Loading...
HomeMy WebLinkAbout020-1088-20-000 O D) O m ~ c 3 3 - CD C) -0 CD ° c C (D a: 0 n O N N O O'o W C N N "OVA• O N O C]/l CD (h x 0, A` W' Q O Z d N O M 1 (o D ~t (D ~ N Co N ~ ~ O 3 C)0 0CD o 0 C) CD O (D o n (u n o o (D 61 N O _ _ Ow o 0) R 7 N A O C lei a (D m c a O N Cf) _4 00 (n co v (D 3 0. rn_ ' 0 O O O ID Off ' rn w w y a a 3 ° cr Q < Lrl z 3 ((n cn ° D 4 6 v v 0 41 o m ~ m N cn d 0 0) o 3 w m (D N z-~Z o D (D ° cn N 7 O w' N d N lV ~ (yam 000 m CCD c v~J o 3 c w m (nym m m a 0) CD (D --i cn C n - j ? m Z C N N Cl C) CD O Z C N N W (D < O W i a Z 3 W '0 a CD ° Z m o N 3 m ~ O N Z O (D A W 1~\ w a y (D oo= , n 3~voon o T OmO0:, C,- 0 _ c v x ~ a.a) o c 0 m Q- ID 019 v O m N Q ID it4~l N n < o ° o y 3 e ° m 3 O N O (D < O (D 0) (D oCDC Co CD \ p co Q 6 Ll O N O 3 w O V O y ?O N N A~// N S\Cl O A r 0 O ! ~ A N (D r 60 O r O (D a p L r 0 cn p v n o f C d p d m c o m ~ ~ f4 r r: Q 2 5, o A CO = w o N 3 O r O O Q N Q M.r Z4 qo c C) co ~n =3 N N N O- p co N D co 00 \ 1 O O O (n W 11 0 0 0 p N (D S p V NO cn .01 p W Oil N C m O 0 lV O C~ ((D cn a N \ W N W (D C C_ - O 7 O O W ti \ p N CD (D (.0 CL cn co co A A= to o c N (n ro N N ~ v v ° m O O O C y y pG (n Z 3 ~ D v q A 0 o w 0 (D (A CTI a -0 rn m d - N N w m m z -i z D o D S ID (D "At • c') cn CD cn !V (D N A_ (D C "6 N (_J~M - N (D CD (p a 3 (D CD 1 .p Z CD N C ~ ~ n A z O Q C) 3 ZZ w C (D < ((0 N CL I - z o - iz ;o ° z (n m z m (D A W ~ < y CD s Cx (D = Cl o - Q :3 T N ~ C d z O a (D 2 i i A Z ti J W O O ~ A O (D O O - C) CD O i 7 v y . Wisconsin Department of Commerce SOIL EVALUATION REPORT page / of 3 i.- ision of Safety and Buildings in accordance wit e 'M 57- R x_ Attach complete site plan on paper not less than 8 1/2 x 11 "inches in size. Plan must Count - • C 0 / - include, but not limited to., vertical and horizontal reference int (BM), direction and 1 /V ejr?r percent slope, scale or dimensions, north arrow, and locati and i e ad. Parcel J.D. Please print all fnformati n. rah Ind %FevidWed Date Personal Information you provide nmy be used for secondary puq4es (P&icilil Q Iep< /f Property owner d N k~ Govt. Lot M 1/4 114 S T N R E (ar) Property owner's Wiling Address ~i ~ Lot # Block. # Subd. N C5 Cc- city State Zip Code Phone Number City Q Village ITown Nearest Road # ~OSo~ w/ € syai~ I (?i5 )3g/ 17 7 k ~f l1DSo ~ 5 %~4~EGi iV~ i New Construction Use: ❑ Residential I Number of bedrooms ~ Code derived desion flow rate GPI) _1 Replacement f4 Public or commercial - Describe. P-rerd material /S 104,~q 60740 14, Flood Plain elevation if applicable ft. General omyr eras s recommendations. `Ea # ❑ Boring /(D •3 , ~a f i l lzst pit Ground surface elev. ft. Depth to limiting factor I v Ora. . aoi~ t- ,~cat;c3n Rcte i Hortzon Depth DominaritColof Redox Description Texture Structure Consistence Boundary Roots GPQ fR in. Memsefl Qu. Sz. Crane Color Gr. Sz. Sh. *EIT#1 *Et l o V3 SL 2fs S CS ~f . S Z • 3 ~s R s/ n~ . S d . s ~ c ~ ~ Z o ~ nod • S p ~Q- i F r I i E Boring # 0 Boring < 7- -767 > r Pit Ground surface elev. ft. Depth to limiting factor, ` 0 in. # Sal! Appl ication Rate ' I Horizon Depth Dominant Color - Redox Description Texture Structure Consistence Boundary Roots GPDM i in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Z Z l0 v G 7 s t S j x ~ r 9 r i 's 5 y t3 Effluent #1 = BOD > 30 < 220 ax,}PL and TSS 030 150 mgFL Effluent #2 = SOD < 30 rng& and Tsar < 30 nVL CST Name Please print ~0 B CH ~T- l Signature CST Number tC / h l / g ~GEr 2.2 3~ S 1,41b dins & Associates Elate Evaluation Cpnducted Telephone Number o~~ • zZ- ~o0 3 -2/S 77,a -3 _ 2812 10th Ave. Spring Valley, III 54767 ?-or4L DE-Y4 A4,~ 7S '763 S. A 4~4y 13i~~15 1- ~ l0 ~d`S, 4- 7~ 00 ~ S s t Prop" Cramer Cod (MII•V; ~y Gi !1/AJ` Parcei iD # Page a Borinc ./G f Pit Ground surface elev. ft. Depth to limiting (actor in ~O in. Soil Application Rate I Horizon Depth Dominant Color Redox Description Texture structure Consistence Boundary Roots GPf?f~ # in. Mu' m elt au. Sz: Cont. Color Gr. Sz. Sh. 'Eff#1 'EfT#2 A I (f-- i Z 2 VP q11 D• s t ~ i - - - TE BOring # El Boring _ E) pit Ground surfa,, elev. n. Oe e tt -SC{d ` ~(Gcstipr7d3t6 ` Horizon Depth Dominant Color Redox Description Texture Structure CoMistence Boundary' Roots GPDM { i in. Munsell flu. Sz. Cont. Color Gr. Sz. Sh. 'Ef1#'l 'Ef1V 3 i z I 1 i 4 1 i 3 " Y 3 Boring 3 Boring 0 # Ground surface elev. _ ft. Depth to limiting pit Soil Application Rate } Horizon Depth Dominant Collor Redox Description- Texture Structure Consistence Boundary Roots GPDIft? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'E11#1 'Eff#2 3 t f i$ 33 1 l ` Boring # Boring El El pit Ground surface elev. 5t1i? A: Rate j tiiortzon Depth Dominant Color Redox Description: Texture Structure Consistence Boundary Roots GPDtft` in. Munsell flu, Sz Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2 a t Effluent #1 - B OD. > 30 < 220 M91 and TSS >30:s 154 rnglt. ' Effluent #2 = BODs < 30 mgit, and TSS < 30 nxA I T!e r)cf)ar mcn¢ of k.omniecc:,- i an e dual opportunity service provider and employer. lfyou creed assistance to access services o=" uecd material in art alternife format, please contact the department at 608-266-3152 or',TY 6€18-264-8"??. r D ,7'' Z~ N 'VI ♦ o 3 N \ 6 00 \r% "A n T& N34 A4 ~p may' tv b CA-V u d v Q0 N d TOP I 77 ~ n , = Safety and Buildings PO BOX 7162 MADISON WI 53707-7162 TDD (608) 264-8777 Vhseonsin www.commerce.state.wi.us/sb Department of Commerce www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary November 07, 2003 C g639~- ATTN: POWTS Inspector ROBERT W ULBRICHT ZONING OFFICE ULBRICHT & ASSOCIATES CO ST CROIX COUNTY SPIA 2812 10TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 11/07/2005 Identification Numbers Transaction ID No. 940402 SITE: Site ID No. 668219 Assisted Care Home - Collen O'Shaughnessy Please refer to both identification numbers, 469 Stageline Rd above, in all correspondence with the agency. Town of Hudson, 54016 St Croix County NW 1/4, NE1/4, S32, T29N, R19W FOR: Description: Replacement Non-Pressurized In-Ground System / 978 gpd Object Type: POWT System Regulated Object ID No.: 930173 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: On pages 1, 3 and 5, this approval assumes that leaching chambers to be used for this system are the II" Standard model Biodiffuser as manufactured by ADS, Inc. Refer to page 1 for the actual physical 0. %1 features of these leaching chambers. Conde A copy of the approved plans, specifications and this letter shall be on-site during construction and open to PP inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of DEPAR r' construction/installation/operation. DIVISIO In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions shou 4Z ~ t Gi't1;S conditions arise making them necessary for code compliance. Asper state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. ROBERT W ULBRICHT Page 2 11/7/03 Fee Required 17 5.00 Fee Received 175.00 Balance Due 0.00 /ir <Rreeviewer, l Private Sewage Plat Integrated Services WiSMART code: 7633 (608)266-2889 , M - F, 0630 - 1500 Hrs pepagel@commerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 Parcel 020-1088-35-000 02/27/2008 04:10 PM PAGE 1 OF 1 Alt. Parcel 32.29.19.371 C5 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 - O'SHAUGHNESSY, COLLEEN COLLEEN O'SHAUGHNESSY 469 STAGELINE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 1.260 Plat: N/A-NOT AVAILABLE SEC 32 T29N R19W NW NE LOT 6 OF CSM Block/Condo Bldg: 5/1391 RE-SURVEY OF CSM 2/366 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 32-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 01/03/2006 815441 JDGMNT 03/06/2000 619212 1494/033 WD 02/13/1997 555596 1223/115 WD 2008 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.260 52,000 0 52,000 NO Totals for 2008: General Property 1.260 52,000 0 52,000 Woodland 0.000 0 0 Totals for 2007: General Property 1.260 52,000 0 52,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 3S055S CERTIFIED SURVEY MAP Located in the NW 1 /4 of the NE 1 /4 of Section 32, T29N, R19W, Town of Hudson, St. Croix County, \ Wisconsin ~ N 890 05' 52" E 1307. I I LEGEND \ ® \ N 1/4 CORNER SECTION CORNER MONUMENT \ SEC. 32 - 29- 19 0 1" IRON PIPE FOUND i° co 0 i"X 24" IRON PIPE WEIGHING S~ \ } m 1.68 LBS./LIN. FT. SET NOTE o°,~ss 60 OR ASSUMED BEARINGS REFERENCED TO O° , THE CERTIFIED SURVEY MAP RECORDED O" ~9 SS ~C N IN VOL. 2, PAGE 366 N DO0 F q~ \ 90° tS; \ c~2 \ N B ° O" X90 0° 2a3 \ OO 0~ p Nom; 00°, ~AOi \ cn 110° 18 59 'LT gyp/ a" ~ O • o°/ m oo ~ boj v> ~ eS ~ NOTE: a2 , ooi ~ ft) Ceti \ POLE SHED ENCROACHES LOT 6 BY 1.5' 20 1 common access ease- ment \ah ss6o 9O r J~/ rl Og' 00 SSF ~~f; 146015' 32" 6 F IL o JAN1, 1984 p. CO (0 O ai (0 j"IS O' ONNELL oOi r. V~ (p M K"Mu o *864 Q_ : Sy Wtx ty, GT o a Wb 9 cli N ri ~t~ CO 40 a LOT 5 )PPRO ~ M Q Q o JAN 11.1 84 w a M ~ LL N OD iD J 3 a ° J ST. CROIX CC I-,TY (D CO QWAPREHENSIV.E P,hRK PtA`NNIN6 Uj W O N M > to o N eNO zt~.DGtLG ~4' .keE N h~ /0 2 °o h~ R° ~ S 89 05 55 W 288.89 UNPLATTED LANDS I SCALE IN FEET I"=100, PROVED 0 25' 5d 100' 200 300 M« 1984 COW Volume 5 Page 1391 R 'O O a) c~ O N i Q fR y n oo a) M c N a ° ' Cl) C) U O N V) O L CIA U O M C) d. i -0 CD O O ti O O W U a) O N N y N E O O w ~ n. J 2 a 16 CL CD (D ~ G C o~ o CA ~ U W to C O N o a o > CL Z Co ~p 0 0 0) x 0 m O cm U LL 00 a adm C J N N O) N 6 ~_-a0 N -0 Q) Q > VO) O d L r- 0 co 3 M O Cl) Z V) CD, N W w0 Z O a) ry v E ° (D ED v cfl d d rn LL m o co H Z N a) T -a y (a C C~ -O -O co" O Z 7t c a) Z U) F- r a) a) U C E a) 0 N O C j E O a E a) a) 0 0 N N U a a) N N a) a) (D a) L) cn N O Z F Z N m N f6 ~ O O - O a (D a ' m O 0 N a) a) o ItT D O a E Z In > F- F- F- E ~ o 0 o a •N m o a. a a a N 7 O N T- 00 00 N U) J U -o rn rn a) }vy Ca r a co O I~, \ CA a= O O O O r r C O co N a O a0 1- u, Q } cn m CO In y N ❑ O O V 1_Np C OO U C T O O E N O O O 0 3 r avi s c a °o °0 0 0 r \ s, N M r- 0 H (n , N V) M 0) - C6 < • O M 2 m V O Z N= F- O c^ V v~ y m € o at ° L a MT • a m 2 m c Ln A U a n o N 0 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T G N-R / W ADDRESS ST. CROIX COUNTY, WISCONSIN i SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM L~ i l =7 / d 4 i I i I i 4 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used` ~o Elevation of vertical reference point: Jr~~ Proposed slope at site: 7 SEPTIC TANI,: Manufacturer: y ~ 5 Liquid Capacity: Number of rings used: Tank manhole cover elevation: d=j" z!'' Tank Inlet Elevation: Tank Outlet Elevation: Number of fe.t irons neui -~sL ltuciu Side .eat feet from nearest property line Front, 0Side, 0Rear, 0 feet Number of feet from: well building: 1' r (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE hE:VI?ItSI: 51111? PUMP CHAMBER 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, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSOR-PTION SYSTEM Bed: Trench: ----K ~ Width: Length: Number of Lines:_. Area Built: 7 Fill depth to top of pipe:'?" Number of feet from nearest property line: Front, O Side, ( Rear , Ft. Number of feet from well: Number of feet from building: y~ (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 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: 7 Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.___ _ Number of feet from well: J Number of feet from building: Number of feet from nearest road: Alarm N.anufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.(?. f30X 7969 BUREAU OF PLUMBING MADISON.,WI 53707 IN CONVENTIONAL ❑ALTERNATIVE State Plan I.D, Number (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER . ADDRESS OF PERMIT HOLDER'. INSPECTION DATE. Ashley Brooks R. R. 3, Hudson, WI 54016 9 -~y BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV. NW NE, SEction 32, T29N-R19W, Li Town of Hudson Name oI Plumber MP/MPRSW No.. County. Sanitary Permit Number. Roger Timm 3224 St. Croix 49504 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. ITANK;NLET ELEVTANK OUTLET ELEVWAR/VING LABEL LOCKING COVER 1°R-(.]--V, IDEDPROVI DED1 DYES ONO ❑fS ONO BEDDING: VENT DIAr. VENT MATL. fGH WATER MBER OF RADPROPERTY WELLBULDING VENT TO FR H LARM FEET FROM LINE / r AIR IN OYES NO L" € EYES LINO NEAREST DOSING CHAMBER: MANUFACTURER r:-INGCITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDEDPROVIDEDYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NaTH DIAMETER MATERIAL AND MARKING or excavation. llf soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LErrryyyGTH NO. OF DISTR. PIPE SPACING COVER JINSIUE DIA #PITS LIQUID BED/TRENCH TRENCHES MAj,rIAL PIT DEPTH. DIMENSIONS r } ? y" GRAVEL DEPTH FILL DEPTH JB~E THPIPE DISTR PIPE DISTR. PIPE MATERIALNODIST NUMBER OF PROPERTY WELL. BUILDINGVENT TO FFJESH BF LOW PIPES ABOVE COVER V. INLET ELEV. END PIPES LINE. AIR INLET FEET FROM i`4t r I. L 1f NEAREST► ? 4 ( p 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- OYES O meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS OYES ONO OYES NO DEPTH OVER TRENCH B75 DEPTH OVER TRENCH: BED DEPTH 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. ID ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA. ELEV.. PIPES. DIA.: ELEVATION AND DISTRIBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS'. NUMBER OF PROPERTY WELL'. BUILDING'. FEET FROM LINE OYES ONO OYES ONO NEAREST Y~1 F(-,c Sketch System on RetColn e for audit. Reverse Side. 7 SIGNATURE. TITLE . DILHR SBD 6710 (R. 01/82) Wisconsin APPLICATION FOR SANITARY PERMIT COUNTY ~DILHR (PLB 67) UNIFORM SANITARY PERMIT # OEPRRTR1EnT OF - InDUSTRV, LR60R 6 HUMRn RELRTIOnS •1 -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 PROPE TY OWNER MAILING ADDRESS l L PROPE TY LO CA ON W t L G-E-: 1/4f~ 1/ , S Tom'N, R ` (or).,JIV? owN off r r' , LOT NUMBER JBLOCK NUMBER JSUBDIVISION NAME NEAREST,ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED ` ja0 `0,T- o? 4 1 or 2 Family Number of Bedrooms. Public (Specify): THIS PERMIT IS FOR A: IN 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 A 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 f` Manufacturer: 1 + ' 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 I) Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): C? 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): Signature: , MP/MPRSW No.: 1PhoneGNumyber: Plumber's dress: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ~7 ❑ 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 i~ 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. APPIICATION FORT SANITAkY 111g:i0l[ I° 100 Th[., appl icat ion I orw iS ro be couiplet I'd in I ull and sir,Iicd by tlrc owuer(:>) 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 ~~old and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owuer of Property' ^j Lucnt ion of Property ~4 Section T Zl N - R - W M, i i l i n g A d d r e s s Subdivision Name l Lot Number Pr- t' vious Owner of Property Total_ Size of Parcel Date Parcel was Created Are a l corners and lot lines identifiable? Yes No l.s this property being developed for resale (spec house) Yes No Vo l truce and Page Number / as recorded with the Register of Deeds INCLUDE WITH 'PHIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty 1W 2. Land Contr.t 3. Other recordli , iw In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refereur_es to a Certified Survey Map, the the Cert i l i cd Survey Mal) :;bull ilsu btu requirt,d. PROPERIV OWNER CERTIf1CATION 1 M! ccn ti6y tha-I aft, statetttents on -tka 6onm aAe Vane. to the, best o~ my (uuwc) knowledge; that 1 (we) am (anc) the owne.re (s) o~j the pnopc~t.ty deheh i-bed ~ rt tGws tn6onmati.on 6onm, by v"itttue o6 a waAAanty deed'Lecorcde.d in the O66kce_ 06 the County Regtis-tea o6 v. -,A"3, as !,'I, I_ui,..,L I (-,,,,4 rb~n 1 (we) Oni"entty own the Cvcopoaed site 6o't the sewage system (on. 1 (we.) have obtained an eabeme.nt, to n"un with -the above desn'Cled pLopenty, bon the coi"lstnuc ion,,o6 said sybtcmi, and the same has been ditty neeonded in the 066ice 06 the Counts Reg-izten o6 "Deeds, as Document No. 7SS SIGNATU E 01' OWNI?l: SIGNATURE ON CO-OWNER (II' APPLICABLE) DATE SIGNED DATE SIGNED Alo C 3`;0553 CERTIFIED SURVEY MAP 1,ocatcd in the N'X 1 /4 of the T""r 1 of Section 3Z, 'T29NI , R II-P V, 'i'ovvn of lludson, St: C, oix County, Wisconsin ° 89° 05' 52°' E 1307.11 LEGEND N 1/4 CORNER SECTION CORNER MONUMENT SEC. 32 - 29 -19 \ ~n 0 111 IRON PIPE FOUND O I"X 24" IRON PIPE (NEIGHING S~ 1.68 LBS./LIN. FT. SET <9 T 00 60 ASSUMED BEARINGS REFERENCED TO ~O. 0° Off, ~ C\j THE CERTIFIED SURVEY MAP RECORDED -0- ~9p SSA ~O~ Q IN VOL. 2, PAGE 366 ~ ~ ® Q a0 p~ 'S0 & rn 6 NOTE: O SHED ENCROACHES LOT 16 41 ?0 BY 1. 5, 2fl c;ornmon .ears access ease- ment O a0 ,~cl m e nt S ~C./s - - 146° 15° 32" 6 C9 L1 rp a a N q Bn N~/ cv a v~ a CQ ST. C'LOIX C-011 U > O 41 gs u - - - S 89 05 55 W 8. 1 2 II 8.89 UNPLATTED LANDS_ ED RRrr SCALE IN FEET I°=100' J_ O 25' 50° 100° 200° Z~ol. 5 P.1394 CoN E :sa THIS INSTNUIMENT DRAFTED 483-588 5 aTO a ulua CT PTex a1~'~T xoAe~ uogoS a7eQ uospnH-JO A719 aLll 30 T_r n~0 add I- Ac{a.rau sl d-eut sltTl £00'i OOL`£I, 99Z'1 001 `SS 9 bS9'£ -PLI`6ST £ZL'£ LLI`Z91 S sato~ 7aoj axerlbS s0xoy 7aaT 0xenbS 'ON 107 ~M`,~O` LIIJI2I 'kV.M -,g0-,.T:H.01U :3NIQf1'~I J.~~ ONTC:X.C17 :~NI sv-,Iuv LO7 JO a'I£Iv.L £0£SS I\Tyq 'e'{ouy MN Iule7_eme 1Od I Z Z91 s~loo.z£1 .GaT1ls V : xoT p-DAOA.znS ,IxaT 7 uA,0 1 O7T CI _ ~a7'~-►ay nspnH TO umos, a'17 3o pzeog ~zh~u1 aI{_ dCq p7AO.xc(c! Ac{axOCl s--,- deuz s ri1.:L e~`FGy £86i `Gi xJCI070O ,5~ ? a to ski 01,c ulsuoosl,&~, 'lzos-pnl-l m r ~aaa 7S puoOOS 1 ZI,~ 9L£ I R S aOt\OAdrnS pue utsuo r.M I M .pEpC{ pue kIUIpue7sx0Pun 'O~IpOTmouul leuoissojoxd I.ux 3o 7s..ocl oY17 o7 aOuj~ulpao UOTSTA_fpgnS UOSPnl-I JO ut*nO L Dill PUT? ' aOUeutpx0 -UOTSTAIpgnS 1junoD XTO zO `7S 'sa7n7e7J ulsu0oslh1 OiIJ ~O y£ • q£Z xa7C1'V??Ll J 30 SuOTSTAO xd '01-11 XMA'1 PaTTd1u00 Al-[nI aA'eLl 11e111 pue :paianxns pLIeT 0111 To salxepunog zoixaIxa 0147 To Lloilelc,asa xdOx 7oaxxao pue an:c-1 e ST 7eld dons IT-,ill :17xado.Ld Paglxosap anoge oql paddelu Pine PaAaAxns OATIq 11u111 ATIJlxaa AgaxaLl op 'aOAZ)Axnc; PUP-1 utsuoosihl pax0}sT`iax 'LlosnU •a[ souil r 'I •PtoOO:c -10 s.luelaOnoo pure suoT.10Ix~s0.I 's~ualLZVSea TTe o.1 70aCgns 9upq pure '53x01? 886`{/ -to ':{aa; a:rer.bs LL7,`2,I7 t~uT11111UOO ;,3u1umT ?aq To 7LIIocI Dill o7 ,£6'eZZ i„00,S009aS '30UMIJ '.d1'W IROnxnS pal1z7z0~} pivs, To ouTT I amll7.Tou 01.11 'k)'uOTT IT°8°5£ :I„0£c9 O4£t.T ' ~0ua111 .d1-.1,~ ~Sanxnc, paT;T7xa~ pIL., To Oui{ 1i7no5 pa1uatunLsouz .uaLl~i `'U7'~.Gi: :~Ia,70,7IO()N ' O"l7 f~uO{e ,W88Z A1„SS,SOo68S 00u0-c11 `,L8.6T9 M„90,9£o£I1,1) a0L~01I7 `Vutuulk~ag To tiuiod Ou7 07 300.092 M„OO,SOO9 )_N O0110111 :IGS'806 A1„ZO,ZIoOS a0uall~ II *LU£l (cIel~l I.OA nr, patTi~xO.~ pros 01 Paouax03ax 211txeocl p0uznsse} 'I„ZS,SOO681\I Ooua111 :Z~ UOT7a )S pees"-JO .xauxO-_) I,/ iN 0117 7e 9UI3Uau1UIoD :se popxoaax A1snoTA0xd sem xaa.zOO 1lolllrx., 199- QT>cI 'Z OLUt11OA uT p0pxO00x d-eyq ADAxnS p01311x0 7eti1 jo £ 10-1 To x011xoo 75e711j.ToN a1ll 7e 211CUTl VOU :snnOTToT se Paglxos0p 'uTSUOOSTA~ 'A4UnOD xloxD •7q 'uosl)ni_I }O IMOL ` 1.61 2T N67L ' Z£ UOZ1oaS 30 P/ I aN OLI7 f0 1,/ I MN 0117 LIT Pa7c3OT Piful, jo Tao:Tud; ST C- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 2.. ROUTE/BOX NUMBER IL le' Fire Number------- CITY/STATE /~c~ ~~1~- 'L I I'-- - - - PROPERTY LOCATION: _/~I4, Section TY-_N, R-- W, Town of St. Croix County, Subdivision /21ff Lot number---:5=__. 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 Lhree years or sooner, if needed, by a-licensed septic tank pui) r.. What you put into the system can affect the function of the septic tank as a treat- ment.stage in the waste disposal system. St. Croix County residents ma be eLib::.le to receive a grant for 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 ne_w_ 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. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposa system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County `honing Office within 30 days of the three year expiration date. SICNE DATE__ - St. Croix County Zoning Office P.O. Box 911 Hammofid, W1 54015 715-7)6-2239 or 715-425-8363 Sign, date and return to above address. DEPARTI\4ENT*OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS 'IN~DUSTFi`~', DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: 11 SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.:SUBDIVISION NAME: NW 1/ 1/ 3 2- /T 1`( N/R ►y E (o) 4 1vD.S6,V . - stir - COUN Y: OWNER'S/BUYER'S NAME: MAILING ADDRESS: Sy. /I S G& 13,Vo0,(s 116 22-/ /06fMJY. /U CU. 4,uo-4, A*.,~ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence xNew ❑Replace I N14- RATING: S= Site suitable for system U= Site unsuitable for system CO)ENTI . MOUND: ©~IN-G® T-i PT RE: SYSTEM-I©ILL HOLDING©NK: RECOMMENDED SYSTEM: (optional) ©S ❑U E]U S U S Ueo okAvmia f/ - P.10 ,ra ' F [un Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the de r s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: IN DECIMAL FT"• PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEEPTH OBSERVED EST. HIGHEST TO BEDROCK IF BSERVED (SEE ABBRV. ON BACK.) B / /•0' /40•y~ .F3'AA-641. A~ISu S wIf,Q, 51' .v. , . B-2- 19.0 > 0 0 0 ' 0.0 s i.i s ,41. a ~ . q-,4,,jk 57, o ' AV CS 3. 6 Am. v cs 3 PPP 6 ,A . B3 0' y2, ) ~0 S/, 5'2' /3a. S. w _J7 41 q 5 B- ~•0 yl > Y 0 i 1.j-"13,0.r1 , 'Tr4v. . S. ? Xfv e v cs G~2 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN AFTERSWELLING INTERVAL-MIN. PERIODI PERIOD 2 PERIOD3 PER INCH P- (a. O nu-- Z A-EV601A, 7M E.5 S T /•v < t P- U -5 S ,efi 1 ids 6f e. P- L . O L P- " 0 E Od vS% ST .u71 1~~'~l/NCO P- IX- 0 Zrr57 7614-n., A /fitiu S 6 fiT 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. /Sp 777f rt Srf-lhM, 9)(G4V)'T1~ 4p f/ ' / ~ `7-' SYSTEM ELEVATION JW,7 see_ T" - • r I N This test site APPROVED for a conventional septic system, 3 i i ' 1 1 3 i 3 i ( F I 1 ~ 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: ~IOIVIESITE TESTING CO. ~ 2-t~h! - If p ADDRES CERT)FICATIBER: PHONE NUMBER( opti l): MINNESOTA LICENSE NO. 00663 J 3 2- 'OL WISCONSIN .55-02482 'NEIL RD., HUDSON, WI 54016 CST SIGNATUR RT. 3, O DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - a legal 4sp'r-t,^''.i %5,~~1 nl3ofibe, .1r s7f,r , C"3., ,8a l ~sia(~~ 4, k s m a .€,p of ,E .I C'O r?; ' i_, s .1 ,.ro Sf "r?., t d3';! s, r; ...f'f S>, F I_• . L AS' i €Yt, ahb ultip wi~ ~hov n here fo3 w? tEi f~f ii{ [1~"i ='zc>C.3 aTP ons c;t eCS cofil p o:9cI C, LF -'.1IBLE diacjr.i1C1 itif"sitr~i€ir7 S .>t ,ca,. ns, € ii vyiy t.€.") S€ ak< is ref ,-r(,,CI, sY:a [p r'.; 3 ` r .3 .3.~1 €,k vd tiL23 ~ . ~k•;Pl~:; (J,: F"~E. }Y~ €,f€ a €'!$1 s h ow [tr ~ti€.. ~o Pet at- L.',,K:s is io al s, ir,)5):d plain daiii 'pet c l ions 1.3:,7 c;xa --to B R Be, S F P, "o 1 S ;v L c. La In i r a C H 'i ' hf)?n € k 3r= 91 „1'3vr)I,tl r