HomeMy WebLinkAbout020-1185-70-000~artment of commerce PRIVATE SEWAGE SYSTEM
.ling Division
I SPECTION REPORT
~NERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide maybe used for secondary purposes [Privac aw, s.15.04 (1)(m)).
Permit Holder's Name: City e Y. Township
Larsen, Br ant Hudson; Town of
CST BM Elev Insp. BM Elev: BM Description:
TANK INFORMATION EL ION DATA
TYPE MANUFACTURER CAPACITY
Septic
~~~ yt
~ p (1 U
wt~a.~~ 2 ~° ~
Aeration ~ S
Holding
TANK SETBACK INFORMATION T ~I/L-d•[~ir~---
TANK 70 W E L BLDG. ent to Air Intake ROAD
Septic
~/
rn2Cif ) j r 35 /~~
Aeration 6~ Vt
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Friction Loss System d TDH Ft
Forcemain Length Dia. Dist. to Well
county: St. Croix
Sanitary Permit No:
506382 0
State Plan ID No:
Parcel Tax No:
020-1185-70-000
Section/Town/Range/Map No:
21.29.19.1169
STATION BS HI FS ELEV.
Benchmark ~ ~ w ~` /~ ~ Q
~^
Bldg. Sewer
S~'h
i
SUHt Inlet ~~
S Ht Qutlet ~ ~ G~~d D
/ 7
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Header/Man.r~~~ r ~, ~ l
/ q 3 3/
Dist. Pipe /~ S 7 • (oGl ~ r
Bot. System ~. U ~
9 ~ •
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Sluff G
(3 2i
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Cover , /T~V 2•
O-
c~ p.
C
SOIL ABSORPTION SYSTEM Z % P.Gte~~ l,cn~1/-f7t.>La1~
BED/TRENCH Width Length ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~ -l~
_l
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manuf u~/ - - ~, /
INFORMATION CHAMBER O ~j YQ7b"t-/
T
e S
stem: /
yp
y
/
~ r
UN
Model Number:
~~ } I~
DISTRIBUTION SYSTEM n:~ ; a, i n , _„ / SC-i~ ~v
Bader/M nifold ~
( Distribution r r
Pipe(s) r/~~' ~/
~ x Hole Size x Hole Spacing Vent to Air Intake
Dia Length I
Dia Spacing l
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade SVStems OnIV
Depth Over Depth Gver xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center (n ~
llff// Bed/Trench Edges Topsoil L r--
~ Yes i _i No f J
~ Yes ~ No
a~
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~/~ Inspection #2: / I
Location: 553 Wagonwh~eel Court Hud"s'on, WI 54016 (SW 114 SE 1/4 21 T29N R19W) Prairie Vista/1's~t,A~ddaLot 11 Parcel No: 21.29.19.1169
1.) Alt BM Description = 10'7 0~ i~ ~~jl,~~,~L(Q!L ~~ s" - / ,,~j/~~~,~ ~~ ~ ~r~
2.) Bldg sewer length = ~IGL ~G~--Sy.1~~'h'r
- amount of cover =
%" ~ _ .
;. ,
Plan revision Required? i Yes ~ No ~~ ~ /~ '1 .~ f '%~ I ~ . ~ w ~~ ~~ ~y
Use other side for additional information. V I ~ZCii~.
SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No.
P f7 I n rP m>°~n ~--
COmmerce.wi.gOV Safety and Buildings Division County
~ ~ 201 W. Washington Ave., P.O. Box 7162 St. CrO1X
~ sco n s ~ n Madison, WI 53707-7162 ber (to be filled in by Co.)
Sanitary Permit Num
Department of Commerce Q
5~ (p 3 O"
Sanitary Permit Application State Transactio er
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental Project Address (if different than mailing address)
unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS aze
submitted to the De
artment of Commerce
be used for seconda
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"
I. A lication Information - ase Print All Information ~~ °~ G j
Property Owner's Name Parcel #
'
R~CE! V CL
!
.
Bryant & Neda Larsen 020-1185-70-000
Property Owner's Mailing Address O C T
2 9 2 0 0 7 Property Location ,
.
553 Wa on Wheel Crt. Govr. I.ot
City, State ~ deOUNTY hone Number SW '/<, ~SE '/<, Section 21
(circle one)
Hudson, WI 5 715) 381-1750 T 29 N; R 19 w
II. Type of Building (check all that apply) t #
^ 1 or 2 Family Dwelling -Number of Bedrooms 4 ~« 1 Subdivision Name
Block# ~~ //~~
Prairie Vista ~S fdri~~t ~f`
^ Public/Commercial -Describe Use
^
Na city of
^ State Owned -Describe Use CSM Number ^ V' !age of
Z-• p ~S~" C2~l.S ~ ZZ k22 t.~i-,a- Na °~ of Hudson
III. Type of Permit: (Check on y ne box on line A. Complete line B if applicable)
`~" ^ New S stem
Y Re lacement S stem
P Y ^ Treatment/1-Ioldin Tank Re lacement Onl
g P Y ^ Other Modification to Existin S stem ex lain
g Y ( P )
B•
^ Permit Renewal
^ Permit Revision
^ Change of Plumber
^ Permit Transfer to New List Previous Permit Number and Date Issued
... ,...... .-
Y
BeforeExpiration Owner ~~~~~ /~~/ f~
~
IV. a of POWTS S stem/Com onent/Device: Check all that a 1
on-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil
^ Holding Tank ^ Other Dispersal Component (ex ^ Pretreatment Device (explain)
V. Dis ersaUT'reatment Area Information: 4 Infiltrator "Q-4 W" chambers 20.0 sq.ft EISA /chamber + 2pair end caps 5.8 EISA = 891.60 s . ft.
Design Flow (gpd)
600
~
d Design Soil Application Rat gp s ~ e quired~
0
7 i
i
il 8
15
ft Dispersal Area Proposed f)
891
60
ft System Elevation /
92
50'
,
gP .
n-s
tu so
57.
sq.
. .
sq. . .
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units ~ o v ~
New Tanks Existing Tanks
s
~ l
SZS ~ [
a~ ~ ~
~ Y ~ ~
~
a
a
t.
w ~ ~ w
Septic or Holding Tank 1,000 1,000 1 leser Concrete X
261 261 1 Weeks Concrete X
Dosing Chamber
VII. Responsibility Statement- I, the un ersigned, assn responsibility for i all n of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber' igna r MP/MPRS Number Business Phone Number
James K. Thompson 'S---- 30021 715) 248-7767
Plumber's Address (Street, City, State, Zip Code)
340 Paulson Lake Lane, Osceo a, WI 54020-5413
VIII. Coun /De artment Use Onl
Approved Disappro it Fee
Perm Date I sued Issuin ge nt Signature
f
$
~D ~ ~ ~~ ~~ ~,
^ iven Reason o enial 7
IX. Condit~i~~~ieasons for Disapproval
1. Septic tank, effluent filter and
dispersal cell must all be services /maintained
as per management plan provided by plumber.
2. All se>A~ack requirements must be maintained
as ode / ordinaltus.
Attach to complete plans for the system and submit to the County only on paper not less than 8 1n x 11 inches in size
SBD-6398 (R. 01/07) Valid thru 01!09
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' Wisconsin Department of Commerce
Division of Safety and Buildings
SOIL EVALUATION REPORT
in accordance with Cnmm 85. Wis_ Adm_ Code
2097
Page 1 of 3
A.C.E. Soil 8 Site Evaluations
County
Attach com lete site Ian on
p p paper not less than 8/: x 11 inches in Pla
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020-1185-7 -000
Please print all information. Review By Date
Personal information you provide m , s. 15.04 ( ~~ t3~ ~ 7
Property Owner Property Location
Bryant W. Larsen Govt. Lot SW 1/4 SE 1 /4 21 T 29 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
533 Wagon Wheel Crt. 11 Prairie Vista
City St a Zi o on r ~ City J Village ~ Town Nearest Road
Hudson ~ - Hudson Wagon Wheel Crt.
New Construction Use: ~ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
1~ Replacement _f Public or commercial -Describe:
Parent material Glacial Outwash Flood plain elevation, if applicable Na
General comments
and recommendations: Site suitable for conventional dispersal cell at
0.7 gpd loading rate. Recommended install
ing4
chambers in 2 trenches at elevation of 92.50'.
a Boring # Boring
>119"
~+- Pit Ground Surface elev. 98.36 ft. Depth to limiting factor
in• Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Ift2
in, Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. *Eff#1 *Eff#2
1 0-17 10yr2/1 none sil 2fcr mvfr cs 2vf,fm 0.6 0.8
2 17-31 10yr4/4 none sil 2msbk mfr cs 2f,1vf 0.6 0.8
3 31-40 10yr4/6 none gr Is 0 sg ml cw 2f,1vf 0.7 1.6
4 40-83 10yr5l4 none s 0 sg ml gw - 0.7 1.6
5 83-119 10yr6/4 none / s 0 sg ml - - 0.7 1.6
QZ~ ~~~. ~
Soil observation elow 192" completed by use of hand auger.
~!
Z
/r ~ '
Boring # J Boring
J Pit Ground Surface elev. 8.14 ft. Depth to limiting factor >118~, in• Soti Application Rate
Horizon Depth Dominant Color Redox Description Te re Structure Consistence Boundary Roots GP D/ftZ
in. Murrsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-14 10yr2/1 none sil 2fcr mvfr cs 2vf,fm 0.6 0.8
2 14-33 10yr4/4 none sil 2msbk mfr cs 2f,1vf 0.6 0.8
3 33-43 10yr4/6 none gr Is 0 sg ml cw 2f,1vf 0.7 1.6
4 43-76 10yr5/4 none s 0 sg ml gw - 0.7 1.6
5 76-118 10yr6/4 none / s 0 sg ml - - 0.7 1.6
~~ • 76~~ q2.
'
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Soil ervatio ow "completed by use of hand auger.
* Effluent #1 = BODS> 30 < 220 mg/L d TSS >30 < 50 mg/L * Effluent #2 = BODS <30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signatu CST Number
James K. Thompson -s 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane. Os o a. WI 54020 10/20/2007 715-248-7767
Property Owner Bryant W. Larsen Parcel ID # 020-1185-70-000 Page 2 of 3
Boring # ~ Boring
Pit Ground Surface elev. 97.73 ff. Depth to limiting factor > 113" in~ Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-3 10yr2/1 none sil 2fcr mvfr cs 2vf,fm 0.6 0.8
2 3-17 10yr4/4 none sil 2msbk mfr cs 2f,1vf 0.6 0.8
3 17-31 10yr4/6 none gr Is 0 sg ml cw 2f,1 of 0.7 1.6
4 31-70 10yr5/4 none s 0 sg ml gw - 0.7 1.6
5 70-113 10yr6/4 none ~ s 0 sg ml - - 0.7 1.6
Soil observati el 97" completed by use of hand auger.
^ Boring # -~ Boring
~ Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
^ Boring # --~ Boring
_f Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS <30 mg/L 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.
SBD-8330 (R.o7/o0) A.C.E. Soil & Ste Evaluatbns
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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'va~-,~ ~''rJ,~/ ,C~scr, residence located at:
~ ~.J '/4, s ~'/a, Section 2/ ,Town ,2y N, Range /9 W, Town
of ~~~[~,~ , 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.
Most recent date of service (~,u~, /S. ~7
-~ .
Did flow baci< occur from absorption system? Yes ~ No
(if no, skip next line.)
Approximate volume or length of time: „e~.,gallons 2y ~ minutes
Capacity: ~ 4Q.
Construction: Prefab Concrete ,r/ Steel Other
Manufacturer (if known): ~,~~ ~,G,-~
e of ank (if known): _ ,:~s6c.e~eQ/ t~/o9,1~9 - /9Yr~s.
icensed Plumber Signature)
~in~S ~G. / ~~~~h
(Print Name)
(Title)
~G~~ a9 ~~
(Date)
(License Number) ~t'JMPRS
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/> ~3rva>„~~` rlee~a L~~s~,-,
Mailing Address 533 ~ag~ (,~~~ CrL, ,1~~~~ ~/ 5~p/`
Property Address ~~_
,// // (Verification required from Planning & Zoning Department For new construction.)
City/State /~'~t~-~S~'; t,J/, Parcel Identification Number d-~- //gS-7d-G~
LEGAL DESCRIPTION
Property Location .5~ t/a , SE t/ ,Sec. ?~, T ~N R~~W, Town of /Yuo~so7-~
Subdivision ~r-Cti/'i~e !/i S r ,Lot #
Certified Survey Map #
Volume "- ,Page # -
Warranty Deed # ~05~?-z/37 ,Volume ~/c3 ,Page # 1~9~
Spec house no Lot lines identifiable yes
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 inro
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 [han 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 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.
I/we certify that all statements on this form are true to [he 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.
Nu ber of bedrooms ~'`
IGNATURE OF APPLICANT(S)
~o l?sio ?
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
n al
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-I0705-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 515' 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 I /3 the 1tquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR
1 i 3, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. 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 carnidge 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 tray 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 DeparUnent 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. Sail 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-March} dictate that the system be heavily mulched for frost protection.
Influent quality into the system may not exceed 220mg/L 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 Ievels shall be reported to the
owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring.
Effluent 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 an a two-year cycle coinciding with septic
tank inspection and maintenance.
Continaen1cy 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 into proper operating condition.
Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715)
248-7767 or the St Croix County Zoning Department at (7iS} 386-4680.
r~
v~~.1613~~~~ ~~3
pocument Number WARRANTY DEED
This Deed, made between RODNEY S PITZKE and BRENDA M
PITZKE
husband and wife
AND BRYANCW LARSEN
,Grantor,
Grantee,
642 1 ~~
KATHLEEN H. WAL3H
iiECiISTEF: OF DEEDS
ST. L'FiOIX CO. , WI
RECEIVED FOR RECORD
04-05-2001 9:30 F.'I
YARkAHTY DEED
EXEMPT M
CERT COPY FEE:
COPY FEE:
TRAHSFEk FEE: 645.00
kECORDING FEE: 10.00
PAGES: I
Witnesseth, That the said Grantor, for a valuable consideration of one
dollar and other valuable consideration, conveys to Grantee the following
described real estate in St. Croix County, State of Wisconsin:
This IS homestead property.
Together with all and singular the hereditaments and appurtenances
thereunto belonging; And Grantor warrants that the title is good,
indefeasible in fee simple and free and clear of all encumbrances except
and will warrant and defend the same.
LOT 1 1, PLOT OF PRAIRE VISTA FIRST ADDITION IN THE TOWN OF
HUDSON, ST. CROIX COUNTY, WISCONSIN.
r~
Dated this~a day of ML~t'~. 20Q i
~~~ ~ ~~
` RODNEY PITZKE
AUTHENTICATION
Signature(s)
authenticated this ,day of
signature
type or print name
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stats.)
TFIIS INSTRUMENT WAS ~ ~LINA
Rli1~~~~t'Y pUBUC N
gTATE OF WISCON~
Recordin Area
Name and Return Address
RETURN TO:
~u~~et itle~ ~~~
iEatlrn..~, m
n ~- v~~3%~sv~7
(Parcel Identification Number)
020-1185-70-000
.~
~B NDA M PITZK
ACKNOWLEDGMENT
STATE OF "'~s Stn
COUNTY OF ~j"~ C
Personally came before me this LD~da of ~~~` 2001
the above named RODNEY S PITZKE and BRENDA
M PITZKE , huolDC"~`~''~ "~`~~
to me known to be the person(s) who executed the foregoing
in try ugient and actcnow dge the same:
signature W ~ ,(1~~,
type or print name V v
Notary Public County,
My co ~an is permanQnj.I (If )not, state expiration date:
'Names of persons signing in a~ ny cn apacity should be typed or
printed below their signatures.
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AS BUILT SANITARY SYSTEM REPORT
Form-STC- 104
OWNER ~~ /,j,~~Id/~ TOWNSHIP ~4 ~,~~ SEC. ~~ T ~N-R~~
ADDRESS ~~~~,t~0h' ~2-~f Z. ST. CROIX COUNTY, WISCONSIN
~`4 ~s o ~ Gd..X" v~~/D/G
SUBDIVISION /f~'r/'~ `~ jfy LOT ~ ~~ LOT SIZE Z. , ~b ij~~~!'S
PLAN VIEW
Distances and dimensions to meet requirements of I•ZHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~s ~' ens
~G ,;~ ~ ~trc /l
atXs
~_
~~
~ ~:- yv ,
/~ 1
.- / ,v
.~
~~ ~
~, ~~
~~~ w~-
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used ~ ~~ ~a'~ ~~'~'~ sc G~ ~ts~2~slr-a r
'~
Elevation of vertical reference point • ~~a• ~ ~. ~~~ Proposed slope at site: ~~ ~ Sok
PURR' CHAMBER ~/~
Manufacturer: /y
Pump Model:
Elevation of, inlet:
Liquid Capacity:
Pump/Siphon Manufacturer: Pump Size
Pump off switch elevation:
Alarm Manufacturer:
Gallons per cycle:
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: LoK /aKl~~~n~. Trench:
Width: ~~ ~ Len$th: ~ 6 ~ Number of Lines: '~ Area Built: ~~
Fill depth to top of pipe: yZ ~~
Number of feet from nearest property line: Front, O Side, Rear,O Pt .G Z ~
Number of feet from well: / ~,/4 ~
Number of feet from building: /D D
(Include distances on plot plan). ~ ~,~ S
SEEPAGE PIT ~ ~-~
Size:. A/ ~'t`" Number of pits: Diameter:
Liquid depth:
Area Built:
Bottom of seepage pit elevation:
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: ~(/ ~ 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, nFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Bottom of tank elevation:
Alarm Manufacturer:
I
t
,.
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
'LABOR ~ HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
P.O. BOX 7969
MADISON, WI 53707
', SW~,SE~,S21,T29N-R19WCONVENTIONAL ^ ALTERNATIVE
Town of Hudson ^ Holding Tank ^ In-Ground Pressure ^ Mound
T., 11 T)...., .. TT, .. ~.. 7.,t A.t .aiti.~...
SAFETY & BUILDINGS
DIVISION
BUREAU OF PLUMBING
State Plan I.D. Number:
III ass~gntall
JNAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
~ ,` ~~
Sam Miller Route 1 Box 282 H s n WY 1 - -
BENCH MARK (Permanent reference pom U DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELE V..
Name of Plumber: MP/MPR SW No.: County Sanitary Permit Number:
Doug Strohbeen 5432 St. Croix 106119
SEPTIC TANK/HOLDING TANK:
MANUFACTURER
LIOUID CAPACITY.
TANK INLET ELEV..
TANK OUTLET ELEV.:
WARNING LABEL
LOCKING COVER
.
a ~~ ~ t ' ~~
1 ~~ PRQOV~ID~ED:
U~YES ^NO PROVIDED-.
^YES 5JN0
BEDDING. VENT DIA.: VENT MATL.. HIGR WATER NUM BER OF ROAD. PROPERTY
LINE: WELL. BUILDWG. VENT TO FRESH
AIR 1
LET
^YES ®NO ,/ Tr
~'1 ~~
v``"' ALARM
^YES ~NO FEET FROM
NEAREST ~/~
W ~ ~ =
DOSING CHAMBER:
MANUFACTURER BEDDING: LIOUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LO CKING COVER
PROVIDED: P VIDED.
^YES ^NO ^Y S NO YES ^NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY E L L ING VENT TO FRESH
AIR INLET
(DIFFERENCE BETWEEN FEET FROM LI"E
PUMP ON AIVD OFF) ^YES ^NO NEAREST
Check the soil moisture at the depth of plowing
SOIL ABSORPTION SYSTEM LENGTH DIAMETER Mar IAL MA IN
.
or excavation. (lf soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
I.VIV V CTY 11VTVNL J
BED/TRENCH TA I CIYI:
W IDTF~:
/~
LENggq~~rry,,rFF(II
~~
NO. OF
TRENCHES.
DISTR. PIPE SPACING
I ~
COVER
MATERIAL',
PIT
INSIUE DIA
55 PIiS
LIOU10
DEPTH
DIMENSIONS ` .,.. ~
GRAVEL DEPTH FILL DEPTH UISTH. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: O. DI NUMBER OF PROPE RTV WELL BUILDING VENT TO FRESH
B FLOW PIP
ESL
,, AROVE C^OVER. EV INLET E(~+LE V. END: ~}
~
~ PIPES
~ FEET FROM INE
~
'~ '^~ AIR IAN L/E~T
W 'Ia
~
-
T G~ ~1 1~,~~ 1 NEAREST- =~ ~J ,
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
^YES ^NO
OIL COVER TEx TURE PERMANENT MARKERS OHSEH NATION WELLS
^YES ^NO ^YES ^NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER. EDGES.
^YES ^NO
^YES ^NO
^YES ^NO
PRESSURIZED DISTRIBUTION SYSTEM:_
WIDTH: LENGTH. NO. OF
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD
E LE V.. ELEV.'. DIA..
ELEVATION AND
.DISTRIBUTION
INFORMATION HOLE slzE HOLE SPACING. GRILLED CI
^`
COMMENTS: PERMANENT MARKERS:
{ ~ ^YES C
~ q~l
Sketch System on
Reverse Side.
DILHR SBD 6710 IR. 01/82)
ISTR. P
LE V.
H
PES
PLANS
^YES
noNweus NUMBER OF PROPERTY
FEET FROM LINE:
^YES ^NO L NEAREST
~ 7
3~
Retain in county file for audit.
TITLE
Zoning Administrator
~lC~-,c_
~' n y~l
'~ ~ILHR sANITARY PERMIT APPLICATION
Adm
Code
05; Wis
ith ILHR 83
-1n a
d co" T" in RD/
.
.
ccor
.
w IT #
STATE SANITARY PERM
a
l~~~~
-Attach complete plans (to the county copy only) for the system, on paper-not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION
~ NO
^
I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. YES
FOR VARIANCE
PROPERTY OWNER PROPERTY LOCATION
~,~- .SAC/'/4 5~''/4, S 2 T .2y, N, R / E (or
PROPERTY OWNER'S MAILING ADDRESS
`
~ LOT NUMBER BLOCK NUMBER ~SUBDIVISION NAME 1~J
~
' ~/
~.~''~
Z 2
/ ~m X ' l~ /r
J~/4i ~ i ~ i
TATE
CITY, S ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LA/NDMARK
VILLAGE :
//
4d,Sa7~'1 ~/~ SSIf~ /~ 3$' ~ 4 'SO /7 .c/ l h ~ `,~'CG /~-
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family ~ OR ^ Public (Specify):
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 SanitaryPermit 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. ~ Conventional 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):
~S
~ ~
S - ~ Feet ~+p~
J~ Private ^ Joint ^ Public
VI. TANK CAPACITY
in allons
Total
# of
r's Name
r
f
t
M
Prefab. Site
Con-
Steel
Fiber-
Plastic
Exper.
INFORMATION New xisting Gallons Tanks anu
ac
u
e Concrete
structed glass App
Tanks Tanks
Se tic Tank or Holdin Tank / f0 BO W Q r S C r ^
^ ^
Lift Pum Tank/Si hon Chamber
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plu er's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
S~ro 4. b t~cv~ ~ /~~`Sy3 Z Zy z33
Plumber Address (Street, City, State, Zip Code): Name of Designer:
f~--12 t+ N ~w (~ : (~ ~ ~ w ~ a ~~ st ~o ~, ~
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST #
D ~~ s C r; spa hQrs~~ /~~
CST's ADDRESS (Street, City, State, Zip ode) / Phone Number:
-
S g
w~ ~ yell ~S 3g
( L
/~1 bg-J
ts
jf
o:~
,..
~-i
~
IX. COUNTY/DEPARTMENT USE ONLY
`Approved ^ Disapproved
^ Owner Given Initial Sanitary Permit Fee
~ ~ ~~
~ Groundwater
S~j'charge Fee
a ate
a~~ Is ing Agent Signature (No Stamps)
Adverse Determination
s cb
X. COj~MMENTS/REASONS FOR DISAPPROV L: /n~ l , /~~~
~
~ G
'
a>0 l~
~
l" ~~ h ~~~~r~~~ `~
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 in 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//septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fitl 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; wells; water mains/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 Ater --~-
included the creation of surcharges (fees) for a number of regulated practices which Wisco in's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasurB
is used in your building is returned to the groundwater through your soil absorption o
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, _...W
it's worth protecting.
SBD-6398 (R.03/86)
I
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/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 -~-~ /yl, %~dr
Location of/Pro~p/erty S~IJ ~ S~ '~, Section a ~ , T ~ 9 N-R~~
Township !'`~ ~J` S®~~ __ ~ .
Hailing Address / ~ X'~ 2$' Z
~yv __
Address of Site ~~'~S o<~
/~r.t d sD r1 /~J____r__(o / ~
Subdivision pane ~~~ ~~ i i' ~- U,'s~.c ~S/ ~G,' f , A>~
:Lot pumber '~ ~/
Previous Owner of Property
Total Size of Parcel 2, / ~cd~S
Date Parcel was Created ~- ~ 0 ~ Q~
Are all corners and lot lines identifiable? ~~ Yes No
Is this property being developed for resale (spec house) ? ~ Yes No
Volume _ ~ . and Page Number ~~ as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warrantq 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
1 (We) cen.ti.~y zhax a.Q,Q. ~sxatemenza on .th.i.a ~oh.m cv~.e -th.ue Zo xhe be~s.t o6 my (owcl
knaw.~edge; xhat I (we) am (cute) .the ownen(b) o>i the pnopenty de~schi.bed .~n .th.is
~.n ~o~-mati,on Bohm, by v.v-,tue o 6 a wcuvcanxy deed econded ~.n xhe O ~ h~.ce o 5 zhe
County Reg.csxeh. o~ Deeds a~ flocumer~t No. ~ ~ ~-~{~ 1 and ~h.at I IWeI nhoaent~u
18TH , FIRST AODITIOM
p IN THE !M- I /4 Vf THE sE I /4 ANO THE NMI 1 /4 pf
NU~RIlM~TOMiN Of MUOlON~lT CROIX COUNTS ~
OF' DEDICATION
certify that we caused the land described
divided, mapped and dedicated a•
fe also certify that thin plat i• required
~e submitted to the following foe approval
of Development; Department of Industry,
~s, St. Croix County Comprehensive
g Commission, Town of Hudson.
seal of said owners this ~9 day of ~JU1/•~
1
~r Y . • enoy
at terine A.Benoy~
CatherrinyAayl3enoyorto me'known to beove
e foregoing instrument and aclmowledged the
.__
a~e~l, Wisconsin
xpires / ~ :, ~~/
~-~-~
CERTIFICATE OF TOWN CLERK
STATE OF WISCONSIN)
1SS
ST. CROIX COUNTY 1
1, Rita Horne, being the duly appointed, qualified and aetlnq town
clerk of the Town of Hudson, hereby certify that copies of this plat
t+ere forwarded as required by a.2)6.12 12- on the t r• day of
1987, and that within the 20-day liwit set by ., 2)6,12 (~) fno '-
objections to the plat have been filed) tall objection. to tM plat
--h~~a//ve been met - . y
Datf Rit Norne, Town Clerk
COUNTY TREASURER'S CERTIFICATE
STATE OF WISCONSIN)
ISS
ST. CROIX COUNTY -
I, Mary Jean [:ivermore, being the duly elected, qualltied and aeting
treasurer of St. Croix County, hereby certify that the record. in tsy
otfice show no unredeemed tax sales end •nd no unpaid tattea or specie
assessments as of ~2-3,!-8S affecting tba lands laclttded in the
plat of Prairie Vista, F~}st A dition ^
~~ y / O -.~~ ~~+s1t~N
Date Mary Jean oerspre, County ! ~aayrer ~~ ~~
~NSt~ ,
6i. gMQ N, wM.
6tist1e1l.6tes161t~
.;
"'s`~/i~
- r
".~ ~
."~~~~~
~ ~ ni,
II. • @9CK v~t~ f~n''~.. t~ TM16 EFACE REiERV[D FOR R[GOROINY YAIA
+{ DOCUMENT NO. WARRANTY D~~~
' STATE BAR OF WISCONSIN FORM 2-1Y88
43909 RtGISY~R'~ OFFICE
~I, i i
~r,~:: _ ST. CROIX CO., WI
_ RK'd for Record
Sam E Miller,..a_ single man
.:~ ::..'_.. ~u~ i 1988
.... .
of 11:00 A
conre)a and ~~'s.rranta to .',~homas M. Gannon. andthalhy . M. ofannon,
hus.baad .and-.wife .aa marital properpty . 8h ~ (9 ~-
. ApisNr a1 Oa~ds
eurvivosship ..._-- ~ -
. .
_.,, Fl7UFN l0
. ... ..
First Federal S6L of Le Cross
.......
... _....
201 S. 2nd St.
Hudson, WI 540
... ....... ..County ,
-~ '~~' ~~ St. Croix
......................
the following described real estate rn .
State)o[ Wisconsin: Ta: Parcel No :.............................
Lot,/11, Plat of Prairie Vista, First Addition in the Town
of Hudson.
moo
FEE
This _1S. IIO.t.......... homestead propert;:.
(~ (is n6t)
Exception to warranties: easements and protective covenants or restrictions
of record, if any.
~^ ~ June 19 88
Dated this ~.7(/ da>' of /'a ~ ~,~j~/
(SEALJ ~~ 7fj,~.AJ ~~ ~v""
Sam E. Miller
(SEALI
AIITgSNTICATION
Signature(s)
authenticated this ........day of......... 19.
. - ...
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, ............._...._.. .__.
authorized by 4 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BV
Lois A. Murray, HEYW00D, CARL & HURRAY
p.O.~Box 229, Hudson, WI 54016
(Signatures may he authenticated or acknuwled>:ed. $oth
are not necessary.)
t~F:Al.I
t~E.al.t
ACKNOWLEDdMENT
STATE OF WISCOti3IN
ss.
SL...CLUix....._... .. Counh'.
~ • ~ da~• 8f
Yersunull)• came before me this .
_. 1J 88 .the abu~•e namcli
,71ine .................
Saa 1;.,..Mitlle>;..
to me knu~cn to be '•'\J~CrwJ~,"1~,. •, ~chu esecated the
forehoint: instruinetind acknAv.ie~lt:e, file ~aule•
'•• NOT^RY .
(, ~ •
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\ota''~ uhlir aS ~y7'
>l~. 9,• it'tV:Ali/•R~'~~,~'gAt. >tutr i•':r Catinr:
('~~ uui~=ion I ... ~ ~
date
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UNPi,ATTCD LANDS_
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109035 Square Feet
(6.503 Acres)
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Sertion Corner Monument, flerntaen Cap
• 1" Iron Pipe Found
O t"x I0" Round Iron Ftipe WeiRhint 3,65 LAa/1_in. Ft. Bet
11"x21" Round Iron Pipe ttleiRhly 1,6t Lb•/Lfa. FY. Bet
at all Other Lot Corners)
Common Driveway Point - 20' on eaeA Lot runnint
40' afoot common lot iinc.
_ _ Drainage and utility easement (width ae shown),
UNPI,/-TTCD LANDS _
0109 ouare Feet 0'
,574 Acres)
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t~ 123477 Square Feet
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(2,558 Acrea) r ~6' EAttMENT ~
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(2.044 Acrea)
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101373 Square Feet I
(2.327 Acrea)
107355 Square Feet
(2.465 Acrea)
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138050 Square Feet i 'Ei~ ' l ~ _e ~,
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ll! 2Y9f E p01M ~ ~ ~ W ~II--.-'-~ `t `~ ~._N ~~N _ 1
SE Corner
Section 21 -----_ _.~,~,~ _
Tt9N, R 19W ~~~
ST C- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER S@.~ ~,~~~Q'i
ROUTE/BOX NUMBER ,~,~~~BeK'~ZS ~- Fire Number ~`
CITY/STATE~~So« GjZ `I.IP S~%~0~~
PROPERTY LOCATION:SGI/ ~, S ~ ~, Section Z / T ~' N, R / W
Town of h`t~4-sns-~ St . Croix County,
Subdivision~a~~r ~¢ UiS~q ~S~ca~~ 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 licensed septic tank dumper. Wliat you put into
the system can affect the function of tl+e septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents m_~
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 requlrement that
systems properly
The property owner agrees to submit to St. Croix County 7.oning 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), t}re 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 WLsconsin Depart-
menC of. Natural Kesources. Certification form must be completed
and returned to the St. Croix County 'l.oning Office within 30 days
of the three year expiration date.
St. .Croix County Zoning Office
P.O. Box 98
Hammond, WI SG015
715-796-2239 or 715-425-8363
SICNE ~,~ ~~ t~ _^
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Sign, date and return to above address.
•DEPARTI~ENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, CC DIVISION
HUMAN I4EDLATIONS PERCOLATION TESTS (~~J) MADISON W 53707
(H63.0911) & Chapter 145.045)
LOCATION: S
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Sr SECTION:
a l /T~`l N/R/ya ( TOWNSHIP
d LOT NO.:
~~ BLK. NO.:
- S BDIVISION NAME:
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COUNTY:
S7~• C./~di OWNER'S BUYER'S NAME:
~ M /'~~ /~tr MAILIN ADDRESS: / /
rv~c.~. Qi^oo/~ ~. /~llNSa., t~5 ..fYvl~
/SE
NO. BEDRMS.: COMMERCIAL DESCRIPTION:
Residence ~ A ` /e New ^ Replace.
`s / /7 So.`/ ~t~P
RATING: S= Site suitable for system U=Site unsuitable for system Q G- .S^.f`~
DATES OBSERVATIONS MADE
PROFILE DESCRIPTIONS: PER OLAT ON TESTS:
,p S 3 ~8" s-.~ -~d'
/ ~ /f DAM
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional)
If Percolation Tests are NOT re wired DESIGN RATE:
Q If any portion of the tested area is in the
under s.H63.09(51(b), indicate: ~ Floodplain, indicate Floodplain elevation: ~/~
PROFILE DESCRIPTIONS
BORING TOTAL/ D PTH TO GROUN DWATER-FP1CFi~ES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH.Ffd; ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
r .~ el~, •Y Bhi, , y eHs/, ,sBh r~s,
B- -2 ?..~5` ' ,r.~.lr~ ~ 7.S' ~ Btl,~ cBr s!`s6 Bh ~r /Sj ,Z. 61f.1~-s
B- 3 ~r
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O cf
~ ~ ~ ~]' jy'i / /.2 q / 8 gn S' l~ /. / E3n ~~- /S~
B- .S~ r r 7 ~ ~ 7 B ~ l~ . ~ Bri /~ . S' ~n~ r S/~ . C Bn ~r /'si
B-
PERCOLATION TESTS
TEST DEPTH/ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER FN1y~•FES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P RI •PER INCH
P- / .3' a 2 ~.3
p_,Z y,• O Z L
P- o ~ 3
P-.
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope,
SYSTEM ELEVATION Jam; 7 ~ ~S~le ~~~= Y°
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TN
EITR~1~Ti®NS FAR CaMPLETING FARM 115 - SSCt - 6395
To be a cornplete anci accurate soil test, your rel>ort must ir~ciu<1e: ~,
~. Complete legal description;
2. The use section rrrust clearly indicate whether this is a residence ar rommercial project;
3. MAXIMU~II number of bedrooms or cc,~mmereia{ use t~lanned;
4. Is this a new o+ rep{acement syster~i,
5. Co n7p?ete the suitability rating boxes. A SITE IS StJITA6LE FOR A HC}LDING TANK ONLY IF ALL
C~TF{ER SYSTEI~IS ARE RULED C}i.1T BASED N SC)IL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing,.profile descriptions ar~cl completing the plot plan;
7. IVIAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
sei~arate sheen rt~ay be r.rsed if desired;
B, ft~ake sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, if appropriated
7~3. If infarmation (such as flood plain, elevation) does not apply, place IV.A. ire the appropriate box;
i ~ . Si~ `je form ancf place your current address and your certifjcation number;
32~ Js~ legible copies and distribute as rertuired. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY Ut;'ITHIN 30 DAYS OF COMPLETION.
~1313R~V9AT8NS F®R RTIFIEC.~ SCDIIW. TESTERS
Soil ;separates arad Textures Other Symbols
st -Stone (over 10") BR - Bedrock
cob - Cobble {3 - 1(}"} SS -Sandstone
gr -- Gravel #under 3"`} LS - Limestone
~~s - HGlrJ -- High GroGrndwater
is - ~~ Sand Pere -- Percolation R<~te
med s ~a~~ , S:;nd bN - >~Vell
fs - F r ~ :'r;nd E3idg ~- Building
(s - Loamy SanE ~ -Greater Than
'`sl - ~dy Lc>arr~ ~ -Less Tian
`I _ -,~ Bn - Broswn
~siC - ~; Loam BI ...- Black
si - `; 't Gy -Gray
'el -Clay Loam Y - . Yellow
-_ 5 ; rdy Gray Li~a'm ~ R - ~Recf
_. ,, ~°'ay Loam not - Mottles
-- ...~ly Cfay w;' -with
~,' Clay ftf -few _ _, fain?
~'e _ ~ cc -- core :arse
pt _ ;~r~rtt -- Mari ~m
rr`r --- .. `~ ~ d -- distir
p ~ prom:
Ht~1L -High ~evel,
Six er3eral textures s
fior lit~uic' °° ^ disposal BNl - Be
VRP -- Ves Point
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