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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LA?OR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. B05C 7969 BUREAU OF PLUMBING
MAG'',SON, WI 53707 '
ICONVENIZONAL ❑ALTERNATIVE State Plan ID.Number.
(If asslgnedl
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
S/ /SIG FR
71-
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELE V.. CST REF. PL ELEV..
1419- 02 o~o-~'` 573P
Na-! of Plumber: P/MPRSW No.. County. Sanitary Pt,-1 Number:
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
I ( c,--~'s PROVIDED: PROVIDED.
L~.',v~.~t v,~ f 'I P I •1 I ❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.. VENT MATIL HIGH WATER NUMBER OF ROAD'. PROPERTY WELL. BUILDING. f NT TO FRESH
ALARM FEET FROM { LI INLET.
❑YES ~ NO ~ C, ~ ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. JLIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COV
PROV IDEO. PROVIDE
❑YES ❑NO ❑YES ❑NO ❑Y~E O
GALLONS PER CYCLE: PUMP AND CO ROLSQPj ATl NAL NUMBER OF 'E+OPERTY wELL BUIIDIN(, IFRESH
(DIFFERENCE BETWEEN FEET FROM >E AIR IrLEr
PUMP ON AND OFF) YES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowi g I "r.~l~ nIFH MATERIAL AND MARKING
or excavation. (If soii 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 i. R PIPE $PACINa covEft INSIDE DIA - rPiTS. LIQUID
BED/TRENCH TRENCI / roRr PIT f DEPTH,
DIMENSIONS / Lam' I _
C,Rir I Ft PTE FILL DEPTH DI$T I PIF PE= IDISTR PIPE MATERIAL. NO _D TR NUMBER OF ~PHOPERTV WELL BUIVDING'. VENT TO FRESH
BE L: VV [PI J ABOVE COVER ELE h N w PIP LINE- AIR I LET'.
• FEET FROM
s 3 , i7 t 7,2 NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Chick the f xture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound sy ems to. make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets tl],e Vria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BE D DEPTH OVER TRENCH: BEL? rEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENIER EDGES f
v ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NLATERAL SPACING. GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.. ELEV. DIA. ELEV. PIPES. DIA.:
ELEVATION AND
DISTRIBUTION
HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS
❑YES ❑NO ❑YES ❑NO
WELL: BUILDING.
ROP
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: N UM BER OF [ rPERTV
FEET FROM uNE
t 1 ❑YES ❑NO ❑YES ❑NO NEAREST-
U
Sketch System on AiIi' Retai in e my f le for audit.
Reverse Side.
SIGNATURE
DILHR SBD 6710 (R. 01/82) -
r-*-.-- - 9 1 State and Co RfeE,VEO State Permit # PLB 67 Permit Applic n JUN 24 19$2 i. County Permit # T
J
for Private Domestic S e Syste~BWING County
*DENOTES STATE APPROVAL REQUIRED Offl(E Date Approval Received from State if Required D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: '/4 5 Y4, Section , T 24 N, R a (or) Lot#City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township f i( y C %'l
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family f/ Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPI~CITY Total gallons No. of tanks
Prefab concret/ - Poured-in-Place Steel Fiberglass Other (specify)
New Installation 6--.- Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. idth ,Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width Depth 0 Tile depth (top) ? ~ No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope
WATER SUPPLY: Private Joint El Community El Municipal El
Owners name as listed on EH 115 if other than present owner:
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 Certified Soil Tester, ! - ~ 1 /
NAME C.S.T. # ~ and other information
obtained from , f (owner/bu~derL, Z
Plumber 's Signature ~e~•~-r 1 S 1'~ / 4 Phone # t 1 ?
MP/MPR W#
Plumber's Address " 7~ - 7
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT US ONLY `
17
Date of Application Fees laid: State rJ County Dat_
Permit Issued/R (date) Issuing Agent Name
Inspection Yes h _ No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78
iUSTRY, NrOF
Il1STR r REPORT ON SOIL BORING AN®
SAFETY & BUILDINGS
.8, DIVISION
iOR AND y ,'"VINE'®6 ION TEST (115)'
MAN, RELATIONS 1.5 t P.O. BOX 37969
707
' ` ~ MADISON, WI 53707
A7 O-iV. 1 r^^^~--A
70WNSH P/MIJNfCApAk'6TKa ; LOT NO.. BLK. NO.: SUBDIVISIQN NAME:
V43 N1111v r €r5+.ar
fN -'7y OWN, T-U '§NAME.
_ A IN AD
_._t i:yt fr ~ pe ~ W
t• F
. fPt I{ DATES OBSERVATIONS MADE
itesirience «f ~ S:
A yT (1(31 UI r i ONew ❑Roplace
ING S= Site suitable for system LlSite unsuitable for system a • t r r
VENTIONAL. MOUNQ: -
IN GROUND-h1itSfUA V~I'FM- N-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
IS 0"
Cl S ClU
Idtion Tests are NOT required - _
~f)FSIGN RATE `V51T I'
s I 9(5)(4), indicate: If any portion of the lot is in the
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
NG TOTALFI UNDWAf R.INCHE CHARA TER OF SOIL WITH THIC NESS, COLOR, TEXTURf-AND DEPTH
E_R DEP7"FI IN, ELEVAl'ION ~C18` IiV .m.) Cj4
_775r TO BEDROCK IF OBSERVE -D-(SEE ABBRV.ON BACK.)
/
qj r arty Sax i i [j ( I i
,-,~,p,..,~,.~ .,,n,,, ~ Vy4_ t..., s3 id ! yA ° L'Z ~ ~ f J e
T„ ~ • ; .ate
11 , i'
! _w f~Q it tw`lr Jf.
c.7 t ' E•'t -f std t j t'~x° ~ e- h , -
r ,
PERCOLATION TESTS _
DEPTH WATER IN HOLE TEST TIM _
N INCHES AFTER. SN LLING Iq ERVAL-MIN. DI O I W_ ER 1_EVEL-IN HES RATEMINUTES
rt _
('lap~QUp -
_ y?t---,• p~1?1SZ - P R _ PER INCH
:t
,T-3
-
77
.AIM.-+9..• . ~
VIEW: Show locations of percolatlon tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
d vertical elevation reference points and show their location an the plot plan. Show the surface elevation at all borings and the direction and percent
lop.
TEM ELEVATION
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,lersignad, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
native Code, and that the data recorded and the location of the tasteare correct to the best of my knowledge and belief.
int
,:'TESTS WERE COMPLETED ON:
CERTIFICATION NUMBER: PHONE NUMBER optional):
CST $1 NATURE: .
ITION: Original-Local Authority, 2nd page-Bureau of Plumbing, 31d page Properly Owner, 4th page-Soil Tester.
+D-8395 (N. 03/81)
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Parcel 020-1156-60-000 10/07/2005 10:52 AM
PAGE 1 OF 1
Alt. Parcel 17.29.19.873 020 - 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 - ZEZZA, PATRICK J & SANDRA L
PATRICK J & SANDRA L ZEZZA
445 GREEN MILL LA
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 445 GREEN MILL LA
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.039 Plat: 2277-PARK VIEW ESTATES 3RD
SEC 17 T29N R19W PT NE SW PARK VIEW Block/Condo Bldg: LOT 79
ESTATES 3RD ADD'N LOT 79 (1.034AC) INC
PARC A CSM 7/2019 (0.05AC) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
17-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 823/381
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.039 24,700 185,600 210,300 NO
Totals for 2005:
General Property 1.039 24,700 185,600 210,300
Woodland 0.000 0 0
Totals for 2004:
General Property 1.039 24,700 185,600 210,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 211
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00