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HomeMy WebLinkAbout020-1317-00-000 Dr - ar tment o f D i vi sion Commerce d F cgs D PRIVATE SEWAGE SYSTEM Count INSPECTION REPORT St. Croix .L INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ` (formation you provice m ay be used for secondary p u rp o s es ( Law s.15.04 (1)( 353239 m .+older's Name: ❑ City ❑ Village ❑Xfown of: State Plan ID No.: caret, Paul N. I Town of Hudson CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.: IWO , �;�' � 020- 1317 -00 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic �� h P dp Benchmark J, , fp to2..� CT _b Dosing Alt. BM v/.d Aeration Bldg. Sewer ,�O -�,4V r Holding St /Ht inlet TANK SETBACK INFORMATION St /Ht Outlet 51 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >'5-6 .,, 62 ` 14 ( (o Dt Bottom Dosing A Header / Man. `` --� 6 3 ° 6 • io 9 - 184 Aeration NA Dist. Pipe 0 7. Bot. System PUMP / SIP ON INFORMATION Final Grade ( �� Manufact nd St cover 3. 98.s Model Number GPM TDH Lift Friction Sys TDH Ft oss Forcemain L Dia. f Dist. Toweu SOI SORPTION SYSTEM BEB' RENCH Width Length No. f renches PIT No. Of Pit Inside Dia. Liqui IME 15 1 T6 a DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Ma rer. SETBACK CRAM INFORMATION Type Of r ?8� _ Moe Num er: System: �. "rg NIT DISTRIBUTION SYSTEM Header/ anifold c o� Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Lengtl5 Dia. l Leng ang 7 `E a SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Ov r xx Depth Of xx Bed /Trench Center f 4 Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 05_/V / &v Inspection #2: / I Location: 858 Daisy Circle, Hudson, WI (SE1 /4, NEIA, Section 24 T29N -R19W) - 24.29.19.1610 (o G 1.) Alt BM Description = �f� 2.) Bldg sewer length = 1 `f 4— - amount of cover= 'r r8 S;4 cbv-� L Plan revision required? []'Yes No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E s x Y } M I , F t I } E I � I � o 1 E II k""'TARY Safety and Buildings Division PERMIT APPLICATION 201 W. Washington Avenue P o Box 7162 i Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. 5 • See reverse side for instructions for completing this application State sanitary Permit Number . 3 5"� Z 3 q/ Personal information you provide may be used for secondary purposes Check if revision to previous app ion [Privacy Law, s. 15.04 (1) (m)]. �11 t AT State Plan Review Transaction Number I. APP ICATI N INF RMATI N - PLEASE PRINT ALL INF N Prop y Owner Name Property Loc do S L T , N, R E (or)o Property Owner's Mailing Address Lot Number Block Number c et SS City, State or Zip Code &d so T hone Number Subdivision Name or CSM Number .,v e .SY0 16 ] -54,u kfd e 11. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 0 (3 C ity OF e" ' i ed 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 0 2-0 1 ❑ Apartment/ Condo ac��Z j - 11�,( c, 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. Ig New 2. ❑ Replacement 3, ❑ Replacement of 4 ❑ Reconnection of 5. E] Repair of an _'_~_' System ...... System ----- ----- Tank Only-- _________ -__ ExistingSystem -------- Existing System B) Sanitary Permit was previously issued. Permit Number - 35 - 3 2 - 11 Date Issued I,/ -/ -) 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 I I' 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill _b = 5 0 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day; 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev.. 1 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Ele a�on Feet Feet Capacit VII TANK in Ca g Total # Of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App New Existin strutted Tanks Tanks Septic Tank or Holding Tank a 2QQ 1 g , fe C Aj ra ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vlll. 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 P MPRSW No.: Business Phone Number: Ar Plumber's Address (Street, City, State, Zip Cod ): e2 C IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) MA roved Surcharge Feel pp ❑Owner Given Initial Adverse Determination 5© - � -t `1' X. CONDITIONS OF APPROVAL / R SONS FO.R DISAPPROVAL: «.uZ I tr`(Q !l zo - 45 2 SBD -6398 (R.12/99) DISTRIBUTION: Original to C unty, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 4 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. It. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. IIL 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 isto 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 wl can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. F r _ s r e- h 7 Pee �F 1 vmcuuubiuj WOP&IMI 11t Of Vommerce SOIL AND SITE EVALUATION P age _I o f _ Division Safety and Buildings r Bureau of integrated Serv ices in accordance with s. ILHR 83.09, Wis. Adm. Code Attach compote alto plan on paper not less than a 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference polm (BM), direction and � percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel F.D. # b APPLICANT INFORMATION - PMase print all Information. Re viewed y Date Personal information you provide may be used for secondary pumosee (Privacy taw, a. 16,44 (1) (m)). Property Owner Property Location Govt Lot S� 1/4 1/4,S �4! T� g' .N,R �f E tor} Pro Owner's Mailing Address Lot # Block# Subd. Name or S ps y M# ve— City state Zip Code Phone Number Cit Village Town Neatrest Road *Now Construction Use: MrRealdential / Number of bedrooms _? Addition to existing building ❑ Aeplacsment ❑ Public or commercial • Describe: c Code derived dally flow da gpd Recommended design loading rate '7 bed, gpd/ft gpd/ft Absorption area required 7,5 bed, ft trench, ft 2 Maximum design loading rate 7 bed, gpd/fl - �F trench, gpcvf 2 Asoornmended infiltration surface elevation(s) T ' %jj ft (as referred to site plan benchmark) Additional dalgNsite Parent material ��a c•` a. j& �c �� Flood plain elevation, if applicable — ft 8 Suitable for system nventional ound n• round reasuro ystem m I Holding a U u nsuft le for system x s❑ u �( a -Q u ®-s ❑ u ( s❑ u ❑ s u ❑ s u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture structure Consistence Boundary Roots in. Munael! au. Sz, Cont. Color Or, Sz, Sh, Bed Trench 2 M 6 blY P1 !� CS Ground . y — S hi — elev. Sri • i tt• Depth to limiting X v V-D factor 3`f S,d � • 6 Remarks: Boring # G S F 40 7 E f ` Ground o' 9'l" fit• Depth to lirrddng ram► in. Remarks: CST Name (Please Print) Signatvn Telephone No. ,'lliit s� Nc v lS - .Zi%G Addross Date CST Number cgacc 'd� o�s•ass :sxaaweti .� z ao>toe; Buq}wll ou U2dsG - ASI6 , PUno 4 # Bubo$ :e�!>�uay •uI AMOK cumuli 4;dea AOp punoap # Bu�aog . 4s IZS'a0 MOO Iiuop'zs'np PIMA ul yousal ' pee Slood kvPunoS soue WOO ean;ona>s aarti>tal seployy aoloa luvupoa 4idea uo H :8�1 @W 6d •vi � 1030>!y $ul�tull u 'Aals Punoap # BUPOS S�Jgwqu UI77I of 4;dea £' Pump it rl S 3010 -iuoO •z S •np ylssumyi ul Lpu®J� Peg u8 'xs a0 e seluoW iolo0 ivauluxCl �pd®a uoxlloH # 6u IJ0g siooi� ksPunog sausss►suo0 sm3analS Z —� aaNnno ti.d3d0ad ' 7 40 ` abed 1li0d3H N OIldIbOS30 '1105 "© 4 �u laa u 5 -c 5.'tc I2o� ,83 l OP a A r 0 i 1 I ON Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Viscons P 0 Box 7302 Department pf Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on - tess - ` Cou t than 8112 x 11 inches in size. �' • See reverse side for instructions for completing this application ' tats S$ri Permit Number Personal information you provide may be used for secondary purposes" �. < < y E QQheck If nevi ion to previous appiic tion (Privacy Law, s. 15.04 (1) (m)]. f State Plan I. Number I. APPLICATION INFORMATION - PLEASE PRINT AL INF AT I O fk Propert Own r Name Pcopf jam , N, R E (or) Pr perty Owner Address Lot. _ ;', Block Number Cit , State _ Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned E] it Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ° Villag f 0 !v 111. BUILDING USE (if building type is public, check all that apply)SjWU,,, Parcel Tax Number(s) On --, 0 l � � bD �6Z� 1 C] Apartment / Condo . 16 10 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. p&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 ( Y ) 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 i , 42 ❑ Pit Privy 13 Seepage Pit C R) � X / 6 C> 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) mq,. O Elevation G'a'd 1 /hod lea f4' ,Ua.. 7,75 Feet t 2,�5 Feet VII. TANK Cap acit y gallons Total # Of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic ank or OD i B,S'Y` -t- / 91 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MPRSW No.: Business Phone Number: rz.7 1 .9 rr'O /,3• .-312! Plumber's Address (Street, City, State, Zip Code 3: IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issui A nt Signature (No Stamps) ❑ Owner Given Initial 2TSefy Surcharge Fee) &&Approved Adverse Determination 160 L1 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 76 4 ` SBD -6398 (R. 4199) 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 Adrrrinistrative 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 rr►ust include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the sj sbem 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. 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 manufaaurer;_ D) crQ ;s section of the soil absorption system if required by the c45unty; 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) fora 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. 41 VP 3 a 11rC� vs � pea R *' 0 a a6 i rke as Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY sT c �t?o�'X Attach complete site plan on paper not less than �nehgs in size. Plan must include but not limited to vertical and horizontal referenc%Oinl M diraetipn,apd % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location ansl dist#nce to nearest`FOad,Y , 4 APPLICANT INFORMATION -PLE OE PRINT, AIL(INFaRWAYON REVIEWED BY DA E Z 4 PROPERTY OWNER: PROPERTY LOCATION �t H 1 y/ GOVT. LOT � 1/4 Alf 1 /4,S2yT 29 ,N,R //` E (o,y� PROPERTY OWNER':S MAILING ADDRE fi LOT # BLOCK If SUBD. NAME OR CSM # CITY, STATE ZIP C PHO NUMBER OCITY QVILLAGE OWN NEAREST ROAD t U12,5 0 CJ l , eil0 1 . 10 A1 yovvG- /f p . (q' ew Construction Use (piesidential / N 3 1 f/ (] Addition to existing building (] Replacement ySD ` ] ) Public or commercial describe Code derived daily Now &oO gpd Recommended design loading rate bed, gpd/ft � trench, gpd4t Absorption area required uIA bed, ft trench, ft Maximum design loading rate bed, gpd/ft Uerich, 2 Recommended Infiltration surface elevation(s) S� 3 ft (as referred to site plan benchmark) 7 Additional design / site considerations C", �i'E- �Gl�,t S o" 40- .0 Parent material 4ti5 Flood plain elevation, if applicable N A- ft S - Suitable for system CONVENTIONAL MOUND 11 �/ IN -G UND PRESSURE AT -GRADE SYSTEM IN FU HOLD ING TANK U= Unsuitable for sy stem ( S` U C1 S 03 t!_'S 11 U DS O S C�'l7 SOIL DESCRIPTION REPORT i 1X = AvoT ���O�tHeaD Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoLnfly Roots GPD /ft in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. Bed Tmrch 0 - y /o y " e z i. --_ _._._ z-f sl e /4. -6R s a-F- ' 57 . L z y /y 0 YX 3 1 1 - s/ f sAe 4 . 0 62 Cs 2 f , 5 Ground 3 <;/7 2 S6x /h+ C S / elev. �( /o5, o ft. 1 1O ye Y/r yr 7� .S . s S Gi S • s �i Dep to De 5 0 /o limiting 9 Yee y!Y S. O S 9 11C facto ` Remarks: Boring # z z - 7 ye y s/ /f 40e s Ground 3 Of -G 7,5 VA `r/ /oaf ti 7C G S � S CS //3, elev. �tL Depth to limiting factor >— a Remarks: CST Name: — Please Print 12 o (3 Ep T U jj3 p t'C &, 7— Phone: 71 j - 3 .0(; • g/ 8s Address: CSTiY 2 "yQZ Signature: Private Sewage Consultants Date: CST Number: 655 O'Neil Rd. Hudson, Wis. 54016 OR Irikl A i f l i PROPERTY OWNER S1 3 Ru Sc SOIL DESCRIPTION REPORT Pa of 3 PARCEL I.D. ! Z OF Ste` 5 iDG 45` Boring # Horizon Depth Dominant Color Mottles Texture Structure �tence Bcun�3y Roots GPD /ft In. Munseil Qu. Sz. Cont Color Gr. Sz. Sh. g� � /a Z 5 1 f S6i� .w. Fti° C V - 1 3 S / / / 1 fSt44 Av,-F4 C / � , S , Ground ,3 3 o /D /� �/7 s! �x S�i� /►ti+f.e �"s 's elev. /07 &0 It. � O - Jf /-0 �4� 7� S. d S � CS , S ( , (o S Depth to S - /Q - limiting ' factor Remarks: Boring # �- 7 �6 ,e z z 5� / fs6,e nh fr2 c S a-F , y s i Ground 113 50 ft. Depth to S S S 0 S limiting factor i >-fo'L S ��o' Remarks: Boring # l o - lam /o l z Stl 1 - f S4k 4, fit CS Ground i elev. It, Depth to S 0 - /4 I l • -S � S AC s' �-- -- . S �e limiting factor �� 1 Remarks: Boring # Ground elev. tt. Depth to limiting factor Remarks: oOn oeenib ncrn n+ o o b m o w W O H b W • '--'.� • -� �� X11 ry N fi L i n tj 41\ o W w � N • 1 V 1 0 • " • y} , , ,� S �'� { (`f 1 + vit U', C t r'' iLz +x' �". � 1 � 1 . ,� 4 7tP k� ♦t1 • 1.,X, fr ` 1v{;} �lr 3 �� j.r• r''x }rt j . • J ( j I.1:�{.. ` 4 R ' T .'.. r ' y .. I i . Via. • u�" L ' {.F� { + t t �'� rj �'�� �J } 1 1•t'f ^. �.l W • � 1 ,7, . • ' � • t���'' a t ^:y�iy'�r3y,�s s • �`�AY`' ";Sig''' "s �' },lam Jl.�.•�h 7 '. • rn . � fi ', mac 7 , 11.1 +j t , ^ • � jr�t w �.�,. �r j • �' �. CJ� . .��, ��L �� f•' '�.� ` roc . ..� ), • 4 , {^ 4 ♦ •. +� ��j,•{ r .�' � - f \ � � S Y ET � ` • � � �• r , i � f y�../.`�hS y ,,, ��1 ;�',RyS.t' '�'1�t 4 �'r�' �: Y {' ii i t�R1}a;t �p�.�t '��, ,, { '�'J\ �.t 9•�1 1 � `�+t t - • t , y ..,s�, �1^,•'F' �t F �. i � f. r f �T�Y ir�i is i. + 1 � � L'} .i,s !�• , i A '� � i } �' i 4 q,�, . • rah < * i �• ,. ` L am`. � ;- ' �A'. n A� O ,� t • . 'I� r } 1 }' �1 f i •.t .t ,` 1 �5�., �Tr 21-1, .. k $ . ,a M r i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM, OwnerfBayer 0 6L/' Z 5 2 7- v J am' � � Mailing Address � .�s Property Address _ ff6T _e �4 4 (Verification required from planning Department for new construction) �— - � City /State ___ Parcel Identification Number © - /3 J 7 .___ - W LEGAL DE SCRI P TION Property Location .S 'l., '4, Scc. � ems T, 49__N- R.jy__tiV, Town of Subdivision 5'� & ,t " ' o-e — Lot # C'ertitied Survey leap # _ .�— _ -, -, Volume _ Page # Warranty Deed # - O � Volume a a 0 , Page # �� Spec house ❑ yes Wj no Lot lines identifiable E yes 0 no SYSTE MA INTEN ANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes - Proper maintenance consists of purnpi,ng out the septic tank every tluee years or sooner, if needed by a licensed purnper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal System. Ilie property owner agTees to submit to St. Croix Zoning Department a certification form, signed by the. owr,Fr and by a rtaasterphunber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is w proper operating condition and,'or (2) after inspection and pumping (if necessa.ry), the septic tank is less than 113 full of sludge - Uwe, the undersigned have read the above requirements and agree to tn.aintaitr the private sewage disposal system with the st 03— ru set forth, herein, as set by the D art nt of Commerce and the Department of Natural Resources, State of Wisconsin. Cettification stating that ptic systeP . as en maintained must be completed and returned to the St. Croix County Zoning Officc 5�ithin 30 days of three ar e i i date.. SIGNATU 1 OF APPLICANT YA4 O CE F1' L T1 - I ify that all e.nts on this form are true to the best of my (our) knowledge. I (we) ani (are) the O%Vner(f) of the propdrty desc. d ab0 t'irtue of a )Nvarranty deed recorded in Register of Deeds Office SI( NATU Q' Al?PMCANT DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department_. •" Include With tills a licati z: a stamped wa ant deed from the Register of Deeds office I p of p d rr Y 8 a copy of the certified survey map if reference is made in the warranty deed ------------------------------------------------------------------------------------------ - - - - -_ Ii i _ is { 1 A ?0P �,, 627 601788 � � I WARRANTY DEED KATHLEEN H. WALSH Document Number DEEDS REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between, WILLIAM M DERRICK and JEANNE B. A. DERRICK RECEIVED FOR RECORD husband and wife Grantor, (14 -22-1"9 9_30 M and, PAUL N SKARET and CHRISTINE C SKARET YARRANTY DEED husband and wife, as survivorship marital property Grantee. EXEMPT D I Witnesseth, That the said Grantor, for a valuable consideration of one dollar and CERT COPY FEE: COPY FEE: other valuable consideration conveys to Grantee the below described real estate in TRANSFER FEE: 150.00 i St. Croix County, State of Wisconsin. RECORDING FEE: 10.00 PAGES: 1 3 This is not homestead property. 1 Together with all and singular hereditaments and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except Recording Area easements, covenants, and restrictions of record, and will warrant and defend the same. �- •'� • ; J (Parcel Identification Number) r 'l JcuCT ;1 020 - 1317 -00 -000 I LOT 55, OF THE PLAT OFSURIDGE I' IN THE TOWN OF HUDSON. C t 'sc 0 199. ' a WILLIAM M DERRICK ' EANNE B. A. DEIRR I ICK AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN COJNTY ST. CROIX y� Personally came before me thiw�' day of fit : ; 9 1Kjthe above named WILLIAM M DERRICK authenticated this _day of JEANNE B. A. DERRICK, husband & wife to 1 E.NE K. LINN i s me known to be the person(s) who executed the foregoing signature public instru ent aria acknovi9ge t same. Notary Z 1 type or print name t3siof• Em ola s M Cote type or print name r'1 (A n n n TITLE. MEMBER STATE BAR OF WISCONSIN Notary Public County, . . ( , �• . ?C / (If not, My commission is permanent (If not, state expiration date authorized by ;706.06, Wis. Stats.) P� �� r . ) THIS INSTRUMENT WAS DRAFTED BY 'Names cf persons signing in any capacity should be typed or Robert F. Wall printed below their signatures. (Signatures may be authenticated or acknowledged. Both are not necessary.) 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