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Parcel #: 030- 1097 -10 -000 02/25/2005 05:04 PM
PAGE 1 OF 1
Alt. Parcel #: 32.30.19.354A 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): " = Current Owner
"
DENNIS G & JOYCE C DREWS DREWS, DENNIS G & JOYCE C
1224 ROLLING HILLS TR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description * 1224 ROLLING HILLS TR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 11.970 Plat: N/A -NOT AVAILABLE
SEC 32 T30N R19W PT SW SE LYING SWLY OF Block/Condo Bldg:
TN RD AND NLY OF A LN BEG 390.49 FT N OF
SW COR SW SE; TH N 58DEG E 584.25 FT; TH Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
N 43DEG E TO CL OF TN RD 32- 30N -19W
Notes: Parcel History:
Date Doc # Vol /Page Type
07/23/1997 586/298
2004 SUMMARY Bill #: Fair Market Value: Assessed with:
5628 307,600
Valuations: Last Changed: 07/08/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 76,100 127,700 203,800 NO
PRODUCTIVE FORST LANC G6 8.970 98,800 0 98,800 NO
Totals for 2004:
General Property 11.970 174,900 127,700 302,600
Woodland 0.000 0 0
Totals for 2003:
General Property 11.970 102,900 103,700 206,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 308
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
OWNER DZj - Gd S TOWNSHIP S L 2� = SEC ____T3aN -RIQW
ADDRESS 9 7 ll��nC�S /7 /// CROIX COUNTY, - WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW 0 30- /01 ,1 D --dUG
Distances and dimensions, to meet requirements of H63
THING WITH
N 100'FEET OF SYSTEM
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S �c� 6RDE L.15ufL ,
BENCHMARK: (Permanent reference Point) describe : wd,pv I ,u�CE PosT, A�ti��° eED
� 7 d 10
Elevation of vertical reference point: 0 S lo p e at site:
Ca
SEPTIC TANK: Manufacturer: W Cl S� e - S L Capacit P y : I odo 6A/ 1 atiS
Number of rings on cover Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; total capacity OF
distribution lines gallon: size of pump_ head;
gallon per minute horsepower brand name of pump
and model number
Type of warning ev ce
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Ty e of'warning device_
SEEPA ;E PIT SIZE: um er o pits feet diameter
feet liquid depth seepage pit in et pipe- elevation
bottom of seepage pit e, evation feet. i
SEEPAGE BED SIZE: number of lines 3
w t / length depth3
SEEPAGE TRENCH: width length BU ILT Z7 PERCOLATION RATE / ��_ U D �
INSPECTOR
DATED PLUMBER ON J B
LICENSE NUMBER
a L'I VoKI o I NS III ('I ION INVI VI VUAI ';I WA(;1 ;V'; I I M �•�
, lrr Ir / 'epic
tirrlrr ti('Ilr(r
AMI - — Tuwnehip St. ('nor x ('1014vl111
1 r1r(((r n _Secti.or Lot M S( d 4vie4 on
I I'11(' TANK
galtone Number of( eompantmen.t's
(rrr r
If W('YY Bu- iIij'.rl
Hi ghwa to n
'iMPINI; CIIAMHI R
�� •'I' gattone, Pump ManuAae.tu'ke.K Model' Number
�II)ING IANK
gal'Pune Numbea 06 Compan,tmentA
Nurnfr( _ A,taAm Syetem
tanc.'c' (Thom? Wetl___ Bui..Ed.ing 12% elope -
H.i.ghwate t
h`;ORI'f ION SITE
Red T4 ench
L. / -J —
f a nc e chum Wetl Bu< d.cng A 27,_5 12% e Pope
Hi.ghwaten
';()kr'IION SITE DIMENSIONS
W(dth
4#4 the,neh - - At Reyui lied area__ ((
I myth .u6 each tine_ _ _ - At Depth oA hock befow t4fe (rr
Num(r(h (,/( Depth o(( hack oven tiYc'___ trr
f,r(,(Y ren,1101. o6 Unee _ - _6t Depth o6 tile below ynade <n
U(A (rrnr(' between Pinee At Slope ( tneneh tn. 1.•('n 100 At
I , (Ir�r,gjrtiun uheu -- y et Type 06 Coveh: Napeh uh A tnnw
i I V I M I W S I O N S
Nu►n(,rn u� p�.te GnaveY ahound pc to ___yee nr
Oute(de diameters At Depth bee-ow irifet _----- -_ -._.
)nt(iY nbe(inpt.ion aaea �t
Anet; neyuihed At
NtiPI CII U KV v 'n TITLE k2 Cj
LI'ROVI U 7"CT� DATE -- � 19
DATE 19
I AIWN I OR REJECTION
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S tate and County State Permit # q 72
PLB 6 7
Permit Application County Permit # CW6
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
I
A. OWNER OF PROPERTY Mailing Address:
�,.t� _4 JO- M,6 W� ,eT, z 410w-- ��s T�A;� , yU�� �, 01 -r.
B. LOCATION: 1 � 40 ' / 4 5h ' /4, Section 3Z T_30 N, R E (or) _a Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
�COff /�(T 7j /��f T�ly /L Township 57- TOS4,VA—
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) * Variance
Single family X Duplex No. of Bedrooms 3 No. of Persons
D. SEPTIC TANK CAPACITY /GrO Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete X Poured -in -Place Steel Fiberglass Other (specify)
New Installation Replacement X
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement X Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top No. of Trenches
Seepage Bed: �_ Length - 3'� Width�_Depth 5 " Tile depth (top C- No. of Line 3
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits j0
Percent slope of land 796 Distance from critical slope �E '�'�
WATER SU Private ® Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other tha pr esent owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certified Soil Tester, p
NAME _RO6CRT Zl16.0'66 C.S.T. # b " o�-yQ z and other information
obtained from sa%L T� S (owner /builder) .
Plumber's Signature Znj4g MP /MPRSW# Phone # ��� ,3�r'o
Plumber's W /S
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
Ss ED tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
AT74tA property. If well has not been drilled please indicate.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE 0N11(
Date of Application �7 �d �� Fees Paid: State County �� D e 1� — d
Permit Issued /Rejsoted (date) ,10 Issuing Agent Name
Inspection Yes X_No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 7/1/78
s
15 Re,. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53707
� 8
LOCATION ' /a, s � ya, Section 3 Z ,T • N,R / E (or) W Tow nship or Municipality TOSEP
Lot No. ,Block No. '# �Q ,1 ' pt p��' County
�,PEw Su bd ivision ame
Owner /Buyers Name:
Mailing Address:
;eT 2 - /%N 11 ill; TAI' /Z U',rO,✓ 40i s .
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TYPE OF OCCUPANCY: Residence X No. of Bedrooms 3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT X ALTERNATE SYSTEM,¢ q
DATES OBSERVATIONS MADE: L BORINGS A f /FOPS PERCOLATION TESTS
SOIL MAP SHEET SAS NAME OF SOIL MAP UNIT elLeArk-
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN /IN
BER ,1 INCHES WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- n L „ vT �.J. L co " O�
P- �L / nab �G
a ry /3 "
P -2. i� ` AAJ L / "L/ N • L j 7 "OTC. SL / J'
P- 7 " O? • Cf
P -.3 3(0 9 "QN• L „ Lfl3�v. L 8 "O'P.CS
P- -------
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- 0 No v-c Jo a" a. L /3 ` �� L , /6 ' _7'
B- /VONR T gy 7'13A�, L &^ Ll• (3a. v /3 "Lf -a SL S - ,? A-13,U cs
B " ,dN. L 12 " L /S L�• Aj. SL SO" 'e. e>S
B- 6 'W. /.3r,, L 2 - 2 " /O "C f • IBS ,C S
B - 33
B_
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy &5_ • H' IM Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope. D.QifIAJ
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I, the undersigend, hereby certify that the soil LF i reported an this form were made by me in accord with the procedures and methods
specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
�� �T /6,PicyT s =oz y�L
6 Z/ s
Name not Certific No.
(p rin t )
Aiddressl O,U O.So'v CZ) .
.Name of installer if known :z' Al oxA
Copy A —Local Authority CST Signature
1 15 Rev.9 /7B
r REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: ' /., s� ' /., Section � ,T 3 0 N,R1,E (or) W, Township or Municipality "
Lot No. , Block No. � r 0� It 1^76
� A County 57 - �FOI x
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Owner's %Buyers Name:
TO y Ion Name
Mailing Address: /1;r' 2 Ol� /�S /Z/f/
TYPE OF OCCUPANCY: Residence X No. of Bedrooms 3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT X ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS %:!�e ( g dd PERCOLATION TESTS
SOIL MAP SHEET ACS yZ _ N AME OF SOIL MAP UNIT �el�TE, --
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTEF INTERVAL MIN /IN
BER 1ST WETTED SWELLING' IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P —
P—
P—
P
P—
P--
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B— 5 22
B—
B—
B—
B—
B—
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy d .Indicate scale or distances.
Give horizontal and vertical reference points Indicate slope.
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I, the undersigend, hereby certify that the soil tests reported on this form re made by me in accord with the procedures and methods
specified in the Wiscon$in Administrative Code, and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
Name (print) rpA - 4 /be1`C 7 Certification No. — 0) Li 19Z
Address T OA-) '
Name of installer if known 92 A B AO S .
CST Signature 7 A 66 / •�
Copy A —Local Authority '
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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
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)). 363910
Permit Holder's Name: ❑ City ❑ Village ❑ 176wn of: State Plan ID No.:
Drews, Dennis & Joyce St. Joseph Township
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
trp O r fit. * 030- 1097 -10 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic ? Benchmark t, (p ( a
Dosing Alt. BM
Aeration Bldg. Sewer t �,
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet -'
Air
Septic �� (� - NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe �. oa
IS. $
Holding Bot. System
L_ . S
P / SIPHON INFORMATION Final Grade
Man ularr emand St cover gmt-
Model Number GPM p�5-r ( - - wx �`,� gj
TDH Lift L ction m TDH Ft
F main I Length Dia. Dist. To we 2.02 -
SOIL ABSORPTION SYSTEM
8E$/ NC Width ( Lengt , No Of renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 (o •Zs _ DIMEN SIONS nn
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Man- du er: - S i�2t
SETBACK CHAMBER
INFORMATION TypeO r Model Num Number.
System: AV . S3 ! l5 a OR UNIT
DISTRIBUTION SYSTEM
Header/ Man old f istribution Pi a s) x Hole Size x Hole Spacing Vent To Air Intake
Length a. f ength 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 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) t6 1
Inspection #1: 03/ 2-q Inspection #2:
Location: 1224 1224 Rolling Hills Trail, Hudson, W 54016 (SW 1/4 NE 1/4 32T30^^Nnn R19W) - 3230193
1.) Alt BM Description = �I(w�t fw ('u�. - 2 `t- 3 1� � ��. v � �`^ 7 (° ' � T
2.) Bldg sewer length
v
- amount of cover = ?
PI revision required? ❑ Yes ❑ No o � Zg l Z(p
Use other side for additional Information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH t
SANITARY PERMIT NUMBER:
111 m.�.m.-
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Safety and Buildings Division
� 2 01 W
SANITARY PERMIT APPLICATION W. Washington Avenue
`•iscons P O Box 7162
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. S r
• See reverse side for instructions for completing this application State Sanitary Permit Number
3G3 -7 /0
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. (e 4 P I t State Plan Review Transaction Number
I. APPLICATION INFOR > MATI N -PLEASE PRINT ALL INF RMATION
Property Owner Na a Property Location
' S0 1/4,S 3X T 3o ,N,R / 9 E(orr
Property A Owner's M In dress , , _ _ � Lot Number � � � Block Number
Cit , State Zip Code Phone Number " f lir Subdivision �Name or 4SfjQ Number
y
II. TYPE e) ❑ State Owned 3 o C it Nearest Road
Public Wrr TF i l I' - No. of bedrooms Town OF t El.�o �. •
III. BUILDI SE>�Cf►1i type ic, check all that apply) Parcel Tax Numbers)
Clr1.� r-
1 ❑ A n; / C,QRcig d
2 ❑ Asse Hail 1r '- '' caax
6 dical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
sT
3 ❑ Cam gt` nd �pu1`/ 7 rchandise: Sales/ Repairs 11 E] Restaurant/ Bar/ Dining
4 ❑ Churc / ool 1 a obile Home Park 12 E] Service Station/ Car Wash
5 E] Hotel/ ffice / Factory 13 ❑ Other: specify
IV. TYPE OF P (F k y one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. CK Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
Sntem System Only 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 i Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12J4 Seepage Trench 22 ❑ In- Ground Pressure / i 42 ❑ Pit Privy
13 ❑ Seepage Pit Z k S` 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (s ft.) (Gals/day /sq. ft.) (Min. /inch) 84 , .Sr ,k Elevation
�( s® 1-11 $G,3 t/ $4+� Sz . 8 Feet qo;dy.. Feet _V I
Ca cit
VII. TANK in gallons to s Total # of Prefab. Site Fiber- plastic Exper.
INFORMATION New Exist in Gallons Tanks manufacturer Name Concrete st �e ied Steel glass App.
Tanks T nks
ticTa orlfelld+ng�arlk /OOO 600 /1lAr 9 El 111 11 11 11
Lill u ❑ ❑ ❑ ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print)) 1 ! / Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
�at. l�� ti •re �.I�. r 1 W p' 7 L d - 7 LSD 74 Q - 33 a,;-
Plumber's Addres (Street, City, State, Zip Code):
!O7 t+ 10 )K� { a Lb. `wo
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps)
pproved ❑ Owner Given Initial Surcharge Fee) /
Adverse Determination �>Z �O C3 b Z0 a A•
X. COND ITIONS O A REASONS FOR D A PPROVAL: 3rr ' Sewas
-
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9 i
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SBD - 6398 (R.12/99) v -D ISTRIBUTION: Original to County, One copy To: Safety & Buildings Diu4sion, Owner, Plumber
i
INSTRUCTIONS Y
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 subm tted to the
county prior to installation
5. Onsite sewage systems must be 'properly maintained. The septic tank(s) must be pumped by 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 ar.the State of
Wisconsin, Safety and Buildings Division, 608 - 266 -3151.
To be completeand'aau'rate this sanitarypermit applickion must include: ` X,.:
I. Property owner's name and mailing address.,Rroyide the legal description and p,brc.el tax number(s) of wh,er�e the
system into 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. «oa
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replaea iient or repair.
V. Type of system. Check appropriate box depending on system type.
VL Absorption system information. Provide all information requested for numbers 1 through
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 septjc, 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. NIP, 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 (ounty. The plans must
include the following : - A) plot plan; drawri 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; purrip 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 ;' soil test data on a 115 form, and F) all sizing information.
------- ----- -------------------------------------- ---- ----- ------ ----- ----- ----------------- ----------
GROUNDWATER SURCHARGE
d
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.
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Wisconsin Department of Industry SOIL AND SITE EVALUATION / .3
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County _ 5 7 - , 4:;e01 X
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. #
030 • /O f • /0 • oVv
APPLICANT INFORMATION - Please print all Information. R ew b Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). IvL
Property Owner ► Property Location Cv
' DR. ✓il N 0; �t soic G (J .5 Govt. Lot $W 114 SE 1 /4,S 3Z T30 ,N,R / 9 E (or W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
122-Y � lb 77P• f s 4 ov,JfS -
City State Zip Code Phone Number 7/s Nearest Road ��
��• -Sy0 �3 (Sy f) Co ��lo El City S T ❑Tloge Town iiv lT !T /1/S Te . el
❑ New Construction Use: [RIlesidential / Number of bedrooms 3 Addition to exr ting building
(Replacement El Public or commercial - Describe: ilJ /,P = �JD 7 XEca 'i -0P
Code derived daily flow 7 gpd Recommended design loading rate 7 bed, gpd /ft ' 8 trench, gpd/ft
Absorption area required _ bed, ft2 5&3 trench, ft Maximum design loading rate '7 bed, gpd/fl gpd/ft
Recommended infiltration surface elevations) S.G�- - 3 ft (as referred to site plan benchmark)
Additional design/site considerations "'V U' N W s�ff 1-7;;47 4 7 L -""S .
Parent material AFS S' O&EV S,JWVY Flood plain elevation, if applicable N ft
S = Suitable for system Conventional Mound In -Ground Pressure A -Gr nk
System in Fill Holding Ta
U = Unsuitable for system 9 El S El O U L7 S El LA'S l❑ U [ �❑ U ❑ S EFU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
�.. 0. 10Y4 31f( SL z s ,� 6 4- • s ; . cP
Z 7• /b 0 Y16 S /L 2 f S k /%M 7 C s / f • S' • Co
Ground 3 Aphe Y/& L..5' AM /1N I/�i C' � .
. �
elev. • 17 i D
y3. - 1 - ft. • v • /oyie to �i. *zrZ GS /i+, Q.c '
Depth to (y w , ' / T
limiting, 4 �XISTI•l� �T' rs ! ��t - 9�•Sa
factor
/in, L
Remarks: s0 /1S ' A14 t 18- Ge!f% 1 • ,4C7 �! •2/ -
Boring # 013 / � y � 3! — SL S k' Im Ae ZtJ /f ` l ' . S
Z
2- 3•�B . /VY,e — s/ L /f s he fie w i� • 2 . 3
8.3 • /o k 16 S/ L 24f dry '''' f e • S: .
Ground 7• R Y/6 �— Ls 1*4 ,? 4* v7' / e C5 _ .7 .g
g y
el ft. S ego s • s . 4 IS, ldz - • 7 ; g
,<.
Depth to �� Z � pqS
q �- v
limiting 3 I � �(,•�i
factor
N/ Remarks:
CST Name (Please Print) Signature Tel hone No.
&&k- 7 �Gl�i�� 7 7 /S 3 • $l9S
Address Date CST Number
Ulbricht & Associates 3 '2 S
Private sewayeet
655 O'Neil Rd.
Hudson, Wis. 54018
NAL
OR1G1 .
PROPERTY OWNER 11 SOIL DESCRIPTION REPORT Page Z of 3
PARCEL I.D.# 0 3 0 - 1 0 f 7 �� • ���
Borin # Horizon Depth Dominant Color Mottles Structure 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
3 l o•i - Io ye 3/
Site / fs he f�' w • Z ' • 3
Ground - 3 •3 - io s� L �,� �� • ' S . s ; .
elev.
gg.o -ft.
Depth to
limiting
factor � $• z Y Zy �� rr '
7
446 0n.
/ Remarks:
Boring #
2
Ground
elev.
tt.
Depth to
limiting
factor
In.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
Ground
elev.
ft.
Depth to
limiting
factor
In ' Remarks:
Boring #
Ground
elev.
tt.
Depth to
limiting
factor
in. Remarks:
SBDW -8330 (R. 08/95)
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ST CROIR COUNTY
SEPTIC TANK MAINTLNA'INCE AGREEMENT
AND
OWNERSHIP CERTIF'CATION FORM
Owner/Buyer D-ja ,
Mailing Address f A of l R -��,
Pro Address _ /nay R '
Property L4, 5yo ! �•
(Verification rcquirrd from Planning Dcpautmcait for new construction)
n,
city/State Parcel Identific< ion Number o 30 ._. v 4? -!o - oao
LEGAL AESCRIPTION
Property Location S ' /<, 5 %<, Sec. .3 2 . T 3o N -R W, Town of .Sf•
Subdivision IV � Lot # -
C.ertif'ed Sarvey Map Vol.me Page #
Warranty Deed # 3 3 - Voll me S 8 (e . Page # 4 8
Spot- hOUSC ❑ yes Et no Lot Iin,x identifiable_ ® yes ❑- no
DANCE
lit q %w p er t=tad =imtcaa=ofyuwscpftcsysc=coddrcaAiiLitspr ��tobandicwastcs .Properaaaiat===
�a
consi O Sic -t o of tie t CMY 6= Yc= cr sonar{ if: wc&d by s Uccrosed What yam pat. into t= system
- �� - tccatmcznt stYge is the viastc di- Spasalzysrcm, - - -
TlW F. operty ow= agrees to sabmrt to SL Q uix Zmft DTutmcat i cafficatioa form, signed by &c 4nmcr and by a
md � r Phmd)cr-jO= q == P l=bcrrcsEc tedpkmbaor - &UC=Cdr' =
is is Pmper Vc ating C=Moa and/or (7) after kgxctioa and p=pun g.Czf noocssary), ire septic- taak.is less .than W full of sludge.
tmdasigoed I7avr rttd the above to L raiataia tt e
set fQ4 hctcm.0 sd by the Department of Doma=e and the c disposal system widr the ztaadaids
septic Depart of Natural Rte State of Wisoomsi
y n.. Certificafion
systembasbornmaidm be complc(cd and re m wd to the St. ()mix - County Zoning Office within 30
da1►s of t$re flare expiratica date.
OF CANT DATE
O'GV M GERTIITCATION
I (we) oatrfy that all statements oa this foray are true to the txst of my (our) lmowtedge. I ( am (are) the own er(s) of
Lbov- , by virtue of a warranty decd mooriW h Register of Deeds Office.
OF CANT DATE
*s « «sa Arty information that is mu- rcpresentcd may result is the san tuy pc=t being revoked by the Zoning Department.' «« «««
tndade witty M apptieation: a tbanped warranty deed &um the Register of Deeds of icc
a copy of the certified survey map if reference is made in the warranty dcod
DOCUMENT NO Q STATE BAR O V, "S, - -r %- FORIA i
-
5 P V J ^ -f 2�8 WARRANTY DEE
Vo l V
T /lea 5!'•�'.a R: � 4.'. � A
' 3533w
This Deed made between - Frank W. Trudell and REGISTERS OFFICE
-
..... ......... -- -
Mary Elizabeth Trudell, his - wife as point tenants ST. CRO)X CO., WIS.
_ ..... .... -• . .. .... ...........:. . Recd. for Record this 71t
.......... ..... ........ ... ...... .. _Grantor day Of A.D, I9
and.Denn.i& G ;ews ..and. - boy- ce- _Cr-- Drews -,- ,husband -and wife. .— S.oc._. -_ �3
as j - oint: tenants -� � M.
... - - -- ...
.. ......... ...... . ..... .. - -- `1
......... ......... .. ....... •--- Grantee, pplat a
witilgIsetb, ThSt th said Grantor, fSr a y1u ble considerat
One dollar ( 0 an other goo an va ua a consi eration
_ - -- ---- ----- ---- --- ----- -- ---- ------------ .__. - -- -- --- -- - - - -- - - - -•- • - - — v
conveys to Grantee the following described rest estate in _- St . CrolI ncrunN TO
County, State of Wisconsin:
All that part of SW'L of SE'Z of Section 32 -30 -19 lying Tax Key No. _ .... ........ ..... _........
SWly of Town Road and Nly of a line commencing 390.49
feet N of SW corner of said SA of SE'k, thence N 58
584.25 feet and thence N 43 49'E 445.0 feet to centerline
of Town Road.
TRANSFER
FEE
Transfer Fee Due S 62.00
This -- --.- .-- 13 ............... homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereantp belonging;
And Frank W. Trudell and Mary Elizabeth Trudell, his wife
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same.
Dated this .... — . ... --- --------- -- day of - -• ........ ... December . ...... 19. 78
- - -- ..(SEAL) J.d - ..._(SEAL)
-- - -- ----- --•-• -- -
Frank W. Trudell
-- - --- - -- ---
...... _ (SEAL) u .. (SEAL)
M y Elizabeth Trudell
AUT$SNTIvATION ACKNOWLRDOMENT
Signatures authenticated this .. .. .. .. .. ...... day of STATE OF WJ800ftWk MINNES TA
19----- -- ss.
� ilash_ington --------
._County.
_
_-- ---- ------------..._.------ . .....__. ......... .------------- . ...... personally came before me, this . - lst___...day of
- - DecembT,1978 - -, the above named - Frank W. -
- - - - - -- - - -- - -- - - -- -- ---
-e
TITLE: MEMBER STATE BAR OF WISCONSIN Trudell ,and_- Mary -El- zabe Trudea -1 -,_ hi - s. wife
(If not, _ . - -- _.. .
authorized by § 706.06, Wis. Stats.) . - - -- - - -- -• - - -- •... . - • -•
:. ................ .... I .... -.... • - ......
TH.S IN$TR' NT was D AFTED BY to me known to be the person .._ _.. who executed the
Roger E. Hetchler, Broker foqgoin instrument and ackno ledge the same.
Currell Inc.
521 Second Street .� --
Hudr.on; Wisconsin; 541116 - ------
* MARY1 KELLY AM PUft 'C nty, Wis.
( Signatures may be authenticated or acknowledged. Both My C ., 1 xpiration
are not necessary.) 9 ) 1
dates M[�rOrttmlaawn E.Mrra filq t� t97g'
8 Namc -a of persona sittoing in any capacity should be toped or printed below their aignaturaL
WARRANTY DEED STATE _ BAR_OF WMCONB71f V —_ n•fn Zvqu a'srk Cn, tnc _
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
a" 'FOR UTILIZATION OF AN EXISTING SEPTIC TANK
J bala ,`
w C This is to certify that I,have inspected the septic tank presently
serving the
!� residence located at:
Section � T�N, R _L�_ Town of
x
Upon inspection, I certify that I have found
the tank and baffles to be in good condition, andit appears to be
functioning properly.
Last time serviced: '�-oCP
Did flow back occur from absorpti system?
Yes No (If no skip next line
l Approximate volume or length of tii;e : ! e Q b gallons minutes
Capacity
loo
Construction: Prefab Concrete _ Steel Other
}
Manufacturer: (If known):
Age of Tank (If known):
An A1AAQ
(Signature (Name) Please prin
QV 69
a� # (License Number)
� b f
3� r
Date
y' Form to be completed by licensi plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (aR 113 Wisconsin Administrative
4 a
Code )
y 1 k
Plumber (applying for sanitary pet Certification:
} In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the besl"'of my knowledge will
conform to the requirements of ILHa 83, Wis. Adm. Code (except for t
inspection opening over outlet,baffle).
Name Signature � P /MFRS
a
t x