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030-2064-60-000
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A 3 Z 'j w CD CD CD CL CL z C r: o %* Z O N Z y CD I v ' p g .A w CD CD D y to ° x. m o? a m a a N a s ID O K O ao� o c o ° t7 v c ° CD v c ° irl CD c z c � Z a ° N CD O ° Ol ° 0 3 (n CD ElF CL j 0 a ry; at a A ro m o � C m n ay N CD I t ro y I a � - ' N o ) 3 o f°3 s a cD O O tv b CD fD ti o o c CD CD CL I �3 RECEIVED 3 6 1 2 7 7 5 VOL 20 PAGE 5108 KATI?& H. vXC9 _ MAY 15 REGISTER OF DEEDS RECEIVED CERTIFIED S AP 11/23/2005 68:69AN LOCATED IN PART OF GOVERNMENT LO R 730N. R20W. RECTIFIED SURVEY MAP REP FEE: 13.00 TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN. COPY FEE: 3.00 PAGES: 2 U_ _NP_L_A_TT_E_D_LA_N_DS_ OR7H LINE OF GOV. LOT 1 N6956'23 "E 2643.22' N1 /4 COR. NW coR N89'56'23 0 E 400.32' SEC. 35 SURVEYOR: mac' 2242.90' DOUGLAS J. ZAHLER --- S dk N LAND SURVEYING. INC. 2920 ENLOE STREET HUDSON. vN 54016 4. 72' SCALE IN FEET 1" = 100' PREPARED FOR: 100 O 100 DON ANDERSON 4 Jim 1273 HWY '35" HUDSON. wl 54016 LOT 1 8 4 Note: A possiWe S 7.505 ACRES violation of the St. 1 `f, Z I r O 326.899 SQ. FT. Croix County Zoning O Ordionce will be So a created If the = I r IV existin structure r o located within 100 of e lineeverh houses z g livestock or poultry. rn y r- G ARAGE I cn o c SEPTIC AREA HOUSE 1 t( '—WELL ® ® 1 ACCESS EASEMENT ® w r RECORDED IN M L293" \ N . 12570 DRIVEWAY f s \ _ 1*i I Czi ® C 1 N. ® 1d 7r • •. ® 1 CA .; (a 69 \ N. N. LEGEND\ ss• FOUND ALUMINUM \ A�► COUNTY SECTION \ �. •y 6' CORNER MONUMENT \ .� �. <. FIELD FOUND 1" OUTSIDE DIVISION \ \ ��54 I , DIAMETER IRON PIPE ® BUILDING ® SILO --�- -- FENCE \ \ \ I SET 1' OUTSIDE DIAMETER BY O 18" LONG IRON PIPE. WEIGHING 1.13 LBS. PER LINEAR FOOT \ THIS INSTRUMENT DRAFTED BY: WILLIAM KANE .1043 No. 6540 -01 DAIS 11/10/05 I(' I l /22/c.S SHEET 1 OF 2 SHEETS Vol. 20 Page 5108 I Parcel #: 030 - 2064 -60 -100 09/08/2006 02:23 PM PAGE 1 OF 1 Alt. Parcel #: 35.30.20.605A -1 030 - TOWN OF SAINT JOSEPH Current ! X j ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 03/14/2006 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co -Owner 0 - ANDERSON, ELIZABETH A TR ELIZABETH A TR ANDERSON C - ANDERSON, LAVERNE ET AL 1244 HWY 35 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description " 1273 HWY 35 SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 17.000 Plat: N/A -NOT AVAILABLE SEC 35 T30N R20W GL 1 EXC PT S & W OF Block/Condo Bldg: HWY 35 & EXC PT N OF HWY AS IN 412/474 & EXC CSM 20 -5108 Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 35- 30N -20W Notes: Parcel History: Date Doc # Vol /Page Type 05/24/2006 826079 QC 11/23/2005 812775 20/5108 CSM 2006 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/26 /2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 17.000 3,100 0 3,100 NO Totals for 2006: General Property 17.000 3,100 0 3,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 030 - 2064 -60 -000 09/08/2006 02:26 PM PAGE 1 OF 1 Alt. Parcel #: 35.30.20.605A 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 03/14/2006 00 5 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner RETIRED ANDERSON O - ANDERSON, RETIRED Districts: SC = School SP = Special Property Address(es): " = Primary Type Dist # Description SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 25.000 Plat: N/A -NOT AVAILABLE SEC 35 T30N R20W GL 1 EXC PT S & W OF Block/Condo Bldg: HWY 35 & EXC PT N OF HWY AS IN 412/474 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 35- 30N -20W Notes: Parcel History: Date Doc # Vol /Page Type 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 03/14/2006 Description Class Acres Land Improve Total State Reason Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division'' i INSPECTION REPORT Sanitary Permit No: 479467 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Anderson, Elizabeth I St. Joseph, Town of 030 - 2064 -60 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: /X) 8 M C-A 35.30.20.605A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic J C ' Z Benchmark / Q o `0G ©e9 Alt. B F; I / ZS (,)CJ*_, Oc>+ -- 7, Z 93 Aeration Bldg. Sewer ___ .... .7 R 2 $ Holding St/Ht Inlet TANK SETBACK INFORMATIONy� St1Ht Outlet �.53 TANK TO P/L WELL *BL Vent to Air take ROAD Dt Inlet Septic f � i � Dt Bottom � 7 Dosing .... Header /Man. & •9 O TC) r Aeration Dist. Pipe lb , q cu) i Holding "'� ° - - Bot. System t PUMP /SIPHON INFORMATION Final Grade `7. 93, Z-- Manufacturer Demand St Cover �bG 9_7 3rd GPM 1— .J Model Number �. __.,T_ _._.....,....,.._......, TDH Lift Friction Loss System Head TDH Ft ~ Forcemain Len .---- Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width j Length .y— o. Of Trenches PIT DIMENSIONS No. Of Pits Inside Di Liquid Depth DIMENSIONS ? (,, �- �� SETBACK SYSTEM TO �vv P/L JBLD2 WELL LAKE /STREAM LEACHING Manufacturer.. t S INFORMATION CHAMBER OR Type Of Syste e f / UNIT Model Number. �� t DISTRIBUTION SYSTEM P5 4 15+ Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air I ke ? f Pipe(s) ` ` \ ` Z r..- Ti L Length �`� Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound or At -Grade Systems Only Depth Over r / j Depth Over j xx Depth xx Seeded /Sodded xx Mulched Bed/Trench Center 1 ` IZ Bed/Trench Edges ` Topsoil Yes i J No Yes I j No COMMENTS (Include code discrepencles, persons present, etc,) Inspection #1: / / Inspection #2: Location: 1273 Highway 35 Hudson, WI 54016 (NW 114 NW 1/4 35 T30N R20W) NA Lot Parcel No: 35.30.20.605A t I n � 1.) Alt BM Description = F.` 1 44, — Ch ���~" �Z- � � e r5 e _ . C r\_ 2.) Bldg sewer length = 1 - amount of cover = 1 J _ Plan revision Required? I I Yes No ` Ce Use other side for additional informs on. � - -�-- J Date Insepc s Sig ure Cert. No. SBD -6710 (R.3i97) r - tialcty uxl 1luildiT4a t)ivi:cwlt Cuunty ` 201 W Waeh t tun Ave, I'.0 Ilux 7162 ;scores n Mudist 1, ) E® 'an"'y I'ennu Number to filled in by Co.) Department of Commerce A 08 2t Sanitary Permit Applic tiolt�F.p 0 ?�o fa Plante D. Number In accord with Comm 83.21, Wis. Adm. Code, personal in! oration you provide may be used for secondary purposes Privacy L;nv, s.o4(�I�,CR tat COUNTY Project Address (if different than mailing address) 1. Application Information - Please Print All Information , VIVO -rJ Property Owner's Name Parcel # # Block 4 Property Owner's Mai ing Address P roperty Locatio - - — �4 , Section City, State - - �� Zip C ode 1 hune Number (Circle 9w) __ ] T Q N; 1�QE q 11. 'ype of Building (check all that apply) 43 / -$ {j will #IEA Subdivision Name CSM Number ( 1 of 2 Family Dwelling - Number of lledrooms . �A`-xT ❑ Public /CummercialDesctibv J c, -- —_ � �- Township of ,uuc'Jtvnr l uescr be tisc -of l'ertuit: ((:heck u ul) , one bo x o l A, C outptcte lute B if applicable) A' ❑ Re U TreauncnVlioidin Y g Y New System placement System y,'fank Replacement Only ❑Other Modification to Existing System B. ❑Permit Renewal C] Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner 1'UWTS System: (Check all that a I tl Non - Pressurized Iii-Ground Q Mound > 24 in. otsuitable soil E Mound < 24 in, of suitable soil ❑ At-Grad e ❑Single Pass Sand Filter 13 -- _ Constructed Wetland Q Pressurized In- Ground Q Holding'I'ank ❑feat Filter Q Aerobic Treatment Unit ❑Recirculating Sand Filter El Recirculating Synthetic Media Filter ❑ Leaching Chain the less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: C r S Design Flow (gpd) Design Soil Application Rate(gp red (st) Dispersal Area Proposed (s� System Elevation ..,T Z, � /" _ t. I'm Ca Cap acity in NUmber Manufacturer Prefab �// Site Steel Fiber Plastic V1.'I',tnkittfo I� Y Uallons Uulious oi' Units Concrete Constructed Glass Nvw Existing T.,uks Tanks � r septic or Holding Tank Aerobic Treatmcot Unit V11, Rcsponsibilil Statement- 1, the undersigned, am line respo nsibility for installation of the POWTS shown on the attached plans. Z TV Plum' ureic (Priltt) Pluutbc 's Sii;, - c MP /MPRS Number Business Phone Number c Plumber's Address (Street City, State, Zip Code ) VIII. C Quntv /De artment Use Only Iss Sanitary Permit Fe (includes Groundwater Date Iss ed uin gent Sign ee ppro I Surcharge Fee) eason for Denia 350 IX. Conditions of Approval /Rcasous forDisaphruval SYSTEM OWNER: 3 �� 1. i 8eptic tank, efituent filter and {1V (� ' Q� dispersal cell must all be services / m ain ` M aintained �CwI� Y�.(� Q a as per management plan provide . ov otumb 2- AN setack requirements must be maintained eIL as per applicable code I ordinances. Altaih com pletr phuu :;ry thr Cowrty u,u�) iur thr system on prpor nut Icss tlnm 8111 x l l hubrs in site j A SBD x398 (R. 01!03) J /c�-af ti- �a�,r•- r Ali _ _... N , ew ///o/ee Q /_,� 5 ro I i loo ses �'h/,_{o i I O ' y �S i �i i f Bus;E Csyl lcl low - /�7 y3 �/�/� 253 i RECEIV --D Wisconsin Department of Commerce SOIL VALUATION REPOR Page_ _ Of Division of Safety and Buildings G in accordance with Comm 5, Wis. ' �kdm. Code { Coun ' Attach complete site plan on paper not less than S 1/2 x 11 inches sizeoo CpUN include, but not limited to: vertical and horizontal reference point (B ), dire Pa 1. D percent slope, scale or dimensions, north arrow, and location and CE 6 26 Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4 1/4 S T N E (or& Property Owner's ailing Address Lot # Blodc # I Subd. Name or CSW a - s City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road New Construction Use: Residential / Number of bedrooms Code derived design flow rate (. /i'� GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material L4a22 Flood Plain elevation if applicable ft. General comments and recommendations: F/ I R Boring # F1 Boring i� Pit Ground surface elev. 22/9 — ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#1 *Eff#2 a � 4 a a a S� �4 q Boring # F! Boring Pit Ground surface elev. 99, ft. Depth to limiting factor > 3,!!' in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fi? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *EW2 e 9 4' Q � * Effiuent #1 = BOD > 30 < 220 mg/L and TSS >30:5 150 mg/L * Effluent 92 = BOD < 30 mg/L and TSS a 30 mg/L CST N le ri ] Signatu CST Number Addre§s ' Date Evaluaoii Conducted Telephone Number I Property Ovmer Parcel ID # ®^ ' D/ lD- Page 4 , of _ a Boring # ❑ Boring ice' pit Ground surface elev. ,�2 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff? in. Munsell Qu. Sz nt Color Gr. Sz. Sh. *Eft#1 *Eft#2 e 3. f 11 U' F Boring # F1 Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 i I F Boring # Boring ❑ ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f1z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 i * Effluent #1 = BOD, > 30 5 220 mgfL and TSS >30 < 150 mg/L * Effluent #2 = BOD < 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. SBO -8330 OLOI/00) Property Owner jq,� y j Paroel ID # � � ®^ D/� �/1- � Page —. of Boring # ❑ Boring a pit Ground surface elev. ft Depth to limiting factor z � in. Soil Appl ication Rate Horizon. Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz nt. Color Gr. Sz. Sh. *Efi#1 *Eff#2 3 -3 7 a -3 17 a 4 r/ b� F] Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP • in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#1 I *Ef(#2 F-1 Pi Boring # ❑ Boring t Ground surface elev. ft. Depth to limiting factor in. ❑ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = SOD,, > 30 < 220 mg/L and TSS >30 150 mg/L * Effluent #2 = BOD < 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. SBA -8330 K07 /00) A/ src 3�t r3n.✓'�D�,J /�q 33 �AsaA) �l DS z'21 f� --4 �sr �Je, Y6 , I 7s I �aYd�oaSF.p s//�O Jar 4, a> ay� S ROIX COUNTY SEPTIC T K M INTENANCE AGREEMENT AND OWN SH P CE7 "_I�IA CATION FO OwnerBuyer Q Mailin g Address Property ddress 4� 7 �W p ert y (Verification required rom Planning Department for new construction) — City /State A[vr /St?w" GtLr Parcel Identification Number 030 Z.o (oy ' (06 oO� LE GAL DESCRIPTION V r/ Property Location ' /., '/4, Sec. , T_A W, Town of R Subdivision Lot # Certified Survey Map # , Volume , Page # Warranty Deed # C ,229 j'��( , Volume , Page Spec house O yes N no Lot lines identifiable yes 13 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 taak every three years or sooner, if needed by a licensed pumper, What y ou p ut 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, joumeyrrman 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 aad 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 three year expiration date. SIGN 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 owner(s) of the property described above, by virtue f a warranty deed recorded in Register of Deeds Office. �O SIGN RE OF APPLICANT DATE Any information that is mks- 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 POWTS OWNER'S MANUAL & MANAGEMENT PLAN , , Page Lof —;2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al D NA Permit # Septic Tank Manufacturer �� ❑ NA DESIGN PARAMETERS Effluent Filter. Manufacturer o f ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units _I� NA Pump Tank Capacity aal I'NA Estimated flow (average) 0 0 _____ gal/day Pump Tank Manufacturer 2-NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ANA Soil Application Rate � gal/day/ /ft2 Pump Model ;X NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit NA Fats, Oil & Grease (FOG) X30 mg /L ❑ Sand /Gravel Filter ❑Peat Filter Biochemical Oxygen Demand (BOD,) 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :0 50 mg /L ❑ Disinfection ❑ Other Pretreated Effluent Quality Monthly average _ Dispersal Cellls) -O NA Biochemical Oxygen Demand (BOD 530 mg /L ,9 in- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L jd NA ❑ At- Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other. ❑ NA ' Other. ❑ NA Other: :t, ❑ NA c * Values typical for domestic wastewater and septic tank effluent. Others' s r `� ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum -3 years)' ❑ NA Inspect condition of tank(s) At least once every: ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume I Q NA ❑ month(s),, (MaximuMl yssrsf ❑ NA Inspect dispersal cell(s) At {east once every:' '` year(s) ❑ monthls( ' ; ` " ❑ NA Clean effluent filter At least once every: year(s) ❑ monthls) NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s). , , JNA Flush laterals and pressure test At least once every: C3 year(s) Other. ❑ month(s) NA At feast once every: p year(s). Other: ❑ NA t MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing. Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the. ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface, The ponding of effluent on the ground surface may indicate a failing - condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume; the entire contents of the tank shall be removed by a Septage Servicing Operator and of in accordance with chapter NR 113, All other services, including but not limited to the servicing Wisconsin Administrative Code. vlcing of effluent filters, mechanical or pressurized components, pretrlftment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. - Page ,2 of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemical:, that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the, infiltrative surface. - During power outages pump tanks may fill above normal highwater levels. When power is restored the excess�wastewater'will be discharged to the dispersal cell(s) in one large dose, overloading the cells) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to thu effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump'eontrols tc restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. ' Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. , ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure. that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: r • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a °code compliam replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the "replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. i Replecement must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area: If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal -of the- biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that times < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES, DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLS POWTS MAINTAINER Name _ Ll Name fr: ; c Phone Phone t,r..,rr:. SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.6411), (2) & (3), Wisconsin Administrative Code. r - Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or.:other chemical:, that may impede the treatment process . and /or damage the dispersal cell(s). If ,high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior tq -use. System start up shall not occur when'soil conditions are frozen at the,infiltrative surface...,,.. -_,, .,._. �. <., ., _ .. •» _• During power outages pump tanks may fill above normal highwater levels. When power is restored the,excesi3 wasfewster`will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup-or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump`oontrols to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or: park over; or otherwise disturb or compact, the area within 15 feet down slope of any mound or at - grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease;, herbicides; ' meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps 'shall be .taken to insure:th'at the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: t, r • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed: ..,. ? ' • The contents of all tanks and pits shall be removed and properly disposed of by a Septaga Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and . the yoid space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide ✓!_"'Code compliant replacement system: m A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should L not.be infringed upon by required setbacks from existing and proposed structure, lot lines and wells.. Failure to protect<'thaFreplacement area will result in the need:for a new 'soil and site evaluation to establish a,:suitable replacement area. 1 Repleceimeritsystems:must comply with the rules in effect at that time. - - ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS, ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal -of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in, effect -, at�.that t)met < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A.TANK MAY BE DIFFICULT OR IMPOSSIBLE. - >- - - - - - - ADDITIONAL COMMENTS POWTS INSTALLS POWTS MAINTAINER Name Name tr, ov, ;J tti.r Phone _ Phone }ref', rites :fit :, SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REgULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1 ), (2) & (3), Wisconsin Administrative Code. DOCUMENT NO. >t#11�1T�I �E0 i Uot ? PACE 7 htl` a id�t►�p► ! 21988 RaVO OFIrtGE TFIME INDENIUn, Made by Eq$er G. I{ennedy ppd Franees H. ST. CROW C?O..: IS- !, Kennedy, his wife. 28th - FOec d' for It�i tie__ _ _ day d AWrII.AA19- 65 i grsntor s of coulity, ' , herby commys and warrants 8t__3 1115 -- - - -tlp to TmVer ne a M A.w=LtTl__ ; Ot C roix, County, Wfaconain, for the sum of Thir Z, th©UsAnd and one bu red dollars the following trabt'af land in St • CroiX County, State of Wfaeonai r, ' South ©ne• -half of Southwest Quarter Twenty -six (6); Northeast Quarter of porttVe t Ri 03? (� of Section 'Thirt -five (55; a Lot Qne in Section Thirty -five ( 71 a ll in Tovas ip T r North, Range Twenty (20) West, except t pbas said tat One (l) South and 'West Of St" M*u "35" and except a portion pf sal 8` as follows: Conmencin at the Sou�thvemt corner° *t babd Sep t Went t26), th enctL East Three hundred svnyi " feet 7 � , thence South Five hundred rt� feet (' 3S thence West Three hundred seventy` -five feet 3��j � ;he�t� North Five huadred thirty feet (530') to p41>tit of be it . r bj }k IM W T WFI=aO p' the Via* grantor $ ha !e, hereunto set the ha : s and ae „ tls Yt1 day of A 1 r? ST LD AND SE,Ai llrb IN $ , *ff 6 ) a a e, .. (SBAL) Es R. �►u eer (S (SEAL) SmATE a» Personally case before men !this _ day of Apri a D +'9 65 _ the above to me k �°etl�bitig' fAtnum%id •acknororleded y M I { This' neft -U* ouaty, Wis. Alex VM 3ts8`*Z& k f. mamo, of WARS ls� 'L!!{ "' . ^: � •f!r a 1i. J1. aaW�Oit'ao.. ti�ra+�I1RR Parcel #: 030 - 2064 -60 -000 09/09/2005 10:55 AM PAGE 1 OF 1 Alt. Parcel #: 35.30.20.605A 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): O = Current Owner, C = Current Co-Owner LAVERNE ANDERSON O - ANDERSON, LAVERNE 1244 HWY 35 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 1273 HWY 35 SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 25.000 Plat: N/A -NOT AVAILABLE SEC 35 T30N R20W GL 1 EXC PT S & W OF Block/Condo Bldg: HWY 35 & EXC PT N OF HWY AS IN 412/474 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 35- 30N -20W Notes: Parcel History: Date Doc # Vol /Page Type 2005 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 05/31/2005 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 21.000 3,800 0 3,800 NO OTHER G7 4.000 34,900 137,300 172,200 NO Totals for 2005: General Property 25.000 38,700 137,300 176,000 Woodland 0.000 0 0 Totals for 2004: General Property 25.000 38,800 137,300 176,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 BELISLE EKCAVATING, INC. - 489192ND AVENUE — SOMERSET, WI. 54025 Phone 715 -247 -3254 Fax 715 - 247038 DIGGERS HOTLINE LOCATION REQUEST 1 - 800 - 242 - 8511 General Information: Caller ID Number: Company Name: Belisle Excavating, Inc Contact Name: Annie Olson Phone Number: 715- 247 -3254 Fax Number: 715- 247 -3038 Locate Request: Desired Start Date Field Rep Name To& Belisle Explosives will be used NO Equipment to reach more than 14 ft. overhead XX y es no Will excavation take place more than 14 ft overhead XX no •fit Nature of work A ey ffo �f E cjl 'Work being done for os 1 - ) . , Al z Y.) County S'T� C 0-0 IX Place C N of Street address or road name X- II W V- gr Nearest intersecting road /(A/ Y 35 Distance & Direction from nearest interesting road Marking instructions Township, Range, & Section # E S f P• Subdivision name �. Lot # Verification Called in by: Start Date: Ticket # Additional remarks/info l r i ANDERSON, LAVERNE STATE OF WISCONSIN BILL NUMBER: 6243 REAL ESTATE PROPERTY TAX BILL FOR 2004 IMPORTANT: Correspondence should refer to parcel number. See reverse side for Important information. TOWN OF SAINT JOSEPH Be sure this description covers your property. This description is for property tax bill only and may not be a full legal description. ST. CROIX COUNTY SEC. 35, T 30 N, R 20 W ACRES: 25.000 SEC 35 T30N R20W GL 1 EXC PT S & LAVERNE ANDERSON HWY 35 & EXC PT N OF HWY AS IN 412/474 1244 HWY 35 HUDSON WI 54016 Parcel #: 030 - 2064 -60 -000 Property Address: 1273 HWY 35 Alt. Parcel #: 35.30.20.605A Assessed Value Land Ass'd. Value Improvements Total Assessed Value Ave. Assmt. Ratio Net Assessed Value Rate 38, 800 137, 300 176, 100 0.9838 (Does NOT reflect Lottery Credit) 0.014201118 Est. Fair Mkt. Land Est. Fair Mkt. Improvements Total Est. Fair Mkt. A Star in this box School taxes reduced by See Reverse Use Value Assessment ❑ means Unpaid Prior school levy tax credit $ 204.41 r Year Taxes. 2003 2004 2003 2004 % Tax Taxing Jurisdiction Est State Aids Est. State Aids Net Tax Net Tax Change Allocated Tax Dist. Allocated Tax Dist. STATE 35.81 COUNTY 133,436 571.24 TOWN OF SAINT JOSEPH 176,205 315.79 SCH D OF HUDSON 2,373,476 1,383.09 WITC 65,917 194.89 Total 2,749,034 2,529.78 2,500.82 Lottery & Gaming Credit Net Property Tax 2,529.78 2,500.82 Make Check Payable to: Full Payment Due On or Before January 31, 2005 Net Property Tax 2,500.82 CHERYL A. SLIND $2,500.82 COUNTY TREASURER 1101 CARMICHAEL ROAD Or First Installment Due On or Before January 31, 2005 HUDSON WI 54016 $1,250 715 - 386 -4645 And Second Installment Payment Payable To And Second Installment Due On or Before July 31, 2005 CHERYL A. SLIND $1,250.41 COUNTY TREASURER 1101 CARMICHAEL ROAD HUDSON WI 54016 Previous year comparison FOR TREASURERS USE ONLY • • FOR FULL PAYMENT (2003) is not available for Pay By January 31, 2005 PAYMENT I,. � 2 , 5 00.8 2 this year BALANCE Warning: if not paid by due dates, installment option is lost PLEASE RETURN LOWER and total tax is delinquent subject to interest and if applicable, V PORTION WITH REMITTANCE T DATE penalty. (See Reverse) REAL ESTATE PROPERTY TAX BILL, FOR 2004 CHERYL A. SLIND Bill #: 6243 COUNTY TREASURER Parcel #: 030 - 2064 -60 -000 1101 CARMICHAEL ROAD Alt. Parcel #: 35.30.20.605A HUDSON WI 54016 Total Due For Full Payment $2,500.82 Pay to County Treasurer By Jan 31, 2005 OR PAY INSTALLMENTS OF: 1ST INSTALLMENT 2NDINSTALLMENT Pay to County Treasurer Pay to County Treasurer F Check For Billing Address Change. $1, 2 5 0. 41 $1,250.41 BY January 31, 2005 BY July 31, 2005 I LAVERNE ANDERSON 1244 HWY 35 FOR TREASURERS USE ONLY HUDSON WI 54016 PAYMENT BALANCE DATE 5 r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER bAyKrZN-, Ami)ep,S ©N ADDRESS a y y H w t,, 35 St SS SUBDIVISION / CSM# LOT # U SECTION 35 T 3V N -R U W, Town of TJ k "\ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 ecxz oan Horn - Sept'c l4' Wes I NQ �f N INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form- Provide 2 dimensions to center of septic tank manhole cover. i f - � BENCHMARK: b d"T f oyWDAt! /`J cop'"? R ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION 1 Manufacturer: Wee Liquid Capacity: 1 Setback from: Well 6t'j House ��� Other Pump: Manufacturer Model# Size Float seperation Gallons /cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: I Le ngthl3� e , Number of trenches Distance & Direction to nearest prop. line: fa Setback from: well: 1 67 ' House 35 Other ELEVATIONS Cov e F 9 S 0 �Na 9Ya8 - gY•a� Q _ Building Sewer ST Inlet: 90Y ST outlet 1� PC inlet PC bottom Pump Off Header /Manifold Bottom of system 93•ya Existing Grade 97. Final grade 9 70) DATE OF INSTALLATION: �a chi 7 PLUMBER ON JOB: 11lYY.2 LICENSE NUMBER: 3 7 UV INSPECTOR• 3/93:jt Wisconsin Deportment of Industry PRIVATE SEWAGE SYSTEM County: Labor and I- rn, % Relations INSPECTION REPORT ST. CROIX Safetyacd .,ildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: PeffilLdP_r' eLAVERNE ❑ City E] No.: Village Town of: State Plan if CST BM Elev.: N Insp. BM Elev.: BM_ Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S oQD Benchmark /00, Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet G� ,�� TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 7Q5 / b � v NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe qy, 2_ Holding Bot. System 31 PUMP/ SIPHON INFORMATION Final Grade q 7, 7 Manufacturer Demand 5 i( 80 Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width, / Length No. Of Tenches PIT No. Pits inside Dia. Liquid Depth DIMENSION � / DIMENSION SETBACK SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: _ INFORMATION Type Of 7 a CHAMBER Model Number: System: - 4 /� / �5 �/ 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: St. Joseph.35.30.20N, NW, NW, Lot 1, Highway 35 Plan revision required? ❑ Yes ❑ No / H 51 T(& / 1 Use other side for additional information. Cv fa 1 SBD- 6710(R 05/91) Date Inspector's Signature Cert No. I HR SANITARY PERMIT APPLICATION COUN . J X In accord with ILHR 83.05, Wis. Adm. Code 3 R 0 STATE SANITARY PERMIT # – Attach complete plans (to the county copy only) for the system, on paper not less than al 9g55' 8% x 11 inches in size. ❑ Check if revision to previous application –See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. Pz o. verrie - PERTY OWNER PROPERTY LOCATION & h Qy. hOya,S3J T3 E(or PROPER ER'S ( AIILING A_ DQRESS LOT# / BLOCK # NA 1. CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NA E CSM NUMBER 7 4 - y II. TYPE OF BUILDING Check one CITY NEAR ST ROAD ( ) ❑ State Owned O VILLAGE ❑ Public Nt or 2 Fam. Dwelling -# of bedrooms PA A UM H E R () 0 3 0 2 a b S S D o s e III. BUILDING USE: (If building type is public, check all that apply) D j) ,C/ — 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sates /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel , 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) ' L New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## , Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43. ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE Y / -3 , REp qED (sq. ft.) PROPO ED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) 47). ��LEV)ATIION J V �0 � 8 YO) Feet / `P ``!� D Feet CAPACITY VII. TANK # of Prefab. Site Fiber- Exper. in allons Total Manufacturer's Name Con- Steel Plastic INFORMATION New istin Gallons Tanks oncr to structed glass App. Tanks Tanks Septic Tank or Holdina Tank I t e e Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage systehl shown on the attached plans. Plumber's Name (Print): Plu HiZSign t u e: (No Stamps MP /MPRSW No.: Business Phone Number: �S ume , n y bl I j 3$ 6-90) b Plumber's Address (S eet, Ci , State, Zip Code d ).1 U U s 1� ��.� U � D � W).�C 7 IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue4 ing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination / Q X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. ksanitary.,permit is valid for two (2) years. 2. Your sanier y be renewed before the expiration date, and at the time of renewal an new y permit may p' y criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 -266 -3815_ To be complete and accurate this sanitary permit application must include: 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. IL Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. V11. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump Performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground - water contamination investigations and establishment of standards. SBD -6398 (R.11/88) P LOT A 1-11) 0 S -1 4 NAME �. e �eR 3aN _....... C ME_ NS r• ,I w 3 • i W ' • Cti . i 51 • �� ` � � �a o0 3 Q+bRoo*. o ► ` Nomk a, S'� (�' r A7 BeN Mpt)< op ?f �ou1.�oP��uN fxo>., L 4r :;; . per. , 'l fi1�>�T►' '? ' KO N T LI T:i AND OBSERVA'P10N'' F'I-PE CROSS SECTION Approved Venn! Cap minimum 12" Above C IL.7 , 4" Cast Iron Above p a Vent Pipe To Final Gradr. M 11, O ~ Synt h etic Covcri.ng -- - - -... Min. 2" Aggrcq'M ` Over pipe �{� '`� - ---- -- - - •- Tee j Distributio_i� " - I pipe _...... 1 � Aggregate rerf.orat:ed Pipe DaIow Ilcncath Pipe �� -- Coupling Terminat:i.ng' T gy•`!a - no t:tom. of. System, Q�dr. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Dyr isionfbf Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code 16 COUNTY Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but S� not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPER OWNER: PROPERTY LOCATION A ycek"*, &44 h GOVT. LOT AI k/ 114 /1/ W 1/4,S T „3p AR ZO F(or)&Q PROPERTY OWNER':S AILINGAD� EESS A41 BLOB# SUBD. NAM CSM # /V CITY, STAT ZIP CODE PHONE NUMBER ❑CITY ILLAGE OWN ] NEA EST ROAD [ ] New Construction Use Residential / Number of bedrooms [ ] Addition to existing building Replacement [ J Public or commercial describe Code derived daily flow gpd Recommended design loading rate .7 bed, gpd /ft trench, gpd1ft Absorption area required bed, ft SG trench, ft Maximum design loading rate _ bed, gpd /ft .g trench, gp Recommended infiltration surface elevation(s) 1 /2 L , ft (as referred to site plan benchmark) 9 Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system (VENTIONAL MOUND IN- GROUND PRESSURE I�T-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem N S El U S❑ U n S El S u as ❑ Ul ❑ S OU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tre & Ground 3 Z' Y /o y 5 / 9 Aae 1 -P; . r L ft ev 115r 1 �/ s v fi 5'a M _ -5 Depth to limiting factor �/'V 7 Remarks: Boring # -• s Ground �i-A h 16y1t r4 54- Depth to limiting f1C r y Remarks: CST Name: PI Pri t �P Phone: A ddress: 0 SDI. k/ Signature: Date: ? 3 CST Number: S d PROPERTY OWNER SOIL DESCRIPTION REPORT Page L of 3 PARCEL I.D. # R .� Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmnch S w 1. S / `1i1 $� �' �/ r � K/ Y . s 2d -3i 1 y - s j ,,, s6 14 r4 e 1 S �_ n L Ground .3 yb > y 5 � li'7 e ft. / 4 = ~ /0 Y12 q . S All — , 7 . g Depth to limiting factor OS Remarks: Boring # Ground elev. ft. Depth to limiting factor I Remarks: Boring # 4 Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor LL Remarks: SBD- 8330(8.05/92) Py. 3a�`� a� Z A-6,41 7 r" 30 5� g3 3 vi g' �S 81 /D 2 `�S I STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County O WNER/BUYER MAILING ADDRESS j PROPERTY ADDRESS (location of septic sy (tem) Please obtain from the Planning Dept. CITY /STATE 2 ,tr��p '-J PROPERTY LOCATIO 1/4, 1/4, Section = , T ��e, N -R '�� TOWN OF j J < ST. CROIX COUNTY, T WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME " PAGE ,LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of .a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 fill of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning fficer within 30 year ex days of the three ration date. g Y Y SIGNE A DATE: St. Croix County Zoning Office Government Center 1101 Cannichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the aPpropriate deed recording. Owner of property Location of property dl /4 �1/4, Section T N -R __�___ Township ?-,ailing address ,— Address of site f ai Subdivision name Lot no. Other homes on property? es Y - - 4— No Previous owner of property Total size of parcel _ ,/ Date ,ry !i o [°2' parcel was created j Are all corners and lot lines identifiable? - ___ -- Yes No Is this property being developed for (spec house)? Yes No volume and Page Number of Deeds. as recorded with the Register ------------------------------------------------------------------------ INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid deliYs of the reviewing process. If the deed description references to a Certified survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION '(we) certify that all statements on this form are true to the Lest Of my (our) knowledge that I (we) am (are) the Owner(s) of the property described in this information form, by virtue of a arranty deed recorded in the office of the County Register of Leeds as Document No._ * 7 9 o•w n the proposed site for the sewage disposal system or I e (we ) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of Count NO , � ��� , y Register of deeds as Document Signatur foe applicant Co applicant Dat of Signature Date of Signature WARRANTY DEED DOCUMENT NO. STATE OF WISCONSIN —FORM 9 27, 9 . 88- 0 THIS SPACE RUMVI D FOR RSCORDBIG DATA F2eGISTLRS OFFICY. THIS INDENTURE, Made by Rog er G. Kennedy an ST. CROIX CO WIS- Kennedy, his wife, 28th Rec d for Record this__ _ ____ day of_ April!_---- A.D.19 gran s of Ramsey _ County, �32K9E8 Wn, hereby conveys and warrants at --- 3 - :1----------- Me to TaVeype - And erson. its er f D e gram RETURN TO of Ste Croix County, Wisconsin, for the sum of Seven thousand one hundred dollars �fvdJa w :f . the following tract of land in Ste Croix County, State of Wisconsin; Part of Lot One (1) in Section Thirty -five (35 ), Township Thirty (30) North, Range Twenty (20) West, described as follows: Commencing at the Southwest corner of said Section Twenty -six (26), thence East Three hundred seventy -five feet (375 '), thence South Five hundred thirt feet (530'),` thence West Three hundred seventy -five feet 0375 thence North Five hundred thirty feet (5309 to point of beginning. nee ' IN WITNESS WHEREOF, the said granto — haVe_ hereunto set their hand s and seal 8 this �Eth day of Apri 1 , A. D., 19 _615- . - S NED AND SEALED IN ESENCE OF - �'� (SEAL) �e�•C,� -�--� r G. Kenne Valaria Hecht �. (SEAL) France H. Kennedy E sther R. Sauser {SEAL) (SEAL) NXIDWOM WISCONSIN STATE OF , St . Croix County. Personally came before me, this 26th day of April , A. D., 19.L5. the above named Roger G . Kennedy and Franneg N Ke �d3t his wife to me known to be the person S who executed the f instrument and acknowledged t same. Alex S. Kosa - <NOTA*Y �~ $eft St. Croix This instrument drafted by Notary Public County, Wis. \ > . 2 `� Alex S. Kosa, Atty., Hudson "si �u..,�Y MyCommiseion (Is) Permanent (SecHoa co 59.31 (1) of the Wisconsin Statutes provides that all Instruments to be recorded shag have plainly printed or typewritten thereon the names of the grantors, grantees, witnesses and notary). `7� WARRANTY DEED —STATE OF WISCONSIN, FORM NO. 9 VOL 412 �� � H. C YILLLN CO.. YILY'AYKLL