HomeMy WebLinkAbout020-1002-50-040Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information'you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holtler's Name: City Village X Township
NWP Holdin s LLC, fka Suzanna Johnson Tru Hudson, Town of
CST BM Elev: Insp. BqM-•-Elev//: ~~ BM Description: tt ~{~''
! . ~[~ '• J ~~ I
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic ~ ~ ~i ~~ , ~~
mg mod, ~
Ae~:t•Eiesv
F~
m
Holding
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake
~Cvw ROAD
Septic
I Z~ ~ l ~ ' ~ ~ ~~!
.....
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH L ft Friction Loss System TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County: St. CrDIX
Sanitary Permit No:
515273 0
State Plan ID No:
Parcel Tax No:
020-1002-50-040
Section/Town/Range/Map No:
07.29.19.5A40
STATION BS HI FS ELEV.
Benchma~ , Gam? ~ • t
J ,~I ~,'
t. BM /~
e a~' Ji.IL~' t~ //~.
Bldg. Sewer
~ ,
V~
,
.~,.
St/Ht Inlet ~
_.
.~
SvHt Outlet ~,,~ /~~ 7
D,~~r zt,1 ~2. ~ io3. S
Zaot o i Z, 3
~Q
. ~o
Header/Man. 7. a7 ~~•~ ! /i G
•
7I
Dist. Pipe 7•~
~i .
Bot. System oq Z q
rJ
Final Grade ~
T• ~
40. ~
St Cover ~ r
y~
~~ t~ +~ MW ~...
~~
I~
BED/TRENCH Width Length ~ ~ No. Of Tren s PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 `s~! ,~ ~ ~ t ~t^ ~
/
SETBACK
INFORMATION SYSTEM TO P/L BLD
G WELL ~ LAKE/STREAM LEACHING
CHAMBER OR Manufacturer: ,,,.jam ~+,~
.l.~ry
Type O~~st~~ ~ ! / ' j/ I _ UNIT Model Number J,,~
DISTRIBUTION SYSTEM IUeC1.1_ Zit ~-Zc~+/4 = ~d
Header/Manifold ~~
~ Distribution x Hole Size x Hole Spacing Vent to A}'~Int
~ Z Pipe(s) ~
~ D
~ ` ~ 1t rd d~+\.
Length
Dia Length
ia
Spacing
SOIL COVER ~ x Pressure Systems Only zx Mound Or At-Grade Svstems Oniv
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center ~ ~ ~ Bed/Trench Edges ` Topsoil ~ Yes 0 No Yes ~ No
~P
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /
Location: 338 Krattley LaQne jjH~~ud~s~on, WI 54016 (N 1/4 SW 1/4 7 T29N R19W) NA Lot 4 Parcel No: 07.29.19.5A40
1 J Alt BM Description = ItJ~~rWr~ d Y ,~i d4~~~~7 ~Z ~/~^• d h ~e,~L~''(~
2.) Bldg sewer length = ~ J
- amount of cover = ~~~~~
/l
Plan revision Required? ~ Yes ^~ No I~ '~ / _ 7
Use other side for additional information. (O
Date 1 epctor's nature Cert. No.
SBD-6710 (R.3i97)
Safety and Buildings Division county
commerce.wi-S~ P.O. sox 7162 ~ ~t7 1^
201 W. Washington Ave.,
~ scon s i n Madiso,~y1 7-7162 Sanitary P~rnu`'Numb~ to be filled in by Co.)
~rtmesetotCanssssroe ~.` $ '~:r,,. 5E L7. 3
State Transaction Number
Sanitary Permit Application
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental
unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc Project Address (if different titan mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary ~~
u oses in accordance with the Privac Law, s. 15. 1 m , Stgts. f
I. A lication Information -Please Print All Information cal #
Property Owner's Name ~ ~ ~i. ~, ~'~~,1,J ~ ,,, ~ ~ _.. G'
~, 1
periy Location / ~ ^ ~ ~ /r
Property Owner's Mailing Address ~ ~ ~ C ~ jf ~/`CJ
~o~o G vt.Lot
Zip Code P ne Number ~/.~~ '/+, Section
City, State _ $T. CROIX COUNTY ctrele o
1 l ING & ZONING OFFI E [~' N; R~ r W
NP y) L - - _ -
Ii. Type oI Buildlug (check all-that a i Subdivision Name
or2FamilyDwelling-NumberofBe o - U~ / ~ ~ ~~ ~~
- Block l
^ Public/Commercial -Describe Use { ~ ^ City of
CSM Number ^ Village of
^ State Owned -Describe Use ~ - M `' ~~~ ,7 n of -
III. Type of Permit: heck one box online A. Complete line B if applicable)
A. lacement System ^ Treatment/Holding Tank Replacement Onty ^ Other Modification to Existing System(explain)
^ New System ReP
List Previous Permit Number and Date Issued
^ Chan a of Plumber ^ Permit Transfer to New
B. ^ Permit Renewal ^ Permit Revision g Owner
Before Expiration
IV, a of POWTS S sternlCom onentlDevice: Check all that a 1
Non-Pressurized In-Ground ~ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. of suitable coif ^ Mound < 24 in. of suitable soil
^ Pretreatment Device sin)
^ Holding Tank ^ Other Dispersal Component (explain) ~ f y ~~ ~
V. Dis ersaUTrea ant Area Information: ~ s Syste .Elevation
Dis areal Area ( fl
Dis areal Area Required f) P
Design Flow (gPd Design Soil Apptication Ra dsfl P ~ ~ ~ / ~Y~ J
.~ 0 /
~ Total # of Manufacturer d
fo Capacity in ~ o
In ,. ~ 'r'
VI. ank one Units U
Gail u
Gallons ~ d ~
°3 .~ ~
~ o
New Tanks Existing Tanks ~ p,~ U ~ vl wU 0.
,8~ , ~
Septic or Hording Tank +~
Dosing Chamber P„
VII. Responsibility Statement- I, the undersigned, asau a sponsibility for installation of the POWTS~ ~w R Numbea~ed PBu .mss Phone Number
Plumber's Name (Print) Plumbe ' afore _
~ ~ - -a - `'
Plumber's Address (Street, City, State, Zip Code) ~) C
?3 J ---
oun IDe artment Use Onl Issuin A Signatur
Permit Fee Date sued g
pproved tsappro $ ~ ryL ~ ~ G7 f d
caner en Reason for ental "'~ ,/~f ~ / /_
IX. Conditio easons for Disapproval 3' Q ; ! / ) n - . _ /~ +~ ~yv; ~ /1(,t,t,~ /'Ids
s~7~~~8~i~ 4?/ atty. / ieGVG ~+
1. Septic tank, effluent filter and ~ t _•, ~~r~,~~„~Q,,, !I'l~'b1~~a.'E't`C'~
dispersal tail must all ~ titvfces I ai a ~, ~ ruts
as per management plan prowded by plumber.
~„ qu:st~aOk requltentents must bemairttained ~ L, d ~ «'
ac o rnmp e p ana or a system and su t to the County only on paper not less than B.iZ x l l i~~ in sla I
SBD-6398 (R. Ol/07) Valid thtu 01109
LOT PLAN
'PROJECT NWP Holdings LLC ADDRESS 573 Ctv Rd A Hudson Wi 54016
NE , 1/4 SW 1/4S 7 /T N/R 1 W TOWN Hudson COUNTY ST.CROIX
6/14/10 BEDROOM 4
MPRS Shaun Bird 226900 DATE
CONVENTIONAL XXX IN-G ND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1200/261 LIFT TANK SIZEnone DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 1200 # of chambers 60
,BENCHMARK V.R.P. Top of Wood Post ASSUME ELEVATION 100' Filter BEST Filter
^ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 5.5' below grade On inspection
New Lot Line
Vents
~B 30
30' _ I ~~M~40' _
$'
B-1
0' S B_4 Weeks ST
~ -~
20'
~o'
Upper Ce1121 chambers,
Middle Ce1120 Chambers
Lower Cell 19 Chamber
20% Slope I
3
85'
B-2
Pro Lot Line
B-3
~~~
30
ST
30'
50'
Existing 4
Bedroom
House
0'
`Future
Driveway
Vents Staked at the
time of
installation
All Lot Lines and
Setbacks with be
verified prior to
installation
Well
RECEIVED
JUN 16 2010
ST. CFt01X COUNTY
Plans Designed Using
Conventional Powts
Manual Version 2.0
Properly Owner _
SCI n:s
n //Parcel 10 #
C~m~inrlc~vra~~olov~//D~ +op
Page of
-'~-~ -- ~ ~~~~~~~' ~----~ ~~~~ Soil licadon Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP O/it'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eft#1 'Etf#2
~_ ~~ r .._._---
C~ J ~
/I.~~
i
/ [ (/
~ f3~ 30 0 ~' - ~' s
t
Boring # ^ Boring
^ Pit Ground surFace elev. ft. Depth to limiting factor in.
Soil ication Rate
Horizon Depth Dominant Odor Redox Description Texture Structure Consistence Boundary Roots GPD/if
in. Munsell Qu. Sz. Cont Cdor Gr. Sz. Sh. •EtT#1 'Etf#2
n:a Ground surface elev. ft. f]anth to )imiBnn r~,.r... i..
Soil Iication Rate
Horizon 'lepth Dominant Color Redox Description. Texture Structure Consistence. Boundary Roots GP Dlff
in. Munsel! Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Etf#2
'Effluent #i = 6006 > 30 < 220 mglL and TSS >30 < 150 mglL `Effluent #2 = BODE < 30 <
- _ mgll and TSS _ 30 mglL
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to acctss services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD.B330 (R.6I00)
• PLOT PLAN
PROJECT NWP Holdinas LLC ADDRESS 573 Ctv Rd A Hudson Wi 54016
NE 1/4 SW 1/4S 7 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX
MPRS Shaun Bird 226900 DATE6/9/10 BEDROOM 4
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1200/261 LIFT TANK SIZEnone DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 44
,BENCHMARK V.R.P. Top of Wood Post ASSUME ELEVATION 100° Filter BEST Filter
^ BOREHOLE O WELL *H.R.P. Same as Benchmark
`30' `~~M~40' ~ SYSTEM ELEVATION 96.1/94.0 5.5' below grade
5'
20'
B-1
20% Slope
85
2-3' X 88' cells
with >3' spacing
B-2
90' Weeks ST
5'
35'
ST
B 3 40' S0' 10'
Existing 4
30' Bedroom
House
50'
Well
Vents
Plans Designed Using
Conventional Powts
Manual Version 2.0
Pro Lot Line
To Krattley Lane
All Lot Lines and
Setbacks with be
verified prior to
installation
cop`s
.~ PAID
Wisconsin Department of Commerce SOIL EVALUATION REPORT Pager of
Division of Safety and Buildings
in accordance wfth Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1 /2 x 11 inches in size. P County ~ ~ '~ ~ ~
indude, but not limited to: vertical and horizontal referen Parcel I.D. ~ hk
percent slope, scale or dimensions, north arrow, and I ion a ~ road. ~,L ~ ~~,~/(.~ ~- ~~ ~ ~~U
Please print all informa on. { Reviewed by _ Date ,
Personal irdormation you provide may be used for secondary pu es (P v~, s~1 ~ (~~(m)). ~/ ,,.~- ~~'~+~~~'`~ /
Property Owner Pro ~pcatio
~i
1~~
t` i ~ STNG & X C~~ P 1/4 ,~.y/1/4 S~ T p2 N R 1 E r W
Vt.! Y
Property Owners Mailing Address o Block # Subd. Name or CSM# L 3 5
Cily ,.? State ''p rCode ` ,Phone Number Cdr ^ V' lage T 1^ crest >Ro~ad/
r~c1 G%~~~1~ ~ I ~c J i I ~`7 n O N~( ) ~i ~ O~. J -~-~ ~ ~/~/'aC~f-l ~!_ f-o. r~
^ New Construction Use' esidential / Number of bedrooms `"~_ Code derive rate ~ Ciri 3 GPD
Replacement ^ Pub-lic o~J com al Descri - __-_,____~______ __-
Parent material c~.C1~-~ lood ain el 'o ' f a li le "~ ~ ~ ft.
General cortxner>is ~ f' d~~ ~ ~~'`171,~~' ~~V ~ ~ _/ ~ ~ I `_ ` ~ ~' ~ ' ,~ ~SC•tl j /'~
and recarnmendations: -I;` yt
rye - tr~~ ~,U- ~ ~~ ~ `~_ ~'. ~~:s ~ g
! ~I / ~
$ st Ty System Elevation
~A
~~ # ' ~ Boring _L_.~
®Pit Ground surface elev. ~ ~ ft. Depth to limiting factor /~ ~/ in.
Soil lication Rate
Horizon Depfh Dominant Cdor Redox Description Texture Structure Consistence Boundary Roots GP D/f~
in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. •Eff#1 •Eff#2
r /t ~.,
-Y ~---' S G ,~ z- ' ~ e ~'
~ ,~
ti
Boring # ~^,f Boring g
~hpit Ground surface elev. ! ~r ~ ft. Depth to limiting factor ~ in.
Soil licetion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
-l3 ~3/z- r` C ~ -~ <
,t u
• Effluent #1 = BOD > 30 < 220 rng/L and TSS >30 < 150 • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Marne (Please Print) Si CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 02 -~~~~ v 715-246-4516
T
Property Owner
Parcel ID #
Page of
3
^ Boring
Boring #
pit Ground surface elev. 1 y ~ t ft. Depth to limiting factor in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft°
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
~ U ~ ~ 1 z. S ~ -- ,,w ~
L 4-18 s/ c m ~ ~v ~ ~ ~
3 y -I~ ,. ~ .,-- os I ~~ ~ - ~ .
r~
Boring # ^ Boring
^ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Boring # ^ Boring
^ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil ication Rate
Horizon 'lepth Dominant Color Redox Description- Texlure Structure Consistence. Boundary Roots GP D/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mglL 'Effluent #2 = BODS < 30 mglL 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 (8.6/00)
Property Owner
Parcel ID # Page of
Boring # ^ Boring
Pit Ground surface elev. ~ ~ ~ t ~ ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfft`
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
_l 1 U ~~i z s` ~ ~ ~..t.,
L ~-~~3 S~ --= C ~ ~ er ~ ~ ~ ,
3 y -I~ ~ ~ .-- os ~ ~~ ~ ~ ~
r~
Boring # ^ Boring
Ground surface elev. ft. Depth to limiting factor in.
^ Pit
_ Soil Hcation Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
^ Boring # ^ Boring
^ pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon 'lepth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GP D/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SB0.8330 (8.6/00)
. ~ ~, Soil Test Plot Pla
Project Name NWP Holdings LLC Sha ird
Address I-'
M #226900
Lot ---- Subdivision Dat /10/10
1/4~~,~J 1/4S ~ T 29 N/R19 W Township Hudson
Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Wood Post
System Elevation 96.1 /94.0 * H R pSame as Benchmark
IV
Scale is 1" = 4-~~ Parcel is being
unless otherwise subdivided and
existing drainfield is
1'1(1tP(~ not nn thie
Cover Page
Shaun Bird
Bird Plumbing Inc.
1008 192nd Ave
New Richmond Wi 54017
715-246-4516
Date: 6/9/10
Owner: NWP Properties
Location: NE1/4 SW1/4 S7 T29 N,R19W 338 Krattley Lane Hudson
System type: In-ground absorbtion system(conventional)
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-5. Maintanance and Conti ency Plan
6. Filter Specifications
7. Utitlization of Exis ' ptic Tan orm
Signature
License nu 226900
PROJECT NWP Holdinas LLC
NE 1/a SW 1/4S 7
PLOT PLAN
ADDRESS 573 Ctv Rd A Hudson Wi 54016
N/R 19 W TOWN Hudson COUNTY ST. CROIX
85'
2-3' X 88' cells
with >3' spacing
MPRS Shaun Bird 226900 DATE6/9/1 O BEDROOM 4
CONVENTIONAL XXXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1200/261 LIFT TANK SIZEnone DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 872 # of chambers 44
,BENCHMARK V.R.P. Top of Wood Post ASSUME ELEVATION 100' Filter BEST Filter
^ BOREHOLE O WELL *H.R.P. Same as Benchmark
30' B M 40' SYSTEM ELEVATION 96.1 /94.0 5.5' below Arade
L
5'
20'
B-1
20% Slope 35'
B-3
_ 40'
B-2
/T 29
Vents
90' Weeks ST
5'
30
ST
10'
50'
Existing 4
Bedroom
House
0'
Well
Plans Designed Using
Conventional Powts
Manual Version 2.0
Pro Lot Line
To Krattley Lane
All Lot Lines and
Setbacks with be
verified prior to
installation
}
I
Soi! Absoratlon System Gross Section
4" Schedute 40
PVC Vent Pipe
Wdh Vent Cap
~ft
Final Grade
ft
Leaching ~,,
Chamber ~_ Q~ ~ ~ ft
3v ~ System Elevation
ft `eft
~`~ ~
Soil Abso tion $ stem Plan Vlew
ft
3 ft
J
ft
4" Dia.
Header
~.eachirts~ Chamber Specifications `
Manufacturer And Model ~,~ ~, ~,/„~~~ C~~ `7
EISA Rating °~ ~ sq ft per chamber Soii Application Rate ~ ~ gpd/sq ft
~G~ gpd Design Flow ~ , '~ Soil Application Rate .~ 02 J EISA = ~ Chambers
2 rows of vZ ~- chambers each.
Page of
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4.Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
Option #1. If system fails, determine cause of failure, use alternate area and install new
yst m ested replacement area.
Option #2. nstall system at a lower elevation, by removing chambers, removing biomat,
nd inst new system.
Option#3. No adequate area is suitable for replacement area, and system elevation
cannont be lowered. Install holding tank as last resort.
3. Replace any other failing components as needed.
Plumber: Shaun Bird 715-246-4516
St. Croix County Zoning 715-386-4680
Pumper Tom Mondor 715-246-5148
Shaun Bird #226900
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
`t'his is to certify that I have inspected the septic tank presently
serving the P ~ i~z S residence located at:
~~_;, .5W ;, Section ~ T~N, R W, Town of
,,~~ ,~ Upon inspection, I certify that I have fcund
the tank and baffles to be in good condition, and it appears to be
functioning properly.
%.~ast time serviced: ~ ~ ~" J "~ ~ ~
i~id flow back occur from absorption system?
Yes ~_ No (If no, skip next line)
Approximate volume or length of time: gallons minutes
.apacity: / a [7Z~
Construction: Prefab Concrete~_ Steel Other
Manufacturer: (If known) : ~/~0~~~
:age of Tan (If known).: ~'~ ~ ~re/LQ
(s Lure)
~~~ ~
(Title)
~ -~-ice
Date
~~
CL L( r L~ ~f !~ _r.
(Name) Please print
~~~ ~~~ _
(License Number)
corm 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:
zr, accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best f my knowledge will
conform to the requirements of ILHR 83, Wis. m. Code (except for
inspection opening over outlet baffle).
Nam / ~ ~ r. Signature ~/ MP/MPRS ~ ~~~~
e~fi ~z ~ ,~-~ r.~
ST. CROIX CUL'~NTY
' ~ SEPTIC TANK 14I1~l~TTENAAiCE AGREEMENT
' Ai~TD
' OWNIERSI~ CERTIFICATION FORM
Ownelr/EuYelt ~'' ~ ^
f}
_ _ ._. ... ,C 'l °~ /~; n ~ ~ !~ i ~1 /n , ~,. 1 a 1 ~ ~`~ 1~ ~ ICJ
~er,:yaa 3~~.-~
a~
~ zoo Dada-twat for r oa~L~tion.)
City/state ~~.c~/1~--~ L~.~ ~ Parcel id«itificaxioa xumba Qc~ Q ~' 113L~ ~: -, 5G - DF`l 0
~~.oAS. D~s~n~toN nn J p~
cation %a Std '/4 , Sec. ~ , T o~ ~ N R t / W, Town of „~~~~~~
Property Lo ,~1~ a .
~~, ~ ~~ . ~ - Lot#~.
Subdivsicm
Ma # ~ ~ e~~a ~ ,Volume o~',,._~- P~ # ~~~
Certified Swrvey P
Warranty Deed. # ~ ~ `S
~ house ®~°
Volume _ ,Page #
Lot limos idratiSable ~ sso
~g~M,urs:x~r>f;wex[SF AND OWNER. CERTII+~CA~TiON
' ~ ascd n ~' ~ ~c ~~ c~aid zesalt in its pore to lade warier unto
woe oomaists of gam out tiu acpti+c teak every t3~ree years or sooner, if aeeded~ ~* a h P~• What you p~
system caa affect the of tine septic taalc as a ~ the waste disposal
83.52 l aad is Cdr
x+eaQoasn'b~ities era specified im §Co~aso. E) ~ - St Cm~ COY Sa~Y
'Tttie prpp,ercy owner to submit to St. Croix Coaaty Plarnoin8 ~ ZO~'8 DaP`„ ,ate, ) ~ ~
ownier aad by a masDez g 3o'~°ng' reatrlcted pluaaber or a licensed ~ ~ ~c teak is
~ ~~ ~ ~ ' ope~mg oonditioa aad/or {2) agar iasp ~ PAS {if tmce9~y)~
less than l/3 full of sYadge:
vwc, t>~e ~~°:esd ~ above regs aad ~°~ao ~ Pub sa++vaSe w~~e
of commerce and ~ Depazu~ of Nsaasl Resotrtocs, Staae of Rtisconsia.
stems sec forth, ls~c'e~fn, as set try ~+ to 1hC St. Croix Couinty Plsamdug &
Cron stating that Y~ septic system bas beaa noa >~ 1x c~P aad retum+od
~g wrtlan 30 days of the t3tree year won date.
Uwe arcti£y that all s oa this farm are true to the beat of my/agar lmowlodge. I/we anolaxe the o~vvaez(s) of tl~e
y d above, by vi~rtwe of a wa3x~Y deed recorded in R~egistes of Deeds t~o~ .
PI of b
DATE '
OF
~ ~*«
•**pny that is miscepa+aserrced may result is the sanitary pern~dt basztg revoked by the Plaaaia$ & Zoe
~aciwde with this applic~tiaan a rccardod warttm~y dead from the Register of Deeds Office aad a coPY of tbne certified sar~vey ~ ~
nee is made in the wanaatp dead
(REV. 081
IIINI Iflll I8"' 4!I~ ilf1~ ~~I~l il~~ ~~~III III ~I~~
CERTIFIED SURVEY MAP
LOCATED IN PART OF THE NE 1/4 OF THE SW 1/4 AND IN PART OF THE SE 1/4 OF THE
SW 1/4 OF SECTION 7, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY,
WISCONSIN, INCLUDING LOT 1 OF A CERTIFIED SURVEY MAP RECORDED IN VOLUME 3,
PAGE 805 AT THE ST. CROIX COUNTY REGISTER OF DEEDS OFFICE.
PREPARED FOR:
NWP HOLDINGS, LLC.
484 EAST COVE RD.
HUDSON, WI 54016
SURVEYOR:
TY R. DODGE
S & N LAND SURVEYING, INC.
2928 ENLOE STREET
SUITE 101
HUDSON, WI 54016
COUNTY TREASURER'S
CERTIFICATE
State of Wisconsin)
County of St. Croix)SS
I, Cheryl Sllnd, being the duly elected, qualified and
acting treasurer of St. Croix County, do hereby certify
that the records in my office show no unredeemed tax
sales and no unpaid taxes or special assessments as
of ~r..~,,,Lz-,• ~(, a,•~_affecting the land included on
this Certified Survey Map.
P
~~
cr-
Ch ryl Slind, Date ~!_J -pg
County Treasurer ~ ~
I P
LEGEND I
® +
FOUND 1' STEEL SURVEY MARK NAIL ;
FOUND ALUMINUM COUNTY SECTION ~ ~
CORNER MONUMENT
~ FOUNO 2" OUTSIDE
DIAMETER IRON PIPE
SET 1. OUTSIDE DIAMETER BY 18•
O ___
LONG IRON PIPE, WEIGHING 1.13
LBS. PER UNEAR FOOT
O FOUND 1-1/4.OUTSIDE
DIAMETER IRON PIPE
( ) RECORDED BEARING
AND/OR DISTANCE
-- ~- - FENCE
• PROPOSED DRNE
•••••'•'••••••••'••••• 50'ROADWAYSETBACK
to ~
N Cf m n m SURVEYOR'S NOTE:
The location of the center of section
~ m ~
z ~ perpetuated hereon appears to have been
ored
i
h
t l
t 1964
id
d
z m
z
•i on
s
nce a
as ev
eas
ence
b
d b
J
v y a survey prepare
y
ames Simonet on
o ~^ m a portion of the property included in this
B
d
O ~ ~ survey.
ase
on measurement abilities at
o the time, and the fact that all subsequent
surveys within the section also honor the
~ m _ m
y 1 " ~ Simonet location, I believe that the center of
section has been established and overrides
~ ~ a a mathematical position based on straight
a
3 SO
~ line measurement intersection between
c v
i opposite quarter comers.
SCALE IN FEET
I~
~~
~~
:~~-
8$4328
KATHLEEN H. WALSH
REGISTER OF DEEDS
ST . CROIX CO. , NII
RECEIVED FOR RECORD
11/17/2008 09:55AM
CERTIFIED SURVEY MAP
VOL: 23 PAGE: 5588
REC FEE: 13.00
COPY FEE: 3.00
PAGES: 2
~(Q1
~4=~ 150.05' ~5' 240.51'
10.36' NORTH LINE
OF THE SW1/4
' Z
m0
O PIPE FOUND
0.5~'WEST OF/
~_..... ~PR
\\
E
V
T OP
RT
W
m m LLIIIJ~ ~ ~o.o~.~.
V
~ ~ -- -__ ___-----
4G~ m®LL. ~
J ~QA. ~®oPll ~?
"
LOT 4 ~ i
"
33.593 ACRES ~
"
PIPE FOUND
1,483,313 SO. FT. ? /:
33.485 ACRES ; j °'u~ ~ ~~
PROPERTY W
1,458,628 SO. FT.
EXCL. R-O-W
ZZ
a
Ca ~ N I i N
~
m ~ ;i w
N
Rl 5~pp ~
W 'I
~ '
EASEMENT SHOWN ON ;
.
C.S.M. VOL. 3 PD. 805 IS
VACATED.
i '~ '
T
r a. ~'' ~r'
n
~
W~1E c
$-2484 ~
KEAR LAKE,
........' '
4.
_
-Q ~
1''.1-1 3-8
,
, 9.4:
SEE DETAIL ON SHEET 2
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149.18'
~ ~ ~ ~ ~o~~~~~ a.~a~ -
~ . ~ ~ ~f~l6tldla I~G~1~4~
---r----- --
LATER OF
C. 7,
BN, R19W
rE: FOUND CENTER
'39'6TE 1.90' FROM
ORETICAL LOCATION
i®
i~
i~ m C
~ m
a ~
--~ ~
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i® ~'-0
k~
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~~ ~~
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E®
{~"'0
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lL®~ ~ ~.a~.~. v
~~ ~®~~ a M ~' ~ SY COR.
~~_ ~®~~ SEC. 7,
T29N, R19W
EACH PARCEL SHOWN ON THIS MAP IS SUBJECT TO STATE, COUNTY AND
300 0 300 TOWNSHIP LAWS, RULES AND REGULATIONS (I.E., WETLANDS, MINIMUM
LOT SIZE, ACCESS TO PARCEL, ETC.) BEFORE PURCHASING OR
DEVELOPING ANY PARCEL CONTACT THE ST. CROIX COUNTY 20NING
THIS INSTRUMENT DRAFTED BY: WILLIAM KANE OFFICE AND THE TOWN OF HUDSON FOR ADVICE.
1 of,~7B NO. 6427-03 DATE: ,0/26/2006 SHEET 1 OF 2
t pL~p
1 -a8--~ 1
~ "r
L_ .
1 e38.oz'
WESTy COR.
SEC. 7, ,
T29N, R19W
Vo! 23 Page 5588
State Bar of Wisconsin Form 7-2003
TRUSTEE'S DEED
Document Number
Document Name
THI5 DEED, made between First State Bank and Trust
as Trustee of the Trust Created Under the Last Will and Testament of Charles G.
Johnson, deceased ~ ("Grantor," whether one or more),
and NWP HOLDINGS., LLC, A WISCONSIN LIMITED LIABILITY
COMPANY
("Grantee," whether one or more).
Grantor convoys to Grantee, without warranty, the following described real estate,
together with the rents, profits, fixtures and other appurtenant interests, in
St. Croix County, Stat$ of Wisconsin ("Property") (if more space is
needed, please attach addendum):
Legal description attached hereto as Exhibit "A"
1111111 IIIII 1141111111 IIIII IIIII fill !11111 Ill! IIII
X 8 8 14 5 2 2 2
V ~~
KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIx CO., WI
RECEIVED FOR RECORD
09/17/2008 10:15AM
TRUSTEES DEED
EXENPT t
REC FEE: 13.00
TRAMS FEE: 1110.00
PAGES: 2
Recording Area
1~~
Name and Return Address
River Valley Abstract and Titie, Inc.
1200 Hosford Street
Suite 201
Hudson, WI 54016
z~v4ys~'
ozo-IOOZ-so-ooo; o2aloo4-90.000;ozo-IOO3-IO-ooo
Parcel Identification Number (PIN)
Dated ~/ / S ~ ~D
=' V~~fv3 * First State Bank and Trust, Trustee
;;
..~ ,<.•
* , , N• (SEAL)* (SEAL)
AUTHENTICATION
Signature(s)
authenticated on
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by Wis. Stat. § 706.06)
THIS INSTRUMENT DRAFTED BY;
Brent R. Johnson
Locomen Abdo Law Firm, Hudson, Wisconsin
ACKNOWLEDGMENT
STATE OF WISCONSIN )
~. ) ss.
_ ~ ~ C~~~P ., COUNTY )
Personally came befare me on ~ieP',, !'S, Lbsw=;~' ,
the above-named Ki~L~+es ~~~~rst State Bank and Trust, Ttuske
of the Trust Created Under tha Last Will and Testarnwt of Chutes G. ]ohoson, deceased
to me ow be the person(s) who executed the foregoing
ins t cknowledged the same.
* ~
Notary Public, State of Wisconsin f`~
My Commission (is permanent) (expires LG1~ ' ~~ ~fT_ )
(Signatures may be autbenifcated or acknowledged. Both are not accessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
TRUSTEE'S DEED ®2003 STATE BAR OF WISCONSIN FORM N0.7-2003
• ~'~gnarne below signatuttis.
ADDENDUM
TO
TRUSTEE'S DEED
020-1002-50-000; 020-1004-90-000; 020-1003-10-000
GRANTOR: FIRST STATE BANK AND TRUST,
AS TRUSTEE OF THE TRUST CREATED
UNDER THE LAST WILL AND TESTAMENT
OF CHARLES G. JOHNSON, DECEASED
GRANTEE: NWP HOLDINGS, LLC, A WISCONSIN LIMITED LIABILITY COMPANY
LEGAL DESCRIPTION:
Part of NE 1/4 of SW 1/4 of Section 7-29-19 described as Lot 1 of a Cortifiod .Survey Map recorded in the Office
of the Register of Deeds for St. Croix County, Wisconsin on May 22,1979, in Volume 3 of CSM, page 805, as
Document Nu. 356998.
Together with a Cfi foot wide private roadway easement for ingress and egra¢s as shown on said Certified Survey
Map,
and
1=.asterly 365.54 feet of westerly 2,20333 feet of SW 1/4 Section 7, Township 29 North, Range 19 West, except that
liar! thereof lying south of the highway.
All that part of SW 1/4, Section 7, Tov~n~sl~ip 29 North, Range 19 West, North of lawn highway except the westerly
2,203.33 feet.
EXCBPT
A parcel of land located in the SE 1/4 of the SW 1/4 of Section 7, Township 29 North, Range 19 West, Town of
Hudson, St. C:ruix County, Wisconsin, mere partieulary described as follows; Lut ] of a Certified Survey Map,
recorded August ]7,1.977 in Volume 2, Certified Surveys, at page 437 ac Document Na, 342400 in fhe Office pf the
Register of Deeds For St. Croix County, Wisconsin.
Exhibit "A"
2of2
1
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II
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Parcel #: 020-1003-10-000
05/18/2005 10:05 AM
PAGE 1 OF 1
Alt. Parcel #: 07.29.19.5G 020 -TOWN OF HUDSON
Current ', X', ST. CROIX COUNTY, WISCONSIN
. Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * =Current Owner
* JOHNSON, SUANNA TRUST
SUANNA TRUST JOHNSON
338 KRATTLEY LA
HUDSON WI 54016
Districts: SC =School SP =Special Property Address(es): * =Primary
Type Dist # Description * 338 KRATTLEY LN
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.500 Plat: N/A-NOT AVAILABLE
SEC 07 T29N R19W NE SW LOT 1 OF CERT Block/Condo Bldg:
SURVEY MAP IN VOL III PAGE 805 ORD
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/11/2000 622867 1510/82 PR
07/23/1997 1047/629 TI
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.500 43,000 137,500 180,500 NO
Totals for 2005:
General Property 2.500 43,000 137,500 180,500
Woodland 0.000 0 0
Totals for 2004:
General Property 2.500 43,000 137,500 180,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code
Category
Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
.:: ,
,;
2.,
,
~• -f:29N--R -i 25
.20 9 W.
SEE PAGE X99
i :'r'R:o ~ . .::... . t t cStcztc o
o~,~w~ , .,~y~: W/scores%n
........ ~W/L L OW8 ~
, :ry ~
b C ::: i ::::::: :.'t ~R/V .~
~;:dCyp~tEAGLE::::: '.~
. p C~9 :::127:4.GiE :::::. } MCP f~O f
~~ ~
~0~
8 Z.tl
7~
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rsQ /~
ee
o, b 9
r
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~~ ~/:
vviw.
N
W
l7
W
W
_y
. ~ .985•A
~ C~C~C~~~~ •®
Z 2
u
.. FILED
St CROIX COUNTY a' ~~ ~ 197
~~,~~~g SURVEYOR'S RECORD
~Nr ~
CERTIFIED SURVEY MAP ~ "''~ '
NE I/4- SW I/4-SEC. 7, T 29 N, R 19 W 8 V
N
BEARINGS ARE ASSUMED
NORTH ON THE N&S I/4 LINE
100 ~ O 25~ 50~ 75~ 100
SCALE IN FEET
LEGEND
o- I" X 24" IRON PIPE SET
WEIGHING 1.68 LBS. / LIN. FT
• -FOUND I" IRON PIPE
7H IS INSTRUMENT WAS DRAFTED
BY B.R.P. JOB NO.
~~.~~~~~~~l~r~~
at.t~N C.
~ NYHAG!~N ~
S-1407
HUflSOPI,
i ~ WtS. ~. ~p~~o
~° ~S ~D SUR~~
z. o~ bra/°'~~ 9 <
~~O .
~.
P. O~
~Q.
J. Q. ~`.
v ~•
~ a
rn c
~~ ~~ ~ o ~
O • P..
• Qv.
. W
Q
N 89446'-46"W _~
_66.00' M
O . -~ .
~~' ~• ~ .
~. ~~~ • ~•
P~~<v•~.
~ ~'~. ~
Q'Q~ Q.
S 89°- I i '- 34" W
o43s,, 271.69'
~2"
EXISTING
POLE
SHED
LOT - I
2.50 A.
~~
CENTER OI
SECTION 7
T 29N, R 19
FOUND
I I/2" IRON
PIPE
~.
v
~.
~P~~.
~- ~ ~,.
o~
0
~ N ~ •.
0 0 '
z ~
EXISTING
p ~` HOUSE
rn
_ N , Q
` ti At9.
C'~ • °~ `~
W
270.14'
~ N~~
Q
W N
w -
W j~ W
Q
~ a~C' t0 ~~.'G,. -L 2.
M 01 PO• ~~'
M
O tC~° ~ QvQ ~O~' x ~
66.00'
in S 89°-46'-46" W in
M ~ KRATTLEY LANE ~''~
in ~
M M
H
0
Z
~`
..
.~
o•
m~
N-S I/4
LINE
r- - -
• AS BUILT SANITARY SYSTEM REPORT
.OWNER L ~S ~~ SO/~ , TOWNSHIP O/'tOSEC.~ T~N, R~W ~~
P:O. ADDRESS c /V ST. CROIX COUNTY, WISCONSIN. •
SUBDI~jISION LOT LOT SIZE
PLAN VIEW
•Distances ~ dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
SE~'TIC TANK(S)~L MFGR.~~ ~ ~ ~ /C S CONCRETE STEEL
N0. of rings on cover Depth _ DRY WELL
.f TRENCHES N0. of width length area
g BED no. of lines~~~ width ~'leng4h~ area
depth to top of pi e
AGGREGATE (-~ ~ d I J~~i~ ~ os-1~ • f 9 K ~~
e PERK RATE ~ AREA REQUIRED AREA AS BUILT
Disclaimer: The inspection of this system by St. Croix County 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, if failure is noted the County will make every effort to
determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM ~i
`~~
_~._
D41TED ~®° ~j ~ •' I q~O PLUMBER 0~ N JOB ~~ ~ ~~~
LICENSE NUMBER
Z
REPORT OP TNSPECTION_INDIVTDUAL SEWAGE SYSTEM
i
San~.~arsy Persm~.~-~~`
,~r S~a~e Sepx~.cZ
I /~ 9 L
NAME ~ - awn.ah~.p S~. Crsa.i.x Caun~y
L a ca~~,a nl~~ % a ~, ~l~%, S e c~.i.a n~ T,~i'~N, R~w
SEPTIC TANK
S~,ze rr~ ~ ga.2~.an~s .
P
D.c.b.tance Frsam: we.~.~
Numb en ab Campan~men~~s~_
DISPOSAL SYSTEM
D~.b~ance Frsam:
FIELD DIMENSIONS:
~~. 12% on grsea~en b.~ape ~ b~
Bu~..~d~.ng~~~. Gle~.2and~
GI e.~2
~~.
Bu~,.e.d~.ng_L~~~.
H~.ghwa~en r----- ~~.
Gl.id~h a~ ~nench ~~ ~~.
~~CJ Length o~ each .~.Lne~~~.
f ~ Numbers- a~ .~~.ne~s 3
~ ~a
2~~'o~a.e, .2eng~h o~ .~.cne~s~2 ~ ~~.
D.L~~anee be~cueen .~.%ne~s~~.
Ta~a.~ abd anb~d.an arsea$~_~~2
Requ~.ned anew (, 2.~ ~~2
PIT DIMENSIONS:
Numb en a ~ p~.~~s
OuZb~.de d~.ame~
Ta~a.~ ab.aanb~tion anew
Arsea nequ.Lned ~.t2
INSPECTED 8 /~-~~ ~ TTTL~ _~~~
APPROV ~~~~ , "SATE ~ ~ 19 7~.
REJECTED ~ ;DATE 19 7_
D ep~h
Depth
Depth
S.~a pe
Depth
Dept
~.t .
12% an gnea~en e.e.ape --- ~~.
we~.~andb F~.
a~
a~
a~
a~
~a
~ ~
na cFz 6 e.~aw ~~i.2e~~ ~.n .
Hach. avers ~.1.2e 2 .i,n.
~~,.~e be.~aw gnade~G ~.n.
~nench - ~.n pen 100
b edna eFt - ~~.
a gnoundwa~en -- ~~.
Gnave~2 arsaund p~.~d ye.a_
Depth b e.~aw ~.n.~e~ ~~.
2
~~
na
~~.
z
A
rn
`_
~~
~,
`~_
,~H 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES - • '
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH ?;
P.O. BOX 309
MADISON, WISCONSIN 53701 '
~'" ~ REPORT ON S~Or IL BORINGS AND PERCOLATION TE_S/TS `~,
LOCATION: ~/o,c.~/4, Section .~, ~~N, R! L ~lor-~fownship or Municipality~T~~'~'`'~
Lot No. ,Block No. County ~~`` G°i'O~`X
"/ ~ ti--. / Subdivision Name
Owner's Name:
Mailing Address: ~~ ~
TYPE OF OCCUPANCY:
t
.-.
Residence ~ No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ~ ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS-,~o-~~ 7 7 PERCOLATION TESTS// ~a ' ?2~~7
SOIL MAP SHEET .Z~f'"'S-~ SOIL TYPE 63 C- ?~ O~l.~~.`.Q /f.dA-~•'~
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS
LE WATER IN
HOLE AFTER TEST TIME
INTERVAL DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HO
1ST WETTED
SWELLING
IN MINUTES
PERIOD 1
PERIOD 2
PERIOD 3 MIN/IN
BER
P ~ ~r s~¢ ~ ~ ~ /~o ~O oz ~3 ~j ~o
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH- THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B- ~
q6,,
~'~
Al-c~,tQ
4
>Q'6•.
7
6„ ~f~ yS•, ,~C -i-Gr~ ys~, S~16r ,s-l ~s S,C ,•
S" ,2 '` ~ ~~rr 3~~ So~~v S~'~ r
B_ ~ Y~ `' ~•~ ~~,. ~., ~ yy.. ,s ,FGA., ~/ "Sf r g .s ~C~G,-
PLAN VIEW (Locate percolationtests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square ee ~~uitable areas. ~ndic to ~
needed for building type and occupancy. c~rJ
or distances. Give horizontal and vertical reference ,pynts~jdic~ slope.
of absorption area
-' Indi to scale
P/~ .-..~
--~1
~N
r
/_~ •
P ~ ~ ~ ~ State and County State Permit #
Permit Application County Permit ~
for Private Domestic Sewage Systems County C~'- ~T
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required
State Plan I.D. #
A. .OWNER OF PROPERTY Mailing Address:
C~ /L~.tS'~N S OA.t W ~~ o
B. LOCATION: ~'/4 S~ '/, Section ~, T~ N, R~ ~ (or) ot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township S'a~a/
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family ~_ Duplex No. of Bedrooms 3 No. of Persons ~~
D. TYPE OF APPLIANCES: Dishwasher ~ YES NO Food Waste GrinderYES1N0 # of Bathrooms?-
Automatic Washer AYES NO Other (specify)
E. SEPTIC TANK CAPACITY ~Be~d Total gallons No. of tanks _~_
*Holding tank capacity Total gallons No, of tanks
New Installation X Addition _ Replacement _ Prefab Concrete X
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ~ 2) 3) Total Absorb Area sq. ft.
New Addition Replacement *Fill System 6/SPA ~~te'I~
Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length sa, Width ~ ~ Depth "Tile Depth ~j" No. of lines
y„
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land- ~ o !~-~ /^ ~j istance from critical slope ~
T~ i ers~c e.~ ~rz c~i,~ / r' ~7'~ . SIi ~it' ~I~td~
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 Ce ified Soil est
NAME t~ C.S.T. # S~ /~Q and other information
obtained from ~ owner/ ). ;
Plumber's Signature MP/MPRSW# l Phone #~~b_ ~ ~J
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
:--.
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