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Provide 2 dimensions to center of septic tank manhole cover. y BENCHMARK: Ott WFCC ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION Manufacturer: /~~~lCf Liquid Capacity: .L©d Setback from: Well House / Z Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location `:SOIL ABSORPTION SYSTEM Width: / 2- Length_ 7 Number of trenches Distance & Direction to nearest prop. line: > Setback from: well: House Other - ELEVATIONS Building Sewer ST Inlet; %6.s 2 ST outlet p6.~ PC inlet PC bottom _ Pump Off Header/Manifold .76 - Bottom of system Existing Grade J > G Final grade 9T-,46 DATE OF INSTALLATION: U 9 PLUMBER ON JOB: LICENSE NUMBER: ~ INSPECTOR: ',4 r 3/93:jt i Wiscon;in Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor andHumanRelations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village a Town of: State PI o.. JORDAN, LINDA X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: i COQ OU , a :z ci_r: ` w %f%=f%0229 1 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi ng Aeration Bldg. Sewer 3.ha X7,38 H F olding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet 5! 9y' Verit TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet Septic /a >5' NA Dt Bottom Dosing NA Header / Man. ' Aeration NA Dist. Pipe L? qa, 13 Holding Bot. System g 79 41, y II PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand rn ,.~.f,r c 3.33' Model Number GPM TDH Lift Loss System TDH Ft Fi Forcemain Length Dia. Dist. To Well - I A F SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of T nches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING manufacturer: SETBACK INFORMATION Type Of 7Z;ZZ_F_ y S g Al ' CHAMBER 0/ ' AJ1_4 OR UNIT Moe Number: System: 1 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 v~a~- d r Topsoil E] Yes No C] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.16.29.19W, NW, SE, Lot 14, McCutcheon Road Plan revision required? ❑ Yes (ff'No Use other side for additional information. oz y ~ c,~,u SBD-6710 (R 05/91) Date l/ Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i Safety and Buildings Division 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 Coun than 81/2 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 it revisibri td previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prope y Owner Name Property Location W1 /4 1/4, S T , N, R E (o _tg Property wner's M Ad ress Lot Number Block Number City, Zip Code v~ Phone Number Subdivisio me o ( iuJ Ill. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cityy Nearest Road ❑ Village E] Public 1 or 2 Family Dwelling - No. of bedrooms Town DF A4 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ^LD ` 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10E] 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 SystemSystemTankOnlyExisting 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 22E] In-Ground Pressure 42E] Pit Privy 13 ❑ 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 6~d P Feet Feet Capacity . I? ill'oef VII. TANK in gallons Total # of Prefab. Site Fiber- Exper- INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank f ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume re onsibility for installation oft onsite sewage system shown on the attached plans. Plum er's Name: (Print)- f- Plum is Signature: S) IIAWMPRSW No.: Business one Number: ~2~' 7 6s l 4. 1 ber's Address (Street, lty, Stat , Code): 1,7 4Z o CO- o-- 3 I COUNTY D PARTME T USE ONLY Disapproved Sa ryPermitFee (Includes Groundwater aIssuin AgentSignatu (No Stamps) Surcharge Fee) []pproved ❑ Owner Given Initial O ` Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: IV t7 SBD-6398 (R. 05/94) DISTRIBUTION: Original to Counly. One copy To: Safety & Buildings Dive ion, Owner, Plumber INSTRUCTIONS 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: 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. 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. Absorpt,on 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, numbe- 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 co rnty. The plans must include 1.he following: A) plot plan, drawn to scale or with complete dimensions, location of ho cling tank(s), septic tank(s) c,r ether treatment tanks; building sewers; wells; water mains/water service; stre irr , ar,c' lakes; pump or siphon tanks; d stribution boxes; soil absorption systems; replacement system areas; and the location o the building served; B) horizontal and vertical elevation reference points; C) complete specifications `or pumps and ontrois; dose volume; elevation differences; fricticn loss; pump performance curve; pump model and p,.mp manufE~..t. o er D) cross section of the soil absorption system if required by the county, E) soil test dataon a. 115 florin; and F) II -izing 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. ~/W h G X X r,v O r ST /0 r I QGt,Bs/ ~ u fee All 411-1~ C~rsuu+e Ipo.v' u,r /07t- yS'1- OQ6> ~ rH /fraNhcl ~ DAVE FOOMY KUMW'1 4 Ljc r T"tor Plumber kk/L y Road ' Phone ROBE! . WIGS 3 / i t~j g etCL i ~ , Ii~ 1 A A A ' ~ of Vl N ~ i Ok o a ~ i I I Wisco~ sin 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 8 1/2 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 REVIEWEDBY DATE PROPERTY OWNER: PROPERTY LOCATION paj GOVT. LOT Gv 1/4,5,46 114,S14 T~ N,R E {o PROPER WNER': ILIN ADD S LOT # BLOCK # SUED. NAME OR CSM # e V - CITY ATE ZIP CODE PHONE NUMBER []CITY ]VILLAGE PrOWN NEAREST ROAD 0 -4~ - 2- [/I New Construction Use Residential / Number of bedrooms y [ J Addition to existing building j ] Replacement [ ) Public or commercial describe Code derived daily flow 6p0 gpd Recommended design loading rate , 7 ed, gpdfft2 trench, gpd/ft2 Absorption area required _Z,~'d bed, ft2 2:;-o trench, ft2 Maximum design loading rate . Zbed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) lY y ft (as referred to site plan benchmark) Additional design / site considerations 0 7'E T EA5Q-4 e AM g &-2Zw9 Q&2 I'VE 3 Parent material Flood plain elevation, if applicable ft r~U=uitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM W RLL HOLDING TANK Unsuitable for system [~1 S❑ U El S [A U 0S 11U El S Q1 U ❑ S VU O S [ 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 Tmr& ~d 'e -17 /d - co X C Ground L _ 2 Z. 3 S z . 7 elev. 93 6 ft. f Depth to T j -S arc - limiting factor P~ Remarks: a 3j7 c AND G'p x Boring # A, 4 Ca 7 2. r- C .5 4 Ground elev. P.L.-k- ft. . 7 Depth to `3 A" r o All limiting factor 5 eD Remarks: CST Name: Please Print 0~ t Phone: Address: v CV 7- 3 7/~ 3 G !Gr 2 Signature: f_X le a Date: CST Number: PROPERTY OWNER 7D/Zt-,- VA) SOIL DESCRIPTION REPORT Page 2 of PARCEL I.D. # CDr" #l Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground Z _ 3 c f 4s z f. elev. RZF ft. Depth to limiting factor Remarks: XQ- J!t K .s2.c~D ~nf~ Boring # Ground f q elev. /DD•~ft. Depth to 3 42- /0 - _ 3; ® G cs f limiting factor V s-~ .5 Remarks: Z /g, L Boring # J Ground <o _ L ~cc C A4 lel' v -C ~y 4( .S-- elev. /pefz ft. Depth to 6 -53 ° - S,p c s o [ , I' limiting factor Remarks: 3 20- 'R,gry l- f /p~e csA Boring # Ground elev. ft. Depth to limiting factor Remarks: . Lo7 - ' 13 i e®#z ~I3 ® 3 T/t<_'E ~zuF 7s' ' ,¢CT`XN,FT~ j s r.~t /cF~ ry-ro q t,7 yak S SzT~ ~ 1{ous~ ~ Sr 7- E !f / ~ Q -z r I Lot ,y 7-v 5 4 = 13~,/ ToP o r,.~~t[~,9D IF2 St.1~'vE~o,~l' /APE ~.oT L.z'xIE~ ~.4~PL-~6~' sb T csT B/YI~ rgsSN~sr~ /p~.~ " = 47 Y, ir,"7 for li it Fotw1vb Q - wECc I J) I,, 7o SzTT S~oP~ /~.vi~ TiS<E L.S~c/~ o~ 41axlc rrELD ,7 rr~Go/€rror~ of pr y'~ x I/~DcuFVFTL .2'T IS 7~ dE ,UoTE-p T/Lz3' ,EL~vi~TTDrI. PuTt YV, ?h~G #Z 1,1o.e;rZON w/ZTr (5ll,pol4vEL Aivr-'- cod - 72V SIC 11.59NLX /,IeIAVAAFn.4>S GS)Vll AGL DF 7R-P FT EL D F--is-1 I ~ 3 ~3 %UPN frlZociND DAVE FO6ERTY IOLL VMNNG - - #~2 uowftd Perk Tester i Plurr%W 33 I 03233 03249 fl~yy N Road Phonf 149- Y` /-`J'am ~sJ(~VF~ ~A1F ' I ands Human Rent of In ustry, SOIL AND SITE EVALUATION REPORT Page of3 Labor Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY $'T. G (Z O 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 (INA100 E• 4v14 X ON GOVT. LOT A>EST -5 1/4,S Ko T 21 ,N,R. 1 q E AF) PROPERTY OWNER':S MAILING ADDRESS LO BLOCK # SUED. NAME OR CSM # S y 2r • 'zn • A / PlE*#VS ArJT vtEw CITY, STATE ZIP CODE PHONE NUMBER CITY []VILLAGE OWN NEAREST ROAD vOS0,0 cuts. SYo /c- (7/5) $G- 3y38 HuDSo,J cry. RAW. f1- [ New Construction Use [ Residential / Number of bedrooms 3 40 y [ [ Addition to existing building j ) Replacement ( J Public or commercial describe - f5zo Code derived daily flow &5 gpd Recommended design loading rate ' 7 bed, gpd/U2 ' 00 trench, gpd 11 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate • ? bed, gpd/ft2 •0' Irench, gpol(t~ Recommended infiltration surface elevation(s) 5-w- p y .3 ft (as referred to site plan benchmark) Additional design / site considerations Parent material SCS 69 0a fo rA-• Flood plain elevation, if applicable N yf' • it S = Suitable for system OONV IONAL MOUND IN-GROUND PRESSURE AT-GRADE SYST FILL HOLDING TANK U = Unsuitable fors stem IRS 11 U EW ❑ U as'' ❑ U C.S, ❑ U C 0 U ❑ S SOIL DESCRIPTION REPORT ' Boring # Horizon Depth Dominant Color Mottles Texture Structure Cons is~ Bound3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed oxh l 1 0-N o ye 3/Z-- S/ 2~ S,f 7S S . s Z 30 AO 0 313 s A 2 4*% R 45 C s 310. • S •G. Ground ye. io '1 - s yR y1G C.S. D, S G~~C ~ . 7. elev. 100 o fc Depth to limiting factor o > Remarks: Boring # /0 ye 3/2- S/ s~K Asti s El z • !g /o y9 3 f z ~l s es . s 13 3 • y0 7•s ye YAe S. D, s a~:2 cs Ground u/nd l elev C. L9 Sq fL Depth to limiting factor n Remarks: T Name:-Please Print 12p 13ER r 21 L t3 R l C h r Phone: 715- 3 SM - 8185 Address: (.55 0' N et• L -RD, t+u OS.D ej W IS . 5401 cSrh 24 8L Signature: Date: CST Number: ORIGINAL test-site APPROVED for & conventWal B ptw syete". PROPEMYOWNER V~RrJ w~Xonl SOIL DESCRIPTION REPORT Page? PARCEL ID. ft Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Band3y Roots GPD/ft in. Munsell Gu. Sz. Cont. Color Gr. Sz. Sh. B~ El ( 0• !t /ol~R 3/i s 7Z-744 7S C S S . G 2-- /1-/f io y/t 313 r:rZ Z Zf d C.5' Z w► . S Ground j / 7, S 2 G sS . O, S d/~p S i • 7 fs el~ft l • L 161A 516 • 7 . •d Depth to ! limiting factor Remarks: Boring # (9 • 16 31 S1 2 5~4 ejX S Z," • S ~ • ~ • S . 6 Z • & /o YR 3/,3 WS4 CS' .2 Ground Y, v elev. O /D R 51-1, C S. D, S ~-Q i . 7! /oD • /o ft. Depth to limiting facto p I Remarks: Boring # 0-9 /o Y le 311-- S ( Z ,N, S~iC 454 S .2,k, . G RA EY/ f 110YA313 S. G Z 75YR 11((o D, s Ground elev. /0 i Depth to ' limiting i faCtDr J2- Remarks: Boring # Ground elev. ft. -lo Depth to limiting factor Remarks: eon 01s4nio nc/(1m J P i 1 G -v C O ~ rn ~ o r ,~H o~ z U n a 0 CIA H H ~s- c coo N ~ m s . - c ~ ra > w • V) N o t°v w h (lr 1 r x ti J -`n ^An ...r ► # ,a 1.ilro ar•,-. q. ~ ,.,:1 . _ . /J 74d 1'1'&e ON SKETCH ~kd ~~>~~t GLZ~ C~ PLEA SA NT VIEW, A LOCATED IN THE SW 1/4 OF THE EE 114 AND IN THE NW :N OF THE SE 114 OF SECTION JJ~ rAaor 1{, T29N, R191% TOWNSHIP OF HUDSON, ST.CROD( COUNTY, WISCONSIN / urt OWNERS4 - VERNON AND IRENE Y1AxON \ NOT[: BEARINGS SOUTH LI I N[-5[ BEARING. UNPLATTED LANDS OWNED BY OTHERS 9 39CTION I9, I \ " 2 570. 15 ' "(Ow" OF HUDSON. . moo 10' is "IS •47.51 - I - --t91o.a4')-----ass' sass'--•--- 0 4 9.04' \ ~ 4'1 rs'1 TrRI \ w 3 ! 1 Iw \ r 4.36 ACRES o 2 sill p ( 190,039 Sc PT.1 O O 6.92 ACRES p I o (A301.632 SO FT) O I • 11 AC. E%C. ROAD EASEMENT p j 0 I29"164 30.'T.) O \ _ 100010,111 -320.0 - 3to. 00 190.00. I PONOIN{ / / 1 140.00 Al EASEMENT 00 t 471.0 ~~~4 0. ~t10 or. to f 00 CO Not / ti \W 7 8 - - ~ s 2.62 ACRES 2.00 ACRES ~ / • ir301 09'55 E 210.77 1 / ~ I \ ' 1 1 - PONDIN4 /l 114,092 SOFT) \ 6 7, n l so. FT.) r 2.00 ACRES / /EASEMENT 1{71332 SO. iT.) w f0 1h (O GO • 1 \ ► \ •A , a - • /4 2.00 ACRES s . 467,0 \(67, 170 SO.fT.) : _ q ors 7 AND 6 VVV COMMON ORIVEWAr C.S.M. 6.28 ACRES / ° to • . / (273,64! so.FT.I YHE --Pt/ \ \ ea / i tC eL/C~ tat I o _ So. BUILDING SETBACK LINE TEMPORARY `PtEQ ' • © •t \ CUL-DE-SAC • ID (80'RADIUS) _-1i6/!//~I l.J~'lL 'oi t.aef too 2?/ r 493, 14 Or A lose 0 mill 4 All -12.20 ACRES ,96, 014 s0.FT.) - / I - 13 • I a 2.12 ACRES 12 (Ill 210 sa.FT.) A. _ _ • 2.01 ACRES / a W • - - 1 stoil r-274.49 -7 a /A (47,473 SO.FT.) 4 A 2.00 ACRES I 6+ (87,213 SQ.FT-) 6. ►►R01f. NORTH LINE / OF THE sr- BE Z~~I A., //S I p 1: / e. N -J ' - - - - - - - - - - - - 1- - - 150.00' /L - 190. oo' - - - 339.91 - - IS. 14' SO. 23'43"E 21)5.05 THE SW- sc EAST LINE OF THE Mr-!E UNPLATTEQ,LA DS OWNED BY OTHERS NOTE ELEVATIONS SHOWN ARE SEA - LEVEL DATUM FROMU. S-6.3 /p BM. 4 LOS. PER UNEAR FOOT. 1' K u- IRON PIPE Z O r_ /l 0 - 7 ~J _ l~ 1 SET AT ALL OTHER LOT CORNERS. rwi $CAL 'AVE BEEN MADE TO THE NEAREST ONE 0 50 100 200 300' ThI s In 7 31EASUREMEMM HAVE BEEN A1ADE TO THE SHEET 1 D F 2 SHEETS TO THE NEAREST SECOND. I _ STC-105 SEPTIC TANK MAINTENANCE AGREEMENT / St. Croix County OWNER/BUYER MAILING ADDRESS L1,91 ~S 106 PROPERTY ADDRESS GtJQXSdyi hl (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION1 1/4, f 1/4, Section /,t/,, TA_N-R_W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION 0fe r LOT NUMBER CERTIFIED SURVEY MAP , VOLUME 4&, PAGE T-, 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. UWe, 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: J DATE: 7-,) "CIS St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, \VI 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 r~ Location of property 4_114, Section ,T_,~4N-R l!f W Township Mailing address c l0~ Address of site Subdivision name Lot no. Other homes on property? Yes No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? /Yes No Is this property being developed for (spec house)? Yes No Volume //.I> and Page Number 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 o fice of the County Register of Deeds as Document No. 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 tAe offi e of the County Register of Deeds as Document No. f7 J Signature of licant Co-Applicant -7 -,)6- ys Date of Signature Date of Signature 531874 State Bar of Wisconsin Form 2 - 1982 WARRANTY DEED DOCUMENT NO. vo►_ 1132PAGE60C'~ ,..1l CIT. f Vernon Waxon a/k/a Vernon E. Waxon and J U L -31 1995 Irene axon, a a rene axon, us an an wi e, 8:00 A. conveys and warrants to John E. Jordan and Linda M. Jordan husband and wife, - THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS/ the following described real estate in St • Croix County, State of Wisconsin: h;~s p ± (Parcel Identification Number) Lot 14, Plat of Pleasant View in the Town of Hudson, St. Croix County, Wisconsin. This is not homestead property. )QW (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of July , 19 95 (SEAL) (SEAL) * ,Vernon Waxon, a/k/a Vernon Waxon (SEAL) (SEAL) * *Irene Waxon, a/k/a Irene S. Waxon AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. St. Croix County. authenticated this day of 19 Personally came before me this day of July , 19-9-5-- the above named APR pU~ Vernon Waxon, a/k/a Vernon E. Waxon, * and Irene -Waxon} a/k/a I ~ne S. _ TITLE: MEMBER STATE BAR OF WISCONS Waxon husband and wife (If not, - authorized by §706.06, Wis. Stars.) F. S Oe~ld to a known to be the persons who executed the f going instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina O gland OFWISCO~- - - 1tRR~a~ * Attorney at Law No ar Public r _Q County, Wis. (Signatures may be authenticated or acknowledged. Both are not My ommission is permanent. (If// not, state expiratio e: necessary.) -~lo 19~.) *Namcs of persons signing in any capacity should be typed or printed below their signatures. I WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin l.rgnl RLrnk Go, low ;i FORM No. 2 - 1982 Milwaukee, Wig; -t ST. CROIX COUNTY WISCONSIN L ZONING OFFICE C N N p p N N N N nrrd ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road =1 - ~ Hudson, WI 54016-7710 lr = (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 14, 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, Mar7~ /yen ki n s Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure cc: Pat Collins f PTTs._ t SERCO Laboratories " 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 y ~o LABORATORY ANALYSIS REPORT NO: 462 4'1 F i'/i 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 14 Pleasant View SERCO SAMPLE NO: 126194 SAMPLE DESCRIPTION: Lot 14 Pleasant View ANALYSIS: - Benzene, ug/L 2 Bromobenzene, ug/L <0..2 Bromochloromethane, ug/L <0 <0.2 Bromodichloromethane, ug/L <0.5 Bromoform, ug/L 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) <0.2 Dibromomethane, ug/L 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) <1.0 1,3-Dichlorobenzene, ug/L (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: 46234 PAGE 3 of 3 08/30/94 SERCO SAMPLE NO: 126194 SAMPLE DESCRIPTION: Lot 14 Pleasant ANALYSIS: View 1,1,2-Trichloroethane, ug/L <0.1 Trichloroethene, ug/L <0.4 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. ST. CROIX COUNTY WISCONSIN rr■r■w■■■ - ZONING OFFICE "i"" ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road - Hudson, WI 54016-7710 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM et 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 arrangements with this office to insure that entry can be gained. V-Water VOC's ( ) L-ol $185.00 ❑ Septic $50.00 ❑ Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria retest $15.00 Owner: 9)Qn,,.,., o,, ( J a,( 6 Requested by: Address: tz~ A Address: ZIPS ZIP Telephone W: ( -71S) 3g b - 4- Telephone W: ( ) Property address (Fire W & Street) : Location:;, Sec._L(C_, T q, N, R jj_W, 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 FORM* Water sample tap location: Is the dwelling currently occupied? ❑ Yes ❑ 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? ❑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. )ther comments relative to system operation: ertify that the above information is complete and true to the of my knowledge. OWNERS SIGNATURE: DATE: t ~ .I 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 Ft.2 OBed ❑Trench ❑Dry Well ❑Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: ❑House ❑We11 ❑Prop. line ❑Other Dose tank Setbacks: ❑House OWell ❑Prop. line ❑Other ❑Locking cover ❑Warning label OPump/Floats ❑Alarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House ❑Well ❑Prop. line OOther ❑Ponding: ❑Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title .1 ST. CROIX COUNTY WISCONSIN 1' ZONING OFFICE r r x x n u x■ .P..d ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 October 7, 1994 Vernon and Irene Waxon -7 SS 3 549 County Road A Hudson, Wisconsin 54016 RE: Water (VOC) Inspection for Property Located at Lot 14, 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. Sincerel Mary Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure cc: Pat Collins 7 m SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46739 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 SERCO SAMPLE NO: 145624 SAMPLE DESCRIPTION: Waxon r, K 14 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. d• SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46739 PAGE 2 of 3 10/06/94 SERCO SAMPLE NO: 145624 SAMPLE DESCRIPTION: Waxon 14 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. SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 46739 PAGE 3 of 3 10/06/94 SERCO SAMPLE NO: 145624 SAMPLE DESCRIPTION: Waxon 14 ANALYSIS: 1,1,2-Trichloroethane, ug/L <0.1 Trichloroethene, ug/L <0.4 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. -77- 4f ST. CROIX COUNTY WISCONSIN ZONING OFFICE r r N _ 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 A/b winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. X Water (VOC's) $185.00 ❑ Septic $50.00 ❑ Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria retest $15.00 Owner: Requested by: Address:"` N Address: ZIP E4 a ZIP Telephone Na: g4 ~F3St Telephone N4: ( ) Property address (Fire If & Street) :441 Location:,11) Sec. T9,N, R_Lj_W, Town of /ejy~ _ 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: Septic tank last pumped by: Date: 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. 10 Other comments relative to system operation: CEIVED I certify that the above information is complete t€ue to the best of my knowledge. SEP l } 13911 ST C:PU>, OWNERS SIGNATURE: DA0t*NTy . R, iNG OlRf1CE 'v~~ 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: OBelow grd ❑At-Grd OMound Approx. size 'X OGravity ❑Dose ❑Pressurized Ft.Z OBed OTrench ODry Well OHolding Tank ❑Outfall pipe OBSERVED DEFICIENCIES OOther ❑Unknown Septic tank Setbacks: ❑House ❑Well OProp. line ❑Other Dose tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover OWarning label ❑Pump/Floats OAlarm OElec. wiring Soil Absorption System Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Ponding: ODischarge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title