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Parcel 020-1010-90-000 12/02/2005 10:23 AM
PAGE 1 OF 1
Alt. Parcel 10.29.19.45B 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
THOMAS J & BARBARA ARAS O - ARAS, THOMAS J & BARBARA
1050 SCOTT RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1050 SCOTT RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 20.428 Plat: N/A-NOT AVAILABLE
SEC 10 T29N R1 9W NW SE LYING SELY OF RR Block/Condo Bldg:
R/W AS DESC IN VOL 618 P27 ORD & INCL.
ABANDONED RR R/W 100' IN WIDTH Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
10-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 824/195
07/23/1997 618/27
2005 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 69,000 56,700 125,700 NO 05
AGRICULTURAL G4 17.428 2,100 0 2,100 NO 05
UNDEVELOPED G5 1.000 100 0 100 NO
Totals for 2005:
General Property 20.428 71,200 56,700 127,900
Woodland 0.000 0 0
Totals for 2004:
General Property 19.430 41,700 46,200 87,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 111
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
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Parcel 020-1010-90-000 09i27i2006 11:03 AM
PAGE 1 OF 1
Alt. Parcel 10.29.19.45B 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 - ARAS, THOMAS J & BARBARA
THOMAS J & BARBARA ARAS
1050 SCOTT RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1050 SCOTT RD
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 20.428 Plat: N/A-NOT AVAILABLE
SEC 10 T29N R19W NW SE LYING SELY OF RR Block/Condo Bldg:
R/W AS DESC IN VOL 618 P27 ORD & INCL.
ABANDONED RR R/W 100' IN WIDTH Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
10-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 824/195
07/23/1997 618/27
2006 SUMMARY Bill M Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 69,000 56,700 125,700 NO
AGRICULTURAL G4 17.428 2,100 0 2,100 NO
UNDEVELOPED G5 1.000 100 0 100 NO
Totals for 2006:
General Property 20.428 71,200 56,700 127,900
Woodland 0.000 0 0
Totals for 2005:
General Property 20.428 71,200 56,700 127,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 111
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 020-1009-30-001 09/27/2006 11:03 AM
PAGE 1 OF 1
Alt. Parcel 10.29.19.36D 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 - ARAS, THOMAS J & BARBARA
THOMAS J & BARBARA ARAS
1050 SCOTT 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: 3.000 Plat: N/A-NOT AVAILABLE
SEC 10 T29N R1 9W SW NE ABANDONED RR R/W Block/Condo Bldg:
100' IN WIDTH EXTENDING OVER SW NE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
10-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 824/195
07/23/1997 700/85
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 3.000 10,800 0 10,800 NO
Totals for 2006:
General Property 3.000 10,800 0 10,800
Woodland 0.000 0 0
Totals for 2005:
General Property 3.000 10,800 0 10,800
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
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
San4_ta~r_y Pe~(m, t I-If
Stake. Sep;I`2.e _R--
NAME Townbhip _St. Cat-o,i,x County
1_ocation- Sectionlaot # -Subdivi6ion
SEPTIC TANK
Size gafEan,5 Natrnbeh of eompaAtmentI
Dt"h tance ()n"orn: W(ef,f~-- - - Buy 2di vi 12 0 6 P-ape
HighwateA
PUMPING CHAM13ER
S.tize" _gaZfon4 Pump Ma-nu(actuAeA Mode..t, Numbe.A
HOLDING TANK
Si ze gaP2an's Numbest of CompaAtmentd
Pumped--- Aeah.m Sy~tP_m
0ti6to n c e (nom: w eU--- - S ui Z di n g- -12 6 a I' o p e--
NighwateA
ABSORPTION SITE
Bed Tlt-cnch
04'. tavice. (horn: CUcff But~di.ng ?2o hPape.
Highwate.~i
ABSORPTION SITE "DIMENSIONS
Width. oo tAeneh ~t Requ-i.Aed area (t
Length of each_ i,ne._ (t Depth of ?toch, below ti.Ye ~n
Numbed a( Depth o{ Aock oven tife tin
Tota, Zen.gth o(j ine.e _ - (t Depth of tie e, below p_ade in
Distance betweevn P.in.e.h -(It Stope- o6 tit 100 ()t
Tota.f. ab6oAption aAea - -~(,t Type of Cave-A: PapeA on DVicuo
PIT DIMENSIONS
Nu_mbeA a( path - Gnavck alwund pits _no
Out/)ide di.ameten" (t Depth. befow inf"e.t__ --(t
Totak ab,~onp.ttian area-- --("t
AAea Ac qu4',c,d ---(t
INSPECTED BY TITLE
APPROVED DATE 198
REJECTED DATE 19 8
REASON FOR REJECTION
l
a
199
PLB67 State and County State Permit #
Permit Application County Permit #
for Private Domestic Sewage Systems County d~ -
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: S1 Section T N, R- - E (or) W Lot# City _ 55,E
Subdivision Name, nearest road, lake or landmark Blk# Village
~
J~ Township e
U-~~
C TYPE OF 0 UP NCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons 3
D. TYPE OF APPLIANCES: Dishwasher _-APES NO Food Waste Grinder YES C--WB" # of Bathrooms-2-
Automatic Washer Z--Yr$ NO Other (specify)
E. SEPTIC TANK CAPACITY-/ Total gallons No. of tanks_
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement- Prefab Concrete _
*Poured in Place Steel Other (specify)
F. EFFLUEN DISPOSAL SYSTEM: Percolation Rate 1) J 2) 3) Total Absorb Are sq, ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin . Feet Width Depth Tile Pepth No. of Trenches
5 Seepage Bed: Length Width Depth 3S Tile Depth -;~2. No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size y
Percent slope of land 6 Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certifie Soil Tester, /
NAME / ~~rf I~lf~< C.S.T. # L/ and other information
obtained from (owner/builder).
Plumber's Signature Gte MP/MPRSW# -/Z7 c/ Phone #
L
Plumber's Address ~ -.7
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
Do Not Write in Space Below O FOR DEPARTMENT USE ONLY
Date of Application ,ter-, 5P- 1 Fees Paid: State County Date -
Permit Issued/Rejected (date) -Issuing Agent Name r
inspection Yes No Valid# Date Recd
o - DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
E_Wwl15F!ev. 9/78 F_. !
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATIONc ~ ~ ey' ~ %
:%-5-w ,Section ID TlfN,R-L2E (or) W, Township or Municipality Hl/c-
Lot No. -,Block No. S County
u vision afn1z
Owner's/Buyers Name: A '
Mailing f ii i h 7 S
Mailing Address: -3 c/ ZER /Vv ii Q y e
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET -NAME OF SOIL MAP UNIT Z_ /Ze /P
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES _PERIOD 1 PERIOD 2 PERIOD 3
P-
39 .5e e-- r
P- E t F t; 4
P
P
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES ~j
B- 1 ZL 7 7 7 o-CMy--
B- ~z 7 J l` p 3
L x
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the locatio a96-square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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I, the undersigend, hereby certify that the soil tests reported o~{I{1iisform were made by me in accord with the procedures and methods
specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
f G Z )1-'S Certification No. y f 3
+~an~e (print).. f i C~~ ~lJ
1 k" I t el t S 6~X / 2
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1► AS BUILT SANITARY SYS'T'EM REPORT
OWNER TOWNSHIPY Jy q~5e_,,j SEC./0 1, -R/~W
ADDRESS,~f 2, ST. CROIX COUNTY, WISCONSIN.
I
SUBDIVISION LOT LOT SIZE CZ-e,,u
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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LLL
BENCHMARK: (Permanent reference Point) Describe:
m
I Elevation of vertical reference point: %D eL= Slope at site: -'G G
D 6
SEPTIC TANK: Manufacturer: V/"- (f, z_ Liquid Capacity: d-n
Number of rings on cover Tank manhole cover elevation:
Tank inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle- gallons; Total capacity of
distribution lines -gallon: size of pump, head;
gallon per minute horsepower ;brand name of pump
and model number ;
Type of warning device
HOLDING TANK: Manufacturer----- Number of gallons
Elevation of manhole cover
Type of warning device _
SEEPAGE PIT SIZE; Number of pits feet diameter
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines ,2-width - length J..2 file depth
SEEPAGE TRENCH: width length
PERCOLATION RATE AREA REQUIRED GfS AREA AS BUILT_
INSPECTOR
DATED PLUMBER ON JOB ,r_,,•,ti
LICENSE NUMBER j~~5'g
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LAa30R & HZIMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
EXCONVENTIONAL ❑ALTERNATIVE (IState f .lan D. Number
(f assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTIO DA
Thomas Aras RR#2, Hudson, WI GV
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
SW NE, Section 10, T29N-R19W,Town of Hudson
Nam, of Plumber. JMPIMPRSW No. County Sanitary Permit Number:
Richard Hopkins 1059 St. Croix 38509
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV TANK OUTLET ELE V.. WARNING LABEL LOCKING VE
PR ED: PROVID
LiL~ I -J•~~. YES ENO O
BEDDING: VENT DrIA.: VENT MATL_ JHIGH WA ER JINUMBER OF ROAD: PROPERTY WELL: BUILDIN,,G. VENT TO FRESH
l ( ALARM FEET FROM LINE: / AIR INLET.
❑ YES NO \ ❑ NO NEAREST
DOSING C AMBER:
MANUFACTURER BE DDING. LIQUID CAPACITY PUMP MODEL 17~ ON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
DYES ENO DYES ENO EYES ENO
GALLONS PER CYCLE: 7PANDCONTRALSO R TION L NUMBER OF PROPERTY WELL BUILDING IVENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) EYES NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depgth f plo i "g t ENGTII DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shy cease til tORCE
AIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH. LENGT NG. OF ISTR iPE SPACING COV INSIDE Dlq st PITS LIQUID
BED/TRENCH TRENCHES ! Rj L_ PIT DEPTH.
DIMENSIONS - - i
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. _FR NUMBER OF !PROPERTY WELL. BUILDING'. JVIITTOFRESH
BF LOW PIPES AB E CO ER ELEV. INLE i ELEV/ E,N9 t PIP FEET FROM r L A O AIR INLET:
_JC"OY1
-('0 •'T ~7 NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DI RAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERS IDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS M SURED.
DYES ENO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES EYES ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED -7 01 TOPSOIL S SOD D S ED JMCENTER EDGES J D E NO
D YES 01-1 DYES ENO YES
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATE SPACING. G AVEL DEPTH BELOW PE. I'LL DEPTH ABOVE COVER
BED/TRENCH TRENCHES f
DIMENSIONS
MANIFOLD PUMP MANIFOLD STR. PIPE M NIFOLD MAT IAL. D ISTRPIPE DISTRIBUTIN IATERIAL & MARKING
ELEVATION AND ELEVELEVDIALE VIES DIA.'.
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CO RECTLV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
YES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
EYES ENO DYES ENO NEAREST
1.60 G_
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Sketch System on i county file for audit.
Reverse Side.
S . TITLE.
_ 2-
'-HR SBD 6710 (R. 01/82)
wlsconsln APPLICATION FOR SANITARY PERMIT
-'~IDJ L H R COUNTY
(PLB 67)
oERRRTmEnroF UNIFORM SANITARY PERMIT #
-InOUSTRV,LRBOR&HUTRnRELRTIOns
-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
PROP TY OWNER MAILI G'jADDRESS
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PROPERTY LOCATION &VT_y--
~ 1/4 N6~ 1/4, S T ~ ~N, R / (or) W TOWN : o l1
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NE REST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
A
TYPE OF BUILDING OR USE SERVED Q - 1 o
1 or 2 Family Number of Bedrooms: ❑ Public (Specify): Al
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.
XSeepage 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: e S
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): PROPOSED (Square Feet):
6, 2 / Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signatu7,~ /MPRSW No.: Phone Number:
Plumber'~jAddress: Name of Designer:
?'Address: O
~ % J ~ i / 7 t C. 1 /t 2
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Age/n't}:s e: Date: X Approved Disapproved
` / I^ 1 ❑ 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
y .
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.
1'o rm - S T C 100
Owner of Property
Location of Property ~4 Section l C T N R W
Township SC'v
Mailing Addres
Subdivision Name A/C~1'
Lot Number f
Previous Owner of Property--
Total f~OG'~/~
Size of Parcel
Date Parcel Was Created 11JI2~
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 (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 - S k' ; 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.
A z?
IQ TURE OF OWN". SIGNATURE OF CO-OWNER (IF APPLICABLE)
E SI 0 DATE SIGNED
DEPARTME,N•T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
5Jvv /Tai' N/Rl9 9 (or) W NI o IVA /V,4 e, o s
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
S 7- o ' o
USE DATES OBSERVATIONS MADE -
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 IV A New ❑Replace ~ //G~S ~ S- ~3
RATING: S= Site suitable for system U= Site unsuitable for system
CONVE STI❑U . ( OUN . EIV IN-GROUND S P❑II RE: SYSTEM-IJILLHO❑LDING ~K: REC~ ENDED SYSTEM: (opti )
J
If Percolation Tests are NOT re uire I DESIGN RATE: I If an
q a any portion of the tested area is in the
under s.H63.09(5)(b), indicate: lI SY/y`~5 Floodplain, indicate Floodplain elevation: /4-4
7Ol~yi PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH-W, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- / r /
/7 /
B- z , 51-e A _3?
B 7-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER TANNifeS AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P so < 3
P- 2-
Y
P- , Z2 /2V a
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 `IO , S`3
a _ ~/V W ems,. a-.~( =~1_ mg'
3
D flog'
8 M'
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I, th 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:
ADDRESS: l CERTIFICATION NUMBER: JP:
/jam- '
CST NATURE:
L
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN [RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
E.O. BOX 7969 BUREAU OF PLUMBING
MIADISON, WI 53707
ElcONVENTIONAL OALTERNATIVE State Plan 1. D. Number:
❑ Holding Tank El In-Ground Pressure ❑ Mound (If assigned)
r, 1\
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Aras, Thomas 369 Edmund Ave., St. au , MN
BENCH MARK (Permanent reference po nt) DESCRIBE IF DIFFERENT FROM PLAN. Roy Hopkins S u U V s i O n REF. PT. ELEV.: CST R PT E LEV
SW NE Section 10, T29N-R19 , Hudson Township
Name of Plumber. /P/MPRSW No.. County Sanitary Permit Number:
Richard Hopkins 1059 St. Cr ix 34833
SEPTIC TANK/HOLDING TANK:
MANUFACTURER . LCA [CITY' TAN INLET EL TAN OUT\LEV . . WARNING LA L LOCKING COVER
PROVIDED-. PROVIDED.
DYE ONO OYES ONO
BEDDING: VENT DIA.. VENT MAT HIGH WATER NUMBER OF ROAD: OPERTY ELL. BUILDING. VENT TO FRESH
ALARM FEET FROM L E: AIR INLET.
OYES ONO OYES ❑N'O NEAEST 31.
DOSING CHAMBER:
MANUFACTURER JBEDDING: LIQUI CAPACITY PUMP MODEL. P P/SIPHON M NUFACTUR ER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
OYES ONO DYES ONO EYES FIND
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PH PERTY IWELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM L E AIR INLET
PUMP ON AND OFF) OYES FIN NEAREST
SOIL ABSORPTION SYSTEM. Check the soil oisture at the depth f pl ng I I NGTH I AMETEK MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wir construction shall c `se u til FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
LE NGTH. O. OF UISTR. IPE SPACIN( COVER rRR BED/TRENCH WIDTHECHES MATERIEPTH
D IMENSIONS
GRAVFL DEPTH FILL DPR OPEBFLOW PIPES ABOVE COVER EL I FT ELEVIPESILINEAIR INLETMOUND SYSTEM:
Mound site plowed perpendic la t slope C ck the t xture of e fiPROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mo nd syste s to ake ON REVERSE SIDE. SHOW ELEVA-
meet the crite f ediuTIONS MEASURED.
OYES ONO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ONO DYES ONO
DEPTH OVER TRENCH 'BED DEPTH OVER TRENCH BE DEPTH OF TOP IL. SC) ED SEEDED 7YES HED
CENTER EDGES
OYES ONO OYES ONO ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH . NO.OC LATER L SPACING. AVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH THEN s.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE NIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
. PIPES DIA.:
ELEV.. ELEV. DIA. ELEV. A
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
DYES NO DYES ONO
COMMENTS: PERMANENT MARKERS: Z OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE.
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TIT LE.
DILHR SBD 6710 (R. 01/82)
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DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
ININ~ISTRY, FOR SANITARY DIVISION
LABOR A(D PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner: Mailing Address:
3 ~cyo ~yh,rti 5 5-~e
Property Location: .Qty-,Vi"9ge-orTownship: County:
Gv t/a AL---i/aS T N 191 (or) W L S L
Lot Number: Blk No.: Subsion Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
/ (If assigned) /6/Jf
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required. 41
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY r G~
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): 91-New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
l ~J~G. ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: J Owner's Name as Listed on Soil Test Report (If other than present owner):
4 Private ❑ Joint ❑ Public d
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of umbe/r: l Signat PAP/MPRSW No.: Phone Number:
Plumber's A ress: f Name of D gner:
COUNTY/ DEPARTMENT USE ONLY
Signat re of Issuing Agent: Fee: Date: Sanitary APPROVED Permit Number:
~Z C la "'Z` ~'ry J, DISAPPROVED T d SJ~
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (8.07/81)
J r
Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701 eN
~N/ /V I w
NG ~ --4111
00
~}}~~/4, '/o, Section-LO-J2 N,R_L E (or) W, Township or Municipality
,_OCATION:,5hL' j
~ County 'zI
Lot No. , Block No. u vlslon a
Owner's/Buyers Narnei
1
Mailing Address:
L~/ f ---""COMMERCIAL
I"YPE OF OCCUPANCY: Residence No. of Bedrooms
R i
REPLACEMENT r-------ALTERNATE SYSTEM------OTHER
EFFLUENT DISPOSAL SYSTEM: NEW ~ ...-PERCOLATION TESTS
DATES OBSERVATIONS MADE: SOIL BORINGS PE r-
SOIL MAP SHEET NAME OF SOIL MAP UNIT
6 H
PERCOLATION TESTS
HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
SINCE HOLE HOLE AFTE INTERVAL
TEST pE1rTR CHARACTER OF SOIL
NUM THICKNESS IN INCHES 18T WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD
BER INCHES MIN/IN
/
P- I 3 2~ r G
l~-►p
P ,2 t 1
P
P-
P-
P-
SOIL BORING TESTS
CARACTER OF SOIL WITH THICKNESS, COLOR,
I EST TOTAL -
DEPTH DEPTH TO GROUNDWATER, INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSEHVED IN INCHES
-7 7
'.0 71-1 2 3
' 7
PLAN VIEW (Locate percolation tests, soil burr; holes and suitable soil areas.) Indicate on the pl' i the locatio ar # square feet of suitable alcas,
Indicate number of square feet of absorption area needed for building type arid occupancy .Indicate scale or distances
Give horizontal and vertical reference points. Indicate slope.
r. '
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tests reporte -ors m iStorm were made by me in accord with the procedureesss no myhods
1, the lie Wiscconsin orm certify that th,eColl specitiecj ed in n the Wi Administrativ„ Code, and that the data recorded and lUCdtlOn of test holes are correct to t
knowledge and belief. __-C--~---
/ / Certitication No.__
Aridress~__ 1.~ - ,f le-
Installer it known Z
iir n~lri/ t
CST Signature
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