HomeMy WebLinkAbout040-1262-80-000 - I
wiscoo EM County
Department of Commerce PRIVATE SEWAGE SYST
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)1. 363898
Permit Holder's Name: ❑ City ❑ Village ❑ jown of: State Plan ID No.:
Sa m Troy Township
CST BM Elev.: Insp. BM Elev.: BM Description: gW Parcel Tax No.:
coa 10 — 040- 1262 -80 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (Z5a Benchmark • C(� a �p �Ofl.O
Dosi ng Alt. BM
Aeration Bldg. Sewer
Holding St /Ht Inlet $ 23 Gl( (
r y
TANK SETBACK INFORMATION St/ Ht Outlet Q•62. 5-,�8�
TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet
ir
Septic rb + Z 2—' NA Dt Bottom
Dosing NA Header/ Man.
Aeration A Dist. Pipe 9�
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufa rer Demand '
St cover (0-10 M
Model Numbe GPM
TDH L iction System TDI Ft
H
Forcemain Length Dia. Dist. To n
SOIL ABSORPTION SYSTEM C 4
TREN Width Length No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N { (ox S% DIMEN I NS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK 100IF1=uS&LS
INFORMATION Type O r CHAMBER Model Number:
System: q,V, 5ID -( ( `'—` OR UNIT '' 6
DISTRIBUTION SYSTEM
Header / M fold k Distribution Pi e(s) x Hole Size x Hole Spacing Vent To Air Intake
y'
Length Dia. ngth ia. 0
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 E] No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) Inspection #14 /)8 /tX> Inspection #2: • ,L!
Location: 543 Tulgren Street, Hudson, Wl 54016 (NE 1/4 SW 1/4 5 T28N R19W) - 05.28.19.1416 Frontier -Lot 8
1.) Alt BM Description= "/A J ;
2.) Bldg sewer length = 2'' I� " . s s
- amount of cover = i,__
1n
Plan revision required? ❑ Yes 9 N
Use other side for additional information_ 0 1% oCO 1 4-44 -
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Sanitary Permit ApplicaYzax:° r„
Safety & Buildings Division
in accord with Comm 83.2 1, Wis. Adtn. Code PO Box 7302
l i' �" 20! W. Washington Ave.
NN& �+ �r See reverse side for instructions for completing - Ws application
s � 0 Personal information you provide may be used for set ondary'lftirpape l " Madison, WI 53707 -7302
oepEirYment of > @ammerce (Privacy Law, s. 15.04(1)(m)) bmLco pleted form to county if not
* state owned.
Attach complete plans to the coup co only) r the stem, o r not less � 9d' - i/2 x 11 ' fla in size.
h , State Sanitary Permit Number eck if revision to-•pit P I. . Number
D
3� \ Y
I. Application Information - Please Print all Information 6n:
Property Owner Name � -� _. perry Locat�io /n p�
1 f'1. ( L. (� a A,,,. N 51 /4 S '7/4, S �TZa,N, R/ /P W
S � �
Lot Number Block Numbe
Property Owner's Mailing Address
3 4D ' I -'r / -
City, State Zip Code Phone Number Subdivision Name or CSM Number
l) O 1. Z 4C2o 4 T
II. Type of Building: (check one) ❑ City
❑ Village
V 1 or 2 Family Dwelling - No. of Bedrooms : N7own of
Public/Commercial (describe use):_
❑ State -Owned
- e. /
P�argcl Tax Y2 n eV sj
III. T e f ermit: Check only one box on line A. Check box on line B if applicable) if
A) I. New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
Permit Number " Date)ssued;
B) Sanitary Permit was previously issued 4 1 �, S ' - ` "
IV. Type of POWT System: (Check all that apply) ❑ Sand Filter ❑ Constructed Wetland
*ion- pressurized In- ground ❑ Mound ❑ Single Pass ❑ Drip Line
• Pressurized In- ground ❑ Holding Tank g p
• At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dis ersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (GalsJday /sq. ft.) (Min inch) Elevation
5 rT - - 70.Z.
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
ng
Tanks Tanks
❑ ❑ ❑ ❑
5E :AC T% t<
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Business Phone Number
Plumber's Name (print) Plumber's Si ture (no stain: MPMIPRS No.
r zz,003 (0
Plumber's Address (Street, City, State, Zip Code)
t o H✓ ,4'/rP jt X 10 6 1E 6 uU I U
IX. County/Department Use Only
❑ Disapproved
San Permit Fee Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
MApproved ❑ Owner Given Initial Adverse S�rcharge Fee)
Determination
X. Conditions of Approya� /Reasons for Disap royal: {
Safety and Buildings Division
SANITARY PERMIT AP 201 W. Washington Avenue
Visconsin P 0 Box 7162
Department of Commerce In accord with Comm 83.05 e4� Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the sy on ess ` county
,r
than 8 1/2 x 11 inches in size. S+�
• See reverse side for instructions for completing this appli R. n Y r, ,. ) State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ST (J#OX k if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. j� W ` , Plan Review Transaction Number
FlE1E
L APPLICATION INFORMATION -PLEASE PRINT ALL TI ON --
Property Owner N me ti _�"'�,�
5 i t , 5 S T Z N, R/ E (cidg
Property Ownn r's'�ing Address Lot Number Z_C ck Number
'�� 3344 � --
Ci , State Zip Code Phone Number Subdivision Name or CSM ber
L) 0 S 0 / �, ( �) t ?G fro �
II. TYPE BUILDING: (check one) ❑ State Owned ❑ It Nearest Road
❑Village TO LCQ &W 'ST
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF vv ��
111. BUILDING SE: (If building type is public, check all that apply) XRepa�' mber(s) D5 ale, !a7 /V �I w
1 E] Apartment/ Condo L 2- _ NO _ O oo U
2 ❑ Assembly Hall 6 E] Medical Facility/ Nu10 E] Outdoor Recreational Facility
3 ❑ Campground 7 E] Merchandise: Sales / 11 [] Restaurant/ Bar/ Dining
4 E ] Church / School 8 E] Mobile Home Park 12 E] Service Station / Car Wash
5 [] Hotel / Motel 9 C] Office / Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box online ck box on line B, if applicable)
A) 1. New 2. E] Replacement cement of 4_ E] Reconnection of 5. E] Repair of an
Syfstem ________ System Only______________ Existing System Existing Syfstem
B) ❑ A Sanitary Permit was previously issu Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution P/2Mound rized Distribution Experimental Other
11 []Seepage Bed 30 E] Specify Type 41 ❑ Holding Tank
126Seepage Trench ix �qcµ In- Ground Pressure � 42 ❑ Pit Privy
13 Seepage Pit INS I t'1 �>K�4 Z S3 t 43 ❑ Vault Privy
14 ❑ System -In -Fill ��t $ 3 i lKs ''•j ) - , EA C 0 'Z q - Ter$ L.
VI. ABSORPTION SYSTEM INF RMATION:
1. Gallons Per Day 2. Abs . Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
�n Requir O . ft.) Pro pose d (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) J# Elevativ
74 1 + '�� X Fee O fdl,&V Feet
aclt
VII. TANK allo s
In a Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
P ew Exist' strutted
anks Tanks
Septic Tank Holding Tank 1' �!' ❑ ❑ ❑ ❑ ❑
LI p Tank /Siphon Cham kf r ❑ I ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILI as STATEMENT
I, the undersigne assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: I& Stamp MP /MPRSW No.: Business Phon Number:
140 a 1.306
Plumber's Address Stre City, State, Zip Code):
AD a H� �tL 0-1OGF_ a 0.0 p u,0 .110 0 4 f ,Y
IX COUNTY / DEPARTMENT USE ONLY
❑ Disapproved anitary Permit Fee (Includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps)
A roved Surcharge Fee)
pp ❑ Owner Given Initial aDLL- _,
Adverse Determination 5`
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD -6398 (R.12/99) DISTRIBUTION: Original to County. One copy To: Safety a Buildings Division, Owner, Plumber
r
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:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to oe installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) 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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BioDilfuser Specif ications
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OC] OO DD OO OD OO QQ OO OQ
QQ oo QQ oo QQ o Q Q oo QQ
Chamber
O�7 �� QQ DO QQ DQ Q�Q DD OQ Height
QQ OO OO OO Q OQ
00 00 0 o QtQ o 0 oQ o 0 0_ o 0
OO DO OD DO �J O Or7 OO OO OD
Chamber
Height
_ End View
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34" , I
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4" Knockout
Universal End Cap
Available Sizes '
Length 76" 76" 76"
Width 34" 34" 34"
Height 11" 14" 16"
Invert 6.5 9 11.3
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Wisoonsiri Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safe and Buildings D' �' g in accord with Comm 83.05, Wis. Adm. Co de
A.C.E. Soil &Site Evaluations
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.#
Prt of 040 - 1021 -90
APPLICANT INFORMATION - Please print all information. R viewed B f?�te
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
th
Property Owner Property Location
Miller Sam Govt. Lot NE 1 /4 SW 1/4 S 5 T 28 N,R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
P.O. Box 151 8 — Plat Of Frontier
City State Zip Code PhoneNumber ❑ City ❑ Village ❑Town Nearest Road
Hudson WI 54016 715 386 -2769 Troy Tower Road
❑ New Construction ❑ Residential I Number of bedrooms 4 ❑Addition to existing building
Use:
❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 600 gpd Recommended design loading rate 0 bed, gpd/ft .7 trench, gpd/ft
Absorption area required 857 bed, ft 857 trench, ft' Maximum design loading rate 0 bed, gpolft .7 trench, gpd/ft
Recommended infiltration surface elevation(s) 92.0' ft (as referred to site plan benchmark)
Additional design / site considerations Install trenches using high capacity infiltrators.
t Parent material Glacial outwash Flood lain elevation, if a licable NA ft
le for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank
table for system ®S El N S❑ U ® S❑ U ® S❑ U ❑ S N U ❑ S® u
SOIL DESCRIPTION REPORT
Horizon
Depth Dominant Color Mottles Texture S ere Consistence Boundary Roots GPD/fF
Bonn
9# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ;Trench
1 1 0 -7 10yr4/2 None Is 0 sg mvfr as - 0 0.7
2 7 - 10yr5 /4 None is 0 sg dl gw - 0 0.7
Ground 3 21 -52 10yr6/4 None s & 0 sg dl cw - 0 X 0_7_
elev
95.38 ft 4 52 -124 10yr6/4 None s 0 sg dl - - 0 0.7
Depth to
limiting
factor O S�
>124"
Remarks: - - -- — - - -- - - --
2 1 0 -5 10yr4 /2 None A 2fcr mvfr as - 0 0.5
2 5 -23 10yr5 /4 None is 0 sg dl gw - 0 0.7
Ground 3 23-61 10yr6/4 None s & gr 0 sg dl cw - 0
elev
95.19 ft 4 61-135 l Oyr6 /4 None S 0 sg dl - - 0 0.7
Depth to
limiting
factor
>135"
Remarks:
CST Name (Please Print) Signature: Telephone No.
James K Thompson �— 715- 248 -7767
Address A.C.E. Soil &Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, • 54020 12/31/1999 3602 1156
PROPERTY OWNER: Miller Sam SOIL DESCRIPTION REPORT Page 2 of 3
' PARCEL I.D.# _ Prt of040- 1021 -90 A.C.E. Soil & Site Evaluations
Depth Dominant Color Mottles Texture Structure nsistence Boundary Roots GPD/ftz
Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0 -5 10yr4 /2 None sl 2fcr mvfr as - 0 0.5
2 5 -17 10yr5 /4 None is 0 Sg dl gw - 0 0.7
Ground
elev 3 17 -42 10yr6/4 None s & gr 0 Sg dl cw - 0 0.7
98.09 ft 4 42 -80 10yr6 /4 None s 0 Sg dl - - 0 0.7
Depth to 5 80 -136 10yr6 /6 None S 0 sg dl - - 0 0.7
limiting
factor
>136"
Remarks:
4 1 0 -4 10yr4/2 None Sl 2fcr mvfr as - 0 0.5
2 4 -18 10yr5 /4 None is 0 Sg dl gw - 0 0.7
Ground
elev 3 18 -47 10yr6 /4 None s 0 Sg dl cw - 0 0.7
99.59 ft 4 47 -128 10yr6 /4 None s & gr 0 Sg dl - - 0 0.7
Depth to
limiting
factor
>128"
Remarks:
5 0 -7 10yr4/2 None sl 2fcr mvfr as - 0 0.5
2 7 -19 10yr5 /4 None Is 0 Sg dl gw - 0 0.7
Ground
1
F elev 3 19 -41 10yr6/4 None s 0 Sg dl cw - 0 0.7
100.23 ft 4 41 -125 10yr6 /4 None s & gr 0 Sg dl - - 0 0.7
Depth to
limiting
factor
>125"
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
\ 3 o-(3
Owner
'75a.n 11'(A -
P o, ,69- / S778' down
/-�cc aiSa�? cJ 1. 00.cf
LoCa� "v�-i
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W%consiir Department ofCommerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 8 ,,Wig', , c 6c�de
A.C.E. Soil 8t Site Evaluations
ol
Attach complete site plan on paper not less than 8'/: x 11 inches in sine. P nsk County
irrclttde, but not limited to. vertical and horizontal reference point (BM), di and St. Croix
percent slope, scale or dimensions, north arrow, and location and dis i>6arest ,.. Parcel I.D.#
Prt of 040 - 1021 -90
APPLICANT INFORMATION - Please print all inform i � Date
Personal information you provide may be used for secondary purposes (Privacy is. 15,C 4 4
Property Owner Pro )a
Miller, Sam Govt LINTY
NE SW 1/4 S 5 T 28 N,R 19 W
Property Owner's Mailing Address 'Lod# Block Name or CSM#
P.O. Box 151 8 , �� Plat Of Frontier
State Zip Code PhoneNumber ❑ e ®Town Nearest Road
Hudson WI 54016 715 386 -2769 Troy Tower Road
® New Construction Use: ❑ Residential / Number of bedrooms 4 ❑Addition to existing building
❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ft .8 trench, gpd/ft
motion area required 857 bed, W 750 trench, W Maximum design loading rate •7 bed, gpdff •8 Bch, gpd/ft
Recommended infiltration surface elevabon(s) it (as referred to site plan benchmark)
Additional design / site considerations y'stall trenches us' high capacity infiltrators.
Parent material Glacial outwash Flood Main elevation, if applicable NA It
L S =Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system ® S ❑ U ® S O U ® S ❑ U ® S ❑ U EIS ®U ❑ S ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ftZ
fi
Horizon
Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
1 0 -4 1Oyr4 /2 None is 0 sg mvfr as - O
1
2 4 -12 10yr5/4 None is 0 sg dl gw - 0.7 0.8
Ground 3 12 -48 10yr6/4 None s & gr 0 sg dl cw - 0.7 0.8
elev
94.10' ft 4 48 -120 10yr6 /4 None s 0 sg dl - - 0.7 0.8
Depth b
limiting
factor
>120'
a3.2 ot•2
Remarks:
1 0 -6 10yr4 /2 None sl 2fcr mvfr as - 0.5 0.6
2 6 -15 10yr5/4 None is 0 sg dl gw - 0.7 0.8
Ground 3 15 -55 10yr6/4 None s & gr 0 sg dl cw - 0.7 0.8
elev
92.33' ft 4 55 -117 10yr6/4 None s 0 sg dl - - 0.7 0.8
Depth to
limiting
factor q6 A 7. q6
>117'
Remarks: �,
CST Name (Please Print) Signature: T _ Telephone No.
James K. Thompson \ ' ' z 715- 248 -7767
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, 54020 12/31/1999 3602 1156
PRMEMOWNEk Milla Sam SOIL DESCRIPTION REPORT g ��� Page 2 of 3
PARCEL LDA Pit of 040- 1021 -90 A.C.E. Soil & Site Evaluations
[ Horizon Depth Dominant Color Mottles Texture Structure sistence Boundary Roots GPDr
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 1 0 -4 10yr4/2 None A 2fcr mvfr as - 0.5 0.6
2 4 -20 10yr5 /4 None is 0 sg dl gw - 0.7 0.8
Ground
elev 3 20 -58 10yr6/4 None s & gr 0 sg dl cw - 0.7 0.8
94.66' ft 4 58 -92 10yr6/4 None s 0 sg dl - - 0.7 0.8
Depth to 5 92 -125 10yr6 /6 None s 0 sg dl - 6 0 •8
limiting
factor
>125'
?q• 9Z /fs.Iz
Remarks:
4 1 0 -11 10yr4/2 None A 2fcr mvfr as - 0.5 0.6
2 11 -30 10yr5/4 None Is 0 sg dl gw - 0.7 0.8
Ground
elev 3 30 -56 10yr6 /4 None s 0 sg dl cw - 0.7 0.8
90.35 ft 4 56 -115 10yr6/4 None s & gr 0 sg di - - 0.7 0.8
Depth to
limiting
factor
>115'
Remarks:
5 1 0 -12 10yr4/2 None A 2fcr mvfr as - 0.5 0.6
2 12 -17 10yr5/4 None is 0 sg dl gw - 0.7 0.8
Ground
elev 3 17 -56 10yr6 /4 None s 0 sg di cw - 0.7 0.8
95.77 it 4 56 -112 10yr6/4 None s & gr 0 sg dl - - 0.7 0.8
Depth tD
limiting
factor
>112'
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
30'3
Owner
P 0. /5'1 87.78 • do
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` ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer S
Mailing Address
Property Address 5 u L. 6 k fiv U F F T
(Verificati n required from Planning Department for new construction)
City /State H U Parcel Identification Number O q O - 12
LEGAL DESCRIPTION
Property Location N f, V jk '/a, Sec. ` . T Z 9 NA Town of 7 P. O Y
Subdivision 4 Lot #
Certified Survey Map # �� Volume _ Page #
Warranty Deed # / Volume J y 2-- . Page # A l Z_
Spec house yes ❑ no Lot lines identifiable yes ❑ no
SYSTEM MAUTITNANCIE
Improper use and maint Hance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the sep 'c tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the se 3tic 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
masterplumber, journeyman plu ber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Dep artment of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system bas been maintained must be completed and returned to the St. Croix County Zoning Office within 30
of the three year ex� 'o date.
/
SIGNATURE APPLIC DATE
OWNER CERTIFI
I (we) certify thments on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
the ro erty described abtue of a warranty deed recorded in Register of Deeds Office.
l 5 as
TUBE OF APPLIC DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this applicat on: 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
V01 1442PAGE 42
" STATE BAR OF WISCONSIN FORM 2 - 1996 606841
— WARRANTY f)FFD KATHLEEN H. UALSH
REGISTER OF DEEDS
This Deed, made between Kathryn B, Tuleren, and Ferris — ST. CROIX CO., UT
R_ Tilg rerl . wife ttnd htulbarad RECEIVED FOR RECORD
Grantor, conveys and warrants to 07 -14 - 1999 11:00 AM
Sam E. Miller, a sin�Derson. YARRANTT DEEI
EXENPI
Grantee. CERT COPT FEE:
Grantor, for a valuable consideration, conveys and Warrants to Grantee COPY FEE:
TRANSFER FEE: 2221.10
the following described real estate in; St, Croix County, State of RECORDIN6 FEE: 12.00
Wisconsin (The "Property'): PAGES: 2
Recordim Ara
Name and Return Address
0104022.10: 0011122.30: 010 - 1021.90:
O40- 1 029.20:040. 1026 -70
Parcel Idcndfkadm Number (P1M
This is not horn mad property.
(See Attached Exhibit "A ")
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any
Dated this 13th day of July,. 1999.
• • Kathryn B. ulgrcn
Ferris R. Tulgren
AUMNTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
authenticated this _ day of St. Croix County )
Personally came before me that j'L_ day
of July, 1999, the above named Kathryn B. Tulsren.
TfILE: MEMBER STATE BAR OF WISCONSIN and Ferris R. gren, w fe-artd —
to
(If rot, me rown t the per s) who executed the foregoing
authorized by 4 706.06, Wis. Stars.) instru and aqua I � the sane.
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristlua ORlaad
Uudson, WI 540i(i NQt4yllublic. State of Wisconsin
(Signatures may be authenicared or acknowledged. Bush are nor My Commmsso rapt nent. If not, state expiration date:
0eCCUUY.) $rcada Poulin ! f f d 0
Notary Public
State of Wisconsin
'Names of persom signing In any capacity should be typed or printed below their signalurca
WAAAAxry oaan aTArt w or WISCO M
roam N. I • 1"s
1Nf0KWr)WPA0Fe6a+0NA / 3r0WANy FONDWtae.Wr 80006620:1
'1
:�.1442P�G� 43
EXHIBIT "A"
i
That certain parcel of land loc in the NE'/• of SE' /` of Section si 28 North! Rang 9
ALI. in' ow
Croix County, Wisconsin more f thle described
N8be51 0e "Eow:
o f SW '/• and the NE ' /' of SW /` °f Section 6,, 5 follo
West, Town of Troy, S uarter comer of said section distance o
Beginning at the West q q uarter line of said Section 5) a 288.00 meet to a
(recorded bearing on the East -West q said East line,
854.00 feet; thence N87 °51'08" ,
2342.24 feet; thence S00 °13'24 "E' thence along the
E corner of said NE'h of S W' / ,� • of g \N y.
thence a ong
Dint on the East line of t to he g• of SW ' /'� a of said N ° 54 "W .
P 08 fee 67 54
S() 0013024 E. 466. y, and the South lin
South line of said NE' /+ of SW N00 °30'28'E�
170.48 feet', thence S nCe along said
2372.41 feet thence f SW % t
Sg7 °54'5 "W. est line of said N 941 26 feet; thence
3.91 feet to the monume rded a 40 feet d W re corded as
NOp °30'28•E corded 32 38 "E),
° 4 458. to the
27 3 E ( line of said NE '
West line. rded as N63 5
N64 °57'47 "W (recd said No�hrlecorded as 25'/• rods) to the Point of
of SE 1 A of
sectio ad 89 24;42 "E; 4 8.69 feet
S88 °40' � 9 a
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ST. CROIX COUNTY
f- WISCONSIN
ZONING OFFICE
ONE NNINN M••.i ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
+..'
1 Hudson, WI 54016 -7710
(715) 386 -4680 Fax (715) 386 -4686
August 31, 2000
Home Realty
Dave Anderson
602 3rd Street
Hudson, WI 54016
RE: Septic Inspection for Sam Miller located at 543 Tulgren Street,
Frontier (Lot 8), Troy Township, St. Croix County, Wisconsin
Dear Mr. Anderson:
A septic inspection of the above referenced property was conducted on 07/18/00. This
property is located in the NE 1/4 SW 1/4 of Section 5, T28N R19W, Frontier (Lot 8), Troy
Township, St. Croix County, Wisconsin. At the time of the inspection, this septic system
was found to be code compliant for a four (4) bedroom home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
Kevin Grabau
Zoning staff
cc: file