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CbMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730 Cj:A: w ~4'
715-962-3121
800 - 962 - 5227
CROIX ZONING REPURT NO.: 1!337/01 PAGE 1
CROIX COUNTY REPORT HATE: 9/25/91
OURTFOIlSE DATE RECEIVED: 9/24/91.
=;DSON, WI 54016 _
WNER: i America Ba e
`:ICATION:
3LLECTOR:
JERPRETATION: Bacter i o to,, i c. L Ly 6t<.
7 ppm
Above 10 Ppm exceeds the tt
4rID IL~.tlsj?iL.ihti4: t' Rt ilYSFib
WI Approved Lab No. 19 rim ^f
c~
cD Z ~ U
c s
\NDEPEND
r 'r ~V D
-D
T
o PROFESSIONAL LABORATORY SERVICES SINCE 1952
- - - - - - - - - - - - - - - - - -
a3-q/ !3-~'l
\Ck~ ST. CROIX COUNTY ZONING OFFICE
911 4th Street
Hudson, WI 54016
Telephone - (715)386-4680
The St. Croix Co. Zoning office offers the service of septic and
water inspection to Lending Institution, Realty Firms, and
private individuals.
COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE
LOCATED.
Please provide the following information, enclose appropriate fee
made payable to ST. CROIX CO. ZONING, and mail, along with form
to the above address. Testing will be done as soon as possible
after fee and form are received. /
WATER TESTING FEE:$ 25.00 l~
(For nitrates and coliform bacteria)
WATER TESTING FEE:$175.00
(VOC'S)
SEPTIC SYSTEM INSPECTION FEE:$ 25.00
PROPERTY OWNERS NAME: f fi 4 Mal(-",4 ~~t \
PROPERTY OWNERS ADDRESS: CITY: 14c)6
Legal Description 1/4, 1/4, Sec. , T N-R W,
Town of /4u,0sc0- , Lot, No. , Subdivision SPViPd i /c~~E
FIRE NO. LOCK BOX NO.
Color of house ou~~ Realty sign? Vr-_S_Firm:
D~
PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e., COPY OF PLAT
BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
Telephone No. Co - 8a3&
REPORT TO BE SENT TO: A-S -r-- 4~~- p"04
cc s7 - 0 s':vL-)
-7
CLOSING DATE : p7'. /Qql
Signature:
ST. CROIX COUNTY
~r
WISCONSIN
..1 f yr1 F l.~ y`~tyh}
ZONING OFFICE
' ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
Sept. 24, 1991
Kernon Bast
Edina Realty
700 2nd St.
Hudson, WI 54016
Dear Mr. Bast:
An inspection of the septic system on the property of MidAmerica
Bank located at 584 Spurline, Hudson, WI was conducted on Sept.
23, 1991. At the same time a water sample was obtained for
testing. The results of that testing will be sent to you as soon
as we receive them back from the laboratory.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and
did not involve any excavating or chemical analysis.
Accordingly, there is~the possibility of hidden defects in the
system not discoverable by this inspection. This does not in
any way warrant or guarantee the continued proper functioning or
operation of this system. It is recommended that the system
should be pumped once every three years. Therefore, the
prolonged life of this system may be dependent upon proper
maintenance of the system.
Sir~cerely,
Mail Xjtnkins
Assistant Zoning Administrator
cj
AS BUILT SANITARY SYSTEM REPORT
///NjJ~-R W
OWNER TOWNSHIP r SEC . T l
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of, H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
rr
A k,
A ` I d i jtWw bTL1
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: n
Number of rings on cover : r' -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 width length tile depth
SEEPAGE TRENCH:; width length
PERCOLATION RATE AREA REQUIRED AREA AS BUILT
INSPECTOR
DATED PLUMBER ON JOB Iz' J
LICENSE NUMBER
DEPART. MENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
.LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O,BO; 7969 BUREAU OF PLUMBING
MADISON, WI 53707
IN CONVENTIONAL ❑ ALTERNATIVE State Pl an I.D. Number
(lf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER'. ADDRESS OF PERMIT HOLDER'. INSPECTION DATE:
Lundgten, E,2don 1503-2nd St.,Hudzon, W1
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. own o (,I. U o n REF. PT. ELEV.: CST REF. PT. ELEV.
SE NE, See.16, T29N-R19W,Lot 16, Narcth Lane Stattian II
Name of Plumber MP/MPRSW No.. County Sanitary Permit Number:
Rogers Evenson 4183 St. CrLokx 43685
SEPTIC TANK/HOLDING TANK: 1 17
MANUFACTURER LIOUID CAPACITY. TANK INLET L TANK OUTLET EL V.. WARNING LABEL LOCKING COVER
C !p PROVIDED PROVIDED
❑
J~~,/J , YES ❑NO ❑YES [:]NO
BEDDING. VENT DIA.. VENT MATL.: HIGH WAT NUMBE F ROAD IPF30PERTY / WELL'. BUILDING: JVENT TO FRESH
i ALARM FEET FROM ; LINE AIR INLET
❑YES ❑NO ❑YES ❑NO NEAREST /
DOSING CHAMBER:
MANUFACTURER JBEDDING'. LIQUID CAPACITY PUMP MODEL J PUMP/SIPHON MANUF AC7UREH WARNING LABEL LOCKING COVER
.
PROVIDED: PROVIDED
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NU BER OF PROPERTY WELL BUILDING IAER NLOT RESH
(DIFFERENCE BETWEEN FEET FROM LiNE
PUMP ON AND OFF) ❑YES ❑NO N -AREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LFN(c TH rnAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until 1/41RCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH IN111 DISTR. PIPE,SPAQNG. COVER INSIDE CIA. - #PtTS LIQUID
F MATE~AL: PIT DEPTH.
BED/TRENCH N TRENCHES
DIMENSIONS L6' 4k'
GRAVFL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER EL EV.INLET E.~IV. END PIPE FEET FROM Z AIR ET
] + ! / 'L
If i ' -
G~ / > NEAREST
MOUND SYSTEM: E
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-
meets the criteria for medium §and. 1"IONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE 4SODDD ANENT MA, ERS OBSERVATION WELLS
VFTN ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED JDEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SEEDEDMU LCHED
CENTER EDGES
❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM: t
WIDTH. LENGTH. NO. OF LATERAL SPACING. IGRAVI'ELI)EPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIF LD MATERIAL: NO. DISj H. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA. ELEV.. PIPES DIA.
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
❑YES ❑NO ❑YES ❑NO NEAREST
7
4 .S~
Sketch System on Retain in county file for audit.
Reverse Side. ~S16NATURE nTLE 7, Z~
DILHR SBD 6710 (R. 01/82) - -
unsmnsm APPLICATION FOR SANITARY PERMIT
DILHR"~' P- Otx COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
~ OEPRRTTEnT OF
e I lIOUSTRV, LRBOR 6 HUMRn RELRTIOnS /
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
PROPERTY LOCATION
q+ISM!±o!6 E:
t / is a t ? P, i / 1 ,
1/4 SIC 1/4, S - , T~ N, R a*w) W y TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST UQAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
ar++ ~rNE ST~4Trun/ ~v+~. L rr~+~ (G.I..~
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
[~J New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total # of Prefab. Site Al teeFiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity J j ;a 1
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: (
=4
IF THIS IS AN ALTERNATIVE SYSTENJI 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):
< 3 i a T7 (p 4 ;j Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the privy e sewage system shown on the attached plans.
Name of Plumber (Print): Signatur MPjAAPRSW No.: Phone Number:
o,-7 E, W_ V e ~j,04N, 4' 1 8 :S ( 71 Sr) 3 SGT-3 G
Plumber's Address: Name of Designer:
4-1 E2 1 7:-77,
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
C, ( ❑ Owner Given Initial
,Q 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 lwelise r,ias5i
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
Form - S T C 100
Owner of Property Lpc.,nJ~a.JI,`.' r•f
Location of Property 14 Section T ' N R 1 W
Township ~4 tjD
Mailing Address ,~~r _ _
Subdivision Name y L I
Lot Number l
Previous Owner of Property - E~ ht-tVl !'°'t<'~ ' - ~ ~
Total Size of Parcel r
i
Date Parcel Was Created S&'_ V- a LA-'T
f
Are all corners identifiable? Yes No
Include with this application one of the following:
.Certified Survey Map
.Deed
.Land Contract, or
.Other I:egal Document which describes the property
PROPERTY OWNER CERTIFICATION
(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 Nozj ~ O and that I (we)
presently own the proposed site for the sewage disposal system (or I (vve) have
obtained an easement, to run with the above described prop.-rty, for the
construction of said system, and the same has bcen duly reworded in the Office
of the County Register of Deeds, as Document No.
SIGNATURE OF OWNE4 SIGNATURE OF CO-OWNER (IF APPLICABLEI
DATE SIGNED DATE SIGNED
i
" t._.~
?~~IJ, b,t J_i1C7
l MAD
W53.090) 8A Chapter 345-045)
ATir?`t T 2CTIU^i iJ tVSHI-,?iIUNIC.IPA LI f Y: Or PJ~,I_K ll tl)IVISIO J J?.' _
-4 ,l 'i3 1a v _ _ 1 ^r m i ri ° ) +I t- 1,1r _ ,1t`,}
`1 1 rt ./Rtl f P' ; N yv1E7 1.' I LING ADnRr7Sa L
t
r
DATES OBSE PVATIONS MADE _
- -
{ O 3tDHti6 : CO',ilvlER~IAL DESCRiPTiON: r-~ PROrIL DtS~RlPT10 VSE AiT(~N Ti I S -
r L 1Re^lact, ?
~Resldcnce ~ A t N s vu ~ • j ~ ~ >/~->"f .J ~ _ _
uns+,i'abla f a, r " ~ _
, 1 1 fie S° t;! au;tahte tar vysir,-r U- . size sy5'H*n
l Vtt,1[iO,IA+{ r~!Glytii~: iN(~f2()liilDrr~cSt~l~tiSyJ+~^,1-IN-rILLttOLUIM61AN' l,iELCirti1Lt ENDED SYSftM:(wbonal) Eels E! U E-] ii 10 S "j
f arcolation Tests are NOT required DESIGN RATE' if any portion of tree tested area is in the
t _
per s::4'S3,^S;5}(t,1, indicate: ~i.,,;~cy a i siooctpla!rr, Indica!e Ftoodptain elevation: .t°aL•-.
31? 'r:t PROFILE DrrC~, fPTIO S
d' ilv~! TOTS+tz Sri T(ti t rtn' IRI( CT-,I R INC H ES CHAi3 C;TEF,, OF SOtL WITH THK-HKC.OLGR, TEXTURE,
r.,v.13Er~ DErrTrr jcL VATlG h S 'P2~r G L-rSI H4 G'- c$ TO BEDHUCk_ IF CBSEHV D (SEE :,BbHV, ON BACK.)
s ',t3tar b Co. cJ' Ni
-t
i r Ate'. it v;~lfL~CO
U. aw 1
&L 4-
6- 3
J ~ 4 L ~ 2 r v e7' t3t3N~'; i- r'L j 6, 7 c~' +G3 tee'
L w~ ea . g U ` u N 3
Q, 5*0' 13 L.; ! • 5 U ' 3A/
L'.dPly t4 1 l~ _Ct)L.~#~ ► wAJ 7' ST f/N.t f;lGf+t.
PERCOLATION TESTS J ~-i.? ,aA 'R, nr7- rz ? t)v
J2 P 5!wt"nt o S
tS± vvAI iNHO LE rFSTTiME DROP IN WAIER I-EvEL-INCHES FA1EkifIII U - r
fiC H
~_+7gFF2 tdVwiwb AlER` YVELLING I INTERVAL WN. PFRIQDTy PER O _P,RT~ Ph _ft IN
Lr-
'1-Z;T Pi Aft: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
and vartrca.l elevation refarenetr points and shorn theSr Location on the plot plan. Show the surface elavauQn at~l borings and the direction and percent
~`0
d slope. W<:"
11:1 VATION
F F
t
t.._...a) f 1 _..E..... i ~..r. l - 1 I ~I ~l `.~-..t..t a...-... J..n. • __.-.rr->~
e u river uanr~t, hes~hy certify ?ttat V, f soil tests reacr vx; c,n this form were mails by me in ac d with the procedures and methods specified in the'Nisconsin
-irn ,tr . ; e Gorda, and that the data recorded and the l ,c:,tion of the tests are correct to the betsf ut my knov,jledge and belief.
tr (print TESTS WERE COMPETED 0-N:
° + ' } er
?_i_,. CTtF L:AT1O'i luiVl ,as,~i'r ~r 1..,. Sr•-i'-t~-..i:vn~it-I
t JC
art
SrR}3U7IGN: Original 9n+ nn? ropy ro t_ry,,il AuYh,)ri!y. l''opei ty O`^rn•rr anti Soil u5ter.
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