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I �t i 11i k� t1 1 i- ly- vo`P -� r'' yv� 7— sisT , 15 s� N� X3, 3 1 L-OT �s�1 H V Aej PL VOP - 1 P440 T+ d Z7 r. ORIGINAL, ate$ pssocl ulbrleat 8, e Consultants Private gew9 • 46 a Rd 18 855 , 540 Wis p H �� ��i IJ � �� � s fi�l��� �, •, s 22*3 - 7 5 mG ( g ,� Bo I L-T PLOD P t A t**J y Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM v= Safety and Buildings Division Count ST . CROIX INSPECTION REPORT fj GENERAL INFORMATION (ATTACH TO PERMIT) U SanitarMd�rlit -Nn.: Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)], / bb �� {{ GARTH & JENNIFER [�>� Ilage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TdL &- : 1063- ' I i D TANK INFORMATION ELEVATION DATA A9800066 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic w l� c ✓ I too r7 Benchmar Dosing A t+ 9,1A ¢j Aeration Bldg. Sewer Holding Inlet S -1 3 1&- TANK SETBACK INFORMATION G d.I, 9 o TANK TO P/ L WELL BLDG. A;ake ROAD Dt Inlet Ic q d ''�, 0. 1 S t 15 NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System 99 PUMP/ SIPHON INFORMATION Final Grade C�,3g q Sr.cf� Manufacturer De nd Mode GPM TDH Lift Friction S ste Ft Loss Forcema Dia. Dist. To well SOIL ABSORPTION SYSTEM BED RLMW Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liqui Depth DIMEN 3 S� Z DIMENSION vMi Manufactur SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAISI LEA CHI INFORMATION TypeO / , '-- CHAMBER Moe Z ber: Sy OR UNIT -- DISTRIBUTION SYSTEM Header/ Manifold `a 1-1 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length s' Dia. �� Spacing � �3 1�r ] �� 5;�« 100 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over i Depth Over xx Aep Mulched Bed /Trench Center �� Bed /Trench E Topsoil - 0 es E] No ❑ es COMMENTS: (include code discrepancies, persons present, etc.) LOCATION: HUDSON 23.29.19,SW,SE 807 DAKOTA RIDGE t /. 'v^c.,.' 1 �c r t v _e, / I ca Gi z �. l t lG ,/ / o v - T7., y Iti C6 Plan revision required? ❑ Yes [g No Use other side for additional information. SBD -6710 (R.3/97) Date lnspector's ignature No. V SANITARY PERMIT APPLICATION 201 Saf Washngto i In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County s �, than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Number 347(077 The information you provide may be used by other government agency programs ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name Propert cation a E? t f Q•L� yd- ArtlneS 7 Stv 1/4 5� 1 /4, S 2 T '� `� , N, R 9 E (o Proper Owner's M ddres VQ Lot Number Block Number �I J x.7 j City, State Zip Code Phone Number Subdivision Name or CSM Number I VY /P�GGs.�o,�v ' s o(? (71S ) 92- S l esm 52g4 c[ vol. lo, P • Z4'3 S II. TYPE OF B ILD N : (check one) ❑ State Owned ❑ !t Nearest Road �? ❑ village f f V OsO rJ 13ADt OW ko Public 1 or 2 Family Dwelling - No. of bedrooms own OF III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) ! 1 ❑ Apartment/ Condo a3. aq. 19. R44 0 2o- to43 - so . co 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) 1New 2 E] Replacement 3, E] Replacementof 4 E] Reconnection of 5. E] Repair of an __System ________ System ______ _______ Tank Only______________ Existing System _________E System Existing 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 [fr5epage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 2-0. slDEly% �c - �. . r 43 E] Vault Privy 14 [] System -In -Fill T FGA_ ,3 X 5Ce 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 451 Re uired (sq. ft.) Pro sed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) V Elevaation S . Q I V . 50 Feet O •d Feet Capacity VII. TANK in Ca allons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App New Exist in structed Tanks Tanks epticTan O� lUtl� l N ❑ 1:1 11 1:1 1:1 Lift Pump Tank /Siphon Chamber tiu I ❑ 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 r: (Print) Plumber's Signature: (No Stamps) P /MPRSW No.: Business Phone Number: k'�x G�'� R0,3 ,eQT ZllM Ic4 2Z4B375 ?1S • 34 •�'��S Plumber's Address (Street, City, State, Zip Code): &5S d`N��G. �Z • 4 OPSd -0 S C/o G e IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing gent Signature (No Stamps) E] Approved E] Owner Given Initial I &A Surcharge fee) Adverse Determination 10 �VV X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6M (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, /kwdw I Ora Y I� I �x v5 l ,C2 --- __.. w d (3 70 .-0111 y W Ln Ph b d N m '. u, t Co � I � I Wisconsin Department or Industry, SOIL AND SITE EVALUATION REPORT p of 3 Labor and Human Relations Division of Safety & Builcfings in accord with ILHR 83.05, Wis. Adm. Code COUNTY s r. C�Po/'X Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. (720 - APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: j PROPERTY LOCATION ' 4 /QN /E U/tl v 12 1 /0,f S T GOVT. LOT S 1/4 S£ 1 /4,S �-3 T 2 9 ,N,R /9 E PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK ff SUBD. NAME OR CSM ft 71S 13*,94,-,, RIP . 3 e SA4 p &•vv /00 &_ CITY, STATE ZIP CODE PHONE NUM E ❑ B R CITY ILLA GE N NEAREST ROAD HvOso'o &C-71S. ,s"yoi& (7 3 8G- 3737 SO,J r3AULAND5 New Construction Use (Pf Residential I Number of bedrooms ( ) Addition to existing building ( ) Replacement ( ) Public or commercial d$stxibe Code derived dally flow (06 O gpd Recommended design loading rate bed, gpdM • F trench, gpolft Absorption area required P 5 - .ff bed, R 70 trench, ft Maximum design loading rate • 7 bed, gpdM ' $ trench, gpdM Recommended infiltration surface elevation(s) 5- P I- • 3 ft (as referred to site plan benchmark) Additional design I site consi rations sT/PO•A.) L �E't�t E.v BEN S Parent material ScS Flood plain elevation, it applicable IV lit S = Suitable for system c 0 UL O MOU ND �1 ��o U ESSURE B GS of srsT t-1N FILL 0 SNa T U U = Unsuitable for stem Lys ❑ CC'S SOIL DESCRIPTION REPORT O Depth Dominant Color Mottles Texture Structure Consistence Botxxky Roots GPD /tt Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed o- /o W 3/3 S/ �, 3k lwo/e i y IG /o VR S /(� Ground elev. Depth to limiting factor 7 e Remarks: Boring # �3 ,S� Z.at S /wr �/�IC GS 3 /O Y/E 5/t/ �S / �iP Gli� C S r . '7 ' • d Ground elev. ��9• Z -7— It. Depth to limiting factor 7 U Remarks: �• p F se Print R O (3E R T" u L13 R l c4 T Phone. 7 '�l 7 J ! 5 7- 3300 e 5 � t L R 17 14 V DSO-) W l . Sy O1 Co y' �y sr�v 2- 11P2— Dale: CST Number: K. 7,f . ' 44- r � s PROPERTYOWNER SOIL DESCRIPTION REPORT Pap -Zof PARCELI.D.! �/ 3 Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Boring # Horizon In Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed renfi 0-12- /o / S y s ,� s 5 z f .5 . G FW� o S/4 C5 Os Ground elev. Depth to Amiling factor 1 Remarks: / Boring # /C /Nor �� QS L G - /o 51G Gs D, s Ground elev. i .3 It. i Depth to Amilfng factor 77 L Remarks: Boring # l s . col Sl4 Ground elev. i r Depth to i limiting factor f Remarks: Boring # t Ground elev. It. Depth to smiling factor Remarks: r'+n eeonro nc rr\� PROPERTY OWNER V/�,ll V�/t?S SOIL DESCRIPTION REPORT PARCEL ID A a tfE 3 �� Structure Con Bourxtary Roots GPD /It Depth Dominant Color S Bed Boring #, Ngrizo in. Munsetl Qu. Sz. Cont Color Texture Gr. Sz. G t� Z f . • G /0 3 S/4 G O G�� 2 — Ground elev. �. b �—ft. Depth to AmilIng fac Remarks: Boring # /d y G s � i►vr S�k � �� Qs Z '� • S Ground elev. I Depth to Nmi6ng fac ff Remarks: c jr 2 S Boring # j O - /L. /4 3 s /4•+ s �� G S r' 13-- /o Sl4 Ground elev. �-�'� • � It. i Depth to limiting fac Remarks: Boring # f Ground elev. It. Depth to Timiling factor Remarks: Ern�� l Ln m� kA VIC Zb I � - � ►!6� ! fin v5 - 510 �� m r � r Zia - �� o � o z _ 61 u, Cl N r I w oc ,,, Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pag of 3 Labor and-Human Relations Division of Safety b Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 5r. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. A not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY DATE APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION PROPERTY OWNER: EGovr.LOT ATION �/QN U/}.vl7E/R 1/0 ST 1/4 $£ 1l4,S i3 T 2 9 ,N,R �9 E (o W � PROPE RTY OWNER':S MAILING ADDRESS K A SUED. NAME OR CSM # � IP , cS A4 p &•vv l v CITY, STATE ZIP CODE PHONE NUMBER AGE N NEAREST ROAD Hbigso &;IS. s"yo�� (7IS) 38 6- 3737 ,� 13AULANPS [ New Construction Use [ 'Residential /Number of bedrooms [ ] Addition to existing building [ [ Replacement [ ) Public or commercial describe Code derived daily flow �� gpd Recommended design loading rate bed, gpoltt • trench, gpddt Absorption area required 958 bed, 11 75 trench, 111 Maximum design loading rate • 7 bed, gpd/ft ' g trench, gpddt Recommended infiltration surface elevation(s) 5- P • 3 ft (as referred to site plan benchmark) Additional design/ site consi erations er1PdA.19jy F Parent material ✓C5• S 13 vdek �}R07' Flood plain elevation, if applicable ft Suitable for system C MOUND IN -G PRESSURE AT -GRADE SY _ ST 01-IN FILL HOLDING TANK Unsuitable for system CC'S O U [] S es Lam. U ❑ S CC'S [] U [Is SOIL DESCRIPTION REPORT — o Depth Dominant Color Mottles Texture Structure Barmy Roots GPD /ft Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 5Y k Irvte C s 3 F s Ground elev. it. 1 Depth to limiting tac��, Remarks Bo o - G /O IP 3�3 31 2-,t t S 4X- EMI tl7 GS 3 f S . ye e ::: /151G — �S D,s .7i. Ground V ' elev. ft. This to t sit IlimitingD Ve tionaf s ptf factor 7-� Remarks: CST Name: - Please Print R O QE R T U t-B R 1 C1 0 - Phone: a J CST! ZYPZ— Address: � ss 0 rN �. I L 1!217• 14 U VS-0^) Gc� (. ,S�Q/ (o y �y /� Signature: Date: CST Number: t , __ - 1� U17� - .r -/ ORIGINAL S L tie 1 - � � a w 1\ N \u W 0 - 4 0 � o b N y � Q 4 W w > r' w e W Z PROPERTY OWNER V4N� VOR5 age SOIL DESCRIPTION REPORT p 3 _ of PARCEL I.D. # Ld l 3 De Dominant Color Mottles Structure p t rucure Boring # Horizon De I Texture Consistence Bou�ary Roots GPD /ft In. Munse I Qu. Sz. Con, Color Gr. Sz. Sh. Bed Trench 0 ISI- Ground elev. ft. t Depth to limiting factor ` Remarks: Boring # 3 .w Silt A f of QS Z t • S 1 - 6.v i Ground ' elev. ft. ` Depth to ' limiting `• factor Remarks: Boring # 1 0A /O 3 - ---- -- S Z •�, S �S CS Z f S . Ground elev. ft. Depth to limiting '• } factor /6 P � i Remarks: Boring # :;M Ground elev. ft. Depth to limiting factor Remarks: con aq-10 ^CIA — n C AA Iff r �r-,D � D 7 &VY.W, y CAo SS SEC TioA,) ©IC TAP6�v�s / 7- �(' U,v %vsp�cT�o v �, 101^/ Iff out K 9 1, Trwc/u c 9y ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer !l.ya" (ID�.S I /3 7.5 �S �" v� . N /P �� Sao! Mailing Address ( 0 � Property Address O 1 � ��T l i VC 0 (Verification required from Planning Department for new construction) City /State Parcel Identification Number 02 LEGAL DESCRIPTION Property Location 54) '/4, '' /4, Sec. 23 , T _±_?' N -R /9 W, Town of Subdivision Lot # 3 Certified Survey Map # �-s� 5 / 7 + , Volume ' ''' , Page # l -3 j Warranty Deed # � S7 y 3 �� , Volume 30 Z , Page # 3 ? L Spec house ❑ yes Clno Lot lines identifiable Q'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, he ein, as set by 7 ent of Commerce and the Department of Natural Resources, State of Wisconsin. Certification sta ' tha your septic n maintained must be completed and returned to the St. Croix: County Zoning Office within 30 ys of a three ea x SIG ATURE OF APPLio& DATE O TIFICA I (w ertify tha 7byvi ts on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of th prope d cribe a ve of a warranty deed recorded in Register of Deeds Office. SIGN Of APPLI NT 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 VOL 130? PA0, 72 574341 STATE BAR OF WISCONSIN FORM 2 19% DOCUMENT No. WARRANTY DEED Ar VanderV and Karen VanderVorst, Karon E Penman, r OFFICE Husband and Wife R111T!R S conveys and warrants to ______ Co WI 57 ' R R fV 3111;1 34 Garth VanderVorst and MAR 0 5 1998 Jennifer VanderVorst Husband and Wife, _ 8:00 A M R U e later `�`� o..dA i the following described rea! est,lte in St Croix CourtX State of Wisconsin: RETURN TO 020 - 1063 -50 -100 Paces Identification Number (PIN): Part of SE 1/4 of SW 1/4 and Part of SW 1/4 of SE 1/4 of Section 23, Township 29 North, Range 19 West, St. Croix Cotmty, Wisconsin described as follows: Lot 3 of Certified Survey Map filed June 8, 1995 in Vol. 10, page 2935, Doc. No. 529911. TRA,gSFER S �FE This i8 homestead property. (is) (is not Exception to Warranties: Dated this day of Febraary 19 98 �� _0 (SEAL) — Kau&,1E —' (SEAL) Arnold VanderVorst Ka-ren E. VanderVorst (SEAL) (SEAL) AUTNEtJICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix Comity me thla authenticated this day of _ ,19 Psrsonagy came before day of Febr:ary ,19 9R the above named rr*if--' d VanderVorst and _ Karen VanderVorst TITLE: MEMBER STATE BAR (:F VISCONSIN to me kr*wi 10 person ��tewted the auu.onzed by Sta!s) foregokv and acknowted THIS INSTRUMENT WAS Dr: TED Oy � \ — O 1 ' r c - }-- ✓� � St . Cr z ,s�- ` ' �� ctt _ N9!!I "Petit -- Ts �— = S�yunty,fTJ+It. Z (Signatures may be nuthentica •_d or acknowledged. Both are not My Commsss+en Is permanen (H nql,. stale expirpfiQ� necessary.) date: 12/23/01 _ ;}') "hamas of persons mgrl.ing m a _ �p�dD 1 oa iypod or p-1.d b.tow Rs+ I"twa. $92 NTF 002tA WARRANTY DEED STATE BAR OF WISCONSIN NBICO, Inc., PO. Box 10209, Green Bay, WI 54307.0208 Form No. 2 -- 1996 6 i r JUN & 1995 k C ER T I E .I ED SURVEY MAP Located in the Southeast quarter of the Southwest quarter and the Southwest quarter of the Southeast quarter of Section 23, Township 29 North, Range 19 West, Town of Hudson, St.Croix County, Wisconsin. SE Corner Owner: \ i Section 23 Arnie VanderVorst flat of Fox Valley_ / � LOT I_ (SERNTSEN CAP) 752 Badlands Road LOT 2_ S 00' 19' 59 "W 615. 2' 7.44 I Hudson, Wi.54016 399.11' 216.41' 1 I 1 Bearings referenced to the South line of the m I I SE1 /4, assumed to be (� w I 6 1 N89 0 58 1 09 "W. N w w w <� In wl Outlot 1, Pka.t of_ o5O, 12 E. a m w 1 Fox _Valley_ sob 0 �, v N w I i I Uj 125.'3 ® _ rn I W IFa� w v` N Z) a 1 P':1 I- oi °Im IW LL O r ® I N O <t w LEGEND cv W I "' o m 3I ? W 2 Z — r 00 l rn v w y �- Section corner m W Y I 3 (V I o u- ,� D U to U) monument (as •° w ''. 0 m I oi CID noted) . ° a P' w v m • Iron monument �rn M v � I mw �zl % found. 0 1 X24" Iron pipe cn ® co � �' 4 I Z:i Uj weighing 1.68 lbs. � a o ¢_a per lin. foot set. _ _ — .� N I - z Uj S 1 65.23\ L 1 � 39.87' 214,57' SCALE IN FEET 1 150' I O DEDICATED TO THE ♦'UREI — I " = — N 00'01'51 "W 0 0 I S 00'01'51 0' 75' 150' 300' o 204.81' ; I N SHED o :� m I C OR. W � ; pp cpps W SHED N00° ? 1(P. .° y fa C G M w (NAIL) w � c W N N HARVEY G. — - HOUSE a • icy= JOHNSON w "' C\j ;I!nNl�!_ S - 1899 �I m r�No HUDSO al mQ'I w ti WIS f Q , S- IL LINE TABLE CD ,� ZI m , �yj < 9N ""'��JE �� 01 z LINE BEARING DISTANCE I N'1�� 1 S 88'21' 10 "W 19.94 2 N 00' 01 ' 51' "W 205.10 II N 00'22'26 "E 615.56' UNPLATTED_ _LANDS SW Corner Section 23 This instrument drafted by: J?.I. Sheet 1 of 3 4952339 ( Berntsen cap) Volunie 10 Page 2935