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161-1095-40-000
Wisco�isin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division t r INSPECTION REPORT Sanitary Permit No: 515097 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 X Village Township Parcel Tax No: Paton, Earl & Starr I Village of North Hudson 161- 1095 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: d t Section/Town /Range /Map No: 13.29.20.757 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. E,.; s+-, w L'. 7.35 M Z. ✓ aZ, Septic , Benchmark Dosing �- 5 ✓ o r Alt. M. ` C 7• Aeration _. -____ _ Bldg. Sewer Holding I ,/ �- St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet 7•�� 9y .�! TANK TO P/L WELL BLDG. Vent to Air Intake ROAD et+nfet- Septic / Dt Bottom -7.% Z °!y, 5 Dosing Header /Man. .S 93. S Aeration Dist. Pipe 9 v, 93 . I - S Holding Bot. System PUMP /SIPHON inal Grade � ON INFORMATION '�. 7 Manufacturer Dema St Cove t x Model Number TDH Lift Friction Loss System H TDH Ft 1 7Z -73 Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM \/. t BED /TRENCH Width / Length to'Of Trenches PIT DIMENSIONS No. Of Pits Inside DW_ L DIMENSIONS 3 66 �� 3 «�� GIB `" -- SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer , 1� INFORMATION Type Of System: ♦ CHAMBER OR c:, �t c. � Z7 n r,;\�. UNIT Model Number: DISTRIBUTION SYSTEM Scnj�..,_ •,¢ s 16+-1 1:5 4r ��¢• Header /Manifold // Distribution i x Hole 'ze x Hole Spacing Vent to Air ntakr- Pipe(s) %.-_ \_ � N__1 3r Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over j xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center fi� 5 0 Bed/Trench Edges Topsoil Yes ❑ No Yes 0 No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 240 Station Lane Hudson, W 54016 (SE 1/4 SW 1/4 13 T29N R20W) St. Croix Station Lot 33 Parcel No: 13.29.20.757 1.) Alt BM Description = 4- / -.J-_ a -• 1 7r J-•— Cam• ...: 2.) Bldg sewer length /l) vwt✓G � . �iJ-- /V�e.. - 7. � - amount of cover = V G k ' 1 t _ � - 7 , V Plan revision Required? ❑ Yes No --7 7_4� — Use other side for additional information. _._____ ___ - __p YJ J SBD -6710 (R.3/97) Date Inse cto s Si n re Cert. No. I P A� ID i�- 1 commerce.wi.gov a and Buildings Division County N 201 W. Washington Ave., P.O. Box 7162 St. Croix i s c o n s i n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce S� Permit Application State Transaction Number Sanitary 1�P Na In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary p urposes in accordance with the Privacy Law, s. 15.04 1 m , Slats. I. Application Information — Please Print All Information Same Property Owner's Name REC EVVED Parcel # 161- 1095 -40 -000 H. Earl & Starr Paton / y 3 Property Owner's Mailing Address JUL 0 8 2009 Property Location 240 Station Lane Govt. Lot City, State Zip Code Sft OFFICE SE' /e,SW' %, Section 12 Hudson, WI 54016 P 6 - 7018 (circle one) II. Type of Building (check all that apply) Lot # T 29 N; R 20 W ®1 or 2 Family Dwelling —Numb r of Bedrooms 3 ! 1 J f, 33 Subdivision Name ���/// ✓J " Plat of St. Croix Station Block # ❑ Public /Commercial — Describ Use Q El / Na City of ❑ State Owned — Describe Use ® �/ ,/� CSM Numbe r Village of North Hudson VA� �,"k • Na ❑ Town of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A, Fj New System E Replacement Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) System B. ❑ Permit ❑ Permit Revision ❑ Change of ❑ Permit Transfer to List Previous Permit Number and Date , I "Psued Renewal Before Plumber New Owner r'qt� # SO ` l Y Expiration IV. T pe of POWTS System/Component/Device: Check all that appl ® Non - Pressurized In- Ground [:1 Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil le soil F Holding Tank ❑ Ter Dispe ompone (explain) P etre�tment vice plan Hoot H - 600 / _ Q V. Dis ersa reatment Ar formation: � Design Flow (gpd) Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed s System Elevation 450.00 sq. ft. 0.50 900.00 sq. ft. 917.40 sq. ft. 92.75 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o o U New Tanks Existing Tanks u 0 F w a Q F Septic or Holding Tank Wieser filter 1,200 1200 1 Wieser Concrete El 0 El El canister 2-0 C 4 A (�/ p �ts � 5a Dosing Chamber I U f hmv ❑ VII. Responsibility Statement- I, the and signed, assu a responsibili costa on of the POWTS shown on the attached plans. _ Plumber's Name (Print) Plumber' S MP/MPRS Number Business Phone Number James K. Thompson 30021 (715) 248 - 7767 Plumber's Address (Street, City, State, Zip Code) 340 Paulson Lake Lane, Osceola, WI 54020 - 5413 VIII. Coun /De artment Use Onl Approved _ Disapproved Permit Fee Date Issued suing Age t Sign r Owner Given Reason for Denial $ j /, , / ' y - ,� _ IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: e� d 1 Septic tank, effluent filter and dispersal cell must all be serviced / mainta ined ,try vi 0 as per management plan provided b y p lumber. � / 2. All setback iuquilq I -- Ohp. URWY6 ns or a system and submit to the County only on paper not less than 8 1/2 x 11 inches in size as per applicable code /ordinances. SBD -6398 (R. 01!07) Valid thru 01/09 c e; p syo s6r -6a� Za lc C V // dsa '7, 4.04 sv64 0 I 4 /6 ,�- . Cro,, - s E//ysw�y, sec.. /z, f Tn aF 44�dsv>! r/iI /age o,'-'/Z S- ,Grojx X 04 EX�'s nq welt U dr! ✓e�ay EXi,5 �i n a V-4 ac : 46&m Ole 5,b4�. AssaMCO/ I � ol. fll /S�,4e ir r r r��fb3�{CPi�Cdrrlsn��rs�OC/Sq 16X!1. �- ,+�' /+`l�i'UC .Sw� ; I ! /r r /S " Q'S ( �T - i 1 F/l�1L�G1O ir7 (CIS �r /a 14 6v 6e inSEu/ /ee✓�v ,� r EreneJL. F.�,C; /frQ�rk' Sk /�U a / /ow Sy�s6— 64 , cia- & e. r ,1 r°,P.S, PY ��. 3 oF, Soil Absorption System Cross Section -- --�..� 94. zs ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap 9j27� ft Leaching Chamber 9-� 75 ft System Elevation .2.83 ft 6 .6 0 ft ft Soil Absorption System Plan View WO ft �. &3 ft to ft Leaching Trench 1 Chambers 4" Dia. . Trench 2 Header Vent Or Observation Pipe Trench 3 Leaching Chamber Specifications Manufacturer And Model EISA Rating .20.D ft per chamber Soil Application Rate 0.50 gpd /sq ft i 445 0 -0 gpd Design Flow 0.1 Soil Application Rate + -. EISA = 5 Chambers 3 rows of /S chambers each. Page of � ■ So, /e ✓a /c�,S%nnPl� ♦ 67v3-b-) y y de e(ea: Lo ca.�P� �ptCia. S � Cal *W- 11.2/69 lll� 1 4 syo s6r-6 ?n O Lo�33,� /Q�ac'S6.Croil�� -�'on, S E//ySwyy, Sec.. 12, 7 Z 91I., ,P 26 (.).� Sb • Cro Ca. cJ4 Safi ors Lrc ne_ U dam; ✓e�ay 0 L7,r, ng btrl CG : ern of 5, y. i .4sttciYjGd GIGµ= /OD•GD, a EXi Svc nq /, c0 � i l�ropostd �� A0' CP C/ 1 cu en ✓al ✓G i e �d�- , � /' � l.C�iCStt COriCfGSG �;lE'¢�Cl+•niS�� ,4 r Propescd r9ah am 416 dis / eel/. ° �� � /s "Q -•1 "T- ++F.' /eYsda^ Cha..,Gvs�� da /dC {p r bci "SEca/(cc✓fv ,' r / r r r 6tencl�. F /6ad�S.�ii�ce 6 6e �' rr i B2 ere�l� bG= 9,2.7 da.6e. ' / r r 33o•ao' r r /6.6 al 0 0 564 5.-- ��. 3 oF•3 , r PAI i 1 2169 ' 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 Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 161- 1095 -40 -000 Please print all information. Reviewed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner KhCI=IVtZLJ Property Location Earl & Starr Paton Govt. Lot SE 1/4 SW 1/4 S 12 T 29 N R 20 W Property Owner's Mailing Address JUL Q 8 2009 Lot # Block # Subd. Name or CSM# 240 Station Lane 33 St. Croix Station City State Zip Wt0opeNwIll City _0 Village I Town Nearest Road Hudson WI WAdWY & Z �- T-5018 North Hudson I Station Lane New Construction Use: 0 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement J Public or commercial - Describe: Parent material Glacial Till Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for replacement conventional POWTS using 0.5 gpd /sq.ft. loading rate. Boring # J Boring 16 Pit Ground Surface elev. 98.40 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 -10 1 Oyr3 /2 none sit fill na na as 2f, 1 m Na Na 2 10 -17 1 Oyr4 /4 none Is fill na na aw 2f, 1 m Na Na 3 17 -32 1Oyr3/4 none Ifs Osg dl cs 1f,2m 0.5 1.0 4 32-43 1Oyr4/4 none Ifs 0 sg dl cs 1fm 0.5 1.0 5 43 -65 1Oyr4/6 none fs 0 sg dl cs - 0.5 1.0 6 65 -112 7.5yr4/6 none s Osg dl - - 0.7 1.6 Boring # I Boring 16 Pit Ground Surface elev. 99.35 ft. Depth to limiting factor >122" 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 -7 1Oyr3/2 none sit 2fsbk mvfr as 2fmc 0.6 0.8 2 7 -21 1 Oyr3 /3 none Ifs Osg ml cs 2f,1 me 0.5 1.0 3 21 -51 1Oyr3/6 none Ifs Osg cil cs 1fm 0.5 1.0 4 51 -62 1Oyr4/6 none s 0 sg dl cs 1fm 0.7 1.6 5 62 -72 7.5yr4/6 none Ifs 0 sg dl cs - 0.5 1.0 6 72 -122 10yr5/6 none s Osg dl - - 0.7 1.6 i " Effluent #1 = BOD? 30 < 220 mg/L ind TSS >30 < 50 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) Signat 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 6/22/2009 715- 248 -7767 Property Owner Earl & Starr Paton Parcel ID # 161 - 1095 -40 -000 Page 2 of 3 $ # J Boring ]Boring i/ Pit Ground Surface elev. 97.55 ft. Depth to limiting factor >106" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -5 10yr3/2 none sl 2fsbk mvfr cs 2f, 1m 0.6 1.0 2 5 -19 10yr4/4 none sl & gr. 2msbk mvfr cs 2f, 1 m 0.6 1.0 3 19-46 10yr5/4 none Is & gr. 0 sg ml CS if 0.7 1.6 4 46 -62 7.5yr4/6 none gr. s 0 sg ml Cs - 0.7 1.6 5 62 -106 10yr5/4 none s 0 sg ml - - 0.7 1.6 F-1 Boring # J Boring _f Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Gp Dtft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # Boring _f Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD s.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 & Site Evaluations r Jo;�2 ✓Q /Cc�fi'�1Pi� A 5N:3 grade elea SE y y scv{�, Sec.. / T z 9i/., ,Pza �•, Tn. aFw-dsvn, 0F/Zort� s-, Gra yr Co. cJ /. o9 6Ea:6 orq Lsctic EX�'sfi�c Well cr�bc \ V dr; ✓e�ay 0 .� EXiS�in Asf4MtEJ� �G[�` : /OD. CD v i W: c Sa r Cvr er C X81 aq i tan E /ec, a 6 0U ti4-7 = 9s! Sri' -' i ol,�,ol�saJ C'� //. � � ��' � � Pro/�std�cp,Eacan�rt d,•S�ocis4 /Ce! /. s„ /�la�i'vC �corkiee i r i 7fi, (a) ter4c4.esael.b3:r(.L e ! c v = 9 OS "T-{, F,' /bid►^ Cha.,, bcrs,arr !/a.1r/C 6einsEri / /GL✓�U a 64 ere be = leuse�d ada,�cc�r.�e '� i i r B2 da. 6 e 14 /E. Q r : off / s62 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND / OWNERSHIP CERTIFICATION FORM Owne f� Z�� � Mailing Address Property Address �rrl2 (Verification required from Planning & Zoning Department for new construction.) City/State cJ/. Parcel Identification Number S5y6 LEGAL DESCRIPTION vi ll Property Location _J6 1 /4 , S� 1 /4 , Sec. /2 , T - N R W, qtr of Subdivision :S crnk s o5 ' , Lot # 33 Certified Survey Map # , Volume da , Page # Warranty Deed # 39 79X3 , Volume 7� , Page # Spec house Lot lines identifiabl yes 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 all statemen n this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by o w ty deed recorded in Register of Deeds Office. Num f _00 SIGN 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) Conventional Septic System Management Plan P Y g 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 5 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. Pump Tank The pump (dosing) tank shall be inspected at least once every two years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. 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 a diversion valve. Valve to be switched diverting effluent from dispersal cell currently in use to resting cell on a two -year cycle coinciding with septic tank inspection and maintenance. Contingency Plan If the septic tank or an of its components become defective the tank or component shall be repaired or replaced to keep the P Y P P P P P 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. DOCUMENT NO. STATE DAR OF WISCONSIN —FORM I WARRANTY DEED it THIS SPACE RESERVED FOR RECORDING DATA �q V" 1. 700 po r �ec-I,,.-de� �q/ This Deed made between ... Charles..E_..G .... Charles- -E. - -• Larson ................ .------------------------------------ --- •---------- - - - --- -- -------- - - - - -- ---- -- ------------------- ------------ ...................... •- ............................. �•�o S /� - Grantor and. - -. H-.--Earl..Pat4zl-- and -- Star r --- E.•-- Eaton --------------------------------------- - -- - - - - - -- - -- --- ................................... -------------- - - - - -- ............................ - --------- ------ _-_------ - - - - -- ----------------------------- - - - - -- ------ .- .......- - - - - -. -• -• -- ....... _.... - - -- - - ---- --- ------- ------ -- ._................. •-- - -• - -- - Grantee, • Witnesseth That the said Grantor, for a valuable consideration..... - --- ------ - - - - -- ---- - - - - -- ------------------------ - - - - -- Y - ------- - - - - -- t. C rOlx " TO conveys to Grantee the following described real estate in ... ............................... County, State of Wisconsin: Lot 33, St. Croix Station in the Village of North Hudson. TaxKey No ........ ............................... is not homestead p This .......... .. .... . property. 0 (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And ... graator.,. ClLarl.as... ,... ,... ?rson -aka• Charles _E,..... arson .---••--•-------• .... ........................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and will warrant and defend the saple. Dated this day of - -- .November • ... ..................• 19._ _. .............- ......• -•--•. - -- •-._._......._._._......_.. (SEAL) .... ......-. (SEAL) -•--....._.. .- •-- -•-....................... (SEAL) ..... ..................... ............... •.......................... (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this . ................. day of STATE OF WISCONSIN 19........ ss. St. Croix .... County. ______________ _____ _____ ____I................ Personally came before me, this ... _. ..__ .......day of i c as »sgdcl +IM 'aa�n *�ifT4 LLAS S'ON )quo3 asna Li �uI 'oo Kuelfi f+aa'I utsuoasfM MONOOSUA SO *dya 511VIS SajnlvuEp 11,7143 molaq pajulad .ao pod.<S aq p1no14e S;loedea due u1 auluEls suosaad jo 90WIN. Ullll (--- ..----- st ' ....... . �cJ / � ('Ad4:SSaDaU IOU D.11 uo;..acdxa a3g�s '.ou ;I) •}uauuutaad st uo►sstU 00 S1q gjog •pa$patMOUxog .ro papniauag1nu aq Auut s3.:natlwllS sc .: `Rlunoo ----- �r"i.odr' �� atigna 6igIoH I zE0 ., Tanwvq fq �,i���•i••`"....� ( * . .. .......... ..•--- •- -...._......._....._..- ---- -- ................... . 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BM Elev.: BM Description: Parcel Tax No.: 161- 1095 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding F Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number GPM TDH Lift Friction System TDH Ft oss 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 DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manufacturer: SETBACK INFORMATION Typeof CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l: / / Inspection #2: Location: 240 Station Lane, Hudson, WI (SE1 /4, SWIA, Section 12 T29N -R20W) - 13.29.20.757 I Plan revision required? E] Yes ❑ No L� Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH , A SANITARY PERMIT NUMBER: _ _ 8 8 e t r F # 6 j [ i k i s, a a >a „.3 ...... ._A. .... .., ,. ;.b. .,,.,,.E : r•®,:. ...,.,....,._ .. » ”, „ _ ....... ..s. � e..,, p s— r y a a "e. r z 8 # 3 e f � f 3 e }T s z a e y 5 E .,...... m "., .,».. ..._, ,e,. mom. ..._. _d '3 e £ e b a � t 8 � r m� �.. .., „. _.e... ........... ...._..... � >, ..� ....s�,� ........ ...... .h-� . ., ---?. ,.. ...._ _'.. _... ,_ ..�,.,.. .....,...; _.. _... ,_ ... .. i r j r . i x } i cV .. .... ._ ” r _a_ s _w " r € P k a t # SANITARY PERMIT APPLICATION 2o 1eE. W and ashington Av e sion I P.O. Box 7969 In accord with ILHR 83.05, Wis. Adm. Code Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the syst o County than 81/2 x 11 inches in size. s • See reverse side for instructions for completing this application � to Sanitary Permit Number (. VF® 6 The information you provide may be used by other government agency pr rams AI//^ eck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. _ n6. � � Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINTA F r Property Owner Name �^ py rty Location To.� 5 !�j i1k; L T Z Ci • N• R 2 E (or)� Property Owner's Mailing Address Block Number City, State Zip Code Phone Number Su n ame or CSM Number S L /!9 •7401 S . C ro' 4 a C_ i v.1 II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road Villae Ej Public 1 or 2 Family Dwelling - No. of bedrooms 14 O J!r jown g OF 4 S + <A \o+4 ( III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) I �1 Za X1 1 ❑ Apartment/ Condo / (. / -10q 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. E] !Yew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ;K Repair 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 1 eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 [] In- Ground Pressure 42 Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑System -In -Fill = It1c it 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) S Elevation ' (5 a � `1, . '1 Cr 3 U Feet `l7• eet Capacity VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ I ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, th S undersigned, assume respon ' ilit for installation of the onsite sewage system shown on the attached plans. s ame: (Print) Signature: (No Stamps) RSW NO.. Business Phone Number: m yr or., S - 3 (z A 1 3 0 s Address (Street, Otly, State, Zip Code): ' / IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssu Issuing a Sig e( o Stamps) p []O Given Initial Surcharge Fee) + /1 u 7 Adverse Determination I Q-5' X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber I INSTRUCTIONS 1 1. A sanitary permit is valid for two (2) years. 2_ Your sanitary permit maybe 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 - 3151. 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 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) fora number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Wisconsin Department ofCommerce SOIL AND SITE EVALUATION Page 1 of 2 Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8'/ x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dirnemsions, north arrow, and location and distance to nearest road. Parcel I.D.# APPLICANT INFORMATION - Please print all information. i6 /— S- C/o Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). By Da 7 zs g 4 Property Owner Property Location Earl & Starr Paton Govt. Lot SE 1/4 SW 1/4 S 12 T 29 N,R 20 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 240 Station Lane 33 - St. Croix Station City State Zip Code PhoneNumber ❑ City [] Village ❑Town Nearest Road Hudson WI 54016 715- 386 -7018 Hudson Station Lane ❑ New Construction Use: Residential / Number of bedrooms 4 ❑Addition to existing building ❑ Replacement ❑ Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ft trench, gpd/ft Absorption area required 857 bed, ft' trench, ft Maximum design loading rate -7 bed, gpd1ft trench, gpd/ft Recommended infiltration surface elevation(s) Existing system elev. = 93.05 ft (as referred to site plan benchmark) Additional design / site considerations Soil evaluation conducted for Terra lift rejuvination of existing hydrolically failed system. Parent material Outwash s & gr. Flood plain elevation, if applica ble NA It S= Suitable for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system ®S ❑ u ® S❑ u M S❑ u ® S U ®S ❑ u ❑ S® u SOIL DESCRIPTION REPORT Boring# H orizon Depth Dominant Color Mottles Structure GPD/fl in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 1 1 0 -5 10yr3 /2 None A 2fcr mvfr cs 2f, lm 0.5 0.6 2 5 -19 10yr4 /4 None A & gr. 2msbk mvfr cs 2f, lm 0.5 0.6 Ground 3 19 -46 10yr5 /4 None is & gr. 0 sg ml cs if 0.7 0.8 elev 97.22' ft 4 46 -62 7.5yr4/6 None gr. s 0 sg ml cs - 0.7 0.8 Depth to 5 62 -96 10yr5/4 None s 0 sg ml - - 0.7 0.8 limiting factor 7 D >96' Remarks: CST Name (Please Print) Signa e: Telephone No. James K. Thompson 715- 248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, 54020 7/23/99 3602 1075 9 10 �4 sr C�o� 1999 s 20 �GN X N� G TY i Aa a z N � $, d r;ve k` V U U 5tat-, Lade- P. A S A r l (p A N �-,%, 3S N ` r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer En, r I k n a Mailing Address Property Address (Verification required from Planning Department for new construction) City /State kA .-& c�— , Parcel Identification Number G f - lv Ct S LEGAL DESCRIPTION Property Location 5 E V4, V4, Sec. / , T - Z 9 N - R "?o W. Town of Subdivision r : x S }t ?'� o' , Lot # '33 Certified Survey Map # , Volume . . Page # Warranty Deed # 3�'1 °� Volume yy . Page # �- Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, 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 Zoning Office within 30 days of the thr ' tion date. p� / SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of U a perty des 'bed ab ve, virtue of a warranty deed recorded in Register of Deeds Office. Q U /4 / T n OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed r w Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER L ' ?. t t' r{ TOWNSHIP T L�';' N -R :: _ W ° V ADDRESS ST. CROIX COUNTY, WISCONSIN ` � a SUBDIVISION .: �✓� „i` LOT LOT SIZE PLAN VIEW i Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM }} J4 Ham /I' 3i 6 f J, la' 1 Al aO, Pkup A9 11 N e INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: I�ieSe Liquid Capacity: lo� Number of rings used: ! Tank manhole cover elevation: Tank Inlet Elevation: � Tank Outlet Elevation: Number of feet from nearest Road: Front, Side ,Q Rear, O V feet From nearest property line Front,O Side, Rear, O feet Number of feet from: well 5 0 building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /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, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: 0 Lengfth: 9 I Number of Lines: 3 Area Built: �V �i Fill depth to top of pipe: I- ID Number of feet from nearest property line: Fr ont, O Side, ® Rear,0 Vt // Number of feet from well: UVU� Number of feet from building: 3 1 (Include distances on plot plan). SEEPAGE PIT 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 Manufacturer: 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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated • Plumber on j ob: License Number: �} 3/84:mj l ��-•' DEPARTMENT OF INDUSTRY,` � 1 \ INSPECTION R ORT FOR SAFETY & BUILDING ^LABOR & HUMAN RELATIONS PRIVATE SEWt SYSTEMS DIVISIOI P.O. BOX 7969 BUREAU OF PLUMBIN( -MADISON, WI 53707 XXCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: (11 assigned) ❑ Holding Tank 11 In-Ground Pressure ❑ Mound PLUMBER TRANSFER NAME OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPE TION =TE: — Earl Payton W. Krattley Lane, Hudson, WI — 5 . 3 � BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: SE SW, Section 12, T29N— R20W,Lot#33,St.Croix Station,Twn.of Hudson Name of Plumber: MP /MPR SW No.: County: Sanitary Permit Number: Richard Hopkins I 1059 St. Croix 58918 -T SEPTIC TANK /HOLDING TANK: MANUFACTUR R: QrI,4, I� LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: tAR1ING LABEL LOCKINSii CO ER t V h q IDED: PR 0 I •O I -7 7. YES ❑NO LJ'YES NO BEDDING: VENT DIA.: I VENTM TL.. HIGH WATER UMBER OF ROAD: PROPERT WELL BUILDING: VENT TO FRES' ALARM FEET FROM . C IO LINE / / I 1 AIR IN J DYES ONO OYES ONO NEAREST M DOSING CHAMBER: MANUFACTURER. 7ING . LIQUID CAPACITY PUMP MODEL. P MP /SIPHON A UFACTURER. WARNING LABEL LOCKING COVER _ PROVIDED: PROVIDED: ES ONO i ❑YES ❑NO I DYES NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERZ A NUMBER OF PROPERTY WELL BUILDING: VENT TO FRES (DIFFERENCE BETWEEN FEET,FROM LI AIR I NLET. PUMP ON AND OFF) DYES NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plo ng FORCE LENGTH DIAMETER MATERIAL AND MARKING or excavation. (if soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: yD WIDT : L GT NO. OF J . PIPE SPACING. COVER INSIDE IA *PITS LIQUID 1 epi-T ENt3H TRENCHES r r ERIAL: P I DEPTH. ,IMEIUS►OIS !� — / G RAVEL DEPTH FILL D DIST . PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRES BELOW PIP S ABOVE COVER: ELEV. IN LE EL EN PIPES LINE: / AIR INLET �� �� �7• / �D Z / 2 9 NEAftES TM D 6 O 3 I � ('I MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE: R NENT MARKERS: OBSERVATION WELLS NO DYES ❑NO DEPTH OVER TRENCH!BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL.: S SEEDED: MULCHED: CENTER. EDGES: S ❑NO DYES ONO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: {" " 'p WIDTH: LENGTH: NO. OF LATER q SPA NG: AVEL DEPTH B LOW PIPE: FILL DEPTH ABOVE COVER: E#? #REt110FI TRENCHES: �'O(11lfIENSIONS . q r MANIFOLD PUMP MANIFOLD DI R, PIPE MANIFOLD MATEFVAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: d ELEV.: ELEV_ OIA_. E V.- % PIPES: DIA.: I.EV AT) C)N,AND DISTAIS JTION LNFQiiMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑YES ❑NO 1:1 YES 0 N COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF: ". PROPERTY WELL: BUILDING: FEET FROM; LINE: 7 DYES El NO DYES ONO NEAREST Sketch System on (/ `f Reta' in county file for audit. Reverse Side. TITL DILHR SBD 6710 (R. 01182) I 'wlSC°^51^ APPLICATION FOR SANITARY PERMIT S HR -D1L r OUNTY oEwxaTmer;TOF � UNIFORM SANITQ.RY PERMIT # If 'USTL7V,LRBOi16 MUrnR7 RELQTIOnS - Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /2x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS Jg� i¢ OA✓ wEsT ��/f 77 Gil - 1o%' PROPERTY LOCATION ,,�� 114Sk 1/4, S 11 , T�/, N, R "E (o W TOWN F: /j�U� ''✓ LOT NUMBER BLOCK NUMBER SUBDIVISION NAM NEAREST ROAD,'— STATE PLAN I.D. NUMBER 3 3 GWl f S r+71oA , -' �k�Tr� 1,4J TYPE OF BUILDING OR USE SERVED PQ 1 or 2 Family Number of Bedrooms: ❑Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. A Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity X Lift Pump Tank /Siphon Chamber Holding Tank capacity N Manufacturer: rl ,L IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total *of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPO D (Square Feet): �� Private El Joint ❑Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): HOMESITE SEP P LUMBINI"*. ature: MtP' /MPRSW No.: Phone Numb �� RT. 3 O'NEIL RD., HUDSON WI 1.54016 .3.30 7 1 /f 1 30(O O/ �f Plumber's Address: ROB -1. Name of Designer: WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. MIN N, INSTALLER & DESIGNER LIC. NO. 00663 COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: F Date: ❑ Disapproved ❑ Owner Given Initial 1 ,2 — tS7 Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber . P .B.L. 67 PL.O T_AN D CR S EC 10 ?fN P ROJECT P L U M__B E 1� N A M E NA ME L O C AT 10 N _ L I C E N S E - DA E _�- P L0 M A P �T~ O i J f 6` m 3 -�-- N 411, a 3 .� i a i .R _ 1451 VW 5 y t ao� g o a< S,(�,)• �.o� C o fir_t� FRESH AIR INLETS AND OBSERVATION PIPE CROSS SECTION f Approved Vent Cap Minimum 12" Above Final G a d FI NI S Le d Gr Ad e 100. S Ft. on �ess ' !c5 M�Xi mu�n o� ° FF 4" "Cast Iron Above Pipe Vent Pipe To Final Grad Marsh Hay Or Syn Covering Min. 2" Aggreg� e Over Pipe Distributio Tee Pipe S Aggregate Perforated Pipe Below Beneath Pipe Coupling Terminating At �G Bottom of System J DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, 1 DIVISION BOX 7 JLABOR AND HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP W7H +TY: LOT NO.: BLK. NO.: SUBDIVISION NAME: SF '/4 '/4 i /T-'f N/R a°E (o 33 S/ c oix sTf Tio u COUNTY: OWNER'S NAME: MAILING ADDRESS: 51 4o / •X �1ipL Afro �vFS7 ,P�rT 4 ;,a . /UO�o h�v ofo� 40 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE TIpNS: PERCOLATION TESTS: Residence N � New ❑Replace I QG� Zf; � RATING: S= Site suitable for system U= Site unsuitable for system S S 'CS' / * ' " S 11*0,41W CONVENTIONAL: MOUND: IN- GROUNDPRESSURE:S STEM- IN- FILLHOLDINGTANK :RECOMMENDEDSYSTEM:(optional) ❑ S au OS E DS ©U El ©u OS DU h oa v� s sre.,� wired DESIGN RATE: 4 If any portion of the tested area is in the under s.1-163.09(5)(b), indicate: Fl in Floodplain elevation: If Percolation Tests are NOT re PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH , ELEVATION OBSERVED EST. HIG HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 4AJ s 3.p • reu -Gx s ca/ -f. . a,e -Gy. B- / /.d 3 Hofs .f7 3 a.o 's,•47 .s fvv Wiol -k aA -6 Y. �'►o f s , /. D ' Mo t�ti< v s / �,� Gee . B r -2.� Ra -� /s w/( N.� /tip ,ail ops of /O Al ` F -C f . Gg -6 , Y d7`S 4 7 - B i s ; V - I s -s Oxp1an = m. 2 ERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN.j PER 1 PE PERIOD 3 PER INCH P- P- P- 1!�GOw o T -fu i 3L= eov vjc 10 v9-L P- LL v - 32 , 1 v P_ Svc cJ L X PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori. zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION SEF IE� OA7 too 4Pe_-fX of= I-PF . tN E I ! t E - - { - i - - - —� — — 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 Y-. HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 QC ADDRESS: CERTIFICATION NUMBER: I PF(ONE NUMBER optionall: WIN. MASTER PLUMBER DES NO. 3301 , 0015 S. _D� y� 3 p6 _ J " / E ST SI NATURE: d DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — ,.DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABO N REL,/aTIONS PERCOLATION TESTS (115) MADISON WI 9 6 9 (H63.090) & Chapter 145.045) LOCATION: SECTIOWF TOWNSHIP LOT NO.:BLK O.: UBDIVISION NAME: 1 /4 1 /4 /1- J N/R 10 E 33 1 X COUNTY: OWNER' NAME: MAI Ll NG ADDRESS: Cr 4 ,4 Z_ ID l�rr L,v. 1 .a 1/61pia-1-- Ikv s USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: 1 PROFILE DESCRIPTINS: R A 10 TESTS Residence t Newt/ ❑Replace Q�J 2 / _ �j oC� Z �—� RATING: S= Site suitable for system U= Site unsuitable for system �7s — 1D � SV s CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: S STEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) Qs ou � s ou JS ou OS ou OS �u �oUVENr ;o��� If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: 0 SS —77— Floodplain, indicat Floodplain elevation: PROFILE DESCRIPTIONS BORINGI TOTAL DEPTHTOGROU NDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER IDEPTH IN, ELEVATION OBSERVED EST, HIGR TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) Pe aN • , 2,33 N ,co VA° S R. .S 1 . B- / 9O 3 - ' 9 0 o,4- a a . lv� Cs --; Ir P. r /67' Dk Ra. (S /.S "Qv - &r. S� j o3' 4. 15 jLA. BJ /0 0. %Co � > � � , < s' / / k /s / ya ' r8a • /s . S� " G1/• Q 4 . I s a , ,� � . AJ B- 7 JA 711f 10 cr B- 1 d .e . , B- ?AN CS 6- R ��S �slN CS PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER IN AFTERSWELLING INTERVAL -MIN. P IOD 1 P RI D 2 PERIOD 3 PER INCH P_ 3, 2 % Z P- P _ L 3• X / / S• P- P- Y o C� P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori• zontal and vertical elevation reference points and show their location on the plot plan(Sh w th e surface elevation at all borings and the direction and percent /3vT of land slope. /)�� _ r SYSTEM ELEVATION /�► � r © F� �R � !� / o - � �. c i i item. h V y! O z r p V E E - T _ .N 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): HOMESITE SEPT TESTS WERE COMPLETED ON: RL 3 O'NEIL RD., HUDSON, WIS. 54016 OC1• 1 — / f? ADDRESS: VAS. MASTER PLUMBER -RR NO. 3307 M.P.R.S. CERT UMBER: PH NUMBER ( MINN. INSTALLER & DESIGNER LIC. NO. 00663 S f ` 0Z y 1--- 34 6 + P C �JGNATURE. DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — PLB 7 � 3 llw4�'rl �roja PLOT canci CRO55 P� SEcT1oN PIANS v • O J 5 o S E� b N � W 3 t 5 SiCil �E " 3 0 t 1 t 1 690 1 1 3 1 - 1 , 1 , At j56 7 S% swa s,� r,y R2-zGv LOT CD ,E',vF.P S' G N " s7� -- , , Qc .1 7 Fr. LicE�l/SE 7 n r r n �c � H MFCiTF c�;�,=emai • fi RT. 3 O'NEIL RD., HUDSON, WIS. 54016 TJf�T� ROBERT ULBRICHT MINN. INSTALLER & DESIGNER LIC. NO. 00 663 Fresh Air Inlets And Observation Pipe SOiL'resriA5 (3Y HOMESITB TEST NG 1 :0. Approved Vent Cap RT. O'NEiL RCj e `) HUDSON, WIS. !,40116 Minimum 12" Above Final Grade Sao 5' M,4 iM �,� °r tt d e Y) "Above Pipe 4 Cast Iron LESS , Vent Pipe - To Final Grade Marsh Hay Or Synthetic Covering Min. 2' Aggregate Over Pipe u n� Distribution Tee �GST Pipe 0 0 0 0 0 C lill/I,�O�/ = tt Aggregate 0 Perforated Pipe Below Beneath Pipe Coupling Terminating At � �1 f %, o p 9 9 co Bottom Of System • y S T C - 105 r SEPTIC 'TANK MAINTENANCE AGREEMENT o St. Croix County OWNER/ BUYEC "=- ar + O�hd Sf'Qrr PQ, -#''O f� m ROUTE /BOX NUMBER Fire Number CITY /STATE No r`f"h f-lwJson , Lj _ZI1' PROPERTY LOCATION: JAC 1 4, %.J '4, Section 42, TJ? - I, R ZO W, Town o OA Ai,tcLld St. Croix County, Subdivision C Lot numbe Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance cun- sists of pumping out the septic tank every three years or sooner, if needed, by a 1_i- cen_sed septic tank LmELLi:. What you put into the system can a tec= the function of the :,•;)tic tank as a treat - mvnr sta_e in ti.= disposal system. St_ Craig may be eligible to receive a grant for a maximum of ob: u r:.Ixe cast of replacement of a failing system, which was in opara—i opera— u prior to - July 1, 1078. St. Croix County aec_uted this ____� august of 1080, with the requirement that uwncrs u` a neu z± agree to keep their systems properly maintained - The pruu_r_y ow___ to submit to St. Croix County 'Zoning a certific.Ll,ir, f-z __gee? by the owner and by a master plumber, journeyr.an plu =`r, __sZricted plumber or a licensed pumper veri- fying Ehat (1) :L= wastewater disposal system is in proper operating condition (2) after inspection and pumping (if nec- essary), the septic rank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 L I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in •ccordance with r the - standards set forth, herein, as set by the.Wi onsin Depart- ment-of Natural Resources. Certification form m be completed and returned to the St. Croix County Zoning f K. within 30 days of the three year expiration date. SIGNED DATE 1yOY. �, CL St Ctloix County Zonin Office R- H a mm o r d , 31 W x or'�71�5 425 -8363 -g Sign' date�and��reu�rn ago, e' add'ress:.J '*`..'. ^; �. �c�- .- rx- '- '�•�.`�.r..- a�^- ,ry. �- � j-b -. 'r. ° �M. vd.`c�. .. ++..' .� 7r •: . • ' APPLICATION FOR SANITARY PERMIT S 1 1' C - 100 d b the owne (s) of the form .La to bu c:um�.lut:u�l 1u full and signe c. y ( ) This app licati on ri b lh P1 I property being developed. Any intldc.cluacius wil.1 only result in delays of the permit issuance. Should th duvelopment'be l.I1ti:nded for.resale by owner /contractgz, ( "spec house ") , then a second form should be ruLainud and completed when the property is sold and submitted Lo 1-111:3 office wick the appropriate deed recording.' - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Owner of Propert H a I Location of Property SE SI,eJ SF„ S('- c: 12- I T A N - R W Township /'- Mailing Address W Subdivision Name St Cr'o) k 3 1 c I.ot Number �✓ Previous Owner of Property _ Total Size of Parcel �4- azAfJ Date Parcel was Created Are all corners and lot lines identlfli,bLe? Yes No Is this property being developed for reside (spec house) ? Yes � No Volume and Page Number _ _ — as recorded with the Register of Deeds INCLUD WIT THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Dood 2. Land Ctuit.rnt:l 3. Ot:ller ruc:ut d I imli I' l l i ll „I I l� I I It 1• I u1- +t of Deeds Office In addition, a c:urt:11 :1od out:vity, It ov,il I,ililu, would be helpful so as to avoid delays of the reviewl.ng pr.t:IC:c:ttit. If Lht: (Irt:,l references to a Certified Survey Map, the the Cert l f: led Survey Map :;hall n l ;,o hu required. -- -- — — - — — — — — — — — — — — — — — — - -- P R O PER Y owNI KI CH,!TIFICATION I (we) ctU a6y .th6t.t dtl' s.t tt,tenletl.t6 oil (11j.1 6onm ace tAu t but 06 my (oun) kriowtedge; Biat I (we) tun (cute the of ic)t (s) o n ch' bed i th,&S ,in6onmation 1 6onm, by v.iAtue o6 a wavttutty elect )Lecoaded in ,tlte 066.ice 06 the County Reg iA test 6 D . d6 as Document No. and that 1 (toe) p)te�6en.t,('y oun L p po6ed 6it.e 604 the bC%agt' w1-! poaak .6yatem (on T (we) have obtained an eaz emet to It.un with �h1- about. dc� cvl,i.bed f,) &opelt ty, 6o1L the constiLu 'or, 06 s tf system, and .Ae. -stone Iut.S beer dtt,C A oitded in the 0 66i.ce 0 6 the C ur t Re test. o eed5 , a� Uucunu �l -t No . ^� —� SIG A"URE OF WNER _ SIGNATURE O1' CO -OWNER (IF APPLICABLE) `N ka ©� . 1•� � t Jul o � . l � , 8 DATE SIGNED DATE SIGNED DOCUMENT NO. STATE DAR OF WISCONSIN —FORM 1 WARRANTY DEED it THIS SPACE RESERVED FOR RECORDING DATA �q�943 o 7 G ye / �ew�AtJ _ h iq y I,U o J p Wt tV, :1 This Deed made between ... Charles..E _G_ Larson.. aka ...... Charles ..E._.. Larso n............................................................................... Grantor and.... H-.-- .Ear1. . Sat-an - and - -Starr -..E. - -- Eaton--------------------------------------- _..... • •------ •---- •------- •- •- • - - - -- ...................... -------------•------•--------•---•---•---- ----- - - -- -- -------•--•---------_..------------ -- --- .---- .-- ----- ------ - - -... Grantee, Witnesseth That the said Grantor, for a valuable consideration...... --- - - - - -- - - •--- - - - - -- --- ------- - - - - -- -- - - -- - -- - St. CrOiX RETURN TO conve ys to Grantee the following described real estate in ... ............................... County, State of Wisconsin: Lot 33, St. Croix Station in the Village of North Hudson.' Tax Key No. ...................................... This J s not homestead property. (is� (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And - -- ,_. fson _aka Charles.E, - -- Larson--• .............. • ........................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and will warrant and defend the same. Datedthis --- ----- ------ day of --••-- __--....__....___........____. 19-•84 . - • - - - - -- .. .... �l (SEAL) .............................. . ...... ............................ * -- •- •- ..........••••- ........... ............................... .........................(SEAL) ---................. .............................•. .................(SEAL) * .................................................... ............. * .....................-•---•-•...... ._........._......- •- •- •......- AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this ... ... ............ day of STATE OF WISCONSIN ---------- ------ -- ------- -- •----•-- •-•- - - - --- 19-- - - - - -- ss. St. Croix County. ........... ............................... .......... . -- Personally ame before me, this _....�5 day of November, 1984 th above named ........................ TITLE: MEMBER STATE BAR OF WISCONSIN ... Charles - •E_.G.. -- Larson ................................... (if not, - . - • -- -- • . . . .. .......... .• - - . ..... aka .Charles ..E.... Larson--- . - - - - -- authorized by § 706.06, Wis. Stats.) ....................:... ....... .... ... ... .............. ----•----- •-- •• .. ......... ............... ....... ............................... THIS INSTRUMENT WAS DRAFTED By to me known to be the person who executed the foregoing instrument and a w 4g ckno' the same. HEYiq.O.OD., CARI.. &. , lURRAY.......- - ----- •--- • -• - --- ,.� j1 ��_GZt�_� P.O. Box 229, Hudson, WI 54016 -- .. ...... . -----• ..................._._...----------------- by Samuel R. Cari ` aT: �-oPa ( -!G ...........County, 17 '1s. k Signatures may be authenticated or acknowledged. Both Notary Public ............. tire not necessary.) My Commission is permanent. (If nut, state expira date: ........ R`� .......................... 19......... mm ) 'Names of persons signing in any capacity should be typed or printed below thir signatures. WARRANTY DEED STATF. BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No.1 — 1077 Milwaukee. Wis. (Job M {`Y ), • •'f`/ 'R 'f •�y - . f t �aY i w •L 1 t 3 p�.e"`4nr 4 r4 01k . t j .. Rit •.'��yy. q l•;�4.:,sYrk•} „•.. m 5 •N >' 1... • '��uk� IpO•t0 i� r• r' ` '� � F� : t...fi'•.�r �• r :.V 1ot tp " Y .. • ►OT.E �r••f•R• , :.. . <: z L t y � i, Y t • ` • w000 fr• .r. rf o v S �R'� � �';� e , 8f S, tom•• �•-�^ AdL � � t ►o.o • •ro {it '�' °'"ia +er � too oo• •`" '�R• o. I N + Y s tI I N� f . 4 + i �,~ � iv o �•: `' « l_ �. �,�MO)L•_i N;N ..��� ! �^, a • gt c••' _� �b �u 8 �� �._ �� _ - -._.' 8. j f a Nn� s,89 A s ,.N i•_ II .` t ' - ,• \ r te® 'f i+f JO,f•' � = `SN M •1�y! I-iI I -.� 7 3 b. • ..\ . ' �• P�16L1 s' c -sr ' � `} i ��� ° Sri � � t c r • ,� ' 1���� '�� � r0 �' � � M ••� �� � � ��} s I p lt rY f V M •V•l4 I I`J '�. ' ••.y �• i • y I I ` r r y r. - y f yvr •rtf't 1l tL _ �«' I P. 0`s t , a' M (•' L.'t w •� rrk n �1 A f1 �• � + � �i' � � s � ^r#s -ten /�• fo oo' •w•d .%�. � �.!. 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Yt1� err :' 1 p,v 'i ♦.i ��,� ,' ri rY n• 1 W ' y 1 ■ ` - t'. !q� c 3 n7W�<.Mi.^6 ,�.��r �I ♦ �N� b r f6 4 �i� � � ���F tl � .\ �.. R � z r f.YR! .;' / 44 rP • � y r PrON, EARL SE SW, Section 13 75 , W11.'' Krattley Lane y T29N -R20W Lot#33 Hudson, WI St: Croix Station, Town of Hudson San.Permit #58918 -T 3 -25 -85 R. Hopkins Conventional, New INSTALLED 4 -4 -85 PATON, EARL SE SW, Section 12 W. Krattley Lane T29N -R20W i Hudson, WI 54016 Lot #33, St. Croix St. Town of Hudson San.Permit #58918 12 -5 -84 R. Ulbricht Conventional, New Form —STC -104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP i /u/ %t •+ j�,� EC. IO� T -R W i ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION ,.. ► µ . ~ LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Y C3 ed Pa oc/. 31` 0 i 0 Y I N } a0' P.ROP,,(A 1 j N e INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: (,t� ESQ' Liquid Capacity: I � Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,5) Side o Rear, O feet <.From nearest property line Front,O Side, Rear, O feet I Number of feet from: well �0 , building: I I1 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /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: Trench: Width: I O Length: I Number of Lines: 3 Area Built 1 Fill depth to top of pipe: Number of feet from nearest property line: Fr ont, O Side, ® Rear, O Ft. Number of feet from well: (90 Number of feet from building: 31 (Include distances on plot plan). SEEPAGE PIT 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 Manufacturer: 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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: ( !' 3/84:mj n DEPARTMENT OF INDUSTRY, -N6 �/ 'ti�� T INSPECTION REPORT FOR �/ SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAa SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 f X' CONVENTIONAL ❑ALTERNATIVE State Plan I.D. NumbeC 11f assigned) ❑ Holding Tank ❑ In- Ground Pressure El Mound PLUMBER TRANSFER NAME OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPE TION ATE. EarA Payton W. Krattley Lane, Hudson, WI —gs — ' : 3o BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.: SE SW, Section 12, T29N- R20W,Lot #33,St.Croix Station,Twn.ot Hudson Name of Plumber MP /MPRSW No County Sanitary Permit Number: Richard Hopkins 1059 St. Croix 58918 -T SEPTIC TANK /HOLDING TANK: MANUFACTUR(R: LIQUID CAPACITY: _ TANK INLET ELEV.. TANK OUTLET ELEV.: tAR1ING LABEL LOCKI CO ERf D 01 v rrii IDED: PROVI 99.0-7 V- YES ONO S NO BEDDING: VENT DIA.: VENT MAIL. HIGH WATER UMBER IN� ROAD: - PROPERT WELL BUILDING: IVEN TO FRESH ALARM: FEET FROM (]O L So 1 AIR IN LET. ❑YES ONO �� [:]YES ONO NEAREST - !! // DOSING CHAMBER: MANUFACTURER. BING: LIQUID CAPACITY PUMP MODEL. P MP /SIPHON A UFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ONO v ❑YES ❑NO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERZ A N'.UMB.ER'.OF PROPERTY WELL. BUILDING: JVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plo ng LENGTH AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORGE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: CH WIDT L NO. OF DISTR. PIPE SPACING. COVER INSIDE DIA.. * PITS LIQUID �EaJTREN TRENCHES / r MATERIAL: PIT DEPTH. D MENSIOUS GRAVEL DEPTH FILL D DIST PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO ISTR NUMBER OF PR OPER TV WELL BUILDING: VENT TO FRESH BELOW PIP S ABOVE COVER. ELEV. INLE E L V EN PIPES LINE. AIR INLET: fi C ? . 2 2 3 IFUEA F RO M 10 6 0 3 I 3 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES 0 N SOIL COVER I TEXTURE R NENT MARKERS OBSERVATION WELLS i N 1:1 YES 1:1 NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL S SEEDED. MULCHED: I / / CENTER. EDGES. ES ❑ NO DYE ONO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: ` WIDTH: LENGTH. NO. OF LATER SPA NG. AVEL DEPTH B LOW PIPE FILL DEPTH ABOVE COVER: TRENCHES: 'I MANIFOLD PUMP MANIFOLD DI R. PIPE MANIFOLD MATE AL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.'. ELEV.: DIA.: E V ! PIPES. DIA.: �LEVATfOt�ll ANG1 OISTRIIt1T1#1N HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL: tI�kTION VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES El NO ❑YES El NO COMMENTS: f PERMANENT MARKERS: OBSERVATION WELLS N(JMBE S R OF PROPERTY WELL: FEET ROM LINE ❑YES ❑NO ❑YES ❑NO NEART t \— Sketch System on Retain in county file for audit. Reverse Side. TITL DILHR SBD 6710 (R. 01/82) APPLICATION I'OR SANITARY PE U11T 11111 This application form Ln to be comp.lit.cd in full and signed by the owner(s) of the property being developed. Any i.nadequac:ics will only result in delays of the permit issuance. Should this duvelopment'be tntcnded for.resale by owner /contractgz,( "spec house "), then a second form should be retained and completed when the property is sold and submitted to eh.l.s office with the appropriate deed recording.' Owner of Property r � a 1 +cr n Location of Property _SE '� �� 5 1;, Section �-- T / N — W o Township / ` Mailing Address W Subdivision Name S -• C.r' © J k a� 1 Lot Number 33 Previous Owner of Property — Total Size of Parcel Date Parcel was Created Are all corners and lot lines ident:L.flabLe? Yes No Is this property being developed for rosale (spec house) ? Yes ✓ No Volume and Page Number _ as recorded with the Register of Deeds INC1,11D WIT TATS AP1 ONE OF THE FOLhOWING 1. Warranty Irood 2. Land ConL,ta 3. Oilier roc of d logii 1 "Hod 111tH 11 of Deeds Office In addition, a curt llo.d ctuivIry, it iiv.ill.il lu, would be helpful so as to avoid delays of the reviewing procut,t4. i;f the d, c:.l (It-rr,rlption references to a Certified Survey Map, the the Certifi flurvey Miip nha I I be required. 1'ROPI:Ia y O(UNI R CLK'l 1 FICATIDN I (We) cma6 y that a ti, '5 tattenie.it.tb utt .this 40)1111 an.e ttcu #tJte 064ice but 06 my (ouA) knowledge; Biat I (we.) am (cute .the otorte)t (s ) o pn chi-bed in t{tii,s 6 to o)unat i- on Oul, by vixtue o6 a wwva, tt ty dect )teco)tded in o6 .tite t a d hart T we , County Reg�teh. 06 D ..rte a.5 Docu,uu,.t. Nu, r1 .t ( ) pne�sentty oun .tile p) poeed 6it.e bon the �,Cwcige c.erf poaa' dy�tem (on 1 (we) have obtained an easemer. to )tun wi,t: {t .tile abooe. de oiLi.bed pan.opeAty, bon .tile co" tiut ov, 06 a d sye.tem, and .the same has beerdt C .d in t he ��ti6.i.ce o 6 .the Cur t Re te)t. o eed5 , a Uoitttmctta No . � —� pa� SIC A' URE OF WNER _ y S LGNATURE OF CO —OWNCR (IF APPL.ICA.BLE) F -- DATE SIGNED DATE SIGNED DOCUMENT NO. ! STATE BAR OF WISCONSIN —FORM 1 WARRANTY DEED p� U e I THIS SPACE RESERVED FOR RECORDING DATA V ol, / ?OO p I D L l �ec.v�rdtc� 3 �?7 3 made between a__ -_ -_ °Jp her a �y This Deed, -•- Charles __E___G,..Larson__ak Charles - -- Larson - - -- ---------------------- - - - - -- -------------------------------------------- - - - -- -••• -- .................... Grantor and ---- H-.--Ea-r1-- Fat -on- aria -- Star -r-- -E. - - -Eaton --------------------------------------- •--- - - - - -- i - - - - -- -•-------------••--------------•------- ----------- ---------- - -- --. - Witnesseth That the said Grantor, for a valuable consideration..____ - - -- - - - - -- conveys to Grantee the following described real estate in ___ ___ St. Croix RETURN TO __ __________ County, State of Wisconsin: Lot 33, St. Croix Station in the Village of North Hudson. TaxKey No. -- ................................ This - - -- is not homestead property. 0 0 (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And --- grur_L_or.,.__Char_l.es -- ,_. G, -- Larson - - aka • Charles E. __Larson --- - - - --- ................................ warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and will warrant and defend the sane. Dated this ------------------ day of -- - - - - -- November 19__84._. - •---- -- -- - - -- - --- - - - - -- -(SEAL) --- •(Gf�I E -- •• - -•-- •- --- (SEAL) ------------------- •--- --•- -•-- •--------- •- -- -- -• --- -•- - -. - - -•- --- •- - - - --- •--- -•• -••-•- - •--------- ---- - - - --- - ---•- -•-•---- -- ---- ----- • - - - - -- ........ (SEAL) -•----•---•-•--•----•--.-..---•-•-- ..._..._.__.._....•••• - - • - - • ....(SEAL) * -------•---------•--------•------ ----------------- •--- •-- - - - - -- * ................................ AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this ____ ________ ____ day of STATE OF WISCONSIN -- •---- -•-- -- - - - -- -- - - - - -- 19- - - - - -- ss. St. Croix . - -- County. —� Personally came before me, this .................. day of November , 984 - the above named ---- -•- - - - - -- TITLE: MEMBER IS STATE BAR OF WCONSIN --- Char- Les•- E. - • - G. - -_Lar son----------------------------------- (If not, ---------------_----------- - ---- - --- -- ._.-- ------- ------ ---- aka - - Charles - -E..__ Larson- ........................... - • - - authorized by § 706.06, Wis. Stats.) ----•---------- ------- - -- ------ -- ---- - •: ----•----------------------••----- -- ---- -- -- ------ — ----- --- -------•------- -- - - --- -••- •- -- --- ••--- -• --- -- --• --- THIS INSTRUMENT WAS DRAFTED BY to me known to be the person - - . who executed the foregoing instrument and acknowl de the same. HEYh100D.._ CARL--&. MURRAY ----------- ---- -__------------- �� P.O. Box 229, Hudson, WI 54016 -- - -- -- - '.�- -`"-:_-c-- ... --- '-•1--- /-- L- � -- t- ----------- • ----- - - - -- L-.- ...._- by Samuel R. C ---------- 1 e aT. g.i- fC.._._- __.._Count "'is. (Signatures may be authenticated or acknowledged. Both Notary Public ___________ _ Y� ", :on are not necessary.) My Commission is permanent. If not, state expirrs date: _ ------ i - ��----- - - -- -- ............... mm 19._.. -_..) -Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATF. BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No.1 — 1977 Milwaukee, Wis. (J ), DE OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION Y.O. BOX 7969 BUREAU OF PLUMBING MADISON, W1 53707 r UZ ONVENTIONAL 1:1 ALTERNATIVE State Plan I.D. Number: IH assigned) El Holding Tank El In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: I ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Earl Payton W. Krattley Ln., Hudson, WT BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: SE SW, Section 12, T29N— R20W,Lot#33,St.Croix Station, Town of Hudso Name of Plumb — MP /MPRSW No.. County: Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 58918 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LA EL LOCKING COVER PROVIDED: PROVIDED: DYES ONO ❑YES ❑NO BEDDING: VENT DIA.. VENT MATL.: HIGH WATER NUIV OF OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH FEET FROM LINE: JAIRINLET. OM DYES ONO ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER: 1 6EDDING: LIQUID CAPACITY. PUMP MODEL. PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO 1E:IYEs ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF .PROPERTY WELL. BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET' FROM LINE: AIR INLET: PUMP ON AND OFF) OYES ❑NO NEAREST .SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH J DIAM _ CTER. MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: J ILENGTH. NO. OF DISTR, PIPE SPACING. COVER =NSIDE DIA.. #PITS. LIQUID BS:TTR`ERI F ' TRENCHES MATERIAL' DEPTH: e ,,OIMEN$IONS GRAVEL DEPTH FILL DEPTH IDISTR. PIPE IDISTR . PIPE IDISTR. PIPE MATERIAL: NO. DISTR NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH BELOW PIPES ABOVE COVER: ELEV. INLET ELEV. END. PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES meets the criteria for medium sand. TIONS MEASURED. ❑NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS 1:1 YES El NO ❑YES 1:1 NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED. CENTER. EDGES: DYES 0 N 1:1 YES 1:1 NO El YES 1:1 NO PRESS DISTRIBUTION SYSTEM: =I'� �i'7sESI.`F' WIDTH: LENGTH. TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE R. : FILL DEPTH ABOVE COVE �Il1RENSS . '' MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING rFi1LE1iATjON I ANO . ELEV.. ELEV.. DIA, . ELEV: PIPES: DIA.: DISTki84iTC}N !HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED *4 woRmATiON PLANS. 1:1 YES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMIBER OF 1 PROPERTY WELL: BUILDING: FEET FR£iM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEARST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710 (R. 01/82) A */f01t o,) "�W7 1416f aG 1-07-- 1 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS ( 115 P.O. B 7969 HUMAN RELATIONS \ MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNS HIP - TY: LOT NO.:BLK. NO.: SUBDIVISION NAME: sF 1 / 1 / j2 /T-1 N/R 2 PE (o4 / 1 93 s/. C,10/;?( 57"f7io u COUNTY: OWNER'S/BtMfft`S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DESCRIPT19NS: ER ATIONTESTS: I Residence �� KNew ❑Replace oL -/ , ?6 � RATING: S= Site suitable for system U= Si unsuita for system -< S' 0 ✓l/ � f 4S �( / ✓ /"�F� CONVENTIONAL: MOUND: IN- GROUND PRESSU SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) [is DU ZS ❑U ❑ S ©U RE: [IS CCU EIS ❑U I lW s sr-f-� If Percolation Tests are NOT required DESIGN RATE: Q � If any portion of the tested area is in the under s.H63.09(5)(b1, indicate: Floodplain, i n d icate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- d 3 .4ofs a r ? -:9-0 ' S/L "A.1,0 w ids. OA -C- Y. ha E;- , B- -2. ? 03v —(y l f /s wig .vveoe0 /466 ,891 , 0as o, - /o 4 14 F f . ba -G y Ai 4 r B- ; Ott Y B- ee expl system. na ERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD2 PER PER INCH P- P- F� eve, P- I V O T f' i sLz e'Ov v If P AF S iG E P _ c� v 7,2 3, o PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION � 6F IMOAT /: 04 � 0,A 4,07 . f _ � 1 ' i Nt I j RDX M _ i I } r I I tN I. _ T r.s1' t .V�-; I [ I � 1 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): HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: RT. 3 O'NEIL RD., HUDSON, WIS, 54016 Qc / . �2 G — P / ADDRESS: CERTIFICATION NUMBER: P ONE NUMBER optional): WIS. MASTER PLUMBER LIC. NO. 3307 MARS y�Z 3�6 _cP/ S- L NO, 00663 ST SI NATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — r INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete. and accurate soil test, your report must induce; 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAX IMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the, suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 0. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 1. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A ;cpa €ate sheet may be used if desired; 8. Mahe sure your benchmark and vertical elevation reference point are clearly shown, and are perrnanent; q. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tionif appropriate, 10. if the information (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box; 11. Sil1r) the form aid place your current address and your coil tification number; 12. Make legil ,)ie collies arrd distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates arid Textures Other symbols si - Stone {over 10 ") BR - Bedrock c - oh - Cobble (3 - 10 ") SS - Sandstone gi Gr a el (under 3 ") LS - Lirnestoile, s Sarr(# HGVV High Groundwater c - Coarse Sartc3 perc - fleiceolation Rate nied Medium Sand l Fine Sand Bldg -- 8u6&-)g s Loamy Sand - Greater Than sl Sai)(1y Loam t - Less Than -- Loam Bn - -_ Brouln sil Silt Loam 131 Black Si -- Silt Gy - Gray o _ Clay Loarn Y .._ 'te11ov scl -. Sandy Clay Loam -- Red swi - Silty Clay Loam mot Mottles sc - Sandy Clay v a_ vitI sv, , - -. Silty Clay fff -- fevv, fine, fainf C Clay ce - cornmon, coarse pi - Pt:at mm - Many, niediurn rn - Muck d - distinct ` p - prominent HWL - High water level, Six general soil textures surface water for liquid vrraste disposal BM - Bench Mark VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit: application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. DEPARTMENT OF REPORT ON SOIL BORINGS AND S AFETY &BUILDINGS INDUSTRY, DIVISION LABOR HUMAN LJ4TIONS PERCOLATION TESTS (115) MADISON WI 79 • (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP LOT NO.:BLK 0.: UBDIVISION NAME: S� 1 / 1 / 1-2- /T�-1 N/R 10 E (0) 11U OSOAJ .33 �f,/ i X 5 /oAv COUNTY: OWNER'StOtPi& •" NAME: MAILING ADDRESS: s� 4J IS USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER LATION TESTS Residence A, New ❑Replace a�1 2 / _ (J 1/ IO s7 -- RATING: S= Site suitable for system U =Site unsuitable for system sc s Of ffv/S�3oz) Ar - CO o e 11 s t s0 CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: STEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) RS 0u Els 0 ®s ❑u SY os au ❑s Ku 6 1 , P I t J eo' f If Percolation Tests are NOT re uired DESIGN RATE: q If any portion of the tested area is in the under s.H63.09(5)(b), indicate: CLA ss -Z - Floodplain, indicate F loodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH N UMBER DEPTH IN , ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 9. r �f.3 9 > / O z /. 1l. S 2. 3,E • AfA3 .CO OA IS 4 441 GA'., s • 17' /G7' A(- GO. (s /.S "Q� -Gr. s 83" If. Ll s. is 3 B- Z �• � �f y4 ?zo > 9k • /. ' is 3 . p " a . C's 4 GR B- 3 / 2 � /O O. yY�� ) 9Z , is' /3/� /s / ya' 6a. /s� . ST /,'1- (34. (s .--I- / S. 7 w C S 43 " D,� (3►�. (s 7 . l7 • ,[RAJ. B- 70 /o a •7 .1 > �`'O ,e � �ti cs ' B- ?AN C /_121- 6-R , ��S ��N CS PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER IN AFTER SWELLING INTERVAL -MIN. PE RIOD 1 PERIOD 2 PER1003 PER H P _/ 3• /p P- P _ 2- 3. / / S• P -- P- . o O 7 0 , 7 / / P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Sh w the surface elevation at all borings and the direction and percent of land slope. 130 M ( _ �( O F ���R oFLor SYS ELEVATION p � - _ - Rho • W n a'co __ - �J�/ em. e } 6 A J 2 ' - a hh' E ' E O `ll o - E . _ r, • 18 3 ; h r i ,,C3 _ T N 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): HOMESITE SEPT PLUMBING CU. TESTS WERE COMPLETED ON: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 ROBE RT III RRICHI HON P;YZMB ADDRESS: CERT yylS MASTER PLUMBE R LIC. N0. 330) M.PR.S I L IH P ? NUMBER(optional): MINN. INSTALLER & DESIGNER LIC. NO. 00663 S S ` Ja 6 (P/( CSI—SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — - l INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6595 To be a complete and accurate soil test, your report must include: 1. Complete legal description; � 2. The use section must clearly indicate whether this is a residence or commercial project; 1 MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; S. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; B, PLEASE use the abbreviations'shown here for writing profile descriptions and completing the plot plan; ]. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; B. Make sure your benchmark and vertical elevation reference poirit are clearly shown, and are permanent; 9. Complete all appropriate hoxes as to dates, names, addresses, flood plain data, percolation test: exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does riot apply, glace N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12, Make legible copies and distribute as required. ALL SOIL, TESTS MUST BE FILED WITH THE LOCAL AUTHORITY INITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil (Separates and Textures Other Symbols St - Stone (over 10 ") BR Bedrock cols CohNe (3 - 10 ") SS - Sandstone gr Gravel (under 3 ") LS - Limestone x s - Sand HGUtr - High Groundvrater cs Coai sr., Sand Pry : Percolation Rate m d s Mi;cliuni Sand VIV - VV t - F nle Sand Bldg - Building Is — Loamy Sand > _ Greater Than `sI -- Sandy Loam < Less Than '; -- Loam Bn - Brovr n 'sil Silt Loar,a BI Blacl< si - Silt Gy - 'cl — Clay Loam Y - y', -11ovv sell. - SaanUy Clay Loarn R --- Rid sicl — Silty Clay Loam mot -- Monies sc - Sandy Clay w/ - with sic — Silty Clay f few, ling., faint xc .__ Clay cc -- common, coarse p __. Peat mm — Many, mediuin rn -- Muck d — distinct p — prominent HWIL -- High water- level, Six general soil textures surface water for liquid waste disposal BM - Bench Mark VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit, The sanitary permit must be obtained and posted prior to'the start of any construction, n PL B (o 3 l PLOT and CR O55 5Ec PR °� o T1ON PIANS no � o 4 N � W 3 - -- I p � f ° 3 0 G 6 1257 s07 VO4y— 4o> 4 4 PA v i d S7"If7 R /6AZED PO44 3 F� 'ed S- A) LOT caelvF.P L SS � �y 7r HOMFCtTF ccnnr 1 � , b duf�.��faa-CtT— RT. 3 O'NEIL RD., HUDSON, WIS. 54016 ,D ROBERT ULBRICHT MINN. INSTALLER & DESIGNER LIC. No. 0066.3 Fresh Air Inlets And Observation Pipe S OIL TESTIA45 By HOMESITE TESENG r:V, C1 Approved Vent Cap RT.-3, O'NEiL RO ,`) HUDSON, WIS. 'A0116 Minimum 12 Above k Final Grade 6 D. 5 / x M�X;M Of: yZ "Above Pipe 4 Cast Iron LESS , Vent Pipe - To Final Grade Marsh Hay Or Synthetic Covering Min. 2 Aggregate Over Pipe L Distribution Tee (J TEST Pipe —+ o 0 0 0 0 1 1friON = 2---______ :eneath Ag g r eg a t e 0 Perforated Pipe Below P i p e 0 Coupling Terminating At � / � 1 f% � V Bottom Of System . v v m °vcc m m � cD o o a3 v`° c ? w R M = c - t-1,�m C C W w (A `� pu N m c S (D -0 a. (D (D O, O {a z CD Ch 20 ((DD a 0 O O N O " („D co m y ( D '�m 0) (o .► � o 3 a O „n o m (D aD a vr 0 CD 0wo� w 0 0 O O C 3 -c %< <-c = (n w 0s c °,<3oao Q M :E o c �_'CD O ti M pt (D C -.' O a CD (D coo '° D m m (a Q o O .�r C A O >c m A -� C — p O W A = O (D a = CD 0 m O y O? a 1 0 y C ��u v,m��w CO) � --T � - 0 ) - � �' D a(D0 3��csa Z M -.. � ,� N co D D »tea °� -1 t7 0� ; � ?g� m �v viva c °a(a -� =r O A. fu ( _ D . C CD 5 a CD m 0 C m 0�_�(o CD x D -i 3 ° m� 0 CL N y c Q O 0) =w CD r" a cD a o a CD 0 c to ° p'O'� a ?N 0 O M c %< (o ?: m 3 ai a° 00 oN71 oCD 0 a e c o a o �� �� s c O m o >: :< m N 3' a o < o Z = i p •:.`: > O C N' IL 0 O C _ 4 O o U O Vl 0 c � 1 O U 0 m..... �+ M y .0 w cd C L L. C vi a� O L ui O O •p C O N c0 C c0 V c0 3 O p 4 O O c dl � C Of U. L O C'o O O N 'C O O y C O 1 W ►L- •- 0 e y v 0 E o\ IL VN 3 i 0 o: " e`d C O C C _U W y . }. c' OL U O -'D M W " o 3 c Q ~ C m cm v, " O � ,� N Q U N . 3 C Fes- U r.. O O O C Z U) eo a m c -0. o o ,� o O 4) U cl1 O �wR 3 «. C :: O d .0 0) zq Q O i N U C7 0.0 cm � y O j Q CL CL G o crl o c c r..rn— y v — o c C y C 0 r p O O c c0 N C i «' .' co p 'a OC a >. O 0 C — = M 0 \ .. C C C „0)O R1 O 7 w O CO N N p U "a U u N �L Cv— OL «. �• i !T ni b m e 0 m O Q 3 p m 00 . 0— o 3�n�... o �a� •- o v c O N O C a N O' �+ Y " L O E C % C Z i cd (� O O %.. y a CL ` p W== � — C O i i O C N 0 . 3 `p OEc.�wv rA J D _W _ SANITARY PERMIT 6IL4-ee- COUNTY D ILHR TRANSFER/RERML UNIFORM PERMIT # .. m (PCB 6� -� �'8 9 / 1 T PERMI RENEWAL DATE: PERMIT TRANS ER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: PRc5PLRTY LOCATION: CITY: ' /4,S 4 Z -. N,R 2 (o OWN 16 (c� LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: A T ROA .LAKE OR LANDMARK: PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SAZITARY PERMIT TRANSFERRED TO: NAME = E: NAME: PHONE NUMBER: �C A� a ADDR,ESSS PHONE NUMBER: ADDRESS: -tom �L I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUM BE SIGNATURE: PRE OUS eLUM6 S E (IF CHANGED): PLUMB R'� DDRE� ' PRE US PLUMBER'S ESS:. v WP /MPRSW NUMBER: PHONE NUMBER: MP /MPRSW MBER: PHONE NUMBER: j (7fs► �Yd - 5��� 3307 ( ) SIGNATURE OF ISSUING AGENT: DATE APPROVED: DISTRIBUTION: Original - County Copy - Bureau of Plumbing o p� Copy - Owner DILHR -SBD -6399 (R. 5/82) Copy - Plumber -� D p -� r .Z Z G1 r r N a U) o N O C co 0 (D z rn O � o0 OD :10 O :10 N � O — O C=) cleD m k� � x W < :30 W cn " rn m oo r o. rn Now 0 r 00 -� b C� O0 z r - O = D n m o —1 n :10 X 00 m C t� Cl o yc Cl) :30 - n z z C O r o � -� z n z n ■ O Oz � m C Z O m O W 2 sD rn D 0 ID ? 7 y 7 W T r m a� 3 o m m — <d fDo -o D m 0< m 7c �QQ< o� �� m O 3 cos �d o�m'D H 3o m 0 � � �m ? rn o _ �H G N - N 5 a H N `G "� C C O <y 7 7 07 (t1 0 :r - 0 _.3 ° v = =E v v n _.c n m �o d v_3 O m nvN 3 c-1, 2 CD O 7— C C m Day H .. < .. _ m m '� o o Z _ m o01 y I Z 7 IG N 7? �. q C " c a < a cD O o. m D 1 '0 ?; o y m3 �o f < 0 7 m m o 7 3„ C N d '~ N m o yam' y E. Lyl D 3 o 'D < n' a o p 7 •O !. N o _. 3 0 0 00 ti P F J 11 A �ji it x •. ltd j �� t p r . tm 41 A � '..: {q. IS - 5 Yeti e .. •ww .1 w y so yam�,,,,,,"",„, .,,. P' 9 VIM sr 4 1 0 � R t ............ �� e � • +); a .. +."� t i. ^ cr Ll t W oe kMvra. P�B.L. 67 PLOT AND CR SECTION P R O.J EC T PLUMBER NAME E A R To NA ME LOCATIO L IC ENS Ems._. PL T .._ M A P SV �, St O k r ►o 1 0 i 0 :i i +- ' " G a 3 E t o a _ 1 e e R ao' Soa� L 2 - B. /* Vep' e R 03 s. W. cot t Co�cr c FRESH AIR INLETS AND OBSERVATION PIPE CROSS SECTION Approved Vent Cap Minimum 12" Above Final ,r a h ri nn S �e GrA e oP, Iess M►�Xi muM o� .. 4X 4" "Cast Iron Above Pipe �— Vent Pipe To Final Grad Marsh Hay Or Syn Covering Min. 2" Aggre e P Over Pipe � ,V Distribute o n Tee �- T Pipe .._ S� V �ef T n Aggregate Perforated Pipe Below Beneath Pipe Coupling Terminating At ��,(� �T• Bottom of System STC - 105 r H SEPTIC TANK MAINTENANCE AGREEMENT 0 St. Croix County i4 OWNER/ BUYEI PCar - and Starr pt. � O (� rn I ROUTE /BOX NUMBER Fire Number CITY /STATE Nor + h 1 1 SOn M _Z11' PROPERTY LOCATION: `-L, Section � 1'i`�, R ?►C7 Town of N��,k <�� St. Croix County, Subd.ivision �( �. Lot number & %3 I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance cun- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed set tic tank pumLr. What you put into the system can af fect the function of the SL-I)tic tank as a treat - menr state in t1.e waste disposal system. S *__ Cralx may be eligible to receive a grant fur a maximum of bt2_ u_ :ae cost of replacement of a failing; system, which wss in opa_a._?nn prior to' 1, 1978. St. Croix County acc_preL this August of 1980, with the ruquirument that owncrs a a n 6 sr� tm-s agree to keep their systems properly maintained. The prutu_rLy o: r = to submit to 5t. Croix County 'Zoning a certif ic.3t - r, f-ZM , .1 Lei by the .owner and by a master plumber, journeyman plug ar, r_stricted plumber ur a licensed pumper veri- fying tilat (1) ts_ a:i-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 I /WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal' system in Accordance with x the-standards set forth, herein, as set by the Wi on sin Depart a ment of Natural Resources. Certification form m be completed and returned to the St. Croix County 'Zoning f within 30 days of the three year expiration date. SICNED DATE St. Croix C-3unty,.Zoning Office:. Fox 98 4 z u s ' J z n�sn ? .fF Hammon d, WY 54015,1 ; b r .x , � , y m `r z p3 l�y 715 =7t 6- 2239'or 425 8363�,f "` >��� �� n Sign, r date t ir o . °addresses f K -,. � ` J -.. t i .. YA Y. � y."k'n.3:.1 .: 3 ✓.M R'' 7' w�. � _�'. 2 ^4 - ;Y �:' +.i •'�".f. .4:.. c4kf pr 'v S r 7 `,_�` t< { B i ii ; , s i•vIV ! •, o a C p/A IM. Ir ♦. ^pra •* ;` k�� � �,� �'��'f�... , �• Yoa7/' ; � ..:R ► o t �t r•O'�,Le yam. S 1L •`•. r' '� �S� `•.. • Wo.00' •�1 4 14.4 �r •►irA'4t • e • 4 KrY�x $j'._ �,,.� ,,.,,,.,.• � �•�. ts0 •t0. �it e yh + s 70 a s a t oo• NOn Soo IF < '.. a� •� t ^ `? �; � 'o z q 'b w� w 88 ' B�u P` 8 � + + � r � l n� ,F ..; i ='' •�y .1 Iq O .LMT NA =1 rhf .� k.Q s • a • b. ° ? llg� / 4� � 'i BEET' � �•f sw. ✓ice y�� �.�� xP( "�• 5 M �• !.'t need w ,'� /•..y��•^ n �1 p A ar` t•'�''�,yyq 3 ^S.Ka ry • �� "' y ;�``.: + y w I I N-4 O dr� SJ s i3 n _Y a - Now li ri + u I z t ♦ d b b� �� • I � s � 2 O I!d 1 4' +f {. »• '� •�d _ fi .� N ". . ✓' Zia `Y A A, 44 I N IV O i p". " i..•'Zi's w,,•. (J)�' • m yy�p.; g I f. y_ .' '4 �� �� d L. �`�T � • s.R �..'� � ,S !06.00 "T L.�o' � L••• '. r� . ,^•'»p�p�i'i.•r�, }f9 Y' y t�`f .ems'` 4 . �, �• �` � y,.: # •- Io•od �.'" ►saQia L_' N• I r C_ 0 gg q • �. `'`�'k y F's ° .''$ •s ,�, . ,7 j s3 '. •,s _ ,_ ` M w.R 0 _ L.OY _ g - I ff• p� r. it r `' Y r { •t.�.w 4.11 _ g 'G . A '% c _ I w * m - cn 'r�J'kt +�•G&��h '' f� w '.I rky ' q. �•f1'! � �W ; �� /��" o� � j ( � 7 xi, +'� an i !00.00' "/ / _ 8 "A'M• UI "3 fir•• ✓ / 1 •• r- a �. a Z �• �., � 111 `.t �Fw �i � " ip.. +; :�Y f•, r -.A II Itl3 I y�'s: `.IP q , /(�� O 4 R I Z b +)n'•'af �y �.' +'� " -� � .n ,� ttr� ��... � y� i � `` .. ' � / .; o'•••. ft r wY rl j 1 p k Y r !1 �• ` • oo' LIMITS id= ult. r Uw- L�1T[U ,1.�iroS. ;h �'' �' •'x" x r � �> ea � S I � - s TI A 1 gg Y. i� • YL� ri I Pr t va *. yl) ,•i' F _` 4; }� 4 Su .y W `d . _ 3c iy r j t It 1 • t 111 ;4 e � n �.} �3Ti � ` S � .••� u < � 1(. Il. �"A it 'A _ �... 3 '� 4 %. x • I \ s r. I ��'w�scons�n APPLICATION FOR SANITARY PERMIT 13ILH C OUNTY (PLB 67) OEORRTmEriT OF � UNIFORM SA �T�,RY PERMIT B # II"yJUSTRY, LAOR 6 HUMRn RELRTIons (J — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS 9 rfYTO / GvF ,;o,f /— ,, GPI llvAc PROPERTY LOCATION 'CI•ti<Y: 6 = : �I S'F 1 /4s /4, S L , T;-f, N, R 20 E (o W TOWN OF: LOT NUMBER M NEAREST ROAD, STATE PLAN I.D. NUMBER 33 f . G�ojX STS Tio•� .Pgrr� IAI TYPE OF BUILDING OR USE SERVED A 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair r- Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. A_ Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic _ Gallons Tanks Concrete Constructed Septic Tank Capacity / . 4 X Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: i l� v ,L IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPO D (Sq Feet): 0 a4X �� / Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): HDMESIT ature: MIP /MPRSW No.: Phon RT. 3 O'NEIL RD., HL e umber: DSON, wl . 54016 ,33 7 Plumber's Address: "S. MASTER PLUMBER LIC. N0. 3307 MARS Name of Designer: MIN N. INSTALLER & DESIGNER LIC. NO. 00663 COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: F Date: ❑ Disapproved �/� El Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber .w INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 0 - S13D.098 � To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be ro erl maintained. Have a licensed pumper clean our septic tank whenever necessary usual) ever 2 to 3 ears. If y ou have q uestions P p Y P P Y P Y Y Y Y Y q stions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.