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020-1146-60-000
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)l. Permit Holder's Name: City Village X Township Marcello, Paul Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: , p~ C TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~S~'rL ~k- !oo ~ ng `_ ~ ~ ~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L W~FJk B G. o Vent to take ROAD Septic r ~ , R 4~+ng /1 l ~'~-t`~ ~ Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift F ' on Loss System ea Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM / ~ /~ 1 Ft ELEVATION DATA STATION Benchmark Alt. BM Inlet S t Outlet • Dt Inlet ' Dt Bel4enr Header/Man. Dist~~pe. -L C • ~ ~ °"J Bot. Final Grade ~- uh~ St Cover w f/~ /" C County: St. Croix Sanitary Permit No: 506173 0 State Plan ID No: Parcel Tax No: 020-1146-60-000 Section/Town/Range/Map No: 26.29.19.775 BS HI 3 ~> )03.3 FS ELEV. iov. e ~/. 37 . 9~, 9 3 s,J qb:~d~ s.2 9d-os ~ .2 ,~, i y 3.05 # 2 - ~/• S 9/ • ~S b JL ~ ~ /..rY, .~ 3 ~ . /S 9(• / BED/TRENCH DIMENSIONS Width ~ Length) /~~ q/ / N9. Of Trenches IMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLD WE LAKE/STREAM LEACHIN Manu urer: INFORMATION CHAMBER -- Ty e Of System: ~~//~/ / -7 / ~ Mo l" ~~l/ ~ / ~ y DISTRIBUTION SYSTEM , (D ' / 3l• / ~ -P~~ Header/ fo Length d f Dia Distribution ~ ~ / Pipe(s) ~ ~~ Length Dia Spacing x Hole Size x Hole Spacing Vent to Air Intake SOIL COVER x Pressure Svstems Onlv xx Mound Or At-Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~ Yes 0 No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / ~ Inspection #2: / / Location: 766 Meadow Drive Hudson, WI 54016 (NW 1/4 SW 1/4 26 T29N R19W) High Meadows o`t"10 Parcel No: 26.29.19.775 1.) Alt BM Description = ,,p~~ 2.) Bldg sewer length =~O (iYt(,(i-~L ~~-'h.~ tr:tyj/t~~.~~~?.~-~U/G~?i~ ~CC`~~--'" - amount of cover = ~ ~o -~C-(;~-vt ~1'~.,~1../,-,:, r~ ~ r f?i~/"~'l ~ ~J _ ~ _ 1 >~- ~ - ---- ~ --- -~~--- ---- 7 -____. l / ~ _;7 Plan revision Re uired~ Yes o ~ p, D/) ~ _ ~ ~ ~ q ~ ~ ~ ~ )_ Use other side for additional Information. y' _~~ ~ ~ ~ _ _ ~"'~`~`'' ---- _ ~~/~!G~11. ~ I [~ _ ~_ ~ - --~ -- Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) eommercE.wi.gov Safety and Buildings Division County ' « « 201 W. Washington Ave., P. Box 7162 Y _ ~D ~ ~ ~co n S ~ n Madison, WI 53707 Sanitary Permit Number (to be filled in b Co.) Department of Commerce ~v~ / ~' Sanitary Permit Application ~ e'TransactioAn/Number ' In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmenta ` unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information ou c or econdary ~/_ j y~~ ~ ~~ l l ~ /, u oses in accordance with the Privac Law, s. 15.04(1 (m), Stat P t ! V~ L A lication Information -Please Print All Informati n / P ty Owner's Name f MAY 0 2 2007 Parcel # ~~ ~~~~ `~~o ,~~Jp Property Owner's Mailing Address T LINTY CROIX CO Property Location ` ~ ~~ ~ ~ S . Govt. Lot City, State /~ " Zip Code um er ~~jt /' , L~ /+. SE Y., Section ~~ t r` 5 V® s ~~ ~-~ (circle one E or~ T ~ N; R lam ll. T e of Building cheek all that apply) Lot # _ - I m' 2 Family Dwelling Number of Bedrooms ~ /'D Subdivision Name ~~(/„S'~7'yl a~ !!// Block # ~' ^ Public/Commercial -- Describe Use -- ----- ---- ---- ^ C' i tv of ^ State Owned - Descrilx` Use CSM Number ^ Village of -------------,---- Town nf~GL SD~ Ill. Type of Permit: (Check on mte box on line A. Complete line B if applicable) A. ^ New System eplacement System -----'~- ^ TreatmendHolding Tank Replacement Only ^ Other Modification to Existing System (explain) B. ^ Permit Renewal Before Ex iration ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New O List Previous Permit Number and Date Issued ~/ ~~ ~~ rl9~Q p wner IV. T e of POW'I'S S stem/Com onenUDevice: Check all that a ~ 1 ~CJ~`+On-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ Holding Tank ^ Other Dispersal Component (explain)/b ~ I ~ S -s.7~` retreatme vice (expl in) V. Dis ersal/Treatment Area Information: Desi n flow ( ` pd) ~ ~ Design Soil AQp ication Rate(gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) Syste on 9~ ~ N- ~ ~ 5 a ~ 11aS ~ 0• s ~- 9 ' 0 VI. Tank Info Capacity in Gallons Total Gallons # of Units Manufact rer ~~/„/ ~~ LU~ .n ~ e ~ H New Tanks Existing Tanks ~, / /S ~ (j'G ~ o ~ ~ rn .mod. v ~ `-~ ii C7 a a H i . Septic or Holding Tank ~ /(~0 D 1 i .\ ~ I C p p W d'SJ~ Dosing Chamber _ -/ J ~ (( L L ~ j y ~ a~ _ VII. Responsibility Statem e n t- t, th e undersigned, assume res onsibility for installation of the POWTS shown on the attached ans. Plum er's Name (Print) PI MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) io~lJ ~~~ ~~~~ i~~osu~ ~~s~- S ~~I VllI. unt /De rtmen se Onl ~ pproved ^ Disapproved Permyit Fee J'~ ~ $ ~ ~ Date Issued ~/~ ~ ~ is ing Agent S natur l < `~ ^ Owner Given Reason for Denial / t/ /IX'~CYonditions of Approval/Reasons for Disapproval ~~~ / _~ r ~~ STEM~ OWNER: ~~ 3~l ~p .SGZ~~ L~GGI,/~, Septic tank, effluent filter and l.% dispersal cell must all be serviced /maintained ~It~7.~7- r"I~'-' ~r ~~ ~ as per management plan provided by plumber. ~~~ ~i1i~~ h~~ .d- -~~.~ ~. ~,~~ ~e.~a~.n ~ eyun,~rypyttµZoyhyltdN plldrfitrd10166dt~647 and suNmit to the Courtly onl7 on paper not less (han g t/2 . as per applicable code/ordinances. ~~,~~t~~ ~~~ SBD-6398 (R. 01/07) Valid thni 01/09 (~~~. x t~ siz~ -~ ~~ ~~:~~~ o a me ~. ~~ ~ ~~ ~ ~ l1~ J; nn ado u -fie mees ~ G.Ge~.se a!~dQo ~ ~~ ~pUU qb! S4~'J~ C.ll ~/ i ~ ~ ~ ~~~ ~~ ~~~~ ~~ ~'~~s ~~ ~~~ ~~~ ~,~~. ~k1 o~ ~12Rl~G~s - 3)t~~ ~ ~PC~ latn,< ~ ~. ~ ~~ ~- i~~G~ - 3 ~ 8 I_~ s -13 c~„~,~ 13~' _--___`a` ~1 ~3 3 ~s~ . ? ~ o' ~ i v C~pri~. Ei~ v ~. -(?Q ~ ~ ~~~~ _ ~ '3rd -~'c~.-~ _ ~. 9f9f9f ( ~(Z~i;~ j r ~ are ~~~~~r~ ~ ~B~j ~ ~ ~ ~ r ~ 0' ~. ~~2oN ~ ~e f ,~~'`' ~'~o iM ~~f _. N qa•° ° ~_. ___. --__-_ ~~ ,~ ~_ ~ s lI ~.me ~~l J L~io~ 7~~ ---~- /y~,,~~el% Tm l~umees~e~ M~~~ ~r G<<ense ~~1dgo~ N ~~~ ^ -~NS~1ofi-~~ '~~~ ~p~r ~:~~ ,,~ ~ ...~ g<~'C Ir,~i~~ Q~~~ Ruti ~o' t~ 3erc~ ~ar~~ E~~V ~ ~Oa'. Q ~ _-~~ p o~ ~ ~ ~ ~ Cdvr ~ a~ ~.x~s~`~N ~~~ ` ~~ ~. as T° ~P a ~- G~r~ n~.c ~ l o un ~~~ ~~~~~.~: F ~~ ~ ~: a _T~~~~s - 3x~s ' ~ ~P ~T~N` I' IRpNG~ ~ ac $ I-~ S- ~~ Chnlr~l N ga,ao r, ~.I.S ~ 9oS ' `~scansin SOIL EVALUATION REPORT #1566 Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3 Division of Safety and Buildings Schmitt Soil Testing, Inc. County Attach complete site plan on paper not less than 8%= x 11 inches in size. n must St. Croix inGude, but not limited to: vertical and horizontal reference point (BM), on and percent slope, scale or dimensions, north arrow, and Location and distan ton t road. Parcel LD. ago-114x-so-aoo Please print al! information. Revie B Date Personal information you provide may be used for secondary purposes (Priv Law, .04 (1 T 3 0 Property Owner ~'EC Property L ion Marcello, Paul J Govt. tot NW1/4, SE1/4, S26, T29N, R19W Properly Owner's Mailing Address o 2 0 ~ 7 Lot # Btodc # Subd. Name or CSM# 766 Meadow Drive APR 3 10 Nigh Meadows City State ip CoSgde Pho NNuL Ci ~Ila a Town Nearest Road Hudson WI 54016T~ CROIX~oU~~ ^I ~' ^ g ~^ Hudson Meadow Drive New Construction Use: ~ Residential /Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement ^ Public or commercial -Describe: Parent material Outwash Sand (Burkhardt- Flood plain elevation, ifi applicable NA tt. General comments and recommendations: Area is suitable for a cornentional system with a 0. ossible system elevation for replacement area is (3 step trenche tg~ Mid 91.5' Low 90.0'. Boring # ~ Boring ~^ Pit Ground surface ekv. 98.05 ft. Depth to Limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consisten Boundary Roots GP D/(t= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Etf#1 'Eff#2 1 0-10 10yr3/4 none sl 2mgr mvfr as 2vf .6 1.0 2 10-20 10yr4/4 none sl 2fsbk mvfr gw ivf .6 1.6 3 20-34 10yr5/6 none Is icsbk mvfr cs ------ .7 1.6 4 34-96 10yr6/4 none s Osg ml ---- ------ .7 1.6 This pit was evaluated to verify soils for existing drainfield, A valve may be installed to utilize the existing drainfield. Boring # ~ Boring ^ Pit Ground surface elev. 96.40 ft. Depth to limiting factor 98+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consisten Boundary Roots GP D/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efl#t 'Eff#2 1 0-5 10yr3J4 none sl 2mgr mvfr as 2vf .6 1.0 2 5-12 10yr4/4 none fsl 2msbk mfr gw ivf .4 .8 3 12-32 10yr5/6 none Ifs lcsbk mvfr cs lvf .5 1.0 4 32-4 10yr4/6 none grsl lmsbk mfr a ----- .4 .7 5 41-98 10yr6/4 none s Osg ml --- --- .7 1.6 2 ~- ~ ~ " ~~ ,y ,, 'Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mgrl CST Name (Please Print) Signature: CST Number Thomas J. Schmitt ~~~~~-~a~ 227429 Address Schmitt Soil Testing, lnc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 4/20/2007 715-247-2941 Property Owner Marcello, Paul J Parcel ID # 020-1146-60-000 Page 2 of 3 Boring # ~ Boring ~ p8 Ground surface env. 95.05 ft. Depth to limiting factor 97+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description . Texture Structure Consistence Boundary Roots GPD/ft' in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 1 0-7 10yr3/3 none sl 2mgr mvfr gw 2vf .6 1.0 2 7-20 10yr4/3 none sl 2fsbk mvfr gw 2m,2f .6 1.0 3 20-30 10yr4/6 none Ifs lcsbk mv(r a 2f .5 1.0 4 30-47 10yr5/6 none Ifs lcsbk mvfr gw 2vf .4 .8 5 47-84 10yr6/4 none Ifs Osg ml cs ----- .5 1.0 6 84-97 10yr6/4 none s Osg m ---- ----- 1.6 col- ~ h~ !a " b e~ ~S~ ~ ~k ~ ~~ yl~ ~ ~ ~ 3 ~ ,z,rz,. 4 Boring # ^ Boring ~~ ' `~ _ ~`G ' tD ' ~--------~-~ PR Ground surface elev. 93.35 ft. Depth to limiting factor 97+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Etr#'I *Eff#2 1 0-9 10yr3/4 none sl 2mgr mvfr gw 2vf .6 1.0 2 9-20 1Oyr4/4 none fsl 2csbk mvfr gw 2f .4 .8 3 20-39 10yr4/6 none fsl 2msbk mvfT gw if .4 .8 4 39-55 10yr4/4 none fsl 2fsbk mfr cs ------ .4 .8 5 55-68 10yr5/6 none Is Osg ml cs -- .7 1.6 6 68-97 10yr6/4 none s Osg mt ---- ------ .7 1.6 Boring # ~ Boring pit Ground surtaoe elev. 90.45 ft. Depth to limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 *Ef(#2 1 0-8 10yr3/3 none Ifs 2mgr mfr cs 2f,2vf .5 1.0 2 8-22 10yr4/3 none Ifs lfsbk mvfr cs 2m,2f .5 1.0 3 22-43 10yr4/6 none tfs lcsbk mvfr a 2f .5 1.0 4 43-66 10yr4/4 none fsl 2msbk mfr cs lvf .4 .8 5 66-79 10yr5/6 none Is lcsbk mvfr gw ------ .7 1.6 6 79-96 1Oyr6/4 none s Osg ml - ----- .7 1.6 ' Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 a 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.07/00) Sdimitt Soil Testing, Int. Page 3 of 3 Conducted by: Conducted For: v .Schmitt Soil Testing Inc. Name: Paul Marcella Thomas J. Schmitt, CST 227429 Address: 766 Meadow Drive .1595 72nd St. City, State, Zip: Hudson, WI 54016 New Richmond, WI. 54017 Phone: 715-247-2941 Subd.Name: High Meadows s;~~ Lot No.: 10 n8c" ~/~/~ Legal Description: NW 1 /4 SE 1 /4 S26 T29N R19W ~ Backhve pit Township, County: Hudson, St. Croix County ~ Bench Mark El. 100.00' Top of vent cover on existing drainfield D Alternate Bench Mark EL 101.25' top of garage floor (Bottom of garage doors) Slope= 11 °!o Scale 1 " = 40' ~~ ! v--~ ~~ c~ ~~ `/~ ~ e .3~~ ~a' ~~ /~ S' zs~ ~ y, yb . , ., , ~~ p~;~~ ~~~ Ervva ~~ ~!-~e ~ Arc1MS Viewer . ' S ~-`f ~' ~ f,U i http:!/72.21.230.178/website/LRPortal/ARCIMS/MapFrame.asp?PIN= ~ "_ ~~ ~ Page 1 of 1 F 4/20/2007 ., ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEP`T'IC 'I'ANY. This ipps to certify that I have inspected the septic tank presently serving the ip~' ~ ~~bl~<~ ~~ Q residence located at: ~~ ;, S ~ ;, Sec. ~_, T~_N, R~~W, Town of ~i~VSO~ , St. Croix County, Wisconsin. Upon inspection, I certify that I leave found the tank and baffles to be in good con it'on, and it appears to be functioning properly. Last time serviced a (~~ Did flow back occur from absorption system? Yes line. Approximate volume Capacity: Construction:~Prefab Concrete~_~ Manufacturer (if known) : ~tlSen Age of Tank (if known) : ~ a ~, ~1 (Signature) 1~ P ~ S~ (Title) ~ a ~~ (Date No_ ( if no, skip next gallons _ minutes Steel Other 3i r~ ~n a r~.Q~e ~~,~ (Name) Please Print aka ~ ~`~ (License Plumber) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name ~i 1rY, 1~6}~ 1M-p-~S ~ _ S ignature MP/MPRS a as 9Uy or length of time: X4/30/2@~~ 14. ~3 77 ~a3t315~2~ R~MA?C A~~QC PLUS PAS X211 ~ . ._ - ,..~..s.s. v. Kra: L-ram r . 10101 P 1. C~[Q~ ~ V I\~ SEPTIC. TAiVIC MAI1~I,~ICE AGRTP.,ME~' AID O'WNF~SHIP CERTIFICATION EOR11~I OwstedAuy~r /~ Mailing Addrtxv~ ~~~~~~~~~~r ~ ~f~4~~ p~erry.~,ddnss _~~ ~.._-~~~~~'i lam/ S`SIO~G~ (Vexifxatian tbt{trirleti ftnm Plaattiag ~ Zoning Ifcpsrh»ent for rtes c~nst,oction.) ~~~ l'ttrcct Ideattificgkios~ I~tumabcr d / ~ILL.._~r~0- QED LEGAx, D T~. pN Property I,OCetio~n~~ ~/ , _ . %4 ,Sec. ,~, T ,~N R_/~W, Tawxt of C~~~~l Sulidivisioe tl1x~~ ~ D,rr/5 ~ L.or, # /D - y CtatrtlC~d Satrvey Mete ~ _~ ,Volume , p~ # Warrn-tY need ~-~~~.2_ _..~• Volum~e~~j , Pam ~ -~~ ._.....: ~` hO~ ~ ~ Lot lines iddatit~ahk~ tw 'STEM AiA~I`r~l:NSlvtr~ Alm O~~RTIF~CATTON ltnptriPer arts and m~aitttertattce of your septa system coukl,resnlt in itr pt~errtattrtt faihtne a- htto~dle vv~tstes. Prapec maitttetstsorce ecrosirn ot'ptttt7pittg oiit the sgttic tsuNc every tlseie Yeats of ~ortet, if needed, by a licensed pampa. Whwt yon pat iatp tbn aysteoa raw t~ the fattstian d the tank as ^ treatment Legge in. eltc wnstt disposal eYs~at, pryget malttteaantt: iaitZeB,se spocifisa to ~Cntntn.1t3.57.(i } tt„ td in r 12 - St. c'ro+x Conttry s.tahuty Urdlrurtce, t-vmer anti bb a~ apeas m subnatit to St. Croix C,crur-tY Pllat~ ~k y.,ott~ I1~Brtment a ccrtitacatioa form, siPuetl by the Y P a41~Y . rt~tritxt:d pbianba a a 13c:ertmd pwtp~ vtrifyusg tint (1) dtc on-site .rsstewitdr disposal syaoem is im prvprr appratiutg Cottditio» tntd(ot t2) allcr inspCCtivtt and i t! last than Ili fall afstttdgc_ P~ ~ l ~ n~~'Y), ~ tank is aaiedndc ~ ~ ~ t~r®ted have teas d-e ttbova attd ttga+ee ro ttn;nwee the private tlttvo je dspt>s! sYattau whit fire forth, herleia, ss taa irY the ogCeanrtteree ttrnd the IetN of Natuta) Resowcd, $ttNe of A-tawnain. Certification atatistg 1Mt ytnar septic systtmt has bran mast be oosn¢ktett and :attuned oo ~ St. Ctais County lr d; DePartatem welhitt 30 days of tl~ t~r+ee Yert agtitation due, ia""utg l/vre certify tME a8 statenteuls ~ ~ Ram ttr~ frne to tltc brat of ttry/oar 1odoAtetfge. 1/we Rgthtre t6c Q~(y~ 8f tfie pr~Y demarbed ttbovc, by vntoe of a w~artatsly deed rtac+uded in Regisset of Deeds Oittoe. Nam6er at.bre~iroottaa SIGNA F 11,1° ICAN1'(~) G~J~i D_ t DATE "'^a~+ Sao that is ~d mry reanb is the sttnitsry pemtit being revolted by ttte Planenng & Znrdag ncpatancat. •+• lnehtde wit11 stria appt;catipn • aertrtaelY deed fiiom the Register of Deeds Offroe sad t oapy of the cettitked altr'VOy rasp if rafetntce ie made in ale vtasrottty dt:md. {~i~v. oti/ss~ APf2-~0-c~007 t'lON t3R:~rart tn-~...... ~_..,.... _ ",~....... POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION Owner D Permit # ~ r _ / DESIGN PeReMCrcee cQ Number of Bedrooms ,~ ^ NA Number of Public Facility Units ^ NA Estimated flow (averages 3 al/da Design flow (peak-, (Estimated x 1.5- S 7 gallday Soil Application Rate ` gal/da /ft~ Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease IFOG) <30 mg/L Biochemical Oxygen Demand (BODfi) 5220 mg/L ^ NA Total Suspended Solids (TSS- 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODg) 530 mg/L Total Suspended Solids (TSS- S30 mg/L ~NA Fecal Coliform (geometric mean) 5104 cfu/t00m Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA varues typrcar for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Inspect condition of tankis) Pump out contents of tank(s) Inspect dispersal cell(s) Clean effluent filter > ~Zn~~m~ Inspect pump, pump controls & alarm Flush laterals and pressur f Other: Other• SYSTEM SPF[_IFlrer~nnre Page _~ _ of v Septic Tank Capacity 1 () Q ~ al ^ NA Septic Tank Manufacturer ~~'i ~~ '~ ^ NA Effluent Filter Manufacturer O NA Effluent Filter Model ~ (O ~ ^ NA Pump Tank Capacity G ~g~~ ~YZ~~-c.~/C~ al "B NA Pump Tank Manufacturer ~ NA Pump-Manufacturer Z9.NA Pump Model ~E3,NA Pretreatment Unit --ANA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Dispersal Cellls) ~In-Ground (gravity- ^ In-Grou~(pressurizedl ^ At-Grade ^ Mound ^ Drip-Line ^ Other: Other: ___ ^ NA Other: ^ NA Other: ^ NA Service Frequency At least once every: ~ ^ month(s- (Maximum 3 years) O NA ®'Yearls- When combined sludge and scum equals one-third IYI of tank volume ^ NA At least once every: ^ month(s- ~_ -~i vearlsl (Maximum 3 years) ^ NA -- •- o„o, r. At least once every: ~ ^~ ^ year(s) onthls ^ yearls) ^ NA NA 74t least once every: ^ monthis) ^ Yearls) ~A At least once every: ^ monthlsl ^ yearis) NA ~,,NA ~'AINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankis) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal ceII1s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 or more of the tank volume, the entire contents of the nk shall be removed by a Septa a Serv' ' sed of in accordance with chapter NR 113, onsin Administrative Co e. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment i~n'Its, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. `i'o avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Oo not drive or park over, or otherwise disturb or compact, the area within 15 feet down s{ope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ~» A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ,,.,, , . ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomet at the. infiltrative surface. Reconstructions of .such systems must comply with the rules in effect at that timei 1~r+~ ^' < <WARNING> > • SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT; ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A` PERSON FROM THE INTERIOR OF A TANK MAY..BE DIFFICULT OR IMPOSSIBLE. - ADDITIONAL COMMENTS „, POWTS INSTALLER _ --Name - ~~~ Phone 7~~~ ~g ®~ !~ +i.,. ~, l:EPT~f~E SERVICINt;i OPERATOR (PUMPER) Name , . F""~:. Phone ,- POWTS MAINTAINER Name •''•' Phone ~' LOCAL REGULATORY AUTHORITY Name /` .~ ZU Phone This document was drafted in compliance with chapter Comm 83.22(2lIb11111d1&If- and 83.5411), !2i & 131, Wisconsin Administrative Code. 04130/2007 14:33 7153815720 DOC'tJMraNT NO. REMAK ASSOC PLUS ve1,1430~ac~ S1 WARRANTY DEED Tb~ls Deed made between WAYN>i; )P. SCOBFY and TA.BATHA R SCOBEX, husband and wife. Gra»tot8 a.nd PAUI. J. MARCELLO and JUDY J. SAMIQU[ST, as joint tenants, Grantees, WAtneseecb, That the said Grantors convey to Grantees the following described real Mate in St. Croix County, State of Wiseo»sin: Lot 10, )''sigh Meadonvs itt the Town of Hudson. This is homestead property. Together with all. and singular the hereditatnents and appurtenances thereunto belonging: PAGE 03110 6~400rb KATHI.EE:N M. YALSH REQISTER Oi DEEDS ST. CROIX CD., YI RECEIVED FpR RFC(Mtb 06-OS-1999 10:00 AM YRRRIatITY >1F~0 £1El~T 9 C~OORY ~' FEE TRRi~SfER NEE: 39'1.50 ~4:IN8 FEES 10.00 Tax Percel No. 020-1166-60 RRTURN TO: /~F~. cr And Grantors warrant that tbC title is good, indefeasible in tee simple and #F+ec attd clear of encumbrances, and w,/ill warrant and datcnd same. Aatcd this c~ a day oFMay, 1999. Wayne P. Scobey ~oL~a'~n ~ ~~C./..•~_ (SEAL) Tabatha it. Scobey STATE OF' WiSCOTTSIN ST. CROT.X CaUNrX )5S Ptrsonal.ly Dame before m.e this ~ 25 _ day of May, 1999, the above Hamad Wayne P. Scobey attd TabAtha R. Scobey, m the known. to be the persons w executed a foregoing ir-stttrrncnk and acknowledged th.e aarne_ ,~ grcada. Poulin ~ ~- StU~L "~ '~~,',.: C~r~,tiit~ NOtaty Public, Sta of V tsca»sin My Commission {expires): - / ~ ~ ~ er OZ? 27 TDIS tNSTItUMENT DRAF'7<'>ED BX: Robert W. Mudge, Attorney MUDGE. PORTER, LUNDEEN & SEGUIN, S.C. 110 Second 5trcct, P.O. Box 469 Hudson, wiscott3in sao16 (0 ' 04130/2007 14:33 7153815720 REMAX ASSOC PLUS PAGE 0Bl10 G:i~ANBE,RG SURYExtNG 1779 Cltf "L"' t'ktrRieM~endvut 4aDi7 1'ele (CIS) 746.7779 Dez (715y 7~6-0SOA L.ll~ P'[C 99.207 ~' Satt 1." ~ !0' Mot'tpA>ja Mek Dn~wing !tip FIRST F&1)P1tAL Dru OSt1fN99 Owncrll3uyer PAUL J. MARCELLO & IUDY J. $ANDQUI3T 97o7aJt7 N i soab ~^,= sar S IIP' 37' 22" E 4'08.88 _ - - 1tM"ra0ar intl. ;~.ti5 PraeMh, addreu: 7G0 Mwtlow anvU f ! ~ Wud.art. WI. 516te ^~~'`y~'j~. onoa Ql ,' r~ / / g dweWnowltln.oeMOe ~ V~ 'V~ NC-E: ne vbtlhM w.ep. S ~ ~6i ~~ n / • -Iedkelrw hpn coney mpnyleanl feuAa•• ~ (eo nemd) -~' LOT 70 OF ~ ~` / HIGH MEADO{M5 ~ 2 / ,~, CURVE 1NFORMAtrO)J Z ~tngWC ~nnt nwl+ro•te7.aD' oeis• 68 tear ~ 1 tro• rtieM fi0. C6wq. 15T.Se' luee e,•oPe / ~ tm° r.crn and ~ N U6" 00' 00' E 13T. ~ / j~4c~ydy MEADOW ~ : ~~'~ ._~. 1 r ~~,~. _: ~,. e do 111. ~s ~N• i.at ten (t 6 y o~ the Plat of High Mcadotn. Said p)at being Ituated In tho NW %, of the B) SG, the )3B k P9'the SE'/,the SE'/, oFtA6 SE Ya ald tAe SW K oCthe SE cif ofSeet(en 26, Z'29),t, R19W,1'ovm of ~tdiroo, St. Croix County, Wisrnnwt. 7' be loutiea af' ext+hvcmm~ts ee Wh Amw>ty; me epprexlln6te. Tha lot dimcfygn~ ale ILkOn faoz ~,.y ann dnxY of Cawty rtmrtlf. ~T'lus dfow161I to fo[ aalfmcud¢ezt tla~oelce aa<y' eed Puatld ~ be taeda~ a ppfptfoz tend Rsrvey. .. ~ ~ fukral tfpll PISlccd to v/f1YC thOp` 1tlQbi(eaiellk of q-87.Ot AnE7.QJ. A-St.p3_ A-~7.Ot. ~.: f:; ~ i){SI, and A~>.07..7'Lc'Iwpoze ofMlo b fe f~-N roTOb'witA A.Pa7.at [7). 04J30J2007 14:33 7153815720 . ~~ ~Q~.. ' J .' HE 70WNSHIP TOWNSHIP AFTER ~ BITUMINOUS ~ N tD N ZCN, 1979. ~ 1979. '~' au e O a° 2 a '9 ° 37 22"E 300.02' 's, °p its N N I 2.038 ACRES fn 6D 0 O 43?.35 •~-~300.13~= -•-- REMAX ASSDC PLUS PAGE 09110 ~~ `~ ~ I < '` o .? ° `~h f0 H M~ ~``, m z ° 0 ,,~, ~ _~ n ~ i ~.w '~° 205.92 o ~ ' -~ S 89° 37' 22~~ E ~' 620.92' • fir' _/ / ~~ / ~, / a •' I O / ,' 1/ O ~ ~ / ~5rls, ~ / tV 2.836 ACRES ~ / ss~ +% _ by ./ ~ eft ~0~' ~,~ J pO ~' S 89° 37'22"~ 409,$@' ey~~ ~ M 0• O~ ro"' ~ ati tcj ~• '` cy~~ ~ ~\ O f ~ ~/ K1 2,156 ACRES ` 'S' 2.434 ACRE: f>'6„ ti~ 'S8o/ ~ E.138 ACRE: rmosi~ QQ/~ Jl 8 a '~~ / `~ .a ~ . ~ ~am9j.oo, ~ ~~~ o~ ~, j• ~, ~>s9ps S9. - {37.22'- -`'~`~~ ' %~~~. s3e'' ~~-'~~'~ ~~, , o - - . ..~ • cA .~ •~~ I I I ~ 7 p3j 3 N C O 1 I °D fl- 3' Z a ~ y c_ ~ ~ ~ Si 41 pWj f=p a o ~ ~ ~ ~' m ~ 3 ~ ~ n I ° I ~ ~ fn -f A N N ~ Q W ~ _ - 3 - ~ ~ ~ I ~ y I I z o W ~ I ~ n 3 I ~ in m I ~ N a Z I O I =~ ~ ~ O o_ C W (~D ~ N Z ~ O ~ I o I I I I v_,-o m ~ D ~ y n I o~~ y o: ~" ~ >=~ m ~ CD ~~o~i o I ~v~ s ~ ~ ~ ~ I ~ ~ ~ I ~~_~ mac ~ ~ - N ~_ .. o- ~ o ~ o: d O fD ti C ~ O O ~` ~ O C ? ? 0 0 G 0 c~tn0! 3~~ d o ~ ~ ~ ~ c o ., '• ~ v eo s :~' ;, ". ~: ~I ~ ~ ~ \ 1 ~ ~ .. j ~ O '' C I O ~ ~< I = N O C ~ N t~ ~1 ~ y 7 n N P = ~ J ~ l i-•i ~! ~ o~~ ~n ~ ~ c~,b ~Q rn o ~ ~ ~ .y+ C Ot ~ ~ a ~ a o, ~~~ O ~' ~ 0 o y' I y~ e Q 3 ~ ~ 000-i N ~ ~ ? ° ! cn to to ~ :. '~° w rni '~ ~ ~ e o ~~-~, ego ~ a :: 3 °-' I ~ ~ .. ' N Z W Z ~ D a ~ 0 ~ ~ lr. ~ N ~ C ~ ~. f0 N N d I O J A ? n c -~ ~ .r a j' ~ ~ W W CZ N rn < fD e~ pp O ~ Z . ~ I A T1 3 '•' ~ m ~ ~ ~! z w i _~ c a a, m a, I a ~ A '3 O to O O V A M 'V ry~ _Y ~ A w H v ~ ~ ` Parcel #: 020-1146-60-000 01/03/2007 11:05 AM PAGE 1 OF 1 Alt. Parcel #: 26.29.19.775 020 -TOWN OF HUDSON Current XI 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 - MARCELLO, PAUL J PAUL J MARCELLO C - SANDQUIST JUDY J SANDQUIST JUDY J 766 MEADOW DR HUDSON WI 54016 Districts: SC =School SP =Special Property Address(es): " =Primary Type Dist # Description " 766 MEADOW DR SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.158 Plat: 2077-HIGH MEADOWS SEC 26 T29N R19W HIGH MEADOWS LOT 10 Block/Condo Bidg: LOT 10 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 26-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 06/01/1999 604000 1430/081 WD 06/25/1998 581753 1334/591 WD 07/23/1997 1123/639 LC 07/23/1997 663/17 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 162251 230,700 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Totai State Reason RESIDENTIAL G1 2.158 75,600 144,300 219,900 NO Totals for 2006: General Property 2.158 75,600 144,300 219,900 Woodland 0.000 0 0 Totals for 2005: General Property 2.158 75,600 144,300 219,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSM ENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION Distances . PLAN VIEW ~~ ~ ~ ~ ~: >- (~; & dimensions to meet requirements of H62.20 SHbW EVERYTHING WITHIN 100 FEET OF SYSTEM _ V _ _ %o_ ep ~c j diEa~e SCALD: SEPTIC TANK(S) / M~'GR. ~ CONCRETE ` STEEL NO. of rings on cover ~ Depti~ ' PUMPING CHAMBER SIZE PUMP MFGR. `-J2L N0. GALLONS Per Cycle TRENCHES N0. of wi~tTi' le gth area BED N0, of lines ar_Q width ~ le gth-`~p~area Quo d dep t to top o~ pipe ~ NUMBER OF SEEPAGE PITS Outs a. a ameter total pit area AGGREGATE / f /2 ,~ , PERK RATE- ~® ~ REQUIRED 9~}S~ AREA AS $UILT 9G0° Disclaimer: The inspection of this system by St. Croix CcSunty does not imply complete compliance with State Administrative Codes.' There are other areas that it is not possible to inspect at this point of construction. 'St. Croix County assumes no liability for system operation. However, re a the County will make every effort to determine ca failure.' GREASES AND OILS SHOULD NOT BE DISPOSED T IS SYTEM. Ct) ~. DATED ~ ~. /~" - PLUMBER ON JOB LICENSE NUMBER TOWNSHIP SEC . Z~ T~9N, R,~W ST. CROIX C UNTY WISCONSIN. LOT /~7 LOT SIZE s-'-?,~c rc~S° J ~ ~ P1 = AS BUILT SANITARY-SYSTEM REPORT '~iER ~ , TOWNSHIP SEC. T ~ N, R ~ W . 0. ADD~~ ~. ;~ t ._._ __._._.. __ __~_.~. _,.. , ST. - CROIX COUNTY, WISCONSIN. LOT LOT SIZE _.,._.,,. .y~, r~ •Distances-S~dimensions to meet requirements of H62.20 _ - N 100 FEET OF SYSTEM ~ I I 1 I I I I I I I I L I I I I I ! °~'n~•'rt' ' ~ ! ' ! ~ ! ~ ! i --7 ~QTIC TANK(S) MFGR. -:` CONCRETE STEEL, _ - ~ N0. of rings on cover Depth DRY WELL -. :t~.'~CHES N0. of width length area _ . ~ no. of lines width length area ~ "" - ~ depth to top..of,_ppe ~ • ~6?~EGATE . ~'~: RATE AREA REQUIRED AREA'AS BUILT - • I~~tiaiaiers The inspection of,this system by St. Croix County does not imply complete o;~liance with. State Administrative Codes. There are'~other areas Lhat it is not possible so in~gect at this point of construction. St. Croix County assumes no liability for -~Stepe"operation. However, if failure is noted the County"•will make every effort to tterrn~ne cause of failure. ~~F.~SES AIJD OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. ~ . /3p~P~s ~ ~~~ /9i~E :af~~ SEf" /~Fe~rS~ iV e~iE T~sT ~'C'~" E M 115 Rev. 9/78 ~y -- ~%/~ REPORT ON SOIL BORINGS AND PERCOLATION TESTS /J~~ WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES Z~ii D~ T~~sD jL P.O. BOX 309, MADISON, WISCONSIN 53701 .7i~9U£!~ dtf 7V .SUi T q 1' E•t~i`/ff/o~r~ LOCATION:~~'/4, ~~'/4, Section L~ ,T Z/ N,R ~ E (or) W, Township or Municipality ~7U.,~,('S~~ Lot No. /~ ,Block No. , ~~ y/~ /"IE~}QOI~S County S7~ C~PdIX --~u~b `iwslon ame Owner's/Buyers Name: ~• ~ • ~/s~~~~U/ ~s M Address: C~U C~ ~ilJ ~.~,t'O/(J , ~T ~ ~f~~~4~t~ ~/S. TYPE OF OCCUPANCY: .Residence ~ No. of Bedrooms ~ COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT qqpp ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MAD - SOIL BORINGS AiO~ll 17', ~/~ ~/O~PERCOLATION TESTS ~~~~~ ~~ ~~~~ SOIL MAP SHEET,j'CS ~~ NAME OF SOIL MAP UNIT //~~~y~~~ ~ ~~~~- PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE RATE NUM- BER INCHES THICKNESS IN INCHES SINCE HOLE 1ST WETTED HOLE AFTE SWELLING INTERVAL IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- Coo "Dx~aN. s/ 19"~,v s/ / "G7!~ P_ S/ ,5.,, ~>E~. s ,vim zd -- o - /L) y s " ~ P_ „c~~s~- s/ /3''f~Es 2 "~Eo.s ~v -o - 3d / zo P- D .=DF~v r.4- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, MOTTLING AND DEPTH TO BEDROCK TEXTURE NUMBER INCHES OBSERVED ESTIMATED HIGHEST , IF OBSERVED IN INCHES B- .vO,JF > ';~v.ta~rSc S/ 1~-~ "~~,Bv S/ 8'a~,Ep. S /8°'•~:aE /S . B- ~ ~VD,I.~~ ~(~ 31 "/3N. coctps~ S /9"6~iS.~..f/ I3" ~ S./G'"DER s /2" ~S B- 3 /o iVoA1t ~ ~~~ '%3N~ s/ /2" L/~B.J. Si/ /1 "S/ 1 ~~ 1~wty /S " CS. B- G ~l/O.t>t > ,S';6/. C~ot~fE f " tf .~;,. S/ b "~f/~ S. / ' ~Eo• S / '' B- ,vO,vE ~ y~ ZS';l3N . S/ l7"-fim,v /S 3" " D,P,r.,v E C'S ~ ~~E ,P. B- ,vodE > lP . S/ / y" ,13N . s./ '~ s/ ~', f;~t s '~ cs PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy ~ys ~~ ~~• .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. / ~/ /Q G ` ~~~ 0 oS ~ ` ~ ` ,~ /~ fO~I~ ~ ~~ ,~'0 t DEFT ~o ~ sEp~~ ,. h'> ~ , z~ _; __ ~~~ ~ .. P / po ~ ~ ~y ~ S~o~~f i n, _, E/Ev,~3T~o.~J ~~ o ~~ ~ / ~Eft~ty~ NE ~ ~ i.. ~ y~ ~ °~_ ~Z , . 4 PUl,,c~T.S E t ~ ~IOE _ . ~y y ~ ~ _ ~ e _ ., r g~~ .~ ~ ° p _ ~ --~' , /3 yo' ~ ~ ~. rb~~. ~ a-9 .as ~' ~~ ~~ ~ /1/1 W ~; A - -- - ,p~ ~ w P Q' ~.4>>~L i oi~~ 1, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print-~ohFeT `°' /~~lc ~ ~ Certification No. j ~ ~~ Address _ /~/ • ~ ~ i(,/EiL ~!~• ff yD.SO~/ W !S. ,l~yD/~p .Name of installer if known Copy A -Local Authority CST ~"°~ ~. State and County PLC 67 ~ ~1 ~~ Permit Application for Private Domestic Sewage Systems *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # State Permit # ~` rJ / 'S~ County Permit # County - ~f'. ~°O 0 K A. OWNER OF PROPERTY Mailing Address: /~~d cv, ~. ~stR,h~f~ B. LOCATION: lj/(,U'/, ~Lcl '/,, Section oZ T~N, R~ ~ (or) W ,L`ot# ~ City Subdivision Name, nearest road, lake or landmark Blk# ~7 f~f~ Village /nef3r~OwS Township U SO// C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify} *Variance Single family _~_ Duplex No. of Bedrooms 3 No. of Persons~_ D• SEPTIC TANK CAPACITY /OOC.~ Total gallons No. of tanks D //~ HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete X Poured-in-Place Steel Fiberglass Other (specify) New Installation , x Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E_ EFFLUENT DISPOSAL SYSTEM: Percolation Rate ® Total Absorb Area sq. ft. New_~ Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile. depth (top) No. of Trenches Seepage Bed:. X Length~~ Width a~ ~ Depth •• Tile depth (top)_~`' No. of Lines-s3 Seepage Pit: Inside diam ter Liquid Depth No. of Seepage Pits Percent slope of land__ ~ ~ Distance from critical slope ~~ 5 ~ WATER SUPPLY: Private ~ Joint ^ Community ^ Municipal ^ Owners name as listed on EH 115 if other than present owner: / s ~~ ~ lti J O Y-S I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I Have sized the effluent disposal system from the EH-115 prepared by the Certified oi! Tester, NAME / r@~~- O C.S.T. # ~~ = 5~5~~' and other information obtained from ~ i2 S (owner/builder}. Plumber's Signatur MP/MPRSW# ~~9 Phone # '~/S (o~4~-c~o~7~ Plumber's Address ~C.~ Wi.v i S PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. ~' ~~OpbSe ~ /AQ-~~ ~a ~n' ~°~. ~y o~ ,.- f® ~'- .~,~-- t~ B3 _ E o ~°~~~~ s _~ ~~~ ~ , a ~ p . .._ _ r _,~.. . _:/ ~' M,. ~ ~ . KS e ~_ __.. d~ . ~~ ~e _- ,~.~ _- - m. __ f . .~ +/ _.. W ~~ _ f_~~. ~ _ ~ .. s __ 4° ~ ~ ~ __..~ _. D ~e . _m , ._ .._ _ 3 .. ... ., ~_~ -. ~. i ; I ,__ e .~ _ ~ d - __ -- Oo Not Write in .Space Be>low - FOR COUNTY AND STATE DEPARTMENT US~ONLY '~, Date of Application-(- ~f~ Feepps Paid: State ~~©~ Co~ ~ Date - -gd Permit Issued/ (date) ~ l- P~ ~ Issuing Agent .Name III, Inspection Yes~No State Valid# Date Recd ' II 1. county (white copy) 3. owner (green copy). DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1 /78 „~ ._ . EH 115 Rev. 9/78 I " ' ~~E ~~s~,/~~ ` REPORT ON SOIL BORINGS AND PERCOLATION TESTS "'~~- 4,j~~ f~(J~ ., WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES 2~/Y D f ~~~/rO~L `' P.O. BOX 309, MADISON, WISCONSIN 53701 Sf~9UE7~ Off ?!~ $'U/T 1 ~ E,9tiP5`/f1fp~ LOCATION:'Y~'/<, '~~'/a, Section L~ ,T ~N,R ~ E (or) W, Township or Municipality ~7V~'t°'tJ Lot No. /~ ,Block No. ~ ~E~~OWf County ~~ G~d/X GU. ~ • 17/STiC//,3l>T S wislon ame Owner's/Buyers Name: ~/ M_ a g Address:'~U ~LfilJ W/'~,~0/(J , ,~T 1 T7'V~~O.t3 ~/S TYPE OF OCCUPANCY:. Residence ~ No. of Bedrooms 3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW x REPLACEMENT qq ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MAD SOIL BORINGS /QQ~~~ 17, 2/~ /l~OPERCOLATION TESTS ~~~/~ Z~ ~~~ SOIL MAP SHEET~CS ~~ NAME OF SOIL MAP UNIT ~~~~/y~/ ~'~TTiP~~ PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS - WATER IN TEST TIME ERVAL DROP IN WATER LEVEL, INCHE RATE NUM- BER INCHES THICKNESS IN INCHES SINCE HOLE 1ST WETTED HOLE AFTE SWELLING INT IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- "e~tsF s /3"'f,~vE-s. 2 "~.Eo,s ~c~ -a - 30 20 P- O ~'DEbc! ra P_ !moo .. ~~ ~ Zv _ O _ 3 O .y ~ ~ / ~ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, MOTTLING AND DEPTH TO BEDROCK TEXTURE NUMBER INCHES OBSERVED ESTIMATED HIGHEST , IF OBSERVED IN INCHES B- .1iD,~F > IC~''~~,~vS/8',wEp. s /8"~,D~' /$ . ';~V.t.'e~iSc S/ I B- /V~N~ q / ~O O 37 ~ ~F~. tOG7P~fL'' S IO ~Lf /~J. ,f/ ~,3 " ~ s. IG "~lE~ s /2'~ ~ S B- 3 ~1io,vt ~ /0~ '%~v. s/ /s -~ G~~ B.J. Si/ /l "S/ 2 " ~ryw /S '~ C S. B- iVO.t1C > ,,S'~iJ. L'oN.°fE f "lf ~v S/ 0.,,~/.r~S. / ''~11ED•s ~ ~' B- /t/ptlE ? 9(P Z,f';13,~ . S,/ l7~~r~ /5 ,f' „ p,P,~,v ~ cs '" 5:.~~ ,p. PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas, Indicate number of square feet of absorption area needed for building type and occupancy ~ys FOB ~~• ,Indicate scale or distances Give horizontal and vertical reference points. Indicate slope. m r _~ a / ~" O OS f~' _ ~ ~ f`tOM~ ~~ ~ Q r fEt~ 3 ` ~ ~'~ /~ ~ l~oM~ h m _ __-_______- ~ ~ ,~Eprrc, ~. ~ e ~ , ~ ~.. ~ ~ ~.~ q ~ 3 ~ n ~~~! Qo _ ~ ~ ~ ~ e _ .. _ _ ~ a._ e p po Zy , S/o~~"S / / e = E/EI/~Tio.~t~ ReD ~~ ~ P3 , / e . ~ _. ~ .p Et~~itra~ ~T ~~E 9, = /QO ~• Biv= I: $uRv~~QS o~E~ W W ... ~30,PE S%TFS f1,PE 'E f~PoM i~uDicyT~/~ >~~S e r~Es _~ ~ ~.._ e State and County ~•_ ~ ~~ Permit A lication r Pp for Private Domestic Sewage Systems *DENOTES STATE APPROVAL REQUIRED Date Approval Received .from State if Required State Plan I.D. # State Permit # ` ` 'S ~S~ County Permit # County ~f"• ~a / x A. OWNER OF PROPERTY Mailing Address: /hid ~Rr•~,A[.L~ c,y, g. ~~stR,h~-k B. LOCATION: ~_'/4 W y4, Section o~, T~ N, R~ @ (or) W Lot#~.( /~~ City Subdivision Name, nearest road, lake or landmark Blk# /y~X !7 Village _ /Y)ciq~pwS Township U~SOn/ C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family _~ Duplex No. of Bedrooms ..~ No. of Persons_~ D• SEPTIC TANK CAPACITY_/OdD Total gallons No. of tanks D!/e HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete_~_ Poured-in-Place Steel Fiberglass Other (specify) New Installation x Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E, EFFLUENT DISPOSAL SYSTEM: Percolation Rate ~ Total Absorb Area sq. ft. New. Z~ Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top)_No. of Trenches i ., Seepage Bed: X Length~Width vZ~ Depth~~Tile depth (top)~_No. of Linec ~3 Seepage Pit: Inside diam ter Liquid Depth No. of Seepage Pits Percent slope of land- ® ~ Distance from critical slope. ~a Jr ~ WATER SUPPLY: Private ~ Joint ^ Community ^ Municipal ^ Owners name as listed on EH 115 if other than present owner: ~ ~ ~ ~ S T/~~ ~ >A~O irS I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified oil Tester, NAME V i2~~- C.S.T. # ~v`y- 5~5~5~ and other information obtained from G ~ S (owner/builder),.,,, ~ ~~`~ Plumber's Signatur MP/MPRSW# ~~~Phone # `~/~ (o~~f-~~7~ Plumber's Address /~ cr/irc. c S PLAN VIEW: Provide sketch below of system (include direction of slope and alt distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. r ..~ - .Z REPORT OP TNSPECTIJN INUIVI~UAL SEGlAGE SYSTEM • .. -yl _ ~ San,i.xany Penm.~~ ` S#a~e S P p~~.c / S ~ ~ ~ _ NAME '10 l'ownah.~p ~~ ~~-~-~J S~. Cno~.z Cvun~y .,; . ~ loca~.i,ax /~Cv . JGcJ Sec~~,on -- . SEPTI+". TANK -• ~' S.lze a.C.~one. Numb en o Com antmen#b ~ P o . fl.ia~anee Priam: tve.~.~ 06 ~#. i2$ on gnea~en a~ape,~~...1s--.~~ Bu.i,.ld.~ng- ~~~. H~.ghwa~ten - ~~. 'DISPOSAL . SYSTEM . ,. ~_ fl.tb~anee Pnom: Gip.$.! ~•~--~~. 12$ on gnea~en a.~ope~~~~~. . Bu.i.ld~.ng ~ O ~~. W e~anda ~._,_ _ Px. '~ H.lghwa~en bx. _ flEt'D'UIMENSIONSc : ~ _. l ~ G1.ic~Zh o~ #nench ~2 . _~.t. t?ep~h o~ Hock beQow z.i..~e ~ ~ .i.n. each .2~.r~e-~;~-~---~~t. Depth os noefi oven ~.~.~e ~.n. ~, 0 _lengxh a~ - Numben, o~ ..e.i.nea g flepzh o~ ~~..2e below gnad .i.n. ~ .. ~~ . ~U ~ o#a.e..~engxh o ~ .~..ine~ ~~.-. S.~ope a ~- ~neneh .Ln pen 100 fix. ~ _ _ I~ ~ a..a~ance be~ureen .e.~,nea~~. Vep~h ~a bednaek - -- ~~. .._ ',~ ~'G ~Taxa.t. abbonb#:i,on area ~ ~~2. Uep~h ~o gnoundwa~ex ~- I~ _ ;..... l 2 ~_. - ~ Req.u.ined area 7 ;~ 7ype o~ Caven: ~Papen o Stir. . ___., . _ __ I, P~T...DI~MENSIONS: ~, I ~ Numb2~c_ o~ ~~-~ _ _ na .~ anound p.i~b .yes no _.. fi- _ . Ou~a.lde d.i.ame~ten y ~ ~ Depth be.~ow ~,n.Ze~ ~~t. P t . ~_ ~' f ._.. _., _. <... e_ ~ ~ m elf r ~' .~ ~ P -8 Y ~'~^.' TT Ti INS ECTED M...w _ _~: -~ i 7 ..~.._._ .DATE r,' .. ...~...._.._...~....4... _.. ~._ _...__.~_. M1_ . .. ~ _ ., .