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020-1099-50-000
• ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner 1)6e )"o Address ©6 �6�27(1 of City /State /><U�'S�,`,.,� rq Legal Description: `— Lot 8 Block — Subdivision/£g" �rt,E,e fr ,&L,0 '/. 5w '/,2c , Sec.,33 , TAN -RZW, Town of _�r'�sazJ PIN # ago — /oP9 —S'a SEPTIC TANK -- DOSE CHAMBER — HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC/ e/ Setback from: House � Well P/L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fires intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM• Type of system: ��n Width /2 Length 7 2 Number of Trenches Setback from: House i Well 7 /SD p/L — Vent to fresh air intake -;- /,so ' ELEVATIONS Description of benchmark �o� of �r/.��r �- sue " rc 0,41 TRH Elevation 16w ' Description of alternate benchmark Elevation Building Sewer ST/H-T Inlet ST Outlet 2y. GY PC Inlet PC Bottom Header/Manifold p3. 6� Top of ST/PC Manhole Cover 9�' o� Distribution Lines () �3 . S1' () () f/�d 70 Lo w,c! Bottom of System () J'2 7FI Final Grade ( ) 96•� ( ) ( ) hcru �*/ Gvar.�� why. Date of installation /a //f /9d' Permit nu ber 3/ Sig / State plan number �--- Plumber's signature License number 2 a / d' 0 Date /a4 1 1 Af Inspector l rl Es (i r c; o e— Complctc plot plan r I 1 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. PLAN VIEW r b ,VL'Cx 6I P� ZLy 7 �v '4 r INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT S 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)]. 315981 P��q�[tEiQ�der�?(TA�D �HUDSONage Town of: State Plan ID No.: CST BM Elev.: i Insp. BM Elev.: BM Description: Parcel Tax No.: ►oU r '� �.µ a� (dfl;►�cz 020- 1339 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e l Benc Dosing Aeratio !dg. 5 wer Holding St /}Wlnlet TANK SETBACK INFORMATION fi �, St /�E Outlet 9. T �' ROAD Dt Inlet TANK TO P/L WELL BLDG. Air Intake Sept' /Oa Q NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe /0 _q 13 , Holdin Bot. System PUMP/ SIPHON INFORMATION Final Grade J/r b�•� Manufacturer and . b� Model Numb '` GPM TD Lift Fri Syestem TDH Ft Forcemain Length Dia. FFii Dist. To Well SO BSORPTION SYSTEM BE RENCH Width f Lengt ° No. Of Trenches PIT No a Dia. Liquid Depth I MEN I N DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM L G Manufacturer: INFORMATION Q W , A 64 I r CHAMBER Model Number: � I (� (pb ---- OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake r Length Dia Length — 70 Dia. Spacing �C4 ' 21" 1 j 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.) 3� 4 LOCATION: HUDSON 33.29.19,SW,SE 601 SUMMERFIELD CIRCLE Su b t - °b a , ( MAPO,,-� Scar - , I g 1_'e.-e'�Zj Cd w, t +. f' u1r v clita't iN_&j t, o j • Plan revision recfuired? ❑ Yes [(No ro Use other side for additional information. j i "toed SBD -6710 (R.3/97) Date Inspect 's Si nature Ce Vi scons i n SANITARY PERMIT APPLICATION 201 ashn 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 8112 x 11 inches in size. e • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency pro rams Check if revision t prev4us application [Privacy Law, s. 15.04 (1) (m)]. &V / (�! It�✓1mpN e /_/ /' �r+� State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location ,C GT� "S? fW /alE 1/4,S 33 T_�F ,N,R E(orep Property Owner's Mailin Add ess Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or i�mM fu.r�.ir�rr� fi' cl rest Road II. PE BUILDING: (check one) E] State Owned C] Cit Nea Public 1 or 2 Famil Dwellin - No. of bedrooms _V__ D Town OF ly�s Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 [] Apartment /Condo 33 a� �9• /�0� .zo --- 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. V1 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 0 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit f2�X �Y r 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) Elevation 1?4 9 K AIF/ 7 7 9-2.7,' Feet 5K p Feet Capacity VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper. INFORMATION 9 Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank orJ�T nk 2Dd Gt/ S ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber — I ❑ I ❑ I ❑ ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the site sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps U MPRSW No.: Business Phone Number: AUr 6 f- FlZTt a Z it fd 7 -3 S, Plumb 's Address (Street, Ot , State, Zi bo de): /30 o6t�rAR Val _t IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) []Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: �i><s 1 ,eve,ev,E�0 To' L s u/c /L j-,1- ELI /= ,E r//� 7�v�/ �-�/ Ta �� "Cdt// =!Z �I�. 4d�2 ,�oRcic �if•�/� u�ff�� c,�vs's�'�+v� r- t/.��".���`v�t}i', f��. ,voT Gocr¢T,�p It.��'fKE o L - ,CrN. cG i9 cf� SBD -8398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety 8luddings Division. Owner, Plumber Al SANITARY PERMIT APPLICATION Sa fety 1 W shingtonA Ave. %sconsin P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison Wl 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • 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 if leGision o�ouslapplication [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION ---= Property Owner Name Property Location �. C $T!9lif W /4 1/4, S j'3 T Z , N, R E (or� Property Owner's Mailing Address aa __ Lot Number Block Number City, State Zip Code La7v hone Number Subdivision Name o�#enrber Gt1 12 ' a 0 L II. TYPE OF B L ING: (check one) ❑ State Owned ❑ Cit y Nearest Road ❑ Village /�,,��, Public 1 or 2 Family Dwelling -No. of bedrooms Town OF f' III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) D D / /,24n 1 E] Apartment/ Condo T 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 1 6 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 [21 Seepage Trench 22 ❑ In- Ground Pressure, i 42 ❑ Pit Privy 13 ❑ 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 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation P' 3,y Feet Ca aclt , f Feet VII. TANK in Capacity Total # of Prefab. site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Se tic Tan an -- .747 (,�/ ❑ 1:1 El 1:1 1:1 Lift Pump Tank /Siphon Chamber EJ I ❑ ❑ ❑ 1 ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation o he onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb 's Signan�:(No S ps) * P/MPRSW No.: Business Phone Number: AAt4l* 9. .Z.a:. 10 657 u ber's Addre s (Street, City, State ip Code): o ,e" �.3 IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Iss ng nt i n ture (No Stamps) Approved E] Owner Given Initial 0 /0 /rcharge Fee) Adverse Deter mination (/�/ (, // X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: S866998 (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety III Buildings Division, Owner, Plumber DAVE FME f Y PL UMOM LlCensed Perk Totter & Plo tt df Fogerty Heights #Nd ROBERTS. WISCONSIN $023 Phone 749-36 rs E�r ;1 1 / 38 1- 1 r4 6 8/7lff J a r - UM AAJF/ 01A arv. I p �OE3 Q j v �' aF Nye- m tw a*"' T,PFX �. p3 y , /3( i .r¢33�il�E laa o ECEY. 40 X = 13occ ARE& 4c07 �oR✓v- Gc�,CoQ 2 ' O r cvrz 1 7 Q / 1 .2,w cry- sT r%Y - ?j- �� �-�'✓ t�Td.�c,� J r�ccauWl'�� 9�oR� A _ _ Ucensed Park Testor & Plurnber 03233 0253 arty Hei. %hts Road ®BE I'S, WISCONSIN 54023 Phone 749 -3656 1 « . y r. ' r 3 i � •' i Wisconsin 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 Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 9a Parcel I. D. # ->. 0 �o - -570 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 Govt. LotL� 1/4 f� 1/4,S T ,N,R E W Property Owner' s Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road z New Construction Use: Residential !Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow A r e gpd Recommended design loading rate bed, gpd /ft trench, gpd /ft Absorption area required _,_ bed, ft trench, ft Maximum design loading rate bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevation(s) AF 4E�� ft (as referred to site plan benchmark) Additional design /site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S❑ U ;?Is ❑ U VS ❑ U ZS ❑ U ❑ S U [JS )?TU 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 Ground elev. ft. Depth to limiting factor in. Remarks: Boring # o � .; s , Ground elev. ft. ' Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. "'r -2 7 `r- �6 S Address Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground elev. ft. Depth to limiting factor in. Remarks: Boring # ........................... .......................... ........................... 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 # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) I Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division Safety and Buildings Page —L of Bureau'of Integrated Services - -i rdance with s. IWR8U9, Wis. Adm. Code Attacti complete site plan on pape o I than 8 2 x 11 it h4s" b Plan mus GPunty include, but not limited to: v,e onz a poil�t`$ 'directio and' percent slope, scale or dimensi rjbrth arrr ion an u 'f}c�e to n" t �t td; Parol I.D. # APPLICANT INFORMA Ol , Pi~ease rintW&O #0 Rl3vie y Date S cRofX _ Q Personal information you provide maybe ju pd for sec oses (Pri i iN, s. 15.04 1 11 011 J V 12 Ki r gpfpy- lSdfaon Property Owner ;y f FG7 _ Govt. Lot 1 /4 S, 1 /4,S . T ,N,R E (or) w Property Owner's Mailing Address LCA 4 obk Subd. Name or 69M# H +..i.. ...L... City State Zip Code Phone Number ❑ City El Village [Z Town Nearest Road Wx- ( ,Z New Construction Use: 0 Residential/ Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow - gpd Recommended design loading rate ._ bed, gpd /f? trench, gpd /ft Absorption area required bed, ft SO trench, ft Maximum design loading rate bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevation(s) 9.Z. y r-Sa E NOTE' A 2- ft (as referred to site plan benchmark) Additional design /site considerations AlY)IVE Parent material Flood plain elevation, if applicable 4&2 ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S❑ U S❑ U VS ❑ U U s ❑ U F ❑ S Q U ❑ S O 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 -t S m ` 2- o- - 1 Ground _ _ S &A 10 L 1QS elev. ft. M - 4 4 VISE R Depth to 7; - L ,11 AAL _ limiting f to Remarks: Boring # 1 -z s �• _ ? p Ground elev. ,9f _-1 Depth to limiting actor (� j Lein. Remarks: I-O j Z CST Name (Please Print) Signature Telephone No. ,4-vr �a Ls'L Address Date CST Number PROPERTY OWNER Aee 1¢ SOIL DESCRIPTION REPORT Page PARCEL I.D.# D20 109' — 5 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench .8 oval— Ground elev. f�.Lff. Depth to limiting factor Remarks: Boring # I ' I Ground elev. n , 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 # I d E bstiz t Ground elev. ft. Depth to T limiting M E � jt' i;7 �- A. - W factor in. Remarks: •• — ,E tv,2GL S Iz Boring # .......................... S Ld '-gyp a E d ^ P1,K / i Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) X V DAVE FOQ t'Y PL.UOI�LsINt'i Licensed Perk Tester & Plumber #3233 #3259 Follow Heights Road ROdEI I 54023 k 149 - I I �y 7, I Sr -�kFv uT -> C=P -��' f 1�7, v v 4 = /' des ' O -OWE y/ SL -v aAk r �_� IIAXWWle IWO zrn�G Cif q Wisconsin Department of Industry SOIL AND SITE EVALUATION 1 3 Lpbor and Human Relations _ Page of Division of Safety and Buildings I gr�Jc an9e s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less tha / 11 incha6in size. ' plan ust County include, but not limited to: vertical and horizon I rencet�} directi .£ @ percent slope, scale or dimensions, north arr d location an� distance to n e t road. Parcel I.D. # APPLICANT INFORMATION - Plea a int all W~ion. r " Reviewed by Date Personal information you provide may be used for sec aA purpose w s. t ( (m)). Property Owner operty Location Dick Stout \2, Govt. Lot SW 1/4 Se 1/4,S 33 T 29 N.R 1 9 E (or) Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 1 353 Awatukee Trail 8 = 57 iri I) co/. 2 eq Y 3 r City State Zip Code Phone Number ❑ City ❑ Village ® Town Neare Hudson Wi 154016 (715)549 -6731 Hudson High Ridcre ❑ New Construction Use: ® Residential / Number of bedrooms 3 — 4 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 600 gpd Recommended design loading rate _. 7 bed, gpd /ft _,8_ — trench, gpd /ft Absorption area required 8 58 bed, If 2 750 trench, ft 2 Maximum design loading rate • 7 bed, gpd /f 8- trench, gpd /ft Recommended infiltration surface elevation(s) r imary 9 2 2 0 a It 9 S 4 0 ft (as referred to site plan benchmark) Additional design /site considerations Parent material Glacial Deposit Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [ S ❑ U [AS El U R ] S ❑ U OS ❑ U ❑ S R I U ❑ S q U I SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /11 � 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 1 0 -14 10yr3/2 none sl 1mabk mvfr cs 1m .4�.5 2 14 -30 7.5yr5/6 none HIS osg ml cs if .7'.8 Ground elev. 9 Depth to limiting factor 3 0 __in. Remarks: Boring # 2 2 10 -28 7.5 r5/6 none ms osq ml cs if .7 .8 i Ground elev. 9 5--a0t. Depth to i limiting factor 2 8____ Remarks: CST Name (Please Print) Signature , / r Telephone No. / Address Date CST Number l ? r s Al 6L-L L.J s S ZZ 9 �2� PROPERTY_OWNER Page Dick Stout SOIL DESCRIPTION REPORT Pa e 2 of 3 PARCELID1 Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 ;' 1 0-14 10yr3/2 none L 2mabk fr cs 1m .4 -.5 2 14-36 10yr3/3 none sl 1mabk Tivfr cs if .4 -.5 Ground 3 36-80 7.5yr5/6 none ms osg U 1 cs -- .7 '.8 elev. 9 Depth to limiting ; factor 8 Remarks: Boring # 2 14-40 10yr3/3 none sl 1mabk mvfr cs if .4 ;,5 3 40-981 7.5yr5/6 none ms osg ml cs -- .7 , .8 Ground elev. 9 5 0t. ; Depth to limiting factor 9 8 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 # 1 0 -1 0 1 0 r3 2 none L 2mabk f r cs 1 m .4 .5 5 2 10 -28 10yr3/3 none sl 1mabk vfr cs 1f .4 .5 3 28 -96 7.5yr5/6 none ms osg 1 cs -- .7 .8 Ground elev. 9 - T - . 6 O ft. Depth to limiting factor 9-6_in. Remarks: Boring # ....................... Ground elev. ft. Depth to limiting factor 'n. Remarks: SBDW -8330 (R. 08/95) A/ a 4,g rh ZfZ el d - _ I ► 1 2 /r�c'�1 ttJ '�"� tai ,0 ✓ [3�� u.aedf'asT 9F<, I I I I I I ) I o �3 Iv �6 0 a V 0 0 a i s' va: t I I'd- L ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 4"f v SAO �L�Icio- .s OZZ Property Address (Verification required from Pla ng a artment for new construction) City /State A- fUZo// uzr- .Ny /g Parcel Identification Number &E? = LEGAL DESCRIPTION Property Location Sw '/4, 5� E '/,, Sec. 33 , T -R f _ W, Town of Subdivision ��-'''' ° "' "'_ ��1�?t ^,� �1C,�L , Lot # Certified Survey Map # , Volume 2- , Page # - -- . Warranty Deed # .5'71 S' 1 , Volume t, age Spec house ❑ yes [1 no Lot lines Identifiable V1 yes ❑ no SYSTEM MAI 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 pro P � g P a owner a grees to submit to St. Croix Zoning De artment 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. 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 d th a ear ira SIGNATURE OF APPLICANT 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 des ' d a ve, by virtue of a warranty4eed recorded in Register of Deeds Office. 6 1 4a�_T_ g /�"t S GNATURE 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 ♦�`= ^;,� • aT . .; .4 ° tr :.tt tii. " a :�;. ?s , ` rA- ° +.+a �".' , .. < .,Y4k.... : Document Numb Document 75de REGISTERS OFF,';' ST CROIX CTY.. WI wda a rt,*er APR 21 1991 at 1:30 PAA - i',ocj .- A fwplt�r W Dw'b Recording Are+ Nam* wA Return Addrm ei't A a-.r d Y44t 135 AWcf�Qe 7 - /? . t � .. cdI sva g. o va- 1699 -so Pasta Idaz6fica6m Nmmber pram TRANSFER "THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" T s iotoemation mot be compteted by erbmiaet: dacmnay dde. none.& nmsn addnm. and PLN fif-fd -4 0&cr fio—wd a 1"ch —the gig So kpd dettrW as ,gay be placed on #At A peso of &c &--a or may be placed on addidamt Pale+ 4 94 c doemnart moor: Use of dcir toner page a" one page m your docmnart and =2,40 ro & monffnr c wErcauin SAaeau. 39-517 WDA I!% "A ~. t f t, 4;,, �1 ]ix xX.1 .'.. V2A - its A,` " - .. - F r � ,� fit` X b * .. n. _•*, r. �T �.!t '-!c. � : .� t � 4 �. � +•� , °'� #rM� ,. '.'�'?+ • `, i:I' ., _ ; .1 .:: ,_+ �` .'.� ...[ •'` 3'. tea° v � 3� - •.# a. �� • ;+ t?OGUMENT N". A�ANTY DEED *pus SrP.`:E Rrs[nv[o rcR R[GOROING o.iA � ,TATS BAR OF WISCONSIN FORM 2 -1982 II i! I ELIZABETH R HO .. ..... . -- ...... ...... - -- - - .. . . .. ...... . .• - ...._......__.._.. ..............._........._.__. ii i cvs:•eys and warrants to . • .......... .. ..... ............. ....._ - - j IR14'f6t ,RU_..0.t__$TOM . ............................... I - - - - - -- - - - - - -- - --- •--- - - - - -- - - -- --------------------------------- - - - - - -- - -- -- 1 in consideration. nf -- $14A,00:0.00. _._.... - . ..... ...... .. .. ..... _.. Pi URN TO .; I E Richard 0. Stout . ...... ...... . .. ................................. ...... - - - -• .._............._..— ... - -- -- 1353 Awatukee Trail t the following described real estate in ------ .- St.._.. Cro- ix .................County, R- Hudson, WI 54016 - State of Wisconsin: Tax Parcel N _1099 :7 5Q.. - _ The following described land lying in Section 33, i T29h, R19W, St. Croix County, Wisconsin: That part of the SWk of the SEk described as Lot 2 of Certified Survey Map dated July 20, 1977, recorded in Volume 1 of CSMs, Page 448, of • the Register of Deeds office for St. Croix County, Wisconsin. I I I I I �` I I - j! This .._....is ....... ......... homestead property. � (is) (is not) Exception to warranties: } 21st �t 1Da :� the ... .... -• - -- .. - -- - -- day of ......... _ Apr t9 97 ; I __.. - - (SEAL) " SEAL) w Eliz beth K. Holmes .. -•-- ---.... . - .... _,SEAL) -- _ (SEAL) AUTHENTICATION ACKNOWLEDGMENT i I S*uaa+re(s) -----•• - -- --- - --- -- --- •----- -- --•- -- --------------- STATE OF WISCONSIN — _---- --------- ---- ST CROIX as aadbmticated this -------- day of ........................... 19...... Personally came before me this _ .�.1_St_. day of II , A rii ......... -- 19.9 the above namnl ------•-••---- -- •-- -- •- ---- •------- • -• - -- --- -- -- - --- Elizabeth K. Holmes - - _.... -- - - -- -- ---- •--- - - --.. -- TfrLE: MEMBER STATE BAR OF WISCONSIN et3aica (If not, ................ - ----- --- --_---- -- -----• -----...--••---- - authorized by 1 ?06.06, Wis. Stats Notary Pnbft - -- •--•-•------ � i to me known to be the i n executed the foregoi instrument aTi�kRdwltr�Q°!Mme. THIS INSTRUMENT WAS DRAFTED BY �/� ' William J. Gilbert, Atty. -- ..... ........ 2(T6SeconB St TFTUdsn7[ - Wi --- 54 6 ...... ( ---- 3-8.1-nl.609-- ----------------- -- ------------- -- Notary Public . ....St . Croix _. -- _.County, Wis. (Sirsatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration are sot necessary.) - date: _L.'�.... N e1 Wrwae P"ItnrnQ in any c.pw.ity ■h—ld be typed or printed below th r iRnnt�.�rca, � N AXP ATI DEED STAT(: 13A R OF WISCCNSIIY WrsGOnS- Lngal plank Co., I . FORM No. 2— 17A2 Milwaukee. Witr,ons�n • - f - t �+ i '}•t f ° :119'16" E 34.19' . 1 74'31'22" E 50.17' N 2317'57" E 43.72' I N 15'23'54" IE 56.00' N 4410'53" E 15.38' I I C.S. AI VOL. ,2; PG. 4413 ----------------------- - - - - -- I 80.89 (S89'56'19'W 1280.91) FENCELIldE IS OF LO 320.68 320.68 LOT 7 2.476 ACRES } w H.W.L. = 908.0 107,868 SQ. FT LOT 6 •� ,�, oH .W.L. - 923. 2.511 ACRES - • � > 109,382 SQ. FT . _R8 • •-�i /Q� to r 0 o U0 z •� � LOT -4 0 >u'° 6 C9 . 4, 1p ILI If NTO j' c: iT /vim �✓ ' , , � ' \,p O o O to o LOT 5 ) 2.047 ACRES 69,164 SQ. FT o 'J Q� "`� / LO �1= r n • • 2.098 CRES ri 91,366 `5Q. FT p w USGS ! F 1.80 I \— NET 13UILDA13LE ACRES ELEV MARK 1►M 1929 . . . . . . . . . v .�Mf 33'33' L . . . . . . '324.28 ,n ` RJZ o�, 'ilo 0 °a. u' l 79 2 VARIABLE R/W N 89'5 19" E 64.6.4-9' •• VARIABLE R/W - IF.IIG.W RIDGE DRI VE — LOT 2 LOT I; '` � 1 -f � • , {{ �.� • — ` "' � 'Pr`ifi�f'!E A , •.. 1, e / 1; Tier; r., �r,'7.;►r, .,., �� % ' :( I Y:�. . 1.'II:F J ' , I •1 i �.1 ) 1. 4' r .1i, •�7:'.�tl ;1; .l � �'1 •i' 1 ... • 1•. :�il ., •. Wisconsinpepartment of Industry, PRIVATE SEWAGE SYSTEM County: 0abor and Human Relations INSPECTION REPORT ST, CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 2#4331 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: S9MUT, RICHARD HUDSON Parcel Tax No.: CST BM Elev.: Insp. BM Elev.: BM Description: 0211-11699 w000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION B HI FS ELEV. Septic c%, C,• r7 ~Q ¢ riIJUs% Benchmark Dosing Aerati Bldg. Sewer St Ht Inlet Holding ' TASK SETBACK INFORMATION St / Ht Outlet 761 TANKTO P/L WELL BLDG. vent to ROAD Dt Inlet' Air Intake Septic NA Dt Bottom y 3s Dosing NA Header/Man. G Aeration NA Dist. Pipe y6~' y Q -C-/ /o.~-z " Holdin ::Bot. System PUMP/ SIPHON INFORMATION Final Grade ` Sb ber M kForcemai r Demand Fricti Syste ength Dia. H Dist. To well SOILABSORPTION SYSTEM BED/TRENCH Ewidth Length No. Of Trenches No. Of Pits Inside Dia. Liquid Depth N ~ DIMENSIONS DIME anufacturer: TEM TOP / L BLDG WELL LAKE /STREAM HI SETBACK CH ER Model Number: INFORMATION TypeO D UNIT System: DISTRIBUTION SYSTEM Air Intake Header / Manifold Distribution Pipe(s) ole Size x H Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At- rade System 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 33.?9.1 .400B,SW,SE 593 HIGHRID RD L9T 2 ~ r lee Plan revision required? Yes ❑ No Use other side for additional information. Date Inspector's Signature Cert. No. SBD-6710 (R 05191) I ADDITIONAL COMMENTS AND SKETCH t 3 SANITARY PERMIT NUMBER: Safety and Buildings Division --~■p SANITARY PERMIT APPLICATION Bureau of Building Water Systems ri•~L■7~'1 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Num r OW3 9 1 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)]. S93 State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ki-v'J TosvT G) 1/4 1/4, 5g? T,2q , N, R/ E (or Property Owner's Mailing Address Lot Number Block Number 3 4,- e I 2E City, State ZjpC dePhone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned ❑ city rest Road ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Towwn OF c ~r III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number (s) 33. V-l9. 40046 Dvo- 14mot- 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. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. [Reconnection of 5_ ❑ Repair of an _____System ________System________ _ Tank Only______________ Existing System _________E----gSystem 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 5J 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/day/sq. ft.) (Min./inch) Elevation ~a4 ! I ;z 5 11-3d < f d-1,1 Feet Feet VII. TANK Capacity site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION Gallons Tanks Concrete glass APP. New Existing strutted Tanks Tanks Septic Tank or Holding Tank lGJ'rQ ln,G~c✓~ST',t!Y•✓ El 1:1 ❑ 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ Ej ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): D D O e-21 Al Zd IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved rry itaPermit Fee (IndudesGroundwater ate Issue Issuing Agent Signature (No Stamps Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: original to County, One copy To: Safety & Buildings Division, Owner, Plumber i 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 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, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. 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 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 practiceswhich can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. $~el e i.- r i r 257 y 6sa ~V 1 3 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and.. Human Relations Page I_ of Divirion of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code County Attach complete site plan on paper not less than 2 $1 inches' in%iz Plan must ~ include, but not limited to: vertical and horizo fAe]ceTtce point (BM)„direNion and Croix percent slope, scale or dimensions, north arr IocatiQlAiar.4istanL~e fo~kearest road. Parcel I.D. # APPLICANT INFORMATION - Pf print all i Tnfor n.~ r ' Reviewed by Date h. . Personal information you provide may be used f -jrjndar set a aww,, s. I 4 1) (m)). Property Owner ..q.rd`Y Rroperty Location Beth Holmes V - i~ k\ rGOVt. Lot SW 1/aSE va,s 33 T 29 N,R 19 f (or) w Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 603 Hyw 35 j 2 CSM City State Zip Code Phone Number Nearest Road Hudson Wi 540161( 1 Hudson ❑ City ❑ village ® Town Hi h Ridge Road New Construction Use: ® Residential / Number of bedrooms 6 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow q 0 R gpd Recommended design loading rate • 7 bed, gpd/ft2 • 8 trench, gpd/ft2 Absorption area required 1286 bed, ft2 1 12 5 trench, ft 2 Maximum design loading rate .7 bed, gpd/ft2 • 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 94.7 ft (as referred to site plan benchmark) Additional design/site considerations Parent material Pilot silt loam glacial deposit Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [3 s0 U Lei S❑ U ® S El U ®S ❑ U ❑ S nu ❑ S nu SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench -L 1 none L 2mabk mfr cs 2m 5 .6 2 14-48 10yr3/ none sil mfi cw if .5 -.6 Ground 3 48-90 10yr3/4 none ms Osg ml cw .7 ; . 8 elev. 98.7 ft. Depth to limiting ; factor 9 0 in. Remarks: Boring # 1 0-1 10 r2 1 none sil 2mabk mfr cs 2m .5 .6 2 2 16-48 10yr3/4 none sil 2mbk mfi cw if .5. .6 3 48-91 10yr4/ none ms osg mi cw .7. .8 Ground elev. 9 8 . 2 ft. Depth to limiting factor 91 in. Remarks: CST Name (Please Print) Signature Telephone No. i"t 5C Z4 At a Arne Address Date CST Number / U D s o~ y41~ Y 9 aROPRTV OWNER 13eth Holm SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D.# 3oring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots QPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 - none sil 2mabk mfr Cs 2m .5 '.6 2 14-4 10yr3/4 none sil 2mbk mfi Cw 1f .5 '.6 around 3 8-810yr4/ none ms osg m1 Cw .7 ; . 8 ;lev. 9 )epth to imiting actor 89 in. Remarks: 3oring # 1 -18 10 r2/1 none sil 2mabk mfr Cs 2m .5 '.6 4 2 8-4 10yr3/4 none sil 2mbk mfi Cw 1f .5 ..6 3 8-9 10yr4/6 none ms os m1 Cw .7 -.8 around elev. 99.2 ft. )epth to imiting actor 96 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 # 1 -1 4 10 r2/1 none sil 2mabk mfr Cs 2m .5 .6 5 2 14-4 10yr3/4 none _ sil 2mbk mfi Cw 1f .5 .6 3 2-8 10yr4/6 none ms osg m1 Cw .7 ..8 Ground elev. 99..7 ft. Depth to limiting factor $g_in. Remarks: 3oring # around .elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) S'ca ~ c 1 ' = 4~D I~ ~3rl1 / "-T6yNic~ 10t6a d,>,'Tfi 1.-tA GeT~csernr~`'Gnrd~r ~~tU io, 0 a2 S.c t•. { ~1 i©, inC L,J '~'1 n 7'! i.L / ~ eT ~ p3-,r/~ Y ~ e v /64~S/ ~ a z 67~. Al Q/ o r-~h ~O t ~ L ~ ~t s .e ~r bey (G ' Ga~~me C7 ~ ~ ~ i` N ~ C1 ro 2 FILED a e. `r ° n ° ~ ~ ,v r~ 6 o :4 g Y < - APR 2 2 1997 ► s° ► p $ T r o KATHLEEN H. W"H 3 m g Register of Deeds ~5 316 _ St. Croix CO.,m ? This in trument drafted by Douglas J. Zahler Job #97-3 ti z z IH co (A CA IG7 C mo p%0 CD z p a m rat O 0 C2 LA) o.. ;v CL W I~d 10 ° >ON >w co W C~ rt tD Z D to m ItV m c co z~ 0. atw,lii O O Ci. 00 to 0 I -•I VJ rrG--~ N~ 0 0 O W Oi w raw I =J o D _ZC w w m v o. n n I o ►d o o •G N y r'' rr cr 0 ze c( 'D C G I C 1> z O - aC% V t~.~ N o c► co °c rt rrt I'~ IH ~ - Cj ` O cct' W vi 0 rh kC H NC o 4- .9 g 0 K) -I a+ a w rt c t cn o n m S.T.H. "35" ° 0 En -4 0 N - - - -4 = rn o L„ As NO°23+E~#87~rb' ' V1 w v o s d rrt ° N00°23'41" 486.91' ° w 210.00' 210.00' 66.9 ' c m .1 Right-of-way II ❑ 0 VFW rt n cm A I - - O 100 HWY. SETBACK p ct r0r rt I O i N H Zo OD 1 tDD W O O Ln ❑ M M IOt, I in zpm two ZO tko 000 w I N x to S -i 0 *Q5 H H H H rt - En rn N ~ 3 c 000 v~ hi ~ r r w . N ~ F~ I co ur%, mW c %.0 m O O O t=! MO M (A I~ 1° 0 it r a a. a n u u m ct 10 CJ1 r f+ it. w t1i pt N N a nj 11-3 J C C n H0 H I : C i 1 tid I r .9- H H I N N m A ~--K I ICI X: 'O I O . 0 O d N Ln to O I N f?] I i r H Cj p fA ca T 00 j O Fl- W A c r i p r t r W 1. N 10 0 m M M H H C~ r 210.00, 10.00' 00 rt rt S00 23' 41 " 42 .00' t° 1 N Fro+• • I~ b m r' 0 C I~ I o° r o IM0o P E, rt O H H r m m 3 1- f c m 1 w r-- c c a y a. woo H. 0 3 I o w m o e~OM tNi~ n n 0 w 101 ' r ~ H IN N m OE J1S1 m 00 N 1 I v fA m ] -gr w •d co 00 I r ;o rt m N 10 _ to I H I ~ ~ z 1 I ao O II--~ p rt ' m phi II m _ S00°02'59"E 659.98' rt m r STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 6: Ta 1, 7'-- MAILING ADDRESS / S 3 4 a ~ 76, /V<_--0__ d , d PROPERTY ADDRESS (location of septic system) P ease obtain from the Planning Dept. CITY/STATE 4.) c' PROPERTY LOCATION 54/ 1/4, S 4 1/4, Section T 2 QI N-R W TOWN OF ST. CROI K COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP S,S' 3! VOLUME-f_;7, PAGE-, LOT NUMBER 2 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60%. of the cost. of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: _ z DATE: I St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ss8248 34 PAV1194 306 7'1~ WAOMO7Y __~EE.D Document Number J L_ Document Title REGISTER'S OFF ST CROIX CT'.. WI fed br Raoor~t APR 21 1997 4 1:30 . P.M w,.:. `I# IdAk fieyleter of Deeds Recording Area Name and Return Address ~l C,l a-r C( or c~~" r3s3 AwcF,,ea e_ 2 . C) 0 ao-~o99-6-0 Parcel Identification Nwnber (PM $ TRANSFER E il. ~ • 4XINTY Per11995 M • DOCUMENT NO. I YO D EED THIS SPACE RESERVED FOR RECORDING DATA I STATE BAR OF WISCONSIN FORM 2-1982 ELIZABETH K. HOLMES, a single person _ _ conveys and warrants to RI C ~?...0.t...S.T.QTJT in..c.on.si.der.at1on-.of...$144-,.00.0y CLO RETURN TO ~I Richard 0. Stout 1353 Awatukee Trail the following described real estate in .........St.....r-ro.ix ..................county, - i=- - 2fY--- State of Wisconsin: The following described land Tax Parcel No:02Q A9.! 9-50_.•_. g lying in Section 33, T29N, R19W, St. Croix County, Wisconsin: That part of the SWk of the SEk described as Lot 2 of Certified Survey Map dated July 20, 1977, recorded in Volume 2 of CSMs, Page 448, of the Register of Deeds office for St. Croix County, Wisconsin. i~ I I ~i i I I I This ........iS homestead property. (is) (is not) Exception to warranties: I~ Dated this ..............21st April 97 day of 19......... , (SEAL) SEAL) Eliz beth K. Holm • es I (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. ST. CROIX ..................................County. authenticated this ........day of ..:.......................119 Personallv came before me this ___2.1_St_ day of I Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: tabor anJHuman Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284330 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: STOUT, RICHARD HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1099-50-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION HI FS ELEV. Benchmark Septic / 01 Dosing ~c C .2,75~ 1. S/ oar U,. % cv Aeration Bldg. Sewer msE yia Holding St/~!'C Inlet 7 TANK SETBACK INFORMATION St/ 10 Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic i ~NA Dt Bottom NA Header / Man. Dosin Aeration A Dist. Pipe 7 Pa Hol Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Loss mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS oZ DIMEN Jj N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHIft&-- Ma SETBACK CHAM . Moe urn er INFORMATION Type Of System: OR IT 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- ms Only FD epth Over Depth Over xx Depth O xx Seeded / Sodde xx Mulched ed /Trench Center Bed /Trench Edges Topsoil ❑ Yes C] No r-1 Yes r-1 No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ~iU~SONF, 33.29. J/Jp40 B, SW, 5E 591 HIGHRIDGE ~RD LOT ~i ',`i- G sift jr~ r. Ct~ ,Yte j ~ r ter. LAI' ` r U Pl~ah revisionrequired? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature. Cert No. Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County n'~, than 8 112 x 11 inches in size. I ~ 0 lz~l • See reverse side for instructions for completing this application State Sanitary Permit Number X84 330 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 INFORMATION Property Owner Name Property Location T/wr- 1/4 1/4, S_32 Tat? , N, R lQ E (or Property Owner's Mailing Address Lot Number Block Number C.4(~GL Yact City, State Zip Code Phone Number Subdivision Name or Number t'4lads W~` SIuG'G 6! ( ) X73/ CSI~,7 II. TYPE OF BUILDING: (check one) ❑ State Owned City sorest Road /It ^ /QeG Public 1 or 2 family Dwelling - No. of bedrooms ~ j Towage OF A4d So 111. BUILDING USE: (If building type is public, check all that apply) Parce Tax Number(s) Q~ v- ro ~~.-se 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 / Mote[ 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B, if applicable) A) 1. IU 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 R[ 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/day/sq. ft.) (Min./inch) Elevation ' 761d 615- l (3 d IS' eL CG IT Feet O0•3 Feet TANK Capacity VII. in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks r Septic Tank or Holding Tank Lift Pump Tank /Siphon Chamber El ❑ ❑ ❑ El -0 1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. 1, 6 Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP PRSW No.: Business Phone Number: Plumber's Address (Street, City, State Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) .Approved F] Owner Given Initial (-:6 n Surcharge Fee) Adverse Determination Vo I-V X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBO-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber _ INSTRUCTIONS i1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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 Bvildings_Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. 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. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 112 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) 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. a 0 -5X 11 Ta B.~b .c ,C31• D ~~P~<<G ~Y lv Oe. B~.z Wisconsin Department of Industry, AND SITE EVALUATION Labor and Human Relations ff Page 1 of 3 • Division of Safety and Buildings s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not I s n 8 12 County / mn siz~.-f'fan must include, but not limited to: vertical and tal referen`ce`pdi BM), di(, cti0 and St. Croix percent slope, scale or dimensions, no w, afc lgcation and distanci -w r earest road. Parcel LD. # 6 ' 4rl y" APPLICANT INFORMATION - r e print 4gWprmati Reviewed by Date Personal information you provide may be used fo eco arj! V. '5.04 (1) (m)). Property Owner Property Location Beth Holmes / 1 =y iM Govt. Lot 1/4 SW SE 1/4,S 3 3 T 2 9 N,R 19 XNor) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 603 Hwy 35 3 CSM City State Zip Code Phone Number ❑ City ❑ Village © Town Nearest Road Hudson WI 54016 ( ) Hudson Hi h Ridge Road New Construction Use: ® Residential / Number of bedrooms 6 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 9 0 0 gpd Recommended design loading rate 7 bed, gpd/fe - 8 trench, gpd/ft2 Absorption area required 12 8 6 bed, ft 2 1 12 5 trench, ft 2 Maximum design loading rate • 7 bed, gpd/ft 2 • 8 trench, gpd/ft2 Recommended infiltration surface elevations 96.8 ft (as referred to site plan benchmark) i Additional design/site considerations Parent material Pilo silt loam glacial 6e po s i t Flood plain elevation, if applicable ft Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank S = Suitable for system I U = Unsuitable for system [As ❑ U ® S ❑ U F I ©S ❑ U N IS ❑ U ❑ S ®U ❑ S Flu SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 1 1 -14 10yr2/1 none L mfr cs 2m .5 ,.6 2mabk 2 4-1 10yr3/4 none sil 2mbk mfi cw If .5 ,.6 Ground 3 8-8 10yr4/6 none ms osg ml cw 7 8 elev. 100.8 ft. Depth to _ limiting factor 8 9 in. Remarks: Boring # 1 -16 10yr2/1 none L 2mabk mfr cs 2m 5 .6 2 6-4 10yr3/4 none sil 2mbk mfi cw If 5 .6 2 3 6-9 10yr4/6 none ms os m cw Ground elev. 101 .4 ft. Depth to - limiting factor 92 in. Remarks: CST Name (Please Print) Signature Telephone No 5;'~ X44 V1 a A-9 - - - 7l S --„BG_ - 31x7 Address Date CST Number I la *'71:P' led ZZCt '?ROPEFtW OWNER Beth Holmes SOIL DESCRIPTION REPORT ' Page 2 of 3 PARCEL I.D.# 30ring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 1 0-16 10yr2/1 none L 2mabk mfr Cs 2m .5 ..6 2 16-44 10yr3/4 none sil 2mbk mfi Cw 1f .5 .6 around 3 44-90 1Oyr4/5 none ms osg m~ Cw .7 .8 :lev. 101-.-6_#. depth to imiting actor 9 0 in. Remarks: 3oring # 1 -14 10 r2/1 none L 2mabk mfr Cs 2m .5 .6 4 2 14-4 10yr3/4 none sil 2mbk mfi Cw 1f .5;.6 3 2-9 10yr4/5 none HIS osg mi Cw .7;.8 around =lev. 101 . 3 ft. )epth to miting actor 9.0 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Boring # 1 0-1 10yr2/1 none L 2mabk mfr Cs 2m .5, .6 5 2 16-38 10yr3/ none sil 2mbk mfi Cw if .5 .6 3 38-94 10yr4/ none HIS osg m Cw .7,.8 ^around alev. /61j-ft. Depth to limiting factor 9Y-.-in. Remarks: Boring # Ground alev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) ~ w PR r~ " 5 uv~iG f v a.? .L`as,c ~-ne_..,-1-eo,~,vc-vGr1,'7'h ~ a.fh l'QQ'.O ynl Qin a ~'3-S To S T t/ 3 S G G 'Ccz se fn c,~Jt Adr a C7 f ~rrr~ c'~~=~~ ~~vcoC7 ro FILED 2 a ip L) ? r1r 3C, ~ V L~ n ~ „ . L V APR 2 2 1997 ► S T' r Trs '6 3 << eg1 ~of s H m 55 X16 v SL Croix CO., Wl This inptrument drafted by Douglas J. Zahler Job #97-3 n 1H 10 ozo -r 7a...._..__... z o 10 C m o m 00 rn~. . N G ryt o 1 x H Ln 0 ~0 ct m m m n 17d 1~0 ° tC' a m a w v c w C] I F-1 I~a co Z O to N c = . • {r~!' fD 10 i~ rrl ~ A wn 00 \O O N O N W7 F fi iG W 0 CL I O IC' ° 37 G7 y f r rn r ct E c ct 'D Id I C I~ m ~Di~ Y O N N 0 X* 0 9% ( a c r rt c+ Ln c+ k4 1 HNC O o. r " 0 0 --j Ft *-j pia O1 w ct 7 ct CC ° a 0 S.T.H. "35" V O - :3 En to - - w (Rec. AsNO°23'mE k87'-R v, Un w u, o' rt ° NO0°23'41" 486.91 ° W ° E 210.00' 1 210.00' 66.9 ' a m Right-of-way 1 El m &0 n OQ .O t-l 03 100' HWY. SETBACK ct r0 H r m 1 u N ri N N 00 OD I to t.0 O O o n o ❑ t h F h H I N ~rLn rn m fr C~ rt r r r m W Ixl N a-li(n z n o~ Z 0~ 00 H c m co 3 N 3 p 00 V] ►sJ laj i=J C'~ 41 w N FU cA 1 1 I o rn N rn ~!J c Z m 0 0 0 M F-n O C7 I u N u N ° rt O p L=i 11 II U m rt 1O 1 N o, to 10 raaa~ w,~.~. a,. L- v, Ln m l~ rn N N a N 11-3 N, y ~t t,.WO LO vh m C7 o a, ca I L"1 d r- m I o co 1 DC : N 'J v m 10 w H H I '0 a 0 ::V 7 C=1 1~ ti ti W F~ N N m .O --I I I I C £ tr 10 . O O p N In In r-i ri 1 go -n I N Vi p N to X 11 1 I- 1 O Irk H H I'd I'd .db O '7 m m 210.00' I ' 10.00' m m p rt ~t S00°23'41" 42 .00' ~O 1N 1-4 ~ rt • ~ r°t, C/) I f7 al 1\ b m 0 0 0 Cn 10_ N i ono E rt r°t w w m In. n 1-r'1 I ~p om y W r 0 0 a r 1• r- - cn Q w O O d 3 1-4 I al _ n 00 .y In 0 n C w I~ 1 w y o vo O W I F-+ I i cn W r" I N N r O~ m O 00 .un _ 3 - I f N I I rn 1.0 " y I F 4-- N CA PO N• 0 \ co "CF I N zo rt m N 10 ~O 4- I q I .4 z 1 00 0 II-' I rt I I I i m w S00°02'59"E 659.98' rt m STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNEWBUYER ~1 &hOA6t Sf-611 f- MAII.ING ADDRESS l 3r23 //lLvG! fir k-(e TT PROPERTY ADDRESS Jr'yl ~✓~`Af Q et9"e- Jp (location of septic system) Please obtain from the Planning Dept. CITY/STATE /u, d s v ~J zV,` PROPERTY LOCATION SGtI 1/4, S~ 1/4, Section 3 3 , T J-q N-R / W TOWN OF4 yL5'o.cl ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP 55 &31~o , VOLUME~, PAGE fh%4&, LOT NUMBER 3 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. UWe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: _ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, %VI 54016 1 1/0 b T C - i00 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property et('h64 a Location of property_5L)_1/41/4, Section 33 T -2c1 N-R_Zj_W Township u Gl $'d,,J Mailing address / 3S ~ W ~ T~~dso~ Address of site X 41 /y, y` subdivision name C SYYJ 55 3/6`//~ Lot no. 3 Other homes on property? Yes3 No Previous owner of property /j2~h fh Y/jLI ~ Total size of property 20 QC~ t' S Total size of parcel 3 Date parcel was created .22- 97 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume l~ and Page Number 1941 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. j 5 ga and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signature of Applicant Co-Applicant Y /--2 ~'/9 7 Dat of Signature Date of Signature