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HomeMy WebLinkAbout020-1289-50-000 h 1� bq y a o � N a N O V! N O I q L � U y C N 4 I > x h U) .2 o YQ a� w yr O ARD U) C Z 7 N LL (6 is C m> O O)> 3 ocy) Q O°' CD I I M v 3 I Z a rn U E °o z € a9i (DCN am II I o z 0) zz �w N a y O o 0 o Q N O Z H Z Z Z o N = d V7 N p — to CDI _ L C G CL E 0 �w N N N fA V 3 3 3 •►� 000 0 a � I 0 N _ (D W W N V II rn rn } >_ 5 o O 'C3 N N co m y CD E CO M N rO LO °� o. a corn °o o v p of ~ c E E c �' oo v Lo 00 p r O) O y N FL- F- 0) C N • ~ N 7 >N� O H E E O t6 U N O z N zi .Tt fn O y w a a CL m :� d a L` E C :� �1 A L) CL ' 0 U) C) f OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION IN ��. ell �11:zol r TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? OYes ONo Soil series per SCS Soil Survey: sheet # Type of soil absorption system: OBelow grd OAt-Grd OMound Approx. size ' X I OGravity ODose OPressurized Ft. -' ❑Bed OTrench ❑Dry Well Molding Tank 00utfall pipe OBSERVED DEFICIENCIES 00ther OUnknown Septic tank Setbacks: ❑House OWell OProp. line 00ther Dose tank Setbacks: ❑House OWell. OProp. line 00ther OLocking.cover OWarning label OPump/Floats OAlarm OElec. wiring _Soil Absorption System Setbacks: ❑House OWell OProp. line 00ther OPonding: ODischarge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N I Inspector Title ST. CROIX COUNTY ',' •-�' _ � WISCONSIN NMMRlip -� ZONING OFFICE 1 I - ST.CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710(715) 386-4680 SEPTIC INSPECTION, / WATER TEST REQUEST FORM Please specify , desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. ❑ Water (VOC's) $185. 00 Septic $50. 00 0 Water (Nitrate & Bacteria) 45. 00 ❑ Nitrate & Bacteria O Water (Lead Concentration) 21 .00 retest $15.00 Owner: �Z- _LuA Lak e,r Requested by: lb."Lt( L36 Lek Address: 33 Wlea ow Lk Address- 7- `` S-t, AJ Telephone Aso, �s ZIPS'fo/b- {-�`'te g W ZIPS4�(/ P (1 LS ) 38( -S 2/8 Telephone W: ( •1lS) �- Property address (Fire If & Street) : 3 N eaj o w Location: ;, Sec. , T N, R W, Town of tgan Realty firm: Lock Box Combo: Closing Date:L-30-9`7 029 — 1989 — 50- 000 2&. 1 TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Water sample tap location: Ne)(f + a­t D ao Is the dwelling currently occupied? J9 Yes 0 No If vacant, date last occupied: Age of septic system: Septic tank last um ed b �- p p Y= fe�`4 Date: Previous Owner's Name(s) : Have any of the following been observed? ❑Y PW Slow drainage from house. ❑Y 91 Sewage Back-up into dwelling. ❑Y ON Sewage discharge to ground surface or road ditch. ❑Y JOIN Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. OWNERS SIGNATURE: DATE:-4 7 1 /94 l /v �,� •�', ,�� ST. CROIX COUNTY * WISCONSIN ti ZONING OFFICE w a N x w■ r�r� ST. CROIX COUNTY GOVERNMENT CENTER -- 1101 Carmichael Road Hudson, WI 54016-7710 _ (715) 386-4680 June 13 , 1997 Darrell Wold 612 4th Street N. #15 Hudson, WI 54016 RE: Septic Inspection for Robert Lotzer, 733 North Meadow Drive, Hudson, Wisconsin Dear Mr. Wold: An inspection of the septic system serving the Robert Lotzer, property located at 733 North Meadow Lane, Hudson, Wisconsin was conducted on June 13, 1997 . At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this system was based upon a surface inspection and did not involve any excavating or chemical analysis . Accordingly, there is the possibility of hidden defects in the system not detectable 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 be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Enclosed is a copy of the As Built Sanitary System report which was completed by the plumber upon completion of the system installation. I have also enclosed a copy of the Inspection report for your own use. If you have any questions regarding this, please call our office at (715) 386-4680 . Since ely, ames K. Thompson Assistant Zoning Administrator Enclosures sm i i STC - 104 AS BUILT SANITARY SYSTEM REPORT i OWNER / R LLE E' L FN ADDRESS©X Z~ W c,,~(~ SUBDIVISION / CSMJ H 16 FI M y (a✓ S LOT 3 SECTION _,o T _o1- N-R / ' r W) of Alt/L) SON ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /Y S r~~ ~ `~y~= Icy s." S ALTER D a2 (v E w ►4 Y G,a.~MC~ , OVA - - DI I k)E LL h/07' es' 3r' i i , VET' p W z NSr~r u ~ ~l• a ~-9r as,)" I ~ 13411 76P °F RE13AOZ c l . /OCJ,Ov' --s INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ,r. r ' BENCHMARK: B41 S (o~ /1C~ /gyp UU ALTERNATE BM: Zn ,EPTIC TANK ~J PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: y Liquid Capacity: 102 OU 64 Setback from: Well ~r House / j other ao , 70 Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width:- Length ( o O Number of trenches Distance & Direction to nearest prop. line: _5_.'5-' (v r ~ Setback from: well:-~ _jo~ House Other --76-r., S~ ELEVATIONS Building Sewer ST Inlet. ST outlet -7.7 PC inlet c- PC bottom Pump Off Header/Manifold -7, L5 Bottom of system q. ~ S Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: , C71, 3 C1 INSPECTOR: 3/93:jt s . sin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labofand'HumanRelations -.S:afety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI MILLER, SAM/GLEN WAXON X CST BM Elev.: Insp. BM Elev.: BM Description- ' Parcel Tax No-: 1 A9500354 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ' Septic Benchmark 7 X' 149,a2 Dosing I [ , o`I gip' /es -5 Aeration Bldg. Sewer Holding St/* Inlet ~d >'6 TANK SETBACK INFORMATION St/,Kf outlet 7179' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > 5-0/ NA Dt Bottom A 2q= Dosing NA Header~~ 7. Aeration NA Dist. Pipe H g Bot. System 7,21 i PUMP/ SIPHON INFORMATION Final Grade Man facturer Demand `S' T ' d ~a3 Model Numbe GPM TDH Lift Lriction H Ft Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION .J 3 DIM N I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LE G r' SETBACK INFORMATION Type O nt r 4 AMBER + Moe Number: System: t~eS~cS "S$~ 35 OR UNIT DISTRIBUTION SYSTEM Header / ManIld Distribution Pipe(s) x Hole Size x Hol t7Errt~~i.Llntake length ,2 Dia Length ~ Dia. _JZ/ " Spacing / SOIL COVER x Pressure Systems Only xx Mound O -Grade Systems Only Depth Over Depth Over xx Dep f xx Seeded/ Sodded xx Mulched wrench Center- Tom` ftdJTrench Edges 3 ~a Topsoil C] Yes No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOC)ATTIION:, H~udson,.,2/6..29,.y199W, , 11E, Lot 2, N(7:th Meadow Drive d/ Plan revision required? ❑ Yes P-90 Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No- Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water System, 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. q~- UM • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ~O~ G ~14X cJ~~~ L 1/4 5JE 1/4, S T a r 111, R/ E (o fZ Property Owner's Mailing Addr ss Lot Number Block Number R g_ CD)( z Z - City, State Zip Code Phone Number Subdivision Name or CSM Number 44t, 1) N N W d o Q% Ata) 2 7 !o X11G C4 /,n ,E ,?,>o c t J S 91>0UV6 II. TYPE F BUILDING: (check one) E] State Owned E] ~ VII iliage I Nearest Road 2 Public 1 or 2 Farnil Dwellin - No. of bedrooms/ Town OF Z~D,51) Al D©t4,) III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0?_ o _ i8 q - Sb 116- 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 I IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) j A) 1. pg 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 I V. TYPE OF SYSTEM: (Check only one) i Non-Pressurized Distribution Pressurized Distribution Experimental Other j' 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 "Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq- ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 5-0 l ©O 4 v S 91q-00 Feet /e f dofFeet VII. TANK Ca in aacctltos Total # of Prefab. Site Fiber- Ex per. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank oQ ' ❑ ❑ ❑ ❑ ❑ 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/ PRSW No.: Business Phone Number: IV 14.e ~ Don LL ~ ,p~~ 5-03X00 -~6 M ( vr/ Plumber's Address (Street, City, State, Zip Code): ,2.Et oewlec- zx/VF oso IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing A nt Sig ture ( tam ) pproved ❑ 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: L Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance 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. - Safety and Buildings Division ~~i~'■•i'~'ii SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County /y than 81/2 x 11 inches in size. J~-: • See reverse side for instructions for completing this application State Sanitary Permit Number a4j5~/6 The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location /EN AXWV S4 /f1 A/LLE~C_ 11iLd1145jL 1/4,SZ Thy N,R / E(o1(a Property Owner's Mailing Add ess Lot Number Block Number Yt Z$ Z Z City, State Zip Code Phone Number Subdivision Name or CSM Number ~~,~so w s~1or~'~>z7~9 /G~ M~ADDuJ S ~~/YE . TYPE F BUILDING: (check one) E] State Owned ❑ it Nearest Road ❑ VII age Public 1 or 2 Family Dwelling - No. of bedrooms Town OF SO l be7f{ DOW Pies E III. BUILDING USE: (If building type is public, checkall that apply) Parcel Tax Number(s) 1 E] Apartment/ Condo 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. ❑ 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 RSeepage 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 LI50 1700 1D0. S Feet " /O 44,19 Feet otal # of Prefab. Site Fiber- Exper. Cap HExisti VII. TANK in T INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New structed Tanks Septic Tank or Holding Tank /000 ❑ ❑ ❑ ❑ ❑ 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: (N Stamp MP/MPRSW No.: Business Phone Number: k = D oft ~F<<s-a~soa Plumber's Address (Street, City, State, Zip Code): 1-161 6e-4cll /)V/I& IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (Includes Surcharge Fee) Groundwater ate slue IssuiLAnt SI t e (No a ) / Approved ❑ Owner Given Initial (~j~ ~3 Adverse Determination /o v X. CONDITIONS OF APPROVAL / REASONS FOR-DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One (opy 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: I_ Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7_ VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. i 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. M yo/'T~f ~I /~DOcc~ v.2 vc , z a m~ _ rn o, 0 0 + ~ r V% or 1 o cO `'goy o rn r W 1.0 zt, w f ~ o p b o f T M b r k> N AA W yy O C ° 17~ y W \ VA, 1 -Jul, sC lop b U, C ^ i I z b p v rn o 0 0 ~ ~ Iw ~o Z i ~ - - cA~_ ~ ~.9ST ,CoT LiiyE d9o- SD ' a 1 ~ ti rZ I I J , 1 m I ~ m d m I ~ I I l Q I ~ I ~ I I I' r v 1 M~ N m I N' D I 1. to 1 O I - - - W I z i t _ I m ~o c J ..J 1 ° N_ O O i 4'. 4A rn LA n Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of Labor,and'HLman Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST C*eQ i k not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OW4f l: PROPERTY LOCATION p ~/h 1171 GOVT. LOT IJ W 1/451_ 1/4,S Z6 T ~Z9 N,R /9 E (a) W PROP RTY OWNW00 LNG -64 3t# BLOCK # SUBp/ NAIVE " #d ~dvT' Z hI 6 CITY, STATE ZIP CODE PHONE NUMBER CITY ( ) OVIGE OWN NEAREST T FPAD &_,c, rJ /11EA,&0 w N K New Construction Use Residential / Number of bedrooms xJK [ J Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow I Sa gp0sat-n Recommended design loading rate 0.4 ed, gpd/ft2(a-- trench, gpd/ft2 Absorption area required bed, 1112 trench, ft2 Ma)amum design loading rate bed, gpd/0trench, gpd/ft2 Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S = Suitable for system 212VENTIONAL 0 ND U ROUND PRESSURE AT-GRAD SYSTEM LL 7HOMLSD I TK U= Unsuitable fors stem 441 S O U S U WS ❑ U E7 S AfU O S Q~J U U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mrch 13 1 C) -4d 149C5 p.q d 6-74 lby,> 4 4 F'S ~ -1'r rl~r CIS j- 6A 01S - r n Q,7 Ground 74 -121 10 4/4- elev. / Oft. Depth to limiting Remarks: Boring# ©-3~ /&Y,0 414- S 0 ©f r►!rr d,q `O.S /6-/P 4A /-/3U ILa' O 4- m 5 rVI r 9 0.-7 by Ground elev. /d 4 ft Depth to limiting Remarks: CST Name _Please Print ! Phone: 4-6 K O AJdiuda: ila ay C)lJ I`I ~SC~~1 _ 4-- Signature: Date: / / CST Number: 95 j -4 PROPERTY OWNER SOIL DESCRIPTION REPORT Pa2e•ZL of 3 , PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Ba.rxl3y Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ierch 3 Z7 P14 r c5 0, a Dz - -4 b\J 4/t - S L r n r 5 O.4 6 Ground 93 -FS i ) d P, S 13r n, S - 07 0 e ev, /Mll ft 194 LM 16)YP4 hl y,, ] CC7 b,% Depth to limiting factor Remarks: Boring # 10N/k 4 4 SL °r m r C~ _ b.g DS 87- 1 0A 6,~ IS>t Ground 3-t y~ 4' s r' it~► O elev /bC I ft Depth to limiting factor Remarks: Boring # g, t~ 3a /oyk4 4 5 - 'S r m r G s o.4 1:6.,5 13 $ - ~S by 4 A - S 0 7 cs o 4 o.~ Ground elev. Depth to limiting factor Remarks: Boring # i JjNGIC 1 ~ ~L t"S WAS a"Al JAI '9 Td n6) L 43 6 ova ~ /NG S ~ Ground -r)J ii Si-rt '4 8 l W ~ T elev. b~ GJ~ ~p /nK L o« r, ~/s ft Depth to limiting factor Remarks: SSD-8330(R.05/92) i H Pa 3 0~ 3 Flo m K4 dow -hie ►JW ~ ~o so3 N 7; Z ►No p ~ z ~ W 0 I 1G ch1 1A o~ 3 e o ~N ~ z9o.sa' - I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS iINDUS'.tRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 ,HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATIO : SECTION: TOWNSHIP/MUNieaPAt+TY: OT NO.:BLK NO.: SUBDIVISION NAME: )aE' /.aU- aso 3Z ' H f&ff MfAbows__01- 1/ SE V/ -2& /T29 N/R0 E (ar)W Uxi I 1L ti COUNTY: MAILING ADDRESS: 54. C'ROC X 6~LZ'.v C IJ.XO) 7Z (o 6nQ J"ry T-D. Ali , tj v j).Sda W 19 TV6 USE 3 ^Z2 S DATES OBSERVATIONS MADE NO. BEDRMS,: COMMERCIAL DESCRIPTION: 7RAZOWTILEE =DESCRIPTIONS: PERCOLATION TS: Residence 3 ,op- 4 N, &New ❑ Replace U01-:11E 1461 IS 1111 J-u,3 .4 1 t~ 5CS Cod S Naw s /4-s ~F RATING: S- Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional) ❑ S 0U ®S ❑U ❑ S DU ❑ S C1U ❑ S CJU Nlo 6),, If Percolation Tests are NOT required DESIGN RATE: It any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: L,t 5S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B f r 0 _/6' /oey/P 313 1/5, 1W %If,p.r„ ; L/~ Z v "/o yrP s'/~ s B- RL - 72 I ✓ ' 70 ' ZJ 2' ~71'19R, /H1iC Zd "1- 7~ ~V //C ¢/~I r5~ ( Q,fW 1; 7z 0 y'R 5 y ati , -vtio s 0 /0 ilk 316 B- 1 S / F9 R F R H, , I d( oR - Cr y, Mo TS COd l G D/~LE /J C~-i~ 3/3 15, 101t,^ g R j n, x 0 /0Y'e 31, 5, 30-yy"/0yR 2/, IS 2~-Sbk,r-,fi ; B- Z AT 3Co 3 01(-VA/ yN-L o " I o yR y/ 4 5i t 3 S 9) nN i w a„ zeC_ &073 B- -3 7 0-12 " io V R 312 s , /A-Ag'Q A., FR ; I2 it -/R'/' ye r/& 5 , Z 9~ y2 - 3 14- 3 3 " 7• s y ~s ,mot q le e ' 3 3 " -7 2, " S %/Z 1-l , $ w e' li *1'a / " /3~•-os B- aF '7..f vie 31y 512-vff-5 R, 'e wr'"t, C"-f,' ~J nMC~Q . PERCOLATION TESTS 1.5 T/;"tT- M0 5 (g yR 51p EST DEPTH . WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES f NUMBER INCHES AFTERSWELLING INTERVAL-MIN. P Rt D 1 P RI D PER INCH P_ r L o- 3 v I N ! S/!~ / /G 2- P. 2 20 3 0 / e 2-2.9 P- 3 o D l~ l~ Z Z P- 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 percent of land slope. 9yS SYSTEM ELEVATION. i t _ i I I i ~ S be PT", , 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: ~ J t,A,E- i7 11"? _ HOMESiTE SEPTI_C.PLUtd81t`t(W.-------- ADDRESS: 665O'NEIL RO., HUDSON, WIS. 54016 CERTIFICATION NUMBER: PHONE NUMBER(o tional): ROBERT ULBRIGHT _ _ 3 g~ 1 t S PLUMBER LIC. NO. 3307 M.P.R.S. CST SIGNATUR : ~ r' a4 NtNN. INSTALLER & DESIGNER LIC. NO. 00663 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. f PLOT PL-A& LoT ~ 2 J 5c,a~E ~ l = 3 0 J HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT WRIGHT c 5 T vis. m.,%STER PLUMBER LIC. NO. 3307 M.P.R.S. ^TAILER & CESIGrIER LIC. NO. 00663 ~z 10 - fPZ / 5S 12,0 I p, - ~ II 3 Ili (00 I ~v sT G o T c oco~~~ i~'oti ~ai2 /o 7- 1 L o 7' UNPLATTED LANDS LAST-WEST W4 LINE Of SECTION 26 N89.37' ' w 1221.08' f 440.06' 66.00' 300.02' M5.00- 33! 33' I ; 0 0 N LOT 36 • ' 108.332 S0. FT. w N ^ - R 2.49 ACRES N > 's e LOT 29 LOT 28 - o o0 ob 92,550 So. FT. 128.018 SO. FT. $ D: i 2 S4 ACRES .12 ACRES z z 2. I.6' S89• ST 2Y E i 440.04' 1 7,3.02'- I 300.02'- - 415.00' N89.37'22-w 849.37' 8 LOT 35 g " 40 - - WAXON 0 N 93,261 SO. FT. N 2.14 ACRES - 589.37'22-E 848.59' 3 0.02' 413.00 r.. I V - I -715.o2'- RAN IMAGE i EASEMENT ' o , f 0 S89.3722•E o ZSO o •`r' o 440.03' I 1 .I S,!P;~C • h A in DRAINAGE EASEMENT LOT 31 _ p LOT 34 ° • 8 8 ^ 90.135 50. FT. O j' LO 30.07 ACRES -j~ 136.318 S0. FT. W B7, 999 SO. FT. 2 N N I ; z 2.02 ACRES 3:13 ACRES o i I=D. ?~-/t8y_y4 8 30:x; S89•37'22-E . 440.02' 0I w ~ A N89.37'22-W = \A` I h DRAINAGE 300.02' W 1 R ISS' EASEMEmT m S89037'22'E di LOT 33 g$-Q o 67.997 SO. FT. 1°v ' ~ 10 N 2.02 ACRES I , N ° LOT-32 LOT 9 0 _ a 87.150 SO. FT. 3 N 2.00 ACRES # S89037'22'E 440.01 LOT 32 MUST GE SEINED Gr A YORMD O I TT►E SEPTIC SYSTEM. O LOT 2 OF CERTIFI_D)URVEY MAP Z-n- 6-6 I - Z to 8 020 -10 72 - v O-/OO v 1 S89.37'22'E 300.02' I IN VOLUME 9 , PAGE 2420 o I o I = M LOT 10 W F' 8 L OT 11 LOT 12 co z M St o m / Q~,P • N g z I -DRIVE - - -g~----MEADOW - h88.00'00'E 4 66.03'- .L STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 64oF-&& L-JA-XO xZ " 11 MAILING ADDRESS 7Z G Co. /Pd, Al PROPERTY ADDRESS -733 No- o',/y f cJ AD 2 1 U~ (location of septic system) Please obtain from the Planning Dept. CITY/STATE PC.,, h .S o 1V W t S y O ( PROPERTY LOCATION 1/4, S t- 1/4, Section a(o T a9 N-R / W TOWN OF -jj L) D S o t ST. CROIX COUNTY, WI SUBDIVISION 14 /,e 14 ME A DO C.tj _17T LOT NUMBER J' Z CERTIFIED SURVEY MAP Y7S2Y0 , VOLUME 1 , PAGE ,~V?.O, LOT NUMBER & Z--- Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: ,/G2 f DATE: , c u r; 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 491,E,41 W14,(,a~V Location of property_6~U/ 1/4 S.E 1/4, Section Z T Q,9 N-R /9 W Township 44o S a~! Mailing address -72-6 co. 2c( N 44 1A) _s0M Uj I cyD t6 Address of site _'73 ~ F+t H re f r4 D OW p g tvf Subdivision name H I G tf MiEA DOW S =aP=_:: Lot no. -3'Z- Other homes on property? Yes X No Previous owner of property flftfl~~ W; n m /t5` Total size of property Z, 00 4 r, Total size of parcel n n 04 C__ Date parcel was created /I- I - q Are all corners and lot lines identifiable? X_Yes No Is this property being developed for (spec house)? X Yes No Volume s~ and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. s(p7r~ y 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 ~7!~! Signature of-App scant Co-Applicant Date of Signature Date of Signature sour,; MM~ j WARRANTY DEED.-To Husband and Wife as Joint Tenants FORM 399 (Revised) u H c w, x. c I . ' =256'764 x ..:..aZtxd day of .----•--------J.17[3Aa.ry in the year This Indenture, Made this of our Lord, one thousand nine hundred and .....tfifY'..in... ..................between.......... Hedwig_ W indolff,, .a/kJ;Ek. n_....e u ii Hattie Windolff n part.y- ..of the first part, i and ...................-Glenn_Waxon_and..Vycglla-,M,---Waxen,--husband and.wife------.....----........ j~ of-- H S $4E~.,._ 1?V &.~o~6xxat......... - husband and wife, as joint tenants, parties of the second part. Witnesseth, That the said part.-y- of the first part, for and in consideration of the sum of Six Thousand ($bj000_,.~U1---------_------_--:-_-------.--_- ---------r.--.----.------.Dollars, - to__. her .._.__..in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and acknowledged, ha -Ve.._.given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do.... give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of the second part, as joint tenants, the following described real estate, situated in the County of... _...S.t-....Cro.ix- and State of Wisconsin, to-wit: The North One Half (Nl/2) of the Southeast Quarter (SE1/4), the Southwest Quarter (SW1/4) of the Southeast Quarter (SE1/4), approximately .54 acres of land located in the northwest corner of the Southeast Quarter (SE1/4) of the Southeast Quarter (SE1/4) described as follows: Commencing at the northwest corner of said Southeast Quarter (SE1/4) of the Southeast Cuarter (SE1/4), thence East along the North line of said Southeast Quarter (SE1/4) of the Southeast Quarter (SE1/4) a distance of 76 feet; thence South and para- lell to the West line of said Southeast Quarter (SE1/4) of the Southeast Quar- ter (SE1/4) a distance of 312 feet; thence West and parallel to the North line of said Southeast Quarter (SE1/4) of the Southeast Quarter (SE1/4) a distance of 76 feet; thence North along the West line of said Southeast Cuarter (SE1/4) of the Southeast Cuarter (SE1/4) a distance of 312 feet to the point of begin- ning; all of the land described above being in Section Twenty-six (26), Town- ship Twenty-nine (29) North, Range Nineteen (19) West. Also, the Northwest Quarter (NW 1/4) of the Northeast Quarter (NE 1 /4) and all that portion of the Northeast Quarter (NE1/4) of the Northeast Quarter (NE1/4) lying West of the re-located town road, all of the above being in Section Thirty-five (35), Township Twenty-nine (29) North, Range Nineteen (19) West. a ill ii Together x%ith all and singular the hereditament." and aplnirivnuu(ces thereunto belonging or in auN rise apper- taining; and all the estate, right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their heredita- ments and appurtenances. To have and to hold the said premises as above described, with the hereditanients and appurtenances, unto the said parties of the second part, as joint tenants. i. BOOK - c.? PA^E~~c> . I i y And the said_- Hedwig. Windolff, a/k/a Hattie Windolff i -part. y... of the first part, for her - .heirs, executors and adtuin6trators, do..es..._._......covenant, grant, bargain, and agree to and - i oath the said parties of the second pa-t, and to and with the survivor of them, his or her heirs and assigns, that at i the tithe of the ensealing and delivery of these presents she_iS. well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever, and that the above bargained premises in the quiet and peaceable possession of the said parties of the second part, as joint tenants, his or her heirs and assigns, again-st all and every person or persons lawfully claiming the whole or any part thereof, . she. will forever WARRAN'C AND DEFEND. In Witness Whereof, the said part y of the first part ha s hereunto set her hand . and seal -..this 2nd... day of January . - - . A. D., 19 59. . Signed, Sealed and Delivered in Presence of I t Hed; W indolff - - - John W. Davison / (SEAL) - - - - (SEAL) Kathleen Tobias STATE OF WISCONSIN, PerC e-.._------- County. Personally came before me, this _.-2nd------------- day of..... Ja.nuaryt-..-------------- A. D., 1959.. the above named _Hedwig Windolff, a/k/a Hattie Windolff . - - - - - to me known to be the person.. who executed the foregoing instrument and ackn edged the same. d L ~C'12 THIS INS,,MV'Zj1T WAS DRAFTED f?Y Lei IZ%D VII . E. D ;ViSn WHIIE, ATTORNEYS John W. Davison Al t/J', !NV_~R FLLLS, WISCONSIN 'I C.'. S Notary Public,...... px~xcQ` _CoUntyi; lj~l4 My Commission Expires __:-.Dec ,11Q,11W.AL , , (Section 59.51 (1) of the Wisconsin statutes provides that all Instruments to be recorded shall have plainly printed Of 19p[titiThlriNn the names of the grantors, grantees, witnesses and notary) 4i I xt W W rs 7~i ; A,I 44 ON. r." 0 C: U2 L I " cd; to - o oG bi a C c1' H m 3 - k 'd , z C1C ri w ,C Q o (v~7 Q -cj i ( o I ~ I