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020-1139-30-000
r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division S anitary Permit No: INSPECTION REPORT 538706 0 GEN,EL INFORMATION (ATTACH TO PERMIT State Plan ID No: Personal i rmation you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Gherty, Mark Hudson, Town of 020 - 1139 -30 -000 CST BM Elev: Insp. BM Elev: BM Description: nn Section/Town /Range /Map No: /tt I 1 7 n' \. 1 G5T 29.29.19.704 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER A.,, CAPACITY STATION BS HI FS ELEV. Septic Benchmark I,J. e,� � 5 , , V1 - . i � lAOD b 0. 7� /�. 75 /� 9 / Dosing Alt. BM Liee,lc,5 3 26 1 1 2C. 1 Coop. /. 90 9S. B'5 Awatiorr P bLC. 52S 1 Bldg. Sewer 6661/ Holding S t/Ht Inlet 0/ c�/ 1i• — — . A A..., , TANK SETBACK INFORMATION ✓ SUHt Outlet .7 `I cig TANK TO P WELL BLDG. ROAD B4 E6.a ... / 3 / OeJt _ sp d-+r Zia I TA. 5.77 . 94/, 9 (... Se tic / Dt Bottom : � 55 �7 1 75 _' Z(oI 604-- 5.93 c L V 7. Dosing / 1 1 Header /Man. 2-lo % la ‘ 5 "7 `7.0 y 3. 7Z r Aeration Dist. Pipe 1, 7 ( W/. 97 Holding Bot. System t i t7Co 16 - 4 Final Grade PUMP /SIPHON INFORMATION id4 ti. 78 15 -77 Manufacturer Demand St Cover o�� �_ GPM 2to 1 GOJ - ,� 7 s .7 Model Numb Va.l Ln... 5.'5 I`/' 5 TDH Lift Friction Loss System He TDH Fi"----„,„ , ie CI) 4--Ale.) 5.4 5�t g Forcemain Length 'Dia. 'Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / 'Length ' No. Of Trenches ' PIT DIMENSIONS 'No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 6'40 Ens 3 Ire �� � -- �- -� SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: /1 / INFORMATION / CHAMBER OR �i`d — 7 F!q Type Of System: r UNIT M odel Number: ^ • ` k I / Li Go �A, e•.�„ 15 z7 �� ,�1 r�-- (.yam �f DISTRIBUTION SYSTEM AL cLL i y,,-p-,/}L/5,L -. � Header /Manifold / /1 Distribution x Hole Size x Hole Spacing Vent to Ai Int e Length / Dia s) �1 / 3 Length Dia ` \ Spacing �— ` • SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only e+-1 Depth Over Depth Over xx Dept of xx Seeded /Sodded xx Mulched Bed/Trench Center 2/ 7 s Bed/Trench Edges Topsoil \ Yes No Yes cl No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 747 Gherty / Lane Hudson, WI 54016 (NE 1/4 NW 1/4 29 T29N R19W) Gherty's Addition Lot 3BIk4 Parcel No: 29.29.19.704 1.) Alt BM Description = 1 ; � L._ (. 60 ex. (Z4o: Cz 6044„, , 0 v..., ZC t 2.) Bldg sewer length = 1 4 6G rE , �, - amount of cover = FMr._.e.� J 1 Plan revision Required? 0 Yes No Z� /b AilMir' JL� ^�► / Use other side for additional information. � ' / SBD -6710 (R.3/97) Date Insepctor� gnature Cert. No. ! , commerce.WL.gov Safety and Buildings Division County Olisitt II 201 W. Washington Ave., P.O. Box 7162 St. Croix S V O fl S 1 fl Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce Es 1 53 O 76 LP Sanitary Permit Application St ate Transact In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the app Project Address (if different than mailing address) unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are submitted to the Department of Commerce. Personal informa • vide may be used for secondary Same f A/7 es in accordance with the Privac I. A • • lication Informati I . leas Print t ) ta, Property Owner's Name v Parcel # Mark & Maeta Gherty OCT 020 1139 - 30 - 000 Property Owner's Mailing Address C 0 7 Z� Property Location r / 5 747 Gherty Lane ST. CROIX COUNTY _ ( � Govt. City, State PLANNI Vfbi� Nt.i UF Number Lot Hudson, WI. 715 - 2 &I -757 NE ' /<, NW ' /,, section 29 (circle one) II. Type of Building (check all that apply) • __ Lot # 0 T 29 N; R 19 E or W ❑ 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name a Block # Plat of Gherty's Addition ❑ Public /Commercial - Describe Use { 4 ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of 3 :64- c d 1.,/ / i1 /4 di.4.14eit Na ❑ Town of Hudson III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Re lacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) Ys �P Y g P Y g Ys ( p ) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component /Device: (Check all that apply) CS' ❑ Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of s table soil ❑ Holding Tank ❑ Other Dispersal Component (ex • lain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information. iltrator "Q-4" standard chambers & 3 pr. endcaps, PolyLok PL -525 ef Design Flow (gpd) ' Design Soil Application ' : yo dsf) / Dispersal Area Require st) Dispers era 7 sf) System Elevatipn 600 gpd 0.70 gpd/sq. ft. �' 857.15 sq. ft. 857.40 sq. 11. 91.00' VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units a 0 o o N Tanks Existing Tanks w 8 r IL,' _' A a U n is m r i w (7 LL Septic or Holding Tank 261 1,000 1261 1 Weeks Concrete & existing X Wieser Concrete Dosing Chamber Na I Na Na Na VII. Responsibility Statement - I, the and reigned, a- me responsibili installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum. , 's Si MP/MPRS Number Business Phone Number James K. Thompson ..s.�„ MPRS 30021 (715) 248 - 7767 Plumber's Address (Street, City, State, Zip C • , • 340 Paulson Lake Lane, Osceola, WI 54020 VIII. County/Department Use Only / - Approved ❑ D Permit Fee Date Issued Issuing ant Signature / ❑ . $ en Reason or Denial 7c Pill Pill /0 ■ IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1. Septic tank, effluent filter and dispersal calf must all be services / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code / ordinances. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 f ■ Se./e ✓a /ua•Eio-,/ • -jc/'s -6 ( � race e l e 1. • /acn.-C ec/ is .5 4 /': / = / 5/O , /4f /PI, e 4.a C ti /Ey 7`17 e ti dy 1-a il.e N �7 //ads„,, w 1. se/0/6 /6 1 Lv6 3 61,E• g f WC Proposed d,s ?e/5a./C'e,1 /. / Are e (J a 4. f,- iJ. s o - 62.8,9 x 58 .a wt ),. 77' 9n.,le /9w•,T. ' luds /5/-;i4`/era.6-o>- '6- g.0.,,,,6es 5'E. er0, - wi c T �6 c L hC� /t�c�5 ? S e , at 9 O'an Cen4A-r ,,..F• /traw'✓•e r �3 .Surface e l t lae = 9/. ct ,' cy 0 o t 151 El/736i 2 /g SC ' ■ -. x _ / 1 4 d s/.'er_ / C e //. T., 4 :- /ria_{rve O / acbwr ed C4 ScscCa e/e�`_ 92. _ 1�,'v�rs yr vw /vc be f, / £o / /ed a / / cuI _ _ /a a /l. '' ', 's 4 Al b:; f r es ,0,05c i I G kLY�y E,Y.:36 7 cJi eser Corcriik. , tve.e6 /Tm valve \ I 1 Lane. /,at dad See>6e . r ,- 1 1 1 :f —� r - 1 _ _ 1 _ 4F�or?`X. /off. - I • ..e"-'. 1 � f b6...,,"e,d Ex,sE:.- q comer 1 "-- � _ 1 ■ 1 �as /,',1e. (^°' pz_ • ty :sf - ^'a R-0/4 amid We es Gmcr' e ' I r -> 2.1.190-e. , 1_6arr,�, .. ..2. / L --- Ae$,- /�' �ice i Qa Pa , A / PL-S,25 I de cK \''' pin 2S I - \ Q144.1/E drvt/eK747 I I Pr n es f-'1.n es I ► z o x it Conventional POWTS Index & Tilte Sheet Project Name: Gherty 4 bedroom Replacement Conventional POWTS Owners Name: Mark & Maeta Gherity Owner's adress: 747 Gherty Lane, Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot3, Block 4, Plat of Gherty's Addition Legal Description: NE1 /4 NW1 /4, Sec. 29, T.29N., R. 19W., Town of Hudson, St. Croix Co., WI. Parcel ID #: 020 - 1139 -30 -000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Treatment & /or Filter Tank Cross Section Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of existing septic tank Page 11 Waranty Deed Attachments: Soil Evaluaiton Report Mater PI r • er Restri ed Service: James ompson, Dep't. of Comm. Credential #30021 Signature: - Date: /0 Page 1 Of 11 Design pursuant to In- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01 /01) a So, /2 ✓a /ua-fie' ' a Ejc -e.,'n rade e (e v: • /oea - E-e�o'/ /'. S 41 ../':/ 5/0 -' so_r,. dL 4 if l . 1404 Gh&(y 7 G titr-Ey'.Q41e //eason, - 1. 5ya /6 N Cl L06 3 61? g igoe 0. Proposed 1 (D 6 4 4, , ,,Eke /W,% Szc-. .lame. PA at 2.83'x 58 ,u�'cv T2 9 /9 W., 7. / /s/X-r 'C,7- q'C- v. 5E. ero ;XG, uJi 1 ae/& - ene4. - 778,e t&s io 6e,5 ced j /c-/ o / /39 -3) -ae at 9.0'al cen -63r: T (;' /tea -6' ✓ )8 .su e le+�: be = 9/. co.' • J o 0 ... 37 /7' �� q 61 /1 1 I • e V..S6 ) /8 x 3 ' '/ l 0 /sie / //. / - _'de - 9 X' 2 °c- m 4) -4. � C: " /ric {i of Cc 6ad� ¢d ce.AI.ItT. ✓. .Surfa 1e�`; 92.✓8' J > - - / , . - 5 /OY2 t.i /crs.'vn va/vc 1 ' 4 1 %n S Ea //1.� -(xi a //cw w E G /4 / u SeaFLe. /� , -� 9, J 1 C ite-riy I n zs ,ppos / Lane EY.sEly I.Oreser ('onc%•Vfe_ - ISW✓ei i 1 val✓c l 1 /, pi she, \ki -- - "' fLe. -.r4' EY:sE:' c,.)¢( deck' . I • V \ C m 14 pz_ E ,. pr t.Je.e.e5 Gmcreie � b e c�r 7.G 19o-P. 5 ett tare r...) .__ C.S / %JP Qa raye, Alyla44 9k0kLf �W 4 J I _ pines dec aseAge /E dr,'✓e y P n es - r'in e1 I ,M 7-5' i r).2c4'l/ I Soil Absorption System Cross Section No EN __ ft IN , 4" Schedule 40 Final Grade PVC Vent Pipe ill With Vent Cap 92.6' ft I Y5.25-X2.0 n n rTh Leaching _- Chamber f-- 9/c29 ft System Elevation .2 • .3 ft 6.66 ft 4• ft Soil Absorption System Plan View 58. ft .2.E15 ft { • • 'd . 6,6 ft Leaching Trench 1 n Chambers —_I I i t t -- — :Jr ---r-------T- 1 0 C \ 4" Dia. Trench 2 Header Vent Or Observation Pipe E Trench 3 Leaching Chamber Specifications Manufacturer And Model T 3 /tia -for "0-q" 664., p/ EISA Rating ,Zo. o sq ft per chamber Soil Application Rate 0.7 gpd /sq ft GGl),I gpd Design Flow o, 7 Soil Application Rate ÷ £6'.0 EISA = 4//. V Chambers 3,rows of /i chambers each. Page of 0, VO/W Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10705 -P (N.01 /01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October - March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two - year schedule by use of diversion valve. Effluent to be diverted from new dispersal cell to old cell at 4 year anniversary of new system installation. Old cell to be utilized for a 1 year period. Afterwards, effluent dispersal to be alternated between cells to allow use of each cell for a two year period. Continency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248 -7767 or the St Croix County Zoning Department at (715) 386 -4680. EFFLUENT FILTERS PI: 01 /SDK "The PL -525 has 525 linear feet of 1/16" slots. It has an automatic shut off ball. When Alarm �^ AcraPts PVC the filter is removed for cleaning, the ball will accessibility �- - - - - -� e. tension Handle float up and temporarily shut off the system so the effluent won't leave the tank. No other 578 linear feet filter on the market can make that claim" of 1,18 filtration sluts S Rated for over 10.000 GPO Accepts a" & 6" , „t' SCMO aD Pipa ., { r�r Gas deflector ___11 Automatic shut on � . ball when filter y 13 removed "The PL -122 has over 122 linear feet of 1/16" slots. Rated for 1500 gallons per day, and ` Accops "PVC can be manifoided together with other PL- Alarm Switch 122's to double or triple the GPD. It has an .� _� 122 Linear h automatic shut off ball that stops flow when of 1,16 inch Filter Slats the filter cartridge is removed for cleaning. Comes complete with it's own housing, no Fiher Housing gluing of tee or pipe and no extra parts to with Pipe Adapter buy. i , 3$ M `�—• Gas Deflector Automatic $ b Shut-Otf * • Et II When f k Filter is uy„ Removed From Tank Order # Model D e # ascription List Price PK -525 PL -525 Effluent Filter System 203.50 PK -122 PL -122 Effluent Filter System 62.50 6 -10 1. / . ad,/ a9/Av Vc 411,1 attigi;v1 -4) ho u.5b62 /9 c acfc/74 4 .6 0 s s , C 0 ij 4w skio/ <.75.strik az A 2 tt 6 c i 1&12 eOltrIALVe/ . c du 4 S ,rid ('I.kible_.. , Ir , ,, ■•■•••=111111•11111=11•11 1 J ----- _02L / 4 i i - i i i _....._..------ • - • ______,___I A * ti la I 1 1 g / i 4 Liyalac lo 1 ..vi-./ 2 4, _ ,5(oil 0 Sc --,-3 1 ,2-4 • i/. 1 WEEKS CONCRETE RAY L WEEKS /1 1832 215th St. ; 1 >- New Richmond, WI 54017 P3- 700 i • 6sz.45' • e • 308. ' t . • , ■ J 1 .65 , ' 1 f - '" .n�' 900' 1g4 :244'. s 4 OA =50 ` . \' �� �, 305. ' . , . ` ! \ \ S , 1 • N "2 O H . • r^.- a) r _ r C z g, ' .w . BLOCK ° , , � r 1 - ; 301 ' 1� • 2 NO2 °15'00" 05.75 g ' 338.75' ' %. • - G -1-4- E - IR - T - Y ------ Ept4_E_____..........._______________.__________.1_____ ; _ i __________________ r ___,...„..... , -- .. , ., /7 ' .502°151,00"W 581.561 253 .14' _ �......,_.,....-- _..._.._— ik 244.13' 84.28' * 1 _2.61'. o • ■ ■ V g 7 o � � I � � ' 1 c iUl • 1 y1 , ', \ ".- ! { BLOCK 1 . 25 .8' . .' 1 ) 8 q . 1 1 253' 244 � fl .07r/ ..:, . ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner r 1/1"V-' r)7 €;&? Mailing Address gAv -,- -Z7 Property Address 60 -rn4... (Verification required from Planning & Zoning Department for new construction.) City /State gtt ds01 t.D /. Parcel Identification Number &2 6 #39-3 LEGAL DESCRIPTION Property Location n '/a , /9 G-) '/a , Sec. - , T 27 N R 1? W, Town of / e/so Subdivision G 1 4w S �/ Z�r U) , Lot # 3 . Certified Survey Map # ✓1 a , Volume , Page # — Warranty Deed # 3 7090, 3 , Volume Co ? , Page # 35// Spec house Lot lines identifiable ye) SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber 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. Uwe, 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that . ements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, e of a warranty deed recorded in Register of Deeds Office. Number of s edrooms ial-7l /o SIGNA URE 0 "PLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Po. 900/ ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 7g/7 c - Line_ located at: //E ' / 4 , , (A)'/4, Section _9 , Town 29 N, Range /9 W, Town of lu.sc•-) , St. Croix County Wisconsin. , Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No j (if no, skip next line.) Approximate volume or length of time: Ma gallons minutes Tank Capacity: 4(X Construction: Prefab Concrete P- Other Manufacturer (if known): 1.07ese4' ear,c„re4 A!: e Tank (if known): ) yetrLs ' ermit umber (if know Q97a �'�!'►� • _ L • / Z ,npso icensed Plumber Si:' ature) (Print Name) l) �, �o,/ �i fie- �'yl. /� �. 3Ce-2 -/ (Title) �r/a /uad> -�S'- (License Number)ttMPRS (D, a-oJ0 (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 . ) 00f -- • : •u. - .aGetras,.swen., O F ! - STATE BAR: OF W)$CO$B)H -_ FORM-2 : 370903 - V()z �+ F A "v( - -`� _ . _ _ THissn•ze ftsSERVED YOOR 4o4O DATA Y REGISTERS O NCE _ Geraldine M. Marty, a widow, _ - Si CROIX CQ., - . ----- Rtyc'd. for Record this lath cotreexs st+d wearanta to Mark 3. Gherty aryd. seta L. day of Il aa . A.-0.192- - McKenzie Gherty, husband and wife as at- 12:05 P = *aint tenants tom_' -// : - • s` to - the 11200. r/rt9 cleecrited real estate in S t. Croix county State of ellaconstix An undivided one -half interest as tenant z-n . common to Lot Three (3), Block "4", Gherty-48 . Addition to - the Town of Hudson, - located in Tax trey too. the East one -half of the Northwest Quarter (Eh of NW]W1/4) of Section Twenty -nine (29) , Township Twenty-nine (29) North, Range Nineteen (19) West. TRANSFER ilirsia This -i nvt32omestead property. , Os) (te not) Exception to warranties: Subject to easements, reservations and restrictions of record. Dated this 15th day of May __ . 19 Si (SEAL) lJ i/J� ,.:.`.i - .05 1 f"_" (SF.,At4 • • GERALDINE M. GILERTY G' (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGEMENT Signatures authenticated th 15th day of STATE OF WISCONSIN May , 79 $1 Ss" County. Personally came before me, this day of • S'T'EPHEN DUNLAP , 19 TITLE: MEMBER STATE BAR OF WISCONSIN m444/ the above named This Instrument was dratted by STEPHEN 3. DUNLAP I ■ Hudson. Wisconsin to me known to be the person ,f who executed the foregoing in- E strument and acknowledged the same. c (Signatures may be authenticated or acknowledged. Both are mot - _ necessary_) - . -Nemes or persons signing In any capaciy must On typed or printed Meow their signatures. Notary Public County, a My Comm ission Is permanent, (if not, state expiration — e _ _ ion d . . i - 9TA�rp - SCA rE UAA W- liVin 1� H.ktiCIACl922. Z — 7N!! —'-- .•� _—.. _. _ _- � --r_— _ _�_ -- • z-as= 6.//0/:// P I D 2229 Wisconsin Department of Commerce SOIL EVALUATION REP L> Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations County Attach complete site plan on paper not less than 8 x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM •'rection and percent slope, scale or dimemsions, north arrow, and I. - . . • . r to nearest road. Parcel I.D. �� 0.4 -11 9- 30-000 P leas • = Revi d By Date Personal information you provide • y be ,, . r secondary purposes (Privacy , s. 15.04 (1) (m)). �, 1 /6/ / 2 Property Owner O l 2010 Property Location Mark & Maeta Gherty oC� Govt. Lot NE 1 NW 1 i S 29 T 29 N R 19 W Property Owner's Mailing Address SS CROI �fFICE Lot # Block # Subd. Nam; or CSM# 747 Gherty Lane : � 0 , 4114G & i. 3 4 Gherty Lane .4dd a City State C , Phone Number _J City J Village a Town Nearest Road Hudson 1 WI 1 54016 1 715 -386 -2651 Hudson 1 Ghertyt Lane 1 New Construction Use L /J Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD / Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.7 gpd /sq.ft. /day loading rate. Proposed trench elevations to be 91.00'. Existing dispersal cell elev. = 92.88'. 1 Boring # 1 Boring , e Pit Ground Surface elev. 96.48 ft. Depth to limiting factor >111" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f1 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 1 0 - 16 10yr2/1 none I 2fgr mvfr cs 2fmc 0.6 1.0 2 16 -27 10yr3 /6 none sl 2fsbk mvfr gs lfmc 0.6 1.0 3 27 -32 7.5yr4/6 none sI 2msbk mfr gs 1vf,f 0.6 1.0 4 32 -42 10yr4/4 none Is Osg ml cs 1 of 0.7 1.6 5 42 -111 10yr4/6 none s Osg dl - - 0.7 1.6 �- X02 il w 2 Boring # A Boring to Pit Ground Surface elev. 95.88 ft. Depth to limiting factor >102" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 - 17 10yr3/2 none sI 2fgr mvfr cs 2fmc 0.6 1.0 2 17 -28 10yr3/4 none sI 2fsbk mvfr gs lfmc 0.6 1.0 3 28 -36 10yr4/4 none si 2msbk mfr gs lfmc 0.6 1.0 4 36-42 10yr4/6 none Is Osg ml cs 1vf,f 0.7 1.6 5 42 -92 10yr5/4 none s Osg dl - - 0.7 1.6 ik s Effluent #1 = BOD 30 < 220 mg /L d TSS >30 < 50 mg/L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L CST Name (Please Print) Signet e: CST Number James K. Thompson �', _ � � 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 10/4/2010 715 248 - 7767 T Properly Owner Mark & Maeta Gherty Parcel ID # 020 - 1139 -30 -000 Page 2 of 3 3 Boring # Boring J Pit Ground Surface elev. 94.95 ft. Depth to limiting factor >92" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 - 14 10yr2/1 none I 2fgr mvfr cs 2fmc 0.6 1.0 2 14 -22 10yr3/6 none sl 2fsbk mvfr gs lfmc 0.6 1.0 3 22 -30 7.5yr4/6 none sI 2msbk mfr gs 1vf,f 0.6 1.0 4 30-41 10yr4/4 none Is Osg ml cs 1vf 0.7 1.6 5 41 -92 10yr4/6 none ' s Osg dl - - 0.7 1.6 I 3'QQ 3 ti - s Boring # J Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Bonn # __J Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color , Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 <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. SBD -8330 (R.07 /00) A.C.E, Soil & Ste Evaluations • So. /e ✓a /ua,Fior\ p A - X /S•E. rade e I e v: M • /ac.a.-(- eLcf/O.af? S6.-4 r4u - dee a -a GI & /fy 7'/704tyJ -4-" NN ,44 dsun, z„..)/. 5 6, 1v63 1 , ° /aewcA,, y s 0 � d " .d "1 , ,,Eye /w s ZC-. -0, 77; 34 'P. 19 w., T. o'r ,4so> - d - 4-. e.ro d)(6. ,j 4 4 "-/ g0.20- //39 -3 -dz D , Q k• o - / 0, BSI / . T)'/S J 9 /c 9;- ■ - — i dis //. ioet a /Ce / J ero� lecca4 - ,c..-a_ &de • r aFbayred e•wer.. ✓. ,Su /ACC -e lei'. ' = 91.8' 1 A1 v0- /vc'6) bL ` 1 f 1 /�s / /Ld - 6Aa / /av ...� 1 b3 P 1 c k w y iYts J k. � - • 1 ZCLne EY.sE+�q c '( plCr'i � e I o • /, clb ? Sepb't, - . /, �j i — �- • _ 4 ro'7r. /o j''' f"_ -- �1 T _ I �ir.r,'Gd . — 1 qas /;h� ExisE;.� ,el l -- ` deck' I • J Z 4 • __, Ey,sfrliq F 1 Qarafe, - -- A/ eSiclt'nce 1 0 ' decK - Z tt� pines \--- \ as044 /f de ;veway \ . P1nes knes 1 411- 7-5' I ►j. 3or.3 I 0 C o 0 E 1 0 f \ = G ® = 2 0 3 DD # - 0 4 - o , £ c n co ° _ . 7 § « z — z Q = s z \ 6§ E§ 8 . & e ° 0 o q= i 0 0- e *.4 • \ / /}� �� � \\ k \� §/ §• _, .4 / K k § ƒ co ( I 2 \ ƒ ) j k 2 2 G \ - \ K \ E E t E E t % 8« rg) E ( 9 k m ° /§t % �j E, ¢ / \ = r \ CO ƒ / o = @ 8 } o 2 } i. = @ p K3 c § p -• c torifti e § -a + \ E / 22R / 2\ CO CO ¥ ¥ A & \ z 0 2 0 \ _ 0 0 0 \ �- $ ƒ ƒ 2 §) / § § % § $ CM \ p/ '0 0 o I 9 0 v o / � CO § o � ƒ` I tD %� \ , a) - 6 % . ; . \ E E . z § r F i - / ( I > k 0 \ g t g \ / § ƒ \ \ a . 2 ƒ § _ co 2 } & } \ f E E - a 1 a } a - ƒ § ( z , a , �zm & k 1 c . 33 & / a E + § K = 07 1 03 1 f § § E § a § k $ k F k F z(0 3 m 1 3 z k - I ± I co CO I CD I i3y I a yy i 2§ * z I / E E * ( - G ) C � m . \ C co m / ƒ F ( I — ( 2 � � -� } = /g I I g / q ■ ƒ i x I CA ki CDG I m ® K\ k ƒ 1 0 I § ( w ) I G \ 0 E ■ � f ! 0 $ / / j § • Ea I @o � k k o 8& kE � % i 2 0 - 7/ - 3e•- AS BUILT SANITARY SYSTEM REPORT OWNER Yitaiv k -T (-, /7e '/ TOWNSHIP 44,eitso SEC .4.5 TaN - R /yW / 0 ADDRESS 'FIJI° 3 ST. CROIX COUNTY, WISCONSIN. 5‘/:-.. -G'- zJ �Vv /ec, . SUBDIVISION 01,er - /104 LOT 3 40' `/ LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 _ .s: EVERYTHING WITH N 100 FEET OF SYSTEM IIIII ...a ._ � IMO w... -- 111 ■iva11aa■ ■11I 1111111■ IIMPFINI u■ia■iui_IIU 11111_ E lli IIIIIIIIIIIIIIIIIIIIII IIIIIIII MAME WA ' 11111101...a A.II MIN 1111111M IIMININII 111111Mireilll MIMI IIIIIIIIIIIIIIIIIIII i MIMI 111610210/11111/11011/11111111111E=1111111111111 ■ _ �I M/ Gir ill _ . Imo E�Ir� as !ra ! iUU mP ■r . ■ IIIII%JrsIIIOIIAVI�ii■..'il ii" META III ci/lI11O111111111111111111 MEIN M . 1111111111. t om , III . cmgdom iliie 1 lliii I di a 1 e o th Arrow 1 ' kcr SC•LE: OP v F ,-a 47,42, /�� ear BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: NO Slope at site: /// SEPTIC TANK: Manufacturer: LJ to L r iS Liquid Capacity: /CCQ ga Number of rings on cover :. Z Tank manhole cover elevation: /D3 3 Tank Inlet Elevation: /p Tank Outlet Elevation: 99,51 PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set for a cycle gallons; total capacity of distribution lines gallon: size of pump head; gallon per minute ; horsepower ; brand name of pump and model number • Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: Number of pits feet diameter feet liquid depth seepage pit inlet pipe- elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines ,q width /g- 1 gth 36'tile depth SEEPAGE TRENCH: 'width length PERCOLATION RATE OlusS AREA REQUIRED (n, ARE AS BUILT ,W INSPECTO ,Ci1 � >> (7. Al4/4 DATED 0 1 PLUMBER JOB ti LICENSE NUMBER 3 6k. A •c, • RI 1'OK1 O IN ' I'1 ('I (O INU►VI UUAI. NIWAG ( SVtill M tiun rUnlr I't'' i • stilt(' S el) 1te y� • T. . JAM, T(rtunbhip qt. Cnu i x ('i (ii iii a t( .•n , Sec..tio * Ir rat M Stbtizvi.elon 1 I'll(' 1ANK QU� � a l tune Nt nrb +� o 4 carry t. n t,�e 111n,'!' 6 h(Im: W ( t •.� __..... I Bu4td4n9 '---....--%,- " � tape' Hi ghwa te.n --- - JH fIMI'INI; ('l1AMKfR tii (' galfone Pump Mdrau�actuaen I Mode t. Numbe 'I VIN(; LANK ' , ., gat tune Numbe�y d t`'amp�an.tmt ('�, mr��, n ACd�rrri .r ', a tart ye (.nom: Wet'`-- f '' � _ ;" `" R .,... � ;� � ���.��� �d ��' �� , �,� # gyp • w�i wa � 7 If �Ii�;vRrrrvN � f.1�� `' J T a , y i si Bed / 4s A v {'x 'I''''''''.0 +' ;' 1 tans(' nom: Wet � # ; �c , "�, d ,� r .. . `' � i i wighwa to n ,, s'ti0KI' SITE DiMENS1O / NS . i k ,g (1)4 .l th o tnpnch �'(_ 1 .. R e:qua �t �. , ca_.. ,/5 ( r I.pn�rt1i a ea t� <ne_�J �t De Mo ck .b e.�',aw ti to / . , 1 , , __�_ YI Ni�m(,��n u� Yineb Dept', * A00.17 auen. .tit't� � n I,� r:�n►lth u� Ci neb g ,t POP h • :2 ; � ; p iLe be: rrw grade _.. 6, 4 �/i (a nrr between t.inPe i�0 • 3 � . fix Sup n1 j�tt. n ch <.n. r► 100 I • b // �� ►,,�,�� ��[���,nNtiun anew c n f It Type u� Coueh: Papen un 6tnaw '1 1 U►M1 NSIONS ■ Numr�� n u p GK a ve . t ` a/i.tiu n d pa'.te y e e�- n' Ou to i,h' di ame ten 64‘. Depth " rvw met r T(1 t(41 nbboap.t.ian an.ea � .� Alva nequ•ined y 6t :6,,(N,>,,,,Y,I,,'',. C;)e,'=‘,.,',.) rITLf .' 7 --- I'I'ItOV� U DATE //I 19 8 1' 1 r (c r 1 v PATE ' 19 K 1 1 (AON 1 OR REJECTI • lF .it t a Y � ati F k; ' ' :,`'",-+:- „ 1 - i� ! � } Y ` ' °+s�C7 ' .x .1. x _. 1 ,* i �” + t" • ' ' r ' k v o i P -. ,,, L State and County State Permit # 9 - E B -. 6 7 i { ilia� 1 '11 / Permit Application County Permit # O 7 ;; «r l '` for Private Domestic Sewage Systems County ,,,11 - -:4. *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # 1 . A. OWNER OF PROPERTY Mailing Address: gas( i- . 6 her / 0 vie .3 74 4tlen 41 .5; / o /Ad B. LOCATION: 3 E 1/4 Iv 4.) Y4, Section , T N, R jq '. (or) cID Lot# ....2 __Cit Subdivision Name, nearest road, lake or landmark Blk# .4// Village G j P � 1 /J /) /ef Township ,y��Sox_ C. TYPE OF OO * Commercial *Industrial *Other (specify) *Variance Single family )( Duplex No. of Bedrooms No. of Persons 3 D. SEPTIC TANK CAPACITY MV Total gallons No. of tanks / HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete X Poured -in -Place Steel Fiberglass Other (specify) New Installation 7 Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate (' /a SS ( Total Absorb Area eoyp sq. ft. New X Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (toy) No. of Trenches Seepage Bed: >c Length -3 Width Width / -- Depth 4 / � ,, Tile depth (top) 3.1- No. of Lines 3 Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land V ° ?s AZ f. Distance from critical slope WATER SUPPLY: Private XI Joint Ei Community ❑ Municipal ❑ 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 1 have sized the effluent disposal system from the EH -115 prepared by the Certified Soil Tester / J NAME .� / , 5 �j „,,ii „-,, , C.S.T. # s5' -/5s 5 and other information / obtained from _57 - >�e %, (owner /builder). Plumber 's Signature , „ ,__ VIP /MPRSW 3, ,AV Phone # 3 S 6 y Plumber's Address 3/.'a ''r< 5t . 4 I/ it /, /.:c .S'SFO<(o 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. t t 1 i .� zg .. .... e.. ..... ... ,, o e t . s .. .. a. ...._ ma..... +>«„ _. .®... ,� ..,....... m ..._ �,.,... Pw fi ea.. 1 d l , f t } 1 ,-- c �wr+m+ f 1 t i t 3 i E c t I i ... t i ry . 1 mm»._ ... e.P e.— ;,.�. �.... w .. e .. .. .. 1 ...,g. ., e" ,. P...., ._.„�} ........... .. .. . ....�. s e.. .�... m,- ........., .... ..-..,..m ... .. ` W.a ...,.�.... _ , ...:� ' e..., s. . e r 5 Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application 41'_/7 - / Fees Paid: State /'{, ' County ./, ()-4) Date 4/ � 7 - FJ Permit Issued /Rejeeteel (date) �/ /7 -fi� Issuing Agent Name % ��1�, - �l��'Cc I.Li Inspection Yes 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 E H . 115 Rev. 9/78 6 6 REPORT ON SOIL BORINGS AND PERCOLATION TESTS be WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES�o =2 .• P.O. BOX 309, MADISON, WISCONSIN 53701 CO o c c j rri al LOCATION.. 4G- %,,Y /e, Sectiond ,T N,RaW(or ownship or Municipality .4. .. =3 Amp Lot No. 3 , Block No. ! , C44r 4b,✓ County A w � , -1 _� � ubdi ision ame Owner's /Buyers Name: Mailing Address: - . , 4 ,_ 1 a - ' - f ei V4 TYPE OF OCCUPANCY: Residence X No. of Bedrooms -3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW, X REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 9 B ii PERCOLATION TESTS V 9 ef SOIL MAP SHEET 4'6 NAME OF SOIL MAP UNIT PIA fe/61' LYE 104,4 PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE ■'UM- SINCE HOLE HOLE AFTER INTERVAL BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN P- / 'Y8" Set_ ¢- 1,1044. // Wes 3 G 4 6 . ..5" P - .2 %1 /t f ' ,c Vs/ - , 6 0 C -3 / C� 6 4 6 • J P -3 a ii qg tt 4C f i A 3 �O sS' P- P- P- ' SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED D HIGHEST t� IF OBSERVED IN INCHES / B- / 7 " 1410,4 C. .7 6'6 s / "7 ; //"A , 7 " £r. 5 d . B- 2.. 96°' Ace- 'X" S' K t$ /d - ", 7©" ,Br. J'.. -Gr. B- 3 ?6" >`�6fe /3" TT ir' A 4tr" s+G -s-. B- `.1 11 IVO _ IV I. I I, _ ., ' r J IP P. B- s Q6" 7 ` e /0" � e?o w 6 Y " • Br. .5N -6r, B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the,PIan the location anlsquare feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy ail, rS'j ,1 a9 � L"" �� � Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. $'c i it tits-04 Pa, ■. A 1 ? a E i 6 t , ho t c< % . r, t - 1 E i i $ [ i � r E t i 1 . ___I __ � A • f - t Od e e, - i I _. .S . E r . i i g i l ' 3 imi 1-- ., . _. F '� swam 'trr t , 1 i 3 1 " ---1 ,, I -4 --4 . imt A u Le ramme.dia i 1 ' I 4 is, y ,....,. _. r IL ' . 42 ' R . } _ . .:� 4___H_ r --- - t" • allaltill 1 - t - 1 4 ‘ ia' mmumMilliFra - l P PiII!I W- I, the undersigend, 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) if "eAdic[s`S P 0 4;:s 1` d it c A/ Certification No. S S - / Address ! J/ C 4 Aire rt.1 it)-1/4. lE. ISOAA 14- , , q'0/ C Name of installer if known A Copy A — Local Authority _ CST Signa • 13'385 REPORT ON INSPECTION OF SANITARY PERMIT # 9 9 7 (1) Name and Address of Permit Holder Person /Persons at Site (2)Date of Inspection Name, Ad' ress, tic se No. of tnstarring plumber Time of Inspection ,� 'L.. 3 / 9 c-am. ,9) 3)IN ALLATION CONSISTS OF: ['Septic Tank ['Seepage Trench ['Dosing Chamber ❑Seepage Pit ❑ Seepa a Bed ❑ Holding Tank ['Fill System (4)BENCHMARK:(Permanent reference Point) Describe: Elevation of vertical reference point: Scope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well (7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number • Is the warning device installed? OYES ❑ NO Wired? OYES ❑ NO (8) HOLDING TANK: Manufacturer ; # of gallons ; construction depth to the cover ft; If septic tank is being used are baffles removed? ❑ YES ❑ NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ NO; Wired? OYES ❑ NO; Locking device on cover? OYES ❑ NO; Diameter of vent and material ; Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than ; seepage pit inlet pipe - elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. (11) SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% failing away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? OYES ❑ NO (13)' Has system been installed in floodway? OYES ❑ NO Floodplain? OYES ❑ NO DILHR- SBD- 6095(N.05/80) Signature of Inspector: r L -,-- — 1 . . .A, *.t . • * !.. t ; .- ... ll• 1 ' ;11 i 1 4 t'■ ,' 1 ... ......7.-__,......„ h • - • - i . , i I /1 4 - NA ' ' ...... k , 1 , ' \ \ I s 1 I s. I N. 1 • 1 --i- 1 ! • ,i i I ....) , I - 5 --4-- N. I \ 1 ••••■ ' 1 -LI 1 i I \ / 1 sc,,,T,..-• --- ' , 1 , ••••••.„, I \ 1 • a I e. =-1 i_____ I._ _ ..t , N \ ■ ' r 1 . 1 ..., I • , , 1 1 `\ , , • ": Al \-• 4 ' , ' '•••‘ 1 ' i ' I \ . I I M -'-'; • I ' I '\ . N N 1 -1-j \ / '• . i ' . . , ' -... 0 1 \ , - , ct , ,... ... , ...., 1\ -1 , , —1-1 -.. __,,,,,, \ 1 -t. , „.....•.. — t 1 ....3„...: 1 ..-t- I ,,, , , •t • - -- ..., 1 i l i N 1 ".... \ L , i '..... \ \ i `•-•• -- '4) „,) ....-•,,, -• '''' -,...• 7 ,,,.." I N' / -"- . .•- ... ••••• --..—..i.—....--......--- i \ \ j 1 \ • .,,,,,„ , I \ 1 \\■". i \ / 1 ' I / \ I f \ 1 _. , - .-- - C...i _.------- -- - - - :- - ..? .. -- •-•-•-•-"". - ..J .',1 '-'...J •Yi C.) --)._ * _ , -....., . I , Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarrrr'i.: Personal information you provice may be used for secondary purposes [Privacy Ltv, s.15.04 (1)(m)]. Permit Holder's Name: I R iU13�C71V rityglpillage El Town of: State Plan ID No.: GHERTY, MARK � CST BM Elev.: Insp. BM Elev.: BM Description: Parcel tr(5o.:1139-30 -000 TANK INFORMATION ELEVATION DATA A9800180 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark � Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. V to ROAD Dt Inlet Air Intake Septic - NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Foss ion Syestteem TDH Ft Forcemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold ( Distribution Pipe(s) p g I x Hole Size I x Hole Spacing I Vent To Air Intake Length Dia. Length Dia. Spacing 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 I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 29.29.19.70 NE, NW 747 GHERTY LANE Plan revision required? Yes q ❑ ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. • v�uu rurr SANITARY PERMIT APPLICATION Bureau of uii i Division Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not Tess County n r . �� than 8 1/2 x 11 inches i n size. }T • See reverse side for instructions for completing this application State Sanitary b Permit Number The information you provide may be used by other government agency programs ❑ Check i t6 pr4viou a (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �—.. Property Owner Name Property Location MG.t\& G- \—.. AgTi4 NW1/4,S 7 , T Zal,N,R ice E (or)(5 Property Owner's Mailing Addre s Lot Number Block Number, 14 1 C-1.1..e ril 1.._, i 3 'rat City., tate Zip Cod Phone Number Subdivision Name or CSM Num er 1kd . IA s 5 . (7/s)366-z15/ C i t..1 4- 5 4 U # i o w II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village ❑ Public 1 or 2 Family Dwelling - No. of bedrooms zi Town OF NIA J604 C -v 4-` / Z. A/ i III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 020 — 113 - 3c 1 ❑ Apartment / Condo 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) Teir 1 A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 Jfreepair of an System System Tank Only Existing System Existing System 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 It 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 ' 4 6 C - G H 3 o 1 �-- s - et_ /d0• h Feet _ Capacity VII INFORMATION in gallons Total # of Manufacturer's Name Prefab con Steel Fiber- Plastic Exper. New Existing Gallons Tank Concrete strutted glass App. Tanks Tanks _ / ILL. SepticT r.. lobo /ocw , ! .i T _ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for i nstallation of the onsite sewage system shown on the attached plans. plerrRer's Name: (Print) AliorrtTgrs Signature: (No Stamps) o.: Business Phone Number: cP/ is Ii9 ra in 7 /5� 3g6-2/3o PI. s Address (St et, City, State, *4e): 4e): /b Let — � 1H E �, i . b-'' IX. COUNTY / DEPARTMENT USE ONLY _ ❑Disapproved ( mdudes Groundwater g a t e ssue. � in A nt Si nature (No Stamps) anitar Permit F e g g' Approved ❑ �1! � . � Surc Fee - Owner Given Initial X I ) � , .� _Adverse Determination (� , . • X. CONDITIONS OF APPROVAL / REASON FOR DISAPPROVAL: 580 -6398 (R. 05/94) DISTRIBUTION: Original to County" One copy To: Safety & Buildings Division, 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. II. 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, etc.), 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 by the county; E) soil test data on a 115 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. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN,EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the Iv1c,4 \k GVve_vV. 1 residence located at: 1\1 6 1/4, 1 4 kJ 1/4, Sec. Zq , T 2.9 N, R /q W, Town of 1-L1/4 .bc".I Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced 412-118 Did flow back occur from absorption system? Yes X No (if no, skip ,, next line) Approximate volume or length of time: gallons minutes Capacity: tbc.o Construction: Prefab Concrete X Steel Other Manufacurer (if known): Age of Tank (if known): - mc ezz c.3i (Signature) (Name) Please Prfftt CX.4v.rtIA5p. Sos (Title) ) (License Number) 5 1a�I `i (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature MP /MPRS 5/88 • y f� ST. CROIX COUNTY AN001A WISCONSIN �.� ZONING OFFICE � II !��i CROIX COUNTY GOVERNMENT CENTER • 1101 Carmichael Road Hudson, WI 54016 -7710 _ (715) 386 -4680 AFFIDAVIT OF SYSTEM REJUVENATION Property Owner: Ill\ �k Address: ` 14 1 1 C r Day time phone: (7/5 3f3( - 2GS 1 Parcel I . D. # (5Zb - // 3°J - 30 Legal Description of property: NE / 4 ;, sec. 2C/ , T. N., R. /G W., Tn. of � eLca,4 St. Croix County, WI As owner of the above described property, I acknowledge that the septic system serving this residence (/is not) undersized by current code standards. I understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that system meets current code sizing requirements, nor does it im ly th t the proposed procedure will be successful. I also acknow dge th t I will make this information available to any future parties . nterested in purchasing this property. / 41111°P.- ,- ' � signature � i 1 Date: /A/ 5/97 ' f 577E 4 SoiG & ) k 7it'.'4 • G97 Ae Wisconsin Department of Industry, SOIL AND SITE EVALUATION / 2— Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not Tess than 8 1/2 x 11 inches in size. 0 t � County S . et include, but not limited to: vertical and horizontal reference point (BM), ' ectp nd percent slope, scale or dimensions, north arrow, and location and dist In nearest.�ed. r LD. # r {{ E'E 0 0. 1/39. 3 k. 5���: APPLICANT INFORMATION - Please print all infor Win. - :d Date Personal information you provide may be used for secondary purposes (Priva4r f , s. 14(i)(4) 66 �: Property Owner Pro cation M4A t ( y QouiLli6iatn 1/4'A/ /4,S T 2 ! ,N,R 1! E (o Property Owner's Mailing Address < f Lot # Block# , 'Subd. Name or CSM# 7e/7 Gh eQry 4 N• ` - '` GtiE,e7Y 4PD'7i0.0 City State Zip Code Phone Number / Nearest Road Hu 1JS e,� 1 i sclo/(o (`1►5 2loS / El City Village Ly' Town ' &'it.eL,.?(Y • ❑ New Construction Use: E31<sidential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 7 ✓ gpd Recommended design loading rate • r �j 7 7 bed, gpd /ft P trench, gpd /ft Absorption area required 64 S bed, ft 5-6 3 trench, ft 2 Maximum design loading rate • / bed, gpd /ft • d trench, gpd/ft Recommended infiltration surface elevation(s) 5 t, 5 / /Ns S! ST - /.6 • 5 ft (as referred to site plan benchmark) Additional design /site considerations 2_, / /Gt.? 74) / D_ 7 , si _r o. o - f '- Parent material •S4fvoY TW/} / Flood plain elevation, if applicable 96 /74' ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [a --S❑ u u u B-s— ❑ u ❑ s I -rr El s SOIL DESCRIPTION DESCRIPTION REPORT Boring # H orizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 0./2- /0Y, 2 f LS /, y e 4i+vf�e If .7 ; ) Z ' »30 /0YR /f 5L if fie / — . ; • s Ground G .� ;7: • e elev. 3 �o� �oy�s /� D, s /./O ft. Depth to limiting factor } !f in. Remarks: 6- X"7"6 SyST /'S 5/ 1 A- 2 Ce9E COAtio /� 4,)TT . 5-0(45 Boring # - - - / • Ground elev. ft. Depth to limiting . factor in. Remarks: CST Name (Please Print) ,eo /E/p r ?l /L7 d% a l / Signature � �� Z � J"v1 7/ 5. Telephone 3 g • g i S Address • � CST Number d , Ulbricht & Associates Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 ORIGINAL ,,, `% 1� N.4. G t 't`.,. a .4, 11 I % 1 `'N t ; . , ------ - ( I NI y nit X00 �� \ N lay r ( Z ^ V f.. fI 4. 1 ct %,, I-_ i 1 0 q:1 N k, - 1- - — — -L.: —. I ., 1 -.(1. i 1 -, . o______*___. I t N \ b o. J �1 1 - - •C‘ o o E , ci, , Q • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT • AND OWNERSHIP CERTIFICATION FORM Owner/Buyer tV\ e.' C h eJ A Mailing Address 1 4 Z G Nr. c.41y L,. Property Address _ 1 a- C, k, , ) b b (Verification required from Planning Department for new construction) • City/State Av a sc,,a t W 1 Parcel Identification Number v ZCD - t / 39 - 5 a 1JEGAL DESCRIPTION Property Location A/ l;" %, hl kJ, V4, Sec. 2-t , T Z Cj N R / e ( W, Town of )La ch 4 . S u b d i v i s i o n C-V\ e 4 k. (' s A el a.% 0.4 ,Lot# 3 Certified Survey Map # , Volume . Page # Warranty Deed •# , 3'10 9 O3 , Volume (Zq , Page # 341 • Spec house D yes VI no Lot lines identifiable Cl yes D. no SYSTEM-MAINTENANCE Improper= anduraintenanceofyourseptic sy couldresalt fa itspumiataretarre to bandiewastes.Propermaintarance . consists of pumping out the septic tank every lance years or sooner, if aecdedby a Eceasedpampe " "With you put into the system can affoctthe function of the septic taalc as.ateeatmcatstage in the wastesposal.sgstcm, - property-owner agrees to bmit to St Croix Zoning Department a catificalion fort, signed by the owner and by a . s Iiceasedpampery ring that Mike onaittRastewatardrsposalsysbeth is in proper operating - . oa and/or (2) after inspection lad pamping.(iif necessary), the septictanlcas less than 1/3 of sludge. _ Uwe, the ... . _ u' _.. -' . the above /��_� � to maintain u private sewage disposal system with the standards as . by e'-. -.. ... — o f Commerce mdthe ofNatual i that your _/ Dot Resources State of Wisconsin.. Oer4 . h -ei', ., system , been maintained mast be completed and returned to the St Croix Comity Zoning within 30 days-of the tare -. cxpirati. date. 4 / l / ei I( DATE OWNER CER ► i • CATI 1 N I (we) • that all -. • on this form are true to the best of my knowledge. mY (our) edge. I (we) am (are) the owner(s) of tae ... - • demon _• above, .y virtue of a warranty deed recorded in Register of Deeds Office. , :j"G111.. 11 . 1 e.101. . ' 1/4- /2// l',..Y St 7"/".7: OF • •LI DATE s «s « «« Any information that is mis .�R**R - rtodmay result in the sanitary permit bei 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 decd P 6 A� � ��I�Qr� P "f � �. usr i sr�tot �ctttata taltt Geraldine fit. Gherty, a 3+�ov, 4 -, iT. " +a cf . _dga�ary♦ aadwrnrttato. Dar J. G� and !laeta L . _ � � 1lcKe27i t ertv'1 hua lEt rif ! a of 12 ' r Join tenant w , . Y =. ; cl r the A.acs1bsd reed aet.els to $t. Croix s 6 ' � „tea sea a� r v' ', Fr An undivided one -half interest as tenant iia 's ccesso to Lot Three (3) Biock • 4" , Gherty � ,n 7 Addition to the Tonne of Hudson, loca in ' KW--- -- -- =* — the East one -half of the Northwest Q uarter ft- (E of 14N-4. of Section Twen -nine (29, the Ea ip Twenty -nine (29) , Range North Ran a Nineteen � '` 4 ''` s (19) rest. ,, - • *Iw is not etsd prop«. a• �n Exoptbn t o warrant Is .• ' ,, : Subject to eas reservations and restricti of record. tt+ts 15th day of Max . Dated $i GERALDINE 11. GHERTY (SEAL) f ` AUTKEMT1CAT1oN AR�CM01M LEDGEMENT Sipnatwa authenticated this g ist d ay of STATE OF WIBQONSMi ) sa. Peraona»y can'. sell).* Rif.. thle day M • S EPHEN . DUNLAP tv TITLE MEMBER STATE BAR OF W 1 the abaft tousled Thie was drafted by STEPHEN J. DUNLAP Hudson, Wisconsin to nw known t °i e "' Y° "°^ -- '"h° execatee ttls torsyafns in- ftrwnent and adanoea+Md 'd the same �ipnatures may tie authsr►t or acknowtedped. Bath are not necessary) • „y Puo+tc County, Wis *pianos °r ___ • 1 "'"V "*"*Y """ a e ti °f I ' ' °MS "' ""' My Commtss o" is p+wssnent (H not, state expk�ebn da w�turc= ss � 7 ., T - i _ _ -