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HomeMy WebLinkAbout020-1125-00-000\ � \ } � !� | cn !/ �CL �z\ a ID� � 0zcm , kkk ( CL .2 !c O z c I V \�§j •% zi k§� )77 �AA ƒoo � ® % \ �7 • �ooX CO\o qx 3±� I� ; 2 0B� !§ Q12 Uu E \ ■ km E2 a jf\ �aa 0 m§� E�m� /EE 2d§ ((( c 2qw ;a , / !g }ƒ )31 k(§f «a!! armor {222 #kk I % !�) k!- \ &7 see �Ao IL� 09n) \ §0 f A kst kk 0 ol z,2! a �AtZ tD (D a C o A w n E+• (D O X (D rt (A O z m . w c N O (n r* .. :F: rr rr H r Cn rY (D r+ Cn N (D V1`G (D '4C O A Ln 00 orw (D w m zm � � g (D ' > H (A •s w o w o (.0 cT n o A (D r-. wC N:E as a. �n a (D O Z O a �a a o (D y A� A H cD y LA o n r V . (D V O� M ) � . ) � ■ \ � ! 2 § � � k 2co �4) COO \ 2 ■ 2 k ■ a $ | <a «k 0 ! � �§ z2 z! kkk [ $ E f V CL 0, fn 8 0 'c 2 �$ ƒ ©_o p 23I 2 )22 a V �e ? coZ e� t eo!IL § �o!! JE(L k � k .2 % �9L9LC £IL&m )77 ' �&& ' � \ JE 0IL� •wm�%� ` 7$ §} \ k06C &. =§■r Un) ,ate • �\\) z8o $j&\:�aPA'$� 7)/0 cn o « £ 2 ■ - |aI @! w ), C Lam» �)- a` a, G�2 $3$2J T0:17153864686 03/29/2012 11:07 AM Page 1 of 1 Memo To: All Employees From: H.R. DEPT Re: Airline Travel Program I Land Package For a limited time only we are offering to all employees' access to our company vacation, packages at the wholesale rate (you save $3000 per couple). Please review the vacation details Destination: CA N C U N, CAB O DOMINICAN REPUBLIC & JAMAICA a Duration: 6 days & 5 nights»»»» 175 p p • Dates: You choose your dates. Packages are open dated and valid for 1 full YEAR Included in package: • Resort stay- Choose your 5 star resort • Corporate Meal Plan -All Meals and Drinks (Alcohol/non-alcohol) included 24 hrs a day Children stay and eat for free • Unlimited activities including non -motorized water sports FREE BONUS 5 DAYS 4 NIGHTS ORLANDO FLORIDA Booking and Reservations at ( 8 8 8) 676 5870 Reservation Code TRAVELAA For fax number removal, please call 1-888-393-1379. Q'I;y 93 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE / /0 / 00!,n •dVeJ • HUDSON, WI 54016 (715) 386-4680 )N / ATER TES EQUEST FORM -emit appropriate fee with application. ften turned off during winter months, __ _ ___ _ _ ____ ____.._ ..acessary. Please make arrangements with this office to insure a time when entry can be gained. ❑ Water (VOC's) $185.00 Water (Ni//��trate/n/& Bacct-elria) $35.00 Owner•S&tOPtq 4 !7M'1 Lz�1fad Requested by Address: a e Address: City & State: , W1 City & St._ ❑ Septic_ $25.00 (Visual inspection) Zip Code: 5 0/(o Zip Code: Telephone W: (?L) 380-1 /9, Telephone W: ( ) Property address (Fire If & Street) : 44 A4aWe� 44--ek b�/ 4j►F''ccll Location: ;, h, Sec. �, T N, R W, Town of u gcm lf, St. Croix Co., WI. Tax ID If Parcel ID N° Li m elJON House color:A1f10- Realty firm: Lock Box Combo: Water sample tap location: Du+' e auc� �rry►f c%pr fiftehr 1 TO BE COMPLETED BY .PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Is the dwelling currently occupied? If vacant, date last occupied: Septic system installed by: Septic tank last serviced by: Previous Owner's Name(s): Have any of ❑Y ON ❑Y ON ❑Y ON ❑Y ON ❑Y ON the following been Slow drainage from Sewage Back-up int Sewage discharge t road ditch or body Slow drainage from Foul odors. )Sr Yes ❑ No Year: Date: observed? house. dwelling. �Cj I/ ground surface of water. li1111 / the dwelling. zo m ) 7 j Other comments relative to system operation: I certify that the above information is complete 9Td true to the best of my knowledge. J!_/-0 OWNERS SIGNATURE: DATE: 0'" d�t 36 "193,. OWNERS DRAWING OF HOUSE & SEPTIC t IN YSTEM LOCATION TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ❑Below grd ❑At-Grd ❑Mound Approx. size _'X ❑Gravity ❑Dose ❑Pressurized Ft.' ❑Bed ❑Trench ❑Dry Well Molding Tank DOutfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other_ Dose tank Setbacks: ❑House Dwell ❑Prop.'line ❑Other ❑Locking cover ❑Warning label ❑Pump/Floats ❑Alarm ❑Elec. wiring Soil Absorption System Setbacks: DHouse ❑Well ❑Prop. line ❑Other- ❑Ponding: ❑Discharge: General comments: COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 B00 - 962 - 5227 FAX -715.962-4030 0 ST. CROIX COUNTY GOVERTUNENT CENTER 1101 CARMICHAEL ROAD HUDSON, WI 54016 ATTN: THOMAS C. NELSON Coliform Bacteria/100 al Nitrate -Nitrogen, ag/L REPORT NO.: 52537/01 RFJMT HATE: 11/12/93 DAIS RECEIVED: 11/10/93 OWNER: Stefan 6 Amy Rabirad LOCATION: 404 Krattley Lane, Hudson COLLECTOR: M..lenkina DATE COLLECTED: 11-08--93 TINE COLLECTED: 2:OOpa SOURCE OF SAMPLE: Outside faucet DATE ANALYZED:11-10-93 TINE ANALYZE101:2:OOps COLIFORM,MFCC: 0 /100 al INTERPRETATION: Bacteriologically SAFE NITRATE-N: 7 ppa Above 10 Ppm exceeds the recoaaended Public Drinkinq Water Standard. 1 CID LAB TEC>NNICIAN: Pas Dane CY G yqd`° WI Approved Lab No. 19 � 9 Means "LESS THAN' Detectable Level Approved by: PROFESSIONAL LABORATORY SERVICES SINCE 1952 PAGE 1 r m IL r ♦1 ' ,♦F A STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 51e�Wd AMU I�Pi�I�A�i ADDRESS L ANe SUBDIVISION / CSMI ER4ik LOT f �— SECTION _T9N-RW, Town of !'+V j ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM n 3 &oKoorl Horne LANe — BUJ RUN VAIVe PRivew' �N INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t- BENCHMARK: -roe 6 VQ►jt (3m 3I1 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING -TANK INFORMATION Manufacturer: W1 5QK Liquid Capacity: 1000 Gf- I r Setback from: Well N0% SO House ay' Other Pump: Manufacturer Float separation Alarm Location Width: 5 Length Modelf Gallons/cycle: SOIL ABSORPTION SYSTEM Number of trenches Distance & Direction to nearest prop. line:_ Setback from: well: ovtR 1 House Other �4 4y.3o N oio Sy�iw pew 5)sTt�. ELEVATIONS Neaoo� Building Sewer ST Inlet. 3. IS PC inlet Header/Manifold Existing Grade 9a.97 - Size s C pt'l cccove K y�R`.-S ST outlet 4 •3 a PC bottom Pump Off Bottom of system f .05 9(1• 38 Final grade $�- 38 DATE OF INSTALLATION: 3 `U y PLUMBER ON JOB: LICENSE NUMBER: 3 y 0 INSPECTOR: 3/93:jt LQfi,&TjRUrt 9;6t7yt 29.19W, %VATS SEVYAdE Syt�fV1ey ,Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Permit Holder's Name: ❑ City ❑ Village I,R Town of: ev.. Insp Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic E l ' CC C Dosing {� Aeration Holding TANK SETBACK INFORMATION TANK TO P / L WELL I BLDG. Vent to Au Intake ROAD Septic ti /Z7Al(_ NA Dosing NA Aeration A Holding PUMT/ SIPHON INFORMATION Manufa Demand Model Number [Fo H LiftI Loss Frictioncemain Lengt Dia. Dist To well cnu wQCADDTInkI CVGTFM WE or-wilir-11 A9400038 3/// /9 STATION BS HI FS ELEV. Benchmark Bldg. Sewer (A" St/ Inlet rr St/)g Outlet Dt Inlet Dt Bottom yl Al Header,511ieRt. d, 35I Dist. Pipe ,a s6 Bot. System / 5/Lf Qd Final Grade gy,w r a., �n JF. �,if N BED/TRENCH DIMENSIONS width 5 r Length / No. Of Trenches PIT DIMENSIONS No 01 Pits Inside Dia Depth SYSTEM TO P/L BLDG WELL LAKE/STREAM >LEAHIITu acturer. SETBACK INFORMATION Mo a Num erSystem: Type r`e�..efitdj nICTRIRIITION SYSTEM Header Distribution Pipes ■Hole Size K Hole Spacing Vent 70 Au Intake Length I Dia Length Dia Spacing COII rOVER x Pressure Svstems Only xx Mound Or At -Grade Syste I Depth Ow I r/ rl Depth Over it xK Depth Of I x� Se dded xx Mulched Trench r t 1 r+6 _ 72 rl AW Trench Edges � - 1Z TopsoJ -- ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.7.29.19W, NW, SE, Lot 37, Krattley 7' " /cc,� Plan revision required? ❑ Yes G-0 Use other side for additional information. SBD-6710 (R 05191) -)� A5 &—/1L ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION 17- DILHR In accord with ILHR 83.05, Wis. Adm. Code �r�•�mmmoms �' —Attach complete plans (to the county copy only) for the system, on paper not less than STATE SANITARY PERMITN ❑ X89 I 8%x 11 inches in size. CMok0revisiontop vkwsapplication -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWNER N r pn, Pb PROPERTY LOCATION Q W 14 S f %a, S TQ /, N, R 9 E or LOT /1 3 7BLOCK # 1 M PROPERI , P R'S Mf� IN DrRE S b Y F-A11 CITY, STATE ZIPCOO � P "ONE NUMBER Q U4 SUBD ION tWE OR_CSN NUMBER � 1 T II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE NEAR RO upior� RN �t N ❑ ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms TAX NUMBER(5) 111. BUILDING USE: (If building type is public, check all that apply) 13 DO _ I I C)5 _ O 0 V 1 ElApt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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: (Checkonlyone in line A. Check line B if applicable) ❑ 2. ♦"`!,Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an A) 1. New System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 IR Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4, LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE ft.) (Min./inch) ELEVATION [ RE UIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. A V S rj t 0 - 8 p T.�.�$ Feet -3U Feet VII. TANK INFORMATION CAPACITY in allons Total Gallons Tanks Manufacturer's Name Concrete Site Con- atructed Steal Fiber- glace Plastic Exper. App. New istin Tanks I Ta ks Septic Tank or Holdinu Tank Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: 31�oi Business Phone Number: 7/3 rn �0L4ln e� Plumber's ddress (Stregt, City, ftate, Zip Code). S C lob M')(AAQlsor Si. t,v 00 LJI IX. OOUNTY/DEPARTMENT USE ONLY Lj Disapproved S�itary Permit (Includes erounawaur Issuing A t Sig e m rchargs Feel /oQ 4 Approved ❑ Owner Given Initial1_111/9V ��Adver a Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy I o: sarery a ouuamys VIVI31on, .... I INSTRUCTIONS f 1. A sanitary permit is valid for two (2) years. R 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 (SOD 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 S Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application trust 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 in line A. Complete line B if permit is for tank replacement, reconnection, or repair. , V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'f2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, 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-ditlerences; 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 monitorinb groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) IM �Sba7vreesI In 3 Y69__—.. GIs aN -sp A lirml 1 . Pipe old r y s fN d-'BA�k hog Pit r NO�t W4l1 15 Foitt 4i l k pN. SU' ��►� ����e- i- Byrn,' � N,-�t , pd�p«Nfi Iet-Ssl W2�1S p¢f, �pfl,�l.�n 1 hpN 1ou ffi �KuM St�i�cSy�o� FRESH Ail? T0W.,Ts AND OBSERVATION PIKE _ CI103S SECTION Approved Vent Cap Minimum 12" Above Final Graiie___\I,_.I —� (0 � F•�Nnl GRpvc Above Pipe To Final Grade Marsh Ilay Or Synthetic Coveri Min. 2" Aggr.c(.j;.ii Over Pipe V Distributi P i p c _....._._. , 1 A" Cast Iron Veni Pipe �I q_1_ Tee ,-A Aggregate Perforated Pipe Below �a.Oj% Hencath Pipe I _—Coup),ing TerminatingA Bottom of System IKconsinDepartrnantotlndustry, SOIL AND SITE EVALUATION REPORT Labor and Human Relations M."".. M c.r.w a n, i"..... .. _ Page L of -? • _ 111 QVVy1V n1U1 IL. . W.vJ, •�J• /�V,,,. w.a..r COUNTY Altabh complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. i not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY DATE APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION PROPERTY OWNER: PROPERTY L ATION _ GOVT. LOT �d 1/4 1/4,S % T 29 %� E rQ . ,N,R PRO ERV OWN ':S MAILI ADDRE Zr T K ar SUBD NA OR # CITY, T T ZIP CODE PHONE NUMBER ❑CITY ILLAGE OW EAREST ROAD ( -) 6- V ( I New Construction Use Residential / Number of bedrooms .3 (I Addition to existing building A Replacement (I Pudic or commercial describe Cade derived daffy flow tO gpd Recommended design loading rate bed, gpd/0-,-�trench, gpd/tt2 Absorption area required P13 bed, R2 563 trench, ft2 Maximum design loading rate _bed, gpd/ft2, trench, Recommended infiltration surface elevation(s) U.orl ft (as referred to site plan benchmark) Additional design / site considerations Parent material A �D' ~ Flood plain elevation, if applicable ft S = Suitable for SySlem TONAL ❑ U �ou ND IN -GROUND PRESSURE J245 ❑ U ®S ❑ U T-GRADE S ❑ U SYSTEM IN FlLL ❑ S U HOLDING TANK ❑ S J�U U = Unsuitable for stem Boring If Ground ccft. Depth to limiting %tor or Boring M al Ground M-- Depth to limiting factor SOIL DESCRIPTION REPORT Horizon Depth in. Dominant Color Munsell Mottles Ou. Sz. Cont Color Texture Structure Gr. Sz. Sh. Consistence Bares, Roots GPD/ft Bed Trench /541 Z elAr b t l m ✓lr e S IVI Z. 3 3 y V s` n o i 7 s y y ,' S; l / 6-;k 1 z �e�zek, 0116- C a w I - Z ,3 5 9~ �orR is > 'Wv Rem=Am, ©m�l��r���a® Remarks: Nddrose* o;o.t�� .?s It/�ik�soH w SYple Phone: �/� Number: ,Y7 PROPERTY OWNER SOIL DESCRIPTION REPORT PARCELI.D.# Page Z of I Boring # 3:; Ground ft Depth to limiting ® Elm .�.�®®©® M IMMOMM Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks: Boring If 13 - Ground elev. ft. Depth to limiting factor Remarks: Boring # is Ground elev. ft Depth to limiting factor Remarks: SBD-8330(R.05/92) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTCI TANK This is to certify that I �jhave inspected the septic tank presently serving the Ste F a 1. A k',r Q I residence located at: _&j)_1/41 5 E_1/4, Sec. 7 , T_4 cL__N, R_Ly W, Town of I iu ds o A) Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced a I a �, ► gy / Did flow back occur from absorption system? YesJ No (if no,skip next line) Approximate volume or length of time: gallons Capacity: 1060 9A/l` Construction: Prefab Concrete Steel Other Manufacturer (if known) : W-t 1 f-tR Age of Tank (if known): (Si tore) (Name) Please Print rYl Ante n pi 1A rn 3 qo q (Title) (License Number) 31g1�y (Date) minutes Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) ----------------------------------------- Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baffle.) Name,TIYh BMA M k e c kIz Signature MS/MPRS STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 5� �,,A/ltJ 4#t y ,3�Frs�,ear� MAILING ADDRESS 47ef Ag4ArTL-e y l /i PROPERTY ADDRESS � is rn P, (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION � 1/4, SE 1/4, Section , T ;2 9 Al Ntw TOWN OF #U054A) I ST. CROIX COUNTY, WI SUBDIVISION ER646 AID6E , LOT NUMBER CERTIFIED SURVEY MAP . VOLUME , PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: 3--� —1 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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), 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 STEFAN 4 4Y4Y &¢4IOUD Location of property AAA11/4 -!�El/4, Section 407T , Ty��_N-R­ZLW Township�� Mailing address ZI4y !.CMT%L15y 4,4Ai6 Address of site �`� :�A%T��/ 6/¢4J& Subdivision name jFk1 E A06E Lot no. 37 Other homes on property? yes___No Previous owner of property _RoAl" `/, $E11It 0A) Total size of parcel .2, QQ lyges- Date parcel was created J� Pj��+►'1 '1� aws- Are all corners and lot lines identifiable? _Yes No Is this property being developed for (spec house)? Yes X No Volume 9�and Page Number 3J % 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.JiSS�Ci�/ 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. r Sign t re of ap¢licant o p cant f Lill Date of Signature Datt of Signature Q o m rn W M a D C 7 9" z aE r R d g g L a a¢ z m Z 8 oad H y y (D CL I 6 OD cc S m L Y p C g � _ m � n m a 9V)0 81 g d c 0 2 E L a 0) c 0 z0 v c7 0 3 z N c 0 N • , • Parcel #: 020-1125-00.000 03/31/2005 03:29 PM PAGE 1 OF 1 Alt. Parcel #: 07.29.19.566 020 - TOWN OF HUDSON 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 • FISHER, JAMES W & PATRICIA A JAMES W & PATRICIA A FISHER 404 KRATTLEY LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ' 404 KRATTLEY LN SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.990 Plat: 1925-EAGLE RIDGE SEC 07 T29N R19W EAGLE RIDGE LOT 37 Block/Condo Bldg: LOT 37 Tract(s): (Sec-Twn-Rng 40114 160114) 07-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 04/17/2000 621425 1503/427 QC 07/23/1997 1180/215 WD 07/23/1997 921/357 2004 SUMMARY Bill M Fair Market Value: Assessed with: 48656 266.500 Valuations: Last changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.990 45,900 160,300 206,200 NO Totals for 20G4: General Property 2.990 45,900 160,300 206,200 Woodland 0.000 0 0 Totals for 2003: General Property 2.990 45,900 160,300 206,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 131 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Chargas Delinquent Charg99 Total 27.00 U U0 AS BUILT SANITARY SYSTEM REPORT OWNER fi0ha(a/ 5AIr*1 ah TOWNSHIPSEC.ZTnN-R(IW ADDRESS 14 u,d 4ror7 L,✓icra4 S/h ST. CROIX COUNTY, WISCONSIN. SUBDIVISION F#$If A ja c LOT -3 7 LOT SIZE 2 c 9 4 PLAN VIEW Distances and dimensions to meet requirements of H63 �� rr■Ei ��MM■ Mi■MMM■■■■���■■■■■■■■■■■■ ■r ■■Mid■■■■■■■■■■■■■■■ ■ ■■OMNI ■■■■�tL�■S■■IC: C�■■:.CC. IN MEN N■■MEM■EEM■M■■■MEMO■ MEN ■E■ E■�ii�i■■■■■EMMEMEMME■■MMMME ■ ■■=■■M■MM■■■MMMM■M■■M■■M■■ M■■■MEM■■MM■MMME ■E■■ME■■ ■ ■■■■■E■■■■■■■■■■M■■■ ■■■EEM■■MMM■MEE■■E■M■■ ■EE■MM■ � [ �■ 1! . - ! BENCHMARK: (Permanent reference Point) Elevation of vertical reference point: Describe: 7 o a' Slope at site: 4� /o SEPTIC TANK: Manufacturer: Wic' Liquid Capacity: 16 19G Number of rings on cover : 2 Tanimanhole cover elevation: ank •Inlet E tion: PUMP CHAMBER L77, Manufacturer: Number of gallons Number of gal. pump set for a cycle— gallons; total capacity o distribution lines gallon: sized pump head; gallon per minute horsepower brand name of pump and model number ; Type .of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: Number of pits feet diameter feet liquid depth seepage pit in eft pipe -elevation bottom of seepage pit a evation feet. , SEEPAGE BED SIZE: number of lines �•n r ? c;th C'¢ ri 1 ��yh 3� SEEPAGE TRENCH: wid h length PERCOLATION RATE__ U D 2 BU LT INSPECTOR DATED o?O, /�'�/ PLUMBER 0 J B o 6 LICENSE NUMBER Z RI PORT OI INSPICfION IN01V1UUAL SIIUAGL SVSTlM Sani tans! 1'enm4 t 7 Stag? Septic�Q NAMI �jQ-1 ��LLE�D —-Townehip— _S.t. Choix Cuunty location /�( _ _Secti0n_7_Lot 0 .37 _Subdivi6ion_s1fP.4s f f 1'1IC LANK Si'r gaffone Number o6 eumpantmen,te� Ioc ti f,(kwv Alum: Well _ — Building /g�7_12% elope Highwa to n 1'11MP1NG CHAMBER Size gallone 110LDING TANK Size .gallone Pumps/1 Dietance 640m': ` Well Highwatert ABSORPTION SITE NcNtrance AAvm: Well _ � Highwaten Pump Manu6actu4e4 Numbe.h 06 Comparttmente Alarm Syetem guitding But ng J A1;ti0RPII0N SITE DIMENSIONS width a6 tnench__� rIF.-At Length o6 each tine_,L-40-6t .Numben 06 tine,4 j Total length o6 l.inee J 6t i.etanee between li.nee6t L Total abe oapti.on area / J1�,6t I DIM1NSi0N$ Number o6 pite Ou to i de diametert Model Number 12% elope 12% elope—_ Requi.ned artea J t Depth o6 hack below ti.Pe._ Depth o6 rtoeh oven the 0z in Depth o6 tile below grtade Jn Stlupe. 06 trte.nch�in. pen 100 At Type o6 Covert: Papers o at uw Gnavef around pite yea _6t Depth below inlet total abeotption ahea 6t Area n.equi.ne.d 6t IN.NVI CTFD 89 AITKOVI 1) i'1 11 l• I I U 1:1ASON FOR REJECTION TITLE DATE DATE 19x 19A PLB' 6 7 State and County Permit Application for Private Domestic Sewage Systems State Permit # O9 County Per County 'DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: dg RIA A B. LOCATION: AJ /. %, Section T_:ZJN, R E (or) W Lot* `I 7 City /Subdivision Name, nearest road, lake or landmarkBlk# Village Township S .t TYP OF OCCUPA Single family l� . .,.......,�....a. nmuaanei viner tspeciryl. Duplex No. of Bedrooms �_ No. of Persons D. SEPTIC TANK CAPACITY ! O O O Total gallons No. of tanks _L HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other Ispecify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-PlaceOther (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Aram sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. De th of Line I Ft. Width Depth Tile dept (t p)__No. of Tren hes Seepage Bed: �ength Width Tile depth (top No. of Lin Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land C 7n Distance from critical slope WATER SUPPLY: Private 57Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have Wisconsin Administrative Code, and that I have sized the effluent by the Ce ified Soil Tester, NAME Al O ^ �OrIC.S.T. obtained from or s*t (owner Plumber's Signature do MP/MP Plumber's Address c v reported is in accord with Section H62.20, disposal system from the EH-115 prepared # 7 t L/aand other information R$W## Lt, — S f 3 ZPhone 7- 3 3 PLAN VIEW: Provide sketch below of system linclude direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY/ Date of Application G // f� Fees Paid: State�4�-�/ Co nt Dat Permit `Issuedffiojemed (date) Issuing Agent Name i Yes No State Valid# Date Rec'd white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 spy) 4. plumber (canary copy) Revised Date 7/1/78 EH 115 Rev. 9/78 r*41: REPORT ON SOIL BORINGS AND PERCOLATION TESTSWISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICESP.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: L—/�{t/<t1�'/<, Section�,T�N,R a (orajownship or Municipality Lot No.,3 7 , Block No. �1� .'916 Q- County e O ` ��u Subdivision Name Owner's%Buyers Name: / a •`� Q � Mailing Address: jd.y . %vt S• jr4/a! TYPE OF OCCUPANCY: Residence No. of Bedrooms —3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOILBORINGS ro27-11 - PERCOLATION TESTS .S Rdi"If/ SOIL MAP SHEET di / NAME OF SOIL MAP UNIT AG 8 A?d&'17`40 .s;`/f �O,sy.• PERCOLATION TESTS TESTDEPTH NUM- BER INCHES CHARACTER OF SOIL THICKNESS IN INCHES HOURS SINCE HOLE 1ST WEETTED WATER IN HOLE AFTE SWELLING TEST TIME INTERVAL IN MINUTES DROP IN WATER LEVEL, INCHESRATE MIN; IN PERIOD 1 PERIOD 2 PERIOD 3 P- a Sipe86►� O �7 40 Q P- 2 3G" .See- Aox, Z o 3.0 wz ,Z P-3 d" e o 0 30 13 1-Yv P- P- P- SOIL BORING TESTS TEST NUMBER TOTAL DEPTH INCHES DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK IF OBSERVED IN INCHES OBSERVED ESTIMATED HIGHEST B- Z fig•� 7 •• Q •YY,4�. •• PLAN Vim (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on th! plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy /�Zs'0 ;0-70-5 Indicate scale or distances. I, the undersigend, 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 location of test holes are correct to the best of my knowledge and belief. Name (print) / IffAe S Certification No. ji Name of installer if Copy A —Local e � S`. Pop 1o�5e e d V b � 11d/J� b✓