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HomeMy WebLinkAbout030-1026-95-000 / \ / / 0 \ \ � / \ � \ � � § / � k \ \ 8 I » \ L � � \\ CL 4j 0 CD ƒ \ § 2 5 = ) k $ < 3 \ m w = / a CD / � .� a) & f ) Q ) \k ® .. } ƒ \ . 4) 2 E ) ~ ) ■ 2 ) k _ $ 2 s § k 2 { / \ ƒ § 3 /\ . � § § § k -� \ / a a a & \\ _ 0 � r o 0 2 j q \ f \ \ ƒ \ / j § 2 2 \ 2 3 % ® § k \\ g . c � ) c § < / ) 2 , § r © k $ / / \ \ \ \ � _ �<� @ _ - -� a / ) © \ % = 7 ) o \ d / / . 2 6\ k \) \ 4) k 3 & 2 e c / g o / \ m m o / Q)I k } . � aE§ e — «_. -ate E 7 ] \ k a \ / J a 2\ J 3 U I ST. CROI K COUNTY ZONING DEPARTMENT— AS BUILT SANITARY REPORT ( fih s tea n Z F R ► 'E'VED Property Address S'.Z, TI-our t3ro a T*<4 rL City/State 1' y S G h !,y I n ' 7016i ST CPO X COUWY Legal Description: , o► Lot _ Block — Subdivision/CSM # _ JE 1 /4 C 1 /,, Sec. - - 6 - , T2IN -RAW, Town of S�'' Z06CPA PIN # 6 - '?P-00 NMC TANK — DOSE CHAMBER — HOLDING TANK MORMATION Tank manufacturer fir, n y Size ST/PC ! o00 / Setback from: Houma 1 Well �O P/L Pump manufacturer — Model Alarm location — (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location S OIL ABSORMON SWUV,� Type of system: C o h ve n A z "a 1 Width ! Length S - Number of Trenches Setback from: Houma qb_ Well (go P/L 2 o' Vent to fresh air intake 126' NATIONS Description of benchmark S w c ter- 01 p u wef Elevation / 0 0 '0 Description of alternate benchmark S/'.•!G�- ; � ! S " o� k �� r �w� S r s rte++ Elevation 7 o� Building Sewer ST/11T Inlet `- ST Outlet PC Inlet p,•Sr rlox PC Bottom Header/Manifold qV- -2 Top of ST/PC Manhole Cover Distribution Lines (1) g ZS� (2) 6 2 v ( ) Bottom of System (1) 7 ' o �, t?,I� ,• ( ) Final tirade (1) IN C . G 7' (2) 1 7 ,' . 2 1 ( ) Date of hu tailation 1 4 1201 vc Permit number 3 C 3 5 f( State plea number Plumber's signature � � License number 9 A 22 2 Date 3 /12 -o/ Inspector Ke u- n Gr b COMPIM PWPw°' 37 � Av C� o r" - s • o 1 t w i e O awln A � • 4 n a • 1 Wisconsin Department of Commerce Count y PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)l. 363518 Permit Holder's Name: []City ❑ Village ❑ 1b vvn of: State Plan ID No.: Stanze, Keith St. Joseph Township CST BM Elev.:- / Insp. BM Elev.: BM Description: cST g n k Parcel Tax No.: C*•D I C � 030- 1026 -95 -000 TANK INFORMATION U ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION B5 HI FS ELEV. Septic Benchmark Dosing Alt. BM E n o Bldg. Sewer g St/ Ht Inlet s °• TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Air I ntake ROAD Dt Inlet —' ir Septic >5b > 2 f –� NA Dt Bottom Dosing NA Header / Man. . Ito e °e L� b • s2 •23 Aeration NA Dist. Pipe Q N t Holding Bot. System - S 9 .40 PUMP/ SIPHON INFORMATION Final Grade Manua errand St cover Model Number GPM TDH Lift L Ion Syste TDH Ft � �. 65 cl$. I o t -1 F Forc I n Length Dia. H Dist. To Well b P q,3a 1 -16. 15-' SOIL PTION SYSTEM �� lv + TRENCH width / Length t No. f renches PIT No. Of Pits Inside Dia. Liquid Depth DI I 3 DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING M r: ' CHAMBER INFORMATION Type O t Model Number: System: O �� / t7O OR UNIT DISTRIB Head M fold.,(, ribution Pipes) x Hole Size + xHole�lpacing Vent To Air Intake Len th YJ D ° ia ` . c Len Dia. Spacing I SO ER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1: oS/ IZ /Ob Inspection #2: Location: 352 Trout Brook Trail, Hudson, Wl 54016 (SE 1/4 SE 1/4 6 T29N R19W) - 0 9.19.10 e t 1.) Alt BM Description= 2.) Bldg sewer length= (f2� �� /�. � �Q�-- L�,.�,��✓' ��. - amount of cover = Plan revts kgwre Yes No U e o er side for additional in orm�tion. S D -6710 R.3/ 7) [� D 41"4 Inspector's Signature Cert. No. ( 9 ) Sdc Q c,� x �c"'v T-•sti,;o ) v1 P� �w - J ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: �. € ,a g f �. ... ti ...., � f t . v , r t s a , 1 E � e m i € F 1 4 i s es s e t f j ... .... �... s .... .: � w ..moo. .am e... .. .... i j a S S E j fl j f E i p s �f V. k a S E x � 3 [ r 3 € , 9 � c �o x� t F 5 g € F m m,- e..... . . y .., e .., . - e _.... —.. a �..,.. .n . ..... ..... ......... ... m� ._ _._ _ e.� .. .P e....- _v _ #. ... .... mm .. m - e s ._..��. ..x..ns a �We a,m m e .... e m �a .mPe -a { .a 3 e m, c f w S 3 s � E � s E L 4 3 �L r e e 9 SANITARY PERMIT APPLICATION Safet and Buildings t n Avenue n N*h wonsin 2U1 W. Washin P O Box 7302 Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy on em, on paper not less County than 8 1/2 x 11 inches in size. • See reverse side for instructions for co thipplica ' vrr\_ State Sanitary Permit mber 3638( �� t �D Personal information you provide may be used for e`crrdary p Check if revision to previous application State Plan I.D. Number [Privacy Law, s. 15.04 (1) (m)]. r ❑ ''-, 1. APPLICATION INFORMATION - S , I>1 T? + � , F ATION Pro Own Name y'( Propert Location 1`S l: I`TH 5�1` ,4N Z� ".�� COta E tia /_ tia, S T 2 �j , N, R I �( E (or)SP Property Owner's Mailing Address � of Number Block Number S� r►� �.�- 13 1-o o K rha ( 'L ..._ - . Cit , 3tate Zip Code ;j;/)� q1 e Subdivision Name or CSM Number 11. TYPE OF B I DING: (check one) ❑ State Owned ❑ Vil age It� Nea Road ❑ i i /e 3 7 A Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town OF �� t J'oSc 7`h v III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 030 _1 oZ 6 — 7,5 ' — 00 f0, x/. 16k6 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recr ational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2_ g Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an ------ System ________ System __ ____ _____ __ Tank Only_ — - -------- - Existing System ________ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage 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 �..A/'F�L = 0 �1 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate ystern Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. .) (Gals/day /sq. ft.) (Min. /inch) y, t S Elev9pn L11510 -6 3 a, �/ o g S, a Feet I Feet VII Cap acit . TANK in allo s g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank t V a I ()0 I ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 1 ❑ ❑ ❑ Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Pl Signature: (No to MP /MPRSW No.: Business Phone Number: 0i9RRELL 14U136C :LL U 1 RoR 1073 7t5 --9.! 1 -1021 Plumber's Address (Street, City, State, Zip Code): S� l'.'r�- f =�L1`S LL/ t S' 02� IX. COUNTY / DEPARTMENT USE ONLY E] Disapproved S Itary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) �,— Adverse Determination �`��� X. CQ�IDIT15 OF APPROV�A L /REASONS FOR DISAPPROVAL �^ �j � a� �►tila, Gear . 5 (� � �.Ce Ad ��3 Ct �o�'- �/ - AJ -6398 (R. 4199) [;Y( " " - U fT� I TIpN; .Qr p ount a copy To: Safety & Buildings Division, Owner, Plumber IC� INSTRUCTIONS 1. A sanitary permit is valid -for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of , Wisconsin, Safety and Buildings Division, 608- 266 -3151. - To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. r 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 1 Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 10 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. I CONVENTIONAL SYSTEM DESIGN RESIDENTIAL APPLICATION INDEX AND TITLE SHEET PROJECT KEITH STANZE OWNER KEITH STANZE ADDRESS 252 TROUT BROOK TRAIL HUDSON WI 54016 386 -0474 LEGAL DESCRIPTION SE114 SE114 S6 T291 W TOWNSHIP ST JOSEPH COUNTY ST CROIX SUBDIVISION NAME LOT NO, PARCEL ID NUMBER 030 - 1026 -95- 100 .......... .. PLAN TRANSACTION NUMBER INDEX AND TITLE SHEET PAGE 1 SYSTEM CALCULATIONS PAGE 2 PLAN VIEW & CROSS SECTION PAGE 3 PLOT PLAN PAGE 4 DESIGNER DARRELLLLL HUBBBEELL LICENSE NUMBER 221073 SIGNATURE 1 90t w eiffa 5 LL PHONE 715- 425 -6517 DATE 419100 PAGE 1 OI F 5 Member SAS Tk em ch t SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Chamber Sod Absorption Systems Permit Number ® Date x °x" Gravity Distribution only i Pressure Distribution 3 ft Suitable Soil t Note 1: Bury d ss per manulact"r 16 in Chamber Height 2 8 ft Maximum Bury Depth S & gad Estimated Daily Peak Flow 80 gpdNe WashWWdW Infiltration Rate 562.5 tt Code SAS Size % Oown Sizirp Credit 213.8 f Reduction ( -) � SAS Elevation 348.7 ft W. SAS Size 800 Sri Aoeeplable Finished EL At) 13 oft Grade Ufr>lEation SAS Elevation SO" Minimum I Maximum Number Elevadwt 22 Delm on) Lowest I H�heet Elevation? 102.33 11 108.83 1 102.67 77 9925 100.67 Yes 2 9 Be 94.73 9523 No Fill required 3 97.23 55 94.81 9533 No Fill required 1. DwM of suit" sot f q*vd bdm the >nftom surface for treatment Z Total twipht of dWnbw in inches. 3. Mart m bury depth as per mwgg8*"ft recomffWxk *. 4. Based on dwom syebem develion. and dyer height Top of dwmmber to sgtiA"* % bop of agprap*%. The additn of tH for cover a the reduction d fYri *W grade may be fo*wed b meet minimum or mmdmum code standards. SBD•10553•E (8.05/98) Chamber SAS CbGh 2 SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Chamber Sob Absorption Systems Permit Number 4/9/00 oete x ~ X ° Gravity oisldMon only 1 Pressure Distribution 3 tt Suitable Soil t Note is Bury depth es per menufactuirw 16 in Chamber Hsight 2 8 ft Maximum Bury 0 3 N 38 gpd Estimated Darr Peak Flow 9Pd� Wastewater Infiltration Rate 562.5 ft Code SAS She 95 Down Sizing Credit 213.8 if Reduction ( -) � 348.7 ft Nat. SAS Sine Proposed SAS Elevation Sot Surface Acceptable Finished Grade EL 4 so" Grade I.hrt�aUon SAS Elevatbn System NNrimum Maodmum Number Elevation (M DOM ®n) Lowed Highest Elevation? 97.83 1 104.33 1 102,137 77 8925 100.67 No 2 V 1s 94.73 95.23 Yes Fill required 3 97.23 65 94.81 95.23 Yes Fill required 1. DW6 of eoitaW =I required bdm the kdbWnne solace for tress na 2. Toter hsidd of dwnbw in inches. 3. Maodmunr bury depth as per mwwftduWs n mmmendatlons. 4. Based on dween system dwabon, arm dwmber heist Top of dwmbsr a equt WW* to top of apgr69ate. The adMon of M for oover or the reduction of A NdW grade may be rsgcdred to meet aw trnwm or mardmum code standards. SBD- 10553 -E (8.05198) PW 3 0 d'r View 5e -- PLeA 77enc-i► StoPe 7 17 'r o ;2 3 cwawwl VA --lo r pi-p a c T'wc dky&.,eiif Tv 6e ..a *I 3yTy �a►v 0 Q o r c # � E s v r NT t yC 3 1� • P, i A — i w ^�J, \P1 oN0 a 1 f l i t r n . r � . O pj 1 } 1 ��I ¢ ' is CIA \ A 0 Pate S' of l" Wjsconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page .J._. of Labor and Human Relations Division of Safety & euildings in accord with ILHR 83 .05, Wis. Adm.`COde•, COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ST. CRO not limited to vertical and horizontal reference point (8M), direction and;% of slope, scale`or PARCEL I.D. 8 dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION wEQBY DATE PROPERTY OWNER: '.PROPERTY LOCATION - K2=1t S rW$ SE . 1/4 ,�tl4,S b T �� ,N,R (9 W PROPERTY OWNER's MAILING ADDRESS LOT N $L-0CIFM" ' SU NAME OR CSM rr Z TRoU.T '6Root( - ft -A \t_ CITY, STATE ZIP CODE PHONE NUMBER QCITY QVILLAGE OWN NEAREST ROAD 110 otJ Sti o 0 IS) 386 - 04'1 sr. SasEPM ��,1 3"1''` A ,L�tuE (] New Construction Use (X) Residential / Number of bedrooms 3 ( ] Addition to existing building �Q Replacement ( 1 Public or commercial d Code derived daily how _4 S0 - gpd Recommended design loading rate 0,_7 _.. bed, gpdm 0.5 trench, gpd/ t Absorption area required 1, Li 3 bed, ft 6b3 trench. h Maximum design loading rate _6.7 tom, gpd /ft 0.1 trench, gpd/ft Recommended infiltration surface elevations} R ee•�r' � -�i (as referred to site plan benchmark) Additional design / site considerations — S 0 Parent material Flood plain elevation, it applicable &)A ft S = $Ultable for syst c0 vFNT10NAl MOUNO IN•GROUND PRESSURE E . SYSTEM IN FILL HOLDING TANK U= Unsuitable for s s m S❑ U ZS Q U I Rl S O U D9 S❑ U ❑ S 9U Os XU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /tt Boring ;11 Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rirtdl 2 -f .5t 4 f m*f , Q s <4 44. Z 2- K 3 /3 t 2m ob15 Yr fir Gs .S" Q(o Ground 3 1 y -ZO 10 4 4 - 1 rn3by, 0• Z- 0 3 elev. 1o L4 20- 1 0`/23/ 1 s 0 GS 0. '0 - Depth to S Li 0 3 I o v rc4 5 S m 1 CS limiting factor 7 " G. x 7• yn�r q . fo ]S Q r .7 0•S� Remarks: Notctzonl S NRS G2gvE-L HoR1ZAM b 14A .1 SYDrvFj Boring # f -5 jOYrrC�Z r sl 3� r^ MJr 10 14 �3'3 511 (msbK r GS J 2'0,3 3 Y -Iy IovK ii 1-5 Os rnl c5 o,� 03 Ground elev. 2 .5 v ►z 3 / 1 5 rn] -' J 0, 01 Q7.23 ft. Depth to limiting fact, „ I__t__ i T Remarks: CST Narne:— Please Print PriOi" y M FEg 7� yib I17� dross: 75 O '' AjF NU E ! t)�2 FA = o2Z S' natyry Date: CST Number s / - ( ZOa D Ma 3-10-7 r PROPERTYOWNER - 5 ✓ SOIL DESCRIPTION REPORT Page 2 3 PARCEL I.D. # Boring Horizon Depth Dominant Color Mottos Texture Structure Consistence Boundary Roots GP M in. Munsell Qu. Sz. Con Color Gr. Sz. Sh. 8ed Tre nco) 2 • S -y roY � — stl 3 my o 0.10 3 Z 4 to \Ir2 3 Sr 1 Z vI-Xe 1 r- CS N!° O.Z Ground 3 1 -23 10 q 9,3)3 m S & rYM�r CS 1 ti Q3 elev. C n .23 ft. 4 23- 7.5 K3 f (4 ._. S O S m� 0. 1INSj Depth to limiting factor G ,f Zf, . 7 Remarks: AINKIzorl L4 ttf-S 'G Z)Q*E g'TbA1E,3- Boring # YS' Ground eie v. ft. Depth to limiting factor Remarks: Boring # Ground elev. tL Depth to limiting factor Remarks: Boring # Ground elev. rt. Depth to limiting factor Remarks: SBD- 8330(R.06/92) PROPERTY OMER: A 5TANz6 L. CZNP; I "= 0 ' PARML l..Ot 7E' O )J N- tf I ToPflF WAX 0r--'TZ;- BA6E OlF THE SE\ 0 ZI-W SE EC 2 AJ EkF�cWsc Z. AAIt_ tAJTRToE ' ztl RI w CR_0� A 0 E \M1D u PRC - d4s3y F-1 - 50 1L PORING W/ PACK} a NO COMM 83 5 PffK PROPLEM5 0 a m e A �a a 3 BEp 2otYA MOLASIC Er isrW& SEPTIC f K O � o J EL 1 oav o� ' 97. 1CL- 97.2b' '�.iVf�TE ROk� - T►2ov.T $�.00V, 'hc� +L 519 LOCATION; � \YiE Rp- 51GNEP C5t S "707 PATE; AP094 I ZDOO i TF� ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: SC %, S C Y., Sec. T �( N, R W, Town of J St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced ^ .�2) —2-006 Did flow back occur from absorption system? Yes___ No (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: /(BUD 2 Construction: Prefab Concrete X Steel Other Manufacturer (if known) : Age of Tank (if known) : (Signat re) (Name) Vlease Print 0 w / ft -r-rtAtr a 8 O `s 5 r. (Title) I (License Number) // d (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer MR. 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet affle) . / Name 4 a l r v� �S( Signature KP- /MPRS 10 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer KE r T H 9 rA NZ E Mailing Address 7 R o u t 13 iooK 7 - 1"zz c'L Property Address So? T f our 13 k-o o k T r a (' L (Verification required from Planning Department for new construction) City /State 14 Ud S y n w Parcel Identification Number ©.j 0 — Ua `jS= 00 LEGAL DESCRIPTION Properly Location �9E y., SE V-, Sec. 6 . T a q N -R_LLW, Town of Subdivision 9 Lot # Certified Survey Map # Volume . .Page # Warranty Deed # . Volume . Page # Spec house ❑ yes ❑ no Lot lines identifiable 0 yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da of the three year expiration date. � 4i /f y 1171 20 SIGNATURE OF APPLICANT DATE 0 aC 9 107. OWNER CERTIF ( e ertify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of rty scribed y virtue of a warranty deed recorded in Register of Deeds Office. pr . q / a/ Z M K �' SIGNATURE PLICANT 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 L DOCUMENT NO. STATE DAR OF WISZ�NSIN FORM 1 --1fiN I Alts enaes sessarsa ►at sseeae/ate BATA Wi RRAUnr DEE f s , = PA'E 2 REGISTER'S OFi~iCE This Deed, made between .............. ......... 3T. CROIX C4 .......... -.. 1 , Mn t -..:Q !? *!i ..J��nns._ ..•..�.�.Ql�_,.._h4!R �lncl.... !� Reed for Record t Iw�id :c.-- t�n(t>:. *... �{ JAN 3 19`�O 1 ... ..................••__......-....._........._.._......._..... ........_...................... Grantor { df aid ... K!�3.4.h.. Jerome _.StADZA.=d.Jud.i_th_..C' - ..�t�ooxn ........ ..... ...... � 8:30 A. M H = ........ ht�i.. k±r. n-d__± �! �! �t_. l�. ifm..l�a_..�a�i.nx--- t�r�ients . ................. ...... !€ ..................__......_._.........__............--•--•--••--•-----•--.._...._. .........._........._..__...... 41110Nrof0e8,; ....... ......... . .. .............. ...................... _ .................. Grantee, Wftaesseth. That the said Grantor, for a valuable consideration..__.. { Raher._sl..!�c►l_.�l4�ncle �_1 Qm.--•• ............. .......... ..................... conveys to Grantee the following described real estate in .... St— Croix__..__... ( RtTYRN TO County, State of Wisconsin: ! West 385 feet of the North 208 feet of Tax Parcel No: . .......... SE% of SE% of Section 6, Township 29 North, Range 19 Wsat, St. Croix County, Wisconsin. Subject to a 33 feat easement foi roadway and utility purposes ' across the South 33 feet thereof. 'I TRMSr This ........... i13_............ homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And ........ icherd._.��41.__, Jeanne. 8iq!n warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements,restrictions and rights -of -way of record, if any. and will warrant and defend the same. I Z C{ 'i"h Datedthis ..--- •------- ........................ day of ......... January ...... ...........•- - -- -• ................ 19__.�Q_. t - ---- Jet -... (SEAL) - ?!t?-- ���.C�- k:Cl ......... (SEAL) '. R chard J. Blom .J)banne M. Blom • ....................... .•-- •- •• -• -•- -- •-- - - - - -- .................... ......................... .................. (SEAL) - - - - --- --' ......................................................... (SEAL) F AUT13BNTICATION ACBNOWLBDOMENT = Slgaature(s) .-- ....__...--•--•--- ----- -..... I_ --- --_--- _-- - - -_ STATE OF WISCONSIN �PGI n r1c M ---- - - - - -- - R f ---- ••___ __________________ _ _ __ St. Croix so �Y1t /��v G ...................................... County. authentiea >a -------- day of --- ---, 19..�__ r ? q�i;ly came l before me day of / t fi v1 �C u >^ � J-- u� rYY -- --- 19_ �. the above named - •----• .. ................... .•_... --•- ----•-....•---•.._.._...._..---- ` (/iG - . -- . ...... B 1aI---- ---- - M -- - Blom - • - - --- --- - -- ---------- •--- - - - - -- • Richa J. lom Jeanne . TITLE: MEMBER STATE BAR OF WISCONSIN - ----- •---- --- ------ -------- -- •--- .....- --• •------ ,......---- --- •------ _._...._. (If not, ... .... ...:..................... ....: . . - - authorized by t •7118.06, Win. State.) me known to be the s _ person ____._.___:_ who executed the foregoing instrument and acknowledge the same_ - "IS INSTRVMEN'r WAS DRAFTED q* ' Kristine Ogland Lundeen .................................... --•---------_-------- ittt at Low ......................................... Kristina Ogland Lundeen •---- •--- ...••-- • -• - -• • -- - - - -- ---------- .................. - -- Pier o - _ - -- Nota Public _______ - ... County, Wis. - -- - - (Signatures may be authenticated or acknowledged. Both My Commission is perm. ent. -- (Tf - - - not, state expiration are not necessary.) date. _ x i alfaram of Inrsons sicnlne in any espaeity should be typed or printed below their signatures. I W4MANTT DEED a7ArR BAR OF WISCONSIN Wisconsin Lees) Blank Co. Inc. FORM tie 1 -1982 Milwaukee. Wig. M a e� �� i � \� � �o \I�'� � ��� COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715 -962 -3121 800 - 962 - 5227 4:11V 16 ST. CROIX ZONING REPORT NO.S 34900/01 PAGE 1 ST. CROIX COUNTY REPORT DATES 10/12/89 COURTHOUSE DATE RECEIVED'# 10/11/89 HUDSON, WI 54016 ATTNS THOMAS C+ NELSON OWNtEFtS Richard Blom LOCATIONS 352 Trout Brook Trail, Hudson COLLECTORS St. Croix Zoning SOURCE OF SAMPLES Kitchen faucet COLIFORMS 0 /100 ml INTERPRETATIONS Bacteriologically SAFE NITRATE -NS 5 ppm Under 10 ppm is safe for human consumption. 'FORM + NITRATE ftl i�r P LAB TECHNICIANS Pam Gane OC 1 6 19 1 WI Approved Lab No. 19 ST cF 001��1 s r t m�, C Means "LESS THAN" Detectable Level. Approved by' PROFESSIONAL LABORATORY SERVICES SINCE 1952 J ST. CROIX COUNTY ZONING OM6,4, St. Croix County Courthouse.. Cr (\ 911 9th Street Hudson, WI 54016 , I Telephone - (715)386-468'0 The t. Croix County Zoning Office offers the service o•f',.eptic and water inspections to Lending Institutions, Realty,F}rms, and private individuals. Completion of this form is essential so that the property can be located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING--------------------- - - - - -- -FEE: $ 25.00 -2�`5 0 (For nitrates and coliform bacteria) M%TER TESTING FEE: $127.00 (For VOC'S) SEPTIC SYSTEM INSPECTION---------- - - - - -- -FEE: $25.00 (Determines if system is properly functioning at time of inspection) U ( Property owner's name Property owner's address Legal Descri tion S�: 1/4 of the x_ 1/4 of Section _ , TN -R Town of L Lot Number Subdivision Name FIRE NUMBER ` s, LOCK BOX NUMBER A . Color of house Realty sign b house ?(.,;-,o If so, list firm: PLEASE INCLUDE, IF At ALL P SIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH OCATIO SHOWN AND A COPY OF THE LISTING SHEET. 5 . ,j� uk Testing of residential water requires a sample hat is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: Telephone Number � Y REPORT TO BE SENT TO: C• / ( C���� �� ��� Closing date " Signature (1 J J�3 - T K � (�� pfv k ST. CROIX COUNTY yk , WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, W154016 r (715) 386 -4680 October 11, 1989 Judy Steiner 700 2ed St. Hudson, WI 54016 Dear Ms. Steiner: An on site investigation of the septic system on the property of Richard Blom at 352 Trout Brook Trail, Section 6, was conducted on October 9, 1989. At the same time I also obtained a water sample and submitted it to the laboratory for testing. The results of that testing will be sent to you as soon as we receive them back from the laboratory. At the time of the inspection, the sanitary system appeared to be functioning properly for the existing use. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system is totally dependent upon proper maintenance this system. Should you have any questions regarding this subject, please feel free to contact this office. Sincerely, Z ? t�' Mary a ins Asst. Zoning Administrator l