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CROIX COUNTY WISCONSIN a NON NNII ZONING OFFICE IIAI rrrrb - ST. CROIX COUNTY GOVERNMENT CENTER • ' 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 October 7, 1994 l _ > Vernon and Irene Waxon 549 County Road A Hudson, Wisconsin 54016 RE: Water (VOC) Inspection for Property Located at Lot 6, Pleasant View Dear Mr. and Mrs. Waxon: Enclosed is the original test results from SERCO Laboratories for water (VOC) inspection of the above property. If you have any questions with regard to said report, please do not hesitate in contacting me. Sincerely, Mary J. Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure cc: Pat Collins ST. CROIX COUNTY WISCONSIN ZONING OFFICE l prxrNNrull r~~~6 ST. CROIX COUNTY GOVERNMENT CENTER M 1101 Carmichael Road _ = Hudson, WI 54016-7710 (715) 386-4680 August 31, 1994 Vernon and Irene Waxon 549 County Road A Hudson, Wisconsin 54016 RE: Water (VOC) Inspection for Property Located at Lot 6, Pleasant View Dear Mr. and Mrs. Waxon: Enclosed is the original test results from SERCO Laboratories for water (VOC) inspection of the above property. If you have any questions with regard to said report, please do not hesitate in contacting me. Sincerely, Mary ?'jnkins Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure cc: Pat Collins Ira SERCO Laboratories n w.~ ~i1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46233 PAGE 1 of 3 08/30/94 St. Croix County Zoning DATE COLLECTED: 08/18/94 1101 Carmichael DATE RECEIVED: 08/19/94 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins CLIENT'S ID: Lot 6 Pleasant View SERCO SAMPLE NO: 126184 SAMPLE DESCRIPTION: Lot 6 Pleasant View ANALYSIS: Benzene, ug/L <1.0 Bromobenzene, ug/L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 Dibromochloromethane, ug/L <0.4 1,2-Dibromo-3-chloropropane, ug/L <1.2 1,2-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46233 PAGE 2 of 3 08/30/94 SERCO SAMPLE NO: 126184 SAMPLE DESCRIPTION: Lot 6 Pleasant View ANALYSIS: 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) 1.1 A 1,1-Dichloroethane, ug/L <0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-1,3-Dichloropropene, ug/L <0.9 Ethylbenzene, uq/L <1.0 Hexachlorobutadi.ene, ug/L <0.3 Isopropylbenzene, ug/L, (Cumene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isopropyltoluene) Methylene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L <1.0 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ug/L <0.1 Tetrachloroethene, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichlorobenzene, ug/L <0.2 1,2,4-Trichlorobenzene, ug/L <0.2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46233 PAGE 3 of 3 08/30/94 SERCO SAMPLE NO: 126184 SAMPLE DESCRIPTION: Lot 6 Pleasant ANALYSIS: View ,1,2-Trichloroethane, ug/L <0 Trichloroethene, ug/L 0.5 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <1.0 1,3,5-Trimethylbenzene, ug/L <1.0 (Mesitylene) Vinyl chloride, ug/L <1.0 Total Xylene, ug/L <1.0 This sample's analytical results are below the U.S. EPA's SDWA Maximum Contaminant Level of 01/30/91 for those requested compounds which are also on the SDWA MCL list. A: This compound was observed in the laboratory blank at a con- centration of 0.5 ug/L. The analytical results in this report pertain only to the items tested. All analyses were performed using EPA or state approved methodologies. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, Carol A. Kuehn Project Manager < means "not detected at this level". 1 mg = 1000 ug. Y'M 1~ 1-941 C ST. CROIX COUNTY WISCONSIN ZONING OFFICE N I I N N N N ■..■i ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during 4'. winter months, making access to this office to the insure that entry can gained. d arrangements with h Q Water (VOC's) L_0 $185.00 ❑ Septic $50.00 ❑ Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria retest $15.00 Owner: Requested by: Address. Address: ZIP ZIP 61 b Telephone W: ( ) q~ -:1+ 39' Telephone N°: ( ) Property address (Fire S CStreetT~ N, R W, Town of Location: Realty firm: Lock Box Combo:_ Closing Date: TO BE COMPLETED BY PROPERTY OWNER PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: Is the dwelling currently occupied? ❑ Yes ❑ No If vacant, date last occupied: Age of septic system: Date: Septic tank last pumped by: Previous Owner's Name(s): Have any of the following been observed? ❑Y ❑N Slow drainage from house. ❑Y ❑N Sewage Back-up into dwelling. ❑Y ❑N Sewage discharge to ground surface or road ditch. ❑Y ❑N Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. OWNERS SIGNATURE: DATE: 1/94 OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION [IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ❑Below grd ❑At-Grd Mound Approx. size 'X ❑Gravity ❑Dose ❑Pressurized Z Ft•Z ❑Bed ❑Trench ❑Dry Well ❑Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other Septic tank ❑Unknown Setbacks: ❑House ❑Well ❑Prop. line ❑Other Dose tank Setbacks: ❑House ❑We11 ❑Prop, line OOther ❑Locking cover ❑Warninglabel ❑Pump/Floats ❑Alarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Ponding: ❑Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46740 PAGE 1 of 3 10/06/94 St. Croix County Zoning DATE COLLECTED: 09/22/94 1101 Carmichael DATE RECEIVED: 09/23/94 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins CLIENT'S ID: Waxon 6 SERCO SAMPLE NO: 145634 SAMPLE DESCRIPTION: Waxon 6 ANALYSIS: g/L Benzene u Benzene, . Bromobenzene, ug/L <0.2 (L Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <O.2 Bromoform, ug/L <0.5 '..°r Bromomethane, ug/L (Methyl bromide) <1.0 r. n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 Dibromochloromethane, ug/L <0.4 1,2-Dibromo-3-chloropropane, ug/L <1.2 1,2-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. Ira W SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46740 PAGE 2 of 3 10/06/94 SERCO SAMPLE NO: 145634 SAMPLE DESCRIPTION: Waxon 6 ANALYSIS: 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) <0.5 1,1-Dichloroethane, ug/L 0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-1,3-Dichloropropene, ug/L <0.9 Ethylbenzene, uq/L <1.0 Hexachlorobutadiene, ug/L <0.3 Isopropylbenzene, ug/L, (Cumene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isopropyltoluene) Methylene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L <1.0 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ug/L <0.1 Tetrachloroethene, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichlorobenzene, ug/L <0.2 1,2,4-Trichlorobenzene, ug/L <0.2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. p~loy.s > ~d►f z SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46740 PAGE 3 of 3 10/06/94 SERCO SAMPLE NO: 145634 SAMPLE DESCRIPTION: Waxon 6 ANALYSIS: ,1,2-Trichloroethane, ug/L Trichloroethene, ug/L 0.5 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <1.0 1,3,5-Trimethylbenzene, ug/L <1.0 (Mesitylene) vinyl chloride, ug/L <1.0 Total Xylene, ug/L <1.0 This sample's analytical results are below the U.S. EPA'S SDWA Maximum Contaminant level of 1/30/91 for those requested compounds which are also on the SDWA MCL List. The analytical results in this report pertain only to the items tested. All analyses were performed using EPA or state approved methodologies. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, Carol A. Kuehn Project Manager < means "not detected at this level". 1 mg = 1000 ug. {So ~ C mnsv~~ f~ ST. CROIX COUNTY T" _ WISCONSIN trrr~N~■; - ZONING OFFICE rrrn ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM q p Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make (1Q arrangements with this office to insure that entry can be gained. 0 Water (VOC's) $185.00 ❑ Septic $50.00 ❑ Water (Nitrate & Bacteria) 45.00 0 Nitrate & Bacteria retest $15.00 Owner: Requested by: Address : 4 4 Address: Tele hone N°. ZIPS e/-~ ZIP P ' (7~) 3 B'4-3 13 4' Telephone N4: ( ) Property address (Fire If & Street) Location:)ViV ,S L_;, sec./(. T j_N, R_JT Town of Realty firm: Lock Box Combo: Closing Date: TO BE COMPLETED BY PROPERTY OWNER PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: Is the dwelling currently occupied? 0 Yes 0 No If vacant, date last occupied: Age of septic system: Septic tank last pumped by: Date: Previous Owner's Name(s): Have any of the following been observed? OY ON Slow drainage from house. ❑Y ON Sewage Back-up into dwelling. OY ON Sewage discharge to ground surface or road di ch,. OY ON Foul odors.< Other comments relative to system operation: NED I certify that the above information is complete a d e best of my knowledge. sr cfloix GO~eMITY ' OWNERS SIGNATURE: 1/94 _E OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? OYes ONo sheet # Soil series per SCS Soil Survey: Type of soil absorption system: OBelow grd ❑At-(~rd OMound Approx. size 'X OGravity ❑Dose OPressurized Ft.2 OBed OTrench ODry Well Molding Tank Ooutfall pipe OBSERVED DEFICIENCIES OOther OUnknown Septic tank Setbacks: ❑House OWell ❑Prop. line 00ther Dose tank Setbacks: OHouse ❑Well ❑Prop. line ❑Other OLocking cover OWarning label ❑Pump/Floats OAlarm ❑Elec. wiring Soil Absorption System Setbacks: OHouse ❑Well OProp. line 00ther ❑Ponding: ODischarge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector_________ Title 4 .t 9 'o 0 STC - 10 4 AS BUILT SANITARY SYSTEM REPORT RAID. OWNER sr r; cox .w ADDRESS / , Y POT SUBDIVISION / CSM_~J~j~~~+; LOT d SECTION /6' T;2 Z N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTE < f°~' -6 x INDICATE NORTH ARR W Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r- BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~,,,Q ~m._. • Liquid Capacity: Setback from: Well House r ~a Other Pump: Manufacturer Model Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width • 57 Length ~ Number of trenches_ Distance & Direction to nearest prop, line: Setback from: well:/ House Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: - INSPECTOR: 3/93:jt , Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: -6aborandHuman Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL (ATTACH TO PERMIT) Sanitary Permit No.: INFORMATION P%j 11 fi , ffs N I2RY & CINDY El City ❑ Village C7 Town of: State Plan o.: CST BM Elev.: Insp. BM Elev.: BMDescription: X Parcel Tax No.: r , " TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark O oci /DD Dosing Aeration Bldg. Sewer H F f. olding St/Ht Inlet 5 47,0 TANK SETBACK INFORMATION St/ Ht Outlet 441 Vent TANK TO P/ L WELL BLDG. A irl to ntake ROAD Dt Inlet Air l Septic ~ZS ~a NA Dt Bottom Dosing NA Header / Man. yy; q3 06 , Aeration d Si Qy.'{9' NA Dist. Pipe io.3i qy~~ Holding Bot. System A: 0~3 9~~99 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. Fi ead Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3, DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: a(> ' /a( ~IUU ' OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.16.29.19W, NW, SE, WAXON LANE / ' P 6-A Plan revision required? ❑ Yes ❑ No Use other side for additional information. 9 FajLdl-:240 SBD-6710 (R 05/91) Date spe o ' Signature Cert. No. Safety and Buildings Division v~~■:'■'■R SANITARY PERMIT APPLICATION Bureau of Building Water System: 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County n than 8 112 x 11 inches in size. (2 srs~ • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency Y Y Y programs Check if revision top vtous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location e rvr r d1/4 , 1/4, S lG T g of , N, R`e E (or)47 PropertrtyyO_wn /er's Mailing Addr~cc Lot Number Block Number City, State o~ Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms 57 Nf Town of !u r s III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo © GT o ! J6 0 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System _-------System _ Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy, 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/dayr/sq. ft.) (Min./inch) Elevation Feet Feet VII. TANK Ca in galloacits Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p New Existing strutted glass App. Tanks Tanks Septic Tank or Holding Tank S ST ❑ ❑ ❑ ❑ ❑ 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. Plumber's Name: (Print) Plumber's Signature: (No Stamps) rPRSW No.: Business Phone Number: r~iL 1 J Plumber's Address (Street, City, State, Zip Code): o W V dl IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved $nitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) it Approved Surcharge Fee) ❑ Owner Given Initial 0 Adverse Determination 93 LJ O!D_ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: z~~ /~~u'c. ~ .uryu SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. lit. 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. Vill. 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 than8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks-, building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes,- soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls,- dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) 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. _I ea) ~ ~~,•J r 44, F C'A.-e ~ vh ~r r v n e I 1 ,?&TE7 . T o~ Nov SyS rf-y E ~faUs~ pis s. rev oves~e 7KQ- OOR r&Ai A-Z_ So,-e_ T&5 T- A;ejt--,t, 1*1&' -<y57- lv,,fS rO~,q~C ot~ r o,c. *Wisconsin,Department of industry, Opt 1&Ao 1 SOIL AND SITE EVALUATION Labor and Human Relations Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. r A-; f Attach complete site plan on paper not less than 8 1/2 x 11 inches in size, Plan must County low& include, but not limited to: vertical and horizontal reference point (BM), direction and 577 /l RECEIVED percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel 1.D. # '!Y Z O 199 APPLICANT INFORMATION - Please print all information. Reviewed by e Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.14 (1) (m)). _AJ Property Owner Property Location 912k , IAJ o y ^111/11 Govt. Lot 4/4) 1/4 1,S /~Q T (or (9 Property Owner's Mailing Address 3 S 1 GT y, PD . A Lot # BI k# Subd. Name or CSM# Cp P&5fSfAj z' U i ~ccJ City State Zip Code Phone Number ~ Nearest Road [+VP&0 J W/1 SVO& (7/5 )3X-1176 -116 ❑ City ❑ ilia Livs D AJ o"~" WAY 0A.1 44J . LBNew Construction Use: R2Aesidential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 7~d gpd c Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 T 36 trench, ft 2 GMaxi~design loading rate r bed, gpd/ft2~trench, gpd/112 Recommended infiltration surface elevation(s) _ 44P ' J v ft (as referred to site plan benchmark) Additional design/site cons _ "ions ~SE ;F-_A 4'05 40/ PROP 8,04 D /S *"R 6e IJ r/D AJ Parent material 8 ROR eA,44012 7 Flood plain elevation, if applicable ft S = Suitable for system Conven 'onal Mound In-Ground Pressure AT-Grade System i . Fill Holding Tank u unsuitable for system Is ❑ u El s ®'s ❑ u ❑ s p s u ❑ s SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Consistence Boundary Roots • Gr. Sz. Sh. Bed Trench Ground _ c - S2 eev ft. ,1p ~D ,3 S 6~ /yNT/e es D l S e•s. ~ s - - 7: •8 Depth to limiting factor Remarks: Boring # _g yore J/z C s 4 ' . S io 3 3 s fs~ fie es q ; - s o _ Ground w Q S , 7 f' elev. Depth to limiting factor _?,C_In. Remarks: CST Name (Please Print) Signature Telephone No. Rotce> T- 24 Lt k Ic t,-r- 3g6- 8185 Address Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.DAi Boring # Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. n. Depth to limiting factor in. Remarks: Boring # Ground elev. n. ' Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/I? in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # , Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in' Remarks: SBDW-8330 (R. 08/95) r -L-P 1 -n °o J ~I R rq _ c I N L b° I ® I s~j ~ I Is ~o ~ I - ~ I ICI I I I I I I I q i I~ II I II 'oa v I,I I I I I i I I I ~ I I I I I W •~s CA = 00 TOO d Department of Industry, Labor PRIVATE SEWAGE SYSTEM County: and Human Relations Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI MIL LIN, JERRY & CINDY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA *9500358 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet vent TANK TO P/ L WELL BLDG. A irIto ntakeROAD Dt Inlet Air 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 Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type0 CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/ Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx :Seed_ed/:SSoddedxx ulched Bed t Trench Center Bed / Trench Edges Topsoil ❑ o ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.16.29.19W, NW, SE, Lot 6, Waxon Lane Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature CertFM . No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: Safety and Buildings Division b, SANITARY PERMIT APPLICATION Bureau of Building Water System: 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 81/2 x 11 inches in size. ~f T U • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if revision toprevious application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location L7e 1/4, S To 19 . N, R/ P E (o'Cy Prope y Ow is Mailing Address Lot Number Block Number Kddd City, State zip Code Phone Number Subdivision Name or CSM Number e S y /C (71_r 1194-074 Q s' ^ ecJ II. TYPE F BUILDING: (check one) ❑ State Owned o 'tyy Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town of p vkdodz Ill. BUILDING USE: (If building typeis public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 a2 0 - l3 0 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. pg New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 PC Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. L7Final . Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) levation W-ys Feet y' Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p New Existing I tructed glass App. Tanks Tanks Septic Tank or Holding Tank R] ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No S m s) PRSW No.: Business Phone Number: r6~ 7 3FG Plumber's Address (Street, City, State, ip Code) .s O_4 ,f e IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater [Date ssue Issuing Agent Signature (No Stamps) /qyApproved ❑ Owner Given Initial Surcharge Fee) ~j ¢(JJ~ ~ Adverse Determination 1 d.3~5 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any nevi criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwei'ing. 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 13 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 tan'k(s)oi~ other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. J ~O r c 7 G ~~V ~ 1 ~ fy/o s l Q 3 ~ e, Mtn o Q 12 gl~ d - Wisconsin Department of Industry, 2 Labor and Human Relations SOIL AND SITE EVALUATION Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. ra ! 7 ✓ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and W percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel 04 = APPLICANT INFORMATION - Please print all information. Revie ~ by Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner JERRY Property Location A/W t-' , ,1r. 114, ' 7 E (ore 1 C (ODY m i t (I IJ Govt. Lot 1145,6 q Property Owner's Mailing Address Lot # Block# Subd° Name or 3 51 cry. 2 p • 4 P14~~ ,fti 7- Ui~Gt> City State Zip Code Phone Numbe Nearest Road H-UZ OAD W I. 5goli(o (,715 ) 3 -x176 ❑ City ❑ villag o,S own ~iU XOA.) G A,I ❑'1 ew Construction Use: iesidential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd q Recommended design loading rate ef' bed, gpd/fe trench, gpd/ft2 Absorption area required bed, ft2 t 3,? trench, ft2 Maximum design loading rate bed, gpd/ft2 0 trench, gpd/112 Recommended Infiltration surface elevation(s) P C1 • Z ft (as referred to site plan benchmark) Additional design/site considerations Parent material JCS f -P Flood plain elevation, if applicable ✓U ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system B.!5- El U ❑ S ❑ U ❑'Sr El U ❑ S 1:1 U E3-9 ❑ U ❑ s Ei-vi SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots _j in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh° Bed , Trench 111. 0-f2- foyk 312-s/ f 56k d,5A ~s 2 .y: •S ' .fps 2- a, 2-/0 YA 513 ° S 1A01 4C 5 CS .'7 d Ground Z- 7.5YR y/ ! CS CS i -_7 elev. dz 12-.50 ft. /d S/lQ . S 0 S . Depth to limiting factor Remarks: Boring # /0 311- 5 17C vim'4t z&/, GS Zf . S 7 Z a /0 313 9~P d/y / S!J ~S - .7 0 .-7 Ground IO Jr~ ..S. Os em r • • 9 elev. Depth to limiting fact pr 7 cf -In. Remarks: CST Name (Please Print) Signature Telephone No. 71!5r-- /5'- 3 ,?6 PI Address Private Sewage Consultartta Date CST Number - A- _n - 4 4- - c7-A,, -1 S/t~7 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D.M Boring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to - - limiting factor Remarks: Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots ~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. Depth to limiting ; factor in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) • e c,1.. W N ? • 4 ~ J J Q - Yl ~ I 1 S 9r i • cp • W 4 1 ~ - J lU QQ 7 EU (5 I I I. a• I I 1 4, w •S oo i tv I z I CL I I I v, w ~ i _ I 0 O I o 1 ~ J 41 . o I H .Cl! Ild o 2 zu f" w ca r ' *wconsin Departrnent of Industry, SOIL AND SITE EVALUATION REPORT Page ` of 3 Labor and Human Relations Division of Safety.& Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY S-I-. c Ro t' ~l Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION VET A0V E. WAX 0 At GOVT. LOT ">ES r -SW 114,S 4 7 2 9 ,NR- 1 q E (o~ PROPERTY OWNEIT:S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # . s 4 r-r . Izn. A PIEhSA14T tJtEw CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD vDSo.~ 4.-tS. SYo (7/5) 94.3'138 HUDSO J [-fNew Construction Use [ Residential / Number of bedrooms 3 4C) J Addition to existing !wilding _ I I Replacement [ ySo J Public or commercial describe - Code derived daily tow &06' gpd Recommended design loading rate 7 bed, gpolft2 ' trench, gpd/R2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate • 7 bed, g(xlv=- Trench, Pie Recommended infiltration surface elevation(s) 6-w .3 ft (as referred to site plan benchmark) Additional design/ site considerations V f C W T EA JCA ~s 0.v Is lo/+•e w/ X-40 P Parent material SCS $ 8 j,~v,P,~kctvL~ Flood plain elevation, if applicable Al- ' • R S = Suitable for system CONVENTIONAL M-OOND- IN-GROUND PRESSURE AT-T-GUDE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem LgS ❑ U C-S U [31- 11 U EM ❑ U 0-8--o u ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tertdt t 0-, ior,,,4 3/i s/ 2-AL" Shy 7 . s I .CD z g• t2- io yk 31y1 j,extlal Ground 3 Zi y /D Y/? S/(o elev. Fy. Sa f4 Depth to limiting factor Remarks: Boring # /o Y/f 3/ z S/ 2 6, dyL ,~F S E3 • ~Z ~0 V t 3/y _ ~Jvr~y 5l 4-1 Nit' d j; CS • S . S 0 S Q;2 cs IL•3& s yR 10 "VA 'j Ground elev. -y'p /O y/2 y~~ f;.. koIL Depth to limiting factora Remarks: CST Name:-Please Print Rp SER T' 2t L 13 R i C k r Phone' 715-3-?(,- ?IRS Tess: &55 0` N E I L 'RD. t{- u tOSo Aj w t S. S 4 0 r 4o S'70 cSrh 2 y 8L Signature: Date: CST Number. PROPERTYOWNER U'eoo WaX~'J SOIL DESCRIPTION REPORT Page 2 of .3= PARCEL I.D. i Boring # Horizon Depth Dominant Color er Texture Structure Consistence BourXI3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tench 3 r 0- G VX 3/2-- 2 ,w~ S.G.C s s 1.., • S • Ground 3 7~`/ 7•SYR y~~ .S. s d~ CS r • ^1 elev. yy. 2.v It. O • y' /OOX s/~ •S. D, s ex - . 7 , Depth to limiting I facto Remarks: Boring # 10-/.j- /0 Y/e sv W F,4 s ; . C 2 -3 /oY,e f/6 s/ !-f sd~ c' s lv , y I. S So 7-Yyl~ Nip 0. Ground i elev. 0 (o /D S ~o - C S' S ~iQ - 7 f y'fj-o ft Depth to limiting I factor iI zs~ I . t Remarks: Boring # 0.6 l 6 yA3/ Z- S/ Z S~,C QO SA S 2 n,,,, ..S 3 . 31 Aq, 111,e d4,1 05 ~Z 7SYR e.5,- O , S .7 Ground elev. - /D A 5/C, c'. S. O, S 0~~2 .7 I It. { Depth to = limiting i facts y Remarks: Boring # i Ground elev. fG Depth to Nmiting factor Remarks: con 0013^10 ACM01 i rri a m 0 O id.3 I ~ ~ co M c o Z, ~ 0 tip { -o RI ti ;o p\ o tj C111)" STC-105 SEPTIC TANK MAINTENANCE AGREEMENT ~St. Croix County OWNER/BUYER i2: r- (~irC4 MAILING ADDRESS 35-1 C y4, ,61 4 A d ~j4~~; PROPERTY ADDRESS J 26 &f mxOn~A~1Q yds on Gc1i 5"yo/ (location of septic system) Please obtain from the Planning Dept. CITY/STATE /7y /So',V , ail, PROPERTY LOCATION NW 1/4, .S~e_ 1/4, Section T 29 N-R-[9 TOWN OF _ aooeAI ST. CROIX COUNTY, WI SUBDIVISION / V / `C.) LOT NUMBER CERTIFIEDSURVEY MAP , VOLUME //-?a PAGE 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 y,~ar expiration-date. SIGNED. ~ DATE St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 'r 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 Y- 1N Location of property NA/ 1/4 S'f 1/4, Section Aa T 2~N-R W Township , Al Mailing address 36-1 Address of site IJ U Subdivision name .c uJ Lot no. Other homes on property? Yes No Previous owner of property A.) o ~ 1Gd 6l Total size of property le, 21' Total size of parcel y/ ap/ Date parcel was created 11,71119t 19K- r-- Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes __X _No Volume //30 and Page Number /S-6 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. 53// / , 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. j- ig ture of Applicant Co-Applic t Date of of Sign{, OD - a -N 90°0000" a N89057~26"W 332.08 o v ~ a ~ Ib .W D 01 -N8 90 3 2 12 81' E-216.77 N N D \ N I OD T1 cD D n I \ n 1,0 \ OS 'I (n 12, \ CD r^ \ \ \ co cn u 1 00 r i a) m 0 \ \ v _ v - a I z \ o m c~ \ z z ro N ~ ~ ~ m (1) / 0 OD I o / o I cO D CY) t0 M / -n M N m ~Ln N I /4 a I o o n~~ _ 1 a° cM =N J or--0 wQ Doo 09 5 o m D \ ~ a rv ) 11~ Z\ \ C7 / N = I \ N o N O 0% ~ N wl , _o va -4 0 co ~ N \ \ a%$ ~Q Cl) D o C a O `4r. i N 0 cn r rJ C7 O 0x0 aoD_\ C~ 3n-1 \ 11 m I n O 9 3 r to (n O \ \ Or ODD \ G, O. Imo yOo1-LN C VI M > CD C O n \D'~ O 16r& TN~S E R[`CRV ED F. R~rnR:+-,NG O~fa . WARRANTY DEED isaz - p~sUMENT NO. STATE BAR OF WISCONSIN p 2- v4. L.. r. IV, E %'0 12 19 5 as. his wife..and 10:45 A• Vernon .W.axon and Irene Waxon, ~t -her..o~?I?..right - - fl~ Raj, 1,6:, ~ ttua_J•----- A.. Millin..and-- Gerald -Marital SurtTOrShlp conveys and w trr.+nts to fe as Millin-,-.husband - and ' property - RETURN TO County. Croix the following described real estate in Tax Parcel No; state of Wisconsin: 51 i' Lot 6, Pleasant View in the Town Of Hudson 13-I1ot.....--- homestead property. This - •--rights of way XM (is not) and ri Sys, easements warranties: E7CiStln$ Exception to of record . . 119.95 - - day of July- 11 - - Dated this - 1.1. j 44-r- (SEAL) -------(SEALI Waxon (SEAL) -(SEAL) * Irene. Waxon----- . - ACSNOWLEDO gNT AQTUBNTICATION STATE OF WISCONSIN Sa. Signature(s) - Croix _ County. (lam St. - day of personally came before me this t;;•:.: a:::. - Ve named 19~~t 19----- July------------ authenticates this -.------day of yoz~.Waxon. az>d_Ix. r~ L o 3. = , - azbd.~a~.fa It "J U7 - s- B-•- - OF WISCONSIN 2-- . y the - TITLE: yIEMBER STATE AR , g (If not, __.____-.06.06. Wis. Stats.) to me known to be the ume nt and ackn anthor►zed by 4 foregoing _ ~ - ST A~. •r' L _ , ~ N tuc7RUMENT WAS DRAFTED BY l~ - - .