Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
020-1167-20-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township Coyer, Daniel Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: f06 o I lo o , a 5w 0* �Cuu TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Vent to Air Intake ROAD Dosing cton Loss System Head Aeration Forcemain Length Holding Fist. to well 29.29.19.1033 TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic cton Loss System Head TDH Ft Forcemain Length Dosing Fist. to well 29.29.19.1033 Bldg. Sewer Aeration St/Ht Inlet Holding St/Ht Outlet � PUMP /SIPHON INFORMATION Manufacturer St. Croix Demand GPM Model Number ELEV. TDH L[ft cton Loss System Head TDH Ft Forcemain Length Section/Town /Range /Map No: Fist. to well SOIL ABSORPTION SYSTEM DCO7TRENCH' Width J Lengl DIMENSIONS a SETBACK SYSTEM TO INFORMATION Type Of System: DISTRIBUTION SYSTEM No. Of Trenches Wslkz= , LAIN r Ar � ELEVATION DATA County: St. Croix Sanitary Permit No: FS ELEV. 488265 0 State Plan ID No: Parcel Tax No: Alt. BM 020 - 1167 -20 -000 Section/Town /Range /Map No: 29.29.19.1033 STATION BS HI FS ELEV. Benchmarkyy�� p!pe(s) _.. Alt. BM Length Dia Spacing Bldg. Sewer St/Ht Inlet ! G St/Ht Outlet � Dt Inlet Dt Bottom He an. 7 Dist. Pipe 7 Bot. System ` — Final Grad 4- rW St Cover j 7 C S No. Of Pits Inside Dia. A LEACHING Manyfact4 CHAMBER OR L.L+ UNIT Modal Nun Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake p!pe(s) _.. Length Dia Length Dia Spacing SOIL COVER x Pressure Svstems Only xx Mound Or At - Grade Svstems Only Depth Over Bed/Trench Center Depth Over Bed/Trench Edges xx Depth of Topsoil xx Seeded /Sodded -- - - ��es No xx Mulched Yes EM] No COMMENTS: (Inc a code discrepencies, persons present, etc.) Inspecti n #1 'x :- ' � / - /�' Ins otion #2: 7 /_ Location: 465 Country View Hudson, WI 54016 (SW 1/4 SE 1/4 29 T29N R19W) Country Lot 2 Parcel No: 29.29.19.1033 1.) Alt BM Description 2.) Bldg sewer length 10.17 ` i.' - amount of cover = ` r -j j y 7 , y Plan revision Required? [] Yes t=t(Y 0 � A Use other side for additional information. / Date SBD -6710 (R.3/97) Signature Cert. No. Safety and Buildings Division m 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 - 7162 County G t t Sanitary Permit Number (to be filled in by Co.) lseonSin (608) 266-31.51 I'$' Zrj Department of Commerce scare Plan I Number Sanitary Permit Application �� In accord with Comm 83.21, Wis. Adm. Code, personal information you provide be used for secondary purposes Privacy Law, s15.040)(m) Project Address (if different than mailing address) may Oeta I. Application Information - Please Print All Information Property Owner's Na me Parcel y Lo Block X f 0 7 7006 - Property Owner's M ailing Address Property Location ST. CROIX COUNTY 1 4 - r;,/ �'A, C_ u. Section X 29 (circle one �o33 City, State Zip Code �y / - 9 T �9 N; R /9 E o>® H. Type of 18ruilding (check all that apply) / Gx'tb , �`�j Subdivision Name CSM Number IS 1 or 2 Family Dwelling - Number of Bedrooms haw ) o ❑ Public /Commercial - Describe Use ❑City_ ❑Village ®Township of /l rvn/ ❑ State Owned - Describe Use W X5.15 j. /'s G - M. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Ig Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner 114 1 IV. Type of POWTS System: (Check all that appl a ® Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Coasi acted Welland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dis rsal/Treatment Area Information: Design Flow ( Design Soil Application RauKgpdsf) Dispersal Required (sf) Dispersal A (st) System Elevation I Area 1 Proposed 9osQ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Tanks Existing Tanks A. f 1 Septic or Holding Tank lA Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) gnature MP /MPRS Number Business Phone Number /Q ZZ m - S o Plum is Addre ss (Street, City, State, Zip J'r AA Z1.,1 411 S , * l d VIII. Count /De artment Use Onl pproved ❑ pp Sanitary Permit F (includes Groundwater Date Issu Lssuin at Si (o S ❑ Owner en Reason for nial Surcharge Fee) �w . W 7 /D ()�p IX. Conditions of Approval/Reasons for Disapproval �► SYSTEM OWNER: 1. Septic tank, effluent fitter and a � �a, J� d . ' P� dispersal cell must all be servitses / maintained i (•a.t� -�. � as per management plan provided by J 9 plumber. 2. AN setback requirements must be maintained V f sa per spplkatble code / ordata WAM. i ' i ^ . 6 , t3d't vtti- tT'O 6e- -- - mpme Ili lto the t:ottnty may) tor system on paper not less than aiiz x it mcnes in size ` . CR1 ST1tj ` " K" 'PLOT �t CROSS SECTIOt'I n1 mw—n uNT � ° PRO►IHF'f W�tl. �, ►�C r s tenlE �o �Q 1 Cou,cITQ (le�w A. - r*wK T 6 — , Iat8Av4oalUe:io � - ��'�. s��rec T wr ,� {� R�DE��� ?itl3Ld � igcq� t'` iG T�'? `Jl ' (Jkitk.rF.e�/t+eK ^ �� of Lca�JcRe 5�..4� �4T s•w.co ?NEAP o� /+tou E. E O .o� f ... A r A m �o , r Kj FE c.Jarct 8 , T o..r+ • ® ;��; ��� -`k,� � tgQ a �a� . E�� J, -� 0 3.3� , 1, o tJ c 4 SCA P V T �_I'r SYSTEMS INC MAN Q STi4A�0'C/l�dAIBEA Gutdc4 Standard Chamber FRONT MSS DATE: '7 • o sa�.T�i1�gsY: • • Q . rT 90 3 Sq. s' ELEVATION OED OOTTOM PER SOIL Two FT MultiPort End Cap . y�ppA .poi. EXCAVATIA IN I.wM'p tMMT I { ! Cxt � /��P � �ewr►�t r�6a5trAE_ 6C' ) Vi • t PQ� Posam ` RNa -G&JO - rwk- T i3- As*6 P►10ouElo to w 41 z Ale F LA A.*T E 6J C � R�aEW�� _ && e 0 4 0 . &K — IS f o r= C OAJ C R c Ir SI—AA AT S•w.CdQ,uel? ofr /4u4E. Et,EV. /oo•a Acr p oi Teo? of K*1 & c ^t-1 o 6 ?1-e. E l<</, •/'?3.3 ,0, A ll II SYSTEMS iNC 0 WeAW STAAiMcMMw t MultiPort End Cap NCEm: ,U z1l S'7 DATE: • ° ;EFFECTIVE LENGTH! j 3 • S FRONT VIEW QtAck4 Standard Chamber �r ELEVATION WD 9WOM PER iOM Two F 1975 Wisconsin Department of Commerce SOIL EVALUATION REPORT pap 1 of 3 Division of Safety and Buildings A.C.E. Soil & Site Evaluations in accordance with Comm 85, Wis. mum. Code Attach complete site plan on paper not less than 8'/ x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. 020 - 1167 -20 000 Please print all information. Revi gy Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Q Q Property Owner Property Location Daniel D. & Kristine A. Coyer Govt. Lot SW 1/4 SE 19 2 T 29 NR 19 W Property Owners Mailing Address Lot # Block # Subd. Name or CSM# 465 Country View Rd. 2 na Plat Of Country View City State Zip Code Phone Number _ j City Village 1/ Town Nearest Road Hudson I WI 1 54016 1 (715) 386 -2399 Hudson 1 46 Country View Road New Construction lase: Y' Residential / Number of bedrooms 4 1i Replacement I Public or commercial - Describe: Parent material Glacial outwash General comments and recommendations: Site suitable for replacement conventional POWTS @( 0.7 90.5', 89.5', & 88.5' using 15 "Quick 4" chambers per Boring # I Boring 0 Pit Flood plain elevation, if applicable Na >dlsq.f:,ecommend Installing three trenches, S.g� bd." r. LQ 44 0n ' Go d v Ground Surface elev. 95.03 ft. Deoth to iimitirm factor 121" in. Soil Applicalion Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ftz *Eff#1 - Eff#2 1 0 -28 10yr5/6 none mixed fill na na aw 1fm na na 2 28-48 10yr2/1 none I 2fsbk mvfr cvi/ 2fmc 0.6 0.8 3 48-68 10yr3/4 none Is 2fsbk mvfr gw 2fm,1c 0.7 1.6 4 68-75 7.5yr4to none Is 0 sg ml cw 1fm 0.7 1.6 5 75 -91 10yr5/6 none s 0 sg ml aw 1fm 0.7 1.6 6 91 -121 10yr5/4 none sicl 1fsbk mfr gw 1fm 0.4 .06 7 121 -130 10yr5/4 m2d 7.5yr5/8 sicl 1fsbk mfr aw 1fm 0.4 0.6 1 a Boring # Boring Pit Ground Surface elev. ft. Deoth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ftz *Eff#1 *Eff#2 8 130 -138 10yr5/6 none s 0 sg dl - - 0.7 1.6 Effluent #1 = BOD ? 30 < 220 mg/L a TSS >30 < 150 mil- * EM6ent #2 = BOD <30 mg/L and TSS <-30 mg/L ,ST Name (Please Print) Signature: CST Number James K. Thompson 3602 kddress A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 4/1842006 715 - 248 -7767 Code derived design flow rate 600 GPD Property Owner Daniel D. & Kristine A. Coyer Parcel ID # 020 - 1167 -20 -000 Page 2 of 3 2 ,� Boring # Boring Pit Ground Surface elev. 92.39 ft. Depth to limiting factor > 118" in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots P *Eff#1 *Eff#2 1 0 -28 10yr2/1 none I 2fsbk mvfr as 2fmc 0.6 0.8 2 28 -50 10yr4/4 none sl 2msbk mvfr cw 2fm,1c 0.6 1.0 3 50 -58 10yr5 /4 f1d 7.5yr5/8 sil 1fsbk mfr ai 1f 0.4 0.6 4 58 -118 10yr5/4 none s 0 sg ml - - 0.7 1.6 H#3 is an irregular, discontinuous band of sift loam - not continuous throughout pit. Redox features due to greater metric potential of sift as compared to underlying sands. 24" rule applied to discount redox as limiting factor. 31 Boring # Boring 01 Pit Ground Surface elev. 96.33 ft. Depth to limiting factor > 128" in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots *Eff#1 *Eff#2 1 0 -15 10yr2/1 none I 2fsbk mvfr as 2fmc 0.6 0.8 2 15 -32 10yr3/3 none sl 2msbk mvfr cw 2fmc 0.6 1.0 3 32-46 10yr4 14 none sicl 2msbk mfr cw 2fm,1 c 0.4 0.6 4 46 -128 10yr5/4 none s 0 sg dl - - 0.7 1.6 F—I Boring # I Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDM *Eff#1 *Eff#2 Effluent #1 = BOD ? 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD <30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777. E,N'S r<7�q o r&de a /e ✓. 4 G4 �tAe h'o e N ,Dan e xr, s C'oyar�orep /ot: ofcoc44 V ;eso, , Se c. � s/is Q4' �� E,Yi:sfin Cc Zo 6& sa`r *ne,,d a' �a �a.aye EXiS�Jn �QtSi dsnGG Poe/ Por }:s.l( r.�aeded Yard op ort Co�cre ,Ec S /a 6 a t 6, &J, =/el.4r 7epo?C''�nee /boetvo 01- - CA`. E/ev s /03. 7 /f E.54(,naie d e leo n P.3o{3 of ' r r ' 61 f r w�odel r ' r ' r r i ' ► i r r , r r � r �c' r � r i��� S✓o�e I ' r r y' b i S S�flir+ urea Y � r �a.aye EXiS�Jn �QtSi dsnGG Poe/ Por }:s.l( r.�aeded Yard op ort Co�cre ,Ec S /a 6 a t 6, &J, =/el.4r 7epo?C''�nee /boetvo 01- - CA`. E/ev s /03. 7 /f E.54(,naie d e leo n P.3o{3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Mailing Address Property Address (Verification required from Planning Department for new construction) City/State �A ���v ��y Parcel Identification Number LEGAL DESCRIPTION Property Location ��h ,7k, %4, Sec. .9A T _RN -R \qW, Town of Subdivision Lot # D Certified Survey Map # , Volume , Page # Warranty Deed # 733 9, rA' , Volume Aj ` , Page # _�2 Spec house ❑ yes 9 no Lot lines identifiable 0 yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. C � qSG OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. �(,� C� /�� SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pw. of FILE INFORMATION Permit F DE9,IM PARAUFn= Number of Badroome 4 O NA Number of Public Facility Units Wieser f3cNA Estimated flow (average) 400 Effluent Rtw Modal A -1800 Design flow (POW, (Estimated x 1.51 600 gal/d Soil Application Rate .7 d /W Standard MHuMmt/Effluent Quality Monthly swap Fats, ON A Crease IFOG) S30 m9& Pump Model Biochemical Oxygen Demand IBOD 5220 moll O NA Total Suspended Solids ITSSI :9 moll Disperse! Call(s) O In- Ground Igravityl O At -Grade O Drip -Line Pretreated Effluent Quality Monday average Biochemical Oxygen Demand IBOD S30 mg/L Total Suspended Solids (TSS) S30 mg& O NA Fecal Cowarm (geometric mud 510 chu/100ml Maximum Effluent Particle Sire K in din. O NA Other: 33MA • VakMS typieel for dmM ft wastewater and septic tank *f&W t. 'Septic Tank Capacity 1250 g d O NA Septic Tank Manufacturer Wieser O NA Effluent Filter Manufacturer Zable O NA Effluent Rtw Modal A -1800 O NA Pump Tank Capacity m NA Pump Tank Manufacturer m NA Pump Manufacturer M NA Pump Model m NA Pretrestrrhsnt Unit O Sa nd/Gravel Fiber O Mechanical Aeration O Disinfection O Peet Filter O Wetland O Other. 10 NA Disperse! Call(s) O In- Ground Igravityl O At -Grade O Drip -Line O NA O in-Ground 1pressurkod) O Mound O Other: Other: M NA Other. 8 NA Other. ® NA MAINTENANCE MISTRtICTIONS inspections of tanks and dispentel cob shah be made by an individual ewrying one of dw %kwin0 licenses or certifications. Master Plumber: Master N mtber Restricted Sews.. POWTS inspector; POWTS Maintainer: Sstappe Servicing Opsats• Tank inspections must include a visual inwection of the tanklsl to identify any massing or broken hardware, identify any tracks or leaks. measure the volume of combined sledge and scum and to check fog any back up or pandirp of affkunt on the ground surface• The dispersal collie) shall be VWUW inspected to check the effluent levels in the observation pipes and to check for any pondit of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals wwthird (V or more of the tank vcume, the entire contents of the tank shall be removed by a SePtage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. AN other services. including but not united to the servicing of effluent filters, mechanical or pressurized COMPonents, Pretreatment units, and any servicing at intervals of 512 months. shall be performed'by a certified POWTS Maintains. A service report shad be provided to the local regulatory authority within 10 days of completion of any aerviee event. OilAYll µ/0t1 Page of • START UP AND OPERATION ucts a other chemicals For new construction. Prior to use of the pOWTS check treatment tankls) for the WOW" Of Painting prod that may impede the treatment process and /or damage the dispersal Cdls). If high Concentrations are detected have the contents of the tankls) removed by a $Wags servicing operator Prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. power pump tanks may fill above normal highwater levels. When power is reMtored.ths excess wastewater will During pow outages be discharged er the dispersal cei ls) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of void this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring effluent. To a power to the void hi pump or contact a Plumber or POWYS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 16 feet down slope of any mound or at-grade soil absorption arse. proton the Pfa of the Reduction or elimination of the following from the wastewater stream may improve the performance g POWYS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss, diapers; disinfectants; fat; foundation drain (sump pump) water fruit and vegetable peelings; gasoline; grease; herbicides; most screps; medications; oil; painting Produce; pesticides; sanhVY napkins; tampons; and water softener brine. ABANDONMENT wing steps shall When the POWYS fails and /or is permanently taken out of service the follo be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings seated. • The contents of all tanks and pits shalt be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the yokl space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWYS fails and cannot be repaired the following measures have been, or must be taken, to provide a code comp liant replacement system: � A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by lot lines and wells. Failure to protect the area will required setbacks from exist and moos oration to establish a suitable replacement area. eplacem systems must result in the need for a new comply with the rules In affect at that time. E3 A suitable replacement area is I not avai nstalled ! as l a last resort to technology the failed POWYS limitation Barring advances in POWYS technology a holding tank may E3 The site has not been evaluated to identify a suitable replacement area. Upon failure df the POWYS a soil and site evaluation must be performed to locate a sukable,roplacement area. If no replacement was is available a holding tank may be installed as a last resort to replace the failed POWTS. [3 Mound and at -grade soil absorption systems may be reconstruc es in effect attha�t tune. the blomat at the infiltrative surface. Reconstructions of such systems must compel with the < <WARNING> > NOT SEPTIC, PUMP AND OTHER TREA'i'M TREA TMENT TANK UNDER AL�RCNSTAN ES DEATH MAY RESULT' RESCUE OF A ENTER A SEPTIC, PUMP OR OTHER PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POW" MAINTAINER POWYS INSTALLER Name Name B oth ) Tr ' Count Ben Mor an Phone 715 -386 -2 Phone 715- 386 -2 SEPTAGE SERVICWG OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Tri County (Ben Morgan) Name St. Croix County Zoning OffQ e Phone 715- 386 - 4680 Phone 715- 386 -2130. This document was drafted in compliance with chapter Comm 83.2212)(b)(11NI &M and 83.5411 (2) & (3). Wisconsin Administrative Code' m Page of START UP AND OPERATION Series process th at new construction. prior t may impede the treatm a use of and /or damage the dispersal cell(s).1 high a concentrations • are detected have the contents thaent . of the tanks) removed by a $Wage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored .the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator p pr u 'ior t� power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the Performance and prolong the life of the pOWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline: grease; herbicides; most scraps; medications; oil; painting products; pesticides; sanitary napkins: tampons; and water softener brine. ABANDONMENT n out o f serv When the�pO � S f and or in permanently take with chapter Comm 83.33. following sops shall tie taken to Wisconsin Administrathve Code: insure that the system is properly N • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of 811 tanks and pits shall be removed and properly disposed of by a Septoge Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN a code compliant If the POWTS fails and cannot be repaired the following measures have been, must be taken, to provide replacement system: )a A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and Proposed structure. lot fines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. soil d an site E3 The site has not been evaluated to identify a suitable replacement ff . Upon smart area is POW a holding tank evaluation must be performed to locate a suitable �eplacemen may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules In effect at that time. < <WARNING> > NOT SEPTIC. PUMP AND OTHER TREATM TREATMENT TANK UNDER ANY CIRCUMSTANCESDroDEATH MAY RESULT. RESCUE OF A ENTER A SEPTIC. PUMP OR OTHER PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS pOWTS INSTALLER POWT'S MAINTAINER Name Tr ' Count Ben Mor an Name B ^the nc . Phone 715- 386 -21 Phone 715- 386 -2 LOCAL REGULATORY AUTHORITY SEPTAGE SERVICING OPERATOR (PUMPER) Name St. Croix County Zoning Of f & e Name E715-386-2130. ri County (Ben Morgan 715- 386 -46$0 ) Phone Phone Thi docuxnemt was drafted in compliance with chapter Comm 83.22(2)(bill)(A Ifs and 83.54011 (2) 8 (3). Wisconsin Administrative Code• 2344 P 4 93 STATE BAR OF WISCONSIN FORM 2- 2000 WARRANTY DEED THIS DEED, made between James R. Van Dyke and Christine L. Van Dyke, husband and wife Grantor, and Daniel D. Coyer and Kristine A. Coyer, husband and wife�Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: Lot 2, Country View in the Town of Hudson, St. Croix County, Wisconsin. *Bls ,Marc+' .Slu'viVo,-fA�p flrotsiar 4, Metro Legal Services EDIRET 396893 A 28660 WD 209317 Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Name and Retu ddress: �p Edina Realty le, Inc. pt aoo S . 2 . — Suite 115 3 3 2- ' ^ D ✓� nArro� �t �� 396893 54016 57 , P�� mru � l 020 - 1167 - 20 - 000 Parcel Identification Number (PIN) This is homestead property. Dated this 30th day of June, 2003. 19 James R. Van Dyke AUTHENTICATION Signature(s) authenticated this 30th DIANE NA. BA * f Wisconsin TITLE: MEMBER ST SIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Edina Realty Title — Doug Berg 400 South Second Street 4115, Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature Recording Area 733-Z+55 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., W1 RECEIVED FOR RECORD 08/04/2003 08:00AK WARRANTY DEED EXEMPT I REC FEE: 11.00 TRANS FEE: 720.00 COPY FEE: CC FEE: PAGES: 1 U.,, - 4. IVOL Ql * Christine L. Van Dyke ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. Personally came before me this 36 44— day of M-#— A003 the above named James R. Van Dyke and Christine L. Van Dyke, husband and wife to me known to be the person(s) who executed the foregoing ins entt and acknowledged the same. G u / 7 1. vl. *Diane M. Barron Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: 11/19/2006 ) WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2 -2000 Parcel #: 020 - 1167 -20 -000 07/10/2006 10:34 AM PAGE 1 OF 1 Alt. Parcel #: 29.29.19.1033 020 - TOWN OF HUDSON Current *1 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: 3.000 Owner(s): O = Current Owner, C = Current Co -Owner 196,800 275,800 Woodland O - COYER, DANIEL D & KRISTINE A 0 DANIEL D & KRISTINE A COYER Totals for 2005: 465 COUNTRY VIEW RD General Property 3.000 79,000 HUDSON WI 54016 Woodland 0.000 0 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 465 COUNTRY VIEW RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.260 Plat: 0211- COUNTRY VIEW SEC 29 T29N R19W W1/2 -SE1 /4 LOT 2 - PLAT Block/Condo Bldg: LOT 2 OF COUNTRY VIEW EXC PT TO HWY AS DESC 879/273 Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 29- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 08/04/2003 733455 2344/493 WD 08/17/1998 585082 1348/449 WD 07/23/1997 879/273 07/23/1997 759/85 more 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 79,000 196,800 275,800 NO OTHER X4 0.320 0 0 0 NO Totals for 2006: General Property 3.000 79,000 196,800 275,800 Woodland 0.000 0 0 Totals for 2005: General Property 3.000 79,000 196,800 275,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 152 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 F4 o o a n; a e ° o N O ti 0 N V � 1 r O V O W r � � v Z r rn N u Q5 (D z v U) H r N 5 c 7 U N m EL N J U C O C� FH CC C 0 0 O c c l V � C y 7 O N 2 Z a a m :0 C 7 c0 a � 0 0 ° � O ° « ° y y I � I � I I •� CL I I CD C N N m 3 I � 3 o > t c (D .. 0 4) U 'm I I '0 1y I I G N O Z O a N C 3 y W, a °, z z° c z 6 0 C C C C T LL _ :r3 LL _ 'S C LL +- @ O co c 3 0 E ¢ Q ca ¢ H 3 0 M cd M N x N Z N E E E ° o ° o I }' V }' O € 0 IL m a m a m 0 C U 7 0 0 o o w o Y) 0 c c P E E E v Y 0 m co y '7 O N 7 j j a a y p N D N N U) N U °' `1 O U) N C O d io L d L a L O O z O z c z z m z z m 0 U) z y y rn y c I E E O is E N R Q .. Q .. R C. « .. N C. C m 0 (� 0 + ° 'oca 0 `m C gNNI oea Dam . o N rr rr j a a N co U) H o a U) ` co to U) E `oo a 2 o 0 N N 0 0 0 O o O 0 o o l �aac. _aaa 0 c U) co ° o c co co m m w 3 S rn rn 3 rn rn z I N ° z m - O — — n } _N r > in iri O) I .LD O 2 ° tC 0 l G O m E > O .j N O .� - O C 70 t d Q Z U) N cc -6 U Q Z co C o Q .� U) t m - i° H C co U C � y C O p N _V c0 0 N y E y N N c O E N a f a� • � C;) c c v y c y c u o m 0 0 'E € 0€ m (D m E m Q C m d N C m d '00 O Y CN N d w d !U C N N 0 0° d C o i o W = 0 of o ro 7 = N t U v o v z � z rn n o c`a z '� Z S > M LO o Z `!' z z cn I = € I = E I a m a € a m ::ate �ay� I �a� C a C C a C C r C omc� � ter• d O O H M i' � I I i r� � N l V r V r `IV v � W Z rn N 1- C/) O z d Fy r 4) z`v N F- 'O c LL c � m E U 0. 0 � N E O O a m 6 N c ai 0 0� B c � "O Y Q) U N '5 7 d N � N Q) O O w d Z Z '01 w y o of C O I � 0 z c m C O p `1 d N t� 0 CU 1 0 el 0 Z @ CD �i 0) on a S �) CL C 1° m c a-. , o D D d U N Q ,. F' F- F- O O C4 o Z E! �! a O Z i - O O O " o o 1" E 0 a a a a r CL 4 n 7 O C UI ° cD <D C] `o o 0 0 rn = N N 3 o co T > 0 0 C i N iz: m > a') C Y .O U o o p ` a c O M c V i 0 Mo 0 H @ N O O Lo N C,j O O0 CO O N T U O •m a CL a. E 3 m c 0 i n om . 2 O N U '01 w y o of C O I � 0 z c m C O p `1 d N t� 0 CU 1 0 'O c LL a� Z yj E O O N d a m C 7 o m c a m o N O 7 @ N °- N @ N @ CL � Z m Z C a) N E L .. R I m r m a w 0 o a` O O O _ a a a N W CC) co o 'O r _ - O Z. - c a m 0 U H c CD a o rn � � O . E a m a T c d :°. O N v O at o O ° � 0 C O 2 rn 0 a) L L 3 a) CL m a o as Z C m c .m a0ci .n o _0 •, w c 0 E a) 0 N 01 0 O Q c a) E 0 o 0 S m N ¢ >' 'Z) `o U 0 cc m c m m O O 0 Z c LL c 0 > M E O O CD m C 0 m I c N N O n a N � N Z H Z c a) <6 E � _ d O G .@ w Lo _ o o a N O O O m m a 3 rn rn D7 � � r (D c E @ CA a) O co c m > co o w .E a d a m y c c S . O to L) � O O v c O 3 0 0 N w c O @ O N C C N _ N L 0 c � 3 2 0 V N E Cl a J �w m a �3m O U O O Z O N N m acw °- L)) .3 0 t N a a) @c ¢ F- 3 @ c 0 E Q) 7 0 � o 0 L U� O w O O Z; O C m . c m 0 0 d � el 0 Z @ CD �i 0) on a �) CL m @ N a-. , 0 d Q ,. m O O C4 o Z E! �! a O Z i - a` C " o o ; E 0 _ N CO 7 r CL 4 n s» Q) a) is C UI T CC Z C] `o o E rn O 0 'p N !ll C C i N iz: m > a') Y %n 'O c LL a� Z yj E O O N d a m C 7 o m c a m o N O 7 @ N °- N @ N @ CL � Z m Z C a) N E L .. R I m r m a w 0 o a` O O O _ a a a N W CC) co o 'O r _ - O Z. - c a m 0 U H c CD a o rn � � O . E a m a T c d :°. O N v O at o O ° � 0 C O 2 rn 0 a) L L 3 a) CL m a o as Z C m c .m a0ci .n o _0 •, w c 0 E a) 0 N 01 0 O Q c a) E 0 o 0 S m N ¢ >' 'Z) `o U 0 cc m c m m O O 0 Z c LL c 0 > M E O O CD m C 0 m I c N N O n a N � N Z H Z c a) <6 E � _ d O G .@ w Lo _ o o a N O O O m m a 3 rn rn D7 � � r (D c E @ CA a) O co c m > co o w .E a d a m y c c S . O to L) � O O v c O 3 0 0 N w c O @ O N C C N _ N L 0 c � 3 2 0 V N E Cl a J �w m a �3m O U O O Z O N N m acw °- L)) .3 0 t N a a) @c ¢ F- 3 @ c 0 E Q) 7 0 � o 0 L U� O w O O Z; O C m . c m 0 0 d � 0 Z �i 0) m a-. , d d Z ,. m C4 o E! �! a y a` C C C N _ N 7 N O O C UI T CC Z tqi o M y N a M r,. C h O O N O w C •r N 0 �r 0 w by C� Gi c� r> zt �W z rn N F fA . � C LL G 3 " z 0 a m O Z +. ce .- C a o. � a Z m Z c ? {p ' O O U N S S IL a a C US c co co fA J V O a0 a0 y d) 0) 2 r o 0 0 m I � m i 7 � 7 av� O O j co 4 co O t N O ~ lfl fC W c fn r O p j N ` r N O 0 N � i 7 O N 2 a) I- o I Xk w w a d M d CL �'+ d a E ` c m c c 3 � a) 3 6 O wl� O c O R O. N O N w L • 3 � C m o . N O Z c C .. � O O Q as w d N L L a W O 0 c a� L L E FL a } O m c a � o m U 'O ate✓ O O Z c m I I I i I I I I -3 z CA I 'co I � If m I C c I Q 0) C N N a I � a Z m Z c d r a � d Cc c a` o m m a N I � 3 0 W d r r c r 0 U V Lo m II, to I y a c E m CN I m O N C Cl) � U') O I F � a d a N V 3 0 O 6 c C O d tC C 3 U � C f0 f0 3 Q) 6 '> a N 7 � O a a C � y •y L_ N C p 3 0 O ' Z O p C O � � Y O a U J C 16 .a w ._ Q H 3 O c N E N N a� L C m ca ) F � 0) 7 O C m c m Q Z U) C F C O N N O V d O N O Z Z C O 0 Z 'O M c 0 U w 0 z 'O C N c ,o U N N O) a Z f0 7 V d C C N d 7 C N •� L g cn I I I ( I i I I I I I I I I I I I I I I I I I I I I I I I I I I I 04 LO 00 C, N N LO LO 40isconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT %GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. Permit Holder's Name: Van Dyke, James ❑ City ❑ Village Town of: Town ofHudson CST BM Elev.: Insp. BM Elev.: 7 M Description: TANK INFORMATION P / L TYPE MANUFACTURER CAPACITY Septic Septic Inside Dia. Dosing DIMENSIONS Aeration Dosing Holding TANK SETBACK INFORMATION TANK TO P / L WELL BLDG. ir Air I ntake ROAD Septic Inside Dia. Liquid Depth DIMENSIONS NA Dosing DIMENSION NA Aeration SYSTEM TO P/ L BLDG WELL NA Holding Manufacturer: SETBACK INFORMATION i PUMP/ SIPHON INFORMATION Manufacturer Demand Model Number GPM TDH E ft Friction System TDH Ft oss Force main Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sani353232 it No.: State Plan ID No.: Parcel Tax No.: 020 - 1167 -20 -000 STATION BS HI FS ELEV. Benchmark Alt. B Bldg. Sewer St/ Ht Inlet St/ Ht Outlet Dt Inlet Dt Bottom Header / Man. Dist. Pipe Bot. System Final Grade St cover RED/TRENCH Width Length No. Of Trenches Vent To Air Intake PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION i CHAMBER Type Of Mod Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing Topsoil ❑ Yes ❑ No ❑ Yes ❑ No SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No cn� : 1InCl d de sC e d s S etc) ulJpcl:11U11 rrt: r r u1bYcUC1U rra: r r Lbc "ahon. 465 C oun - i o ew, u�s�n,� (9M, 9OXNction 29 T29N -R19W) - 29.29.19.1033 1.) Alt BM Description= 2.) Bldg sewer length= - amount of cover = Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. �.; SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code • Attach complete plans (to'the county copy only) for the system, on paper not less than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application The information you provide may be used by other government agency programs [Privacy Law, s. 15.040)(m)]. Safety and Buildings Division Bureau of Building Water Systerr 201 E. Washington Ave. P.O. Box 7969 Madison, WI 53707 -7969 State Sanitary Permit Number 353 2 311- ❑ Check if revision to previous application State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name 3i aWv_ \ la Property Location :S-%J1/4 Str /4, S 'Z T 'Z9 . N, R 1RA(or)W Property Owner's Mailing Address Lot Number Block Number Cl St to Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned 3 El it E] Village Nearest Road ❑Public E] 1 or 2 Famil Dwelling - No. of bedrooms Town OF s ��.t —i .dos, III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 2A. i{9 - L d 3 r2 �J 1 ❑ Apartment/ Condo CD Z v 1 , - 'LO ^ v C30 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 ❑ New 2_ ❑ Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5, epair of an System System Tank Only______________ Existing System ______ExistingSystem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 eepage Bed 21 E] Mound 30 E] Specify Type 41 [] Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: .1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation I LA So (.4 . '_i Feet q L, 6 Feet VII. TANK INFORMATION Capacity in g allons g Total Gallons # Of Tanks Manufacturer's Name Prefab. Concrete Site con- steel Fiber- glass Plastic E App xper. New Existin strutted Tanks Tanks Septic Tank or Holding Tank 600 W L - (fir. ❑ ❑ 1 ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT the undersigned, assume responsi ' 'ty fo in Ilation of the onsite sewage system shown on the attached plans. r s e: (Print) s Ignature: (No Stamps) Business Phone Number: G,� .phmpWo is Address (Street, ity, State, Zip Code): !v z q Y -1 t. 0 ..i �J � a !G IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sat ytary Permit Fee (includes Groundwater ate Issue Issuing g ent Sig t e (No Stamps) Approved E) Owner Given Initial Surcharge f ee) a A j CJ�r JZ / �/ /� Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHO -6398 (R. OS/94) DISTRIBUTION: Original to County, One copy To: Sdfety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years_ 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V_ Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7_ VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, et(.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes, soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county, F) soil test data on a 115 form, and F) all sizing information. ----------------- --------------------------------------------------------------------------- -- - - - - -- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Wisconsin Department of Commeroe SOIL AND SITE EVALUATION Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Page 1 of 2 Environmental By Des*n Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County include, but not Imited to: vertical and horizontal reference poird (BM), direction and St. Croix percent slope, soale or dimemaions, north arrow, and location and distance to nearest road. _ Parcel I.D.# APPLICANT INFORMATION - Please print aff information. - 2c� r"o Reviewed By Date Personal irrrornutim you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Van ke James Govt. Lot SW 1/4 SE 1/4 S 29 T 29 N,R 19 W Property Ownee Wing Address Lot # j Bkxi # I Subd. Nano or CSW 465 Corm 'ew 2 Rossitt Co 'ew City State 2iip Code PhoneNumber u City ❑ Village "Town Nearest Roar! Hudson Wt 54016 381 -9653 Hudson Frontage Rd ❑, New Construction I❑ Residential / Number of bedrooms 3 ❑! Addition to existing building Use. Replacement ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpdff .$ trench, gpolfP Absorption area required 643 bed, fF 562 trench, t'F Maximum design loading rate .7 bed, gpolF .8 tr ench, gpdfff Recommended infiltration surface elevation(s) 94.3 ft (as referred to site plan benchmar Additional design / site consideration Bore hole for T erm l ift Parent material LOESS OVER OUTWASH SAND Flood plain elevation, if applicable na It for system Conventional Mound E In- Ground Pressure AT -Grade System in Fill Holding Tank Un teble suitable for system I MS ❑ U ®S ❑ U ® S❑ U 1 ® S❑ U ❑ S M U ❑ S® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles I Boring# Horizon I in. I Munseii I Qu. Sz. Cont Color Texture Structure GPDIIF G• Sz. Sh. ICotsistenco Boundary B Roots Bed ; Trench 1 1 I 0-26 10yt2_/1 I - I l I 2msbk I mfr I c5 2f ► ,5 i .6 2 76.17 7 _ a flag m I �e - 7 l Ground 3 37-44 10yr4 /4 i - Is 2msbk mvfr I cs - .7 ? .8 elev I l I I I 96.W It 4 44-90 I 7.5yr5/6 - s Osg ml - - 7 .8 Depth to I I I ! I I I limiting 2/ L factor 13f. �' >90" CST Name (Please Print) Sgnature: TP Thomas C. Nelson �� 715- 246 -2454 Address Enviroamerttal By Desip Date CST Number Ref # 1432 120th Stream New Richmond Wf 54017 1 �/ c 1227387 274 Remarks: 2 FTT Ground elev Depth to limiting factor Remarks: CST Name (Please Print) Sgnature: TP Thomas C. Nelson �� 715- 246 -2454 Address Enviroamerttal By Desip Date CST Number Ref # 1432 120th Stream New Richmond Wf 54017 1 �/ c 1227387 274 COL 114 vl -19 State Bar of Wisconsin Form t - 'S62 5850 S2 I WARRANTY DEED DOCUMENT NO. - - - -� - - - -- --------- - - - - -- - TIIISDFED, madebetween Dale C. Einhardt nd Edna M. Einhardt, husband and wife Grantor, and JamesR - Van Dyke and Christine ' Van Dyke, husband and wife, as survivorship marital property Grantee, NVITNESSETII, That th_ said Grantor, for a valuable consnlerarw.n conveys to Grantee the following described real estate in St • ' 7roix County, State of Wisconsin: Lut 2, Country View in the Town of Hudson, St. Croix County, Wisconsin !o °°� -' Ff�Gl�l'��`5' 0�'FICE ST. CROIX CO., WI Recd tw Reaord AUG 17 1998 9:10 A. M -+k LJ.xj, Righter of Diode T1Q S t,ESERVE FQR R_E_ DATA NAME AND RETURN ADDRESS: 904 5, )•V4 tip � t4 34S 020- 1167 -20 -000 PARCEL iOENTIFICARON NrAJ BER TRA 4 s FE This is homestead property. (is) (i%nt)t Together with all and singular the hereditaments and appuitenences thereunto belonging: Grantor And warraflts that the title is good, indefeasible in fee simple : t free and clear of encumbrances except Easements, roadways and restrictions of record. and will warrant and `d1e{ffeend the same. Dated this «� 1 day of (SEAL) (SEAT AUTHENTICATION Signature(s) authenticated this a ly of 19 TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Section 706.06, Wisconsin Stand s) THIS INSTRUMENT WAS DRAFTED BY MICHAEL H. FORECKI EAU CLAIRE, WISCONSIN (Si anues may be authenticated or acknowledged. Both are not necessary) • NaNCS of persons itgninr ur any capacity ehould he typed or prinled t+cluw ntcir u August 19 98 1 (SEAL) Dale C. Einhardt 1 (SEAL) Edna M. Einhardt ACKNOWLEDGMENT STATE OF WISCONSIN sy� County. ))) 1 �,, 1 � Personally came before me this I day of August , 19 99 the above named Dale C. Einhardt and Edna M. Einhardt, husband and wife to me known Io he the person s whu executed the instrument and know ledge the same. z Tuf) � • \' I &a 6 Kathleen R. Videen Notary Public Polk County, Wis My commission is permanent. (1f not, state expiration date: 7yu, �q . .+.Z«'j APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) 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 sold and submitted to this office with the appropriate deed recording. Owner of Property '1d-- ��y` V� V-r Location of Property � 3 34, Section �� , T a Ci N -RLL W w Township ]ci Mailing Address Q Address of Site C-) V-, w c� Subdivision Name Co V ,l r `� U Q w Lot Number Previous Owner of Property fS 0. ✓tin. ��; �, c v Total Size of Parcel Z . [ c a v Date Parcel was Created Sf Z Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes x No Volume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING A Warranty Deed which includes a Document number volume and page number and the Seal of the Register of Deeds In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATIO 1 (we) ceAti.6y that att statements on this 6onm ace tAue to the best o6 my (our) hnowt.edge; that i (we) am ( ace) the owner (,$) o6 the pnopen ty dens ch i.bed in zh ie in6o4ma.tion 6onm, by vdhtue o6 a wavcanty deed %ecmded in the 066ice o6 the County Regia.teA off( Veeds as Vocument No. ' : and that i (W0 Mt OAO&Ithl • Form - S T C - 104 t AS BUILT SANITARY SYSTEM REPORT OP{NER ' All TOWNSHIP SEC. Q1 T ��� N -R ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISIONLo,;� LOT S LOT SIZE Z, -L' PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used i e Elevation of vertical reference point: Proposed slope at site: • PUMP CHAMBER Manufacturer: Pump Model: Elevation of inlet: i Liquid Capacity: Pump /Siphon Manufacturer: Pump Size Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, Q Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: `I 'r C; L Trench, ,r Width: Len$th: 6 Number of Lines: Area'rB f It : Fill depth to top of pipe: Z i Number of feet from nearest property line : Front, O Side , Ream,O Ft Number of feet from well: 7 t z } ., Number of feet from building (Include distances on plot plan). /67 ZO �0 SEEPAGE PIT Size: Liquid depth: Area Built: Has either a drop box O or distribution box O been used.- on'any of the.above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line:` Number of feet from well: Number of pits: Diameter: Bottom of seepage pit elevation: Number of feet from building: Number of feet from nearest road: Front, O Side, O Rear, O Ft. Alarm Manufacturer: DEPARTMENTQF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISIOr P.O. BOX 7969 BUREAU OF PLUMBIN( MADISOM, WI 53707 � EM ONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: + ED Holding Tank El In-Ground Pressure ❑ Mound (If assigned) NAME OF PERMIT HOLDER: RESS OF PERMIT HOLDER: INSPECTION DATE. Sam Miller Rt. i, Box 2821) Hudson, WI 54016 BENCH MARK (Permanent reference points DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV. SW SE, Section 29, T29 —R19W, Town of Hudson, Lot 2, Country View Name of Plumber: I MP/MPRSW No Emory. Sanitary Permit Number: Douglas Strohbeen 5432 St. Croix 79191 SEPTIC TANK /HOLDING TANK: MANUFACTURER: e LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET E LEV IWARNING LABEL LOCKING COVER BED/TRENCH �QO a7 PROVIDED // �p YES ❑NO IPROV DYES ❑NO BEDDING VENT DIA. SPITS HIGH WATER NUMBER OF ROAD. PROPERTY WELL BUILDING. G(,W VENT TO FRESF ❑NO I [( 7�MATL ALARM FEET FROM J LINE OF - PROPERTY 1 AIE YES VENT TO FRESF p/ • ❑YES ❑ NO iVEAREST PlPFS ELEV. LINE ?13 DOSING CHAMBER: MANUFACTURER - LIQUID CAPACITY PUMP MOD L E MANUI ACTOHEH WARNING LABEL LOCKING COVER a 70YE /� I PUMP,SIPHON PROV IDED. PROVIDED: ONO ❑YES FIND []YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF COVER MATERIAL WELL BUILDING (DIFFERENCE BETWEEN ❑YES ❑NO I PI1OP1HTY FEET FROM LINE COMMENTS: PERMANENT MARKERS: I VENTTOFRESf AIR INLET PUMP ON AND OFF) DYES ❑NO NEAREST 0 PROPERTY WELL BUILDING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE I I N(,TH TEH MATERIAL AND MARKING; or excavation. (If soil can be rolled into a wire, construction shall cease until J DIAMI ❑ YES ❑ NO the soil is dry enough to continue.) MAIN —�-- -fir CAN \ 1FNITInIUA1 CVSTFM- BED/TRENCH WIDTH �� LENGTH I NO OF T11 FNC S DISTH PIPE SPA(;IN(I COVER M E PIT J INSIDI DIA SPITS LIQUID DEPTH DIMENSIONS (p DIMENSIONS G(,W GRAVEL DEPTH - FILL DEPTH JOIS TH PIPE DISTH PIPE DISTR PIPE MATERIAL NO DISTH NUMBER OF - PROPERTY WELL. BUILDING. VENT TO FRESF BELOW PIPES ABOVE COVER EIEV. INLF! ELEV END J PlPFS ELEV. LINE ?13 DIA AIR INLET: �( � NEAR EST' - -i► a d /� 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- 1:1 YES E:1 NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE I II IIMA111 NT MAHKFHS J OBS111V AT ON WELLS EYES 1:1 NO ❑YES ❑NO EPTH OVER TRENCH BED DEPTH ENTER EDGES OF TOPSOIL ISDDDFD I I I ❑YES. [!]NO DYES ON DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: Sketch System on Reverse Side. DILHR SBD 6710 (R. 01182) WIDTH LENGTH LATEHAL SPACING GRAVEL DEPTH HE LOW PIP[ FILL DEPTH ABOVE COVER BE /TRENCH TRENCHES DIMENSIONS rl. MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL 8, MARKING ELEV.. ELEV. DIA. ELEV. PIPES DIA ELEVATION AND DISTRIBUTION INFOR ON HOLE SIZE HOLE SPACING DRILLED COHHECTLV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑Y ES 1:1 NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER DF PROPERTY WELL BUILDING: FEET FROM LINE: ❑ YES ❑ NO ❑ YES El NEARES —�-- -fir Sketch System on Reverse Side. DILHR SBD 6710 (R. 01182) I:: wlsconeln APPLICATION FOR SANITARY PERMIT �1 01LHR (PLB67) DEPRRTTEI"IT OF IrIOUSTR 0. LR801 6 MUTRrI RELRTIOnS C OUNTY UNIFORM SANITARY PERMIT # 0 ? Q/ 9/ — 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 xo Z-9' z PROPERTY LOCATION - &I+*.– Gt/1/456 1/4, S Z, , TZj, N, R/9 E (orb TO G,/50 LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED y 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: X 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. Signature of Issuing Agent: ABSORPTION AREA REQUIRED (Square Feet): (. /Y s I _ ABSORPTION AREA PROPOSED (Square Feet): (o �/Ssy ;1 T Seepage Bed ❑ Seepage Trench C] Seepage Pit El Disapproved El Owner Given Initial Adverse Determination ❑ Holdiny Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # Name of Plumber (Print): issued Signature: ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. MP /MPRSW No.: Phone Number: Total Gallons #of Tanks Prefab. Concrete Site Constructed Name of Designer: / &A. �- // Steel Fiberglass Plastic Septic Tank Capacity Do O I Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure N Total Gallons #of Tanks Prefab. Concrete Site Constructed Steel Fiberglass Plastic Septic Tank Capacity F t Pump /Siphon Chamber nufacturer: PERCOLATION RATE (Minutes per inch): Signature of Issuing Agent: ABSORPTION AREA REQUIRED (Square Feet): (. /Y s I _ ABSORPTION AREA PROPOSED (Square Feet): (o �/Ssy ;1 T WATER SUPPLY: ❑ Private ❑ Joint ❑ Public El Disapproved El Owner Given Initial Adverse Determination Reason for Di va . Alternate course(s) of Action Available: I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: 1 /1 7 MP /MPRSW No.: Phone Number: Plumb 's Address: R � N a , w f� kG� /710 v1 Name of Designer: / &A. �- // COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Q p Date: (p O ICJ Approved El Disapproved El Owner Given Initial Adverse Determination Reason for Di va . 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 r 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. Form - S T C 100 Owner of Property So—m a. Location of Property S W i4 _5F_ Section R� TownshlP�1�_ soil Mailing Address- Subdivisio n Name_ Lot Number Z Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners identifiable? _ Yes No Include with this application one of the following: .Certified Survey Map .Deed .Land Contract r .Other >~egal 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 &V'I- ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an casement, to run with the above described property, for the construction of said system, and the some has been duly recorded in the Office of the County Register of Deeds, as Document No. X7-3" ), c SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER Sa ,,,W � ROUTE/ BOX NUMBER &0� #V ' eon( 2 $� Z Fire Number CITY /STATE �Gc�✓<O�1 g2 ZIP �Va/4- PROPERTY LOCATION:. 1 4, S 14, Sectio T g�f N, R , Town of /7 Se 1 St. Croix County, Subdivis ion eaaH lyU ;z a/ Lot number Z 7 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 three years or sooner, if needed, by a licensed septic tank pumper 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 m be eligible 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 new 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 disposal 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 Zoning Office within 30 days of the three year expiration date. SIGNED DATE /.. / O V ,L St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715- 796 -2239 or 715 - 425 -8363 Sign, date and return to above address. v r x x N CD O :r 7 moo.. o =r CD o c CD c A 0 0 m A % - CD A 3 a .�. S 3 ° cc Z � ww O 1 CD w N < M Ch CD C C C � w m w M m w �w � N m C1 m A :a 0' NCD 0 a 3 m o CD C :r Cn CD a C 0 c w � Q. CL o w aim N O .., +n tp 7 O Cc a Ica a�3 9- " N m •► •-• m N w ? N C C 3 0 7C' CD o A m c C � :r7• C O w N N 7c ` •a am m ° o? m o co U) g w 0 m X CD Su � CD 61 _. O 0 0 0 M m W A w o o SU � C- C C U) 0 C a G c Q c 0 - �c CA o o a� Q P m C A c tc Q 0 A 0D� -m = w A 0 C7 o m M N 0 co M 0 =r i m 3mmm ?a M CD °w 'o = ? - A 5 7 CD (A a CD CS C A f m CA 0 a� C s CD N �. rn < n = .CC cc m "�°�N�' w_ ��cawo CD N 7 Cr7 !� d?N , < Cc . ? " 3 O A` A m O C m N 0 O o� 0'13 O• m = o S , a O m 0 -% O C N Z a v _ D "♦ . D M c m n 2 — a � G) m A e 7 n O DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS lNDUZRY • DIVISION ABOND PERCOLATION TESTS (115 MADISON w 7 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: ,5w 1 / 1 / SECTION: . /Ta9 N /R c T OWNSHIP/ /16calsak LOT NO.:BLK. NO.: SUBDIVISION NAME: COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: S A C P O IA $;;q M M -'//ems- T t 4� R' u w G✓�'s. s^Ycv 6 USE s�,�i MAC RATING: S= Site suitable for system U= Site unsuitable for system DATES OBSERVATIONS MADE (PROFILE SC IPTI NS: ER ATION TESTS: ' 8x C Z- Buf Aef -.l t — ri!'lfre ( 1, CONVENTIONAL: ZS oU NO.BEDRMS.: COMMERCIAL DESCRIPTION: IN- FILLHOLDING S EI S ®U Residence 3 1 10 A I XNew ❑Replace s�,�i MAC RATING: S= Site suitable for system U= Site unsuitable for system DATES OBSERVATIONS MADE (PROFILE SC IPTI NS: ER ATION TESTS: ' 8x C Z- Buf Aef -.l t — ri!'lfre ( 1, CONVENTIONAL: ZS oU MOUND: ®S �U IN- GROUND - PRESSUYSTEM- ]S QU RE: IN- FILLHOLDING S EI S ®U TANK: El ©U RECOMMEND SYSTEM: (optional) CU�'� riI/U/j/ PeJ If Percolatio If any portion of the tested area is in the n Tests are NOT re uired DESIGN RATE: Q A under s.H63.09(51(b), indicate: Al/,4 Floodplain, indicate Floodp elevation: xi PROFIL DESCRIPTIONS c.v i BORING NUMBER TOTAL( DEPTH ELEVATION DEPTH TO GRO UNDWATER DROP IN WATER LEVEL - INCHES S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) OBSERVED EST. IGHEST B- / o.9' �G`a �' ,0' A (o S/ 2.6 An 3,f Aft rS B- 2, 11.0' /10 . Y ' Voae P- 0 ' 0 9 I 2. s 3. 9 � S B-3 0' /0 ,,S' Ala, 7 , 0' . Y B IS 21 9 r / `. go, S B- `l Y, 0' 13 ,3' A&,ae_ 7 .0' . 3 8/s 4 S S' .0 S B -s ,o' //0- /l&ae- r /.-3 /S/ .2 A4.4 /3 /S '/./ BA /• S B- PERCOLATION TESTS TEST NUMBER DEPTHS ' "moo WATER IN HOLE AFTERSWELLING TEST TIME INTERVAL -MIN. DROP IN WATER LEVEL - INCHES RATE MINUTES PER INCH PERIOD 1 PERIOD 2 P -1.10D 3 P _ / o o S S' P_ Z ' Iua /O 5 P- 0 - f_t-46 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 �d 9 Le6eo*L �'N E - f_t-46 - r 4 � f t 6� 76 . _ -.. �'N To he a complete and accurate soil test, your report must include: 1. Complete legil description; 2. The use section must clearly indicate whether this is a residence or cornmercial project; 3, MAXIMUM number of bedrooms or comiliercial use, planned; p-. Is this a new or replacement system; 5. Complete the Suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately loe;ating your test locations. Drawing to scale is preferred. A ;,epar sheet may be used if desired; S. m""ik<e sure your benchmark and vertical elevation reference point: are clearly shown, and are permanent; 9, Complelp all apili boxes as to dates, names, addresses, flood plain data, percolation test exernp- 'ioii, if appropriate; 10. If #(ac; ;nformation kiich as flood plain, ele>.vaiion) does not apply, place N.A. in the appropriate box; 1 Sign the form and place your curient address and your certification number; '12. Pvlakc legible copies and distribute as recluired. ALL SOIL TESTS MUST BE FILED WITH THE OCAI- AUTHORITY WITHIN 30 DAYS OF CDMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil S,:parates and Textures Other Symbols s _- Sitinu jov(!r 10 ") BR -- Bedrock cou) - Cobble >, C;3 - 10 "1 SS -- Sandstone g i` - Gravel (r;F3d• °I 3`) LS - Limeswrle x s<aild HGW High tats ml(t i C's _.._ Goal..`; Sand PE:rc _.. Pe - o latilon Rate r k=slitlrtl ..«3r7L1 b�� - -. � " ' Bi d(] 1 Lo =i n y Sand j __ G €gate° Than r.1 Sandy Loa; ..-. LO,ir, Bli ... -. LBiuv, Loa-'m _..... ttli, Sil G s l riy Lo :a ?it Y _. Z / e li# scl ._ Sa!icly Clay Loan, R _ P, d sicl Silty Clay I_,>fam mot - IIvIi t1: s sc S rtcly Clay Af t-Ji11, sic lt;r Clay f 1 - t G (, €Fa, f ciao Pea[ trill) -- rv m difICFI p ,aromiri -)t HliNL - High cater 1evel, Six ci :-'wral soil texrures rlat :c: blr£ltE'i f(;; Iigit i (i v%'IfaSte. dISpo 5eal BM -- Berta Mark VRP tIc ti;c.<a1 Rrtietence Pint T O THE OVVNER G&fOI& 1 5 2qW aoxq f 94 0 Z .a NO �r dt o; � 00 >v re— a � � � r Q 5,+ fn M L LL E R �okN'''` Vit w L # Z O In *-b f o a. 2" L a" r i f Qi la A T,8. VO ,IN. 1 4.7' 13 8 o ra- S �B,r kD a., a rfeM 9 - lo a s /opa. :S.W. sA+., �� Gk� r1 / o u►1� �1 B l- 8 2 rO / a ; n Dce`rh . !?aQu; rd. mxn'tS M, �'I i �w h r Y Iz -.4 %A% c f ri E �► � ! t ! s y �t s / o L . 0 .,n. M 3 n " o' P r � .. F 9. _C ,8 I I � I I i • I r . 1 F P r> S' z f ► �' gip°' $ • Ns .!n` V Q ...•• tots .• CeX• •r- "•c •�.� � • �'t�'t ttM � Nwtf is dot 1% mes on, a of to * yje st•+ : ` a �: 40 of v s 08 P 2 9 *a s ce&* to *WOO the Z° t'°e Ste' otii4 ott�t of SA ae $ s� ,rev ,a of ew , is ° 29. Z ay es �" s8 t� ss tie , he ioO ct►e 4Q to tii G ' Z • Go 4 �' c t. °t Secc �pti t° 'S� Qt b9 a o tisY Lo cste� °f tide y�eo a ea$e.�.sS Vol. ace a s - t t Fi►v' ti bpn6e 19 c1 p� EA$ de aica� ea a OV A � ° 'A Ir.Y► 9, 4"( 0 6 area i t of tti oeoSo j o8ecbe4lst ae as saia he t�qb ro a Q cats °O ti oo di i y ail ovc� t1� $ S�bje ° a to , aaY y j�rb °ot de to aed as a • . ;• O iooS•i.� s c Y` .� ► ` ``SKfe be r exemp ' TJ ho�e�tet'd S O �tpri`en�y A ttee Yd • 1 f a0y Y H 'ap el n�l*t t i et� lee si00 �� O of tec° rthi* sad i11et. essibie 0 t� ;Ctio S x Stp• ' ia °'j - s.. i1 Oro v �� ecri CoVeOS p , t °ba AI 00 Qtot na the a¢cn �sY o� E � i y , Atd d ate Sata , his �' V tot 3 ,, �' (al • .may °�' ` he t�`g ��� � 6 : 'ONS � IP�� • • '0F w is � • � fo a '�� • � � 16 • ��.,� g'S ASS' •1 S`Q�) s .��.';�� �'�����'�, bll � g v g by IS sue° eNi � #s pa � 5tie�bJ " ta9 A __: & Gott+ cL0 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County w OWNER /BUYER ��� In r CI _ ROUTE /BOX NUMBER Fire Numbe CITY /STATE Ut, X001 ZIP �,la PROPERTY LOCATION: 5W , S 1 4, Section T 0 N, R 9 W Town of [-tttidScs,` St. Croix County, Subdivision pti ✓l ` I�hU Lot number 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 three years or sooner, if needed, by a licensed septic tank pumper What you put into the system can affect the function of tt►e septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents m a maximum of 60% of the cost of which was in operation prior to accepted this program in August owners of all new systems agree maintained. be eligible to replacement o July 1, 1978. of 1980, with to keep their receive a grant for f a failing system, St. Croix County the requirement that systems properly 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 disposal 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 Zoning Office within 30 days of the three year expiration date. SIGNED DATE :S St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715- 796 -2239 or 715- 425 -8363 z Ln H a r r a H H 0 z 0 a H Cif H 0 E z x H b Sign, date and return to above address.