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HomeMy WebLinkAbout161-1062-40-000 o N O o N 0' 3 d c d r_ °c s 3 C B m d o I A� I w •" rr O o w= 2 2 in Z n! 4 w rn• V z CD O O (n O O) 0) C O v a . i (D y U1 d a y v O O O O ol N N a 7 N !G C�" (p O O R O 0 0 r C O n f�D (� CY N Z Q O _' a 0 3 y T1 O 7 N i,, = O CD O �1 cn o _ o y m v�o D a4� m � a 3 CD W .. 3 CD y IW O O N 3 o �_ tD 0 co o too (D a N c o N c °° °° cn : �� Q �+ a T O O O o � o= o c lA to v s l 3 3 N N N c D C) o d g O G c � 0 0 o C', �y 0 0 3 y c d CL o 0 ' O o Z o00 0 D@ rn l O D a m O o v !r O C CA m CD C, y C C d. N C CD a W fD a `D CD 3 N Z CD o A ? o N =+ a a A I W CD e W -0 Z w a a a 3 Z 0 N y � F o D D CL o ayou a c co y 0 o v c m c o`:• a a o o a a N ti CD m m m � : CD y �• 0) y o 7 O I 3 a CD o a cz oD v N " C) a Co � A o CD N O tv 69 0 O Parcel #: 161- 1062 -40 -000 02/16/2006 04:16 PM PAGE 1 OF 1 Alt. Parcel #: 13.29.20.5299 161 - VILLAGE OF NORTH HUDSON Current [X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - HACKWORTHY, CYNTHIA S TRUST CYNTHIA S TRUST HACKWORTHY 216 SOMMERS LANDING RD N HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 216 SOMMERS LAND'G RD N SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.000 Plat: 0876 -CSM 03/0876 PT OL 87 & 88 1.8A LOT 1 CSM VOL 3/876 Block/Condo Bldg: Tract(s): (Sec- Twn -Rng 401/4 1601/4) 13- 29N -20W Notes: Parcel History: Date Doc # Vol /Page Type 03/03/2004 755714 2520/222 WD 03/03/2004 755713 2520/221 WD 1018/126 WD 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 108341 737,700 Valuations: Last Changed: 05/20/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 379,600 342,200 721,800 NO Totals for 2005: General Property 0.000 379,600 342,200 721,800 Woodland 0.000 0 Totals for 2004: General Property 0.000 205,200 342,200 547,400 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 107 Specials: User Special Code Category Amount Special Assessments Special Charges 00 Delinquent Charges 00 Total 0.00 Parcel #: 161- 1062 -40 -000 02/16/2006 04:24 PM PAGE 1 OF 1 Alt. Parcel M 13.29.20.52913 161 - VILLAGE OF NORTH HUDSON Current X1 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner CYNTHIA S TRUST HACKWORTHY O - HACKWORTHY, CYNTHIA S TRUST 216 SOMMERS LANDING RD N HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 216 SOMMERS LAND'G RD N SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.000 Plat: 0876 -CSM 03/0876 PT OL 87 & 88 1.8A LOT 1 CSM VOL 3/876 Block/Condo Bldg: Tract(s): (Sec- Twn -Rng 401/4 1601/4) 13- 29N -20W Notes: Parcel History: Date Doc # Vol /Page Type 03/03/2004 755714 2520/222 WD 03/03/2004 755713 2520/221 WD 1018/126 WD 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 108341 737,700 Valuations: Last Changed: 05/20/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 379,600 342,200 721,800 NO Totals for 2005: General Property 0.000 379,600 342,200 721,800 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 205,200 342,200 547,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 107 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 i rn 0 N 'W 866.56' �,-mm -� rn NZO OD 0 URV -- � � Z PA G - - Z O\ t CD -� - -- - - z n z ' vV /v 111111011111, � c � urn ,,,, � fill 3.0 � ., • (A 2 +o • � C7 �. it � uuuuuuuu uuuun uu �� uuuu.uula X3.00 % t • \ ^� g + r y I J Q A 17 m 0 \ 7 • v 1 \ ~, r • AS BUILT SANITARY SYSTEM REPORT 'OWNER C'1A II &� I I �', C: C�t C/ Z T l� l SEC. T N, R W ADDRESS ST. CROIX COUNTY WISCONSIN. s SUBDIVI mere �c LOT z LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM A � f a > >fl 3 { I A r I di ate North;Arrow j SCALE: SEPTIC TANKS) �FGR. �� ec �?s CONCRETE STEEL N0. rings on cover („ Depth " PUMPING CHAMBER SIZE 1, PUMP MFGR. f MODEL NO. / GALLONS Per Cycle _W TRENCHES NO. of width length_ area BED NO. of lines _ width ,jam' length area Zo depth to topes pipe - NUMBER OF SEEPAGE PITS Outside diameter total pit area AGGREGATE / -// _ PERK RATE 5 AREA REQUIRED AREA AS BUILT ,o yy Disclaimer: The inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. Howev , if failure is noted the County will make every effort to determine caus of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THRO GH HIS YTEM. INSPECTO R DATED PLUMBER ON JOB LICENSE NUMBER .3aa REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM S anitaty Petmit State Septic NAME /,J� Township /� St. Ctoix County Location Sect.ion Lot _ Subd.iv.i..�s-ian SEPTIC TANK S� -( 1 �� ga.P PC n,! Numb o 6 com pat-tmen , t6 Di6tance 6tom: Wett S. � Z? ` Building 2140 1.2% .scope Highwatet PUMPING CHAMBER Size Fe s � &� _gattonh ,Pump ump Manujactut Mode. Numbers —` Z/ — _ HOLDING TANK Size ga.- .Eon.6 Numbers o6 Compattments Pumper Atatm Sy Di.s lance 6tom: Wett Bu.itding 12% .tope— Highwatet ABSORPTION SITE Bed /1?_ Ttench Distance 6tom: Wett J J_ Building .12% 6tope Highwatet ABSORPTION SITE DIMENSIONS _ Width o6 ttench l 6t Requit area , � �, J� 6t Length a6 each tine 15 6t Depth a6 tack be.Eaw tite tin umbers a ti - nes Depth o6 lock over tite /�- in ata.E tength o6 tineA � • _6t Depth o6 tite below grade Z in )0 6tance between tines 6Z Stope o6 trench y tin. pet 100 6t p 1Y Wat ab�satption area 6t Type o6 Cove apet �5 taw Io ot PIT DIMENSIONS Numb et o6 pits Gtavet around p,it,6 yeas no Outside diamexet 6t Depth betow inf-et 6t Tozat aba otption atea 6t Area tequ.ite A ,!�Z 4 6t -7 /f x..;447 REPORT ON INSPECTION OF SANITARY PERMIT # a (1 ) Name and Address of Permit Holder Person /Persons at Site (2 )Da of Inspection c. Ti he of Inspection ame, ress, License o. oT insfaMing Plumber ' (3)I6STALLATION CONSISTS OF: Septic Tank []Seepage Trench Dosing Chamber ❑ Seepage Pit OSeepage Bed ❑ Holding Tank []Fill System (4) BENMRARTTFermanent reference oin Describe: � Elevation of vertical reference point: j b Slope at site: ® Yn (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: (� o �'.e a > Liquid Capacity: / 2 6 Tank Inlet Elevation: // Tank Outlet Elev: 49 / . S # ft to lot or property line: / �" # ft to well: 4-01 t MDOSING TANK: Manufacturer: # of gallons: Jj # of gallon pump set for a cycle .� �J y gallons; total capactiy of distribution lines gallon; size of pump head; gall o per minute ; horsepower ; brand name of pump and model number p d Is the warning device installed? COYES ❑ NO Wired? MES " [:]NO 8 HOLDING TANK: Manufacturer # of gallons construction depth to the cover ft; If septic tank is being used are baffles removed? YES []NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? C] YES ❑ N0; Wired? []YES ❑ NO; Locking device on cover? []YES ❑ N0; Diameter of vent and material Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe - elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; i0 tile depth; �l i.neal feet ti 1 e; .- j - � ft to residence; �?/ 7 `ft to well; / �5F e ft to lot or property line; A?W ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed al J ft. 11 SEEPAGE RE Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in a rea indicated on EH 115? VVES []NO (13) Has system been installed in floodway? ❑ YES 0 Floodplain? []YES X10 DILHR -SBD -6095 N.0 /80 State and County State Permit # o� 9 � PLB 6 7 Permit Application County Per it # for Private Domestic Sewage Systems County _ *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: C Y aty , ) e s &. B. LOCATION: IV IJ '/ 4 ' /a, Section 12 , T N, R _ A 2,0 1� (or) Lot# / City //� __ Subdivision Name, nearest road, lake or landmark Blk# Village /V� �1C Township r� E't'1 VrL t r' T vl t C. TYPE OF OCCUPANCY: *Commercial_ *Industrial *Other (specify) Variance Single family ?t: Duplex No. of Bedrooms �'S No. of Persons D. SEPTIC TANK CAPACITY C190 Total gallons No. of tanks / HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber &6�O Total gallons Prefab concrete —.N<— Poured -in -Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate CZ Total Absorb Area New k Replacement Alternate (Specify) Seepage Trench: No. of Line5l Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: W Length S8 Width — _Depth I�V Tile depth (top 3�' ,� No. of Line 3 Seepage Pit: Inside diameter s 7 I iquid Depth No. of Seepage Pits Percent slope of land a - 3 ° 70 A 0 Distance from critical slope WATER SUPPLY: Private ® Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Soil Tester, /f C NAME &Ln k Ili 4Z A C.S.T. # ��� 7 and other information obtained from a (owner /builder ` Plumber's Signature P /MPRSW# 3a°z Phone # 'j /$� �(i - 8�ilo y Plumber's Address rc � � B v PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. f E E. , e I £ a ; ..�.. .. ,e m a .. I € i 3 ( 1 a...mem i P ] t t I e . Eli 115 Rev.9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309,MADISON,WISCONSIN 53701 LOCATION:,44/1/4,M014,Section /-3 ,T a/N,R Fa(or Township or Municipality �' ifg0-e , r Lot No._, Block No. 0 4rs "cif' 6-- County Cf'.)C / ,l,' ��Fr ' / ubdivisionName Owner's/Buyers Name: C ./fr/4 ' ( Ad, All. �� JET �: Mailing Address: /c L At /4"Mt `;4,f /'S��i-- j //' �IS, ry.21- Iut " / -CM(' TYPE OF OCCUPANCY: Residence X No.of Bedrooms - COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT� ALTERNATE SYSTEM (5 C. t , RS t�J DATES OBSERVATIONS MADE: SOIL BORINGS . -a2/ PERCOLATION TESTS 7- r - SOIL MAP SHEET 5—7 NAME OF SOIL MAP UNIT /h gur Alt r 4 1611141 PERCOLATION TESTS HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN TEST DEPTH CHARACTER OF SOIL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- See Bove P//A M .2 / � /0 //L /Y' /`. 8 P-2 S�.' S'ee- � /O�"re /A , 02`7 /10 /0 37' 3* 3 Xf. 3 P-3 i" See /gore Nfl71A II fik /0 1%( /%, /Xf 47 P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- / ?6" A/Aldt-_ 7.76'' /a'' t5, 51"is (--fr-,-COS /y,"SY6i--) fa", B- Z 96" /S.9,cte- . ?'6"" //1' �)t Y?" /S*/c7 k--4-e,h' /Z"sy-6v, AP.$ B- 3 761/ / e- ?76'' /,3''1�, 5/''45 44-d h' i 6' 54‘V'i /6"- B- 76" e ►. e.. �96''" /a '7S 6c 1s .t-61-�-6j /a S , " ;� is&-, -s B- .� 76„ 4 7'7 " //"r-S 314 Ls-f - + e.q. 's', s y-6fr/ /6•"-C B- 6 f6" >96" /y"15, yf" is 4-64- ,- 6-4 /8"X 4 Gr, /40"-5 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the Ian the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy 6/01 , o? $''9- 1 Indicate scale or distances. Give horizontal 9nd vertical refeà /.4ace ce points. Indicate slope. / .Scc,`i ae/G /4- o SeA/2 - /9 c)" odel R 3 ,Q' ,>u. /1nen5 620;bcg-0' ) 'A \ l' ''N:e.2---...tate,-.V44-e(1 6.7 N.S,, t ® A'ef.dr�rsre A �t4 ; O 0 A3/10 tN V "fit `L I.7-A'c)wes / p O o L '1 i 0' D 6 1. c...) . le 1_- 'Z'z /V' NoR//4' ,pie X B3 -CL = /off' ,s--Cl `f -C-a : /0/5— 4 07` CAl,ed_ ,Si \ 0C-- CSC = /©D.s' .L.And' B'6 - r/ ` /°y' v `/0' I,the undersigend,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct to the best of my knowledge and belief. pq Name (print) 1 M1,S P ci!,5>6e/.-�,�, Certification No. ss-�-c( / Address //l 6 4941to/ ,ie, liaelsoxe/ U.). , ,�' '6 Name of installer if known Copy A—Local Authority CST Signature r � a C; f/ 1 r l i i g oc� .. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT bT • CROIX GENERAL INFORMATION (ATTACH TO PERMIT) sanitaINrgi ".: Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)). Per it H IdeLilName: - R �V V kff wn of: State Plan ID No.: CST BM Elevv-: Insp. BM Elev.: BM Description: tc �� Parcel P611o.:1062-40-000 TANK INFORMATION ELEVATION DATA A9800545 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake 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 oss Forcemain Length Dia. I f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O model Number: System: OR UNIT 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 -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: VILLAGE OF N. HUDSON 13.29.20,NW,NW 216 SOMMERS LANDING Plan revision required? ❑ Yes [:]No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION B ureau ofBuilding Water Division Systems Buildis 201 In accord with ILHR 83.05, Wis. Adm. Code P.O E. Washington Ave. 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 31 1 The information you provide may be used by other government agency programs p Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Pro ert Name Property Location ►� . 4 k �n� N&j 1/4 /)h/1i4, S / T 2� , N, R 76E (or)o Property Owner's Mailing Address Lot Nu ber Block Number Z 1 6. o rn �. Li C Cit State Zip Code Phone Number Subdivision Name or CSM Dumber g 76 Hud.se ��.I f s 140 (30C.) i�vc�3 I d / . II. TYPE OF BUILDING: (check one) ❑ State Owned ci lla t y ge TN Road Public 1 or 2 Family Dwelling- No. of bedrooms > Vi 'town OF Ill. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo / 1 (, Z 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_ R] 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 1 1 'Seepage Bed 21 E] Mound 30 E] Specify Type 41 [j Holding Tank 12 ❑ 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 7 6 10 - 7 - .2- �' 9 6'0 Feet U , O Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex p er. INFORMATION New Exist Gallons Tanks Manufacturer's Name Concrete con Steel glass Plastic A p p stru Tanks Tanks lc Tank nk 19 ❑ ❑ ❑ ❑ ❑ Lift Pump Ta p on Chamber I ❑ 11:11 ❑ ❑ 1 ❑ RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. iMORIbEr's Name: (Print) s Signature: (No Stamps) Business Phone Number: hC % r &I V SL (� - Z/ 3D ms's Address (Stre , City, State Zip Code) , : IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Perm t Fee (Includes Groundwater D ate Issued IssuingApenj Signature (No Stamps) 1 Approved ❑Owner Given Initial Surcharge Fee) � Adverse Determination — to )1`�w gz� X CONDITIONS OF APP / REASONS FOR DISAPPROVAL: rte 7>'� 6 vl i ✓1 De a `C v Y74 �k 4`Ya p � yo SHD -6398 (R. 07/94) DISTRIBUTION: Original to count y, One copy To: Safety & Buildings Di --ion, Owner, Plumber ST. CROIX COUNTY WISCONSIN rrrrrrr "� ZONING OFFICE "' " "' ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 � — (715) 386 -4680 AFFIDAVIT OF SYSTEM REJUVENATION Property Owner: ack Address: a Day time phone:( spa k Parcel Legal Description of property: KW � 1 Sec. _!.3_ R. 20 w. , 2R o f St. Croix County, WI As owner of the above described property, I acknowledge that the septic system serving this residence current code standards. (� /is not) undersized by urita I understand that the issuance of a ry permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. Signature:" Date: 5/97 .Sore � s.rE- Fv,�lv�t -nov wiz 7��'� • ��'i�` Wisconsin Department of Industry SOIL AND SITE EVALUATION l Z Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and ST'- ��� /•� percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # /CP / /e l* Z " yo 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 1 Govt. Lot �j /4, 1/4 �S �3 T 2 -1 ,N,R 20 E (o W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 2/(o Soti.� -rFS L���ivG— CS Ud /• 3 a 4 Ci State Zip Code Phone Number �dQ 3 ❑ Ci Villa e F-1 Town Neare Road a v� o Dti�r�i'S LtiO. ❑ New Construction Use: Rgesidential / Number of bedrooms ✓ Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Q Code derived daily flow 750 gpd Recommended design loading rate bed, gpd/ft O trench, gpd /1`1 Absorption area required ? L bed, ft 13 91 trench, ft 2 Maximum design loading rate • 7 bed, gpd/ft trench, gpdfft Recommended infiltration surface elevation(s) ���STi�� `sYsT - qS. ft (as referred to site plan benchmark) Additional design /site considerations Parent material _5*A'Dy Flood plain elevation, if applicable tt S = Suitable for system Conventional Mound In- Ground Pressure , AAT- Gr / ade System in Fill Holding Tank U = Unsuitable for system ❑ U , L - 7 • S ❑ U ❑ U L� S ❑ U rEl S El S [�tT 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 /.. iE /0YX z/3 � /0 31 S� 17e , k I'm >1� c5' /f . 4 f .S Ground �'� d� — L�'• I lk, /Jva C s �- . , • O 0 elev. T / I 0 ' Q--- - o 4— 14M /Yl 7 -- Depth to limiting factor Remarks- , �qV 11 w 7` . Boring # 13 Ground elev. ft. ' Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. T 21l% 1°i Si ��_ r ,•s ..•, PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D.# Borin # Horizon Depth Dominant Color Mottles Structure G D/ft2 g Texture Consistence Boundary Roots P 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: SBDW-8330(R.08/95) l' r bk) .• 2, O - 34 30 • 1 o i ? 611,f>..,------, C et Atvi'l45 Of git ,OS -1/..:„ /00. 0 e 0 0 ' , , PK : i' o-\ 1 ,o-, e1/• fiS2 -Ty 6f 4_/ . Z(v/T 5-5 0 \ "Ir , i -2', , r/ , T' 40,4/Mr t L V sVsr - ff,-Sa 0 cJ v T<AI OttIcht&Assoe consultants i 65 O'Neil Rd' s c,4/� ` 30 Hudson,Wis. 540 4. _ - P/r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 2 Mailing Address Property Address (Veriricatioa rcquircd from Phmniag Department for new coasttuetioa) Cit3Mate 1� ", �ao h� Parcel Ideatification Number / - n/ � -yh REGAL D TS CI 1PTLON Property Location N w <, �_ V4, Sec. _Z,�, T 2 9 , _ N R v�gCk of N Subdivision Lot # Certified Satvey Map # Volume rage # warranty Deed # 0 13 Z Volume Page # Spec house CI yes no Lot Iincs identifiable p yes ❑. no 1 �NA1yC lw ggpm � enr =MofyseptiC coald�rltmitsPz�ra�. tol,andle�rastm can affba.the fun�ctkm of du septic ft*.. sugge m" duo Waste Iro�sed the di..grosal.�ysbcm. WI>at �� _ W may owner agars to subca to SL auk Zoning D .oesfi5aatioa f l�rymaaP �ctodplua>Z�ori lioeased that 1 �• b9 .the o� and by s stailagdot � m° °gonaad/or(2) st}er- �y�g ( j�eoaaiteRrasteavatcrdtsposalsysbcm. mspoctioa and paatping g3e septictank icss tbaa 113 �rll of shtdge. by Dr�mmea,t of and due Depaament of Isataral sewage Wz$t tha standards da f due t has ban odmnst be completed and retutnod to tie State of wnconsin.. Q oa year OThatioa date. County Zoning Office Within 30 SI 0F 1 �cS OF DATE OWNER CERTIPTCAT QN I (We) certify that all stattxncats oa this foil arc true to the best of my (our) kn due y dccod above. by virtue of a water deed recorded in � I (we) am (are) the owncr(s) of Register of Deeds Office. ^nics� jL �z-c, O DATE ss « «ss Any information that is mis todmay result is the sanitary permit being revoked by the Zoning Department. s�sssa Include W th this app[ication: a stampod wmuty deed fMM the Ragistec of Roods otYice a Copy of the Mffted survey map if retcrencc is made in the warmaty decd ,a..s :stFe!•a5a- �sa;faY. DOCUMENT NO. WARRANTY 3 ARRANTY TNIi iPyCa ft"C"" POn MCCOMINO DATA y STATE SAX OF WISCONSIN FORM*—"" REGI WILLIAH ... M1l...SR A" KAY .. WAZ,SR, hus _. .............. - 8T slid rifer .. ............•......._.......... - RAa'd far Poo" .. _ _ ................. conveys antt warrants to 2 8 _ to 4L>r2'_ x . ' �+rou i m at - ....... ..............._ .. .. .......... .......... ......... .... .................................... .. - y i 3 -€ the fuUowinP dueri6ad rral estate in - s�tr r....�'a�i 0 �F . - - - - -- ------ State of Wisconsin: --- -- Tax Parcel No: ........_..___._... � ; ' t +'� } Lot 3 of Certified Survey Na in V o l . .. P 1 . 3 Page 876, Doc. No. 360462, vX" 3 being part of outlots 0 870 and "88" of Assessor's Plat of the Village�� i of North Hud son, St. Croix County, Wisconsin. ,• �• �.�+ _ N fRMS.C, A 1 S This ..... is .--- ----- °.._. homestead property. s (is) (is not) EeePtion to warranties easements, restricts d rights -of -rap of s record, if any. itl Datgd this . day of .......... J e 9 a y Ho t Mud Ct under i Power of Attor y ed 4/23/93 ? �`< - ------ - k .... (SEAL) - - - - ...................... -(SEAL) an E. Walsh .................................................... Ray S. Walsh i ••---• •--- ------ -•-••----------- ----- ---------------- (SEAL) ----- — - (SEAL) � •. # • __ ______ _____ • 1 y AUT81s TICATIOA S S R) = ACKNOWLBDGMRNT STATZ of WISCONSIN .� ..41 3/_ -93 ---- •-- - -.... _•- . �. .... S Cr oix �• - - day of - ' PsEmonaily came before me t • I 4 - J ane '� �y x' , • - _.__- -_--_---- _ ___ _____ __________ - -___9 19___ - -__- the above named * 1 .ICT YSS ?A William 8. Walsh, Ka -- •----------- - - - - -- <.�..r 4 •1 BAR OF WISCONSIN - !.. S Walsh TITLIE l[BI[BEIt STATE ----------- •-- - - - - -• - - - - -- ----------------- ------- - ----- --- -• - - -- _. by ! 70A.Oq, Wis. 8tsb.) --- -- ,. - - - -- -- to are &an to be the perso tod tte T,119 1 "S"UMENT WAS DRArMa I Sn�i a ,. Rristina Ocland .. l► _ . w >✓