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HomeMy WebLinkAbout020-1132-70-000 nco) 0 0M 0' 3m o d ~1 tv f l O c C 3 0 co m -0 T A CA 3 - >v ~ \ 1 rT O I _ CI Cn $ -1 7 Z C-il 'O G p 7 Z O W C v N • 0 0 -4 K) 0) 0 -4 ` m Z CD H o 3 0 H 00 3 o Q N C N p" N N p tq CO N O N CL O O 7 0 7 O W v ►1\ 0 C O O C) O v' 3 3 m a y y < O C) v U, o d c co A i D a OR N D a co ao c CD y W o_ m N o. O" IC. A O n O QO- O `t O N j CD =A F~ Z! Q~ O Z7 to a ~ d CD -4-4(D y 00 00 CD N 0 N cn O c lV 00 OD N M 0) 0 3 Z 000 000?I o myl ~y' W~ prq n m C' U! (a > ° c Ul CO) Cn 0 v v ' o v ° o (o :3 ;o o cn = CD N 0 _ = 3 o v 3 N CL a ° a oZ D W o D o ° O n 0 n ~r s CD v m m n U) x 7y E m y 0 (n lv O D) G rt H y c CD N C CD M. 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Completion of this form is essential so that the property can be located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail, received will be done as along withform to address. Testing soon as possible WATER TESTING FEE: $ 25.00 (For nitrates and coliform bacteria)FEE: $127.00 WATER TESTING (For VOC'S) --FEE: $25.00 xx SEPTIC SYSTEM INSPECTION--- (Determines if system is properly functioning at time of inspection) Property owner's nameRonnie and Susan K. Bernth sani h Property owner's address 908 Willow Ridge Road Hudson Ti; T L. N-R! I Legal Descri ti n 1/4 of the 1/4 of Section Town of Lot Number = Subdivision Name U FIRE NUMBER LOCK BOX NUMBER Color of house Realty sign by house? No If so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is water line the home is vacant, an has been so before the must be purged by by run 9 test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. if this is the case, please make proper arrangements with this office to ensure time when entry may be gained. r Firm or individual requesting services: The First Na~'^^~' R^^U ^f n Telephone Number 715/386-5511 REPppggT TO ~ES SENT TO: The First National Bank of Hudson 3D7 Secon treet, Hudson, i Closing date 11 24 89 Signature COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 Aaw ~4j 715-962-3121 800 - 962 - 8378 (WI) 4MEW 800 - 962 - 5227 ST. CROIX ZONING REPORT NOO 30223/01 PAGE 1 ST. CROIX COUNTY REPORT HATE: 6/16/89 COURTHOUSE DATE RECEIVED! 6/14/89 HUDSON, WI 54016 ATTN: THOMAS C. NELSON OWNER; David a Gayle Williamson LOCATION: 908 Willow Ridge Rd., Hudson, WI COLLECTOR: Mary Jenkins - St. Croix County Courthouse SOURCE OF SAMPLE: Outside Faucet COLIFORM: 0 /100 mt INTERPRETATION! Bacteriologically SAFE NITRATE-N; 5 ppm Under 10 ppm is safe for human consumption. COLIFORM + NITRATE LAB TECHNICIAN; Pam Gane ~ilg WI Approved Lab No. 19 i ~.\NDEPFgDf~, . O y SA C Means "LESS THAN" Detectable Level Approved by: ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CR'OIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE f 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 November 2 , 1989 Audrey Barr 307 2ed St. Hudson, WI 54016 Dear Ms. Barr: An inspection of the septic system at 908 Willow Ridge Road was conducted on November 27, 1989. At the time of the inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system is totally dependent upon proper maintenance of the system. Should you have any questions regarding this subject, please feel free to contact this office. Sincerely, 'br. y Mary enkins, Assistant St. Croix County Zoning Administrator cj .COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 ST. CROIX ZONING REPORT NO.: 17099/01 PACE 1 ST. CROIX COUNTY REPORT DATE: 1/24/92 COURTHOUSE DATE RECEIVED: 1/22/92 HUDSON, WI 54016 ATTN: THOMAS C. NELSON / OWNER: Ron Bernth LOCATION: 908 Willow Ridge Rd., Hudson COLLECTOR! M. Jenkins DATE COLLECTED: 1-21-92 TIME COLLECTED: 2:00pm SOURCE OF SAMPLE: Kitchen faucet DATE ANALYZED:1-22-92 TIME ANALYZED:2:00pm COLIF'ORM: 0 /100 ml INTERPRETATION: Bacteriologically SAFE NITRATE-N: 4 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 ml Nitrate-Nitrogen, mg/L 9 10 0 ~y LAB TECHNICIAN: Pam Sane ti WI Approved Lab No. 19 < Means "LESS THAN" Detectable Level Approved by: t ~T PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY ZONING OFFICE 911 4th Street v Hudson, WI 54016 Ol Telephone - (715)386-4680 The St. Croix Co. Zoning office offers the service of septic and water inspection to Lending Institution, Realty Firms, and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING FEE:$ 25.00 V (For nitrates and coliform bacteria) WATER TESTING FEE:$175.00 (VOC'S) SEPTIC SYSTEM INSPECTION FEE:$ 25.00 PROPERTY OWNERS NAME: IF-0 Al'All6- 9 0 $ ~Vi1towRUkt tevto , PROPERTY OWNERS ADDRESS : CITY: IrUeso 'tJ Legal Description z-Lb,.J4/4, • 1/4, Sec. , T N-R W, Town of Ata sna- , Lot: No. 30 , Subdivision Z FIRE NO. O $ LOCK BOX NO . 0a?G` 6 Z -7(/' cJ Color of house N*i-4.g wsrd Realty sign? Firm: - ` PLEASE INCLUDE, IF AT XLL POSSIBLE, A MAP, i.e., COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. D Firm or individual requesting services: Telephone No. 3Q(6- 56 33 REPORT TO BE SENT TO : -e_ !'j h j'.e 4 `T 20 Cre s4 "T t P'-v Pr( V--9- / Tom SKo / - a Z4 Z CLOSING DATE: 1'~t rraar /b Signature: e dle~cr p - •R. Nl q 3 o S-, z 7 S 3r- ;Y- 577V /-txf 2 C. I C-- fit' G✓/ ~r 47 G z T • ~ 4 Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER 3 TOWNSHIP SEC. T N-R_ ADDRESS BoX--1}-~---- ST.' CROIX COUNTY, WISCONSIN Nd~~ SUBDIVISION r~ 0 f czj~LOT 3 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 tem J INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: a Numbar of r!.ngs used: , Tank manhole cover elevation i Tank,Inlet I:levation;_ Tank Outlet Elevation: Numb(r of f,.-et from nearest Road: Front,O Side,O Rear, O feet From iearest property line Front, 0Side, 0Rear, 0 feet Number of feet from: well building: ° . (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturers 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, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORBTION SYSTEM Bed: Trench: t., Width:- 1.2 Length: Number of Lines:-w Area Built Fill depth to top of pipe:. 01 i Number of feet from nearest property line: Front OSide,QRear,OFt._ Number of feet from well: F 1 t Number of feet from building: (Include uistancea on plot piau). 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, 0Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer Inspector: Plumber on job:.. Dated: -tom License Number: 3/84:mj Parcel 020-1132-70-000 06/29/2005 10:06 AM PAGE 1 OF 1 Alt. Parcel 17.29.19.639 020 - TOWN OF HUDSON Current I X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner " WILLIAMSON, DAVID J & GAYLE S DAVID J & GAYLE S WILLIAMSON 908 WILLOW RIDGE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 908 WILLOW RIDGE RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.500 Plat: 2624-WILLOW RIDGE 2ND ADD SEC 17 & 18 T29N R19W WILLOW RIDGE 2ND Block/Condo Bldg: LOT 30 ADD. LOT 30 ASSESSED WITH P638B Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1089/096 WD 07/23/1997 844/501 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/19/1993 Description Class Acres Land Improve Total State Reason Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 0 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 Parcel 020-1132-60-000 06/29/2005 10:08 AM PAGE 1 OF 1 Alt. Parcel 17.29.19.638B 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 DAVID J & GAYLE S WILLIAMSON WILLIAMSON, DAVID J & GAYLE S 908 WILLOW RIDGE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.180 Plat: 2624-WILLOW RIDGE 2ND ADD SEC 17 & 18 T29N R19W WILLOW RIDGE 2ND Block/Condo Bldg: ADD. BEGIN NW COR; S 83 DEG E 305.12 FT S 36 DEG W 178.2 FT N 89 DEG W 261.18 FT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) TO WEST LN; N 20 DEG E 187.62 FT TO POB 17-29N-19W ASSESSED WITH P639 Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1089/096 WD 07/23/1997 844/501 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.180 41,100 203,400 244,500 NO Totals for 2005: General Property 2.180 41,100 203,400 244,500 Woodland 0.000 0 0 Totals for 2004: General Property 2.180 41,100 203,400 244,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 128 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT ;WNER / d I TOWNSHIP fvl_h_SEC. ~ TN, R~ W .0. ADDRESi a , ST. CROIX COUNTY, WISCONSIN. UB DIVISION LOT LOT SIZE 70 -66D PLAN VIEW 1039 -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM D~( W~I~QW r ' t PTiC TANK(S)/ 'd 60 MFGR. I tr_ CONCRETE STEEL NO. of rings on cover Dept `ENGHES NO. of ~ DRY WELL width length area A no.. of lines 3 T width leng ~ = area_ go J4. depth to top of pipe " GREGATE - f ~2 ARK RATE AREA REQUIRED AREA'AS BUILT _.sclaimer: The inspection of this system by St. Croix County does not imply complete umpliance.with State Administrative Codes. There are other areas that it is not possible =w inspect at this point of construction. St. Croix County assumes no liability for -stem operation. However, if failure is noted the County will make every effort to termine cause of failure. :.EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. --INSPECTOR . • DATED PLUMBER ON JOB LICENSE NUMBER PUEPORT -Or IhSPECTIO'_1--Ii1DIJIDUAL SEWAGE DISPOSAL SYSTEU Sanitary Permit r State Septic 5.0 . AME TOtlIdSHIP Yeti c Z t. Croix County SEPTIC TAMI seize L t3 gallons. `umber of Compartments Distance From: Well ft. 12% or greater slope Building ` S _ft.. Wetlands Highwater -./Aft. DISPOSAL. SYSTE".1 Tile Field or Seepage Pit(s) istance From: Well ~ ft. 12%.or greater slone' ft Building 35 ft. Wetlands 7FIELD ' `r;ighwater Total length of lines ft, !lumber of lines. Length of each line' ft. Distance between lines ft. Width of the trench ft. Total absorption area sq. ft. Depth of rock below the J-2-in. Depth of rock over the Z. in. Cover aver . rock Depth of tide below grade f n. Slope of trench ~in ner 100 ft. Depth to Bedrock ft. Depth to ground water A. a ft. P ~ . 'lumber of pits Outside diameter ft. Depth below inlet ft. Gravel around pit: yes no. Total absorption area sq. ft. .Square feet of seepage trench bottom area required %:quare feet of seepage nit area required Inspected 1iy:'`'a•" ; ~`►Fitle': Approved Date 197 Rejected Date 197. DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING MADISON; Pill 53707 CONVENTIONAL EALTERNATIVE State PlanLD.Number: III assigned) Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPEEN DATE. David Williamson Rt. 5, Box 47, Hudson, WI 54016 (3-46 - ~ i BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PL ELEV. NE NE, Section 19, T29N-R19W, Town of Hudson, Willow Ridge II Od 3Q Name of Plumber: MP/MPRSW No. Cnumy Sanitary Permit Number: Richard Hopkins 1059 St. Croix 83778 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACI V. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. f _ EYES ENO OYES ENO BEDDING: VENT DIA.: VENT MAT( A HI LGAH A EH O- ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ET R' LINE. AIR INLET: DYES ENO EYE NO NEAR ES DOSING CHAMBER: MANUFACTURER BEDDING- LIQUID CAPACITY PUMP MODEL PUMP;SIPHON MANUF ACTUHEH WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: EYES ENO EYES ENO EYES ENO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF ~PHOPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE (AIR INLET' PUMP ON AND OFF) EYES ENO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JAME TEH ]MATE RInE 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: BED/TRENCH WIDTH. LENC TH NO. OF DISTH PIPE SPACIN(; COVER API NSIDE OIA -PITS LIQUID ? it TRENCHES M _HIAL: DEPTH: DIMENSIONS ~C1 GRa.GEL LL PI .I FILL DEPTH I)ISTI PIPE DISTH PIPE DISTR. PIPE MATERIAL NO 1115TH NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES ABOVE Co VER ELEV. INLEr ELEV END . PIPES FEET FROM L1N\F•,,~ AI~~`'N.LET. Z 3 7 NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material f PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain t t i ON REVERSE SIDE. SHOW ELEVA- meets the criter r medium san TIONS MEASURED. EYES ENO SOIL COVER rexruRE P HmtnNl KERS oeSERVnnoN wELLs ❑Y ENO _EYES ENO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF OPSOIL 5< D ) ISEF 11FD MULCHED CENTER EDGES EYES. NO EYES ENO EYES ENO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO OF LATE7SPACIN G AVEL DEPTH BELOW P PF FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS' MANIFOLD PUMP MANIFOLD i DIS R. PIPE ANIFOLD MATERIAL IN DISTH DISTR PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. CIA. /V . PI ES DIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACIN CHILLED COH CT LY COVER MAT RIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS EYES ENO EYES ENO PERMANENT MARKERS noN WELLS oasERVn. COMMENTS: : NUMBER OF PROPERTY WELL. BUILDING: FEET FROM LINE' - EYES EN(O~ EYES E(NO , NEAREST Ll- o Sketch System on unty file for audit. Reverse Side. SIGNATURE TITLE. DILHR SBD 6710 (R. 01/82) EM 11 5 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 _ MADISON, WISCONSIN 53701 V REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: Section IS, Ti`fN, R 10, (or) W, Township or Municipality V C-L Lot No. `acv Block No. " VU, I o~,, )5 1 County T, C ro 1 Sub(livision ame Owner's Name: .a Mailing Address: vti, ( ty Z n S TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW t~ ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS// 7' PERCOLATION TESTS -Z. /7 1;- - -3 /go SOIL MAP SHEET 25A - Z Ft= q I SOIL TYPE - a , Ir Is ko, n4-t - 4 a acv 3, PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- / *4' Ar 15c, 1cJ l P-Z -2-)II 1 $ sL.~ lit S+a Y{d l z y~ r p_ it ~g sL )z +1 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- } 714 ~I A1~avt e- S) S+ G -7 tA it If of B_ a l+ Z B u a I % -7 q -7 q PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Ipcl Ie number of square feet of absorption area needed for building type and occupancy. 6 1' ~ ~ Indicate or distances. Give horizontal and vertical reference points. Indicate slope. R rc, e rc, o Hale- 1N) r 1.. r 113 o Q o~ F tOWTIO o , 3 ~t G~Zeu g ~ 1 a of I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct Self to the best of my knowledge and belief. S~ Name (print) 1~ te'i /VV 0..9 ° 4 Certification No. Address 07 6o K 47 Name of installer if known CST Signature r! C.... COPY A - LOCAL AUTHORITY L ; PLB67 State and County State Permit # S Permit Application County Perm' # Y_ for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: &J (le 14 V.1'e- 0640//V RcX 2 -2- j0411i` Wt IIII ~ 160AI 12~~ Get s. S' /~r![~ B. LOCATION. Section TN, R_/f a (or) 4!n~ot# 3n City Subdivision Name, / nearest road, lake or landmark Blk# Village _i~LOw ~a A,11 Township ,y C. TYPE OF OCCUPANCY: *Commercial o *Industrial *Other (specify) *Variance Single family -4~ Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher --X YES NO Food Waste GrinderYES_XNO # of Bathrooms Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY aOO Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation -Addition- Replacement _ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)_/3) Total Absorb Area sq. t. New IL Addition Replacement *Fill System Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches Akfr Seepage Bed: Length ! Width Depth Tile Depth No. of Lines A IV Seepage Pit: Inside diameter Liquid Depths Tile Size Y~ Percent slope of landO W ~ 4L Distance from critical slope - 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 Certifi d Soil Test r, NAME 4W C.S.T. # y and other information obtained from s owne Plumber's Signature MP/MPRSW# `9'Zd'V.3 Phone #T~~' 3.P Eby Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). t p © a ri _ led /Flo Do Not Write in Space Below F R DEPARTMENT USE ONLY Date of Application Fees Paid: State Qd County Date / O Permit Issued/ date) 21 Issuing Agent Name Inspection Yes No Valid* Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 wsconsin APPLICATION FOR SANITARY PERMIT COUNTY 93ILHR1 - OEPRRTTT1EnT OF (PLB 67) II"IOUSTRV, LRBOR 6 MUTRn RELRTIOnS UNIFORM SANITARY PERMIT # S (x i -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/Zx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNE MAILING ADDRESS PROPERTY LOCATION CITY: VILLAGE: E I 1/4, S , V I N, R E (or) TOw OF: L NUMBER BLOCK NUMBER SUBDIVISION NAM NEAREST ROAD, LAKE O LANDMARK STATE PLAN I.D. NUMBER TY BUILDING OR USE SERVED I 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System 0 Tank Replacement ❑ Repair X Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. S. 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 - El 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 LD O _ Lift Pump Tank/Siphon Chamber v 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): ~0 ? Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Na e,of P}umber (P-rr'nt): Signa e: r MP/MPRSW No.: Phone Number: 2- W' p -6' Plumber's gddress: N e of esign ' COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ❑ Owner Given Initial ,rl liE~tc t/ v (p O b Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBO-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 S.TC-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/contractq', O spec house"), then a second form should he retained and completed when the.'property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - _ - - - - - - - - - - - - - - - - - - - Owner of Property La,J~cl c~_titid GaU (~P_ V.W t H 1 0-yvl so yl Location of Property !VZ-, Section , T N - R W Township a V\ Mailing Address S v x 47 Subdivision Name Lj ~l ow Blida Q-- and' A Lot Number 30 av d pav-E `off ok 97 Previous Owner of Property R er I f3e~fe('.~~- Total Size: of Parcel a y~`7 o- ev-e s 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 7a~ and Page Number as recorded with the Register of Deeds .INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 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 1 (We) cena6y bia:t aee btatement6 on thi,6 6ohm aAe tAue to the best o6 my (ouh) hnow.Cedge; .ghat 7 (we) am (ahe,) the owjen(6) 06 the pnopenty de uLibed'.in thi .in4o4mati.on #6onm, by viAtue o~ a wauanty deed aeeoaded in the 066.iee o6 the county Regi4 ten o j Deedb as Document No. 3. 7 6q and that 1 (we) pnebenttey oun .the puposed 6.i..t'e bon the 6'ewage di&pozat bybtem (oa ,1 (we) have obtained an eabement, to nun with the above dedefubed pnopexty, 'bon the cons tn.uc ti.or, o6 6a.id 6y,6 tem, and tJte Game ha6 been duty neconded in the 066.ice o6 .the County RegizteA o6 Deeda, as Doewnent No. 31/ -J LOA SIG A OF /OWNER SIGN URE OF CO-OWNER (IF APPLICABLE) L~Q U ~/o2G~ /~S~ _ _ DATE SIG ED DATE SIGNED H G cn H Y STC - 105 r, r SEPTIC TANK MAINTENANCE AGREEMENT r+ 0 St. Croix County 0 y OWNER BUYER i a.,ui o-v,,d W1 l1j~ayylSo v, ROUTE/BOX NUMBER 5 Sax 4-7 Fire Number jOS$ CITY/STATE ~~dsav~ -zip S`f0l(o PROPERTY LOCATION: 4, 14, Section N, R - t_ Town of St. Croix County, Subdivision UJ. low RidgQ T Lot number 30 a A,,-c( Port o-F Lo+ aq Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- silts of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank umLe_r. What you put into the system can affect the function of the sL•ptic tank as a treat- ment stage in the waste disposal system. St. Croix County residents maw be eligible to receivu 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 prubram in August of 1980, with the requirement that owners of ail new systems agree to keep their systems properly maintained.-- The 'property owner agrees CO 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. 0 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- 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 / C(.L~ DATE a6~86 St. Ctloix C_,unty Zoning Office P.O. I-ox 98 11ammord, WI 54015 715-7S:6-2239 or 715-425-8363 Sign, date and return to above address. r m x 33 CD d ao a a~vi v, n~3 p v cn w.. N 0 < o ° ° (D ° N 0~ s s co w H ° a 3 ~ `~o c o w w ~A~ 10 3 ccncn o o, Vm '0 c cD a N o- i a N O N - 9 * 113 to o a p 0 ° (D ~ CO CD (D - a 7c tOD CO w A i_ 0 -0 CD CA < N r aOmw 3 o c ac Zs c 6 S.3 Z5* a 00 l<CD cr :3 F w w u, • jw=r 0 ~o05. a3• D te ao-.-ac ° Q o w < N ca a ^ m N C a' D S. CD ° n O c ca ~ ~ o gasCL CD = Om 0 =r 0~N N°~awN• Z _0 Z D 0 a n (D 8; o Fr ° m ~,va -'w?cw°_ F ?w a aC ° :E (D w C m m a c s v a CD = a v? m j N CD (°!1 (D n i ID w' ID a w w V! 0 c C ~0 7 N CL = ao ~ c c aw o m w3w (D -vwNv a s a CL cr `G (0 w B CD U) 0 G)=c acD~3 s o FD* 0 c t0 ° F 0 W o C 0.0 _ d C0(a Q. -1 N C (~D m " w N vlq a°3 o"mo°3 as a3' am ° o 3 vi 0. o < ST 0 c O o DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,, DIVISION LABO49 AND • PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION- JJ~~_~ SECtTIION: ou p Q TOWNS ,IP`/XQNICIPALITY: LOT NO.:BLK. NO.]SUBDIVISION NAME- l` i/W4 ! f A i N/R / 4(or l.l lT~ Q~ W/~~QLC1 / e COUNT OW R'S BU ER'S NAJ MAILING AD RESS: . rc~ x A v) L01 J i m on s ~o t sin Lull S~(C-~, In USE DATES OBSERVATIONS MADE NO. BE RMS.: COMMER IA DESCRIPTION: PROFI ED E IPTIONS: E ATI TESTS: Residence ❑New Replace / / j RATING: S= Site suitable for system U= Site unsuitable for system (y (f J (tJ ICONIIN4 ENTIONAL: MO ND: IN-GROUND-PRESSURE: S STEM-IN-FILL HOLDING TANK: RE OMMENDED SYSTEM:(option 1) S DU S oU S ❑U EIS NU D S U rwe A-W coa~ is If Percolation Tests are NOT required DESIGN RATE:' [Floodplain, an y portion of the tested area is in the u [ 5 nder s.H63.09(5)(b), indicate: indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH OBSERVED EST. HIGHE T TO BEDR CK IF OBSERVED (SEE ABBRV. ON BACK.) B yg`,.78~ 33 s, /1 017 5~ .33 nsI),75-gam s n -Ps .N 191 1.5 0-119, dh IBS 3 •cO n S B- ,n9` X13.39'~C~g' B- .3` 95.V~ > _713,:;~ I 1.93 6n -5j 5 ,0?t5n 5,.D nsj7 C A B- B- _ B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. --PERIODI PERT D2 PERIOD PERINCH P- .76" l~ G 3 P -2 4) j9- 5 P- IVIA 3 3 '3J/ (p : P- P- P_ 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 elev tiop at all borings and the direction and percent of land slope. SYSTEM ELEVATION R'/, .3 _ __m - - - 4 i p ! I 214 I 3 I, 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. NAME (print): TESTS W RE A-] PLETED ON: Va. n W 16 ADDR SS: CERTIF CATI UMBERPHOIJ~ NUMBER(opt' Hal): 1& 33 t~S o ► w l ~c{0 ! (C Co IS- 3 7/ CST IGN T E:/ t DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - o 1 `r +P B.. L 6 7 + P f . LOT ANC I OSS SFC-TIC 67 C; T PP0J PL UMHE k 4r t m i .h t _ ,SAME NAME FL 0 CAT 10 L IC ENS E=//- MAP PLO T: N f f ~ a o }3 t 4 sr FRESH AIR INLETS -AND OBSERVATION PI.Q1; CROSS SECTION _ _Approved Vent Cap 44t Minimum 12" Above' Final 4" Cast Iron Above Pipe vent Pipe To Final Grade--- .j { Marsh Hay Or Synthetic Covering Min. 2" Aggreg~ile Over Pipe Distribution w Tee Pipe _..._...._.I _ Aggregate- Perforated Pipe Below I Beneath Pipe 4--- Coupling Terminating At Bottom of System MOP Red