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020-1292-70-000
~ cn o ~ c d f i 3 ~ ~ A ~ I m 3 3 r: i n c.. ~~ O ~ ~ ~ ~ N y O fD .:a ~ °' ~- tY ~ 3 ~ ~ CIY ~ ~. ~ CO rn ~ ~ ~ CD 7 °. ro ~ ~ ~ p W ~ = b3 I ~O ~~ 3 3 w o m I °~ m fl °' ~ c' ~ ai I~~~ o o ~ ~ l . N o~ ~ V I 3 3 ~° w i `° ~ ~ y N = i I ~ to ~ ~ d ~ C a - m ~ ~ ' Z D m c~ w ~' a 3 co t. D ~' -~ c ~ ~ m ~ -~ c ~ N ~ •"~ ~ '-« ~ N N ~ ~ •~ O~ N O d ~ -t ~ A ~ W a ~ -G N vi O o z A O ~ -p Occ OCC G G CO ~ ~ A z O W '9 O c~i O C ~ fA fA (/1 ~ ~ n C C N °: O ~ N gy ~ O <D v O ~ ~ ~ f ~ ~ ( p ~ N ~ ~ ~ °' ? ' °' m _ ' ° !; I N m Q O ~ ~ ~ d I N Q _L M y I z ~ ~ Z l77 Z O =~ m O D ~ °,' o I m O ~ ~ ~ ~ ~ ~ ~ N C ~ ~ C CD ~ ~ ~ I W m a I w ~ a ~ ~ I n 3 Z ~ ~ Z ~ ~ ~ N O ~ N M ~ ~ ~- N ~ ~ I 0 ~ ~ ao v I i a ~ ~ o =~ N Z fD ~ W I Q ~. r. ~ a ~ I N v C ~ ~ O Q. Z O a y I N I LU n i ~ 3 fD N N I 3 I ~ ~ O O Q i p ti p ~ C7 N O ' ' ~ b o ~ ~ , 3 o i ~ ~ 3 ~ m ~ ; w ~ ~ 3 __ '•~ O A N D O (~ ' C V OD S ' ! ~' N 'O (D , to ~p cD W '. o N ~; ~ I '„ ? A A ~ O O '! 0 O N N W d ~ _ m •°•' -n a m i ~ ~ O OOD O ~ i a I o e rn rn a N ' ' o i ~ 3 .. ~ ' d 0 0 0 ~ f~/1 N N A ' I 0D c O I~ ~ v vv ~, Q d a ~- ~ ~ 2 3 °' `~ 7 ~ .. Q D ~ ~ ~ I o v ~ 3 o ~ N ~ N ~ ~ ~ 3 N a a m ~ ~ ' ~ ~ Z ~ ~ c ~ ~ ~ a A Z ~ W ~ a 0 3 o ^' N ~ fD A p~ N m `z T C 7 a .. m N ~ z ~ ~ m d A~ ~. A~ ~'S tC FBI O ~7 fi A C Q` 1 4 N N O O V A M MM N VY ~ ~ \ v 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 sewndary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Scheel, Brian Hudson, Town of SST BM Elev: Insp. BM Elev: BM Description: /4D ~'M 1 GST TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic E~ ~~ l-Je~e..~5 3 ~~ Zoo ~ zov~ ~ l~ ~ t olding TANK SETBACK INFORMATION . en o it na e ~b ~ ti ~ ~ F~ ~ l o~ ~ 5 I / zy ~ zS ~ _... era ion c~ o mg PUMP/SIPHON INFORMATION anu ac urer eman GPM o e er nc ion oss ys em rce aln n la. su-t. Htsaurcr ~ wn ~ r ~ ~ can ELEVATION DATA county: St. Croix Sanitary Permit No: 488166 0 State Plan ID No: Parcel Tax No: 020-1292-70-000 SectionlTown/Range/Map No: 27.29.19.1444 STATION BS HI FS ELEV. Benchmark ~ ~ ~w , $ w /~~ Alt. BM t,.Jg,lk, o~~ Qcc ! - 3.545 /A~ , ZZ Bldg. Sewer ~~ ~'ir '~ t/ t n et 6~--i ~ t t ut et (o.z ~l7~ F;~~ (~•LZ `17,58 ~~~. O~ 6,~! ~i7~ 3 7 ea er an. (~,'~(p 91p , ~r is . ipe o. ysem ~,b °I~~,~ ma ra e 5 ~ b ~~, ~ g over /boa- oa+. ~ ~ ,, / /I ,v !'~ DIMENSIONS ~ ~ p 7~ C, C ~ -~j-r~ `i ~` '~. ~- ~ INFORMATION CHAMBER OR ~ ~~ ~ ~a~-`, / / ~ UNIT ura r r~rov ~ wry v r v~ ern ~ i ~~ r l~ t--/ . z~ ~a~SL, ~ / ~ / L ~ ` Di ` acin ~ S ~ ~- z ~ Dia Length ength a g _ p e ,~,d! JVILVVVCR XYreSSUreAY5Lem5Vnry n~clnVWwvi'+PVIa4GVyaLCln~......~ Bed/Trench Center ~ ~ Bedffrench Edges \ Topsoil ~ Yes ', No Yes ~~ No GOMMtN 15: (Include code discrepencies, persons present, etc.] fnspecuon ~~: ~ ~ ~~~~yC~~~.,~~ nom. _ Location: 763 Hill Farm Road Hludson,WyI~..54016/(SE 1 4 NE 1/4 27 T29N R19W) Humbird Hills 1st Addition Lo/t-18 Parc~Lel~No: 27.29.19.1444 1.) Alt BM Description = ~ `~ b "" ~,+ ~ ~ E Z Ga ~ ~~ 6 ,,~ tom, ~ ~.,.~„ V ct, ,~1~ 2.) Bldg sewer length = L ,~ l we . ~e}-~ ,n. -amount of cover = ~ 'Pl v vw~ a~--p A.~ ~ 0 G~ _ __- - - - Plan revision Required? ~ ~ Yes No r_ Use other side for additional information. ~ 3a ~`C' ~. __-~-Sate-~ - SBD-6710 (8.3197) 'J p b ~ ESL cvJ., 8 ~ b ~ ~' , . S~' naT~, Safety and Buildings Division Coanty w ~ ' ' 201 W. Washington Av ,~ ~0~~ ,n Madison, WI 53707 - 7162 (608) 2 Sanitary Perm u ¢yr ( be filled in by CoJ K De astment of Commerce ~= ` ~ U Sanitary Permit A licatio state P '.°. Numb« pp In accord with Comm 83.21, Wis. Adm. Code, personal information ou prgvAt~ ®' % u ~'" may be used for secondary purposes Privacy Law, s 15.04(1 # m) ~IVV~I NH T~ Project ddress (if 'event tlun mailing address) I. Application Information -P{ease Print All information ST. CI~;;x CCi~ ". Y ~G~~~ Pro rty Owner's Name Parcel # L ot # Black A ~li / Q /U Property wner's Mailing Address ~ Property Location aw D~ ~ ~ City Sta Zi C d Ph A• ,=-Vr~ ~• S~tion ~~ , p o e one Number ;~B/. ~~~[,Q tP ~ U circle T ~ N R~E ~ II. Type of Building (check all that apply) ; o ®I or 2 Family Dwelling -Number of Bedrooms ~ /j Subdivision Name CSM Number ^ PublidCommercial -Describe Use !/yt ~ ~uf~~~ ~ ^ State Owned -Describe Use ~- ,~ ,L ^City_^Village If~ownship of III. T ype of Permit: (Check only one box on line A. Complete e B if applicable) A' ^ New System eplacement System ^ TreatmenUliolding Tank Replacement Only ^ Other Modification to Existing System • B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and~yRat issued Before Expiration Plumber Owner ~ ~ ~ ~ ~j ~ - ~ 7// / 9 3 IV. T of POWTS S stem: Check all that a I n -Pressurized In-Ground ^ Mound >_ 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Conswcted Wetland ^ Pressurized In-Grou ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirwltuing thetic Media Filter hing Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (ex lain) V. Dis al/I'reatment Ares Information: Design Flow (gpd) ~~U Design Soil Application Rate(gpdsF) °~ Dispersal Area Required (sf) ~~ Dispersal Area Proposed (sf) ~~~.~U System Elevation N"~S.v~ ~4y•s~ti gY VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic Gallons Gallons of Units Concrete Constmcted Glass New Existing T Septic or Folding Tank D Aerobic TteanraM Unit ~ ~ Dosing Chamber VII. Responsibility Statement- I, the Wade ed, assume reapoasibllity for iastal4tion of the POWTS shown on the athched plans. Plumber's Name tint) PI m Si re MP/MPRS Number Business Phone Number ~' ~~~ 9d ~!~ 3d'6 - 9v~ Plumber's Address (Street, City, State, Zip C e) ~/ D .~J~ ~ W.~ ll~ VIII oen / De artme t Use Oel Approved ^ Disapproved Sanitary Permit Fee includes Groundwa Surcharge Fce) ~ U vii Da Iss { /p suing Ag Si (No ps) , ~ ^ O Gi R f ~OO ~~~fff"' Y O ~ -'/ 0 G~ ~~ wner eason ven or Denial IX. Conditions of Approval/Reasons for Disapproval ~ --~-- -~ SYSTEM OWNER: _ /, ~ v ~ O ' 1 Septic tank, effluent filter and (,Q'7) dispersal cell must all be serviced maintains ~~ Q ! as per management plan provided ~~ / ~ A~~a ~Q t be maintained ~ ~ 2. All setback requirements mus as per applicable code/ordinances. G~~~~~ tl/12 t!~ /W~-~ ;~x..~. wt"tca compreh piam tto fy oMy) far the system on aped aot than 8 R x I lt7itc in siz!` ~ ~ ~ - t ~~~ SBD-6398 (R. 01/03) ~~~i„t~/t'L. ~~dYl-~G G uo ~1.~ /~A.Ir1e ~ria n ~c~i ee L aGCt. 10l ~ 7~.~ ~`~l ~a~ ~ ~~ ~~ /'- /off /dap R3 ~ "T~ h+ c ~ r ~~~~, q chR~,~~ t-T~,: ~~, w",~~, ~ ~ C~,„~ ~Q ~c r ~~~~~ ~ Tm l~umees~er G~~er~se ~'qa~ D`~ Ja'` L ~~ 'rl/ p~ f ; t y~,~ ~fv c ~ ~R R k -Q~11 1Ks~~ 11 m~v c .Aa~l;w ~(~uq~,l Sip r ~~~ `~ ~ r r; ~P att. -~xi1~Ny ~p~f ~ ~~DUSp~ ~/~ ~.~ --, 1 pPp IZUUYv~ ~ T1'~l ~~~ ~w ~ -~ ---~ a-F ~7 ~-./~1e~nan ~c~iee~ COGQ.~%OA 7G3 ~'~/hzrm i~ c.~i~l, ~ Chn~ ~-Tn.r~: c~, w~ i~ C~,h3... ~~ ~`~l~v~a~rd ~ Ba .. ~io~ ~1Q~, Tm I~uIVlees~e~ G~~e~se'*~dgo~l 1,,~ ~ •. "%~ rti ~ti~h m~n]~ - ~ ~~ v~lv ~5 S~p~}i ~ ~~ll~p) ~~ ~~ ~~ ~~ /yt~, h~ 1e /gyp ' Q ~~ ~ ~w~s~ S~G{c°~ = 1~, 26~ ~w~ii -____ s~ ~ ~, R> s 'Wismrrsin Depauirttent of Corrxrrerce Division of Safety area ergs RECEr~ ` ~~UATI0N~P0 T ~ ~ of rn aoooroa ,nnm - tsp. . „~. 1 i l t i6 t l 8112 Ait l ri h -- 5 'T • G R'D / e e s e p an on paper no ess res oanp >an x ac inc~de. but not tirnitad ~: vertical and harinorNai n#en~ce peroentsbpa.sca~or~.rrortl,ennow.aaatocationana ~ NT y tmaa. 1.D odd-/q7g'~• U-Om(J Please print all information. ~' Da<e P'eworatl kN~eation you a+oride Keay bs used for seoond~r F++~Poses (Pri+racY ~. s. tso4 it) tm}j~ ~ b ~c PraperlyOwner ~ ~+~~~ ~ FropertyLot: aGon - C (~1 Quin J H ~G/d..~ S S 7 -7 Grnrt. t.at / W 1/4 N E;1 S C:. ( T 2~ Pt R I q E (Or Props N1a~gAdtftess ~ # Block # Saba. Name or CSNti! ~ , City .State Zip Code Phone Nunber ^ ~ ^ ^ Town Nearest Road t-JudSoh W! 5~v/~ (7/S,3 ~lv-~yy ~u sON ~' 1 ~an.M ~-P. Q New Cau~stnrctiart t>se:~ Residens~ / hhanber of bedrooms - code derived desi~ flow rate D ~O ~ Replaoamerrt ^ Pub6c ar commero3al - Descxr~e: _ Parerrt material Hood Plain elevation ft app~blg cene~ and tdarmns: Any _.. Spot .,.,-..Tested suitable tot . ~ tzOnVentional Ingt'o~ind system (P.O.W.T.S.) GPD O 99s~ ~ ~ ®pit Grorxrd surfaos elev. R ~ to limiting factor ~ 4 3 ~ rn. Sol 1 If cation Rafe ftorimn Depth Oornirrant Redox Desaiptiorr Tex4ra Sftudure Cot>sisterroe Borrrrdary Roots OP OVIF in. ttArrr>SeN tlu. Sz cont. Cobr ~ S"z. Sh. 'Eilft1 'Eilrl2 ~ O -'7 Y~. ~/z - fr 3 20-3 to R4/ S ~ - v l•b 2 # ®~ Ground surface elev. R7.3 8 ft. Dept[t ~D fgrd6g factor 9 io ~ .. ~ Rate t~loriaon Depth Dotter R,aclou Desaiption Texture Sbrx~ae Cor+oe 8aturdary Root; GP OJI~ in. tau. Sz. Cora Cobr tir. Sz Sh. 'EfFft1 'Eiriit2 -r to ~i~ 2/z - r w . ~ 2 /- loYrt. /z - 1 S a w f . Z . 3 • #t = BoD > 30 <2~o mgit. and TSS >30 < 1 5o mgA. • EftM>esrt ift = 8oD _< ~ mgA. and TSS _< 3o mall. . car weme (Please ~ ~ csT rilutrtter J a~N ~'f ~- s_ F169935~ Address Date Evaluation Conducted Telephone Number ZBtZ Ic.>'~'_'' ~d G SPrc:riJ4 ~~r~~EY. W ( 8''l2-p5-- _7~5.7~2.•3`h• ~~'":~%y~~: ~ A~SOCiateS Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 ~°~ ~lar~~ ~vpeny owner S' hG i 1 d s Parcel to # ~ z ~, 3 0 ®Pit Ground sine ele,~.q 3 , R o~ ~ >a~~ in. soa rleee # ~ ~ ~ Ffcrizon Oeplh Domtisar~ i2edox Texture SUuctixe Consistence Boundary Roots GP DV~ ~. MurueB Qu. Sz Cont. Color Gr. Sz Sh. "t~Jf#i "EN#2 ! 0~ -oY~.z/2 ~ - „~ ~ 2 r h~i-fi^ A s 3-F g2• lo~rt~ -- S - ~ ~ # ^ ~s [] pd Grouse surFace elev. ft. ~ b in. ~ Horimon Depth Dorranartt Redooc Description Textrre Strucbre Coenoe Barxlary ~ GPNirz in. MunseN emu. Sz Cont. Caor Gr. Sz. ~-. - 'EtTIR'1 1 ~ Graxrd staiaoe elev. ft Depth b factor in. a~# Soil tiwtiar Rate Wotimn Depth Dome~arrt ftedox Description. Texture Structure Cor~benoe Boundary Roots GPDJlF h Museti t1u. Sz Gortt Cdor Gr. Sz Sh. `f3f#1 ^ ~ ~ Graxrd sur~oe ele~+. ~. oeptn m rsnffing t i,,. ~~ ° ~ sal Rage g ttoriatxr oeptlr (n, Dorr~rrt Redooc Desc~tion. t1u. Sz. Cost Color Texhie Strtwiure Gr. Sz Sh. f:aoe Botsxlary Roots GP '~1 OIf 'EtFaY2 • ttR~~ !Ct ~ t3~D ~ 3tI < ?201rralL and TSS >30 <_ 150 mglt_ ` Foment #2 = Bpps < 30 mgJi-and TSS < 30 mg~t- ~- 5 tf~~~5 ~, t, . ~- , ~hs-r ~RopE~.TY coar~2 5 0' 'S5~ Q' fa ~ \ -- o Ulbricht & Associates Private Sewage Consultants 2812 1 Qth Ave. Spring \~ailey, Wi 54767 o W G L.~.. L 55' '`t'S' S3 ._ Nv 2T~t ~pRvp~U1.-cY Go2n1~ ~a (3i = 99•So q3~~5 S2 ~ ~-~.3g F33~ q3•~o~ ~yMt"~' -rdp of n~tgat~o~~' co~e2„s IOO.oo ~ M2. = fa°T'roM a F LOt~J~ST 5 ~ DlN ~ ` / 0O .2.0 ~ ~rs-rE-M ; a 5.9 0 2g~ ~ ~9 •raD R-~. 38 //% ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~ C ~, Q,>~ ~ A V i ~ ~ G~ ~~ L. Mailing Address l ~~ ~ ~ ~ F (~R~ RO~t (~ Property Address ~~ ~ ~ ~ ~ ~ ~~ (ZM ~~ ~},Q (Verification required from Planning & Zoning Department for new construction.) City/State ~u~ S~,N,~ (,~ L Parcel Identification Number ~~O - f~ ~~ - ~O -2SOa LEGAL DESCRIPTION • ~yy~ Property Location „~" '/a , ~'/a ,Sec. ~, T ~N R~~W, Town of ~,[ S Subdivision ~y~{m ,~j ~ ~ ~ ~/ ~ ~ ~S ,Lot # ,~. Certified Survey Map # Volume ,Page # Warranty Deed # ~~j'/9~p;/~ ,Volume /(~~_, Page # ~d Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping {if necessary), the septic tank is less than 113 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 Planning & Zoning Department within 30 days of the three yeaz expiration date. Uwe certify that all statements on this form aze true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Nu er of bedrooms SIGNATURE OF APPLICANT(S) D~ / 2~ o'~ DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) BJLL M SCHEELL 763 HILL FARM RD. HUDSON, WI 54016 FILE INFORMATII Owner Permit // POWTS OWNER'S MANUAL & MANAGEMENT PLAN DESIGN PARAMETERS Number of Bedrooms Number of Public Facility Units Estimated flow (average) Design flow (peak-, (Estimated x 1.5) Soil Application Rate Standard Influent/Effluent Quality Fats, Oil & Grease (FOG) Biochemical Oxygen Demand (BODS) Total Suspended Solids (TSS) Pretreated Effluent Quality Biochemical Oxygen Demand (BODE) Total Suspended Solids (TSS) Fecal Coliform (geometric mean) Maximum Effluent Particle Size Other: ^ NA L~ NA ~~V " / gal/day/ft Monthly average` _<30 mg/L x220 mg/L ^ NA 5150 mg/L Monthly average 530 mglL 530 m9/L NA ~ 1 -° 100 Ye in dia. ^ NA ^. NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Inspect condition of tanklsl Pump out contents of tankls) Inspect dispersal cellls) Clean effluent filter Inspect pump, pump controls & alarm Flush laterals and pressure test Other: I At least once ev a t~ o l~J e e 1 Page (. of ~. h bQ. ~-L~u ^ Peat Filter ^ Wetland ^ Other: ^ NA ^ NA ^ NA ^ NA NA NA NA NA NA ^ NA ^ In-Ground Ipressurized- ^ Mound ^ Other: NA NA NA ery. ~C ~ year(s) (Maximum 3 years) ^ NA When combined sludge and scum equals one-third IY31 of tank volume ^ NA At least once every: a ~ yea (sllsl (Maximum 3 years) ^ NA At least once every: ~, ~ ^ month(s) ~yearls) ^ NA At least once every: ^ monthls) ^ year(s) ~ NA i4t least once every: ^monthls) ^ year(s- NA At least once every: ^monthls) ^ vearlsl ^ NA NA MAINTENANCE 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 tank(s) 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 cellls) 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 IY3) or more of the tank volume, the entire contents of the tank shalt be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services--' uig but not limited to the serve err f effluent filters, mechanical or pressurized components, pretreatment units, any' servicing at intervals of 512 months, shall be per o ed by a certified POWTS Maintainer. A service report s a e prove a to t e oca regu story authority within 10 days of completion of any service event. SYSTEM SPECIFICATIONS Septic Tank Capacity Septic Tank Manufacturer Effluent Filter Manufacturer Effluent Filter Model Pump Tank Capacity Pump Tank Manufacturer Pump Manufacturer Pump Model Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection Dispersal Cetlls) Ib.ln-Ground (gravity) ^ At-Grade ^ Drip-Line Other: Other: Service Frequency ^ month(s- Page ~ of v START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cellls-. If high concentrations are detected have the contents of the tank(s) 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 cellls) in one large dose, overloading the cellls) and may result in the backup or surface discharge of effluent. `To 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. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope 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. • 'YMi •iMtiiff~r 1!f YII 1NMMi MWiI bttr i1HNl1 Mr rWMhViM f1flN Ii~fMiiMFI~ MId~11MMMM A~1 MV M ~i-11!Flyii r1MPVIMINf1 ppM-M1M1~~ 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 techy~ology a holding tank may be installed as a last resort to replace the failed POWTS. °f~ ~he~ site ~s not been e~ated to iden~tif`y a suitable rme to Ioca a s as a last reso place the Upon fai~of 1f~e POWTS area. ~f no repl~ent area is~vaftd6~e a holding ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. .Reconstructions of such systems must comply with the rules in effect at that time. +•~~+~ < <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 PER50N FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. . ADDITIONAL COMMENTS ~~" POWTS INSTALLER Name ~ i y~„ 0 L 1n, ~ - )'\. Phone ~ l ~ " ~ ~o ' 4 () ~ U SEPTAGE SERVICING OPERATOR (PUMPER) Name ~p,t,>ZP ~ s Phone ~, S ' ~ ~ ~. ~ . POWTS MAINTAINER ~ ~' Name „~;,,. Phone ~ ~'t LOCAL REGULATORY AUTHORITY `' Name S - ~.leb1 ~ b?v ~ w ` , Phone ~ ~ ~' ~ ~ ~ ~ . This document was drafted in compliance with chapter Comm 83.22{21(b1(1lldl&Ifl and 83.5411), (21 & 131, Wisconsin Administrative Code. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certi11fy that I have inspected the septic tank presently serving the ~~a_n _~hee ~ residence located at : ~1/,, ~%, Sec . ~, T~N, R~W, Town of ~u.~pYl St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good cond'tion, and it appears to be functioning properly. Last time serviced ) U ~~ Did flow back occur from absorption system? Yes No~ (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: /DaD Construction: Prefab Concrete / Steel _ Manufacturer (if known) : Pi~sPr Age of Tank (if known): / ~rs ~-- ~ ~ ~^ ~~~^~~-r J ~1~ (Sig ture) (Name) Please Print (Title) (License Number) ~ ~ I d (e (Date) 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) . J 1 Si nature Name _ .J 1 N1 ~U Jy) e~ i TPA g MP/MPRS ~~(~,{9p~/ZC Other nc~r:uMt~rvT r~<, WARRANTt OEEO :• ~ ~ ,.,- ~',,~ k, ,~, -.... ' s'r:•,T.. SAK OF VViSCt~N~I~ r•O$1t ~:-1982 ~193U6 _ VQL,~S' ~.,:nQ9 REGfS(~~. t ;~ ST. CRVIX CO., Wi Sam E. Miller, a single person, Reed for Record Jt1L 2 1 1994 8:30 A. runveyr an~a Uarrtnt w .Brian D. ScY:~el and Jill M. Scheel, ~ 4_'~ {~~~ M husband and wife, ~ Rc~`~'er Of Deeds ) uc fullu~~~ing descrtl:,ed real estate in St. CroiX L,,,;t.t~ ~tatc ..f L~'isccnsin: . Tax I`arcel No:._ .. -. -_ _.... Lot 18, Hurnbird Hills First Addition, Town of Hudson, St. Croix County, Wisconsin. BRIAN D. SCHEEL JILL M. SCHEEL 763 HILL FARM RD. HUDSON, WI 54016 T}~is ~iiysyynot "`N"l (is cot) F:xcept~n to warranties homestead pmpert}~. 3/0~•-~0 Easements, restrictions and rights-of-way of record, if any. u 14tted chi: ~ S day ~~f (sE:At.} _. - _ (SEAL/ AUTHENTICATION Signature(s) authenticated this .-.-._.-day of .........................., 19.-. TITLE: MEMBER STATE BAR OF WISCONSIN (If not- -------- -- --- - - --- ----- - - -- - - - suthorized by § 706.06, Wis. Stats.) THiS INSTRUMENT WAS DRAFTED BY Kristina Ogland Attorney at Law July ~,, 94 Sam E. Miller tsf..~t., ACgNOWLEDGMENT STATE OF w'ISCONSIN ~3. St.Croix county. ~ '~t71 Persot;ally came before me this __-. _ -_ -.day o; ------July_._ .--. -..-. 19.94.. the above named Sam .E. Miller, a single persons -, ..,. _ r ............... to me 6nown to be tha per<on - { ~: ' jwl;~ exety`ted the foregoing instrument and acknrdw~ie<}k tt~-sat~t ~. ~ z J ~ : ~,7 . ~ ~ •• C, . ~ @ .: `~ ~ Notary Publi S~L~~K .'.- •'• .._(:ouptQ ~L~ M.• Commis on is nermar.ent. t I t'' not, atAt~ 'e?H~~Ne~liptj cfrnO 3vn d c ~ ~ c ~ ~ ~ ~ I ~ ~ ~ n A •e ~ ~ N. • I 3 r: ~ .. ~ ~ ~ 'S N O V N ~ r~~j • ~' pl ~ 3 C .~i _ CO d IV ~ FBI C ~ tD ~ cD ~ O ~ ~~ O ~ CD ' ' O rC 1 c D ~ A O 7 n I V O ~ ~ O ~ ~ p R ~ O V 3 ~ W ° ~ ai vNi = I = ! ~* ~, o o ~ I I ~ m U) co ~ D N ~' c m co a d ~ W I c ~ I ~ n O c "' c °' N ~ I ~ co m m ~ ~ ~ N o c I ~ ~ °: ~ ° o 0 0 0 ~ ~ N gg gg N~ N~ 2 w om N s~ ~ c ~ ._- I O ~ QQ ~ ~ ovv ~ A N ~' ~ O 7 tD ! D "* ~ •D a ~ ~ ' _ 1 !r C O1 3 m ~, N I a ~ ~ •• I ~ ~ Z ~ .. ! D N Z W Z ! a 0 ~ O D n ~ o o ~ v ~ ~ I N • ~ ~pp ( (D N ~ N ~ C ~ O C ( p ~ ' I ~,, ~ a ' n m ? I Z O c co -i N A Z ~ !A C I ..1 T M a A Z o v i ~ .. fA ~ N W ~ m N V O ~ ~ B '' ~ Z a c z ~ I i 3 I ~ m y _ A I W I a I ' ~ I o m m c I o a I I ~ m I I Q ~~ ~• v v t v p A I o tv I m aro :o c» O ~ `'^ v o ~ `'' I - ~~` ~ STC - 104 y'~ AS BUILT SANITARY SYSTEM REPO. ~~~~ O s, /~ ,; ~ OWNER SfI/~i /(/I / L ~E~ " Spy' %~y ADDRESS /.PBX # Z 9Z. ~~~ ~ Z~~'G~p~~/~ ~ ~~CF N y D 5 o N ty~ SS~~ ~,G ~ ~ I ~ ~~ SUBDIVISION / CSM# Hr~M Q 1 ~l~ ~ ~ ~~- S LOT # ~ SECTION~T "2-~ N-R %' W Town of H J DSO ST. CROIX COUNTY, WISCONSIN PLAN VIER SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 'g. /~t~ . TO ~ O ~ ~~F ~C6 }~S7 ~~• - /DO pd -~ji ~~m-f~f a. ~. r~ - /o S« /~ ;" ham- 4D--~ xt8. J,yQ~s ~ ~Z,Zq, / _ ^ _ _ - ~ fig' ~ ~ ~, SSA 8~- ---- -------_u't1, n~ ~ ~ z ~E ~ '~ fi `~ AL7FR IJ k1 F °~o,/", .~ ~E A ~/~ ,~,~'~aT~ET G ~y_ y,. ~ ~ / i ~S ~ ~~a~e y~ - ~~ / 7 ~ 3 Ki L L ~f~,e/l'1 R~ ~/< < ~ Lo]' ~ /S/ ~~~ T \ ~~ ~ ~~ ~ ~~ ~\ ~~ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. s BENCHMARK: TP o~ Fa-n~a, ~a.st /~~,1'~ To ~u~a~ ~/a-¢ ~l = `f- G = /Of7.00 ALTERNATE BM: / o ~J ~ ~i ~~ ors l~.lk da~ ~aSm ,~+c ~ j ~er~ ( ~ ~, _ (o~ ~S SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: W~;S~ Liquid Capacity: /0 © O Setback from: Well S S House Z z--- Other Pump: Manufacturer ~~ Float seperation Alarm Location---- Model#~_ Size `~`~~ Gallons/cycle: ,._._ SOIL ABSORPTION SYSTEM Width: /~ ~ Length ~/~ ~ Number of trenches Distance & Direction to nearest prop. line: 70 ~ To -F9S/ ~ ~~ h~ Setback from: well: ~? House 'f /~ Other ELEVATIONS i , Building Sewer ST Inlet ; $. ~~ ST outlet 9. / PC inlet -- PC bottom -- Pump Off ~-- Header/Manifold ~• ~z Existing Grade ~ G DATE OF INSTALLATION: Bottom of system io. ~ Final grade ~-6~ PLUMBER ON JOB: ~J'~ ~ 6 ~ ~;,e.~~!_ LICENSE NUMBER:..~~i//P_ ~~,,3 ~ r INSPECTOR• 3/93:jt .. . L~~~s~n~F1'art~~b~~uSt~y7.29.19W, ,~~~tE SEWAGE SYS~~I~A LOT 18 LaborandHuman Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Permit Holder's Name: ^ City ^ Village [~ Town of: U N CST BM Elev.: Insp. BM Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Do ~ --~ Aeration Holdin TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Airlntake ROAD Septic ~' ~ / ~ ~/~ NA Dosing NA Aeration -- NA Holding__ PUMP/ SIPHON INFORMATION M'ariu~ecfuTer~ Demand Model Number ~`'~ _ GPM TDH Lift Friction edem~_ TDH F Force Length Did. Dist. To Well SOIL ABSORPTION SYSTEM ELEVATION DATA rmit an UGV~'1LyL-/V~V A9300363 {~~~ STATION BS HI FS ELEV. ark Benc hm 3 ~~ ~ ~ '' // Bldg. Sewer Stl~ inlet ~(~/' fig' St /yl'E Outlet 9 ~' ~ ~ Dt Inlet Dt Bottom yE Header-> , ~ ~ ' Dist. Pipe s ~ 3,99 ' Bot. System a-~S~ ~,~~ Final Grade (~ 3g' 7,~~ ' ~ ~_ s ~ ~ ~'' at`~ J, ~ ~ ~ , BED /TRENCH Width / Length i No. Of Trenches PITS --- No. Of Pits Inside Dia. Liquid Depth DIMEN 1 N ~ DIMENSI N SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHI Manufacturer: SETBACK ^ CHAMBER INFORMATION TypeO ho.-~ ~-^ ~ . ~ / e er. System: ~-L ~~ ~ OR UNI __~ DISTRIBUTION SYSTEM Header /Manifold i ~~ Distribution Pipe(s) ,~ x Hole Size x Hol pacing Vent To Air Int ke Length ~ Dia- Length Dia. ~ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sy s Only Depth Over ~, ~ Depth Over xx Depth Of _ ,___ Seeded /Sodded ed Bed/Tcc~+~Center - ~ Bed/TrenrlrEdges ~~~ - ~S Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) ~C~~ ~~Z`~~r~ ~'~~~~~~//7f LOCATION: UDSON.27.~.19W,SE,NE,FARM ILL RD , LOT 18 f' , Plan revision required? ^ Yes to ~ / Use other side for additional information. tU ~ ~ 9 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ~; SANITARY PERMIT NUMBER: ~DILHR SANITARY PERMIT APPLICATION ~^„'~~ In accord with ILHR 83.05. Wis. AUm. CoUe In accord with ILHR 83.05, Wis. Adm. Code ~~ ~awwu~O~aw~ COUNTYC ' t/ ~.1. STATE SA ITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ' 1 ~9 ~~ d fi x 11 inches in size: 8 ^ Check if revision to previous application -See reVerSe Slde for InStfUCtlOtiS fOf COmpleting thlS appllCatlOn. STATE PLAN LD. NUMBER 1. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNE PROPERTY LOCATION may/"' $ ~ %a ~~ '/a, S L T Z°r, N, R / E (o PROPERTY WNER'S MAILING ADDRESS LOT # ~ BLOCK # Z.r / , CITY, E ZIP CODE PHONE NUMBER SUBDIVISION NAM OR CSM NUMBER ~ ~ ~ r ° II. TYPE OF BUILDING: Check one CITY ~ Q ~ EST ROAD / ~ ~+ ( ) ^ State Owned p VILLAGE = a 1~, ^ Public 1 or2 Fam. Dwelling-~of bedrooms RCELTAXN BERG 111. BUILDING USE: (If building type is public, check all that apply) ®Z ~ .. ('~ Q ~ ~ 1 ^ ApUCondo I 2 ^ Assembly Hall 6 ^ Medical Facility/Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ RestauranUBar/Dining 4 ^ Church/School 8 ^ Mobile Home Park 12 ^ Service Station/Car Wash 5 ^ Hotel/Motel 9 ^ Office/Factory ~ 13 ^ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an System System Tank Only Existing System Existing System B) ^ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) ressurized Distribution Pressurized Distribution Experimental Other Non-PP ll 11 L~ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^ Seepage Trench 22 ^ In-Ground 42 ^ Pit Privy 13 ^ Seepage Pit Pressure 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6, SYSTEM ELEV. 7. FINAL GRADE ELEVATION REQUIRED (sq. tt.) PROPOSED (sq. ft.) (Gals/day/sq. tt.) (Min./inch) q ~ ~C~ ~,. ~ S'" Z.~ o, - f 2.m ~ Feet 9$.Oe Feet VII. TANK CAPACITY in allons Total #of M ' N Prefab. Site C l St Fiber- l ti Exper. INFORMATION New istin Gallons Tanks anufacturer s ame oncret on- ee glass as c App Tanks Tanks structed Se tic Tank or Holdin Tank tr ~~ / Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's A dress (Street, City, State, Zip Code ~ ~ / ~ Z~- ftW ~Q ~~~'/MO4t.~~' ~ IX. LINTY/DEPARTMENT USE ONLY Approved ^ Disapproved ^ Owner Given Initial S tary Permit Fee (Includes Groundwater ~~ Surcharge Fee) a e ssue Issuing A ent e o Stam d9 !' s.._.. a Adverse Deter ination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly P1b-67) (R: 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber a' INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new . criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the. permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety 8~ Buildings Division, 6C18-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit. is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new a.nd/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or :site constructed and tank. material. Complete for a// 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, eta), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'f~ 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) ~. i Lam' '~ T `~ O b 0 ~ ~~~ ~ ~~~ ~-a 1- P - ~, o 0 _ u n ~-~~~r~~' " ~ QR3 c ~ ~ ~ ~+ ~:..~ 'R N .r ~ ~' 3 ~ "~ ~ n A 1~ 0\ Z 1 ~~ ~} 1'~`~ '' m ~, `'~ b- 'n a o r ~~~~ ~ ~ ~ ' a p ~O a ~ r r ~ -~ ae ~ w R'V "~ p Qr ~~ ( o ~~~ ~ ~ r" 3 R. ~ D ~' 3 ~ ~ T_ i ~ ~~ ~ pQ1 o$'~ ' ~ ~.W 'bZ ~O ~( ~ _ _ lf_ _ 1 SSS , ~,~ ~ ,K~L. ~ i ~ ~,/ _ _ d. _ _ _ 1 ~ ~ ,r d ~ ~ ~/ $l10 .D ~, ~ s ~- y a ,. ~ ~ , ~ 9 d',_ N ~ H / °p ~as / _ Cl1 0. ! rt., ~ A e ~~ T ~~ ~~ S N s a_ !~ \~ s r L _~ ~,, '\ 1~ ti ~o 0` '~` `~ _V N "~ ~_ ` lO s :r i iW ';~ W ,D ~i2 ~U i 1' Wisconsin Department of Industry, SOIL AND SITE EVALUATION R E P O R T , Labor said Human Relations Division of Safety & Buildings __~ ...:.~ n ~ in nn nc ~~r.. e.a.., n,..a.. Page ~ of _~ COU ~ ~~Q 1X but Plan must include lete site lan on er not less than 8 1/2 x 11 inches in size Attach com a , p p p . p # PARCEL I D not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or . . dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OW/~ER: ~~~ ~ (I LLL~ PROPERTY LOCATION GOVT. LOT ~~ 1/4 /v,~ 1/4,SZ-jT Z ~ ,N,R ~ 9 E (or) W PROPERTY OWNE ': MAILING AD SS ~~ ~~~ LOT BLOCK # ~ SUBD. E OR CSM ~ ~ ~ C,SC~~~ ~'Q j ~ t~i~2 Z)7 i(~Z,S CITY, ATE ZIP CODE PHONE NUMBER ,SO~tV ( ) ~IfJ ^CITY (]VI`L~ GE OWN NEAF~ST ROAD ~ t~1~[ A+ +dS .t NCJ . ~J New Construction Use [ ~' Residential / Number of bedrooms [ ]Addition to existing building j j Replacement [ J Public or commeraal describe Code derived daily flow ~~ gpd Recommended design loading rate ©-~ bed, gpd/ft2~~trench, gpd/ft2 Absorption area required ~ ~ S bed, ft2 ~~`~ trench, ft2 Maximum design loading rate ~ ~ ~ bed, gpd/ft2 (~.`t~ Uench, gpd/ft2 Recommended infiltration surface elevation(s) ~~i:.: {'~AL;C"~ ~+ ~ ~ ~i~hl ft (as referred to site plan benchmark) Additional design / site ~nsiderations Parent material Flood plain elevation, if applicable ft S = SUltable fOr System i l f ~~oo~~J1VENTIONAL ®S ^ U -~WND PSl S ^ U 1 - OUND PRESSURE ~S ^ U BADE ~S ^ U $Y TEM IN FILL ~S ^ U HOLDING K ^ S U ors stem tab U =.Unsu e SOIL DESCRIPTION REPORT Boring # ,::;. :.'• ti::..:..:.> Ground elev ~~7~ ft. Depth to limiting 7 ~~~ Boring # yr axuo>.~:4 Y ~:y, Q 4 \;,;~ Ground elev. 9~~ft. Depth to limiting f for ~~.58 Depth Dominant Color Mottles Text re Structure Consistence Bourtdl Roots GPD/ft Horizon in. Munsell Qu. Sz. Cont. Color u Gr. Sz. Sh. ry Bed Trertdt 1~ ~f~'~ 4 .~ '- ~ f ~-r n, r ~ ~ .7 C~ ~3 S~ ! 4 ~. ~ ©~ ~ r ~ n.7D~ Remarks: '~ ~~ ~ ~ ~ ~ ~ ~-~ /'Yf~'r C Z. 0.~ t~.~j g3 Za r ®v 4 ~ ~ r ~~ ~ O•~~rJ~ Remarks: Name _Please Print Phone: ~6, ~~ ~~ ©. ~ I ~~ Qsav Signature• Date: CST Number. ~~~4 PROPEI~OWNER ~~~ 1'~i~L~~:~-- SOIL DESCRIPTION REPORT Page?-of PARCEL LD. # ~T' ~ ~~ (~~' ~~ ~'~ Depth Dominant Color Mottles re T t Structure Consistence Boundar Roots GPDfft Horizon in. Munseil Qu. Sz. Cont. Color ex u Gr. Sz. Sh. y Bed Trer~d~ ~ _? /COY 3 ~ --- G. D ~ r, r ~ ~, ~ . q C3.s ~, X7'34 ~. S Y~ q -' ~~° r n~, ~ ~ ~ Q ©.S Remarks: ~~-t~7 / ~~4 4 ~" ~ ~- ~ 0:7 ~~ Remarks: g ~~~ io ~ ~ ~ 3 - s ~- ~ ~, r ~ ~~ `z c~.4 ~, $ 3 ! 1 I Dye', 4 `~ 5 ~, ~ ~ ~~ 7 ~~.~' Remarks: Remarks: SBD-8330(8.05/92) ` gE~lC>aMl4kk- To~~ ,oF l~i$BoN~~ ~'EnicE~ST l2~, F~:bM CEa~ar~s_ 9 ~ P~~~ 3v~.3 ~~.V14TIt7N ~ ;lar7~!~~ ~ L.o- IBS ~, J "~ ~ ~ ~ i ~~ oaf rJ ,~ A P ~ ~~~ ~l.~L~ , `~~ ~ PS ~ 1 ~~ '~ i ~~ ~ D i 0~ 'J, lZ~ i, ~~ i ~ ~~ ~,~~ r A _~_--,~------ ~~~ ~ ~ ~, ._- _ _ _ g-3 '1 ~ ' ' ~~~ ~~, ~ " ~ j ~ 17D To Lof ~ ~~ ~ I ~ ~ ~ ~ ~.1 N ~ ~ ~ ~ r..- ~~~ 1 "I , i, a g-Z ~h. ~ . ,' 9 ~, / ._ ;~ - ` 47' 3-4 ! I ~ ~~, / ~ o~ ~ - ~ AA ~, ~o \ '~° ~~ R ~r o ~ ~ ~ '~ ~ ~; ,'i y ~ ~ : ~ ~a ~o~,..rr aF CueV~/Ta~c,e~v~' i ~ ~~~-~ .~~ ~.~, . i / \ _ \y~ ~ j ~ ~~ .---- ~ /~ ~ ~ ~ A _ q~ ~. ~ E '~ l ,~i is I ~w~~ ~~ r, r y v. 4'', 4 40 II 6 ~.I ! SOD'0• N i ~ O w I ,_ ~ ;i ~~' ` r, ' ~ II ~ .' o s z v_ c+ ~D i ~so, 0 ~, ~ v~ 2 i I ~, O~ Olv' ~ ,. B F ~ T _ _t~~ . _ *S. 7 ~ I ,_ . ~ ~ , S `rS . 4s • . , ~ ' ~ ~, sue. ~ 9s ~ w *~ F v ~ 00 °.o / 4s d Y ? ~ 0~, ~. O / ~' ~ S ~ ~ ~O . ~ ~ - ~.. ~- ~ S2o ' d ~ c0 . ~I / ~ ~ X11 ~ II ~ ~. `A~ ~ / S' f ` O ~ o I I ~ 21214.3 Z ~ ~~ ~ li, ,- ~ z > > ',i~ I N O N ~ ~ y ~n C~ O Z I; tT ~ i O o C71~ ~ ~ N O_ ~ N : \,11 ~v r ,~ woo ~~ji~ p .~~~ m ~~ ,_ \O. (!1 ~ f1 ,P ~ ' ~ ~s'J cT_ ~ ~ , ~ ~ ~, ; 4~ U - o ~I! \ ,n ~ !I f \ _' i ~I I' \ \ \ Z ~ \ N K 0 .~ - 344.96'' \ \ o •\ - ~ N 280 .04' r ~1, 125 .00 ' \ _ "'-o; , ' d ,~ om I o }!, i ,' ~~'~~. z -v 0 z G7 m rn 0 -o `o rn n O z -n r~ 0 'b b m w (~ Z O X ~ ~ ~ ~ ~ ~ .p. -, ~ < ~~ < ~ ~ ~ ~ ~ z° ~ ' I w rn I r i D ~ i ~ I ~ m I Z i z v m o Z oa -o m r ~ z -+'. ~ ~x o ~ ~O ~ _ O ~ ~ ~ ~ ~ X ~ -~ v ~z -n ~ mO ~ O m~ ~ z ~ ~ ~ ~ i ----- ~ I ~ I I I ~ ~ a ~ ~ ~ I r ~ a ~ I ~ , `',~ ~ m I I W ~ o rn ~ w ~ ~1 ~n _ ~ ~rn ~ nC r ~ -v rn ~ `0 w I ~~ I I I ~- w 4` -Py -I = m o ~ r m - o b m ~; I- S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT ~St. Croix County OWNER/BUYER Jam' ~~ YY1 /~I ~~ ~~~,.,. ADDRESS- ~~}~` ~ ~'" '`~...., FIRE NUMBER arr.,._ CITY/STATE ~ ~~ r Q ~ ~.~ ZIP- T" 1~ ~,fi' PRO~'ERTY LOCATION : S ~ 1/4 , ~1/4 , SECTION L ~ , T~N- / TOWN OF__ ~M. ,'.6 bv~~. , St. Croix County, SUBDIVISION_t"~ t~ Ih1,~9,+t~", ~ +~• !~ "~, , LOT NUMBER ~~ Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pump~,ng 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 treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60~ of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. _ The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, .restricted plumber or a licensed pumper verifying that (1)• the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/tae, 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 DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Officer within 3o days of the three year expiration date. SIGNED:< <~~~ DATE: /Z~ S'"~/'3 St. Croix co. Zoning Office 911 4th St. Hudson, taI 54016 ' 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 rESUl~ ~n delays o;E the pormit 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 _S~1~'-/ /,~/,`~/,~.~° Location of property=l/4 /L- _1/4, Section ~~, •T 2 S N-R /y Township /-~~ ~3 ~.~r-~.. Mailing address ~'~ ~ ~" ~ ~~ ~_-- Address of site ~~ 3 ~~4 ,y,•/~ ~.~ ~/' subdivision name ~u ~w,~,.'ar~~ lye,' ~ ~ ~, Lot no. •/ other homes on property? yes=_No Previous owner of property ~. we [P9~ ~ ~ ~~. ~ ,C- ~~,: Total size of parcel _ ~ ; ~ `~ ~ /4 C bate parcel •was cxeated _ ? ' / 2 `• 9 ~ ~ . 'Are all corners and lot lines identifiable? _~_____yeS No Is this property being developed for (spec house)? ~ Yes No volume~G Zland,Page Number ~ as recorded with the Register of Dee s . INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEAD which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & TIIE SEAL OF THE REGISTER OF DEEDS. ,In addition, a certified survey, if available, would be helpful~so as to avoid delays of the reviewing process. If the deed description .references to a Certified Survey Map, the Certified Survey Map' shall also be required. PROPERTY OWNER CERTIFICATION ~. I(we) certify .that all statements on this form are true to the best of my ( our ) knowledge that I ( we ) am ( are ) the owner (s ) of the property described iri this information form, by virtue of a warranty deed recorded in the office of the County Register^of Deeds as Document No . _~_ ~ ~ Z a q , and that T ( we ) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded. in the office of County Register of deeds as Dc~cumranf- ~. _ !~• ~ ~ ~ _. t i t DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1--1862 WAHfiANTY Dpp£1=D ThiB Deed, made between ,-Humbird Land Corporation, -A_-Minnesota-.Corporation authorized to do business in Wisconsin .....................................................................•----........---•--....._...., Grantor, and....Sam--E.,Miller .............................................................................. 'i ................................................................ Grantee ...................................r , Witnesseth, That the said Grantor, for a valuable consideration...... conveys to Grantee the following described real estate in _..$.k.:..Gioix_,-,_-----.-•- County, State of Wisconsin: TNIt tr'AC[ RE9ERVE0 rOR R[COROINO DATA ' REG!S1~ER'S C1=FICA ST'. C~Z01X CO., 4ti'I R~c'd for Rccord J U L 1 2 1993 at 4:20 P. D~1 Register of Dceda - 1 RETURN r0 n - ~~',:L} </~-ids cLh.~ C~(/~.c. Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 in the Plat of Humbird Hills, Town of Hudson as filed Ta: Parcel No: and recorded in the office of the Register of Deeds for St. Croix County on April 7, 1993 in Vol. 5 of Plats, Page 99, Document No. 497107. Lots 13, 14, 15, 16, 17, 18, 19, 20, 21,lZ, 23, 24 and 25 in the Plat of Humbird Hills 1st Addition as filed and recorded in the Office of the register of Deeds for St. Croix County on ~ April 7, 1993, in Vol. 5, Page 100, Document No. 497,108. ~Rp,~IS~ o . ~~$~ 4 This .......x;3..AQ1:......_._ homestead property. 4ia1 (is not) Together with all and singular the hereditamente and appurtenances thereunto belonging; Ana...Hualbi.xd_.I.attd..Co.l:.p.os.ak.4?~ ....................•--..........-...............................................................------ warrants that the title is good, Indefeasible In fee simple and free and clear of encumbrances except easements shown on the above mentioned plats. and will warrant and defend the same. Dated this ........12LI1 ................................ day of ...July..__....---..._......................................_..., 19..93_.. Humbird Land Corporation, a Minnesota Corporation authorized to do bu/sin~ess in Wisconsir .....................................................................(SEAL) BY_..........................1~~~.'~~~t:~e_..'..."........(SEAL) Austin J. Baillon, President II •--•----•--•-• .............•--......._...-------•-•--•-......._...__.(SEAL) ........---...._....._..............__......_.............._........(SEAL) . AIITHLNTICATION Signature(s) ..---•--------------------•-•- authenticated this ....__..day ot ........................... 19___.__ TITLE: MEMBER STATE BAR OF WISCONSIN (If not...-------•----•--........--•--• ..............•-----•-------- suthorized by ~ 706.06. WIs. Stats.) THIS INSTRUMENT WAS DRAFTED BY -ICuepper s,. _Hacke 1..~ _ 1Cuepgecs-•----------------------- -1350--Capital..Gentre}._St....Pau1,..Mi`i. x.5.102. (Signatures may be authenticated or acknowledged. Both are not necessary.) ACHNOWLI3DOMi3NT STATE//O~~F WISCONSIN ~t/~• ~~'LI~ aa. -------------•---•-- --•------County. ~/ Personally came before me this ....__~St•~-day of -------_-.du~x•--------------•--.,..., 19_.93.. t>le aba0~~red ~- ..--------------•----------•---------------•-----....~..f \ ~-•--•- ~ -~- -- ...Aua~i.tl_.~,_. Baillon,-_ President .o~"'••"'••. ~o ~ ., ---Rulnbl,Fd_-l,an¢-_~orporatio7_'!_:'..~_1.~. r... ~~ } to me known to be the person .....___ ~? klrh~ ecuted tll~ foregoing ' strument and acknowIedg~tP4E aa~~ Q N~: V . cl~~N p. N~Y~D•Q.k....;'~ f~'~ - ....----~---------- -------------------~--=-a---+- ....-~' Notary Iic .-._.5.7"__....~ .Q./.~_....__-..County, Wis. My Commission is permanent. (lf not, state expiration date- -------------------------•---....._...._......._........, 19..----...)