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0 WIm. nsin Department of Industry SOIL AND SITE EVALUATION 2
Labor and Human Relations Page of ::✓
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 112 x 11 Inches In size. Plan must County /�•
Include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale of dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # M a ��
DZD— J057 — GD 2670 � /- )
APPLICANT INFORMATION - Please print all Information. Re by , Date
Personal information you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)).
Property.Owner Property Location G
1 G G IAI T Ile GER ,5� 1/4 &U _ 1/4,S 2 T Z9 ,N,R. // E (o OW
Property Owner's Mailing Address Lot # BI k# I Subd. Name or CSM# FAVAt o y–
G 7 /fey - cs V30 KO O17
Ci State Zip Code Phone Number , �/ Nearest oad .
71 5 ' ) 3630 921 City u Village I'1 Town 1,1w / Z
01 New Construction Use: 31 residential / Number of bedrooms ' + Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: -
Code derived dally flow fP0 d gpd 1j Recommended design loading rate bed, gpdfft •' trench, gpd/ft
Absorption area required _lU / i� bed, ft trench, It Maximum design loading rate bed, gpd/ft ' UP trench, gpdHt
Recommended infiltration surface� elevation(s) see • 3 ft (as referred to site plan benchmark)
Additional design /site conside s Wye LOV 1f End W
Parent material 5 6. M S .¢ 11 1,17— l G • Flood plain elevation, if applicable
S = Suitable for system Conventional MM I In Grroun!d ressure AT -% a System in Fill Holding Tank
U = Unsuitable for system S ❑ U Ei 5 ❑ U as ❑ U L`JS ❑ U [Is [Is
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
ff
Z/ o z SiG Z ff6 S z' • 3
G 3 0 � SiG z,.. AV- .ter e:!;7
lot) e e
Y-0-ft.L Slc /err
Depth to
limiting 6 `a D
factor
/D
Remarks:
Boring #
° /o 2
-3 10 3 /G s
Ground /O
elev.
Depth to
limiting
factor
/OD_ln. Remarks:
CST Name (Please Print) Signature 7 Telephone N
�oC3�1L'7 Zl�d� /CGiT� , . 7l S• 306 §18-5
Address Date CST Number
y 2- It csr ee
Private Sewage Consultants
655 O'Neil Rd.
Hudson, Wis. 54016
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PROPERTY OWNER SOIL DESCRIPTION REPORT page �- of 3 �
PARCEL I.D./ T C S I
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GVpjg2
,,• In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
/o z — SQL /fsile �►fi� S / . Z • 3
M 9 j - .10 /o z 5'14- S Ground 2 f Z , • J elev.
o� Q
Depth'to
limiting
factor
Remarks:
Boring #
Z U or /W 3/:Z , 5; • 6
3
Ground
elev.
/o /-.ZzLft-
Depth to
limiting
factor
In.
Remarks:
Horizon Depth Dominant Color Mottles Structure D/f
Texture Consistence .Boundary Roots
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # /3 16 Z s/L /fsjl f s' r-- ,
A
�C 4c--7
Ground �j /X s V s G��( — ? •�
elev.
ft. ft
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
It.
Depth to
limiting
factor
In. Remarks:
SBDW -8330 (R. 08/95)
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ST. CROIX COUNTY ZONING DEPARTIVIEN ;
AS BUILT SANITARY REPORT
h am^
O wner I
Property Address
City /State ST r
ZOMNG FFIC
f �
Legal Description f �.
Lot Block Subdivision/CSM # -
.SIL t /4 may '/4, Sec. , T_-4y N -RA W, Town of PIN # 7D
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION
Tank manufacturer Size ST/PC lAe I Setback from: Hous Well I P/L
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: _ B� Width 2 Length Number of Trenches
Setback from: House 3 1 t o� Well P/L ,V Vent to fresh air intake 3!f
ELEVATIONS
Description of benchmark Elevation c �2
Description of alternate benchmark Elevation
Building Sewer 9St l/ ST/HT Inlet 97_x_ ST Outlet ���_ PC Inlet
PC Bottom Header/Manifold ,5Y_ Top of ST/PC Manhole Cover yak ys
Distribution Lines
Bottom of System
Final Grade
Date of installation // /.3 & P rmit nu ber State plan number
Plumber's signature License number /�/_? Date
Inspector (A
y 1 1 7_� 1 C1 �� Complete plot plan
" � ;� q
1 5
NOTICE Please provide the following:
14
• 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.
PLAN VIEW
mss
1 7G(i5K
I i
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= yd -44-
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Counttti _ CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita
Personal information you provice may be used for secondary purposes (Privacy w, s.15.04 (1)(m)].
Permit Holder's Name: nnC� illage Town of: State Plan ID No.:
N ELSON, GARY & JILLIENNE riUll §U
CST BM Elev.: [ Insp. BM Elev.: BM Descriptio Parcel ftOA -1057- 70
1
16b - b
TANK INFORMATION ELEVATION DATA A9800574
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic }� a Bench c S45 /034
Dosing —
Aeration -- Bldg. Sewer
Holding St /Ht Inlet (o Z5 7�-
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ai Intake ROAD Dt Inlet
Septic ��� 24`.�; 2 ` NA Dt Bottom --
Dosing — NA Header/ Man. 7,03 9G J0 —
Aeration -- — NA Dist. Pipe 7/� 9G 3/
Holding Bot. System Y,�b 9,,5. 3q
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number -- _ GPM
TDH Lift Friction System r TDH — Ft
oss Head 1
Forcemain Length /-' Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
("'BED—TRENCH Width Length ,.! t No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
EN 1 N �Z �� DIMENSIONS —
SETBACK
SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Moe Number:
System �On � - 3 O 1 4:!2> OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) � x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Y Spacing A-ST rA 27 9
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 22,29.19.217B,SE,NE 870 CLINT'S TRAIL — LOT 3
Plan revision required? ❑ Yes (Z No
Use other side for additional information. 7 7
SBD -6710 (R.3/97) Date Inspector's Signifture Cert. No.
Safety and Buildings Division
`•I �onsin SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. S '
• See reverse side for instructions for completing this application State Sanitary Peerr'mitit Num r
Personal information you provide may be used for secondary purposes ❑Check if vision Co previ s application
[Privacy Law, s. 15.04 (1) (m)]. n n ,�� p _
O(/l�/r�{�! State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prop" Owner Ndmje Property Location
- va k lZ 1/4, S T , N, R I`(br) �Ol.
Property ner's Maili Address Lot Number Block Numb
r
City, ate Zip Code Phone Number Subdivision Name or CSM Number
S - G I ( ) l
II. TYPE OF BUILDING: (check one) ❑ State Owned 0 Cit earest R ad
12 p Village
Public 1 or 2 Family Dwelling -No. of bedrooms Town of 2 r _ ,
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) ��. �p- / 9. g / &C
1 [] Apartment / Condo OZ — 7
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-V New 2_ ❑ Replacement 3_ ❑ Replacement of 4, ❑ Reconnection of 5. ❑ Repair of an
------ System ________ System _____________ Tank Only______________ Existing System Existing System
B) 0 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 [A Seepage Bed 21 [:]Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure f / 42 ❑ Pit Privy
13 []Seepage Pit Y S 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION: GCpO
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 . /i ch) Elevation
S�Q 2 ,..s f� Feet 99 Feet
Ca aclt
VII. TANK in allo Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete st acted Steel glass Plastic App
Tanks Tanks
eptic Ta mg Tan IN ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins Ilation of the on ite sewage system shown on the attached plans.
Plum er' Nam : (P t)r Plumb s S atur o ps) MP /MPRSW No.: Business Phone Number:
P umber's Address (S,t ity, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue � Issuing t Signature (No Stamps)
Surcharge Fee)
>Q,Approved []Owner Given Initial � Q' (90 - , , /g /
Adverse Determination 0 /
X. CONDITIONS OF A PPRROVAL REASONS FOR DISAPPROVAL: to 0, W (, C, ra-u iw -C tj
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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Wiscorrsin'Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with s. ILHR._83.09, Wis. Adm. Code
f�f7 4
Attach complete site plan on paper not less than 8 1/2 x 11 inches A&U�ce �@ +�,lan` must County
e
include, but not limited to: vertical and horizontal reference point ( sctio ar> ,,.
percent slope, scale or dimensions, north arrow, and location and to' yola Parcel I.D.
APPLICANT INFORMATION - Please print all in tio �'' rr �"; Reviewed by Date
Personal information you provide may be used for secondary purposes (Pri "1w, s. 15.04 L IN C, /) •
ProperW Owner , gation'
Govt. Lot x`1 /4 1 /4,S T N R E (or
Property er's M_ ai i Address L I ot # Block Subd. Name o _g L
1 : 5 - 94. -
/ i /)-0/ - -11�
City Statp Zip ode Phone Number ❑ City illage ® Town Nearest Roa
( ) r
�L] New Construction Use: Residential / Number of bedrooms J ' Addition to existing building
❑ Replacement Public or commercial - Describe:
Code derived daily flow 9pd Recommended design loading rate bed, 9pd/ft -,f— trench, 9pd/ft
Absorption area required bed, ft . � S trench, ft 2 Maximum design loading rate bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerati ns
Parent material - ,Z4 Flood plain elevation, if applicable 4Z , 7 ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holdin J
U = unsuitable for system s❑ u LZ S ❑ U f 3 S El ® S ❑ U El S 2r U El
SOI L DESCRIPTION REPORT
Boren # Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
' J
And
Ground r '
elev.
ft
/v 0 0Z
Depth to
limiting
factor
«,1/ in. Ll -
Remarks:
Boring #
�»r
Ground 3 - G / ) f
elev.
Depth to
limiting
factor
in. Remar ks:
CST Name (PI a [Print) Signature Telephone No.
Address _ 'c' Date CST Number
'3 /,— t - �y �W_ � ]:�ia
_ j SOIL DESCRIPTION REPORT '
PROPERTY OWNER — Page of
PARCEL I.D.# 4,2f- f-s L /f
Boris # Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground
1 13
elev.
Depth to ss�
limiting
factor
_in.
Remarks:
Boring #
[3
Ground
elev.
ft.
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 # ;
13
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in ' Remarks:
- AD - 8330 (R. 07/96)
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Wisconsin Department of Industry SOIL AND SITE EVALUATION
Labor and Human Relations Page / of : 3
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 81/2 x 11 Inches in size. Plan must County
Include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale of dimensions, north arrow, and location and distance to nearest road. 'Parcel I.D. #
APPLICANT INFORMATION - Please print all Information. / Reviewed Date
Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m))
Pr O p _ G
Property G /A- /�f-T� li,5 Got. Lot 5,r o -
/4 Nj! 1 /4,S 22— T Zp ,N,R E (or OW
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
4 G 7 try. / 9
C State Zip Code Phone Number Nearest Road
f vD,Sa -cl 4,71. 1 SYo 1 (715 - ) 3936.9Z1Y ❑ city 0 viu2ye� p'Town , /Z
L- New Construction Use: Residential / Number of bedrooms ' Addition to existing building
❑ Replacement _ ❑ Public or commercial - Describe:
Code derived dally flow Co4 CJ gpd Recommended design loading rate '� bed, gpd/fl gpd/ft
Absorption area required _bed, ft ��� trench, ft Maximum design loading rate • 7 bed, Qpd/flz a — pd/f
trench, gt
Recommended infiltration surface elevation(s) Ste- 3 ft (as referred to site plan benchmark)
Additional design /site considejaNW9
Parent material SCS �2 S 1'-$ 21107— 167— ' Flood plain elevation; if applicable ft
S = Suitable for system 0mve tional rMoouund In- Grrouuq Pressure , ATT G de System in Fill Holding Tank
U = Unsuitable for system (S El L
U J s ❑ U CUs El t� S ❑ U � ❑ U ❑ S
SOIL DESCRIPTION REPORT
Borin g # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
/ o// /0YR 21Z 5 1L, ifs ,e 17e
. 7, / No /6 v 3 4 ''* CS , Alf . z '
Ground 3 3 /0 3 51z— ---1- Ae /1M jQ e 5
elev.
Depth to
limiting
factor
TO—
,6 0 In.
Remarks:
Boring #
/ o -g /o y SQL XfSA� 4e S , 2---3
2 Z 0 2 S/G .Z{5�t
3 o SL .17
G
Gro 3 3 Z 0 — Z 5 Al a S • 7 '
f �• ft. 0 ,s' ' •8
Depth to
limiting
factor
In. Remarks:
CST Name (Please Print) Signature Telephone N .
Zl /b� /G4T 7/5- 3061. AI SS
Address Date CST Number
y 7 y- t csr-� zy�
uldriclit & Asses 1611696
Private Sewage Consultants
655 O'Neil Rd-
Hudson, Wis. 54016
ORI GINAL
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PROPERTY OWNER 11- SOIL DESCRIPTION REPORT Z 3
Page of ,
PARCEL 1.131 1- -0 7- C Si"J
Boring Horizon Depth Dominant Color Mottles Structure 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
L D YX J .S/C At'-sh l.,,•rx S'
Ground b /�- C(, 5 i 2 •, j
elev.
Depth to o /0
limiting Cvi'/� if leV f �i� Gvf� -mss 6 d« S' 0 1
factor
Remarks:
Boring #
� 3 Mo Z L Si G /fs�� 40-f $ 64- - L -3
Ground .S O Y S V c s _ • 7
elev. !3
/0 /-- D . p r .� 7 , • o
Depth to
limiting
factor
in.
/- Remarks:
Horizon Depth Dominant Color Mottles Texture Structure oConsistence ry Roots PD/
In. Munsell Qu. Sz. Cont. Color Gr. Sz Sh. Bed , Trench
Boring # D VX Z l /�. /��G /� • L ' • 3
Z z -3
Ground
l0tl. el ft. s • S a c
Depth to
limiting
factor
Gin. Remarks:
7 j —
Boring #
Ground
elev.
n.
Depth to
limiting
factor
tn. Remarks:
SBDW -8330 (R. 08/95)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer S ca4( 6/6 cz c' S — - /V /Z �-/ �.� < 5 C' r..J
Mailing Address _ / �G %U T ��' /ZG
Property Address cl
(Verification required from Planning Department for new construction) '7
City /State Parcel Identification Number Ov�U '�� / o — ���
LEGAL DESCRIPTION
Property Location s, '/4, ' /a, Sec. T 9 — N -RW, Town of �,�5_
Subdivision 4 s& ,Lot #
Certified Survey Map # i "�'��,L , Volume Page # -
Warranty Deed # �8"7�20_7 U , Volume 1 2 J c , Page # I ��
Spec house; yes ❑ no Lot lines identifiable � 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 s}' ;tern
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
SIGNATL► F APPLICANT DATE
OWNE CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner,,::) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
l C r
SIGNkfUR 01 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
Iti STATE BAR OF WISCO`SIN FORM 2 — 1982
J 7`ZQ rQ M'ARRANXY DEED
DOCUMENT NO. 9L j:Z9fjair;f
Clin_ -EL - Hetchlerr - _ single- - pergQn.--------- - - - - --
— Rfc'd for Q.00
conveys and warrants to _Garv Ne1SOn and Ji 1
tier �. *Jelson JUL 16 1998 M
husband and wife
_ - - -- - 8:00 a M
� � Ivlz
THIS SPACE RESERVED FOR RECORDING DATA
,r
NA A D RETURN A DRESS 's
the following described real estate in S • CroiX __ County, C I r K� of �,-
State of Wisconsin:
ow
r
t
ayogjS
f I 020- 1057 -70 -100 _ }
f. PARCEL IDENTIFICATION NUMBER
Lot 10 of Certified Survey Map filed June 3, 1998 in Volume 12 of Certified
Survev Maps, page 3462, as Document No. 580314 being part of the SW'k of NE-
and SE's of NEk of Section 22, T29N, R19W, Town of Hudson, St. Croix County, ;
Wisconsin.
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FEE'
This is not homestead property. ,
Xj4k (is not) '
Exception to warranties: Easements, restrictions and rights of way of record, if any.
7 � 4
Dated this day of w
' (SEAL)
(SEAL)
•. clinton E. t
Hetc er I ;, •-
(SEAL)
w �
AUTHENTICATION ACKNOWLEDGMENT
Si °nature(s�
� ) _ State of Wisconsin, t�. Y
// ss
' — �T• / / X County °
ti authenticated this day of , 19— Personally came before me this �]. day of Wi
�T t111P 19 —CI$_ , the above named L
a _ Cl inton F. Hetchl r, a sinylnoPrcnn
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, - - - -- —�
authorized by §706 06, Wis. Stats.) — - -r
to rx>r known to be the per, m ___wha executed the foregoing •�� >
Notary Public �'Lment and acknow;edgr the same.
THIS INSTRUMENT WAS DRAFTED BY State of Wisconsin
Attorney Kris Ogland
Hudson, W1 54 016 - -- r, Plubht,
- - -- _
— County, Wis
(signatures may he authenticated or ackno"ledged Both are not M% _ommission is permarret (if not, state cvplrauo tr- E Y
necessary) r
a
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• N.un (.....,,.. �.4 °•�h in a,a hoald iir ��•+rd r �,..,,rd txlo,, ,h—
WAkR\\TY DF.I,D STAI - 1 BAP OF ttr -.: 0%,1% ,. :rc,.r r- �•,�Cc .n ' '�
turm \o. 2 - r ._ �`i $..
s JU N 3 1998
8 KATHLEEN H, W r1a►
Re 1t of p� sS 3
o1.c Croi�Co, WI
L �
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CERTIFIED SURVEY MAP
LOCATED IN THE SE 1/4 OF THE NE 1/4 AND IN THE SW 1/4 OF THE NE 1/4 OF SECTION 22,
T29N, R 19W, TOWN OF HUDSON, ST. CROI X COUNTY, WI.
NOTE • HIGHWAY BUILDING PREPARED FOR: CL INT HETCHLER
SETBACK IS 150' FROM THE
CENTERL INE OF U. S. H. " I2" LOT I C S M: VOL 9
AND 50' FROM R. 0. W. OF TOWN • • .. • • ' • • • 45' X I B' iq
ROAD. , PAGE ,.2490• SIGN EASEAENT '` S 89 ° 53' 42'E
N. L I NE OF THE S 1.12 OF THE NE 1 7 4 14. 59'
N89 ° 42' 26 "E 571. 63' n
U. — '------- • - - - -- - --
"� °_ HIGHWAY UDICATfD T — THY • Vj
NOTE: BEARINGS ARE "LL 89 55' 47" E 50.64' -- I '
• 45
C7 DEDICATED TO
EEW OUARTER l NEE - Q, ~ _s �0,44'39'�TR'ANGLE g ro iq THE PUBL I C
(RECORD BEARING). o �,� ....,,,.. `. ... : � . - 134n
I
L V 9 ? gi 4.4T .1..�•.At.01
N N 2.63 ACRES
N OTE • . THIS MAP IS A SUBDIVISION ( 114,388 SO. FT. )' y 30 ' W m =
OF LOTS I AND 2 OF THE a A; co st VOL ; 7 PA , 2070
CERTIFIED SURVEY MAP VOLUME 7,
PAGE 189 I. N 89 ° 42' 26 "E 50 . 63'
° $ �
0 2.53 ACRES , I 0 0
( 1/0, 263 SO. F7.) R On`0 y 66. 00'
to N 2. 50 AC. EXC, iW X33. N 89 0 57' 16'W
o ( 1081 963 SO. Fl. ) 47
39. ' 33. QO :......................
'
� .• :O 3 505. 63' p S00° 1 1'41'E
I N 89 ° 42' 26 "E 538.63 I 46.83
no APPROX. L OCAT I ON I' ' 1. 5 3 • Z
A :X '`�1 :a :C*) OF DRIVEWAY 3 EXISTING 66' WIDE
�� �g9. PRIVATE ROAD
EASEMENT.
19 8 LOT I I
: cn
lo 8.64 ACRES S 68 00912I1w
�
(376,447 S0. FT.) 222. 90'
8.59 AC. EXC. R.-W WEST LINE OF THE SE -NE
(374,227 SO. FT. )
TOTAL AREA OF ROAD DEDICATION
1.28 ACRES (55,592 SO. FT.
HOUSE 0 OFF I CE : D
NOTE: THE PARCELS SHOWN ON THIS MAP
l„ •rn ARE SUBJECT TO STATE, COUNTY AND
N 34 °3T 45 "E 0 LOCAL LAWS, RULES AND
172.35' a REGULATIONS.( I.E. WETLANDS, MINIMUM
I^ LOT SIZE, ACCESS TO PARCEL, ETC.).
Z BEFORE PURCHASING OR DEVELOPING ANY
° PARCEL, CONTACT THE ST. CROIX CO.
ZONING OFFICE AND THE APPROPRIATE
N 89 0 50' W E O N TOWN BOARD FOR ADVICE.
3 S. 93' OUTBUILDINGS v)
• E 114 CORNER OF
d SEC. 22. ( COUNTY
MONUMENT FOUND).
p N
Z
32 53_49' 13 1 9 '
N89 °50' 17 "E S89 °50' 17 "W 651.09 S89 °50' 17'W
EAST -WEST QUARTER L INE
w 114 N C ORNER OF UNPLATTE LANDS
SECTION 22. (COUNTY ................Q......
MONUMENT FOUND). °,��. j .. I`�►�
VA
O - SET I' X 24' IRON PIPE WEIGHING
1. 13LBS PER LINEAR FOOT. JAMES M o
WEBER
•
I' IRON PIPE FOUND. a, S P
SPRING VALLEY
WIS.
200 0 200 400 600« 9(o
GRAPHIC SCALE -FEET � ,
JAMES M 't q 04
97070 THIS INSTRUMENT DRAFTED BY JIM WEBER SHEET i OF 4 NELSEN - WEBER LAND SURVEYING
DATED � \ \RR�•
Vol. 12 Page 3462
=Department of Commerce
Buildings Division PRIVATE SEWAGE SYSTEM Count
` Safety and
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [[Privacy Law s.15.04 (1)(m)]. 315982
NELSON, 5 GARY ❑HI�DSON Town of: State Plan ID N°.:
CST BM Elev.; Insp. BM Elev.: BM Description: Parcel T No.:
20- 1057 -70 -100
TANK INFORM ION ELEVATION DATA A9800371
TYPE M UFACTURER CAPACITY STATION B HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATIO St/ Ht O let
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inl
it Intake
Septic NA Dt Ottom
Dosing NA Hader / Man.
Aeration NA ist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Dema
Model Number P
TDH lift friction System TDH Ft
m ead
Forcemain Length Dia. Dist. To wen
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length I No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIME I N
SETBACK
SYSTEM TO I P/ L LDG I WELL LAKE / S REAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe( x Hole ize x Hole Spacing Vent To Air Intake
Length Dia Length Dia. Spacing
SOIL COVER x Press re Systems Only xx Mound Or At -Gra Systems Only
Depth Over Depth ver xx Depth Of xx eded /Sodded xx Mulched
Bed /Trench Center Bed/ rench Edges Topsoil ❑ s E] No E] Yes E] No
COMMENTS: (Include code d' crepancies, persons present, etc.)
LOCATION: HUDSON 22. 9.19.217B,SE,NE 870 CLINT'S TRAIL — XT 9
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
SANITARY PERMIT APPLICATION Safety E and h v D ivi sio n
sconsin P.O. Box 7969
e 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.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3I5c S�
The information you provide may be used by other government agency programs ❑ Check it revision to previoGs'application
(Privacy Law, s. 15.04 (1) (m)]. Plan I.D. N
State a umbe r
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Prop y Owner Na Property Location
1/a 1 /a, 5 T N, R (or
n r M a il ing N umb e r
Property e s all ng Address Lot Q Block Number
City, M Zip Code Phone Number Subdivision Name or CSM Nu ber
( )
I1YP L IN : (check one) ❑ State Owned ❑ C it y . T ea rest Road
❑ Village
Public N 1 or 2 Family Dwelling - No_ of bedrooms Town OF 4L:i:o44 r
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
(D 7o
1 ❑ Apartment/ Condo
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 online A. Check box on line B, if applicable)
A) 1. g 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 IN Seepage Trench 22 ❑ In- Ground Pressure I 42 ❑ Pit Privy
13 r Seepage Pit X 43 ❑ Vault Privy
14 ❑ System -In -Fill
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
Re wired (sq. ft.) Prop ) (Gals/day /sq. ft.) (Min. /'nth) Elevation
7 Feet Feet
Capacity
V!!. T ANK
NFORMATION in gallon Total # of Manufacturer's Name Prefab. Con- , Fiber- Plastic Exper.
steel 9
Gallons Tanks Concrete lass App.
New Existin strutted
Tanksl Tanks
Septic Tan 11 ❑ ❑ ❑ ❑
Lift ump Tank /Siphon Chamber El 13 ❑ 13 13 1:1
VIII. RESPONSIBILITY STATEMENT
I, the, undersigned, assume responsibility for inst I ion of onsite sewage system shown on the attached plans.
Plum e ' Nam M(Pr'�t) y / Plumber' Si t a s) MP /MPRSW No.: Business Phone Number:
0 1
1
PI ber's Address (�� ee City, S Zip Cod
�C
IX. COUNTY /IDEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fe Includes Groundwater at I ssued Issuing Ag ure (No Stamps)
Approved E] Owner Given Initial urcharge Fee) I
Adverse Determination G /
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, PkaMw
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