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020-1047-60-100
~ ~° I m ° I o I ° o ° oc ti ~ p ~ I p ~ I o~~ ~ y I y I d a' ~ I ~ I ~ m p~ I I L ~ O ~ w0 N N R O E I T~ w O x ~ C X y, ~ ~ O OD tl N j ~ ~ ~ ~ I a, ~ N N f0 C ' I I ~ ' ~0 3 oY ~ ~ o=cvc a co a~ -- o ~ I I I I c ~ ~ 0 'a ~ y X N j I ~ I y w mB u~ ~~ ° 3 O I ~ o { z L .. ° ° ~ ~ L o ~ I ~ z° ~ I c L ,~ a C Vl ~ C y D c L 3 C ~ I I l t0 O ~ L '_ N U~ C E L l ~ ~ L N U L N 'a ~ N 3 I O N Q 1- C f0 OII- N ~ ~ Q~ I U 3 v f0 I c fO I a a~ ~ Z ~ m I ~ I ~ ~ Z = p ~ ' ':' p ~ Z ~ °'w O ~ ~ am I ~ I am I I N F- Z I o I O Z~ c I ~ v I ~ ~ ° ' > ° ~ > o I = •'= o I a i Z ~ V) F- r C N r I C .-.. N . O . ~ I d ~ . ~ M ~ _ C p ~. N I C C 7 N a ~ ~ ~ I a ~ ~ o ~ I c o ~° o m c a i zm~ I Zt7» !«. I Y E I w E Z I M m ~ { y ~ c I N ~ ~ _ ~ N ~ _ > ? N a N R l a~ w Y ~ .. t0 L .. a Y n I N N ~ ~ N N ~ N d ~ . N~ c ~ p ~~cea ~ ~ ~ I~ooa - N ~ ~ ~ L ~ Z M ~ ~ to t!1 to ~- L a~ I ~ V1 N ~ ~ acn ~ I O O~o I y _ 3 i~ Z Q^f`1l ~ 1 a N ~~ a ~ w ~ J o ~ s p l o 0 0 fp U ~ b i _ } X N N I } I ~~°_' ~ O ~N~ ~ 0 ~ N ~ J p p .. ~ O r. _ ~ ~ ~ J `- I ~ m ~ ~ a a~ ~__ '~ m N ayi ~ a~ 'c v N ¢ ~ ~ °.3 M~ ~ O 3 a~ V I O N N ~ r'a _ O ~ i H ~ N C ~ N ~ ~ °~ o ~ c I m va~.o l V r U I U C N N N( 0 fr,y ~ ~ C ° _ ~ ~p ~ d ~ Z _ ~ pp 1 O 7 ~ ~ = C`O I C H ~ y N 9 O = ~ N a i ~ ~ ~ vrn O ~ ~ ~ C ~ ~ t 6 ~ IV ~' O N= O ~ to .- O Z c FO O N C O to Z ~ D,. t ~ (n I I r \ w ~ ik ~ ' Y = E a+ I E v ~ a; ~ ~ i ~a I ~a ,.., a ~ 'u l :: a ~ f ~ a ~` ~ ~ ~ L •~ C M ~ C M ', I ~ tt ia~ oa ° ~ ° o ~1 A t ic v v ic ) ' Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ' f1 "~ INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Stout, Richard Hudson Townshi SST BM Elev: Ins . BM Elev:i BM Descri tion: !1. i i ~ , jam, ~/ S~ ~--~. TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic S-~ t 2 `SU sing ~ r- ~ ,-.,` ~U Aeration w ~~X ~~C,i~_ ~'' 6 Holding -SL~IL~ ~~(~ I.L''(.~~ `Yc / ' " / ~ ~c ~krts~~C-' TANK SETBA~K INFORMATION V ~! ~' ~ d TANK TO P(L ~S~ ELL BLDG. Vent to Air Intake ROAD Septic ~u / L. ja,~ - , ~g l lit ,~ Aeration _ _ - Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number / TDH Lift rich n Loss System Head TDH Ft Forcmain' Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 42049$ 0 State Plan ID No: Parcel Tax No: 020-1047-60-100 STATION BS HI FS ELEV. Benchmar rL ~ 1 ~ ~~ Alt. BM S-r .~v oz . a-s Bldg. Sewer ` ~ ~ I ` da ~~ SUHt Inlet ~~ SUHt Outlet ~, Z Dt Inlet ~/ ' ~- Dt Bottom Hea r/Man. ~ ~ ~ Q Dlst. Ipe l dQ e ~ ~/ (o Bot. System ~ .,'7 ~ • Final Grade ~~ ~.3s q9, St Comer f 3 . oZ. BEDlTRENCH Widt / ~ Length f No. Of Tr s PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS h ({``33 e ~ SETBACK INFORMATION SYSTEM TO P/L~ BLDG W L LAKE/STREAM LEACHING CHAMBE `/ M re Ylzt f~'i ! S~! S Ty Of System: ~~"/ r .h- / IT ~ .. 7 Model Number: ~~ / ~ t DISTRIBUTION SYSTEM Lt:F.~Gte~.A~~• ~" Header/Manifold f H Length ~ D Dia ~( Distribution Pipe(s) I tr ~~~ . f Length Dia Spacing_~ x Hole Size ~ x Hole Spacing sue-' V it tntaked S~ , " SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv Depth Over d/T r i ~` B h C t Depth Over d/T B h Ed xx Depth of T il xx Seeded/Sodded ~ , / -,_ renc en e e .~J-'h. e renc ges opso -- Yes ~ ~I_;j No ', Yes ~W,i, No COMMENTS: (Include code discrepenc~es, persons present, etc.) Inspection #1: ( ~I I ~/~ry Inspection #2: / / Location: 490 Prairie Lane Hudson, WI 54016 (NE 1/4 NE 1/4 20 T29N R19W) NA Lot 38~~ Parcel No: 20.29.19.185A1 1.) Alt BM Description = S~ C-0Yti~le- CQLYS~ ~ ill ~~t>~t.~- " " "~'~) `Q_,~,c,,~ ~ ~ ~d S~`d 2.) Bldg sewer length = ~ T ~~~ t 5~~ `J'~S~P/h'+ ~ /~!/U~ ~•~' "'`~' "`5( ~~1 ~~e~~ - amount of cover = ~ /~~ ~ -~ d,Q~f a,~yu-~.11.,~.d. Plan revision Required? Yes i~ No ---Y_-- _. - _. - --- / ~/~i ' Use other side for additional information. I ~_------,!! _- __ ___ ,--- _--_ ,_, _. _~~!~ .. Y,~- ~ II_l.v `~ ~~~ ~ SBD-6710 (R.3/97) Date Insepctors ignature Cert. No. !,~" '~~~ ~1t~,r6G xx Mulched J Safety and Buildings Iaivision County • 241 W. Washington Ave., P.O. Box 7162 Jr ~CYd (` J~ ~S~O~S~l~ Madison, Wi 53707 -- 7162 Site Address ~jD P2A-- De artment of Commerce ~"3o~0Y 3 d ~'~ Sanitary Permit Number Salutary Permit Apglication ~fzo`~9g In accord widt Comm 83.21, Wis. Adrn. Cade, personaltnfo ou provide [} Check if Revision aaa be used for second ses Privac I.aw, 5. State Plan I.D. Number I. Appiicadon Iafartt~atton -Please Print AlI Information ~ / ~"~~ Property Owner's Natrre ~~^ ~ Parcel Number ~ ~ ~' u r^a( S'Ta~ I ~ 20 ozo ,. ~,~~-"l~6-I6a~tSsa~-t az9 -- ~o`f -: Z~ Property Locadon Property Ownec's Mailing Address ~ONI1~ ~ ~~UNT x.5"3 ~~le-~ T~ 4~ U~~Frc r ~ ~a ~ u• S ao T ~9 N R ~?' City, State Zip Cade Phorx Number I,ot Number3~. Block Number i Subdivision Name CSM Number ~' .S'yil~ SYY- ? G,~/n Uri .7os6 o II. Type of Building (check aII that apply} ^Cicy -Number of Bedrooms llin Dw il F ~ QVillage g e y am 1 or 2 ^ public/Comtatrcial -Describe Use ow»sbi fit/ ^ ~~ ~'~ / Nearest Road III. ~ of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. 1 ^ New ~ 2 Acplacetneru System 3 ^ Replacement of 6 ^ Addition to For County tae stain Tank Onl Permit Number Eris " S stem Date Issued B. ^ Check if Samary Permit Previously Issued IV. Type of Permit: (Check aII that apply)(nwnberiag scheme is for internal use) -~ -lam 44~Not1 Pressurized In-Crround 21^ Hotted 47 ^ Sand Filar 50 ^ COnSRtlCted Wetland 22 ^ Pressuuized In.Ground 41 ^ Holding Tank 48 ^ Single Pass 51 ^ Drip Line .Q r1 .._r.M.r. 46 ^ Aerobic Treatment Unit 49 ^ Reciiculating 30 ^ Otber Design Plow (gpd) Area Dispersal Area ~ you npptuxnv4 .~°.....°~ ._- - Rate(Gals.lDayslSq.Ft.) (M~•~h) ' ---- --- Flevadon 9ed /a ~~ t3~8 ~) - ~ ~ ..yam.- 9a ae ioz, d~ rte. T8ok j~o Capacity in .Total Number Manufacturer Prefab Concrete Site Sorel Fiber Plastic Consuttcttd Glass G~lons Galtons of Tanks New E~stlog ~,~ Taolcs /as~~- Sa SeQtlc er Holding Tank ~. / - d' 0200 SL 17osioy Chamber ~ R onsibility Statement- I, the trcderslined, assume responsibAlty for lion of the POWYS shorn en the attached plans. VII . Plumber's Name (Print) Plumber"s Sigtuwtre RS Number Business Phonc Number od e) Plumber's Addtess (Streit, City, Sate, Zip C ~QtJI, 1 j /_ P` 1. ~ S'e~ ~ LAG/ i ' J~~~~ VIII. count ripe arcmetu Vasa vru Sanitary Permit Fee (inciudas Groundwater Date Issued Issu' Agettc Signature (No tamps Approved ^ Disapproved Surcharge Fee) ^ Owner Given Initial Adverse ~ ~s-l" D . ~ •~ ~~~ pctemtination IX. Conditions of ApprovaUReasons for Disapproval ~t-- ~ ~ ~ ~ N w~a~~ not lets than 81/2:11 inc6a Sn site Attach cemoplete Phan Uo the County onl7) for the alrstom oa papa' SBD-b398 (R. OSf01) I' ~~r.~ ,Sou- ~ ~. e ~' ,~8 ~f~/.r~ry s~o T~ 4 ~l~ t,~ T° r,J,/ aF ~~ ds~ .v 4 ~ ~ ~ ~f Tl~eriC /-f /iaaf~_1`6 ~..v6Ts/l Q S~ifcfL ~---- rt_ ~ ~ ~ ~ ~"" a~~ ~~ ~1 \~~Y / 1 3° Bl ~~, ,~Q ~ c,P~ 'f ' ~, ~ ~ya~~b¢ la +o b a ~, ~~`~ --t_ , ~x,st ;~~ syst`~ .~~, vN ~ y~ ~,~~_~ ~~~.2~9'Yd ~~/ice/e~- .~~,'ch~,:~ ~'~o~- ~ s, c T' 38,~fiy,Ut~ s~o T.~ 4 /~l~' !/ T°~,/ of r~/adso .y ' ~ ^.. ~~ Tli el/e /~S 2i a a,ln ~`6 .trv s'Ts // Q S`/i fcfL r .. /sac ~ //~~ sfi~~ ~~r h ~ ~, s, .,/ /~ / `~ ~~ /®/. ~ w -~ • / ~ ~- ~~ ~m p~yl~ 1 .y ' ~~. ~~`~ d ~Lya ~~~,b .o ~ -- ~X,s f, ~y sys~ r; ~~~v ~ y wisconstn Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance with Comm 85, Wts. Adm. Code County Attach complete site plan on paper not less than 8112 x 11 Inches in size. Plan must parcel I D. include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location, and distapce to nearest road. Reviewed by Please prirri al! informaition. , Personal information you Provide may be used for secondary purpooes (Privary Law, a. 15.04 (1) (mJ). Property Location Property Owner Govt. Lot ij/r 114,~j ~ 1!4 S AC' ~ LOt # Block # Subd. Name or property Owners Matting Address Z G ~ Jp i ~ _ tarp 'o de Phone Number ^ City ^ Village [~T~++r' ~~ sds~~ New CorrsWCtbn Replacement rent material ~S General comments and recommendations: I wt ~ S'No cce 1 t ~c> > .5 7y-u T ~~ , Use: ® Residential !Number of bedrooms -,.,_s2..- ,u~, Public or cammerdai -Describe: ___, 7 ~ ~ u~ S Flood elevation if applicable OCT 1 7 2002 ST.//C~;=;CY,X COUf~~'r ZV'~~~'l l'~i l] I..if ri~it Pape ~ of ,~ Date j-a,,,__ p~.a~, ~; T ~~ N R /y E (or)C~ Nearest Road 1 GfT d ~} _ GPD .t/ / ~ tt. ' Boring # Boring ~ Pit Ground surface elev. ~ n- Depth to Iirrdting facto ,-~_.,-,.. in• Soil Application Rate 2 Horizo n Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft 'Eff#1 'Eff#2 4 in. Mansell Qu. Sz. Cont. Color ~ ' 1 Gr. Sz. Sh. ~''~ S ~'~ , s`- , ~ ~ 1 0 -~ y p 3(Z - ~ rat b - S ~ -~r ~ S ~ ~ S - z 1 H-2 ~ / - w- ~ ~ ~ 7 Z j ~l -1~ m 1'1? OS .- a~• zv • 33~1(v (~ q • L ~~ Q aoring o~ 1 ~~ # ~i1 ~~ Ground surface elev. ~Z- fL Depth to iimlgng factor f~ in• ail gppupy~ Rate Horizon Depth in. 1 avJ ~ Dominant Color Redox Description Texture Mansell/ au. Sz. Cont. Color ~ 3/ ~ 511 d~ ~ ~ ~~ -J` .~ SWcture Gr. Sz. Sh. ~rnabk d Consistence ~ -~ ~ Boundary ~ S C `- Roots GPDIft~ •a+fr#i •i<tf#2 lf/ r r r ~ Z 1, S~. to R3• ~a ' Httluent #1 =BODE > 30 _< 220 mglL and TSS >i(0 < 150 mglL CS7 Name {Please rnni) ~ ,.. 14davv~ SG >M.~ ~,4~ ~U~ 5~~ .Sa~fS~~! w~, Zlaz,~`, - Emuenr rFL ~ tyVV6~ JV ~uyrV auu r v.. ~ -.•~ •••:- CST Number s o Evaluation Conducted ? ~l~ y ~e yB~ 8; y -Z ~ -aZ ~P-ro~pert~y Owner I ~ 1 eortng # ^ Boring Parcel SO # Page • ~ of I "• ' ' ]~J Pil unxma surraas Dian. l --.- - - ~~ ~N~~ W JI!{YYlfa ~Yb RA , + ~/ ~~~. Soil Application Rats Horizon Depth Dominant Color Redox Desaiptbn Texture Strvchrre Car>.sistence Boundary Roots GPDIiI' in. Mansell feu. Sz. Con( Color .~ ~~ ~~"~ Gr. Sz. Sh. ' ' 'Efffli ~ •E(1µ2 . I ~ -1 l0 3/ ~ S r' .. and Yh C ~ 1 v - ~ ;..~,_ ~ -Zd/ p ~ L m ~" ~ , ~- Z~l -~/ ~ 4 --- ~~ ~ Z ~~ ~ L.....J Boring # ^ Boring (,,,.,~J ^ Pit G~nd stuface elev. _,~,__,_._ ft. Depth to fimittng factor in. ~i A~~figtion Rut Horizon Depth • Dormant Color Redax Description .... ,Texture -Structure Consistence Boundary Roots GPplft= In. Mansell Qu. Sz. Coral. Color Gr. Sz. Sh. 'EffIF1 'Efff12 Cl Borfng # ^ eorinp ^ Pit ~ Ground surface elev. _,,_,,,__ it. Depth to QmifJng factor in. Soil Ap iigtion Ftal Horizon Depth Dominant Color Redox Destxiption Texture SUvr~ure Consistence Boundary Roots GPD/lt= in. Munsel! thr. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Efi112 - • Ettluent #1 = BODE > 30 < 220 mg1L and TSS >30 < 150 mg1L ' Efftuenl ft2 = BODs < 30 mg/t, and TSS < 30 mgll. The Dcrsartrnent of Commerce is an erp~al oppot~tunity service provider and empSoyer. If' yoit need assistance to access services ~~r need material in an alternate format, please contact the department at 606-266-3151 or TI'Y 608-264-8777. sunr»o (R o~rooi PAC7E~U1•~ SCAI~E; 1"= BM [ F:LEVA'TIUN /DU - O i „ 1jM 1 DI?.SCRII?TIUN~ - , ~ ~~ r~ ~ • ISM L.EVATION 0 I ~ ...~ eG..a._~ . I3M 2 DESCRIPTIUN~~ 6~ ~JC- P ~ P ~ SYS'I"I~M F.I.EVATIUN OIL ~Z O SYSTEM TYPE ('0 ~ v ~ ~~ ~ ~ ~`-°~ C;UN'TOXJR ELEVATION IOd ~ ~~ !aZ • cJ v o n ____ ... __.__. _-- 0 o ~: .~ ~~ ~ o~~ 5 ~~ SIGNATURE ,~~ s --°''-~ TE - ~S = ~. T ~/ b 3 ~_ • y \ P ~ 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 ~ G~aro~ Sr~~ residence located at : ~1/,, .~%, Sec . ~O T~_N, R~ j~_W, Town of ,~~~sd~ St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced ~f/j`~~0~ -~ Did flow back occur from absorption system? Yes No~ (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: j2~Q ~ 7S'O~al~~ Construction: Prefab Concrete ~_ Steel Other Manufacturer (if known) : !~,)~~kS' Age o f Tank ( i f known) : ~ ,~,.s ~ Y~~-~-.~L~~ G/ // .' sc s~ ~ .~C li cc s~+- s ~c a (Signature (Name) Please Print (Title (License Number) ~1 /1 ~'/a~-- (D te) 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 for inspection opening over outlet baffle). Name C~%~l~`a ~ S c ~~ .,~ a 1~~,~ Signature Gt~.-~`~-.~y MP /MPRS a S17?9 O POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ' of Z FlLE INFORiMATION Owtt~' ltt~2~D STo ~"~- Permit ~ ZO ~ q DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~JA Estimated flow (average) ~ al/da Design flow (peak), (Estimated x 1.5) of (30 al/da Soil Application Rate Q .~-- al/da /ft~ Standard InfluenUEffluent Quality Monthly average ` Fats, Oil & Grease IFOG) 530 mg/L Biochemical Oxygen Demand IBODb) 5220 mg/L ^ NA Total Suspended Solids ITS$) <_150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (B005) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510` cfu/100m1 Maximum Effluent Particle Size Y$ in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. ........~....,.,r_ ~...~~.,.~~ ~ svSTEM SPECIFICATIONS Septic Tank Capacity ~aeo t t2~o = 2`f~ al ^ NA Septic Tank Manufacturer ~ ~~,. ~~c I,~T ~ ^ NA Effluent Filter Manufacturer ~~ ^ NA Effluent Flter Model ~. - (o'o ^ NA Pump Tank Capacity al ~NA Pump Tank Manufacturer DIVA Pump Manufacturer I~IA Pump Model ~ ~ NA Pretreatment Unit ^ Sand/Gravel Fitter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ANA Dispersal Cell(s) ~In-Ground (gravity) ^ At•Grade - ^ Drip-Line t ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other. Other: ^ NA Other: ^ NA Other: ^ NA mru~~ ~ c~~wwc .wr ~cvv~ Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ month(s) (Maximum 3 years) ~ ear(s) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^monthls) (Maximum 3 years) 3 (~ yearls) ^ NA Clean effluent filter At least once every: ^monthls) " ~ ~ year(s) ^ NA ^ monthls) g~q Inspect pump, pump controls & a{arm At least once every: ^ year(s- ' ^ month(s) Q NA Flush laterals and pressure test At least once every: ^yearls) Other: At Least once every: ^monthls) ^yearls) ~A Other: 6 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tanks! to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any Ponding of effluent on the ground surface. Tha ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page ~f o~ START UP ANO OAERATION Fa now construction, prior to use of the POWTS check treatment tanklsl for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replacement system: ^ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not. be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evacuation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. 00 NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name lt_t_t ~,~,~p.~~ Phone S"- 3Pt - 312! POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR IPUMPER- REGULATORY AUTHORITY Name Phone LOCAL Name S-r, ((Lp t ~ i ~l Phone ~Y~ ~b This document was drafted in compliance with chapter Comm 83.22(211b1111(dl&(f) and 83.54111, 121 & (31, Wisconsin Administrative Code. PROM :, Schumakcr Pl~:mbinq P~ N0. :7153863121 Sep. 13 2002 06:46flM P1 S'I' CROIX COUtiTY ~L'P T 1C T ,~.NK MAINTENANCE R.GREEMENT AND . UV+"hL•'F.SHIp CERTIFICATIQIti F0~~1 • Owncrli?tivrr ~~~~<•r~ _ST-ou '~ Mailing ,Adt3ress _~~S-~ ~u/.c~~L~r~~.. Tr - Pror~erty Address ._, _ _ . (VeriTication:eG~~ir~? fir. f'taaning Depattmeat for new cansttvetiun) CityMate ~lu~l sd~r/ _ Parcel idetltiflt~tiort Nu~bet' ~~,..~,,~. - Y~AL L'„~ 'rLQ1Y Prrp~,y X„ocatioa _N~ '/.,~t/~t/Y~ Vie, Sx. a4 . T ~y N-~W, Tor^-:i cf }emu o -/'~ Sulillly~~ti7~ - r . .rte-- - r+~--"rw-.~ ^~L ~ ~~ Certii#~d 9urvcy Map # _,_„~, - -• Volume ~ ~ Page # Z~3<~_....• I-z g3~ ~ Waxlart+~-1?aod # ~ ~' ~ _._._ ~ ~ ~..~ Yoluine ~ __, P-~~a # l:outae; ^ y~ ~nc Lot lines idantifiabla 'yes ^ as ~.ac~ ~rc~,-,r w a r>,rr~~r s tvey~. ~p1S7 aill~f..~~i a~aa+.~ -~.~.. • Irapropar tree and maioteuaace of your septic sYtatam oould result is its premature failure to handle wasWa, Proper suapntenasLCe carters s of pon+pin~ oat the septic took dvrty th~-aa yeate cx ~toosut•, if LaedGl by s liceased prosper. What you put iiseo the system caa afttact the ilmotioa o£ tae aepac rank ga a aaut~rnt stage in the waste disposal system. 'The ptope.+~ty owtxr a~ees m submit to St. Croix Zoning Deparno~eat a ce:tltlcation farm, signed by the owner and by a rnaaterplutt~ber. jottrAeyaran plwabar. reccsiorsdplumtwrvr r kesrw+dpun~p6i '~ stiiy^:ag teat (l) the o*.rtite ~tatatyaoerdisposal system is !n proper operating eonditio>iand/or (2) suer ipapectiott sad pttmp~g (if nAOOSSarY~, the sepde talc is less t?~ 1/3 tirtf of aludpe. I(wt, the uadaraigned have read thee above rcquremcnLt sad apsae to ~A-ia ttta private sewage disposal :yatetst with the standards set forth, herein, as set by the Deputntoat of Commerce sad the Dapartttuat of Natur+~l ~esoarces, State of W:econs>n. Certification stating that your septic system has bees toutitsrained must be eocaploted grid mtumed to the St. Croix County ZoniaS Office within 30 days off the thre(e~ear drat-io~a date. ~.,~•- .,PATE SIQNATIJ'YtH OF APPLICANT ~'uvtvlr R Cr_.T3'~' ~~ATY01~ . 1(an) cartily that all statements en this foan are lute to the best of my (our) knovvlodge. I (we) am (eta) the owtler(s) of the property deactr'bad above, by virtwe of a warranty dead receded ui Regtstet of Deeds C?ltice. ~ ~ IC~ DATE SIGNATLJYtE rs••w. Any information that is mis•repnaentod may result is 't.te sanitary permit being revoked by the Zoaia$ pdpseizstent. "•v`~"' •" lncludo with ttda application: a ata:aped wa:raary deed from the ttagister of Reeds offrce s appy of the certified survey map if rofere:tee is t:taQe is the wa*rauty dat:d J s • r~r`i} ~` fig,-9! / ~~. ~l /._ (~ (t> . ! -, ] f. ~Cr'> • ~ ~ IV LAND SU~V~YIN~ • HUDSON ,WISCONSIN 54016 ~..~ \ (7l5} 386--2007 ~'~ ~ ~, /// 3 Nome First Federal of LaCrosse Address 201 South Second St . \\ Hudson, Wi. 54016 Description Part of NE 1/4 of NE 1/4 and part of SE 1/4 of NE 1J4, all in Section 20-29-19, described as Lot 38 of C.S.M.. Vol. 7, Page 2036 Richard & Janet Stout N r~ E S PLAT DRAWING Thi's is not a complete Land Survey ~\ ~, shared well ~ ~ with lot 39 ~ ~ ~ J ~ \~ n 9' \\ ~ ~~ \ ~J i a ,~ ~; / w c~>/ R= 266.00' ,y . ~~ ~e ,~ j „- 107.54' ~ i The location of improvements on this drawing;are;~pproximatcYar_d.are based -,1; n,-, ~rnm bOCUMENT NO. STATE BAR Of WISCONSIN FOitM ~-1M! , WARRANTY DEED A,d~d92 Y l Sc~U PACE 40~ rcauB x, sTOUT conveys and wuranta to ~ % an r, P. STOUT the following described rapt estate in ~ • pro 1X County, State of Wisconsin: Part of the NE :; of NE :; and part of the ~E 4 of Nr, 4, all in Section 20, Township 29~d, flange 15'ti described as fellows: hots 37 and 38 0£ the Certified Survey f•;ap filed Qctober 20, 1y88, in fol.. 7, pg. 203b, together with a 6b' road easer~ent described as follows: 11us recitation is to relinquish all rights and interest in the above described property. This i s n i t homestead property. ps) ps not) Exception to Warranties: THIS SPACte RESERVED i011 RECOIIOINO DATA REGISTER'S OFFICE aT. CROgt 00., w~ Rrc'd for Rgee~egnd M MAR 2 401""~ • a ~, of Datad~ RETURN TO Tax Parcel No: ~~~ DatedMia twenty-f~olu/rth~~(l20714~teh_.) dayot .~~arch ,19 8 , -~-T r-st~L 4~' (SEAL) (SEAL) P~Iaud Fi. Stout rSEAI) AUTHENTICATION Stgnature(s- _ authenticated this day of ,19 TfTIE: MEMBER STATE BAR OF WISCONSIN qt not.- authorized by g 708.06, Wis. State. ) TM1S INSTRUMENT WAS DRAFTED aY Janet P. stout (SEAL) ACKNOWLEQOMEMT STATEOFj~(~il AtiZpild~ -' "- ss. Pima county. ... .. , Personally came Delore me this 24_t... h:'_day of Match , is 89 th~abovetuuned Maud H. Stout t0 me known to be the person wh~.~sxecfiNQ,(ha••'~~ forsgoi ins umen an ac owls a m~., v • Notary Public Pima _ County, ~i ~ (Signatures may !1e authenticated or acknowledy+W. Both are not necessary. ) My Commission is permanent. (If not, plate expiration ~_._. 11,,...,n1. 7r1 _.. CIA . I ~'"_ ~ • • . ~ +ROADWAt 08SCRIPTIOp _ _ .VQL PAoE~~ 3-' ,~ A parcel of land locatsd in part of• the ~t8~ of the NE~t and in part of the SEA of the NEB alt in Section-20, T29N, A29W, Town of Hudson, " St. Croix County, Nisconsfn; further described as followsa A 66 foot wide private road easement to be used for ingress and egress tr~~m Dorwin Road and Lassie Lane to Certified Survey Map in Volumc3 7, Pare 3036 as recorded in the St. Croix County Register of Deeds. ; Commencing at the E~ corner of said Section 20; thence 588°58'40"W, along ` ' the Borth line of Pinegrove Hsights First Addition, 508.46 feet to NW corner of Lot 17 of said addition being the point of beginning of thls descriptions thence N00°58'28"W, 25.00 feet to the point of cuvature of a 200.00 foot radius curve concave easterly, whose central angle measures 17000'00", whose chord bears N07°31'32"E and measures 59.12 feet; thence northerly along the arc of said curve 59.34 feet to the point of tan- gency; thence N16001'32"E, 73.42 feet to the point of curvature of a 266.00 foot radius curve concave westerly, whose central angle measures 16°59'0?", whose chord bears N07°31'58.5"E and measures 78.57 feet; thence northerly along the arc °f said curve 78.86 feet to the point of tangency; thence N00°57'35"W, 883.19 feet to the point of curvature of a 200.00 foot radius curve concave southeasterly, whose central angle measures 90000'00", whose chord bears N44°02'25"E and measures 282.84 feet; t;~ence northeasterly along the arc of said curve 314.16 feet to the point of `_angency; thence N89002'25"E, 266.69 feet to the east line of the NEK of said section; thence N00°57'35"W, along said east line, 66.00 feet to the SE corner of said Certified survey map; thence 589002'25"W, along the south line of said Certified survey mug, 266.69 feet to the point of curvature of a 266.00 foot radius curve concave southeasterly, whose central angle measures 90°00'00", whose chord bears S44°02'25"W and measures 376.18 feet; thence southwesterly along the arc of said curve and south line of said Certified Survey map 417.83 feet to the point of tangency; thence S00°57'35"E, 249.92 feet; thence S88058'40"W, 769.55 feet to the easterly right-of-way of Dorwin Road; thence 500°49'40"E, alon, said right-of-way, 66.00 feet; thence N88058'40"E, 769.70 feet; thence S00057'35"E, 567.27 feet to the point of curvature of a 200.00 foot radius curve concave westerly, whose central angle measures 16059'07", whose. ~horci bears SO7031'S8.5"W and measures 59.07 feet; thence southerly along the arc of said curve 59.29 feet to the point of yangen~y; }hence S15"v~.' ?~"tit, 73.,2 fem.. :v crie point of curvature of a 266.00 foot radius ct:rve concave easterly, whose central angle measures 17000'00", whose chord bears S07°31'32"W and measures 78.63 feet; thence southerly along the arc of said curve 78.92 feet to the point of tan- gency; thence 500°58'28"E, 25.05 feet to the NE corner of Lot 16 of said addition; thence N8G0S8'40"E, along the north line of said addition, 66.00 feet to the point of beginning. } r s AS BUILT SANITARY SYSTEM REPORT Form - S T C - 104 OWNER F1~~,C ~~~/'c~, f~; S~e'~~~' TOWNSHIP ~ ~sr~ ~s~,c~1 SEC. ~ C1 T ~N-R~W ADDRESS / ~ i, 3 ~-,,~;' c~ f~ cc. ST. CROIX COUNTY, WISCONSIN SUBDIVISION -- LOT ~ ~f ,;~,~°~ -~~ LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IZ,I1R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ., ~ j ~ 3 r ~d~~ M ~~` (;~. , ~1c ~ ~ 1 ~(`~ c~ct ~ ~ . ;~~ ~.z~`2.~k s r' 1 ~•~ ~ .~~,~--f ~~ r I < <~~. \, s~ ~fC: r ~ 'G FNi ~~ ~1 r INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 1~ ~" C.O~~-;,,,~~ ~~r. ~,~ Elevation of vertical referencAe point. ) ~ '' ~~ Proposed slope at ite: Q -~ `~/~ ~ i~i0 /fit' /~ ~,._ ~-~1-„ 1/ s ~ n D ~ ~~. ~.1~,~ PUMP CHAMBER a ~ » ~ 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, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: 'L/ Trench: Width: ~_~ ~ Length: ~ ~ Number of Lines: ~ Area Built: Fill depth to top of pipe: j (~~~ Number of feet from nearest property line: Front, O Side, ® Rear,O Pt.~ r ~ Number of feet from well: 5 (, r ~-~~ S T- Number of feet from building : '~`[' ~=-`~ ~ (Include distances on plot plan). SEEPAGE PIT 'f ~~ `,.Size: _ ~r 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). i. HOLDING TANK ~k P rt, Manufacturer: ~ 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, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS P40, BOX '%969 M/~tDISON,11V1 53707 NF%,N~%,S2D,T29N-R19(.V Taws. a~ flud~saw Llxs~~.e Lane INSPECTION REPORT FOR PRIVATE SEWAGE SYSTEMS ®.~ONVENTIONAL ^ALTERNATIVE ^ Holding Tank ^ In-Ground Pressure ^ Mound SAFETY & BUILDINGS DIVISION BUREAU OF PLUMBING State Plan LD. Number. (lf assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: I NSPECTION DATE. R~ cha~ d U S~aut G1I 54016 d~san 1353 Awa~u Fzee Tna.1 ~lu 2 ~I . . . . ,. . , , BENCH MARK (Permanent reference Oo1n0 DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PL ELE V.. Name of Plumber: MP/MPRSW Nn.. County. Sanitary Permit Number ~. Jahn P. S (za~ca III 3212 S~. Ctca~,x 112 ~ 16 SEPTIC TANK/HOLDING TANK: MANUFACTURER-. LIOUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER ' ~ ~ 1 t9'C3 Q G~ , ~ P ~ ~~ RO~r~VID"ED: (AYES ^NO PROVIDED . ^YES NO BEDDING: VENT DIA.. VENT MA71 HIGH WATER NUMBER OF NOAD. PROPERTY WELL-. BUILDING VENT TO FRESH ^YES O /~ '~ v'*"' ALARM ^YES ~O NEARESTO M t 1~~ LINE ~® ~+ AIR INLET: (O _ _ DOSING CHAMBER: MANUFACTURER BEDDING LIOUID CAPnCIiv PUMP MOUEL PU MP; SIPHON MnNUI nC7UHEH WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ^YES ^NO YES N ^YES ^NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PH OPE HTy WELL ILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINF AIR INLET. PUMP ON AND OFF) ^YES ^NO NEAREST-- ~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing _ I N H DInMF TEH n TF HI A D M KING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN /`AIU\/FIU TIf1P1A1 CVSTFM• BEDlTRENCH DIMENSIONS WIDTH I p LENGTH S U NO. OF rHENCHFS - OISTH PIPE SP n(:I N(, ~ r COVER M HIAL PIT INSIUL UTA =PITS LIDUID DEPTH. GHAVEI_ DFPT~1 FILL DEPTH UIS7 H. PIPF DISTR PIPE DISTR PIPE MATERIAL NO O R a NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PI'IES ABOVE COVER r ~ E EV INLF I ELEV ENU ~ S~ , ~~ ^^ P~ ~ PIPE ' ~ NEARESTO--- LINE !~ v ~ ~C AIR INLET-. Q f' UND SYSTEM: Mound site plowed perpendicular to slope and furrows thrown upslope: ^YES ^NO II rn\/FR TEXTURE DEPTH OVER TRENCH BED DEPTH OVFH TRENCH BEU CENTER EDGES .I ~~ Check the texture of the fill material for mound systems to make certain that it meets the criteria for medium sand. PF It n1nNF N f MnH _Y ^YES 'PTH OF T(7PSf 111 SOl1UFl1 ^YES. ^NO q b~ O\ °u 1~ PROVIDE A DIAGRAM OFSYSTEM ON REVERSE SIDE. SHOW ELEVA- TIONS MEASURED. i OBSEH NATION WELLS ^NO ^YES ^NO EE UFU MULCHED ^YES ^NO ^YES ^ Sketch System on ~t~o Retain in county file for audit. Reverse Side. Zavi,%ng Admt.v~ihxic.a .fin ~`~ ~ TITLE_ __. - _..- DILHR SBD 6710 (R. 01/82) PRESSURIZED DISTRIBUTION SYSTEM: SANITARY PERMIT APPLICATION CouNr~ C R x ~ DILHR v/ Code Adm 05 Wis rd with ILHR 83 I c . , . .~oi~~~ . n ac o PERMIT# N ITARY STATE SA // cc ~~ / // GL~ ~V -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8'h x 11 inches in size. -See reverse side for instructions for completing this application. PETITION O ~ ^ 1. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. YES N FOR VARIANCE PROPERTY OWNER PROPERTY LOCATION S' R /~% E (o W S c='C~ T G ) l' '/a /~/L '/a N /1 ~~~ n , , , ; PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME - ~ ~,~3 c E' /Y~~ ~.. _~z ...--~ CIT. ,STATE ` IP CODE ~ PHONE NUMBER ` CITY NEAREST ROAD, LAKE OR LANDMARK ^ VILLAGE : ~ r t 6 > ~~ 7/ ) /~ 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 0 2 Fa '~ OR ^ Public (Specify): ~~J~~ III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable) 1. a. ~ New b. ^ Replacement c. ^ Replacement of d. ^ Reconnection of e. ^ Repair of an System System Septic Tank Only an Existing System Existing System 2. ^ A Sanitary Permit was previously issued. Permit # Date Issued 3. ^ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ^ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. ~Conventionai b. ^ Alternative c. ^ Experimental 2. a. ^ System- b. ^ Holding c. ^ Pit Privy d. ^ Vault Privy e. ^ Mound f. ^ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. See a e Bed b. ^ See a e Trench c. ^ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): ~ REQUIRED (Square Feet): PROPOSED (Square Feet): ~ ~ ~ ~ rr9~ ~~ ~ Joint ^ Publ is i t ^ P _ S ~~ ~ ~ - ~ Feet r va e VI. TANK CAPACITY in allons Total # of r Name f t ' M Prefab. Site Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks er s anu ac u Concrete structed glass App. Tanks Tanks Se tic Tank or Holdin Tank ~~~~ ~ ~L~7 / Lt~c~P ' S Lift Pu T~nWSi hon Chamber ^ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on t attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP PRSW .. Business Phone Number: Designer. Plumber's Addre treet, City, State, Zip Cod, Name of jj VIII. SOIL TEST INFORMATION Certified Soit Tester (CST) Name CST # Phone Number: C 's A RESS (Street, City, State, Zip Code) 11 ~l~ A/, S~.6if`4? `v _ .cW ~~c' c l~(l//\. ~ ~1 ~<S 2~C~.~~aZc%t~ IX. COUNTY/DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee Groundwater ar g e Fee S r c ate ~ Issui Agent Signature (No Stamps) Approved ^ Owner Given Initial ~1- ~ I ~ ~ ~ ~ ^ y!J' ~ ~~~ ~ Adverse Determination -"` ~""~'~~ ~ `"_ hn ~° L : X. OMMENTS/REASONS FOR DISAPPROVA ~ ` ~-~,~~~ SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes irr ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be•pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; - IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a/I septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; Vll. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and-phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8%z 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; welts; water mairis/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the ~ result of over 2 years of steady negotiation and public debate. The groundwater bill Ground star included the creation of surcharges (fees) for a number of regulated practices which Wisco {Cl'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried rea5ure is used in your building is returned to the groundwater through your soil absorption e , system or the disposal site used by your holding tank pumper. ,~ The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) APPLICATION FOR SANITARY PERMIT STC- 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/contractgr,("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 Pro ert n ~ Location of Property ~r~ ~l i~ ly, Section 2 C~ , T_`~~ N - A ~c% W . Township 7'~1.~:lI.I-sc~~~ Mailing Address f s ~'~ ~ ~-~~, ~'~~ ~- ~ K~ / ~^: ~ / - t _.r. Subdivision Name ~~I~ Lot Number ~,~~~f~- .~^ Previous Owner of Property C~~~~r~`~ ~ (.,`~=~~ ~- Total Size of Parcel fj~~f ~~ ~i~~ Date Parcel was Created /~ ~~ r~ /`i ~~~; ~-- Are all corners and lot lines identifiable? ~~ Yee No Is this property being developed for resale (spec house) ? Yes ~_ No Volume 7 ~ ~ and Page Number /~SC% 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 OGlNER CERTIFICATION I IWe I ee~rti.5 y .that a~ e.tatemente on .tF~.i,d ~a~cm cvice fii~.ue ~o the be.s~ o ~ my (our J , knowPedge; .tha•t I (we J am (are J -the owner (s I o 6 .the phapenty des ch,i,bed ~.n th.i,e ~.n~onnati,an 6onm, by vv~.tue o~ a wwvca-tity deed neeonded .in .the 06~~.ee o~ the County Reg,c,e~teh o6 Ueede ae Uoeument Na. /(es ~7 and .that I (we) peed ent,~y own .the pnopoe ed d.ete ion .the a swage poi a ya.tem (on t (we 1 have ob•ta,i.ned an easement, .to h.un w•~th .the above desel+.i.bed pnope~.ty, bon the eonsfi~.u.cti.on od ea~.d dyd.tem, and .the same has been du.ey recorded ~.n .the 0~6.i,ee o,~ the County Reg.cs.ten o~ Veeds, as Doeument No. N/~- 1. DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1968 WARRANTY DEED _ .,~ 1 66Q~ ~52P~LE ~~ This ~ee~1, ma a betwe •--George J. H. Gies and Jean Dorwin Gies ~is wi~e - --------•--------------•----------------... ---------------•---------------------------------------•------------------•---------•-----------. _, Grantor, and_._.._.1Z3.C~?~4~_ 4,__ Stout _ and. Janet- P~ -.Stout,, husband _ -_aBd_ wife.-as-_joint_-tenants_-as-_to-•a-_70%_-interest.;.-and- _ __._- ..Maud_.H~__SzQU><__as_.~Dl~__QWBex._of__~._.~Ol__ia~a~e~t----_-- -_-- ---- ------------- - --------------------------- ---- -- , Grantee Witnesseth, That the said Grantor, for a valuable conaideration___.._ conveys to Grantee the following described real estate in ..$t,_._~~:4~,.~ .............. County, State of Wisconsin: All that part of the NE's of the NE's lying Southerly of the railroad right of way; The SEA of the NEB; The NE's of the SEA; All in Section 20, T29N, R19W; TN18 8YAGE RESERVED FOR RECORDING DATA ROISTERS 4FfiCE ST. CROtX OO., WI$, Recd for Record tfiis 29th ~ !, da of Au 9 • ~85 r ______aa 19_ 9:30 A, p~ ,. r a i~ RETURN TO I' ,' ~. Taa Parcel No- ---------------------•-------...... ,. Si)BJEGT EO all existing highways, platted roads and easements of record. EXCEPTED FROM THIS DEED are all parcels of land previously conveyed in part performance of the land contract referred to below by deeds of record. This deed is given in final performance of the land contract originally made by George 3. H. Gies and Jean Dorwin Gies, his wife, as ve~s~and Robert L. VerDugt and Betty Jane VerDugt as purchasers, the purchaser s i'' merest in said contract '. having been assigned to Richard 0. Stout, Janet P. Stout and Maud H. Stout. IThe original land contract was recorded in the office of the Register of Deeds for St. Croix County, Wisconsin August 18, 1975 in Volume 52?, Page 271, Document ~~328700, '!The assignment was recorded in the same office on September 30, 1982 in Volume 652, i'-Page 447, Document ~~380015. ~~ ~~~ ~rrsF~ This _______..~S._.Ta.Qt.__:._ homestead property. 1 ~~ ~. (ia not) 1 Together with all and singular the hereditaments and appurtenances thereunto belonging; FEE And.__........George-_J_~.-Ht_-Gies-and_-.Jean-Dorwin.Gies.__his•-wife,....,-__•___ ___ ___ _ __ _ _ _ ___ ___ warrants that the title is good, indefeasible m fee simple and free and clear of encumbrances except ~~ ~~~~ - easements and protective covenants or restrictions of record, if anyi conveyances, liens or interest created by the act or default, if any, of the grantees, and will warrant and defend the same. 1st August 86 Dated this ---------------------•----------•--------------- day of ._..----••---------------••-• ------------., 19......... ------•------------------•------------•-(SEAL) . '~~:G~'._.ll___- j..~.'-• -.'~~~-------•---------(SEAL) ~, George J.. Gies ~ i - •----------•--------------------------------------------------------- (SEAL) .- - - r~YV-- •--• --- ------- - - •--- ---- (SEAL) ' -------------------------------------------------------•----._.... Jean Dorwin Gies AIITBLNTICATION ACBNOWLED(~MENT <T6V L~,C J.. 2a. Signature(s) ---------------------------~-1 -0-- -------- -..::_.._.._. .~..__ i'' Dorwin Gies, his wife ss• --------------°----------------------------°-----------°---------------...... County. authen~i ated this __~~ay of..__ August , 19.86 Personally came before me this ________________day of ~-. --------•--------•----____-, 19_.------ the above named ohn D. Heywood TITLE: MEMBER STATE BAR OF WISCONSIN _______________________________________________________ rrf nit- -- ---- ------------------------------------------------- -----------------------------------....--------------------------------...------ _ STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/ DYER ~c~rt.;,%~~ t..'. S`thc,t~ ROUTE/BOX NUMBER j`Sl ' ~,:~c~;~, ;vim ~ ~~p L Fire Number ~ ?~~ CITY/STATE ~~«~,~~;~,, ~~p>; ZIP _5 ~(> I ~ t PROPERTY LOCATION: ~~~ ~, 6L~~ ~, Section Z.C~ T~N, R~W, Town of d,~~ del c~ St . Croix County, Subdivision /L~/~- Lot number 1~. Improger use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents m-.Y a maximum of 60% of the cost of which was in operation prior to accepted this program in August owners of all new systems agree maintained. be eligible to replacement o July 1, 1978. of 1980, with to keep their receive a grant for f a failing system, St. Croix County the requirement that systems properly 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. 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~ ~ "~ ~~ D AT E ~ ~ , `~ ~~~~ G~ 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. DEPARTMErvT °F REPORT ON SOIL BORINGS AND LABOR ANQ INDUSTRY, PERCOLATION TESTS (115) HUIVIAN RELATIONS (H63 09(1) & Cha ter 145 045) NE '/ATE `/4 20 COUNTY: OWN' St. Croix Ric ~ gee N .B DR COMME A S RIP ION: Residence 3-6 n/a RATING: S= Site suitable for system U= Site unsuitable for system SAFETY & BUILDING~~ DIVISIOf`I P.O. BOX 7969 MADISO(\', WI 5370? ION NAME: ~! I /~r+~ ~.nv~ r~u~n coo. ~ R:R.~62, Box 340, Hudson, Wi. 54016 DATES OBSERVATIONS MADE R D NS: ON T STS: ~vew ^Replace, ~ g-16-88 9-16-88 CO ((--N~~VENTIONAL: ~1 S ^U ~ MOUND: ®s ^U IN-GROUND-PR URE: ~ S ^U S STEM-IN-FILL ^ S ®U HOLDING TANK: ~ S ~U RECOMMENDED SYSTEM:(optional) ~ 1 conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS naoP 5R 4TR BORING TOTAL PTH TO GROUN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, ANG DLI'1`E; ~ NUMBER DEPTH ELEVATION OBSERVED EST. IGHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ---1 g-1 6.92 100.00 none >6.92 I 1.25b1.1. 1.67bn.sil. .50bn.l.s. 3.SObn.c.s i g_2 7.09 99.61 none >7.09 .~ .OObl.l. 1.67bn.sil. .50bn.ls.. 3.92bn.c.~. g_3 7.34 99.81 none ~ >7.34 1.25b1.1. 2.OObn.sil. .42bn.l.s. 3.67bn.c.s ~ 4 7.17 99.96 none >7.17 1.25b1.1. 2.OObn.sil. .42bn.l.s. 3.50bn.c.s.. g.5 7.00 gg,24 none >7.00 1.08b1.1. 1.50bn.sil. .50bn.l.s. 3.92bn.c.s. B- decimal' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. p R D P D P PER INCH P_ 1 3.89 none 3 6. b _ __ P_ 2 3.50 none 3 6 6 P_ none 3 6 6 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 hoi 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 percec~c of land slope. SYSTEM ELEVATION 96.11 ~ ~ ~- T __ ___ _ _ _T--~ -- f- f-~ ~. -- - ---- ---~ ~ . ~I -- _- _ I - ,~ . ~- - - ; -- _ ' i I__ ~~~ I `tz ~ ~ __ --- . _ - ` _ -- I - _ 0 ~ ' 1 -- ~ . r-- . _ -- _ _ 1'.~ _. ~_ I i ~ ~ ._. _.. l '., ' ~ .a- z ; -----~ - __ I _._ _ - __ i 1 1 . __ i _ L.._ --- ~-- _ `I ~. T ~ . -- d __ ~ ! -___~ I -_ ___ I ~ _. ~ . _ ., i . , ~ 1 I - , .. _ ..._ .. __ I ~ --- ~ __ ~---- ._ __ i ~ - _ i I X ~ -- I ~ `.. ,-- ~ Qj • 1 - - ~ ~ ,r~ __ _c ~~~~ ~ br~ ~ ~ ~ ~ _~ ~ - . - _._~ ~--~-- _ .... _ ...- i--_ ._ ~_ _._~ ...._-_ __ ___ - .~ ~ ~ .. __. _ L _.._ ...~I ~ ~ ___ , -j- ~ ---~ "I ~ j--- - ~ ~ t ~_ i__ _ ~._._ ~ ~ __ . p TOWNSHIP/I~{TY: LOT NO.: BLK. NO.: SUBDI~ 29 Nl~.9x~ (or) w Hudson 38 n/a PinE ~' N ~~s . J ~wH c>"~ T~'ctC~ls~ ~~ CPr~`'pn~ecQ ~cS'~~'.~~;~ `5~ c~-~ ~ x ce~~t y ~~ ~~~~~ =.~~~ %s ~~~ s~--eke X70 ~ l,~ ~>~- fi /%h ~ '~ ~ i, 9~' ~ ~~ f~ !1f I , ~~ l"/ ~t f S~~~e Ceti r-„~~ ~P~~s j ~ 6x-~ o "j a, ~ ~' ~ ~~ i ~~~ ~ ~ j0.v1 ~C.4 ~ ~ ~ ~~= `J-(~ ~ ,~~~ ~`~~. ~ ~~~~ z -2~~ 7~Y 'V ~„ ~'~. ~~ - i \ M1 ~~ C.v J~ s -3 ,~~ `emu T ~ Z,~ fit' 0 e R fW ~ ~ ~•~~ i \o~ti ,. /,~ ~, P~ ~ • ~ , , ~c.~,~ ~ , . (,~ ~ ~,~ d' y t~ l~ Psy~ .J( 2 ru1;,/~~ ~lP~'S~~z~Z ~~ ~~ P r D OS Cp.; v .1' ~~ ~~ I . ~ /~ 370` ~~