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HomeMy WebLinkAbout020-1025-40-000 • r~ o No 3m o d `~1 X 3 3 A -mv 3 c° a N 13- 2 Z o ao p in nog• o K z a y w 2 0 o N O O N c;l O 0 O 0 C: ID (D 0 1 7 Ol W O p U) CO C O Ul ID W y u~D 4 eCT fD (3, y N d x a W V 3 O = o o _ L Z, Z4 O O co 00 co) 0 C 7 ~ "INA z OC O O v c~_I o N p ~2 a! w Z ul ai ai D ro ° 5 a o c~ lp - CJ7 V N (D A N CL o I o z co o 0) z 0 I ~r O D a l N o cn • CD m .1 N ~+1 0) N 0) C ~~f C N W (D a z CD -4 Cn O_ O O ? (D Vi C i ~ rt 0 A Z 3 O G) O W m~v, M CD CL z c z CA) I N a m o. ~ I o 0 3 co c o o a I m ~ d O 7 ~ y m y A fi ft W lv O a I M 0 A CD DO W C) O ~ ti • 7643 r ST. CROIX COUNTY WISCONSIN y:71:w z y .s . Y'a r - ZONING OFFICE r ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. Water (VOC's) $185.00 ❑ Septic $25.00 ❑ Water (Nitrate& /Bacteria) $35.00 (Visual inspection) Owner: ~oNtas W Azzr"ez►' Requested by: ~5~/ cr ~wsS Address: .O, Address: City & State: / soK s~- City & St. , Zip Code: S-4&1, Zip Code Telephone N°: (-74s-) Telephone N°: ( ) Property address (Fire N2 & Street) Location:;, Sec. 1--5-, T~N, R_,,~ W, Town of a-,- St. Croix Co., WI. Tax ID N4 Parcel ID N2 House color: . ~eoe-Realty firm: Lock Box Combo: Water sample tap location: TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH -OF HOUSE & SEPTIC SYSTEM ON REVERSE r0F1iIS-FORM* Is the dwelling currently occupied? V Yes ❑ No I f vacant, date last occupied : SePticsYstem installed bY: Ye D Septic tank last serviced by: Dat Previous Owner's Name(s): 1 Have any of the following been observed? ❑Y ❑N Slow drainage from house. ❑Y ❑N Sewage Back-up into dwelling. RE(' ❑Y ❑N Sewage discharge to ground surfac road ditch or body of water. ❑Y ❑N Slow drainage from the dwelling. anti ❑Y ❑N Foul odors. d> CAG"~GE ~ldylt~ Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. p OWNERS SIGNATURE : DATE : 'r OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION 4 IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ❑Below grd OAt-Grd OMound Approx. size. 'X ❑Gravity ODose OPressurized Ft.2 OBed OTrench ❑Dry Well ❑Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES OOther OUnknown Septic tank Setbacks: ❑House OWell ❑Prop. line ❑Other Dose tank Setbacks: OHouse OWell OProp.'line ❑Other OLocking cover OWarning label OPump/Floats" OAlarm ❑Elec. wiring Soil Absorption System Setbacks: OHouse OWell OProp. line OOther ❑Pondingi ODischarge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title SERCO Labor ' atorYes ANALYSIS REQUEST FORM St. Paul. Minnesota DIANE J. ANDERSON THE FOLLOVINC INFORMATION IS REQUIRED TO Project Manager PROPERLY PROCESS YOUR SAMPLES. COMPLETE AND RETURN WITH SAMPLES. 1931 West County Road C2. St. Paul. Minnesota 55113 P LEAS E P R I N T . (612) 636-7173 Fax(612)636.7178 DUE DATE: STANDARD: CLIENT NAME• Sf ni PRIORITY: (ADVANCE NOTICE REQUIRED) CLIENT ADDRESS: 06LI-WCL(~'pllk- AM TIME COLLECTED 9.' d~ pM ZIP DATE COLLECTED 1 ~93 ATTN: CLIENT , //~~2Srn~ PHONE NO.: S 38`(a "7~v6C/ NAME Of SAMPLE SAMPLE TYPE:CCIRCLE AT LEAST ONE) CLIENT ORDER NO.: WASTE WATER SLUDGE GROUND WATER SOIL INVOICE TO: _ SURFACE WATER SOLID WASTE Ell PATER HAZARDOUS WASTE COMPOSITE OTHER: PLEASE LIST TESTS REQUIRED FOR EACH SAMPLE. ONE SAMPLE PER BOX. PLEASE NOTE SPECIFIC DETECTION LIMITS REQUIRED OR APPLICABLE REGULATION. AMPLE IDENTIFICATION . . _ _ _ _ _ _ _ _ _ T LETTERS PER LINE, . . . . . . . _ . . . . _ . _ . . . . . _ . . . ONE BOX PER SAMPLE) . . . . . . . _ . . . . . . . . . . . . . . . . . . . . ANALYSTJ- N OF BOTT S T SPECIAL INSTRUCTIONS 01 UNUSUAL CONDITIONS: SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 32356 PAGE 1 of 3 07/21/93 St. Croix County Zoning DATE COLLECTED: 07/06/93 911 4th Street DATE RECEIVED: 07/06/93 Hudson, WI 54016 COLLECTED BY : CLIENT. DELIVERED BY : CLIENT SAMPLE TYPE WELL WATER Attn: Mary J. Jenkins CLIENT'S ID: Dabruzzi SERCO SAMPLE NO: 81123 SAMPLE DESCRIPTION: Dabruzzi ANALYSIS: Benzene, ug/L <1.0 Bromobenzene, ug/L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 {1 . Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <05~:, Chloromethane, ug/L (Methyl chloride) <0..6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 ~ECEtVE~. 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 21 199 Dibromochloromethane, ug/L <0.4v 1,2-Dibromo-3-chloro ro ane u L <1.2 co g/ ~ ST CROtx 1,2-Dibromoethane, ug/Lp <0.2 CouNTv (Ethylene dibromide) fpNtNGO~~tOE Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 9 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. d .F~ v o „ SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 32356 PAGE 2 of 3 07/21/93 SERCO SAMPLE NO: 81123 SAMPLE DESCRIPTION: Dabruzzi ANALYSIS: 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) <0.5 1,1-Dichloroethane, ug/L 0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-1,3-Dichloropropene, ug/L <0.9 Ethylbenzene, uq/L <1.0 Hexachlorobutadiene, ug/L <0.3 Isopropylbenzene, ug/L, (Cumene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isopropyltoluene) Methylene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L <0.2 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ug/L <0.1 Tetrachloroethene, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichlorobenzene, ug/L <0.2 1,2,4-Trichlorobenzene, ug/L <0.2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 32356 PAGE 3 of 3 07/21/93 SERCO SAMPLE NO: 81123 SAMPLE DESCRIPTION: Dabruzzi ANALYSIS: 1,1,2-Trichloroethane, ug/L <0.1 Trichloroethene, ug/L 1.0 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <0.2 1,3,5-Trimethylbenzene, ug/L <0.3 (Mesitylene) Vinyl chloride, ug/L <1.0 Total Xylene, ug/L <1.0 This sample's analytical results Ir& /aare n below the U.S. EPA's SDWA Maximum Contaminant level of 1/30 91 for those requested compounds which are also on the SDWA MCL list. All analyses were performed using EPA or other accepted methodologies. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, V,o-~ A. 4n,, U Diane J. Anderson Project Manager < means "not detected at this level". 1 mg = 1000 ug. a . T Form - STC - 104 y AS BUILT SANITARY SYSTEM REPORT OWNER p/~n ®/,~Vlt2ua~S TOWNSHIP SEC. T C)o N R ~W ,L1LLL~Sor.~ - ADDRESS C ,~j//~,nJ+p,.✓ ST. CROIX COUNTY, WISCONSIN C SUBDIVISION' S LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IMR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM C9 'SC A LE DvC ( Dco~ L .1T 4 Z.!! ~ ^i LST ~RC Ra~~k'7'Y CMG (,JfL[ m ~ r~~' fs'~ ALI i 3~ //3~ Aq,i ' nn a~ INDICATE NORTH ARROW /J/'C~p Of ~NCL` /"os/° SOUrN PrPa~E`/~7y+ BENCHMARK: Describe the vertical reference point used /,eT eo,?,yE(? f-E/Vice #0,,S1- Elevation of vertical reference point: _I00' Proposed slope at site: • v SEPTIC TANK: Manufacturer: Liquid Capacity: A200 4~~7.4L.. Number of rings used: Tank manhole cover elevation: /DS/. Tank Inlet Elevation: /O/- q9 Tank Outlet Elevation: )0/.7Q' Number of feet from nearest Road: Front,O Side,(?rRear, O _310' feet '-.From nearest property line Front,OSide,ke ear, O $ ` feet Number of feet from: well slo' , building: /6' 6" (Include this information of the above plot plan)( 2 reference dimensions to septic to SEE REVERSE SIDE A0jjA 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 Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: L LE. 96 / Trench: Width: Length: Number of Lines: 3 Area Built: Fill depth to top of pipe: 3 S Number of feet from nearest property line: Front, O Side, &Rear'optNumber of feet from well: Z(7' Number of feet from building: s/ (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: nn Dated: S~ Plumber on job: License Number : d 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.P. BfY(7 r69 BUREAU OF PLUMBING • MADISON, WI 53707 5CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: El Holding Tank El In-Ground Pressure El Mound (1f assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA Tom Dabruzzi 606 Third Hudson WI 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: NE-'4 SE% Section 15, T29N-R19W Town of Hudson Lot 3 Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Gar Za a 3300 St. Croix 88418 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIOUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO DYES ONO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. FEET FROM LINE: AIR INLET OYES ONO OYES ONO NEAREST DOSING CHAMBER: MANUFACTURER: 7ING L IQUID CAPACITYPUMP MODELPUMP/SIPHON MANUFACTURERWARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ES NO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PH OPERTY WELL BUILDING. JVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH: DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER =SIDE DIA. #PITS LIQUID BED/TRENCH TRENCHES MATERIAL: DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER ELEV.INLET ELEV. END: PIPES'. FEET FROM LINE: AIR INLET. 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- OYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS OYES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL'. SODDED SEEDED MULCHED CENTER: EDGES: DYES ONO DYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.'. ELEV.. DIA.: ELEV.. PIPES. DIA.: 'DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM OYES ONO DYES ONO LINE: NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: ITITLE. DILHR SBD 6710 (R. 01/82) E:::9 ILHR SANITARY PERMIT APPLICATION CO Y~ In accord with ILHR 83.05, Wis. Adm. Code STATE SANITAvRRY' PERMIT ffy 41 -Attach complete plans (to the county copy only) for the system, on paper no 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 _ /aey '/4, S 45 T Z~, N, R /q E (or). W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME e J CITY, STATE Z`IP/CODE / PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK U 7Ca/6 SS og VILLAGE : V/4422©^/ II. TYPE OF BUILDING OR USE SERVED: 0610- 14a s X6"00 Number of Bedrooms if 1 or 2 Family 3 ORE] Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable) 1. a. X New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. E1 Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one 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. ❑ Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minute$ per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Q y G,«~ / ~~O Feet 19 Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Addres-s(Strief City, State, Zip Code): Name of Designer: y Vill. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST T e,o_ 12 CST s ADDRESS (Street, City, State, Code) Phone Number: ..1 .r. ..T G - IX. COUNTY/DEPARTMENT USE ONLY - -11 ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial 4:30riri Surcharge Fee / _ 9 p - Adverse Determination / Dom` 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 licensed pumper whene.veF necessary,-usually. every 2 to.3 year0p 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: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; ll. 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; Vl. 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'h x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil 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 ears of steady negotiation and public debate. The groundwater bill Y Y Groundwater - included the creation of surcharges (fees) for a nUMber of regulated practices which Wiscortin's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water tha': buried treasure 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. 1-2 The monies collected. through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground t water, groundwater contamination investigations and establishment of standards. Groundwater, '-'s worth protecting. 3D-6398 '.G3"36 f I APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property IUGb~k,S ~ccklr~z~,, Location of Property k1L Section T N-R~ W Township Mailing Address 4~0 3r71 Address of Site ~s~-c~sa ~ ~~i/ p 16 .Subdivision Name t Lot Number `6V11 ('Wa~ 6Z//v, + T,y-=- Previous Owner of Property e-5 Total Size of Parcel /V W(I'e, Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume +*QMV and Page Number A~g as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 (We) ceAti.6y that att statements on thin 6onm cute true to the beat o6 my (ouh) knowtedg e; that I (we) am (aAe) the owneA (s) o6 the pu pW y des ch it ed in thi.6 in6o4mati,on 6o4m, by viAtue o6 a wa Aanty deed neconded in the 046ice o6 the County Registeh o6 Deeds as Document No. Ql_ ,3~q-- and that I (We) pmsentZy own the proposed site 6oh the sewaqe di,spo`S y~ (on I (we) have obtained an easement, to Pum with the above de3cA bed ptopehty, bon the construction o6 said system, and the same ha,a been duC Deeds, as Document retarded in the 046tce a6 the County Regi,aten ob No. 1. SIGNATURE OIL OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) /41 - % 3'4-- DATE SIGNED DATE SIGNED r+ • x En H • a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County x r) a OWNER/BUYER M ROUTE/BOX NUMBER Sr #ZO Fire Number .CITY/STATE ZIP PROPERTY LOCATION: Section T_cl N, R_/9 W, Town of /w011 1C , St. Croix County, • Subdivision Lot number el slw" PcI / ~ be ' _ /a, 33iS~ 3 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you ptit 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 three year expiration. H 0 E I/WE, the undersigned, have read the above requirements and agree z to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. 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. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION:Lpilt SECTION: d TOWNSHIP OT NO.: BLK. NO.: SUBDIVISION NAME: w AC 1/41/4 1.f /Tjf NCR /e / .C (or) w If OJ-20A IL3 u rfiPT 441VAr COUNTY: OW E S R'S NAME: AIL ADDRESS: s, cyeaf x 1 Dy~l3 x u ~z ~ ~~p etj)V aw ws f"ydi~ USE DATES OBSERVATIONS MADE NO. BE MS.: ICOMMERCIAL DESCRIPTION: ~ Replace I ~p • PEITCOLATIONTES Residence 30!) Ne/w~ RATING: S- Site suitable for system U- Site unsuitable for system O[9ST❑U • MOUND: ❑ S IN-GROUND-PRESSUR ©S ❑U TEJ -1N-FILLHOLDING QTANK: U R Ul ti7~/CMI11~.E/t 'y31e QED E.e[tfl1VE J-Ge10 - AvD Z!NEI&a S"GOPsS - If Percolation Tests are NOT required DESIGN RATE: ( If any portion of the tested area is in the under s.H63.09(5)(b), indicate: riL/ff f Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS AEe• -4 BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES HE TO BEDROCK IF OBSERVED iSEE ABBRV. ON BACK.) B- ~^~D /D2. ~8 > ~✓fp G,e s dN . r/~ .~S ',fv v 4s -Mr, 4W - S1 lh 4w..51 o" 7 %'f w B.3 .Oo /61, 30' /1~0 4DS~GA. s j 2.a N • o 7~~ 0E 2"Y /Ul 4.y ?,Of 41 V" B- 2--a 103. )P 40? Sb s :,w .0 , N ' y rij of 6. i B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIUD PER INCH i P_ i p- 2, P- i P t LLL_-_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. i SYSTEM ELEVATION 7(p &=30 I ~ k[>1"i~'. t,FJi.. ~iiilLw[ AAA • wets, I - r. i - is y i- 1~r i t i ty AIpE' ' moo, f% TIN 1QK, Z, tvi; i VGA l L _..l 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. MOMtllfk SEPTIC PLUMBING CO. 1 RESS: HUDSON: WIS. 54016 CERT FIJATIO NUMBER: PHONE NUMBER (optional): LHR-SBD-6395 E print : TESS W RE COMPLETE N• ROBERT ULBRICHH l Y 3~ _ CST SIGNAT E: MINN. INSTALLER & DESIGNER LIC. NO. 00663 RIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - DABRUZZI, THOMAS A THOMAS A DABRUZZI PO BOX 451 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * BAKKEN RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 4.270 Plat: N/A-NOT AVAILABLE SEC 15 T29N R19W SE NE LOT 3 CERT SURVEY Block/Condo Bldg: MAP IN VOL I PAGE 217 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 759/323 07/23/1997 697/219 07/23/1997 666/191 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.270 84,100 213,600 297,700 NO Totals for 2006: General Property 4.270 84,100 213,600 297,700 Woodland 0.000 0 0 Totals for 2005: General Property 4.270 84,100 213,600 297,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 501 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 go ow d CL CP 0 (D 0 N rt W N H. :4 ' O H p, p rt H H ~ 00 00 C Ul Z r O (D 00 , r O 1 1< Oo ` a, HHZ O N t=i o rn N G 0 w a rt •d m w O 0 v r r v, O rt w