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AS BUILT SANITARY REPORT % f Owner Ge fz_P U m v� a L Pro P a rty Address e? 2 n V rt a p 1 - r City /State rya o ti �J 1 S T Legal Description: Lot Block Subdivision/CSM # G �S S R p" W1 %< V4, Sec. J�., T a N -RAW, Town of u L vJ 0 L _ PIN # oL o Jy z9, / 9, 1799 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer w - "Vs Size ST/PC I °b / Setback from: House Well y 0 P/L Lc t Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to a Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width 3 I r l S Number of Trenc4es Setback from: House 0 9 Well ° ° 1' P/LL 15 Vent to fresh air intake ELEVATIONS Description of benchmark f_O 0� Tn N� (u u c 0 Elevation U Description of alternate benchmark Elevation , `� h( Building Sewer ST/HT Inlet 1 3 ST Outlet PC In let PC Bottom - "� Header/Manifold / S y �) Top of ST/PC Manhole Cover Distribution Lines ( ) _ g S () 7 3 k- ( ) 6d a' Wp) g 790 Bottom of System ) y U () 1 � $ U ( ) Final Grade ". 9 U ( ) Date of installation / �'/ Permit number State plan number 5aW W) Date 3 A 5 / OU Plumber's signature - o License number Inspector KV 1 u Gn b Complete plot plan � NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • benchmark if a Show alternate pp licable. PLAN VIEW i 3-XI 1u9 0 G oo 5�� S�pfii l Y� Y sa 3 ' INDICATE NORTH ARROW - Wiscalsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count§T . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaVfSP &6�37 Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)]. Permit Holder's Name: illage ❑ Town of: State Plan ID No.: OLK, GERALD CST BM Ele OI Insp. BM Elev.: t I BM Description: Parceift'Oln.1 -30 -000 V30 4vA/L TANK INFORMATION ELEVATION DATA A9800192 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t (fZSD Benchmark �{. O Dosing Get 6.2.o 19 .4- Aeratio Bldg. Sewer Holding St/ Ht Inlet to ,o ,gip r TANK SETBACK INFORMATION St/ Ht Outlet Joe - 7f co, r ` TANKTO P/L WELL BLDG. Air to I ntake ROAD ir Septic '>(ao --, So NA Dosing NA Header /Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer emand � �, jj ov, , 0 ' Mode umber GPM TDH ift Friction ys m TDH Ft Forcemain Leng Dia. Fi Dst SOIL AB ORPTION SYSTEM lG ~ p4 / TREN IM Width ! Lengt � No. f T ches PIT No. Of Pits Inside Dia. Liquid Depth N 3 DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING F 1 � INFORMATION TypeO / CHAMBER Model Numb r. System: 7*SO b r� OR UNIT #--(D DISTRIBUTION SYSTEM Header / M nifold v 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: HUDSON 14.29.19,NW,NE 987 DROVER TRAIL — GRASS RANGE LOT 3 pNr , how" G�" S t Plan revision required? ❑ Yes KNo Use other side for additional information. d3 22 oe SBD 6710 (R.3/97) ` _Dat�e� _ L� rQ ector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH r SANITARY PERMIT NUMBER: SANITARY PERMIT ren y _ COUNTY C IL.HR TRANSFER /RENEWAL UNIFORM PERMIT # (PLB 67 -T) 3 1 5 Sy 5 PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: PROPERTY LOC TION: CITY: - 1 D /1/lO '/a /VE ' /4,S / ,T N,R E (or TOWN OF: J LOT NUMBER: BLOCK NUMBER: SuBDIVISI AME: 5 � NEAR ROAD, LAKE OR LANDM RK: a aMe- PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: 1, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUMBER'S SIG TUBE: PREVIOUS PLUMBER; N ME (IF CHANGED): PLU ER'S ADDRESS: PREVIOUS PLUMBER'S ADDRESS: /Q '74 1-111A1 "(14 ? a sG , ?7` 9 ' MP /MPRSW NUMBE : PHONE NUMBER: PRSW NUMBER: PHONE NUMBER: ( 71 M 1 . 7 4 SIGNAT O IS UI AGENT: DATE APPROVED: DISTRIBUTION: Original - County 17 Copy - Bureau of Plumbing Copy - Owner DIL R -SBD -6399 (R. 5/82) Copy - Plumber Safety and Buildings Division SANITARY PERMIT AP ON 201 W. Washington Avenue ` is In accord with ILHR 83. e P 0 Box 7302 Department of Commerce JO Madison, WI 53707 -7302 • Attach complete plans (to the count co o forth p p Y c Y) , on pa rt le to unt y than 8 112 x 11 inches in size. ay �Fi QQ "r �` St a Sanitar Permit Number • � t+ y revers i for ins tructions i n See e side o struct o s for completing this a ion x p 9 . � �: 7 Irt N Personal information you provide may be used for secondary purposes ?� ❑Chec sI n o k if re previ plic C _===_ IPrivacy Law, s. 15.04 (1) (m)). r it State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT AL R r ON Property Owner N e l D Pro At do ef� i J r � � > �, S T a , N, R E (or)�o Property n is Mailin Address Block Number y1 77 0 IlL a1f riL K A City, to r Zip Code Phone Number Su Na m or CSM Number , St` UP IN 4 r� �l (7 lS' >3?7 -OVay &nL� ivision 4 � . II. T YPE OF BUILDING: (check one) ❑ State Owned ❑ It Nea st Road �, l Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Town OF i7S �RoVf.rL �KIP1 I III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s). / 7k 1 C] Apartment/ Condo en-A o — 7 — 30- coo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. R 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 Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed ✓ 21 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12'® Seepage Trench 22❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit ( 3 >r7 - 43 ❑ Vault Privy 14 ❑ System -In -Fill t. ,A,, , � - a 3 1 8- �� 3.• VI. ABSORPTION SYSTEM INFORMA ON- ' 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. ystem E) v. 7. Final Grade Re wired (sq. ft.) Proposed � �(sq. ft.) (Gals1 ay /sq. ft.) (Mi /inch) 99- /0 El vation0y.0 4 6 `1 5 U -� Feet N 48•Sc� Feet Capacit VII. TANK in gallo Total # of r Prefab. Site Fiber- Exper_ INFORMATION Gallons Tanks Manufacturer s Name Concr to con- Steel glass Plastic App New Existin structed Tanks Tanks y eptic` a o nk f000 ( tAb-f ❑ 1:1 ❑ El 1:1 '� Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Nam (Print) Plu ber's Si ture: (No Stamps) MPIMPRSW No.: Business Phon Number: Plumber's Address (Stre t, City, State,�ip de): 167 t,-r �s �jvtd> fir(- 5 UI IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issui ent Signatur (No Stamps) �pproved [:]Owner Given Initial ,�a surcharge Fee) o �' Adverse Determination { f X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber ' 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 be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 111. 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_ Wisconsin Department of Commerce DivisiW of Safety and Buildings SOIL AND SITE EVALUATION Page of 3 Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code I Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S+ - percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. I APPLICANT INFORMATION - Please print all information Revi ed b Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Prope rty ` n d ��� Property Location AJU j 4 C I IS ! Govt. Lot 1J4 1/4,S T ,N,R j E or� Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# CC�� y Ci State Zip Code Phone Number ❑ City El Village ® Town earest Road LJ I i 5 4 14 PL f New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: 0 2 1 1 0 Code derived daily flow gpd Recommended design loading rate bed, gpd /f? m ( trench, gpd /ft Absorption area required bed, ft rEsch, ft Maximum design loading rat a r ' D ed, gpd /fi �' t nch, gpd /ft Recommended infiltration surface elevation(s) i 4 g E t . ,C4 w q ft (as referred to site plan benchmark) 1 Additional design/site oonsiderations`" Parent material � `k �,� f , , f �� Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system r S U �o S ❑ U WS ❑ U 19 S ❑ U ❑ S E U ❑ S [ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench I I o -yN I ca r _ S1 Z rw k' P r r c t,,a Z f S ....:..................... Ground U Y 5 17 elev Depth to limiting facto Remarks: fl Boring # 2 ► I 15v r -S/ °� s tY1 to Ito kK '.S r Ground el ` ev v.. Depth to q limitin factor 7 min. Remarks: CST Name (Please Print) Signature �� Telephone No. ►, 2 44 - 2 5 Address t nn Date f CST Number C,J 1 3c 17 2-2. SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. (1 Sz. g� Sh. Bed ' , Trench Ground *I 7.5 f a , 17 elev. w Depth to limiting qv factor -7 Remarks: Boring # Ground elev. ft. I Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # i3 Ground elev. it, Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor ' Remarks: SBD -8330 (R. 07/96) [KV 1432 120'' STREET, NEW RICHMOND, WISCONSIN 715- 246 -2454 Tom Nelson Certified Soil Tester 227387 - -- Registered Sanitarian SR00713 ********** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * ** T -j „ &03 d�� Q2 �i� 77 Q3 97.37 5 ,o OF 3 c. e.2n��c '4rec� I by b r i 5 s�, t fie— s� -�� SCALE 1' _ 1 Nelson BM 1. T o p Jt septi BM 2 PN c n kola coven -- 100 U ►a ne. x �okn& e �eJ�,. � J -� ere �'��.�, ►(� 3. S7 ��cuv -e►z. TRb� k C !� l ALM �- 4- m4lcAu� R.) Y, m - 3k -7 S, 2 Q = a�n4h�IR1 1�'lbN�.lu�e Cu V111 IU Q loon a� f nfiiri Q G s , iV g k 3 7 Safety and Buildings Division `� sconsin SANITARY PERMIT APPLICATION P.O. E. W ashington Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. S' 7` C V v ix • See reverse side for instructions for completing this application State Sanitary Permit Number The information umber y ou p rovide may be used b other g overnment agency p rograms " i ��` - y p Y y q g y p 9 C heck if revi to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Numb I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Prope y Owner Name Property Location �W 1 /4" 1/4, S Ta 9 , N, R E (or Property Owner's Mailing Address Lot Number Block Number 11 1-5 - e !?,' .s.'a.J STve IF I City, State Zip Code Phone Number Subdivision Name or CSM Number C V ��l a.�a ( > Gross II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It age Nearest Road Public 1 or 2 Family Dwelling ❑ Vill - No. of bedrooms 3 Town OF c� o.� III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo 6.2 O 133 7 "jd 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobi Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 D,New 2 ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an System System Tank 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 Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12&Seepage Trench 22 ❑ In- Ground Pressure S 42 ❑ Pit Privy 13 ❑ Seepage Pit S X 43 ❑ Vault Privy 14 ❑ System-In-Fi I I VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 57r, y Elevat�n y.SQ Y 7D ,�� 9� Y Feet pd a ' Feet VII. TANK in gall Capacit Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tank epticTank k 006 FL4 1L LlJQS7`AY.r/ EL ❑ ❑ ❑ El 11 Lift Pump Tank /Siphon Chamber ❑ ❑ I ❑ I ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) @9 APRSW No.: Business Phone Number: P lumber's Address (Street, City, State, Zip Code): le 76 a - tr /v Sa,v IX. COUNTY / DEPAR TMENT USE ONLY ❑Disapproved Sanitary Permit Fee (includes Groundwater D atel ssued Issuin A ept5 nature (No Stamps) Approved []Owner Given Initial < � Surcharge Fee) Adverse Determination DU / 6Z) �� d X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber l INSTRUCTIONS ' t 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 gcest,ons concerning your onsite sewage system, contact your lava: ;ode administrator or the State ^f Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owne.`s nar:^e and mailing address. Provide the legal description and parcel tax numbers) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling, III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. Vt. Absorption system information. Provide all information requested for numbers 1 through 7. V: 1. 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. • Z . 5 e ra/d , 7 73 v 3T .5, '7' a le y, 7e,- 47� Wisconsin Department of Industry .SOIL AND SITE EVALUATION REPORT Page 1 of — Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY I Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but Q+_ Groiw 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 PROPERTY OWNER: PROPERTY LOCATION Kernon Bast GOVT. LOT NW 1/4 1/4,S14 T 29 N,R 19 Wor) W PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM # 948 TaRar= Rd. 3 na Grass Ran a Addn. CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MTOWN NEAREST ROAD Hudson WI. 54016 (715 386 -7775 1 Hudson mr-Cutcb on [ �} New Construction Use [ Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd /ft _,8_ trench, gpd /ft Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate .7 bed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) 99, 4 -98 9- 97.9 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ® S El ©S ❑ U ®S ❑ U ®S ❑ U ® S ❑ U ❑ S iEl U SOIL DESCRIPTION REPORT Boring # [Horizon Y Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed lTw& 2mabk .................. ................. .................. ................. 0 10yr3/2 none mfr 2f .5 .6 2 10 -34 10 r5 4 none sicl lcsbk mfr CrW if .2 .3 Ground 3 34 -84 7.5 r4 6 none cos oscf ml na na .7 .8 elev. 10 ft. Depth to limiting factor +84" Remarks: Boring # 0 none 9msbk 9W 2 15 -44 10 r4 4 none sicl 2msbk mfr c1W if .4 ': .5 Ground 3 - 7.5vr4/6 none Cos osa 1111 na na .7 ` .8 10 ft. r Rf f Depth to � E� limiting factor., f + Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 2002h e. New jLcQaogd, W1 54017 Signature: Date: 5 - - CST Number: _m02298 PROPERTY OWNER Kernon B SOIL DESCRIPTION REPORT PageZ�of , PARCEL I.D. # 020 - 1020 -90 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ................: <> 3 1 0- 2 9 -26 10 r4/4 none sicl lcsbk mfr Ground 3 26 -84 7.5 r4 4 elev. 102 ft. Depth to limiting factor +84 Remarks: Boring # 2 9 -30 10 r4 4 none sicl lcsbk Ground 3 elev. 10 ft. Depth to limiting factor +90 Remarks: Boring # — 4;nf r- 5 2 Ground 24 — elev. 10 ft. - Depth to limiting factor +80 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Rernon Bast 1554 200th Ave. CSTM2298 NW4NE4 S14 T29N - R19W New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246 -6200 lot #3 -Grass Range Addn. N 1 =40' BM.= top of SW lot stake @ el. 100' Alt. Bm. = top of steel post @ el. 104.90' F � X 331 16 Gary L. Steel 5 -1 -97 I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ova &r/Bu &e y- cz_ Ma Ing A, k:ri.ss Prc, erty A J ::ss (Verification required from Planning Deparimcnt for new construction Cit 'State Parcel Identification Number 'j ?a . 1 3 '? 7 —3 e / - I 1T8 MY, 'AL "RIPTIO LN Pro erty L► i.ong2kL 1 /4,,,�1 . '/4, Sec. T_29' N-R_,�/_W Town of Sut livlsio l' Lot # Cej tried ;;c +r Map: 1 Volume Page # Wo ranty .[ 1v 4 # 7 ? Y Page # /23' Volume ZJ_ $ Spt : housc; yes [9 no Lot lines identifiable El yes ❑ no SY TEM ! 1,I)ENTENA 1 4CE 1mr-3 w • use and ma htenanceof your septic system could result in its premature -failure to handle wastes. Proper n:' i itellance coca ;ts of p is ili ng out the E iptic tank every three years or soorer, if needed by a licensed pumper. What you pui' into i I - system can. ffect thy: I �:ir c1ion of the septic tank as a treatment stage in the waste disposal system. The p owner agrees to submit to St. Croix Zoning Department a certification form, signed by fie owric � ;nd by a ma:; rpluml,oj, ; )urneymanj lumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewa%rrdisp: , Isystern is i:^ )toper (1►, :;i Ling conditi(on and/or (2) after inspection and pumping (if necessary), the septic tank is less than '1/3 full :J sludge. I/wc the une r:j;a i aed have re kd the above requirements and agree to maintain the private sewage disposal system with th( sandards set I rth, her: set by the Department of Commerce and the Department ofiNatural Resources, State of Wisconsin. C,:; if stati g that y:it i vptic systen has been maintained must be completed and returned to the St. Croix County Zoning Office; o ithin 30 day! I' the CIJU:f: on date.. - APPLICA] IT DATE 01' N*ER I "I �:,!itTIFICA7,10N I (w:!) (:: ►tify that al. statements on this form are true to the best of my (our) knowledge. I (we) am (are) the o ier(s) of ;the iloperty I v,­);, above, virtue of a warranty deed recorded in Register of Deeds Office. D SIO ATURL . !: APPLICAI 1T DATE Any j :I: rmation thal is mis-represented may result in the sanitary permit being revoked by the Zoning Departure. I clude vi-,O his application: a stamped warranay (iced from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed VOL 1324 PACE TIM 5928 STATE BAR OF WISCONSIN FORM 1 — 1982 j ii I� WARRANTY DEED DOCUMENT NO. i I This Deed madebetween Dona 1 da J. Speer —Bast and Kernon J. Bast �RaaE Grantor, I $T gP' CO., w, and Gerald Polk MAY 18 1888 9:30 A. M I ,Grantee, Witnesseth That the said Grantor, for a valuable consideratio on dollar conveys to Grantee the following described real estate in St. Cr oix THIS SPACE RESERVED FOR RECORDING DATA County State Of Wisconsin: it NAME AND RETURN ADDRESS Lot #3 Grass Range I!Gerald Polk Town of Hudson ��1135 West Division Street River Falls, Wi 54022 020 - 1337 -30 PARCEL IDENTIFICATION NUMBER I TRA 4SFER This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And Donalda J Sheer —Bast and Kernon J Bast 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 1 1 t h day of May 19 A—_ (SEAL) (SEAL) j Donalda J. Speer —Bast ernon J. Bast (SEAL) (SEAL) ii AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, �/`O�•k County c. authenticated this day of , 19 Personally came before me this day of .19-7V, the above named TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Scats.) renda Poulin tom no to be the pe n who executed the foregoing j Notary Public instlu t and acknoyo ge the same. State of Wiscon THIS INSTRUMENT WAS DRAFTED BY Kernon J. Bast ji � ro! Wis. to Public, .� C ounty, ry Y (Signatures may be authenticated or acknowledged. Both are not My commission is p ermanent. ( If not tate expiration date: necessary) /�g o� 19 ) _. • Names of persons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc WARRANTY DEED Form No. 1 - 1982 Milwaukee. Wis. J r' N89 u4 GJ L U ju. J I NUM r1 LW4L 01 111 `L- •/ � 198s.a1' 5.08' 10 , 371.23' U 78 'd / O vi 'LOT 6 LOT 5 � FL 0.5' WEST � 1 2.02 ACRES N 2.16 ACRES OF LOT COR. 87,991 SO. FT. 94,215 SO. FT. S 1.53 AC. EXC. ESMT. M 1.38 AC. EXC. ESMT 4I // I cO I 66,486 SO. FT. Q 60,314 SO. FT. (D Pi LLI I— I o — r - -` 6 — - - - - -- oo — 7-- — ,�- - - - -7Q, I M I v _ HWL885.0 1 3 33, \ LOT 4 lo, 2 9 \\ a�0 I ' 2.50 ACRES N N L 108,900 SO. FT. d' i. N 186 AC. EXC. ESMT. a' 00 Q i 81,218 SO. FT. moo, N r') II M s"o, 8 ' 3026 „F w I —I JI 0 / 4 � N & LOT � 3.1 AC M V9, 139 SQ. 0 LOT 2 1 3..01 AC. EXC. ESMT 41 131,325 SO. FT. o 2.58 ACRES W 112,331 SQ. FT. tp N 2.42 AC. EXC. ESMT. _ K) 1 105,561 SQ. FT. 00) co ° to I— r..L� CSI S88 054'22 "W 852.24''' — 455.74' 1 ":` 96.5 98.00 153.20,' 243.30' S88 5422 "W - 494 N I -S �. FT. iv L 7 T OT 5 ui c. S. M. VOL . 10 FG. 2321 �* w in 0 CD 0 0 3 ' SCALE IN FEET N_ N � `• N 100 50 O 50 100 200 g� — z S 89 37' 39 "W 130.76 389 169.81' =SOUTH LINE THE - RW[7 - 4 OF THE NEI /4 r�