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HomeMy WebLinkAbout020-1142-20-000 cn O 0 o d °c 3 f* LOP) 3 # O n O u~ o O A W C A ON cC• CD rn a w (Np ~~11 O fl- N Z N W` 7 A M 7 O (D Q r ` N Q NO -4 0 v O N \ 1 ~I W O C'1 V N O C, O O K 7 N m O~ O Q N y CL R % FD. d CD In O. w W CD CD 3 Q O - 2 73 O - o n _ 73 C: N O a :3 Ch 0D co N O C cn Cn * a ~ C.n z 0 0 0 o • z O O O o cow Cl) CD v v v v CT (D ° p C) v (n 3 (D d 3 m a Q-A N a c C 7 O Z O O Z ~ Z D m O v O Z p' "wA • CD CD c C 'O N CD (D (a Q W O fD 7 z (o Z C A Z CD O m O Q p z O CL W z --j W * N) -P. a z 3 a A O " cCCn N < < Z C A W O N a 0 n X r. CJJ] T _ ty C > CD Z d > ° n Sy. CD v v CL O a O A C) ~ 0 o ~ z A CL N ti O O a ~o A N O ~ a O V a O b fflo a CD t Parcel 020-1142-20-000 01/31/2005 04:22 PM PAGE 1 OF 1 Alt. Parcel M 34.29.19.732 020 - 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 * KLUCK, WILLIAM J, & JOYCE SANTO WILLIAM J, & JOYCE SANTO KLUCK 664 EDIE LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 664 EDIE LA SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.050 Plat: 2513-STEWART'S ADD SEC 34 T29N R1 9W STEWARTS ADD LOT 9 Block/Condo Bldg: LOT 9 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 34-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 847/95 07/23/1997 716/443 2004 SUMMARY Bill Fair Market Value: Assessed with: 48818 233,500 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.050 30,300 150,300 180,600 NO Totals for 2004: General Property 2.050 30,300 150,300 180,600 Woodland 0.000 0 0 Totals for 2003: General Property 2.050 30,300 150,300 180,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 135 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 r Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. J L T N-R 1`, W ADDRESS / ~S'I'. CRO:[X COUNTY, WISCONSIN SUBDIVISION ~LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I ~ r i 1 1 t ~O V 6 1 INDICATE NORTH ARROW i • I j BENCHMARK; Describe the vertical reference point used T~^l_ Elevation of vertical reference point: U(- r Proposed slope at site: k SEPTIC TALK: Manufacturer: Liquid Capacity: Numbei of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: 0 feet Number of feet from nearest Road: Front, OSide, Rear, From nearest propt>rty line Front, 0Side, 0 Rear,0 L- feet Number of feet from: well building: _ (Include this information of the above ploy j,"In)( ? reference dimensions to septic t' SEE REVERS}: SIDE y PUMP CHAMBER Y 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, 0 Side, O Rear, 0 Ft. Number of feet from well: Number of feet from build in~ (Include distances on plot plan). SOIL ABSORBTION SYSTEM Bed: Trench: _ Width: -D Length: Number of Lines: Area Built: ~ r r Fill depth to top of pipe:~ Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: -D 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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm ranufacturer: Inspector:_ Dated: Plumber on job: ~ &A4 License Number: ~ ~ ~ ~ y! DEPA?TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P O. BCX 7969 BUREAU OF PLUMBING MADISON, WI 53707 17CONVENTIONAL El ALTERNATIVE State Plan I.D. Numbe, (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE. I Jeff Baird 89 Cudd Court, River FAlls, WI -2 2 - y BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST FIEF. PT. ELEV. NW SW, Section 34, T29N-R19W, Town of HudSOn,LOt#9, Stewart's Addn. Name of Plumhe r: MP/MPRSW No.. County. Sanitary Perm,, Number: Thomas Wang 3231 St. Croix 74963 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER ,I PROVIDED: PROVIDED !I ~ DYES LINO DYES LINO BEDDING. VENT DIA.: VENT M, HIGH WAT NUMBER OF ROAD: PROPERTY WELL BUILDING. IVENT TO FRESH ALARM FEET FROM INE AIR INLET DYES LINO DYES LINO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. jLtOUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES LINO OYES LINO OYES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING IVENT-FOIFILSH AIR BETWEEN FEET FROM LINE INLET PUMP ON AND OFF) DYES LINO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I NGTH DIAMFTER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA. #PITS LIQUID BED/TRENCH J/- THENC.N€„S MATERIAL: PtT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PH OPERTV WELL BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER ELEV. INLET ELEV. END. PIPES FEET FROM LINE. AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES LINO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES LINO DYES LINO DEPTH OVER TRENCH BED DEPTH OVER TRENCH/BED TH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DEP . DYES LINO DYES LINO DYES LINO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV. ELEV. DIA. ELEV.. PIPES. DIA.. ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS DYES LINO DYES LINO PERTY WELL: BUILDING: COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PRO uNE. FEET FROM L1 YES ❑ NO ❑ YES D NO NEAREST I'k Sketch system on - \ 'Retain in county file for audit. Reverse Side. SIGNATURE TITLE. DILHR SBD 6710 (R. 01/82) APPLICATION FOR SANITARY PERMIT DUJ,5consi I L H R COUNTY OEPRRTmEnT pF (PLB 67) owmw~ inOUSTRV,LRSORSHUMRnRELRTions UNIFORM SANITARY PERMIT # _ 7y 91713 -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER r--- ' MAILING DDR SS j f 6 a,,, ~ /'N/'% C r T ever ~s~ mss. PROPERTY LOCATION CITY: 1/4S01/4, S , T? N, R 1~ E Or W vl 7 ( O N OF: ~L Sc~ LOT NUMBER BLOCK NUMBER UBDIVISION NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Re air El Replacement Soil Absorption System p Revision ❑ Privy ❑ Alternate System L~ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. El Seepage Bed ~ tla Seepage Trench 9-5' X# >1` ❑ Seepage Pit 0 9,;Z 49 ' L1 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 Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total # of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: 10450 ,l1 A Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Prin Signatu P/MPRSW No.: Phone Number: Plumber's Address: / Nle / ` COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved r r Owner Given Initial Reason for Disapproval: / Approved Adverse Determination Alternate coursels) 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 nam° ~`1~ 'I cte mi1mrinal government unit, (whether this is in a city, village or town` t ~rtt, 2. Indicate specifically what type of use is served, it public is checkup u~i;catc Hype or asc 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 roaster 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. TR/IE REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,, DIVISION LABOR AND HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 7969 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME V4. "u_3 T 1y N/R" E (ON~WT COUNTY: OWNER' UYER'S NAME: MAILING ADDRESS: IT USE DATES OBSERVATIONS MADE v L11R NO. B EDRMS.: COMMERCIAL DESCRIPTION: IPROFILE DESCRIPTIONS: PERCOLATION TSTS: esidence New ❑Replace -7 - r RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUNDPRESSUI SYSTEM-IN-FILL HOLDING TANK: SYSTEM: (optional) ❑S ❑U ©S ❑U ©S [:]U ❑S ❑U ❑S ❑U ? RECOMMEND-ED ' ),`a LH 5 ~x 1 S j If Percolation Tests are NOT required DESIGN RATE: rFlrodplain, n y portion of the tested area is in the under s.H63.09(5)(b), indicae: indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-111 R18#fi€S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH Y*d, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK,) BJ.}t T7 161r- Sy 3n s, I, E Ts • o'Bn si! ; o' 8n s ) B- Gar 13n s i I T~ ; 8 `B n s i I i 7 ' l'` $ n s l B- 7, B-S D~yC3>7s)'~TS;)3'$nsjJ;~o'Bn51; B o 1J J,".~` `~'bn GrcSI PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD TPERINCH P_ 1 b 1Jo 30 2 7 Z Z sly l P_ Z 3 ~~0 3u / ~iZ_ 1 Zv P-~ £i ~i Z 3~{0 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. r -7 1 tS_L 90.6 _ i SYSTEM ELEVATION 42.0' Bg,z' 3- a~ ~~t l E-Z _ . 3 I - _I_`' i Sly Q N1_#2- 1 _ l 01.62 ~4~ . SA t ttlE_ l ~L . ; IOUs 1, ~S a ~ c3T7pvtu~ IIJ g oak w%y l cw $F: Sic. 3 y `zo9 l Ga 8w1 1 i ? ~,-c S r R SSTo'A`n . IiZ E L~xj C, W) G- TAD. 3 E f 11 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 COMPLETED ON: r. 'CRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): r - a ill J 1 l 1 lJ . CST SIGNATURE_- ginal and one copy to Local Authority, Property Owner and Soil Tester. R. 02/82) - OVER - N ST i~. w fyfa, _,Ta b, P tu_, r te. e € f s 4sx. ~.i ~r.-F d E 'r-ji. !TE !S t a_ B UT t:,N aJs d_.~`5 t~ = r 9 Sank i y ~ 3 F +'rY .t f ..i tit LJ E t ~lo t Pt . -3, p ;G - 1t~4 F ~6 P -Ali A r /a fat ~A ,,Rkaver ~ip~ ~bL'~'Pe~ ~n,efl~~k1~J' 6 Amin ~ a ~t(' k. x 213 ©ve ~rc~ ih fia Qcutle e 1. )PI. 6 .3f Ike 15 14^i e noFa~ t(j 93.x) 8 R lacf mrnAl 9~, M to d ~a NPO (W-A ~ Arh) d r f Pi ' c . NRP - 1 L d Z ` O o F, m` °o Dc N 3 CD Env ° d` CD 3 4) it s (a 0 v (M 0 o4)~(D >1 ccm ~V m H E ms rn>, w.c0 ° N Nt.r c-0 ` C y C73~ 4) 0 p NU '0 C N R7 c c`U 0 c"u3=0m= o v~..o o~c y W m E- •E c CL) tv d N 3O3o~c ~c`ovi ~ c C (Lj N ~ • CC W 0 ~0 3L vc`w° o m~ CO Q v= m (D d E U N 3 OF-t,U d OU) c m Z D o) ~ U U) c ` a c co LL 3i . Z _ ~ = rn`- °cvac O)v N io 3C~ ny co i : 3oD~0- (o-rn o o - cc co 0 o U) :3 Q) U L. O 0) ~~Q N c Q aQi00 m o - c o O O O cU co L- T N rL.r O w 0 3 c Z L i0 c U t7 O E c O rnZ co ' cv » o o E _ C t ~ O R1 o 0) w c c 0 0) u 00 0 4) p U U E U = C rL. i. o) N c (D 0) a) c --o o R i U D w m o~ a 3 cn N.. 3 o v7 a~ c o a o c O o O C d O' a >.Y 113 c l- c z Rf L- M w O 0 O Z O) i w cot c n E ` o 2 co coau~a>c waa) 4) 3: `o n O Ecj co vii E 3 m m° « fn C = h _J ST. CROIX COUNTY WISCONSIN A'l ZONING OFFICE t 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 October 23, 1985 State of Wisconsin, DILHR Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Attn: Carolyn Ha_ g Dear Carolyn: Permit # 74963 (Jeff Baird) was issued to replace permit 469677. The system had to be relocated, and there was a change in the plumber. Attached please find permit 4469677. Sincerely, Mar J. Jen ins, Secretary St. Croix County Zoning Office ° = D p I - z ; p MMO qp * c co U) z CF) m z K m ID 0 0 °m° :X) 00 Now m ~p r N ~ ~ 0 m x cleD . rfb n rrn *1 0 - „ oo C) 0 r r C K z n r O m v o D n O C/) Z Z 0 :Duo D 57< ~ 0 79 C ~ D C Z z < C) 0 m o 0 z TI cn -n p U) z n --i Now C Z Z M 33 I oom oQ 02 -a NIL- t M o 3 d- ~ _ ~ ~ ~ ~ M. j m . ii, QID ".d g. N 7. W. m m m .0 M.~ 5. a~ as me = r- m SI~ G am ma »=<m M < i R. -0 O , NS ~ m m mm< 0) 0 M 3 ~M ?;m ~D 30 m a m . r o 3 a ~3 ~ffi H ~°a ~3 m p ti < 7 N. N'< ~~N yl w ca om Y71 ~G tccr~ O C oa~° s~ ^3 3 m o d= 1 IS 3 n 2 o s c y J D ~m d <~m 00 2 -l H ~ a d N C °i ~ 2 _ _ d o c < aye o . f y 10 D O~ 3 T 0 d do 3N' C T 3 3D~ .B d y o C CT) D o 300' <c,m 0 0 > > F rte. W N N N 3 0 0 m DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 )PV CONVENTIONAL ❑ ALTERNATIVE s,a,ePlan l D N mBe, • Iif assign edl ❑ Holding Tank ❑ In-Ground Pressure D Mound __7 NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTION DA FE Je66 Ba vrd 89 Cudd Com t, Rivvt FaU,6, W1 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. PT. ELEV. NFU SW Section 34, T29N-R19W. Town o6 Hud6on, Lat#9,Stewatrt'Z Addy-. Name of Plu tuber. MP/MPRSW Nn -riu i~iv nitary Permi; N.:mber RoyeA Neaon G379 St. aoix 69677 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY TANK IN LET ELEV TANK OUTLET ELEV IWARNINI, LABEL LOCKING COVER PROVIDED. PROVIDED' DYES LINO DYES LINO BEDDING. VENT DIA.. VENT M117: I I(;H WATER IN UMBEFR OF ROAD. PROPERTY [VF-L BUILDING VENT TO FRESH ALARM LINE AIR INLET. FE ET RR DYES LINO OYES LINO NEAREST---~~ DOSING CHAMBER: _ MANUFACTURER BEDDING LIOUI(1 CAP111,1I PUMP M(TDE L F(r 1` SLOW AN11f Al, TUBER WARNING LABEL LOCKING COVER PROVIDED PROVIDED'. DYES LINO DYES DNO DYES LINO GALLONS PER CYCLE: PUMP AND C ONTROLS OPERATIONAL. NUMBER OF P H40PEHTV 11'11 LL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM NF AIR INLET PUMP ON AND OFF) DYES DNO NEAREST-,: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing nvE TE II 1'.1 A T I HIAL AND MARKIN(, 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: NIIDTH J LENGTH NO OF )ISTH PIPE SPA(:I rv, - (:OVEE+ I'vtilnE ITIA =PITS JLIQUID BED/TRENCH NcRFS MATT lvnl PIT DEPTH DIMENSIONS CH JEL DEPTH FILL DEPTH I)IST Ii PIPE UISTR PIPE DISTR. PIPE MATERIAL NO DIGIiE NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH HI L(AN PIPES AaOVE COVER FIFV IN, I ELEV END PIPES LINE FEET FROM 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- meets the criteria for medium sand. TIONS MEASURED. DYES NO SOIL COVER TEXTURE P(HM WENT aaAHKEHS oHSEE<vA n(rv wt Ll_S L_~YES LJNO -DYES DNO DEPTHOVEH THE N(,L DEPTH OVE H TRENCH BEU ri'IHO~ TOPSOIL SI11)I)E l) SFFUE) JMULCHED CENTER EDGES DYES LINO DYES C_JNO ❑ YES LINO PRESSURIZED DISTRIBUTION SYSTEM: JWIDTH LE N(i Tll NO. OF LATERAL SPACING (BHAVF L DEPTH BF LPIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFO LDMATERIAL NO E:ISTI DISTR PIPE UISTRIHUIION PIPE MATERIAL&MARKING ELEV ELEV OIA FLE V. PIPFS IDIA ELEVATION AND DISTRIBUTION INFORMATION POLE SIZF HOLE SPACIN(, URILLEDCORHFCTIY Coven MATE RIAL VERTICAL LIFTCORRESPO NDSTOAPPROVED PLnnls DYES LINO iJYES LINO COMMENTS: PERMANENT MARKERS OBSERVATION WELLS TNEE-I OF PROPERTY WELL BUILDING FEET FROM LINE DYES LINO DYES EINONEAI Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE DILHR SBD 6710 (R. 01/82) wlsconsln APPLICATION FOR SANITARY PERMIT COUNTY D I L H R (PLB 67) - DEPRRTMEnTOF UNIFORM SANITARY PERMIT # In OUSTR V, LR60R & HumAn RELRT10nS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS i F PROPERTY LOCATION CITY: A✓1/4 Cel/4, S ? , T~ N, R 11 E (or)* TOWftOF: LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME NEAREST OAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER C , TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: l'I THIS PERMIT IS FOR A: 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. ❑ 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 - L] An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity ; ump an 7S_10h~auZber Manufacturer: y / 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 Chamfer Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 612 p,. Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installationA of the private sewage system shown on the attached plans. Name of P mber (Print): Signature MP/M4Pfft*-No. : Phone Numb r: Plumber's Address: ;r'-- Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ) ❑ LDisapproved d~~ ti7►'~ ❑ Owner Given Initial L~ Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/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 ~3a 4_e Location of Property /N Section T N-R W Townsh4p Mailing Address Address of Site Subdivision Name j~,~~~~}~ i Lot Number Previous Owner of Property rlA!2i ±~:,15~-_ T Total Size of Parcel iDate Parcel was Created ZJJ Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 3 f.> and Page Number <f`ef''~ 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 Rester 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) ceAti.by that a.e.2. tStatement/s on this boAm ahe ;flue to the but ob my (out) knowledge; that 1 (we) am (ante) the owne,%(d) o6 the pttopetcty des ch,ibed in thtis inbatmati,on 4okm, by vii tue ag a wahhavity deed ttecattded in the 04~ice o4 the County Reg vs etc a4 Deedsa6 Document Na. 6 0~3 ; and that I (we) pne/sentty own the pttopned site 6m the sewage d"posat system (otc I (we) have obtained an e"ement, to nun with the above de~scA bed pttopeAty, 6att the const uct on as said system, and the same has been duty ttecottded in the 0Ajice o4 the County Registett o6 Deeds, as Document No. t SI OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED • H z - H a ST C- 105 r r ° a ° H SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County z d _ a OWNER/BUYER k c 1 H ROUTE/BOX NUMBER Fire Number CITY/STATE ZIP PROPERTY LOCATION: Section / TGJ N, R /7_W, Town of St. Croix County, Subdivision 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 septa, tame as a treat- ment stage in the waste disposal system. St. Croix. County residents may be eligible to receive a grant Ccr 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. 0 E I/WE, the undersigned, have read the above requirements and agree rvzi to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- 'v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Offii~e.within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. N :E CD ' A- n n CD o O h o ~3 ocp 0; w= ~ o c o w w w C 3 c~co w w i o (t I C S fD •n a fD (D Q A N cn > -n N (n cD F . (n :E C) =3 n.4 13, n w o c~D CCD ow Aim CD (D C(ol 3a 51 R coowoc°C 1 _ _ o G w°° L c w C r c~ cr ao c~Dw~cn • : w CD o o a m 3• _ cn -10-~ =70CD w~mc~cDi cn . m ° Q c cn co _Q 41 c C 0 D° C) -r 'a 2 CD ~p o a m w O tt • = N En fn (D w y c ca Z m w Mw 0 --I (D R CL _ (A (D CD CD 0 S ~ m ~ A N a m- IN 3 C a CA wa o? o f 1 Er =r C w CD =r m- C L C 0 :E CD v CD° cn'Nww C to ~m oc~ o wa=m==r ~J 37 G+ ~ = N CD cn 3• CD CL CO =3: Cy _ D --1 0 o COD ~9 cu = N t° c=i ucDi N' C) a o* cc ~ c c~ w w o.aaCD Ca : m rn Q v, ° a3'f - a ~N c N Ica w =r m m°0 ~COC CD,3 r n ao = on a C cn c a o w m -BCD c CD a a CD= 0 0 ai,A~s ~~3 0~ o ° m = o *w s c0 w - CD o 0 o DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN-~?USTRY, 1 1 C DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N, WI 7969 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) COCATION:~ SECTION: TOWNSHIP/MlH+e+P~T-f: LOTNO.:BLK.NO.:SUBDIVISIONNAME: Div) 1/swl/ 3y /TZ9N/Ri9E(4~/W COUNTY: OWNER' BUYER' AME: MAILING ADDRESS: '--v F_ g9 Cv' ~.i~V 2' R l'J~'c fl L1 s S USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: 1PROFI LE DESCRIPTIONS: PERCOLATION TESTS: ❑Residence QNew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:' SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U ZS ❑U Zff ❑U ❑S E" U ❑S EJU If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the nn under s.H63.09(5)(b), indicate: N • PI-1 . Floodplain, indicate Floodplain elevation: N ' r\ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN6,HES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH-F4, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B \ z' 95.E ' Notice ° 'j alt ~7 C S1 I S 1•~ ~h si ; ~.3' L3n S o. y Oc~s = s tr. b2 s 0.1' Dec Gy j3n si 1 ('s i j 4.o' )3 sl ; B Z ~.1 9b.8' t( ~.7' z.a' Qh I 01z GL/ &n S0 %s~)•8'13,) X4-1 R'S -1 s 0-9' B- L/ B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- 1 14 Z 1Jo 3a ~ /(6 1 -2 ) "?/(6 16 P- Z 4 Z t`l a L4 Z P_ P_ 2_ 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. TPL R~4i r1..~F t_ro~ ~ti~N 1~ ~CtCI tJ SYSTEM ELEVATION J 94-5' D 93.- ' L, uF ~498.' gp n ttcvc._Gl?r l 1~_~'z.~o~8i-~ c~a~C s PI Htu. t°rp?, toC- o~ ' Ptwpo~c£u StT Lbclt`f~'h ~SDr~E. $ 300'5. (I)F 4 6 / ~1ov!iE i ~n c~►-`~►a~ ~ s 1, "~E .~~.s r ~y ~~z.~►~+z c~ r= s t=-c. y r~Et.L `Co tie t'tT LNat,;ST .5O' elS Sr T'Ke►,~c~s gs Yoj J'$`I _Z Wt3,p g - _ l S~~ 0 7 I-oT L I ',U E SCALE 1 U 60 ' I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): ` TS WERE COMPLETED ON: ADDRESS: E ~ ICATION NUMBER: PHONE NUMBER (optional): &P 1% 09 T_$J NATURE DISTRIBUTION: Original and one copy to Local Authority, Property Owner ani ter DILHR-SBD-6395 (R. 02/82) - OVER t A A i€; . .xi crt,.c `a..iu r porE {C,C!?.r: _ ipktt' t ~.t?t:ilP ig usesc t,;.t, "i v a t~i;,.3. l~C0 t;t'6°aifdi',€.ta1~:1Y ~3~~'i iV . [14l L ~ ,kq HE, , a S. _ RE 1 UL, 1,1(Vl _FE-~a^ l C?i~~1tBt~,l', " ASE .F,+ ,h F bbi +,a? £7#i5 sh u;! £_i e fo; . x [ ,urc lhk1 , tic cl ip. +._i 7 5 and, GCiml )lotiila the Pl';t Pl an; "i AI<i,-, A 1_1 C.h? ~ £.0city , l£.Csitinca 'Y`L?ur les- =o(.:,.c i;f?C"1 , I~!x,. si..al i4 1:2I"eff rel' 3., osed .r Allal..C t x # x,fh . .t f j v t'k, . d cl x , gat f%', ;.C}af f 7.s ~,:Cr and am ¢~g71lh~Y.ilt; t"o ylete +l m)p c..,ia r_i; U. X as io dOlE , nam . eit, t < .v , ft , ,t :fla. l dalta, € e-l'o"l ation test exemp fl. " ,rlai L. ..a,: t?lr, l3E _ s„ .3 411 f x ,a1`t` l~' . -.'a . „td _r "w in ,ta t;t.i= ,.f.t, %=tlf,Tit,4S u,1f,3 ,F ri{' C.~a., £ Y t z. E )Y 0'0i7-i 2 i tit L 3 I i'l Vv 2i ln~ i Owner's name San. Permit No. ' M H63.05 PLOT PLAN Show: tz~Nlj Location of building served ]dosing chamber Septic tank Vertical/horizontal re erence point i Building sewer System elevation is Effluent system El Well Property lines w/in 50' of system Replacement system area E~I Distribution boxes or dimensioned - - Pump and controls: Mfr. & Model No. Vertical Lift Size Force Main Friction Loss T. D. H. Vol. Dist. Pipe Gal. per Min. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan below: •l +44 g A -7 P By the granting or approving of the above plan, or upon the event of a subsequent permit being issued, Pierce County and the Pierce County Zoning Administrator, does not assume or hold itself liable for any defects in plans or specifications, plan omission, examination oversight, construction, or any damage that may result in or after i tallation. Plu er s sia_na ure License o. raT