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HomeMy WebLinkAbout020-1163-80-000 St. Croix County Zoning Monday, December 13, 2004 at 4:36:47PM Detail Sanitary Information Page 1 of I Computer 020.1163480.000 Sub/Plat: Edgewood Estates Section: 7 Parcel 07.29.19.957 Lot: 27,28&29 TN/RNG: T29N R19W Municipality: Hudson Township CSM: 1141/4: SW 1/4 NW 1/4 Owner: B 8 H Development 1074 Marty Road Hudson, WI 54016 State Permit: 83783 Issued: 07/07/1986 POWTS Dispersal: Non-Pressurized In-ground Permit: New County Permit: 0 Installed: 07/10/1986 POWTS Detail: Bed (seepage) Bedrooms: 3 WI Fund: POWTS Pretreatment: Unknown Notes Inspector As Built Plumber Other Requirements Additional Notes Money Owed Torn Nelson Yes Schumaker, William $000 Signed Off: Yes Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification rd Notification 7/10/2005 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - A 12/13/2004 04:33 PM Parcel 020-1163-80-000 PAGE 1 OF 1 Alt. Parcel 7.29.19.957-959 020 - TOWN OF HUDSON ST. CROIX COUNTY, WISCONSIN Current OX Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * KEYES, JEFFREY L & CHERYL L JEFFREY L & CHERYL L KEYES 1074 MARTY RD HUDSON WI 54016 • =Primary Districts: SC = School SP Special Property Address(es): Type Dist # Description * 1074 MARTY RD SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 1.064 Plat: 1929-EDGEWOOD ESTATES SEC 7 T29N RI 9W EDGEWOOD ESTATES LOTS Block/Condo Bldg: LOT 27 27, 28, & 29 Tract(s): (Sec-Twn-Rng 40 1/4 1601/4) 07-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 745/428 07/23/1997 726/557 07/2311997 726/555 2004 SUMMARY Bill Fair Market Value: Assessed with: 49028 225,300 Last Changed: 10/26/2001 Valuations: Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.064 33,000 141,300 174,300 NO Totals for 2004: General Property 1.064 33,000 141,300 174,300 Woodland 0.000 0 0 Totals for 2003: General Property 1.064 33,000 141,300 174,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 110 Specials: Category Amount User Special Code 27.00 018-RECYCLING SPECIAL ASSESSMENT Special Assessments Special Chargeess Delinquent Charges Total 27.00 U U Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER L ~ TOWNSHIP Al/- _ SEC. T _f~LN-RZZ W ADDRESS ~?G S7-~ ~.l~d ST. CROIX COUNTY, WISCONSIN SUBDIVISION r !./t~ 'LIST LOT r2 Po1o2 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 RING WITHIN 100 FEET OF SYSTEM o~ ~0 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used /15-Elevation of vertical reference point: Z4;fa Proposed slope at site: SEPTIC TANK: Manufacturer: 4~j. ~ Liquid Capacity: /o a V Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: $.C 3 Tank Outlet Elevation: 34Z7 Number of feet from nearest Road: Front SideoRear, O_^ feet .From nearest property line Front ,OSide0Rear,O feet Number of feet from: well ?s building: SU (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Real y Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: ;x Trench: Width:_ l2 Length:--S V- Number of Lines: 2 Area Built: .4-e-~ Fill depth to top of pipe GIB Number of feet from nearest property line: Front, O Side, &Rear'0Vt.Z/' Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: / Inspector: Dated: Q O ~t Plumber on job: License Number: 3/84:mj DEPAe,'MENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS XABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, W 153707 State Plan I.D. Number: NkCONVENTIONAL OALTERNATIVE (If assigned) ❑ Holding Tank O In-Ground Pressure O Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE. T i~O B & H Develo ment 836 St. Croix Street, Hudson, WI 17 -/0:j EV CST REF. PT. EL . BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV. SW NW Section 7, T29N-R19W, Town of Hudson,Lots 28-29,Edgewood Est. SamtaryPerm,tNumber: IName of Plumber MP/MPRSW No.. County 3484 St. Croix 83783 William Schumaker SEPTIC TANK/HOLDING TANK: MANUFACTURER: • LIOUI ;CAPACITY TANK INLET ELEVTANK OULELEVWARNII DLBEL ROK ING OV PROVIDVDED zv_;~ ~ 63 85, J 0 I~SIYES ❑NO ❑ v(/ NUMBER OF ROAD PROPERTY WELL, BUILDING: VENT TO FRESH BEDDING: VENT DIA. VENT YES ~~10 . MATT HIGH WATER LINE.- / AIR INLET. C / ALARM FEET FROM / S0 /J ~a ❑YES NO ❑YES ONO NEAREST DOSING CHAMBER: PUMP; SIPHON MnND{ ACTOHEFi WARNING LABEL LOCKING COVER MANUFACTURER. BEDDING : LIQUID CAPnCITY PUMP MODEL PROVIDED: PROVIDED: OYES ONO ❑YES ONO ❑YES ONO PUMP AND CONTR P O E NUMBER OF PROPERTY WELL BUILDING AI NT TO FRESH R INLET GALLONS PER CYCLE: ET FROM LINE (DIFFERENCE BETWEEN FEET Y O N O FET FROM ~ PUMP ON AND OFF) NEAREST H UInMF TER MATERIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: INSIDE uln SPITS LIQUID WIDTH'. LENGTH NO OF JDISTH PIPE SPACINIi COVER PIT DEPTH: BED/TRENCH 2 TRENCHES M®TEHIAL DIMENSIONS ~ 7 ( " NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH GR.nV EL QEP H FILL DEPTH DISTR. PIPE UISTH PIPE DISTR. PIPE MA rrRIAL NO Dl If FEET FROM LINE So AIP-I~L: BELOW PIPES ABOU COVER E E Itot I E V PIPES ,l(/ ryy ~ Z 7 2 NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ONO pF lirytnNf NT MnRKFFiS ~1111S SOIL EWE LLS COVER TEXTURE ❑YES ❑NO ONO SEE UFD MULCHED DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL S)DUF U CENTER EDGES ❑YES NO ❑YES. ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER WIDTH. LENGTH NO OF S: LATERAL SPACING GHAVEL DEPTH BELOW PIPE BED/TRENCH TRENCHES MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL P PEDISTR DDISATR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELE V.. ELE V. DIA. ELEV. ELEVATION AND IN - VERTICAL LIFT CORRESPONDS TO APPROVED MATERIAL FOR MATION HOLE SIZE E DISTRIBU T ION IZE HOLESPACING DRILLED COHHE CT L Y PLANS ❑YES ONO OYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WE LL: BUILDING: LINE. FEET FROM ❑ YES ❑ NO ❑YES ONO _ NEAREST 700 C/ 14./0 1: 610 4 H 1,_7 76 77 QLL__~~ - 7 7j / Sketch System on g ` R tain in county file for audit. Reverse Si ` sI ATURE ~ TITLE: DILHR SBD 0 (R. I 1 tr O_ SANITARY PERMIT APPLICATION Cou Y ` In accord with ILHR 83.05, Wis. Adm. Code S ATESANITARY PER ITI' T ~~LH~ -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER PROPERTY LOCATION -e- 4 SG/' V, )1%,, S T2 , N, R 7 E (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME - NEARE T ROAD, LAKE OR LANDMARK NUMBER CITY CITY, STATE ZIP CODE PHONE 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ® New b. ❑ Replacement c. ❑ Replacement of d. E1 Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System xistIng System 2. A Sanitary Permit was previously issued. Permit # 75-d !!Y 1 Date Issued 3. An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. Seepage Bed b. E1 Seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): a4 1115-- Feet Private ❑ Joint ❑ Public VI. TANK CAPACITY Site Fiber- Exper. in al Ions Total # of Prefab. Con- Steel glass Plastic App 4New istin Gallons Tanks Manufacturer's Name concrete structed INFORMATION anks Septic Tank or Holding Tank GOO < ~''"`'~J T -1 L Lift Pump Tank/Si hon Chamber VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system sho n on the attached plans. Plumber's Signature: No Stamps) M /MPRSW No.: Business Phone Numbe Plumber's Name (Print): r: re- ti u All AC-e.J- 2 Plumber's Address (Street, City, State, Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION CST # Cer it'd Soil Tester (CST) Na 3 C~ r 4 S n Phone Number: CST's ADDRESS (Str t, City, St lip Code ) ®n _ ~yq O I I S 3 4-qt) g SYNC S J ~O IX. COUNTY/DEPARTMENT USE ONLY IssuinA Agent Signature (No Stamps` ❑ Disapproved anitary Permit Fee Groundwater ate 9 9 / ' A-~~ry~ Approved ❑ Owner Give 010 rcharge Fee n Initial charg e r Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria'in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained- The septic tank(s) should be pumped by a'ticensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description where thE' system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensiQgs, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater biT' G: oundyvater included the creation of surcharges Gees! for a number of regulated practices which i can effect groundwater. The surcharce took effect on July 1, 1984. All of the water that ~itUriedtre s ~;riedasure is u'sed in your building is returned t:' the groundwater through your soil absorpt;cr, system or the dis osal site used b ` - P by your holding tank pumper. ~ Tile monies collected through these surcharges are credited to the groundwater find adminiz>- tered by the Department of Natural Resources. These funds are used for monitoring grourc- to wate , grourdwater contamination investigations and establishment of standards Ground%v3; 's worth. protecting. SBD-6398 (RM/86) CV!`~E S SAFETY & BUILDING` DIV I~A~ RE W ON, SOIL BORINGS AND 7Oh INDUS"TRY, P.O. B BOX OX 7rJ6f L/43,01`2 AND PERCOLATION TESTS (115) MADISON, WI 537W HUMAN RELATIONS (H63.090) & Chapter 145.045! LOCATION: ~Z`~`T- TOWN UNICIPALITY: N0.•B NO.: SUBDIVISIO NAME: NWI/ /Tz9 N/R10( Sor E A s~ C ~ PM L J'rr /Nc ~ ; C,eo lk Sr No kTq /4ud5c)iv r `~4 c~1 ~ DATES 0801111VATtON=MAUR S._ SE Residence ~Jtq *New ❑Replace ,tIN~ r,Ot~S 80MK u Al 0AICZ-0A,rt>tiirt 2 - CNE'I SOILS RATING: S~ Site suitsWe for system U- Site unwit" for sysessn - L a M EM4 ANk: RECOMMENDED SYSTEMaop onalt N 1~ U ❑Y S CQN `~ENTign/At_ c 4 S ❑9 s ❑u ❑ C If Percolation Tests are NOT required DESIGN RATE-- If env portion of the tested eras is in the /A under s.H63.09(5)(b), indicate: C-t_sQSS t L---] Floodplain, indicate FloodPlsin elevation: AIA f PROFILE DESCRIPTIONS + L E , AND DEPTH AC IE:11 1:1 TUR11Tff__4-,T_XTURE BNUMBER Eq ION V TO BED K IF BS RVED EE ABBRV. ON BACK.) B- ®,S N~ 5► O n" M $i~NS 58''Akm S16k ZZ'~3Q NI-I APteft B- Z JI Z'~ 9/•20 > Iwz< ZCh_" gQN S16k&M 20"$-ii ft 8~"$RN MS~f<~R B- 3 l a'14 88.73 r4a r4 } 9.7S r6a MS sou AkN M S 30 "Ale" st6k W cl,h B- 4 -7 ."7 88.94 0 9 ~ •7'~ is''8~►,Srtb~ 6z''$Qnt M S It' /Aft MIS B- q.o Q.SZ o 7 9,d 30" &rqS-16R cam /8ARmMS 600 &,4 MSt6+e & No a -7.0P LAY& ~F IL 114'S A/ SCeAft-b OM. PERCOLATION TESTS D PTH , WATER i HOLE TEST 1 PE INCH NUMBER AFTER SWELLlN INTERVAL-MIN. Z . 3 Z Z 2 P. ► Z Z P. a, > Z J, 1 17 xr- fur. P_ P~ PLOT PLAN: Show locations of percolation tests, $oii tri and the dimensions of suitable soil areas. Indicate scale or distances. Dow" what are the hori' xontal and vertical elevation reference point=30, ion on the plot plan. Show the surface elevation tell borings and the direction and percen of land slope. : i "SY'Si&M GL.b.1A-riQN MPTN MAV U. Al QNV ELEVATIpAA ~1s"TW N B &17.00 "TW AI W ll..l~ SYSTEM ELEYATiaN ~M-101t r iN UAC Ace-a4ALAT A L GEN D . ` ELE C 106,00' GRJbJtTY FtOt.~ SnT M, fkA 61 - SotL$~8lnl4i r P pD ! LcaT Z°~ PU f w 441. 41 •E SCALC r y I'-I 1n ' ~ p•4 'ar~ LC1Gl~TlOPI ~ : 30 -5E01 4-VIEwir T $-i _ r?Q LOT Zg w it / ' w ai~ss■ O ' e d PP~vv,, M AT i; Y i 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the ino an d n Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knuoW 13 / NAME print : - T S R LETED ON: ~uN - z4 /9 36 ional):, ADDR S: CERTIFICATION NUMBER: PHONE NY opt r,+911 "`k E 3` r1~U ASo ry 4 ~s ` 467 D12TRIBUTION: Original and ant: copy to Local Authority, Property Ownrr anti So!! Testor. DILHii•590-6395 (R. 02182) - OVER - 71, ~T 2 q . ~.Q ?ra' ~D sA~O D' No,,r. e op-a PLB 68 ST. CROIX COUNTY SANITARY PER IT N° 75041 CHAPTER 145.135 WISCONSIN STATUTES IPA J'a Pit OWNER I tai The purpose of the sanitary permit is to allow installation of the private sewage system described in the application for permit. a IC. (b) The approval of the sanitary permit is based on regulations in PLUMBER /•,ion force on the date of issue. (c) The sanitary permit is valid for 2 years from original date of f issuance and may be renewed for similar periods thereafter. Application TOWN OF N^~O ~ LO TED for renewal shall be made through the county and shall comply with regulations in effect at the time. an regulations will not impair the validity of a sanitary permit SEC T until the time f renewal. 29 ,99 \ NtR (e) Renew 1. of the sanitary permit will be based on regulations in force at the ime renewal is sought. Changed regulations may impede renewal AND/OR LOT,-?J'-0n?j 0CK (f) The nitary permit is transferable. A sanitary permit transfer shall be ob fined from the county authority. i If you wish to renew the permit, or transfer ownership of the As #&I In/ BD ION permit, please contact the county authority. AU ORIZED I UI 0 FICER - DATE EXPIRES - L S RENEWED BEFORE THAT DATE THIS PERMIT POST I N VIE VISIBLE FROM THE ROAD FRONTING THE LOT • DURING CONSTRUCTION D I L H R-SB D-6499 18. 6/821 ' ST. CROIX COUNTY WISCONSIN ZONING OFFICE ' ~,q~n4,~~Yr 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 July 7, 1986 Carolyn Haag State of Wisconsin, DILHR Bureau of Plumbing P. 0. Box 7969 Madison, WI 53701 Dear Carolyn: Permit 475041, issued on April 11, 1986 has been rescinded due to a new percolation test, and surface elevation. Permit #83783, issued July 7, 1986 has been issued to replace it. Should you have any questions, please contact this office. Sincerely, Mar Hienins St. Croix County Zoning Office Attachment DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS S IVISION LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O. BOX 7969' MAD ISON, W 153707 ~5~ ❑ ALTE R NAT I V E State Plan LD. Number. 'LO`GO N V E NT I O N A L (If assigned) ❑ Holding Tank ❑ In-Ground Pressure O Mound INSPECTION DATE: NAME OF PERMIT HOLDER: AF PERMIT HOLDER: HudSOn WI B & H Development St. Croix St. N., REF. LEY.: CST REF. PT. ELEV.: BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: Ed eWOOd Est SW NW, Section 7, T29N-R19W, Town of Hudson, Lots28-29, g i ry Per i tuber: MP/MPRSW No.: County: Name of Plumber: L ~ O o2 J t . Croix William Schumaker V LIGUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER SEPTIC TANK/HOLDING TANK: MANUFACTURER: PROVIDED: PROVIDED: RER: ❑YES ❑NO ❑YES NO OF ROAD: WELL BUILDING: IAER NLETRESH BEDDING: VENT DIA.: VENT MAT L.: HIGH WATER NUMBER LINE: PROPERTY ALARM' FEET FROM ❑YES ONO OYES ONO NEAREST DOSING CHAMBER: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: MANUFACTURER: BEDDING: LIQUIDCAPACITV. PUMP MODEL. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PROPERTY WELL BUILDING A RESH AIR INLET GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF LINE. (DIFFERENCE BETWEEN FEET FROM ❑YES ONCE NEAREST PUMP ON AND OFF) i ICI I ~I DIAMETER MATERIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) WI INSIDE DIA *PITS: LIGUIo DEPTH: CONVENTIONAL SYSTEM: DTH: LENGTH. OF DISTR. PIPE SPACING: MATERIAL: PIT BEDITRENCH TRENCHES. DIMENSIONS PROPERTY WELL: BUILDING: VENT TO FRESH GHAVEL DEP IH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NU BF O AIR INLET: BELOW PIPES. ABOVE COVER. ELEV. INLET ELEV. END PIPES. EET FROM LINE: : NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAMOFSYSTEM MEASURED, SHOW ELEVA- and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. meets the criteria for medium sand. TIONS ❑YES ❑NO PER ANENT MARKERS: OBSERVATION WELLS- SOILCOVER TE KTURE ❑YES ❑NO ❑YES NO SEEDED: MULCHED: : DEPTH OVER TRENCH/BED EDGES. TRENCH/BED DEPTH OF TOPSOIL SODDED CENTER. ❑YES ❑NO ❑YES ❑NO ❑YES ONO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE covER: WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAV L DEPTH BELOW PIPE: BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: V PESiSTR. DDiSA.TR. PIPE DISTRIBUTION PIPE MATERIAL & MARKIN : ELEV.: ELEV.: DIA.: ELEV.: ELEVATION AND VERTICAL LIFT CORRESPONDS TO APPROV ED DISTRIBUTION COVER MATERIAL: I PLANS. INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY: ❑NO ❑YES NO OYES PROPERTY WELL: BUILDING: MARK ERS : OBSERVATION WELLS: NUMBER PE RMANENT ❑ COMMENTS: OF LINE: F RAREST ❑YES ❑NO ❑YES ONO ETFROM Retain in county file for audit. Sketch System on • Reverse Side. nrLE: DI LHR SBD 6710 (R. 01 /82) SIGNATURE: ~AP PLICATION FOR SANITARY PERMIT &4z~4_C DILHR (PLB67) OUNTY # raV~aeoasMUmanaELflrions UNIFORM/PERMIT# s -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inch/es in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNE y~ MAILING ADDRESS 2 ~o e.v / ' T of ~i~dl-s's.> PROPERTY LOCATION CITY: SGJ 1/4 X11/4, S 7 , T,2 N, R / E (or Tow s - yo LOT NUMBER BLOCK NUMBER SUBDIVISION NAM NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 9-1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): THIS PERMIT IS FOR A: 6, New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. 0 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total *of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity d Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ACL /_T_ 2 2-Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on 'Ate attached plans. Name of Plumber (Print): Signature: MP PRSW No.: Phone Number: Plumber's Address: Name o Designer: c.I fig c ' f COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved 10/a X Approved Owner Given Initial e s(P ~I Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is-in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractax,("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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - V e-L-U ltd l ' Owner of Property 14 Location of Property U~ It ML3 1&, Section , TN - R W y Township Mailing Address K Subdivision Name E6~,-C.1,-,0p8 C 5 T-PTqE7~ Lot Number cam` 8 C)Li Previous Owner of Property Total Size of Parcel Ac-r-e_ -)r- Date Parcel was Created u [ ~ `1~ LV Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? _ Yes No Volumed and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed " 2. Land Contract 3. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we.) eexti.6y that aU statements on this 6oam a%e tAue to the best of my (oun) hnowt edge; that 1 (we) am (a&e) the owneh (b) o j the pno pent y de s eh i.bed in .th i s in6u4mat on 6ohm, by vixtue o6 a waAAanty deed neconded in the 066 ice of the County RegiAten 06 Deeds as Document No. and that 1 (we) pn"entty own the phoposed site jon the sewage poba~byd.tem (o& I (we) have obtained an easement, to hun with the above ducAi,bed ptopWy, 4on the cons-tAuc ion of said bys.tem, and the same has been duty %econded in the 06jice o6 the County Regis.teA o j Deeds, as Document No. 1 . SIGNATURE OF 0 R / SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H r S T C - 105 r 9 ' H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z OWNER/BUYER M f~p r ROUTE/BOX NUMBER Fire Number ZIP 3~o/lO CITY/STATE _ 'r mac,W , C PROPERTY LOCATION:y~i, N ~fL, Section T / N, R _Lj ~ Town of St. Croix County, Lot number Subdivision r Improper use and maintenance of your septic system could result in f' its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents•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 systems properly { maintained. The property owner agrees to submit to St.' Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. ~ Certification form will be sent approximately 30 days prior to H three year expiration. ° E I/WE, the undersigned, have read the above requirements and agree x to maintain the private sewage disposal system in accordance with H old the standards set forth, herein, as set by the Wisconsin Depart- completed ment of Natural Resources. Certification and returned to the St. Croix County Zoning of the three year expiration date. f SIGNED DATE St. CroiX County Zoning Office P.O. Box 98' Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. i ons4n i ~`7 , D SANITARY PERMIT L.J ILHR County - If1GUSTAVIABg61iJfI1WIpE1ATgn5 n O GROUNDWATER SURCHARGE , Sanitary Permit No. On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation more monly known as the groundwater protection law. This change in statues was the reultom- of over 2 years of steady negotiation and public debate. The groundwater bill included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. 2 Si not a of Issuing Agent: Ground Gro nd water Fee: Dat : WfSCO t[a`3' ' buried ' DILNR SBD•7289 (N. 05184)t#ii$ ; i d US :l~,,l "Y OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINI ND NJIIST~Y, cc DIVISION ,ABOR AND P.O. BOX 11 AN RELATIONS PERCOLATION TESTS (11J) MADISON W 53707 109111 & Chapter 145.045) ..OCATI N:'- SECTION: T WNSH MUNICIPALITY: OT NO.: 1K. NO.: SUBDIVISION NAME: s w/fiw' /T-79 N/giS I W u &Sv z~ z9 FdUc,iao ~5- / r AM: AI LING :OUNTY:: { OVNEAMBUYER'S A : L •:~T~ real/t l~l ~G ! M" NT e R6 ST ~ Cod ~T Aio'k 1 /7Lf &i~'J ,J S40 1. JSE DATES OBSERVATIONS MADE N oResidence UN K ONew E]Rsplace IN141°eN ~'~g6cH Z~S J9&U ~ifS % OK sac 49 10is °NCZT pN~Maa' (:641 -Crt~reiC. `iATING: So Site suitable for system W Site unsuitable for system ~sg w vrl N E L: VOUND: JIN-GROUND-PR E: ISYSTEM-INr IL OLD K: RECOMMENDED SYSTEMaoptfonaq S~~ SE]U S❑U ❑S U ❑S 9111 CANVENvo4h. RAIL' f Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is In the ~r ender s.1-163.0915)(b), indicate: C L. 45c5 Floodplain, indicate Floodplain elevation: ' V c Fr PROFILE DESCRIPTIONS jORING AL A I -CHARACTER , AND DEPTH DUMBER EPTH 0. ELEVATION OBS V TO BEDROCK IF OBSERVED EE ABBRV. ON BACK. t:5 HIUHEST J 5 oN l - 8.1 a S' co b 6- Z , 3 . 3 LT$Prl . S4 -9.3 MQ~I.~ 2 c>v 9, 3 L 7!'8-5,7 &4S .O ,Z S Z cTARfis , B- 3 907 0 B- 4 z 9z• 64 >r y 9.7- L`, O5 L-r 190t4 A FT PERCOLATION TESTS TEST QEPTH WATER IN HOLE EST TIME MINUTES HUMBER .ups AFTER SWELLING INTERVAL-MIN. PER INCH P. 1 7, qla Z z 'IC 7A P. elf .Sl D 1 14 P- 4 ' k i.i > >Z P P LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable'soil areas. Indicate scale or distances. Describe what are the hori- •ontai and vertical elevation reference points and show their, location on the plot plan. Show the surface elevation at all borings and the direction and percent ,f land slope. SYSTEM ELEVATION 8,6-so " f 3.~ i- , f 6D ' J i l i.-_ T 1..r.^ ~..._I PA ~_..r 3E3i I~AR~ yt ' . ~ ;•15~ . i . _ _lr,,..... , . I i SOTie-,1 rover Q~tawO "3 ' ,T' LoclMo i• *aLt v rSySTLr I>3 i 15 ;f = 3D+ I i I I . lead 7~ ~ 1, the undersigned, hereby certify that the soil tests reported on this form were made by rraa in accord with the procedures and methods spsdfiad in the Wisconsin Ariministrative Code, and that the date recorded and the location of the tests are correct to the best of my knowledge and belief, NAME Ipiint : TESTS WERE PLETED ON: o N A &#4 28 986 11 949vity AI)PR S: CERTIFICATION NUMBER: PHONE NUMBER (optional): 407 SEtnwe s7kegr /,luQsoN 84 ~$6- 4oso CST NATUR D13TRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, nitl+I^-SRn-F39gj if' n-1--) OVER = Lod/ a da~n~~ r ~0CIo-Y- ~,~FrS ryQ~ a©91 V r -4 1 J. ly o t Old A-~Alv ,Q~ N ~ A OP/