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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 - PETRINI, STEVEN L & KRISTINE R STEVEN L & KRISTINE R PETRINI 373 BROOKWOOD DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ` 373 BROOKWOOD DR SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 1.550 Plat: 2553-TROUT BROOK WOODS ADDITION SEC 17 & 18 T29N R1 9W TROUT BROOK WOODS Block/Condo Bldg: LOT 4 ADDITION LOT 4 EXC COM NE COR LOT 4 N 80 DEG W 311.75'S 72 DEG E 106.41'S 84 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) DEG E 206.85' -POB PER DESC 760/182 17-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 05/23/2006 825886 WD 04/23/2002 676940 1876/340 WD 07/23/1997 693/87 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.550 66,200 196,800 263,000 NO Totals for 2006: General Property 1.550 66,200 196,800 263,000 Woodland 0.000 0 0 Totals for 2005: General Property 1.550 66,200 196,800 263,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 216 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form - S T C - 104 . AS BUILT SANITARY SYSTEM REPORT TOWNSHIP SEC. ~ T N-R~W OWNER ADDRESS 7ROVT ~jD~~s r. CROIX COUNTY, WISCONSIN 171VOl0A) 12114 -2- f ~ - SUBDIVISION 4 ~f)4 r) LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM s --y A 1 30 SZ i i 6ti u \0 30 Q 0vT INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used L 05 /t1" N e_ C0RA,1C4_ Elevation of vertical reference point: y r Proposed slope at site: 'f-/O'0 SEPTIC TANK: Manufacturer: 4-)F FleS -Liquid Capacity: r Fr- Number of riigs used:3 T1' Tank manhole cover elevation: 103. 16 Tank Inlet Elevation: / , Tank Outlet Elevation: Number- of fe,t from neai.est Road: Front, Side,0 Rear, //0 feet From rn-~arest property line Front,0 Side,0 Rear, 0 eet Number of feet from: well 3 2 building: 30 / - (Include this information of [he above plot plan)( 2 reference dimensions to septic tank) SEl? REVI;KSI~: S 1 IIF. PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: _ Pump/Siphon Manufact r: Pump Size Elevation of inlet: Bo om of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from ne- est property 1 e: Front, O Side, O Rear, Ft. Nu er of feet from well: Number of feet: from building: (Include distances on plot plan). SOIL ABSORBTION SYSTEM Bed: v Trench: e ~Q Width: Length: Number of Lines: -3 Area Built: S Fill depth to top of pipe. Number of feet from nearest property line: Front, ® Side, O Rear, O Ft .3 O Number of feet from well: F7 Number of feet from building: Z (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bo - m of seepage pit elevation: Area Built: Has either a d box O or distribution box O been use any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufa er: C city: Number of rings used: ' evation of bottom of tank: Elevation of inlet: Number of feet om nearest property line: Front, de, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm. Manufacturer: HOMESITE SEPTIC PtuiY,L-. Inspector: Inf 3-0'NEIt RD.; -1:1031511- 1-- ROBERT UL'dRi±"a Dated: Plumber on job: PAS. MA STIR PLLiMBEf? SIC r MINN. INSTALLER & DESIi=^' License Number: 3/84:uij DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING MADISON, WI 53707 ~ kCONVENTIONAL ❑ALTERNATIVE state PlanLD.Number 11(assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION D E Dean Hansen 206 2nd St. , Hudson, WI 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. E LEV.: CST REF. PT. ELEV NE SE, Section 18, T29N-R19W, Lot#4,TroutBrookWoods, Town of Hudson Name of Plumber. MP/MPRSW No.. Count v Sanitary Permit Number Robert Ulbricht 3307 St. Croix 49463 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELF TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER V gq / P OV ED PROVIDED UJ U (7 YES ❑NO ❑YES ❑NO BEDDING. VENT DIA.. =HIGH WATR ]NEAREST MBER OF ROADJPROP ERT WELLBUILDINGJVENTTOFRISH t.y}J/ LAH ET FROM LINE AIR INLET ❑YES ~IjvO ❑YES ❑NO Z DOSING CHAMBER: MANUFACTURER BNG LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUF AC7URER ARNING LABEL LOCKING COVER ROVIDEDPROVI DEPES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING NT TO FRESH (DIFFERENCE BETWEEN FEET FROM LI"E jAVIFR INLET' PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Nr,7H 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: WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER BED/TRENCH b THE NC_RES / MAr AL I:] NSIDE CIA nPlrs fIOUID DIMENSIONS PIT EPTH GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. D S H NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BE LOW PIP /ES ABOVE COVER ELEV. IN//LET EL V END PIPE LINE AIR INLET. 1 ( f I I ~ , J~ 1 Z NEAREST- 3D _7 1 FEET MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑ YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS CDEEPNTTEHR EDGES OVER TRENCH H.'8ED DEPTH OVER TRENCH :eEU DEPTH OF TOPSOIL SODDED ❑ YES SEEDED ❑ NO ❑YES IMULCHED. ❑ NO . ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP ELEVATION AND MANIFOLD DISTR. PIPE IM ANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKINC'~ ELEV.. ELEV.. DIA. ELEV. PIPES. DIA.: DISTRIBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING. FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST tl7r 10.E Sketch System on my file for audit. Reverse Side. SIGN TITL&. DILHR SBD 6710 (R. 01/82) wlsconsln APPLICATION FOR SANITARY PERMIT ,t 'fi DIL,HR ' COUNTY (PLB 67) ~ oERRRTmEnTOF UNIFORM SANITARY PERMIT # InOUST R V, ARBOR G HIJMAn RELRTIOnS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in sizV/ee. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS D1 6# 4) #A,USe-t/ 20 6 2 N S~ f l u D.I'a..~ 4~ ►'S . S Y~ PROPERTY LOCATION CITY: /Vt 1/45 1/4, S T )f N, R/~ E (or W OWN OF: A-) LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER LAN T.~r. F/to 40 o ohs 11.000e mod DS BPD . ,U 4-- OF BUILDING OR USE SERVED A 1 or 2 Family Number of Bedrooms. ~ ❑ Public (Specify): THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. X Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: S eD J 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): PROPOSE (Square Feet): Y f / ~3 (9 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): Si nature: MP/MPRS o.: Phone Numb r: 33 0 (pis) Plumber's Address: Name of Designer: ff~vsoJ wif syo~~ COUNTY/ DEPARTMENT USE ONLY 7g;tZ of Issuing Agent: Fee: Date: ❑ Disapproved y / ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval: / Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 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. APPLIU.,TION FOIt SANPTARY P1:RMI'r S '1' C - 100 This application form is to be completed in fui.l 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/contractaz,("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 A( _ IV W c~F Till.. SG1 yy S'i.'ry.%•~'.'~ l Location of Property ,51_ Section T N - R _ W Township Il' o Mailing Address Subdivision Name A ccA Lot Number" Previous Owner of Property Total Size of Parcel f~'2rt Date Parcel was 761 Are all corners and lot lines identi.fiablr.? Yes No Is this property being developed for resale (spec house) ? _ Yes No Volume and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICAT.EUN ONE OF THE fOLLOWING: Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY 01UNER CERTIFICATION I (Wp) eeAti6y tlLat aU statemenL on .tflL( 60AM aAe ;tAUe to the but o6 my (ouA) p~Lope)Lty deanibed 'n ,t{ws fznowtedge; ghat T (we) am (a'L(,) the a~ j~eA(~) 06 the in6o"uliat✓ion i6onm, by vi/L,tue 06 a watvuutty deed necolLded sn the 066ice 06 OLC CuurLxy i:eg i b te/L o6 Deedh as Document No. j~ J ~'tD ' and that I (We) p~L", cnUy oun .tile pnopoaed b-tte 6orc the auuage d.<apo6aT byhtem (olL I (we) have obta ned an ea4eme)i-t, to aun with the above d&suU'bed p~Lopenty, 6WL ;the comt/Luc;tiox o6 aa. d Qyatem, and the same has been du-Ly )LL,eonded in tile 066ice 06 tile COUnA y Regiis.tvL o6 Deeds, as DocwnerLt No. ) . SIGNATUE E CAF OMNER SIGNATURE OF CO-OWNLR (IF APPLICABLE) DATE SIGNED DATE SIGNED DE14TMENT OF INDUSTRY, REPORT ON SOIL BORINGS AND TY & BUILDINGS ' DIVISION H~ AN REDLATIONS PERCOLATION TESTS (115) O. BOX 7969 (H63.090) & Chapter 145.045) N, WI 53707 LOCATION: SECTION: ,4 TOWNSHIP/}{,}FgLITY: LOT NO.: B O.: S, ~a _ OdDS tiC 1/ 1/ /9 /T Z9 N/R 19 E (o ~/v~soAll _ ~ p9 COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: ` S~ GLoi - -DEgA) .US~q/ Zoe , S~. yvplo s. S f~ USE NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBSE A, l~3laflpl. Residence New PROFILE DESCCIOLATION TESTS ❑ Replace L)-. - -3 N,4- V RATING: S= Site suitable for system U= Site unsuitable for system S C5 Cf 7) ~/Hr{ "7- IS V CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) s ❑u ~s ❑u IS ❑u os ®u as ©u n4jO"71aN.,01 Ir-J-36 Funnders.-163.09(5)((Sb), rcolation Testare NOT required DESIGN RATE: If any portion of the tested area is in the n_ indicate: Floodplain, indicate Floodplain elevation: ''V b2CIMAL ft- I PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN • CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i .25 De13,~. S 3 B /02.GG- o*, B,). /s, /~6 ' Y/-)O,) 1s, .~'a Q. -►,.~P, s. is . B- //o A2,0? >~~o ~ SS'Pe i3o. l , 3.S` /30. 75 , /.f'AiX. da 13v. %S 3 ~v, ' "10 /E- SCI. /ttl X• w.4 S a„-O I OA,"i B- y3` Q.5 B-~ 100.22-' >~Q•Q S, 35' 5 CS wi k B- //0' y7 7 y ` - a ' s- • 6,. Is, 3. s(f' BA1. ae. s , B- 90 76' lq ` - > ~ 0 s, 3, yz' r33,~. s, y~'T-sN es . PERCOLATION TESTS TEST NUMBER INCHES HOLE TEST INTERVAL-MIN. DROP IN WATER LEVEL-INCHES PERIOD 1 PERIOD 2 PERIOD 3 PER (INCH ES RA P- P- P- Jcc -e. - .2 i Z,d a Ct d < P- V 5- o /,E- P P- ODA' 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 o,,n(~the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. &7- oM e-+ ~,P Q I 1ES n ) '71.5 f%• J •L fT- (,e(0co SYSTEM ELEVATION V&-;e7% Pi • 74 (JR11 _ -Q O i T t A T *Tr6 3 _ , _ 4060LO BE" 1JeCEssA~~ : -utit, ~p. fT- Af30lDlt ~ oeE AL 4P ou LTA a ll TO R 6- co 1- 6 ~ 1: ~ 1. S 70 jvSa-t Ra ft-1 j S SS-r 110 ?0MbI81- SAND A/0 ,2 i 2-0 N S • 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 (printl: TESTS WERE COMPLETED ON: STATE APPROVED SITE EVALUATIONS (iIERQjj$M 1+A41 'L- /0 - ADDRESS: MINNESOTA LICENSE NO. 00663 CERTIFICATION NUM ER: PHONE NUMBER (optional): WISCONSIN LICENSE NO 55-02482 ✓fi D2 ~/~2-- 31~~(~__ - . 8 0~1IEIL RD., HUDSON,Wi 54016 csT sIIG DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR SBD-6395 (R. 02/82) - 0 VER - ru g MUM t'?l.!('9"!('}c ~ .,i~ ~4~. CTYtsftC?`t5 0; ,E.. .a 3. t Is Lil t..x it new ~y^ Ffs < ,-Hf llt SYSTt,"M. F t TE I S 5 rlt- 'he su tab Std 1 i F r'~-? - a.L.) ew .~LJ 3.. t.. 't:. .e e' CO mrNFA t 't LA ~ fi'm 'ftlttt r t LE (3€ e tt ,i-, c t -t{ [ S t l~IU, #3£ s ._,a r _ ul ,a 1 n ie( o, rt a a,ly =t rTT 'M'd f) tuf' mar"?, .if i. l:~sr` , t.t3 C t1 .'S "o `tEt~, s➢s"v`t1les, ci . ,5~.. s, fic d i~ la aia, r .."aol"mon test e, irT,r . - ~t .c 'ii? in~ `"'U }•t 1T1, e v. fl loo) aoc~ lint ~jpp0y3 N,A, :r . o apFr[cim i,3iE7 b an,. V `fl'y , q ''1 SS 1, Li nss~ t e L ~t't H 4 f tE1 ELF F .,od'~er T.v 3i _ F«F = tst €o, to =re ,1m c of a 1 REPORT OIL SOIL 13ORiN&S 11 PERCOLATION TESTS 115- Poor PLAM PROTEcr ,I'. DArE dk~ to P5 HOMESITE TESTING CU. ( 1~~ ti's . 3, O'NEIL ROAD BOB iJL PLh j(,j r'l~USl)N, WIS. 54016 CSr 7~5-r 02 y402. PROPOSED MovsE mo-sr LIE Z~ Fr. o,t MCrf£ FrPoM . zl- TEsr ,%ee. 5. PRo POSE ® WfRu M tJST LIE 50 r C9~(° fV9,r F-Po ti At4 TEST IJA44.15. X : ~EQG /DCiyT1DNf = f1AuP RO9ElPFD ok 54evEL /.3evzc-5 r • Na,~it . B M ~a U . , T-. L I?5y- Z RT F. L o T ~ o ~e 4 LE GE N D/EV~rdw O,c I/"r ~PEF. Pr /00-6 _ . _ _ y • t-: LOT 5 4- p v ( ~ ~ 'JZ- 30I I • t PL13 ~7 MOT and CR055 S T1oN PIM5 i TZ-s Ito ~v o)p ay', Lo r L L a T~ l 2~ b r 3s , f)(3 6 v ~i 3 e0o wt LoT- y - Titour f3A,0~61c s ~ ~3 S Fresh Air Inlets And Observation Pipe S0JL "rE5T/" y H MESITE TEST'NG RT.3, cr't4kk :L Approvers 'Vent Cap HUDSON, WIS. 1401 Minimum i2" Above Final Grade x; 4" Ca;t Irrn P'B Pa Di • i "1"a Firiu-k Vent Pipe l Marsh Hay Or Synthetic Covering Min. 2" Aggregate ' Over Pipe Distribution ~ - k ee l UA iAxj pipe t10-011 011011,01---. Benauilt f Ipe ~....„,.!'Ni F`t O Coupllnq t'errtilnatlog At Bottom Of System i Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /!i(J SO'~ TOWNSHIP SEC. IP T Z~ N-R~W r ADDRESS ST. CROIX COUNTY, WISCONSIN f/~Dlo~ CIS . ~7~ou-f'~ /3iPo - f ,46"t_ SUBDIVISION _ LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM s L~ lop r 30 1 I . q ~ 3y ~y r 22 Jed L ~ \3'01 Qo oK eooaDS ' 7RoUT INDICATE NORTH ARROW 61t~ Hwj--- /Ale BENCHMARK: Describe the vertical reference point used L- /7 S y- Ar NF- CORvat- Elevation of vertical reference point: AO-0-0 ' Proposed slope at site: JAG 'o SEPTIC TANK: Manufacturer:. ~~tS Liquid Capacity: r Fr• G NumbeF of rings used: 3- t Tank manhole cover elevation: 103. / CP Tank Inlet ELevation: 77 ~ r 0 Tank Outlet Elevation: ft1• 7 i Number of fe>_t from nearest Road: Front, ~Side ,0 Rear, //Q feet f i From nearest property line Front,O Side, Rear, O 73 teet r ! ~ Numbel" of feet from. well J Z building: -10 (Include. this information of CIie above plot plan)( 2 reference dimensions to septic tank) SEE EVERSE SIDE 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 k2CONVENTIONAL ❑ALTERNATIVE (If -,lgneand l ) .D,Numb- assi ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION D E Q Dean Hansen 206 2nd St., Hudson, WI 54016 rf BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. ELEV. NE SE, Section 18, T29N-R19W, Lot#4,TroutBrookWoods, Town of Hudson Name of Plumber: IMP/MPRSW No.. County Sanitary Permit Number Robert Ulbricht 3307 St. Croix 49463 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER l t~ 9 P OV ED PROVIDED l Q V / YES ONO OYES ONO BEDDING: VENT DIA.. VENT MATL.. HIGAH WATER NUMBER OF ROAD: PROPERT WELL. BUILDING VENT TO FRESH 1 ALRM FEET FROM / / LINE. - ^ _2_ ~ AIR INLET. OYES O Il DYES ONO NEAREST b ,<L) l DOSING C MBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ONO DYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL JBUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LI"E AIR INLET PUMP ON AND OFF) OYES ONO NEAREST :ft SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH JDIAMETER 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: LENGTH NO. OF DISTR. PIPE SPACING COVER INSIUE DIA xP1T5 LIQU10 BED/TRENCH WIDTH. TRENCHES IT MA AL: PIT DEPTH DIMENSIONS I b 3 l \ aA. GRAVEL DEPTH FILL DEPTH JUPIPE DISTR PIPE DISTR. PIPE MATERIAL: NO. D S R NUMBER OF PR OPERTV WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER ELEV. INLET EL V END PIPE LINE AIR INLET. n I / I J ND 2 -7 2cl FEET FROM 3~ oL to of NEAREST-s 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. OYES NO SOIL COVER TEXTURE PERMANENT MARKERS J BSERVATION WELLS OYES NO OYES NO DEPTH OVER TRENCH: BED DEPTH OVER TRENCH,6ED UEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES OYES ONO OYES ONO OYES ONO 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. IN O DISTR. DISTR. PIPE CIS rHIBUTION 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 INF PLANS DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE. OYES DNO OYES ONO NEAREST -tP 13.gS S 5- 10.1 Sketch System on my file for audit. Reverse Side. TITLE. SIGN DILHR SBD 6710 (R. 01/82) L q. P ~ , i z r , Y A 1 Wisconsin APPLICATION FOR SANITARY PERMIT D' L H mf~ -COUNTY oeocm~rnenTOF (PLB 67~ UNIFORM SANITARY PERMIT # In0USTRV,LRB0R&HUmRn RELRTf0nS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS D64,v 11,A.USeAl 2-66 2.0 P S fJ u DJ'o..~ 47 i S , S YO PROPERTY LOCATION CITY: N,1/4SF1/4,S~~ ,T>~N,R1 E(or W ~owNoF: Ue~fOA.) LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TA6t, 3Roc}~ 4000,P5/6 o 11 000 e 40"- . Av4- 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 ❑ Repair J Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ 1,:,ecornectian ❑ Petition for Modification !F THIS IS A CONVENTIONAL SYSTEM COMFLETI -rH!S BLOCK. Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny Tank ❑ System-In-Fill ❑ Is -Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Ferriit Is On FFe, Permit issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. otal-~ #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity f Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: ~t0-4) IF THIS IS AN ALTERNATIVE SYSTEM CCNIPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure To:al #of Ptefzb. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber i Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREJ V:IATER SUPPLE' (Minutes per inch): REQUIRED (Square Feet): PROPOSr (Square/Feet): ~ ; ms`s J C r) Private ❑ joint ❑ Public I, the undersigned, hereby assume responsibi" ty-for ir7;tailation of the .:rivate sewage systcrn :'hcwn on the attached plans. Name of Plumber (Print): Si nature: I MP/tiPRS Phone Numb r: [315-P 7- 2l l ~li~ °o c, 7- 3 o (71S ► 3 Plumber's Address: Name of Designer: COUNTY/DEPARTMENT U;-E AL Y Signatur of Issuing Agent: ~ Fee: Date: ❑ Disapproved ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber APPLICATION FOR SANITARY PEIUIIT S' 1, C- 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 75;;1•.' issuance. Should this development'be intended for-resale by owner/contracLqz,("spec housethen a second form should be zetained and completed when the property is sold and submitted to this office with the appropriate deed recording. { - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - K.: Owner of Property N w ~s 'T y~ o f T~2 s w y~ S%cT~ 4) Location of Property Section T ~ N - It ~ W Township Z/' /JS d Mailing Address Al - /-je Subdivision Name Roy7 ISRc6A clj 0 010-S Lot Number' 01, f Previous Owner of Property A6~~~,a rS3y''' Total Size of Parcel Date Parcel was Created Tf Are all cornere and lot lines identifiable? Yes No Is this property being developed for resale (spec house) Yes No 00 as recorded With the Register of Deeds Volume and Page Number ;'•r, INCLUDE WITH THIS APPLICATION ONE O THE fOLLOWING. Warranty Deed "r 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIF=ICATION I (We) CULa6y ,that aiZ statements on ,thus 60acm a.n.e due to the best 06 my (ouh) knowledge; bia.t I (we) am (ahe-) the orgrlen (s) o6 the pn.ope Lty descAibed in .tkis i116o/motion OAR), by viAtue o6 a walvuUt.ty deed acemded in the 066ice 06 -the County Regi-d ten o6 Deeds as Docwnent No. ~~o / ; and that I (we) pnesentey own the pnoposed .bite bon. the sewage cfc,sposat syStein (on I (we) have ob-tc-fined an eazemen.t, to nun with the above descAibed pn.openty, bon the eons.tAuctiox o6 6a. d .6y.6tem, and the same has been duty /Leeonded in the 066ice u 6 the County Reg us tvL o6 Deeds, as DoccUnent No. . 5IGNATUI (~F 0 NEIL SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED D~P iTMENT OF REPORT ON SOIL BORINGS AND -5\ TY & BUILDINGS INDUSTRY , , ~ DIVISION LABOR AND PERCOLATION TESTS (115) 4,-> ~ . O. BOX 7969 HUMAN RELATIONS \ / N, WI 53707 (H63.090) & Chapter 145.045) ~F L0CAf10N: SECTION: TOWNSHIP/M4N+6FPALITY: LOT NO.: B K: O.: S I MIL N~ 1/4 /6' /T29 N/R 19 E (o ~UP3 CA/ ooDS 4 ~ X n! I W,'~ ?r COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: '/0 Dfo %S• S y ~it0% 17E/~itJ i(ISFA/ .20( 14 USE DATES OBSE A NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESC OLATION TESTS• Residence New ❑Replace L Q IVA iU-&- RATING: S= Site suitable for system U= Site unsuitable for system le 5 Of7 e M,I "7_ IS CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) S ❑U WS ❑U US ❑U ❑S ®U ❑S DU ~'ovyEy7~ou~/ /~''X3G If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: IN 'hedHAL f to 1 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- /o 2. io 5-' oe /30. s ' 3. o*ia4. IS is/s, . a-R p' •f'1?& (3,). I5, 3.S' So. /S, I3u. IS B-y110 /02.~Q >//0 ' S. Lo B- y3`'h-4-S. i B-,3 /0.6 /oo.2L 2 >/0•D ' •33' A- /s, /e7' 41-r3-3- s, ~S ~9N 0 ' 7-- c B- //0' 777y' %co- >//0 3.5-(P-~N. ae. s. B `/.0' 764 > 0 ` .~S'AO s, 3, yz' aa. y~'T.,v Cs . PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- P- o%L ojeia P- 7S J+~ - ° i Ze el S 7- -1 C-d c P- o P P- c P ' PLOT PL,~N: 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. B0770M e-f R ~(ES n I C71-5 t/• 4D SYSTEM ELEVATION I i I Y__ E } s ~ Qa-t~N I E Vi ~ (0t I I ~ 1 I cJ 1Q UsvL_ S ,A 40-9, S aR.,~ Lo 1J s ' ? E" A LT€~2 Tr °"j 4360LU tJEC,E-ZA FT, 4//306E Q OBE 7-I I - 4? 60 Lp a To Q cu r ~ f ~dl- 1.5 ROC -4- -q S&& ZD , 70, r V S a - , t Ro ft,~4 ! i 5Se-r w ?aMi1RIC- SAKID IJ/Ok %Zo N S • 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): TTOMESTTE TESTING CO. 4i TESTS WERE COMPLETED ON: STATE APPROVED SITE EVALUATIONS PERC '+P, _ /0 ADDRESS: MINNESOTA LICENSE NO. 00663 CERTIFICATION NUM ER: PHONE NUMBER (optional): WISCONSIN LICENSE NO. 55-02482 ✓~i Dl ~/~L- 3 - • , 0711" RD., HUDSON, W1 $4016 CST SIGNATU E:~ l DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - REPORT ON SOIL SORiN&S ~ PERCOLATION TESTS IIS r Pl.o T PLAN PROTECT' 17-D. DATE (d 't P" P-0-6 l--/ tooops HOMESITE TESTING CO. R- T- 3, O'NEIL ROAD BOB ULI;h"lC:~ OUI)SON, WIS. 54016 e r S3- - 02 YeZ PROPOSER MOOSE MOST CIE z~ Fr. c~ 410te "aAf ul- TEST ^ee,95. PRo POSED W L a M v s r oI E 5oF r Ae f r FiPO~J • ' 9AdceIy F PIE'S O = E,f'iSTA.~J 6- x ELD ` pEQG locA l4vf Rv9EAW o,Q 54avEL 13oXE5 • yoeiz . VCkric,~t eEfrRfAl4r PoiaT' "iD/~ S' . ~T-. # LI75y- 2 4T N.F. L o T co e Aj U - LE GE N All Pr / o o • d Y ST M m u s-r I -A3 IP CAA 3- $ - L oT S Q T y A ° g ~ b R~ 1~' a5 ~p- I i N j i• 1, I 30 I o 'U I ~ 1,4 ' Pa ~3 ' 4 I 60 4- ~ f c , I 30 i~orv~,P ~ox