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HomeMy WebLinkAbout020-1058-24-000 c top 3 'o C) r~ v st ~ I ~ 1 ~ w ~' ~ 4! ~ ` K 3 O ~~ O I C~ N ~ • o 0 f N 3 N O ~ N r '~ a IJ Q FBI ~ y ~~ v' I ~ °' ~ m a ~ ° m ~ co ~ ~ n 3 0 0~ n ~ m ~ n o~ N ~ A ~ ~ O ~I A C ~p 01 ! C 1 O ~ ' N m ~ ~ Q I ll f ~ ~ I ~ (/~ z D ~' _ a .~ c~ ca D a tD d IW N I 3 N ~ ~ ~ m ~ °o A ` ~ ~ n ~ 0 0 ~ ~ O C ' ~ ~i I 'Y ~~ Z o 0c00< ' D D `~ ~ N ~ = 3 to to to 1 I o ~ ~ v v, ~ ~ c ~ .. I ~ ~ m N I z o Z ~ Z 0 I ~ O D-+~ I ~. ~ v I ~ ~ ~ ~ = c ~ I c ~• ! ~ ~ i w 'm (~ °- ~ ~ m ~a ~ A~~ I N Z C ~ ~ A N Q ~ J .. N W ~ a ~ ! ~ z ~ A Z1 C %: Z ~ y C c < < ~ I v A w y I ~ j I m ~ ~ a ~ j ~ I y m a ~ I I = o ' ~ c a i ~ I m o a _ N ~ N I ~ Z I ~ I~ ~ I ~ I A ~ o- I I ~ o ~_ ,,. I ~ O N I .'0 O ~ A I o :^ I ~ do a I o O ~ ~., ~ ,~ ~• y QEPARTM~Ifi OF INDUSTRY, L.AEiOR & HUMAN RELATIONS P.O. BOX 7969 MADISON, WI 53707 INSPECTION REPORT FOR PRIVATE SEWAGE SYSTEMS 1~7 CONVENTIONAL ^ ALTERNATIVE ^ Holding Tank ^ In-Ground Pressure ^ Mound SAFETY & BUILDINGS DIVISION BUREAU OF PLUMBING 8tat~ PUn I.D. Number: 11f ts~ipnadl NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FR PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: n~ aq -~~ ~ Name of Plumber. MP/MPRSW No.: County: niltlry rmit Number: - y~ eeoTln rAwllriunl nlltlr! Tewllr. MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: ARNING LA LOCKING COVER PROVIDED: PROVIDED: ^YES ^NO ^YES ^NO BEDDING: VENT DIA.: VENT MATL.: HIGH W NUMBER OF ROAD: ROPERTV 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: PuMV AN C N L PERA ZONAL: NUMBER OF PROPERTY WELL: BUILDING: V N TO E H (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF1 ^YES ^NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENf+TM UTAME iER MATERIAL ANO MARKING or excavation. (lf soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue) MAIN ' CANVENTInNOL SYSTEM: WIDTH: LEN H: DISTR. PIPE SPACING: INSIDE DIA. #PITS BED/TRENCH TRENCHES MATERIAL: PIT DE TH DIMENSIONS L DEPTH FILL DEPTH DISTR I f DISTR. PIPE IS A IAL: NO. DISTR: BE OF WELL: BUILDING: V NT TO FRESH BELOW PIPES: ABUVE COVER: ELEV. INLET . ELEV. END: PIPES. FEET FROM LINE: AIR INLET: NEAREST MAI WA SYSTEM• Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ^YES ^NO OIL COVER TEXTURE: PERMANENT ARKERS: OBSERVATION WELLS. ^YES DNO ^YES ^NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED. SEEDED: MULCHED: CENTER'. EDGES. ^YES ^NO ^YES ^NO ^YES ^NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE: ILL D H A V O BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD UM MANIFOLD DISTR. PIPE ANI OLD MA EHIAL'. NO. DISTR UIS R. DISTRIBUTION I MATERIAL a MARKING ELEV. ELEV.. DIA. ELEV.. PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZF HOLE SPACING HILLEU CONNECT LV COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ^YES ^NO ^YES ^NO YES L_~ NO ~ ^YES CJ NO Sketch System on Reverse Side. DILHR SBD 6710 IR. 01/82) Retain in county file for audit. /DEP~R~'fil~'NT OF INDUSTRY, LABOR AND HUMAN, RELATIONS APPLICATION SAFETY & BUILDINGS FOR SANITARY DlvisloN PERMIT P.O. BOX 7969 (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8%2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown._A legible reproduction of the soil test report or the owner's copy must be included, Property Owner. Mailing Address: Property Location: City, Village or Township: County: '~.'/4 1U~'/4S iT NiR ( E (or) W V rj v/l~ Lot .Number: Blk No:: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (lf assigned) YPE OF BUILDING ' Number of ^ Public* ^ Variance* ^ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. '~ TOTAL GALLONS NUMBER OF TANKS PREFAB CONCRETE POURED-IN PLACE STEEL FIBERGLASS NEW INSTALLATION REPLACE- MENT OTHER (Specif - SEPTIC TANK CAPACITY aQ HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA - (Minutes per inch-:. PROPOSED (Square feet): ^ New ^ Replacement ^ Experimental ^ Seepage Bed ^ Seepage Pit , ^ Alternative (specify) ^ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ^ Joint ^Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: pn- Signatunre: ~''~_ MR/MPRSW N~o/.~: Phone Number: 6 u P_P~ 1 / t 1 l .LL~A.tt ~ ~ ism a ~_ L/ 5~ (~~) ~~i ~ ~J Plumber's Address: 1 ~/" ~ r ~ Name of Designer: ~Ui-~So~I wU S`Eci (~. COUNTY/DEPARTMENT USE ONLY Si n ture of Issuing Agent: Fe Date: Sanitary Parmit Number: Q~ p ~ APPROVED O ^ DISAPPROVED Reason for Disapproval: Alternate counsels) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior staltation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD~398 (R.07/81) "~ + ~ t 1 ~~ ~ A ~... _ ~ ~ .~ '.1 ..i. {{ £ ~~ w ' ' '~ ~.~ , y _~~ ~ ~ v, t fi_ '\~ Parcel #: 020-1058-24-000 1~i1si2oo5 05:07 PM PAGE 1 OF 1 Alt. Parcel #: 22.29.19.2190 020 -TOWN OF HUDSON Current '. X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner O - RICHARDSON, BARBARA A BARBARA A RICHARDSON 66 E 9TH ST #2405 ST PAUL MN 55101 Districts: SC =School SP =Special Property Address(es): " =Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.360 Plat: N/A-NOT AVAILABLE SEC 22 T29N R19W 2.36AC NW NW COM NW COR TH S 1284 04' E ON RNV 820' T Block/Condo Bldg: ; . O POB; THE 483.02' TH N 224.51' TO RR R/VN TH S Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 87 DEG W 483.81' TH S 201.84' TO POB. 22-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 12/09/2003 748635 2471/01 WD 600/448 7nn~ CI IMMARV Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.360 62,800 160,400 223,200 NO 05 Totals for 2005: General Property 2.360 62,800 160,400 223,200 Woodland 0.000 0 0 Totals for 2004: General Property 2.360 36,900 110,900 147,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSM ENT 54.00 Special Assessments Special Charges Delinquent Charges Total 54.00 0.00 0.00 Parcel #: 020-1058-10-050 11/18/2005 05:08 PM PAGE 1 OF 1 Alt. Parcel #: 22.29.19.218D-10 020 -TOWN OF HUDSON Current '_X'~ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-owner O - RICHARDSON, BARBARA BARBARA RICHARDSON 66 E 9TH ST 2405 ST PAUL MN 55101 Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 7.240 Plat: N/A-NOT AVAILABLE SEC 22 T29N R19W PT NE NW COM NW COR SEC Block/Condo Bidg: TH S 128 T S G 22 4.04 FT; H 89 DE E 820 FT TO POB; CONT E ON N LN HWY TO PT 165 FT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) W OF E LN NW1/4; N TO RR R/VN; WLY TO PT 22-29N-19W NE NW N OF POB; TH S TO POB EXC PT TO HWY PROJECT 8949-02-23 Notes: Parcel History: Date Doc # Vol/Page Type 04/28/2003 718943 2220/163 WD 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason UNDEVELOPED G5 6.088 18,300 0 18,300 NO 05 Totals for 2005: General Property 6.088 18,300 0 18,300 Woodland 0.000 0 0 Totals for 2004: General Property 6.088 12,200 0 12,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner ~ - ~ ~~Ir,~FL, ~'l Address .O . v y ~ City/State fit AS onl (~, ~yv~ ~ Legal Description: Lot - Block - Subdivision/CSM # "' '/. J~ '/, J~1W Sec.,Za ,Tag N-RLW, Town of l-~ct~D S ~nl PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer l~ ~ F ,E/j Size ST/PC~~o~/ Setback from: House /•? ~ Well ~ P/L ~6 '~t Pump manufacturer - Model - Alarm location - (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: -r- cr~.t-~rvQ Type of system: ?~~ N c N Width 3 " Length ! i~• ~ f ~ Number of Trenches ~ Setback from: House ~7D • Well ~.? ' P/L ~3 ~N Vent to fresh air intake ~3' :ELEVATIONS: Description of bencbmark ~''~irF ~~-~.uT o,u mop ~'o,UCQs•t-s S;a~ Description of alternate benchmark GJr/i ~' Pki,ur o.~ Couc ~c r~ Nc~c cab Wiz c Building Sewer cl/- ~ " ST/HT Inlet ,/- ~l " ST Outlet `~~? ff~ ' PC Inlet Elevation ino ~ ~' Elevation 9 9 s5 PC Bottom - Header/Manifold ~• ~ Top of ST/PC Manhole Cover ~ o~~ Distribution Lines () ( ) Bottom of System ~~- ~O. () Final Grade (~) 9~. /~ ~ ~) ~~ ,?~ ~ ( ) Inspector Date of installation `~ /~2 /~! Permit number State plan number Plumber's si nature g cense number ~..~ i,/~~~ Date /v Complete plot plan 4 NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmazk, if applicable. PLAN VIEW ~~~~ R~~ ~?o~~nT~ --~. io' Imo--(~ S.~S ~ ~3. I ~V~1~Nrr~A+?K ~ 2. T~ ~ „ L,,.wr ~ 1V x ~ y` 5AR3S vv~ c~u~.•r r / ~ r ~a w~~c. /bcav(„~~ GuicscgStPn~'r~w< ~ wE~c..~.s~ ~, ~~, 3~u+.,~ K ~ t 7-~~ ~T~~ ' r~ Cc~ 6th /l7G/tfi ~ ~•'t•~ i2 ELtJ_ ~~ro.oo• `Iao' ~~ c,.,fss 3 f3f4~Qoam lRu~ ~f/ L,NE RE9i/,~NLE ~I ~~ ~j~~Tio~J ~, iNE ~: 1 va ._ Q IJo Sc~ INDICATE NOR HARROW ~Gw t R~r~ ~. 99. ~' ~ ~2 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 NorLake Inc. Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: G~ G TANK INFORMATION ELEVATI DATA TYPE MANUFACTURER CAPACITY Septic c ~ Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ` i b L// ~ 7 ~ S / ' Do Aerati olding PUMP/SIPHON INFORMATION TDH Lift Friction Loss E Force ain Length Dia. SOIL ABSORPTION SYSTEM BEDITRENCH Width Length DIMENSIONS 3 SETBACK SYSTEM TO INFORMATION _ _ _ DISTRIBUTION .~-- SOIL COVER Y Prassura Svetame Only Yr Meund Or At-Grade SVSterY1S Or11V Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center BedlTrench Edges Topsoil ~ Yes ~ No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ /~/~L Inspection #2: / / Location: p.0. Box 24~~8~~H~~ udson, WI 5114016 (NW 1l4 NW 1l4 22 T29N R19W) NA Lot NA Parcel No: 22.29.19.2190 1.) Alt BM Description = Lt/~i to Gi r ~~t' W y ~~ ~~ p 2.) Bldg sewer length = ~ 2 r - amount of cover = > b r 3~obs~~t,~,~;~.... P' rt %~sf<l/rod ~`.. Plan revision Required? ®Yes No /n~ ~ ~~ Use other side for additional informati tel. Date Insepctor's Si ure Cert. No. SBD-6710 (R.3/97) to County: $t. CrOiX Sanitary Permit No: 395245 State Plan ID No: Parcel Tax No: 020-1058-24-000 STATION BS HI FS ELEV. Benchmark 3.q,5' 03.E ~aO Alt. BM ~p Bldg. Sewer /Z_zz. q , ~3 Ht Inlet IZ- S t Outlet Z, S 9 ~ ~O Dt Bottom Header/Man. '3 y n~` Dist. Pipe L t;- 3 g ~ d -t ~- 4 - Bot. System 1_ L /y. (~ 4 ' ~ L (~ ~. d Final Grade ~~ / ~ C ~ St Cover s' 9 Depth Z ~d' .SZ r ~(~ w r,.r OR Header/Manifold ,~ r r ~ Length_~ Dia / Distribution ~ Pipe(s) i~ t ~ Length S Dia ~ Spacing x Hole Size x Hole Spacing ~ Vent to Air Intake ~ ~ r ,~~ wl r /a.~10.AA 1 ', • ~ ~ .7 anitary Permit Application Safety & Buildings Division ' In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. ~. See reverse side for instructions for completing this application PO Box 7302 ~~sC+~~+/~' ~~ Personal information you provide may be used for secondary purposes Madison, WI 53707-7302 department of Commerce [privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned. Attach com lete lans to the coon co onl for the s 'o'ri a ess than 8-1/2 x 11 inches in size. County. State Sanitazy~ unit Number ^ Chec vks ,, ~ ,~,~~Pp 'on State PI~ I. D. N~ umber _ ~-~ s ~/ I. A lication Information -Please Print ail Information Location: property Location ~uC/'- ~ ProputAy /Owner Name ~.. ` ~q /V OP ~~K~ ~C. O~ <,(/ LJI/4/l)Wl/4, T'~ (,N, F~E or property Owners Mailing Address ~ ~ t Number Block Numbu 'Q ' s ; r ~ ~ ©1 c~ /Sox a 4/ ~ City, State Zip Code a Id'~1j~., Subdivision Name or CSM Number ~-~os~ ~, ~'yn~ro .~~ ^ city II. Type of Building: (check one) ~ ~ ~ ^ village 1 or 2 Family Dwelling - No. of Bedrooms : Town of ~ ~ljS O~J ^ Public/Commercial (describe use):_ ^ State-0wned Nearest Road t s PazcelTaxNumber(s)~O ~C-Sg_+~ ~~ / C~Y~( . . Z k mil' G III. T e of Permit: Chec x on line A. Check box on line B if a licable 6, ^ Addition to 5 ~ q) 1. ^ New eplacement 3. ^ Replacement of 4. Existin S stem S stem S stem Tank Onl Petmit Number Date Issued B) ^ A Sanita Permit was reviousl issued Type of POWT System: (Check all that apply) ~ !~ ^ Sand Filter ^ Constructed Wetland d ^ M oun Non-pressurized In-ground ^ Sin le Pass ^ Drip Line ^ Pressurized In-ground ^ Holding Tank g ^ At- de ^ Aerobic Treatment Unit ^ Recirculatin ^ Other: V. Dis ersal/Treatment Area Information: Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation El v~ n rod 1 . lsJday/sq. ft-) (MinJinch) p/J l~ , sed Rate (Ga ired Pro ~ R g } ~ ~j / VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Con- Con- glass Information Gallons Gallons Tanks Crete structed New Existing Tanks Tanks ~ ^ ^ ^ ^ (~J~ES~Q /Ors - /coo / GJ~E~~? ^ ^ ^ ^ ^ VIII. Responsibility Statement the undersi ed, assume res nsibili for installatio of the POWTS shown on the attached lans. Business Phone Number I , Plu beds Name nnt) Plum s 'gna o ): MP/MI'RS No. ~2~757 7~s ~ 3~~'~~so ~A~i~ ~T~~,~kc Plumber's Address (Sh+eet, City, State, Zip Code) h`~ 4' ~`5'~ ~. ~Q'SOYt) W r S~CY~o IX. County/Department Use Only o slam s d g Agent Si (N P ^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue 'Approved ^ Owner Given Initial Adverse SuIZ~ ~ ~ f ~ .~~ ` ` T Determination ~A ~ n -, -' "~~" ~o ~ a~j l /Rea1sons for Disapprpval: ~ ~ ~ Ulel' r rova ~+~t p p X. Conditions of A `^ w C t/AJ Xlt ~ 1 ~ ~ ~^ ~^ ~_ + /ny ' } _ / ~ f ~~ ~ Mme' ^~u''"" d!Ul~t~Or S~- ` CJbur/ rS ~- ~ bl>« i..AAw. ~ ~S ~~ [ ~ ~ ~t•`. ~~t*~,/ ~ ~ ~ /L~ ~tlK~L, S ~ ~ ~I Wvw^~ ~ Tom' ~ G+J~ ~ A~.M i MA.O.~. ~ •. _'` ~ ~ ~ ~ U ~ A l_ ` `/,~"" / Irv-v~KNr~ ~ 1r~ - ~ ~~~5. 1/ C- N D ,~A^I- ~ ~ Al ~ ~ ~ ,/1y~ ~~~ ~ ~ ~~ / y i~ o~~= . ...p 0 L ~~,,t~j~vk:~~.} c1.~ Tv ~YJ~T PLOT it CROOi 08CTtON F'UVrO f~~35o~ Pr/o,J ~eaK ~~ ~~ ~t~ ZIWPA p9~800. 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N ~ s H GQhoE Side View ~ FEE f ~~lio.J T F„J< H ,Bc troy. 7EQ so.c "wrLST End View T ,I. ~ t6' `w 15° .~ 34• .I ~vAE~ ~ ~~ ti r35O ' P7"1 r»r..~ ~ ~~~ ~k~~~ c1.a 'acs ~Y~G;:T PI.QT i- CRObd OBC'TION PWJd ~ ~e~n ~v /~~ t~a-~ 7APPA BROd. E!(G1VATiNh INC //V~,~_ j~~P7'~`~ 1(~€Q~l~rt~~rt~~`rt~ P1.UMBIN~i UMT .. ~~(~ ~Ort~ r '~ o ~~~~~ ' ~ B~ a ~. 5' .. PFiO~JECT o P~~Kc ~€.u~~c ~ ~ ' l c,~ y ~2 r /J~LJ rNt'1~Q' ~~Eiv ctF~ •- ~ ~ ILO ~ ~bric -TitvK I~I:v~- ~ y i UY=( c'-1..'_S 1 c,. 1~i•G. ~P~~ry! JvGI, /V 31 ( g ~, ~' l /~' ' 7n ~ ~ ~~ ' ~/CJ , i ~' _ .~`~ ~~~ ~~ ~_ /-~. r a~ ~~c:S/G1~,r.1Ct ~+~E,uc(~1 t~RlC-7o~ o~LcvUCec:7'c Nt-x't- ro GJc[r_ /~~~~ T! /~~ovcMri1~h21C- TnP o~ S~-cps Luau/r't r't'!N'f - ~ ~j~~TrL~r~ L,...~~ w 7 /~btl iriNA'l ~rZ~ ~J$ rIN~Sf"1 `p~QIE4~ F/NrSH CpQggE. ~~cJ /OCR ~0/1~ GJlLfsf~? ~GO7lL `r~E.Vk' t.~ rr(f ~rE ~C~ ~~ 80o C.C.~'1 ~ ~'r ~ c r~re~ /~~cJ ~ a SC/{~o xhJL~,.I.ve N w ~°~~ E. j`~O '. $ CAL@ 810NED: UCEN6E: ,~Z.~ ~/~ S'7 DATE: ~ ~ O j ^ ~' l , y • tvc S~ N yo R P~ ; sa~~~T>ePt~q ~v: ~ • /`'t~+x, ~4~. 9~'" . Aa~v~ .~.,F~,n,ss~ /--t'3T/,y~~-J off. ~ ~.;~ ~"? To ~!N - s H G4ha~ , Side View Fic ~ATio,J T r:~l < H Bo tTo.y. y'6Q so ~ ~ TCST End View . ,T I. I . ` 16. ,z.. ,, ~~ ?~ - , t St of c ,.- t •~.t a~R /'"i iGH ~AA.~ [1'~'}~ /~~()El :1 f Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of / Division of Safety and Buildings ~„`~ in accoroan ,~vu,~trttipmm sio,Nvts. ream. ~,oae . '• 1 .,. County ? ~ ~ ~, , t Pla i "11 i ~i 2 ' t X Attach complete site plan on paper not less tha rym ze. nch in s s yt 'a d ectio D I include, but not limited to: vertical and horizon percent slope, scale or dimensions, north an- ~ ~ n nce~~k d~r locati a to neares~road. . Parcel . ~~~'4C~S~ "Z'~ ~~d Please print al In '~, t l O n . rnla R 'ewed by Date b d f E~ ( ~' QQ nn ("` ~~ ( l/- 04 (1) (m)) L~aQ!k~ 15 (~iv`~c 6~3d e use or Personal information you provide may . . y s ary p Properly Owner I`~d ~~~k~ ~~ ~ ~Y ~ ZoNtrIG oFwl Property Location Q ovt: tot n4 W 1/4 Mi,~ 1/4 S ~ T ~- ~ N R / / E (or) W P erty Opwner's Mailing Address ~ ,~ ~.ot #k>' Block # Subd. Name or CSM# Phone Numbe City State Zip Code ^ City ^ rllage Town Nearest Road ~ I ~ ` J JJ ~~ ~.~Sd~ ~ ~ ~~ (~ ~'b ( i/S) 6 _ ~ iGr1L~,ay , ?iC~Z U~(~ ^ New Construction Use>~ Residential / Number of bedrooms 3 Code derived design flow rate ~<-c7 GPD Replacement/~. ^ Public or commercial -Describe: Parent material CJ ~~ ~ 4 ~ < [`~ t.3s CJd ~ l ~ 1=1ood Plain elevation if applicable ~~ ft• General comments and recommendations: a Boring # ~ Boring ~~ .~ - Pit Ground surface elev. ft. Depth to limiting factor ~ in. Soil A lication Rate l i C tion i d D R Texture Structure Consistence Boundary Roots GPD/fg Horizon Depth in. o or Dom nant Munsell escr p ox e Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 *Eff#2 ~ ~Q %,~ p;~ ~ --- ~ 2 cb~ rrvi~r C. ~J 1 .S 4 .~ ~9 r~«-4 .~ -' ~oL n, sbk ~r t.s ~ ~ ~. 3 ~° by e ~¢ ~- irks ~~ ' r-~ - iJ .7 1 ~. L Boring # a Boring O~ , 4 ~J Pit Ground surface elev. 1 ft. Depth to limiting factor ~ ~~ in. Soil lication Rate H i th D t Color D i tion Redox Descri Texture Structure Consistence Boundary Roots GPD/f1? zon or ep in. om nan Munsell p Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 --z~ i~~ ~> - L ~. s~~ ,~, ~r ~ ! ~ ~, s o - 6 `Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' tmuent rfz = nw ~ au mcy~ anu 1 JJ _ Jv 11Iy,L CST N me (Please nnt) ° Sig ~/t~ure CST Number Address ` ~c,_j Date Evaluation Conducted Telephone Number ~ r, Property Owner , V d~ L-/~ 1~~ Parcel ID # ~~~" /~~- ~A'dOp Page ~ of Boring # ~ Boring Q pit Ground surtace elev. _I ~'~ ft. Depth to limiting factor ~ ~~~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 -' 9 , ~ ~ z --~ ~ Z wt ~ K ~ ~' w ©. D . ~ a•4- • sv ~ ~-~ ~~.-y ® Boring # ~ Boring fop ~/ (~ Pit Ground surface elev. `~ '~ ft. Depth to limiting factor ~~ in. Soil Ap lication Rate Horizon th De Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 -~ y,~ ~ -- L Z ~ S bK ~ r^ ~w 1 ~ .s o .~ , y ~ -~~ ~a~ ~` rhS 5Ci rw,1 CS _ D-~7 ~~~ ~~ Sl~l gay 4 3 `~ ~-~ SCE ~ ~- [~.~ /, ~ r, .Y iSZ • ~ ~sg os~,l Boring p Boring # Ground surface elev. 7 ~ •~ ft. Depth to limiting factor ~ in. I~ Pit Soil lication Rate D th i t C l D Redox Descri tion Texture Structure Consistence Boundary Roots GPD/ftt Horizon ep in. or om nan o Munsell p Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 ~3Z v -' ~~~. ! a~ r - n.~ a. ~SC 4 -- ~-' C; rn 1 _' ~ ~- ,~s rn l - 1. <<~ ~ sz `Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L `Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.6/00) ,~ q' ~ £ Z ~ ~~ ~ J ~° r ~ 4 3 ~ ~ r! ~ ~~ 04d°`' ~ ~ ~ d F- ~ n~ ~~ ~~~ ~3w I c ~ I,.,b~. Y •~ -- o£ -~~ •- i '~ I ~, ~ ~ T a°_- cb` t ~ ' ~- ~ 4 ~ ~ .~ ~ , a ~ A ~ ~ J J qL F' d U E ai i ~~ I 1 I '~` t~ ~_ ~~ -,~2 Q Lam- i - ~ ~ .- M ~ ~_ M ~ ~' W ~ ~~ N ~ .Q 1 ,~ ~ ~ 4 4 ~ ~; ~ ~ ~ W W ~ J ~r~ a I ~ I ~ 3 ~~ ~~a ~~ $ ~, ~~~ a '° ~ h' ~Q ~ H N _ t~ _-~ ~ s '~, M L o M ~ W 4 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 fife at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- Table 1: System Design Specifications Sanitary Permit Number 9S 2 Number of Bedrooms Design Flow -Peak (gpd) ~ p Estimated Flow -Average (gpd) pu Septic Tank Capacity (gal) o Soil Absorption Component Size (ftz) , p 3~S Type of Wastewater Domestic Table 2: Soil Absorption Component -Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow -Peak (gpd) - ~~- Maximum Influent Particle Size (in) 1/8 Maximum BODS (mg/L) 220 Maximum TSS (mg/L) 150 Tab le 3: Maintenance Schedule Septic Tank Inspect and/or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years 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). ~~~~: c~ ~~i The operating condition of the septic k and outlet filter shall be assessed at least once every 3 years by inspection. Th utlet filte shall be cleaned as necessary to ensure proper operation. The filter cartridge shou not be removed un ess pr isions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component 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 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 performed 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. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason wifhout 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 difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. 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 include 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 clogging 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. 2 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~z. - /`_,~..,~C Mailing Address ~0 .~d~r a~ %~ /~c~~a..y !~/~ _ S~'old Property Address ~~~~ (Verification required Planning Department for new construction)~~ City/State ~i~~.,a ~ , Parcel Identification. Number ~o-iv d - ~ y- o ,~ o 0 LEGAL DESCRIPTION Property Location ~ %+, ~ %,, Sec. ~~- , T ~~N-R~~W, Town of l,/~o..i Subdivision ~~,9. ,Lot # d4/9 c . Certified Survey Map # Volume ,Page # Warranty Deed # ~~ ~~D~ .Volume 6br, ,Page # ~'~'~ Spec house ^ yes ®no Lot lines identifiable ~1 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 master plumber, journeyman plumber, restrictedplumber or alicensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 yours tic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of a thre ~+ear xp' ion date. ~b Q+~ o~ 4~-iv~s ~lal l°~ IG ATURE OF APPLICANT DATE OWNER CERTIFICATION (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 pr rty de ibed abo , by virtue of a warranty deed recorded in Register of Deeds Office. ~ dr v c,~ Op.~-vim ~~w~ `s O~ l d ~ l O 1 SIGNATURE OF APPLICANT 0 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 We certified survey map if reference is made in the warranty deed . ?i t t .jryy try • 00 UMENT N4. ~ / ~_ ~ f~!`~~e(( I( [~C~ 5TATb: BAR O1T WISCONStN FOYAt Z • --. ~;til lJl-L~ , a ~ -~ ~ V INARRANYr ()EfD t>•IS SP4%E P`SERVED FOR RECORDING OAT/ ..;.y. _._. _-~ _ --.. _ _ RE t. _. _ _- _- _ _ 8:lRBAR11 B._-RTCHA.RDSON~ _ Grar~tQr_,_ _._ __..___ convr.s end xdrrants to _NQR-LAKE~ .IPICQRPORF~TED,__C>raritee _ t!x fvllawing described real estate in $ta?c aE '~~isconsrn: St . Croix __i~_____ County, G15TERS OFFICE ST. CROtX CO., W t5. Recd fvr ^.eaord thi:_~+~ j day of ;;,:,or,• A.D. 19_~`> at - ~ .,1- -~ ~ y bvYrv of t?Nds t RET4RN TO '_~~ '-_+' Gavin, Gilbert, twin & Mudge 430 Second Street , ,Hudson, Wisconsin 54016 __ ~.~ i R ;parcel of land located in the NWT of the NWIt Tax Key No. ~._~ of Section 22, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin, further described as follows: Commencing at the NW corner of said Sec. 22; thel.oe South along the West line of the NW 1/4 of said S~:c. 22, 1284.04 feet; thence S89°-33'-07" E along the North right-of-way line of a town road end U.S. "12", 820. G0 feet tc tt-.e poi~t- of beginning; thence continuing S 89°-33'-07" E along sand North rig:. ~f-way line of U.S. "l2", 483.02 feet to the East line ,, of the NW Z/4 of the NW 1/4 of said Sec. 22; thence N 00°-05'-09" E along said East line, 224.51 feet tta the South right-of-way line of the C. &N. W. R.R.; thence S 87°-45'-40" W along said South right-of-way line, 483.71 y~- feet; thence South, 201.89 feet to the point of beginning. Prove described parcel contains 2.36 acres. eaM.atwaoonMR `TRANSFER ~ do~it~y art ~ ~nwt M a ~k ~~~"'=a''~" Into and oornct ~ at tar doct~rttent oI~ ~$ ~ and of ni~oaid iA ~ Mor-apd has lNaa This iS .I10~o;nestead propert,. ~~ (is) (is not) 3...~...r....~ ate( s Exception to warranties: NOrie. . r Dated this. 4th day of Sept _;Z±er T , 1979 -(SEAL) ~ F,AL) Barbara B. Richardson (SEAL} ,-(SEAL} At1TNENTfCATtON Signatures authenticated this n/a gay of n/a tg n!a ~~ n/a ____ TITLE: I.tEh:EER STATE BAR OF WISCONSIN Qf n*Jt, authorized by `~ i0E.0~fi, Wis. Stats.) This instrument was drafted by Hugh F. Gavin, Attorn~ GWIN, GILBERT & GWIN Hudson, Wisconsin 54016 ~} (SignatuKS may }>e authenticated or acknowledged. Both r are not necessary) ACKNOWLEDGMENT STATE OF WISCONSIN a. ___ St. CroiX County. Personally came before me, this 4th day of ~~• 1919 the above named Barbara B Rich~rd~It; _ to me known to be the person`. who exrcuted the fore- going instrument and acknowledged the same. s ~ _ S ~ '~ ti Notary blic ~ {bunny, Wts.~ "A Com is i e e ~:- I no , of te, a ration '~~~ ,tire _ _ .. ,... -~19 .1 , i l1BiItC~ i~IK4 j?ti~ i0~ ~ !~ ti*~?39t t0 ~~+!t nib Jfl1~~i!'.~?rAp~ N /!2 S1 SCnLE IH FEET ~~~''~~ o ioo 200 X00 +~' ~~ MW CON. sec zz ; E ' ~ 1 218 C I ' ' `3 N i/4-N e~m i ~~~ ~ Y I ~ ~ 1 I 218 8 I~8~ 219A 1 i~ j8~ ~_ .----- ~ _._--- / d/1 -" " ~~ N ~ ©UJ ;, 218 D-- t o 1~?1"_ 219 D 2!9 C " " 1` __~ 4 ez o +e3 oz t_'_'. _- _' ~-~ ~\' /' 1196 /282 \~,~ " `~~ I / ~ SEl/4-NWJ/4. S W l/4 - NW !/4 ~ /, I I 221 220 ` 1~~ ~ 1~ z l ;? . 't I~ 1 _ - - -----'- W I/4 CCq. SEC 22 ~c. ~2 ~ o~N OF, HUB ?~N~ ~~9~ " "' Boa. SEC 22 -_ t f ~ 1 r ~ 1~~ ~ ~l . _ 2I5 A J -- ``'1-` a 1J ' ``a sE ~J». ~ 2: ! 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' ' ' 7 ~r ti217 /J ~ D 906 /6 r4 1 ! ~. ~E Ii1 WA. SEC. 22