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040-1033-10-200
0 o a o w ~ ~ I o I N ti 3 i C Zt T 0 "DO N ~ 'a z c {L O E Q 'O 3 M d z P N , rn W N = °o O V) am o ~ o z a 0 z z ti) FZ- E N N Cl) C a) ~ I . `n z .0 c O Z F Z w z M d ~ ~ I o) N V d A ` Y C otrotrow al in z .n> ~0 0 0 z •N R CFa.aIL ~ a I N 3 oN ~ U) -A U ! 2 oo) a) ° I U O O U P 'Q - co a c y ~ i 0 N H O v O v w c Al N V_ O c c = O ~ O OP O IP y y U) V d °o c r P a E CL -0 O O 40 d N T r O H H c L • O F- m N 0 z y 2 (n 0 cc I _ I a v c. ' c j 0 a rw d c r A 0CL2 0 U)0 r . Q ~ O a) O 0 LO i 0 d c ~ Jam! c ! ~ I O~ O o 3 mt ~o 0 L3 CU OCOC C) "O N N Al ~ 0 3° N 3 N fy m c p c ~ I U O O ID 4) CL .ON 01 0 N N I'I C Z N E L C Z 2 N ~ 7 63 7 U 3 W LL c LL C 1- -,may . O C L CL O O ` (6 E O 0 d Q U O_ C a Q ik D v _ Z y z N 1 W E O p p O z ~ £ v` E .p 00 d m N W a m 1- I- O O C -p (6 'p 76 O Z :!t C w 7 N - o o 0 o c o in FZ- O Z O N z c E -2 E -a a~ '0 0) 2 col Ml 0) m %v N O, O N O_ O N U) N •A~ L L O U L O ! C O N C O O z z Z Z p N C E Z E z O f6 C (6 O = N O N 41 L O _ O. l4 w Y c G- w Y LL (D cc ^o 0 y m ~~a E ° co D O a a U) LO > LO 0 o a t- LO 333~acn o -333 FL U) o o o` 2 0 0 0 z a a •rv ~a~ 8 caaa to J V ' m rn O M rn O 6) Z C, 0 n d ~ a LL O ° a (1) a d <t z m Uj -c a z r f ° ° C U) O O V N C N C y O T p ~ r O ~ "O ~ O O C C d O 4E O N C LD O C U N Y Y C O N O p- E C '6 ~1 co - U3 E V M O N N 7 N C L N O ~O' C 6'' O r.r. O H co co U7 ° ,mom., (6 t~ N 'O O w co 0 0 w rn H o ~c 0 o co co Q N f6 (0 ro 0 O N E o o • y' O O I- CO N O (n 2 g U) CO N O N Z U)© ~ li I = I y a `m a dt 0 L: a L: a w a a m d y c c c r- o :6. A U a 0 U) L) 0 U) Parcel 040-1033-10-200 07/22/2005 10:00 AM PAGE 1 OF 1 Alt. Parcel M 7.28.19.110C 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * BRATHAL, JEFFREY D & VICKI S JEFFREY D & VICKI S BRATHAL 406 S FORK CIR HUDSON WI 54016-1534 Districts: SC = School SP = Special Property Address(es): * = Prima Type Dist # Description * 406 S FORK CIR S~W p~ C 2611 SCH D OF HUDSON SP 1700 WITC y Le ion: _--_.___A 2.630 Plat: N/A-NOT AVAILABLE EC 7 T28N R19W SE SE 2.63 AC LOT 5 CSM~ Block/Condo Bldg: 7/1930 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 07-28N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1093/068 QC 07/23/1997 'L- 07/23/1997 07/23/1997 4 2 G1 2005 SUMMARY Bill Fair Market Value: Asse Valuations: Last Changed: 07/19/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.630 80,000 213,700 293,700 NO Totals for 2005: General Property 2.630 80,000 213,700 293,700 Woodland 0.000 0 0 Totals for 2004: General Property 2.630 80,000 213,700 293,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 119 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 r, V 43327 FILED DEC, 2 1987 SO1°04'40"E 69.89' m m m c, ` west line of the SE4 loom z (n p AMY. c O0 C> t0 m ~7 ~`~'l1 to 0~~ WU~poM j M U) Cn C~ ~ ~O m O O - = O (n - E m 0- ? CD V ) . - n O Cn N C. O O W O, C70 O 2c ~Un c') t o O- 7- O O O F CD r; rt rt 0 O 7 r• 0 -0 qi S s~00 , ro < Cr (0 Ln f 1 3 n a O- O O T SOS 6` S'i/ 0 S (D v cn o to r- rn O> (n 0' /J - - -D It- O (D a o Cn Ln Ln c rt m O a - c~ a o - - - C) N I i W E cn a n m F, c' io > o - Z z x -3 x M s N 0 0 E en z O d (M F O, Cl) N m I +~1 \ n- I v a CJ, F u, n O f•.. F I' 1 0 O Ci O O O O C c r• - a O' I v \ = C.a cn w a) cD I o , 1 O V' " V' Z7 rt m r r r r I 1 0 ` rt - - - •G a -3 O O O 0 C o f \ \ o W o 0 rt N• -n I o- \ Cn F, Cn M Cn m rt rt rt rt T ct• I I_ \ \ N C» (n_ (n 0 O V CJ, F W N :3- C. mc m m OD co co 0 o m F N N N O N F O Oo CO F 4- W -3 LO t, I w ° I o c, m S a n W CD m U) rt N a 1 S01 04I40I IE m o W t1o 255.77' _ - - r 0 „ -n M psi ~ ~ I c m ~ rt rt rt rt n Oq C> t x m 0 CC) C/") m F N F CD N N N CL (p :TL -7 V H oo rn N 7 N, °i w w j ,ay. m Cn v V rt O o 0 -'r, v F F I rt F F Cn r O O O O W CD N O O I O O V N W a s a Cl. 00 - ° fV co i . n C-) - - - C, a m CD - Z I 'D O O O a C/) = i~~ co I -I r- L, a N rn I c o l a O I =3 2 N Z O I N C'7 O O O F F C 1TL cn :0 ;-0 1 LO iW - 3:. i o m to CO O PRCA ~ Irt Cn tI O m h Ln CJ1 (T 2 N 1 rt - - rn m n - c~ I O_ o m ' ° 255.77 - o- 00 O CT 0) CT V Z 'v 1 tD i CT N I a V I r r f m m o a 1 w-+ I`C O 1 7 Cn O 1 O O m I C1 - F C7 ' In Lr N l a D N- Z fn m I O, - I M w -1 F O CO - v. i E m cn m o co z 1 ` w I ' z o $T. CACO( 7 ° M CD N C) Cn co.... v i n o \ J F w Ca, o cn_ AANNW, ~ o i w LhJ C.. ° w o cn Ln ' ZOMING c_ommnv e ;a O . O Cn O -j 00 V Irt O m n 0 0 f n rn I S N = m n Z 1n.J` a ~O CD 41 2$5.77' C/) :10 o t r y.1 r N oo m --ray. 'c •~'!';.t4%3 CJ F ^ OO N '•••X•+ra - O = j u) CD 0 C:~ CD O O _ O nal~ S00°44'04"W Z oT w 220.00' _ 248.771- ~f:,--, N80' i o Ln 'j I co 11- O 4 to V i ra z o 0 Cn Irt N N T w I co Z t0 N Cn 00 z I Cl. O C/) V O CO . m m C:) Ln I c cn `o° j C7 a a y C) o w o cn ° , rn =r I a CT N S O l a rj Ln I rt O F - N U, ti+ 1 7 c O O I rt - F v m Ln I d r 2 1-+ to Z m r• n ~ N F Z CT o, l 0 O rn O. O CD a V I - O V O " I S r---1 rt I ~ 10 O I CD L 12 O, W O 1 O- -1) O N I v, O - O I CD 0 Cn N 1 - - I CT O -n N rt D Z m t o to 1.~ m 1 g.; I m ~ c•) 1 O = I •0 m o , o ~ V cn N cn _ ...I co m (n O Cn o 1 co O rl~ n c cr 4- ' I 0 cn CO o r- - - '3' O I a O Ln _ rt I rt ME m m rt s Irt _ - fD N M•• CD I N E m O o 1 7 O VOLUME 7 P.ACe 1930 Wis sin Department of industry, PRIVATE SEWAGE SYSTEM County: Lr and Human Relations INSPECTION REPORT ST . CROIX Sa ty and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PlgA@ffo7 3: BRATHAL, JEFF CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: C9 , /00 / TANK INFORMATION ELEV 'TION DATA ~ObO ~f~ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ~3 ©C) R. Dosing Aeration Bldg. Sewer 5 9 9~ ? ~9 Holding St/ Ht Inlet S gS~ 8 TANK SETBACK INFORMATION St/ Ht Outlet itTANK TO P/ L WELL BLDG. Ai nake ROAD Dt Inlet Septic ?5 W > 2-0 NA Dt Bottom Dosi ng NA Header / Man. 8 S 93, 6 g 8,37 93, Aeration NA Dist. Pipe e, 43, 93.53 Holding Bot. System S. y 8 9a,~6 PUMP/ SIPHON INFORMATION Final Grade ; S g %,2 Manufacturer Demand u t`t~C 0 9~, Model Number GPM TDH Lift Lriction System TDH Ft oss Forcemain Length Dia. hi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH widths Length ; No. f Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 9DIMENSIONS SYSTEM TO P / L QLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK CHAMBER t 7 Model Number: INFORMATION Type Of 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 + r l xx Depth Of xx S eded-TS"o~- Iched Bed /Trench Center Bed /Trench Edges ' Topsoil ❑ Yes No ❑ Yes No COMMENTS: (Include code discrepancies, persons present, etc.) ct,t,. V LOCATION: Troy-7.28.19W, SE, SE, Lot 5, South Fork rive ~F C u. . I~b UI rIe 5 { c A,J Slrl ~ y,r Plan revision required? - es ❑ No Use other side for additional information. ~a Ix 4 1 u, t+~ SBD-6710 (R 05/91) Date I p ' Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH I SANITARY PERMIT NUMBER: 4 , I. N~ 1 WOO 0 nrl~0~ x l1 , I 46 < 14^1 , s : } - w .w _ ~ , 1 ;.~r 7 a-. r yy ,v ~i-... } r. ~ _w~ r w_ ~ A .a { w J ~ ~ * l . E ; 'Y i { ` ` a.. ^ ..o: f v ~ ~ , F r~ i v -_j.....;~ i i { ~ a AP~LrAlPa-e-r lee- OF Z R CS771il rI Wisconsin Department of Industry, Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page ~of 2 Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 x ii Ian must include, but not limited to vertical and horizontal reference 4 ' ire~ction an ope, scale or PARCEL I.D. # dimensioned, north arrow, and location and di .,to nearaAlroad. c~ APPLICANT INFORMATION-PLEASE IANfi AlliiNJATION REVIEWED BY DATE PROPERTY OWNER: n ' "OJERTY LOCATION J~F l3/ A T #4L XV7. LOT S76 1/4Si_ 1/4,S 7 T 2-If N,R IT r E (00 PROPERTY OWN R':S MAILING ADDRESS Y r # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE NONE,NUMBER CITY J~JVILLAGE WN NEAREST ROAD lOS4,~ lvlS . SSr'01& (71571.., rjG : So ~c/~K [ q'gew Construction Use [ Residential / Number of bedrooms [ J Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow ee60 gpd Recommended design loading rate 7 bed gpd/ft2 trench, gpdffl1 Absorption area required _',f!:~Ibed, ft2 7.~rU trench, ft2~ Maximum design loading rate . 7 bed, gpd/ft2 • do trench, gpd/(t2 Recommended infiltration surface elevation(s) 9 S ft (as referred to site plan benchmark '4 Additional design /site considerations uSE Parent d CJE•yG~/f Z.) S 1C $ E~~. material565 73 Flood plain elevation, if applicable ft r=Uun's able for system COI~IENTIONAL MOUND IN G PRESSURE AT-GRADE SYSJSM IN ULL O SING T uitablebr system ITS ❑ U El S LTS _D O S EM 0-S IN SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench -/0 31.2- L7'j Ground 3 If 1 5 elev. 7 ft. Depth to limiting j factor Remarks: Boring # -~o ~o y/z 3/ s/ z 4~ S f hJ- V Ail) Ground' 1 10)V 3 S~ S~✓,~ n+011i- ~s /0l S elev. CIS,_ oe 7 ' 8 ~7.70 ft. Depth to limiting ff'actoor~r// N L Remarks: CST Name:-Please Print I a,85 r Z11-16,el 15 hT - Phone: 71S ,.3 & .~l00S Address: / - Zd Signature: Date: CST Number: Cvi:~ r> 7- 5'7' r'e.v vi Tio vS ORIGINAL Swow / l*"'O ~r~ PROPERTYOWNER /3-P4 SOIL DESCRIPTION REPORT z- Page _ of PARCEL I.D. t Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench /a Yee 311- 1. z f She Im-F-P, s 2-F s. 6 ;...>.,Y - LS / o Y~ 3/ f/~ Zti,-r S~j ~►f~ ~'s if , S G Ground /d ~i~ ,S , S'. S' G(~ , 7 elev. ft. Depth to limiting ct~~ Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # ~M: •{i;r,{.v.•?fin Kt~F iA Siik•'.i i'CF::'v':~':: Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: con 01-0 -Inn% AiFS T LOT L z y I I b ~ I Iii n1 ~ I I I~~ W \ ~ I I I ~ < I ~ I I W -Irk_ . A I a ~ SC(Aj, a o . ~o v N 7, to D 0 o ~ m N~1A N W J 0 ~nl ~fi IN I `.Co.uS7~UcTlo,t~ N~Gt> S`/S?~.~-! , Wisconsin Department of Industry, SOIL DESLKIPTION REPORT SafeV0 & Buhurngs Division ,tabor and Human Relations P.O. x 7969 (Attach Soil Profile Location - To Scale - On A Separate, Signed Sheet) Madison, wl 53707 seS 73 - 13 a4e A4, PDT _ Page / of Z customer Name t va uattoate urrent Lan Use or Vegetative Cover Parent Materials aw'- 1'C'1 ~-A 92 _E S ~i cry/ o w~s~ M/ E /yG ~rE~ jaw'-70 to vadon ustomer reu sUmate a owes rou, ater TFoiiiffl C/o Zip' ~d Leos 7is S77 No ff~vs/o, G>riiCsy,1vG > Rate in on e ountY~~ r Cj2o/ Sip a(/ftj oT•'ip~ Gv ✓ Ystem L 1? T~/_ 71fFti a4 0 Lot Lea escnptton ystem Geometry a Dept Slop* an Aspect C Z row- of sc , S~ Sic . 7, /P19uJ Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores pH ._and other GPD/ft.2 ye 31,2- S/ 1,4, 5'4& ~Q s 3 f s ' S . S y//~ y 5 l,-F sb,~ ~5 3 -F 32, ~Yk ? 10 ye si4 s e S z S/,EF t1A 7-10,,21 v~}rw.t~ Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading In. Mun sell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H and other GPD/h.2 +°-Ll /e Y4 31Z S,/ 1,f -51k aQ S 3f cs' - 3 r 33 /o ye g/¢ sd e z f s , 3 ioY" s/G S 0 S ILI Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loaning In. Munsell u. Sz. Cunt. Color Texture Gr. Sz. Sh. Consistence Roots Bounda pores, p H and other GPD/ft.2 4 y $ ~~f She ~h ,S PsY Xa4'- 7-i~ ' ^1 Y 6o I ~3G 16►R'4 /S Ito, Horizon Depth Dominant Color Mottles Structure Remarks: claYskins Loading In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H and other _GPD/h.2 /J sik ~s I f s . s 'B y,e - sl 04, sh/t: Horizon Depth Dominant Color Mottles Structure arks: clayskins Loading In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Bou oo*e-s'bhL and other GPD/ft.2 Y /o yie 51141 51 she s 2 f , s s-/y Ho ye s/ ~a-f sha ed/ rf s - , s 3~ /0 Ye `567 ~ U f 1r ~ S ~ glu, cry V4r 4111.1" '11\Y H0MESITE SEPTIC PLUMB114G CO. db:i O'NEIL RD., HUDSON, WIS. W16 ROBERT ULBRIGHT C S r # L y JIS, MASTER PLUMBER LIC. NO. 3307 M.PAS. ~.w tsV`TAi 1 17'7 1 111«Ctf;nlFFl 1 If` 10) nflW4 / \ S/'T MAC/ iP~f y~iPF ffG7ii-r-kA 7-10 ?,ISM 7"~,~-~G~ S ' S tv i a.,t, /o /uo, 49 T OiFft P ~.v " , '/~tJ.~-T/d uS Cv/ P-0 r ~o X O S T el;50 Other Site Features: 3A61 PIP -5- Limiting Factors/Depth: CST Signature Date Signed Telephone No. CST F 5Od-8330M 01190) E~Ey~TiaA) sUyf4=57jW 5y,77e--,y ~a i 14r' Gk 7reeAJl O- 107,0 3 /00./7 63 /6~. oz v of y 5-7 ova 40e S 3- j~y c ~ l~'sS S-f~E~ JAW@ 190 ,rINiS4-a rjiPrfO E r 13 ~ SYSTEM ) I r ~ P LT£RN~17C 1 39 N I B.M. Ser AU 0to r ' ~ PE 01 • = j3,gC~h~o>~ f i'T$ ~/~U~Tiay = /DO.O r HOMESITE SEPTIC PLUMBING 00, L 0 T # S 655 O'NEIL RD., HUDSON, WIS. 54016 J` O iyBZ ~d ROBERT ULBRIGHT c57- WAS. MASTER PLUMBER LIC. NO. 3307 M.P.RA MINN. INSTALLER & DESIGNER LIC. NO, OW A t EVE ~ 7- eclA e z sv/3o~r~/Sio,✓ kf> { \ DA ` £9'9b2! L8' S01 3„I9,0OoIOS w - -19nd- - M ° M 1S,OOo 10N - a ,00"0£9 \ r~ co N \ ,60'692 F 3 3I MtlO.ION LL _ wl cn - - (0 \ Cy w 0 l!n rh N 0 r\ j U) I 3 C CO C\j 0 U-) tw7 Dl o f tT ! N 9 9 Ln ! O in N M (D 0~ OD I Cti 3 N' Z ZI (nj C) 0 O ,Ob ,Ob p! SIN LL 10 O z l W I o f~ O !A I O! w o r~ o w - ~ I O 100 3 01 rn a o f111 N a N O ,00.0£S o o O 00 N U I o LLJ ' w ,00. ION -1 0-I N co N E- i 00 z I ~I ~I I wI V i J I OG 4311b'-IdNn o 01 U-1 OI ,LL'8bZ ~o I' Z~ I ,Ob o b M„Ob,bO.ION NI I ~W I \ <I I 1 > J, ~I I wi > CIO Xi OI p :D I M I 3 ~zZ I ~I O ~I ~i N lD V~ 0 Cn 0 l o~ Wi CSI ^o I 0) I a. l O I - r` I F-I Z LL,~ CO WI . WI til cr I W I F'i VI JI I ~I 01 I i I UI >I UI OI mI ZI i I d'I -I I DI I of <I I QI I 96 JI ~I U- 0 w z o u z O ~ U W ~ (n v M M wl 2 I f O co rn O v (D 01I Sb ' 9 Z Z Z9' 9 b Z 00 N ,8S'SZ8 3' m; 31oN3noee - os'LZ9 U n W, ,LS'6bZ rn Z - LS'6L L - 3 , co z 0' - t` V I o• z Z, o QI J, F 3 3 w 0 I o ir; o L. u O LLi Q o O r I N m to m rn QI _ o Z w J I W a I co N Li ZI _ ~I It 0 w _z J z0 6bZ j ,Z0~6LL Mrrl 0 I 8311d-ld A9 a3NM0 SGNd-l 0 o m ~L ~ o N I w W O z O m G Ld O F JI Q a U o ~ Cn O z w c i z STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER &A-4 't. ADDRESS ~0[0 ~ Vv 1 SUBDIVISION / CSM# S,.& -7 LOT # SECTIONT G~ N-R )j W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. S BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off ' Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department ofIndustry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No_: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Pla BRATHAL. JEFF X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P/ L WELL BLDG. A irl to ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Lriction System TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER 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 E] No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TrOV.7.28.19W, SE, SE. Lot 5. South Fork Drive , Y~sL~, Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. L I ADDITIONAL COMMENTS AND SKETCH , SANITARY PERMIT NUMBER: I, I Safety and Buildings Division v~■■..r■r,• 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. 9_1 • See reverse side for instructions for completing this application State sanitaly Pew t Num er The information you provide may be used by other government agency programs Check it revision to pr3JvioLs application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Na a Property Location cF~' 4--rh .C 145 1i4,S Ta~' N,RrQ E(or Property Owner's Mailing Address Lot Number Block Number 41-04 5 47! r=0 e City, State Zip Code T(P hone Number Subdivision Name or CSM Number A,,~et ) S'd II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town of Y• Sv Awe III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(sT 1 F1 Apartment/ Condo 04o - I clap-;ii- `of 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 online B, if applicable) A) 1. UKNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting 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 KLSeepage 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 e2 01 6V ? &-d 1,9 'WA91- 70C Feet .Ir2 f Feet VII. TANK Capacity in allons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. strutted Tanks Tanks Septic Tank or Holding Tank 7?~ .e El 11 ❑ 1:1 E] Lift Pump Tank /Siphon Chamber ~ ~ ~ ~ El ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Zps) KAF~MPRSW No.: Business Phone Number: A.).11: a... -Te.A e, Aw^jAW ~ AJ 5g¢-3 /.z. t Plumber's Address (Street, City, State, Zip Code): t►. deli IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Start]~5 XApproved ❑ Owner Given Initial Z Surcharge Fee) - V Adverse Determination i(J 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 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 systern, 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. Il. 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, o, 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, nurr b,?r of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all sE ptic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received expermental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number wi Lh 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 with complete dimensior,., locat!on of h )lding tank(s), septic ank(s)orother t-eatmenttanks, bUildingsewers; wells; water mainshvat~rs~~r:ice;str~.ar~~s irdiakes,pumporsiphon tanks; distribution bores, soil absorption systems; replacement system areas, a; -l the Iecatto ~)f the building served; B) horizontal and vertical elevation reference points; C) complete specificatiore for pi mp;z: 1< controls; dose volume; elevation differences, friction loss, pump performance curve; pump model and jump n anuf,lc.-wer; D) cross section of the soil absorption system if required by the county; E) soil test data ona 1 15 'o-m; ~Ird' f) a l sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated bract ceswhich can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards Safety and Buildings Division v~'~I(Il~.si SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size.: L. ~2 • See reverse side for instructions for completing this application State Sanitar Per it Num er ~~aW 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 Na a Property Location e FF a Tha4 1/41/4,S T a~ ,N,R/,~; E(or Property Owner's Mailing Address W-1 Lot Number Block Number 4/ % e, S /-O Y City, State Zip Code Phone Number Subdivision Name or CSM Number 41 41 r S ( ) S6li Al" II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road E3 age sU dV Public 1 or 2 Family Dwelling - No. of bedrooms Town of Yv 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/Condo `~}U ~021V)._ (v 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 online B, if applicable) A) 1. (g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation ~G 7-`14 7 SG' i ?o? • 7 Feet 5- Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p New Existing strutted 91ass App. Tanks Tanks Septic Tank or Holding Tank e ❑ ❑ ❑ ❑ 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) P PRSW No.: BPhone Number: arl, f- /,'a sh S s-3 aia t Plumber's Address (Street, City, State, Zip Code): AQ -2 /1 -q e e X7 C/ IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater :Date Issue suing Agent Signature (No Stamps) A rOV Surcharge fee) ) C77 pp ~ p.Owner Given )nitial3 Adverse Determination r " r X. CONDrn NS`OF AP OVAL117EAS`ONS R ISAP,ROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber N''STR'FJCTION A sanitlIry t -'rr ` L i5 N;aii . io tw (2) yea! 2. You rsanitary perm"_ m: y b.; re! 'Wed bcforw u expiration date, and ai i t!rne of i! or r e.o. ritcFia ~n the Wisconsin Adtministrati• ~ C,-.de vill be applicable. 3. All revisions to this peri,tit wust )e approved by the permit. issuing authority. 4. Changes in ownership or plumL r requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be )roperly 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 s initary permit application must include: 1. Property owner's name and r wiling address. Provide the legal description and parcel tax number(s) of where the system is to be installed II. Type of building being serve( . 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 e ie on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system- Check appro )riate box depending on system type- VI. Absorption system informati n. Provide all information requested for numbers ? through 7. VII. Tank information. Fill in the apacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indica e prefab or site constructed and tank material. Complete for a!i septic, pump/s phon and holding tanks for this system Check experimental approval only if tanks received experimental product approval from DILHR- VIII. Responsibility statement. In, alling plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. lumber must sign application form. IX- County/ Department Use On X. County/ Department Use On r. Complete plans and specificz ions not smaller than 8 112 x 11 inches must be submitted to the county- The plans must include the following: A) pl t plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment to ,ks,- building sewers; wells; water mains/vvater service; streams and lakes'- pump or siphon tanks; distribution boxes; so, absorption systems; replacement system areas; and the location c;f the building served; B) horizontal and vertical el, ration reference points; Q complete specifications for pumps z nd controls; dose volume; elevation differences frictio loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system f required by the county; E) soil test data ar a ' r form; z.nd F) a sizing information. GROUNDWATEI pc3 1983 Nisconsrn l,~+ 4`0 in uded t "e -eat!or cl's'Jr`h r _ 1.3t _ 4 .."i w~llcl can effect groundwater The ri o :c-s col e gl, 1~c 'surcha-ges are fo, r m,litr ~~c ` ^ l.ar'1'r at t IVeS'IgatlOnS and esta`_ hshmen!_ of stare ar °Safety and Buildings Division @MEN.HR SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State sanitar erp,it Nu ber The information you provide may be used by other government agency programs ❑ Check it revision to previous application I Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Na/Na Property Location .7c ~F ~/yLt Titer L 1i4 1i4, S T N, R j E Property Owner's Mailing Address Lot Number Block Number 41-r G S "c-, v ~-k ' City, State Zip Code Phone Number Subdivision Name or CSM Number K L d O G~J S ( ) - ~~~u. 7/t f c ,r fn` II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ott Nearest Road Vil.e Public 1 or 2 Family Dwelling - No. of bedrooms 1[jr 1 To wn OF 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)/ t 1 ❑ Apartment/ Condo t✓J~+ (y~~ 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 online A. Check box on line B, if applicable) A) 1. [X 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 11E] Seepage Bed 21E] Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 [Q 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 U 7S4 7.c61 c ~ Feet v9 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p New Existing strutted glass App. Tanks Tanks Septic Tank or Holding Tank X 1-2 -C'0 / fi ;d,,i, C9 ❑ ❑ ❑ ❑ ❑ 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) Plumbers Signature: (No to ps) P PRSW No.. Business Phone Number: Plumber's Address (Street, City, State, Zip Code): - IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Starr ,Qs) Surcharge Fee) _ Approve , ❑ Owner Given Initials - d ~wrAdverse Determination X.. CONDITIONS OF APPROVAL / REAS' NS 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 Ii ne 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 8 112 x 11 inches must be submitted to the .:ounty. 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; we'ls; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the'ocati _>r of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps 3rd controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufa('surer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 1 1 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983'vV!sconsin Act 410 included rile creation of surcharges, (fees) for a number o; r~, julated prat it Ens which can effect groundwater The rr c.i- ii_ cl through tr : , s~ rcharges are used fo, monitoring grown:av~,a, cortarima'ion investigations and establishmi~r a o` standards 5 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER_ ) f fr'e T) 3 ()I CC S Tr c,4 0, ADDRESS 4'4; arEA:tie"4 v nr L FIRE NUMBER -4/ee, CITY/STATE UQZ n LO)-5 ZIP_ 5110)Gs PROPERTY LOCATION LJ S~ 1/4, SECTION---, T~?_,N-R TOWN OF roc/ , St. Croix County, ' SUBDIVISION 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 a 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) of ter 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 Co. Zoning officer within 30 days of the three year expiration date. SIGNED: DATE:-- St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 • DOCUMENT NO. j THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-1982 G -9 7? i UFFICE C3i;O1X CO., Im John K, Dawson and Debra R. Yndestad husband and wife Rn'd 4br Record - ---.n - I' 1 ST. - OCT 3 1994 - - - - - - - - - - - - - - 11:15, M con- ys. - effre... ~(~~-~AM ~i Brath. -ve and l.wa rhusband-and J_w fe _D. Bra............. d urvivorshi _ marital _ro ert BAs rof - - Deeft . ~,/(_~.~.Q. ____//-T•_ RETURN TO *-r^~`i-~ l St. Croix the following described real estate in County,,-/ State of Wisconsin: Tax Parcel No: Part of S 1/2 of SE 1/4 of Section 7, Township 28, Range 19 described as follows: Lot 5 of the Certified Survey Map filed December 29, 1987, in Volume 7 of Certified Survey Maps, page 1930, as Doc. No. 433278, St. Croix County, Wisconsin. li This iS--TIOt---------- homestead property. W (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. I 30th Dated this day of September----------------------------------, i9.94.... -------------------------------•------------.------(SEAL) ?L.. ........(SEAL) J 911n K. Dawson C-.. (SEAL) (SEAL) - - 4 * Debra Y. Yn stad AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN St. Croix Ss. County. authenticated this .--day of 19 Personally came before me this 30th .day of 5eptember---------------------- 1994--_- the above named ---John. -K-.--Dawas.oa-and-Debra -Y.--Yn&s Udd husband..and- -wife-,---------------------------------------- TITLE : MEMBER STATE BAR OF WISCONSIN (If not- r - --f---- \ -..v , authorized by § 706.06, Wis. Stats.) ~ e 11 to me n wIY ko~ be' G } e SorL Qu-_--------- who executed the for I;I" a rr9r~nd no-43 e e same. THIS INSTRUMENT WAS DRAFTED BY ( - y Q na_Ogland-------------------------------------- Jane ,T`~rls l n Attorne at Law - Notary ublic St, _Croix---------- County, Wis. (Signatures may be authenticated or acknowledged. Both My C mission is `perm&n~nt,.(If not, state expiration are not necessary.) date: ----May.... 14....... 1995-__.) *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No, 2 - 1982 Milwaukee. W:saonsin SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code c : PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than STATESOOH`))T!!11ry((.)''1/ 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION a -rA SAF t/4S 6- '/4, S T.2lr , N, R / j E (Or)aov PRO ERNO R'S MAILING APqRES LOT# BLOCK # V b ~ byu~--~ 15- 1 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER C1 ITY VILLAGE NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned E-3 I72L TOWN OF s' aA4 ❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nu ing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sa s/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home P 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in a A. Check line B if pplicable) A) 1. XNew 2.E] Replacement 3. ❑ Repl ement of 4.E1 Reconnection of 5.E1 Repair of an System System Ta Only Existing System Existing System B) ❑ A Sanitary Permit was previously issue P mit Date Issued V. TYPE OF SYSTEM: (Check only one) 0; VY Non-Pressurized Distribution Pressurized strib 'on Experimental Other 11 El Seepage Bed 21 El Mou d 30 El Specify Type 41 El Holding Tank 12 D9 Seepage Trench 22 ❑ In- ound 42 ❑ Pit Privy 13 ❑ Seepage Pit Pr ssure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA' ABSORP. AREA 4. LOADIN\RTE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) OPOSED~(sq. ft.) (Gals/day/sq. ft.) (Min./inch) /Qt/r d ELEVATION 7 SO sv. N~ 162,0 Feet Feet VII. TANK CAPACITY Site in gallons otal # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank Dd rrv Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system sho on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): h 7 0 57 a so Q IX. C UN DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A nt signs S mps) Surcharge Fee) pproved ❑ Owner Given initial f0 ~ ? /1 ~s 0 i / C 7 Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) 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) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list"the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks receive.-d experimental product approval from DILHR. VIII. Responsibil' atement. Ins ling plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), hon n tuber. Plumber must sign apPFfcation form. IX. County/Depart X. County/Departme it Use On y. Complete plans and s is i r.* not smaller than.dlf x 11 inches must be submitted to the county. The plans must include the fo A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) of other treatmen6anks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; diibution 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,;6ontrols; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) ~ O v 4 y Ilk, !T c M ,~Sx ~S^ rvwr o* ^tC C4. 16 Q ,v` e A C I~A fof r 4 • Q r Wisconsin G,fpartment of Industry, SOIL DESLrdPTION REPORT Safety a Buiturngs Division 7969 Labor and~Human Relations Ma Box wl 53707 (Attach Soil Profile Location - To Scale - On A Separate, Signed Sheet) Madison, , WI seS 73 - 1-3 elAt A^,41DT _ Page of Z Soil Evaluation Data r u rrent Lan Ust or va9etatwe cove; Parent Matena is Customer Name 1014E /I,1G ~rE~ Tuu~ /D 9i y,P~ssE s ~~,4c.:r/ o w~f S at^ sumats a owes rou water 57T customer rat p Le sT. NG !/v f0 v ,i0~. s`r4/( I CTo ty rP~S ' ar ru-cer o./~ ystem Lw ~nq _,,,n da onsTPedr p. t. Per G(1~~~ " by f untY.7~r Tr'~~ :1 1 ' Legal scnptioe ystem eometry a Dept opt an Aspect Lot R~a~Gtl Lo ','r- TRoy T,f'E uG~ S - lI -fV 2,6 90 Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Bounda ores H and other GPD/ft.2 Ye 31z s/ 1,4, S* s 3 f s s . s YR y s -1 sie ds 3 -F X1,2 ~ s • 8 32- /OY/e /3 Ia ye s/4 S s i Remarks: clayskins Loading Structure Horizon Depth Dominant Color Mottles In. Munsell u. Sz. Cont. Color Text urr Gr. Sz. Sh. Consistence Roots Boundary ores Hand other GPDlft.2 S./ 1, f s6,C ,~l S 3 f c S - 3 r ' 24 A9 Y4 3/2- yie 4/¢ S1/ i, f s6,e z -F s , 3 Horizon Depth Dominant Color Mottles J Structure Remarks: clayskins Loading In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H and other GPD/ft.2 ^ry sbk S Z s S- 7-0 2q_1 100 YA -.416 (-0 0 X4 d /0 Y/e i F /.!E7 vet d Remarks: clayskins Horizon Inp. Dominant Color Mottles Structure pores. ing Munsell u. Sz. ont. Color Ture Gr. Sz. Sh. Consistence Roots Bounda ores Hand other GPD/h.2 /og 3i s/ 1,4 sik )by?- 41e - sl '~A 3 f s - S j 9 3 Horizon Depth Dominant Color Mottles Structure arks: clayskins Loading In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots 8oun4&fj-- rams. and other GPD/ft.2 o-Y /oyie s/ s/ I, she S' 2 f , S s/ /,ash if s r , s f n v. , s v C -l50 S S ~ S GQ~ -7-- r H( MES17E SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. W1 ~ ~ ~ c/ ~Z ROBERT ULBRIGHT «JIS. MUSTER PLUMBER LIC. NO. 33D7 MA FM t N IN. 1 STALLS l & DESIGNER LIC. 140: OOM l~V~~ Auultlonal jwmarKs: ej 1,9 C Sao /tit 1- D~i~ftT /C 04.7 /d t>>~ ly ~o x D ms's T .P.iSv t cc~.~ , Other Site features: I I C I 9 limiting fa(tors/Depth: CST Signature Date Signed Telephone No. CST F Stl0 tl))0(N 01,90) Ey+T/oA)S s v y~4=5 rED Sy ST~~ E/~~r d~S /00, /Y 14( gay, o' 1070 (3Z i00.i7 63 /d6, oz of 5 7 G S 3- i~ ti- f3 S y,~,~-s 4o y 135 ~ ~ ~ ~ ~a ~pv%O ~ /ASS S"f~E:~ 9y ~ a 5S 0 •133 y.0 P~T£RN.~TE h FBI B M. StT 23~ N 0 P- Lo T L • = 13,q~~h~os~ f~~'T$ ~/~U~tT/ate _ /DD.D I HOME-SITE SEPTIC PLUMBING CO. 1-07-:4 S 655 O'NEIL RD., HUDSON, WIS, 54016 ROBERT ULBRIGHT C57- # 2 y~Z J~ O L) ~0 R 'MS. MASTER PLUMBER LIC. NO. 3307 M.P.R.& MINN. INSTALLER & DESIGNER LIC, NO, OM 111. ~e \ s~~oir~:s~c.✓ , A r iVE ~ T cop,,., 433278 FILED DE0,2 1987 S0100414011E 69.89' C-) C-1 n 1Vli a west line of the SE~ = - t~OM~tMVN = A 0 0 4 44 m ~k cml* a 0) uoi m m m - N -3 rt m z Iv 71.47 N cn QOO Whig W ro = d m N N CD IC7 O O N rt 0 U) fn CO N N V I' co N C d c m 41- N co N O O. IY O O ~ A (7 V O N $ m c- 0 m ` ---1 C) N Ln Q) cN0_ O O U, ~ r 1--• N CI E rr O CI) Ln ~I 'O • • U) rn OD CD O d - r 1 O W V V m 7 7 O A Ln - Ln V O Z Z V Ln - Ln 1= O N A ••h -t, m -rn = Im - r m -1 O O O cn N o. V A = E 1 0 a T O o o r m n m r o o sO0 3 o rt C) 0 o A o n f0? ~4/ O] i < m ~ - V C> Cn a C/) 0 I- 1'~0o6v't) ~0 w o cn cn Ln c rm i rn N 26/ Cn V C7 a G7 1 W o - - N r7i 0 C> o I ~0 s = z O o x m x d N 9 rt 1~ A S N a C' 01 r o n N I rj s a i' o 0 m 1 \ a 1 V o 0 0 0 o C c N 1 o rn o W cn w c> C1 o I \ 0 crl cn co rt m.• r r r- r- w m l N rt 1< d-3 0 0 0 0 \ S C) W o o rt It rt rt < o S m I I \ N (.1) Cn U'I C) O 'O L" r W N O r w I o : d m m • rt v r 00 00 co m I rot- ' o m V v ~I C i o\ o E m N m C-) m r N N N O rt m V r N .r-• O OD CD r r C O Z O (O W J N N N N CD .0 co I S01°04'40"E 0. 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V i-r O U r+ O) .r-• .aCY'fi.YnM: jTyf`i ~q O 1 p• co CC) C> C) rn ze C-) s c s ao o r > 4 i z ~TJ ro i CD 0) z -v 0 . fA by % o m --I m -P, 255.771 - I CD Y f ,y y A z I-1 r :1 V C.~ i~ a ` ° rn 661 3- -n r o c m r o 0 Cl) `-r m rn -r-z V CO O X --C n Ln O - r Cn O O O r (7 ' 4- o. ° S00044'04"W ;m r> o ° w m 220.00' m -D r_ r E Ln V I C H Cn N En m 248.77' -80' i~ I z o co V Irt Cn T ' O Irt N N W W I m O V Z cn O 1 7 co Z CON Cn Z I a O (/7 C B C5 C-n 1:D co I' o w o cn - lJ1 to - n N rt O o c2 ca n o w N s ~ I O r N - Ln Y 1 7 C 7 O r - z V 0- - r m U1 N m m r• N i CD V d O N X- Z CT O) 1 0 O O O' m tY ' 0c, -j C) lD O I m z -t, I N m CO r 7E I O m N I d A cn C, - 00 Co rt. N z N N I N d S m m ~ 7 C O E - I 'O rn N N m O , E I ,_.I O m C0 A Ia V O rl-T I I Io m m o a O 1 m cn - I N ♦ Ln O 1 I N r• m rl, O I m g m O i m p 7 I VOLLM 7 PAGe 1930 STC-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), thenia 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 FF ,~,ft~~ Location of property-a- 1 1/4, Section T 2~$N-R~W 7 Township I r-c, 4/ Mailing address ~/6G Scw7?i 7~orfi'~~~ v~ lr~•dsr~ty' A,,,`X4e Address of site ov 4, de X/S_ /Z4 w-.,e c4l S"YQ1'6 Subdivision name Syc~A Rolle ZLLCI"410,`'? Lot no. Other homes on property? yes V No Previous owner of property zcf .A1 Dn a/s~✓,~ Total size of parcel ~ 19~1'f~ Date parcel -was created `e--r Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ~No Volume,4(j2and Page Number rlilf 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 & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid. delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map- shall also be required. . PROPERTY OWNER._CERTIFICATION. I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system,. and the same has, been duly recorded; in the office,:of County Register of deeds as Document No. ( _t c. Si 0 o applicant.. 160-applicant- _ Date of, Signature Date of Signature