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020-1185-80-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building E ivision INSPECTION REPORT sanitary Permit No: 538725 0 GENERAL INFORMATION (ATTACH TO PERMIT State Plan ID No: 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 Parcel Tax No: Elert, Gary A. & Kathleen Trust Hudson, Town of 020 - 1185 -80 -000 CST BM Elev: Insp. BM Elev: BM Description: mn Section/Town /Range/Map No: /00' 0 100 D 81��' l 1 21.29.19.1170 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 2,/3 /0213 / Septic �/ I �� /, 000 Benchmark s /-194:- z� /00,6 . D51/ C�` l l. { Alt. BM Z ,(� 1 ��-0/I�C�YI�G� %�� 4.• 1- 92 °� rtAr,In't. e�.uii Aeration 0 - -4'� ` Bldg. Sew Holding \ St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet s � � 1 � 8,0 9 o 9 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD ' et ` ,,, \ k?� tko... l b►.' $ .6, 13- q f Septic/ G . :r : 1V ZU ►I 7 !f � ` i � / (X q 5 b' C& J Header /Man. - L�, jy , q3 Aeration Pi d IIn 641 . 4 S Cl3. Holding Bot. System ,. , , , ' Ile] S, r >3b Wour 9, '/t/ ° Final G PUMP /SIPHON INFORMATION/� - fj, ARly 5 .. w . 9f, 6' Manufacturer `� � ` J Demand St Cover / GPM C ' � h,�et $ Model Number 1 b-ck. fl (� .ia Gip VG" �;I 011 ,, X , TDH (Lift Friction Loss Sys - Head TDH Ft Forcemain Length Dia. Dist. to Well // SOIL ABSORPTION SYSTEM . a I � � 61 p , r C� BED/TRENCH Width / Len No. Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P /9 BLDG WELL INFORMATION ILAKE /STREAM EACHING Manu er� 1�� CHAMBER OR .J�� I� y0. V y Typp, Of System: 1 UNIT It�VI 4 ►l Q/l (.16 00 / ) 15 Model J�I}�!nbel/l� ( l Ant ( DISTRIBUTION SYSTEM 1 e A ut ,, - �� (t ✓S /c — i J:a.O.ci f a/A- ai11 (,( k1'"' Hea anifold & r Distribution x Hole Size Hole Spacing Ven t it Intake ' /2,1 r Pipe(s) 4. r / �� Length Dia - 7 ` Length D i a Spacing �(/ 3 1.00 5 ( jA j SOIL COVER WWI"' 6. / ressire Systems Only xx Mound Or At - Grade Systems Only -- -- C/( yo PVG Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched / Bed/Trench Center Al-- Bed/Trench Edges Topsoil Yes 0 No El Yes 0 No • COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: I ! / 1 / / 1 y .q) inspection #2: / / Location: 551 Wagonwhe I Court Hudson, WI 54016 (SW 1/4 SE 1/4 21 T29N R19W) Prairie Vista 1st Add Lot 12 Parcel No: 21.29.19.1170 1.) Alt BM Description = n`I d 1TCr J"'r`^" - 2.) Bldg sewer length = '/ A - amount of cover = J ._,D . Plan revision Required? Yes L J%�o ( / I l D / / /� (, / _ b ��� Use other side for additional information. � cC' Date Insepctor's Signat re Cert. No. I SBD -6710 (R.3197) L - t. Commerce.wigov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix j 1SCO n s i n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in b Co.) Department of Commerce ti L-� 3)' 7Q Sanitary Permit Applica Ii�� PAID State Transaction Numb .1 „ ^ In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form ■ the apprnprinte gcw rnrytental Project Address (if differ t 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 information "you l fbr sePondary 551 Wagon Wheel Crt. purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. 4�e 1/ i1 i� L,/ I. Application Information - Please Print All Information Property Owner's Name Parcel # Gary A. Elert NOV 1 0 2010 020 - 1185 - 80 - 000 (. /,moo Property Owner's Mailing Address Property Location 140 South 3` Street ST. CROIX COUNTY P LANNING & ZONING OFFICE Govt. Lot City, State Zip Code rnone IN mom , , Stillwater, MN 55082 SW /< SE /<, Section 21 (circle one) IL Type of Building (check all that apply) -- ., Lot # T 29 N; R 19 E or W ❑ 1 or 2 Family Dwelling - Number of Bedrooms I 12 Subdivision Name � / Block # Plat of Prairie Vista 1 Addition ❑ Public/Commercial - Describe Use Na ❑ City of ❑ State Owned - Describe Use CSM Number ❑ >11age of Na R'Towt, 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/Holdin Tank Replacement Only ❑ Other Modification to Existing System (explain) Y P Y g P Y g Y ( P ) B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner // 9S-05. 6 P/ 67 / 49 ? IV. Type of POWTS System/Component /Device: (Check all that apply) Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain --_ ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Informatia�t'. 42 Infiltrator "Q-4" standard chambers & 3 pr. end . • s, Pol Lok PL -525 effluent filter Desim Flow (gpd) Design Soil Application Rate gp • i r- a , ea ' equlre i s s ispersal Area Proposed s ystem Elevation 857.40 sq. ft. (over sizing 450 gpd '/ _ 0.70 gpd/sq. ft. ✓ 642.86 sq. ft. / & per Owner's re uest t/ 93.00' VI. Tank Info Capacity in Total # of 1anufacturer Gallons Gallons Units t ° New Tanks Existing Tanks +� G i A a. U rn . inn iw C7 at, Septic or Holding Tank Na 1,001 1,000 1 Wieser Concrete X , hamber Na Na Na Na •J4er can( skr VII. Responsibility Statement I, the un.. igned, assu 11 respon 'bility or on of the POWTS shown on the attached plans. Plumber's Name (Print) ' • ber' ignature A p r MP/MPRS Number Business Phone Number James K. Thompson / j. • 70s MPRS 30021 (715) 248 - 7767 Plumber's Address (Street, City, State, Zip Code) 340 Paul i n Lake Lane, Osceola, WI 5. 120 VIII. 'ounty/Department Use Only II Approved ❑ Disapproved Permit Fee Date Issued suing Agent Sign u • ❑ Owner Given Reason for Denial $ ��' �/ l'/ L0 ! 0 _ -- �-1 L/042 A-._- IX. Conditions o s of Approval/Reasons for Disapproval a n S (/JL , ��7 otttAt Gt,� SYSTEM OWNER: Q 1 Septic tank, effluent filter and lti -) o 2 : 3 - yP.f c) G,✓oo�2,�2 4A , G!J`tiLotf' dispersal cell must all b se rviced / maintained as per management plan provided by plumber. vY�� 2. All setback requirements must be maintained / as per apNlit,ableA a plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 • [.4-kz9on ee cc 7t"Pc.' 242 C-. de --Sac- I .�r/ e d4 /ua ,14 • EXis6 yra-de ¢lei/• • Lo cc 562 e Gary e /e/ pro�p'/ v SS/u)a / yon cohee( Cr . f/k_ofso/ �/. Sk2/6 `06/2, 3 /aep{ ,5cv,SE Se e .2/, 7.294., /e /9u). 7. of Acisan 5e. Cro ix G. �/ , ° " / o c% S oto - / /8s= 80 - aaa �� a ' 0 6.c: cX /inq �Q�,jci 3 bedr-00. dea�'� i ,t es � e.7ee - S' 1c-A on(' &z% i o SC/in- . �-- e s4:7 c l(. e/4c . a ' 55C4 rued a /eti a / eV. ev' / ° f oP OF K.4 // CaS, iaq - /a. os d/E. L3rr(. :T. 4r .,, , / U Co /'r: E /evt = 97 77.' 9garA •/ reposed LOteser Co.�et C'Q.n. 4 - 6 !' eXis•{.iiaqW:esciConcre 1 0 /L0eA - 2Se /au c. re. %N� w c P /ecg /!?g 6% - $ ' 7 ' 1 �' 044/4-6 e lea c 9W 3s 1 6 ,r`' , , \ ' ! —Pr opesed cr,•v LA Ye. EXis i na dits /ee / /a.� Si / i� , ■ \ t, 4 f " i�5t/R 303 9 /gYC, Ctlz%ue.rb /,'nc (&add /8 X.96, /e,-a- ve } of ..''• � r,ra '> 's; - - . Su ce e %v 93.75 - • , f1 Proposed drsppu:sa/ee! /. 7AeccCO ii € �' � 98 � aE 3;r 58 :Sj4eeda .E 9 'o� ee.- -e: L / d s i�,�y 4'e i ' zee Sp rekce -re , /f , e/evavc o., 606e = y.�oo,' 4787' ' ' cJ , � 62- • p,3 y ,r %3. 97. 3-0 / a e_r.4 may- / g8 p �� / c 4 9S. Conventional POWTS Index & Tilte Sheet Project Name: Elert 3 bedroom Replacement Conventional POWTS Owners Name: Gary A. Elert Owner's adress: 140 South 3rd Street, Stillwater, MN 55082 Site address: 551 Wagon Wheel Court, Hudson, WI 54016 Project Location: Subdivision: Lot12, Plat of Prairie Vista 1st Addition Legal Description: SW1 /4 SE1 /4, Sec. 21, T.29N., R. 19W., Town of Hudson, St. Croix Co., WI. Parcel ID #: 020 - 1185 -80 -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 8/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 P1 ber Restric ed Service: James K. Thompson, Dep't. of Comm. Credential #30021 Signature: �'-~— Date: C2r ,le/e Page 1 Of 11 Design pursuant to In- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01 /01) • 1Ak4Qon • ■.��i�. u / T C04' 12.23 i l (G.. -C- de -SI G a ,.9i7 e1/a /aa bn • E,xis6 g rade ales` a Le j oroPr.Ar Si6a Cary t i 0 co er 65/ t."-' or ghee/ Cr6. ,c%aisor5 co% Sfior6 Lob / z , 10/ a C a; r,.e V, s 62, 1 6tvSESee. 77.294., ,P /9c J., NA 7. oc dsor; SE. Cr e;x e b-/. i l l "n l oci ci A - / /p 8o -cry f • 0 6c: nq z. SB a uses, des ence 1 /3 ' , J) 0.44: Qoz" o s o/i n - . �--- EX,34 6.-4_1(. Ele U. ¢ ' ssarned e1eir = /eV. C14' a / o rap at ec.4 / / Cas.ix} o/os - i AIL Q :Topo/'s.7. rrl.n 44/c. / U Co ✓'r: E /ems = 97.77' 91.08' / reposed Loreser C&..csc6ekiE.e. ca v.:1 eXrs'6%q Wrest, Corere e ,' 40 / loo ylok'PL- 5'25 Mr/Aerie )4/6"! WLP /dvd /nR f%c -6..e! ok.le.6 e /e at c 9t�3s '?` n^ , �`�— _P , OPosed ¢"ver bn ✓aive. j '_q die5,0.ers¢ /er / /a i \ \ ■ � G7' " 4Szi�l 3os ( A ✓.C. e{r/cof /Incf/1ead� /8 ;36', U t ' /�/a -hide + - .63' 0 .4 • / . › %., - Skr{acee /ev. =103 75- o � 9& 1 . ______• 40 '_,t ProposrSd /cel l77freeCOir errites 0 at. 3' SS .SPacedaf 9'ar7 Came. ".. Pe-epos SySee'n :n,4y � i ' ✓e jar�Caee Spruce t « r e /eV & o., 60 be= 9a.ao,' r r 97 S a s, 8.2.. • ,f 83 ,ri so,, 97.50 / v C.,.../4.0.,.- / 9B.30' e�? r q 98. oo ' ib .2074'// DISPERSAL CELL SIZING CALCULATIONS 1. (3 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 450.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.7 gpd/sq. ft. 3. Absorption area required: 642.86 sq. ft. Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end cap (pair) = 5.80 sq.ft, EISA 642.86 sq. ft. — (3 pair endcaps)(5.80) = 625.46 sq. ft. 625.46 sq. ft. /20.00 = 31.28 chambers required 4. Absorption area as proposed: 857.40 sq. ft. (42 chambers total — over sizing dispersal cell per Owner's request) Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end cap (pair) = 5.80 sq.ft, EISA (3 pair endcaps)(5.80) — 17.40 sq. ft. (20.00 sq. ft)(42 chambers) = 840.00 sq. ft. 857.40 sq. ft. Number of trenches: 3 @ 14 chambers per trench Trench width: 2.83' Trench length: 58.00' Trench spacing: 9.00' on center Total system area w/ 6' trench spacing: 21.00'x 58.00' PO 3 a{ // Soil Absorption System Cross Section ft A q 7, ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap rTh Leaching Chamber 1— `6 ft System Elevation .2. A3 ft 6.6 ft le. v ft Soil Absorption System Plan View ft 2.83 ft { ( ft Leaching J Trench 1 Chambers C \ 4" Dia. Trench 2 Header Vent Or Observation Pipe L - I - , Trench 3 Leaching Chamber Specifications Manufacturer And Model /tla - ' 4 .560- r , dat.ci EISA Rating „O. d sq ft per chamber Soil Application Rate 0.7 gpd /sq ft 5 gpd Design Flow ÷ 0F7 Soil Application Rate + x,d EISA = .32 Chambers 3 rows of // chambers each. Page of 1/ / . /e3Ci/ • 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 /1 -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 on schedule to allow use of new cell for two years and old cell for 1 year. Contingency 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 PDLYdOK "The PL -525 has 525 linear feet of 1/16" slots. It has an automatic shut off ball. When the filter is removed for cleaning, the ball will P3arm °0e f1 ocaesslbility - - -�_ Pts PVC ..�rlJ ~ r xl rnsion noodle float up and temporarily shut off the system so the effluent won't leave the tank. No other 575 linear feet filter on the market can make that claim!" of 1/16 filtration sluts Rased fo 10.000 r GPO over - v+, Accepts 4" 81 8" SCHO.4OPip.� i 9 ` X ^. sa r l 3 � e 6 Gas deflector Automatic shut -ort 5.11 wh.n lilts is removal "The PL -122 has over 122 linear feet of 1/16" slots. Rated for 1500 gallons per day, and < H 112 PVC can be manifolded together with other PL- Alarm Switch 122's to double or triple the GPD. It has an ^=` 122 Linear ft . automatic shut off ball that stops flow when — ' of1/16inch ( � - Filter Slots the filter cartridge is removed for cleaning. 1 , le Comes complete with it's own housing, no Finer Housing gluing of tee or pipe and no extra parts to with 3'& Pipe Adapter buy. (1) Fj b 6 Gas Deflector g Automatic Shut -On !q Ball Whon � Filter is Removed From Tank Order # Model # Description List Price PK -525 PL -525 Effluent Filter System 203.50 PK -122 PL -122 Effluent Filter System 62.50 6 -10 P.oOr l 43 i D mm O n m A m Z - 1 D D D D m i 1 . r = rri D7) U1 m z rmD • On 2^ rn Dr- N N - W 372 ff 2" z m 6 „ O l -- n m - r- .) 10 4 I 1 L D 1 mD 0 oz � _ o n — I C O rn 18" MIN. i ivy —e .1 . . . - 73 i ` A. G D n p O 4 n rt r O z 37 I I 22 t-) _ ' 1 N ., 0 — m p m 0 N m N r -{ D U Z 0 1 r N D N — i* x,m X D r n c) 7JO Z D I 71 m -H r pi 0 m D-i X ( .r . 1 D r M n �� 0 m D D D z r r C_ U) O —I z-< FILTER CANISTER DETAIL SCALE:3 /4" = 1' REV NO. DATE: m WIESER COOCAETE DRAWN BY:SWT z 111 SEPTIC MANUAL W3715 US HWY10. MAIDEN ROCK, W 54750 DATE: JANUARY 2008 J \� REV. JAN. 2008 800-325-8456 - FILE: SHEET 13 u. N 00'51'27 "W 954.89' 4 • F31 .89' ] _ N •r *AP ,e i / r T 0 � • N N • N „_ -.1 O i ''1%• • r-, / 01 A. .0 v 9 / �� — / n G 4 !C/J j (D 41) cp cit co/ ,a CD • m / � �1 ��v ,Y • , w F / "•(:). C.' IS o I f ■ O N O \ / _ d / 1 ii:\ ti • � �� N / e co 0, z O O u 2 0 / CO) 0 n ..0 w N - *I N V to 11 k ------ • 1 \ 12 7'0 1 N� X456 • os ? • 0 � v 01 i. r A 1 0 .9 F N ~ O � W ! 2 9 6 , O N � /10 CO • • N 3 '4, N 11 .,r • \ co O l m OD 4s 6 6, \ 'Y (l) (A N " --I cn v ' . � � K d '� C/) { � ,F 9 06, n A) to n 4 .. ii 4 G \ •9d\ � o N 4 a 4 rn m N x CD 1 CO A. 0 Ch 3 33' to i Gj ' * N / m 00 ^ N CBS w, N b • I • .p \ 9 J , N N \4c1)' 2 Q ez> „, cv N • ..._.. a, i> 0 °° g f n c " . 0 - _ . 295.58' CD 8 y , • \ y m 79.58' 03 6 0051'49 "E 216.00' m n 0) ' 0 a ,0 — • s 00'51'49 "E 145.58' ■ I X5.8 001 oe!,• 1 m ° r 0r ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND �r OWNERSHIP CERTIFICATION FORM — C � Owner /8 O1)/ e/e Mailing Address l /� Property Address 557 Gt a ff — ,-i �Ae 04 (Verification�fequired from Planning & Zoning Department for new construction.) City /State //u- . -) �/. Parcel Identification Number 49 // �s gd ". � , LEGAL DESCRIPTION Property Location .564J IA , i CI /a , Sec. 2 / , T 2- 9 N R /9 W, Town of h. czso r . Subdivision PrR ;rise U %5 , Lot # / . Certified Survey Map # a4 , Volume , Page # `— . Warranty Deed # ij 3 / 1 690 , Volume O SD , Page # ` . Spec house no Lot lines identifiable 40y ,,.• 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. I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedroo s 1b IGNATURE OF APPLICANT(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) 6 9 e%/ 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 E/ 537 Gc..t &ket. L crL. residence located at: 5(0 '/4, SE 1/4, Section z/ , Town .29 N, Range /9 W, Town of , 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 service Oc.... -Z iC /0 Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: y64- gallons minutes Capacity: /ow", Construction: Prefab Concrete Steel Other Manufacturer (if known): 4 ew C'CriC,e' e, ge o ' ank (if known): _ s /45.1. Le /c2i 4 Ark 410 e—irtrioo5c-in •censed Plumber Sig ature) (Print Name) (Title) (License Number) /MPRS (Date) Fonn to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) eat o c// DtaCUMcN NO. . STATE. BAR OF WTSCvl%i$Ii: FOP T —$ t ; 7,,,, sawct P�egyca :FON R<GOROtNO DATA • r WARRANTY DEED 5OP *GE 223 REGISTER'S OFFICE Ix Sam E. Mill er, a loin a 3st�an;._ Tills -Deed, ma3e between -- ------- �.--•-•----- L'�Cf_fgt. G4'C} -. - at S i P 011989 , Grantor, M and G A Elert and Kathleen J. Elert, husband and C c ife as survivorship marital property _ -__ i Register of Deeds i - L Vitnesset h , That the s aid Grantor, for a va luable : consideration _ TU _ - _- =-,:._ - - - ___ _ - -_- RETURN TO conveys to Grantee the following described real estate 'in St. Cr2 - -- County,• State.of Wisconsin: =Let 12, Plat of Prairie Vista First Addition in the Town of `Hudson. Tan Parcel" 1�Io : t ' ,, Ta i Th -..--(1,413-; iS not __ homestead property- - " "(is no t }� -` 'Togethir' - w tn` alt and singular the _hereditaments and appurterances thereunto belonging A grantor Sam ...... M iller i t� _ - - `warrants that the title is good, inde.easibie in fee simple a , free and clear of encumbrances except r 1 easements,:covenan -ts and, restrictions of record; if any, l l and will warrant and defend the same. Dated this _:,• 3-lst.--- - day_of August 19 89 - �- (SEAL) (SEAL) Sam E. Miner "" (SEAL) (SEAL) P. [IT1EidTICATION AC7I OWLEDGMENT Signeture(a) STATE OF WISCONSIN ss. n St . Croix r.,,,,nty. ^ - 31st .da_v of :rthenticatcd thin day or -- --- (q Persanaily came before me tr,;s August 19 $ the above named Sam E. ;•tiller TITLE: ,\IElil1E it .: -1TE 1 3h f)N' R' i.""f "G ^+;rti ID.' r.r,t .- -._.. .._ nathortzr-d by 7•ic.0 , tt r :-.t. •..s,) ` `„ 1.,, *t,.> r, .../.... >+ n r., n<...cj. n�.nn S. _. _ .c 1.o executed the — i r:rr, oir}e tr trutnsnt atilt acknowledge the same. C - I it c , '`), •' HEYWOOD and CARI by Samuel R . Carl `$ ` - `. Tarn ra K FIert t P.U. Box 22'). WI S401.6 \-,,:- t., . >i . F- ..... ,r, 1.t'; " • .. 12 -22 . ii -'1 •t 2233 Wisconsin Department of Commerce SOIL EVALUATION REPORT 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), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 0- 1185 -80 -000 Please print all information. R iew Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). U1/1/1.,3-j- l / I/ 1 0// 6 Property Owner Property Location Gary A. Elert Govt. Lot SW 1/4 SE 1/4 s 21 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 140 South 3rd Street 12 Prairie Vista !st Addition City State Zip Code Phone Number 1 City J Village A Town Nearest Road Stillwater 1 MN 1 550821 Hudson 1 Wagon Wheel Court New Construction Use: J Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD e Replacement 1 Public or commercial - Describe: Parent material Glacial Outwash Flood lain elevation, if applicable na P PP General comments and recommendations: Site suitable for cony . ': - POWTS dispersal cell with 0.7 gpd /sq.ft. /day loading rate. Propoaed trench eleations to .e 93.00' Existing system elev. = 93.75'. 1 Boring # J Boring Pit Ground Surface elev. 97.64 ft. Depth to limiting factor >115" 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 -10 10yr3/2 none sil 2fcr mvfr cs 2vf,fm 0.6 0.8 2 10 -25 10yr4/4 none sl 2msbk mfr cs 2f,1 of 0.6 1.0 3 25 -34 7.5yr4/6 none gr Is Is 0 sg ml cw 1vf,f 0.7 1.6 4 " 34 -800) 10yr5/4 none / sD 0 sg ml gw - (0.> 1.6 5 \- 1317-15 10yr6/4 none s 0 sg ml - - 0.7 1.6 -5-- "Col l VW. (4 * Soil observation below 102" completed by use of hand auger. 2 Boring # J Boring M Pit Ground Surface elev. 97.72 ft. Depth to limiting factor >112" 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 -14 10yr3/2 none sil 2fcr mvfr cs 2vf,fm 0.6 0.8 2 14 -26 10yr4/4 none sl 2msbk mfr cs 2f,1vf 0.6 1.0 3 26 -38� 7.5yr4/6 none gr Is 0 sg ml cw 1vf 0.7 1.6 4 38-75) 10yr5/4 none r 0 sg ml gw - 0.7 1.6 5 75-112 10yr6/4 none s 0 sg ml - - 0.7 1.6 g(o " G 02 oil obs rvati n below 98" completed by use of hand auger. * Effluent #1 = BOD 30 < 220 mg /L a d TSS >30 _150 mg /L Effluent #2 = BOD <30 mg /L and TSS < 30 mg /L CST Name (Please Print) Sig ture: / 110P CST Number James K. Thompson o� _ ?CI— 3602 Address A.C.E. Soil & Site Evaluatio Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 10/29/2010 715 248 - 7767 Property Owner Gary A. Elert Parcel ID # 020 - 1185 - - 000 Page 2 of 3 3 Boring # ___I Boring ✓J Pit Ground Surface elev. 98.37 ft. Depth to limiting factor >114 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 - 10yr3/2 none sil 2fcr mvfr cs 2fmlc 0.6 0.8 2 9 -22 10yr4/4 none sl 2msbk mfr cs 2fm1c 0.6 1.0 3 22 -32 7.5yr4/6 none gr Is 0 sg ml cw 1vf 0.7 1.6 4 (3 10yr5/4 none Ls) 0 sg ml gw - (0.7 1.6 5 72 -114 10yr6/4 none s 0 sg ml - - 0.7 1.6 Soil observation below 95" completed by use of hand auger. . , . . , Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rat e 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 Boring # __,f Boring 1 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 (8.07/00) A.C.E. Soil & Site Evaluations . 1 �. -//�. �u /"� 12,4 2-42 C41_ Cie - 3Q e • . et/4 AtZ iOr1/ - • FX /- 9 a-de Q lel/' G4r/ E7ere/OroS./ 6r 6 (.,4) on cOhee./ Crt. Lob /.Z, 1 0 /e'eor Qirie (/.564, 1 54.).SE, See.2 /, T.29/., ,Q /9ov. ( gy p 7.of'/ d5 l Sf.Cr»iX (o'. 1 y 0 �l Pc ...,2.O-//5- 8o -aaa �� ,11 11‘ U 4 z. SB a cress, Cx /:gin, .> iQ�3C 3 bed deu / roo/n � 'I 7 �S � , ic S' Fifth. c-e nc-A ew;‹: •Qo m o S oli n - . 4 off --- e l,.k,l(. SSG. rrtGd e /eU; a /OD. Ct� / c-o o { Y) / / l ' a .S, ix� ., i e s / �/ 414. Q.,N : TopoF.S.T. n14 / CL/sr : E /ems = 97.77' 980 ; / EX/S'Ei�9 WreScr Ce»cre - rx ,' WL/ / i[pec -64,k' r 0 'e /.e eta- c9.3S'r te n^ �, / Ex /s�n_q di�, e..s2 /ee / /a>{ / '� ��97G7' , l/ .5,44.-Ace. e %u = 93 76 :. } o spruc tf« / 97,8 / j , 3• .. ,c,, S ec Y / / a4 'E 99.•30' 4��� / c 9B. co' ib.30{'. I ocaol E : Col 3 m A -1 d co r) • Fe 1 AT ■ Cn 3 EEIKF, °-a 3_ N c rill • °° n S . ` Z y o m N ' m o 0 N 3 > (.0 O A CJ1 r N a = ` 1 F. ° -0 n 7 7 CD a O '' ° O a a * 1 -'' 8 S 1 t % r t, o W co c m iit c\ 0 a 1 le■ftr C ' -< m co n r cn I co N, v I "0 '0 v = i gi � y , u • o u.) 13 N � M I 0 O to to cn i ool Q' W f m W (D Zi 3 CD • FP C) 3 v N o csi z m 3» a (�� 0 0 oco • • 0 0 co m !+r • m co m y ,y 3. C N N • fD I w m a • • I a 3 7 CD Z C a p Z m m a A 0 �I a. X 1 1 0 Z a A .T1 Y co Ilk F! Z m 1414► w • • • \ D a o' — w a a • � m N yi A. • (� y A. 1 I • W ft °c)1 a . • 11 A N O O a Q I O t • Ob { et H • Efl v • V 0 Its ti• • r 06 05:13 PM Parcel #: 020-1185-80-000 02/15/2006 1 OF 1 Alt. Parcel #: 21.29.19.1170 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co - Owner O - ELERT, GARY A & KATHLEEN J GARY A & KATHLEEN J ELERT 1378 HILLTOP RIDGE HOULTON WI 54082 Districts: SC = School SP = Special Address(es): * = p Property Primary Type Dist # Description ` 551 WAGONWHEEL CT SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.380 Plat: 2354 - PRAIRIE VISTA 1ST ADDITION SEC 21 T29N R19W LOT 12 PRAIRIE VISTA Block/Condo Bldg: LOT 12 1ST ADDITION TOWN HUDSON Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 21- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 850/222 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 92992 241,700 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.380 76,500 170,000 246,500 NO 05 Totals for 2005: General Property 2.380 76,500 170,000 246,500 Woodland 0.000 0 0 Totals for 2004: General Property 2.380 31,900 134,700 166,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S4/27 " l 24/ TOWNSHIP /y _z ' ,A i SEC. z,/ T 27 N -R ADDRESS y Z ST. CROIX COUNTY, WISCONSIN .3 SUBDIVISION f (a r r` & V i s l c( LOT f Z LOT SIZE Z•O / / C¢,✓5 PLAN VIEW Distances and dimensions to meet requirements of I•LAR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM wQgo wl,4.a_ l 're a; t A o F a 3 No s 20"i 6*r4 tt Ga � a tv X$2 ; • 95 s /off A 46 I\ INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used / � /07 1',_ ///. (U Cor ice✓ Elevation of vertical reference point: 110-4 /OOoo Proposed slope at site: /-e% $• W SEPTIC TANK: Manufacturer: (.dam,' s Liquid Capacity: /000 ✓ G o ,/ Number of rings used: / Tank manhole cover elevation: yy _ P. S Tank Inlet Elevation: 7, 7V / Z/ Tank Outlet Elevation: d = q7. 8S Number of feet from nearest Road: Front,. Side,O Rear, O 13 /-/ feet From nearest property line : Front,OSide,ORear, O � feet Number of feet from: well 75 , building: H (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 4 "D PUMP CHAMBER ,�/ Manufacturer: /� Liquid Capacity: Pump Model: I:Imp /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed:(ar J . e %,4 ( Tr Width: C Lonjth: Number of Lines: 3 Area Built: 6-7z '1 Fill depth to top of pipe: t/f e Number of feet from neare A. property line: Front, O Side, © Rear,O Pt d Number .cif feet from well: 9 S" • Number of feet from building: I'D VA (Include distances on plot plan). H 91fr° 974k5 p 11 on, 56 N SEEPAGE PIT 9 i'S Size: / Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: 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 � y� Manufacturer: / �/r Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: 411 21L. _ License Number: _51-7 3/84:mj r - - •DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION ^. O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 SW1/4, SE4,S21,T29N -R19W MCCONVENTIONAL ALTERNATIVE StfassPgned)D.Number. Town of Hudson ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound Lot 12 Prairie Vista 1st Addition NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSP TION DATE Sam Miller Box 282, Hudson, WI 54016 - ,Z5-ef q i o; aryl H MARK (Perman refer ence point) DES IBE IF DI ERENT FR PLAN. REF. PT. ELEV.. CST REF. PT. ELEV i Alails., i ( 0 Name of lumber `\ MP /MPRSW No County Sanitary Permit Number: Poug Str , 5432 St. Croix 119505 I SEPTIC TANK /HOLDING TANK: 1 h4.4, -4 JJ MANUFACTURER LIQUID CAPTY TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER ��11 '' �� Il JJ y'' PROVIDED PROVIDED .?/ f V V � ,� - '' ', l3 -DYES ❑NO OYES .❑NO BE* •ING: VENT D A.: VENT MATL.: HIGH WAT R NUMBER OF ROAD PROPERTY WELL BUILDING: VENT TO FRESH , ' A /..• ALARM FEET FROM l LINE AIR INLET El YES I NO / ❑YES • O NEAREST— ✓ 1 DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY. PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CON OLS PER TI A NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) 0 S NO NEAREST*. ) SOIL ABSORPTION SYSTEM. Check the soil moisture at the de th low ng FORCE LENGTH DIAMETER 'MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction s all cease u til MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH LENGTH. NO. OF DISTR. PIPE SPACING. COVER 'INSIDE DIA. #PITS LIQUID BED/TRENCH TRENCHES: TERIAL' PIT DEPTH DIMENSIONS VJ .t `)..A) GRAVEL DEPTH FILL DEPTH DISTR. PIPE IDISTR. PIPE (DISTR. PIPE MATERIAL: NO. tER NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH I3 BELOW PIPES A ' E COVER: ELEV. INLET ELEV. END ^ PIPE LIN AIR INLET \� �` 911 C U 101 I U s dk� 3 NEARES T ... >r• , MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER (TEXTURE PERMANENT MARKERS: OBSERVATION WELLS ❑ YES ❑NO ❑YES ❑NO 'DEPTH OVER TRENCH /BED 'DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED CENTER. EDGES ❑YES ❑NO ❑ YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: �s WIDTH. LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER ° BEDENH , ' ' '. TRENCHES DIIMIENSIIS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR. STR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.: ELEV.: DIA - . EL PIPES DI DIA.: ELEVATION AND I+t s RMA 1 1111 V HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED II RMA ION , PLANS ❑YES ❑ NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS NUM RR F , PROPERTY WELL: BUILDING: FEET FR LINE: ❑YES ❑NO ❑YES ❑NO NF Tw ( A '-' 5 t,,,,,,,,,,--,_,___________,,s, 3 71 / :>, ( O u 1 Sketch System on - 1 Retain in county file for audit. Reverse Side. 0 SI U: E: ( TITLE 0 • 1 i Zoning Administrator I DILHR SBD 6710 (R. 01/82) /�� ".,y, c) SANITARY PERMIT APPLICATION £DIL.HR Coin �o / x In accord with ILHR 83.05, Wis. Adm. Code STATE SANITA Y PERMIT # - Attach complete plans (to the county copy only) for the system, on paper not less than // � s05 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Sash / /e-/ SW ' /asiE'/4,Sz/ TZ /7 E(O0Y) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # /2-- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER #Isat 60 S%% (3 $G ) 2769 P /� I /7 /sty{ /u/ II. TYPE OF BUILDING: (Check one) OILY NEAREST ROAD ❑ State Owned ❑ VILLAGE /./„. f/'S c ® TOWN 9F rl Par hJlias� Kok v7 Public p 1 or 2 Fam. Dwelling - # of bedrooms PARCEL TAX NUMBER(9) / III. BUILDING USE: (If building type is public, check all that apply) / 1 ^1 to -1115 5'cn 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Hom 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 in line A. Check line B if applicable) A) 1. IN New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 N Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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 SO /S 60 4 q ( 0. f 9 3 94 • Z Feet I 7. 2 Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. Tanks Tanks llCC�� structed Septic Tank or Holding Tank k /OoU / 4, • . ¢s . Fl _ _ _ _ — Lift Pump Tank/Siphon Chamber El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature (No Stamps) MP /MPRSW No.: Business Phone Number: Do stcox 6QicH �.crc G� /SIP -Sy3 Z. ( - zVV7) 32. 3 Plumbdr's Address (Street, City, State, Zip Code): teie N`..4- i � h ,ems / /rvl s yon 7 IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater . a e ssue . Il ing Agent Signature (No Stamp L S Approved El Owner Given Initial {/�� Surcharge Fee) / 9-� Fx � / Q / 1 Adverse Determination '7 �J CO � A,' X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: • SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber r "" ' . j INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the 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 & 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 in 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 in #1-7. VII. Tank information. Fill in the capacity of every new and /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'.6 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; E) 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, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) Fr-;.1-' I.. 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_�,,-, 1,77: / /dv Location of property S ') 1/9. S 1/4, Section / , T?' N -R " 9 Township /4fu�, - Mailing address idox4 z 8L_ /41 5'ge) 16 Address of site /J2 1 kJ //ei K; 4 i` - Subdivision name / ( K' cr /- Stec /7 Lot number Previous owner of property Total size of parcel z- 390 Ile'/ce' Date parcel was created ?/ Are all corners and lot lines identifiable? _Yes No Is this property being developed for resale (spec house)? Yes No Volume and Page Number `/`V 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 references to a Certified Survey Map, the Certified Survey Map shall also be required. 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. yZ ,? G,$' ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. 04 c-yco ). Signature of Owner Signature of Co -Owner (If Applicable) Date of Signature Date of Signature L_ , * ,`S a ?'; °""' *er s "� `�' , R , , . .,fi,"'NVIralortzi'4, .; ''-i 'i;r:1 '''':. ,, , '''''''''''',.':":1.47,‘Ii;i'.; .il#,,:ll'ii? :i'i?:.!7',!%.14'llit.) ! ,.. d '1444/ y f .. „�' rr . :2: ',. w � w • • t 4.=,=.,:, .-.?..r.:=74/isoisi . -,:,,,i .....,.......iiigirrir:P s e x ' , , ';'''', ' .1�. Nw.. k � � s - g ' i: Ake' #„ f r 1..:. i - --. ��..�, •M y ,' ',Y* STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER ROUTE /BOX NUMBER Zo} - FIRE NO. CITY /STATE A4 /sc-,., j' 2- ZIP S % /(.- PROPERTY LOCATION: 4.4 1/4 S 1/4, Section , T- N, R i7 Town of /4. a , St. Croix County, Subdivision erf am- '�zr 77" , Lot No. /� 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 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 verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), 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 Department 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. SIGNEDt� DATE d77 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address --- -- -.- l. (.tJa901. Wk4_4_ \ C-0 * ; s or L1 — �... LDL — A. c:. — 5 (L I I /Zs i '' d 510 ■ 1 - ,�,, N i \ 1,, .-..\ , V lo 8`F — so' Dy F as' ' �, h o v , '. / \ /OO -- -- _ _ / / C L U .i ... .2 s . p �( / �p 4� V �/ RS" �� / / z a 8 , t•Fo,r s , .{{-- Ji5e_ro - ro, f ',. 2 Y; S lea I .51 M M. i # 12 3S Sys E I V. = 96.. Z/ 5c_Q \ ._ „5, -._,i. 7. r � Y�XSZ • 11`S.M- '�s tt",_ ytr + L+b(: 124F. t0;�."t o,-t- 1-1.‘ c 1 �1 M. W, t o fi C ar aav o urt a po� o. I \ C 1enk -P',rc- ` '.((A5s S 'Ely. = /dC. o j Et -13or4 (t3q, K , 1 N Y b- i ( Tc.rtc30 . 11 - 0. IV. _ 9(.,.z') s`.; t, 4 fa- 4 ✓`,, 1' Au % s/0 ,.— 5_ L,v ...,-.3 ,,,,,,,,......,, j ::x---,__ 4 _ e „ , \ /frt to — j -- i. 2.___ /(. :I 1 P _ I _.. so..f„ /6”" N S32 ]) ( 4 /o sce. ,,/,..) L 7HueP.AN ARr"14MTO REPORT ON SOIL BORINGS AND SAFETI� &6UILDINGS / USTRY, DIVISION AND P ERCOLATION TESTS (115) MA N w 53 07 f4 c.aTa I S (H6308111' & `Chapter 145.045) ; LOC,,ATI O N, "` : LOT NO.:BLK. NO.: SECTION: TOWNSHIP / I SUBDIVISION NAME: ' /4 & /4 1 ' . WL9 N/I � (o Jo: ,4i- 1/' ,,,,_ vi /�£ 7" CQ UN'V�• + Y :' OV NER'S /BUYER'S N AME: ' 'MAILING A ' ' /� - 1 0.41 sf r � E DATES OBSERVATIONS MADE NO. BEDRMS COMMERCIAL DESCRIPTION:' PROFILE DESCRIPTIONS: PERCOLATION TESTS: pc Residence New ❑ Re lace 3 R p /o -� Y aP�' /o -� y _ s oy ' / iw.o /!I RATING: Sft Sit• suitable for system U. Site unsuitable for system ( 6- ; . f r g e , �d .�° /� � ' �jt..• £ � �,V �T`I(�f�f1L: MNO: �� IN -G y Q � •S E� � . N-F�LLHO RECOMMENDED SYSTEM:fo�onail ��„ +� ,TZ M � T J(J(,„,,,��IUU SS [gU S 4U Co.As , / c !,Pict,. _ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the unders.H63.09(5)(b), indicate: /a//7 Floodplain, indicate Floodplain elevation: .f //9' PF1 E DESCRIPTIONS BORING TOTAL/ • P H • R. NDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH' NUMBER DEPIN ELEVATION OBSERVED R :I[iElL 111.1TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.) 15111 ,,,,.., , 7 i6/ , ,S is • . :r,. ' 00. ' 7.J'' , ..,, s s .s'' tlo,S"' > 7..r' /. � a/1 6 B.. /, • 7 AI - s /, • l /47 ''' ''':, NEM o/ 7 ,f--, i !' s a, PERCOLATION TESTS . . ATER IN HOLE TEST IM • - • • I WA R L V - L -I' H S RA INU y " : H AFTERSWELLING INTERVAL-MIN. a�(: .. t • • �;ZgJL•]!1c PER INCH e . 0 , � ai P O'I'PLAN; Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the,ho ltal.' vertical elevation reference points and show their location an the plot plan. Show the surface elevation at all borings and the direction and p eiIc ent of i ilppe; " 3 ,SYSTEM ELEVATION 7 E:52. i fs g , e ct III��� to ` J i � y.w ' ( / /� i. . ' l , f . r , i 1 1 , 0, ____I r , , o ; I ! ) , ,. d s 1 ` I 1 air . u.' ' w / , , .,., ,.. 3 3j r L-.) ,.. 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 the location of the tests are correct to the best of my knowledge and belief. ^NAME print): "' ' / TESTS WERE COMPLETED ON: h f� i 1 ` ' [// `c` s k � A "' .Z r- ri7� AbDR CERTIFICATION N NUMBER: PHONE NUM$ERfoptional }: `‘ i er L� d. it." . o/. 3 f - o s 14 ,, 7 D['$TRIBUTIONtQri hl and one copy to Local Authority, Property Owner and S' 9 Y oil Test er. DIi HR•SBD -6395 (R. 02/82) — OVER -- , , , it „14 r 1 7 ' ..%.-"° ' ± op (A 'S la A 4 A A s s\\)` - • . J .. ..t 0 I .( \ \''}. : ..N • 4 . . F1 . ............-.1%.+,.................,- .1, ... .. 6 rip H t .� • h W • G q t 6 .1 1 o P ?1 I P • �' l - 4 .,..,.i.:"..p -,.....,..----•;. . .1 • --I- r . D • $ A '�'' o -d . �r I 4 "} 0 3. H . p � '�--_� 0 .-- s Q 0 s s. . • o , , . t P ..t, • • , .--� P o . • • o� • s