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HomeMy WebLinkAbout020-1269-60-000 M 0 6n 0 6 p61> o o m s a C. i r ° m r - a) O O L N c 3 it a n `m w E ~ I U) U) E o r' a > N CLw to x b .E E a N m (D c~ 04 I I Ch 0 M O a) c F_ ! N w O N- p M p O Z wQ Z (D-6 z 04~ LL CO O LL o 0) 0) U. O N co 00 U I H2 N O - " O N N o y Q I-k Q W Q I I ~ co N m N M Z y z y z y Z E E E Z w O _ O O O O O L ` ` N 3 a m a m (L m N 1- Z ' i I O z V IX c c: =3 h :3 vi z o r o 0 N O a m aci rn m c c c E O O O N N N 0 L4 0) O'IN1 N 'j N N N N M U) U) CO ~v '0 'D Q Q z m z O z co z O z co z O N M w N c d ~ m d I ~i co `mr `m - d y y a M r 41 Q. m a N> N d O O N d a N N a) ID N d O N o «f ° o c a Q o 'o a s L ° o o a o C) ° H F- F- ~ L) I O H t- f- O 2 O H H O X333 ° 33 w 333 0 0 0 x 3 X 0 0 0 0 0 0 • ►~,l R a. 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C v ° L O d m cli N H Z 0 o z c a~i z ~ ° ~ o I N f- c cu Z 0 -o ~ M I N N 01 ~ m N I WJU N n U) CD 0 C o _ o 'v L cn d m Q zo 5 o co z a N M N z _0 I m m _ m J a w L N c o L N a g °o c G a M co H F- 7 OL N 3~3 n cn zC • fir,) m a a a 5 o CL o q) J U o a) rn ° y „ z ~o _ T O N N O O _ 0 N co m -j U) C 'O 2 a m ~j 0 O N O 00 C hy, ° O am Q 4 O O C a) E V N N \ -7 ° 3: 'It CL V O'do M H co n E N N O N O s CD ~ O N co a) ID E L • a. o c~ I g o o " z N U) rr/~^ L • C. m u y a A 0 a 0 in V } Y i STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /11i1V2 & A/ I IC 17e Z- /Z ADDRESS 799,1-1(i-e- I Ae /1'/ QOi44 it - SUBDIVISION / CSMJ~~ (p S AND /Yr. LOT SECTION / T ~j N_R / W Town of- ST. CROIX COUNTY, WISCONSIN 'PLAN VIEW SH W EVERYTHING WITHIN 100 FEET OF SYSTEM s '11TEe a No~E: S/ t~TH?r BFEN m A4 J MRAE o /V FAs T 37w S/D£ 77 41*,W rYl,N 757- >>F yE2rT/4 -5 -E,4 Rcard r cIJ 3~E A10T F Af e)P /e)' 3o -s _j- wFc,L NAs ,~FE 1NorY6T NST.4 t 450 / lV N 37W 3')E W.EIL De~vru,,~y i WALL INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form- Provide 2 dimensions to center of septic tank manhole cover- r Y ' BENCHMARK: (pP CAF 7E1, ~t f~ .~JS S of P02E~ = /2,~ / ALTERNATE BM: 7 ®-P oL Ile d34- 3, IO Z SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: W Liquid capacity: loco J64t ~ Setback from: Well House aI Other 3 To IV,' qy Pump: Manufacturer Modelt - Size Float seperation Gallons/cycle'.' Alarm Location SOIL ABSORPTION SYSTEM Width:/S Length y4 Number of trenches Distance & Direction to nearest prop. line: //g • T F'4ST LoT UNE Setback from: well: ~S House Other ELEVATIONS iYIANl+~LE `/yo = ~0 1. Building Sewer - ST Inlet. $ ~f f5 ST outlet B.Ss 103.~~ PC inlet _ PC bottom-- Pump Off - ~0 3•ys Header/Manifold XT9 Bottom of system J'6' 6r = (0,? -Z- o' Grade prod /0 S,Final grade ~d = lCSs,3, DATE OF INSTALLATION: PLUMBER ON JOB_ LICENSE NUMBER: I~Wle5- ©,3,f',66 INSPECTOR: 3/93:jt SANITARY PERMIT APPLICATION Bureasafetyu o oand ff BuilBuildiinWater S ngWater stems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size.. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs Check itrevision 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 /~l 4Y;Ii 1010,ek q , AC_14t No1A NW 1/4, S 2/ T zg , N, R/ ? E (odo Property Owner's Mailing Address( Lot Number Block Number if Z- F City, State Zip Code Phone Number Subdivision Name or CSM Number UQSa I VO ( > 3 C0P~ 1 L/Xt D/N~ IL TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road Villae Public 1 or 2 Family Dwelling - No. of bedrooms 3 To wn OF I UD S a --PR I4P 1 t LAN E III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment / Condo / 3 3 Q O 1? 0 l L G - <c0 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 13E] Seepage Pit 43 ❑ Vault Privy 14E] System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 1 (S L 3 t D Z 3 Feet (o. 0a Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel lass Plastic App New Existing strutted g Tanks Tanks Septic Tank or Holding Tank X ®o WE1 SEe El El ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps MP/MPRSW No.: Business Phone Number: IM l%~ vl`-17oN~C~ ✓D ~ fJ~s'o3Soo 3 ~~-FS~ z. Plumber's Address (Street, City, State, Zip Code): L l 2E0/4L 4-ANE /~ut~SoN w r S~C~/~ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved surcharge Fee) ❑ I ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One. copy To: Safety 8 Buildings Division, Owner, Plumber I 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- 11- 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 3 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 number . through VII Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material- Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or wil:h complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers,- wells,- water mains/water service; streams and akes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of ,.he building served- B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county,- E) soil test data on a 115 form,- and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. n.DeparRmentofIndustry, PRIVATE SEWAGE SYSTEM County: or an Human Relations INSPECTION REPORT ST. CROIX ,~fety an~Build'ings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI EBACHER, MARK A. x Tff Q_ ell CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /00" TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic f / Benchmark a.3 ivo Z&A Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet 8. to 1, TANK SETBACK INFORMATION St/ Ht Outlet 6_s 5' /0 3, -5' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic D33 15 ' NA Dt Bottom Dosing NA Header / Man. g, gam' /o 3_ Aeration NA Dist. Pipe Holding Bot. System 7. o /0-5-,3 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 12, rJ ~i lr c^ow ti~ Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain Lengt Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /'F DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Mode Number: System:-," OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.21.29.19W, NW, NW, Lot 37E, Prairie Lane 4' t . f _PPllan revision required? ❑ Yes ❑ No ( - Use other side for additional information. /0 SBD-6710 (R 05/91) Date t In pe br's signature Cert No. ADDITIONAL COMMENTS AND SKETCH 3 Apo SANITARY PERMIT NUMBER: t I SANITARY PERMIT APPLICATION Safety and Bildis 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. ° 0- "e0 / • See reverse side for instructions for completing this application state sanitary Permit Numb r o~21q~s The information you provide may be used by other government agency programs ❑ Check i( revision to prev s application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATII Property Owner Name Property Location p ~,c3AGfj E~ 141W14#eV 1/4, S Z I T Z 7 , N, R~ E (o Prope is Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number ANP Al 06 II. TYPE F BUILDING: (check one) ❑ State Owned ❑ !ty Nearest Road ❑ Village / 14")xAllelE14AIAff Public 1 or 2 Family Dwelling - No. of bedrooms Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 0 ZCO-la~C1 --10C) 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. rA 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.) (MinAnch) , Elevation , . u S~ v ?Zo ' 740 04,,00 Feet 09 z SFeet -7Z 3 VII. TANK Capacity Site In gallons Total # Of Manufacturer's Name Prefab. Fiber- Plastic Exper. INFORMATION Gallons Tanks Concrete Con- Steel glass App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank $ E R_ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII: RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: Plum er's Address (Street, City, States Zip Code): IX. LINTY / DEPARTMENT USE ONLY ❑ Disapproved Sa Mary Permit Fee (includes Groundwater ate Issued Issuing Age t Sig a (No S mps) (Approved ❑Owner Given Initial Surcharge Fee) Adverse Determination 1~1 X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SOD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any 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 (")BD-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. Ill. 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 E; 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 curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. AA ARK A, EBAcffEK zyr83" Ti4 c o b s 4,4,v 6 Paz- 3 7 ZUr PIEX 3-7E 7c.t) 5C,1I1 E ray„ , sy-SrF S y 'T E Mv1 E I w! ~06 ,L' ~ ~ ~ ~ - I moo, 7, ~ ~I~2s o3sa /3 r /t r 1~47~- wT 3 Se L6 T -;?-,7 i I A ? ~ I I aI ` 1 y?' \ jl~ ~ ~I 1 5 /n P~ f V i o a `V I I G ti v 41 37 WEST BAs r ~ WELL W LL 7> L~ o z 4 o .a =a o tl w a Lf~ V a Z3: ~d LLJ Uj F-~'o :il o o ~ S T T X oj LLJ `N a I M I oz F W~ 71- a R~ I io z I a M ~ I a I I I a0 U. z to a i i a I I I a I W 10 I I I Q M j co I I 1 I I w I I i 4 ~r1 I _a I I CL a i j 1 3 Y I I 1 I O ~U I z ~ I m i I O w ° i w U I I a. I I z 3 I 1 I I - 10 0 LZ I I I > ~ o LAJ 4EPAR1 MIENT,OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 NW, NW, 21, 29, 19W F_XX Ste signed) 'Number: Town of Huctson CONVENTIONAL ❑ ALTERATIVE Jaco ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMI HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam MiUefc Box 282 Hud6on, W1 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Dou &6 StAohbe-en 5432 St. Cnoix 128771 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES E] NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO 11 ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ 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 MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO MBER OF PROPERTY WELL: BUILDING: PERMANENT MARKERS: OBSERVATION WELLS: 4ARES COMMENTS: ET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO T ketch System on Retain in county file for audit. S Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) Zoning AdministA_ataft Thomas C. Netzon SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY ' STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ h 7 8% x 11 inches in size. c ec revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION <71 k~ NWt/4fl)V/4,S Z/ TZq,N,R Ict E(o W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Eo -Vz$z 3 7 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C M NUMBER ~`Ivlt. 3%. a7 Taco ~s 1-o ; I,, II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned VIL LAGE : SO i o Q OWN0 ❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms3 AR I ;EAX NU BER( III. BUILDING USE: (If building type is public, check all that apply) 3 3 O 1 ❑ Apt/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 N. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. IX 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 - 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 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 JJ,, REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION / _1~1 (o &'4-M 0-72-- 3 ,OOFeet /4511-Z-S'Feet. CAPACITY VII. TANK Site in alIons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Q Septic Tank or Holding Tank 000 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. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: P u f~ s 5 tiv bec ,`'1 r 9 ~y 1` 1 31 j Plub is Address (Street, City, State, Zip Code): 7? IX. C LINTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing gent Sign ture (No St Approved E] Owner Given Initial 2urctiarge Fee) „ e Adverse Determination 71 r X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: f I SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS' ` 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at 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) msst 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, !ocation of holding tank(s), septic tank(s) or other treatment tarks; 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 11 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) r+ to - ~ i w LS, t E Id w M ~ M+f fr ~~M~I ~ `N s 1 can . ~ ~'1 rj 7 M yC o O/ 'a p / y a) L rJ d ul 0 M , ,~r• u 1 N U cI ' 1 fl. LL C, O O 7 I r rO VI ! i l F~. Q tit ~t 71 i a- 77I l 1: l CL W O li i Ili ( ~ cn a. 1 III ~ i l ~ ,g ! I ii ~ III W i i } I ~ l 't ~ ! i 11 ~ l1i f } ~l c0 lil ~I II 1, 'i. I ~ i !lI (ail a i ~ •at ii ~ ~ i !i lJ Ii ~ l I I I~; Q if 11 I p I i~ II~ W Iii U U I ~ I f 1 (l I~ tl. ,I •D.- Il z i' J " f. Il e~ r 1 P ► ,1. 0 NOURTMENT OF REPORT ON SOIL BORINGS AND SAFETY & gUiL ISIO N I NDUSTRY, • , DIVISION 7969 LABOR AND PERCOLATION TESTS (115) P.O. BOX 3707 HUMAN RELATIONS MADISON, WI 53707 (ILHR 83.090) & Chapter 145) t~UCV_ X LoT LOCATION: SECTION: o OWNS IP/ >4tffY: OT NO.:BLK. NO.: SUBDIVISION NAME: NW V/ N,j j 1/ 2 I /T-z9 N/R/9 E (or uASo 37 - Jaco LpNn►NG C UNTY: ~~,~~yy MAILING A R SS: , I~ r I ~TCQO\X <-AM M ICLF-Q OI,T Y i ju&eo11,., w 1 USE DATES OBSERVATIONS MADE X Residence COMMERCIAL DESRIPTION: PERCOLATION PROFILE DESCIRWONS: TESTS: 1LlJResidence New ❑Replace I 1996 l/1 ~ ,mss gQdK Gl ~ S l ~b'f'`I r -Z - tuk li~gxi'W- RATING: S= Site suitable for system U= Site unsuitable for system 1 CONVENTIOONU. IMOUND: ❑V IN-G OU D~F.SSU E:S S S I❑~LHDS 91JNU.REC~owVEAjncvvALtione 1\ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: Cass / lFloodplain, indicate Floodplain elevation: 14 cc Fr PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH, ELEVATION OBSERVED EST. r HIGHEST— TO BEDROCK IF OBSERVED (SEE QABBRV. ON BACK.) B- ' q,~~ /~r'.U4 fVON~ ~I O! C LTA 1', vQ~IJ ~!p$QN~~`~`~~N~ NCS B-3 0,07 0%.41 Nonlg' '7 10.0 / " LLTS /S""garvsf~ 4"6QNCS14R SI'&eN M5 B- 4- fv,ZK 11,0 ONLC /().ZS ~A LLTS DQNSIL C~~JQN l S i &C RIJ CS B- -7 g,~3 1) 7.0% N©NLC 7 .33 6"$CC rs ,,BQNS/C 3,,~r'$~NCS~41Q~2'B~NCS B- 4Z ?.6G o > 9.41 /z" Lc7-s / '&NS,C 46Aq,cs-i6le 3'8a,rCS B- PERCOLATION TESTS EST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER TMWES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D PER INCH P_ i S.ov r"6rx 1I.00 3 >Z >'L 7 43 P. Z 2.SO t 616 /DIS-S >Z > < P- S . O ..W60 > > G P- P_ E L Lq A`71 w P- PLOT PLAN: 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 the.ir location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope, SYSTEM ELEVATION. /OL60 _ T- 1~-pT LAN N 11rK V E eS{ 4-- '3 ? EAST N I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: U4P-\I&y J04IJSO>v JoN So►~ ~f~~J YI„~ l/ /996 AD RESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): noun 5r ~u~O~N S4o~G 4'~4 1A6-40U CST S ATURE•: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD•6395 (R. 10/83) - OVER - CDQ_F.1 ~pS I i ' i ` Q I 6X/ g-4 $3 L SZ d . A, £ Fl- -r641 Gp2N~'Q Q°~ J SEPTIC TANK MAINTENANCE AGREEMENT ~ St. Croix County ~ .r 00 rr OWNER/ BUYER Sa i?-i ter, th 0 Z Z._. Fire Number- ~ ROUTE/BOX NUMBER oX - d • so CITY/ STATE y e u J T ZIP S' 4101(- r PROPERTY LOCATION V k,1rU, Section, T N, R 1&:Y) Town of St. Croix County, Subdivision Lot number 22.F__ Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licens'ed' 's'ept'ic tank pumper. What you put into the system can a ect the unct on o, the-septic tank as a treat- ment-stage in the waste disposal system. St. Croix County residents maybe eligible to recieve 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 's't'ems agree to keep their system properly maintained. The property owner agrees to. submit to St.. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or..a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and •(2)•after inspection and pumping (if nec- essary), the septic-.tank is less than 1/3 full of sludge,and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- w went of Natural Resources. Certification form must be completed •d and returned to the St. Croix County Zoning Office within 30 days of the three year expiration.date. SIGNE DATE 0 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. APPLICATION FOR SANITARY PERMIT 8TC-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 thtss should the completed ts when tl e property Is sold and submitted to this office appropriate deed recording. Owner of property Location of property 4 /4, Section -7:2-- T-a-1JL% Township Mailing address 7-- Address of site Subdivision name ~m 6 L Lot number - R 7 Psavloue owner of property J mac; ti a a~*So~ Total also of parcel _S Date parcel was created K - Are all cornets and lot lines Identifiable? _Yas ~,Jla is this property being developed for resale (spec house)? as No Voidse ~,Qand Page Number L'k Z as recorded with the Register of Deeds. ---.t------------------------------------ INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PAC? NUMBIR, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certifled survey, if available, would be helpful so as to avoid delays of the reviewing process. it the deed description references to a Ceitilled Survey Map, the Ceztlfled Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(Ws) certify that all statements on this form are true to the best of my tout) knovledgel that I (we) am (ate) the ownerts) 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. Z/3 4/ /;2 1 and that I (We) Presently own the proposed site for the sewage disposal system tot I (we) have obtained an easement, to tun with the above described property, toe the construction of said system, and the same has been duly recorded in the office et a Count~Rl egI te,pI Deeds# as Document No. 7 use of Owner Signature of Co-Owner III Applicable) at g_9,3 Date of Signature Date of Signature s 110C'U►.Iri'll NO WARRANTY DEED I MS SPA,A lit SEnyttl .lie atcMltlM.r t: oArA J, J ST,\TE BAR OF WISCONSIN FORM 2-10132 462 REGISTER'S OFFICE I /-t , r"`-1'7 `nom ST. CROIX CO., WI Recd for Record Virginia M. Manson, a sing,.e woman MAR Z2 8:00 AnM com,•~- nn.1 n..iranls to Sam E. Miller, a single man otww &I D"4 t ' i St. Croix J the fMIlMwint dew•ri},e.l real eetatc in CMur.t~, State of %ViAconsio: Tax Pnrcel No: West Half (W'j2 ) of the Southwest Quarter (SW'c) III Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of the nubiic s highway and except Lots 5, 6, 7, and 8 of Certified Survey Flap it Vol. 6, Page 1747, Doc. No. 419479. , i That part of the West Half (W') of the Northwest Quarter (NW'&) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolis and Omaha Railway Company. i • •i'RANSf.~ 00 i $ EEF This is not hnnm•:lead prnla•rt . tiAX 1 is licit) F:xrel•~.i:m tM wnrrnnlies: easem_nts of record and protective covenants and restrictions of record, if any. ' 1101.4 ibis S' y~ dad r.f i l ~ ~ t: ~ 1!r 88 l lit:At.► Grp- IS l:Al.l Virginia M. Hanson I~EAI•► IMF:AI.► AUTHENTICATION ACKNOWLEDUMENT Signature(s) STATF OF %VISCONSIN i SS. Vt, l~nUnlt'. authenticated thin day of 1i1 Pvrs(lnally1, came before mr lhia 6%, of S f+ N r% 'L 'L- 88 the above nnowd S Virginia M. llanson TITLE: MEMBER STATF. BAlt OF 1CISCONSIN f not. authorized by 4 706.06. Wilt. Slat.A.) fit me Lmm-ti in ho lhr I.o:hon tehM ostruled the hirevitin • trtnnrnt mij ai•knnn•kd~r the s:mat•. T't'i INSTRUMENT WAS DRAFTED nY i U• Lois•A. Murray, •lleyy!)od, Cari 5 Murray P.O.'hox 229. liudson, W1•.. X4016 w / J ota• • uAIU' Pr~ y14 f r. ('nunl}. I~ is. t (Si¢nnturrs cony he nuthentienled or nrkn,,wlyd;;I•d. 110th 'Mv 1'•„11•10A011 y.•4t~anr•rJ.l if not, stale e;t• ri1i...l nrr not necessary.) . i { 'Names of i..Mnn. rlRnlnt, I., •ny -1-it)' •1.•.y'.t 1. I), I.'..t•d I. A WARRANTY DUED STATP, nAn DP RIFI'II\fW tt,.•.,,.;n 1•.,.I Hi:,• . i.. 01110=1 MMI STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERBUYER~ ~C /4 e t3h'C t/~~ MAILING ADDRESS -7 9 /q/Z Z ICW,fe/l) X,!:PXa PROPERTY ADDRESS y / ~ ;~xlzl,C (location of septic system) Please obtain from the Planning Dept. CITY/STATE y [/O S O y (x ) I yo/;-~- PROPERTY LOCATION N W 1/4, /yw 1/4, Section T a`1 N-R 9 W TOWN OF A/ ST. CROIX COUNTY, WI SUBDIVISION O 9 -5 ~iYl> /,f/,6 LOT NUMBER CERTIFIED SURVEY MAP S bF , VOLUME, PAGE LOT NUMBER 3.a 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 l 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,' T Location of property_[Z~,) _1/4 1/4, Section Z/ T< N-RI Township fYU Jj S n Mailing address /V/L C R 0 ~~s o M L i t six. Address of site$ x~,A / X21 E ta4~/E Subdivision name o.@ S Z,4 YG0/NC Lot no. P7„E Other homes on property? Yes_/_No Previous owner of property SA-1V'1 (I~/LZ-4L Total size of property /F/ 1+4 Total size of parcel j, I'V Date parcel was created G- Z - Ss~ Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? X_ Yes No Volume,aj// and Page Number-7 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. yD 6k , 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. S3 yo(0 g I n,,-x agwa~j 'Ir!~: Si nature of Applicant Co-Applicant Date of Signature Date of Signature o r-~ f o cH/CqGO lvoRrHWes7 y ~ RN RAILROAD ~ N 77. 3S 4s~ ` 40 ON 47. ~3 . 38 138,548 SQ. FT. ( 3. 181 .AC.) l ~ F I 3T 138.548 SQ. FT. (3.181 AC.) 36 ~ 0 135.348,/SQ.-,FT. e _ to ( 3.107 Ac.) pR2s ~ \ 218 0 r`.--PONDING \ ` 1 39 EASEMENT 09 286.; , 'r T, (2.509 AC. 1\3' t \ _ LAN E 89 10 .;56 E 41 #i • •2Z ab p f 44~ a 45 / 130.099 SQ. FT. 87, S'Q FT. ( 2.95'7 AC. ) A"t s A, c. All z DOCUMENT NO. STATE; BAR OF WISCONSIN FORY. 1-1967 THE. •rACr ern(..r0 on ^tcono'tij BATA WARRANTY DEED _ 5340f8 V11L 1141Pi<'JE 7- REGISTER'S OFFICE ST. CRON CO., W1 This Deed, made between a m _ . i 1 1 e r r_ Reed for Record a...s.1.~3..5....F?grson.........................--- . SEP 2 1990 , Grantor, Y. and ??a.rk._.A nt 3: 00 M .E.>3.G.h.4~-r.......... • Re¢ttrr of Deeds Grantee, / Witness th, That the aai Grantor, for + valuable consideration . 1 9J = j(~i r( yvlo ~ ~.!t......(~.~J.c.LlsLr~... Sl'...can~(-l-~rRr:°~ _ • conveys to Grantee the following described real estate in S.t._-_LrD-Lx...... RETURN TO TO Mark E b a e h e r County, State of Wh onsin: C"-% }k r )k A t •rk• 2id c ZL (o0 6G Tax Parcel No:._ 0 2 0 269 _-...7_ Lot 37, Jacobs Landing Third Addition in the Town of Hudson, St. Croix County, Wisconsin rI 0 This 1s..AQt......... homestead property. (is) (is not) Togetaer with all and singular the iereditaments and appurtenances thereunto belonging; And............ C~ r-na.t.o r . warrants that the title is goodindefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. Dated this day of `.42L_em5e-r 19..°.5... .........................................................(SEAL) (SEAL) i Sam E. M i her (SEAL) (SEAL) AUTHENTICATION ACHNOWLSDGAIRNT 9lgaatnrs(a) Sam E, H t 1 i er _ _ STATE OF WISCONSIN .............County authenticated this day ot_ 5 ep t em b e r 19. 9 5 Personally came before me th' !7"'T''1-day of S e p t e m b e r , 10 _ the above named Sam- E. H i l l e r - TITLE: MEMBER STATE BAR OF WISCONSIN If not . aathorized by 1 708.08, Wis. State•ICL/~7GR p~~ NOTARY PLIALI m6 known to be the person who executed the t~ in nt and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY •TA*M 1 •1!A.. Thomas Van flec . . k u.m.._........._....... Kenosha W l ry Puli........ .......County, Wis. (Stgnah red may be authenticated or acknowledged Both my Com salon i per anent. ([f not, state e:pi: fjon are not necessary.) Qf~j/,~, ) date. 19 •Neme of persons ,lanlne fa •ny capacity ,boold be typed or prfawd beto- flex are.mres- WARRANTY n►►n STATE nAR O► wT%M%(CIM w; I. 1---I nl-.1 r. I- ` Y STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /1~.P Eds°~~.v~L ADDRESS SaN w SUBDIVISION / CSMJ SA L 6 5 ~OJ A141) /A(~ LOT SECTION !;~~T~N_R Z2 , Town of_ llV p se /V ST. CROIX COUNTY, WISCONSIN PLAN VIEW SH W EVERYTHING WITHIN 100 FEET OF SYSTEM 0 .;37 w 0 3~E X08 ; ~r F-~&_ NOTE- CKt HA s BEEN MADE f , bN E A51- 5 (DE ifB' 70 MAINT4 N ' vowr P EP71 S r o~ (ts I ~ N1 3 41*4d9 qo tt L L DRIyE wAY /~IOTF' toeN 12 s c~E cc 5 Nd ~ N KE Z' 4 5TA} L L F'3 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. I Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: TOP Ot TEL ~iw 14r 5 uJ ngAlere f/' /2 3 -lock " ALTERNATE BM: /oT OF I4Du,5£ SOW AIDAT/0N F Z- EPTIC TIJa;>/ PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Z, AEA Liquid Capacity: 1000 ~ L Setback from: Well y~- House Other „Z/ Pump: Manufacturer Modelt Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: 12' Length Yoe Number of trenches Distance & Direction to nearest prop. line: /o g To ,F-A Setback from: well: SQ House Other -e!~Iy~1'o 6,.vti4 L ELEVATIONS AAf}q go I- E Building Sewer ST Inlet. 8`/S p3 yS ST outlet 817,'` IO~,S3~ PC inlet - PC bottom - Pump Off- - fa, I ar Header/Manifold l D, Z" Bottom of system • DO / OG. 3 Existing Grade StOO' W/3Final grade `6' CC - l04/3 DATE OF INSTALLATION: PLUMBER ON JOB: ~!t r-}?/ ~r~/GLcnI/ LICENSE NUMBER: INSPECTOR: 3/93:jt wi v sin Depagmentof Industry, PRIVATE SEWAGE SYSTEM County: Labor aAd Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI EBACHER, MARK A. X CST BM Elev.: Insp. BM Elev.: BM Description: Htlelsen Parcel Tax No.: /00. k95ee349 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing 10 2 Aeration Bldg. Sewer Holding St / Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet 75 ' b3, . Verit TANKTO P/L WELL BLDG. Airl to ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header/ Man. (0, F,7' (0 Aeration NA Dist. Pipe /0 Holding Bot. System 19,0 c(,3 PUMP/ SIPHON INFORMATION Final Grade g~C) 0 Demand X07, 6 Manufacturer X Model Number GPM TDH Lift Lrictio System TDH Ft oss Fi Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Lengttl, , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth S _ I I DIMENSIONS DIMENSION / SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Moe Number: t.d- /pFS a 7' ~1 ~A OR UNIT System: 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 30" Bed/ Trench Edges CV 9 - 36 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Huudson.21.,2cc9.19W, NW, NW, Lot 37W, Prairie Lane ~ .ar O / lJ . /f/ 6?t 1 1 C..~r' Q W2~.G v rl 'r af.: ?J • ✓ ~ 2uF~f?~t Ct~ ~fyv`.~.1 ~ ~jG`(~?~~~P..~ir_te'b,TJ Plan revision required? ❑ Yes ❑ No / Use other side for additional information. /O 3 v ~rS _~.n (v SBD-6710 (R 05/91) Date Inspecto s Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' IllAl ~r Safety o and uildin g Water Systems l v■=.■;'~' SANITARY PERMIT APPLICATION Bureau 201 E. Wash I ngton Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. 57. U I • See reverse side for instructions for completing this application State Sanitary Permit Number ,;?41q 755" The information you provide may be used by other government agency programs ❑ Check it revision to previous application IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location 4K 14, 4de4e >E2 &,)IA 40 1/4, S 2 / T L qr , N, R/ 9 E (or( o Propert Owner's Mailing Address Lot Number Block Number iy/4G ieN'! i4e°o,40 City, State Zip Code Phone Number Subdivision Name or CSM Number vVso cod o/ (391(-> ogZ z74e_off _5 4 s~-iYD/ ~ II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road L~ ❑ Public 1 or 2 Family Dwelling - No. of bedrooms VllTown OF /iVOSo ~~E III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) //1 ❑ Apartment/ Condo ©Z /2- 9 _ Y 0 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4,_ ction of 5. ❑ Repair of an System System Tank Only ~xlsttng Sy B) System B) ❑ A Sanitary Permit was previously issued. Permit %U.' l 2 770 D to Issued /st 6 a V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Other 11 )?[Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 1 f❑_ 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 if S lf) 7 L v 20 /Op, '7 S Feet /03.2 o Feet VII. TANK Caaact in 9llo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks 94-, Septic Tank or Holding Tank W t $ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (N amps MP/MPRSW No.: Business Phone Number: -cam 38~ff~ . 5D o .ELC. % tLAe~ Plumb is Address (Street, City, State, i Code): L D A/ 14 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Ag t Sig ature (No Sta s) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF -APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration ,date, and at a time of renewal any 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. 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, purnp/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 curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. AAARK A, EB cftE ZYs;sa' / ~ R T,q c o g 5 ~AXp /K6 LoT 3 I Zv'=PIEX 37E / SCALE SgS -r /v ~ S ATE NI Fl, 37E ~ ~Ob C~,• y IVi E I, 3 w l(o01 D a 1 3.18) AL t ~ o 5~ II ~ ~ I ' I ,LS /u P f ~ j o w 3.7 WE ST FA"r vVV) ~ v I(~P e p ar E WELL A WE L L %s. w• ~ o° E mil, L~ L~ NE F LL, ~ w ~ °o Q CL = v w w a a w O YZ O a W 0 I~ h- C9 Y X lJi 0O 0 ~ I- O T o l a* o X a~s Z ~o a I I In m z I M F w 1 { a o1 ~ i wa ~ I ~U 1 1 ~ ° d.. 0 { U~ I t z I - v i a. I 1 _J a U i i t i Lli t I I I I AQ J Al I I Q M 1 ZD I ca 1 V1 I a I I I d I a I I I o { J LLJ S~ I I I z i m I 1 I o o I w v 11` I a I I a ~ I `ll 1 a~ I I Z 1 I I I ~ ~ I 1° Z > O - DE;3ARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION 'Number: MADISON, WI 53707 State Plan NW, NW, 21, 29, 19w (If assigned) Town o6 HucliSan L1 CONVENTIONAL ❑ ALTERATIVE El lava NA - Holding Tank El In-Ground Pressure El Mound ME OF PERMI HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam M-(Ueh Sax 282, Hud6on, W1 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Daugt" Sttahbeen 15432 St. C'%oix 128770 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF El YES ED NO NEAREST -I► 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 MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: VATION WELLS; El YES El NO 777 ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST' Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) ZAdmin f 6tAgalt T amass C. Ne,P~san Qi~HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ~a 7 7 Q 8'14 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. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION /71; /g/ NW'/4Nw%,S-z T-2 N, R E(o W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # p #Zy Z 27 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER cc~Sah wI `j0/ ? _a cob Le-k II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned O VILLAGE : IIfGt.lSor ~rQ. l d, L f n~~ ❑ Public 1~ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NU BER( ) Ill. BUILDING USE: (If building type is public, check all that apply) 3 3 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 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 in line A. Check line B if applicable) A) 1.0 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) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 9 Seepage Bed 21 ❑ Mound 300 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ~SU (.1,5" grg d . Z G 00. ,5 Feet D3-zo~Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted I Se tic Tank or Holdin Tank / von r'S ¢ r F-1 E1__ 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. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: 5, -1 Plumber's QA /ress (Street, City, State, Zip Code): / / ®I IX. C LINTY/DEPARTMENT USE ONLY ❑ Disapproved S Permit Fee (Includes Groundwater a e ssue Issuing A nt Signat a (No S ps Approved El Owner Given Initial / Adverse Determination Surchar Fee) ' X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 3 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 (SE 'D 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, 6,38-266-3815. 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. Ill. 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. Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'f2 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, vocation of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mairs,'water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; rep',a;ement system areas; and the location of the building served; B) horizontal and vertical elevation refe-renre: points; C) complete specifications for pumps and controls; dose volume; elevation differences; fricti )n 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. - - - - - - - - - - - - - - - GROUNDWATEIR 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) " w r r r a d In 3 I 6 r ~ 1 ~ I- h d .,J N m yS" ti9 r ~i W O d no ° h 4j UN a. M 1 O M t d l .O fi \0 • N w O ~ ~ c W/ CCU ; 0 O O = v 4 JZ tz 0 C) w = N C) X ~k p O 00 '0 s g V1 I r~ M 00 O I i~ z 1 w rp I ~I Ow l l I Il w4. ~ ~ U 1 l I O ( w 1 I I z I O V) 4. I ; ~ a ~ U I l I CL Lj ~ I I I ~ > j I l I m 1 I I j ¢ l I I 1 I I i I LU I ~ I I ~ I i 1 cD ~ zo I <a i I ' 1 I I ~1 W I t 4 I I Q I I IL IL I I p 1 1 ~ I 3 I ~ l .n I ~t., ( OJ l O I w 1 O i ~ I O ~ I ~ II i (i I ~ > 1 it ~ Ill j a U I4/ 1 J 1 II I 1 ~ I ~1~ - - - I A CL I N ~ ~ r00 Z DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION W 79069 HUMAN REDATIONS PERCOLATION TESTS (115) MADP.O.ISONBOX (ILHR 83.0911) & Chapter 145) -pnftLX LOCA,/ N\'W'/ SELiIO~TZ9N/Rr (o TOWNSHIP/ OT NO.:BLK NO.: SU ~ VISION yAME:/N4 9 6liP" ASo)y 37~/ .1 CoB.L//v~, COUNTY: MAILING ADDR S: STC~o ► x SAM M I LL,0 Q - uT cxN dU &5dr' USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMM R AL S RIPTION: I AT PROFILE DESCRIPTIONS: PERCOLATION STS: ,Residence 14N K New ❑Replace A /o /996 14v, /996 S,42 TIP N RATING: S- Site suitable for system U- Site unsuitable for system I ek L-, lid Q Q'I C KI STIE1U . 171S . ou IN-GFj a~ RE: S~EM-IN❑FILLHODLDING T : RE OM~M(option~IlE~ ISU If Percolation Tests are NOT required DESI N RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: IdSS Floodplain, indicate Floodplain elevation: 'y 14 &r-FT PROFILE DESCRIPTIONS BORING TOTAL P H T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH t%. ELEVATION OBSERVED EST.HI HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- Z /o.od o~.l,S NoNe ?io,OV 9i~4CTS i6~~~eNS,L 0S4 le eV e-0, C_ S B- 3 /0,0 /0'k,4-7_ IV C >ip.67 16~9LL-r- $ ~,S L q C1 59`$e„ Y'IS B- $.G7 1S-24 lVoigif > g.67 33`9LLZ5 ZT $eN Sfc ~Z' ~3aNCS~c4,c /a.qg v r >//.33 ZG°$<<TS 36r8a-Sr" 4 J a►.,C'S V Z9 QN CS B- 9,42 ~0~.6 L 9,qZ ~ZJBLLZS ~ts'~ ~,~Sfc "$e~cs~G~e aNc~ B- D c PERCOLATION TESTS EST DEPTH . WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES NUMBER DES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P_ S o as 7o 3 >Z >Z >Z < P. rloN>< at .4 12 Z > Z c 3 P- S,oS o cos $O p / 4 4 P- P_ F VA f i N A-{ id _P_ PLOT PLAN: 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 percen of land slope. SYSTEM ELEVATION. /00.75 i ~3 7I ~ - 'sS1 8LE I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print) \ \ TESTS WERE MPLETED ON: I-~dpvly JOHNS N JdN>.ISo+.► <w*q vn'J4 ~Nz NL4(-)Sr /9M ADDRESS: CERTIFICATION NUMBER: PHONE NU BER(optional): 4UINSn-l" V1J 1 S4~ r 6 ~4Fs~ o o CST SIGN URE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, DILHR-SBO-6395 (R. 10/83) - OVER - L ILI' Gb 1 I 1 I t 1 1 \ /~Z J ~ I $3 L Sz d it 4- R ~ E PZ T i E 8z I i ' FA U`-PNON~ A-T _ pi",4) n~~ N 03 SEPTIC TANK MAINTENANCE AGREEZIENT St. Croix County OWNER/BUYER - ROUTE/BOX NUMBER -96)( 2 Fire Number o CITY/STATE yr~d~s-v'~ wZ ZIP rt PROPERTY LOCATION:'.' Section a 1 , T_N, R Town of~ c " St. Croix County, Subdivision ~ccobS Ld j4 L,,, Lot number- • Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licens'ed 's'ept'ic tank pumper. What you put into the system can a ect t e' uncC on of the septic.tank as a treat- ment-stage in the waste disposal system. St. Croix Countyy residents-ma~'be eligible to recieve a grant for a maximum of 60% of the cost.of replacement of a failing system, wh c 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 sys't'ems agree to keep their system properly maintained. The property owner agrees to-submit to St.. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or..a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and •(2)•after inspection and pumping (if nec- apthan 1/3 proximatelyfull 30fdayssludge essary), priordtoc~. the sformcwillkbessentless Certification three year expiration. y 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 Depart- meet of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration.date. ti SIGN DATE_ 02 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. APPLICATION FOR SANITARY PERMIT STC-100 ts) This application form Is to be completed in full and willa onlydresultein delays of the property being developed. Any inadequacies the permit issuance. Should this development be intended got tesals by owner/contractot,(spec house), then a second form should be retained and completed when the property Is sole and submitted to this office with the appropriate deed recording. Owner of property S ItI, Location of property Z /l * Section 2- 1 Township walling address # Address of site Pr'"4/ Subdivision name Let number w Previous owner of property Total else of parcel 2 c Date parcel was created 2 Are all corners and lot lines Identifiable? V_Yes ~ No to this property being developed lot resale Crpac house)? '2L-yes No Volume b 2 and Page Number - as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWINGS A VARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUMQ AND PAGE NUMBZR, and the ORAL Of THE REGISTER OF DEEDS. In addition, a cettifled survey, if avallable, would be helpful so as to avoid delays of the reviewing process. if the deed description references to a Cestilled Survey Map, the Cettifled survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(ve) certify that all statements on this form are true to the best of my (out) knovledge= that I (we) am (ate) the owner(s) of the property desctlbed In this lnfotmatlon form, by virtue of a warranty deed recorded in the Office of the County Reglstet of Deeds as Document No. ~~_,,S"'//7 - / and that I (We) presently own the proposed site for the sewage disposal system (or r (We) have obtained an easement, to tun with the above described property, lot the consttuctlon of sold system, and the same has been duly recorded In the office e County gReglste I Deadsj, as Document No. -41.35 y/7 Signature of Owner signature of Co-owner (If Appileabie) Date at Signature Date of Signature n(:,(-uportIl NO WARRANTY DEED 1)415 s►A,.t ntstnytfe pool Ircconutr.u UAIA STATE I)Alt OF WISCONSIN F711,Mt 2-1002 , A35 A17 KOO" ►Xsc Q REGISTER'S OFFICE ST. CROIX CO., WI Reed for Record Virginia M. Ilanson, a single woman `i s MAR ~2 '469 M 8:00 A M , c4)m,•.. :alit L..rr:(nl, to Sam E. M111eC, a Sillgle mail 0sh4Nr of Oaai 1 u. t,:nM To file ff-lb. •iut; desrrlhed real estute in St. Cru1x t'.4u4a~. Slate of Wieteonsio: V Tax 1'nreel No: West Half (W')) of the Southwest Quarter (SWI,.) (it Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of the Itublic highway and except Lots 5, 6, 7, and 8 of Certified Survey Map n Vol. 6, Page 1747, Doc. No. 419479. That part of the West Half (W') of the Northwest Quarter (NW1r) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolis and Omaha Railway Company. Y •RN SMIA 0 slyw a } This is not hfenlrtU:al ltregn•rt;:. tixk f is life() L. t:xre+.tian tt. Ie,irranties: easem•~nts of record and pro':ective covenants and restrictions of record, if any. r T• 11IItrd this d:I}' of 1 , ' /~1 ( 1•' 19 88 4 i w 1 S E A I.1 1 • Virginia M. Hanson 3 ° I~F.AL► t~P:AT.► ,t AUTHENTICATION t Signature(s) STATF, OF WISCONSIN 1 1 ss . 0,v ~k. count, e. authenticated this day of 19 PerFi)n:dly came beffere me this ` day of M t 1 rL t^ 19 88 the alr44ec name,( . Virginia M. Ilanson a TITLE: MEMBER STATF. 11A1t f1F WISCONSIN (If a authorized by 70r;,0P, Wis. Slats,) r In III,- Lnoieil to be tile iwrpon tt•hn exrruled the f tro: ' T•4'S INSTRUMENT WAS DRAFTED nY - -ru2,11,10AVen roment anll nKI10n•It•41gr the saihe. a Lois_ A. _Murray,.,Neywgocf, Cart & .Murray l'.0, ' Box 229, Hudson, W1...., 4016 %t)t:(• P`~ f r (Si¢nntures nlny he authenticated or urknualyd;;ed. lifeth X14- r~ fit IRAs 1ai1r•IJ.I if not, stale wo; atifet( are not neerssnry.) dal..: , t( 19F I .1 "Name. nr prrann" Arnin• In any rapn,•ity •1..•x'.11.. /.t...4 t.•nt•.1 b •..a tl.•,r -r+. WARRANTT DEED STA'IP. RAR OF V6fA('1J%'c'V Nt••. a•Ln I•enl 1!la• 4 Fe"111M Ile 2 - 1 r 11 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERBUYER z!5W I -AC MAILING ADDRESS :Z'j? I Z-Z- /;71 PROPERTY ADDRESS ,L }I/II-4- (location of septic system) Please obtain from the Planning Dept. CITY/STATE U~ S O N W I "r--VD /So PROPERTY LOCATION 4", 1/4, 1/4, Section T_7N-R W TOWN OF &/_/o SQ ST. CROIX COUNTY, WI SUBDIVISION Z /W , LOT NUMBER , 7 C'o CERTIFIED SURVEY MAP VOLUME X/, PAGE 73 , 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: ~a,~ ? ,,p DATE: g f y 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 property adoe-, A Location of property_,&L~,/ 1/4(&21/4, Section _-,Tam/ N-R / W Township N-() b S© iV Mailing address 79? ,fir LL zWX ln RV syo~42 Address ofsite _t9g Pe 1<4 le- 16- L, 1VIC Subdivision name .TfgLO Q I -AA / /A/ 6 Lot no. 3 7 Gi-) Other homes on property? Yes_,~,! No Previous owner of property '514-M Total size of property 3 , / g ) Total size of parcel 3, Date parcel was created 9 'L-a -:Z:5 Are all corners and lot lines identifiable? C Yes No Is this property being developed for (spec house) ?/xC Yes No Volume and Page Number -75 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. -n-3 yp Gg-' , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signatur o Applicant Co-Applicant Date of Signature Date of Signature . o°"f-- 4 CH/C4(; N4RT NINESTERN RAI LROQ 0 77- 400 1347. 38 138, 548 'SQ. FT. i, ( 3. lei ,AC.) a j t r~ID M 3T 138.548 SQ. FT. W (3.181 AC.) N 36 0 135.348,,=40.. FT. ~e to ( 3 tOT AC. 3 09.. ` _ \ 62 J8• \ ~ w ~9~ RONDING EASEMENT • 09, 266-,t S.Q. 'FT . \ x:93" (2.509 11C.) 1 \ - LANE N 89 1 •58 E' 24741 _ lim $3' . ~ II 40 / 130,0995SQ. FT. 8740 01 M FT. (2.98'7 AC. ) 9.6fe Ac a• DOCUMENT NO. STAT1; BAR OF WISCONSIN FORM 1 - 1861 nna 4PACr Rr!(t.ro FOR Rtc UROIN3 DATA i WARRANTY DEED . 5340G S - y''L 111 Pa,E 73REGISTER'S OFFICE ST. CRO This Deed made between c DI CO., d ~ am...:......' ~..~.e r-r---•---•--_._.. Recd for Record i A---5-1-ng. i.S-...p e rs o n..._............................................ S E P 2 t) 1995 . ' G- - -....rantor, . fIt 3:00 Y. M and HA.rK.! UA.G.h.e.f_......_.........._............. ' . [W,. . Grantee, Witt'~y eSS~ th, That the said Grantor, for vA bie wmideration...._. .!1..._..1.,!C. (4~~... H. Q..A.f_er.._Canl, C,et'o`~ RETURN TO conveys to Grantee the following described real estate in S.t- LL o. Lx...... &08 S. !Sark AE 'b a e h e r County, State of Wit :onein: ~~bcr ~4 A•t k- 6 Tax Parcel Nu: 0 2 0 1 2 5 - 9 7 Lot 37, Jacobs Landing Third Addition In the Town of Hudson, St. Croix County, Wisconsin 1,J0~ This IS...n.at......... homestead property. (is) (is not) Together with all and singular the : ereditaments and appurtenances thereunto belonging; And............ Grna.t_nr______________ ib free - warrants that the title Is good, iadeteasible in fee simple and free and clear ear of encumbrances except and will warrant and~deefe..n~d tthe same. 41r, Dated this day of 1.e21:em5e_r 19_.°.5... .......................................•---......_--.....(SEAL) ......r.~ihR~"....................(SEAL) • Sam E. M i her (SEAL) (SEAL) • • AUTHNNTIC 4TION ACHNOWLBDOMSNT Signature(s) STATE OF WISCONSIN County. authenticated this day of__ Se p t e m b e r 19-15 Personally came before m• th' day of September - 19-9 the above named Sam E. Miller • _ TITLE: MEMBER STATE BAR OF WISCONSIN (If not . authorised by 4 706.06, Wis. 3tata ` q~ and known to be the person who executed the NOTARY (~~]PI~ALI in t cat and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY STATE C"T Thomas Van @ e cku.m Kenosha W l - ry Public ota ............County, Wis. (SignatLres may be authenticated or acknowledged Both my Com '3610'1 i per anent. (If not, state expir pion are not necessary.) date. - G _,C . 19 *Nam" of penooa SISmInor in any capacity sboold be typed or prlnud blow tlei uaaaw, . WARRANTY n►►n STATR nAR OP WTarn WsIN w~ i. 1---I il'-•L 1~-