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HomeMy WebLinkAbout020-1055-60-300~\~ fpartmentofCommerce PRIVATE SEWAGE SYSTEM County: -"~ o~ ~ Buildings Division St. Croix ~°~~ INSPECTION REPORT ` ~'~~ ORAL INFORMATION , {ATTACH TO PERMIT) Sanitary Permit No.: al infprmation you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(mjj. 363863 ;Holder's Name: ^ City ^ Village ^ TdLvn of: State Plan ID No.: er, Sam Hudson Township CST BMElev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: ~ j~ p Z3 ~ - ~ a ~,) 020-1055-60-300 TANK INFORMAT{ON ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic ~ ~, ~-~ Do ' Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG, vent to Air Intake ROAD Septic 7 t ~d ~ 3 Z~ ~ 3 ~ NA NA A ion N Holding PUMP /SIPHON INFORMATION turer Demand Model Number GP TDH Li Friction S stem TDH F Fo cemain Length Dia. owes 501E ABSORPTION SYSTEM t 7. .-L ~ _ ~_..G ra.rL STATION BS HI FS ELEV. Benchmark , ~'~ ~ S 0 v Alt. BM 2 , ~ 5' d Z, ~' Bldg. Sewer , l~j'"~ q~'- ~ Ht Inlet S ~ ~ , 3~ I Ht Outlet ~.-„p/ q ~, ~ Header /Man. Dist. Pipe ~`~ Tz ~` 2 - ~ Bot. System Cy> T ~ 1S. Z 3 Final Grade ~ ~ a0. St cover ~. 9 fl /a/ BED / EN IM Width 3~ Length No. Of Trenches S~ Z PIT IM 1 N No. Of Pits Inside Dia. SYSTEM TO P / L BLDG WELL LAKE /STREAM LE Manu ctu SETBACK INFORMATION Type O ' ~ , ~ ~ s 3 HAM E o e System: ~ p., T ~~ DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spv Length ~r Dia. ~ length ~~~ Dia. N Spacing --r! t- ~ ~. SOIL COVER x Pressure Systems On{y xx Mound Or At-Grade Systems D ` Depth Over Depth Over ~ xx Depth Of xx Seeded / Se Bed ~ Trench Center Bed /Trench Edges Topsoil ^ Yes [" COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l:.$~ ,' Location: ,Hudson, WI 54016 E 1/4 SW 114 21 T29N R19W) - 21.29.19.206A30 -I 1.) Alt BM Description = -fob o~'~u.~a.~',~,. ~ .. 2.) Bldg sewer length = 2~ ~ -amount of cover = ~i~~' t f -` Plan revision required? ^ Yes ~No Use other side for additional infar ation. ~( SBD-6710 (R.3/97) >, ~ , •' spector's Sig~~, t' ADDITIONAL CQMMENTS AND SKETCH ANITARY PERMIT NUMBER _ <~ _ __~._V _..~. ~.~~ . ~, ~ ~ ~ C ~ ~~. ~_ . __ _ _ ~,. ~ ~ ~ ~> ..3 ~_~ ,~. e V ~, ~ s I _ ~: ., .; J~ ~ ~ i f 3 ~ fj i s f ~ ~ 1 y { _ _ _ .-- --~ ~ E a~ _.~. _ _ ~~ ~ - ----- s ~` ----- ~ .- P ~ ,_ ___ ~. _~ ~ am .~_ ~.._ . ~ ~. -4 _ ~. ~ E a ~ ~ t i t ~ I ...e.~ { ~ ~ ~ ~ i e ~ ~ ! ~ # ~ ~ ~ _ ~ ~_ ~ s ~ j ~ i ~ t i ~ ~ t } ~ ~ ~ k f ~ ~ ~ } i ~... 4 .~.......... 5 r..~,.y~ ~ ~ ~ ~ ~ ~~ ~~ S # ~ 1;I;ff F j#p f { t ...H, ...... ,.' „. j ...~~ -. - ~W ~,.RN.. ~,~ r ~.~~~,,_.,... _~ ~ _ ~ .~ ~ ~ ~ # 1 ~ _.~ _ ~. ---- ----~r----- ~ - ~ -.~. ~ .__~__~_._.__~..~ _~ _~ s n~ ~...~. ~ .. ~,.~~.~, v 1 ( ~ ~ ~ ~ ~ E ~ iM ~._ M .~~~ ~ ~.~ ~ ~,~.~~~ f ~----- ~ ... ~ ~..~ ~ ~..~~ _~... # _ ~ ~ _ .~m. a ~ ~~ ~ ~ 3 ~ t s~ ~ ~-~--.~ _ ~ '~ ~ ~ ~ ~ I ~ # t g } ~ i ~ I ~ ~ i ., ~ ~ i { r 5t ,..~.~.. b~~ _ - - ,. .~., ' ~ ~ ~o~ ~~`-~ ~ _~_" P __ __!~___. _ _._ ~_~_.__ ._...____F v~_,n.~ . W__ m ~ a ~ ~ ~ ~ r ~ ~ ~ ,~~ ~ ~ ~ ; f ~ ~ ~ ti _. ~ ~ ~ ' ~ # ..~. ~. f ~ f t ~ ~ ~ ~ ~~ ~_ v~ ~ ~ ~ ..; _ _.. ~~ ~.~, ~ w. ~__~ ~ __~- __. ~. d~ ~.~ ~,_._. ~...~~... ~..~....~. . ~, . ~, . _M, ~, ~. ,. ,,~~N `~SCO/1S%11 SANITARY PERMIT APPLICATION Department of Commerce In accord with Comm 8 Code ~ . '1 t 1 , -s~'-~ Safety and Buildings Division 201 W. Washington Avenue POBox7162 Madison, WI 53707-7162 • Attach complete plans (to the county copy only) for m, o~'-n~}iafp,~r°npt less ~ county '~ , ~ .~ ` - ° than 8 to x 11 inches in size. ~ rv I 5 t . ~ ~~/~+ • See reverse side for instructions for completing pplica~'iKi8~~0~~D " ~~ State Sanitary Permit Number 3 l0 3 g~ ~ _ Personal information you provide may be used for secondary p s ~"-h ~" f ~ .~ f;t°j ~ p Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)j. ~ 1 ST E ~U ~_ Y State Plan Review Transaction Number I. APPLI ATI N INf RMATION - PLEASE P I A I ATI Propert Owner Na a Cam. ~ 6' rop c tion va, S Z / T Z'' , N, R ~ 1 E (or Pr erty Owner's Mailing Address 8 Q ~ / s ~ r Block Number ~". City State J+~+DSoA1 w l Zip Co a a Pone Numb r ) Z~~ Subdivision Name or sM Numb ,~~,c.. refs II. TYP B ILDIN (check one) ^ State Owned o Its/ p village ~ ~ a N NeaArest Road ~/~~ ~Q~ ~ ~~ Public 1 or 2 Famil Dwellin - No. of bedrooms Town OF . III. BUILDIN SE: (If building type is public, check ail that apply} Parcel Tax Number(s) Q ~ ~ ~ / ~ ~ ~~ ~ a ... ~ Q 1 ^ Apartment / Cor}do 2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/ Repairs 11 ^ Restaurant/Bar/ 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 box on line A. Check box online B, if applicable) , q) 1 _ ^ New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an ______System ________System_____________TankOnly______________ Existing System _________ExistingSystem B) A Sanitary Permit was previously issued. Permit Number 3 6' j~'~ 3 Date Issued ~ z a V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed ..AA 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank ~ ' 42 ^ Pit Priv hLEl'+G,~ 22 1 I T d P S G y ~ renc roun ressure eepage ^ n- 1 ^ Seepage Pit rai~~c rQaro~. ~ k 3 X 1S 43 ^ Vault Privy 14 ^ System-In-Fill ~,,~ .-~,. 3 ~, Q ~T ~' ~ ~ 15 ~ ~., 3 VI. ABSORPTION SYSTEM INFORMATION: 7. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev_ 7. Final Grade /I~n~ch) ~ s 30~ Elevation n. ~ ~ Required sq. ft.) Pro ~sed (s q. ft.) (Gals/day/sq. ft.) (Mi ' ~ ~ ~ e 7 Feet OO• S Feet VII. TANK INFORMATION Ca aclt in allo s Total # of Manufacturer s Name Prefab. site l St Fiber- Plastic Exper. N E i i Gallons Tanks concrete ee glass App ew x st n strutted T nks Tank eptic Tank Holding Tank ~Z ~ ~ W ~ / ~j~., ^ ^ ^ ^ ^ Lift Pump Tank /Siphon Chamber ^ ^ ^ ^ ^ ^ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) ~~ ~ ~t:~~~ ~ Plumbec;s Si nature: ( Stamp ~ MPlMPRSW No.: z 2 s~ ~ ~ Business Phone Number: r ~~ ~gb• ~~yz . . _ Plu bgr'~ ~ress,(St~ t,~~jjyat~, Zip de • ~~I~' IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) (Approved // ^ Owner Given Initial Surcharge Fee) ~ ~/ _~ Adverse Determination o X. CONDITIONS OF APPR/OVAL / REA50N5`F/O' R DISAPfPROVAL: /' ! 1 rs IC Pu r Sr o-~ Gt.vt S SivD~r f~jf~ ~j /l' t'/~ Q/P ~i m v~ C ~t'a.•.~-~ P- -~~..` ~G -Q f~ qs 3a- SBD-6398 {R.12l99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a 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.priortvinst'allation 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 and Buildings Division, 608-266-3151. 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. III. Building use. If building type is public, check all appropriate boxes that apply. iV. Type of permit. Check only one online 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 for numbers i through 7- Vli. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all 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 1/2 x 1 1 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 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; 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 contamination investigations and establishment of standards. ~. ` , ` ~~ ~ 5 s /eo~ - SANITARY PERM APPLICATION ~~scons~n , f3epartment of Commerce In accord with Comm 83.05, Wis. Ad _ ~, ,~.~, • Attach complete plans (to the county copy only) for the syste ~ er not less than 8 v2 x 11 inches in size. _ f ~`, .A~• ,;~ • See reverse side for instructions for completing this applic~to ~~.~' Personal information you provide may be used for secondary purposes ' , r ~~fi~ [Privacy Law, s. 15.04 (1) (m)]. ~ ~-~ "~ ~ ~~~ -,~ ~T. . Safety and Buildings Division 201 W. Washington Avenue POBox7162 Madison, WI 53707-7162 "bounty Stat Sanitary Permit Number , 3633 ~'Cfh k if revision to previous application I. APPLI ATION INF RMATION -PLEASE PRINT ALG NF RMA : O Property Owner Name 5 ~L~.~ l,_ P:17~ cati ~ iias~, ~ TZ.9 ,N,R~ E(o W Property Owner's M~ ail fng Address t ber \ (,, ~ Block Number ~ ~_ Cit ,State iD ~ I Zip Co a ~ ~ Phone Number (3 G > z~ to Sub ivision Name or CSM N tuber ^ ~, t - s ~:.JN~ 3'l~b II. YPE B ILDIN (check one) ^ State Owned ~ 't Neattr~~est Road ~ E rL~ N~ ~) ~ ~ ~ ~ rowan Public 1 or 2 Famil Dwellin - No. of bedrooms . r` OF (J .S O III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) a ~ ~ .' y ~ ~ ~ 7jp O LO - ~ C9 SS- ~~ ~ 3 ~ ~ 1 ^ Apartment /Condo 2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/Bar/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 box on line A. Check box online B, if applicable) q) 1. New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5_ ^ Repair of an -______ystem ________System _____________ Tank Only______________ Existing System ________ Existin~System - B) ^ A Sanitary Permit was previously issued. Permit Number 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 t.~'{~C-N 22 ^ In-Ground Pressure f i 42 ^ Pit Privy ~ ~3 X ~ ~ = `~ 43 []Vault Privy 13 [] Seepage Pit ~ ~[ t t ~.T~.ATd2 y ` ~ "' °" 14 ^ System-In-Fill 1. ~ (, ~ ~, t~ r ~„ f.},t~ IMQLt~ 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 t _ Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) Elevation d a ~ 9' ~ °` c,p ~ Q t,p ~---- Feet feet CX9~$ VII. TANK INFORMATION Capacit in allo s g Total # of Manufacturer s Name Prefab. Slte Con- St l Fiber- Plastic Exper. N E i i Gallons Tanks Concrete ee glass App ew x n st strutted Tank Tanks eptic Tan r Holding Tank Z,r o '~ ^ ^ ^ ^ ^ Lift Pump Tank/Siphon Chamber ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Si nature: (No Stamps) MP/MPRSW No.: Business Phone Number: N, 4 Plumber's Address (Street, City, State, Zip Code): ~ ~~ ' t v ~ p o ~ ~ IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (I^dudes Groundwater ate ssue Issuing Agent Signature (No Stamps) Approved ^ Owner Given Initial Surcharge Fee) ~vZ S~ ~ r Adverse Determination - . j X. GVNDITIVNS OF APPROVAL/ REASVNS FVR DISAPPRVVAL: SBD-6398 (R.12I99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber { INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a 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 and Buildings Division, 608-266-3:151. 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. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on 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 for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all 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 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot p-an, 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 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; 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 contamination investigations and establishment of standards. ~.yE 3.~ r~ ~~ 1 ~~ A ~~ ~~=~~R~~ ~ ~z~~~~ ~ ~+ _.. ~ ~ 1 a p r-- ~ ~ ~ ~ ~ ~ f` ~° ~ ~ ~ ~ ~ ~ ~ r •~-# ~"' `~ ' ~l~ -~ "ms s ~ rD ~. ~~' ,~ ~ -~.- 1 ~'~`1 yb L -+ ! "1 ~ ..(r EGA T` 9` t~ ~ #uv ~ ~ ~ ~ ~ r1. 1 ~ ~' - f N f '`~ w ~. O , UJ i `... ~ "~ ~ ~~ t -~ W_~ ,,~ r ,: ~. ~~~ . ('fit ` ~ '~ `M r ~ ~~ ~ .°1a. J~ ~~ ~ ~ V ~. VJ~ ~~~ ~ • ~. W:' 0 -. Z ~~ ~ ~ ~ ~.~ ~U W ~ ~° w0~~ ~ C/~ U '~.. '. . r.-._m..,...~ ~ ~ ~ _ v -° ~ _ ~~ E ~ r- M apt a:. ~, ~. ~a x cro ~ ~ .° ~ ~ T' 1 _ a i N ~ Q Q (b 6i ~ O N C ~ C7 N -- ~ ~ E = O ~ ~ O f0 O C ~ ~. C O ~ N O N .Q O ~ r _ :, 0 ~. a~ ~ .fl .~ c b U X R C ~ t0 ~~ ~~ •N O ~ Q ~ ,1 X 4 ~ ~ W ~t«C ~ =L4= ~ U ~` Q~ C p C U C •p ~ ~ ' ~ ro.c ~ ~ : ,~ , ~ C .~~ ? ~ o o rno ~: R1 N ~ > O ~ it ~ . J l0 LL E O ~ = U 'fl ~~. b , ~~ w ~ ~ N o ~/ U ® e ~' °~ ~ ~...~, W .g v w w a ~ ~ w ~ a ~ .. o ~' ~! !p a {~~ i; ~~ i~ ~~ i~ ~~ ~~ !~ ~~ ~~ ~' ~~ ~~ as ~~ ~~ i ~~ ~~ ~~~ ~' y a m a a, a © Vo ~3E o- ~ U = v 2S ~~ .• ~W • E ~ g ffi ~ ~ a ~ ~ a `' ~: a e •. ~ ~ a "~ ' ~ ~ 9 ° h---- ~ -I ,. ~w t of com~c~e SOIL AND SITE EVALUATION Page 1 of 3 ` [3ivision of S~ety and Buildings in accord with Comm 83.05,. W is. Adm. Code AC.E. Soil & Site Evaluatiooss ~!~: P~tach eanptete site plan on paper not less than 8'/: x 11 inches in size. Plan mast ~ !`~ ,~; . ~ ~ ~ County include, but r-d lmroted to: vt~ttcal arxi horizontal referent:e point (BM), direction aril ~' 1; ~, ~ St. Croix percent slope, scale or dimems, north arrow, and loc~ion and distance to rtearnst road. Parcel F.D.# APPLf~ANT ENFORMATfON - P/ease plfnfall irlfo-n-atiorl. ,-~ ~ ~" ~ '-PQ~~o~f020-1055-60-0OU Personal information you provide may t~ used for secondary purposes (Privacy Law. s. 15,04 (t) (m)}. •:- ~ , .. ~ ,; ~~~,V~'~--_ vHC.=i. ~ a.~ '~' ZOGU Property Owner P,~~NiNC, ;i' ;,. Miller, Sam Govf. ~t: f .~ ~1~ SVV~ 1. S 21 T 24 N,R 19 W Property Ovmer's Mailing Address lot # ~ 8lgctc.#._.- ... ~~:,~d or CSM# P.O. Box 151 4 ^ " ` " ~ Proposed CSM ~- City State Zip Code PhoneNumt>er ~ Cry ~ udson ~ Town Nearest Roa 3tagecc~ch Trail Hudson Wl 54016 715 386-2769 ^ New Construction fie: ^ Residential / Nurr~er of bedrooms 4 ^ Addition to existing building ^ Replacement ^ Publc or commeraat describe Code Derived daily tkwv 600 gpd Recommended design loading rate •7 bed, gpolft2 •8 ~~, 9p~ Absorption area required 857 bed, ~ 750 trench, ftz Maximum design bading rate •7 bed, gpolft~ .8 trench, gpd/tt2 Recommended infiltration surface elevations} 96.00' tt (as referred to site plan benchmark} Additional design I site considerat~ns Install trenches using high c2pact~ . Parent material Glacial outwasl- Food ain elevation, if 'table NA ft S=Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U=Unsuitab~ for system ®S ^ U j ^ S ~ t! ®S ^ U ®S ^ U ^ S ®U ~ s ® u Boting# Ground elev tinn ~~ e limiting factor >120' 2 Ground elev Ana da e Depth to limiting factor >11r Depth Dominant Cokx Moths Sere i d B Roots ~~ Horizon in. Mansell Qu. Sz. Cart. Cola' Texture ~. Sz. Sh. sten Cons oun ary Bed ;Trench 1 0-12 10yr2/1 None sl 2fcr ds cs 2f 0.5 0.6 2 12-19 10yr3/4 None sil 2msbk dsh cs 2f 0.5 ~ 0.6 3 19-31 IOyrS/4 None sl 2msbk dh aw If 0.5 0.6 4 31-75 IOyr5l4 None s Osg dl gs 1f 0.7 0.8 5 ?5-120 10yr6/4 None s Osg dl - - 0.? ', 0.8 .,~- 4G .o ~ ~ 3D ,a;.s2~w2s ~ ~~o, r, Remarks: Horizons #4 dz ~ contain approx. f tyro coovte aria swne 1 0-ll 10yr3/2 None sl 2fcr ds cs 2f 0.5 ~I 0.6 2 ll-34 IOyr4/4 None si 2msbk dsh cs 1f 0.5 0.6 3 34-44 I OyrS/4 None sl i 1 csbk dh aw 1 f 0.4 I 0.5 4 44-87 IOyrS/4 None s Osg dl gs - 0.7 '~ 0.8 5 87-117 10yr6/4 None s Osg dl - - 0.7 ~ 0.8 ~0 9 4' Remarks: CST Name (Please Print} Sign Telephone No. James K 'Thompson _ 715-248-7767 Address A.C.E. Soil & Site Evahrataons Date CST Number Ref # 340 Paulson Lake Lane, Osceola; 54020 11!5/99 3602 1128 pRe'~-, . PARCH ..u Ground elev 10t1.86 f Depth to limiting factor >119` Mrlter Sam SOIL DESCRIPTION REPORT 1128 ~ 2 Of 3 e (` F Cnil ~ Site Evaluations ~ >_~" Depth Dominant Color Mottles Structure i t d B Roots GPD/ft~ Honzon in. Munsell ~ Qu. Sz. Cont. Cobr Texture Gr. Sz. Sh. s s ence oun ary Bed ~ Trench 1 0-11 10yr2/1 None sl Zfcr ds cs 2f O.S 0.6 2 11-31 IOyr3/4 None sil 2msbk dsh cs 2f 0.5 0.6 3 31-40 10yr5/4 None sl 2msbk dh aw If 0.5 ~ 0.6 4 40-85 10yr5/4 None s Osg dl gs - 0.7 ~ 0.8 5 85-119 10yr6/4 None s Osg dl - - 0.7 0.8 ,32, ~-~~ ~ ~ n_ - ~N 4 Ground elev ~n~ ~~ e Depth to limiting factor >115" 5 Ground elev 100.67 ft Remarks: rtonzons rr~+ ~ ~ conram approx. ryiu ww~ ~.u ~.~,..~. - - -- 1 0-10 10yr2l1 None sl 2fcr ds cs 2f 0.5 0.6 2 14-31 10yr3/4 None sil 2msbk dsh cs If O.S 0.6 3 31-44 lOyrSf4 None sl 2msbk dh aw if O.S ~ 4.6 4 44-91 lOyrS/4 None s Osg dl gs if 0.7 0.8 5 91- 11 S I Oyr6/4 None s Osg dl - - 0 7 I' 0 8 ~-' I{emancs: nuncixr~ rr~c a ~ w„eau. aYYi.,n. ,.,.o ~..,...,~., ~,., ~....,.,. _ - 1 0-10 10yr2/1 None sl 2fcr ds cs 2f O.S ~ 0.6 2 10-29 10yr3/4 None sil 2msbk dsh cs 2f 0.5 0.6 3 29-36 10yr5/4 None sl 2msbk dh aw If O.S 0.6 4 368 10yr5/4 None s Osg dl gs - 0.7 0.8 S 88-118 10yr6/4 None s Osg dl - _ - 0.7 ~ 0.8 Depth to limiting factor >118" Kemarlcs: nonzarr5rrw oc ~ wrreaur aplnox. ivio wvvic a.,.. ,".,.,.,. Ground elev Depth to limiting factor a. .. F~ ~-~ 4 ~ ~ ~ ~ ~~~ ~~ ~ o ~ ~ ~ ~ ^ ~ • Z ^ ~) ~ ~ ~ ~ _~i ~ ~~ a ~ .8 ~~ ~~~ '~d ~ , ~;~ ~ ` ° `~ ~~ ~~ ~ ~~ ~ ~ ~~ . ~~ ~ ~ . .~ ~ ~ ,~ ^ ~ y.l ^ ~~ ~ a ~~ , m ~ X43 ~ ~~ o .tea o ~~ ~. 3 ~ 3~ °~ ~ ~~~~ ~~ ~ ~ ~~~3~ ~ 3 ~~ ~o~ ~~~ %' ';~ ' , ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT . AND ' OWNERSHIP CERTIFICATION FORM OwnerBuyer ~~ /1'~ ~`~ ~ ~ ~ ~ /2__. Mailing Address ~ ~ ~ ~ -~ Property Address from Planning Department for new construction) City/State ~ U DSO N tt.l f Parcel Identification Number d Z ~ ` ~ 0 ~ (e0 - 30 0 LEGAL DESCRIPTION property Location /~ '/s, S ~'/4, Sec. Z ~ . T ~ 9 N-R~ Town of D Subdivision ~~ I ~ ~~ ~E~S ~~ ~~~ ~ ,Lot # ,~. Certified Survey Map # ~ ~ ~ ~ ~ / , Volume ~ Page # Warranty Deed # ~ ~ b 7 S 3 , Volume L~ ~~ ,Page # `~° Spec house ~ yes ^ no Lot lines identifiable yes ^ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da of the three year expiration date. rJ Cj 2 i0`fi A OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. ATURE F APPLICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed j WAHiI-. iY LESL- IJ:'...:. n.1R~r• :V .:., i-•:i:;'•1 2 10821 61075 I A r' I iCA 1 ~i! EEN H. wALSH !~ • YAL 1`}~~FAriE ~~ ;~ kEGI:iiEk OF DEEDS • - - .. - __ _= _ =-1' ST. CkOIX CO. , WI 1 ~I RECEIVED fOR REtORD j' Humbird Land Corporation, a Minnesota Ccrporat~~n '~ ................... ... ~ ........................................................ .... .................. D9-zz-1999 e:JO an ...... 1~ .... .... ........ ....... ..... ................ iiARRAHTT DEED • .. ..... .................................... `:... EXERPT M t'nnvt•yar and wnrnu,ta to ........... Sae Miller ~.. ~ CERT COPT FEE: 1 .. . ...,............ COG'! FEE:II ..................... ..... ........... . _..... .... ... ~ ............. TRANSFER FEF: 517.50 .................................... ............ RECOkDI)IG FEE: lO.DO .. ... ... RAGES: 1 ... ... .... .. ..... .............................. .......... ... .... .... n[lUf1N r0 ~...:.....~ ......::.•::._......:~ .:::.....::.::.:.:.....:.:::... :.::.:::::.:...:•: fF~~ Uro following described coal estate in ......S,t,.,,Croi z ....County, -'- ............... ......... . State of Wisconsin: The East Half (E71) of the Southwest Cuarter (Si'!~-) EXCEPT aarcel Ta,c Parcel No: ~.~~~'~~~~ conveyed to Alfred L. EkDlad in .ol.me 498 y ~ .........0'. parcel conveyed to Leslie L. Swe^san in Volumegky884; and EXCEPT (~^~ /D~ 6 EXCEPT parcel conveyed to Donald f. Johnson in '~olumea50050pagen525; and EXCEPT parcel conveyed to Lk-^al~ R. Jordan in Volume 580, page 354; and EXCEPT parcel platted as we!'s faryo Sta*_ion in Volur-± 5 of Plats, page 89, as Document •478658, ALL in :cCtion 21 (21 j, Township Twenty-nine (29) North, Range Nineteen (19) west, Town of Hudson, St. Croix County, Wisconsin. Subject to unrecorded agreement _ated October 12, 1491 by and between Donald R. Jordan, Cail Gordan, John A. Elbert and Eric J. Lunde~l regarding future lano transfers and roadway conveyances. Subject to covenants, conditions, -estrictions and easerents created by preliminary plat of wells Fargo Station First Addition. Subject to easements, restricLi_-s, -esrrvations, and r~;hts-of-way of record, if any is not Th;s ............................ h_^~estcad proper:•:. (1Wp (is ant) 1•:xcchtim, tv warrnntics: ss ^oted above Dated this .. ..,,...20th ...._......... ...... .. Jay ._ .(SAL) AUTFiENTICATIO:V Signnturo(s) .............................. .................... a•ritr:r,[icut2d :hia ........: ^,. .. • ~ ~ 7t.. ....... .. , '' Tf'PLE: 11C~tBER S'fATE BAR 'J I' `.V1~'"~iV_1`: (If not . ............................... authorized by b ?OG.Ou, Wa. _.;.ts.) THIS INSTHU MENT '.v,>9 ;~a,~p-g ,- 8'r Hu^Dird Land Ccrporati,c~ (Sisnn:l,rc; may be auti:rlt:.a _' .r ...n::o•,et; !~;~ 't Ara nni r~.rsa ,. .. 1 August 99 .................._..................., 19... HUMBIRD LAND CORPORATION -,--.(SEAL) Austin J. 8aillon, Its President ........................................ (SEAL) ACKNOWLEDGMENT ST:1I'FIOF XXDB436YISiXT MINNES07 ~ ss. Ransey ...................County. Ir;;r.r~i:y c.,uw b~_iore me this ...2Cth-_.-..day of A".gust .........................-- , 1!`39.... the above uamcd Austin J. Baillon~ President of ".:.^ibi.rd Land..Corancatino....--• .. ............................... :a n:c knotivn to i:e !Le person ..._........ who u.ecuted the iorcti~in : in,trumcnt me a.~i:.,wvwlcd,pafl•I+,q.,Ys„tuR ' Pau1.A 33iltrn, - ~ ~ ~^ v .... ~ Li Nasni..givrr '~ _.:CdG~•tY~`N~t>Si' N I~ _. ~I ,r: ,'~ n a ne. rnn,.r it ([f r.ot, state exlnrnt;on ~!/1 1,~ I u~T z. L(li IR I I I __ - ___ ~__-.._~, _ I I N Q --- Z N C~ Z D Z Q J N m O U Q - - -~ f. C ... O . n J W Q ~ _J = X W ~ W m N O Q ~~0~ o c~ V N Z Y U N Q Q Z X J °- O ~ m cn z Z~m w~- o U - Z ~ o Z~,d, ~ ~O z ~w W ~ ~ ~ O N N O LL O ~ z W Z J ~-J 5 z - ado ~'~ ~ a o ~ i~3 a z I ~ 0 U O X O Z ~ N U ~ ~ ~ ~ ~ n NQS WELLS FARGO STATION ~ ~ ~ LOT 7 LOT 14 ~ LOT 8 ~E SOUIHEASfi 1/4 OF THE SOUTHWEST 1/4 COUNTY, WISCONSIN, INCLUDING LOT 4 AND 4, PAGE 3796. AND PART OF LOTS 2 AND 3 COUNTY RECORDS. __,~,~,~ E UNE C.SM. L07 ~ BE~l~dildABtS~. 1" IRON PIPE AT R/W SW CORNER PRAIRIE LANE AND COUNTY TRUNK HIGHWAY 'UU' ELEV. 916.39' 2' IRON PIPE AT NE CORNER LOT 11 JACOBS LANDING FlRST ADdTION ELEV. 908.44' (ASSUMED DATUM) W \ •^ LOT 2 ~N ~ o0 ~~~s ~ 'O. o~`~J _~ -- ~~ ~~~ I~.~~.I ~ I r, I I ~~~ 1 I !I ~133•'~I ~ I °°' 1 I ~ ~~ ~---- $ ~~ ~,~~ 1~ r~ I~ I N I~.,,~.I III iVQ~$: --ALL BUILDINGS TO BE CONSTRUCTED IN PROXIMITY WITH H/CH WATER EASEMENTS SHALL HAVE A FlNISHED FLOOR OR NINDOW WELL ELEVAflON NOT LESS THAN THREE (3) FEET ABOVE THE HIGH WATER ELEVAAQN SHOWN. --STREET RIGHT OF WAY NITHIN 1HE PLAT BOUNDARY SHALL BE DEdCATEO TO 1HE PUBLIC. unurY FASex1ENTs --NO POLE OR BURIED CABLES ARE TO BE PLACED SUCH THAT THE INSTALLATION WOULD DISTURB ANY SURVEY STAKE: OR OBSTRUCT NSION ALONG ANY LOT LINE OR STREET LdJE. THE dSTURBANCE OF A SURVEY STAKE BY ANYONE IS A NOLA710N OF SECTION 238.32 OF M/SCONSIN STATUTES UTILITY EASEMEN75 AS HEREIN SET FORTH ARE FOR THE USE OF PUBLIC BOdES AND PRIVATE/PUBLIC U71U71ES HANNC A RIGHT TO SERVE THE AREA. GENERAL NOnCE STATEA/ENT --EACH PARCEL SHOWN ON THIS MAP (PLAT) IS SUB.ECT TO STATE: COUNTY AND TONNSHIP LAWS, RULES ANO REglLATKJNS I.E. WETL.AMID$ MINIMUM lOT SIZE, ACCESS 1O PARCEL, ETC.) BEFORE PORCH OR DEVELOPING ANY PARCEL OF LAND, CONTACT 1HE ST. CRpX COUNTY ZONING OFFlCE AND THE APPROPRIATE 1ONN BOARD FOR ADNC& -K- °---~~~ -f1- ~~ S~.oa ,~ z ~.~ ~ SHEET 1 OF 2 . ' RA~R E~TAT ~, LOCATED IN PART OF THE NORTHEAST 1/4 OF THE SOUTHWEST 1/4 AND PART OF SECTION 21, TOWNSHIP 29 NORTH, RANGE 19 WEST, TOWN OF HUDSON, S7 PART OF LOTS 1, 2 AND 3 OF THAT CERTIFlED SURVEY MAP RECORDED 1N V1~I.U OF THAT CER11flE0 SURVEY MAP RECORDED IN NDLUME 9, PAGE 2503 OF ST. C f , ,',~.,~ - .. _ scALe t• -ton ~ ~ i`~ `f NDING ARE IIEFDIENCfl1 ro~ `same LnE of 1fE' SOUtf1NEST 1/s ~~. .~_ FlRST ADD! 0 2s ao too soo ~ ~ , a SEOttoN tl. TOIMi91R' q`NOKRL RAItOE to NEST. NFR011 6 •n~lRlm ro srAR-s ea at~ :r' w. g 1Q 11 I F~NQ y ~, ~1~' rsiu~ em+ ro nlc rrArasr E u+r .NOOas uRawo fwesr lR- R a oas+rr sECncw atloett ttoNUMCNr 9F-~ r. Au ANaAAR MEASURCMr~tts ARC ~~ _ - N ootwunv ro nc rrCARCSr awr Iwf sCOarc. Aar oowtrr eosttsot NAIL - - - - _ _ - • ran~ID 1' IRON PFE LOCA710N SIOITCH S LADE GSM. Lor • C DETE/rT10H POND/ vARr aF sECTaN z+. rtar, Rtow ,~ • rand s• ataet PsE tank of Nuas>a+L . Lxaa awNrr. Nrsoartsnt c I 1 O sEr Y x x• ntoN F~vE nCrarrw 'as. I~ M.NA np.0' T ~ aes rouvos ro+ tr~AR Foor. sEr t• x ss• nraw rrFE NERiMfO f.Ce POInAS rEll !!•'AR FOOT AT Au ortNx tar a>NNenS (R-) RECamfD AS PROPQSEO DRIYEM6~T tAGTfQN - • • - ao• tnwcr+o ateA« LIE liar a+ cr.N. v) - - t2' NIOE utRm. CAgworr __-- slaw N11TER REtD1t10N ARCH ro Irtal N417ER EtEVA1tON •M--N-•i!- rflICE UI~E C ~ RAJA bI ESTATES 11 ~~ 71 ~~`9. id ~'~ ~<g _ ~ d~ Ul ~ 1 \ 1 1~~ q.~ ~'~ 1rORANAOE ~~ \ ~~ (COUNTY SEIM/TSDt NAN.j • DOWNED ~ QmEB~ tod ... ,. ~, t ~ 2~t~\ a u+C aSM. Lor s I ~ , N 'OB' W 49S 40' $ X33' 33' ~ - - sn.a• es.+ta rr 1 ,. 1 ~i LC)1 8 I I- I s ~I F 11 2.7 SOAK' f ( ~~ I ~ ~ ` S LIE C.SM. LOT 4 F s fOJ 14. 'm1 I ~~ ( UowNEro 6YQIHE6S LOT 12 ~ ~ "147` W p 1 I ~ I a~332 so ~: ~, ~ „~ ~~' W I a ~ Sw cat. RSM. !AT s lntE GSM. Lor 4 2005 AG ~ y ~ ~ ~ ~~~~•~~• `~ LOT 11 ..~.~:~ '_ aa,>a2 ~' ~ --N Ol'09'SO'• W 5 -- s~ . \ e 1 ~~°iar~ 'q~, ,,J~ 20 ~~ ~ E _ _-~RAIRIFkANE--- = ~ 2024 AG ~ •~,~ 9J8tG ~ $I ~ I "r~ ~:~ ~DJ 51' /~ ~ ,d-~1P ~ ~ N hqy JS1.L I 13; I '~ 293.01 ~~ ~~~ \ ~'~ ~ ~ i*1,~°'~' ~r E w ~ ai ~ I ~ Ir` ®~ 1 ~ s amreT>~ m ~ PI!{1G \ ~ ~ ~ ~ ` ~ $i ~. ~~% ~~ .. w~~ ~awNAta CA ao+i N I ~ Ia ~,~ ~ ~~ UNPLA77ED ~$ ~3, ~ ~\ ~ ~ ~..-.. . ~ /• ~, LC s ' g ~ c~~ I ~~ 9.l~lEQ BY 9~iE85 '3 ® ~~~ ~ ~• ~~ ~• • ~ .. ~ 1081 S 00'+7'106 E l~ IDEEDEO TD THE At1lA[~MT LAN!>nINJERI ~i ~~\ ~ - 101' ~Y.O C/~ ~ .R~ I 1 34.40 ~ ~\ ~ 4101'011 .,w ~• . ~ ~ _ ~.I~•~ QD~a I ' I( tar ~ `\~ i E lntE C.SM. LOT 4 ~ E ly ~ T I i I ~ 2 ~-, I ~ I I 1 E tMtE GSM. L07 4 •. I ~ ~- I ~ I I CERTiFlED SURVEY MAP VOLUME 9, PAGE I I ~ i I I I~ I i i ~I ' , I ~' I ~' - ~' - - - - --~--- - - _ - - - - - - - - EAST ttE SW,-/•_ I , sa,tN ,,. caaCw SECRON ti, T ti K R /0 rK' (OaMtY 9OVIIS01 NAy ( 1 I _. . - I I I ~ ~. I I I ., .. ,. .. . '33133 i , tws C+stRUiwCNr auFtra sr .atAto ~ tARaaw 1101 Carmichael Road Hudson, WI 54016 Phone: (715)386-4680 Fax: (715)386-4686 F Fau To: Tammi From: Shawna Moe Fax: 386-9281 Date: September 12, 2000 Phone: 381-5000 Pages: 2 Re: Septic verification letter CC: ^ Urgent x For Review ^ Please Comment ^ Please Reply ^ Please Recycle •Comments: ~,~ r`~, ~~`~ ~~-.. ~~ --~ -~ - ~, ~_ --s _ ---- ~rxe~x^s^ - M..i r,~„ • i. - September 12, 2000 First Federal Attn: Tammi 201 S. 2nd Street Hudson, WI 54016 ST. CROIX COUNTY WISCONSIN ZONING OFFICE SL CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 Fax (715) 386-4886 RE: Septic Inspection for Sam Miller located at 540 Raider Drive, CSM Vol. 14 Pg. 3796 (Lot 4), Hudson Township, St. Croix County, Wisconsin Dear Tammi: A septic inspection of the above referenced property was conducted on 05/17/2000. This property is located in the NE 1/4 SW 1/4 of Section 21, T29N R19W, CSM Vol. 14 Pg. 3796 (Lot 4), Hudson Township, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a four (4) bedroom home. If you have any questions regarding this, please contact our office at (715) 386-4680. Sincere ~~ _ on Sonnentag Zoning staff /sm cc: file