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HomeMy WebLinkAbout020-1261-30-000Wisconsin Departmen~o>iCfmme~ck~ PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL`iNFORMATION (ATT:~~H T~ PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ermit Holder's Name: City Village X Township Reinhardt, Eric Hudson Townshi ST BM Elev: Insp. BM Elev: BM Description: / t~ i . ~ ~; f 0 f ~ l ~, ~r• f ~ ~-h...t e ~. .. c'1 ~, ~- "a c:, ,_._ ~;~ ~(~~ n ~- SANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing ~ L'v i ~ 4,~_ ' 7 S L, _ Aeration -. ...~~'-..-~-----_- Holding _._.,~ ~~.t-3----L 4~ ~ ~ ~- TANK SETBACK INFORMATION ~~ r~ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD ~ ..~, ~ ; ..,. ~~ ..~ 3 ~ -- Aeration _ _ Holding ~ PUMP/SIPHON INFORMATION Demand GPM to SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 453166 0 State Plan ID No: Parcel Tax No: 020-1261-30-000 Section(rown/RangelMap No: 21.29.19.1265 STATION BS HI FS ELEV. Benchmark ~ `,~, ih~y~ /v j _/ ~` Alt. BM sldg. Sewer SUHt Inlet SUHt Outlet q ~~ y ~j.~. u y Dt-Iplet ST- tt_ ? _ -mot.-~-~i Y.~ RN.~i~ om ~.-r. ~~ ~ rri•~ HeaderlMan. Dist. Pipe n,. ~ ~;z,t lc ~ ~ c T~J.ZC, Bot. System '^ 1( ~' ~b5 . i l _2C~ 73 10 Final Grade St Cover BED(rRENGH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ >~ r~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer. 1 ~ l ~ INFORMATION CHAMBER OR . L., c v c Type Of System: ~ ~ ziv- • c ~^ ~ n ~ ~ ~;7 y 1 ~l ~,,~,~ ~ ~ ~ UNIT Model Number: ~~ : C ~ ~ . .. ~, 1 "~ DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake (' ~(h 2 ~_.._-_~ Pipe(s) _ '- ~ ~~ ' -- Dia Length Length Dia Spacing SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedlfrench Center ~ ,_t ,~ ~`~" Bedrrrench Ed es g To soil p ~ ®No Yes Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: '~ / %" / ~~~ r Inspection #2: / /_ r Location: 561 Stagecoach Trail Hudson, WI 54016 (NW 1/4 SE 1/4 21 T29N R19W) Prairie Vista 2nd Addition Lot 26 Parcel No: 21.29.19.1265 1.) Alt BM Description = ;,,,,~~ ~~~ .~,~~ . ,~ 2. Bld sewer len th = ~ ~~ ~~ ~ `_ ,_ - - -amount of cover = ~, ,~ - ,--- Plan revision Required? ~~-" Yes~No I~ -~~ ~ ~ Use other side for additional informati n. L ~ /L ~G ""''~ ~-~- ~l Date In epctor's Signature Cert. No. SBD-6710 (R.3/97) S •" ~ _ Safety and Buildings Division 201 W County S j C ~~ r ` m ~ ' . Washington Ave., P.O. Box 7082 /~ 's COn~,n Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) De artment of Commerce (fig) 261-6546 ~T'~ ~ / • • Sanitary Permit Ap hcah~gt ~ ~~ ~ State Plan LD. Number ~. ~Y ' hs accord with Comm 83.21, Wis. Adm. Code, inf ~ ~y" ~,~~ inaY be used for secondary Purposes Privac Law, si gym) ~ Project Address (if different than mailing address) I. Application Infortaut6an -Please Print All informati , n ~, ~ ,~ "' i1 " ~ ,~,4 - ~ , ~~~5 ( /, D21~•/Z( 30.0 , __ , ( r Property Owner's Name ~~~'•soti ~'o ~-~S o~ ~ ~, ~G ~~,~~~~v Parcel # Lot # Block # 2 ~ Property Owner's Mailing Address " "°°-°~ Property Location f N~ 'Z s~ ~ ~ C,(it~y, State /. , / / v0,~ ~it> W ! - Zip Code cs L f ~ ~~ Phone Number ~ ! /., Section /'' ~ Z C i 5 ~ "' O ~ ! '' f r / (c rcle one) l IL Type of Building (check all that a I T N, R __~or W or 2 Family Dwelling - Number of Bedrooms ,~ Subdivi sion Name Number CSM ^PublidCommercial-DescribeUse ,/ Q 1 (//•5Tl~ E ~F~/~~ ^ State Owned - Desrn3e Use re / ^City^^Village Ie1'ownship o~~~~ f ~ III. Type of Permit: (Check only one box on Gne A. Complete line B if applicable) - A. ^ New S ystem eplacerrrent System ^ TreatmentlHolding Tank Replacement Only ^ Other Modification to Existing System B • ^ Permit Renewal ^ Permit Revision ^ Cbange of ^ Permit Transfer to New List Previous Permit Number and Dace issued Before Expiration Plumbs :Owner / / G>' (,~~J / / j5 I V. T of FOWTS S stem: Check aU that a i N ]L! Non -Pressurized In-Ground ^ Mound > 24 in. of suitabk soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ ~ ~~ Constntcud Wetland ^ Pressurized ln-Ground ^ Holding Tank ^ Peat Filter ^ Auobic Treatment Unit ^ Recirwlating Sand Fiber ^ Recirculating Synthetic Media Filter Leaching Chamber Drip Line ^ Grave6kss Pipe ^ Other (ezplai Z V. Die rsallTreatment Area Information: Design Flow (gpd) ~So Design Soil Application Rate(gpdsf) .7 ~ Dispersal Area Requiral (sf) ~07~. y~ Dispersal Area Proposed (s ,j z3 , sd System Ekvati / q3. o ~ ~ VI. Tank Info Capacity in Gallons Total Gallons Number of Units Manufa }~er ,-/ ~/„ J / ~ / Prefab crae Site Co~tructed Stool F7rer Glass plash New Existin /C'1 /' W 7 ~A/ i`7~C['i( f Tanks g Tanks septic «xotaiag rank / ~~jl U ~ V I "~S~ ~.. j Aerobic Treatment Unit ~~ Dosing Ctnmber VII. Responsibility Statement- I, the undersigned, assume respoasiblGtyYor instxllatloa of the POWTS shown on the attaehed plans. Plumber's Name (Print) ~oQ~ 2T` ?,~l6Ra'cG~ ~ Plumber's Si re MPlMPRS Number ~ZCe 3 ~ S Business Phone Number l s • 77~ • 3 y4/ Plumber' d ~(Z_ City. ~ t©Za'p Code) ~ 'l~ ~~,1 /,/t/ (T V ~f / ~/. ~ ~~ f/y'w !/ .VIII. n /De artment Use Onl proved ^ Disapproved Sanitary Permit Fee (inchrdes Groundwater Date suing A ent Si atwe ('No ) Surcharge Fee) ~-7~ ~ ~ ~ Q ^ Owner Given Reason for Denial ~J v ` IX. Conditions of ApprovaVR aeons for Disapproval /~~ J( ~ N E G ~ ~ ~ ~ ) Y~1~ 1 Septic tank, effluent filter and ~ 3'S'1~ ~'~m ~ -~~Z~ ~ '~-t/ jQ `,1~ dispersal cell must all be serviced /maintained J~~ / ~C''~~'''" OG~~ as per management plan provided by plumber.. p/ 2. All setback requirements must be maintained ~ ~, /~s er a as licabl din n d / GUS' Q ~G /~ ~ Ste' '`'"~~`-~ ~ p pp e co or a ces. e - i I - 1 1 ~. '~ ~~ - ---~---- •- •-- -.....~..,~ ,•.~.. ,..,.~..,.. R,..... o..~ ....~~ ~ ~~ ~i~~ ail! d"~ - ~ ~ ~ 12 SBD-6398 (R. 08!02) /~ „ G/ "/" ` ,~~~/ ~ ~ ~ 3 yy LL a i ~..~_ Q O I ~.r e ~ o cy rt` ~ -~ ~ _ ~ -~ rt N ~ ' f, O ~ ~ ® ~ ~ z ti N Z ~ .~, , ~ c~ ~I I ~ ~ ~ ~~ ~ b' ~~~ ICI G ~ W I I ~ I i t `~ III ~ I it ~ 0 x I{ {I.{` t J I~ ~ I {r ~ II II it 14w ~ ~I ~ !1 i I ii • ~ l~ s ~! .~` ~ ~"~ I w ~~ M -s N ~ ~ h ''1 ~ ~ , .p ~ ` ~ ` ~` O ~ ~~ y Z ti ~ Z (~ ~ W _ O II ~?~ --i ~ ~ °C) ~c ~- h ~~Z- ~• ~~= m~~U ~ N ~ ~ A ~ ~ mDa~ m -o ~ ~~m~ ~ mom ,, a - ULBR~CI~T & ASSOCIATES CO. 2812 10th Ave. • Spring Valley, WI 54767 715-772-3442 Reg. Designers of Engineering Systems Private Sewage Consultants PROJECT INDEX ~ PLAN ID # N~/~- DATE ~~~~ / ~~ owNER <<sso,,1 .l o~uSo~ ' ~S ~ 33/• 05 gS j~E%yfffl'fZ©~ PHONE 7 _ ADDRESS S ~ ~ S ~`~1-G'~"G0~4-~1r/ T~i4! L.~ LEGAL DESCRIPTION Go f' ~ Z~ /~,p~i-~~iE f~J57~~f-- PtN v20 • IZCQ/. 3D. o-aa N ~ S~~ S.~c - ~../, TLS, /~/~ Cc.> TOWN OF J~{U~Sr1 ic1 .. COUNTY s ?" G~'Ot ~ CSTM ~ • ~ 61~~U GG1~T- ~ S l r J~ LOCAL AUTHORITY/ SUPERVISION 5T• CJ~D/`lC G1`% ~Dtiy•'V G-" PROJECT DESCRIPTION: w ~'~ f!- ~if r'L ~ ~v G-- ~ ~~~i'/t'1.' Sys T~-P.~,~. .- w~-S ~f ~ ~j-5 l3~4G6~~D ~'~ ~ ~~ i ~~ N~ ~W^~-~c S ~~ D U~ ~ ~ ~~ 7~ s s ~-~ ~.. s ~~~~ ,~,;; t'O~b'T SYSTEM SHA~.L INCORPORATE PER COMM. 83.44(2)c A PROPER ZABEL FILTER MODEL # a . ~~ Pg.l INFILTRATOR SIZING WORKSHEET Pg.2 SYSTEM PLOT PLAN Pg.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. pn _ a ~~ ~~ .. ., .. -- ~.ftb~-i~r-~t Privai~ ~'.~~'~°ciaies vii ~ {~ ~~~t, is l!c?. °nsuttants ui0. ~~~~ ~~ WI5476~ ~ z~ 3 .~ S f -- fi ~o azls adTd (~ulwou ~ s~ sadcd auan 'sayaut ~ 'atatldsozu~~ a~ pue ~ezaX~t uoc~nqu~sip aye uaan~~aci .ite 3o h-o~ ~.~ a nnol~~ ~srnu sdra ~aaA •s~uq~[~ zo d~a loan a 3o suraw aq~ ~Cq paennvnnop ~tna~~ ~uptado Juan atp tprnn ai~ttnwa; sadrd ~uaA •apet~ ~~ an e s aut P~ ~Ialef uor~cigrz~sip nn ~ain~z~ oR ~ . Z I ls~at le o~ do pua~xa oI3 a~ 30 ~eq zaddn a~ of aaaaczoa `paI(~isur ~c `sadid 1ua;A sadrd aot~¢nzasgp - S azagt3 •etlat ..6 s6ut~dneq ~~¢dab ,aque¢ep Bu~ep¢a~ ~o dej ~¢Itfl3 teso~ ~eleAp ~aa¢}e~ ®~ulUai 'oleo ..9 ~'~ ioiS dtia ly&~i ta~¢~ azn~~ aas •sarlauc ~~o azrs adid ieutarou ~ s~ ~'drdFd uoi~enzas o .S ~ Minn aa~mtuza~ u~ a .rS q ~' 'dxa a~t~I~.ra~¢n~ algenouzaz P PE q~ anoq~ zo o~ do zagcu~ua 3un~a~al. aqi 3o doh a~ g8rto~t~ aa~~zns an~~ez~ aq3 anogra satlatn~ ~ a~~stp ~ urog PualXa `saoilanzlstt[ zagtz~ga a~ ~~ aau~pzvaa~ ut sz a a o . Pa~urzd s~zaan~aE~nu~.u zoo sadid uor~~nzas - Q ~ i Paria~~~~ a~ s[uals~fs x~a $utga~ q~ 'i[~m pros st add uor~ngp~s~p ate aAO~ II,~rc~ ~ ~~ Pa~~ols st s~ua~s~is a3~~at~8e auo~s zo3 adid uor~nq~.r~sip ayl ,noiaq adcd no~~nz o anoq~ zo ;~ ;rood ~ o~ szagw~~r ~utga - ~ ~A ~o aot~zad ate, •apez~ qs~ ~ 3o aprstn aq~ Luog .ro scuais~{s a~daz~~~ auo~s zoo aa~~ns anc~z~~uc ar.~ ~o,~ pua~xa sadid uoi~enzasgp •dn ~o suEauc ~ rm a uazd aze ptu~ span uopn~~s $a ~~ ~~ tuayl ~uanazd oa Suuogau~ ~. P P. qW rp ~ . p ism az~ sadrd uop~arasgp t~~Inn aauepzoa~ uE ale sraqutaua ~'unla~al3o saor~~ a '(~nu~tu spl~ ~o £ a{q~y ~I~aa-nP P~~[d a~ sa ~.ue a ~ . a ~ u.L ~[aa uol~ngrrlsrp aq~ ~a uro~~oq aq~ ua ~ q ~[ ~'I 'aP~ Ieui~'cza a~ nnolaq zo lE az~ sda~ zaq~a $arga~a~ ' ~ ~~ . ' . E?wtier/~3uyer ~ ~ y~ .5'~' CROiX COUN'ii'1~' SEP~'iC `T'ANK MAINTENANCE AGREEMENT ` AND UWNERSIItP CERTICICATION I<ORM Mailing Address _~ _ Pt'opetty Address ~Ll'-~1~-- c~; ~- %~~a~ ~ %r~ ~~ (Veri!'rcativn required troth Planning Department fot new construction) City/Star ___'~~~/f ~''~ Parcel identiCcation Na ~`='~L~ ' ~1,~'~, -~ ~r ~ ~T~j~ tuber LEGAL UESCRIp'I'lUN ' ... ~ ' ~. Property L.ocatson ~~ '/., ~~ '/., Sec.~'~ , T~~ N-It~ ~ W, Town of f~I~LS~~ °~% Subdivision ~~~~T ~f ~ ~~ ~/~ ~5~~-~-- ~ ~ Loi # ~ ~. Certitled Sarvey Msfp # Volame Page # '~Vrrrrnnt Deed # lJ/ 0 ~ 3 ~ j ~~ 1I ~j S .~p ~ 9 , Volwne ,Page # Spec hoase ~ yes ~no Lvt lines idettliCtabte t~yes i] nv SYS'T'EM MAINTENANCE ( ~ improper use and maintenance of your septic system cotdd result in its premature faitare to .handle wastes. Proper mainie~ consists of pumping out the septic tank every three years or sooner, if needed by a licensed pamper. What you put into the. s} can aReet the Pemctfon of the septic tank as a tteatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Departtmnt a certification Corns, signed 6y file owner and master plumber, journeyman pltmrber, testriciedpiumberor a [iceasedpumper verifying that {t} fire on-site wastewaterdispasai sy is in proper operating condition atrc!/ar (2) alter inspection and pumping (if accessary), the septic tank is lose than I/3 fait of s!u thus, fire tmttcrsigned have read the above regrr;cements and agree tb maintain the private sewage disposal system with the stan~ sef forth, herein, as serby the Department of Commerce and file Depattrnent of Nature) Resources, state of Wisconsin. Certitic stating that yore septic system has been maintained must be completed and returned to tare St. Croix County Zoning Ot'fice withi der sot the titres year expiration date. ! l L/ UC A1'I'LtCANT DATg' _ ' OWNER CERTTP'ICAI'ION T (we) certit'y that aH statements on this tuna ate true to the best of my (art) knowledge. the ropetty described a ve, by virtere of a wattanty deed recorded in Register of Deeds Otf'rce. ~J . rN ~i~Uftl? or• ~tPFLtcAN~r I (we) Am (are) the owner( DAB ** **** Any inForntation that is alts-represented may result in the sanitary permit being revoked by the Zoning Depatttrtent. *`• * * tnclndc with this applteation~ a stamped warranty deed from the Register of Deeds otiice a copy o[ the certitted suwey map if reference: is -made fn the warranty deed ~ _. ,t. 1 217~#~' 231 SCRIVENER'S AFFIDAVIT 7 1 3 5 4 9 KATHLEEN H. 11ALSH REGISTER OF DEEDS S?. CROIX CO. , ~lI RECEIVED FOR RECORD 83/18/2083 89:~AM AFFIDAVIT EXE1~T # REC FEE : 13.80 TRANS FEE: COPY FEE: CC FEE: PAGES: 2 Nave aed ~efote Address Barry C. Lundeen P.O. Box 469 ' HudsonWI 54016 020-1261-30-000 Faced Idesf~6eMiosi Nmsiber 8~ Z~is ietemutlaa mwc 6e oee4iwnd iq- absittses ~~. ast Ell M+~R ~R seek as /Mr ~ eletrrs. ~ lnea~jsise, as: ~ ix~6eie[ a MrA~a+eP~r ~str luartett ar a~qr 8r /best ws ~Mteetltiw ~/ie doeaete~ ~' We gift ortrr~r eii ees reds as ywr leaves of iZ00 r it naao~r A~ 1RN.+~wis slrrrr. ?111. ~LLt Zi91i . = t. ~~ . ~ 217y7 X32 AFFIDAVIT STATE OF WISCONSIN ) )SS ST. CROIX COUNTY ) BARRY C. LUNDEEN, being first duly sworn, on oath, deposes and states: 1. He is an attorney at law with offices located at 110 Second Street, Hudson, St. Croix County, Wisconsin. 2. That your affiant drafted a certain Warranty Deed between Peter B. Wildes and Janine F. Wildes to Eric Reinhardt and Alison Bailey Johnson recorded September 5, 2002 in Vol. 1968, page 556, Doc. No. 689361, as appears in the Office of the Register of Deeds for St. Croix County, Wisconsin. 3. That when preparing said Warranty Deed, a typographical error was made in the legal description. The recorded deeds identifies "Lot Z5, Prairie Vista Second Addition, Town of` on", when the correct legal description should be as follows: Second Addition, Town of Hudson." all other respects, the Condominium Warranty Deed is correct. 5. This Affidavit is executed for the purpose of correcting the legal description to the real estate as contained in said Warranty Deed as referenced in paragraph No. 2 above. FURTHER YOUR AFFIANT TH NOT. ~% Barry C. L deep ', and sworn to before me day of~March, 2003. ~~~ ---' Public, State of Wisconsin ,may A. Bakken Commission expires 10/2/2005. Notary Public This instrument drafted by: State of Wisconsin BARRY C. LUNDEEN, Attorney MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. 110 Second Street, P.O. Box 469 Hudson, Wisconsin 54016 li ,~ DpG'UMENT NO. U 1968P 556 WARRAN7`Y DEED This Deed made between PETER B. WILDES and JANINE F. WILDES, husband and wife, Grantors and ERIC REINHARDT and ALISON BAILEY JOHNSON, husband and wife as survivorship marital property, Grantees, Witnesseth, That the said Grantors convey to Grantees the following described real estate in St. Croix County, S~~tat~~e of Wisconsin: Lo~25, Prairie Vista Second Addition, Town of Hudson. ff This is homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging; 6 8 9 3 6 1 1{ATHLESH H. MALSH REGISTfiR OF DfifiDS ST. CROIX CO.. MI RECEIVED FOR RECORD 09-05-2802 10:40 Aq aaNrt nEEn EKEMPT Ik R£C FEE: 11.00 TRANS FEE: b90.00 COPY FEE: CERT COPY FEfi: PAGES: 1 Tax Parcel No. 020-1261-30-000 RETURN TO: ~7,a . TITLE OP1E PREIABt tIROI~, I-I~ 706 19tH STREET SOUTH HU060N.1M 54016 And Grantors warrant that the title is good, indefeasible in fee simple and free and clear of encumbrances, and will warrant and defend same. Dated this ~7~~ay of August, 2002. fj. C~/~G...o (SEAL) Peter B. Wildes • ~ ~i?~ (SEAL) J ne F. Wildes STATE OF WISCONSIN ST. CROIX COUNTY )SS Personally came before me thi ~ da of August, 2002, the above named Peter B. Wildes and Janine F. Wildes, to me known to be the persons who executed the foregoing i ent and acknowledged the same. Notary Public, State of Wisconsin My Commission (expires): 17 - THIS INSTRUMENT DRAFTED BY: -~~~ ._, a ~rzer Attorney Barry C. Lundeen Np;;_~r~• Puolia MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. Stata c; -,~; ;; ~ons~ \~ 110 Second Street, P.O. Box 469 Hudson, Wisconsin 54016 t~r~~ ~ _ r, ' «~ r ~,; ~ ~ , Q (1 C S J = THE 'SE I/4 OF THE sEl/4 ~ ~ (!~}-~ 1~0'1'r:: When future u~vGtupers extend the such developer ;shall be r oneibl Cul~?e,-~ ac ~ c strut ~ `' - , Cou~C~r eta>~ ~a~ad: ~~ - ;t have been cbstbe~d. r the ' owner s will be ~ae}~d lis or aay the same . LJa~~~~,,-~,~~~ (Zoned Commercial] iii _... TI LI' 22 100129 Square feast (2 , 299 acres) N • f+ ~ ~ 103846 Square feet - ~+ ~ 103859 Square feet - ~ 10384b Square fast ~;~ ~ • ~ (2.384 scree) ° ~ (t.384 acsse) r ~ (Z.3~4 scsse) 0 i ~~ ~s ~s' ~~ _~-"~__ ~ - -` ~--- 8 ,__ PRAIRIE_ _ LANE--------- - -__ _ ___ - - - -- -- ° ------ - --- -- --_- - _,~ ~ --- I \~ S rl~° S9 ~ 46 ~~ E 4$3. 4 ~ _~Q t 1'0'~ 12' ~ 66, 00' ( ~ 1 25 26 27~ :058 Square feet 103799 Square feet 146029 Square feet ~ (2.802 scree) (2.4$8 scxss) 0.434 arse) w 11~11r5 s ~ c • ~ I 3 2 ~n I t- _' ~ f• • -~~ ~ • ~ Win Depaxtrnent of commerce Division of sarety arrd e SOIL EVALUATION REPORT ~ I ~ ~Y ST. G~{p IX Plan er n t mss than 8112 x 11 inches in size ntt let ite l n on p d, ca p . a np e s a ap o arclude. tx~ not lirrdted to: vertical and irorizantat reference point (BM). direaion Paeei I.O. O 2 O - 12 b I - 3 O • D OO percent slope, sole a dimensions, norff- arrow, aid location and stance to D Please print all information. e ~~ artomretion you p~wrde may ba used br seccnaary v (Prive~7~ taw, s. ~s.o4 n) ~ .5 Rt ~ ~ ISO N J O}-~ ~ S~ (J Govt. Lot` N E 1/4 St.1/4 S 21 T 29 N R ~9 E (off ~~t~+owners Mar'ferg Ad~ess TR . 5 (v I ST~t(~ ~~pACH 26 # P R R I ~ V I ST A Zp Cade Phone Jr ^ Cily ^ Yrllage 0 Town Nearest Road ~~Onl W I 5~}•olb c~15~ • 0595 ~ H v Dso -J ST~4i/t ~caact-J ^ New C.onstrurfion Use: Residential / Nunber of bedrooms ~_ Code derived design flaw rate d GPD ,~Reptaoemer>t ^ Pt~b6c a commercial - Descr~e: - -- f ~---°p-~ Parent material L..O ~ s 5 OVER S A ~ 1~ .. ~ eteva6on'f ble I~/ a R Generef oorrrrretgs O N?w A ~,a ~ bAn)DO(~l o icf sus-IeM ~`~~t ~I ~ ~~I~~ gASFD aIV F3a~2~NC-1 #~-y- ;, c ;,_;,r L,~;,;-: ~~~ FFIC ® Pit Grourxi s elev. ~• iL Dapfh b facOor ~ ~ Rye Horizon Oepfi DorNrtartt Redox Oesaiptiorr Te>dure Stnx~rre Consistence Roots GP DVff= Mr. Mta>Se0 tlu. Sz Cont. Color Gr. Sz. Sh. 'Ei~1 'Eif#2 ~ 0-9 / K a - arm rnfr s 3vf . ~ . 8 2 9-ZO k - i I ~sbk mfr 0.w a~f .2 •'3 ~ 2 - I -- S O5 ml ab aof .~ I.fo 4 37- 10 •3d 5 R9• S O s n~ 1 a b 1 v'f .~ I• b 5 9-9 ~s - s 0 ml - - .~ ~.~o '3 0 ~ ~O2 N`' ~Y `' 2 ®Pit Ground surface elev. 9 ~' 7> ~ ri. Depth m rardbng factor ~ ~ ~ in. ~ ~ soil Rate a~~ Horizon Depth Dominant Redox Oesaiption Texhue Strucdue Consistence Bound~y Roots GP DN~ in. Munsetl Qu. Sz. Cori. Color Gr. Sz. Sh. 'Eif1l1 'Eff#2 ~ 0'13 10 .R 2~ _ 02 m mfr of . 6 . $ 13- - i 1 1 Sbkm m /fr w av-F ~ 2 Ei ff1 = BOD_ > 30 < 220 moll and TSS >30 < 1 50 moll ' Effluent t12 = BOD_ <_ 30 maA. and TSS < ~ melt. Nanme (PIee98 Prtnq $Ignatu<6 CSTTNsr~ber ~~N ~~ L~t i b 2.tcrt-r ~L~~ ~5 9 9 3 ~ _ Address ~ Date Evaluaffort Catduc.4ed Teleptrorta Number Z ~ I Z I O ~" ~,, 6 • S pR l~ ~ ufl LI,~'~T InJ I '4' 12-~-~ o `I' '7 15 • ~77 2.3~F42 _~, CIRIGINAL . , ,, ~,: , p~yp~ ERIC ~ f}t.i5or~ Jb~1N~~ paroeliD# O ZC~-~Z(~l-3a-oo Page 2 of # ^ p - ®Pit Ground surface elev. _ / ~ ~iG~ ft. Depth b tacxor ~ ~ ~ in. Horiacxt Depth Dominant Redox Sad t~ Oespip6on Textue Strucdxe Consist~oe Boundary Roots GPDiNF b. MunseO Qu. Sz Coat Cotar Gr. Sz Sh. ~q 'EtE#2 ' O-li to R 1 - asb~(f -~-F~ CS 3vf . b . g 2 ~-- ~g I R 3 -- ~~ I sbK~ mfr W o f . 3 3 1~-z~f IoYR 4/4 - SG I 3abKm n-~-Fr C w av-F . 9- . fo 9' 28.37 IoyR9J6 - 5G t,_ asbKm m-~r 0.w lv f .y~ , ~ 5 3$-39 IoyRS ~3f IoyR, 2 5 d s m l a b ~vf •~ i- b J ~ # ^ - ®Pit Ground surhace elev. 9 ~ R Depth b CanBing factor ~~ ~-. SoN Rate Depth Dort Redox Destxiption Texture Sbtxture Consistence Boundadary Roots GPDAP in. MunseM flu. Sz Cont Color Gr. Sz Sh ~ 'Hf#1 'Eit#2 ~ 0-11 IDyR31 - SCI a rf mfg cw 3vf •`t , b ti-28 ~oyR3 - St I aSbKc mfr w avf . ~ 3 2$-5 ~ o R 5 m 5 y- Q,s a m -~ I Q, ~' ! v f . ~ / • (o 4 52~ 5yR ~ rn3 /0 r a Si mv-f,' - -- d ^ Pit Graxrd surface elev. R Deptl~ b 9 factor in, a# ~ ~~ Sai Rate Hotixon ~ Datn~ Redox Oesaiplion. Texture Struct<xe Coos Baiardau~- Roots GPDIfP in. Murtse8 Qu. Sa CorM. Cobr Gr. Sz. Sh. 'Etf#1 `Eti#2 F-fNuer~t #1 = BODs > 30 ^220 ngA. and TSS >30 < 150 mglt. ' Eflluert #2 = 80Ds ~ 30 rr~lt. and TSS ~ 30 mglL The Department of Commerce is an equal opportunity service provider and employer. If you aced assistance to access services or need materisi in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. } ,~ s r^ fl ~ ' i • , rD. r rn r . m 7~ t Iv ~' ~ 0 N~ ~ (~ Id ~, ~ ~ m s - ~r N 'r ~ o o ~~~,o ~ ~' o 3 z o o -.~ !+ Q- ~ ~~i~ ~o~ ~ ~m -~ N o~ p.q i •~ m X ..~ UJ ~ X ~-P N _ ~T t~ ~ Z ~ ~J ~~ r o R 9 ~V ~ 0 ! ~ ~ ~ ~ ~ ~ A v ~ ~- ~~~ o ., o N - ~- N R~ ~ N ~o c~ ~°-~ ~ ~ rn~ ~ ~ N - rt ~~ 1 0_ ~_ ~' ~ - o J W ~ C aD o a ~, ~ -~ m W ~ ~ i ~' • r ~ y 0 ~ N z~ ~ O y O y ~ IN a~ 0 Z 0 ~ ~~ ~ I~ (O N L O fyD S O N C m 3 m N ~ o ~ N ~ a m ~~ a~ ~- ~ o' ~ w~ ~ ~ 7 j ~ a w z ~~~~ n m 0 ~ ~i m ai ~ . ~ V l ~ D. N N ~ O N ~ ~ ~ N ~ 0 0 W N ~ p' mynr ~ c y ~ 3 m m ~- m ~^ c ., s ~ N ~~ 0 m an O 0 o L C 3 ~ c d A B 3 ~1 ~ • ~ ~; ; d ~ ~ 3 ~ ,~ ~ ~ n ~ ~ A ~ 1"r O ~I O N ~ ~ ° H ~ ~ ~ t n ~ ~ A ma . ~" 7 ~ N w y R O ~ N ~ ~ S O p7 r. 1~ ` ~ N ~. ~ lll ~~ O k3 ~ ~ a ~ e~ 4 m C ~ ~ ~ N o ~ ~~ J °1 ' ' o - : ~ ~ ~ c~ r cn 3 ~ a h .. ~ ~~'oj O O ~ N ~ N N i Q ~ ~ ~ ~ ~ ~• ~ d 'O ~ ID = ~ ~ (/~ ~ d 3 _ ~ N fD 7 D. :'! D C Do Z ~. a °' ~ ~ ~ ~ o ~ i m t N N t C 7. i i a ~ O ~ ~ ~ A ? n c ~ .Z1 •*. ~ d A ~ ~ Z -i Ni a j Z C^' ', (n c0 3 m ~ ffl Z -~ f w ~ '~ I T c a i I S A r a ,tea ti ti 0 A A_ b ~° ti v .:. ~ r i ~ t ~ ~' • LEGAL ST. CROIX COUNTY, W ISCONSIN OLD TXSCR02 REAL ESTATE TOWN OF HUDSON COMPUTER NUMBER 020-1261-30-000 Parcel Number 21.29.19.126 OWNER NAME: First ERIC Last REINHARDT - S6~ ~ PROPERTY ADDRESS: Hse # 1/2 PD --Street Name-- Type SD artment 561 STAGECOACH TR SECTION 21 TOWN 29N RANGE 19W'/<160 '/440 Line Description Line Description '~ TOTAL ACREAGE 2.428 PLAT PRAIRIE VISTA 2ND LOT26 ~ 01 SEC 21 T29N R19W NW SE 15 ~ , 02 LOT 26 PRAIRIE VISTA 2ND 16 ~Q 03 ADDITION TOWN HUDSON 17 ~ ~ d 04 18 05 19 06 20 07 21 08 22 09 23 10 24 11 25 12 26 13 27 14 28 F1-General, F4-Prev. Parcel, F5-Next Parcel, F7-Valuations, F8-History, F10-Exit C ~~~ II _ IA / i~ r ~ m N n H °b° ~ ~o a I U? Z D I ~ D y ~ a W i a ° ~ o 'o c ~-~ ~ m m I I~ I m C N I 3 m I I I I I I N ~ a ~ ~ a I a ma ° m ° ~ -. m Z I ~°a~ m I m 3 N fD ~ ~ N N Q C 7 y n O ~ O 7 ~ N ~ ~ O 1- O N ~ ~ ~ ~ ~ ~ ~ ~ 3 3 °-'g ~~ N ~ I W S m a s ~a~' a •• ~ i .. ~ ~n ~ m ~~v '~ 7 N N ~ ~ '0 c o N N N ~ ~ d O - o ~ A o 3 °-' °' ~ .. C OD Z x a ~ c N N a c a ~ ~ a °o :' 3 ~! z m w ~ c 3 a 3 m o ~ ~ 3 ci ~ v m _ ~ N ~o a o .cNO ~ N ~ ~ W ° -' N N ~ ~ O v' y M C 3 ;.. ~ ~ m u' m M D a a o~ ~ N p Z ~ ~ ~ .' p 2 O .. ~ Z -I cNo .~ Z ~ ~ m ~ .~ d ~_. i r~ ~ ~ "! d ~~ O ~• l A 'O~ w ~: O~ O A ti O d0 V tp ~ ti t~ a ti ~xr5~ N ~~ 3 , r4~rP~r . s~Z~~ s~ 1'~'e sysT~-vt ~,eQ,ee~ ,~- s . s S'I'. CROIX COUNTY ZONING llEPAIiT ~`--'~ '~ AS BUILT SANITARY REPORT ECEIVE~ Owner ~i'SSoN ~al~~.SO~ ~ fi/~/'G /?C%v`j~q~D JUP~ I 0 2004 !',.drls:^s s~/ ST.q~~-~j~ COi'!'r~ T/c~ . ~$ S City,~`State ~~UD1•o~ 4J/ . S 5's?%~~ Legal Description: / L,ot 2Co Rlock Subdivision/CSM # ~~~~~~ U~'S f'~-- - ~ •a l l~~ f ~~ '/~ '/4 , Sec,~_, T ?~N-R~W, Town of PIN # OZ.O • ~2!//• 3(~ • ~z~~ 000 ~~_ ~.~+. n.t~i.x~. -- uv-3L ~.~~tslr~lifLlc-- liVL1111~I1T lAlrlS. llrl'V~.I;IYlA 1 1V: ~YiSTi~ s,T• -- /p-~ 75~ titw 5.7". } ~ > N~ T'ank manufacturer w1~S~"~? Size STlPC / Setback from: House 32' Wel! SD P/L S~ Pump mamrfacturer Model ~llarrn location ~'x -' S T t' N (r- s• I = / C ' ~iP~ ~ . . ~, - - (HOLDING 'T'ANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location ~j ~J y,V l~'/~ L Tit2~1'TD ~' Q v~'Gt ` ' '~ C¢.~Q S SOIL AI3SOTil'~T'TON SYS'T'EM: . Tyhe of system: T IP~'UGr~,~ S Width ~ u 3 Length 5~ Number of Trenches / Setback from: House ~~' Well _~ P/L ~~' Vent to fresh air intake ? -~ r • ELEVATIONS: Tai o~ w ~-« /da - p Description of benchmark ~ Elevation llescription of alternate benclunark _Td/~ ~/"' % ~'.4L/" T • ~Gn~' 7~ Elevation /~~ ~ ~, t S1't sc>/ .~ ~ s ~~' pLo r- I~L,9-.v 5 Building Sewer ~ S'T/II'T Inlet ST Ouilet PC Inlet PC Bottom I-Ieader/Manifold Top of ST/PC Manhole Cover Distribution Lines ( ) ( ) { ) i3ottom of System O O ( ) .Final Grade ( ) ( ) _ { ) ~~~ goo y d~_~~ llate of installation ! / Permit number ~S 3 ~ G G State plan number N/T n~ M A-Y z~ I'Inmber's signature ~ `'Oo License number Z~' ~' 3 ~ -s Date / / Inspector /GIA'j26C ~iH rt ~ y cam, ~,p-p . Ulbricht & Associates Private Sewage Consultants 2812 ~ 0#h Ave. Spring Valley, Wl 547fi7 Corrq,kte plot pier C Cp'~-~/4c ~ K 5 ` I ORIGINAL ~ ~ , ~ i ~ ~ ` + c ~ ~ Z y ~~ ~~ ,,~ ~ R'f ~i ~ ,~ Q ~~ - ~ A ~_ o ~ ~ ~ a ~ ~ ~ o~~~' -...~_c _ '~, . E s -y ® ~ v~ °~ o ~: p ~ ~~ S: ti N ~ ~ I~ j ~ l 1 G J b. a ~ ~ , ~, ~ ~ ~ ~ ~ 1 ~ ~ ~ ~` ~ C~ ~ ' ~ c ~ ~ti ~ ~~ w~~1 ~r^1 R, 1 1 0 ~. N '' . _. ~ ~' ~ ~ `~' ~, c - ~ ~ n ~ ~ ~ ~ ~ ~, ~. ~ - ~ ~ ~, ~ ~ ~ ~ \ CAN-p ~ oo = a •, _ In y 0 , -+ ~ IV W =• _ ..A ~ ~' ~ ~~ J ~ ~ ~ ~ ~ CD ~ ° ~ ~, ~ ~- - N ~~ ~ . O • ~~ In ~ ~ ~ /~ u ~\ N h 0 3 ~_ ~~ Q -~ Vim- -r-ilAn~ T^\ y N 0 ~ ~ ~ m D m ~ { ~Om-~i ~ ~~m a t I~ I r ~` +. . ~ +. i Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER j,/,~/LLy,~ ~~Nby TOWNSHIP 1~(fD.Sf?ilI SEC. ~~ T ~N-R~_W ADDRESS 2~~ ~lE~~ AP~UF ST. CROIX COUNTY, WISCONSIN ~U~Isor/ Gy/SC, SS~o/~ SUBDIVISION ~/~~(/~/f Ul$TX~ LOT #~~ LOT SIZE a~ 7` ~~ PLAN VIEW Distances and dimensions to meet requirements of I•I,IiR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ( (Ob. o o K ~00 =o'' BEuu+ ~~ INkRlL ~~~8 Q'1.~g ~~ a 4 ~~V ~ ~, b$-0 , ,. ` .3.~ o ~~ ~ J E~~~~ 1 ~(,I 3 ~ E D ~©bwl {-{ ov5 E. ~ '~~ a9 ~.. 1,~ ~; ~~~, ~~ ,~ vim, ~oN,N~,~ INDICATE NORTH ARROW No Sc~-L.E .BENCHMARK: Describe the vertical. reference point used _TOP OF NE C'~NE2 P/PE y!!A2/ Elevation of .vertical reference point: /QQ OQ Proposed slope at site: a ~~~g ~~q''s8 ~ ~.~, of 6~e R'7. o0 f ~~o , 0~1~ ~,. Eid ~ ~~5~ ~ z-y' E~~ T Ecd, OF /11A~Jt{otE op ~ ~ (pO, 535 ~~'~ r i ~ ~ ^ _ I PUI~ CHAMBER ~ ~ ' Manufacturer: ~ Liquid Capacity: - ~ Pump Madel: 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 neares 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.: / ~--~ J~o~- Trench: Width: ~ oZ Length: ~r~-- . Number o f Lines : a- Area Built : ~oZ :r Fill. depth to top of pipe: i Number of feet. from nearest property line: Front, O Side, Rear,O Pt.~ O Number of feet from well: .~ a ' Number. of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: , Liquid depth: Bottom of seepage pit elevation:. Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of .feet from nearest property line: Front, O :Side,. O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm 1Manufacturer: pEPARTMENT OF INDUSTF~Y, ~ INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION "P.O. BOX 7969 ~ ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: Nr~~, SE, 21,29,19W ~ CONVENTIONAL ^ ALTERATIVE (If assigned) Town Hudson ^ Holding Tank ^ In-Ground Pressure ^ Mound. E €R ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Verl Beno 766 Meadow Drive Hudson 4dI 54016 BENCH MAR (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: Jose h A. Stan 1 6921 St. Croix 119485 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ^ YES ^ NO ^ YES ^ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ^ YES ^ NO ^ YES ^ NO NEAREST-~ DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ^ YES ^ NO ^ YES ^ NO ^ YES ^ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: 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: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST~• MOUND SYSTEM: 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: BEDITRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIP E: FILL DEPTH ABOVE COVER: TRENC HES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL 8 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 COMMENTS: PERMANENT MARKERS : OBSERVATION WELLS: NUMBER OF PROPERTY I ' WELL: BUILDING: (~ ^ YES ^ NO ^ YES ^ NO FEET FROM NEAREST-• L NE Sketch System on Reverse Side. SBD-6710 (R. 06/88) --~~7 v ~ ... ~ __ ~? ~ 1 ~~r~ ''~ _/ -~ . ~ L~ / ---.~ ._ ~ ,. Retain in county file for audit. SIGNATURE: TITLE: Zon' Administrator '~htxrlas C. Nelson ~a.„~_, CAd11TADV DCD\AIT ADDI lii'_ATIitlpl In accord with ILHR 83.05, Wis. Adm. Code ~.,~ -~~ couNTY S7- CRo1,l'~ -Attach complete plans (to the county loopy only) for the system, on paper not less than STATE SANITARY PERMI ~~ 7 ~~~ >~ X 11 Inches In SIZe. ^ Check if revision to previous application -See revefSe Side for InstrUCtIOf1S for Completing thlS application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. ~ ~{ PROPERTY OWNER PROPERTY LOCATION UEl2t--~ ll.~ E /U d N dJ '/a $E '/a, S c~-/ T o2 , N, R / E (or) W PROPERTY OWNER'S MAILING ADDRESS ~~ ( ~vIE Oo w piQlllF_ LOT # ~L BLOCK # CITY, STATE {+v~5 ~ ZIP CODE Ol PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~A lR V/S~ 2 N Q II. TYPE OF BUILDING: (Check one) CITY ~ NEAREST ROAD ^StateOwned D VILLAGE (fOSDiI/ ~'O(JUT ^ Public ~ 1 Or 2 Fam. Dwelling-#~ of bedrooms ~ PAR ELTAX NUMB R j III. BUILDING USE: (If building type is public, check all that apply) r ~ ~p 1 ^ Apt/Condo 2 ^ Assembly Hall 6 ^ Medical Facility/Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ RestauranUBar/Dining 4 ^ Church/School 8 ^ Mobile Home Park 12 ^ Service Station/Car Wash 5 ^ Hotel/Motel 9 ^ Office/Factory 13 ^ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ®New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an System System Tank Only Existing System Existing System B) ^ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ~ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^ Seepage Trench 22 ^ In-Ground 42 ^ Pit Privy 13 ^ Seepage Pit Pressure 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./'nch) ELEVATION / '" - ~ ~ j~ Feet T J " ( ~ a o, 3 A / ~, 0D Feet q, ~S VII. TANK CAPACITY in atlons Total #of rer's Name f t M Prefab. Site C°n- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks ac u anu oncrete strutted glass App, Tanks Tanks Se tic Tank or Holdin Tank ~d OfJ ~U/E ~ 5 C O Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STAT MENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: JosE P!f A- . ~ ~ is L Q, A'I ~ 6 ~a ~ '1 7~- sy 9 Plumber's Address (Street, City, State, Zip Code . D ,E~tl I S L E w SC 4~~03 IX. COUNTY/DEPARTMENT USE ONLY ,~/ ICI .Approved Disapproved ^ Owner Given Initial Sanita Permit Fee (Includes Groundwater Surcharge Fee) ~ a e ssue ~~~ Issuing Agent Signature (No Stamps) 1~ Adv rse D termination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6388 (formerly Plb-87j (R. 11/t38j DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS ~ •~ ~ ' - ~ -~_ ;~ r 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. , 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety 8~ Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. II1. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for al/ septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'fs 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; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reterence points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manuf~acturer; D) cross section of the soil absorption system if required by the county; E) soil test data on.-~ 115 fol~jY1; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) DEPARTMENT OF., r ,. _ REPORT ON SOIL BORINGS AND LA80R AND PERCOLATION TESTS (115) HUMAN RELATIONS (H63.09111 & Chapter 145.045) SAFETY & B<11LDfPdGS -~--S~VIS~ON P.O. BOX 7969 MADISON; WI 53707 O.A I N: ~ '/ N '/ S-E~UN: ) z 1 /TZ9 N/R(9 E TOWNS~ IP/Nk3'IQiCfI'f[LTTY: v ~so / ' OT NO.: z6 BLK. NO.: - S}~BDIVISION NAME: 1-~ia~Ril; ~-s, ra ~f~ w ~ .or ~ Y u COUNTY: OWNER' MA L N AD R S 5-5-Cleorx u~~LYrV >~;~.Wvy LSE NO. B DR COMM R AL E RIPTION: Residence (~(~~ _, New ^Replace RATING: S~ Site suitable for system U~ Sits urnuitable for system ~k j1y- 'K ~2 iG . ~ ~~R OATES OBSERVATIONS MALE Qa~l~ z~, -9~ ~ May ~ ~9~ ~, ("c,. ' S8 O~~ Q~~ MJ~. ~ / ~7 I- (tea ~ ~ ^~ . S - N~-FILL U O~LDING TANK: ~ ~ S ( R RECOMMENDED SYSTEM:Igptional) ~ ~ ~ Y L 1 , {~ L J ~ 1; ti1T testy ~4 L If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.0915){b), indicate: ~ L.~1~.5 ~ (Floodplain, indicate Floodplain elevation: N~ ~` ,r,,~. PROFILE DESCRIPTIONS BORING TOTAL P H T R U D ATER•INCHES COLOR TEX PURE AND DEPTH HARACTER OF SOIL WITH 7HICKNES NUMBER DEh('H115i, ELEVATION OBSERV D . I H , , , TO BEDROCK IF OBSERVED LSE:: ABBRV. ON BACK.) 8-. ~,~~ Ql,t;~ x~ ~. ~7.5~ _-~_ 3 - b Gy c nct.ust io"~c.~.Taz ~g~.,,`~L S6 ~~..-cs~G~ ~' RAntot, B- 3 ~~6~ lU~~,G ~~t ? y,~~ (z°$czT's 3tg~~~,~L /OrGY$t45~Crr~10R"~aTSb $~,t~--MSY B- ,-l~ ~VQ~~~ ~ P~{~.~~ r~' 7,~1 C. ~1 ~`'e~.,(...\f.~ j'`vi t~4?weC. Y ( I.~~Ry~j~~~~"C.1~ B- ~ ~,.~~ 11.,1,19 oN~ ~" ~ ~ 1~ IZn CTS. ~,,,?,~.~QN~ G~i" BAN ~s~Gr~ B- ~ , ~,? ~}I, `~ ~ ~oN~ ~ .~ ~ ~ ~,.~ C L`I'S ~ ~~~8 E'er L t~~ n (.SRS ~~ ~ ~'~E' B- ~~~ r ~. .PERCOLATION TESTS DEPTH WATER IN HOLE TEST TIME D ER L - N H S RATE MINUTES NUMBER tHlS AFTER S WELLING INTERVA -MIN. RI PER INCH P- t a ,6v nl ~Nt; X01.60 3 > 2 > 2 > 2 < R i p_ _._. ~... ~. Y Al' I © hT ~ c P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe whet 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. ~~NCNMtt,~Q1C- ~ ~~1 Qcstia pl'PY r1T SYSTEM ELEUATtON ~7~ ~~ P~~~~,U L.,,~~ ~ NE Ca~~YR O~ L~ Z 6 _.,_ _... ,~~~ ~ \~`~ ~ ~,1 ~, J TN Yi ~~2~ y~ (~~tNO y . ?~ 6 rvI E~~bw O~cV~ ~-E-~ ~ Sb nl v~ csc . S5~ e l ~ t~~{~I2I E. L.l4N~ n_ ,f ~EA~I-~~j~y~'IL I I2oN PIPE b ~7 h1 ~ S~~LF v F - ~~2~Y~ ~ ~,~NO, y . ? 6 G rW E~440 ~1 DI~cVE k4-U056n1 v~csc . S~dI ~ ~I~{~IRI ~ L.J~N~. Dn _ "- -- . _ ~ .. _ ~. ~Eucnnt~/V1I~I~K I ~~ IRo~u Pi PE -*"r NE eORNFR OFLOC Z(P ' ~(,~U14TION (D~~Cd 1 LO ~ ' b ° y ~ ' . 3 ,3 [~.o`i' a 7 s ~ ~- ~ T SCOPE 2% ~ ~ ,~ ~ ° E ' m 3~ S s i s~ ;~ ~,lF~ q~,o0 r z ~- m s . ~~pna 3 F3EO2ovr-~ AIL - ~{-vu5~ .. k ' 'd~ .~~ ~~ 3~ DO ~ .0 s~wFR i?oc~ ~~~.. ~ I-~J D S~~I.F_ k~ .~~ ~ ~ . r ~ ~ a '• t ' APPLICATION FOR SANITARY PERHIT 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 fore resale by owner/contrac or, (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 Qroperty ,,,;~ / .F d ~`a7/7Fv ~ n/~ ~'f• .~~' ~ 'cay -- Location of praperty~1/9 5 ~ 1/9, Section .~/ , T~'-'_N-R /~1 W Township ~,~~^ ~+ Mail-inq address ~• AA~'.~ r> '^.~J~-`~~~,z~~r~~n~J ~-~~~c <:~~c5/ Address of site ~~~ ! v ! c .~ ~~ ~Lr BSc w' ~_~i se ~~lc/l Subdivision name I~,Lr ! 1~/ ~ L~! S i; ~? -~rn,~~~~{~~~.! ~i CiSI Lot number Previous owner of property /7~c~/'© f,c 1~~`~iV' Total size of .parcel :~• ~'~ C~ C' ~ e. ~ Date parcel was created ,~~,r ~ rde d Ma r~e-ii.. ~ zt l~l~"`% Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)?~,_Yes No Volume `!~~~~ and Page Number ~S"5, as recorded with the Regis er of Deeds. INCLUDE WITH TNIS APPLICATION THE FOLLOWING: A tiARRAtiTY DBSD which includes a, DOCUHSNT NUMHBR, VOLUME a-ND PAGE NlflFB$R, and the SBAL 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 Hap shall also be required. PROPERTY Oi~INER CERTIFICATIOti ~(We) certify that all statements on this form are true to the beef of ~ny--- (our) knowledge; that ~-- (we) a~.(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'. ~/~ ~-Z/ ; and that--I- (W~) presently own the proposed site. for the sewage disposal system { ~~ :C~ `-"- at~,.-~~=.~eas~me-ntz k a. run - w:tt #--the- a bane ". de ss r i bed {xr a~per-ty ~ . ~sr _ - t #e c _ ~f -said ystem, ar-~=~l~e--s$me--ha-s been duly-recorded -~:n_the Office o - ~---Ite~~e-r of-Deeds-; as_ Document No,. f ) , ,~ L!, .',;~iY'+ ~ c'am' °7~''..r.( t~i' ~.~...Y, Y / , ~ ~. ~~:`' ~ i,~~='' i ~ UTJPLATTED LANDS ZONED LITE INDUSTRY ^ . ~; R A I R I E VISTA ~, r1t ~ I" y ~- ~~•~~•• c 1 NORTH LINE Of THE SE I/. -~~. a1.-s r~rv_ ~-. _ _ .... _ _ _ I 2E9"7~• _~jj9.79_ _,~j:9. 7~'__.- _ ~cs.IY-__ ¢. ~.Z4_^ j ~ ' ~-' 1 /4 Corner Section 21 IZ 23 22 _ 96115 Square feet z 100129 Square [eat (2.201 aezeel ~ (2.299 acre.) ry° 21 20 19 • ;. ~ ~_ ~ ~ 1o3e54'3q~:re feet ~ 101!46 9gaase !tea o : {03646 Square fart I ~I z g ~; (2.214 aereR) g ~ (2.3!<4 aerM1 g ~ •t (i.ls4 weraa} -;, . •~il z z z Ofeb! e6"MI 2 1 y _ __ ,` ,\ a ~; o . ~ ~• ~r'~v 9r •'- reee' ••ee•w'a• O N se 0'aE M ft M•ree'.e•e ~~ •eM••.'e~f ~ pp..ttpp~'rr ~' ~•t~ i ~ ~ i I t etc ~ e ~ \ "~~ ~'~ ~ _~~-G'iR~.~i iE~.--- - - ~ ~. ~ _.~ ei ee' ~ ~, • RO• R•.e• .ea. ~• o ~. e•.•oa• ee• a e• !o e e .n••o1' uY K ee oe' e.~ • . ro' ~..'• c~={. , ,. W '• `06 ~ 12A390 t300sr. feet ~ . ~-- W N 13.63f sesee) ". =, 14s4Ti ~qt.:e t..e 2 5 2 6 2 7' ~ ;~.~, =e ~~`ir4ta0 AON ~ s 17~20St S~IiLie feet IOSt91 Spars trill! • 106029 i~gdati teals '1 o' • = ~ • (2.602 acre.) ~ rt.42! acre.) (2.434 acres) ~ ! . ~ ``11 n • i~ • n .• °~ 2.6 O. = neA Op• + p ~ ~~ Y g R gel a i3 1 >I~xl~ u -- - zu ~ W« ~ , •l Q ~ ~a r, ~ - 1 ,.. h~ W ~° . ~. e w o ~ ~ .. a •z- w z - 111 ,. ; le. rs' - M h H' .ee 0 t1. !' - N !0 H'. MAR .0! p x 1 p ~~ l2' o J 1 g I n el I = c,GONS : 2 8 .~~~ ~'ti ~ f00 79 D ~D 0 t00 200 300 ~ ~ t} r1ARVEY Q. St L ~ ~ 45209 Square feet JpNNSdN CAS[ IN FEET ~ ~ (2.2SS acre.) ~ I s-Toot! r"• loo' ~~ HU[ISON / o ' wn ~ r •-- \ ~ ' •1 el < -~ ''+rl sl. ~' N ~_ _ _ a' efrt.eteM~ a -- -- - e L- lOY7M AIM[ 0~ TM[ M\~I/. Of TN[ !CI/A +f'i0 M A O 0 1 I s ~ g `, }~ : A .. ~..: •.:t ' .~• • ' t 1/4 Corner • i'1~~ Seollow 21 UN. tT. 0I ROAO IM -RAIRI[ YIOTA = (2• te. ttr f pl~l A~IE _ylSTA secowv •vvlTlaw • :eer• i AA: ~: IiAI \ - n ATrIRAOt lOT 012[ 0- [IRIRt MAIRI[ • " ' ~ ~ '' FIR ST AD_DI_TI_O_ M vI.TA SLAT t:e LoTel.:.s:e Ae 8 Yr11 ~ _ _ ~ 1 7! r f. _ - I . I e ..~ CURVE DATA TABLE I y~ Z ~ ¢, I ~ pdd N Yl/~ fur Ssctiea ! 1 12' s \'~~ ` .~I~N~~~ ~. 1~~ ~ ~.. ~~. it : iii ~S~~i rw•i : ? •ML ~ Ai I7 ~ ~~ iC1rM~ :• ` ~ w ~~ort~ ~'~„?- ~ 8 . Air . ~ ~ ` ,.,. e' ~• ~? w ~~ ~ ~ ~'. , r• Q e M b O a C n O N O GL ;~ •~ Q N .~ -~1~ PV •~ O r`IV r 0 ti d C O ~ i Fri t~ .ter Cr C~ A ~' ~ W ~~ z N H Z C ~ O Z d' 'a. Q: r v ~ H v a N ~6 y a~ a N is a fn J V O o O M cO',) N _ ~ ~ t0 ~ C N p N ~ 7 O N 2 ik ,?` a n, d ;~ c tia~ p °~ N I ~ I d I ~ ~ C y I L ~ w I p ~ ~ 1 . 'O 4J N m I E r> ~ O ~ a~ i a E p ~ ° I c Z ~w I c 1L C ~ ~ I IL 3 I 3 ~ ~ ~~ E ¢ wa I ~ I O. In ~ M ~ y Z y ~ I ~ " 0 0 ~. I ~ p ~ I a m a m I O I C ~ C Q r o I o u~ ~' ~ Z ~ a ~ ~ I 'p e ~ Ch 'C N ~ p N ~ ~ N ~ I ~ ~ y a ~ ~ ~" N C p I y ~ ~ t a O ~ I Z m Z Z m Z Z I d ~ I 10 ~ N N .. W ~ W ~ ~ W c c a ~' ° c c ` I ° ~ l a ~ ~~Nrtir p a ~ ~_rrrnv~vrr~ ~ ~~ o o ~ a a a z I o~ o ~ a a a y I y I~ 0 ~ } 2 rn rn ~ ~ .~ ~ L ~ ~ N I- o v M N 0 V O O p '~ ~ 0 ~ (0 'O 'O d fU c N Q ~ Q Z UJ d d N ~ 'O I y6 ~o m ~ 3 w w ~ N 7 as tOA h C p ~ I~yA C C O ~ n w V N a~ c o d v es °o C I .~ ~ N c ~ O d I ~ ~ .C ~ C y ~. y ~ ~ C w 'D i j J A~ C M '~ r 7 C .t G Q: ~ O Z~ Z~ ~ fA m ~ 0 r •~ i. ~ •C ~a I ~a c :; ~ 3 ~'o c °: ~ 13 ~'o , ov~~ o~n~ ~ °o, O ~ N C 'Tv ~ C ~ N O ~ _ C C aia~E~°' mid-E ~ C..1 T ~ ~ y a 4. ~ " ~ w N lp f0 t0 O N N m ~ a ~_ 3 a~ y my V) ~ = ~ ayia`~~ d zj~cc€ a c_ c ~ ` ° ~ ~ p m c~ m0. T ~ ~ ~ ..6 ~ N O ym ~;. c a~ E d ._ L O t a N m ~ a ~ a cn O Z m C (p O Q } (n O ~ U C 0 ~ € v, N y ~ ~ Z d Z ~' Z Fp-