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HomeMy WebLinkAbout020-1143-60-000 0. 0 N p0 CD 0o r 03 p 6a v o a) C: a M a O O o ~ 1 H O U Ol (DO O E 0 ca M CL X 'y L ~ 1 m •3 0 h ~ x I 1 ai Q. voi I ~ (D 0 c Z rn~ c z LL c •o m U. c 0 d rn I o 3 wp 3 I E U (7 a7 ~ r o a) w E 1 E z z 0 1 0 ~ ~ 0 0 z ~•o I ~v rn d m a m ~ z I c I o co C z g C c w 2 N _ aa) Z ° U) c H p t cm 0) 1 ? c Z ,O N .O ~ M N CM c 6 O N O a) O N O) O CL O O CL d' y N y N C a a o 0 a) w O z co z z m z z y _ :3 "RVr W ~ry CD CL b -j ID U" C7 W d (D o N N O (D v d ~ O _ o O G a ~)L 1 C G a E„ N w ip N fA Vl fn a > U) U) U) > > p O •+~J r r o u~ 1 C O d 5 5 a a~ zcl au) 30IL IL (L 0 vOaa 10 0 = CL v 1 0) 0 o y = ao co a) rn rn N } J V W O Z '0 p O O C D N N O ti~ GO) N O O N CO 0 00 "O U p = O N N m C lll y C n' co U 'O y N p V ,n a) m O 1 m Q} fn .D d Q} (n m Ci U N N CD H to O O Op O W C N C E O b•, O C CD O C CD O W CO 04 O >TO+ O~ O CO 4. d c •O 0- 0) - N C7 'r 't C E O? OD V C O O O O O N N C ~ co y.w O _ LO N v z 12 ~ N N H N Irn O p N y p .dr N m a d• L C4 - F. (n E 10 CD • o t- 0 2 C 0 z H Q N 0 z s U) a I ~ a V a 1 d a • CL d .0 I d c 1 d m c -1 A ciaM c°o 0U)U r 9 71 STC - 10 4 RECEIVEP y AS BUILT SANITARY SYSTEM REPORT FEB 2 N s 11996 ~ cD ST CAOi1- OWNER Z ~GQ FEE ADDRESS-1Z5 ' SUBDIVISION / CSM#__ LOT # SECTION/ 7 T,-~ 2 N-R__1 W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEE OF SYSTEM , 171 gc~ IzX~z )(3 • r l 0' - ~o L L / e . fi INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 4 Cdr _ ° : HOIDgd SN I Gr : HROMN 3SN37Iq :90f NO d3gwngd Z° : NOIDi`IgVISNI JO RIVG ape.zb TeuT3 ape.z0 buTgsTx3 utagsAs 3o utoggog PTo3TUeW/.zapeaH 33o dutnd mog4oq od 4aiuT od gaTgno LS t-/w-7•gaTuI BLS IaMaS buTpTTng SNOI SKA3'I3 any .zauq0 -asnoH TTaM :u1oz3 Xoeq-4aS :auTT -do-id 4S8aeau 0-4 u0T-40a.zTa 13 aouegsTQ ~a s2uoua zq 3o_ loquinN - u.4bua Z :ugPTM W3SSAS NOIZduosav 'IIOs UOT4200-1 uizely :aTOAD/sUOTTeO UOTge.zadas 4eOT3 azTS # TapoW .zajngoe3nueW : dtund .zau-40 asnoH ~T-TTaM :uioz3 Xoeq-4aS :A-4Toede, pTnbt y/1La►~? :.za.zngoe3nueW NOISKW2 oaml XHVL oNla'IOH / HRGx Ro dWnd / XNVL olsd3S Yis 3LvN2 ably .~S %P ' :)IuvxHON3H Wisconsin' Department of Industry, PRIVATE SEWAGE SYSTEM County ST. CROIX Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 2-59411 PejrpjihlD.ltig6kame,AUL ❑ City ❑ Village Town of: State Plan ID No.: CSTTllBBM77EEEleRev.: Insp. BM Elev.:, BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA Q TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark cQ GG . Septic 77 Dosing Aeration Bldg. Sewer y'$• r Hold St Inlet 9 r TANK SETBACK INFORMATION St IX Outlet 95/- TANKTO P/L WELL BLDG. vent to ROAD Dt Inlet Air Intake Septic y~ rfy~ NA Dt Bottom Dosing NA Header' Aeration A Dist. Pipe -20 Hol Bot. System -7. PUMP/ SIPHON INFORMATION Final Grade ~7 MamTa'cturer Demand s 1 96 Model Number PM TDH Lift Fric System TDH Ft mead Forcemain - _ ength Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length , No. Of renches PIT r-- - . No Of Pits _y1side Dia.' Liqui h DIMENSIONS a DIMEN I N LEACHING SYSTEM TO P/ L BLDG WELL LAKE /STREAM SETBACK Ma r' ! CHAMBER Model Number. INFORMATION Type Of ,f System: ,4 OR UNIT DISTRIBUTION SYSTEM Header/ Manifold Distribution Pipe s) x Hole Size Hole Spacing Vent Intake '/a Length ~ Dia- Length ~ ia. ` Spacing SOIL COVER x Pressure Systems Only xx Mound Or -Grade Systems Only Depth Over p r. Depth Over / „ xx Depth Of xx Seeded /Sodded xx Mulched Bed/ Center Bed/ TrF~Edges 36 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) is LOCAT.IIOON: H/udson.17.29.19W, NW, NE, Lot 52, McCutcheon Road 10 ~C.G{r j! C ~i ~ i✓"4.t'~t_ !7"'? ...y.-~ .eG-~ ~ r U' ~l'~~1'f' Plan revision required? E] ❑ Yes Use other side for additional information. d l!o 1Z I SBD-6710 (R 05/91) Date Inspector's Sign ture Cert No SANITARY PERMIT APPLICATION ' ■ In accord with ILHR 83.05, Wis. Adm. Code COUNTY ::5t STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than O~~'7/~ 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLI NT INFORMA ION - PLEASE PRINT ALL INFORMATION. PROPE WNER PR P RTY LgCATION '/a fS `l TZ , N, R E (or PROP ERTY OWNER'S MAILING ADD SS LOT # i BLOCK # / 121 & C 4-t fz; Z - CI ZOA-) E ZIP CODE PHONE NUMBER SUBDIVI N NAME OR CSM NUMBER tt It s 7 lolS .L/c tJf c-=c-cJ 6s=ipts 11. TYPE OF BUILDING: (Check one) CITY NEA ST %AD ❑S tateOwned O VILLAGE ~-f WOWN OF: :5 EL TAX NUMBER(S) ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms ~ PARC Ill. BUILDING USE: (If building type is public, check all that apply) O 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) INA A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Nonrrr-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 El Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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 REQ IRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day sq. ft.) (Min./inch) ELEVATION e-v i N~ C( IV/ e~e) a ; ~ZIe Feet ;23~ eet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank d O L iD c~1e'STL~L Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbf 's N e (Print Plumber' Sign ure: (No Stamps) MPRSW No.: Business Phone Number: i /Y (715 W~32S`2ei Plumb 's Address (Street, City, S e, Zip Code)--. V /"4~., S I / :5-2 S -e -19A , LJ1 4 e Lt ~S 72 .5- IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue issuing ent Sig ture (No Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination / U v X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ' SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 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 the 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 & 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 in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/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% 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) G f ~ y ~ }ire v D h i 1 i r J^al i O t _ rV r., i V Whconsin ` department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 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 f1;"' ~I e~ ize. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), directs % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distanci,10 nest roa 020-1143-60 APPLICANT INFORMATION-PLEASE PRINT-ALL IN.,FMA REVIEWED BY DATE r PROPERTY OWNER: PROPERTY LOCATION Paul Anderson ; GOVT. LOT NW 1/4 NE 1/4,S 17 T 29 N,R 19 for) W PROPERTY OWNER':S MA!i_ING ADDRESS F LOT # BLOCK # SUED. NAME OR CSM # 460 McCutcheon Rd. 52 na Parkview CITY, STATE ZIP CODE'',., PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD Hudson, WI. 54016 (7~L3S6-f5654 Hudson McCutcheon New Construction Use [ ~9 Residential / Number of bedrooms 4 [ ] Addition to existing building "Replacement (J Public or commercial describe Code derived daily flow 600 QDd Recommended design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/ft2 Absorption area required 8 5 8 bed, ft2 7 5 0 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 • 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 93.26 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U =Unsuitable tors stem ziS ❑ U I IS ❑ U ®S ❑ U ® S ❑ U El S ®U 1:1 S EU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Du. Sz. Cont. Color Gr. Sz. Sh. Bed ITte & 1 0-13 10yr2/2 none 1 2msbk mfr 9W 2f .5 .6 1 > >4 2 13-25 1Oyr4/4 none sil 2cp1 mfr gw if np .2 . Ground 3 25-33 7.5yr4/4 none is Osg mvfr gw na .7 .8 elev. 4 33-84 7.5yr4/6 none S Osg ml na na .7 .8 96.76 ft. Depth to limiting factor +84" Remarks: Boring # 1 0-19 10yr2/2 none 1 2msbk mfr gw 2f .5 .6 :..,.v., 2 19-36 10yr4/4 none sit lfsbk mfr gw if 1.2 ::.3 2:1 3 36-90 7.5yr4/6 none S Osg ml na na .7 .8 Ground elev. 96.96 ft. Depth to limiting factor +90" Remarks: CST Name:-Please Print Gary L. Steel Phom 715-246-6200 Address: 1554 200th. Ave., New Ricbmond, WT_ 54017 in-1 -r- Signature: CST Number: PROPERTY OWNER Paul Anderson SOIL DESCRIPTION REPORT Par. 2 of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture I I Structure Consistence Boundary I Roots G P D/ft in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed iTrer& 1 0-15 10yr2/2 none 1 2msbk mfr gw 2f .5 .6 3 AMEN 2 15-30 10yr4/4 none sil lfsbk mfr gw if .2 ~ .3 Ground 3 30-36 7.5yr4/4 none is Osg mvfr gw na .7 .8 96•Vv ft. 4 36-80 7.5yr4/6 none S Osg ml na na .7 .8 Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. f t. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) w. STEEL'S SOIL SERVICE Gary L. Steel Paul Anderson 1554 200th Ave. CSTM2298 NW4NE4 S17-T29N-R19w New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246-6200 lot #52-Parkview N 1"=40' BM.= tup of cement base of steps kV ' 3 f1k' t l i 57, 7~,f \5A r ft r 0 Gary L. Steel 10-13-95 sco> w w Department of kndusuy, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety a BuilcGngs 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 induce, but St. Croix not limited to vertical and horizontal reference point (BAIL), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 020-1143-60 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION [REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Paul Anderson GOVT. LOT NW 1/4 NE 1/4,317 T 29 N,R 19 *(w) W PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 460 MCCutcheon Rd. 52 na Parkview CITY, STATE ZIP CODE PHONE NUMBER CITY []VILLAGE OWN NEAREST ROAD Hudson WI. 54016 (715)386-6654 Hudson McCutcheon New Construction Use [ 3q Residential /Number of bedrooms 4 Addition lo existing building lc#i'l a*oement ( ) Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpoltt2 •8 trench, gpdM2 Absorption area required 8 5 8 bed, fl2 7 5 0 trench, B2 Mainum design loading rate • 7 bed, gpd/ft2 •8 trench, gwR Recommended infiltration surface elevation(s) 93.26 it (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na It S = Suitable for system ( CONVENTIONAL MOUND iN•GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDwo TANK U = Unsuitable for stem i S ❑ ❑ 0 Es ❑ U EIS ❑ U ❑ S ®U ❑ S ou SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon Texture Cor>sist,ertoe Boundary Roots in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tencth 1 0-13 10yr2/2 none 1 2msbk mfr gw 2f .5 .6 1< 2 13-25 10yr4/4 none sil 2cpl mfr qw if np 1.2 Ground 3 25-33 7.5yr4/4 none is Osg mvfr 9V na .7 .8 elev. 4 33-84 7.5yr4/6 none S Osg ml na na .7 .8 96.76 g, Depth to limiting factor Remarks: Boring # 1 0-19 10yr2/2 none 1 2msbk mfr gw 2f .5 .6 2 19-36 10 r4 gyp 2 y /4 none sil lfsbk mfr if .2 .3 3 36-90 7.5yr4/6 none S Osg mi na Ina .7 s .8 Ground elev. 96.96 n Depth to limiting factor +9011 Remarks: T Name:-49s us Print Gary L. Steel 715-246-6200 mss: 1554 200th. Ave., New Ricbmnd, WT. _94()17 JA-11 cstm 02298 PROPERTY OWNER Paul Anderson SOIL DESCRIPTION REPORT Pie -3 PARCEL I.D. # - Depth Dominant Color Mottles Texture Boring # Horizon Structure g 9D in. Munsell Qu. Sz. Cone ce Color Gr. Sz. lftrdmy Roots 3 ` 1 0-15 10yr2/2 none 1 2msbk mfr 9w 2f *W 2 15-30 10yr4/4 sil lfsbk mfr gw 1f Ground 3 30-36 7.5yr4/4 none is Osg mvfr gw na 47 .8 96.Y1~ ft 4 36-80 7.5yr4/6 none S Osg m1 na na .7 .8 Depth W limiting lac +80" Remarks: Boring # au...:x-:. Ground elev. ft. Depth to imi`ng Taft Remarks: Boring # Ground elev. it. Depth to fimiting facto Remarks: Boring # Mt :Y v.i Ground elev. ft. i Depth to limiting faCbr Remarks: STEEL'S SOIL SERVICE Gary L. Steel Paul Anderson 1554 200th Ave. CSTM2298 NWaNE4 S17-T29N-R19W New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246-6200 lot #52-Parkview N 1"=40' BM.= top of cement base of steps J~ 77' 10 k1f. s`s F!M J Gary L. Steel 10-13-95 t STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER t t ~c-~s t~ MAILING ADDRESS 7Cn St'I PROPERTY ADDRESS a S~ (location of septic system) Pl a ob~tam from the Planning Dept. ~ CITY/STATE /,4 L U ! S 1/4, C" 1/4 Section T _Z N-R W PROPERTY LOCATION Lt TOWN OF / / T~ S_-8 ST. CROIX COUNTY, WI SUBDIVISION ,~4-~L C-~ /'t =z cd LOT NUMBER 5_2_ CERTIFIEDSURVEY 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: S- 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. Owner of f~~`y --------1-------' property Location of property ~t. f u.) 1/4 1/4, Section T~N-R-1 W f Township Mailing address asr,~c ) t ,~r s S" YD/ ~ Address of site Subdivision name ~%~,urz,t LJi& , i Lot no. ~;-Z 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? t- Yes No Is this property being developed for (spec house)? Yes cr No Volume &6 7 and Page Number f.27 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. 38'S p/ , 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. s Signature of Applicant Co-Applicant 7 - 9 5- Date of Signature Date of Signature i C.DCUMEr1T No. WARRANTY DEED Taw S ~a._E RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORA 2 -1992 VOL 667 i RFGISTtRS OFFICE SAM E.. MILLER, Grantor, ST. Cfi1-AX CO., WI& Reed. for ~~eora this 30th . . \ dcry ct June A.D. 1983 at 3:20 P con%eyt1 and %%arrants to PAUL. -J,_..ANDERSON_" and _ KATHLEEN_L-ANDERSON,.. husband and_w,ife---as- joint-.tenan.ts,.-.Grantees., . CK-ki of Doody f for and-"in -ConsidEration- of the sum of . - $60,000..00 . . . . - _ . . the following described real estate in ...-St. Croix .......County, " State of Wisconsin: Tax Pa=el No- Lot 52, Park View Estates Second Addition to the Town of Hudson. TOGETHER WITH and SUBJECT TO any other easements, covenants, reservations or restrictions of record, if any, but this shall not be deemed to extend any such other recorded encumbrances beyond the term established by law therefor. TR O j~~ I J This is not homestead property, (is) (is not) Exception to warranties: Dated this 3L day of _ June 19 83 ,//~t (SEAL) lU' (SEALp Sam E. Miller (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) . . STATE OF WISCONSIN NIA....-....------•--- ss. ST. CROIX - - - - ..County. ' authenticated this day of-.................. 19.--... Personally- cacae before me this - ~I June. the abo.' ,4eli a"rn-..E.-...Mi l ler 11 om TITLE: MEMBER STATE BAR OF WISCONSIN $CH~MMfw (If not, _ J}} y~ authorized by § 706.06, Wis. State.) - - F CN tno«n to be who execute C--foregoim ert i7.3 . now dge the same. THij INSTRUMENT WAS DRAFTED BY Hugh H. Gwin, Attorney %r~ LfuY~- Gwirtj-Gilbert-,---Gwi-n,--Mudge &--Porter C~ Hudson, Wisconsin 54016 411~r'e_ - - Nota-•: Puhlic St. Croix (Signatures may be authenticated or acknowle&ed. Both MY County. Wis. MY f ilmmiainn iR.{~•~-,,~~yq}I( If not, state exi,ir:aion are not necessary.) ~l dote: 19 .1 -Nam" of Dom-- .ai;ninq in any ~aparity ;huu;d be tync.i i,:1-- th• it - g-c .n WARRANTT DEED STATE BAR OF OVISCO\SIV AS BUILT SANITARY SYSTEM REPORT OWNER d l fe TOWNSHIP SEC. T_N-R W ADDRESS C4 hPGO(j' ST. CROIX COUNTY, WISCONSIN. H(Idfah w,S -.G`C SUBDIVISION At,"l< U (W 1' S 0'r LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 4 A I di at N r h rr w BENCHMARK: (Permanent reference Point) Describe: r1/ n G 0.- ~ r re _ Elevation of vertical " ference point: IL Slope at site: j 2 y SEPTIC TANK: Manufacturer: Vv n SI'T` Liquid Capacity: 41 Number of rings on cover- Tank manhole cover elevation's . Tank Inlet Elevations Tiank Outlet Elevation: PUMP CHAMBER / .Manufacturer: 1v Number of gallons /v Number of gal. pump set for a cycle IV4 gallons; Total capacity of distribution lines /t/ gallon: size of pump VA- head; gallon per minute A/ /f horsepower A14. ;brand name of pump and model number '4/ A Type of warning device Al HOLDING TANK: Manufacturer Al /I-- Number of gallons 1414- Elevation of manhole cover ` Type of warning device SEEPAGE PIT SIZE; /V Number of pits feet diameter feet liquid depth seepage pit inlet pipe-elevation bottom of seepage pit elevation 4/4 feet. SEEPAGE BED SIZE: number of lines- width length tile depth 3, SEEPAGE TRENCH: width N length PERCOLATION RATE AREA REQUIRED 4~ L G_ •REA S BUILT C DATED PLUMBER ON JOB .c, o eo LICENSE NUMBER k 1 V 3 4\ Q C t V Q .w ~ e Q Sl > r Gs l1 ~ Q 1 ? ~ ^Q r ♦ 1 ~ Fee- DEPARTMAT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS ;,AdOR &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ®CONVENTIONAL ❑ALTERNATIVE Slate Plan l.D.Number: (lf ategnedl O Holding Tank O In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: E! DATE: Sam Miller R#5, Trout Brook Rd., Hudson, WI -03~- /i3Q BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: Lot 5 2 , P a rkv i e w Estates V.: ' CST REF. PT. ELE V.. NE14 NE14, Sec. 17, T29N-R19W, Town of Hudson Name of Plumber: mp/APJMXQK County: t Nmber: Douglas Strohbeen 5432 St. Croix 34795 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: ARNI G LA LOCKIN C r~ P E0: PROV ED C `,1 06~,3 28 -S YES ❑NO NO WATEVI OF ROAD: ROPERT WELL: 1811 IL 1 V i LO FR H BEDDING: VENT DIA.: VENT MATL.: HIGH " JAL M: FEET FROM LINE C/Fy, DYES O E NO NEAREST DOSING C AMBER: MANUFACTURER: JBEDDINII: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING PROVIDED PROVIDE DYES ONO DYES ONO DYES []NO. GALLONS PER CYCLE: PUMP AN CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: V N FEET FROM LINE AIR INLET: (DIFFERENCE BETWEEN PUMP ON AND OFF) DYES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING or excavation. (if soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: JLDIS PIPE SPACINGINSDE DIA*PITSLIOUID BED/TRENCH TRENCHES / MAt Rr PIT DEPTH DIMENSIONS P GRAVEL DEPT H FILL D T UISTR 1 DISTR. PIPE IS 1 A At NO. DISTR. MBE OF ROPERTY WELL: BUILDING: VENT TO FRESH BELOW IDES: AB E ER. ELEV. LEi ELEV. END: ! PIP FEET FROM LINE:~ AIR INLET: e13., `f 3 :10 2 Z NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES DNO OIL COVER TEXTURE PERMANENT MARKE IS, OBSERVATION WELLS DYES ❑NO DYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TREN HlaED DEPTH Of TOPSOIL: SODDED. SEEDED: MULCHED: CENTER: EDGES: DYES ONO DYES ONO DYES DNO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO.OF LA ERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL : N0. DISTR UI I DI THIBUI I PIP MATERIAL & MARKING ELEV. ELEV.. DIA. ELEV.. PIPES DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING HILLED COHRECT LY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS Y NQ I DYES ❑NO COMMENTS: ANENT OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: S _ FEET FROM LINE D YES 1-1 NO D YES CJ NO NEAREST r~ ~QLIw, I^ 01~ V t t~ Q/L f r~ ~1v ~ `r' p S-d 9 : 5 2 .ie~ r Wt.7 EA711% 110 L Sketch System on in county file for audit. Reverse Side. Ifi ~ I sr- 01LHR SBD 6710 (R. 01/82) APPLICATION DEPARTMENT OF SAFETY & BUILDINGS ,INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: M Mng Address 1 : r 4 p Wfe, j I (e Pro arty Location: Q"q'ro'tlleg~r Township: County: ' F .51, ~ 4- Jf ail ` a t x /,,s,17 /T.21 NCR 1 y (or) W f Lot Number: Blk No.: Subdi Sion Name: + ' NeaNearest Road, Lake or /Landmark: State Plan I.'D. Number: y ! < w 1, f ~G ~P S A st CK t C4 .4 6 ~1 1.?4 (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: NOOF or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY (g~ I I HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): Lt 4ew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit G © ❑ Alternative (specify) ❑ Seepage Trench Water S Owner's Name as Listed on Soil Test Report (If other than present owner):. L~!J Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Na a of Plumb/fir: ` Signat re: MP/MQRSMFNo.: Phone Number: 213 0 Designer: Plumber's Address: Name /a S IV ~~ha4 t , a F / 6 c c~ COUNTY/DEPARTMENT USE ONLY Iitary Permit Number: Signat re of Issuing Agent: ID t : APPROVED FSa QCJ 9S (.Jv ~~J ❑ DISAPPROVED 7 Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DI LHR-SBD-6398 (R.07/81) 1 Form - S T C 100 Owner of Property C .Location of Prope ty Section f 7-, T -I N RA-W Township Mailing Address Subdivision Name Lot Number Previous Owner of Property Iu,QAj_ Total Size of Parcel ~ 06' x /SS Date Parcel Was Created Are all corners identifiable? Yes No Include with this application one of the following: .Certified Survey Map e Dead Land Contract, or .Other I:egal Document which describes the property 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) the properly described in this information form, by virtue of a warranty eed recorded in Office of the County Register of Deeds as Document N . ; aril that I (we) presently own the proposed site for the se ages oral system-lor I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the some has been duly recorded in the Office of the County Register of Deeds, as Document No. SIGNATURE OF OW ER SIGNATURFr OF CO-0WNE$t (IF APPLICABLE) DATE SIGNED DATE SIGNED i P DEPARTMENT OF REPORT ON SOIL BORINGS AN & - IVISION INDUSTRY, ~ ~ FF~fE P LABOR AND OX 7969 PERCOLATION TESTS (115) HUMAN RELATIONS ~ MA , WI 53707 A, LOCATION: SECTION: JT / LOT NO.:BLK. NO.: SUBDI/ ME: 6 / 427 N/RM(or lYtLd 0,1/ J dZ A1.4 rC ~/lr~ce/ l~.s /"f COUNTY: OWNER'S /BUYER'S NAME: MAILING ADDRESS: / USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PERCOLATION ROFIL DESCRIPTIONS: TESTS: ~Wesidence New ❑ Replace L~ 11- E3 if K fJ RATING: S= Site suitable for system U= Site unsuitable for system :Iopt onal) rZS ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM ❑ U Ns ❑ U ®S ❑ U ❑ S ®.U ❑ S ®U e%6Ai °c>K~/ / ' X 3 6' If Percolation Tests are NOT required DESIGN ATE: S STEM ELEV If any portion of the lot is in the under s.H63.09(5)(b), indicate: 7(,/ Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS to BORING TOTAL, PTH TO GROUNDWATERINGIiE8 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHJfd, ELEVATION OBSERVED EST. HIGWEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 14" 81 4' 8A S/ V, 74A eftej B- / 7.O' ilo tL ' . 7 ' 7' ,8 1 y n • ,B S/ *-:5 A B-3 75"' F4.6' ltovo_ 7 7E' Ao4' / ,7'Sh 'yams e B- . / , 'I Y' /6 'AA m e B-~ B- PERCOLATION TESTS TEST DEPTH' WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER +fd@++EE AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD2 P R PER INCH P- / X 0 3 G 3 P- .7' o ro 3 P- • 3' c~ 6 -3 P_ PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION 9.2.3 F i a E 3 BT/ 3 -p 4 P / 3 o S 4' "pPP q a RAF. P©t -_t _z` scu top & Fr 4 q Z. y' 6•y ) ~ E.. steel Ce ca- yes) - F~ ' B , M . ` (.9'.'. S •.w po c~ .c- ~io lr~/c~.!~.~s. ,6~'L' sry/~ s~~ ~ r i~ s t~._ee lot L-A 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print : gyp` J TESTS WERE Al- COMPLETED ON: _S7-.P3 AU 'V15 r A ADDRESS: 1)116 ~~4rB UGC. Sow ` CERTIFICATION NUMBER: PHONE NUMBER optional): CST,S"ATUR E: DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. HR-SBD-6395 (N. 03/81) All /I C 0 --7 174 v T33 A ~ o 1 0 } NA b ( .n V a L ICRI e cz% w t~j C> T)l A -A 3 TT7 3 , o aI Q CN, f I ~ I I ' I-IN ~ s i Cr:' s, f^•,4 1 X (i `w•i ..fin? r "C MERCIAL TESTING LABORATORY, INC. . 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 6&@ FAX - 715 - 962 - 4030 ST. CROIX COUNTY GOVERNMENT REPORT NO.; 43321/01 PAGE 1 CENTER REPORT DATE! 6/22/93 1101 CARMICHAEL ROAD ,.,ATE RECEIVED: !5/16193 HUDSON, WI 54016 ATTN; THOMAS C. NELSON OWNER; Terry & Pat Anderson LOCATION; 460 McCutcheon Lane, Hudson, WI COLLECTOR: DATE COLLECTED! 6-14-93 TIME COLLECTED; 24#30pm SOURCE OF SAMPLE; Outside Faucet DATE ANALYZED; 6-16-93 TIME ANALYZED; 26'00pm COL.IFORM; 0 /100 mL INTERPRETATION; BacteriotogicaLLY RAFE NITRATE-N; 5 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. CoLiform Bacteria/100 ml Nitrate-Nitrogen, mg/L 12 RECE VEO N JUN 2 4 1993 Go ST CRUis; ~ ~ LAB TECHNICIAN; Pam Gave COUNTY C, ZONINGOFFICE~ OF.WDECFNpEHr i WI Approved Lab No. 19 g Z4 { Means "LESS THAN" Detectable LeveL Approved by; ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 ~ 3 MAILROOM 912 356 2996 Jun 7,93 12:30 No.005 P.03 r 66ICI1/199_; 09:37 715-366-3593 LOWIV REAL ESTATE PAGE 06 ~O T. CROIX COUNTY RECEIVED ' N WISCONSIN JUN O 9 1993 ZONING OFFICE CROIX COUNTY COURTHOUSE 1 FOURTH STREET • HUDSON, WI 54016 1,91 ' a (715) 386.4680 l SEPTIC INSPECTION / WATE) TEST REQUEST FORM Specify desired test(s) & remit app?opriate fee with application. Outside water lines are often turred off during winter months, making accea s to the home neoeteary. Please make arraengemente with this office to insure a time when eitry can be gained. 0 Water (VOC's) $185.00 Septic $25.00 Water (Nitrate & Bacteria) 1.35.00 Asual inspection) ~11 owner: .2. „r~_ 12e jus>ated bys,y Address : Gc he Adc' toss t11 a city & State: Ci :y & st. , Z P Co a :.5!f a /G _ Zip Codo : "Q Its , Telephone M; ( 0.- Telephone N!: (W) :jX4-_q3 6-a Property address (Fire 10 & Street) : 3/AQ u eo ~dc.wi 41 Location: ,_~„r►t,,_ , Sec.I , T Z9 N, R 1 w, Town of &U jaa St. Croix Co., WI. Tax YD N' T Parcel ID M _Qk/Lr House color: tJD~ Realty firm: r Lock Box Combo: Water sample tap location: i TO BE C4MPLETEDmy6_) ROpERTX M.FKB PROVIDE A SKETCH OF HOUSE & SEPTIC S YSTE ON REVERSE OF THIS rORM* Is the dwelling currently occupied? Yes 0 No If vacant, date last occupied: Wt Septic system installed by,. Year: Septic tank last serviced by: q l- t7r Date: 100 Previous Owner's Name (a) : %h A& 6WI Have any the following been obse)ved? OY Slow drainage from houst. j OY Sewage Backup into dwer31 ing . -121"2`-~'I[/`l OY Sewage discharge to grotnd surface, oad ditch or body of w( ter. OY low drainage from the ewelling. C}Y 9~~Foul odors. other comments relative to system ope2 ation: I certify than the above informatio is complete and true to the best of my knowledge. Y OWER8 SIGNATURE :4 DATE I F MAILROOM 912 356 2996 Jun 7,93 12 : 31 No. 005 P.04 OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION fit X l~ i Le 0*- e TO 8$ COMPLETED BY IN3PECTION AGENCY system design &/or permit on file? OYes ONO Soil series per SCS $Oil Surveyt_ _ _ sheet Tyne of soil.. absorj2ti!p.n system; el ow qrd OAt-Ord CJMound Approx. size __,X 'OGrtvity ODose OPres surized - ----Ft•' se OTrench ODry Well Holding Tank Ooutfall pipe ORSERVED DEFICIENCIES Ootler Ounknown --A Setbacks: QKouse-L?- ell J*&-Gurop. line 00ther s setbacks: Oxouso• Owell C1?rop. line_,.- 00ther T^ OLooking cover OWarn ngla'-el OPump/Floatsi OAlarm OE ems, wiring__ Setbacks t Mouse ~ OWel I C' Prop. line ,'p0ther Opandings ~C+7ischar a ~L enar INSPECTORS SKETCH OF SYet'E4 LOCATION (X1 l i It Spector; x tle - Z.! J ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 1104 Carmichael Road • Hudson, WI 54016 1 - (715) 386-4680 June 17,1993 Lowry Real Estate 1201 Mayer Road Hudson, WI 54016 To Whom It May Concern: An inspection of the septic system on the property of Terry & Pat Anderson, located at 460 McCutcheon Lane, Hudson, WI was conducted on June 16, 1993. At the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon as we receive them from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. *ince.rel.y . . Mary Jenkins Assistant Zoning Administrator js C0)Y MAILROOM 912 7)56 2996 Jun 7,9? 12:30 No .Onc F.03 06!01/1593 09:37 716-?E6-3593 LCiM Y REAL ESTATE PAGE 0E 11 12 i RECEIVED T. CROIX COUNTY N WISCONSIN JUN O 9 1993, ZONING OFFICE CROIX COUNTY COURTHOUSE r1iw~~F1 ,q I FOURTH STREET • HUDSON, WI 54016 91 9 (715) 386.4680 SEPTIC INSPECTION / WATE). TEST REQUEST FORM Specify desired test(s) & rsmit app!opriate fee with application. outside water lines are often turned off during winter months, making accent: to the home neoecsary. Please make arrangements with this office to insure a time when entry can be gained. 0 Water (VOC's) $ 185.00 Septic__ $25.00 Water (Nitrate & Bacteria) (35.00 (V sual inspection) Owner: .2 Po air Re lueated by:, L--j t~ Ta~L Address : Lc he Adt' teas t,,~ A/0 1W a city & State: , Ci ~y & St. , Code: _ _ Zi cods: Telephone M: (U p o- V-7 k 'Y Telephone Nt: (=p ~X L-~3 6- 3 Property address (Fire N' & Street) : 'y!~Q Ae-u71cAeQ43 ~0,P) -e-- Location:.h, Sec. , T 2S N, RAW, Town o , St. Croix Co., WI. Tax 1 Parcel ZD M House color: &J61 Realty firm: Dock BOX combo Water sample tap location: TO BE COMPLETED 3 O ~I>K8 PROVIDE A SKETCH OF HOUSE & SEPTIC E-YS TE ON REVERSE OF THIS FORM Is the dwelling currently occupied? Yes 0 No If vacant, date last occupied: Wt Septic system installed by: _ Year: 12L. Septic tank last serviced by: a, l- oty Date: 100 Previous Owner's Name(s) s6WI Have any the following been obse)ved? OY Slow drainage from houst. OY Sewage Backup into dwe 3 l ing . OY Sewage discharge to grotnd surface, road ditch or body of wfter. OY Ik low drainage from the ewelling. 0Y I Foul odors. other commonts relative to system opal ation: I certify that the above informati0 is complete and true to the /f best of my knowledge. 4 r Jun 7,93 12:31 PIS .005 P.04 COPY MAILROOM 912 356 2996 I OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION t IN X to' TO RE COMPLETED BY XV3PECTION AGENCY System design &/or permit on file? Moo ONo sheet Soil series per SCS Soil Survey:_ Type owl.. absorati2n system: OBe) ow grd Mt-Ord ❑Mound Approx. size , --'X Mrt vity ODose OPressurized _Ft., Mae OTrench ODry •Well Molding Tank OOutfa,ll pipe OBSERVED DEFICIENCIES OOtter OUnknown ~gptia tank ,u Satbacks . C7HOUse_ Dwell C : rop line pother pose tank line pother setbacks: OHouso_____ Owell C,.,rop• oAts ump/F1 OLOokirg cover OWarn g la' .el OP OAlarm OE eC. wiring Soil A so fl`~n system Setbacke: OHouse_,,,,. _ OWel l El Prop. line 00ther OPonding: C+)ischarge: General commentff: INSPECTORS BRETON OF GY600 LOCATION N l i spector T tle .