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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS qS
SUBDIVISION CSM#
/ LOT #
SECTION T2 &7_N-R _W, Town of 9L
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1
Y5
0
0 -PIP
3L9 l
r 1
I 1
( r
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole coffer.
BENCHMARK: C S S Cry 1-t
ALTERNATE BM•
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
r
Manufacturer: LLcj_ ~ Liquid Capacity: / 000
Setback from: Well y,5- House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTAM
Width: g Length Number of trenches
Distance & Direction to nearest, prop.. line:
Setback from: well: &n _ House_,/,,-!5__ Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade ViAal grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: ? KINSPECTOR: •
3/93:jt
NVisconsin'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 284214
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
GILLES, LARRY HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
i
TANK INFORMATION E EVATION DATA A9600479
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark ln9
Dosing 7
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet S-
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottom
Dosing NA Header / Man. ,7b, i• ~5~'
Aeration NA Dist. Pipe /0.4A, 91.3
Holding Bot. System 71' 90, Sa
PUMP/ SIPHON INFORMATION Final Grade S-
Manufacturer Demand '
Model Number GPM
TDH Lift Friction System TDH Ft
oss mead
Forcemain Length Dia. Dist. To wen
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ' 1, ~ DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: 'e 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.17.29.19W.NE.NW.PARK VIEW
Plan revision required? ❑ Yes [!"No
Use other side for additional information. Q6
SBD-6710 (R 05/91) Date sp s Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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:
P26_1/4, Pao 1/4, Sec. /7 , T2LN, R /y w~ Town of
O-Lk4j li 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 9 /Q
Did flow back occur from absorption system? Yes Nolek( if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacurer (if known):
Age of Tank if known): 18
(Signatur ) (Name) Please Print
(Title) (License Number)
as
(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 ~ ~ rG ignature MP/MPRS J
5/88
Safety and Buildings Division
r.■LIr■R SANITARY PERMIT APPLICATION Bureau of 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 ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFOR MATION
Pro erty Owner Na a erty Loc tion Q
1/4 A, S T A40 , N, R E (or)
Property Owner'ssMMailing Address Lot Number Block Number
L451 PR P 314 1
City, State Zi Coe Phone Number s bdivision Name or CSM Number
01 (-7ig) 818
I1. TYPE OF BUILDING: (check one) E] State Owned E] city Nearest Road
Village
Public 1 or 2 Family Dwelling- No. of bedrooms Town O Parkoi-ew
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)0;~d
1 ❑ 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. K 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 DQ Seepage Bed 18 X 3CO 21E] Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13E] Seepage Pit 43 ❑ Vault Privy
14E] 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
4 5O (43 (0443 N l,A QO r75 Feet Feet
_ TANK Ca aclt
VII NFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper.
New Existin Gallons Tanks Concrete strutted glass . App.
Tanks Tanks
Septic Tank or Holding Tank - 11600 070 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installs io the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) PI ber's Sig atu S ps) MP PRSW No.: Business Phone Number:
6995
~3~ U, Q vd 4 7~5-a1a8-
Plumber's Address (Str t, City, State, Zip Code): 1-7 47
I y
IX. COUNTY/ DEPARTMENT USE NLY
❑ Disapproved Sitary Permit Fee (Indudes Groundwater Date Issue in Agent Signature (No Stamps)„
❑Approved ❑OwnerGiven Initial cR /r Surcharge Fee) `
d
Adverse Determination /a V
X. NQITIONS FASO AL/REASO SFORD APP ROV~
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One cupy 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 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 lic-ensed 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:
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 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 8 112 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.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page I_ of
Division 64 Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
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
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
Z. C
APPLICANT INFORMATION - Please print all information. Revewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot " 1/4 1/4,S T2 / N,R E (or)I®
Property Own s Mailing Address f Lote# Block# Subd. Name or CSM# ;a
e G 7 d ! / f' u✓ ~S l 8 r G~31~ GXc.~•
Ci State Zip Code Phone Number
El City r El village J~j Town Near st Road
L )3?4.'R 1 Y3
❑ New Construction Use: ® Residential / Number of bedrooms Addition to existing building
&Replacement , / ❑ Public or commercial - Describe:
Code derived daily flow " 5 O gpd Recommended design loading rate 7 bed, gpd/fF trench, gpd/ft2
Absorption area required _bed, ft2 trenchrft2 Maximum design loading rate z ~ bed, gpd/fi2~Irtrench, gpd/ft2
Recommended infiltration surface elevation(s)- 7r~ ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system AS] S ❑ U - r - K S ❑ U G®-S ❑ U ❑ S U ❑ S [au ❑ S R U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground ` 7 SYJP 3/7 S /rr [ rt~✓
%-"1 ft. r-lla , 5W613 - S A1,4 - ,7
Depth to
limiting
fa for
in.
Remarks:
Boring #
OIL mad aw vF ,Z- 3
z z'&~ sy~~~~ CL rl ow - , z 3
3 6-I/ D- l t
Ground
elev.
Depth to
limiting
7//J in. Remarks:
CST Name (Please Print) Signature Telephone No.
A-1-41, n,'S ,/-/S--7 ?-"97
Address Date CST Number
Z s7- ~sfh e~ Gv t ~Yeb / - /r S C y6 cap
f
PROPERTY owfvER SOIL DESCRIPTION REPORT
Page ~L of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2 .
in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
1~I> s ,Pz sl c L v~ , Z
J:35 s-~R S// c M AVeW ctw 1114= Z 3
Ground 3 y ~l+ t s
gelev.
la.ivft•
Depth to
limiting
faptor
( -in.
Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS I-IGttX4,6~ w-
PROPERTY ADDRESS
(location of septic system) Please obtain fro the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, N ~.J 1/4, Section 7 TQ? F N-R~
TOWN OF lI,(„241- } ( ST. CROIX COUNTY, WI
SUBDIVISION P~ LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , 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 year expiration date. <
SIGNED:
DATE: Z/ -
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, Wl 54016 11/93
S T C - 100
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
,
~ G
Location of property 14 1/4, Section /7 ,T~N-R-47-.n
Township IA-Ae,, Mailing address
Ve 14
Address of site ZY 57
Subdivision name Lot no.
Other homes on property? YesN,o
Previous owner of property Z
Total size of property
Total size of parcel A
Date parcel was created a, - 1197~
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes __No
Volume 1/0~ and Page Number yT 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. R_ej 7 ® , 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.
Signatur pplicant Co-Applicant
/l- 0?l- 9~6
Date of Signature Date of Signature
cD 0
tD
d
40
O m
OD O M
O N N -
6 6, ~v o0 00
00 0
9 23 0.00' 180.00' 180.00' 180.00
PARK S 890 13' 09" W 1228.00' LANE
N 8 9013' 09"E 1228.00'
160.00' 170.00' 175.00' 180.00' 300.00'
1103.00
N 20
NW-NE
0 35
0 - rn
30
M CD O
~t M N
r N j / N
3 N O
OD .
31 32 4 33 N o ` 34 i` CDM 0
in- i ti po 0 O
.51 ACRES w 1.51 ACRES 1.46 ACRES 1.39ACRES z p 2.75 ACRE`
o o
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to ti 181.7 6
'
o0 N _ 176.72 8
ti 171.66 3 0
~ 9~ 300.00'
to
161.57 I.ANp g ha
'03aW 1173.11 UNPI-ATTED_ - cD S89013'09'
o it
m~ o
0
LOCATION SKETCH z UN PLATTED _ L',
MC CUTCHEON-ROAD
NW 1/4 NE 1/4 VILLAGE BOARD RESOLUTION
of
N 1/2 OF SECTION 17~ ~i RESOLVED , THAT THE PLAT OF. PARK VIEW ESTATES FIRST AD!
T29N,R19W ai JURISDICTION OF THE VILLAGE OF NORTH HUDSON, DARREI
IS HERE/BY APPROVED BY THE VILLAGE BOARD.
DATE VILLAGE PRE`
I HEREBY CERTIFY THAT THE FORGOING IS A COPY OF A R Ec.
IANGENT BEARING BOARD OF THE VILLAGE OF NORTH HUDSON.
1134°42'03"E
2° 10'13"W VILLAGE CLEF-
f STATE DA R oF WI SIN FORA I
I DOCUMENT NO w
629 [A"1297 me 61ACE RtfQWRD roll R[COIIDINO DATA
~y
:l
•-y~- Rtr-45TW OFFICE
made between T_e'rw1Ce. P. Zip ieZi'r12I}_.-
This bee_¢, ,man haasband arici ilrife ss_.~^int t ST. CROIX CO., WIL
i r Kathleen A. z~me x -'d for iteoord Nds . 25 h
crasher day .A..19~
„aa ..Lart,3t. T..1des..-_I~.l._M.11e,>-hustr~cL do a 3s30 p
.
. .
MR. Witnesse/y~ Tlbat, ~tM said Grant". for : minable eowddemUoa----
xalvatile._consisiexatit~n ` / 1r+~1
' .i.iJK-. Y\i --R..~iSbt6++•-~ih+K_. arT„D N TO
~1``1tt conveys %a Grant" the following de ODAd real estate is -_St-..• _
County, State of Wisconsin: d &off ~M~,,,•wk
[ jot 34s Parkdew Estates; First PAlition to the TmvWP
Tm Key
r
of Hudson, according to a plat recorded in the OYPZCe -
of the Register of Deeds In St. Qmdx County, WiWxnsln
x ,
SFER
f k
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t •
This i8 boamtead property- ,
t.~
Towther with and singular the herednameab andsDDurttenanew tbenmmft belonging;`
t F And__~~-. .A.•Id.V'•', `•~171YLVF -f7le__
free e and - dear el[ eaemabrances except
warrants that the title is 904 indefeasible in fee Simple and
and wiU warrant and defend the same,
it .
15th
Dated this 7 - - -
I .
(SICAL - - .~..(StAL
} (I~EAL~ . "(88~-.+)
r
} . • SST-
&ajwmOWLSDdMIBXT k :
antbentieated leis &V of STATE OF WISt7ONM
St. crou
e ---County.
of
PssosaII7 come before me, this .__~.1r i b ---_-da e
r eree mee re m earn ed.._.
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f
TITLE: MEMBER STATE BAR OF W23CONSILtei-- tPg----------------------------
' ' snthvrned by d 706.06, Wes- Stats_)
who executed the
TNfa INSTRUMENT WAS pRA[T!D BY to me YIIOwn the same.
Q4 avv:*i . Awirick. Broken foregoing