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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y:
Safety and Buildings Division Count
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTA TO MIT) Sanitary Permit No.:
Personal information you provice may be used for secondary p oses [PrivacA Law, s.15.04 (1)(m)), 315856
Permit Holder's Name: ❑ City ❑ Villa e Town of: State Plan ID No.:
FEICKERT, ROBERT HUDSON
CST BM Elev.:- Insp. BM Elev.: BM Descri ti Parcel Tax No.:
020- 1331 -00 -000
TANK INFORMATION ELEVATION DATA -1-3 ` ( z -
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer .
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Ventto
TANK TO P/ L WELL BLDG. Air intake ROAD Dt Inlet
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 Lift Friction System TDH Ft
Forcemain Length Dia. F Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D IMENSIONS DIMENSION
SETBACK
SYSTEM TO P/L 1 BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type O f CHAMBER Model Number.
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing I 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 1, xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Q Red/ Trench Edges 3�� � t._) I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 23.29.19,SW,NW 741 WALDROFF FARM ROAD
ILI
Plan revision required? E] Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
r � — and Buildings
Vi ITARY PERMIT APPLICATION 201E WashingtonnA a " °n
SAN sconsin 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
than 8 1/2 x 11 inches in size. c Ira i' x
• See reverse side for instructions for completing this application state sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Pro erty Owner Name Property Location
7' ,` c Slit 1/4,t1a1 1/4, S o?3 T,;? 9 r N, R /9 E ( o r W
Property Owner's Mailing Address Lot Number Block Number
a z .c 6 e ld
City, State Zip Code Phone Number Subdivision Name or CSM Number
5' -5 ( ) = veY ye�,� 's
ll. TYPE F BUILDING: (check one) ❑ State Owned ❑ ! t y Nearest Road
❑ Village
Public M 1 or 2 Family Dwelling No. of bedrooms Town OF �-✓ Gv�rl ,-a �" F
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
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 on line A. Check box on line B, if applicable)
A) 1. (10 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ 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 [,a Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 []Seepage Pit 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/da /sq. ft.) (Min. /inch) y �, s p Elevation
F --6 9, o Feet �Q2 q- Feet
Ca acct
VII. TANK in allons Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete st ucted steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank �Q d e 7`e v� ❑ ❑ ❑ 1:1 El
Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ Cl
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber Signature: (No Stamps) M /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
I.-f 2,1 se a rr f ml
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sa itary Permit Fee (Includes Groundwater ate Issued suing Age t Signatur (No a )
Approved ❑ Owner Given Initial ff ,Q //&10- Surcharge Fee)
Adverse Determination /�U � r &( 1 171Fd
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
Sw (Rf 119M DISTRIBUTION: Original to County. One copy To: Safety 6 Buildings Division, Owner, /Iwrber
•'c lee, YT SW y_ uJ se G 23 T f R
i
4
Q . 03
t ,
Wisconsin Department of Industry SOIL AND SITE EVALUATION
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 81/2 x 11 Inches In size. Plan must County
Include, but not limited to: vertical and horizontal reference point (BM), direction and l ✓ GAO/ X
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D. #
P FND r N G---
APPLICANT INFORMATION - Please print all Information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location q q ,
110 G 4N/� 499 Govt. Lot - IrW 1/4 AV 1/4,S 23 T 2 / ,N,R / E (or) @
Property Owner's Mailing Address SA S T Lot # Subd. Name or CSM#
337- M NNCsorh- Sr h �� j BIock#
/ �UER(r�PEE�V E5;7-q-TE7S
City Stale Zip Code Phone Number Nearest Road 1/&,/- /1
ST PAU L M INS S S 1O � � � 1 Z) 222 - 5 5 55 ❑ �fU ❑Village To� clMIC AEr4LY / �
3 -y 4WC+ , - f3y -s
UY ' New Construction Use: Residential / Number of bedrooms Addition to existing buildin
❑ Replacement ySo - ❑ Public or commercial - Describe 2 - i1 S 1 0 - - 1 G Y
Code derived daily flow !a gpd Recommended design loading rate • ? bed, gpd/f1 ' F trench, gpd/11
Absorption area required bed ft2 ZS trench, ft 2
— Maximum design loading rate bed, gpd/ft • — trench, gpd/ft
Recommended infiltration surface elevatton(s) _✓ 1 ' 3 ft (as referred to site plan benchmark)
Additional design /site con atlons
Parent material :5r--5 : ' o /� S�}rT�t'E /D�1�lS • Flood plain elevation, N applicable
S = Suitable for system Conventional M In -Grou d Pressure AT-Gr a System in Fill Holding Tank
U = Unsuitable for system Q S ❑ U t'_'1S ❑ U ®S ❑ U C'p's ❑ U ❑ u ❑ s
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPDflt2
In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench
Z
1 1 -1 6 /4 /e 313 S
Ground 3 /o v K1 5 o S , ? CS —.7 :.
elev.
/0 2. �s ft.
" 10 S/ S
Depth to
limiting
factor
> in. ;
Remarks:
Boring #
loy
3 -s al X3/3 �iL 2fSA,�t
Ground y /� /d Yl $' . �� .S d elev.
6(f(9 • fin. '
Depth to
limiting
factor
> -k —In. Remarks:
CST Name (Please Print) Signature Telephone No.
ROBERT 214 1 -B12i C (tT' 7/,5 3
Address Date CST Number
Associ AOU, 13 - / ff C-5 z Ve>
Private Sewage Consultants
655 O'Neil Rd.
Hudson, Wis. 54016
ORIGI
y
L _ _ ,
PROPERTY OWNER SOIL DESCRIPTION REPORT Z 3
Page of
PARCEL 1 .0.01 G / F aZ W -et
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench
.v:� -' z; •3
2' - 3 /0 Kle fshe cS'
Ground 7.5 /0 3 S, Z f.r �•.� �/ ' a S
eleyv� I/
Depth to
limiting
factor
! in.
Tr Remarks:
Boring #
o-p 100e 3 3 --- �O�y n►�{ -2e els / f c{ s
z -a /o!l y l>e - cS y ; .s
3 - /o ff lQ S o, J 0 0
Ground
elev.
�0 t1 05 ft.
Depth to
limiting
factor
din.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Boring # I 0 -/ /o yze 2/ z S/L �S/�ie ,1,.•, >G CS' /jc- Z 3
5 - �1-31 /o 3/ SL /f s�✓r� C 5 � � 5
- o /G YX 31 Si L /f she .im r'/ ' f5
Ground
eiev.
/0 a ft.
Depth to
limiting
factor
�— In. Remarks:
Boring #
Ground
elev.
ft.
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 l_T O 4 <"r-
Mailing Address aa6' L'f, yt-o -��� �/. P f' - (�4.t, 5 $ I I �►'
Property Address 7Y/
(Verification required from Planning Department for new construction) 61 W
City /State tt LJA Se4r-� Parcel Identification Number d a a —
LEGAL DESCRIPTION
Property Location J W %a, -�( W ' /a, Sec. Z 3 , T Z-9 N -R Town of 4910 /4LA95
Subdivision % rO R-j FS j G t , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # _5�9 b (a6 Q , Volume l , Page # ! 62
Spec house ❑ yes 0 Lot lines identifiable P-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, j ourneyman 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.
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
the thre ear exp Lbimdate.
/! 4
SIGNATURE OF APP ANT DATE
OWNER 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(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
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
VOL 1.330PAu103
580609 STATE BAR OF WISCONSIN FORM 2 — 1982
Q�
WARRANTY DEED
DOCUMENT NO.
REGISI`EF�'S Q'F'ICE
Richard W. LaCasse and Grace J. LaCasse, ST. CROlX WI
husband and wife, RNWO for flovord
JUN U 9 1998
i t
conveys and warrants to Robert R. Feiekert, a single 8:00 A m
person,
Re or of pgedo
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in St. Croix County,
State of Wisconsin: `� " e,2,
1,.
PARCEL IDENTIFICATION NUMBER
Lot 10, Evergreen Estates in the Town of Hudson, St. Croix County, Wisconsin.
TRANSFER
ofd
is not
This homestead property.
(is not)
Exception to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of June A.D. 19 98
(SEAL) C'� SEAL)
Richard W. LaCasse Grace J. LaCasse
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix County.
authenticated this day of
.00 1%1 11111111 1. ,
AEiW_11 � day of
� Fr IhF,_,,�.i,, � Personally came before me this
.TtmP 19 C)8 the above named
�' • t " . 2 -' Richard W. LaCasse and Grace J.
• - .* _ LaCasse, husband and wife,
TITLE: MEMBER STATE BAR OF WISCO41N. _
(If not, P IG
authorized by §706.06, Wis. Stats.) to me known to be the person who executed the foregoing
OF I VUISC ``�� in rument arC ac dge .t �
he same.
THIS INSTRUMENT WAS DRAFTED BY _ CX_A_ t _
� Attorney Krishna Ogland C Lr
Hudson, WI 54016 J
Notary Public, U County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My Comm' 'o is permanent. (If not, state expiration date:
necessary.) �-;Lc ( 19 J
• Names of persons signing in any capacity should be typed or printed below their signatures
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc
WARRANTY DEED Form No. 2 — 1982 Milwaukee, Wis.
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