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020-1240-60-000
35-~~/ ~, -,~~~ tee/"' 1, ~/ IMMMNM~p1A ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, Wt 54016-7710 (715) 386-4680 April 28, 1994 Mr. and Mrs. Richard Perry 512 Jacobs Ladder Circle `~,~ ~~ Hudson, Wisconsin 54016 W RE: Water Inspection Results for Richard and Amy Perry Address: 512 Jacobs Ladder Circle, Hudson, Wisconsin Dear Mr. and Mrs. Perry: Enclosed is the original test results from Commercial Testing .Laboratory, Inc. for water inspection of the above property. If you have any questions with regard to said report, please let me know. incer ly, r....~-1 es K. Thompson Assistant Zoning Administrator mz Enclosure COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ST. CfiOIX COI~[TY ZONING OFFICE ST.CROIX CTY GOV.CTR 1101 CARMICF#~i.. ROAR iitlDSON, WI S401b ATTN: TFit~S G. NELSON Colifora bacteria/100 mt Nitrate-iditrogen, a~g1L -.~.`NDEGENpFN, ~~ h~ 0 ~~ REPOI:tT NO.: bG7i3/Oi. REPORT T.~ATE: 4/?2194 BATE RECEIVED: 4/19/94 QWNER: Richard 6 AmY Ferry LOCATION 512 Jacobs Ladder Cr., Nudson COLLECTOR: Jim Thompson DATE COLLECTED: 4-18-94 TIME COLLECTED: 3ti5pw SOI~C~ OF SAMPLE: Outside tap LATE ANALYZEL~:4-19-94 TYME ANALYZED:2'+OOpm COLIFORM,MFCC: 0 /100 m!. INTERPRETATION: DarterioLogicalty SAFE NITRATE-N: 4 ppm Above IO ppsl exceeds the recommer-ded F'ub L i c Lhiaking Water Standards LAB TECHNICFAN: Pam Dane ~'~~,~~~ 1JI Approved Lab Na. 14 < Means "LESS TI-L4N" Detettabte Leve4 Approved by: PROFESSIONAL LABORATORY SERVICES SINCE 1952 PAGE 1 3~ - ~~ .~ ~~~. ... ~~ April 18, 1994 Richard and Amy Perry 512 Jacobs Ladder Circle Hudson, Wisconsin 54016 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 RE: Septic Inspection for Above Residence Dear Mr. and Mrs. Perry: An inspection of the septic system of your property located at 512 Jacobs Ladder Circle, Hudson, Wisconsin, was conducted today, April 18, 1994. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Also, water samples were taken. will forward the same on tv you with regard to the above, please office. incer ly, mes K. Thomp~ c~ -- Assistant Zoning Administrator mz Once we receive the results, we Should you have any questions do not hesitate in contacting our ~ ~n1 ~ ~,; ~.~ ~3s-4~ ~ ~ ~ ~~ ~~~ ,. ~ ~~~~ ~ ST. CROIX COUNTY "~ ~~~ ~,,,~,~~~, ~ ~ ,~ WISCONSIN J~l ~ ---- 't ZONING OFFICE r r r r p p p a i - r^^.~ ST. CROIX COUNTY GOVERNMENT CENTER '~. , _ 1101 Carmichael Road a .,~ =~--.~ Hudson, WI 54016-7710 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQIIEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. ^ Water (VOC's) $185.00 -Septic $50.00 ~/Water (Nitrate & Bacteria) 45.00 ^ Nitrate & Bacteria retest $15.00 Owner: VC~ ~~ Requested by: V~L ~~r Address : I ~ Ctic~; ~ ~ ~~' +C,I~. Address : ~ ~~ ~.~lti ~ ZIP OI ZIP Telephone NQ: (~~) - ~ Telephone N°: (L) -7b?b Property address (Fire N4 & Street) : '~; ~- ~ gC.pIC~ L~~r iY~1~ Location: ;, ;, Sec. , T N, R W, Town of a(7~ Realty firm: ~ Lock Box Combo: IN ~ Closing Date: ZZ TO BE COMPLETED BY PROPERTY OWN$"~`~ PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVE'~,SE~'{ ~, Water sample tap location:_ Is the dwelling currently If vacant, date last occup Age of septic system: Septic tank last pumped by:_ Previous Owner's Name(s):_ occupied? -®' Yep --. ^ No _ied : .~ ~ Have any of the following been observed? ^Y ~N Slow drainage from house. ^Y .~T Sewage Back-up into dwelling. ^Y~~`~ Sewage discharge to ground surface ^Y R~1N Foul odors . Other comments relative to system operation: ,t - _ ao r, ~r3t;~ ;___, ,. Date: !~~3 or road ditch. Z certify that the above information is complete and true to the best of my knowledge. ,I /1 ,` OWNERS SIGNATURE : ~~ DATE : 7 "~"/ " ~`7 1/94 ~- r .~ OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION I~ o ~~~~.~L TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ^Yes ^No Soil series per SCS Soil Survey: sheet # T e of soil absor ti n s stem: ^Below grd ^At-Grd OMound Approx. size ~'X ^Gravity ^Dose ^Pressurized Ft.2 ^Bed ^Trench ^Dry Well OHolding Tank ^Outfall pipe OBSERVED DEFICIENCIES ^Other ^Unknown Septic tank S tbacks: ^House ^Well~^Prop. line~~ ^Other Dos t k acks: ^House OWell ^Prop. line ^Other Lo king cover ^Warninglabel ^Pump/Floats ^Alarm ^Elec. wring Soil Absorption Syste Setbacks: ^House^We11~Prop. line[~J~~,OOther ^Ponding:~ ~ ^Discharge: General comments : ~~~ ~z~;~.- G~,L1~Q~.~ ~ ~,.~ ,~. ~y,., ~ . ~~ .- O' i. 3~i ~°"- , ~T. Inspecto / '` ' Title INSPECTORS SKETCH OF SYSTEM LOCATION 3 ~ ~ I o d~ C ~+ 3 0 5i ~ c .. 3 d ~ C! 3 ^~ ~1 ~1. I ~ ~ ~ I .,ter ~ ~ ` G ~j <D ~ ~ ~, • ~3 I ~ `° ~ ~ ~ n M ~ j I~ a. ~ ~ ~ N ~ ~ 7 I ~ Z t,~ H c°o ~ ~, o~ N = ir, I,~~ o ~ ~~ ~I ~o ~ ~ lob; ~ ~ I ~~~ ~ O ` J 3 = ~ ~ A N ? ~ ~ fill fyA ~ ` * C N 7 f N N ~ .+ m C 'O ~ O R I ~ cn Z D y I ~ tea cn ~ D C1 m a c a ~. m rn D ~' , , ~ a ~n N ~' a r `C I -o m ~° n ~ I a m co m o a ° ~ 3 I ' ~ O -~ o r 3Nd I ~ c n ~Nf~ l : ~ ,tea , '~'~ ~~~ O ~ Q c 3 ~ 'G ~r ~ ~ 'v 2 I ~ ~ ~ y °: c o ~ a ~ ~ ~ 3 ~ ~ ~ ~ ~ N L ~ ~ 3 ~ ~ o, ~ ~Q ~vv,g Q ~vq Q ~'' ~ ., ~ ~ v 3 °-' ~ I ~ °-' a N . . ~ fG . ~ f~ D. ' * 7 Z O (A Q x a~ D I ~ ~ ~~ ~ I O = a s o o h I ~ o in ~ ~ p c ~ ~ c C x N A a ~ c ~ N. ~ W a ~ 3 s= ~ 3 . 7 I Z m d~ I m ~ -i fn O .~+ N 3 ~ ~ C ~ f/l ~ C p, Z ID .a ~ L*. ~ ~ a I a ~ ~ ~ I ~~ I ~~ i Z -I I ~ I c 3 ~ z c A .Z1 ~ 'Y ~ M ~ t0 C < N ~ y Z < I ~ I ~ 1`ti W pj W I 03K 2m D C X Sl ~ I ~.y a ~' ~ m n ~ °' ~ ~ I ~ m °' ~ I C ~ ~ .n. N -h a N O7 W ~ 7 O=- 7 aC ° ~ o a I ~ m' o a I N n N ~ I ~ , ~ c y ~». O t0 ~ y I am ~~.3 I o I ~.ao m ~ I 3 ~ sm m~Q X m C A ~ C lA N ~. ~ yC d R (O ~ ~ ~ 7 y ~ I ~~° o o I a ~. (~ 7 Q a ` d l0 ~ . m O ~ -~' i ~ O O A :~ W N ya H ~ p ~ p ~ ~ ~ O ~ O ~ O L ti Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ~' 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 Persin er, Rick Hudson Townshi CST BM Elev: f Insp. BM Elev: ~ BM Description: ~ ` l ~ ~ I~~ , ( }Q TANK INFORMATION TYPE MANUFACTURER 5~ ~~ ~. ~; n.c'. CAPACITY Septic j jar r* /?~...J~ ~~..~ ~ >1~ ~' ~Csc_.~' Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD ~~ + ~ ~ 3c~' 3~,' _~ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Numb r TDH Lift Friction Loss System He TDH Ft Forcemain Leng Dist. to Well JVIL H6JVK1"1IVIV Ji.'!1 CIVI ELEVATION DATA County: S{. CroiX Sanitary Permit No: 463170 0 State Plan ID No: Parcel Tax No: 020-1240-60-000 Section/Town/Range/Map No: 21.29.19.1247 STATION BS HI FS ELEV. Benchmark 3 3`~ /03..35 /0~ Alt. BM l~olr~, ' ~~ . ~,~ ~-- -7. ~~ • e ~, ~ 9'~ - ~3 Bldg Sewer ~. ~ n SUHt Inlet ~ y 9y ,~~ St/Ht Outlet ~ ~ , .7 Dt Inlet Dt Bottom ~~ ~. Header/Man. io ~, `i'ii I, ~• ~ Dist. Pipe ~~' y ~ ~jl. -~ dot. System Final Grade ~•~ ~b , St Cover . ~ `j 1! • 5 ~ ~ ~ s ._.~ I '~ . ~ ~ + us V ~ ~ l.i V I '~ ~Z.rj QC~.. J~J BED/TRENCH Width ~ Length ~ ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ .,~~~~\ ~ /~, ~~~~ t'~ V ~ \_ ~_ SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer:,, ~. ,~~~~ .1-n '°~ Type Of System: ~ , f ~ Gr ~ /~ i A ~~ ~+ UNIT Model Number: r C~ ~ v i Z 't _ i t!~ / ~ ~ tl c h . DISTRIBUTION SYSTEM ~k Header/Manifold `~ Distribution x Hote Size x Hole Spacing Vent to Ai Inta e Di h~ L h Di S i ' Lengt _ a__ engt a pac ng q, . SOIL COVER Y Prassura Svsfams Anly YY Mnund Ar At.Grade Systems ~nIV Depth Over ~ Depth Over xx Depth of xx SeededlSodded xx Mulehed Bed/Trench Center L". ~~. 1 ~ Bed/Trench Edges \ Topsoil \ ~ Yes [~ No Yes j I No COMMENTS: (Include code discrepencies, persons present, etc.) inspection #1: / / Location: 512 Jacobs Ladder Circle Hudson, WI 54016 (NW 1/4 SW 1!4 21 T29N R19W) Jacobs Landing Lot 25 1.) Alt BM Description = ~~; ~~•~ °~ '~~= ~`~`~ ~' 2.) Bldg sewer length = ~ t i ~ -amount of cover = ~ ~ ~ ~~~ ~.C~ ~I'~° ~`^~""'~ ~ S~~ t n~ ~- ~ ~ ~ ~, ~.,t~ C _~ ~ revision Required? I i Yes No ~1 ; ,.~ ~~ I 'per side for additional information. ~ ~_ __ 1 ~ 3197) Date Insepctor's Si ature Inspection #2: / / Parcel No: 21.29.19.1247 ~~ ~ ~t~ ~~~' ) I ~ ~ ~ _ ~~ Cert. No. Safety and 13utldrngs urvrsron cou C/1 201 W. Washington Ave., P.O. Box 7162 / /~ ~seons~n Madiso/n,~ WI 53707 - 7 62 Site Address 'fir ~ ~ ~ Department of Commerce O C~ CO yr ~ . 1// Sanitary Permit Application ~ Sanitary Permit Number ,~~ 31 ~o In accord with Comm 83.21, Wis. Adm. Code, personal i rtna ^ Check if Revision ma be used for second ses Privac Law, s15. I. Application Information -Please Print All Information rate Plan I.D. Number ' Property Owner's Name Parcel Number /2 ~L t ~ ST. CROIX COUNTY . Qa ~ ^l~ ff G Property Owner's Mailing Ad dress Z NING OFFICE Pro pe ~ty Location / f ` f~ `7 ~ GZ~~I ~I~PGh-L~ p® , lv ~,f~J~j ~,i : Sr~ ToZ N. City, State ~~~~~~ ~« f Zip Cade/ / ~ G ` b Phone Number ~/~ t Blnck Number bdivisi N , on ame CSM L j mbe II. Type of Building (check all that apply) ^City 1 or 2 Family Dwelling - Number of Bedrooms _ _ ^Village ^ Public/Cornmeroial -Describe Use _ Township ~ ^ State Owned Nearest Road ~~ ~~~1~ III. Type of Permit: (Check only one box on line A (numbering scheme for.internal rue). Complete line B if applicablr~) p'' 1 ^ New Replacement System 3 ^ Replacement of 6 Addition to For County use S stem Taak Onl xisrin S stem B• ^ Check if Sanitary Permit Previously Issued Pertntt Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44 1p Non -Pressurized In-Ground 21^ Mound 47 ^ Sand Filter 50 ^ Constructed Wetland / ` 22 ^ Pressurized In-Ground 41 ^ Holding Tank 48 ^ Single Pass S1 ^ Drip Line 45 ^ At-Grade 46 ^ Aerobic Treatment Unit 49 ^ Recirculating 30 ^ Other V. Dis ersaUTreatment Area Informat ion: Design Flow (gpd) Dispersal Area Dispersal Area Soil Applica[ion Percolation Race System Elevation Final Grade ~ ~ Required 6~~ Proposed ~ Rate(Gals./Days/Sq.Ft.) (Min./Inch) C{i / ~ !/ "7 ` Elevarion ~Bj. ~ .. 6 ~ ~ ~ ~ ~.a VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Seal Fi r Pl: aie Gallons Galloru of Tanks Concrete Constructed Glass New Tanks Existint Tanks / i~ir`~ /O©~ Septic or Noldin` Tank ~ t~O D ~ ~G,~ D p Dosing Chamber __..~ VII. Responsibility Statement- I, the undersigned, assttme responsibility for installation of the POWTS shown on the attached pl„~tu. ~~ Plumber's Name (Print) Plu r' Signature MPJMPRS Number Busirress Phon: Number rum is Addre (Street, City, State, Zip Code) VIII. Count /De artment Use Onl ,~ Approved ^ Disa ^ Sarutary Permit Fee (includes Groundwater Surcharge Fee) Date Issued Issuing gene Signamre (No Stan ps) O n Ini l,~dverse ~ 2~._.... ~( ( q 2 Determination ~ , . I __ l:X. Conditions of Approval/Reazons for Disapproval 3~ (~~(' ~~ J,~~ ~ ~~ ~ U.. i ~ Z~ SYSTEM OWNER: °'^ ~~-t-c~2~a~, 7 Septic tank, effluent filter and Q~_~-S-~-,--- , ~ dispersal cell must all be serviced /maintained ~~ f~S"f ~ as per management plan provided by plumber. _~~ " 2. All setback requirements must ha maintainRrl ~ ~ `` 1.~~}-; ~ i Btn e~l~-IC.t~~~4 ~ „~i . L as per applicable cddb/bt~lir~dclEets!~ eta me county coty3 rot the sy:tem_~ PaP~~nna l~r t' ~ ~,C a;~o(I ~~ SBD-6398 (R. OS/O1) ~t ke.~ b'e(~ l-~'!~` O~P~ n?J~~ ~, ~ ~~ -._' ~~ C~ i,K, C(s~ci~t"( zou i~uG . KEN SCH M ITZ INC. Septic Systems Design & Installed MPRS/CSTM 284173 l ~~ P.O. Box 160 / / ` SHELL LAKE, WI 54871 ~~j' ~'~b 5 ~,,~~l~r/•~ C/.t'c ~t' (715) 468-243 I ,~ _ ~3~- 1~° ~ - ~ ~~`~L ~ ~ ~F 00 ~"~ ~~ ~ _ ~ r~ ~ ~~~~~ ~~ ~~ ~,~~yr 1 ~`T,~ ~( ~ ~,~~ { ®~ ~, r.., r i ~ ~ ._ Q I~t~ ~~' IGR~ . r~ ~~- T q~~ ~- 00 ~~ I' ~'~. 99, S /L 1~3o~~f I ~ 17 ~~ r~ ~F ~~ ~ ~g ~Q ~ ~~~ +~ ~ ~ ~R~ ~actfi~ 1] f~ l ~~ , 3 ti '~` Q C I~ ~E C,p ~l1__T ~~ S' !~~ CQ,~f ~/1/v~/ivy' ~r V 1~° ~~, r~ ~ ~1~~~ l~ ~r nA d~ BiR~P Pte''" ~~t ,~ ~~L _~Lc~ a~~r -~ ~~~ KEN SCHMITZ INC. Septic Systems Design & Installed MPRS/CSTM 224173 J ~~ P.O. Box 160 J SHELL LAKE, WI 54871 _ ,~jq c~d~s ~~~~~~.~ C~~c'G ~t • (715) 468-243¢ _ I ~~ E ~~ . ~ j~ ~~~ ~ ~~~~ ..rah /~ .T-_ Ir z ~~ ~ o ~~ Wisconsin Department of Commerce ~ C~!~~OIL EVALUATION REPORT Division of Safety and Buildings Page ~ of n~ccoraance w~ur wmm aa, vv~s. Ham. was County Attach complete site plan on paper not less than 81/ ¢e Plan must indude, but not limited to: vertical and horizontal ref . n nce gLe~r~{ -~ Parcel I.D. percent sbpe, scale or dimensions, north arrow, and ~ ~ ocati fe rest r ad. © a Please print all info ation. Revi ed by Date Personal inforrna6on you provide may be used for seconds TT pp ~^, purpo Rriv~y C8w2~ l'P~'~ (1) ( )). q (~' ~9 Pro rty, l ' ST. CROIX C PropertyL lion T~ ZONING F • Lot I 1/4 f ~/I/4 ~ T 9 N R ~ ~W roperiy Owner's Mailing Address / bdc # Subd. Name or CSM# City State Zip Code Phone Number ^ City ^ Village Town Nearest Road ~ / R t C c~ a ~s ~ ~o> i ) ~ ~ ~~. ^ New Construction Use: Residential / Number of bedrooms ~_ Code derived design flow rate ~8 GPD Replacement ^ Public r rqm erdal -Describe: Parent material Flood Plain elevation if applicable ft General continents and recommendations: Cr~~~F.' ~~~~ U " / r ~ ~ ~ ~~ Boring # ~ Boring Pit Ground surface elev. ft. Depth to limiting factor ~ in. Soil cation Rate Horizon Depth Dominant Color Redox Description Texture Strud;<rre Consistence Boundary Roots GP D/IF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 °~ - ~~~ 1, -- - , ~i•z 9~- z Boring # ~ Boring Pit Ground surface elev. ~~~ ft. Depth to limiting factor ~ m. Sal cation Rate Horizon Depth Dominant Caor Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eft#1 'Eff#2 .' ~ -- ~ ~ ~ 3.0 fit. 2 9~- Z • Effluent #1 = BOD > 30 < 220 L T < 150 mg/L ' Effl nt = BOD < 30 mglL and TSS < 30 mg/L CST Narr~ (Please Print) ~ _ ~, _ ~.._.,....'. S' ~tur CST Number P.O. BOX 160 SHELL LAKE,_WI 54871 Property Owner ~~ l~ ,'/•.L~i[~,~~~~ /' ~g' i~.`;y t P z yy ~f Parcel 1D # ~v~ ~ %v2''~ ~p "' DD ~ t Page ~` of~ ^ Boring ~ Boring # pit Ground surface elev. ~ ~~. Depth to limiting factor ~ in. , sal ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Dltlz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 ~y v ~ ~ ~ ~ ~ f~f ~ ~r ~ f i eJl .Z /I5,2 D Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil cation Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#'1 •Eff#2 Boring # ~ ~~ ^ pit Ground surface elev. ft. Depth to limiting factor in. Sal ica6on Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/}~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 'Effluent #1 = BODS > 30 < 220 mgll and TSS >30 < 150 mglL • Effluent #2 =GODS < 30 mglL and TSS < 30 nxyL 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. seo-ssso oe.ovoo> ' ` P ` ~ - KEN SCHMITZ INC. Septic Systems Design & Installed MPRS/CSTM 224173 ~/~ P.O. Box 160 I SHELL LAKE, WI 54871 ~?~ CC~S h~¢/1~r~2 C~,F'c ~c' o~,t~~` ~ (715) 468-24304 ~ n i r~n j~~c-',~T ~{ ~~ F,~~ ~'~' ~` '~ -X~y~`"r j`~ 1 j, 7~ .~~ ~~ °~~oo` /~ ~~ z I o a ~ ~~ ~R `'"" f~ e -l~'~L~ ~X~ T~i ~,'v`~~ ~'~. 99, s lR~ ~ ~ p~ r ~~ .B3 ~~ r 3 ,! z ,. J~ ~ ~~ ~~_~_ ~a~so~i f~/~s c 5'~ ~/.~ ~"~ ~ f/irea,ds ~/r~~i,~-~ • KEN SCH M ITZ INC. ' Septic Systems Design & Installed MPRS/CSTM 224173 ~ P.O. Box 160 SHELL LAKE, WI 54871 (715) 468.2434 Owner: ~~. .. ~~ Private On-Site Wastewater Treatment System (POWYS) ' ' Index and Title Sheet .... ' Project Name•and System Type; Location: ~ ~ S ~i~ca,6~i1-~~ ,~~~IlrJ 5~ Legal Descn lion ' - /-~c~~sA~~ .~~. I'` Goo ~,~ G~ bra eft-GQ,~s ,~`y~ ~i•~~-L~ Street Address ~~ r ~ Township/County Contents: Page 1; ~/c_ ~ ~ Page 2; Page 3: /~/9/f/ /~~r~c 4 Page 4; G ~ ~~G ~o~. ~,,~~ G~ ~ Q ~7 ~7 Page S; Page 6; ' Page 7: Page 8; Page 9: Attachments: _ ~~ ~ Plumber/Designer /~.~/1/ ~G/~i~i-j ~ ~Z- Signed: _ ,.. ~ Credential Number: ~~~ ~ as ~/ ~~j Date~~ ~~ ~, Q ~f L ,~ ~, ~ ~ ~~ ~` a 0 O ~ ~ -~ U 3 ~ H ~ c~i a Q •~ .O U c/~ • I~ b :~ w a a O ,~ ti b W ~' ai ~ `~ II II ~ ~ ~ ~ ~ ~ a~ ~ ~ ~' ~ c II ~' ~° -~~. ~ ~ a ,~ ~ ,.a a~ ~ ` '• •'•' > `0 .., ., ., . • ~ ~ `,~ ~ U ~ ~ ... • .c~ ' '' • ~qi. a .~ '~ ~ .' ..' ~ ' o `'l ,~. •• ~ '~ ~ •. , a f.~..•.. •. a ~. II •• ,1 ~~ .. c ~~: ti, a O f '• .• ~~ •_..._ ~ .::. cd IJ I~ h II ~ ~ ~ ~g ~ ~ ~3 ~ W ~g U . bb `'~' o •o ~ !~ id P80PERTY OWNER I J ~J ~ ~ ,~~~ i1i ~/Z TOWNSHIP lyGe 50 T Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. Number of Bedrooms Desi n Flow -Peak d Estimated Flow - Avera e d Se tic Tank Ca aci al D Soil Abso lion Com onent Size T e of Wastewater Domestic Table 2: Soil Absorption Component :Limits of Reliable Operation Se tic Tank Com onent Soil Abso lion Com onent Desi n Flow -Peak d 0 O Maximum Influent Particle Size in NA 1/8 Maximum BOD$ m /L NA 220 Maximum TSS m /L NA 150 Maximum FOG NA 30 Table 3: Maintenance Schedule Se tic Tank Ins ect and/or service once eve 3 ears Outlet Filter Should ins ect once a ear and clean once eve 3 ears Soil Abso tion Com onent Ins ect once eve 3 ears Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The fili;er cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously, Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The , septic tank shall have its contents removed when the volume of scum and sludge in the tank ~~~-rte.. ~.~~~ This management plan complies with Comm 83.54, Wis. Adm. Code, and Ground Soil Absorption Component Manual for Private Onsite Was er Treatmerlt,S~te~~ rT~ SBD-10567-P (R.6/99). PL-s _' tt~~-~/S, ~(o~,. 2`f3 ~ Table 1: S stem Desi n S ecifications ~X Cto-x Cota.wrr'Y ~c~i~ 4 Sanita Permit Number 1 - s: ~$p i>v ice ~~F Management Plan for a Septic Tank and Soil Absorption Component exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be pertormed to maintain less than maximum scum and sludge accumulation in the tank. Manhole 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. i=xposed 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 one should enter a septic or other treatment or holding tank for any reason without being In full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the Interior of the tank maybe difficuk or Impossible. Tank abandonment shall be in accordance with Comm 83.33, Ws. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this• component are shown in Table 2. . The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall inGude recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered. a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is. usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion. of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic Dogging of the~soil. Plantings of deep-rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. - ~ooz ' ST, C~tOIX COUN'~'X SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSI~ CERTIFICATION FORM Owner/Buyer iG~< G~i ~~. ~' Mailing Address _ ~~a Property Address SI City/State ` C~LS(N\ ' LEGAL DESCRIPTYON gom Plannirsg for acw construction.) Pttreel Identi~iCAtion Number l~D? D / ~ ~ D ~Q =,~ p~ '' Prrn~rty T_octticy ,~ y; , J W . , Sec. ~ T ~N R~W, Toum of I l wl s t*JY1 Subdivision ~C(.C010 5 ~C(,Y1+d~,j1r~ ~, Lot # ~. Certified Survey Map # ,~,~/ Volume ,Page # ~. Warranty Deed # ~~Lp 1 7 ~ y ,Volume L Page # Spec house ~ no Lot lines identifiable yes no SXSTE ~Pr'oPa' use ~ tnaintertttuce of your septic system could result in its pt+emature failure to handlo wastex 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 cgu a~'oct the ftwction of the septio tank as a matrtaent stage in the waste disposal system. Owner maintenance responsibilities are specified in § Comm 83.52(1) and to Chapter 12 - 3t Croix County Sanitary Ordinance. The property owner Agrees to submit to St. Croix Gounty Zottiag Departtaorat s oertifiaation form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper vecifyiag that (1) the on-site wastewater disposal system is in proper operating conditloa and/or (2) after inspection and Pumping (lf necessary), the septic tank is less than 1/'3 full of sludge. Uwe, the undersigned have read the above cequlrements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerc~s s~:d ::c L•epa.-m~t of Natural l?esau.~zr, 8taµ of ~*li~aai:,. i ~tificxtion stating that yotu septic system has been maintained must be ocrmplctcd and n-turn®d to the St. Croix County Zoning DepartcYxnt 0 days of the three.year expiration date. ~~ / ~ /~ SIGNATURE APPLICANT DATE O~~"N. L~ Uwe tall statements an this foam arc true to the best of my/our fonowledgc. Uwe ardare the owner(s)~of the property ab e, y virtue of a warnutty deed roaordcd in Register of p~cds Office ~/ ~ /~ SIGNATURE APPLICANT '' DATE """•* Any information that is misrepresented may result in the aAnittity permit being revoked by the Zoning Dcpartmeat. •""'•• Include with this application a atampod warranty deed from the Register of ikcds Office and a Dopy of the certified snrvcy map if refetaace is made in the warranty dbod. - . incuMEivT rvo. ;~ WARRANTY DEED ' ESTATE BAR OF WISCONSIN FORM '1-1982 .. EARL R. FOX and .CAROL. A. FOX- husband and wife - -- - - a§ ~•su~rvi-worship-~inar-i•tal property-""an3-""e'ach' i-ri ~" thei-r owri""right-; title••and-"in~-eres~~'-"••""'- conveys and warrants to .. RICRARD D. PERSINGER and .LISA. ~,-..PERSINGSR.r:,.h_~sban.d..an~,-w_i:fe,--ho-ld~_ng .,.. as_suryiyorship,-,marital.,property-- -----------•.- -..-_.-.. in -~opsi.d~.r.at.i,szia..o.£...$.i.7.4~.9Q0.0.9 .................................... the following described real estate in .......S.t....Cr.Qix ...................County, State of Wisconsin: io - aE~is ~ i_fr5 ~; i i~.F~ SF. CROiX C i t., J~1! w..tiw JUN3 J; 1991 2:20 P~ '~.~4l..... ~ lr~a1`k payietsr ar Duds RCTURN TO rnn R ichard rs.nger G r~'. ___ ,. 512 obs Ladder circle a G3 S'ly' Taz Parcei Noy 020-.1240-.6D_-0 Lot 25, Jacob's Landing Second Addition in the Town of Hudson, St. Croix County, Wisconsin. i Subject to an easement for Shared Common Drive over the South 40 feet, more or less, of the West 15 feet, more or less, as shown on the recorded plat. Subject to an easement for Utility and Drainage purposes over the 10 feet adjoining the road and the rear 10 feet, as shown on the recorded plat. Subject to telephone easements as recorded in Vol. 4,49, page 357, and Vol. 472, page 79, in the office of the St. Croix County Register of Deeds. ~ TRA~~b E^ .____ This .-....... i 5 .............. homestead property. (is) (is not) Exception. to warranties: Dated this .............2~th...-.............--•--... da of June 19.97- y .................._. ..._ .........._............_.. , K. F .... '.... ............. - .-.-(SEAL) . Carol A. Fox t AUTIiENTICATION ACKNOW LSDt3MENT Signature(s) ....--..• .........................:...........•-.-•----..... STATE OF WISCONSIN , ---------•-----•-•----.....--• .................................................. ST. CROIX ss. • ..... ....... .... ...•--• -•---.. - •-----County. authenticated this .__.__..day of ........................... 19...... Personally came before me this ..~~h....day of .................. June_...__..,....., 1997--- the above named ...............................•--•--..._..----•--...----••--••---...----••-•--• Earl K. Fox and • _ Carol A. Fox, TITLE: MEMBER STATE BAR OF WISCONS[N husbdrid and wl fe, (If not--------------------------- -------------------•---...:[3renda PQU.1.i~..- ---.........:. authorized b ----------- --•-•-------•---------- ----•--- ---... y ~ ~os.os, wis, sta~s.I . Notary Bt~bli0no n to be the per n s_......... who executed the .ri[Ste Of ~I46tK0 I-~strument~ein acknowledge the same. TNIS INSTRUMENT WAS ORAFTEO BY t ``~', l`Lf~ William J. Gilbert. Attorney ....... ............_... ..~..........----.-.......--•---................ 206 Second Street. Hudson WI • 54a~6 • .....:.._......-•--•---•-••---•---------------------------------------------- -(-7.1-5- ---3-8}_}€r0(~.-.........-•--•-----•-•--•-•--•--...._... _. -- --=--county, wis. - Notary Public ._.__St..._Cro.iX...... (Signatures may be authenticated or acknowledged. Both My Commission is permanent. 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'w c o ° ' • • m ~ re co y A o i ~ R O~ 1 ti V N O O A O ~ fD a0 ~ ~ OV O ~ ti a o ~ ~ a ' ~< ` ~+ _ Form - S T C - 204 AS BUILT SANITARY SYSTEM REPORT F OWNER _~~~ ~1/d ~ TOWNSHIP ~/~.~~0 r-t SEC . ~ ~ T a 9 N-R /`j'~W ADDRESS.BQ~~Z-f' 2- ST. CROIX COUNTY, WISCONSIN ,~'~ ~~~ 1, Lc1 ~ S ~l0 /,6 SUBDIVISION sa ~ o ~ s ~a ti ~.' ~ac~ LOT ~ Z ~~ LOT SIZE Z - Z 3 ~ l ¢v s T ' PLAN VIEW Distances and dimensions to meet requirements of I•ZI~R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM y ~~-f ~` ~ . -- q~ : ~ ~~ ~'Q-a, .~ ~_ ~ n sa' ~ ~ j l~ r i i ~~ 1 d •k1 ~ " ~~ yo/ ~ ~'XSo ~ 9 , --- ,, r L- ~ s I ~ ~w tcao~ a T _ ~ ~\ ! ( i D - --. -~.,~;A-~z r~ Q~ ___ _ ___ _.__~..._- _ _~ __ _ __._ __ _ _ . INDICATE _ NORTH RROW BENCHMARK: Describe the vertical reference point 'used % /d'f ~,"per ~~S ~ /o~/°~_.h.~ Elevation of vertical reference point : ~D~, C~ ~ `1 ~ (~roposed slope at site: ~ ~S ~ i ~~4 ~ ,,~ - ,. ~ A 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, OSide, ~Rear,~ Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: 1~~~ ~o...~r'onn / Trench:----._ Width.: / z; Len~'th: S Z: Number of Lines: Z-- Area Built: ~ Zf~;g-% ~ '-'T' Fill depth to top of pipe: yy ~_ Number of feet from nearest property liner Front, O Side, ~ Rear,OFt . ~~~ ~ , Number of feet from well: ~~ Number of feet from building: ~D (Include distances on plot plan). SEEPAGE PIT SYze: / Number of pits: Diameter: , Liquid .depth: Bottom of seepage pit eleva ion: Area Built: ~ Has either a drop boxO or distribution boxO 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,~Ft. Number of .feet from. well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer.: rf ~ ADC-A11RTMENFT OF INDUSTRY, INSPECTION REPORT FOR SAFETY 8 BUILDING LAFtOR & HUMAN RELATIONS DIVISION P.O, BMX 796 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: N(.Uj, S(Aij, S 21, T2 9N-R 19(U ~ CONVENTIONAL ^ ALTERATIVE (If assigned) TOWVI. a~} Hud~-vt r ^ Holding Tank ^ In-Ground Pressure ^ Mound E R: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam M.i..P,~.eh Bax 2~2, Hu.clisav~, wt 5401 G s'-/~- 89' ~.3C~ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Dau S~tcahbeev~ 5432 S~. Cxa~.x 119409 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER / ~ r-+ S! ~~ }`~ [J /~~'~ y{ ~~' ~~ PROVIDED: YES ^ NO PROVIDED: ^YES ~1N0 BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ^YES I~NO ~ //y l.~ ~ ALARM: ^YES NO FEET FROM NEAREST -- q~, LINE: 1~ ~/ AIR INLET: ~--.. DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING DOVER PR VIDED: PROVIDED: ^ YES ^ NO YES NO ^YES ^ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PRO R WE BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ^YES ^ NO NEAREST -~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMET R: ATERI LAND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID DIMENSIONS (~ ~a TRENCHES: ^ - + TERIAL: PIT DEPTH: + GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BE40WPIPES: IL y., f t ABOVEVER: 4 ELEV.~L~ET: _ ~ Q EL~.END~ , ,74-01 ~ .y V1`~ PIP NEARES~ ~ LINE 'Z~' - _ ~}p~ ` V ~~/~ tR~ AI I ET - - MOUNDSYST - ~ EM: - - - Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ^YES ^ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ^YES ^ NO ^YES ^ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ^YES ^ NO ^YES ^ NO ^YES ^ NO PRESSURIZED DISTRIBU TION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE : FILL DEPTH ABOVE COVER: TRENC HES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLE D CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ^YES ^ NO ^YES ^ NO PERMANENT MARKERS COMMENTS: : OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: LINE : FEET FROM ^YES ^ NO ^YES ^ NO NEAREST -~ ;~ 9 G~ ~~ ~~ I„ ~D ` J .9~ Sketch System on Retain in county file for audit. Reverse Side. s NATURE: ~ TITLE: SBD-6710 (R.O6/88) ZUVUVt Adm~.vws~.a~a~c ~ DILHR sANITARY PERMIT APPLICATION ~`` C~lj~ C Adm Code Wis ith ILHR 83 05 I d . . . , w ~~~~~~ n accor STATE SANITARY PERMIT # // v -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8'/z x 11 inches in size. -See reverse side for instructions for completing this application. PETITION ^ Y S ~NO I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. E FOR VARIANCE PROPERTY OWNER • PROPERTY LOCATION /a alt/'/4, S off/ T , N, R / E (or~ O ER'S MAILING ADDRESS PROPE U L MBER SUBDIVISION NAME BLOCK R Z Z.- ~ ~ ~ ~ l•~ CITY, TATE . ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE O LANDMARK ^ VILLAGE : ~~ II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 OR ^ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable) ^ Reconnection of e. ^ Repair of an lacement of d lacement c ^ Re New b ^ Re 1 a . . p p . . ~ . 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. ~ 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. PER OLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER'SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ~ ~ gyp{ ^ ^ 1~ ~P~$ -~ • Feet Public Joint la Private VI. TANK CAPACITY in allons Total # of N f t ' M Prefab. Site Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks ame ac urer s anu Concrete glass App Tanks Tanks strutted Se tic Tank or Holdin Tank ~0~ ~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): Pl~er's Signature: (No Stamp MP/MPRSW No.: Business Phone Number: Plumb is Address (Street, City, State, Zip Code): Name of Designer: ~ ~", •~ S ~ ~. b VIII. SOIL TEST INFORMATION Certified Soil Testfe~ (CST) Name CST # ~ ~ ~ • / r! C i S I• ~~ b CST's ADDRESS (Street, City, State, ip Code) Phone Number: !~ •~~ r` ~ IX. COUNTY/DEPARTMENT USE NLY ~j Approved ^ Disapproved ^ Owner Given Initial Sanitary Permit Fee ~ (~ a Groundwater urcharge Fee ~ ate ~ ~~ ~~~ Issuing Agent Signature (No Stamps) Adverse Determination ~ J ~ f^ X. COMMENTS/REASONS FOR DISAPPROVAL: .-~ ~ ~>'.~.~~ , , cam. ~ ~ ~ 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~p~,of system;.- - 4. Changes~in`ownei's11ip or plumber tequires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted~to the,count~~prior to.inst~llati®n; 5. ` Private sewage'systerrts°must be piope~ty~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: .r I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; Il. 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 fur this system. Check experimental approval only if tanks received experimental product approval from DILHR; V11. 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, certific~tipn 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'lz x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with comple#e 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 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The surcharge took effect on July '1, 1984. All of the water that is used in your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. `c . - .. Ground gt~r'-~= Wi$cor s~rl's a buried reasuf•e `; o '' G 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- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) APPLICATION FOR SANITARX 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 ~~~L~l~~~ Location of property ~~~1/4 ~ Gt/ 1/9, Section , T <' N-R / W Township ~~ Mailing address ~,r~•~ ~ +~;ort'~2 g~.- ,Sa H ~• 5 . <a~-~~.~ Address of site ~~~.~ r ~ '~~ Soh t,~JZ- . ~ ~O/~ Subdivision name J4<o~ s ~-~h~;n~ Lot number '#ZS Previous owner of property (l;rc~;ti 4. ~.u,~so.-~ Total size of parcel Z. yG ~«/ 's Date parcel was created 3- ~ 'z - $ 5 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? ~' Yes No Volume G6~ ~~- and Page Number ~ G Z- as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ---------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. Lf 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 same has been duly recorded in the Office of the County Rec~inster of Deeds, as Document No. L/3~y/7 ). Signature of O~7ner Signature of Co-Owner (If Applicable) . , OOCUMEN7 No. WARRANTY DEED STATE BAR OF WISCONSIN FORM ><-iM! ,' ~3~4i7 ~« ,y0~i-~c~ Vl,rgta~..a. M,.. t;lsnapn. ~ .single woman....................... .. . eon~eys and ~~arrae+ts to S.am..E. 1'liller...a..aingle man .............. . the following described real estate in ......St..,Croix , ,, ,,,,,,,,,,,,,,County, State of Wisconsin: ' !~ TNI• !MC[ ab~aYW FOR R[COapINO CAtA ~~ REGISTER'S OFFICE .. - ', STi~CRdOfla K~o-d , ~R ~~ tM s:oo A M ~~~~ IlcrunN To Ta: Parcel No :.............................. bleat Half (W~) of the Southwest Quarter (SWIt) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of the public highway and except Lots S, 6, 7, and 8 of Certified Survey Map in Vol. 6, Page 1747, Doc, No. 419479. That part of the West Half (W~) of the Northwest Quarter (NMt) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the C~ticago, St. Paul, Minneapolis and Omaha Railway Company. TIiANSF'EK~ 0 3:~:..~. REF This ..is .not......... homestead propertg. filic (ia not ) Exre)Ition to warr.ntiee: easemrynta of record and protective covenants and restrictions of record, if any. Sr Dated this . ~ I .... ..... ..day of .. M A r C ~ .. 19.88 .. .. .. .. ......... .. .. t5EAL1 .......................... ...... . (SEAL) ~,1~~~;rt~s~1~// J~~u¢'~t SEAL) .Virginia .M...Hall$on .... .... ... .. AOTH>laNTICAT[ON Sisristnre(a) .......................................................... authenticated this ........day of ........................... 19...... ................................................................................ TITLE: MEMBER STATE BAR OF WISCONSIN (1 t not . ............................:............................... anthoriud by 4 908.08, Wis. State.) THI! INlTRUMENT WA! ORAFTEQ BY {,4):R. A,...(iN):Fi}Y.a..Neywood,,,Cari-.b..Murray.„. .. .ISEALI AC>SNOWL>sD0>19ENT STATE OF WISCONSIN ~ 1 r ~ ~ as. S+.\. ~ v .~ ............County. Personally came before me this ...°~... `.......day of ........(.hp-.~c..4 ................. 18.a$... the slave named Virginia. M....Hanson ...................•--...................... ................................................................................ .............. ................................................................. to me knonn to be the porflon ........... who executed the foregoin • trument and ai~knowledge the same. ., u' .~ .... • ~ .•. 3TC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERIBUYER ~/yl ll~//~/~G/ ROUTE/BOX NUMBER ~X ~Lg Z--- FIRE N0. .---- CITY/STATE ~4~ AS ah ~.~ ZIP s ~ /~_ PROPERTY LOCATION: ~~.u, 1/9 ~,~ 1/4, Section ~, T~N, R-~-~,' Town of ~t%Sa , St. Croix County, Subdivision o , Lot No. Z3-' 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents HAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in Auqust of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after. inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. 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 Department 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. SIGN ' ~_ DATE I _ 2 0 '' ~~ St. Croix County St. Croix County 911 9th Street Hudson, WI 54016 (715) 386-4680 Zoninq Office Courthouse Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, ~ cc DIVISION HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: W '/aw'/ SECTION: TOWNSHIP/ ~ I /~9 N/R/9~ to ~sa,~ OT NO.: zs BLK. NO.: - SUBDIVISION NAME: 000NTY: ~ OWNER'S SUYER'S NAME: MAILING ADDRESS: .5 ~ ~iX ~ Nr, /41.`/ler-- /`e ~ o/~ Son.t ~ll~. D~.~ 1 ISF Residence NO. BEDRMS.: ~ COMMER AL D SCRIPTION: ~/ d New ^Replace Ids / ~"tAf' RATING: S= Site suitable for system U= Site unsuitable for system OG- S`~ DATES OBSERVATIONS MADE PROFI E DES RIPTIONS: P R OLATION TESTS: rCL //// /- /~ti s-/~LS .0~~.,~ ~- 3 iZ.~u ~DA-.~t CO NVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:loptional) ~s I X1-l~ 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: ~/~' Floodplain, indicate Floodplain elevation: /yc /~ PROFIL~DESCRIPTIONS BORING TOTALS D PTH TO GROUN DWATER-I~P}6M'E5+ CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH~IC.' ELEVATION OBSERVED EST. HIG H EST RVED (SEE ABBRV. ON BACK.I BED ROCK 1F OBSE TO B- / ~s~ ~t Z.~ diicQ 1'~ ( ~ ~ (`~+ ' n Q /~ I / f/ / ~I ~ f/ \ l I /S O ~7 6- PERCOLATION TESTS TEST DEPTHI WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 1~16~FCS AFTER SWELLING INTERVAL-MIN. PE IOD 1 PERIOD 2 PERI D PER INCH P- .S' 0 2- 6 16 < 3 P- Y 3 ~ Z-- 6 ~- 3 P- 3 O Z- l(a L 3 P-_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. ' SYSTEM ELEVATION 9~.5;~ 7 ~ ~Sc~-lam /"= yo'~ ~eG~-~ ~_ _ ~ -_ _ _ _ _ _~_ _.~.__ _ 8~ I 3 ; - ---~ 8~ ~ ~-. ~ ~ ; ._ j ~ ,_ _ ~ Q ~3~;.~ _ - ~ ~ ~_ ~ ___ ~ __ ; _ _ _ ~ , ~ _ ..~ ~ _ 4 ~ _ ~ f ~ ~ ~ a ;[ II ' i _,' __ _ ~._- _ ~ I .~ C _ _. i I E .r ~.E_..~ ,~ ~._ 3 ~~ , ~~ 1 E r 1 ~ ~ ' - i ~~ ~ ~.~ ' ~I i s ~ ~ i y i. S~ P i ~ ~ o t ~.` ~.t ; i ,_, n ~_ I _~~ ~_ ~ - i ~. ~ ~ _..' ~~ > __ i t ~ ~ i ~ i ~ ~ ~ € ~ z __ _ ~ __ i ~ ~~ d a.~. ;s . ~~~~~~',_.__~e~ ~~ . t ._ I .,._,,...~ . ~....W.._. F f ~ 1}- ~~y. ~! ~_R.,....~. L.._~ / _,._ 'r^ ; I_ , ILL _..._. ...,QS ; y~/ 9 ~-...--j ~ ~ ~ ~ 3 1 f __d _ ._ ,' __.6M~S~ I I ~ ~ ~ _ - ~--~ ~' t?Q --- ~ ~ ----~ I I 1 ~ -_~~~K ~f~6/~. ,.~ I I .__~ ... __ ~ _ m _ ~ __ _ ___ _. ._.~.. TN ~tVTt~UCT!®s? i.TR CU{Y9T ~Y al~i.7 i'VRIYI ~ iwb a~3Ll - L3..?.7~ To be a complete and accurate sail test, your ~ _~~~st include: ~ 1. Complete 1ega1 description; 2. The use section must dearly ln~iicate whether dais is a residence or cosnn~ereial pro}ect, 3r MAXIMUM number of bedrooms or c<:xpmercia[ use planned; 4. Is tC a nevv or re:l~lacement systerTi; 5~ C" Sri," the suitability rating boxes. A SITE (S SUITABLE FOR A FiOLDPNG TA~1~ OfUL~Y 1F ALL G ~R ~;YSTEIUES ARE .RULED C3UT BASEI~Lt~I SC?IL CONDITIClE115; 6. P[ ; u~a the abt~r~eviations shown here fflr uvritir~g'~profile descriptions and completing the plot plan; 7. ~ LEGIBLE diagram accurately locating your test locations. Drawing to scab is preferred. A 1 se, ra ~~haetm~y be uset~ i[`desired; $. M~' :your benchmark and ttertical elevation reference poir~~C are clearly st~owr~, and are permanent; . Cc a.: appropriate boxes as to dates, names; add#~esses, floprl pdair~ data, percolation test exemp- tiro, i _~propriate; 10. If the " ~rmation (such as flood plair7, elevation) does not apply, plaec~ (V.~\. in the appropriate box; 3 1. Si, ~ `' -n and place your current address and your certification number; 12, Mak- ible copies and distrik~ute as ret§uired. ALL 501E TESTS MUST BE FILED INiTH THE LOCAL AIJTl~ORiT°(WtTHIN 3Q DAYS OF u03ViRLE-f"IOf~. `AE~RREll1ATCC}NS FAR CERTtF1ED UIL TESTERS . Soil Separates arad Textures Other Symbols st - Stone {over 10") BR - Bedrock coh .- Gabble {3 - 10"} SS -Sandstone gr -Gravel {under 3"} LS -- Linaestor~~ -Sand HGW -High Grou3~rd~vater cs-_ Coarse Sand Perc -- Psrc~~lation Ratc < rued s -(Medium Sand W -- Well #s -- Fine Sand Bldg - E'ui" is - Lc}array Sar7d ~ -._ C Than ~sl -- Sandy Loam ~ - {.,-,, ~;ar~ "i - Loan~~ Bra ~-- E,, .., ~sil -Silt Loar~~i BI - B!:. iw si -- Silt {iy - Gr, y ~`cl nl~y Loam Y ~~ Yellc7e~r sr - :: -~dy Clay L<~am R - _3f.1 t :.t C'ayiLc>atr~ rr}ot -- " Clay ~ tvi -... - ,ay fff _, fa y 17t rnrn ar-- ~. rr~ -- ;;s, ~ d - ~- . ~lryL ~- f.: Six gen ~ ~aures :~r far li~pui~' r ~ {:9isposal P>M - ~ ~ , ~- VF~P -- Ar ci,cG Paint ~ .. - e..'g '~ ., ~: "6"f"t "T 6~ C £"ttPSdRt G C~ o L~~N~C ~m~wrt 4f ~L s.~_ ~.t c~kar o~. rto P a ,~ , ~ car I ~' I o`t ~ /~ s5~ .r~l e ~- loo, c", ' ~- L7 T~~c._ f BA,,k~o~~ `1R ~.Qu../El1,ryK S s!~~ 7r.P ~ ~/ .r `~ 9 w N P~ / as So - _-~ ~~ Z 3or,- -~ z! \ v ~~/ $• I ~4G / i ,l ~ ! "V _.... _.. _... ... . e.._.,_... ... _.. ..__ . ~I/e~T~ ~o* ~ ~K=- _ l X15/ ~ ~.~/~ 5~.~/~ P _. . ` ~.~~ v .. ~. .... ., ~ ' ~ ~ d J ~ ,~ a :,< ,. ~ ~ ~. ~ ~ ~,.~ ° ~ 6 . ~ H •~ ~ ' 0 ' ~ . dQ o. J ~ P- o , M ~ ._ CL ~X ~ '~ ` ~ ~-N . , J .~'. J ;> . ~.A r'vi . 7 ,: ., I ; ~~i,t ; te ~ . , Y , a , J, ,~ri}~~ s4 ~ t','i~.~, . ~~• , ,, :::;. ;. .. ~ ~ ~6 Q . J ~ ~ ~ y p d A ; . w y t, i J S a ~ • ~ ~? i ~ F ~ ! m- J y~ ' 1 ~~ ~T ~`~ . ~ <_a ~b~~d . d a s .~ 0 J d H ,, I~" ~: o i :~I i v, s ~= 0 0 ~J Q ~-- u ~T ,. j~ 1 I ~~ 1 J 'I ~ 1 ~ ~ i I I 1 ~ ~ ~~ ~ ~ o ~ .1 i d 1 p ~ 1 i~ ~J ` ~ ? -~ ~ ~ ~- ~ N ~ ~ d ~ > _ ~ ~ .~t}~ in~. J a a a -4 d d .. ,~ ~ 0 ~J _ S L 7 • 0 ~ ~. C N i I ~ ~ I _ c v ~ ~ N a o I o ~ ~ ~ c ~ ~ ~ °1 I I 3 I ~ I o I I ~ a. I N .S I 3 a ~ I Z ~ o_ v> I I o' o' ~• ~ \ ~ W _, ~ a --~ ~ ~ i o ~ ~ I ~~ ~ I O 7 ~ ~ 1 w Q ~ I I i ~ 7 ~ vi O d ~ ~ ~ N o{i o U) Z iD ~n D o. ~ O r. N ~ c ~ I~ 3. Q m 7 ~ C O =m m fl+. ~7 ,.,~ ~ N ~ C a °, C X ~ N ~. ~ 0.(0 N N ~ C ~ fD n a~ o ~ N ~ O lG ~'< X_ d C fD y Q 7 ~ ~° 41 N ~ T. Z 0 ~ v ~ N cn ~° ' m c ~ ~a ~_ N ~$. ~ ~ S CD ~ Cf ~ fD 01 ~~ ~_ O O ~ ~ d O ~ 7 3 ~ O O N 69 Q O O ~- c ono ~ ~ .'. .o ~ 3 o ~ ~ ~ y o cn m x y N ~ ~* ~ N a \ o ~ ~ ~ a N N fD O o ~ A ~ m ~ ~ 'fl 2 c ~ v v ~ ~o ~ .fie ~ y O ~ ~' rn .. x ~ ~ 'o m a O y C C 7. ? a ~ ~ 3 0 ~ C (/~ Q W ~ a O 3 H ~ N W N N T C 7 a 3 d o ~ n 3 ~ a m _ ~ o d IV Q y0 CO ~ ~ ~ ~ ~ S° o o ' f ~ o ? o 'O (Ap O C 3 ~'• °: cNn Q on 7 a cn A 2 cD ~ ~ ~, A ~ 7 CZ ~ ~ < CNO z ~ ~ A d A O ~• ~1 ~• ~~yyH ~ v~ H A O A W O N O A V Op A f0 ~ v ~ ~, a ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is o certify th t I have inspe,~ted the septic tank presently serving the ~ ~ residence located at: ~~~'/4, !.(~1/a, Section Town ~ N, Range~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 0 Did flow back occur from absorption system? Yes X No (if no, skip next line.) Approximate volume r 1 ngth of time: $~0 gallons minutes Capacity: ~d Construction: Prefab Concrete ~~ Steel Other Manufacturer (if known): ~l Age of Tank (if known): icensed Plumber ignature) (Print Name) (Title) (Li ense Number) MP/MPRS (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code)