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HomeMy WebLinkAbout020-1165-50-000 n to O F 9 0 1 C 3 (D > > t7 3 F Z 'o 7 'D ' fD 3 - 1 Iz A: 3 _ O cn z o cn _ o CD (D w 10 a co = n (n O) O (O .3 W 0 O 0 C) ? C 0- 3 a) 0 'a 0 (n o~ N N = O 3 Z) 0 cn O O N 3 ° ~ o 0 0 O (O lot I CD w _ y H e N co co p cn ° a ~ nom' s n7 ~ = 3 ~ N z O S O O F-I Z V [~iy p° c, n co c C N N y N rn co 7J N s 3 Cr~ v I CD y C~i ~ O O 77 ° O O ' .r z cn m m a CD d w N c 3 D (p CD N n z W co z o O rrl -i Z v O ~ W I e~ N Cl ~~OO Z rn c D N N• N ll~il 77 ° N c v z C N O (D W - CL EL O 7 ~ (6 1 N C m (3 s ? n c~ c CL z o0 6 W " < N V (D (D < (D (o C Zy a z 0 3 X o 3 m N C (D 41 w ~ CL v a o ° 3 c _ C 3 O O d (D A N N a N N S 4 O O O f: ~ C 7T N t0 e O N V 3 N M O O A (D PA ts~ O ti a O O (D O 'r ~l ST. CROIX COUNTY ~X,. WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 July 11, 1994 7- Z 9- l c, i~ Z) Jim Henry 700 Second Street Hudson, Wisconsin 54016 RE: Water results for Sharon Bailey Address: 941 Sherman Road, Hudson, Wisconsin 54016 Dear Mr. Henry: Enclosed is the original water test results from Commercial Testing Laboratory, Inc. for a water inspection of the above property. If you have any questions with regard to said report, please let me know. S'ncerely, 7 James Thompson Assistant Zoning Administrator js Enclosure COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, F.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ,ROIX CTY G-O:" a CTR EE ; r u' 1. CARMICHAEL ROAD ~ Wrys. i_.ECTORa Jim Tft+)mL- =t ! = COLLECTED' 6- t 1T1: COLLECTED. 35OURCE OF SAMPLE; DATE ANALYZED:+;_ TIME ANALYZED.>2.G. COt_IFORM,MFCC* !NTERPRETATION NITRATE--N: -0LFf0-1-m RESl,1'_. _ FAX10, c_ 4 CAL"' NDEPENp Approved Lab J s PROFESSIONAL LABORATORY SERVICES SINCE 1952 i ST. CROIX COUNTY WISCONSIN ZONING OFFICE 411Nllpllpll ST. CROIX COUNTY GOVERNMENT CENTER • 1101 Carmichael Road " Hudson, WI 540 1 6-77 1 0 (715) 386-4680 July 5, 1994 Mr. Jim Henry Edina Realty 700 Second Street Hudson, Wisconsin 54016 RE: Water (VOC) Inspection for Sharon Bailey Address: 941 Sherman Road, Hudson, Wisconsin Dear Mr. Henry: Enclosed is the original test results from SERCO Laboratories for water (VOC) inspection of the above property. If you have any questions with regard to said report, please let me know. Sinc rely, mes TYiompso Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure cc: Pat Collins 06/29/94 14:42 FAX 612 636 7178 SERCO LAB. 444 COUNTY CLERK Z002 SERCO Laboratories 1931 Wes[ County Road C?, SL Paul, Minnesw 55113 Rhone (61?) 636.7173 FAX (61Z) 636.7178 LABORATORY ANALYSIS REPORT NO: 45297 PAGE 1 of 3 06/29/94 St. Croix County Zoning DATE COLLECTED: 06/13/94 1101 Carmichael DATE RECEIVED: 06/15/94 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins CLIENT'S ID: Sharon Bailey SERCO SAMPLE NO: 90434 SAMPLE DESCRIPTION: 941 Sherman Road ANALYSIS: Hudson Benzene, ug/L <1.0 Bromobenzene, ug/L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 n-Butylbenzene, ug/L 2.0 sec-Butylbenzene, ug/L <0.4 tent-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 Dibromochloromethane, ug/L <0.4 1,2-Dibromo-3-chloropropane, ug/L <1.2 1,2-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. 06/29/94 14:42 FAX 612 636 7178 SERCO LAB. COUNTY CLERK 0 003 SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAx (612) 636.7178 LABORATORY ANALYSIS REPORT NO: 45297 PAGE 2 of 3 06/29/94 SERCO SAMPLE NO: 90434 SAMPLE DESCRIPTION: 941 Sherman Road ANALYSIS: Hudson 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) 4.9 1,1-Dichloroethane, ug/L <0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-1,3-Dichloropropene, ug/L <0.9 Ethylbenzene, ug/L <1.0 Hexachlorobutadiene, ug/L <0.3 Isopropylbenzene, ug/L, (Cunene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isopropyltoluene) Methylene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L 1.1 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ug/L <0.1 Tetrachloroethene, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichloroben2ene, ug/L <0.2 1,2,4-Trichlorobenzene, ucg/L <O-2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. 06/29/94 14:43 FAX 612 636 7178 SERCO LAB. -+44 COUNTY CLERK IJ004 SERCO Laboratories 193, West County Road C2. St. Paut, Minnesota 55113 Mona (612) 636-7173 FAX (612) 636-7176 LABORATORY ANALYSIS REPORT NO: 45297 PAGE 3 of 3 06/29/94 SERCO SAMPLE NO: 90434 SAMPLE DESCRIPTION: 941 Sherman ANALYSIS: Road Hudson 1,1,2-Trichloroethane, ug/L <0.1 - Trichloroethene, ug/L 0.5 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L 1.6 1,3,5-Trimethylbenzene, ug/L <1.0 (Mesitylene) Vinyl chloride, ug/L <1.0 Total Xylene, ug/L <1.0 This sample's analytical results are below the U.S. EPA's SDWA Maximum Contaminant level of 01/30/91 for those requested compounds which are also on the SDWA MCL list. The analytical results in this report pertain only to the items tested. All analyses were performed using EPA or state approved methodologie=s. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, Carol A. Kuehn Project Manager < means "not detected at this level". 1 mg = 1000 ug. • l ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER l9 , ` r F I 1101 Carmichael Road " Hudson, WI 540 1 6-77 1 0 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. -ftr Water fWoC's) _$185.00 ❑ Septic $50.00 Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria retest $15.00 Owner: SHHIZ~N 3A/L~~ Requested by: _Jim H~rVI?y ^1, Address: _.9,91 5H_ M1gN RD. Address: -70t7 -zkiny S-= ` eo~_10111> wl Z I P~ 1yyvSDN, LA / ZIP 510/ Telephone N°: (715) Q M_ 2.4a-7! Telephone N°: (Z/ ) 3 - gZ•~.~c " Property address (Fire N° & Street) : qy/ SHa IE MAr n~ RoA L Location: 1 Sec. T _N, R _W, Town of Realty firm: apjA),q Lock Box Combo: ?IA_ Closing Date: ~y-gy TO BE COMPLETED BY PROPERTY OWNER PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: Is the dwelling currently occupied? ❑ Yes ❑ No If vacant, date last occupied: Age of septic system: - Septic tank last pumped by: Previous Owner's Name(s): Have any of the following been observed? Ct f;t - ❑Y ❑N Slow drainage from house. l~r<< ❑Y ❑N Sewage Back-up into dwelling. ❑Y ❑N Sewage discharge to ground surface-or raid ditch.. l ❑Y ❑N Foul odors.= ;.r Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. OWNERS SIGNATURE: . ATE: 1/94 OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? DYes DNo sheet Soil series per SCS Soil Survey: T.~ e of soil-- absorption system: []Below grd ~Doserd DElM Presaurized ,X DGravity Approx. size Ft.2 DBed DTrench DDry Well DHolding Tank DOutfall pipe ❑Other DUnknown OBSERVED DEFICIENCIES Septic tank Setbacks: DHouse ❑Well ❑Prop. line ❑Other Dose tank Setbacks: ❑House DWell DProp. line -ump/DFlOthoearts--- DLocking cover OWarning label ❑P DAlarm DElec. wiring Soil Absor tion System DWell ❑Prop. line OOther Setbacks : DHouse ❑Discharge : DPonding:_ Gener_-j comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector- - T i t l e - COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 Agw 800 - 962 - 5227 cz: w FAX 715 - 962 - 4030 G :ROIi CTS. iOllat Ti rlEi U i CAR UC4AEL ROAD r,n ~-Fn! ...ECTOR: J i m Thriv. COLLECTED _yy._ E v COLLEC TI ED a 4 `'CE OF SAMPLE: ANALYZEDib Ate?AL'Y7EI+:?100Fn [FOFii`9rM FCC: L t.!tE E cTAl ION <ITRATE-W Q NDEPFN~f < ,vpr5 ed Lab Nf,a o o M PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY WISCONSIN ~ _ ZONING OFFICE nanuxxxu 4~ ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 June 28, 1994 Jim Henry Edina Realty 700 Second Street Hudson, Wisconsin 54016 RE: Water results for Sharon Bailey Address: 941 Sherman Road, Hudson, Wisconsin 54016 Dear Mr. Henry: Enclosed is the original water test results from Commercial Testing Laboratory, Inc. for a water inspection of the above property. If you have any questions with regard to said report, please let me know. A'Sincerely, FJ ames'Thompson Assistant Zoning Administrator js Enclosure ST. CROIX COUNTY WISCONSIN npnuunau~ _ ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 June 28, 1994 Jim Henry Edina Realty 700 Second Street Hudson, Wisconsin 54016 RE: Water results for Sharon Bailey Address: 941 Sherman Road, Hudson, Wisconsin 54016 Dear Mr. Henry: Enclosed is the original water test results from Commercial Testing Laboratory, Inc. for a water inspection of the above property. If you have any questions with regard to said report, please let me know. Sincerely, ame Thom pson Assistant Zoning Administrator js Enclosure r c" L) r a COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 G i ICvi .UUftc , tJfeLP~L iH'3 1Lr- :ROIX CTY GOV.CTR RLi ui i i+k?i 1. CARMICHAEL ROAD rwTr PFCrTVFr ! 3,-,ON, WI ATIONI 941 Sherman Rd.. Hudson 2 1_ECTOR: Jim Thompson COLLECTEDY 6-13-94 CO ~Wk COLLECTED: 4:15w n. 6 q ~gg4 R'CE OF SAMPLE 41 4 a 2 v, ANALYZEDt6-16-94 GpkJN F1C~ ANALYZED 2 2 2 00pm . . IFORf' tMFCC: 0 /100 ml 8 4RPRETATIONS Bacteriotogicaii.v SAFE RATE-NI 10 ppm Above 10 ppm exceeds the recommended Public: Drinking Wa#e, atandard. i i. _ -P N" t of Ftir 4. Approved Lab No. s a ~Ra7~5 "LESS T, J PROFESSIONAL LABORATORY SERVICES SINCE 1952 07/07/94 11:51 $ COUNTY CLERK Q001 xxcx ACTIVITY REPORTm i TRANSMISSION OK TX/RX NO. 3139 CONNECTION TEL 93861502 CONNECTION ID START TIME 07/07 11:50 USAGE TIME 00'54 PAGES 2 RESULT OK Post-it" Fax Note 7671 Date Pagges~ , To 1 Fro On -X f, - )Nc Go.Mapt. Go. Phone # l PhonC # Fax # Fax # 07/06/94 15:54 $715 962 4030 COMM. TEST LAD y~♦ COUNTY CLERK Q001/001 COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P,O. Box 526 Post-!t" brand fax transmittal memo 7871 seryages. Colfax, Wisconsin 54730 To FrsN 715.962-3121 co. 800 - 952 - 5227 FAX - 71S - 962 - 4030 pt" nda U# - y Qd ti ST. CROIX COUNTY ZONING OFFICE REPORT NO.: 65628101 PAX 1 ST.CROIX CTY GOV.CTF REPORT DATE; 7/06/94 1101 CARi1ICHAEL ROAD DATE RECEIuEW 6/38/94 HLMMN# 411 54016 ATTN; THOMAS C. NELSON OWNER; Sharon BaiLa!- LOCATION! 941 Sherman Rd-. Hudson COLLECTOR: Jim Theapson DATE COLLECTED! 6-29-94 TIME COLLECTED: 9:15am -ME OF SAMPLE; Oatsidio tap DATE ANAL-YZED:6-30.94 TIME ANALYZED:2:00pm COL.IFORMjMFCC: 0 /100 m! INTERPRETATION: BacteriolagicaLly SAFE NITRATE-N: ; Ppm Above 10 pps *:ceeds i5e recommended Public Drinking W:ttr Stand:rd• Coliform Bacteria/100 at Nitrate-iiitrogQn, m4/L RESULTS': FAX'G Oi•J: LAD TECHNIC.TANi Pam Gant PHONED ON: '71s l4+ CALLER: ' S WI Approved Lab No. 17 b L Mans "LESS THM" Detectable L.eveL Approved by: '5 20i l Ptircel 020-1165-50-000 PAGE 1 OF 2 Alt. Parcel 17.29.19.1005 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 SKANES, ERMELINDA L ERMELINDA L SKANES 941 SHERMAN RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description 941 SHERMAN RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.606 Plat: 2284-PARKVIEW ESTATES 4TH ADD SEC 17 T29N R1 9W PARKVIEW ESTATES 4TH Block/Condo Bldg: LOT 88 ADD LOT 88 Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) 17-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 06/18/2003 726431 2281/10 QC 06/25/2002 682576 1916/93 WD 07/23/1997 1151/453 WD 07/23/1997 1086/092 WD more... 2004 SUMMARY Bill Fair Market Value: Assessed with: 49045 235,000 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.608 31,400 150,400 181,800 NO Totals for 2004: General Property 1.608 31,400 150.400 181,800 Woodland 0.000 0 0 Totals for 2003: General Property 1.608 31,400 150,400 181,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 112 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 "Parcel 020-1165-50-000 02/25/2005 03:15 PM PAGE 2OF2 Parcel History: cont. 07/23/1997 743/407 07/23/1997 696/595 r r, Form- S T C - 104 `'✓,r_ AS BUILT SANITARY SYSTEM REPORT r OWNER C TOWNSHIP y, SEC. T N-R ADDRESS *Z Gr~En ST. CROIX COUNTY, WISCONSIN uA'~oh W i 5 . S_y0 / ~ SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 17 J)/.Vd. WOL Z~y 14 ~l N6USt ~f Oa - ~4 X `14 c I 5 y sT~ (i. i y v ►oa.C) i V INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point:4/.ZOZ /00) Proposed slope at site: SEPTIC TANK: Manufacturer: 1f, Liquid Capacity: ~~0C7 q~ Number of rings used: Z Tank manhole cover elevation: Ad Tank Inlet Elevation: 50, -s Tank Outlet Elevation: r Number of feet from nearest Road: Front,~Side,~ Rear, li'S r feet r From nearest property line Front, 0 Side,®Rear,0 5 feet Number of feet from: well -2 building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) F1? P11VEIZSF. (1101" SS T PUMP CHAMBER /G~✓ ~J~ # Manufacturer:: ~i Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property 'Line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: (~4Vd yf, Trench: ~ Width: s Length: Number of Lines: 3 Area Built: Fill depth to top of pipe: Number of feet from nearest property lane: Front, O Side, Rear,O Ft 7 Number of feet from well: -f2-:!S 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 AI Manufacturer: /,C'~ Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property lane: Front, O Side, 0 Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on Job: 7 License Number: 3 / 8 4 : IT1j DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HIJMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 5,3707 [(CONVENTIONAL ❑ALTERNATIVE State PlanLD.Number (lf assigned) ❑ Ho ding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. y V;. JADDRESS PERMIT HOLDER: INSPECTION DATE. Sum M~.tty Thou Btcvvfz Road. Hudson, W1 ~3 t~/ ~.V(1 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. EL V. NW SE, See. 17. T29N-R19W, Twn v{ Hud6on,Lot#88,Pahk, View E.6tata IV Name of Plumber. JMPIMPRSW N... cSanitary Permit NumberDoug S~.vhbeen 5432 t. cAoix 54936 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY . TANK INLET ELEV. jTAN_?0e_LE TWARNING LABEL LOC NC VER PROVIDEDPRO rDE ! , DYES ❑NO Sil' ❑NO BEDDING: [ENT DIA.. VENT A (L HIGH WfATE t TUMRE BER O R OAD, PROPE:/ IWELL. BUILDING. TO FRESH ~IrLEr ALARM T FROM JLI / IAVIERNT ❑YES C~NO ❑ NO ST L > S^ DOSING CHAMBER: MANUFACTURER 7ING L IQUID CAPACITY PUMP MODEL JPUMP,SIPHON MANUFACTURER WARNING LABEL LOCKING COVER ROVIDEDPROVIDEDES ❑NO Al E ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL !NUMB` R OF PHOPFHTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FE4T RROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAR ST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Nc;TH : DIAMETER JMATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MA ID' the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH LENGTH JNO01 DISTR. PIPE SPACING COVER INSI UE CIA- -PITS LIOUID BED/TRENCH r `7 TRENCRES MAr IA PIr DEPTH DIMENSIONS C. i_ GRAVEL FPT#1 FILL DEPTH ')ISTH. PIPE DISTR. PIPE DISTR. PIPE_ ATERIA L. NO DISTR. NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH - Fs LIN, ( r~ AIR INLET BE LOW PREY' AByy~E COV ER ELEV. INLET ELEV E D I ^g PIP O l C t 1' c1~ Lc NEAREST--r l C1 J~ MOUND SYSTEM: 1 Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM O'FSYSTEM and furrows thrown upslope: mound systems to make cer1in that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sated. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE P RMANENT MARKERS OBSERVATION WELLS i ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SO DID D - SEEDED MULCHED CENTER EUGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: G WIDTH. LENGTH NO. OF LATERAL SPACING. R VEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. IN O DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. DIA. ELEV.. PIFES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATE RIAL 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 INEAREST- 'z M v~l Sketch System on C R in county file for audit. Reverse Side. a SI GNAT J11 TITLE DILHR SBD 6710 (R. 01/82) , t ~j' w'S~°ns'n APPLICATION FOR SANITARY PERMIT 7 D ' L H COUNTY °EPRRTmenT OV (PLB 67) UNIFORM SANITARY PERMIT # tt M In DUSTRV, LR6°R 6 HUmRn RELRTI°n5 -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS 5' ' TN" C_ r- ~L-f ' P z_ PROPERTY LOCATION CITY: AIL. c(-5c ~G11 /4 1/4, S T % N, R le~ E (or VowN 07) LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER C ; Gz' ~Qwz. S ¢r TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): 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 ❑ 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 ~j Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure A14 Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Sign ure: MP/MPRSW No.: ~Plhone Number: S r 6 w----~ Al r - (--Z ) - 2 3 Plumber' ddress: Name of Designer: Le 1 ` k l Aer COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ~Owner Given Initial d 7 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. Form - S T C 100 ti Owner of Property Location of Property, Svctionj-7 T_Z2_N k1-! `T'ownship /-/rl Mailing Address c,'f '✓nok ~ y70' ~ 4 4 S G I S Subdivision Names✓~//;~~ iE~ 7-td s- Lot Number #1 ? Previous Owner of Property .O ,-e✓,/ U" T Total Size of Parcel 1.(„0';( cFs S 7~ 0q0-5!3- Date Parcel Was Created Are all corners identifiable? Yes No Include with-this - application one Of the following: Certified Survey Map .Deed .Land Contract, or .Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION I I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 3 3 Y-s 1- ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. 32 3 Z 5- z= ) n 1 SIGNATURE OF OWN R SIGNATURE OF CO-OWN R (IF APPLICABLE) DATE SIGNED DATE SIGNED i H U7 Y • S T C - 105 Cr - Y H SEPTIC TANK MA I NTE'NANCE ACREEMENT r+ 0 St. Croix County J y • H OWNER/BtJYEIt -S Q v Ira It0UTE/B0X NUMB1, It- R- (n Z- Fire Number C1'i'Y / STATE ~.:S'' 1 I' PROPERTY LOCWTION: Sectiolt i"N, Town oSt. Croix County, Subdiv is iun Lot number-_1?3 I lwprOper US(' rod majilt euance of your septic system could result in its premature failure to handle wastes. Proper maintenance cun- si.sts of pumping out the septic tank every three years or sooner., if needed, by a 1_i_censed sel,t -c .tank 1-umper What you put into the system can al-fect the function of the :.cptic tank as a treat- utent stage in Lire waste disposal system. St. Croix County residents uia~j be eligible Lo receive it grzint: fur a maximum of 60% of the cost. of replacement of a failing system, which was fit uperation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the rCquir(+munt that owners of a I1 new system agree to keep the i r- systc+m5 t~ro1) ,rI y maintained 'I'Ite p.ropet_- ty owner agreer> to suhllliC t0 St ruix Cuuuty l.uuiul, a certification torus, signed by the owner and by a master 1) Umber , journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on- site w astewater dis1)usa systt,m is in proper operating coitditi.on 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 r;rnt approximately 30 days prior to three year expiration. ~i 0 1/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart - v ment of Natnr-i I kesotir(•,, Cert ifiCation f -orm must: be completed and returned to the St. Croix CouoL, 7.(-i,lg 011ice within 30 days of the three year expiration (late. S 1 C N E 1) ATE St. Croix County "honing; 01 1 ice 1' . 0. I o x 98 If ammoI d, W1 54015 715-756-22311 or 715-425-8363 Sign, date and return to .tbuvc addrUr;s imWomomm „o-cama, SANITARY PERMIT County DILHR oEOAR. MST OF GROUNDWATER SURCHARGE Sanitary Permit No. - rKXJSTRV LABOR6MXT1AI~ FB♦3-AT~O- ni 9_'~ On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-was the r of r ove monly known as the groundwater protetaebate. The groundwatertbillt nc uded theecreatsult 2 years of steady negotiation and public . The surcharges (fees) for a number of regulated of the water which can is used neyour bui d rages returned to surcharge took effect on July 1, holding the groundwater through your soil absorption system or the disposal site used by your tank pumper. fund admi The monies collected through these surcharges These funds aretusedrfor monitoring ground ~s tered by the Department of Natural Resources. groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. Ground; iew Date: Wisco qtr S Groundwater Fee: _,fy buried loaf} ira ell Signs ure of Issuing A ent: s- ti x DILHR SBD-7289 (N. 05184) ~~yA 1 7.0 DEPARTMEN7°p P SAFETY& BUILDINGS d~! INDUSTRY. ORT ON SOIL BORINGS AND Ll AN 11UM N RELATIONS~f PERCOLATION TESTS r115 DIVISION 1 P.O. BOX 7969 MADISON, WI 53707 (H63.090) & Chapter 145.045) LO ATION: SEC r C)Xf TOWNSHIP/s Y: LOT BLK. NO. S DIVISION NAME: COUNTY: WNER'S/_B.UYER A1AME:~ ~ftE!, j" S # / MAfLING ADDRESS: USE NO. BEDRMS.: COMMERCIAL ESCRIPTION: DATES OBSERVATIONS MADE ,Residence PROFILE DESCRIPTIONS: PERCOLATION TESTS: ew ❑Replace r ~ 7- y RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-I -FILL HOLDING TANK: RECOM ENDED SYSTEM: S ❑ U ~ $ ❑ U S ❑ U EIS XU ❑ S U ~vt,", ~ •a~/ `x~ " If Percolation Tests are NOT required DESIGN RAC : under s.H63.09(5)(b), indicate: Jl If any portion of the tested area is in the Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH4.4. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r S:4 S r B- 7 7-F 6 h/.s/ o s, Ipj 7-S B- 75' • 3 r 14"te- P 7, f '04 _rY 4- B- PERCOLATION TESTS TEST DEPTHo, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES NUMBER klUC".6& AFTERSWELLING INTERVAL-MIN. RATE MINUTES j ,Q a PERIOD 1 PERIOD 2 PERIOD PER INCH 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 I Pr ~r- A,~ G 1 , . _ : 7 / nr /©e If ~ ~,f~,r'x/ ~'orlk,~(-~ ~ ,a l~r~ . _ ~f f~ tt~ • ~c.`1 ~ CC*t-~u ts- - o e V _ 'P.W_'f C'A lie ~s 3 _Qc. Ile A -e,4 . 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 COMPLETED ON: ~ ~ ~i-~ s ~ •l sue. ADDRESS: j/ CERTIFICATION NUMBER: PHONE NUMBER(optional). ' . s s s lard -3~d"- CST NA RE: fgr.nt,: t DISTRJBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - € t i3?e~u FE.zE> ;Pg ~ sNil ~-J (A ..1E, c d~: -re s,rl".i,. r~= ',A E I; .JiE7; ,i a?~S = C3;! =e3 . . CC, r E r>' t..rF { r=' =g E r, r vi )L~ - .ra~.F ~ ,e.~~f ,r t r l" "ro'e ri" Es£1lC t r1; rr t + e~Y~ yr r€ ce E r s . 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