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Wisronstn Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 299081
Permit Holder's Name: ❑ City ❑ village Town o : State Plan ID No.:
LACASSE, R.W. HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax 0-
/Gj, oo /G0, 66 ` ~ -r ' Q s /J 020-1062-50-400
o 9~
TANK INFORMATION ELEVATION DATA A97 0 01 Z
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic /~u ~~C acv Benchmark ' U. GJ
Dosi co 14a, , . rrt . 'o. S d 20
Aeration Bldg. Sewer flo 26, Z
Holding
St/ Inlet 971 S, 3I #f TANK ETBACK INFORMATION St / IOutlet 9<61'
TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet
Air Intake
Septic /j4" NA Dt Bottom
Dosing NA Header
Aeration A Dist. Pipe 1U.3Y' 3. 3~'
Holding Bot. System
PUMP"1'SIPHON INFORMATION Final Grade
Manufacturer Demand
Model GPM
TDH Lift Fri o S stem TD Ft
Force main ji,,din'gth Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length S ! No. Of drenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS C; N I N
N nu acturer:
SYSTEM TO P / L BLDG WELL LAKE / STREA
SETBACK CHAMf1rER Mo a Num er:
INFORMATION Type Of ok,.✓Co~J; Q-31 - OR UNIT
System: fFv~G Sys 14
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) l x Hole Size x Hole Spacing--. Air Intake
Length -L- Dia. Y Length l 1-~ - Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-efide Systems t _
Depth Over Depth Over xx Depth Of,/ xx Seeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes No [I Yes C1 No
COMMENTS: (Include code discrepancies, persons present, etc.) S (J Qc~
LOCATION: HUDSON 23.29.19,SW NW 704 WALDROFF FARM RD 11 ,n~'
Plan revision required? ❑ Yes 94go /
Use other side for additional information. 1/0 117 W
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH •
SANITARY PERMIT NUMBER:
p
SANITARY PERMIT APPLICATION 201eE.Wand ashington Ave sion
Visconsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
',S T C
than 8 1Q 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 E-] Check if revis9ion to 00 previous application
(Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Prop y O~!ner Name / Property Location
L(,C Li 1/4 n,; 6a 1/4, S T j , N, R (or
Prope Owner's Mailing Addre Lot Number Block Number
Cit , Stat Zip Code Phone Number Subdivisi n Name or CSM Num r
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Roa
Village
Public 1 or 2 Family Dwelling - No. of bedrooms -L- -town of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
C r SO - Gam.
I -
1 E] 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
ystem 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 '1 / 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trenchd 7S 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
' C' C, ~ `5_ i 11 - % 52~feet Feet
VII. TANK Capacity Total # of Prefab. Site
App
INFORMATION in galto Gallons Tanks Manufacturer's Name Concrete Con- Steel Fiber- Plastic Exper.
New Existin structed
Tanks Tanks.
Septic Tank or Holding Tank ` oc /9110 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plu 7 (Pri t) Plumber' gnatu (N 5t ps P MPRSW No.: Business Phone Number:
~1~~ Sys _ ~~~s sss
Plumb r' c dress (Str t, City, State, Zip de :
1-~ ~
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
p(Approved ❑ Owner Given Initial OZOA Surcharge Fee)
I agd,~
Adverse Determination A CJ
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS e
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, 608-266-3151.
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 isto 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 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; replacerent 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 manufactuieer; D) cross section
of the soil absorption system if required by the county; E) soii 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 practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations
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 Cou
Include, but not limited to: vertical and horizontal reference point (BM), direction and Tu",,esPO I
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. s '
Parc l
7
APPLICANT INFORMATION - Please print all Information. Review ate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
3321i.,vti Ser+
~ya~ G4'vp srR~t<T Govt. Lot ~c> 1/4 V~1/4,S z3 T z9 N,R 1 Y E (orb
Property Owner's Mailing Address Lot If BlockI Subd. Name or CSMff
7-" /sT" .UIf /,0
Fq, ~yof/ T. r3~v,~- /3 Z es~ oZ=--.vo,,J 6-
City a State Zip Code Phone Number
-4 11f /yam 551 O 1 ((o I Z) z zz - 5555 ❑ Ci ❑ Village Town Nearest Road
Eg New Construction Use: B esidential / Number of bedrooms 7 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow COOZ?
9Pd Recommended design loading rate 7 bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 ?S D trench, it 2 Maximum design loading rate bed, gpd/ft2 ' 8 trench, gpd/tt2
Recommended infiltration surface elevation(s) S -GC 3 ft (as referred to site plan benchmark)
Additional design/site considerations 2(S~ LON il/'i~Ow Tit~E~S w/ j>,PQ~J ~D(~ S%
Parent material 5; 3W/ S
TS oV~i' Flood plain elevation, if applicable
S = Suitable for system Conventional Mound In-Grown Pressure AT G de System in Fill Holding Tank
U = Unsuitable for system ❑ U E S E. U S El U ES 1:1 U ❑ S
E~g
El S
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
0-i 10&,31,ql 51z- ZM me -1$4-A4
Ground
elev S 0
~y ~ft. •
Depth to
limiting
facto
7 In. ;
Remarks:
Boring #
l 0~7 /d S-ie ~S 1 i .3
-2- 14/0 Z- S ~7
es
Ground 0
elev.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature 41 Telephone No.
,vo3EiP7- Z1Gl3rPicGrT- r F 71S 3P6 - e/PS
Address Date CST Number
PROPERTY OWNER SOIL DESCRIPTION REPORT
Page Z of 3
PARCEL 11.01 Z6 _ J~z
Boring # Horizon Depth Dominant Color Mottles Structure 2
In. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots
Gr. Sz. Sh. Bed Trench
z/ - S/L / S w,•fi~ GS hG , 3
Ground /IV
elev. Alp, O
f--Z".
Depth to
limiting
factor
7 In.
;
Remarks:
Boring #
4 Y3 / /a floe S/L , A"79e s /C
~ 1 t C's d
Ground r '
f 7 ~Zn. ,
Depth to
limiting
factor
7 4'W in.
IT Remarks:
Horizon Depth Dominant Color Mottles Structure
In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots D
Bed Trench
Boring
5 Z 75
51-----' os ~-C
Ground
g -7_3R-ft-
Depth to
limiting
factor
7 fin.
Remarks:
Boring #
Ground
elev.
rt.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
W ES/'4'r/Dv$
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c.o r co~PN ~ R . ~ ~v~T~oa = ioo , o .
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Sv~G~sT SST, ~'ir<ovs 330
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FILED
0 g APR 17 1997
558109 ~ v
CERTIFIED SURVEY MAP
Located in part of t e SWji of the NWJ of Section 231, T29N, R19W, Town of
Hudson, St. Croix County, Wisconsin.
NW Corner
Section 23 FARr," CL IN LOT L
W oo U0`. 955
N _ , F G-. "3 12
° S. ICI.
V
6 Previously Recorded as VOL. 107- F 0 2773
C! Ln N89°52'42"W - n ,fin
US HWY S89026140"E 403.35' I _ y
North line of the SWk of the NWk
N
BENCHMARK W Masonry nail in
S89°52'42"E 370.34' m
power pole 275.34' 95.00'
Elev. 929.16 C1 t
.PERMANENT LIMITED o EASEMENT O1 VO_L. 109'_6 o CD
1C)
o PG.
N/ In m
LOT I a
C)
O N p p
v• I n• o< oHWL - 929.0 L
0
ong 0 33' 33' o° 0
c
VQ`. LOT 1 Ic o
£;o z N I~
I-e cn
PG. 20-170 ~ c 4 3.40 Acres Ln
a c N /148,136 Sq. Ft. I(•-
o v o
IT
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I / 3.00 Ac. Exc. Esmt. N I-~
o 130,679 Sq. Ft.
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to
m'
0
N89°52'42"W 370.34'
F, I 330.53' N89°52' 42"W
39.81'
m
N
00 _
02
wm W IL O I~-
Ct , I~ 0 >
H I 17) N IC-'
I.
ca LJ N T LOT 2 ~ ° L71 (A W m Y I r I N cr v
I-I 0 0 _ 'D3
dO W f Tl
o J'm -I I r o 2.82 Acres c o LJ
a m -n 171 I ,.;2,$41 , Sq. Ft. N a
CCD, z- I cr 30 -n~
Em 0 6 6' zcr a
,w d •1
0 -0i,n 1 r t„e W Lamer'
STC - zoo
•
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
11
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property .2 w LgcA4 s6.,-
Location of property 6_1L) 1/4&IAL)_1/4 , Section cT Z.1N-R -Y% _W
Township _ ACAAS.~~ Mailing address 12- ZD oA1cujc4ed 1.._ LL
of site Q
Subdivision name - = Lot no. 3Z Ad P-
other homes on property? Yes L,,-' No
Previous owner of property f f.
Total size of property oZ • 00
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? ✓Yes No
Is this property being developed for (spec house) ? Yes No
Volume and Page Number 323 yas 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 of ice of the County Register of
Deeds as Document No. ,S 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.
01
ignatuie kfAipplicant Co-Applicant
1)'It-0 of F girinatiirp
r
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER . t. cq5 an.. ~sI S
• MAILING ADDRESS 1? Z 0 A xwdd d 4 o
PROPERTY ADDRESS
(location of septic system) Please obtai om the Planning Dept.
CITY/STATE
PROPERTY LOCATION J C.V 1/4, uuw 1/4, Section _Z*Y T Z I N-R_Zf_W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMI3ER
CERTIFIEDSURVEY MAP _Z~_~_, VOLUME PAGE PLOT NUMBER_
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 licensedseptic tank pumper. What you put into the system can affect the function of the septic tank
as a treatUnent-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 ear expiratio da
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
! VOL 1.26~PACE~4 ~6~°~'d
DOCUMENT NO. I WARRANTY DEED I THIS SPACE RESERVED FOR RECORDING DATA
1
I STATE BAR OF WISCONSIN FORM 2-1982
565924
~I
HUMBIRD LAND CORPORATION, a Minnesota Corporati MISTER'S OFFICE
on i ST' CRQIk CQ,i WI
Reed for Reo®nl
SEP 2 5 1997
conveys and warrants to --Richard W. LaCasse and Grace J.
11:30 A M
LaCas s e., . hu s.ban d , and .wife . . . ° °fk 4 "J~
Re tar of p0
RETURN TO
the following described real estate in ................................................County,
State of Wisconsin:
Tax Parcel No:
Part of the SW 1/4 of NW 1/4 of Section 23, Township 29 North, Range 19
West, St. Croix County, Wisconsin, described as follows: Lot 2 of
Certified Survey Map filed April 17, 1997, in Vol. "11", page 3234, Doc.
No. 558109.
$TR IV"ER
This .......is.. homestead property.
bit (is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this 19th day of September
, 19.97....
(SEAL) HUMBIRD. LAND..CORPO... -ION (SEAL)
*B
Austin J. Baillon, President
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF MINNESO A
ss.
•
Rams
ey.................... County.