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02/02/2005 07:53 AM
Parcel 020-1053-60-100 PAGE 1 OF 1
Alt. Parcel 20.29.19.197L 020 - TOWN OF HUDSON
ST. CROIX COUNTY, WISCONSIN
Current ',X,
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* NOVAK, LORETTA J
LORETTA J NOVAK
480 JACOBS LA
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 480 JACOBS LA
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 3.792 Plat: N/A-NOT AVAILABLE
SEC 20 T29N R19W PT SE SE LOT 2 OF CSM Block/Condo Bldg:
6/1525 EXC CTY RD PROJ 96-UU-1
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
12/23/1998 594418 1390/11 QC
05/15/1998 579216 1323/598 WD
12/11/1997 569722 1282/071 WD
07/23/1997 946/43 more...
2004 SUMMARY Bill Fair Market Value: Assessed with:
48025 254,400
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.792 50,700 146,100 196,800 NO
Totals for 2004:
General Property 3.792 50,700 146,100 196,8000
Woodland 0.000 0
Totals for 2003:
General Property 3.792 50,700 146,100 196,8000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 215
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
001-WATER SPECIAL ASSESSMENT 0.00
Special Assessments Special Charges 00 Delinquent Cha 0 00
Total 27.00
I y , M I,
4 Form -STC - 104
w
AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP SEC. T 9 N-R~W
OWNER
ADDRESS ST. CROIX COUNTY, WISCONSIN
I ~
ss L o{ c,,ia! 7
LOT LOT SIZE
SUBDIVISION "
PLAN VIEW
Distances and dimensions to meet requirements of II-HR 83 .~9 L
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~Y, Z2
f
t ! cJ,;~L.
t
-y7`
R ~ I
~r
r
t
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 14 / 962,2 j®/.€
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer:„ ,/Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,® Rear, O feet
From nearest property line Front,O Side, Rear, O _ feet
Number of feet from: well , building
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
.Aik
4
a
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, ORear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: ,r Trench:
Width: / Length: Number of Lines:. Area Built:Z
Fill depth to top of pipe:
Number of `feet from nearest property line: Front, O Side, O Rear, pt.
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, OFt.
Number of feet from well:
Number of feet from building:
Number of-feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: -J 7° ~G Plumber on job: t12~j,,,)42W 6~CC
License Number:
3/84:mj
I NT & BUILDINGS
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR DIVISION
LABOR & HYMAN RELATIONS PRIVATE SEWAGE SYSTEMS
BUREAU OF PLUMBING
P.O. BOX 7969
MADISON, WI 53707
®xONVENTIONAL DALTERNATIVE State Plan l.D. Number:
(If assigned)
D Holding Tank D In-Ground Pressure E Mound
N
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: IS//ECTION ~ DATE
p
Larry Hanson R.R., New Richmond, WI 54017
_~L
REF. PT. ELEV.: CST REF. PT. EV..
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
SE SE, Section 20, T29N-R19W, Town of Hudson, Lot#2, Pinegrove Hts.
Name of Plumber: MPIMPRSW No.. Cnumy.. Sanitary Permit Number.
Cal Powers 1563 St. Croix 79195
SEPTIC TANK/HOLDING TANK:
MANUFACTUR LIQUID CAPACITY. TANK~NLEELEV. TANK OUTLET ELEV.. W OVIID DLABEL PROVIDE DOVER
Q ,5 D N./~ y YES ONO OYES ONO
BEDDING: VENT CIA VENT MATT HIGH WATER NUMBER-OF ROAD'. PROPERTY WELL. BUILDING: ivA ENT TO TRH
JALARM FEET FROM 3
MYES ONO C V EYES ONO NEAREST _ v v
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. P7RC ANUF ACTUREH WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
OYES ONO EYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHOPEHTV WELL BUILDING JVENTTOFRESH
LINE AIR INLET:
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) EYES ONO NEAREST-t
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Dlna F TEH ATE HInL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until the soil is dry enou gh to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH'. JLENI~TH NO OF DISTH PIPE SPACIN(I COVER NSIOL DIA P, TS LIQUID
THE N< TEH IAL PIT DEPTH'.
DIMENSIONS
(_H~VEL I)FPTH FILLDEPTH DISTH. PIPE DISTH PIPE DISTR. PIPE MATERIAL NO I„TH NUMBER OF PROPERTY WELL BUILDING' VENT TO FRESH
BELOW PI ES A ABOV OVAR El V. INLI T ELE END PIPES FEET FROM LINE ~j'~ ~ AI R_IDN LET.
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.
OYES ONO
PEHMANI NT MAHKFHS OBSERVATION WELLS
SOIL COVER [TEXTURE
OYES ONO OYES ONO
DEPTH OVER TRENCH BED DEPTH OVER THENCH BED JDEPTH OF TOPSOIL St)DDFD YE UFD MULCHED
CENTER EDGES
. ONO OYES 0No DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
JND DTH. LENGTH NO. OF LATERAL SPACING GHAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCrR EN CHES
DIMENSIONS
ANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH DISTR. PIPE DISTHIBUT ION PIPE MATERIAL & MARKING
LE V.ELEV CIAELEV. PIPEDIAELEVATION ADISTRIBUTIOINFORMATIOOLE SIZE HOLE SPACIN LG HILLEU CORRECT LV COVER MATERIAL VERTICAL LFT CORRESPONDS TO APPROVED
PLANS
OYES ONO DYES ONO
PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING:
COMMENTS: FEET FROM LINE:
OYES ONO OYES ONO NEAREST _
Sketch System on Retain in county file for audit.
Reverse Side. SIG AT R TITLE.
DILHR SBD 6710 (R.01/82)
7DILHR SANITARY PERMIT APPLICATION COUNTY - ,
In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT #
-Attach complete plans to the count co only) for the system, on not less than 5
( Y PY paper E 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 X NO
PROPERTY OWNER PROPERTY LOCATION
' '/4 t/4, , N, R E (or)
PROP R WNER'S MAILING ADDRESS LOT NUMBER BLOCK N MBER sUIVISION NAME
CI STAT ZIP CODE PHONE NUMBER CITY NEAR ST R[Z, LAKE OR LANDMARK
O VILLAGE :
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. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Cy Existing System
2. A Sanitary Permit was previously issued. Permit # !7 0.39 - Date Issued &2
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. X 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. R1 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):
Feet X 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 stCon glass App.
Tanks Tanks
Septic Tank or Holding Tank
❑ ❑ ❑
140Q 7 &wad El El
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): Plu er's Signat re: ( Stamps) MP/MPRSW No.: Business Phone Number:
Plu ber's Addr s (Street, 'ty, State, Zip Code): Name of Designer:
h24 S16L7
ffA) VIII. SOIL TEST INFORMATION
Certif d it Tester T) Name CST #
6JACBet
CST' DDRESS (Stre t, city, SW e, Zip Code) Phone Number:
~s-
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater. Date Issuing Agent Signature No StampsM
Approved ❑ Owner Given Initial S rcharge Fe
Adverse Determination f V 0 v~
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
d
`
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT-
APPLICATION
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 whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage systern, 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 s to be
installed;
II. Type of building or use served: If public is checked, `andicate 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;
lil. 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'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 Groundivater,
included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's "
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried (reasLire
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 anonles collected through these surcharges are credited to the groun.awrter t. nd adminis-
tered by the Department of Natural Resources. These funds are used for rrIon'Mrlog ground- t
water, groundwater contamination investigations and establishment of stands ds Groundwater
it's worth protecting.
SBD-6398 (R.03/86)
SAFETY & BUILDINGS
DEPARTM~ENT OF REPORT ON SOIL BORINGS AND P .O. BOX 7969 IKDUSTRND PERCOLATION TESTS (115) MADISON, W1 53707
LABOR A .09111 & Chapter 145.0451
1UMAN FZELATIONS (H63 LOT NO.: BLK. N SU IVISION NAME:
TOWNSHIP/ ALITY:
1 SECTION: N/ lorlA
3CAT10% - /4 Q / L
R
AlLI A DRESS:
OWNER'S UYERIS N ME:
C~ NTY:
DATES OBSERVATIONS MADE
PROFILE DESCRIPTIONS: PER OLATION TESTS:
USE : COMMERC AL DESCRIPTION:
NO, BEDRMS. r-~+New Replace _
,JZResidence De
:(Optional)
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDIN12-6 K: RECOMMENDED SYSTE oJ OU S clu S ❑ i S ❑U ®
If any portion of the tested area is in the
DESIGN RATE:
If Percolation Tests are NOT requir Floodplain, indicate Floodplain elevation:
f under s.H63.09(5) (b), indicate:. PROFILE DESCRIPTIONS
DEPTH TO GROUNDWATER-INCHES TCHARACTER O BEDROCK IOF OBSIERVED (SEE I ABBRV. ON BACK jEXTUR E, AND DEPTH
BORING TOTAL ELEVATION OBSERVED EST. HIGHEST
NUMBER DEPTH ra _
B-
B-
B-
B-
B- PERCOLATION TESTS RATE MINUTES
DROP IN WATER LEVEL-INCHES PER PER I CH
TEST TIME pERlo 2
TEST DEPTH WATER IN HOLE ,
NUMBER 11~861.1~6 AFTER SWELLING INTERVAL-MIN. PERIOD 1
P-
P-
P-
P-_
P-
P- percent
` N: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or dist nces. Descri a what are the on-
on the plot plan. Show the surface elevation at all I gs and the rection and p
PLOT PLAN.
and vertical elevation reference points and show their location 1SL
of land slope.
SYSTEM ELEVATION
f~
:
E
t
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t
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i
t
.r E _ 4 I 4 J
E 3
W ~ N
= x
a t 1
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i t
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i 1
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i
ods specified in the Wisconsin
ji_ form were ma . by me in accord ^ is, th *h? Procedures and meth
I, the undersigned, hereby, certif that the soil tests re redo hi
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
TESTS WERE COMPLETED ON:
NAM ri
J t CERTIFICATION NUMBER: PHONE NUMBER(optional):
T TU
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
-OVER -
DILHR-SBD-6395 (R. 02/82)
INSTRUCTIONS FOR COMPLETING FORM 115 - S13D - 6355
a y
To be a complete and accurate soil test, your report must inclu(je.
9. Cor-nPlete legal description;
2. The use secti, i must clef indicate whether this is a r
3. MdA?C(Vr rho of
s or commercial use pla project;
4, Is ne
s=;SterYt;
5.
oxes. A Sl- "UITABL.E FOR A H )L
TANK {7lVLV IF ALL
:l OUT BA OOIL C":'-)l?"IC3tV
7, own her
~i r ' completing the plot plan;
' st
i to ! preferred. A
3 to are clearly shown, and are permanent,
test eXet?lp-
11. _ flood plain, eleuati
2. i tar current addre box;
-')d distribute as rer ~
L C/AL.. TY WITHIN 30 DAYS C '.ET >T BE FILED -VITH THE
~ ~TIONS ITI
cob
p
gr. - I
*s I
HG
cs
id Perc
reeds d
yif
fs F ,
Bldg
Is L
sil -
si _
cl-C
Loarn
sc y
sic - S
P
p~
r
' 11V
}i
Gi BM
VRP - Vet l az7ii t
TO THE C "1
y . Ft.
o to to
permit. _
DEPARTMI( REPORT
INDUSTRY, REPORT ON SOIL BORINGS AND ;
LABOR AND
SAFETY & BUILDINGS
HUMAN RELATIONS PERCOLATION TESTS (115 DIVISION
) P;O. BOX 7969
L CAT1o (H63.09(1) & Chapter 145,045) MADISON, WI 53707
11 1s I //,y H (or TOWNSHIP/M
k1a3 Y: OT NO,: BLK. NO.: SUBDI ISI N NAME:
COUNTY; N S BU ER' N
J E: M ILING,A DRESS: '
USE t
COM R L D SCRI ION: DATES OBSERVATIONS MADE
®Residence rr~ FI
bA1New ❑Repiace NS: i N E S.
RATING. S- Site suitablMO for system U= Site unsuitable for system
JC~ONVENT N~• D:-`
~Y V IN-G ~ UR SYSTE -IN-FILL HOL ING TANK: RECD ENDED SYSTEM: (optional)
J~~ 0 [IS U D S
If Percolation Tests are NOTequire DESIG RATE: 4Q4 w';'I
under s.H63.4$(5)(bi, indicate: if any portion of the tested area is in the
Ffoodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
NUMBER f3E11•i 1M, ELEVATION BSERVED '
BORING TAL PTH T R D ATER-INCHE CHARACTER OF S IL Wi H THICKNESS,
P CQLOR TEXT
GHE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) TEXTURE, AND DEPTH
B- ~ - ~
s
13-
B_
PERCOLATION TESTS
DEPTH WATER IN HOLE TEST TIME
NUMBER INGHEg- AFTER SWELLING INTERVAL-MIN. DROP iN WA R L VEL-INCHES
P_ 3,.'lha f 10 t p RATE MINUTES
PER INCH
P_ . .
r
P- !
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances, Describe what are the hori-
zo land slope.
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings ant9te`directiort and percent
SYSTEM ELEVATION
Al 0)
,
k
F
,
.
I
,
r
- r s a
1
I
,
yu I
1-20
1
) r
I a
the undersigned, hereby certify that the soil tests re6orted on this form we maI by me in accor q~ s proced
d~wlth the
dures and methods specified in the Wisconsin
'kdministrative Code, and that the data recorded and the o ation of the tests are coiI to the best of my knowledge and belief,,-
TESTS WERE COMPLETED ON.,
CERTIFICATI N NUMBER: PHONE NUMBER(optional)i.
C IC ATU E:
)ISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
118-S80-i 5 (R, 02/82)
OVER
1-2
0 4,
i
C_. tai✓~ v.;7~~s
}~~1~Sr,J }S-'G3
i
E
°~~uSF
97
9 S
PAGE OF
Cro5S Bechar 0~ A Zeo S stems
~p Fresh Air Inlels And Observation Pipe
70/7 C~--- Approval Vent Cap
Minimum 12" Above
Fine, Crrad•
i
P
20- 42" Above Pipe _ 4" Cost Iron
To Final Grods Vent Pipe
Marsh Hoy Or Synthetic Covering
i "In. 2" Aggregate
over pip"
Ol,trlbutlon
Pipe 0 0 0 0 0 - Tea
r
Aggregate
Beneath Pipe each Pip•
B o Perforated Pipe Below
( o Coupling Terminating At
Bollom of system
(
I
` PrUPOseD t'inal 119ro c1<
1E /r-
~L~~JnT Ion
SOIL FILL
DISTKiBUTiO" PIPE
APPROVED S4MHETIC COVER
9,. O
Z"OFA$GR~GAIB OR M R'S`N NAyF STRAW
(e OF J2-21~t AGGREGATE
DISTRIBUTIOM PIPE TO BE AT LEA57 ( INCHES BELOW ORIGINAL GRADE
AIJU AT LEAST?-0 INCHES BUT 110 MORE THAI) 42 IAICHES BELOW FINAL &RADE
MAXIMUM ®EPtH OF ~XeAVATIO0 FROM ORI&WAL 6RAoE WILL BE INCHES
rdP(IMUM Mr" OF EXCAVATION FKO^ 01KI61WAL raRADE WILL BE azzL~1- INCHES
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ST. CROIX COUNTY
WISCONSIN
i 9fx 1~ } t
ZONING OFFICE
~.:sa 4 W
796-2239 (HAMMOND)
j 425-8363 (RIVER FALLS)
HAMMOND, WI 54015
June 17, 1986
Ms. Carolyn Haag
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Carolyn:
Permit # 75039, issued to Larry Hanson on 4-9-86 has been rescinded
due to relocation of the system.
Permit #79195 was issued today for that system.
Attached please find permit #75039. Should you have any questions
regarding this, please contact this office.
Sincerely,
Mary J. Jenkins
St. Croix County Zoning Office
wisconsin APPLICATION FOR SANITARY PERMIT
N1 0 1 L-H R (PLB 67) COUNTY
- InpusTRY, LR Lfi DEGgg1T OFBOq 6 MUmgn gELRTlO1"IS UNIFORM SANITARY PERMIT #
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
~-41~ rr v.sa R
PROPERTY LO ATION CITY:
VILLAGE:
/4 Stl/4, S 21) , T -)~N, R / r) W TOWN OF: ►`I
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME J NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
tj p
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
K 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.
X 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
Gallons Tanks Concr to Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: ecN-Q-~4
Aim,
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of L 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):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume resp sibility for installation of the private sewage system shown on the attached plans.
N me of PlumbT~r in t): SignL~,3~_911 MP/ MPRSW No.: Phone Number:
A-A-P'W 1 X63 (7/S►a9'6
Plumber's Address: Name of Designer:
d/
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:: ❑ Disapproved
N v~ ❑ Owner Given Initial
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.); C
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
s
4. Indicate the design percolation rate listed on th -wil 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-Wmit 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.
' F
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
Location of Property 14, Section C:9 , T--L-N-R ~ W
Township
Mailing Address
Address of Site _-Riz,
Subdivision Name P
Lot Number a
Previous Owner of property ~p.? rn q d Q yx
Total Size of Parcel
Date Parcel was Created o
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? J~ Yes No
Volume and Page Number 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
I (We) cetti6y that at statements on this ganm aAe true to the be.s.t og my (oUA)
knowledge; that I (we) am fake) the owneA(s) og the pnapehty descA bed in tW
.ingoAmation goAm, by viAtue og a wa~rAa y ed ne onded in the Oggice ag the
County RegiAten og Deedsas Document Na. and that I (We) pne~sentty
own the proposed site got the sewage dv~ as yst m (on I (we) have obtained an
easement, to nun with the above desnibed pnapetrty, gate the cons;ftuction og said
system, and the same has been duty neconded in the Ogg.ic ag the County Reg.usten og
Deeds, as Document No. )
SIGNATURE OF OWNER SIGNAT OF c6-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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STC - 105 r
. r
a
SEPTIC TANK MAINTENANCE AGREEMENT rH-~
St. Croix County 0
z
d
OWNER/BUYER y
c~
ROUTE/BOX NUMBER Fire Number
CITY/STATE CtJ':& ZIP 5~/C5 / 7
PROPERTY LOCATION: 14, Section T (X/ R W,
W AAA
Town of St. Croix County,
Subdivision P!r%k C MQayQ- Lot number
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 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
three year expiration. H
0
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- b
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning 0 is wit 'n 0 days
of the three year expiration date.
SIGNE
DATE
St. Croix County Zoning Office
P. 0. Box 9&
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, `date and return to above address.
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INDUSTRY, E'NT OF
IhIDUS AND REPORT ON SOIL BORINGS AND SAFETY'& BUILDINGS LABOR DIVISION HUMAN R RE ELATIONS \ PERCOLATION TESTS (115) P.O. BOX
7969 , i, (H63.090) & Chapter 145.045) MADISON, WI 53707
LOCATION: ECTION: TOWNSHIP/M Y: OT NO.:BLK. NO.: SUBDIVISION NAME:
/ N/R (or l'.I , : ~`L ! -r
COUNTY: NER'S BU ER'S N E: MAILIN ADDR SS.
USE Q /
NO. BEDRMS : COMMER L DESCRIPTION: DATES OBSERVATIONS MADE
LE-
Residence PR FI
D 1 I NS: A ION TESTS:
3 [New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
ON0VEcNTI NAL: MOUND IN-GROUNDPRESSURE:S STE~+-I -FILLHOL IINGTANK:RECO ENDED SYSTEM: (optional)
v~~J ®S 11U EIS U ~J
If Percolation Tests are NOT require DESIG RATE:
under s.H63.09(5)(b), indicate: If any portion of the tested area is in the
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING _rOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOI
NUMBER L WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
DEPTH N1, ELEVATION OBSERVED E I HE TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.)
B- ~j
B-
B-
B-
vs-
B-
PERCOLATION TESTS
TEST
NUMBER WGHES- FTERSWELOLING INTERVAL- MIN. DROP IN WATER LEVEL-INCHES
ES
P RI D 1 RAPER INCH
P_ PERI 2 p A PER INCH
P- ► r
P- - / 7
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 elevation at all borings an6 e'
, S
of land slope. direction and percent
SYSTEM ELEVATION ~..5
l
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is
.
1 ,
1 ~
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t ;0" f ~ 3 t
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I
I, the undersigned, hereby certify that the soil tests redorted on this form we ma9l by me in accor with the procedure and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of tee tests are corr€Ct to the best of my knowledge and belief.-
NAME. (print :
TESTS WERE COMPLETED ON:
114'2 :
A S
CERTIFICATI N NUMBER: PHONE NUMBER(optionall:
C IG AT E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82)
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1s / . s- 1A r~SS SZC~II)n o1 ~e~ S~s~
ski Fresh Air I111616 And Observation Pipe
1 Approved Vent Cap
Minimum 12" Above
Final Groda
20- 42" Above Pipe _ 4" Cost Iron
To Final Grade Vent Pipe
Marsh Hoy Or Synthetic Covering
Min 2" Aggregate
Over pipe
Olurlbullon
Pipe 0 0 0 0 -Too
6" Agaregot•
Beneath Pip• a Perforated Pipe Below
0 Cowling Terminating At
Bottom Of System
Pru~o~et~ t'Inkl 9rH~1{ ~ ~
SOIL FILL
DISTRIBLITIOU PIPE
APPROVED SI'INTI-IETIC COVER
r'DFA,GGREGAIE MATEIiII~t OR 9" OF STRAW
OR MARSH NAy
(o
ELEV. OF%p-Z'/Z AGGREGATE
DISTRIP_iUTION PIPE TO BE AT LEAS-T IUCHES BELOW ORICO"AL. GRADE
AUD AT LEASTZO IUCHES BUT 1.10 MORE THAI) 42 INCHES BELOW FlUAL GRADE
it
MAXIMUM DEPTH OF EXCAVATmwi F~oM OKI&INAI, 6KAID€ WILL BE ` IUCHES
M41MUM Mf rkt of FACAVATIOM FRoM 11*141WAL CaRAPE WILL BE y INCHE S
SIGKJED:
LICEUSE DUMBER: L5-G
DATE:
7` ~(p