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Parcel 020-1148-60-000 01/31/2006 11:28 AM
PAGE 1 OF 1
Alt. Parcel M 33.29.19.794 020 - 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): O = Current Owner, C = Current Co-Owner
TIMOTHY B & JEANNE A HALL O -HALL, TIMOTHY B & JEANNE A
584 TWIN OAKS CIR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 584 TWIN OAKS CIR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.290 Plat: 0215-COUNTRYSIDE VILLAGE
SEC 33 T29N R19W COUNTRYSIDE VILLAGE LOT Block/Condo Bldg: LOT 8
8
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
08/12/2004 771551 2637/240 WD
07/03/2003 728746 2301/167 WD
847/323
752/277
2005 SUMMARY Bill Fair Market Value: Assessed with:
92662 306,700
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 .2.290 76,200 236,600 312,800 NO 05
Totals for 2005:
General Property 2.290 76,200 236,600 312,800
Woodland 0.000 0 0
Totals for 2004:
General Property 2.290 31,500 203,100 234,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 140
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
Form - ST C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER r~,rii► - s TOWNSHIP !7t 5O SEC. ~rT ~!Z N-R/1~_W
ADDRESS JZ `I ST. CROIX COUNTY, WISCONSIN
SUBDIVISION S f! eg jOT 2 LOT -=W *J~
PLAN VIEW
Distances and dimensions to meet requirements of I•I,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
fc `
o ~d
j r0' We
98r
N
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used , ~Elevation of vertical reference point:
1d6 Proposed slope at site:
SEPTIC TANK: Manufacturer Liquid Capacity:
C.~ 2L
Number of rings used: n~f Tank manhole cover elevation: J
Tank Inlet Elevation: ,Tank Outlet Elevation:
(ZIN
Number of feet from nearest Road: Front, Side, Rear, O~ feet
From nearest property line Front, Side,O Rear, O feet
i
Number of feet from: well Z building: Z Z5-I
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: So hd *Zk Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer:' A Pump Size
Elevation of inlet: 60:' ottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: _~~ut?R.t Alarm Switch Type: Number of feet from nearest property line: Front, ® Side, O Rear, Ft.? 50~ .
Number of feet from well: ho 0e,1k o.. S
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM / "6(j u,"-A ^ 4 JQ
Bed: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, 0 Side, O Rear, 01?t. 325/
Number of feet from well: ,rip Ut3 e s_
?i
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT l"< I~
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:
< s H
Plumber on job:
Dated:
License Number : _
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
MADISON, WI 53707 BUREAU OF PLUMBING
OCONVENTIONAL UALTERNATIVE State Planl.D.Number:
(lf assigned)
D Holding Tank D In-Ground Pressure ILNound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DAATE:
Perry Rossow 122 - 11th Street Hudson WI 54016 f~ y6/1 v
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
NE SE Section 35, T29N-R19W Town of Hudson Lot 8 Countryside Vil .
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
John Sykora, III 3212 St. Croix 88437
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: JLIOUiD CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
DYES ONO OYES ONO
BEDDING: VENT DIA
VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
JALARM FEET FROM LINE: AIR INLET.
DYES ONO DYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIOUID CAPACITY: PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO DYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET'
PUMP ON AND OFF) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moistureat 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:
BED/TRENCH WIDTH: LENGTH NO OF DISTR. PIPE SPACING COVER JINSIDE DIA UPITS E
TRENCHES. MATERIAL: PIT DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VEBELOW PIPESABOVE COVERELEV. INLETELEV.
ENDFEET FROM LINE AINEAREST-
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-
DYES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
OYES ONO DYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. D MULCHED
CENTER: EDGES:
DYES 'ONO SEEDE DYES ON OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTHIBU TION PIPE MATERIAL $ MARKING
-
ELEVATION AND ELEV.: ELEV, DIA.. ELEV.: PIPES DIA.:
i
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES NO DYES NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WEL S: NUMBER OF PI PERTY WQ
DYES NO E] ONO FEET FROM L NE:
~,.4
0
C
'CIO -7,
Sketch System on , ~ -
Reverse Side. Retain in county file for audit.
~A - ,51 SIGNATURE: DILHR SBD 6710 (R. 01/82) TITLE
t1nV/snf/v
SANITARY PERMIT APPLICATION COU Y
OILHR In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on not less than Dfy9
paper STATE PLAN I.D. NUMBER
8/2 x 11 inches in size. F9
-See reverse side for instructions for completing this application.
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PETITION
FOR VARIANCE ❑ YES ❑ NO
PROPERTY OWNE_p PROPERTY LOCATION
e9s~LW '/4a C '/4, S ~ T4 N, R E (or W~
PROPERTY NER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SyyggDIVISION NAME
L r ode . Ll4
CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST R AD, LAKE OR LAND ARK
f 7& j ED VILLAGE : S 0 1-4
r r
II. TYPE OF BUILDING OR USE SERVED: A114
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): A1l 4
Ill. 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. ❑ 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.X Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. M Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑ seepage Bed b. ~I 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 ~ re Feet): PROPOSED Square Feet): ~s
490 ~7t' 0c~-G Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION w Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tae
Nnks Tanks structed
Septic Tan Mr Holding Tank 1:1 1:1 ❑ 1:1
m Tan Si honChamber ❑ ❑ ❑ ❑ ❑ IL F VII. R ONSIBILITY 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) /MPRSW No.: Business Phone Number:
> 57
Plumber's Adq s (Street, City, State, Zip Cod Name of Designer:
o ,
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST
4, " 3
.2
i~Z_T,S ADDRESS (Street, City, Stat ip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
j ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
V~ Approved ❑ Owner Given Initial ~ Su har9e~Fee
Adverse Determination U
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 whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
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;
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'/z 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 years of steady negotiation and public debate. The groundwater bill Groundwater
included the creation of surcharges (fees) for a number of regulated practices which Wiscorisi is
can effect groundwater. The surcharge took effect on July 1, 1984' Ali of the water that buried tteasdre
is used in your building is returned to.. the groundwater through your soil absorption o _ 'system or the disposal site used by your holding tank pumper.
The monies collected through these SUrcharges are credited to the groundwater fund adminis-
tered by the Department of Natural R soy rce . Trtese funds are used for mon Loring ground- 1
grater, groundwater contamination in es. jaii )n5 and establishment of standa-1s, Gro.ind,,~
i`'s worth protecting.
S9D-6398 (8.03/86)
Labor and Human Relations
Department of Industry,
State of Wisconsin
PLAN._APPROVA~ SAFETY &pfI plumbingslON
PR,I~ATE~ SEWAGE._. Bureau Washington
P.O. Avenue
201 ESox 7969 Madison, Wisconsin 53707
Owner: PERRY ROS~TREE.T
7.2.2 7.1TH WI 54016
SYKORA EXCAVATING HUDSON
ROUTE 2 BOX 75 WI 54724
BLOOMER Approved-, November 10, 1986
Date App October 29, 1986
Date Received 3,29,19W
Plan Number: 86.01499-S Location: NE,SE,3
RE. Day: 450 S'T CROIX
Gallons Per ROSSOW, PERRY - RESIDENCE County:
for
Project Name:
Town of HUDSON this project have been revie e Chapter
This approval is based nCha e
Compl lens and specifications far code. The pl.-
The plumbing p licable code requirements. Hance With
ngent upon camp
with app contingent t be
compliance royal is corrected,
in Statutes and the 'Wis This~.rapp m~nistrat~. noted mu wined
145, Wiscons roved . shall be obt
conditionally app lans. All items that ore county installation
ship this
stamped shown ar' the plans. town i
any sti.pu].ati.ons the city, sponsible for at the
The licensed plumber
All permits requ ired by royal stamp
drtmen ret's app inspector when
prior to construction. lens with the dep the appropriate
one set of p shall notify
shall keep The installer
construction ,site. sanitary
roved or if a Tres.
inspections can be made.
from the date app permit eXp
will expire two years the initial sanitary
This approval ire the day a system code
sewag
permit is obtained, it will expire
fans for private requirements
plumbing has reviewed these p._ the code The fans have not been reviewe 50-64 of the
r d or
el Bureau of only. These p eneral plumbing or in Chapters
requirements 82 for
set forth ~dministrativeR code. g
Wisconsin components only:
This approval is for the foll.ow~ng
NEW MOUND calling (608) 266--•9374.
ties concerning this approve]. may be made by
Inqu'~
Sincerely,
EDERSPII_I...
ANTHONY T l.umbing
Bureau of s Division
Safety and Bu i.l.di.ng plumbiing Consultant
PPP022/0009w/16 UW-SSWMP - Environmental Healt
cc: PERRY ROSSOW County - -e Consultant plumber Owner
Private Sewag sg..._
SAFETY & BUILDIIVuz'
DIVISION
ON SOIL BORINGS AND P.O. BOX 7969
r '4RTMENT OF REPORT N TESTS (11 ) MADISON, WI 53707
,JUSYRY, PERCOLAT10
LABOR q,ND (H63.090) & Chapter 145.045)
HUMAN RELATIONS OT NO.:BLK. NO.: SUBDIVISIttON NAME:
OWN UNICIPALITV: ~pp T/ ON: 1 1 33 /TA N/R/90 to
1 ~ON ~
'S AME: MA 14
COUNTY' W ER B SS~~ DATES OBSERVATIONS MADE STS,
C~ r O S:
/rOI F ~ ~
e Q ~i~ Y
USE .BEORMS. COMM, A SCRIPTION: []Replac R Z
No: N lew
Residence .3 _
table for system A N ILL OLDING TK: rEI ENDED STEM:loptional)
U. Site E; g T IN-F
RATING' S, Site suitable for system GROUNsuiQ~n
ONVE =09T DS lL~ai 0 S
DESIGN RATE: If any portion of the tested area is in the
If Percolation Tests are NOT required Floodplain, indicate Floodplain elevat
under s.}163.09(511b1, indicate:
PROFILE DESCRIPTIONS
GS DEPT
b'
p T R UNDWATER-1IH HES TO BEDROCKOIF OBSIERVEQ (SEEI ABBRV CO B Du IE TURE, AN
BORING TOTAL ELEVAT►ON BSERV D 9~. ~Si~ f,3. gsil y► ~ 3 ~
NUMBER DEPTH IN, s~Gw , 5' p
11 ~
mot @
B. ~11~ cb727 none 30 o' w le
It4Jsil, 3B- o~ p$•. none 3y jmoECp g/~sr~yKdh ,•S~d~s;~,. s'e~~s~5~'
1.0 1611
B. .~s B1 sl 1-4
is ~J h0h~ yV ' t2 15*1
B. ?p . 7
B-
B- PERCOLATION TESTS RATE MINUTES
DROP N WA ER L V L•IN HES PER INCH
DEPTH WATER IN HOLE TEST TIME _
NUMBER INCH; AFRSWELUNG INTERVAL-MIN- P
P. s J ya_ ,
P-
P-
P-
P- 1
LP-
RECEN-0
OCT i9ffi
PLUMBING BUREA'•
STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township/1 4W bM:
NE Se S 33 T 29 N/R 19 St. Croix
Subdivision: County:
Street Address:
Lot 8 Countryside Village
Landowners Name: Mailing Address:
Perry Rossow 122 11th Street, Hudson, WI 54016
I (We), the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
suited for a conventional private sewage system. If approval is granted, I
agree to have the system installed in conformance with the Bureau's approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county official to
arrange the time and date to begin construction of the system.
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
8600
I r Qn
agree to give notice to any subsequent buyer that an application
alternative system has been made and if installed, that the premises are served
by an alternative system and further agree to give the buyer a copy of this
application.
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
]RECEIVED Signatur of Applicant Date
STATE OF WISCONSIN OCT 2 1 IM Subscribed and sworn to before me
SS.
COUNTY OF Pierre PLUMBING BUREV_' This 29th day of September 19 86.
Notary Public, State 4qisAconn?=siZnn1
DILHR-SBD-6413 (N. 05/81) My Commission Expires: 4/24/88
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ry 796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
w
HAMMOND, WI 54015
September 26, 1986
Division of Safety and Building
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation for the Perry Rossow property, located at
the NE-4 of the SE-4 of Section 33, T29N-R19W, Lot # 8, Countryside
Village, Town of Hudson, St. Croix County, revealed suitable soils
at a depth of 30 inches, below which seasonable high ground water was
noted.
This site should be suitable for a mound.
Should you have any questions, please feel free to contact this office.
Sinc rely,
Thomas C. Nelson
Assistant Zoning Administrator
TCN/mj 8499
RECEIVED
OCT 211986
PLUMBING BUREA1'
i
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location NE 1/4, SE 1/4, Sec. 33 T 29 N, R 19 VA W
Town )MFTC W Hudson Street Address
Lot No. 8 Block Subdivision Countryside Village
Landowner's Name: Perry Rossow
The application for this site is for:
® new construction use.
❑ replacement system use.
If this is NEW CONSTRUCTION USE, the alternative private sewage system is:
[.1 to have one of the first five approvals guaranteed for this year. This is
number - - of those applications. (Use one of the first five
quota num ersissueto you.)
M one of the applications needing a quota number. The quota number assigned to
this application is 59 - 15 - 7 .
❑ for one additional homesite on a farm to be occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
F ]for an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by the
department.
[Afor an application on file prior to February 1, 1980.
[_]for a lot that meets the criteria for a conventional private sewage system.
If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is
replacing:
❑ a failing conventional soil absorption system.
Da holding tank that was installed and in use prior to February 1, 1980.
❑ a privy that was installed and in use prior to February 1, 1980.
If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a
conventional private sewage system, check here .0
I certify that the above information is true and accurate to the best of my
knowledge.
Name Thomas C. Nelson S1 re
County Official
Title _Assistant Zoning Administrator Date September 26, 1986
DILHR-SBD-6158 (R 12/82)
24
20 S
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U- 16
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0
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0 16 32 48 64 80 96 112
U.S. GALLONS PER MINUTE
SOLIDS Head-Capacity: SV40 and SVK5e Submersible Residential Sump Pumps
Max. Solids SV40,11/x" & SVK50, 2" Spheres; 4 Pole, 60 Hz.
•
HANDLING 32 _
SUBMERSIBLE
28
- -
z 24 - E-104
20
SEWAGE W 16
0 g
& EFFLUENT `12
I
PUMPS
0 20 40 60 80 100 120 140 16G
U.S. GALLONS PER MINUTE j
Head-Capacity: SP40A and SP50A Submersible Sump Pumps
Max. Solids SP40A,11/4" & SP50A, 11/2" Spheres;
115 Volts, 60 Hz., 1750 RPM
40
- -t -
36
32
- -SKI
010
324 K7$ +
t {
20 7 i
16
412
8
4
0 20 40 60 80 100 120 140 160
U.S. GALLONS PER MINUTE
Head-Capacity: SK60, SK75 and SK100 Submersible Sewage Pumps
Max. Solids 2" Sphere, 1750 RPM
HYDR-0-MRTIC
PUMPS ~
O CT A ~ A Division of Wylain, Inc
' ~ Post Office Box 327, 4191289 3042
1 Claremont 6 Baney Roads, Ashland, Ohio 44805;
il-t2 i $ «t7 ,
~ M GrNdc Wylain Canada Ltd. Ltd*., 120 East d., Brampton, Ontario L87 *C2
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PL P'1P CHAMEER CR6°5 _ECTI01.1 A~JG SPECIE IC!'f"I '!y
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WEATHER PROOF APFROVED LOCKIMG
=ROM DOOR, JUNCTION BOX MANHOLE COVER
25,
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EXTENDING 3'~~ fI-« • y~ ,i `w I I L ARM
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ONTO SOLID SOIL
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CONCRETE BLOCK
9,9
RISER EXIT PERMIITED OIJL4 IF TANK MANUFACTURER HAS SUCH APPROVALRECEIVED
SEPTIC E /Qfl0'5a'` SPEC. IFICATIOUS n
DOSE 106030 It. / OCT 2 19oU
TANKS MANUFACTURER: T~ 1~Etk r W. IJUMBER OF DOSES: 4 DAy
TAAIK SIZE: ~0 ..1 GALLONS DOSE VOLUME Pl.llAW BURET
ALARM MANUFACTUREQ: 4,LT ~I~1-u~ ANC ,S :V11c, INCLUDING BACK OW: GALLONS
MODEL NUMBER: 10
CAPACITIES: A= INCHES OR 6k' GALLONS
SWITCH TSPE: -.WAc~~C=1 ~00.~°1' g a Z INCHES OR GALLOWS
PUMP MANUFACTURER: ~aLJ'd A•4`•'C.. C = 25' INCHES OR GALLOWS
MODEL NUMBER: i. -4-n T„ D-INCHES OR LL GALLONS
SWITCH TYPE: Lu-en C'A&^u (O.Ln~ . NOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE`_GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFEKEKICE BETWEEAI PUMP OFF AND DISTRIBUTION PIPE.. _ FEET ammD
+ MINIMUM NETWORK SUPPLY PRESSURE . . , . .
. ?•5 FEET
♦ -20- FEET OF FORCE MAIN X 115 F o Fr.FRICTION FACTOR.. FEET OCT 21
TOTAL DYNAMIC. HEAD = "LFEET PLUjw
BING BUREA ►
INTERNAL OIMEIJSIONC OF TAKIK: LEKIGTH ;WIDTH ..;LIQUID DEPTH
SIGA,IED:
7 ler, LICEMSE HUMBER: /0//-/AG
DATE
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4 17
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
L CA ION: SECTION: OWN )MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
'4 *33 /TMN/R/91(o
CO~U1NTTY: OW ER'S BuyFS NAME: MAILING ADDRESS:
y USE 0'01~w h/1.4-w,
DATES OBSERVATIONS MADE
NO. BEDRMS.: COMME IAL DESCRIPTION: PROFILE DESCRIPTIONS: ER OL TIO TESTS:
Residence y ❑Replace
RATING: S= Site suitable for system. U= Site unsuitable for system
LUNEIVhNTI0NAL: MQUPID ; IN-GROUND t ivV RE: ISYSTEM-1N-FILL O~LpING ANK: RECOM D STEM:(optional)
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: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATIC)!V D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV BACK.)
B- r♦ r~'~ ~I lsi/,j-'64 54 W++ P064-40 .b?' G
v9"17! none 30~, ar aAO vc eF tx/o . 5' n cs
B- o~ p~,,, ~ ~ none ~ x~, ~gJs;la 3.0' ~ s:l w/~c .nat ~ 3~,.
_3q
- ~•ls~t`10 S_i_,.75`GSV r Csw
B w1.►1o p Cgr~~• 05%'OK614. S'esq S~•~f . S' Bn cs ~5r
B-~ r/70011 $9.3~ hoh(', yW~. ,75'B~~f~ ,~I.Qg~B~sil~l•a5'~nLS~,~1'l~r~-s~ '6y 1 -C;/ 1 9/ 11917 S
B-
B-
PERCOLATION TESTS
TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PE IOD 1 P IOD 2 PE D PER INCH
V6 ` O
P- f „ Z 3 4D
P- / VJA
P- 3v yS- 3
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 and the direction and percent
of land slope.
SYSTEM ELEVATION
F-T- C~LI y
E
C gin to 1'-0' -TA __T
3
Q1C.44)tbh Pic s~ 1 '
-1 tN
_j I
-J W
`f 4
f x ~ i
( ( 3
y a,. _
4 `
~ e
f F
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 WERE COMP. ETE ON:
23 L
ADDRESS: CERTIFICATI NUM ER: PHONE NUMBER(optional
Savo I;!
386
CST SIGN {U E•~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. /C
DILHR-SBD-6395 (R. 02/82) -OVER -
L:
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - ~
T(- } - -)Iete and accurate sail test, yom, report Must include: ~
1. -tI -'ascription,
2. u_. _ must clearly indicatr fl-, is a residence or aject;
3. MAX .,Jf' iumber of bedrooms or = planned;
4, c P cement s`,~ Bern;
5. Cot y > A E Fn- ° A t r rrrr- TANIK ONLY IF ALL
0 L v C
6. P. i shown hE tt. > plot plane
7. IV, gram accuratelt red. A
d 'deli
5
t_ _ to _ in t( 1p-
ti
10, 11 C as flood 'ai s { to box;
11. you cu
1 d d'-1. - 1 THE
t11T IN A)
VI TIONS C - - IFIF"" TF`~
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or(;
tion,
SEEN
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
(1-163.090) & Chapter 145.045)
LO 91 N: S 33 N: N/11/10(o *'5N~ S~U•NICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
II~/GG C.d/ih T/
COUNTY: OW ER'S BUY 'S NAME: IMAILIN(.-,-ADDRESS: J
j~ r
Crof ii /W ssouJ l 2 L ~o~, GJ~• Skl
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMM A ESCR PTION: PROFILE DESCRIPTIONS: STS:
Residence -3 N Poew ❑ Replace p`
__it I
RATING: S- Site suitable for system U= Site unsuitable for system O
ONVENT NU M❑U I_ E:] S E E: EYSTEM :I S -IN-FILL O❑LDING T K: RECOMMENDED STEM:(optional) S UZ J ~ r FA r
If Percolation Tests are NOT required DESIGN
y-b RATE: Llfony portion of the tested area is in the
under s.H63.09(5)(b), indicate: odplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL PTH T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HES TO BEDROCK IF OBSERVED ISEE ABBRV BACK.)
B- 1 14 non el .3 0 `f • 9A' ,61.S;1 ) -3• rS4 SH w ~t n-a4-QP ~?O', . 67' G S'O y i
' A. w ove d' ba0 v . S' An CS aP
B- none r.y-3'gJSil 3.0' $In S;l w/IQ met @ 3~••
.37 •xS',B,~S,.oat''Q~ ail .~S' s.► .6q'&SSi1,.S eav r
''wj" °Q P 8.re#).OY'OK6n , • 5160 5;1,. 5'BnCs 45r-
B- hone y~„ .~s•B~s~~ 1J.00'ensil,Tas'en ks,,7i'd s,
B-
g-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. p 10 13 1 P I D PERINCH
P „ 3 0 /6 f D
" a / ~ 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 elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
't
ii
tt: 04,,lo ~hr l I
I,
%
(Awrw
{ i t i i t- r ;
' • l.Qc4d><►~ p ~ ; (mac lo,~s~; ~ ~ . h.
x=~f~CQI FlLc Phfs w; ~t w~K ~3 .
is ,
ItN
1
4 ~ re N 5~ ~s y4 ~ .
lie
{ n f
601 °t~ i heal' '
i
1. 1 < I i I
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 WERE COMP ETE ON:
/17JGti 23
i
ADDRESS: lb r 71LO61A ~ , ~M p ~ ~i SYO/~ CERTIF GsICATI NUM ER: PHONE NUMBER (optional):
vp 3/`/ s-os7
CST SIGN E•
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
I
LHR-SBD-6395 (R. 02/82) - OVER -
L A'
-in
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
4; HOMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P,O. BOX 7909 BUREAU OF PLUMBING
MADISON, WI 63707
[ CONVENTIONAL ❑ALTERNATIVE State Plan l.D:Nufnbef.
IIr aselgnedl
Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER' ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
-Perry Rossow Rt. 1, Hudson, WI 54016
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT ELEV.-
NW SE Section 33, T29N-R19W, Town of Hudson, Lot 8, Countryside Vill.
Name of Plumber: JMPIMPRSW No.. Coumy amta.y Permit Number Iiiii Roger Timm 3224 St. Croix 83859
SEPTIC TANK/HOLDING TANK:
V"Jjeq1L A[
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.. VENT MATL HIGH WATER NUMBER OF- (ROAD: PROPERTY WELL BUILDING: VENT TO FRESH
~ J J
ALARM FEET FROM LINE. AIR INLET:
❑YES ❑NO ❑YES ❑N0 NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL 7_]FU~HON MANUF ACTLIFIEH WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND C ONTROLS OP ERATIONAL NUMBER OF PH OPE RTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET'
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth of plowing DIAMFTEF 111ATIHIALANDMAHKINa
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 LENGTH NO OF ILISTR PIPE SPACING COVER NSIUE Uln -PITS LIQUID
THE NCHES MATERIAL PIT DEPTH:
DIMENSIONS
GRAVEL DEP R3 FILL DEPTH UISTH PIPF DISTR PIPE DISTR.PIPE MATERIAL NO DISTH NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
BELOW PIPES ABOVE COVER I IV 11,1P i 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-
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PEf1MAN NNt MAHKFRS OBSERVATION WELLS
_ ❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED IDIPTHOV111 TRENCH BED DEPTH OF TOPSOIL S(IUUFD ISIE01t) MULCHED
CENTER EDGES
❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATEHAL SPACING GRAVEL DEPTH BELOW PIF FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL 1'NO_DISTH DISTR. PIPE DIST131BUTION PIPE MATERIAL & MARKING
ELEV.'. ELEV. CIA. ELEV. PIPES DIA..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED COHRECI LY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO _ ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: -NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE'.
DILHR SBD 6710 (R. 01/82)
COUNTY
SANITARY PERMIT APPLICATION"
DILHR In accord with ILHR 83.05, Wis. Adm. Code .
STATE SANITARY PERMIT #
Q S
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application.
PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO
PROPE TY OWNER PRO ERTY LOCATION
SGT%4s~'c'/a, S <_T . , N, R (or
PROPE TY O N R'S MAILING ADDRESS LOT NU BER BLOCK NUMBER SUBDIVISION AME
CITY, STATE ZIP CODE
PHONE NUMBER CITY NEAREST RO , LAKE OR LANDMARK
VILLAGE :
l
4uldo &-Y7 Ej
till `Y4%'7-(
1 51 TOWN OF:
11. TYPE OF BUILDING OR USE SERVED: PA44 - Q!{Q fQ - p7~' JO
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. ~lVew 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. E1 Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ee a e Bed b. ❑ Seepage Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED are Feet): PROPOSED (Square Feet):
~5 7 G~-f acs Ve)7Feet ivate ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total # of Prefab. Fbe Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank ❑ ❑ ❑ ❑
Lift Pum Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumbe ' Name (Print _ Plumber's Signature: (No Stam ) MP/MPRS W No.. Business Phone Number:
/ !mss s-,✓~ i ~ ? 7/ -5,)7-2C ~ Z
Plumber's ddr (Street City, State, Zip Code)): , Name of Des' r:
VIII. SOIL TEST INFORMATION
Certifie it Tester (CST) Name CST #
1 ~ z M~~
CST's ADDRESS (Street, City, Std Zip Code) n Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa itary Permit Fee Gurorcuhndwater ee ate Issuing Agent Signature (No Stamps)
S
a F
Approved ❑ Owner Given Initial g
Adverse Determination `00
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 wh6never nede'asary, usually euery:'~ to 3 years;
.i6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete 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 years of steady negotiation and public debate. The groundwater bill Groundwater
included the creation of surcharges (fees) for a number of regulated practices which WiscOr'm's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that, bur :::1 treasure is used in your building is returned to the-groundwater through your
soil absorptic`r?
system or the disposal-,,site used by your holding tank pumper.
The monies collected through these surcharges a ,e •rredited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination in :stlgations anr' establiFhn) r.t of standards. Groundwat- ~
it's worth protecting.
SBD-6391 (R.03/86)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INiDUSTR'Y, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS 1 / MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOO TION: SECTION: TOWNS HI LO O.:BL SUBDIVISIONNAME j
0~- ''/a A21 N/R/1f (o f an ~r' Sl f/, 9se-
C OW ER'S BUY 'S NAME: MAI~I'GZ D /~E~.~ j it G1 SDI ~.f ~Td Mfr
USE DATES OBSERVATIONS MADE
j NU.BEDRMS.: COMMER IPROFIL D RIPTIONS: ER O AT NTESTSl'Residence 73 ) ew ❑Replace / O / p
RATING: S= Site suitable for system U= Site unsuitable for system fr 3 f0 6 b
CONVENTIONAL: MOUND: IN-GOUNDPRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYS EI~Q:(optiona~~ c
S❑U S❑U S❑U IF-IS ❑S[A'U la
If Percolation Tests are NOT required DESI RATE: If an
y portion of the tested area is in the
under s.H63.09(5)(b), indicate: + ~<3 Floodplain, indicate Floodplain elevation:
PRO DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-1 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH W. OBSERVED EST. I HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- X3.3 • l . 7s'Q~, I~ S `~s~. 33 `!d's 3 %3~
> 7®` 9Z z, O'Rl, :a S;0s4y,,13. z s `B S> 9r
B ` / Q°~JJ 7J ~~~•l7~iy~l,/7`tit'S 6Asjgr
g_ I
Q ° 7S'Qn / , yZ '!3n /s 3,
B-s g~ ,3Z` >8 ys` I,y~z'f; J°I7'$s,! ► 3 `e;,is>~g~, s~3`l3•, s,--
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I
~ -AM
FTERS LING INTERVAL-MIN. PER OD 1 PERIOD 2 P R PER INCH
P- 1 w , 3
P- IV _IZZ-1 3
51
P- 9.612' IV &1 .3 G 3
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 and the direction and percent
of land slope.
SYSTEM ELEVATION.
N
L
eft ~o Loti-i'
E
E
t 3 ,
N~u~nv o~10
r b3i
Sit _ Za_f j 1
N
3
a
~l
f -
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 WEFVE CO PLETED ON:
I
.0y / W/ t
V/
ADDRESS: " CERTIFI ATI NUMBER: P O E NUMBER(orJonal►:
tl
CST SI
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SRI - 6395 V
To be a co.rnplete and accurate soil test, your report must inCIuc4e.
1 a C(-t-- I-al description,,
2° TI ection roust clearly indicate rl -r =sidencc ~ercial project;
3. MAXi,JUM numl er of bedr°oorns or con r = planned;
4. Is this a new ~ I cement system;
5. Complete 'lity rr `'ng boxes. A l - 1TABLE FOR A 1. TANK ONLY IF ALL
OTHER SYS kRE ,.ULED OUT ~ ®0L CONDITIONS;
. PLEASE use th a ov le descriptions and completing the plot plan;
7. M E . A LEGIBLE ;t loc I' )ns. Dr awin, scale is preferred. A
!fie r c ire-
id are permanent;
9° to r b sxes as to r ~rcoiation test exernp-
ti .
10, If the i T uch as fl d plain, elevatioi 'd t a, , n the appropriate box;
11. Sign th , lace v-u° -r-t addrer- - c ,i r;
12= Make lec _p am:` , .rte as rec,L. rl _ 1'° " . BE FILED WITH THE
LOCAL e ' ..I- <-Y WITH ? 3 DAYS CE C DL ETION.
ABBREVIATIONS FOR CERTIFIED }IL TESTERS
e an€' _ s
St R R -
cobSS -
gr r } L . L
*s _ I Idwater
cs Cc _ r Rate
muds -I
fs F
Is - ind =ar€
*s1 L arm
*I L
*sil -
si - Si
*cl - CI gr _
scl - " oam
am mo
y w,
sic - ff
r c€ .
ITI IT
iel,
soil textures .r
v~ ste disposal
l Point
se ~r the Dep< --It may request
thn private
i order to
` permit must t ctai t, rn.
Timm JOB-~_1/~
SHEET NO. L OF Excavating Co. CALCULATED BY
R Box 192, Wilson, WI M7 - +
CHECKED BY DATE _
_ SCALE -
1w
J:
t
i
o
i
I ~
;
PRODUCT 71M-1 (AM-997 inc.. Gmtm. Mme. 01471.
✓ PAGE OF
CroSS 1~ > ~ n
' `c I urp
F(4611 Ali 11`119116 And Ob6iffitallon Pipe
r Approved Vent Cap
Minimum 12" Above -
Final Gr
20- 42" Above Pipe _ 4" Cost Iron
To Final Grade Vent Pipe
MwM Noy Or Synthedk Covering
Min 2" Aggregate
Over Pipe
Distribution
pip* - 0 0 0 0 Tee
6" Aggregate
Beneolh pipe ° Perforated Pipe Below
o --Coopling Terminating At
Bottom 01 Syciem
-
nL.~eJ•.T ►on ~ i
SOIL FILL
DISTK18UT10K.1 PIPE
APPROVED S4MTMETIC COVER
ZMoFg6GREGA'TE s`-r1ATERI^I- OR 9" OF STRAW
OR (AARSM HAY
° Ion OF AGGREGATE
ESE oF9?47 EI
DIS'1"RIIyUTIOM PIPE T
O BE AT LEAST ~ IPICHES BELOW ORIGIIJAL GRADE
AML) AT LEAST20 WCHES BUT AIO MORE. THAI) 42 INCHES BELOW FINAL GRADE
AMIMUM ®EPrH OF F.XCAVAT100 FROM OKI&VJAL 6RAIM WILL BE
ILJCHES
PUNIMUM O£Prtt Of EXCAvrTION FKOM 4*61WAL (3R49f- WILL BE ~IZ U~ INCHES
I
51GL.IEO: 1
LIC-LUSE AJUMBER: ~~5 ZZf~
f
DATE : 3
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
798-2239 (HAMMOND)
r 425-8383 (RIVER FALLS)
Wanllcl HAMMOND, WI 54015
September 26, 1986
Division of Safety and Building
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation for the Perry Rossow property, located at
the NE14 of the SE14 of Section 33, T29N-R19W, Lot # 8, Countryside
Village, Town of Hudson, St. Croix County, revealed suitable soils
at a depth of 30 inches, below which seasonable high ground water was
noted.
This site should be suitable for a mound.
Should you have any questions, please feel free to contact this office.
Sinc rely,
u~► 0. Thomas C. Nelson
Assistant Zoning Administrator
TCN/mj