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HomeMy WebLinkAbout020-1158-20-000Q o m°o I a~i°o h ~ O E» I 0 v> I I 0 ~ 0., o ~ I ~ ~ I II i••i 1 CC C~ Q N G ~ I I m N j ~ ~ ~ L_ • 3 I I A j ~ I I c I ~ I I ~ ~ I I a~i _a I Z a~'i f z° ~ I ~ z° L c 2 L c I I 3 o m ., c € I 3 o ~ ¢ ~o I E I I ~ I M M ~ ~ I ~ a ~ ~ Z N ~ H i _ o I o I ~ v E ~ ~ Z~ rn N I i a m I a m I - fn N I I O I O Z a ~ C I C U_ N ~ I 0 O C O I Z ~ N H S ~ C ~~ Z ~ I ~ ~ I ~ y 'O C y M ~p I N d' 7 U N f0 ~ W ~ C ~ W d C t C a~° C ~ I a U o C ~ °- I L I = ( ~ I Z t~ ~ ~ Z . I Z I y y C I m c ~ 16 ~ O t0 ~ N ~ N d c0 ~ .. t0 r o a O D O ~ .. A I Q ~~ ~ N $' f ~j N d v N~ o , ~ , , ~ N d ~ N S ~ 4 y G G a ~~ O a ~~ u ~ N r r ~~ av~ = U rr ~ ~~ ai= E o ~ 3 3 c 3 a a a I ~ a a a ~ N I ~ ~l a ~ C ~ = 'O ~ ~ y I = V O N N vi fA J U O~~ O } O O O ~ O } ~ ~ ~ A N N o v 0 ~ ~ O ''C 'yp M O Z kG N I w o ~ o = ~ v I C m .- m o o O = O v ~ I c'oo m c I m OD ~ c d I m 'O y y O m m 'fl Vl ~ ~ w I ~ 'O d Q ~ fn I ~ 'O ~ Q A V? N ~l I ~ ~ ~ I ~j Iv ~ ~ " 00 L •y-C fl1 C •C 4-yl C O ~+ Gi O E N pOp O ~ 0 ~ ~ N r V 0 ~ ~ Q O Q O~ C -~ C~ b ~ C ~ i ` N ~ Z (p ~ U (~ 7 ~ ~ of v i I a ~ ~ ~ N ~ ~ ~ M y a~ c O y N ~ O U ~ N ~ N M ~ O N S O O fn O O O O 2 C h N C O (n M O Z c Y ~' to O ~ r r ~ r ~ .: ~~ U d~ a i a a ~ ` te I a~` I • ~ ~ d m~ c m y ~ w _1 A ciao Ov~iC~ Oaiti :Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ^ City ^ Village ^ T n of: Severson, Dennis Hudson Township CST BM Elev.: , Insp. BM Elev.: BM Description: ~ rumen u~rvnmr~ ~ w~~ TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic >,g"O ! ~ j~ ~ ~5- t -" NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION Manu cturer Demand Model Nu er GPM TDH Li ~ S ste TDH Ft For main Length Did. Dist. To Well OIL ABSORPTION SYSTf Ml~i ~ ~ n ~.. _ ~~,.,e.., l ELEVATION DATA a~. z q. ~' . g? STATION BS HI FS ELEV. Benchmark p 6O , ~ Alt. BM -~ Bldg. Sewer 5-f-fN St/Ht Inlet `` St/ Ht Outlet ~' I81 " ~-~65~ q3-~ ~ Dt Inlet Dt Bottom Header /Man. D ~g~t~w S Dist. Pipe 52 Bot. System ~ Final Grade u ~ ~{,OQj St cover kgo ~ D " Io.Ik /.'f I Vin e~i "- ~G~ ~~` ~o. o~.. ~l•_$"( t BfeD / RENO Widtht Length , r- No Of Trenches ~ PIT No. Of Pits Inside Dia. Liquid Depth DIME N 3 j*Zr •~` DIMEN I N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manu ac ~ rer: S SETBACK INFORMATION Type O t ~ r CHAMBER Mo el Num er: System: ~ ~' ~ I ~ ~ 1 ~ --'- OR UNIT - a.~io DISTRIBUTION SYSTEM (~ west' ('(LJ Header / Mani I Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. `-- D Spann 1 ~ ( SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 12 /tr'I'/ O( Inspection #2:"-t--f-,- Location: 714 Badlands Road, Hudson, WI 54016 (SW 1/4 SW 1/4 23 T29N R19W - 232919889 Dell's /W- est~V,iew -Lot 2 1.) Alt BM Description = Nl~ ~~5 '~. ~t~l 2.) Bldg sewer length = -.- s4 ? ~~ ` ~~ ' p- 6 `' ] I' c{ Z r~ -amount of cover. _~? -Co Z) ~ C r ~ a ~~ ~ L ' II ~~ Plan?~vin regtilred ~(] Yes No Use other side for additional information. 1~" 7a~ ~ ' SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. county: St. Croix Sanitary Permit No.: 363946 State Plan ID No.: r------- Parcel Tax No.: o2o-lass-20-o00 ADDITIONAL COMMENTS AND SKETCH ~ e SANITARY PERMIT NUMBER: SANITARY PERMIT APPLI safety and Buil9 ngs Division `~ . 201 W. Washin ton Avenue -scons-n P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis m~C~ e ~ 2~ Madison, WI 53707.-7302 • Attach complete plans (to the county copy only) for the syste ap(pa er~lOtlt~ss rs~ ,~"-" ~ ~gti ' ~ ~- , than 8 v2 x 11 inches in size. r -,J ,,,~;, v~ . ~- - \ 5 l • See reverse side for instructions for completing this applica ior~~ , ys D ~ StateSa~itary Permit Number tE 1 ~ ~ ~~ ~ ~ ~ Personal information you provide may be used for secondary purposes 5'~ C~OiX ^ ghEck~f revision to r ious application [Privacy Law, s. 15.04 (1) (m)]. C~tyTY ' St P n LD. Number I. APPLI ATION INFORMATI N -PLEASE PRINT ALL I ~ ~ A4'1~ Property Owner Name ~ ~L r erty Lo 3 T 2`j N R /9 l~(or~ G dt , , Property`Oaw~r's Ming Address ~ Lot Nu Z ~ BlOCk Numb City, tat Zip Code ~ Phone Number Subdivision Name or CSM Number S ~ (7i X386-32~ II. YP F 6 ILDING: (check one) ^ State Owned Road ~ !t NeaQQrest ~ a Public 1 or 2 Famil Dwellin - No_ of bedrooms ~ /I Iow n OF ~oG~•,e~ 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~~- ~n• /~• S~ 7 ~`'~ 1 ^ Apartment/Condo e~ ~' 1l ~8 " Z° 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) A) 1. ^ New 2. It~l Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an ______System ________ System _____________ Tank Only______________ Existing System ________ Exlsting 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 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^ Seepage Pit ~ , 43 ^ Vault Privy 14 ^ System-In-Fill 3 X ~ ,2~ VI. ABSORPTIONS TEM INFORMATION: 7. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) %i ~~i, $ Elevation _-- Ta B y 7 ~ i Q, ~ Feet Z,Z Feet 1 gj ~Z $ S~. ~ ~ Z ~ VII. TANK INFORMATION Ca aat in allOns g TOtal # Of Manufacturer s Name Prefab. Site Con- ~ l S Fiber- Plastic Exper. N E i ti Gallons Tanks Concrete tee glass App ew x n s strutted Tanks Tanks Septic Tank or Holding Tank j~p jGola ! ~~3 Cr ~ ~ ^ ^ trl ^ ^ 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. Plum is Name: (Pri~nt)~' 4 Plum is Signature: { Stamps) ` MP/MPRSW No.: 1 Business Phone Number: ~/ ' ~ / / Naw/ ~ 21i !' Z ~ z ~Z/f' ? 7L - 3 Plumber' Address (~r~ et, City, Stat~p Code): ! ~ ~ ~~ ' ~ ( IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sa ary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps) Approved ^ Owner Given Initial Surcharge Fee) ~ a2s ~O-~'~ Adverse Determination - X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD- 6398 (R.1 copy To: Safety 6 Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid #or 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. Alt 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 andBuildings Division, 608-266-3161. ' 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. V1. 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 81/2 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 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. _~ 1 TIMM EXCAVATING Route 1 Box 192 WILSON, WISCONSIN 54027 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN roe ,Ql rr~-'S S~ u e i.3o n SHEET NO. OF CALCULATED SY~SI~ V ~ ~"' r ___. DATE (D _ ' S ~ G~ CHECKED BY DATE ~,~` yo SCALE ~N 1 PRODUCT 2051®Inc., Groton, Mess. 01471. To OrGer PHONE TOLL FflEE 1-800-225-0380 wleoortsin Department of Industry, SOIL AND SITE EVALUATION 4•a4or and.Human Relations tMvision of Safety and Buikiings ~ - ~ ~ ~'~ rdance with s. IL.HR 83.09, Wis. a ~ ~' ~` '~ ~ ` ~ ~ County Attach complete site plan on paper not less $iari f3~~~1 ~ in size. Plan must _ St . Croix include, but not limited to: vertical and horizontal reference point (BM), directlort and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 020-1158-20 Page 1 a 3 APPLICANT INFORMATION - Please tlon. Re ~ wed by Date ~ ~ Personal information you provide may be aced for ~u~poift'(Pd~ IsAW, s. 16.04 (1) (m)). ` ( /. ~ . Property Owner `-`' ~,."; Properly Location r ~ Dennis Severson ~`~' ~,+., ~-~~ ~~ Govt. Lot SW 1/4 gW 1/4,S 23 T 29 ~N.R 19 ~Of9tr)w Property owners Mating Address c „~ rr ~ - t # Block# Subd. Name Or CSM# 714 Badlands n~, ;~ ' ~ °- 1, r r~; ;; 2 Dels Westview Addition City State Zip '~ ~,~~ !-.. - H WI 54016 7 d Q' ~~ ~~ son Nearest Road ^ Gty LJ Village ~ Town l d u son, v .~ 39b-3 p ~ ~ Bad an s ^ New Construction Use: ~ Residentidt~urtber pf "' 3 Addition to existing building ~] Replacement ^ Public or conxnercial -Describe: Code derived daily flow ~~,50 Bpd Reoorunended design loading rate • 45 bed, 9Pd/ttz . 55 trench, gpd/f!Z Absorption area required ~nnn bed, ft2_gy8.2-~~~ n2 .Maximum design loading rate .7 bed, 9Pdlft2~_trerx;h, gpd/itz Recorm~ended infiltration surtace elevation(s) 89.8/88.7/87.5 it (as referred to site plan benchmark) Additbflal desigNsite o0rtsidefeticrts insta> > 3 - 3 ~ X 54 ~ Sidewi nder M, Hy,~~~i t~ ~~t~ in 1 a_cha 1 1 ~~ tT2^Ch(: S Parent material sandy/loamy outwash Flood plain elevation, if applicable ~ R S i Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank u unsuitable for system L~ s ^ u [~ s ^ u ®s ^ u ~I s ^ u ^ s ~ u ^ s P9 u SOIL DESCRIPTION REPORT Boring # "<•:w"». Ground elev. 9n-9 ft. D~ ~ facto > 80 in. Boring # 1 2 Grctrtd elev. 93.3 R Depth to limiting ~ ~~ in. Remarks: CST Narw (Plesee Print) ~L/~gj 1r ~,..: t ~ ~ 124.1 c~i. Signature Horizon Depth Dominant Coke ~~~ Structure i C d B R t GPD in. MunseU Glu. Sz. Cont. Cdor Texture Gr. Sz. Sh. ons stence oun ary oo s Bed ,Trench 1 0-5 10YR 2/1 - sl 1 m cr mvfr cs f 2 5-15 7.5YR 3/2 - sl 1 m sbk mfr s m 3 15-35 7.SYR 4/4 sl 1 m sbk dh cs 1f 4 35-46 10YR 3/6 - is 0 s dl s m 5 46-80 10YR~4/4 - s 0 5 dl lm ------- w~' 8~•SO ~ ~.$~~.5 Remarks: 1 0-11 1 YR 2 11-21 7.SYR 3/2 ' w/ occas al f gr , 3 1-2 .SYR 4/4 - is 0 sg dl gs 1m 7 '.8 4 5-43 10YR 4/4 - os 0 sg 1 cs 1f 7 r8 5 3-84 10YR 4/4 - s 0 sg 1 - - 7 ~8 w/ stratifie moos ~ Telephone No. I Address ~ Date CST Number2tz~a•¢ I PO Box 57, Knapp, WI 54749-0057 10/9/95 3065 L PROPERTY OWNER Dennis Severson PARCEL I.D.i 020-1158-20 Depth to pmiting SOIL DESCRIPTION REPORT Page 2 ~ Horizon Depth Dominant Cobr Mottles Structure i C B d R t 2 in. Munsell Du. Sz. Cont. Color Texture Gr. Sz. Sh. ons stence oun ary oo s Bed ,Trench 1 0-5 10YR 2/1 - sl 1 m cr mvfr cs 1f/m .4 .5 2 5-18 7.5YR 3/2 - sl 1 m sbk mfr cs 1m .4 ~ .5 3 18-2 7.5YR 4/4 - sl 1 m sbk dh cs 1m/c .4 .5 4 24- 7.5YR 4/6' - is 0 sg dl cs - .7 .8 5• 29-4 7.5YR 4/4 - is 0 sg dl cs - .7 ~ .8 6 43-1 lOYR 4/6 - s 0 sg dl - - .7 .8 w/ occasio al gr do w/ stratif d mcos Remarks: Remarks: n H i th De Dominant Color Mottos Structure R t zo or p in. Munsell Du. Sz. Cont. Cobr Texture Gr. Sz. Sh. Consistence Boundary oo s Bed ,Trench Remarks: factor in. Remarks: SBDW-8330 (R. 08/95) + ~ 1 t 1 S ~ ~ ~ `~ - ~~~ .~ ~., ; ~, ~z1 ~~. 4. ~~, ~ ~ ~4~ 1 Lo~ t~ ~ ens ~~~~:.... ~&~,.. S w -Sw _ Z3- 2g - 1q ~ 1 ~, ~ ~.c c ~,,,,,,o ~,. C~°°~ .Z`A'P Q .mil ~~ ; tl` ~ ~ i ., ~ ~~ i V Qi,,; CJ V3 ~ e,i~.i-l-a... GiS;b~ t,..Sl.o.,.. ~,~. C'_ -~ ~ o. ~...~ wb ~.,,~ ~~ ~ ¢-~ _ ~ a-~ Cap R, LR ~. oS y ~„`~, ~`~ -, -., ~Vo ~~.~t7 ~e~ ba~~ ~~! _ ~ t s.s~ ~,..4,... ~.~. ~ (~ q:.2~ ~ti ~o 3 0~ 3 . WiscunSin Department of Industry, ; ~. ; ~ ~ ~ .~ IL AND SITE EVALUATION ' Labor and Human Relations ,~ Division of Safety and Buildings ` a\ ,. ~ s~~~ + dance with s. ILHR 83.09, Wis. ~. Preliminary -Soils Only Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 020-1158-20 APPLICANT INFORMATION -Please print all information. Reviewed by Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Page 1 of 3 Dennis Severson Govt. Lot SW 1/4 SW 1/4,S 23 T 29 ,N,R 19 X~C~4lT) w Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 714 Badlands 2 Dels Westview Addition City State Zip Code Hudson, WI 54016 Phone Number ( 715) 386-3290 ^ City yu~son u Village ~ Town Nearest Road Badlands ^ New Construction Use: ~ Residential / Number of bedrooms 3 Addition to existing building ~] Replacement ^ Public or commercial -Describe: Code derived daily flow ~~4p gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Absorption area required 643 bed, ft2 562.5 trench, ft2 Maximum design loading rate .7 bed, gpd/ft'-trench, gpd/f12 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [~ S ^ U ~ S ^ U ®S ^ U ~ S ^ U ^ S (~ U ^ S ® U Boring # Ground elev. ft. Depth to limiting factor `~ 80 in. SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Structure i C d B R t GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. ons stence oun ary oo s Bed ,Trench 1 0-5 10YR 2/1 - sl 1 m cr mvfr cs 1f/m .4 ' 2 5-15 7.5YR 3/2 - sl 1 m sbk mfr s 1m 3 15-35 7.5YR 4/4 - sl 1 m sbk dh cs 1f .4 4 35-46 10YR 3/6 - is 0 s dl s 1m .7 ' 5 46-80 10YR 4/4 - s 0 s dl 1m- .7 Remarks: Boring # Ground elev. ft. Depth to limiting f~ir~tor ~ in. Remarks: _ CST Name (Please Print) Henrv F.. 1 0-11 10YR 2/1 2 11-21 7.5YR 3/2 w/ occasi nal f gr 3 21-25 .SYR 4/4 - is 0 sg dl gs 1m .7 '.8 4 25-43 10YR 4/4 - mcos 0 sg dl cs 1f .7 ~9~ 5 3-84 10YR 4/4 - s 0 sg dl - -~pR .7 ~.8 w/ stratifie mcos 1 ' Signature Telephone No. Address ~ ~ Date CST Number PO Box 57, Knapp, WI _4749-0057 10/9/95 _ 3065 Dennis severson SOIL DESCRIPTION REPORT 2 3 PROPERTY OWNER Page of _ PARCEL I.D.# Boring # 3 Ground elev. tt. Depth to limiting 9f~~~r in. Boring # Ground elev. tt. Depth to limiting factor in. Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench 1 0-5 10YR 2/1 - sl 1 m cr mvfr cs 1f/m .4 .5 2 5-18 7.5YR 3/2 - sl 1 m sbk mfr cs 1m .4 ~ .5 3 18-2 7.5YR 4/4 - sl 1 m sbk dh cs 1m/c .4 .5 4 24-2 7.5YR 4/6 - is 0 sg dl cs - .7 .8 5 29-4 7.SYR 4/4 - is 0 sg dl cs - .7 ~ .8 6 43-1 10YR 4/6 - s 0 sg dl - - .7 .8 w/ occasio al gr & w/ stratif' ed mcos Remarks: Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bo nda Roots GPD/ft~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. u ry Bed ,Trench Boring # Ground elev. ft. Depth to limiting factor in. Boring # Ground elev. ft. Depth to limiting factor Remarks: 'n' Remarks: SBDW-8330 (R. 08/95) " ,• ' ~/ eiMNiS S Q~I Q.rrC Ow. ~~lO 1 • OV ~~ ~~ ~ ~t4r- 134Q~~ iV\ ~ .~ n~ sU.,.(Qp 1, ~ov,~e ,...,} w.. w.~~.c~ »y` `~ K -z ~.., pct -~- `p~ Z, V Pte= ~~~Nr4r •~V4'M Sw -Sw_2_(31- 2g-lg~••~ L= ~n~ ~.~ u ~,~ ~... ~.,~ ~ ,~ _~ ~ ~ _, ~,~.~, r 3 0 ~ 3 (~ ~_ 1 ~. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~idi2~s ~d`oso~ Mailing Address 7 f 5` ~~L~.S ,~ ~~~:~S~i-~ ~~ Property Address (Verification required from Planning Department for new construction) City/State Pazcel Identification Number 020 - //5f>' ~ Za LEGAL DESCRIPTION Property Location S'~ '/4, Sc~J '/4, Sec. ~3 , T Zvi N-R~W, Town of _~,~-~,~yj~~ ~T. Subdivision , Oz/.c ~~e•Q ~y/+~~ ~~~ ,Lot # Z Certified Survey Map # ,Volume ,Page # Warranty Deed # Y~3add 3 ,Volume 7 y'o ,Page # ~~ 3 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, jouraeymanplumber, 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 y expiration date. ~ l/j / ov SIGNATURE 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 (aze) the owner(s) of operty describe above, by virtue of a warranty deed recorded in Register of Deeds Office, ~ ~ l/~l ad SIGNATURE OF 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 oocuw~rt ~. ~1J~1~lklil~- a~tsxs ~uue of w~sc~t~sur s~s~ tr -- s+Ns ~ ~~-~ . ~ F ~~.~.wsurans~s ~a...DSNNI'~~'.F.,..~E'l1ERSf,2iQ._mnd. _....~....... .....~IliTiiS11^-S1~SRSf~i ..~d..tkAd..~~~ .....»._,... ...:. ~tu~'vivGrst~,p..~lttt~~tl.,prepest~ ..............»................... tollawint dNaibod =wi wstat~ b ._._....5~,,...C,~j„g ..................Cwni~~ et WLeominc .~...~ ~~- .d. ~ .r.. ~i~~~fi€yy~/~O ~i ~.RV~A Wp w~ tea. ~ a ~ 9,. t~ , i1:os ~ •eua+ to The Stste Bank o! ~deoe Ta Pried I~:..._~__.._ ................. Lat 2, Plat of Del`s Westview Addition to the Town of Ltudson. THIS DEED GIVEN IPI ~ONFIRMATIO~i OF THAT CERTAIN LAND CONTRAC`T' BETWEEN THE AB0~7E PARRIES DATED OCTOBER 1S, 1986 AND RECORDED ACTOBETt 21, 1986, IN THE OFFICE OF THE ~2EGISTER OF DEEDS FOR ST. C~IX COUNTY, WISCONSIN,. IN VOL. 757, PAGE 356, AS DOC. tJO. 418343. iu~~Q~' Tbi~ >......_ 1S not..... homestead property. (i.) (~. not) S:eeptae to warranties: Dated this ....--------•-26th--------•------------•-- day or ----------------------August ---...------- - -----........, 19...-8T ....- -----tB~AL' ~~E~~""`" --•-~- - •- --- ...- •- -•------ -------(SEAL) ~- ;~--~<rcn ~~ ~~ m~~v ~~ ~A CDrn<~rn oooNNZz ~-~'NO~ rn ~~zz~~~z ~~ oDZ~ _~ i ,gyp --~ ~ ~ ~ rn ? =COO nom=rnN~m >~ZDo~N~ ?~ v~r=~~ C7 D Z ~z ~~om Nm v .N~~,, oor wmrn ~ D -I O r- < p D ~ D~m-n -~Ic z zrntn= m~ ~ ~~~o Nm ~ D N rn 0 W O ~ ~mmz ~~ z v .. o. _~~ z rn= oin °°=m z~~v~"i~ OrnZvX°~ Nc~ D _ nmz~ o~ v m~vm N-~ ~ ~ Q 3 Q Z ZD~D~ 'V -~ maomn-Ni= -~i ~~v- -D-1-DI Z O c ~ ZDprnZ -'IZ ~b~~~~rn n ~N~v Dr o --~ ~ m z r cpDm~v Arno-~Im-~ ~_ i,~m m C D~~I~ BA p L A UNPLATTED LANDS awNEt Nps -_--__ - --`- 2 63.07' 2io. so' N_88° 39_1 I_1 s2.i7' - 0 0 ° O=mD N o~cnr W ~ W ^>=rm - '`! ao Z D m cnDm~ oNO~ ~ W ~_~ ~mm r mfm to D~~ IN m ~ ~oz m ENO ~~ _ o A o ~.,~ y ...i {m - o -~ I° ~ zm Ic ~''~ w Ic ^ I~ o ly m° I~ ° ~O N r IN y I ID -~_•-r ~~ N ~ 4 ~ ~ N N ~D .p O A ~$ ~ O ~ ~~ N (O ~ N ~ ' W ,, Y O n [~ ' ~ ~ pO W ' " ~ ~, m p ~' N , N 89 ° 43 51 E - N~ JsN 418.15' ~' ° w - N ~ N ~ N_ ~ t „ ~+V O n N o ~ ° o m ~ ~ 210.00' 418.47' 628.47' w~ o~ o N ~ W W n~ o ~~ o mA ~~ 628.86' ~y ~N N~ ~ m N cr D W O f'1 01 o mo N. vl z ~COMMfRCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 .715-962-3121 800 - 962 - 5227 ..... , , . , .. ST. CROIX ZONING REPORT NO.: 125b2/01 PA[~ 1 ST. CROIx GOtJNTY REPORT I)iATE: 10/18/91 COl-RTt~1lfSE DATE fiECEIi~D. 10/17!91 HUDSOPt~ WI 54016 ATTNS TF~S C. NELSON ~~ _~ ~_ ~~ . ~ u OWNER: Dennis ~ Cynthia Severson LOCATIONi 714 Badlands Rd., Hudson COLLECTOR! ii, Jenkins ~' SAi~'LES Kitchen faucet COLIFORt42 0 !100 mt INTERPRETATIONS Bacteriologically .SAFE NITRATE-N: 5 PPm Above 14 ppm exceeds the recommended Public Drinking Water Standard. CnLiform Bacteria/100 ml Nitrate-Nitrogen, mg/L LAB TECt~IICIANi Pam Gaf~e WI Approved tab No. i9 < bans "LESS Ti~N" Detectable Level ApPraved by; PROFESSIONAL LABORATORY SERVICES SINCE 1952 !o~//- 4/ T. CROIX COUNTY ZONING OFFICE ~~~` ~~ ' i ~ ~ 911 4th Street Hudson, WI 54016 ./ Telephone - (715)386-4680 ~ z~--a ~ The St. Croix Co. Zoning Office offers the service of septic and water inspection to Lending Institution, Realty Firms, and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be .done as soon as possible after fee and form are received . WATER TESTING--------------------------------FEE:$ 25.00 (For nitrates and coliform bacteria) WATER TESTING--------------------------------FEE:$175.00 (VOC'S) SEPTIC SYSTEM INSPECTION---------------------FEE:$ 25.00 ~/ PROPERTY OWNERS NAME: ~~,;-~,.~; ~, F, + (•~~~-h rn A . ~~e ,E~ DSO n PROPERTY OWNERS ADDRESS : '~ 1 ~ ~ ad Lcu,A S It~i~-ITY : ~ ud c n n W ~ Legal Description 1/4, 1/4, Sec.~_, T~,_N-R~_W, Town of .}~ h~,,,~ , Lot: No . ~_, Subdivisions iA~pc~-~~ ~.~ u! FIRE NO. ~ (1-~ LOCK BOX NO. Color of house arnw Realty sign? A10 Firm: ~- PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e., COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual Telephone No.~_ REPORT TO BE SENT requesting services : ~, ~ 14rne ~-; ~ rte. .~~r~-c ISi4n~ TO: CLOSING DATE: Signature: Oct. 17, 1991 Michelle Dunkel MidAmerica Bank 600 2nd St. Hudson, WI 54016 Dear Ms. Dunkel: ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET ~ HUDSON, WI 54016 (715) 386-4680 An inspection of the septic system on the property of Dennis Severson, located at 714 Badlands Rd., Hudson, WI, was conducted on Oct. 16, 1991. At the time of the inspection, a water sample was obtained for testing. The results of that test will be sent to you as soon as we receive them back from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is~the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. 'n erely, Mar Jenkins Assistant Zoning Administrator cj - Form - S T C - 104 .t AS BUILT SANITARY SYSTEM REPORT OWNER ~~~ ~' /~, ~,S ~Sj~~,y ~'/0,5 ~jTOWNSHIP ~LJ~1~'~/ SEC. ~_ T N-R~W ADDRESS ~ /~ ~ ST. CROIX COUNTY, WISCONSIN /7l~ll~Sj~h/ Li~~ SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•Z,I-~R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~,~~~ ~~~c~y =- btu` ~~ ar~~ ~, -~ ~ S~:E~.~c'c- Rc/~ ~~} INDICATE NORTH ARROW ~~~ ~ ~N,os ~' ~ BENCHMARK: .Describe the vertical reference point used t' Qj [,~j~/L ~'~.4~i"C /~Q~~Ji ~, Elevation of vertical reference point: ~~1/I;(} Proposed slope at site: ~. /~ PUMP CHAMBER ,, ~ .:.. Manufacturer: Liquid Capacity: Model: Pump/Siphon Manufacturer: Pump Size, Elevation inlet: Bottom o ank elevation: Pump off switch eleva Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from n est property line: rout, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: ,. (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench• Width: ~ ~ Length: ~ Number of Lines:~~? Area Built: Fill depth to top of pipe: ~~y' Number of feet from nearest property line: Front, O Side, O Rear,® Ft.~~ j ~~ i Number of feet from well: 0 Number of feet from building: ~, (Include distances on plot plan). ~EPAGE PIT e: Liqu depth: Area Buil Number of pits: Diameter: Bottom of seepage pit elevation: Has either a drop bd absorbtion sytems? HOLDING TANK or distribution box O been used on any the above soil one). Manufacturer: \ ~~ Number of rings used: E Elevation of inlet: ~ Cavarrlty of bottom of tank: Number of feet from near property line: ber of feet from well: umber of feet from building: Number of .feet from nearest road: t, O Side, O Rear, OFt. Manufacturer: DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS P.O. BOX 7969 MADISON, WI 53707 ~W~S~%,S23,T29N-R19W Town of Hudson Badlands Road NAME OF PERMIT HOLDER: I Dennis Severson BENCH MARK (Permanent reference point) DESC -~iNSPECTtON REPORT FOR PRIVATE SEWAGE SYSTEMS CONVENTIONAL ^ALTERNATIVE ^ Holding Tank ^ In-Ground Pressure ^ Mound ADDRESS OF PERMIT HO LDER~ Route 1. Hudson. WI 54016 SAFETY & BUILDING DIVISIO BUREAU OF PLUMBIN State Plan I.D. Number: (lf assigned) NSPECTION DATE: ib = ~ -~~ a' 3~ REF. PT. ELEV.: CST REF. PT. ELEV.: MP/MPRSW No County Sanitary Permit Number: Donavin Schmitt 3447 ST. Croix 99040 SEPTIC TANK/HOLDING TANK: MANUFACTURER: ~ LIQUID CAPACITY: TANK INLET ELEV.. ~ TANK OUTLET ELEV.: WARNING LABEL PROV ED: LOCKING COVER PROVIDED: (~' ~~~~~ j ~'OS ~~' 7~ ^ ^ V / YES NO YES NO BEDDING: VENT DIA.~ VENT MATIr.: HIGH WATER _ ALARM: NUMBER OF ROAD: PROPERTY LI WELL: BUILDING: VENT TORE: AIR Ip0.E L ~ ~ j FEET FROM ~ ` ~ ~ ~ ~ ~ ^YES NO I ^YES NO NEAREST ~ ~ ~ DOSING C A BER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUF ACTURER. 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 FRE; (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 ! ~N/sTH DIAMETER: MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue.) MAIN C(]NVFNTIr]NAI CVSTFM• BED/TRENCH WIDTH. i LENGTH. NO. OF DISTR. PIPE SPACING. COVER INSIUE DIA. #PIT&. LIQUID ~ lJ U TRENCHES ' f MA7~RIAL: ` PIT DEPTH DIMENSIONS b - J GRAVEL DEPTH FILL EPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL NO. DI R. NUMBER OF PROPERTY WELL: BUILDING: VENT 70 FRE: BELOW PIPS S ABOVE COVER. ELEV. INLET. ELEV. END. ~ ~ 2 f PIPES FEET FROM LINE ~7 Q/ ~~ AIR LE(T: L ~ .2- 3.~3 ~~~ S 3 NEAREST--- c/IP J ' MOl1ND CVSTFM~ 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 SOIL COVER TEXTURE. PERMANENT MARKE RS: OBSERVATION WELLS ^YES ^NO ^YES ^NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH O TOPSOIL. SODDED. SEEDED. MULCHED: CENTER. EDGES. ^YES ^NO ^YES ^NO ^YES ^NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: NO. OF L TERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD STR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEVATION ANO ELEV.: ELEV.: DIA.. E EV.: PIPE&. DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORREC LY COVER MATERIAL: VERTICAL LIFT CORRESPON pS TO APPROVED PLANS: ^YES ^NO ^YES ^NO COMMENTS: PERMANENiM R ERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: 7 I OM LINE: ~ ^~(ES ^NO ^YES ^NO NEARES S _. r ~~ ) ~_ ~ ~- ~ - - 'f .- J ~ Sketch System on Regain in cou nty file for audit. Reverse Side. IGNATUR E: `7,~,~-W- TITLE: Zoning Administrator DILHR SBD 6710 (R. 01/82) _ --- " ~-' SANITA Y PERMIT APPLICATION ~ DILHR In acc with ILHR 83 Adm Code Wis 05 CO1^'TM"~j~ ' • ~~~~ . . . , ~° •~-~-^~~ ARY~ RMIT # STAT ~ tJIT r / O [/ 9 7 ' -Attach complete plans (to the county copy only) fo he system, on paper not less than STATE PLAN t.D. NUMBER 8'/z x 11 inches in size. r -See reverse side for instructions for completing this application. PETITION ~'q' ^ I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. YES L~ NO FOR VARIANCE PROPERTY OWNER PROPERTY LOCATION `c '/a ~$!~/ '/a, S .23 T~ , N, R E (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK O VILLAGE 11. TYPE OF BUILDING OR USE SERVED: /L[~ - Uo~LC7 - ~Jt~Q - ~Q Number of Bedrooms if 1 or 2 Famil 3 OR Public S ecif Y ( P Y) E OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable) 111. PURPO S p ~ 1. a. ~ New b. ^ Replacement c. ^ Replacement of d. ^ Reconnection of e. ^ Repair of an System System Septic Tank Only an Existing System Existing System 2. ^ A Sanitary Permit was previously issued. Permit # Date Issued 3. ^ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ^ The System is shared by more than one ownerlbuilding. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #t and only one in #2) 1. a. Conventional b. ^ Alternative c. ^ Experimental 2. a. ^ System- b. ^ Holding c. ^ Pit Privy d. ^ Vault Privy e. ^ Mound f. ^ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. See a e Bed b. ^ See a e Trench c. ^ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): / ~v ~~ ~ J' ~ , Feet ry~ }W Private ^ Joint ^ Public VI. TANK CAPACITY in allons Total # of ' N Prefab. Site C St l Fiber- sti Pl Ex er. P INFORMATION New xisting Gallons Tanks Manufacturer s ame Concrete on- structed ee glass a c App. Tanks Tanks Se tic Tank or Holdin Tank (~ ~~ ~ Lift Pum Tank/Si hon Chamber VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumb 's Signature: (No Stamps M PRSW N Business Phone Number: - ~s ~~~ Plumber s Address (Street, City, State, Zip Code): Name of Designer. O G/I~ ~ VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # r _ E. CS 's ADDR SS (Street, Ci ,State, Zip Code) Phone Number: © ! IX. COUNTY/DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee Groundwater S c h rg e Fee a ate Issuin Agent Signature (No Stamps) Approved ^ Owner Given Initial Uv ~~~ ~ ^ ~ ~ - ~ ~ Q 7 ~~~ ~) r ~ ~ Adverse Determination ` -`v • U ~ ~' ` ' ` .D X. COMMENTS/REASONS FOR DISAPPROVAL: ~/~,, ,~~~v~~ ~y ~~~y ~: ~~ k, ~s SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT. APPLICATION . , TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system;. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. .Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed °~ pumper whenever necessary; usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact yo!~r local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description wl-~ere the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; lll. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a//septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil tesfdata on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more ~' commonly known as the groundwater protection law. This change in statutes was the ~'-~~.~~ result of over 2 years of steady negotiation and public debate. The groundwater bill Ground}~uater T-- ~~ included the creation of surcharges (fees) for a number of regulated practices which Wiscortf~in's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried ~reasure is used in your building is returned to the groundwater through your soil absorption o ~ system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, __. `J it's worth protecting. SBD-6398 (R.03/86) APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property ~~ t'a-,~1 S ~ ~ v G { ~ (} Location of Proper/ty ~~_~ ~S~ ~, Section '' .'3 , T_~N-R~~ W Township f~ u-- QSDN __ ___ nailing Address /~", r ~ .!. , Address of Site _ /~ j Subdivision Name r ,v ~ , ~,~ ~ ~'t (! +~lt~.~ Lot Number ~jj~ ~~ • Previous Owner of Property r .~ Total Siae of Parcel ~_ 1 .~~ Date Parcel vas Created ~~ % ~ - ~~ Are all corners and lot lines identifiable? ~_ Yes No Is this property being developed for resale (spec house) ? Yes ~_ No Volume ~.. and Page Number ~~~ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeda. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PRCPERTy OIVNER CERTIFICATION 1 (we) cent,~.6y that a.Q,Q. ~5.tatemen~ on ~h.i~ ~onm cute ~h.ue .to #h.e be~s~ 06 my (oun) Itnawf.edge; xhat 1 (we) am (cote) .th.e ownen(~s) o~ the pnopenty deJschi•bed ~.n xh.is ~.n~onmati,on bonm, by v.chtue o6 a wa~vc.anty deed neconded ~.n the V~~.ice o~ .the Cow,, Reg.c,a,tten o ~ aeed~s as document No. ~ ~ g '3y ~ ; and .that I (Ule ) peed entey STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~,y/S ~~~~SON _ ROUTE/BOX NUMB''E//R ~T, / Fire Number CITY / S T AT E H"G1 n Sa ~t/ L'C/1~ Z I P ~ _ PROPERTY LOCATION:~~~L, ~''L, Section~~, T~N, R~W, Town of ~f ~/,~,SQ/~/' St . Croix County, Subdivision Lot number Improper use~and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents maw. a maximum of 60~L of the cost of which was in operation prior to accepted thls program in August owners of all new systems agree maintained. be eligible to replacement o .7uly 1, 1978. of 1980, with to keep their receive a grant for f a falling system, St. Croix County the requirement that systems properly The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-,site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. '. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certifica[ion form must be completed and returned to, the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED Y' LV7 DATE~~ St. Croix County Zoning Office P . 0 . Box 98~ Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &'BUILDINGS I;IVDUSTRY, DIVISION LABOR AND PERCOLATION TESTS 1151 P.O. BOX 7969 HU«MAN RELATIONS / MADISON, WI 53707 (H63.0911) & Chapter 145.045) TI ' LO 'CT10 LOT fV : BLK. .: SUBDI VI 1, NAME: / V 4 ~ ~~ u/e COyy~~~~~~Y: O ER'S BUYER'S NA E: A L G ADDR SS: TIC,,,'` ~h ~ S e/ ~• USE id ~ NO. BEDRMS.: COMM DESCRIPTION: lace w ^ Re ~ ence es ~ p . e RATING: S= Site suitable for system U=Site unsuitable for system DATES OBSE NATIONS MADE PROFI D ~R~ ONS: ER ATI N TESTS: C~~TI~~ . IyQ lU~r^~ W G~~ ^~ RE: SYSTEM-IN-FILL HO~LDING TANK: RECOM~E~~ D S,Y~TE M:(9Pti al) ~ If Percolation Tests are NOT required DESIGN RATE ) If any portion of the tested area is in the under s.H63.09(511b), indicate: ~ Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH TO GROUN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, CO~.OR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. G EST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ~ $3 ~ Q~ ~ ~ ~ 3 ~` , $ ~/S /~ ~ y2 ,~1, S l ~q~'j ~. SS d h /1! S g r B-~ //)) ~ lr+~ /J] /h//~j ^''/~~ /~IV/ / 1 - ~ / S , `<s,(~i/, , ~"3 ~ • S' q~', : .off ~~ /yIs f~ t ~ ~ : 33' s , ~ L ~h s"" 9 ~ 7~ z ~~ ~1s~j r, B- ~ ~ , ~' `~ ~> ~ ~~ ~/s/, I, 6 7'8h ~ ~9 ~. 3•SS l a~ r11 s 5,-- B- ~r PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST IME DROP IN WATER LE EL-INCHES RATE MINUTES NUMBER -IAWFIIrS` AFTER ELLING INTERVAL-MIN. PERIOD t P RI D 2 P R PER INCH P- ~ / 2 - P- 2 ~ S'' 'Z 3 P- :33' ~. P-_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION j ~ ~ ~ __ .m ~ i ~ ~ 3 .._ ,. I 1 ' E ~ { ~ ~ ! .I ~ . ~ 7 t ' ~ ~' i ~ { ~ ~~ ~ ^ ~ ~ i 1 ( ~ ~--- _ ( ~4 ~ ~ ~ ~ ~ , ~1 ~3 , ~Lt ; _ ._ ~-- ~- ~ t ~ ~__. ~__. i 3 j ! . ~ r ; -r ~ o j f a~ S i 1~ ~I f _ ~ } ~ ~ ~ , ~~ /1j i _r.. e- ~ ( ( ~...... _..... _. ..._.~ a . ............._ - myr. - v ... _ ~ - - .~.' ~ C ~ i i ~,,.~_ ' _~_....... ~ I - i ,....,_..~ ._.. .,,,,e..,..., _...... ........~.._,~ .~.,_. ~ ,_ .-~M r ~ --` _3 ~ M-. J.T '. ~ _ _~ ~ _ .... ...... ~ ~ ~ I ~~ I ~ ~ ` t _ i i ~ ~ i _. ~ E _ __ ~' _ ~ _ . - ~ .__- E ~ I I ' _ ~ ~ y ~ _~~ _. _ _~ _ }____-_f- ~ K ~ `n ~ _. I i ~ .f' ~ ~ _ ~ ~ E ~2~ (o"~i ~~ ' o , ~" ,a I ___~ r ~ ? ? z ~ ~ _.~__ 1 ~ _.. _,~ ~ _. ~ I ~ _. ~ ...._.._..s. _..3,~._......, ._.. _a. i ~ ~ _ ~ _~ _ ~ ~ _ ~ _ ;.. _ _ ~_ ~ ~ '~ ~ 1.. _--~ ~ _~ ~ ~ _ 1 i _._. TN INSTRUCTIONS FOF~ COMPLETING FOS~M 115 - SRC3 - 6395 To tie a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section rraust clearly indicate wfaether this is a residence or commercial project; 3. MAXIMUM number of bedrooms ar commercial use planned, 4. Is this a ne5nr ar replacement system; 5. Complete the suitability rating boxes. A SI T E IS SUITABLE FOR A I-~OLdING TAi1iK ONLY lF ALL OTHER SYSTEMS ARE RULEd OUT BASEd ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferrec9. A se}aerate sheet array be used if desired; $. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolationtest exemp- tion, if apprcri~riate; 1B. if tl~e information {such as flood plain, elevation] does not apply, place N.A. in the apprapriate box; 1 1 . Sign the form and place your current address and yoirr certification numt:rer; 12. Make legi~de copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LC}CAL AUTI-6C)RITY VItITHl~3 30 dAl°S C7F COMPLETIt7N. ARI3RE~lIAT1ONS FOR CERTIFIEC SOIL TESTERS Soil Separates and Textures Clther Symbols st - St:ane {over 1Q"} BR -Bedrock cab -- Cobble {$- 1€)"} SS -Sandstone gr -Gravel {under 3"} LS -Limestone *s -Sand NGVV -Nigh Groundwater cs -- Coarse Sand Pere -Percolation Rate reed s -Medium Sand W -Well fs -- Fine Sand Bldg -Building is - Loamy Sand ~ -Greater Than ~sl -- Sandy Loam ~ -Less Than ~`l - Loam Bn - Brovvn '~sil -Silt Learn BI - Black si -Silt Gy -Gray ~`cl -Clay Loam Y _.-- Ye(bv~r scl -Sandy Clay Loam R -Red sicl -Silty Clay Loam mot -Mottles sc -Sanely Clay wi -- with sic -Silty Clay fff -- few, 'fine, faint ~~c -Clay cc - Gammon, {:aarse pt -~ Peat mm -Many, rneciium rn -Muck d - < istinct p -prominent HWL -High wet level, ~` Six general soi€textures surf~cx .^ ~«_~ far liquid 4vaste ciispasal BM -Bench VRP -Verb F ~ce Paint { ,, TO TFIE C)V6INER. i-- - - - - -- ~ _ ~- - - - i - _ - - T - --- -- - - - - -- -- - ~~ - , ~- - - ~ r ~ ~- -- -- - -- - ___ -- - ~ ~~ ~ a -- I ~ ~ ~ - - - - - -- -- ~ X ; i i I ~ f ~ ~ ' ~ 3 ~ c - __ _-- __ _, ; _ ~ ~_ _ - - _- I - , ~ ~ I ; --~ ~ _ 1 I - ~ ~ _- - _ - -- - -~ ~ -- - - f i I , f -r ~ ~ ~ Y { ~ ~ - _ - - --- -- I - - ! _ 4 ~ - / f ~ - - - - - - - _ _ ~ ~ i s ~ - ~ __ ~ ~ - - - _ _ - ~ -- -- ~ a- ~ ~ ~ ~ f- i ~ ~__ ~ - ! ~ t - _- f ~ ?- _ - I - -t_ ~_ - I i L- I ___ I _ I - I I I ~ j i - t I _ f ~ r - I - __ r __ t _. _ __._ -_ ._ . _ _ . _ - I ~ ._ __ - _- - __ _ - 1 _ ~.. -- I L.- - - - i ~ ~ ~ - -- + -- ~ I - - - --- t - _ _ - __ ~ - _ ~ -- -- ~ ~ -- 1 ~ r ---1 ~ t ~ -- I - }--~ - ~ - - - - - - ~ r ' -~ -~- -._._ _ f -~ -~ 1 ~_ ~ I _; _ ~ ,_ ~ - _ r ~ -- ~ I- _ - _ _ - ~ - - - -- - - ~- ~ - - - - - rt -- _ -- ~ i ~ ~---~~ I -~ 1 I ee ~~ ~~pp -ii I _ I ~ ~-~- -~ - ~ ll - - - tO _ - --- - -- -- 1 __ +-- ~- + +_ i ~ - __ - - _ ~- - ~ ~ t -- - - ~- ~--- r ~-- I - - - - - _.~ + I -± _ - - ' ~ ---}-- ~ - ~ --~-- - -~- ~ ~ ~ . ~ ~~? ~ //~~--~~ - ~ ~ ~ ----~- ~ ~ 1 B ~` --- ~~ --i- -7T' , i ~ ~ -- - - ~ l - I ~ I t - i L- _ - 4 - t -- _ _ - - _ - - + -- - - ~ -- -- - ~ - - - ~ - - - 7 - . - - - I -~ I II -__ ( + + - ---i - _ - I -- t I - _ - - - - - - -- -- - j ~ 4 -- ~ ~ ~ - - -~- - _ ~ ~ - - I I ~ + 7 I I -- .- ~ _ _ _ __ t- - - - - I ~ ~ _ ~ _'" a ~ - i - - i ~ ~ I ~ i ~ I .~ y ~ ;~ 8 ~ -- - - - ~-- ~ - -t - _ ~ I _ i T - / _ _ - __ _ - r a-- fi I I ~ 1 ~ t __ i ` _ - i ~ i ~ ~ ~ ~ _ i ~_ ~_ ~ ~~ ~ - - - ~ ~ , - - - - ~ ~ ~~ ~~ ~_' ~ -~ ~ - - - ii ~ - ~ ~--1 -L ---~ I -~-- ~ - -- ; ---.-- F_--~ - -~- ~ ~-~ --- - ~ ~ --fi ~ ~- - i ; -+ ; -~ - -- - --~ ~-- - - -- -- - - - - -- __ - - - - -- - - _ - ~ -- - - -~ - - - ~- - - --1 - i , --~- ~ ~-$ ~--~ - - -- -~ -- - - - - - ~- _- ~ -- -~ -~ _ --- - - - - l - - ~ - -- -- ~ ~ ! ~ ' ~- I I ~ ~ ~-- -- - - -- -- -- - - - _~ - - - - _ - _ _ - - -, - - - -~ -~-_ I ~ I - -~ -~--I - -_ _ _ ~ ' f , _ " - -_ G _ O - f -- . 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