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HomeMy WebLinkAbout020-1159-80-000 O N Om o d `r1 iy 0 °o c (ID # ` 1 3 Z+ cn = u z ° ~ v rn ° °c • ° w v o co a ° o m 0-4 ° m N Z d y co 3 O c W o p c o co (D cn 2i a n 0 0 00 O 7 (D (p ° W O O Cp ° S :E 7 p O c 0) 0 N D o p N. c cn p a) CD (.n n1 a (n D = R. m ' m cn' N a- In c W _ Q- = CD 7L O (D l~ G G o 00 a N o c (CD b O H _ r (D rt v ~ h • rt ~ O O O o H. r v V o = v? N ~1 p rt r td c- o ° ° cn cn (n N V1 ° v v v cn zr tQ Co In p CD CD A r Cl) (D O O O (D . N (D lCJ F-+ F n (n CT) y rn m 3 m m N a Q 3 N ° zco z z O CD 0 D ~r tGn n v O - ~ N rfi o' CD CD h • CD 7 (D n CD a) (D F cp a I c CD CD 00 w m _ n CD _ CD --j (n O.' Z ° p Z co O O C1 F-I pi O £ I n C1 7 O' rt G z a. r• ~ O z CC) n w r a, -0 m rt x m x (0 3 o G n o r? z ° rr 10 (n a rr 3 m o P;• rt (n H. N z r• W O O CD A x rt o (n r• 41 o V x G r A D r• O Cb Co CD a G rt 'T m ] - (n CD m o - T N O N N C (n Z Ll ~ N O N CD O CD (D p O 0- A 3 a C c CD N .S. ~ CD O pO O Oo O A X O R7 ~ S A CD /Q O ti CD a S Parcel 020-1159-80-000 02/15/2006 11:09 AM PAGE 1 OF 1 Alt. Parcel 16.29.19.913 020 - 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 O - HARTMON, JOHN A & CONSTANCE JOHN A & CONSTANCE HARTMON 555 SPURLINE CIR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 555 SPURLINE CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.060 Plat: 2216-NORTH LINE STATION II SEC 16 T29N R19W NORTH LINE STATION II Block/Condo Bldg: LOT 22 LOT 22 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 16-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 700/168 2005 SUMMARY Bill Fair Market Value: Assessed with: 92778 231,200 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.060 69,200 166,600 235,800 NO 05 Totals for 2005: General Property 2.060 69,200 166,600 235,8000 Woodland 0.000 0 Totals for 2004: General Property 2.060 48,200 123,200 171,4000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 123 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 - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T N-R ADDRESS ST. CROIX COUNTY, WISCONSIN 4 SUBDIVISION 1 K`` LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ved C 6, . INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used VW r Elevation of vertical_ reference point: Proposed slope at site: S1?J'`T'IC 'T'ANK: Narzufacturer: Capacity: Number of rings used: Tarik m.iiihol.e cover elevation: Tank Inlet Elevation: 'tank O itlet Elevation: Number of feet: from nearest Road: Front,0Side 10 Rear, O ~Y feet From ncaresr_ property line 1, roil t:,0Side,0Rear,~ (y feet I;uuber of f`eC,t from: well 1.uI Iding: (Include this informmari.oii .)f the above plot plan)( 2 reference dimensions to septic tank) ;I:E ,EVIIiSI: SIDE :zagwnN asuaoTq :qo[ uo zagwnld :pa~uQ :zoloodsul :zaznioujnuvN wzuTV :Puoz Isazeau wozj iaaj jo zagwnN : BuTPTTncI wo.zj :iaaj jo zagwnN TTaM uiozj Zaaj jo zagwnN •~lO `zuo-g0`aPTS 0- uo_g :auTT XZzadozd :Isazeau wozj iaaj jo zagwnN :10TuT jo uoTIunaTg :>Iuul jo wo3loq jo UoTZunaTg :pasn sBuTz jo zagwnN :6~TouduO :zaznjoujnuvW NNVZ ONITIOH • (auo ~laatl0) Zsw@IAS uoTlgzosge TTos anoqu aqq jo Auu uo pasn uoaq O xoq uoTZngT ISTp zo O xoq dozp u zag3Ta suH _ : ilTnq uazV :uoTIunaTa 3Td aSudoas jo wo:iloq :q:idap pTnbTrl :zaIawuTQ :s:i-rd jo zagwnN azTS ,Lid H~VdHgS •(utT(I :10Td uo saouuIsTp apnToul) :3uTPTTnq utozj :iaaj jo zaqumN r` :TTaM wozj jaaj jo zagwnN -7 ,311 O`zuaH aPTS O `:Iuozd :auTT Alao dozd isazeau wozj iaaj jo zagwnN :adTd jo do3 of gidap TTTA •y :ITTnq sazy :sauT•I jo zagwnN :lpoua•I :tPpzM A! tpuazs : Pag WHISAS N0110OSgV UOS •(uuld told uo saouulsTp apnToul) :SUTPTTnq wozj -3aaj jo zagwnN :TTaM wo,3aaj jo zagwnN • ( `zuag(~ `apTS0 quo-l3 :auTT flzadozd isazuau wozj iaaj jo zagwnN :ad,ts tlo:jTMS tu.zuTV :zazn~oujnueyl wzeTV : aTDAD , aad suoTTuO : uoTIunal@ gDITMS j jo dwnd uoT~unaTa ->luuI jo woJJoq - :10TuT jo uoT]unaTH azTS, dwnd :zazn-joujnuull uotld-rs/dwnd TapoN dtund :XlToeduO PTnbi7 :zazn~oujnueyl NRH WVHO 'didlld 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. WCONVENTIONAL ❑ALTERNATIVE ISI,,n, II, ID Numbe, (f ass,go) El Holding Tank ❑ In-Ground Pressure ❑ Mound TRANSFER NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE. John Hartman R. R. 1, Box 201, Hudson, WI /;,,7 __2 ; 3 d BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. SW4 NE4, Section 16, T29N-R19W,Lot#22,Northling!Station,Twn.of Hudson Name of Plumher. jMP,'MPRSW N,,. Mt. Sanitary Permit NumberRichard Hopkins 1059 Croix 58909T SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.'. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED DYES ONO OYES ONO BEDDING: VENT DIA. VENT MATL HIGH WATER tNUIMBFER IDF ROADPROPERTY ENT TO FRESH ALARM T OM LINE IR INLETDYES ONO DYES ONO EAREST DOSING CHAMBER: _ MANUFACTURER JBEDDING. LIQUID CAPACITY PUMP MODEL. PUMP, SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. DYES ONO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROV ERTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM INE I AIR INLET PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check thesoilmoisture at the depth ofplOw ing Ftl 1IA47FTER IMATIRIA1 ANDMARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH LENGTH NDISTR PIPE SPACING COVH INSIDE DIA -PITS LIQUID BED/TRENCH ! TCRES MAT EHIAL PIT DEPTH: DIMENSIONS C H:I V CI 1, FILL DEPTH DISTR_PIPF DI! PIPE DISTR. PIPE. MATERIAL: 77NEA6EET NUMBER OF PROPERTY WELL 17i. VENT TO FRESH BE UtN PIPES ABOVE COVER ELEV. INLET ELEV. END. FEET FOM LINE AIR INLET. - s1 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM 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 PERMANENT MARKERS OBSERVATION WELLS DYES ONO OYES ONO DEPTH OVEH TRENCH RED DEPTH OVER TRENCH: RED IL SODDEDMULCHED CENT EH EDGES =OP11 DYES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NLATERAL SPACING. GRAVEL DEPTH BELOW P I P E . F I L L DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & I HKING ELEV. ELEV. DIA. ELEV. PI PES. DIA.: ELEVATION AND . DISTRIBUTION INFORMATION 11111_1 SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ONO DYES ONO COMMENT PERMANENT MARKERS. JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: S O FEET FROM LINE. p OYES ONO DYES ❑NONEAREST-_ IZ 13 Sketch System on Retain in county file for audit. Reverse Side. - SIGNATURE TITLE DILHR SBD 6710 (R. 01/82) SANITARY PERMIT COUNTY C)ILHR TRANSFER/RENEWAL UNIFORM PERMIT # N,..,u..,m..,.. . (PLB 67-T) r PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: 11-1q-y4 A1,4 PROPERTY LOCATION: CITY: W '/4,S /(a T s2f N,R If W VQWN A E: d uels c) n LOT NUMBER: BLOCK NUMBER: S'U'~~.DIVISION NAME: NEA ST RDA, ,LAKE OR L P PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SI TURE: NAME: PHONE NUMBER: ADDRESS: ~ PHONE NUMBER: ADDRESS: I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLU ER'S SIGNATURE: PREVIOUS PLUMBER'S NAME 1IF CHANGED): PLUMBER'S ADDRESS: PREVIOUS PLUM ER'S ADDRESS _ 16 _j/7 3 - ~ t~h 101. E NUMBER: M / PRSW UMBER: PHONE NUMBER: MP/MPRSW NUMBER: P15 a 2 ('ifs) Y4 s v -?30 7 SIGNATURE OF ISSUING AGENT: DATE APPROVED: DISTRIBUTION: Original - County Copy - Bureau of Plumbing V `E d. Copy -Owner DILHR-SBD-6399 (R. 5/82) Copy - Plumber - Q - (o7 PLB PLOT and CR055 s~ SEcTJON PIANS r ig,x P' s°'' Zs TrsT is f ~y f 2- //V IF3 ,or T RB~ ' ~S o IN ( uJpD ~ ~ s oaf 113 36 5c41E -30 wQSfi ~~NE T~'pt = ~ ~'/Eve X00 ~.coW- LG f L 2 1t10X`~t~ z'( S 7l. T(0 Sw iy ,v ~y S'/~ Tz f L~CE~t/SE Fresh Air Inlets And Observation Pipe SOIL TEST/,0g By HOMESITE TESi':NG Approved Vent Cap RT.3, O'NEi1 RO") HUDSON, WIS. '.4016 Minimum 12" Above / Final Grade 114jk Kv~ 4" Cast Iron yL Above Pipe Vent Pipe ro Final Grade Marsh Hay Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee Pipe 4 0 0 0 0 0 So% T~S% 11 Aggregate 0 Perforated Pipe Below Beneath Pipe ~P 3 Z 0 Coupling Terminating At Bottom Of System o -i D p = r r - z o C colpi W cn z rn m 00 o m Now N o X~ ■ u < rn M~4 n cc) r - m Now M / 0 0 c~ z ~ n C~ r p ~ D m o C) N Z ;1 00 Z D o C ~ o x - C C C z z < n o m o Cn n =i ? (n 71 0 z O p z C m t s~ ~oN~ o~ p z z D - m O S m N d S S o S m< Q m d, m S m m m m m mm 3~n aN mm ~n f7 . m e ,m y m m 'o, a~ ~ c = r m o a 3° < d m° 0 3 3o ° m m m m 3 c o a m M W m 3 m a~ 3 •fD m A o m n m" m cJ1 m c- y' d m s H 7 m CD c 71 c y S S 0 3 o m 3 S3 m n _ m n m m m° m a 3 O m ~m m o"orj 3 Z ° :3 - s c ° m N m D a~ <om ~o Z ~o d a W Z < CL M -0 CL m 0. m 3 D d ° 3 N CD m m n ~ 3 3 n d Cn cry D a _ ECT ET 0 00 < -a a ° Ca o 3 ° < m ° a N m goo H 0 m 3 0 m ' ° Ca m ~ - S 3 7 m m DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADI40N,4W1 53707 BUREAU OF PLUMBING CONVENTIONAL ❑ALTERNATIVE SfafePlanLD.Number Ilf assigned) Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PE MIT HOLDER. AD,D~R ESS OF PERMIT H LDER: INSPECTION DATE. ]BE H MARK (Permane f eference REF. PT. ELEV.: CST REF PTELEV Nme of Plumber `lwX 1714 # >1 MP/MP Sanitary Permit Number. SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY : TANK INLET ELE V.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. BEDDING. VENTDIA.. VENT MATL. HIGH WATER ❑YES ❑NO ❑YES ❑NO ALARM FEET FNUMBERROM FLI OF ROPERTY WELL. BUILDING. JVENTTOFRESH AIR INLET. ❑YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER 7YP KING COVER VIDED: ❑YES ❑NO YES ❑NO GALLONS P ER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERNG VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM NE I AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IL ENI;TH 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 1DISTR PIPE SPACING COVER INSIDE DIA #PITS LIQUID DIMENSIONS TRENCHES MATERIAL PIT DEPTH GRAVEL DEPTH FILLDEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL. INDISTR FENUMET FBERROM OF PROPERTY WELLBUILDINGVENT TFRESH U'E COVER ELEV INLE ELEV END S BE LOW PIPES AB . LINE. AIR INLET. NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM 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 [7AIIENT M ARKERS OBSERVATION WELLS YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED =OFTOPSOIL SODDED SEEDED MULCHED CENTER EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAESPACI NG GR AVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTRPMANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA ELEV. PIPES DIA.; ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENTMARKERS: OBSERVATIO N 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. 01182) WI9COnsIn APPLICATION FOR SANITARY PERMIT / (~DlLHR COUNTY (PLB 67) UNIFORM SANITARY PERMIT # pEPRRTmEnT OF r~ InOUSTR4, LABOR 6NUMRn RELRTIOnS ~f~~ Nl - 6 ~-iJ.vFi~ -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PRO gRTY OWNER MAILING ADDRESS 4/ IY/Ti"~ Z01- Gv/ f PR PERTY LOCATION -tiff: S~ 1 /4 ki 1 /4, S , T-'-/ N, R E (o W TOWN LOT NUMBER JBLOCK NUMBEJR SUBDIVISION NAME NEAREST ROAD, I oKF nR I nnlnnnoGtK STATE PLAN I.D. NUMBER 2 2 CVO kdW/' TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. L ❑ Public (Specify): THIS PERMIT IS FOR A: /NL 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 An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity / Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: .U 6,Q d l !5--T~ - IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSE9AS~qua~re Feet): 'ZO ~Z00 ~ /X X yG Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system n on the attached plans. Name of Plumber (Print): Signature: MP,IMPRSW No.: Phone Number: HOMESITE SEPTIC PLUMBING CO. -?,?6 (2 ) D Plumber's Address: ROBERT ULBRICHT Name of Designer: WIS. MASTER PLUMBER LIC. NO. 3307 MARI COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved / ❑ I ~ ~I Owner Given Initial LC. ~ y CC ~ 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 buds 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. tll Dull `.;AN I TAIRY PI~.'itrn:r nlll.tC.Arl~ 1OU This application forty I;. Lo be comp ItAt~d In f u I I and signed by the owner(s) of the property bel-ng developed. Any lnade~luacicta w_[I.1 only result in delays of the permit issuance. Should th.l. t duvelopment'be 1nt(nided for- resale by owner/conr-ractw~, ("spec house"), then a second fOrtrl Should be FuLaLnecl and completed when the property is sold and submitted to thLs office w:i-th the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property t st;, Sect ion - '1' N - F: W Mailing Address- Subdivision Name- Lot Number. = - Previous Owner of PropCrt3t~`j~^G7Y~-~'~ Zt - rr Total- Size Of Pat'c,:I Date Pttrcc_ was Ct'ii,tl nil Are all cornectt and I I I I nt,n 1 h,io I i t ,~l, l f Yu!; No / Is thltt property ht!Int, 11'.\11,l1111od I11i t,ut!Ic (!~Jwc. hon:;c) ? Yes ~ No Volume and 1'ttl;e Nkiml,rr as recorded with the Register of Deeds Rdt:l, IW1 : WITH TIT I APIT I CAT I MI ONE OF THE FOLLOWING: 1. Warranty Dec.:d 2. Land Contr.acL 3. Other recordangL filed with r.hc Itcl;lster of Deeds Office In addition, a certifled survey, if av,iiLable, would be helpful so as to avoid delays of Lhe reviewing procet.:;, i.f tho deal description references to a Certified Survey Map, the the Certlfled Survey M~tp shall alto be reclu:i.re-d. - - - - - - - - - - - - - - - - - - - - - IT'0111N'lV OWNf 1; Ct-I,,'TIFICATION I (We) c.e~t_tt-6U tll,-t t1N, ~ r.atra,,_-_.__---_._ nlett t:S ou tit ('s 6o)u11 ane .tA.ae. to the bu. t o6 my (o(vt ) i~nowle.drle; ~Jtat 1 (toy I tun (anc) .tile ututie.~t (6) o6 ,tltep'topenty dezn,.bcd in ,tUA- .616onnur-t-i_on f6o)tm, bit I,tilt.tue o f t.t wwuttiu (.t./ t.lccd n-e.con-dcd .i n tit.e 066~-ce o tile Couvt;ty Reg-Ate~t, 06 Uee.tl', a. Voctt wr It No and that T(,(bue~. p!tese.n~t,---t/ ours .tlte t.vnopo6cd 64i to bon Cite aCu'r1c (t Spo6aC 6 f6 tem (on T have ob,tcLtned an eCiSe.nient:, to nevi tu~th .tlte_ abuk,o. desc,t.ibed pn.opehtl, bon c(!n,5.tAitc.60r, 06 6aid Mid 01C. ",lief lilt', been (INTY ALICOAded in tlte 066io_e o6 thc, ComoY Rc~lt-6lt"t n6 1Jtc~1:~, a.. 1?u,~mm,)]-t No. _ ) . sLGNATURI (IF OWNEI( SIGNATURE O CO-OWNI, (117 APPLICAI,I.E) DATE S IGNED DATH SIGNED 4 lab ~ .'P a ^ e•ti _ ; 1 IJI .7 Vlr~ - ~C ♦ e 'at I _ L . r t ' - - _ - i t v, S T C - 105 r H SLPTIC 'L'ANK MA I NTLNANCL ACRLLMLNT ri St. Croix County OWNER/BUYEI/ ROUTE/BOX NUMBER -~_L_ Fire Number CITY/STATE t (~7-" ~t..°'•:.> - -----•l. if, PRUPLRTY LUCATION: L, - 4> Section t --;I, R_ _W, Town i,tc-f.9~'~_ St. Croix County, SubdivisioyT ~e/~~.Lot number=~. s I Improper use and maintenance of your supcic system could result in its premature failure to }candle wastes. Proper ma in Euuance con- sists of pumping out the septic tank every three years or sooner, if needed, by a Iicensi:d sci,tic Lank 1! Ll Ili jlt'r :hat you put into the system can affect tiie funCtion Uf Llic ,)Lic tank as a treat - liient stage in tha waste dis,,.)sal system. SL. Croix County resideats be cligibl= L a maximum of 607 of the costof replaCeissent of a :ailing system, which was in operation prior to"July 1, 1978. St. Croix County accepted this program in u;uSC 1330, wi.li !-ic :Iuirei:el:t owners of ail new systc _ a,,ree Lo keep their -:ysz-enis pruperly ilia intained . The property owsii!r agrees to sub:iit to 5L. C r u x ..:iiI "Lui:in_ ± certification form, signed L,-r CilC journeyman plumber, restricted pluinljer ur li tense pumper veri- fying that (1) Elie 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. o I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with w the standards set forth, herein, as set by the Wisconsin Depart- i ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED~L, a~ DATE St . Cil ' oix C.iunty Zoning Office P.O. f•ox 98 Hammor d, WI 54015 715-75 6-2239 or 715-425-8363 Sign, date and return to above address. . v r N n m N ov m vi w ?c c "'3 O m (D (D o n 0 ((DD ° ° WOO N 0 - co =or w ° C< w o 3 w w o c co 0 =-r p ' c fD' 'a a (D (D ° O= A t`n ~y 0 O 0 N (D ~ N N n C-0-000 ;o C, C _ (w~D W Icl 0 ID w 0 (D (D N a N -A, °3a OO°mCDOD a c2D ? N O cp 13: o CD w ° c o w o~O 3 0 C G_ c- N Z C E3 6-Ro O 0 _ O C R N~ (D w~ N O w y O p a (~D O O (D w A W C n ~o »oo o-M o0- ~°~mof 0 w --I =r C<A wCDw r•w=-a~v C Z aw 0 CD CD c, 3'Dm(D?a -I a ID n C,, C O N N a °a w o?$ m CD 0 c 0 a a m v 3 vm° ~ww-.~ C 171 N c ~r '0 a O O m w (D ~D N (D .N. N n j~ O aco W A C (4'o f W O O (D n (D N a o a c c c c F a' w CD a CD (A ~ 171 0 CL 0 m a c CO -4 , =r 60 C ~oNCD DO 3 g Q° 7 o co a c N 7 a ?ow ~a)=N p4.~ Z a 0c w v~ aC 3 0 ~ m o• 0 0 ° `N ~ a- - 3 N' 3a o< 3 CD to o z 0 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND - PERCOLATION TESTS (115) P.O. BOX 7969 HJJMAN VELATIONS \ / MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: NSHIP/~: LOT NO.: BLK. NO.: SUBDIVISION NAME: S~ '/a '/a la /Tzy N/R 1yE(or TOW L)p 0 Zz roe Is-f'Aa'3- COUNTY: 'S NAME: MAILING ADDRESS: 5/~1 #IV 7~-Ilf 0ev. / ~o X 2 a / f~p ~aLJ Gc,i S S f~di ~ USE O D ti4C,_ DATES OBSERVATIONS MADE NO. BEDRMS.: COMME CIAL DESC TION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence / New ❑Replace Nou , 2- r, 0 U .S RATING: S= Site suitable for system U= Site unsuitable for system 6l S /{a~P/ZOit1-~ . MKOjjnb~rG_ UND-PR ESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) S []U []S ©U ❑S 0U rcol [under Peatio n Tests are N OT required DESIGN RATE: I If an y portion of the tested area is in the s.H63.09(5)(b), indicate: L Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS iwr 3btcj,-tQ T4 . BORING TOTAL DEPTH TO GROUNDWATER, CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B > 7~' •y1'A,ta0 .si, x.33 13~.s4,=, 4 )2q,, v ~s w s~~ 71-1 AL) L •33 B C5 w B 3 /2 d . ~ ~r1'"- >/1 t3 " A' . S-/ ~ yl ' /3N . I c s, / T-If ~ cs ~ 'iv T,4 Aj B d~ 1~5.Oy7 > •yi'Ra.s; f3N.cs 6-A 7.7s v c sC 13 6-1V_ S_/ PERCOLATION TESTS TEST nPPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PER IOD 3 PERINCH P- ( .Pi1 COM C d P- P- L 5.0 < r - G^^" w ~ A< f - A 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 -3 Q -0q4' Vol, t aoX f s PRA f~ o S~~? S,v,,,~ r o~ DRivf~rcp se z % -{r S /C /qs • ` ^ ifo ~ ~ s ~ a W -lo Sa s r R ~T / 133 r Cd i°e~ c S/ fps r,c Pf 13 Tclze`~ 3v f4we Poor ro OF solle- ~ f46M es,:4C - iS /00,0 Lr'Vr I, the un ersigned, 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: HOMESITE SEPTIC PLUMBING GO. S- _ 'DSON WIS. 540 -6 ADDRESS: FIT, 0 CERTIFICATION NUM ER: PHONE NUMBER (optional): ROBERT ULBRICHT 01 M.P.R.S MINN. INSTALLER & DESIGNER LIC. 00663 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - i L r ~ S a i s . G' t ` S F %'J'h t_ € d 1 p L, L„ , Go "?b e F a 0 ~ i 0, b a C``„7p-'te and M,--, Fksuse section d'st?P 1 M Lii1! I €<a'n 3'r~ b C d r c,u. d c..,i rf> ion rd_t TtF,sd;d,.. C ,yn he .{.,=.000;{0m_ axes. SITE ISSUITATs;._ CA HER SYTTWSARE RULED OUT HASH; ON SWL CONDMONS; PLEASE use We abbreviat ions sh van herb for o R..9 M0'Tila cl eriPtio ns and zcs~,~>rnritzy ~(~t ~r~ F ..l'Fr"e r ,"n t.'.wdwgr and v , ical el . tivi F, ut3iFe pwi nl .a'•-fr; cj z.l ae slasq, and a r, d M<'°:3C s l d Q ?,1 qq3a R s,.~l.,~'. `s, J to dives, own as, a{'a'';i .~.`~eq t hood r' t da,, istc,0;~ iii ltI;-,dF z An , c'n, _4.s T7..3od ! at'l, vloval:i m,','-f ws no! nflp, p loco fLA, iii the tpplCl. w room Ir-~d ace your curimc aMen and yon rear? 1 ,s }it OR SS sww~~ r i Les, -h Sill (3y - { ay ~ Coy Q.-,I SwnQ Gov 1 M=' 13 FIN "sip d•,'< Low n of, v", f t s sc'i! It-st tt d' the _i il -..1E wi,di f.. o ,.r ,t {3 M sa e> >,°a3'. w t ho wid ;?d" .F vciwiz a._ ..o F, .t' of p1u. , t;)4 we ,7 raJmcx nsj En Any d rl o... cl PLB C,,,7 MOT and CRoS5 s~ SEcrjo N PIANS P, soil 2S rrsr, 13 L 3 ~ s A / ' ~ Off 1% i 5c,4/E 3 wQS1` ~o~ ~/NF 3~ Ion. D PtPo 1,GT- D ~ LG f L Z /t/0/9/44,4 S T~N(~ S41 iy iy s f TZ f le /S w S' ~'UtiFD HOMESITE SEPTIC PLUMBIN(; CO. 3 O'NEIL RD., HUDSON WIS. 54016 ?j ROBERT ULBRICHT WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. T-- MINN. INSTALLER & DESIGNER LIC. N0. 0066.' Fresh Air Inlets And Observation Pipe SotL TESTIAJ5 By HOI" ESiITE TEST NG o;G. ~1- Approved Vent Cap RT- 3, C'NkiL Ron,) HUDSON, Wis. 4o16 Minimum 12" Above Final Grade MA x1 'Above Pipe _ 4~~ Cast Iron ~Z Vent Pipe °i o Final Grade Marsh Hay Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee Pipe 0 0 0 0 0 OQ„ SC O Aggregate 0 Perforated Pipe Below Beneath Pipe 0 Coupling Terminating At Bottom Of System