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HomeMy WebLinkAbout020-1350-07-000 0§ o m-0 0 c \�� °m } k � O / ƒ 7 / [ k ƒ ƒ S q CD E f w 2§. 0 ( \ - e * ( ® / 7 ¥ % k ; / & § § 2 § @ k § 8 / . ` E 0 9* E E � 7 . 2 Cl) 0 E E g , 7 a m � . m 2 � co 3 0 CL ® S q e C « § # . r ■ @ S co t i % % �- T V M cc i o \ 0 0 0 CD § \ 3 2) � ƒ 2\ §% ovg < 2 S ¥ m \ § P ) k , ] z & / E ƒ 0 f \ ° [ - \ ° / J ] ( ° k k \ ) 2 z $ - ` 2 ¥ z o \ R R g 0 0 \ gf Imo{ © 2 7 z o % \ � r §\ . $%\ § � c EaG c . �§k % � & }U F � @ < j CD q 0 \ \ 0 \ k § f 0 k SZ 4= : � 4 Parcel #: 020- 1350 -07 -000 o1r25r2oo5 08:59 AM PAGE 1 OF 1 Alt. Parcel #: 23.29.19.1892 020 - TOWN OF HUDSON Current , X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * PENMAN, DAVID & MICHELLE DAVID & MICHELLE PENMAN 814 DAKOTA RIDGE HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 814 DAKOTA RIDGE SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.006 Plat: 1966 -FOX VALLEY FARM 1 99 SEC 23 T29N R1 9W PT SE SW & PT SW SE FOX Block/Condo Bldg: LOT 7 VALLEY FARM LOT 7 2.006AC Tract(s): (Sec- Twn -Rng 401/4 1601/4) 23- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 06/25/1999 605636 1437/016 WD 02/22/1999 597904 7/41 PLAT 2004 SUMMARY Bill M Fair Market Value: Assessed with: 49904 260,900 Valuations: Last Changed: 10/30/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.006 54,000 147,800 201,800 NO Totals for 2004: General Property 2.006 54,000 147,800 201,800 Woodland 0.000 0 0 Totals for 2003: General Property 2.006 54,000 147,800 201,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 12/0411998 Batch M PRGRM Specials: User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Parcel #: 020 - 1350 -06 -000 01/25/2005 08:56 AM PA GE 1 OF 1 Alt. Parcel #: 23.29.19.1891 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " = Current Owner " ARNOLD REN E VANDER VORST VANDER VORST, ARNOLD W & KAREN E 752 BADLANDS RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ` 810 DAKOTA RIDGE SC 2611 SCH D OF HUDSON ` SP 1700 WITC Legal Description: Acres: 2.006 Plat: 1966 -FOX VALLEY FARM 1 99 SEC 23 T29N R1 9W PT SE SW FOX VALLEY Block/Condo Bldg: LOT 6 FARM LOT 6 2.006AC Tract(s): (Sec- Twn -Rng 401/4 1601/4) 23- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 02/22/1999 597904 7/41 PLAT 2004 SUMMARY Bill M Fair Market Value: Assessed with: 49903 69,800 Valuations: Last Changed: 10/30/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.006 54,000 0 54,000 NO Totals for 2004: General Property 2.006 54,000 0 54,000 Woodland 0.000 0 0 Totals for 2003: General Property 2.006 54,000 0 54,000 Woodland 0.000 0 0 Lottery redit: ry Claim Count: 0 Certification Date: 12/04/1998 Batch #: PRGRM Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT a .. j r Owner P .` r Property Address City /State - { hid i ,r , to 54 / Legal Description: Lot '7 Block -- Subdivision/CSM # V4 t /a, SecoL ZL, TdN -RJIW, Town of Y) PIN # 5q`� 7Co SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer We t 5 r Size STIIr� _ Setback from: House 9 Well ( eO P/L � fo Pump manufacturer Model Alarm location — (HOLD TANKS ONLY) Setbacks: Se ' e road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system Tr n c k Width 3 Length 7,3" Number of Trenches z Setback from: House �s Well > ( o P/L 3 O ' Vent to fresh air intake U ELEVATIONS Description of benchmark To o f pyc d -P - / 1 1 Elevation 160, U Description of alternate benchmark 76e o f AJC ge,k Elevation Building Sewer 10 Z 7 ST/HT Inlet 09 l h ST Outlet /0/ , 71 PC Inlet PC Bottom r-- Header/Manifold Top of ST/PC Manhole Cover Distribution Lines ( ) () Iz &4" ( ) Bottom of System () 9 3� �� () �r • J ( ) Final Grade O ( ) ( ) Date of installation �l / I / 9RPermit number 3 915 76 State plan number Plumber's signature License number 2.25 S / Date -3 /f41/ eo Inspector !1 Complete plot plan Or I . 17 ' 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. • Show alternate benchmark, if applicable. at PLAT i ViEW l� t l � r i 1' h s ytir °� �• V S �'. +v 4, " ° s • 'M I ° , '1 .. N/a ♦6 8 wB • 'p T" 1Y9 r ss'�6 •�� >drs tae, 1r w 8 s�,-' I S °r 11- ' y�w�f yanc> ri Ao�a}�rfv� Mpxrmr�lrs'V _ 4 5 INDICAT E NORTH ARROW I�Z ev �s 6661 9L Jlltl �' CO `r J J 6 N vwu�� - pl n b/� AoJ V IV /d � 9/ 0� �. 1 Wisconsin Department of Industry SOIL AND SITE EVALUATION Page l of 3 Labor and Human Relations Division of Safety and Buildings in ac9plance with s. ILHR 83.0 is. County Attach complete site plan on paper not less than 8 as in size, Plafiloust ` /, S /A�� x Include, but not limited to: vertical and horizontal (eroce point (OM), direction aM "� percent slope, scale or dimensions, north arrow �bcatio ; hiie to nearest road. Parcel I. D. # APPLICANT INFORMATION - Pleas .nf aYVAh f&Aati $ T�weL Date Personal information you provide maybe used for sec dar� purposesivrad3Qhlly, s. 15.040 }(' ) Property Owner ;^� _ /J A BONING OFFICE , 'Proo6rty Location E �//�",tJt�tR v� ~,. S E il45 1 /4,S 23 T 9 ,N ,R (or) W Property Owner's Mailing Address ? 1 I F O Block# Subd. Name or CSM# 75* z 1-3 0 Z f IVPs' !� 4 `= o� �E,t�Di.vG' s'v,80 %�iSi� to City State Zip Code Phone Number Nearest Road /j�Uf�SO 0/. S�/O!!o (�/.5�10 • X337 ❑ Ci v Village Town New Construction Use: Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial Describe: . Code derived daily flow gpd 75 0 Recommended design loading rate • 7 bed, gpd/ft trench, gpd/ft Absorption area required -� — bed, ft2 trench, ft 2 Maximum design loading rate • 17 bed, gpd/ft * trench, gpd/ft Recommended infiltration surface elevations) 3 ft (as referred to site plan benchmark) Additional design /site considerations usE ' L � 7! �� � � ��• sT Parent material .S/'f��y b�T W ��� Flood plain elevation, if applicable N� ft S = Suitable for system Con ventional Moun In- Ground Pressure AT -Gra System in Fill Holding Tank U = Unsuitable for system / 5 El E ❑ U Eat U S ❑ U Q-s— ❑ U ❑ S -a'U SOIL DES CRIPTION 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 "1.5 /O y/Q 31cf L_ , ifS - Je' * , -7 w 2 •S . � s, z r 5 4 3 /py/Q y V 275 CS' /7� Ground /0,/ elev. Depth to 6 limiting factor ? / Remarks: Boring # .� /Dy 3/2-- /7�S s� �iP CS L f �( • ✓ 1 . 3 y •Z /o � f�' cs 1f mss• 3 ' Ground elev. 1. . 71. �o ft. E 3 t; • Depth to limiting factor f — In. Remarks: Telephone No. CST Name (Plea /u se Print) � GAg .0 /� Signature �/. ?TS• ��/ • V � :5 Address Date CST Number Ulbricht & Assoclatss Pfivats Sewape Consultants 665 O'Neil Rd. Hudson, Wis. 54016 ORIGINAL I PROPERTY O WN ER 1 4. 1 !/0/QS SOIL DESCRIPTION REPORT Page L of 3 PARCEL I.D.# ©Z•© - / 2 - o Boring Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots < °u in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench 31" z sl,� �iP cs ..3 / 0-/2- roYR 3/z y . • Z /0 YY e y S/L z s ve M+ av Ground 3 7 • / YX A /oelevft. s /lam S o -- - . � � • 8 Depth to limiting factor l / Remarks: Boring # N g io ioyR 3/ - i f s�6.e „�,� ,e �v z f y s s 2 0-1 /D Z fsiik o p Ground elev, �o ft. Depth to limiting factor 77 Remarks: Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh. Bed , Trench Boring # / /6 low 31� /7S -,- ! Z - 7 0r- •Y . S '� 3 . s y� Y S _ Ground elev. /0/.457 ' ° Depth to limiting factor 7ll'" Remarks: Boring # Ground elev. Depth to limiting factor I" ' Remarks: SBDW -8330 (R. 08/95) GvES T Ato I- a N - Q�3 W N � rn CIS .a N w � N N `r� G � � 0 W I o• , r C ER T -T F -TED S UR V E Y MA P Located in the SE 1 /4 of the SW 1 /4 and the SW 1/4 of the SE 1 /4 of Section 23, T29N, R 19W , Town of Hudson, St . Croix County, Wisconsin, being Lot 1 of that Certified Survey Map recorded in Volume 10, page 2935 • Arnie VariderVorst W J D 2_0 le /0 / 752 Badlands Road ( Hudson, Wisconsin N 89'58'39 "E 462.77' S 89'58'09 "E 221.72' 241.05' 125.80' OiG I w - - -� - -I W i S i o _ IL ® 7T 5 ;� to a m to I iv 1 9 87, 397 Square feet v e ' I .°o a (2.006 acres) N °o N Z i ;p 309.64' S 89'58'39 "W to Z56,828 Square feet W (5.900 acres) — N If cli N lL ® 7T 6 LU z 0� �O / a _ NOUSE � � I I I '- a w Q I - - - - • :;. tn I ot - - - - -- ------- - - - - -- �� Q N O O I N S88 °21'10 "W I I " 19.94 1 97.07' I I - - -- S 89'38'22 "W 442.93' N99 °46 52 B ADLANDS ROAD SW COR - - - - - - - - - - - - - - ' - S 114 COR. - ` - - - SE COR. SECT /ON 23 SECT /ON 23 _ 11111NPfh SEC. 23 s referenced to the South �'X� Bearings � g � line of the SE /4, assumed to be ` G. � HARVEY N89'58'09 "W . e JOHNSON e S -1x99 � s ° indicates a 1"X24" iron pipe weighing '+ HUDSON 1.68 pounds per lin. foot set. ° t,� WIS r • indicates a 1" iron pipe found. Ij < .r • +•......•�� O SCALE (N ,FEET / "- /00' ,00 � *6I UP q 0 1 O l00 200 300 This instrument drafted by 71 4982339B Wisconsin Department of Commerce SYSTEM Count y Safety and Buildings Division PRIVATE SEWAGE • INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: X Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344576 Permit Holder's Name: ❑ City E] village Town of: State Plan ID No.: PENMAN, DAVID & MICHELLE HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020 - 1350 -07 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to I ntake ROAD Dt Inlet ir Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH I Lift Friction System TDH Ft oss Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER model Number: System: 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: HUDSON 23.29.19.1892 814 DAKOTA RIDGE — FOX VALLEY LOT 7 U U Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Visco, nsin In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans to the count co only) for the system, on p ( Y copy Y) Y paper not less County p p than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 3fles - f o Personal information you provide may be used for secondary purposes ,1` ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. )Ve p Q-' State Plan I.D. Number f'P I. APPLICATION INFORMATION - RCEASRINT ALL I t N / FQR J �M f A Property Owner Name Property Location C QVIt + - j 1/4 SW 1/4, S 2.3 T 01 7 , N R Properit Owner's Mailing Address Lot Number Block Number City, S ate Zip Coe Phone Number Subdivision Name or CSM Number So n WT O 1 '0 ( > T YPE F BUILDING: (check one) ❑ State Owned Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Se Town OF Tt,K04M RiCI III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 02s 1 350 - 0 j ;2$. P-q. L9. M - 2- 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor R creational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel./ Motel 9 ❑ Office / Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2 ❑ ❑ Replacement 3. Re lacement of 4 ❑ ❑ Reconnection of 5. Repair of an __ystem ______ 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 Trench 7n 0 Frlafov- 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit se dew.44(fv 43 ❑ Vault Privy 14 ❑ System -In -Fill a J f VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation J O 760 7 63 , Feet Feet VII. TANK Capacity in gallon Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic TankacklcWiwg�ank — Joao / ® El 11 ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu s Si nat re: Stamps) BWAOtHMi No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 9 er das 5q© IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee !Includes Groundwater D ate I ssued Issuing t t e i at a (No Stamps) pp []Owner Given Initial A roved Surcharge Fee) Je !� G Adverse D 7 ermfnatlon � X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: i i I CRr1_ R40R to 4 41071 DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer -- �Ii lid z�2 2 Mailing Address Property Address � 7` a (Verification required from Planning Department for new construction) City/State 41 d/t �� Parcel Identification Number 6C�0 - A 3 °) a LEGAL DESCRIPTION Property Location S W '/4, Sec. a , T 9 N -R�W, Town of (l o �✓ . p Subdivision `I�U�C (�i� /JC y �,� ;'') cl / 7` 0I'✓ , Lot # Certified Survey Map # 0 I✓ 'G A pg f �olume � , Page # -� Warranty Deed # ( ,905 636 , Volume Page # Spec house ❑ yes 0 no Lot lines identifiable 0 yes ❑ no SYSTEM MAINTENANCE tare failure to handle wastes. Proper maintenance Improper use and maintenance of your septic system could result in its prema consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification statin that y septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 ys o the y ar ex p' date. // GNATURE OF APPLICANT DATE OWNER CERTIFICATION state ments on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of tL& d a ve, b irtue of a warranty deed recorded in Register of Deeds Office. I-A SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: ,Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: Six. CRU LX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 344576 Permit Holder's Name: ❑ Cit El Village Town of: State Plan ID No.: PENMAN, DAVID & MICHELLE HUDSON �.__... CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: �fca 020- 1350 -07 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic tr Benchmar f 3} T7,A 3f Dosing A (4, W a, sty la$. u Aeration Bldg. Sewer s, D Holding St /Ht Inlet 5. (00 X02. lS TANK SETBACK INFORMATION St /Ht Outlet & -w( TANK TO P/ L WELL BLDG. Air I to ntake ROAD Air Septic ,.IoO,a ( NA Dt Dosing NA Header / Man. Aerati on NA Dist. Pi a p Holding Bot. System I J& PUMP/ SIPHON INFORMATION Final Grade 5 Manufacturer Deman Model Number GPM .2g 10 TDH Lift Friction e TDH Ft oss Forcemain Leng Dia. Dist. To wen SOIL ABSORPTION SYSTEM 6 RENO Width I Length N Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME 3 a DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuf�ct e SETBACK L: INFORMATION Type of CHAMBER M del Nub ber: System: OR UNIT DISTRIBUTION SYSTEM Header / Distribution Pipe(s) ___� Hole Size x Hole Spacing Vent To it Intake Len h yRTTS. Lengt Dia. Spacing SO VER 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.) LOC TION: H DSO 'e°r l� ,2 ,. 814 DAKOTA RIDGE — FOX VALLEY LOT 7 13wl z if—c"Va ��S4A�11 ow O ' MN ❑ Yes A No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert No. x' ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: t E q e e E s e f # t # # 4 s g i g 1 5.,. .. ,. # e s 8 e r t t S f a ev=ae.. .. m:.* m ®mk,m �..,.. �}�: ...m ff .. .... E ¢ Poq e ..�.... ....�. ... .� .......... ......g ... .�.. Ate. .. _...,� .. .,. .t. ......._� «..�,. ,� ..... �'°� ¢.�.,........ { 7 � J # � F t 3 # # # Wr ... N._.... ..- ........._ .,,. f,... ....... ... ... _. ..... ,..,. .. .. .., g¢ _.me t t 9 e i S # # r #. _ m j s � e 8 E c .......... ..,. - ...�.. _ a f 3 Safety and Buildings Division SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue Visconsin P O Box 7302 Department of Commerce accord with ILHR 83 O5, Wi s . A d m. C ode Madison, WI 53707 -7302 • 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. 1 91. • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes E] Check if revisio to previous application [Privacy Law, s. 15.04 (1) (m)]. pe "'lloull"111% V Y ^ _ State Plan I.D. Number fP 1. APPLICATION INFORMATION - PCEA�RINT ALL Property Owner Name Property Location I 5F avid + 1/4 spa 1/4, S a3 T a q , N, R i Property O wner's Mailing Address Lot Number Block Number f)Ift City, S g te Zip Coe Phone Number Subdivision Name or CSM Number So n 4 WT 1 6 1 -101 G I ( ) Fox Yalle-W oil T YPE F BUILDING: (check one) ❑ State Owned Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms _ Town OF 7A, K04a - R t� 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 620 1 350 — 0 - 1-000 1 ;2s. Xq. i9 . l8'92 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.' OI New 2 ❑ Replacement 3, Q Replacement of 4. Q Reconnection of 5. Repair of an ystem ________ System_____________ Tank Only______________ Existing System ________ Existing System B) Q 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;KSeepage Trench TitffI tnz¢etr 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 5i dew.4d +r It Privy 14 E] System-In-Fill '*- .2 ) �9f. �7v�- VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) �j+�'� Elevation J � 6 . S c? • Feet Feet Capacit VII. FORMATION in gallo Total # of Manufacturer's Name Prefab. Con steel Fiber plastic Exper. New Existing Gallons Tanks concrete structed glass App. Tanks Tanks Septic TankacJWJdiwg.iank low — IWO � J ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ I ❑ ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) I re: (N Stamps) No.: Business Phone Number: d , �r Plu s Si nat �a �5i 7I� , y Plumber's Address (Street, City, State, Zip Code): tV 1? 0130 9 l er av I 5�© IX. COUNTY / DEPARTMENT USE ONLY Q Disapproved Sanitary Permit Fee (InciudesGroundwater ate I ssued Issuing t at a (No Stamps) Approved F1 Owner Given Surcharge Fee) Initial � /f C Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD- 6398 (R.11197) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ' t INSTRUCTIONS f 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 bythe.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. 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. lX. 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 contamination investigations and establishment of standards. r� i � < A 4 /b ` �f r aY �/a U pct ��y��y�art C�R OAX �.... "� I � / �lZft(d116tG 1 Pr` FhJI�lV 1G /h OaG to " k G e 0 Pic D,`str;bt -U,E Box - g' ����.e fl ev �. 1 el l, Sc Jar,k �-_, �3 91.E 0 {{ewse At 'O 4 n I Steiner Plumbing & Electric, Inc. N8230 945th Street Phone 715 - 425 -5544 River Falls, WI 54022 FAX 715 - 425 -8818 [Do - aId peytma scale VC /pause �ry • iL 6 3 At T c , , Pa < C� Sf ,z.6 I/ P hip If i^LG.� �S� �/D /. /Dr /°� . 2- f 3 f Wisr.•onsin Department of Industry SOIL AND SITE EVALUATION 2 Labor and Human Relations _ . Page 1 . of ! Division of Safety and Buildings ; in b9c nce with s. ILHR 83.0 , is. 1 ,7 1 Attach complete site plan on paper not sq than 8 A inc es Ii�ke�. Plan must County s . / Include, but not limited to: vertical an zontal r��j}y'A/ f ii t (BM"reFtion and percent slope, sca or dimensions, n �sirrow, and location and dista use tip nearest road. parcel I.D.' Q2 D 1 • 2- APPLICANT INFORMATION Oase prAff�K.7� forma on,] R e Date Personal Information you provide maybe usr;9� COU convac s. 15.04 (1) (m)). Property Owner Property Location V Q Govt. Lot s 1 /4W 1/4,S 2-S T.2 9 ,N,R / E (or) W Property Owner's Mailing Address t # Block# Subd. Name or CSM# 7S 2- 1_3 4i�,,fCIDS City State Zip Code Phone Number 337 Nearest Road /j�(lf�,so 7 /S Flo ' ❑ CI l Villa own 1>�iCOTfi A:Pd- ' New Construction Use: Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: X4 e Q y�� ^ , N /ft • d trench, gp� Code derived daily flow � gpd Recommended design loading rate bed, gpd Absorption area required 1V9 _ bed, R 7 trench, tt Maximum design loading rate bed, gpd/tt gpd/ft Recommended infiltration surface efevation(s) Sae- A a 3 ft (as referred to site plan benchmark) Additional design /site considerations Lo o G•- /f/ /ed k2 0�S D� `� r ` ``'/ V", }f od 0x4c-S �� Parent material ..�*0PY e & T Flood plain elevation, If applicable N � h• S = Suitable for system , Conventional Mound In- Ground Pressure AT -Grad System In Fill Holding Tank U = unsuitable for system LET s❑ U ❑ S U (/❑ U S❑ U [�'� U El 13 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench /o to Y,C' 3� S /L' /fS�,� 44- S 3 f .,2 ; . 3 3 ©r y s/Z --N �/* 5w 17`1 :s � Ground 3 , Z ' 7 s Yx Depth to limiting factor , Remarks: - Boring # /0YX 3/ S/L ' /7`S`!� M S 3 7' /y io Ground �0 l/ Sl J Di S l ' u A elev. ! �ft. ; Depth to limiting i for 7 Kin: Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number 2S• Ulbricht & Associate$ Private $$wage Consultants 66s O'Neil Rd. Hudson, Wls. 54018 ORIGINAL . �j� V fJ€ �a SOIL DESCRIPTION REPORT PROPERTY OWNER Page 2— of -3 , PARCEL I.D.N Boring # Horizon Depth Dominant Color Mottles Structure 2 In. Munsell Qu. Sz. Cqnt. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 3 a •C io Y/? Y/& A)Cj - he CCU Z . . 3 2 1 14-1 s'-7C ' cS /f s' ; • � Ground 3 Z .� l� f �' '1 . • U elev. l /D eft. Depth to limiting factor 7 �h. ; Remarks: Boring # • !o �� f s •� Around • '� �— elev, /pp D ft. Depth to - limiting factor ln. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G D /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # / 0 • D YR ll � 6L iwl J ie .2- 3 z o 3 �L S Ground ef � e �j -14 -ft. Depth to limiting factor 7 44�.-1". Remarks: Boring # Ground elev. ft. Depth to limiting factor 1 "' Remarks: SBDW -8330 (R. 08/95) ] A) f A +6 r m W � � I w � w � � N cl p e5 7 �� • f C ER T I F I ED S UR V E Y MA P Located in the SE1 /4 of the SW 1 /4 and the SW 1/4 of the SE /4 of Section 23, T29N, R 19W , Town of Hudson, St. Croix County, Wisconsin, being Lot 1 of that Certified Survey Map recorded in Volume 10, page 2935. Arnie VariderVorst D Z b , � 752 Badlands Road Hudson, Wisconsin -s33 N 89'58'39 "E 462.77' S 89'58'09 "E 221.72' 243.05' 125.80' -- - - - - - � - - --� I - S 61 I W Soi G 1 W :. X !L ® T 5 in `' _ N m in 87, 397 Square feet v 1 a 0 (2.006 acres) a °o " 0 IT — — —)� 0 N ..'. iD 309.64' '. t9 S 89'58'39 "W / ?? � 256,8Z8 Square feet I ® 1 (5.900 acres) to N L0 Tr 6 c W / ..J z �(D to / NDUSE Ct I � tn co o° Q N 0 cn I S88'21'10 "W I i 19.9 4' 97.07' — S 89' 38' 22 "W 442.93 N89'46 52 BADL ANDS R SW COR. S114 COR. SE COR. SECTION 23 SECTION 23 SEC. 23 ..% %, s co/V �►` '`k• Bearings referenced to the South �a ++ line of the SE 1 /4, assumed to be � * HARVEY Q, Z N89 58 09 W . e JOHNSON S- ° indicates a 1"X24" iron pipe weighing + HUD t ON 1.68 pounds per lin, foot set. y� W ,r indicates a 1" iron pipe found. SCALE (N . FEET I'= 100' ; UR Aj 1 1 O l00 200 300 This instrument drafted by 4982339B r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer � ' a 4 17J &16181-1ee Mailing Address a //f�/✓�S A c ` /7��J4/1� (�� Sy0 Property Address �' t (Verification required from Planning Department for new construction) City /State 4/40/t Parcel Identification Number bolo / 6)63 a --S�/U/ LEGAL DESCRIPTION Property Location ' /a, S W '/4, Sec. a 3 • T X19 N -R__LLW, Town of CC o �✓ Subdivision I rionl Lot # Z_ . Certified Survey Map # 0 /✓ 1olume , Page Warranty Deed # o a 3 Volume Page # Spec house ❑ yes 0 no Lot lines identifiable oI yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification sta7z hat y septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 the C y ar exp' date. / 221 GNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) c 'fy that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of e pr perty d c d above, b ittue of a warranty deed recorded in Register of Deeds Office. QQ / Xl SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed • I STATE BAR OF WISCONSIN FORM 1 - 1982 ,I 605636 KATHLEEN H. WALSH • i ryp DEED REGISTER OF DEEDS DOCUMENT NO. Ij . AGE 1 6 ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between 06 -25 -1999 9:00 AM Arnnlei Vander Vorst and Karen Vander VnrGt ; i WARRANTY DEED _Formerly Karen E. Penman, Husband and wife , I EXEMPT N Grantor, ! CERT COPY FEE: COPY FEE: and TRANSFER FEE: 90.00 Davi d Penman and Mi r hpi 1 e Penman . RECORDING FEE: 10.00 Husband and Wife, PAGES: 1 Grantee, l Witnesseth, That the said Grantor, for a valuable considerati 3 0 , 0�0 0.0 0 Thirfy ThOucand and NnZ1 - - - - -- conveys to Grantee the following described real estate in S t _ r r o i x THIS SPACE RESERVED FOR RECORDING DATA County State of Wisconsin: NAME AND RETURN ADDRESS EAGLE VALLEY BANK, N.A. Lot 7 Fox Valley Farm Addition. 1301 Coulee Rd., Unit 2 Town of Hudson. i Hudso WI 54016 St. Croix County, Wisconsin n2n 1 n63 -2n I PARCEL IDENTIFICATION NUMBER �j !j !i I! !w I� This y s homestead property. is (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And _Arnn1d Vander Vorst and Karen Vander Vnrst warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except ' ;i I� and will warrant and defend the same. -7 qqqq j Dated this / day of t-f K 'r ,19 (SEAL) C �I.CP/1 1/` (SEAL) '► • Arnnld Vander Vorst Karen Vander Vorst (SEAL) (SEAL) ii i AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, County. ' authenticated this day of , 19 Personally ca �e before me this day of 19 , the above named C• li TITLE: MEMBER STATE BAR OF WISCONSIN (If not, U authorized by §706.06, Wis. Stats.) tome kno to be the rson iexe d tMe 4*egoat� instrument nd ackn dge the sam i THIS INSTRUMENT WAS DRAFTED BY •• J • .' p 4 i Karen Vander VorGt /��•••••'�0,� I Notary Public, County, Wis. !; (Signatures may be authenticated or acknowledged. Both are not My commission , i per j (If not, state expiration date: necessary.) • 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. I 1/4 r C 3y 2 i 10 . Wo. - 241,05 Ll LOT U wqy I 18 2 LOT 6 1�oR i L ...,,5. 1 62 o 1-01 5 CERTIFIED _ L OT 5 q a 1819 0 ° L 9.94 442.90 Q 8 3.95 S 1/4 C OR. SEC. 23