HomeMy WebLinkAbout030-1097-30-100
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Plb. #67 10/69 Wisconsin Department of Health and Social Services
Division of Health
t PERMIT APPLICATION
for '
PRIVATE DOMESTIC SEWAGE SYSTEMS
A.' OWNER OF PROPERTY TYPE OR USE BLACK INK
Name E Address (Street, City, Zip Code)
gel 1 2 7f'f. ✓r I,t.'~~ 1 cI c Y_ , i
ounty
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED
Check One: Li I
CITY VILLAGE LEGAL DESCRIPTION: f' ~"L' ~X
_ TOWNSHIP '
C. IS LOCAL PERMIT REQUIRED FOR THIS FORK? _ YES NO , PERMIT NLT',BER
D. SEPTIC TANK CAPACITY -Ito()- Gallons NEW INSTALLATION -)L REPLACEMENT ADDITION
MATERIALS: Prefab Concrete 'il( Poured in Place Steel other
NUME3ER OF TANKS TO BE INSTALLED:
E• TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commercial Industrial Other
Specify
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC& Food Waste Grinder YES )e NO Automatic Clothes Washer )e-_ YES NO
Dishwasher YES 'NO Automatic Potato Peeler YES _-%t NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW ~ EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet : r Trench Widths Depth' '°Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pits Inside diameter _;2..~_ Liquid Depth
P E R C O L A T I O N T E S T
Test Depth I Character of Soil Hours Water Test Time Drop in Water Level Inches ';inutes
Number Inches Thickness -.n Inches Since Hole in Hole Interval Second to j Next to Last ;o Fall
1st Wetted Overnizht ( in Minutes Last Period! Last Perio Period )ne Inch
Example .
P- 0 36" To Soil 0" Clay 2611 I 25 es or no 30 1/2 I 1/2 1/2 60
~f
_LAI
SA, e N a a fi fi
3c'. c~7 ,SAN 5 v I io ~ f, ~
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
I
empute size of absorption area in acoord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G'S - Minimum 36" Below Pro osad Absorption System
_
oring Total Depth Depth to-Ground Water Depth to Bedrock
umber Inches Cbserved Estimated Obsarved Estimated Character of Soil with Thickness in Inches
xample
- 0 72" 72" Black To Soil 12"• C12 18"• Sand 12"• Gravel 2411
>r/1 .3 w
1 .30
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDE
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Parcel 030-1097-30-100 03/23/2005 04:36 PM
PAGE 1 OF 1
Alt. Parcel 32.30.19.354C-10 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
BLAISER, JOSEPH L & SANDRA
JOSEPH L & SANDRA BLAISER
1220 ROLLING HILLS TR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1220 ROLLING HILLS TRL
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 10.460 Plat: 1830-CSM 18-4651 030/03
SEC 32 T30N R19W PT SW SE BEING CSM Block/Condo Bldg: LOT 01
18-4651 LOT 1 (10.460AC)
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
32-30N-19W SW SE
Notes: Parcel History:
Date Doc # Vol/Page Type
12/05/2003 748446 2469/474 EZ-U
11/14/2003 746671 18/4651 CSM
07/23/1997 477/443
2004 SUMMARY Bill Fair Market Value: Assessed with:
5630 338,700
Valuations: Last Changed: 07/08/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 10.460 165,100 168,100 333,200 NO
Totals for 2004:
General Property 10.460 165,100 168,100 333,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
• AS BUILT SANITARY SYSTEM REPORT
"TNER. c~.!e ,5eg~~ L. ~ Ietl Z:c... , TOWNSHIP ~y -SEC. T-3 ' N R W
.0. ADDRESS 0 5c=.: ~
ST. CROIX COUNTY WISCONSIN.
,UBDIVISION LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
v:
h
i
a
°TIC TANK(S)MFGR. CONCRETE 'C STEEL
NO. of rings on cover Depth DRY WELL
'ENCHES NO. of width length area
:D no. of lines j width length area :'.f .
depth to top of pipe
GREGATE j ;T<t
;z:K RATE r'f;t AREA REQUIRED. AREA AS BUILT>
sciaimer: The inspection of this system by St. Croix County does not imply complete
aipliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
stem operation. However, if failure is noted the County will make every effort to
:-ermine cause of failure.
,ZASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
"INSPECTOR
DATED - yJ r PLUMBER ON JOB
LICENSE NUMBER'
i
{
/'t
i
_ ST. CROIX COUNTY
Oj ~3
WISCONSIN
Y
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
❑ Water (VOC's) $185.00 ,)Septic $25.00
XWater (Nitrate & Bacteria) $35.00 (Visual inspection)
Owner:3pQ d-~x ►~~l ~~GiSk Requested by: iv~~ C ~lC_
Address :1aao Rb\\; roc 1~i -T~~~ ; I Address
~~~Dh City & St.
City & State:
Zip Code: SCI C 1 Zip Code: cj{o I lTelephone N°: ( l5) SZIq -~"1C~5 Telephone N°:
Property address (tire N4 & Street) : a2>U o 1', S TrC~i
~c
Location:;, Sec. 3,) , T ON, R~~ , Town of St. Croix Co., WI. Tax ID N%d D-1011-49 Parcel ID N4
--3u
House color:- Realty firm: Lock Box Combo:
Water sample tap location: Lu eJ 5 zee 1 ,y TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC` SYSTEM'ON REVERSE OF IS FORM*j
~/J1
Is the dwelling currently occupied? Yes ❑ No jC1'7y If vacant, date last occupied: Septic system installed by: i~ Ye : / a
Septic tank last serviced by: t;P,Gcu st~- Date. I
Previous Owner's Name(s):
Have any of the following been observed?
❑Y ON Slow drainage from house.' ~i.`.
❑Y CAN Sewage Back-up into dwelling.y
❑Y [3N Sewage discharge to ground surface, ,
road ditch or body of water.'
❑Y FN Slow drainage from the dwelling.
❑Y Foul odors. ;
other com ents relative to system operation: tJ J
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:
iJ
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
100o
40
i It 1 F1TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? []Yes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: []Below grd []At-Grd []Mound
Approx. size 'X []Gravity []Dose OPressurized
Ft.2 []Bed []Trench ODry Well
[]Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES []Other []Unknown
Septic tank
Setbacks: []House OWell []Prop. line 00ther
Dose tank
Setbacks: []House []Well []Prop. line []Other
[]Locking cover OWarning label []Pump/Floats
[]Alarm []Elec. wiring
Soil Absorption System
Setbacks: []House OWell []Prop. line 00ther
❑Ponding: []Discharge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
N
Inspector
Title
ST. CROIX COUNTY
WISCONSIN
PLANNING & DEVELOPMENT
PLANNING SOLID WASTE REAL PROPERTY ZONING
715-386-4674 715-386-4623 715-386-4677 715-386-4680
August 31, 1993
MidAmerica Bank
600 2nd Street
Hudson, WI 54016
An inspection of the septic system on the property of Joe and
Sandra Blaiser, located at 1220 Rolling Hills Trail, Hudson, was
conducted on August 30, 1993. At the same time a water sample was
obtained for testing. The results of that testing will be sent to
you as soon as we receive them back from the laboratory.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and did
not involve any excavating or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
Should you have any questions, E)lease contact:: this office.
Sincerely,
James Thompson
Assistant Zoning Administrator
mij
ST. CROIX COUNTY GOVERNMENT CENTER * 1 101 CARMICHAEL ROAD • HUDSON, WI 54016
COMMERCIAL TESTING LABORATORY, INC.
,514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730 CFjl:Aw
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030 L
# t;C Rcr'Ukf jATI 9/0
11 CARMICHAEL ROAD i-
,'GON, WI
Ro4ti
°h o
E i,i LEL i cii. 8-30
1E COLLECTED: 2:45
JRCE OF SAWLEf Basement Kitchen faucet
Bacterir;
i pp
P. LL
td:idae ii.
OF."DEGENpf1,`
o` 9p wl APPI-OWd 1.3h NO
Z / \ D
d •~Y a
a,, 5
N-cans "LESS THW
PROFESSIONAL LABORATORY SERVICES SINCE 1952
t
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
SanitaTy Petcmit 00
State Septic
NAME Towns hips
St. Ctoix County
4,.v oi`
L a c a c o a56c/ % a Section
32-- T..~l , R49-GI
SEPTIC TANK
Size gattonls. Numbe/t of Compartments ~
Distance Ft om: Wett it. 12% on gtc.eaten stope
Building it. W ettand.6 ~ .
Highwaten b .
DISPOSAL SYSTEM
Distance Fnom: Wett ~C C' it. 12% oA gteaten stope ~G it.
Building - Wetlands Ft.
Highwaten it.
FIELD DIMENSIONS:
Width o4 ttc-enchit. Depth ob Aock below tite -'in.
Length ob each fine it. Depth o6 tcock oven tite2, in.
Numb en a6 tine,s Depth o4 tite below gtcadez~Llin.
Totat tength o6 Zine~s merit. Stope o6 trench kn pen 100 it.
Distance between Une~s w- b Depth to bedt<oefz
/q Tatar absanbt%on atcea 4rf~ it2 Depth to gnaundwaen^/r it.
Requited atcea a 6t2
PIT DIMENSIONS:
Numb en o4 pits G)cavet around pit,s yea no
Outside diametetc it. Depth below inlet it.
Totat ab,sotebtion area it2. z
A
Area Aequitced it2 rn
INSPECTED BV ~_a1~ TITLE
J
APPROVED DATE 19 72:
REJECTED , DATE 197.
i
t
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N d
pppp-
I
PLB67 State and County State Permit #
Permit Application County Per # _ C
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY [ Mailing Address:
-J C;
B. LOCATION: '/4 S Section iL T N, Rj!T dD (or)V/aLot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township ;'cs
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family -K Duplex No. of Bedrooms -3 No. of Persons
D. TYPE OF APPLIANCES: Dishwasher _K_ YES NO Food Waste Grinder YES X NO # of Bathrooms
Automatic Washer RYES NO Other (specify)
E. SEPTIC TANK CAPACITY 160<-' Total gallons No. of tanks /
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement_ Prefab Concrete
*Poured in Place Steel Other (specify) _
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) , 5--2) 3) Total Absorb Area sq. ft. /
New Addition Replacement .~C *Fill System e4)• -Ireal
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length Width f Depth~Yf' Tile Depth No. of Lines _3
Seepage Pit: Inside diameter Liq/uid Depth Tile Size / ell
Percent slope of land C ` t, c-iDistance from critical slope 3ito'+
I'Al
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 C ified Soil,<Teste ,
NAME C.S.T. #.3 and other information
obtained from 1 owner/ .
Plumber's Signature MP/MPRSW# ~ Phone #7/S -38,6 7--T
Plumber's Address ✓O.v
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
'c + l~r r U.f C G ~
C2 14 r-4 6- C-
40
Fk =/dU~
f"~o J 4 ,
E
Do Not Write in Spac Below FOR DEPARTMENT USE ONLY
Date of Application - r7 - r~ Fees Paid: State X" , County's / Date
Permit Issued4R (date)(---)-
Inspection Yes No Valid# Date Recd
.ounty (vv; a copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
1•
1 2 sate (pink copy) 4. plumber (canary copy) Revised Date 6/1 /76
-1-15, .
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION:`, '/4,1 `/4, Section 4 , T3~' N, R" 2'(or&,Township or Municipality
Lot No. , Block No. _ County SIB oy_%<)e
Subdivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms -3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS /f l--146 ~
SOIL MAP SHEET ___f' SOILTYPE ~yD S~,~CY ~e'S1M
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P 1
s-e / /G% r c~ibr ~ _ r
X/"'J
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)
fB- C', / ci tea/ r / ti~ .
PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas.. Indicate Dumber of square feet of absorption area
needed for building t e and occupancy I Vie.
g yp . / Indicate scale
or distances. Give horizontal and vertical referee e pr'sicate slope. ~ S c?:-
F
I I 1 i ? i ~
e*4- k 44
~
-
1 x , ( 1 0 ~ f t I~ ~ ~ f
"
I
- I__ -
! I.' 6t RL7a' /P~.✓~ I I 1 i I I re 1 S
1;4, C-1 ~07 1 ( , I 1 /t^f " - r
i { " i I i ( ~ ~ i { S I
e I I i
1 i - i ` 1 f { t 4 i j t
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 belief.
Name (print) ~r °~✓~''f' Certification No. -ss'~S-%
Address 1 f G,^• f~'~'. u S (c-,s s , - 5 G}/
Name of installer if known
rt
CST Signat e~~~ =x« - y
COPY A - LOCAL AUTHORI °1,f
I, the undersigned, hereby certify that the percolation tests reported on this forth were made by me
or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to
the best of my knowledge and belief.
NAME AkT_Ndw If A TITLE 'f f
(T a or Print)
REGISTRATION NO. or MASTER P UI'BER LICENSE No.
ADDRESS • ~ lam/ C C~.I L11- /~.h
DATE 1.2 U J~ L° 4 SIGNATURE
MASTER PLRIUE:R MAKING AJ CATION , . ,
MP
Signatures 9 _ ? - ~'e ✓L f~ License Number: r
MP RSW
(To be omp eted by Issuing Agent)
Date of Application 7 Fee Paid
Permit Issued (da e) 7 Permit Number ~7 Z
I
- ~J ~L'~✓ /
Agent (name) For:
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered
and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the
Permit (yellow copy) to the Division of Health. Checks and money orders should be made
payable to the Division of Health.
Do not write in space below - FOR DEPART;-ENT USE ONLY
DATE RECEIVED - / D ACCEPTED BY RETURNED
(Initials) / (Date) See Corres.
FEE RECEIVED l~ VALID. NO. Y~ l PERMIT NO.
(Yes or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
COMMENTS: