Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
020-1102-00-200
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538873 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Thompson, William & Nancy Hudson, Town of 020-1102-00-200 CST BM Elev: Insp. BM v: BM Description: nn Section/Town/Range/Map No: /J Am- 34.29.19.406D TANK INFORMATION j . (4r ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ` /QOO Benchmark 5 IZ • 'I Alt. BM Z b ! r't t, o, -A IF L I O ~ Sz c Bldg. Sewer ~t o J Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD , 1(o 76. (w3 Septic / Dt Bottom ~.32- 7f. IYgpST'g 7 r y3 7 /DO r Header/Man. (0 75. 2l0 Aeration Dist. Pipe 9. / 75. /9 Holding Bot. System /6 tp 74 P7 O k- PUMP/SIPHON INFORMATION Fina de y 79P y~ Manufacturer Demand St Cove r~ GPM Model TD ft Friction Loss S ead F1111 Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Trenches A PIT DIMENSIONS No. Of Pits Inside Dia. Liquid De_ pth DIMENSIONS 3 3 es ,(e. ck-o6 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: Sw~~r 1 INFORMATION 1 CHAMBER OR Type System, ticuC.r I a/J Z 7 add , N4_ UNIT Model Number. Ji G.L T tJ DISTRIBUTION SYSTEM e-l 5 -Jo Header/Manifold ~ 110 Distribution \ x Hole Siz x Hole Spacing Vent to Air Intake / Length Dia Pipe(s) ` Dia Spacing \ SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of Seeded/Sodded T Mulched Bed/Trench Center 4 75 Bed/Trench Edges Topsoil 7 \ Yes [g No No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 644 Cty. Rd. NrrHudson, WI 544016 (NE 1/4 NW 1/4 34 T29N R1 9W) NA Lot 2 Parcel No: 34.29.19.406D 1.) Alt BM Description 2.) Bldg sewer length = - amount of cover VV Plan revision Required? 0 Yes No Use other side for additional information. L~ SBD-6710 (R.3/97) Date Insep or's Si ature Cert. No. J c nmerce.Wir Qvry , Safety and Buildtr~s~i , . ti County ~t 201 W. Washington A 6f Itlepart Madison, W 153 /U /-7162 Sanitary Permit Numher to be filled in by Co.) S I~,c. State Transactior1 Number ary Permit Application N in accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address (if different thanmailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary , / n n ~~//r purposes in accordance with the Privacy Law, s. 15.04 1 (m), Stats. #L!1 I. A lication information - Please Print All information parcel # Property Owner's Name 67/► ~ //t 7 ~ ~b III~~~ v / -I ~J s 1111111111, -73- All Property Owner's Mailing Addres Property Location Govt Lo[ ' Section Phone Number _ Zip Code _ City, State _ Y a p(circle one ~b/`~►/J U.~ D ~ ~ " ~ ~ T N ; R 7 -~-F--- E o 11. Ty e of Building (check all that apply) l .ot # Subdivision Name or 2 Family Dwelling - Number of Bedrooms f Brock # ❑ Public/Commercial - Describe Use 1 ❑ City of - - CSM Number ❑ Village of ) L~(~ w)!1 ❑ StateOwned - Describe Use % Town of 7 III. Type of Permit: (Check onl one box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) Q. El Permit Renewal ❑ Permit Revision List Previous Permit Number and Date Issued ❑ Change of Plumber El Permit Transfer to New Before Expiration Owner IV. Type of POWTS S stem/Com onent/Device: Check all that apply) XNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soilJ¢q ❑ Pretreatment Device (explain) a L. lee tdOe_ I ❑ }folding Tank ❑ Other Dispersal Component (explain)_____ S_ V. Dis ersal Treat ent Area Information: Desi n Flowl (gp( i) Design Soil Application R (gpdso Disper I Area Required (st Dispersal Area/\ pose s f) System ElevAtIon 3~ ~ Capacity in _Total # of Manufactm•er o VI. Tank Info Gallons Gallons Units w c d m New Tanks Existing Tanks / d lad a U A w a L✓ !J ~"a Septic or Holding Tank db p d~ 1 Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWT S shown o the at ached plans.usiness Phone Number Plum er's Na (Print) Plumber's Si ^Pllumber'ss AAddress (Street, City, State, Zip Code) Vill. ount /De a tment Use Oni A t Si natur Permit Fee Date i sued Issuing g g pproved trap $ • ~d Z5 r Given Reas Denial IX. Condil'"JIjAp$ oessoits for Disapproval 1. Septic tank, effluent filter and dispersal cell must all be services / maintained as per, management plan provided by plumber, 2 All setback fequlretinents must be maintained ae. n eomp e e p mrs nr ie system and submit to the County only on paper not less than B U2 x I t inches in size SBD-6398 (R. 01/07) Valid thru 01/09 0001PO/0 Mar au gee A4me 6L t oy ~)t S 4 a 3 -rap S x to ~i VJ vj~ r X30 R~,;,U~)}vf ®f3 ~g~ 1 1 .tom P4~qf COPY i I CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: ~Yy,O S/~E'_r ~Q1' /1~G12 Owner's Name: A ~t Owner's Address: LY Legal Description: A_l~~L!9 Township: A[L11567,0 County: (,1 ol'x Subdivision Name: Lot Number: Parcel I'D Number: Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs.., I Page 5 Maintenance Information Page 8 _ Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plug bet: ~ e5 License Number: Date: O a Phone Number l~a~11" 9. Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 l malp ,i~,um~~C r 3 ; m l:u ees~'et' A4.me SUS hoP /-.o x alvq . ~ J y, r`..P 13(1w4 pig , o ^5 1 t w, I l k J Alt G. M T r CA 4~,Jf Q Soil ,Absor !ton S stem Crass S8ctI0n g ~''l~ `7~ .obft Final Grade 4" Schedule 40 PVC Vent Pipe J With Vent Cap Leaching 3 Stt Chamber System Elevation t' 3 ft_ Soil Absorption System PW 1 ft l ~1 Leaching ~ Trench 1 Chambers 4J 4" Dia. reo~ch 2 Header I-T - rench-2 Header Vent Or Observation Pipe _ ~1'rerteh Manufacturer And Model _ Q~1 F y _ ~ EISA Rating o~ b sr. ft per chamber Soil Application Rate_ gpd/srt ft ~Sb gpd Design Flow _Soil Application Rate 0 EISA = _ . Chambers 3 rows of l 5 _ chambers each. Page of _ PLT525 Effluent Filter,- Effluent Filters • Folylok Inc, Page I of 2 tii;a; te`,I.ri tii F'oMok Inc. 3 Fairfield Blvd Wallin rd. CT 06492 Call T #t r ..i i,'',;,, , gift o Fee; $0-765-9.555 Emlall' polylok•cor» You atrfl liars o, > Product Details i b a, , i . I y 491 ""FFLUPENT FILTER' Raising the bar in filter technola j ;ilr•. II.11i ..I: A~:::. PL-625 Effluent Filter Description Effluent Filters Polylok, Inc is pleased to add its new commercial filter to its existing line of quality efflpent I Wand & LOVO filters. The PL-525 is rated for over 10,000 (BPD (Gallons Per Day) making it one of the lamest commercial filters in its class. It has 525 linear feet of 9/16° nitration slots. Like the ~Risers & Riser Covers na Polylok PL-122, the new Polylok Pt,-625 has an automatic shut off ball installed with every filter, When the filter is removed for cleaning, the ball will float tip and temporarily shut oft ! Distribution Boxes anc !t I , ;.;i r r!rn:;. the sy*tarn so the effluent won't leave the tank. No other filter on the market can make that AGC@9 JrieB cialill! I Pumps, Basins, Pump i and Stop Systems „Orderrr,g Information ` Request a Quote > Related Products Im.-------- - „ ; Seals I Gaskets Features ! !Baffles, Sanitary Tees Deflectors !I * Rated for 10,000 GPD (Gallons Per Day) * 523 linear feet of 1116" filtration Reber Spacers Enlarge for details * Accepts 4" and 6" SCHDJ 40 pipe n • Built in Qas Gletleq#or R~siven Handles and * Automatic shutoff ball when filter is removed a Alarm accessibillty i Signs a Accepts PVC extension handle i Landscape I Drainage The PL-525 Effluent Filter should operate efficiently for several years tinder normal ! conditions before requiring cleaning, it is recommended that the filter be cleaned every I-Fo~s,~ ~1~~~ „ time the tank is pumped or at least every three years. It the installed filter contains an i 8uiyi Sealants optional alarm, the owner wig be notified by an alarm when the inter, needs servicing, Servicing should be done by a certified septic tank pumper or installer. riesrirelS Concrete Accessories Maintenance Instructions: sutra Filters 1. Locate the outlet of the septic tank. Oder Crontrol Product 2. 'Remove tank cover and pump tank if necessary. Reber-Lok and CMU 3, Do not use plumf,7ing when filter is removed, 4. Pull PL-525 out of the housing. pGGeeeoriati' 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank, Rebar Safety and IQ Q 6, Insert the fllter cartridge back into the housing making sure the filter is properly ~ -'mm aligned dncl pompleteiy inserted. Deeorativie Landscape 7. Replace septic tank cover. PL-525 Installation: Waal for residential and commercial waste flows up to 10,000 Gaitons Per Day (GPD). Technical SpmIitCatiot Installation Instructions., R~Pated PrQdyrrtw 1. Locate the outlet of the septic hdnk. Pump, Filter and Sun 2. Remove tank cover and pump tank if necessary, i 24„ x 1la Riser 3. Glue the filter housing to the 4" or 6" outlet pipe, If the filter is not centered under i SmartFilte'rtT Con an the access opening use a Polylok Extenp s, Lokim or piece of pipe to center filter. r trol 4. Insert the PL-525 filter Into its housing. f hftn'I~1,v'lt,'th~r~ ~nlr r990c ~Nit,r`Yc rlr+h; Wb'i ~ ' 6 iilc sic•n~Iyrrulr,nt Tfl-'l Q ~ ~7 'l all m A- o LO 06 r ~y r i W c~ CD a f B CL M d 990 '°N a WHZ l: 6 O 101, b l ~n u is 2010 9.12NM No, 3066 P. 2 r6m~ m0c) 4p a 0 < T D A m -0 m C z r p Q m cn c p -n 3 A c r, ua a' gig ; OREM Az~mrww. ca CD N 4 y [#J ■ W ~ niloG, cn n`~i L O y r u ~f' Q i e- u u 1U.An AM St, Croix County Planl2oning 715-386.4686 1/2 PO W'T$ O WNER'$ MANUAL & MANAGEMENT PLAN Page of FIL9INFORMATION SYSTEaiVI PICIFICATi0N;e91 owner Septic Tank Capsolty u U 1~ el Q NA Parmit # Septic Tank Manufacturer ~S 0 NA DESiON PARAM15TERS Effluent Filter Manufacturer Lb M NA Number of Aedroams Q 9NA Effluent Flltar Modal PL ,S oI E M NA Number of Public Facility Unite C~.Pump Tank Capacity al NA Estimated flow (average) 3 bb al de Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1,5) U al de Pump Manufacturer NA Soft Appllcatlon Rate &~I/dY/ft2 Pump Mode) NA Standard influent/Effluent Quality Monthly avorags* Pretreatment Unit 0 NA Fats, Oil & Grasse (Pool X30 mg/1, Q Sand/Gravel Filter Cl Pont Filter Biochemical Oxygen Demand (BODa) S220 ms/l, Q NA (D Meohanlcal Aeration a Wetland Total Suspended Sollds ITS$) ew9 50 mg/I^ Q Disinfection a Other; Pretreated Effluent (duality Monthly average Alsperael cell(s) O NA 6lccheminel Oxygen Demand (1300 j) 430 mg/1, 14 in,oround (gravity) 0 In-Ground (pressurized) Total Suspended Solids (TSS) s30 MOIL Q NA Q At Grade Q Mound Fecal coliform (geometric mean) 9104 cfu/1 t)Qml Q Drip-Line Q other: her'. iD NA Maximum Effluent Particle Size Ye In d(a, q NA Ur Other, lO NA Dther, t NA *Values typloal for dorneatia wastawater and Roptlo tank affluent. Father. Q NA MAINTENANCE SCK9DULE Seruias Event Service Freglxenay inspect condition of tank(s) At (east once every, 3 © year e}(s) (Maxlmunn S years) C1 NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Ya) of tank volume lO NA Inspect dispersal call(s) At least once every. month(s) (Maximum 3 years) Q NA ❑ aar Clean effluent filter At least once suety; > month(s) Cl ae e. NA Inspect pump, pump controls & alarm At lea" onna every-, Q start (e) NA A ear Flush laterals and pressure test At least once every: month(s) b NA © ear s athara At least once every; Q rrt0nt (e) Q NA Q ear s 4shsr, Q A MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal calls shall be made by an Individual carrying one of the fallowing iloonsea or aerdfloations. master Plumber; Master Plumber Restricted Sower; PAWTS Inspector; POWTS Maintainer; Septage Serv)etng Operator, Tank inspeotlons must Include a visual inspection of tha tank(s) to identify any mfssing or broken hardware, Identify any croaks or leak's, mseours the volume of combined sludga and scram and to check for any book up or ponding of effluent an the ground surfeos, The dispersal ooll(s) shall be visually inspected to check the effluent levels in the observation pipes and to aheok for any ponding of effluent on the ground surface. The ptanding of effluent on the ground surface may Indicate a failing condition and raquires the Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one-third (K) or more of the tank volume, the entire contents of the tank shall be removed by a Septsge Servicing Operator and disposed of In accordance with chapter NR 193, Wiaconaln Administrative Cade. All other services, including but not llmited to the servicing of effluent fllters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall Lie performed by a certified POWTS Maintainer. A service report shall be provided to the )coal regulatory authority within 10 days of complexion of any service event, OMW (Q/Q1) Nov-11-2010 10:45 AM St Croix County plan/Zoning 715-386-4686 2/2 Page - of , START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shat) not occur when soil conditions are frozen at the Infiltrative surface. During power outages pump tanks may fill above normal hlghwator loveis. When power is restored the excess wastewater will be discharged to the dispersal call(s) in one large does, overloading the call(s) and may result In the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintalner to assist in manually operating the pump oontrole to restore normal levels within The pump tank. Do not drive or park vehicles over tanks and dispersal calls, Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade moil absorption area. Raduct(on or elimination of the following from the wastewater stream may improve the performance and prolong the 11% of the POWTS; antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water fruit and vegetable peelings; gasoline; grease; herbicides; meat scrape; medications; all; painting products; pesticides; sanitary napkins; tampons; and water softener brine, ABANDONMENT When the POWTS fails and/or Is permanently taken out of service the following steps shall 69 taken to insurm that the system Is properly and safely abandoned In compliance with chapter Comm 53.33, Wisconsin Administrative Code., • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed, • The contents of all tanks and pits shall be removed and properly disposed of by a Septaga Servicing Operator. • After pumping, all tanks and pits shell be excavated and removed or their covers removed and the vold space filled with soil, gravel or another Inert solid material. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system. A suitable replacement area has been evaluated and may be utilized for the location of a replacement soli absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot Ones and wells. Failure to protect the replacement area will result in the need for a now soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. earring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soil and alto evaluation must be performed to locate a suitable replacement area. If no replacement area Is available a holding tank may be installed as a last resort to replace the failed POWTS, ❑ Mound and at grade moll absorption systems may be reconstructed in place following removal of the blomat at the Infiltrative surface. Reconstructions of such systems must comply with the rules In effect at that time, < C WARNING 7 > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIBN T OXYGEN. DO NOT LINTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCOS. DEAT14 MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL CONiIMENTS POWTS INSTALLER POWTS MAINTAINER Name r` Name Phone 15 U Phone SEPTAGE SERVICING OPLFtATOR (PUMPER) LOCAL RE(IULATORY AUTHORITY Name 2 Name Phone Phone This document was drafted in compliance with chapter Comm 0S,22(2)(b)l1)(d)&(f) and 83,94(1), (2) 4v (3), Wisconsin Administrative Code, ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1 ' n'1 2. ot ALow -,T::9pmA,6oAf Mailing Address Z,.. C_nw 04 to Property Address slime (Verification required from Planning & Zoning Department for new construction.) City/State '14c., 55 j Parcel Identification Number ~OO LEGAL DESCRIPTION 0 Property Location W&I 1/4 , N W '/4 , Sec. 3y_, T _J_q_N R_L'~_W, Town of 1~/,CI 606) Subdivision , Lot Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this forni 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. Number o bedrooms 3 SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) STATE BAR OF WISCON SIN FOR' ~$4~ - WARRANTY )TEED ~ r REGIS'TER'S OF(=IC~ ST. CROIX CO.. W, DOCUMENT NO BC'd for R6G~71'c7 F SEP 8 This Deed, made between ~h at 3:30 P- f4j Asa A Kroll,.. husband and wife trw- - Grantor, ,t Register Deecis i -oil and Nancy ,7 Thompson, William B. Thomgff and hiTghanri qtr a wi FP Grantee, _ - - I' DING UAIA THIS SArE RESENVED FR R!"co 41- Wltnesseth, That the said Grantor, for a valuable consideration - NAME D RETURN AODR ESs Croix Heywoo Cari, S,C, conveys to Grantee the following descrbed rest estate in St, P.O. Box 2 Hudson W1 54016 County, State of Wisconsin: Part of NENLr'ik of Sec- 34-T29N-R19W described as follows: Lot_ 2 of Certified Survey Map recorded in VOL. 7 of Certified Survey Maps, gage 1971 as - Doc. No. 437575 (Parcel Identification Number) 41 r SF'ET, IOU 10 FEE This, _ is homestead property. (is) (is not) Together with a!1 and singular the hereditaments and appurtenances thereunto bel aging - And Thomas F. roll and Lisa A. Kroll, huvh3ndan warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except f easements, covenants and restrictions of record, if any, and will warrant and defend the same. s 6 - - - day of Se~tPmber-~- 19-9-5-.. Dated this (SEAL) - (SEAL) TIiQmgs F, Kroll ` ez, f t (SEAL) (SEAL) AUTHENTICATION -XKNOWLEDGMENT Signature(s) _Thomas_~._~ro sa A Kroll, STATE OF WISCONSIN 1 l anrl__L s. husband _and wife St. Croix County. _ day of authenticated this day of September 19_95 Personally came before me this aeDte1Uber / , 19.95- the above named Thomas F.-Kroll and Lisa A_ Kro11- husband and wi ~ TITLE: MEMBER STATE BAR OF WISCONSIN - - (If not. who executed the THIS INSTRUMENT by §706.06, Wis. Stats.) to me known to be th rsona_- foregoing instrument acknowledge 06-MY PUBLIC ENT WAS DRAFTED BY linda"~cge3 State of Wisconsin - is J _Aeywood & Cari.,._S.C, by__Samuel R.___Cari inda Sin el P.O Box 229, Hudson _j~l 54016 Notary Public St. Croix County. Wis. (Signatures may be authenticated or acknowledged. Bolt are not My commission is permanent. N[^f~Qnot. ostate ~expiratioon7 date: -\amc, of t,a•-- .:gn:ng :n a , capaoiv %hnuld t,, typed or p--,J hck- th- a,gn:+lura•a Wi5cOn5,n Legal Blank Co .Inc WARRANTY DF.Fn STATE BAR OF 1V J982 ISCONSIN :~+Jwauhee. Wis FORM N., `n. t - t~R3 - 7n MAY 2 3 Td JAi.12S wnRcZ' ter of DSt Croix Co., WI N X o to ~i f ii, n r West line of the NW} °o Bearings are referenced to the NOOo06'i7"E, 2644.88' nest line of the NW} of Section 34 2 assumed to bear N00006117"E. 1 2 Z .44 y z °o ~ w z C3 y 0 0 (D O O 0 0 ~ oN ° ° T'S E O w rrt is W w •i s r F•' • r-r r o ~ ~ rh O C~ o ° 12 Unplatted lands owned by others - s West line of the NEB of the NW} of In 0 . • Section 34 ~t 0 w < 0 tt 6' N00007'00.1 500.00' c* CD - N r a6 .00' i r) O x _ G-) 33.0066' ROADWAY EASEMENT / ;t '-h Lm L'z., h] I T ' -any. 2~- n ~ C--) e r w / ' v Ya 1-'• 0 rD M Q' A o• In C X t-j °O T I v o o I O O A`Y p- C C Y ' e'T C n H o a I V o o m K 1 I -1 rt r-r rt' C./3 i rt r(~'~L N N V S V O O m I Of j N• C O O +y O a ! :v rn m o a cam., rn I a to - b" Z rT1 j Q O w rn m i s o . o t` d N• LQ to A~r _ c N_ a w I `m^`_~ a O O O :c- I +w rr r-• I z y co r W O M -_j Cn amn ~D i v o d m W N• fn n r 06 CT n 00 1 rr cc ! N i o I . 9 rs - Ia It I ° I~ m 0 t=j rq w ii- I I rn AL, 0 o SOOo08' 00"W 00. ' 470.03' 29.97' to a a p 0 .r ~ z o ~ v W 1•fi N V V O o r e ~ o n m o I u+ cr_ c.o c m J~ _ yF. r:'... z C- l.7 sit # - tn" rn N ` o C2 r c - O cn ..f APPROVED n 27.761 a I 472.24' ° rt I S00 081 00"W 500.0 LEast line of the NW} of Section 34 MAY 0 3 1988 V 6' >S~Cti00(COIJMY Small Tracts Vol. 7 Pg. 1971 This instrument was drafted by Fran Bleskacek Job No. 87-45 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that. have inspected the septic tank presently serving the 1a1~ll~Qm 3 a- A fo AP-4 J. 1 by rn A5o11 residence located at: nJ U) Sec. TN, RW, Town ofn St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and in, and it appears to be functioning properly. baffles to be in good condi~Tl Last time serviced u Did flow back occur from absorption system? Yes No-IJ (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete V Steel Other Manufacturer (if known): Age of Tank (if known) : ,gym ~70~1 ~n,este r (Sign re) (Name) Please Print Knns (Title) (License DNumber) lb (Dat ) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition,.I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Jo~(YI~P_.S}er Signature MP/MPRS D 2256 Wisconsin Department of Commerce E ALUATION REPORT Page 1 of 3 Division of Safety and Buildings t in accordance with Com 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paps not less tb 8% r size. an must County St. Croix include, but not limited to: vertical nd horiagsrefreei (BM), di ion and percent slope, scale or dimemsior, north ;.7 , and location and dista to nearest road. Please t OIX COUNTY rc 20- -00-200 tiyjgC47MW-OFFICE vice y Fz/ Personal information you provide mabe u r secondary purposes (Privacy Law, s. 15.04 (1) (m)). ( Property Owner Property Location William B. & Nancy J. Thompson Govt. Lot NE 19 NW 1/4 S 34 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 644 Co. Rd. N 2 CSM Vol. 7, Pg. 1971 City State Zip Code Phone Number J City __]Village yJ Town Nearest Road Hudson WI 54016 715-386-1959 Hudson Co. Rd. N k` coon Use: 0 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD ✓f Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.5 gpd/s .ft./day loading rate. Proposed system elev.= 73.75'. _ 19f~ Y 2-00(, s Lla S l Boring # J Boring r+' Pit Ground Surface elev. 79.50 ft. Depth to limiting factor >1 16" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 *Eff#2 1 0-18 1Oyr3/4 none I 2fgr mvfr gw 2vf,f 0.6 0.8 2 18-32 1 Oyr2/2 none sit 2fgr mvfr cw 1 vf,f 0.6 0.8 3 32-40 1Oyr3/6 none sl 2msbk mfr cw - 0.6 1.0 4 40-56 1 Oyr4/6 none sl 1 msbk ml cw - 0.4 0.7 5 56-62 1Oyr4/6 none Is Osg ml cw - 0.7 1.6 6 62-116 1Oyr5/4 none sAfs Osg ml - - 0.5 1.0 H#6 contains irregular, discontinuous bands of 10yr 3/6 Ifs. -7 3• ,t "I IV Boring # J Boring ~01 $01 Pit Ground Surface elev. 78.47 ft. Depth to limiting factor >109" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 1Oyr3/4 none I 2fgr mvfr cs 2vf,f 0.6 0.8 2 8-23 1Oyr2/2 none sit 2fsbk mvfr cw 2vf,1v 0.6 0.8 3 23-42 1 Oyr3/3 none sl 1 msbk mfr cw 1 vf,f 0.4 0.7 4 42-50 7.5yr4/6 none Is Osg ml cw - 0.7 1.6 5 50-109 1Oyr5/4 none strat. s Osg ml - - 0.5 1.0 tt contains irregular, discontinuous bands of 10yr 4/4 Ifs. " Effluent #1 = BODS> 30 < 220 mg/L a d TSS >3 < 150 mg/L ` Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Sign ure: CST Number James K. Thompson k:~7~r S 3602 Address A.C.E. Soil & Site Evaluation Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 8/5/2011 715-248-7767 Property Owner William B. & Nancy I Thompson Parcel ID # 020-1120-00-200 Page 2 of 3 3 Boring # -j Boring Vf Pit Ground Surface elev. 79.71 ft. Depth to limiting factor >115" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-13 10yr3/4 none I 2fgr mvfr gw 2vf,f 0.6 0.8 2 13-30 1Oyr2/2 none sil 2fgr mvfr cw 20,1f 0.6 0.8 3 30-39 1Oyr3/3 none scl 1msbk mvfr cw 1vfr 0.2 0.3 4 39-48 1Oyr4/4 none grsl lmsbk ml cw 1vf 0.4 0.7 5 48-64 7.5yr4/6 none gr Is Osg ml cw - 0.7 1.6 6 610yr5/4 none s Osg ml - - 0.5 1.0 H#6 contains irregular, discontinuous bands of 10yr 3/6 Ifs. 3, ,f ❑ Boring # _j B In*g I` J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Pp in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # J Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) A.C.E. Soil & Site Evaluations b` " ~ Ea'~s~;~, y off,-a~(~ e 1•er~ - ~jr/sf~'ngl/leno-e ~ce>< ~2,zS6 L3, ~ /Ia-ncy~a •~-~/n o~ ~v/frlCe' . ~d. rJ we~►~ ~udscn~ c.J/. sy~/6 0 7,04. 71 _-7 17 w~P" see 3` T14i1 62inq Sato 0c(-,e 1 ~ ' fl I 11 , f Lkc~ ~arK d ( L~riJC.Way , i I 1 j r 1 • 1 i ~ I 1 ~~rv j ( ~ 1 1 1 /~Ssum~~Je/ec~` 1 r' /aca ~ I 1 l 1 - - - Sy5ftn9 .4 r e4 ^ - - - 60.0 83 1 1_ 720' ~ ~ ~ o I _78.0 - - - - - ~',AS.cIF bo•~•FS•.,, aF ssy. ~s /wy rr~ ~ n to O 0 cn O 3-0 n d 1 O A (D (D a c (D (D m y CD 3 3 rr x O 0 0 2 p T. A° 0 0 z o =r c A N ;V • 41 O N N o O Zo O 3 C O W O n N I~1 rryl l CD CA CD 3 z n N A I £J y to v A (ND A c O O W: CO S C O W O O 0 ` N N N N a O cn IU y O 7 (A _ A N r.= \ 1 O o a o C) 0 o m 0 0 CD m d l F a) CD W N 0 Cn 3 N Cn p 70 r K d N N ! N N ' p C gi 3 lV (D 0) U7 D N d (n A y O. G ? o CD ca' N n t0 N 03 T CD N N N 3 n" O O Z CL O CD C .a (0T (`n Z~ Z4 ° 00 O CD d rn rn C O p A w a l~ O (O CA CL n N N z (0 (D z : 0 r- co O co co p o .U p p Z O C CD 0, m c 'n 9 Z -u m O O O a CL O O O co C < N z ,y_ to N N m l 3 3 Cl) CA fn A I,I o D OIQ 3 0 D O Q 0 0 p 0 =r CD m CD v 5'i J 3 ` m co - 3 - N D ( co D 0 D (WD 0 O N Ln C) a O n 3 S ~ = p 3 CD (D CD CD CD (n N '''I • (D 0 -0 In a7 ~ y ll~ll O O CD N CD N FL a c CD c CD CL n to O 3 j 3 7 CD C6 m (6 y 0 =3 (D 0 N O y O 'P Z A m c c r! CL n a _0 Q ~ I 3 z w W W m N A CD (D CD (O. O. A :U 00 0 0 X Z t0 3 3 CD fD CD N D A W W O I ~ 5.0 0 D 0:E D o:E rn = CL n m a 0 N N C'OD 7. T T v O Q- O C 5 3 X 0 ° CD m 0 0-- N y CD N CD Q' 6 O to p_ CD C 7 Q 3 c ~ to ~ ~ fn l 0 :E to C O N N as C Cn O O C (D CD (n , 3 v a O CD n 7 d0 3 ~ 6 N y h O. ~ C N V CD CD O_ N j', OO v 0 O ~ N CD D C H CO ~ En O E» O ~ ya p C 0 X CX ti 0W0 nv)0 30 c d Lo~ Cc C. M ° I I - ~ 2 0 • Z d o c=i c (co o 3$ y ow o CL K) Q H o io T -I O y .I ? o O N N m z a N o00 A (p w (n d y O Cl 0 C COp 7 N CD N = < .I C7 ro (O~ co Cn 3 H A 7 H pj O Q N N A N C 3 w N u? a°~ Co a a, a s ID I N W 7 IW n ''I 1~ CD I o o a c °o coffin V 3 z O 10 0 o m M- N) o A co a rn a z o o z j n r N 0 00 OD o ° m rn rn 2 N o c _ o "w~• 000 °i 000 < Orq 0 - ' j ZD z_ C Oo 13 to fn N o c w cn yr o 8 c IcS O O 43 -04 I c~ 3 CD 3 a N zwz z -+o O O O D a D? 0 "0 0 N C M N 0) cn 9) 6 . p CD M 7 (D (D 7. w 7 a m a 3 CO) CD c6 c6 A Z z a o ? A z o fD a O. G CD oo ~ oo ~ m " a m co a CD z CL 3 A w °o C z (O ¢ N Z N C CO CD fD A CD w N• Cl) 5.0 F S a C a cc a a CD CL 7 S `V 0 G 7 p > > T N N CD N C 0 O S3? 7 7 °Z d CD ~j OZ Q Q C N 7 tT CD N N CL CD cr c l0 C '5.'. `G 3-a v. CSC O N N (D N A y N 3 O °z. (a 3~ N. a CT Q N 77 c y p ~ ' (u N CL (0 CD v °a I o CD N w o0 I o0 00 C, PRIVATE SEWAGE SYSTEM County: St. Croix -Wisconsin Department of Commerce Safety and Building Division Sanitary Permit No: INSPECTION REPORT 103 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: Village X Township Parcel Tax No: Thompson, William City Hudson, Town of 020-1102-00-200 CST BM Elev: Insp. BM Elev: BM De 'ption: Section/Town/Range/Map No: 104).0 j 34.29.19.406D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic )S D Benchmark v 2 /00, 3 p V tl~177 Alt. BM S r osing Aeration Bldg. Se ,,j S/' l a ~b Holding SUHt Inlet am 4A&t St/Ht Outlet TANK SETBACK INFORMATION S 7 7 TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet _ 7r ~0{S. Septic, (t Dt Bottom 00. y Dosing Header/ml. O t Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Lo System Hea TDH Ft Forcemain L gth Dia. Dist. to Well SOIL ABSORPTION SYSTEM h I K BEDITRENCH Width Length No. Of Tr es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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/rrench Center Bed/Trench Edges Topsoil Yes ® No ® Yes Q No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:/ lp Inspection #2: / / Location: 644 Cty. Rd. IN Hudson, WI 54016 (NE 1/4 NW 1/4 34 T29N R19W) NA Lot 2 - Parcel No: 34.29.19.406D of ?7;k4 1 1.) Alt BM Description= J 2.) Bldg sewer length 2A -amount of cover Plan revision Required? 19 Yes No n~ Use other side for additional information. Date Insepctor's Signat re Cert. No. SBD-6710 (R.3/97) y an tary Permit Application on ST. CROIX COUNTY WISCONSIN rt 12 St. Ordinance PLANNING 6 ZONING DEPARTMENT 59 i you provide ondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law1101 Carmichael Road Hudson, WI 54016-7710 C715)386-4680 Fax 1715)386-4686 laps for th t less an 8-1/2 x 11 inches in size. # 3 ❑ s application Application Information - Please Print all Information Property Owner Name ocation• 1/4NW 1/4 Sec g 3 Y ~v jro~ Yv N, R E or W roperty Owner's Mailing Address of Number Block Number ity, State TZip Code r one Numer Subdivislon Name CSM Number I Witting: (check one) i ity ❑ VINage To of l$ 1 or 2 Family Dwelling - No. of Bedrooms: 3 ~X~S~ q ❑ PubNc/Commemial (describe use): ! P \A bS 0 13 State-owned Mo 7/-7v7 faarrcel Nearest Road L Type of P t: eck only one box on line A. Check box on line B if applicable) C Tax Num Her(s) A) f.XRepair El Reconnection [.0 Non-plumbing . ❑Rejuvenation ozQ - 4 z 6G Sanitation B) Permit Number Date Issued State Sanitary Permit was previously issued 0-7 z (o / `l S g IV. Type of POWT System: (Check all that apply) Non-pressurized In-ground ❑ Mound 2 24 in. suitable soil ❑ Mound 5 24 in, suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Une ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating . DIs rsatin Area Information: 1. Design Flow (tmmd) 2• Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed GalsAhkylsq.ft:) (Min:lnch) Elevation 1. Tank Information Capaicty in Ga Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic I -Tanks New __xis Gel - %rete strutted glass -Tanks Tanks ❑ ❑ ❑ ❑ 1. Responsibility Statement ❑ ❑ ❑ ❑ ❑ , the undersigned, assume responsibility for ationlinstallation of non-plumbing for the POWTS shown an the attached plans. A Icense Is not required for terralift r r or the installation of mbi sanitation system. bar's Name (pri P stamps): MP/MPRS No. Businaps Pt" 0- & v'-R k man as 9 1 J 3 8L a u Plumber's Address (Street, Ci , State, Zip C") ,l 6-1b ~ N +~ubsov 06 Sybl~ all. County Use Only Die Sanitary Permit Fee Da a Issued Issui gerN f~lo s ) )Approved r G1 n Adverse >JO EDeleftdnafl6ri 2 5 /9 L7~Q X. Conditions of Approval/Reasons for Disapproval: SYSTEM OWNER: t 1. Septic tank, effluent finer and r ~Cq S (`O >n dispersal cell must all be services / maintained as per management plan provided by plumber. C av~n.►~ ~4 d c~ d~ 5 1~L 2. All setback requirements must be maintained J as per applicable code / ordinances. 4-~ ✓lI/ k L~~ a~ c t- 3 ca5y. 1, , ti)D.-, i 1. 1 o yv~ 1 c~ f ; I ~^te ~j S 1 ~6G n $ p.Q o q c t, V-ky)~P U N P, Ala caM~ N ~ a~ ~.eCp'r k ~ ~ 1 S Iv ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK. This is to certify that I have inspected the septic tank presently servin the ~O~n~SdN g 33 residence located at: Sec. J , T N, R. W, Town of ~ASDr3 County, Wisconsin. Upon inspection, I certify thatI ave found the t• Croix baffles to be in good itio a tank and it appears to be functioning properly. Last time serviced cond $ b ~ Did flow back occur from absorption system? Yes No line. (if no, skip next Approximate volume or length of time:-- Capacity: ga minutes Construction:-Prefab Concrete Manufacturer (if known): _ Steel Other Age of Tank (if known): - A 17 tZ> (Signa re) r- (Name) Please Print (Title) - _ (License Number) d ~ (Date) )4 Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes or licensed disposer (NR 113 Wisconsin Administrative Code) ) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (exce outlet baffle), pt for inspection opening over Name Signature MP/MPRS aaa U ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address C (Verification required from Planning & Zoning Department for new construction.) City/State v,g 3 a 0 Parcel Identification Number 0-20 LEGAL DESCRIPTION 1-16 & -b Property Location 1/4 ,hJ ~J %4 , Sec. 3 ~ , T ~ ~ N RIW, Town of ~1~Cubb Subdivision Lot # a . Certified Survey Map # , Volume _:7_ , Page # -7Warranty Deed # , Volume 3 , Page # aZ X Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site signed by the wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, 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 Planning & Zoning Department within 30 days of the three year expiration date. 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. Number of bedrooms S NA F APPLICANT(S) D / DATE TE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 0 16 E 0, >0� _0 E U) cc (D-0 2 0--a o Z IC, > CD LL. Cl- 0 0 0 U 0 Cf) 0 z chi ca i-C4 LU z a. 0 z v c c z -2 E N .1 = m (D CL (DI C. C -0 0 < z o co z 0 z C t: 04 Cb IL CL C, La 0 cD U) U) U) > C—D FL 5 Z 't z 0 0 0 m a. a. CL 0 CD 0) 0 00 00 0 U) -j 1 z c a. cn m U) CD 0 oof f 04 U') 6 0 E 'o (D 8 0 0 a. E cl 'o c o r- co CF 0 ,no -T r- 0 p , in F z 2 E -C C-4 04 chi S 0 U) cu Z 12 (n O to COL fat EL CL co .2 4) E u 2 c r- 5-- 11 oz loo (ML 22 o U) 0 Parcel #: 020-1102-00-200 05/08/2006 02:30 PM PAGE 1 OF 1 Alt. Parcel M 34.29.19.406D 020-TOWN OF HUDSON Current f] 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 WILLIAM B&NANCY J THOMPSON O-THOMPSON,WILLIAM B&NANCY J 644 CTY RD N HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *644 CTY RD N SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 5.860 Plat: 1971-GAVIN'S ACRES LTS 1/16 032/03 SEC 34 T29N RI 9W NE NW 6.37 ACRES THAT Block/Condo Bldg: LOT 2 PART OF CSM 2/373 N/K/A LOT 2 CSM 7/1971 EXC PT TO COUNTY FOR RD Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 34-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 1139/218 WD 07/23/1997 1004/449 0/1) f G cW D 07/23/1997 849/544 07/23/1997 821/548 P-, 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.860 92,200 226,100 318,300 NO Totals for 2006: General Property 5.860 92,200 226,100 318,300 Woodland 0.000 0 0 Totals for 2005: General Property 5.860 92,200 226,100 318,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 221 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 �i�cwn r,oiot / Lt. s./Y7. J its/ 3 7 4zt 437-1578 P, MAY jds JANIZ \v �, Ro3 / St. }I � V r West line of the NW} o Bearings are referenced to the N000061171IE, 2644.88' z west line of the NW} of Section 34 assumed to bear N0000611711E. ! 1� 1322.441 o z 0 rI� fo � C17 � n y C)• o -h 0 7 7 m o 0 w -f rt rt W 'f :, n r ° ° r t iL ° Co z 0 r f h O (D ° •°'O2 Unplatted lands owned by others (D h . -n I'D O ------ ----- C2 0 -- ------ >✓ s m West line of the NE{ of the NW} of N,� z I tioO • 00 Sec n 34 t-1 O (D r 66' N00007 ' 00. 00 ' r X. th 33.00' 467.00 i rt. 3 x ' rt G) I rn 66' ROADWAY EASEMENT / (.11) ton ry n � n 0 0 _. �, ° .• a 0 70 o -0 0 0 C X t--J, Cr '• 0 > o j c° O a( T M CL G. rt v cn I m S✓ O O M m m 0 I ^� r. I n F3 fr IN (D ::I N rr r:r r cC/1):3 0 O ° N a, = I Cn o o C (D ° ° I w N ~ ❑ ❑ wrn w o .a �J N of -C I c = o ° `J In s - - o O O D Co _ W � I-h • co I b r O = v Cn O O O I o_ O I A Ln I G Ol rt • n O I w I O O 0 rt - - I • d rr O I v t:.S N• . t- N O t,j I O+' N Co w v Co z I7 I o un I Vti 1 d it o z I . 0' `�' W 1 N Q N 470,03' �N M ' ` 29.97' N ja cc CD N D I V V � art'• O O .+ T O - V Cn M on N v w ^' I _ cn O Ln W W C v N r, `c ro R.,rl� cn o �' - n to v a' I to -4— o+ a Ln 2 7 o ro J. 1. 4 7 S' 0 APPROVED 10-n 472.24 I+ ID I II I 0 S00 0 00 W MAY 0 3 1988 � rt 1-6161 5 0 0 . 0 0 N �� Y East line of the NW} of Section 34 RANyg Small .Tracts AHDMomccwKW Vol. 7 Pg. 1971 This instrument was drafted by Fran Bleslcacek Job No. 87-45 C ( I o (/) O ntiO 3m o C v1 C .. 1 o g F o Si f c -. eD a ac r") r: ; I • 1 g u O-. a ' °C O cD — i " N C A co -1 p 0 .- N I -0 I I 7 _s ►'ry f D C N O N N O 0 O _ d 6 0 7 O N O - . p C ` 1 a 3 ca v 0 ° 0 • 3 7 p! O 7 H 01 I 2., O C Z rr c ? ?? 1 a c 3; = m o CD. -< D 4 . 01 v D a a Ei f a m N C a N a m N 137 X 1 m W C) c 0. ° I 0 0 NI 3 a 9. o o ° 0 cn v, Z N O 0 V ° a co C O K3 • CL I 0) — . .+ N N Z 00z! r fA CD CO c N Z o CO CO 0 C o 1 n o p o c �1 CO CD c $ Q� T C 3 ;•. o. !r c "0 'U'0 - a '0 1, 7 i °+ z 0 0 0 0 , O O O �� • CA CA 1 c 3 CA 0) N I o ND aQ E. Q v C v Q 'o v v o o a o - c� - 9 a so Q o 3 O m -CP. O 0. 0 r a 7 ,... o co m tz 7 . • `iii N •v N W 0 m a. 0 CD CD 1 O. 1 a a 3 5 I 5 z o c a cn -1. -1 N o N c c -' a. N fD a a 17... 7 1 = g 1 Z -1 w 1 00 1 W m eD CD eD eD Z 1 co o r 1 o I z � 1 co c D 3 Z I 3 O CD CD A 0 (A CO D) I 1 • O O ? a C C 4 O 0 o ' A- a G 7 7 0 G • N N c� D c o ( 7 ) c o c 4 7 Q O 7 1 03_ z a I m 2' z a = ca o o 7 •O N N . y f O 1 d f C 7 N Q • • 1 dt3no �- c `�• N I c o : Z a ' 1 =y 3-o O I 0 3 I -. v ` I o 1 . m Q N N ! A w x c 1 0 Cr i v co m 1 a N fD 1 0 o o Et o o A CD orQ v � rfl0 w • 0o i I ° o n WisconsinDepartment of Commerce PRIVATE SEWAGE SYSTEM Count St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 103 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Thompson, William Hudson, Town of 020 - 1102 -00 -200 CST BM Elev: Insp. BM Elev: BM De ption: //_- Section/Town/Range/Map No: JI UD Q �b7>� 34.29.19.406D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ' s kis / bl)D — -- a a-33 0O I 33 i 17- Q • osing Alt. BM /4 SM �l'"Pr cCifN'" Aeration ■• Bldg. Seg 3 l /b Holding SUHt Inlet 0 161-11 ' Abtitot TANK SETBACK INFORMATION (t/Ht Outi tLD '' � . Sk TANK TO Pte/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet /61 't / , Septic ^ , t r 12 " Dt Bottom 100 G4 1 1 Dosing Header / t. off Advt., . d �� Aeration Dist. Pipe Holding Bot. System, 0 / . Final Grade PUMP /SIPHON INFORMATION Manufacturer /" Demand St Cover Z /L 97 37 Model Number TDH (Lift Friction Lo System Hea TDH Ft Forcemain Letlgth Dia. Dist. to Well SOIL ABSORPTION SYSTEM s,L, rt i J I - O K BED/TRENCH Width 'Length No. Of Tr es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer. INFORMATION CHAMBER Type Of System: UNIT OR T Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 0 No El Yes iii No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: `5 / 2.7 / 0 c Inspection #2: / / Location: 644 Cty. Rd. N Hudson, WI 54016 (NE 1/4 NW 1/4 34 T29N R19W) NA Lot 2 .1 Parcel No: 34.29.19.406D ! V r 1 1.) Alt BM Description = 5 — *AIL bi e— (,( .3� 2.) Bldg sewer length = 2,L4 / Q amount of cover =' ) / � 4 �G Z / /141/ r d ,--& , Plan revision Required? IM Yes No n Use other side for additional information. ��� IJ r_.-;,,A1PArAJAIIII4 l0 J u SBD-6710 (R.3/97) Date Insepctor's Signat re Cert. No. Fr ounty - anitary permit Application ST. CROIX COUNTY WISCONSIN Ay % „In rd with ' hapert 12 St. Croix County Sanitary Ordinance PLANNING & ZOIHNQ DEPARTMENT ` rmati. you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. .04(1)(m)) 1101 Carmichael Road ST CROIX COUNT Y Hudson, WI 54016 -7710 _ (715)386-4680 Fax (715)386-4686 Mair : • . . plans for theitem r not less an 8 -1/2 x 11 inches in size. ' County Sanitary Permit # ❑ Chec revi to s application /03 1. Application Information - Please Print all Information Location: Property Owner Name rt NE 1/4 f' W 1/4, Sec § 3 �( I' — 11` �Dy� T a1 N, R I9 E(or)W Property Owner's Mailing Address Lot Number Block Number (co 1 c- RA k) City, State Zip Code Phone Numer Subdivision Name r CSM Number �oSou , ,� .-yo Ite 3 tl0 is - /q Il Type Building: (check ene) Q 1 ity ❑Village j'AT of 121. 1 or 2 Family Dwelling - No. of Bedrooms: G,, 3 EX is4' u' ❑ Public/Commercial (describe use): ilp / _ Ft's ,J■ yl, bS 0 +N1 ❑ State -owned F.- 'r. i /l P P a% ' ii• AY— i'1 �,S`i.Q,c Nearest Road 11. Type of P - t: eck only one box on line A. Check box on line B if applicable) �� RA, k) ,j Parcel Tax Number(s) A) 1 Repair 0 Reconnection . ❑Non plumbing ❑Rejuvenation I = - // 0 z -. 6 U - ZOO ' Sanitation g) q Permit Number <' Date Issued I State Sanitary Permit was previously issued 1 / / ✓' / O '"7 / Z (p / / 7 $ g IY. Type of POWT System: (Check all that apply) �/ 54 Non- pressurized In- ground ❑ Mound 2 24 In. suitable soil ❑ Mound 5 24 in. suitable soil ❑ Mound A+O ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Une ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other g rade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Pro _ ..._ . {_Gals.Fdayfsq.ft.) (Min:finch) . . _._ Elevation VI. Tank information Capalcty In Ga ,:, : Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New ilial Gej(gns -- -- Xanks - - -- - - - - - -- _..Concrete structed glass _......�.. Tanks --- ---��� worsm.-- /0 fn, y' W r, ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repalr/reconnencdon/rejuvenatioMnstafation of non - plumbing for the POWTS shown on the attached plans. A Ncense is not required for terralfft repair or the installation of non - plumbing sanitation system. bet's Name (pri 1PkrstamPs): MP/MPRS No. Busines Phone \h, ZkAo.. - ei r i I as 90y ills 38� a p Plumber's Address (Street, City, State, Zip ) 1 b P �� - � � ,DSov ; Sc - ct 5901' VIII. County Use Only ❑ Dis:�. Sanitary Permit Fee D e Issued lssui gent / s r:) Approved ❑ • n : Adverse l / \ Det: .n 2 5/ 9 ko J l IX. Conditions of Approval/Reasons for Disapproval: SYSTEM OWNER: t 1. Septic tank, effluent filter and 3) �� i �� CC4 6 / ! Cc ✓N. dispersal cell must all be services / maintained '_ `� e as per management plan provided by plumber. p '_ �+ , ...tk �-�( 6 v d 2. All setback requirements must be maintained J / is per applicable code / ordinances. t$—G, ✓l.i L , , ,....... 1\ L 0 11 tei 1 Ct g A i\-) ki ( acc i 'vk 0 5 C IS 1 I :- a• 0 ' i r , c,..i c_61v‘ t t-i I \ 1*.k 1 0 1 1 , o ti- C3c.v) , i 1 V i i I i CI I 1 — C., 11 , i 1 i , C 1 • is A i j .'.,, 1 r ---, n .,,, 4....." iii- y t .- g'‘ 11 - 1 k t SO k.-) 7 Lo t ( ct„, 0 r“...:, ) C,) C N1 Sif 1 cl ra J1 J ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the `k , om D) n w residence located at: OE ; , N`,j Sec. 31 , T act N, R 7 W, Town of kADSDrJ , St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good conditio , a it appears to be functioning properly. Last time serviced $ bl, Did flow back occur from absorption system? Yes No o- (if no, skip next line. Approximate volume or length of time : -- garran minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known): N q Age of Tank (if known) : (7 (Signa re) (Name) Please S'vn 00L,"-QRAI4L Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name 5V ' I ethe.)_ Signature MP /MPRS :V\i\rr901) • ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1 1 o 'M. S o iJ Mailing Address Property Address to � I v v erification required Worn Planning & Zoning Department for new ( q g g partme construction.) City /State 1-A% 5 c w Parcel Identification Number 0 20 — NO . – 00 'd-00 LEGAL DESCRIPTION Property Location 1 /4 ,K1 L) 1 /a , Sec. 31' ,T 4 Nit! 9 W, Town of akt15 Subdivision , Lot # a . Certified Survey Map # , Volume 7 , Page # ' 1 I I Warranty Deed # , Volume // 3 9 , Page # 02 / . Spec house yes Lot lines identifiable no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 1 1 - 7717`` U /`7/06 Sr DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05)