HomeMy WebLinkAbout161-1093-80-000
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Parcel 161-1093-80-000 03/20/2006 03:14 PM
PAGE 1 OF 1
Alt. Parcel M 13.29.20.741 161 - 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 - NORDSTRAND, DENNIS L & CAROL
DENNIS L & CAROL NORDSTRAND
210 SOMMERS LANDING RD N
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 210 SOMMERS LAND'G RD N
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 04/38-ST CROIX STATION 1977
ST CROIX STATION LOT 17 VIL NH Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
13-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 987/557 QC
2005 SUMMARY Bill M Fair Market Value: Assessed with:
108574 806,900
Valuations: Last Changed: 05/20/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 412,100 377,500 789,600 NO
Totals for 2005:
General Property 0.000 412,100 377,500 789,6000
Woodland 0.000 0
Totals for 2004:
General Property 0.000 222,800 259,700 482,5000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 112
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
,
AS BUILT SANITARY SYSTEM REPORT
1 V 1 mg air
R T D , TOWNSHIP fj.Hy ap SEC. TZ N. R
e. ADDRESS p o.11's , ST. CROIX COUNTY, WISCONSIN.
__3DIVISION LOT LOT SIZE
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1% 3LiN~y
?TIC TANK(S)_L MFGR. SC R. 'S CONCRETE ~C STEEL -
NO. of rings on cover Depth DRY WELL
.INCHES NO. of width length area
J no. of lines width length! area /D
depth to top of pipe
;;REGATE W V7 b 11/1-11 lea c ,
?.K RATE AREA REQUIRED /a j AREA AS BUILT / p 90
sciaimer: The inspection of this system by St. Croix County does not imply complete
=pliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
:;tem operation. However, if failure is noted the County will make every effort to .
::ermine cause of failure.
ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
1'INSPECTO
DATED - / - 9 7 PLUMBER ON JOB 40 A
LICENSE NUMBER 11
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
Sanitaxy Pexm.i.t-c,),2)6)_
State Septic- z r
NAME Township St. Ctoix County
Locat.i on.5(,U-4 o4_044, Section/~ T,1)A, R_) U!
SEPTIC TANK
I
Size gattoms. Number a6 Compartments j
D"i.6tance Fxom: Wett it. 12% on gxeatex stopel"b
Bu.i tding it. Wettand.6 fit.
Highwatex *0--it.
DISPOSAL SYSTEM
D ance From: Wet it. 12% ox gxeazex estop&AK.
.cb~
BuitdingA7 it. Wettand.6 do' Ft.
H i.ghwatex it.
FIELD DIMENSIONS:
Width o6 trench b Depth a xo cfz b e taw tit e in.
Length of each tine it. Depth o6 rock oven tite ~ in.
Numbex: of tines _y Depth of t.ite below gxade2( in.
Totat .length of tine.6 40Zit. Stope a6 trench in pen 100 it.
Di.dtance between tines t. Depth to bedrock %M"r it.
Totat abaaxbtion axea+ jt2 Depth to gxoundwatex ✓ it.
Requited area it 2
PIT DIMENSIONS:
Numbex ob pats avet axaund pitzs yea no
Out.6ide diameter epth below "i,ntet it.
2
Totat absoxbtion ea it A
Area %eq _it2 rn
INSPECTED By LE
197
APPROVED DATE
REJECTED P DATE 197.
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WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
• ' P.O. BOX 309
MADISON, WISCONSIN 53701
r REPORT ON SOIL BORINGS AND PERCOLATION TEST
LOCATION: J'/4, S-1-4., Section, TaWN, R,2CIP(orOVownnship or Municipality s~'~✓
Lot No. A7-, No. Subv o mCounty Owner's Name: Mailing AddressTYPE OF OCCUPANCY: Residence -A No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOILBORINGS 5=.3v._7 r PERCOLATION TESTS S 731-7P
~y d
SOIL MAP SHEET SOIL TYPE 1- A-/
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL
NUM- INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
BER
P_ ;2X
t Z_
y4V S800- A& A94A
P-,2 K r 0 Q /L 02 3 02 /
P ,2 /
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST / (DEPTH TO BEDROCK IF OBSERVED)
1. -4-
B- _F4 7?
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square get o~j~itable areas. Ind' to rl" Urt uarefe t of absorption area
needed for building type and occupancy. 4 In icate scale
or distances. Give horizontal and vertical reference nts. I t Ape.-► w- t~.k'~~+~✓.
p
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PLB67 State and County State Permit #
Permit Application County Permit
for Private Domestic Sewage Systems County L
*DENOTES STATE APPROVAL REQUIRED
Date Approval. Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY / Mailing Address:
{I~f~tLl~S f~i O X~.~t .de:,U LtJ tr ~~G*
B. LOCATION: LL'/4 faJY4, Section T N, IQ~ (or) Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township A&IACea6f
C. TYPE OF OCCUPANCY*Commercial *Industrial *Other (specify) *Variance
Single family XDuplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher __X YES NO Food Waste Grinder YES_,k NO # of Bathrooms
Automatic Washer _X YES NO Other (specify)
E. SEPTIC TANK CAPACITY Q Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation 2C -Addition- Replacement _ Prefab Concrete X
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ~O_ 2) Z 3) Total Absorb Area .Wl- sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. Trenches
Seepage Bed: L Width Depth 3° Tile Depth 1" No. of Lines
-i 3469
0. W
Seepage Pit: Inside diameter Liquid Depth Tile Size Yr~
Percent slope of land 3-' - 7f~ P lye Distance from critical slope
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 Ce 'fied Soil Te er,
NAME ` C.S.T. # and other information
obtained from ( uild
Plumber's Signature /MPRSW# Phone #3A0 - 2-9S«
Plumber's Address :12-2 'Al OW-4 -A U 16 r,.,o AZT CAI S_ $(A A,
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well). J
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM count
safety and Buildings Division INSPECTION REPORT
Sanitar
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal Information you provice may be used for secondary purposes [Privacy LAW, s.15.04 (1)(m)].
e: Ilage ❑ Town o : State Plan ID No.:
CST BM E ev.: Insp. BM Elev.: BM Description: Parcel Ity
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO 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 I Loss -1 Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
Manu acturer:
DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING
SETBACK CHAMBER Moe Number:
INFORMATION Type O OR UNIT
System:
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 11111 Depth Over Depth Over xx Depth Of =Seeded dexx Mulched
No
Bed /Trench Center Bed /Trench Edges Topsoil No ❑ Yes El
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 12.29.20,SW,SW 210 SUMMERS LANDING RD LOT 17
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. LL11 A L Ll I I I
Date Inspector's Signature Cert. No.
SBD-6710 (R.3/97)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Safety and Building l ng Water Sn
Bureau o of f Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Chec'k if re4ision to previous application
[Privacy Law, s. 15.04 (1) (m)]. 3(,(/1 l , V State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION -Sol
Pr rty Owner Name Propert Location
e % vt /4 ,3 W 1/4, S / 2. T Zq , N, R 2! ' (or)&")
Property Owner's Mailing Address Lot Number Block Number
X 0 h ~N . N. 1-7
City State Zip Code Phone Number Subdivision Name or CSM Number
. 1S 40l4 )38 sot. S4, irS c,4 t 04
II. TYPE F B ILDING: (check one) ❑ State Owned ❑ city Nearest Road
❑ Village
ii
❑ Public 1 or 2 Family Dwelling- No. of bedrooms EI(Town OF ClSe 4Liy/
42
III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) /3-2-7.90-71//
1 ❑ Apartment/Condo / 6/- 1o913-(6(5
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. E] Replacement of 4. ❑ Reconnection of R____System System Tank Only-_--_--_-____- Existing System __-isting Sytem
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.wseepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ 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: 16
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.) esq. ft.) (Gals/da /s ft.) (Min./inch) Elevation
,.tea
o 92„ Z0 Feet Feet
VII. TANK Caacit
ns Total #0 f Prefab. Site Fiber-
INFORMATION in gallo Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic ExpeAppr.
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank g2 ❑ ❑ ❑ ❑ ❑
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.
Plnrrrtrer's Name: (Pant) ° Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
,QNSWIlIll a,.t or a. P7 74S- 2/36
Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
(Includes Groundwater uln A nt Si ;nature (No a s)
Disapproved S n tary Permit Fee 9 9
❑ a /
Approved ❑ Owner Given Initial Surcharge Fee)
S('~ - Adverse Determ
ination /c'J
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SRD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Dive ion, Owner, Plumter
INSTRUCTIONS
1. A sanitary permit is vaI id for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped bya licensed pumper whenever
necessary, usually every 2 to 3 years-
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitarypermit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed-
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7-
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber isto fill in name, license number with appropriate prefix (e.g. MP, etc.
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1!2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wel,s; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated 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 / 2_
.Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and 5T IWI \
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
lCe/. ~a y'3 •
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
T f-UN f• S 1J Q P-s T QA4-T> Govt. Lot Sl.) 1/4 54A/4,S 12- T 29 ,N,R.20 E (or(D
Property Owner's Mailing Address Lot 7i Block# Subd. Name or CSM#
2 o Sv,~,u s GA~v9/a f'r S7'. ceorX sT,f7'geW
gcity State Zip Code Phone Number Nearest Road
;fo S~14'~! 7~5 )3 -5~ ❑ City El villa a L'1 Town SUM li~~/•J
❑ New Construction use: Residential / Number of bedrooms y Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: Q
Code derived daily flow '714) gpd Recommended design loading rate bed, gpd/fe • v trench, gpd/ft2
Absorption area required bed, ft2_,---' trench, ft2q Maximum design loading rate 7 bed, gpd/ft2 ' -0 trench, gpd/ft2
Recommended infiltration surface elevation(s) ~X~S7/'y~' 1 2'Zb ft (as referred to site plan benchmark)
Additional design/site considerations s -SCJI (,f F7 tioaS`r ^ fE U V Pay ArTf O~
Parent material SCJ ~7~y GS Flood plain elevation, if applicable ft
S = Suitable for system ;sv--el[:] tional MMound In-Grou9n Pressure AATGd System in Filll Holding Taankk
u = unsuitable for syu I ❑ l 7 s El u L~'~ ❑ u El S ►~U ❑ S E2-1
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft2
Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
0-20 16rg 2-
PO S6 '117 IVA 5(W /,M AIle
Ground 3 jr CQ,Q,d L S. Oje4w
elev.
jw-ft.
Depth to
limiting ^IKIAI
factor
Gin. UKiVAI
II Remarks: AC:: 3 1"
Boring #
Go ,ve -
Grou O •j S
ele .
ft.
/Depth to
limiting
factor
in. Remarks:
4T Telephone No.
CST Name (Please Print) ~~~1 LZu R -Signature
Ulbri ht Associates 7/s. 3 96O
Address Private Sewage Consultants Date CST Number
666 O'Neil Rd. Y•2S'• J~'~ rsrRazy~L
114-ldaoaIN's 440116
.
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page -,of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev. E 1 .
ft. s
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
ST. CROIX COUNTY
- WISCONSIN
ZONING OFFICE
N N N N N N N■ ■OUNST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
_w> _ _ Hudson, WI 54016-7710
` (715) 386-4680
AFFIDAVIT OF SYSTEM REJUVENATION
Property Owner: 17Z~e-NM , S 1~c,ic~,S~ce.•.1
Address :21 k0
~....,..ett, l.d.J
Day time phone: (-LW %g(,- S 1
Parcel I . D. # t 6 I • /09-S- 5
Legal Description of property: 6Lj ; 51_4 Sec., T. Z9 N.,
R. Zo W. , Tn. of MwGf...J ,
St. Croix County, WI
As owner of the above described property, I owledge that the
septic system serving this residence (3i is no ) undersized by
current code standards. I understand tha a issuance of a'
sanitary 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: SZi47
5/97
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 residence located at: Stl <--w
Sec. T ZEN, R c.) W, Town of 9".4,6.04 , St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced q 9 L
Did flow back occur from absorption system? Yes No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: 11A SC-11
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known) :
VVX Cr Vfi_ - ~`tM VC-1 v C%a. I
(Signature) (Name Please Prl t
(Title) (License Number)
5' gi A
(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 Signature
MP/MPRS
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This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property SFf,"4 L
Location of property_,~) t-j 1/4 5LJ 1/4, Section I -Z_,TZEN-R 2c-) W
Township J.\Mailing address a L-• -6-1
Address of site- Z 10
5~~. « ~aa 1 ~..w
Subdivision name S } . Ccn : Y S4-. 0~ k Lot no.
Other homes on property? Yes__)(_No
Previous owner of property
Total size of property Ct
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Y Yes No
Is this property being developed for (spec house) ? Yes K No
Volume C.40 and Page Number '1"1 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. S-75 3°1,17- , 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.
i
Signature of Applicant Co-Applicant
Date of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER '7L>~~,,,,.s h~ crct~ sicw,J
MAILING ADDRESS
PROPERTY ADDRESS 2l U 'O~aMM-rS
(location of septic system) Please obtain from the PI 'ng Dept.
CITY/STATE ~,,,~sca W"\.•
PROPERTY LOCATION ~S" 1/4, 6W 1/4, Section 12 T?-_N-R 'ZU W
TOWN OF lA,,~sc ~a , ST. CROIX COUNTY, WI
SUBDIVISION %At . Cc o: `t 5 k.. o LOT NUMBER -1
CERTIFIED SURVEY MAP , VOLUMEL-
) , PAGE q7_1 , LOT 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in-operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expi n date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carm ichael Road
Hudson, WI 54016 11/93
DOCUMENT NO. VOL 640 tAa A~~ STATE Q C~K Da~
( Y t) Y rN bT[ O:RO[RW ID CO R RI -FORM
p 4
NO DE3
3753,94
RECASTERS OFACE
Dorothy M. Nordstrand ST. CROIX CO., WIL
Rec'd. for Record Mtk 18th
.
. ...to
. to P..e n...n s . I............................. Nordlstrand . . day of Jan A.D. 1982 at
quit claims
.
1 661st of Dow$
the following described real estate in .....+~tt.•..-~PQ.i County, V
State of Wisconsin: RETURN f0
Lot 17, St. Croix Station in
Tax Key No
the Village of North Hudson.
This Deed given in compliance with
Judgment of Divorce filed with the
Circuit Court of St. Croix County.
This ..-i.S: _ homestead property.
(is) (is not)
Dated this ..-1St11 day of -..-..-January... , ly.. 82.
-------(SEAL) ---......r..EAL)
DOROTHY M. NORDSTRAND
-
- --(SEAL) - _ - - .......-(SEAL)
' .
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this ....1.5th.--- day of STATE OF WISCONSIN
..Jan- January. . is...82
----County. 1
- - Personally came before me, thin day of
► STEPHE J. DUNLAP the above named TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY to me known to be the Gerson who executed t;,e
fore{;u;ng instrument and acknowled e the same.
STEPHEN J. DUNLAP