HomeMy WebLinkAbout020-1145-50-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER c
I ADDRESS/
SUBDIVISION / CSM# LOT
SECTION f
7 TN-RW, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
C~Crsl!/~ Ca
1 I
6f
0
i
3
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: i Liquid Capacity:
Setback from: Well House n - Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width:- 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:
Labor arv+Human Relations
INSPECTION REPORT
tafety and Buildings Division
(ATTACH TO PERMIT) sanitargPF~mit~UIX
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Pltr8R 201:8
X
v!: ins. B BM Description Parcel Tax No.:
/ D -
TANK INFORMATION ELEVATION DATA /o
TYPE MANUFACTURER CAPACITY STATION BS AY150 01 ELEV.
Septic Benchmark
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St / Ht Outlet 3 y"r
Vent
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Septic NA Dt Bottom
Dosing NA Header/Man.
Aeration NA Dist. Pipe '
Holding Bot. System y, 9a 5 g
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: -50 ' "IA 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, SE, NE, LOT 71, WERT ROAD
lit
Plan revision required? ❑ Yes 2-No ~g
Use other side for additional information. f GAY `f 1 ;
SBD-6710 (R 05/91) Date I e signature Cert . No.
I
ADDITIONAL COMMENTS AND SKETCH .
rc 2
SANITARY PERMIT NUMBER:
Safety and Buildings Division
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 1/2 x 11 inches in size. -5 ~ . "
• See reverse side for instructions for completing this application State Sanitary ~ratN um er
The information you provide may be used by other government agency programs ❑ Check it revision to previous 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
~ete 1/4 1/4, S T . , N, R E (or Ide Property Owner's Mailing Addr ss Lot Number Block Number
ek7
City, State Zip Code Phone Number Subdivision Name or CSM Number
a A/ " YO IG` ( > &e6ri acs
rest Road
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ clty Tl-je&,-r
❑ Village /
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF S' a_ III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
® ~2 e
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- 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/day/sq. ft.) (Min./inch) Elevation
Id 71 -7 Feet Feet
VII. TANK Capacity Total # of refab. Site Fiber-
INFORMATION in g Tanks Manufacturer's Name Prefab
Concrete Con- Steel glass Plastic App.
New Existin Gallons strutted
Tanks Tanks
Septic Tank or Holding Tank loud - .Z ❑ ❑ ❑ ❑ ❑
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 Signatur (N Stamps) /MPRSW No.: Business Phone Number:
SPA -4T: Pa
Plumber's Address (Street, City, State, Zi ode):
d ~Y
IX. COUNTY / DEPARTMENT USE ONLY
Issued Issuing Agent Signature (No Stamps)
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Ec
VApproved ❑ Owner Given Initial Surchargeree)
Adverse Determination Xf. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SHD-6398 (R. OS/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber
INSTRUMONS
1. A sanitary permit is valid 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 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:
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 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; 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 (urve; 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.
;66Q 5~" c ~
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A)
• A
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:
Sec. , T -N01 RW, Town of 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 I S' /2415
Did flow back occur from absorption system? Yes No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete I- Steel Other
Manufacturer (if known):
Age of Tank (if known):
(Signature) (Name) Please Print
2
(Title) (Lic nse Number)
z'z 5-57,4.
(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 S i ature
P MPRS e og2
Wisconsin Department of Industry, SOIL AND SITE E V A L F.~4E' PORT Page of 3
Labor ar4 Human Relations
Division olSafety & Buildings in accord with ILHR 83.COUNTY
Attach compl ete site plan on paper not less than 81/2 x 11 inches in si but
not limited to vertical and horizontal reference point (BM), direction andf° slope Ssca(e or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. S - s~
RE}rwl WED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATJt¢ y .
PROPERTY OWNER: PEA f01 ' ,
t-1T Z9 N,R 9 E(K.W)
PROPERTY OWNER':S MAILING ADDRESS L # . NAME OR CSM #
w AZT
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE [MOWN NEAREST ROAD
NDSOIJ~ mil] S~(`J 1b lllS) sy~- "?vt ; 1'N~ Or ~ W' tF T WOAD
[ ] New Construction Use [>d Residential / Number of bedrooms S [ ] AdditiQn to existing building
j~ Replacement [ ] Public or commercial describe
Code derived daily flow SO gpd Recommended design loading rate bed, gpd/ft2 • 8 trench, gpdtft2
Absorption area required `",)--L Z bed, ft2 G 3~ trench, ft2 Maximum design loading rate bed, gpd/ft2 •a trench, gpd/ft2
Recommended infiltration surface elevation(s) • 0 It (as referred io site plan benchmark)
Additional design / site considerations X b D' ~~iyl~unytD . S~ nJ~~ ot.~ \~iN Z~
Parent material S k VT-1 nv C2 S P~vpy 4- G~ . Flood plain elevation, if applicable N fl. It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for s stem S❑ U Q S E) U 0S ❑ U MS ❑ U ❑ S o u ❑ S W U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3Tii:<
......<ti Z 1-~3 L~ `f.lZ 326 - LAS i Z,wt 51~~ L~ e S . S ~ U
Ground -I U3 -9b 1.5 `2R X1/6 - S j - --1 3
elev.
S.3 ft
Depth to
limiting
factor
Remarks:
Boring # S
ti
-L V'1 M
S
\o3 -t V
Ground
elev.
14.9 ft
Depth to
limiting
factor
> 88"
Remarks:
CST Name:-Please Print Phone:
Arthur L. We erer 715-425--0165
emgerer Soil Testing & Design Service-P.O. Box 74 River Fa11s,WI 54022
Signature: Date: CST Number:
cl_ Z -°l MOO576
PROPERTY OWNER ~1Y~ Pcty SOIL DESCRIPTION REPORT Page 22- of
PARCEL I.D. # O V) 1 y S_ 5 O
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trendy
k
3= o- 6 v3 Lt 2 z r z t 2 vn t- C,- S S 6
Z -l S t~ vI R 3 ! - 1. 2 ►v► S~J1 r h~ `Fl- C S - S L
Ground 3 1s SZ 1 O` 1 Cz 31 b - 1_ m S~h vh `4'1- ~S - 5
elev.
els:lft. C( sZ-q~ syl2 ~llb - S u s~ w,1 _
Depth to
limiting
factor ,
7 q.-1
Remarks:
Boring #
f~1U S ? 3 8 E~u L'i p
S ZL Q~ 0 N $U L Ljvs ~D 7~ U\-0 Ground
1Z
elev. s ~ OF .TTM t S'DAj G
ft.
Depth to
i limiting
factor
Remarks:
Boring #
f.Q l.•l
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
I
Ground
elev.
ft.
Depth to
limiting
factor
Remarks: - -
PLOT PLAN Page 3 of 3
SCALE 1"= 30 '
l
-r \Z u~O
zu~I
i'Z9~{g i - bo' a.3'ls~
BoTly~ of BIN)
18 CTI.. ~1.p'
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~3y` 1 - t'1 1 Jl~ • cz~j COhQ C~Z-`'TE 1-fthJDW'- T F=12Uh-,T ~.Zo1Z 1$a 1 $ul~ G {LOVivSJ
c? 67
°l~ (715 ) 425-0-165 M00576
CST Signature Date Signed Telephone No. CST #
Wiscer-ja Department 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
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S`(^• \X
not limited to vertical and horizontal reference point (BNI), direction and % of slope, scale or PARCEL I.D.
dimensioned, north arrow, and location and distance to nearest road. O ZO- \ I y S - SO
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
pr"b Zb6t fl ""j GGW49T S I~E_ 1/4 N~ 1/4,S l_) T Z9 N,R \ q E (ok3w
PROPERTY OWNER -S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # , ~'4
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE CLOWN NEAREST ROAD
Nbs4>J 1-j 1 S~(1)1~ (1IS) 33L-?~oI'3 1 ~~ON lvI R~}D
[ J New Construction Use Residential / Number of bedrooms 5 [ ] Addition to existing building
[J~ Replacement [ ] Public or commercial describe
Code derived daily flow SO nod Recommended design loading rate bed, gpd/ft2 • trench, gpd/ft2
Absorption area required \rO`t Z bed, ft2 X136 _ trench, ft2 Maximum design loading rate bed. gpd/ft2 •g trench, gpd/9
Recommended infiltration surface elevation(s) ct • 0 ft (as referred to site plan benchmark)
Additional design / site considerations x b 14'
Parent material S k \2` oy F_t, S fsijD`i 4- (SI,,. Flood plain elevation, if applicable fl • It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RU_ HOLDING TANK
U= Unsuitable for system ®S ❑ U WS ❑ U E~S ❑ U 0 S ❑ U ❑ S O U ❑ S O U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bandary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trend!
Ground 3 113 -96 5 f2 Y/(, - S O S g r l - -1 'o
elev.
_1 S.3 It.
Depth to
limiting
factor
?fib
Remarks:
Boring #
Z-~4Z
Ground
elev.
~9 ft
Depth to
limiting
factor
> 88 1
Remarks:
CST Name. Please Print Phone:
Arthur L Wegerer 715-425-0165
1e~gerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signate:e_ Date: CST Number:
M00576 j
PROPERTYOWNER `~JY lPt1~1 SOIL DESCRIPTION REPORT Page?- of _
PARCEL I.D. fl O Z-O - 1 S_ 5 O
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
W. h>in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
:3.:: Z-ts joLIR 31i - L 2>~, sbh rn'~ es - S 1.
Ground 3 1s •S 1 ~ 0 `1 R 316
elev.
1tS:1 ft.
Depth to
limiting
-7 cl -1
Remarks:
Boring #
tvU S ? 3 B L.J 1~3
L) 11
A+
S Z113v v ~ ;nU ~ _ t.yv~s ~ 7~ ~.L U ~11Z
Ground
elev. ft. 01= 1 ~1'~ k l S17Ai G / L
Depth to
limiting
factor
i
Remarks:
Boring #
4:•1
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
I
I
Ground
elev.
ft. -
Depth to
limiting
factor i 71
Remarks: -
PLOT PLAN Page 3 of 3
SCALE 1"= 30 '
w tZ-U ~ O
Zuo'
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46,267
1400576
(_715 42,-q-0165-.
CST Signature Date-Signed- Telephone No.. - CST #
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER SPoc Pe_Ama l) r3 n k Fey)moln
MAILING ADDRESS 1-79 yV ,,~_qr t Rd
PROPERTY ADDRESS q 7q We- Y t A ad
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE A d .S 0,I) , W l
PROPERTY LOCATION _5_Z- 1/4, 1/4, Section 7 T_YN-R l W
TOWN OF (,(e, or ST. CROIX COUNTY, WI
SUBDIVISION PQ,r Vie-142 L61 61,C.5 -d n °'hdd, LOT NUMBER-7/
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER.;?z_
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:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 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.
Ownerof property Y'OCK R!nman if ty ma o
Location of property~l/4 1/4, Section T dZ47 N-RAW
Township N ud SO r> Mailing address q 7 c? ~*K t" Rd
1Iu.Cl5on
Address of site 79 GJe v7- dE
Subdivision name far k-y i e_yUSta~t~s ot no. 7
other homes on property? Yes No
Previous owner of property Jc a e- V-
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? 2L Yes No
Is this property being developed for (spec house)? Yes K No
Volume 6oOIF and Page Number 6-131 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. 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.
Signature f Applicant Co-Applicant
Date of Signature Date of Signature
' .4 < .r . nrl
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~ STATE BAR OF WISCONSIN - FORM 2
DOCUMENT NO.
•~'1 ~~'~11(1 1+ `l1 WARAANTY DEED
36-3'1 t i IS PACE RESERVED "OR ~ ECOa_,hu JA'A
SAM E. MILLER, a singlE man,
I3E:nCcC MAN-and BECKY
conveys and warrants to J PEN
PENMAN,husband and wife, as joint tenants, Y,
- -
- - - - - - - -
RETURN TO
the following described real estate in St. Croix County,
State of Wisconsin:
Tax Key No.
Lot 71, Park View Estates Second Addition
to the Town of Hudson, SUBJECT to recorded
easements, covenants and restric`ions.
X01-.OP
FEE
(This Deed is given in fulecord isf ction of 2a Land Contract
dated February 15, 1980, February Volume "608", page 421, Document iio. 362852.)
This is nothomestead protierty
(is) (is not)
Exception to warranties:
Dated this day of "March--_ , 19 80
r ~ i
(SEAL) yzt/ ' Yn- (SEAL)
Sam E. Miller
s (SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGEMENT
z Signatures authenticated this day of STATE OF WISCONSIN
fi
19 ss.
i S-t__Crolx_--- County.
N/A Personally came before me, this 28th _ day of
March
)ITLE. MEMBER STATE BAR OF WISCONSIN the above named .
(If not.
{ authorized by § cos os, W is. Stets.) Sam_ E_ Mi_lle_r___.
Thi instrument #as drafted by
Hugh F. Gwen, Attorney
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12/05/96 16:37 $ COUNTY CLERK 0 001
ACTIVITY REPORT
TRANSMISSION OK
TX/RX NO. 4363
CONNECTION TEL 93869281
CONNECTION ID 1st FED-LaX*HUD
START TIME 12/05 16:36
USAGE TIME 00'47
PAGES 2
RESULT OK
9 ~.~d0'~9 C.A'444' C~"W"A9 C~'~'~9 CO464a CP4449 C~`40"~' ~9 C~
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GOVERNMENT CENTER
1101 CARMICHAEL ROAD
HUDSON WY 54016
DATE: /co
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TO: FAX NUMBER
HAM: /
Fmm: SAX NUMBER: (715) 381-4400
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NAME:
NUMBER OF FAMS mG COVER Sir=
YF COWLEPE A7 LEGIBLE nUOPAM L3 IS WT RECEXVED,
PLEASE Cctm .T:
AiAZ'1E:
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THE NUMBER:
.0 04Qb9 COOC49 c`~40~9 C~9 C~40'~9 C~4C49 C~4G49 C~9 C~4G~9 C~4C49 C,006~
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GOVERNMENT CENTER
1101 CARMICHAEL ROAD
HUDSON WI 54016
DATE:
O /
TO: FAX NUMBER: -3S~.^ 9-2
NAME: Q ~/WU-
FROM: FAX NUMBER: (715) 381-4400
NAME:
NUMBER OF PAGES INCLUDING COVER SMEET:
IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED,
PLEASE CONTACT:
NAME:
TELEPHONE NUMBER:
Ga,dp•p, GV~~ Gb4PP~ Go-ocva 6O4P4a 4~yoo-a'a G~o4ov~ ~ao`d~ cvoova r. vaov~ 6-oce•va
ST. CROIX COUNTY
WISCONSIN
= ti ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
SAN . 1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
December 5, 1996
To Whom It May Concern:
On December 4, 1996, a replacement sanitary septic system was
installed on the Brock and Becky Penman property, located at Lot
71, Parkview Estates, Town of Hudson, St. Croix County, Wisconsin.
The system installation was inspected by the St. Croix County
Zoning Office, and was found to be code complying for a five
bedroom residence.
Should you have any questions, please contact me at the above
number.
Sincerely,
Mary e k ns
q 1! -
Assistant Zoning Administrator
cc: file
Parcel 020-1145-50-000 12/06/2005 09:46 AM
PAGE 1 OF 1
Alt. Parcel M 17.29.19.764 020 - TOWN OF HUDSON
Current X I 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
JAMES R & JAREN N STROMMER O - STROMMER, JAMES R & JAREN N
979 WERT RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 979 WERT RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.560 Plat: 2276-PARK VIEW ESTATES 2ND ADD
SEC 17 T29N R1 9W PARK VIEW ESTATES 2ND Block/Condo Bldg: LOT 71
ADD LOT 71
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-29N-19W
Notes: ~ Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1211/134 WD
2005 SUMMARY Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.560 59,800 174,200 234,000 NO 05
Totals for 2005:
General Property 1.560 59,800 174,200 234,000
Woodland 0.000 0 0
Totals for 2004:
General Property 1.560 30,900 156,800 187,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 310
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
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0. ADDTtESS fu ('77 5 , ST. CROIX COUNTY, WISCONSIN. T
.-3DIVISION LOT_21 LOT SIZE 2-
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r^ - ,
97
t
l f f -Indibate Nozth A~rota ! !
PTIC TANK(S)/ MFGR. CONCRETE ✓ STEEL
NO. of rings on.cover Dept DRY WELL
rl.NCHES NO. of width le gth area
no. of lines Z width_Z_ lengthy area depth to top of pipe
GATE
RATE 5 AREA REQUIRED AREA AS BUILT
aimer: The inspection of this system by St. Croix County does not imply complete
iance with State Administrative Codes. There are other areas that it is not possible
spect 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
elkermine cause of failure.
t.EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
`INSPECTOR
DATED PLUtfBER ON JOB
LICENSE NUMBER tij 'Y 3 y
REPORT. OF 11SPECTION--I:dDIJIDUAL SWAGE DISPOSAI, SYSTEU
Sanitary Permit
r State Septic
T&I-111SHIP
• t. Croix County
SF"TIC TA711
Size
20 gallons. `umber of Compartments
Distance From: Well ft. 12% or greater slope wit.
Building' ft. Wetlands ft
11ighwater ft.
DISPOSAL SYSTE:1 Tile Field or Seepage Pit(s)
Distance From: Well J-0 -le ft. 12%.or greater slope ft
Building; ft. Wetlands f
FIELD Highwater -~-----ft.
Total length of lines ft. Number of lines Length of
each line eft. Distance between lines 4 ft. Width of the
trench Z~•ft. Total absorption area ( 2 . sq. ft. Depth
of rock below the / L in. Dp-pth of rock over tile . Z in.. Cover
aver .rock,, Depth of tile below grade in. Slope of
trench in per 100 ft. Depth to Bedrock ft. Depth to
ground water ft.
PITS _
`number of Bits Out ide i meter ft. Depth below inlet
ft. Gravel around des no. Total absorption area
sq. ft. `
,Square feet of seepage trench bottom area required .
::quare feet of seepa 't area required
Inspected by: Title':. ~•f
Approved Date _ ` ; r~~ 1971
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
• DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
Re+PORT ON SOIL BORINGS AND PERCOLATION TEST
LOCATION: Section Tz`LiN, R/~ iF (or) W, Township or AA~+si{~lity~ <
Lot No. -W-, Block No. 1 County /
Subdivision Name
Owner's Name: C__5~
Mailing Address: Z C~S p r~ I c~
TYPE OF OCCUPANCY: Residence y No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS hi 2 12 PERCOLATION TESTS
SOIL MAP SHEET SOIL TYPE 4~9 Ali-,10
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 MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
G-F - 47-4 l j ;
P 2- Kj I / I/ A )O if /I X/,o
J j SOIL BORING TESTS C
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
Z_ 7S
r
N 7S
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate number f square feet of absorption area
needed for building type and occupancy. /'T ~/3rec Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
e %v CA
00'
C3 p 110 d C~ ll
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I
* -`P% 1167 State and County State Permit #
` Permit Application County v It-# Q
for Private Domestic Sewage Systems Countyy ~iz 241
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
,fin
4z n'1 1 ( ( U", r E~ ~.c r f ` S c -1 6vi 5 .
B. LOCATION: % 4/ E '/4, Section , T~ N, R E (or) W Lot# ? r City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township Hce s-c
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms 7 No. of Persons
D. TYPE OF APPLIANCE ,s: Dishwasher YES NO Food Waste Grinder YESNO # of Bathrooms
Automatic Washer YES NO Other (specify)
E. SEPTIC TANK CAPACITY d!' Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation fie`~ Addition Replacement- Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ~ 2) . .5 3) _L_~_Total Absorb Area sq. ft.
New✓Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
s
Seepage Bed: Length Width Depth ~rrTile Depth 30 No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land ;L7, 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 Certified Soil Tester,
NAME e- 4 r y 4 ~ tm e / C.S.T. # 2 Z and other information
obtained from a Ma -,r (q=er/builder .
Plumber's Signature MP/MPRSW# 3 hone ~1' 3 2 3 3
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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