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HomeMy WebLinkAbout020-1149-30-000 Wisconsin Department of Commerce S~t t83 09*'' RIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division (04 S[679~M INSPECTION REPORT Sanitary Permit No: ~ 4217 y~~ 1,5 (ATTACH TO PERMIT) GENERAL INFORMATION V~ State Plan ID No: 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 Parcel Tax No: Steltzner, Kenneth Hudson, Town of 020-1149-30-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 16D. v~ TOP QF F.0"N 17<I%!~ ~ulcgitwAe 33.29.19.801 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Lo~fc-RGT~ ~~j~ Bench 0e 6. w4U. I ' (a Dosing Alt. BM Aeration Bldg. Sewer Q q1) 96 ST Holding St/Ht Inlet6 Bo St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover D G'Deo GPM F /7 w 7!! Model Number f (V, Stu IE TDH Lift Friction Loss System Head T DH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z'11 ; J SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: M 7 f UNIT Model Number: DISTRIBUTION SYSTEM J Header/Manifold [Distribution x Hole Size x Hole Spacing ipe(s) Length Dia ength Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth over xx Depth of eeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil xx S Fa] Yes R No f7] Yes:: :[2No] COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:_-/_/ Inspection #2: Location: 610 Countryside Circle Hudson, WI 54016 (SE 1/4 SE 1/4 33 T29N R1 9W) Countryside Village Lot 15 Parcel No: 33.29.19.801 D 1.) Alt BM Description = -(ill/&N -)fQELzjf/~ TD GE1- SuFF/c(EiUf KRZ-K ON 8u1G_P(" 2.) Bldg sewer length = 2' 9 of VC (70L 'P K 6u1G-pm)G 5E7 C_0 ~E~• 382. 3b (I 1)(°) Z" - amount of cover = Sap" Fa yYt tZbegV. IF GI 7v REinRiN Exposes F Plan revision Required? 0 Yes No ELE U se other side for additional information. Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) CE with Sanitary Permit Application ST. CROIX COUNTY WISCONSIN r with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT t0d Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER $ J N 0 v [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016-7710 (715)386-4680 Fax (715)386-4686 ST. CR01 om lete plans for the system on paper not less than 8-1/2 x 11 inches in size. ~0MMU u 11 ❑ Check if revision to previous application TG- DZ/ 1. Application Information - Please Print all Information Location: Property Owner Name ~~✓n ~ 1/4 S E 1/4, Sec 3 3 (~h J / n)/y Z 0 e- ~ lV 2 N, R y E (or Property Owner's Mailing Address Lot Number Block Number 6--'l d r 5~ City, State Zip Code Phone Numer Subdivision Name or CSM Number IAJ5117 ~7 2 z z 94 141 Loc-ti py S ld o ~ ST~~TPS II Type of Building: (check one) amity ❑ Village EgTown of JK 1 or 2 Family Dwelling - No. of Bedrooms: / ❑ Public/Commercial (describe use): ~TG o/S eJ ❑ State-owned Nearest Road ~l0 IL Type of Permit: (Check only one box on line A. Check box on line B if applicable) Eott Parcel Tax Number(s) A) 1Repair 12. §Z Reconnection 3.❑Non-plumbing 4. ❑ Rejuvenation ~l Sanitation ZED ' Zj ° t1j B) I Iv Permit Number Date Issued State Sanitary Permit was previously issued 7Z S^ Z IV. Type of POWT System: (Check all that apply) A Non-pressurized In-ground ❑ Mound ? 24 in. suitable soil ❑ Mound 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min.lnch) Elevation IVL Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks /ZOO ❑ ❑ ❑ ❑ L❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) I H__ Plumb s Signature no am MP/MPRS No. Business Phone Number „u~ ~ C~ 3- a~d7a 33 6' Y Plumber's Address (Street, Ci , tat , Zip CRde) 6.1 ? g~ _ 3f 6 (P.U- & (U 16, EJb~ -5-qva III. County Use Only Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps) ( Approved Owner Given Initial Adverse ( z ZS! cG Determination IX. Conditions of Approval/Reasons for Disapproval: L / L / 1 ~X,t✓IGLG► !~Gowfl7t 1( h?(.6Sf .~~ild/1oiT LD~y 4F h0(4SZ ~ 4jj, (v ✓GYJ fF OCGGePdlitGlJ QtT/Gl4v~T ~S rt~u/-rCGF ~ ~ of ~rai'oon,S -rka8f -~aSccur c~d~ ~S }SD ~ -Fy~m ~ ~r~vt t~.~on~uchvn * ,I_o~t 4r 2o4AIrt 4-r L- 5r L ~ /61,C5 i'R-to/L Tb AA9V 1A1-& /,0'1CC 10--V 372' k 2113' 407 YN~ tie~~ / c~ G 7 ' kVl1 house 35® 7 30' driveway 40' 0' ed 451' VOLUME 's. N0*03'34"w i 1344.66' 407-64' :9.91, no.ao" co f- 7 14 16; 3 ACRES 3.44 ACRES 15 4.66 ACRES cc ul) ~n 0 cQ ' z h~ e) 17 161032'05 167041' 4 ACRES N41-4$'E 270° 21,42 'l 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 5te/7 2- n residence located at: 1/4, 1/4, Section , Town N, Range W, Town of 0 h , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. lo 7- /,5- Most recent date of service 6 ~Y_ /7 Did flow back occur from absorption system? Yes No X11- (if no, skip next line.) Approximate volume or length of time: gallons minutes capacity: OOO Construction: Prefab Concrete /Y Steel Other Manufacturer (if known): Age of Tank (if known): 1101 s ~P Ps-c1~ c (Licensed Plumber Signa e) (Print Name) 0t0VQ-V' Cad (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Z ~A Q., Mailing Address S V • L, ~U•~~- ~r,~~~ y~ 5u n - ~10~ (p Property Address (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number 0 a 0 LI 0 Qo C~ LEGAL DESCRIPTION dt 1% got Property Location 1/a Sec. :~,a, T _2q_N R IOW, Town of ~ C" S v n Subdivision Plat: Co- h 1 / y 5 / /4 g e , Lot # S Certified Survey Map Volume , Page # Warranty Deed # (before 2007)Volume ~])_(n, Page # Spec house ❑ yes )(110 Lot lines identifiablekes ❑ no 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 §SPS. 383.52(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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services 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. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIG TURE 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. 04/12) o co o n u; 0 1 F. d -0 0 o d 7 A 3 3 A A N 9 7v • o R cam. R I m c c r c co w w C/) U) CO :r c' 1 'rt tTJ (n ? Z CO 0- 0 n0 c o m 01 c d a two c c~ • ~o X R A R N y j D I W CD Z a y N j ~ Z cal 2v W a m m nOi 0 v W N m , v _ l n < w En 0 Ln 0) 7c V a. 3 m o s ° o ° p~1 U) ('Z) ro a o a U> G D eo ° c 4 C7 co D co p CD co y (n W N 00 a I o c o o o CL 3 00 ~~D CD {1~ QR CD p N N N Oo r~ A C7 ` co fV OZ W CD CD 00 OD CO (D O C Y Lo 1 C C 6 CL CL Z 000? z 000? Z• W~~' V ;s ;s q ro rn a (ci)(otn~I -ft o c (n (n (nom', Oc O O A h a T C C A pp cr (D 0 0 (D CF CD • R R, - v b 3 N = Oy (o r! Z N c>. C~ C~ O c~ ~i D co o z co =Or CL :3 0 N m m N ~y~~i CD Cn CD CD CD 0) C,J`I C N C N CD w o (D _ 3 CD Z CD (6 -I (o in o ° N A A o c f 1 Jy a v a A o to w 7d 7~ d Pd ° C Cn w N W (D F•d n m w '0 W D m w C <D O. 1 ' z rt rj ~J bd w p 3 N w o I d o O m co o N• N 'a 3 y rt c z z CD !!1 j H CD ~ I d A A _s D D N O a C) fl. C G C F-• O O (a 0 N C I ~ N C f oz d oz a N CD n N N O N y CD fi CL Q 00 ~ a I a, A O ' H cn o w t A Fl- O N tTJ cn a N rt "D r\ y a A F- Z m a cn v rrJ bj O rr = W • ~ n ~ I a O td O (A QQ N• O tr] G1. rt 1-h (D Q rt n x n' CD CD p., cn W o ~ o ~ o yy m W o i. I °o : ti o a (D Parcel 020-1149-30-000 02/23/2006 09:01 AM PAGE 1 OF 1 Alt. Parcel 33.29.19.801 020 - TOWN OF HUDSON Current IX] ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner KENNETH N III & MARTINA STELTZNER O - STELTZNER, KENNETH N III & MARTINA 610 COUNTRYSIDE LN HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 610 COUNTRYSIDE LN SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 4.660 Plat: 0215-COUNTRYSIDE VILLAGE SEC 33 T29N R19W COUNTRYSIDE VILLAGE LOT Block/Condo Bldg: LOT 15 15 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 33-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 11/06/2001 661310 1756/259 WD 07/23/1997 669/365 2005 SUMMARY Bill Fair Market Value: Assessed with: 92669 294,800 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.660 85,600 215,100 300,700 NO 05 Totals for 2005: General Property 4.660 85,600 215,100 300,700 Woodland 0.000 0 0 Totals for 2004: General Property 4.660 56,600 167,300 223,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 205 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 , AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC.33 T-29N-R~/?W ADDRESS ST. CROIX COUNTY, WISCONSIN. SUBDIVISIO _ S lI( 7C9 T / LOT SIZE Cv PLAN VIEW Distances and dimensions to meet requirements of H63 01. T191. SHOW EVERYTHING WITHIN 1.00 FEET OF SYSTEM 1 ~ w -34 It I ~ J i I di at N r h zi BENCHMARK: (Permanent reference Point) Describe: 8 Elevation of vertical reference point: I~• Slope at site: ~ SEPTIC TANK: Manufacturer: am Liquid Capacity: _ Number of rings on cover :-.0 Tank manhole cover elevation. 7.74 Tank Inlet Elevation: $,I Tank Outlet Elevation: 9 2 PUMP CHAMBER Manufacturer' Number of gallons Number of gal. pump set for a cycle gallons; Total capacity of distribution lines gallon: size of pump head; gallon per minute horsepower ;brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover ; Type of warning device SEEPAGE PIT SIZE; Number of pits feet diameter feet liquid depth seepage pit inlet pipe-elevation bottom of seepage pit elevation feet. SEEr,P,GE BED SIZE: number of lines width o? length-3 Stile depth SEEPAGE TRENCH: width_ length PERCOLATION RATE AREA REQUIRED A B INSPECTOR DATED PLUMBER ON OB LICENSE MBER l DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR,& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION * P.J. BOR 796' BUREAU OF PLUMBING 'MADISON, WI 53707 INCONVENTIONAL ❑ALTERNATIVE State Plan l.D. Number: ) ( ❑ Holding Tank ❑ In-Ground Pressure E] Mound 1f assigned NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: David Skare RR# 3, Box 99, River Falls, WI /y4:7- BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF PT. ELEV.: CST F. PT. EInv. : E4 SE4,Sec.33,T29N-R19W,Lot 15,Countryside Vill.,Twn.of Hudson Name of Plumber: MP/MPRSW No.. County: Sanitary Permit Number: Byron Bird it 1309 St. Croix 43642 SEPTIC TANK/HOLDING TANK: MANUFACTUR LIQUID CAPACITY _ ;f I) IG/_: TANK IE EV J, TANK OUTLET LEY.: WARNI G LABEL LOCKING COVER 1 r P O ED PROVIDED: lQ- W iLl'-iVf ES ONO DYES ONO BEDDING: VENT D VENT MATL. HIGH WATER NUMBE OAD: PROPERTY WELL BUILDING: VENT T E FRESH / / G LINEf. A IR I DYES ONO C 1 l AL FEET FROM ❑Y N NEAREST L L l ~k- DOWNG CHAMBER: MANUFACTURER . IBEDDING. LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUF At_TtMEJA WARNING L EL LO ING COVER PROVID : P VIDED: DYES ONO 'f ❑ DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: / BXT ER OF PROPE EL BUILDING:I VENT TO FRESH (DIFFERENCE BETWEEN ' FROM LI AIR INLET: PUMP ON AND OFF) DYES ONO AREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Fr1/;TH DIAMETER MATE AL AND MARKLNG or excavation. (If soil can be rolled into a wire, construction shall cease until CE the soil is dry enough to continue.) ' AIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF DISTR. PIPE SPACING COV INSIDE DIA #PITS LIQUID /j TR ENO ES. T RIAL: DIMENSIONS L PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE ATERIAL: NMI NUMBER OF PROP TV WELL BUILDING: VENT TO FRESH BELOW PIPES. / AB E COVER. 1~ET. ELEV. E ~ . PI_ FEET FROM PROP 7 jIR INLE^T~ IV\ NEAREST--viI-13-' MOUND SYSTEM: Mound site plowed perpendicular to slope Check the exture f the material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: d sy ems o ma certain that it ON REVERSE SIDE. SHOW ELEVA- D YES NO ?eel the iter' for edium sand. TIONS MEASURED. O SOIL COVER TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS. I OYES ONO DYES ONO DEPTH OVER TRENCHIBED DEPTH OVER TRENCH/BED E TH OFT SOIL. SODD D. SEEDED: MULCHED: CENTER. EDGES. YES ONO DYES ❑ DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH NO OF LATERALSPACING: JGRAVEL DEPTH BELOW PIPE FILL EPTH ABOVE COVER. TRENCHES: DIMENSIONS 1. A MANIFOLD PUMP MANIFOLD DISTR. PIPE I R MANIFOLD MATERIAL. DISTR. nR. PIPE D TRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: CIA.'. ELEV.: ES: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MPNO L: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. DYES ONO DYES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMB R OF PROPERTY WELL: BUILDING: FEET F M LINE: DYES ONO DYES NE AREST Sketch System on - ~t 'n in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710 (R.01/82) UEPARTMENTOF APPLICATION SAFETY & BUILDINGS- INDUSTRY, FOR SANITARY DIVISION L,ABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property O Mailing ddress: Property Location: • City, illage o wns i . County: '/a t/aS ,T NCR E (or G Lot Number: Bldk,No.: Suubdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: 15 Nl! 1 `,O(,(N'r~ s ( I/ IC_L (if assigned) TYPE OF BUILDING / F-1 Public* El Variance* ❑ Other (specify) Number of 10 ~f Bedrooms: 1 or 2 Family *State Approval Required. 44 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 7 HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental (Seepage Bed ❑ Seepage Pit p~ ❑ Alternative (specify) ❑ Seepage Trench Water Supply: T Owner's Name as Listed on Soil Test Report (If other than present owner): A Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage sys em shown on the attached plans. Name f Plumber: I Si I MP/MPRSW No.: Phone Nu r6' g~ Plum s Addr ss: Name Designer: COUNTY/DEPARTMENT USE ONLY Sign t re of Issuing A t: ee:. bate: APPROVED Sanitary Permit Number: ®O v"bOV S3 DISAPPROVED Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81) DEPARTMENT OF APPLICATION INDUSTRY, FOR SANITARY SAFETY & BUILDINGS ~ABOR AND, PERMIT DIVISION HUMAN RELATIONS (PLB 67) P.O. BOX 7969 MADISON, W1 53707 Attach plans for the system on paper not less than 8% x 11 inches in size, Ift lude a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate se ra 'ng distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must a si ed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible pro ction of the soil test re rt or the owner's co included. py must be Property Owner: t Mailing Property Location: City, Vi age or ow /T c unty: / E (or W Lot Number: Blk N u ivision Na e: t C.~ Near t Road, Lakg d rk: State Plan I D. Number: l~~Ti2y5/16 -E vj L LA- If a signed) TYPE OF BUILDING U ❑ Public*. ❑ Varian e* ❑ Other (specify)* Number s: of- Al or 2 Family *State Approval Required. Bedroo s: TOTAL NUMBER PREFA POURED-N GALLONS OF TANKS CONCRE E STEEL FIBERGLASS NEW REPLACE- OTHER SEPTIC TANK CAPACITY PLACE INSTALLATION MENT (Specify) HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACT EFFLUENT ISPOS SYSTEM PERCOLA RAT ABSORPTION AREA (Minutes r ch): PROPOSED (Square et): New ❑ R lacement ❑ Experimental t,~ Seepage Bed ❑ Seepage Pit a Alter tive (spe 'fy) _ \ ❑ Seepage Trench Water Supply: Owner's Na as Listed on oil Test eport (If other than present owner): Private ❑ Joint Public 1, the undersigned, hereby assume ponsibility for inst lation of the private sewage system shown on the attached plans. Name f Plumber. 7 Signat , MP/MPRSW No.: Phone Nu er h4 0 PI m is Ad ss: Name of De, igne COUNTY/DEPARTMENTUSE ONLY F ure of Issuin Agt: Wg e.itarermit Number: n for Disapproval: d ~7 El DISAPPROVED Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHRSBD-6398 (R.07/81) sA W Q o % ~o zz~ ~C iz V k 1 1 Tv \ ^ ~ f 1 ~ ~ ck\ i ~ w DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION OWANpeNb PERCOLATION TESTS 115 BOX 7969 1~•ILMAN RELATIONS N, WI 53707 (1-163.090) & Chapter 145.045) rod LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOTNO.:BLK. UBD ME. SE ~Y4SE~%4 33 /T29 N/Ri9 mW Hudson Township 15 - Co e COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: St. Croix David Skare 12956 River Road West, Mine lis¢e 6x983 USE DATES OBS TIONS ADE NO. BEDRMS.: CO MERCIAL DESCRIPTION: PROFILE, DE IONS: PER CO N TESTS: Residence 4 N~A ER New ❑Replace 6/16 /83 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: 11101:11 ND: IN-GROUND-PRESSURE: ISYSTEM-IN-FlLL HOLDING TANK: RECOMMENDED SYSTEM: (optional) DS[:] DS ❑V ❑ S ❑U ❑ s au ❑ S ©U Conventional Bed If Percolation Tests are NOT required DESIGN RATE: I If an IL any portion of the tested area is in the under s.H63.09(5)(b), indicate: CLASS 1 Floodplain, indicate Floodplain elevation: N/A PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH OGROUNDWATER-INCHES CIBI TER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OB RVED EST. IGHEST TEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 12.0 98.6 Non >12.00 Sl; , S 1; 132, Bn s & gr. B_ 2 14.5 97.4 No > 14.5 5, sl; 22, S l; 137, Bn s & gr. B_ 3 12.0 96.6 Noe >12.0 B1 sl; 18, 1; 10, s 1; 102, Bn s & gr. B_ 4 8.0 95.3 No 8.0 16, Bl sl; 24, sl; 56, Bn s & gr. B- 5 9.0 6 A A .9 No Wo 17, B1 sl; 25, S 1; 66, Bn s & gr. B-- I \ PERCOLATION TESTS TEST DEPTH, TER N HOLE EST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES A ERS ELLING IN RVAL-MIN. PERIOD 1 PERIOD 2 PERI D 3 PER INCH P- 1 63 None 1 12/16 1 9/16 1 9Z16 2 P_ 2 39 None 2 2 4/16 2 2/16 2 2/16 1 P- 3 53 None 2 1 13/16 1 8/16 1 8/16 1 P-_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATIONORIGINAL 93.1 ALTERNATE 92.5 BENCH CALE It It ELEV. i- 1(TO 00 8-3 a _ 2 3 LOT 15 _ GIM IRON PIPE, FO tN l SOIL BORING, o NLMBE~ LOCATION. B -1 6%-- SLOPE- PERCENT , 2 • . I r _ 4 EST , NLUIBE$ CATION. E_ 163 3'j- j 1011 - E L-264-' T' I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: James T. Swanson, Ogden Engineering Co. 7/11/83 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optionall: 123 E. Elm Street River Falls Wisconsin 54022 55-2152 715-425-7631 CST SIGNAT RE: DIS'RIEEUTION: Original anal ~n3 copy tc- local Authority, Pro,pe cy Owner anti :'soil Tester. DILHI SP1, 5395 }j O vI=F? BBD - 6395 `r i l 1. `P I ALL 11 f L s I 7 1orw - S T C 100 Owner of Property ~{qVA LINE ,Location of Property -S e SE 5 , Section 33 T d-J N R W TownshiptA- 6 Soo Mailing Address_ R-OCL-M Anx -ALA- h S 0'.3 Subdivision Name &J(- k) j p-YS I L f}C E Lot Number 5 Previous Owner of Property FieAa)cc S (D b N Total Size of Parcel 4c4F-s Date Parcel Was Created ~C~• 12 '7 Are all corners identifiable? No Include with this application one of the following: .Certified Survey Map r . Deed J- Contract, or .Other Legal Document which describes the property 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 record in the Office of the County Register of Deeds as Document No.-3&= ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the some has been duly recorded in the Office of County inter of D s, as Document No. J, SIGNATURE 7 POW R SIGNATURE OF CO-OWN IF APPLICABLE) DATE SIG D DATE SIGNE it DEPARTMENT OF REPORT ON SOIL BORINGS A Y & BUILDINGS IN DUSTRY, r' ~n DIVISION LABOR AN .0. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115 ~lr A N WI 53707 (H63.090) & Chapter 145.045) LOCATION: EZCT ION: ~ TOWNS HIP/M40ftetP k+fY: LOT NO.: NO.: I 'aVI N SE.1/sue 3/ T2IN/R IgM(or)W ►-\vosQ~ vs N ve COUNTY: OWNER'S BUYER'S NAME: ¢2S -q 13 MAI LING ADDRESS: + ST, CRS DAv\i~ sKP,~?~ RT• 1 C3o~C 4\S H , 540\~c USE DATES OBSER E ~~,fr NO. BEDRMS.: COMMERCIAL DESCRIPTION; rte" PROFILE DESCRIPTIONS: PER OLATION TESTS: 11xResidence /1 IaVew ❑ Replace RATING: S= Site suitable for system U= Site unsuitable for system l U CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) S [:]U s El ; s ❑u EIS Eu a s If Percolation Tests are NOT required DESIGN RATE. I If an 1 ` L y portion of the tested area is in the I under s.H6o_09(5)(b), indicate: 1~J Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-IIS1~S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHSk OBSERVED EST LGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK,) 31 O, •o' q4..3 uou~ g.o' ~.,s'~3\ s\Ts' t -B- 5'f i 3 covsa`.arreeA \ s j 1, b ' s c.1 ; 3 .rb'2• Mw, s r3Z 1. , 93.1 NovE ~ 1•S' ~.s r3\s\TS' ~.p.rr.,+co.s Q3 1.5' g\.q' ►~o.ae. 71.5' \•e se s\,-s 2.3' a\ slzs Z.O' SC_\ 3.-e' +nED•S 2-S.._- ,1_~S'_ °\Z• tvot~ic > -1,5' z.o Be s\Ti', S.S ' K.eo. S B- to `1 •S °14.3' t~ou~. ~ q . S ~ ► • s • tae slTS` 8.0' .r.~a S _ q3_9' n\svvs, f4vim B- $ l•S Z•1' tJON~c > 1.5 +•o' ~3e s~TS 3.p' sc\ ' Z•S' 1.O' c5 ,r g(3q 1.0' 90 1 - 1JoU _1 O' Z.p' \3\ se~z'~ SA& to (D.o' 913.s' V-~, cN.3 z B- I1 ,O °►Z .3' 1.1ouE -1.p' S 'B\ s\zs', 0.1' s. \ \ •o veryrc5 3 $"~5 _ PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IW@OWS AFTERSWELLING INTERVAL-MIN. PERINCH PERIOD PERIOD2 PER P- 1 4.0 tJor.~E 3 2 , 3 " Z 5~1~'' P Z 4-.D' i..ouE Z 3 Z 3~ Z 73 h q ` P- B-0 ~ONC `/1 Z. Y, t. P_ 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- I t-N%-Z = 8q 5 SYSTEM ELEVATION R~~-~• _ $g•o' Poi ~S RAE ~ix~ L E6 QN:^ H q~D i a,_ 7 Cj _7_ F'l i~CE tngC, i S 4RAHA F i. _ of t L ASC E 4~ ~Rt~~~J ~~`Q 0 p "t 3 € I OdC 5~"C~1K~S SET - mm I _ ~_~a~ IAN U/6 ~i• ~ ~ 0 T i le0 CE i nevi 7 r~ ' V 5 L o to MI6 j a b ' s 0 At Ai € f t I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print l: M TESTS WERE COMPLETED ON: J • ` W ~\3E - KoZEL w cvERE tZD ASSOC. 8 - !_l ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): P' ~X 14 R\VE~ 'FAt~ S OZ.Z Csue' 3Zt4D, \ -115-41S-9381 S ATURE: s DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. D C ILHR-SBD-6395 (R, 02/82) - OVER - i Ire E'w£e - ALL ~i lx, THE a »a- a rte. t"t -r ! O x x x ce. fe rc y X 3 5- ge - l~ 02 1~ e-c~ N/,-/n iG- ly 0 6 3h ~ C v 0