 76S i ~j~ ~sGL W~L ~_ ©~~~ ®ry~j 9 dwmaaurosaMv •Q'~R. pep0~7o67iFgfad~' ~ ~7. ~ Rrr • Ilan 0~7 OfwUs~ fl~ueOfsolp~a7 TsAe~ 9budYn- 9sN1/aY I~Orr k IIIes1 4r. $ CdL Qdof Q. $. Sh '@al ~ • / o~ /or,! ____ SG n~n~F cu, 3 io --- SSG / S~ '~' ~f.S / f . Z - o - - S_ D S 7 ~- ^ sane - rMefmn OrOw ~! frd0e OlSelO/ee Ti~aee S'r1~er ~Y ROOIe fdP011! h ~ Gu. ~ mIL Cf1or R. ~. "Ela1 'E1~ ~-9 AoYR --- SL •.•• 3 . s ~ _ 9 ~ , ~,~, t . y . ~ / /o ~ -- SiG / s ~ .~,. a s . z . 3 /o - s o, ~- -' • .o.~. .e..i.o~ern c~o.esi eMTSReIOsaL - fS~ N.e. ire w~q ~ OBE 1~ ?.d6Ri C1,.T s°"`e° - - , 1 G w~S .w.f. 2812 10~ qll.!_ oree.or+a ~N a wfs . SY7G 27- ~ T+.p~o~»~.as 3 7/S • ?7a • S e1yZ ~•[, w~oT~"' ~Qtc./~Ct~' f~L.P T o~ f~.t~$Ti•a7G-- Ti~v/f iS e?~ .- e nab ~! ~ ~,IP.w ~.P~~ - NE~+e~ ~3;oDi E~ TI~°E'~ S ' . 4sobL d ~ EJt79E'~~~.1~ -- ~} ?„~ ~o TA.~f~ L°r f t+ a. c.; f T ~°vf+P ~.I<fj/f-4r ~ s ~P~4 v;~EV - 7a /~~ ~t.,Gls S,Ge-~.or,~,G.r ft' a~ fiw~ ~~ 's ~ ~~iRE~v A••uy~tr- :yro s•~~ s ysT~. p~~ ~. ~- `~ dRti . h~~,e. . _ ~ ~oHQa, %t~vK woaL7o ~oeav:,~c. ~trJ•v~es Also W ~ ~ ~ /~(w~~ fi f S ~ F ~~ Dd Si.U (r ~ /IPA- ~ ~„~ E/.vf/•~+a.~.S~ 7R rte ~~ ~+ ~ ~ CP1.~S i4' ~ . / _ . _ it ...: L. .f ~ .. i ~f /.n..~. _~rL / O !~ dDS=GO b0 9Z UeC t -d -JAN 26 '04 01= 31PM O*iRLES SCF#.IAB ST. PAtI. I P, 3i4 TAD G~ew~ ~. Z a 3 Propwlr Oars Prod 4 • 3 ~,. a o ~' ry~ 6rwn/ evfitoe atsr. R. Dph r 6ni(n/ laser ~ K Rde fbrlmn taeah t>avtlrr t4e0ee Oae0lpMorr Tasrr 3eYnn Cowklg v ~Y more in, I~eiree QY. 3t. OonL Cda d. Ss. Sh '~1 'EitZ o ~ EoY qw SSG 3M v c 5 / , z •t ~a 3 S~L~ .we.. ~ [ca r . p . o ~oyR 4rz ~ . ~o Yit Ste, r-- / •~. ~ S ~- t 3 • ^ pit ', Grourr0sitsoeerar. ~ R DsPAtoYirilinDfsda N• .tk/ Itab Horhun aPti Demirerr Awlacl7ea~an Tama Seudvv ~Y Rids ~t 11M it Msge~ QLL 9. Cat Odor Gr. SL Sh •~t 'L~ o ~. o o ~ maaWsvrraaefe+ . ~ Oyar~e6+i~fdv ~. w.. Ilaiad l>•~ 1n. COrisA Ussad_ . tierf=Daefpsst- _ _ xir 6c. Car. Odor. Tetra S~ G•. St SR. Yam/ - - Rlees - '~: ~llo~gl Q ~ CsOwfdaahaedM. ~ tlt4atbXersl'r1sA~er I *- Sd ftrts tlstmn ~ h Oeainanl RA~nad Iisdra - Da. Sz Calr Taws SsWNe Ge t.`t 6h tte~rs filaes •!'~t 'Elt2 • ~ • 't~rwsOi~eOD~~3p~~aglLrrA755s70~190wb1 't~MtrlQ~eL>D~c7Cnq~~d7S9~70er~ll • i 77u DepaAstesl of Gbnrterm is sa e9ad appornwiq serviea Orratder and esyloyer. (paa need assisfeem to tacos services or need s~+el in ss aketeste for~ias„ pleos aatrrs ~s d~ann~t et 60k-2~.~]tSt sc 77Y 60E-7E4-f777- ~~~ I ~~ i z-d diS=LO bO 9Z UeC Jars 26 04 07:51 p ~~ Jp4 26 '04 01= 31PM CMpRI_ES SCHJRB 5T, PAI.JL . 0 ~C ~ ~• ~ . ~ ~ ~ ~ __ T ~ r i - ~ , ~ ~j ~ 1 ~ ~1y ' .. 1 Y` { ~ .. ;; o . .~. _ s ~ (~, Q ~ ~ ,_ ~ ~ i 3 ~` ~ ~ O 1 s ~~ ~~ ~ L o ~ ~ -; ~ i i ~ n ; ` ~ 1 ~ 1 ~ ~ ~ o • 1 ~ p G ~ 1 i ~ ~ .. .._ .~ 1 ~ _.._,_„~ d ' ~ ~ ~ ( i p a o . 1 O 14 ov I ~ ~ ~, I~~ a N c ' ~ L 3 z w i ~ ~ R 0 ~i . ~'' c~ ~1 • h /-~ ~ ~ i. ti~ O P,4/4 Y S T ~4 p.3 D ~~ ~~ ~~. s ~~ ~~~ ~~ ~~ -' /~ z~~ ~ ~ ~~ `"' 1''(CI"Vfll VIA JVIL uvrur~~a.~ ni~v DIVISION PERCOLATION TESTS (115) MADISON WI 53707 ~LATIONS . (ILHR 83.09(11 & Chapter 145? ON: SE TION: .,p u TOWNSHIP/M~1Pir•C12A~ OT /NO.:BLK NO.: S BDIVISION NAME: f,, 1 SW ~/ ~~ /T~1 11/R 1C} (or) ~ ~tdl~/ ~~17 ~A~~ Ef.~ S f~ NTY: MAILIN ADORE S: -T Cab Ix SdM +~•.,_ ~'R i ~oc,r~ '~~c~~.. 6 +a ~ ~i,t~~c~v )SE DATES OBSERVATIONS MADE NO, BED MS.: COMM IAL RIPTION: • , A T Residence ~ 11s~ New ^Replace ~ /~r,el` ~ jCigp ~ q q~ ~/lii ~~ls~.. l- ~~ 7DIC.$ ~' //~y-~Y~~1[Kr~i'~'~d-/T iATING: S° Site suitable for system U° Site unsuitable for system ~O~ENTI~NAL: M_~.J~ID: Q~ IN-GF~OUfVD-~ URE: S~EM-INa-FILL HODLDING~A~IK: RECOMMENDED SYST`E'M:loptiona~ ((Y//YLLllYy..JJII SS UU ®S ®S U S U S (L7KpJrU CON~/li=h1 I) DN L Dp DESIGN RATE: If Percolation Tests are NOT required If any portion of the tested area is in the under s, ILHR 83.0915i1b1, indicate: CLdss f Floodplain, indicate Floodplain elevation: I~r.C PROFILE DESCRIPTIONS BORING ....__ . TOTAL PTH TO R UN DWATER•INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH9~. ELEVATION g ERV D H TO HEORO IF OBSERV ISEE ABBRV ON BACK.1 B-) ~,.~~ io2.~o l~o ~6.QZ- o-li - 2 ~~ 34 •- (~ ~- ~Z.,g~sc.TS +Z,,$QN MS it [. oh S~ 6 BQtics,t~,~ ~I~CNI 8- ~ ~ -~~ ~vZ '7~ ~ ~ " 1~ ~Z d$LJf.. ~6''OY~N ("{J ~Zr41 f JL / 7~ ~ll J'lC7~t 74jY"`"'~ 8- ,3 ~,z~ ~ /03.-0 6.ZS v-tr rs -Z.~j 29-33 33 - ~~. 'S~'$cSc.~~ /4"g~~., ~'c.ri~~~.,~;c 2'$~,, /y.~5 B- ~ 7.z~ ,/~3. i 11~t~N 7 •ZS A-I2 i Z - Zd ZU - 31 3 / - ~' T ~'"~~, S il'cr~~'~vS ~ 5 ~ ~N~ ~ ~l S~*~ ', a- ~ ~ •6~ !oq•~/ -~" ~ L-rs Zo B ~ Sc B hiss 99 $eu ~'- MS c~~ B- t\ _ r. PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME D I WATER L V L•IN H S RATE MINUTES ,NUMBER AFTER SW ELLING INTERVAL•MIN. p RI t p RI PER INCH p. I 3 .oo o io2.~ 3 > x > .,x ? 2 < 3 P.Z- 3.3o io.ld 3 >~ > 2 >2 L P. 3.f~v io3.r,a 3 > Z > Z > Z ~3 P- E ' ~ P- 1 N ' ..L P• 'LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- :ontal 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 ~f land slope. SYSTEM ELEVATION. ~~~~~ ~1L ~- R ` ~ ~ p J _ _ ,, ,. ~ ~ g-Z _ ~ ~ , _. o. ._. _ ~ ~-~ P. ~ . ._. I. ~ ~ ~ -3 ~ Q, .. ® ~ q~ ~~3 .a ~ . ~ ~ p~Z ~ D _ ~ J _ ~_ .._ _y_~_~ _~~ ~f_ t: ' Qi 7 Ac, '~ t ~ ~ ~ ~~ • Fora - S T C - 104. ,,. AS BUILT SANITARY .SYSTEM REPORT ~ OWNER _~~~, /1'1~ f luy TOWNSHIP ~~ v~ SEC. ~_ T a~( N-R~~ ~ ADDRESS ~~~~~g Z ST. CROIX COUNTY, WISCONSIN .~ f -F ~.~S o v~ ~` -~- `~~ `/~'l SUBDIVISION -~af ~, ?~ ~,~ ~~cc.~ LOT e :~~~ LOT SIZE ~~~~ H ~ e'~S PLAN VIEW Distances and dimensions to meet requirements of IT.F1R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM z .^ .~ BENCHMARK: Describe the vertical reference point used ~~ ,~ ~[ I t . ~~N ~~~~„~ C,/ i Elevation of vertical reference point: ~p0.~p Proposed slope at site: S% - ~_ ~ Pump Model: Pump./Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: _ Pump off switch elevation: Gallons per cycle r Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: r~ (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed : Con ~,,,~~Q,--.~ ~ Trench : ~~ Width: ~~ ~ Leng~'th: !r Number of Lines:~_ Area Bui1t:~0` Fill depth to top of pipe: yb ~~ Number of feet from nearest property line: Front, O Side, O Rear, J~ Ft.~ C~ Number of feet from well: ~5~ -y Number of feet from building: ~f Z (Include distances on plot plan). SEEPAGE PIT Size: ~~_ 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: N ~~' Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, ~ Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: ~RTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING .sGki & HUMAN RELATIONS DIVISION .O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 NE 4 , SW a ,Sec . 17 , T 29 -Rl9 nn (If at s fined) 'Number: Town of Hudson, Lp~, 126' CONVENTIONAL ^ ALTERATIVE LJ Holding Tank ^ In-Ground Pressure ^ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam I~4iller Box 208 , Hudson, WI 54016 g/Q~/yp BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. EL ~ I 7 , / ,D Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Doug Strohbeen 135462 St. C 135462 EPTIC TANK/ 2" o 't,^ = C3, G. 7 IANUFACTURER: LIQUID CAPACITY: TANK INLET EL .: TANK OUTL LEV.: WARNING LABEL LOCKING COVER W / ~~~ ~ ~ PROVIDED: PROVIDED: (~J /O/.57 /~ /, i~9 YES ^ NO ^ YES NO EDDING: LIF#F~DIA.: yF~GFMATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH r`.O ~ ~ C.o, ALARM: FEET FROM LINE: ~ ! ~d ~ AIR IN ETj ]YES NO ^ YES NO NEAREST -1/ ~~ O (.pS r DOSING CHAMBER: MANUFACTURER: BEDDING: PACITY: PUMP MODEL: P/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ^ NO ^ YES ^ NO ^ YES ^ NO GALL NS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER O PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM INLEr: PUMP ON AND OFF ^ YES ^ NO NEAREST -~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue. CONVENTIONAL SYSTE ~~ ~~' r]v:S~.e.,w~ Fl eu"_ = 99. BED/TRENCH DIMENSIONS WIDTH: ~r L ~ 3~ OF TRENCHES: DISTR. PIPE SPACING: r (,p COVER MATERIAL: '~ PIT INSIDE DIA.: ~ PITS: LIQUID DEPTH: GRAVEL DEPTH BELO PIIPpES: ll FILL DEPTH ABOVE COVER: .~N 3 9 DISTR. PIPE ELEV. INLET: (.~ CO(q ~ DISTR. IPE ELEV. END: ~ ~ , DISTR. PIPE MAT RI L: ~r, pp~~', ~j/~ 7'kti- ' 17 NO. D STR. PIPES: ~ NUMBER OF FEET FROM NEAREST ~• PROPERTY LINE: / ~ WELL: cv~i a `~ ~ BUILDING: ~/ ~ J'/~ VENT TO FRESH AIR INLET: ~ '""' ~IZI MOUND SYSTEM• •~' ~ zo' Mound site plowed perpendicular. to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ^ YES ^ is the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER T E: PERMANENT MARKERS: OBSERVATION WELLS; ^ YES ^ NO ^ YES ^ NO DEPT VER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: S ED: SEEDED: MULCHED: C ER EDGES: ^ ^ NO ^ YES ^ NO ^ YES ^ NO PRESSURIZED DISTRIBUTION SYSTEM: BEDlTRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELO FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS , MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE ERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV. : PIPES: OIA.: ELEVATION AND T DIS RIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORR ECTLY : COVER M ATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ^ YES ^ NO ^ YES ^ NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY LINE WELL: BUILDING: FEET FROM : ^ YES ^ NO ^ YES ^ NO NEAREST ~~ Sketch System on Reverse Side. SBD-6710 (R. 06188) ,~,.~.~ CAd11TADV DCDwA1T ADDI If`_ATIAI-f ~„I,LHR ..~.... ~.... _....... ~.. ---- - - --- - In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY PERM # -Attach complete plans (to the county copy only) for the system, on paper not less than 11 i h i i 34 ^ J~~C~~.,J~ es n s ze. x nc 8 c if revision to previous application -See reVer38 Slde fof IrIStrUCtIOr1S for COmpl@ting thlS appllCatlOn. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ~ ~ ~ F'/a %a, S T~~f' , N, R / ~ E (o W PROPERTY O~,WNER'S MAILING ADDRESS LOT # / ~° BLOCK # ' O TE CITY, STA ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER nn 11. TYPE OF BUILDING: (Check one) CITY ~ /~ NEAREST ROAD ^ State OWned D VILLAGE ~ 6 Se 5 d ~ ~,.~ . UM ) ^ Public 1 or 2 Fam. Dwellings of bedrooms.3_ AR EL III. BUILDING USE: (If building type is public, check all that apply) I Z Z $~ 1 ^ ApUCondo 2 ^ Assembly Hall 6 ^ Medical Facility/Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ RestaurantlBar/Dining 4 ^ Church/School 8 ^ Mobile Home Park 12 ^ Service StationJCar Wash 5 ^ Hotel/Motel 9 ^ Office/Factory 13 ^ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an t i i S ng em ys st System System Tank Only Existing System Ex B) ^ A Sanitary Permit was previously issued. Permit # - 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 42 ^ Pit Privy 13 ^ Seepage Pit Pressure 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE /inch) ELEVATION (Min /d / ft l G . sq. .) a s ay REQUIRED (sq. ft.) PROPOSED (sq. ft.) ( ' ~ ~d - Feet O Z.S Feet Z~ ~ y ~ / Co ~ d. 7 VII. TANK CAPACITY in allons Total # of r's Name f M t Prefab. Site Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks ac ure anu oncret glass App Tanks Tanks structed Se tic Tank or Holdin Tank ~ ~~ m ~ P~ Lift Pum TanWSi hon Chamber Vlil. 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) MP/MPRSW No.: Business Phone Number: Cdr - ~'" ~ ~ "~ ~' ~ ,. Plumber' Address (Street, City, State, Zip Code): ~~// L~ ~ Ni'4 TO IX. COUNTY/DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (3urchargerFeej water g ~ Issuing Agent Signature (No Stamps) Approved ^ Owner Given Initial /~~-^~ dverse Dete mi ation ` J X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: i SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety S Buildings Division, Owner, Plumber INSTRUCTIONS .. '' w ~ .;~ 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building. being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. 1V. Type of permit. Check only one in line A. Complete line B it 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 in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for al/ septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VU1. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8i4 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; v/ells; 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; Bj 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) --~ I, S st6vh ~IV• = 99.00' ~~.....~„ ,.~ ... ...~... ,..~.~~.,. _..~.~.~.~ a.~~.~....~._~-~.---a.-~°•-°"`...-- .__..._ S ~- B M: Tod of . ~ ~ -. ~~ .~ 3 y ~'^ /z- 90 d ~/ v h \` 0~ n ~i a s~ D R S J B- ~ ~ I yB I i ~.~ "' ;sr y T~ 20 I ~~~~5` klb~s~ ~~~X zy~ ~sr'x~/~' S~ ~~ n +~ a ~\°~ Z ~~ i ----~-s+ 6'Z ~s-„ A _ o_ , 3 ~ T 4S~ a ~ I" E -}- SI ~ B-s ti la A ~O n M .b ~i SOKt k" IJ' ,~'~ / i rn¢,. '20 G. Y 3 ~ 1 ^~~ SL~~E T~tE. Ppd. E ~v.. loo. a' DEPARSMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN~~~USTR,Y, DIVISION Fi°~UMAN ~EDATIONS PERCOLATION TESTS (~~J) MADISON WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION: N~ ~/ SW ~/ SECTION: ) ~`7 /T~9 N/R 15 TOWNSHIP/ TY: l OTNO.: ZC BLK.NO.: S} ~BDIVISIONNAME: rN " lor nso~ h ~ / t A2~ 161.V S C LINTY: ~~ ~~ ! X SAM - ~ ~'><2. MAILING ADDRESS: I ~'Q(,J'~ ~ 2bta ~.. 4 A ~ /~l, ~'Sc~ mac DATES OBSERVATIONS MADE ESTS: 9 ~P>Qlf: ~ j 1980 ~ 9D RATING: S= Site s 'Sa1c..S ~~ Lt ~ uitablw for svstwm 11= Sites ~. ~..~~~ti~e 4.,. ~ .~~o... R ~~ LJr~~ Q ~l~_KNN>isd.T Residence NO. BEDRMS.: / COMMER IAL DES RIPTION: N w i ^R f ~K e ep ace ~CO~vTI^~. M~S~~U ING~J ~~ E:S~~ IaYLHC~JGtKtY.RE~On7Vi;*ID)Dhtl,~~.OptCjna~ If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the j under s. ILHR 83.0915)Ib), indicate: CLASS ~ It Floodplain, indicate Floodplain elevation: /V A ~~t~y. PROFILE DESCRIPTIONS BORING TOTAL ELEVAT N PTH TO GR UN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH'lfb, IO O SERVED E I HEST TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) B- ~ ~.4~ /UZ.fia B NoN ~6-4z- f2'6~stts ~z'',$QNMS ll~L o,, 5~ 6"$pNCSrt~~? 36$e.,r' s- Z 7 -Q~ !t)Z.77 >"7 ~`~- r2°$c5t_Tsf~-~BaNl~ts ~2'h-' St i4"~'~'~ Ar;~tG~ 3~~~-~: a- 3 ~.z~ /o3,fo 6.ZS 'S/'~LSLl c i4",~~,.~ ~ ~4'~~ri~~.J `~~ 2"$~„ /y -~` S B- i~ ~.z~ , io3. ~ iTYbN ~•ZS 2' S -r f~"~~~,1'hS ir'~r$QNS ~ 5 ~ ~e,~- - 41 S~~ B- ~ 7 ,6~ IOg,7/ f ~~IQLStIS ?A~B2U sL 6 i~/W MSL 99'$„e~ ~'_ ~s t~~ B- ~~-~~ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L V L-IN HES RATE MINUTES NUMBER 1 AFTER SW ELLING INTERVAL-MIN. P RI D t P RI 02 R PER INCH P. 1 3.00 o ioz•~o 3 > ~ > Z > Z < 3 P- `~- 3.3 0 ~o . l 0 3 > Z > ~ > 2 ~ i P- 3.f~c> io3.ca 3 > Z > Z ~ 2 ~3 P- P- 1: Ifni ;tL 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. ~~ , ~O \ ~.._ fir' ~ . - _.__ v_.. _ : __.. - _ _ __ - ~ v - _ .. _, __..__- ~ ~ _ _ 1 ~-~ P : _ . _ _- __ -_. _ `' T N i -3 LC ._ . QS ~-3 p ~ o ` - - - - . . , 'yl- r ~ ~ . ' z~'`-.. ~ I I r---- ----r ~ o _ z ; Y ~ I ~ + ~ ~ ~ ~' i ~ ~ vZi O h i I i ~ m < ~ ~ z ~ i o 'n I f `~ I b I rn I I I I I I t~ { I I ! ~ W I I A m I i I I I r I I I I y w I ! I I <~< rn r~ n I -o I I `-I ~ I m ~ I I O .p I z I I ~ i I ~ I I I I I p I ~ 1 { I '0 f v~ m I 1 I i ~' z m I I ,-i - Z .~ Oct '"' ~ m ~ 1 z .A. M ~~''' ~ ,•. ~4 ~ i~ x 0 ~ o o -t o ~ o , ~ ~, o ~ ~ ~~ ~ x z ~~ , ~~ ~ xz O ~ o ~ ~ C 'U ~ ~ .P~ ~ z rn , n ~ 2 :, W{ J. ~ ~ O I I ~ ! -o I { Z7 ! m f ~ I, I W ~ C 'v cn ~~ nC 'a 'o w w ~~ W J ~t ` -~.~ . = rn o r m -~ b m 0 .~ ~~~ ~~A o~~~~~ .. r S S APPLICATION FOR SANITARY PERMIT STC-100 This application Eorm is to be completed in Eull and signed by the ownettsl of the property being developed. Any inadequacies will only result !n delays of the permit issuance. Should this development be intended for =e:ale by ovnet/eonttactot,lspec house), then a second form should. be retained and completed when the psopetty is sold and submitted to this office vlth the appcoptlate deed cecordlnq. ____________ Owner of pcopetty ~~. e%% - % ~'~ - ~ ~~ Location of pcopetty cr~.~1/~ .,~~-1/E, Section ~..__.: T~'R-1-Ly Tovnahtp ~/ ~~ ~~ Maliln9 address ~~, ''"~ ~ ~ Z•- Addteas of •!te y~~ -sue ~- •ubdlvlalon name ~~~ ~ ~'~~ ~'STa'~ Lot numbes / ~~° Previous ownec of pcopetty ~ Total else of parcel ~ • `~ `~~ ~ ~ ¢ ~ 5 , Data parcel vas eceated ,_T/ -' I ~ •7 y Ace ail cornets and lot ilnea tdentillableT ~ Yes .~ No is thin pcopetty being developed Eor resale )spec house)?~~Yes _~ o Voiowe ~ ~ and page Numbes ~ '~ as stcosded with the Regialet of Deeds. INCLUDE MITN THIS APPLICATION T118 FOLLOMINCt A YAIIRAI!ITY OBiD which Includes a DOCUNBNT NUMeBR, VOLUME AND pACt NUNBBR, and the SEAL OF TNR REGISTER OF DBBDS. In addition, a certified survey, iE available, would be helpful ao as to avoid delays of the reviewing process. IE the deed deacrlptlon teEerencea to a CeitlEled Survey Nap, the Ce:rifled Survey Nap shall also be required. ---------------------------- RROpBRTIf OUINBR CERTIFICATION 11Ye1 certify that all statements on this form era true to the best of wy lout) Rnovledgej that t lwe) am lase) the ownerla) of the property described In this 1nEocmatlon Eorm, by virtue of a warranky deed :eeocded In the Ottlee of the County Register of Deeds as Document No. a.9 7 Z- 6? 7 = and that I lwe) presently own the proposed alke Eot the sewage dlaposal system tot I Ive) have obtained an easement, .to run with the above deectlbed property, Eor the conatcuetlon of sold system, and the same has been duly recorded in the OEEIce - - - - - - - - - - -- - - -- ---. .._ , a, _.. ~ ~ -~ . ,f,• °'~~ ~,. STC- 105 w SEPTIC TANK MAINTENANCE AGREEriENT St. Croix county OWNER/ BUYER ~ih:,~~/~/ ROUTE BOX NUMBER ~ ~ 2 Fire t3umber - --= / ~._- -~ g . i CITY STATE ZIP ~y4 ~~ • l ~~tc.~ ~ L,i ~ PROPERTY LOCATION:_~,~W~, Section ~~ •,~ T ~f N, R Town of~, ~n St. Croix County., ., Subdivision~L~~/,~~~ .ftc~"Z~, Lot number.. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank .every, three years or sooner, if needed, by a l'icens'ed"se tic tank um er. What you put into the system can a ect t e .unction o, t e~septic:tank as a treat- ment stage in the waste disposal system. St. Croix County residents',m~ be eligible to recieve a grant for a maximum of 60'/0 of the cost.of replacement of a failing system, whic 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 ~s•tems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form,. signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or .a 1 icensed 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. I/WE, the undersigned have read the above requirements and agree to maintain. the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural-Resources, Certification form must be completed and returned to the 5t. Croix County Zoning 0£fice within 30 days of the three year expiration date. _ _ SIGNED,.-~~y1 DATE '~I f v __' ~^D St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address.. ,,. . h '~'£