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` i AS BUILT SANITARY SYSTEM REPORT
.
OWNER 730 H&j h! ti`T Z _ 'TOWNSHIP N U D 50vJ si%c 2~N-RPJW
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 1163
W_.E_VEBYTHING WITHIN 100 FEA,_'T OF SYS'TE'M
U
N
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I Id i . the Arrow I
SC>AL, . N TI p 'SCf~
vp2r 814 /s t3,4.sv ev- .Sw car /,eoti
BENCHMARK: (Permanent reference Point) Desct-il)e:
Elevation of -vertical reference point: Slo1)(' r11 i i k, 8 /o
SEPTIC TANK: Manufacturer: I, i (Itt i d C ap,lc i i y 161tv. GA//o A.)
Number of rings on cover _ ,Tank uiunlao covet- c• l cv,l i i 0 l)
Tank Inlet Elevation: 'l'ank Out let I':IuVill i M I
PUMP CHAMBER
Manufacturer: Nuwt)er o l ~;~i l tuna
Number of gal. pump set or a cycle ga long , i cat gal i i y u
distribution lines gallon: size of pump
gallon per minute v horsepower l~rancl ilmll( )l 1'1[1111)
and model number
Type of warning device
HOLDING TANK: Manufacturer _ Nuual)(~ i (d g a I I ona
Elevation of manhole Gover
.Type of warning device
SEEPAGE PIT SIZE: _ Number of pits Fee r (3 i :imL• t C~ I'
Feet liquid dept-~ seepage [)it inlet- p-ipe-eLevari'm
bottom of seepage pit: e evasion
SEEPAGE BED SIZE: number of lines - ~ width Le'w'11135 i i I(• ►~I,i la
SEEPAGE TRENCH: width - - lent;ril
PERCOLATION RATE . S Y'~--AREA REQUIRED ~p/~ AREA AS BUTL l'
INSPI?CTOK
DATED PLUMM-I'k ON Jolt
LICI-:NSI,. NUMhI-;K
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 1969 A., PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE State Plan LD. Number.
❑ Holding Tank El In-Ground Pressure E Mound (If assigned)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER. INSPECTION DATE'.
l~; n~Z ~t . P 4. rv s
BENCH MARK (Penman Nnt 0- p, c~, Pnmt) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. IT. ELEV.
Iii r 9 w ajsoro
Name of Plummer. IMP/MPRSW No. Cou my Sanitary Permit Number.
SEPTIC TANK/HO NG TANK: Z Q Z
MANUFACTURER. LIQUID CAPACITY . TANE'T ~K INLET YR;OAD TANK OUTLET ELEV. WARNING LABEL LOCKING COV R
1 P OVI ED PROVI ED'
\/..l~L'~t 5 ( BIZ. ' YES ENO NO
NUMBER A F - PROPERTWEBOIVENT OFRESH
BEDDING. VENT DIA.. VEN MATL.. HIGH TE~
LAR FEET FROM L."Eo.AIR INLET
YES Y O NEAREST
DOSING CHAMBER: _
MANUFACTURER BEDDING'. JLIQUID CAPACI IY PUMP MODEL PUMP/SIP N MA OF AC TURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
EYES ENO EYES ENO DYES ENO
GALLONS PER CYCLE: PUMP AND CONTROL E77N UMBER OF 11 HOPERTY WELL 1BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NF AIR INLET
PUMP ON AND OFF) EYE NEAREST )p
SOIL ABSORPTION SYSTEM. Check thesoilmoistureatthedep ofplo i i1H MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction sh II cease til FORC
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO O IS R. PIPE SPACING ;N'S VER INSIOE DIA. LIQUID
BEd/TRENCH / THE HES L PIT DEPTH
DIMENSIONS
RO R T V ELL BUILDING : V E NT TO FRESH
GHA` F PT+I- FII L DEPT DISTH PI Dls P . PI MATERIAL DI MBER OF
BF I l f II f s A AE C R EEv NLr E I ET FROM a F7 CT( AIR?LyET~
~r 19•+4/' C~ 1 NEAREST J
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture the fill mat ,lal for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound system .make cer n that ON RE SE SIDE. SHOW ELEVA-
meets the cri ri r mediu and. T MEASURED.
EYES ENO d
SOIL .`OVER. TEXTURE - / PE ANE A KFHS. =YES ATION WELLS
❑ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH: BED DEPTH OF'TQ SOIL. SDDD SEEDED MULCHED
CFVTER EDGES F
~f EYES NO EYES ENO EYES NO
PRESSURIZED DISTRIBUTION SYSTEM: _
WIDTH. LENGTH No. OF LATERAL SPACING. G A\ L EPTH BELOW FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR PIPE 171FOLD AT IAL. NO. n:YSTR. ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
FLEV. ELEV. DIA. ELEV. PIP F$ DIA.'.
ELEVATION AND
~DIS~`i BUTIO N
MATION: HOLE SIZE HOLE SPACING DRILLED CORHECTLV COVER M ERIAL. PLANSCAL L E LIFT CORRESPONDS TO APPROVED
/ YES NO
I
_ NO
EYES
COMMENTS: PERMANENT MARKERS: 1013SERVAIJON WELLS: NUMBER OF JILINE RTV WELL'. BUILDING'.
FEET FROM LNE.
YES NO OYES E NO NEAREST
i ~ I I3 's. 9
L .7
Sketch System on Retain county file for audit.
Reverse Side.
.
SIGNATURE. TITLE
DILHR SBD 6710 (R. 01/82) - CC G
EH 11.5 /9
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES _
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH ~j .
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS J
LOCATION:-5-t-1/4, N444, Section Tdg~N, R4& (or)612fownship or Municipality f QL /
County S/ r ord/ X
Lot No. , Block No. c_
Subdivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence X No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS -PERCOLATION TESTS J~/`3 7~
OIL MAP SHEET SOlI_TYPE~i Suc~(f~~7/
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
f UM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P- r I, _Se re-
P_ 2-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B- 3
y 9.6 A116A.1 e- ~ •r j L ~1D rc /Ira. 4/ ~/~j
B- P6,11 C',
r '''te
/0,- 4, If (,-S/
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of uitable areas. Indicate number offq~iar? ' >t ;,f ab cr;:' lon ar a
needed for building type and occupancy. 6 i 00a .57" .-AA~ 40 6VCW In iicaje scale
or distances. Give horizontal and vertical reference points. Indicate slope. ..SYS' ~ -I- /~Cj~/~Q,
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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 location of test holes are correct
to the best of my knowledge and elief.
Name (print) S C` 2 Certification No.
Address ' e
Name of installer if known
v
CST Signature
PCPY A _Al, AUTHORITY
qj Pe, ~J~,q sT u f S'T • ~lx Cam- _ 2o.ti, i ,3 G- A DEPARTMENT REPORT ON SOIL BORINGS AN
INDUSTRY,
HUMAN RELATIONS PERCOLATION TESTS (115)
LOCATION SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION N~.
S°w '/a '/a l /T z% N/R 1I E (or) W vpSO,✓
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: I I 1F DESCRIPTIONS DAfION : ER OL TESTS: i
Residence A / XNew ❑Replace ? ^7 ~I
RATING: S= Site suitable for system U= Site unsuitable for system 13, ? 7-
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:( tional)
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V.
If any portion of the lot is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
- C/
BB-
B-
B-
B-
PERCOLATION TESTS
DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUM INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P-
P-
P- i ES S
P-
P- sa Q i` lA),t L
P__ - S" -s E aR 7--
PLAN VIEW: 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 slop. _
SYSTEM ELEVATION' F/ '
= 114w) ?4A&- P1 AeoM 13 119.1 r " • 3
e .
AeoM ~ ~ L[I F I S ~O ~CI~ SQM HOC- ,1
A4sc or L70
5o it- TAF757- 3 N* T To w ~nr s~aP~s R~ ,
/foA✓ 5R f Q 5o r, ,rEs i
71, N
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T /04) p
jEl~. - . f . . . M & f ~Q F
Hogs. '~o
S 1 I2 it 40
v
. Std je01j Date:
I or l,Po
W Inspector'
6613-w
_qvuA Z
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TES S WERE COMPLETED O
14pohb)e F Whle/ c,, 7_ / 3 / ~ ~2_,
ADDRESS: CER IFI TION NUMBER: PHONE NUMBER optional):
{~v~sd,~ ~1 s ~~~i o ~v .2-
CS GNAT URE
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81)
ppr,
DEPARTMENT OF APPLICATION
SAFETY & BUILDINGS
_ FOR SANITARY DIVISION
LABOR AND. PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 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:
if,v 2-- /yy 7 ` ve _ s(5 M,N~ Z ~s
/If
Property Location: _ City, Village or Township: County:
sw ti4'I/ _14S lT zy N/R /9 E (or) W JijluloseAa sf G~o~X
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
L/~ 61J (If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY AA+
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: ZVE)SF
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPO ED (Square feet): New El Replacement ❑ Experimental X Seepage Bed E:1 Seepage Pit
3 j Fr Alternative (specify) F-1 Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
9 Private ❑ Joint ❑ Public _<Z - -
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature: MP/MPRSW No.: Phone Number:
Plumber's Address: Name of Designer:
Z2 ~I D,v~'o~ s/~. /VoRA,
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Age ee: Date: Sanitary Permit Number:
_ I s--R ❑ KAPPROVED
DISAPPROVED 0.4 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 (R.07/81)
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Parcel 020-1020-10-000 12/21/2005 10:07 AM
PAGE I OF 1
Alt. Parcel 14.29.19.93C 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 - HINTZ, JOHN K & MARLENE
JOHN K & MARLENE HINTZ
953 LA BARGE RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 953 LA BARGE RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 10.370 Plat: N/A-NOT AVAILABLE
SEC 14 T29N R19W SW NE COM CEN SEC 14-E Block/Condo Bldg:
1323.9'-N 448'-W691.05'-S 224.15'-W
634.66' TO W LN SE 1/4, TH S 223.4 FT TO Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
POB 14-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2005 SUMMARY Bill Fair Market Value: Assessed with:
91507 287,400
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 10.370 119,200 173,900 293,100 NO 05
Totals for 2005:
General Property 10.370 119,200 173,900 293,100
Woodland 0.000 0 0
Totals for 2004:
General Property 10.370 90,200 125,700 215,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 202
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
Siwcy "%7G• y , ' ~u / y 1 ~2 N
PLB (o7
nor and CRO55
13,4f aF SW L or 11P0v
UE~'j/6~ L ~ ~ TEST
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b
Fresh Air Inlets And Observation Pipe
Y
Approved Vent Cap
Minimum 12" Above
Final Grade
i
4" Cast Iron
30" Above Pipe
Vent Pipe
10 Final Grade ,
~ i
v '-c~sl Nay Or Synthetic Covering
Min. 2" Aggregate
Over Pipe
cam,! Distribution V
Pipe 0 0 0 0 0 Tee V
/Z Aggregate o Perforated Pipe Below
Beneath Pipe
o Coupling Terminating At
13offoll Bottom Of System