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HomeMy WebLinkAbout020-1019-30-000 (2) ~ ~ I a p °1 I v a 0.' ~ o I N N Vj C I I r ~ mm I ? I i c c m°C I co ~ Q o rl- a z o~ LL c v a) I y° I 'a 4) ~t Cl) 3 I z w o) w o Z o I z d d z I!, am ~ o I I o z g c I Q: r c a ° Z I a z C E N ~~ww N 2) M CL ~J :3 ~ I • N i Q1 C I Ai a t o Q Z H Z O N z I rn c f~ d 10 E N a~ I m aD o bap z M EL I z `ooo • _m yaaa v, I a ~ I V1 J V c 0) 0) Z ~i cM~ ~ a~°o I 0 C4 m w a .O. N~ O a H Q} in l0 ~i H H O M C 0O O p C C E 0 O ! m O L U G G C M U N C C o o O 3 n C O O) u0i 'a O y CO N H F- D 1~ O ICI d N 'O 7 CO w 7 C O .C N't O 0 O E E R U I O O = j} N O Z !d cn o. u L a rr`~Iv d o R o 3 oo ~1 A 6 IL ! o 1 Parcel 020-1019-30-000 01/25/2007 09:50 AM ~ PAGE 1 OF 1 Alt. Parcel 14.29.19.91 E 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): O = Current Owner, C = Current Co-Owner O - YOUDERIAN, THOMAS A & BRENDA L THOMAS A & BRENDA L YOUDERIAN 1001 TANNEY LN HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1001 TANNEY LN SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 5.005 Plat: N/A-NOT AVAILABLE SEC 14 T29N R19W NE NE LOT 3 OF CSM V Block/Condo Bldg: 4/1079 V664 P382 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 987/24 WD 07/23/1997 664/382 2006 SUMMARY Bill Fair Market Value: Assessed with: 161126 250,200 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.005 87,000 151,500 238,500 NO Totals for 2006: General Property 5.005 87,000 151,500 238,500 Woodland 0.000 0 0 Totals for 2005: General Property 5.005 87,000 151,500 238,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 107 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 STC - 104 AS BUILT SANITARY SYSTEM REPORT I OWNER :r ( 6 M, S ~/~ND~-dL (Fh ADDRESS Z 7 %l~ N SUBDIVISION / CSM# LOT # SECTION T ~N-R 9 W, Town of h` u d 5 a ST. CROIX COUNTY, WISCONSIN GGjx P PLAN VIER SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Jf Q S'x L o ~ q 1`b i / IkD INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK • C 5'f Z L~ x ~ ALTERNATE • BM: 4V r (Z ~II aS 65_F-,14e" TO, 7 3 SEPTIC TANK / ANK INFORMATION Manufacturer: CAS 4f s Liquid Capacity: ~ch9Z~ Setback from: Well House Other Pump. rer Model# Size ftoat sepera ion Gallons/cycle: arm capon SOIL ABSORPTION SYSTEM ` Width: Length x-70 Number of trenches Distance & Direction to nearest prop. line: i Setback from: well: N HouseC Other ELEVATIONS Building Sewer , 5 ST Inlet: ST outlet NJ? Pr' Header/Manifold 3 Bottom of system D 2 Z Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: koc CA- (V e-c-5 LICENSE NUMBER: INSPECTOR: 3/93:jt Wiscon3in Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations ST. CROIX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: PeYOIEh'jW, THOMAS [I City El Village Town of: State Plan D o.: CST BM Elev.: Insp. BM Elev.: 7_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 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake 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 Friction System TDH Ft oss Fi 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 Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed / Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 14.29.19.91E,NE, NE, LOT 3,TANNEY LANE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. SANITARY PERMIT APPLICATION =i`lll~lllr~ In accord with ILHR 83.05, Wis. Adm. Code coI C STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ - Jop 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. PROP RTY OWNER PROPERTY LOCATION f / ~`d l /(/&4 IUC/4, S / T Z , N, R [ E (o PROPERTY NER'S{M~LING ADDRESS LOT # BLOCK # yy~~ A) C , STATE ZIP CODE PH 9-4=MA SUBDIVISION NAME OR CSM NUMBER 840ib ~ 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned VILLAGE : f p A 1 N L ~ go, IQWW OF: ❑ Public t<1 or 2 Fam. Dwelling- # of bedrooms PARCEL AX NUMBER(S) IV `D III. BUILDING USE: (If building type is public, check all that apply) O 2 o -/0/1 `3V 1 ❑ Apt/Condo 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. PE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1-New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E1 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 `Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min inch) 0 r Z,S ELEVATION t~• ~J OP-- 10,4t 7;Feet # I Feet VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete structed glass App. Tanks Tanks I (Al F-1 F1 Septic Tank or Holding Tank ` Lift Pump Tank/Si hon Chamber 0 LEI Ej Ej F~ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite w system shown on the attached plans. Plumb ' ~~ej(Print): Plumber's Si lure: (No ) MP/ o.: Business Phone Number: Plumb r' dress (Street, City, State, Zip Code): L-C, Q 1?-4- 77 o o IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sapeary PermikAee (Includes Groundwater Date ssue Issuing A an S 1= thamp-W ~?`Approvecl ❑ Owner Given Initial .96 Surcharge Fee) J Adverse Determination 16 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 received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11188) 000 SC~4L~ 13/1 PL z/o ,,,C~~ uEN+s Q ~ d !^Fi #c 1 . N ~C Nv D &A-) PAGE OF citv5 cc Ion o ~Jen Sys e~+-~ , Fresh Air Inlets, And Observation Pipe Approved Vent Cap, Minimum 12' Above _ Final Grade 20- 42' Above Piper _ 4' Cast Iron To Final Grade Vent Pipe Marsh Hay Or Synthetic Covering min. 2e Aggregate Over Plpe 01strlbutlon 19 -Tee Pipe -0 0 0 0 6' Agor4Oet e o Perforated Pipe Below Sanest b Pipe o -Coupling Terminating At Bottom Of System 3,75 050' D f ln' I qr~.~1< t ~~co.~ ton ~ ~~/~j / ~ Cl~ ' IL FI L 2 ' DISTRIBU APPROVED S4MrIETIC COVER 'r' OR 9" OF STRAW Z" OF A6GR EGA?E OR MARS" NA`j _CD ca~ °e %e /d,Z (e OF - / GREGATE ELEV. OF~FEF.T. G~ Z t 6 i DISTR19'JTI4W PIPE TO BE AT LEAST iNCHES BELOW ORIGINAL GRADE - A1JU AT LEAST20 IkJCHES BUT MO MORE THAI) HZ IUCNES BELOW FINAL GRADE MAXIMUM ®F-QTH OF EXCAVATIoo FKoM 0KI&NAL 6KAoF- WILL BE INCHES MKIMUM MfTtt of EXCAVATION FP\0^ 0~14IWAL GROE WILL BE 1MCI4ES SIGIJEO: LICEUSE AIUMBER: ZZe_7 DATE: DEPAkTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, 1 C DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SE TION: N UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: N /4 / E (o !A S C U TY: OW ER'S ER'S NA MAILING A D ESS: ~r ` eria bay S~,ua~~l ~i . USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILED SCRI TIONS: PER OLATIO TESTS: INResidence ESIVew ❑Replace M_t_ W? It RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK:RECOMMENDEDSYSTEM:optional) ®S DU 0S OU S OU OS ®U OS U I Con v. MOA61to 5-n If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) it oJ°~ l 81 .B ~ B- a 30131 s 3o-y~'' r! gr -y~"6h S~'~r. ,s~1 B- 3 8~y'' . a av'' /si (ay 3~ 114 g 3 9 B- #3, dg-dma SY6r aY441,e4 S 36 n S B-~ $ / s Ens ~1~~3d~h v~6r ~ ~ B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- 1 d I I 5 P D ~I P- P_ 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. J ren ekes 4 k1lb. o7s gl+er #3 J/d. a5 SYSTEM ELEVATION At Rv ""9_ a to, >1 aJb ~ Pr "t~_ ~10I - e~er =©r ?fe E 3 eon E .43 -J- y res1~ - _ Sec 3 en r . 17 J vim _ 4J I, the undersigned, hereby certify that the soil tests reported R tt is f eryE madb y me ),6acg6rd with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the locatio of et 6,. re corre' t to th~ b of my knowledge and belief. Q It Q NAME T: q ! 6 £ TESTS WERE COMPL TED ADORES e WIVER W/s U` ,CERTI1I1V (y N MBER: PHONE NUPA ( tional): CST SIGNAT ~ p A~5 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) OVER - i IPLI T PV _ 15 _ C ERTIFI EC SOIL _ L GVV \ 3i tip l i I f s 7 TO THE OWNER: This soil test report is > in securing a sanitary permit, The co y ne Department may request verification of this soil t= .,t in the field prior to , -rmit issuance, " ,t of plans for °:e i "ivate sewage system and a permit application tnL pitted to the attpro; to local authoritz to obtain a permit, The sanitary permit must he e_- _.id posted prior e ~,=art of any .-on. ~a FORNr 0.985-A 'v • N.C M:IIr Conprry~ 371647 CERTIFIED SURVEY MAP Fit Ej) ~ k231981 a ~of 8 L NE CORNER NORTH LINE OF SEC.14,T29N, R/9W 66'i THE NE 114, SEC. 14 COUNTYMONUMENT SB9°4/08"W 594.95' 589°4/ 08"W 728.00' moo , 550.89' ~20 ~ I A, 99 1' 4.06' I Rio LOT 3 WEST LINE 5.005 ACRES TO FORTY LINES OF THE NE-NE M 4.634 ACRES TO ROW I 2180 18 SO. FT. I V)• I 1 in; _ N89041'08'E 593.37' q Z. 550.52 W;I 1 I M J• Q: I I I lal LOT 2 I a 6.221 ACRES TO FORTY L /NE i~ W 4^j 5.778 ACRES TO R.O.W 270987 SO. FT. h I I I ~ J: I 4.• `u Z i I 589°41'08"W 591.40' ,a 550.05 N I 2 ~.I I Z:I Q: I of LOT l SCALE 200 I ~I v` 6.650. ACRES TO FORTY LINES m O' /00' 200' 400 a l 5.761 ACRES TO R.o w. f1 289674 SO. FT. NOTE.' LOT / DRIVEWAY 13 ACCESS TO BE FROM 1 TAWNEY LAAC. p1$, 9\ N8905801%E 549.55' 1'X24"IRON PIPE WEIGHING - - - d- - - - - - - - - - - 1.13LBS./LINEAL FOOTSET _ _ - n----- 33.37' ~ N_89 °49 39 MCCU TCHEO/V ROAD SOUTH LINE OF THE NE-NE APPROVED JUN 19 1981 St. CROIX COUNTY C0AP1EM[4SIV'E IARU nMNING AM ZON NO comet of volume 4 Page 1079 79-81 THIS INSTRUMENT DRAFTED BY RAM i 1 Arthur L. We ever, re&Lstered land surveyor, hereb: certii~-: that in full compliance with the proti~isic,ns cf Chap6ur 23.',.3 ; of e Wisccnj 1-1 Statutes and the provisic;ns cf the St. Croix Counter Su bdLvIsicrl C;rdinance and under t?-ie direction Gf Tom Durke, owner of saLd land, 1 hava sur•v.,; .:'d, di,. ided, and mapped said parcel cf land, that such plat or redly reg. re- sen`s all e. erior bcundari es and the subdi--isicm c,f the land surveyed; and 1_a ,h Ls land -is located in the NE4 of the NE4, Section 14, T29N,R19W, Town of _ udson, St. Croix Couri-~-y Wisconsin, Lo-wi Ccm:.encin a'. iPe i E corner cf said Sect.icn; I hence S C°41rC "VJ alcn the 11 _L Cr't? lane C t'_e I<Ly Cf sa_d Section %2' .1'.J1 1_c _e i:C1r1'iJ O- be6 _Lnt thence coneInuin ; S_ °41~ C "Vi alone; said line 5S'4-(`,' i c ?;.e _,:W corner of r the i of the IvE4y ,hence S3°14'5211W alcng,the West "Line of the ivr.y Ci e C y 131 2 r t c the SW corner Cf the I'vLw of the y ; when-e 1 ~ ° ~ r ~ 3^1SL'' ,"c,~ncC' 1: o?C't ~Y^11 alGrl ~CUt lire Cf `vrle 1`,L4 of L'Il? hE .277 131; . `5 tc t-? e pGint cfbe nnin Said _ i ecl i..i _ Sa=a p~`~ ,rn „el contaIr~s 17- , 7 r acres and _s subj i;c ex.~sn_t; Town head ri; ? Cf -way ever 'he Viesterl,., and Southerly por ions t'r.erecf . LP, ed ?.is 10 day cf Ic3pal Arthur L. Viet; rer Vii s . it . L S . y S - c? r, Li;:._,lcff EnLlneer` ni Co. Li_ er l'a lls , VL 51*C22 S S , ARTHUR L. C WEGERER S-963 ELLSWORTH 100 WIS. .,1 6 ? 8 c9 9~, !G c p Volume 4 Page 1079 i STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~ ~F S YO uonl? //t MAILING ADDRESS _7 w/ .y4lil, PROPERTY ADDRESS T!- A)IVZ L ~uD So ^i wl (location of septic system) Please obtain from the Planning Dept. CITY/STATE p PROPERTY LOCATION c 1/4, ~J 1/4, Section, T_3 2 N-R_L? W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP, VOLUME i, PAGE ~l OT 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: J 3D ` 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 '~J~&444e S (A-AJ Location of property_A).C- 1/4,4J& 1/4, Section ~ ,T-?-2N-R_Z ~__W Township UPf dN Mailing address ~YC,( 61S'o „J Address of site Q N/NE- C dfo r✓ 4l r D/~ Subdivision name /G'7 Lot no. Other homes on property? Yes No Previous owner of property (l (/V get Total size of property _ j ACRES Total size of parcel 5-~CIL S Date parcel was created 1Z:~-UN Are all corners and lot lines identifiable? _>4-_Yes No Is this pro~p7erty being developed for (spec house) ? Yes ~_No Volume ~ l 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 i the office of the County Register of Deeds as Document No. - 41 J~3/ 76 , 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 them office of the County Register of Deeds as Document No. Signature of lYpplicant Co-Applicant 5- Date of Signature Date of Signature DOCUMENT No. II WARRANTY DEED TRIG SPACE RESERVED POq RFCOgoiNO OATA 'STATE BAR OF WISCONSIN FORK 2-1982 4931'76 _987PAGE -24 - - - - - _ - _ j REGISTER'S OFFICE 114. Keyin.T.. Burke, SLCRWCO.,W1 _ Recd for Record • D EC I 2 2 1992 at io:i conveys and warrants to ThOmd A...-X4ude1^.an.-and..-_------_• Brenda -L....Youderian,..husband. -and..wife, _as...-_.....-... --------:-aurvivarshig.marital--proper ty.,-_ how j . - the followi ng described real estate in .......St....Crnix.- County, - ! State of Wisconsin: Tax Parcel No: i Lot 3, Certified Survey Map filed June 23, 1981 in Volume 4, Certified Survey Maps, page 1079, as Document Number 371647, being located in the NE 1/4 of the NE 1/4 of Section 14-29-19. rRAMFEb I S_ 9,7010 FEB This .-..is not homestead property. (is) (is not) Exception to warranties: Subject to easements, reservations and restrictions of record. Dated this 16th............................. day of December 19. -92 ------(SEAL) QG.1l?~F l ~ GT_~AL ' . KEVIN T. BURKE J - ......--------(SEAL) ------.(SEAL) AUTBBNTICATION ACKNOWLEDGMENT Sig18ture(s) STATE OF Wj! W"$Df ILLINO S . *O-Oe7 .1~17~ ....County. authenticated this ........day of 119 /1 Personally came before me this zy..._day of DECem+,)ex--•------•----•---•--•. 19-92 the above named - TITLE: MEMBER STATE BAR OF WISCONSIN y ` (If not,.... authorized 4f 706--•.06-, -•Wis.-•-••--- Stat-...---a.•) - . to me known to be the person who executed the foregoing s r me. THIS INSTRUMENT WAS DRAFTED BY "i}FFI'~lAL ,SEA`" $TEPHEN__J _ DUNLAP IA!1cSTA-4,4kLER. Notary Public, State Of Illingis - Hudson,- Wisconsin :Nfy 6MM'Ssion Expires 8 5 A~ Notary ic _ . Coun ./Wis. ILL (Signatures may be authenticated or acknowledged. My Commission are not necessary.) Both expiration date: 19 Mains of persona siinlns, in any capacity abould be typed or printed below their sianatur . WARRANT! DgD aTATR BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. FORD No. 2 - 1982 Milwaukee. Wisconsin ~ `lc _ ~ ~ . (1 . ~J ) ~ ~ 1 r ' ~ ~ < < f ~ ~ a. ~ ~ 1 i ~e ~ ~ O % , ,1 ~ ~ ~ ' ' _ ` , ~ ~ ~ / ~ ~ 5~ / , ~ ~ ST. CROI C U f WISC ti t ZONING OFFICE NOR if N ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road _ Hudson, WI 54016-7710 (715) 386-4680 D Zo - l,o 9,- "3 0-00-b /01 1 June 15, 1995 I ` Tom & Brenda Youderian 1001 Tanney Lane Hudson, WI 54016 RE: Water Test Results for Tom & Brenda Youderian Address: 1001 Tanney Lane, Hudson, Dear Tom & Brenda: Enclosed is the original test results from SERCO Laboratories for water inspection of the above property. If you have any questions regarding these results, please do not hesitate in contacting our office. Sincerely, Mary J. 4enkins Assistant Zoning Administrator db Enclosure SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 51848 PAGE 1 of 3 06/14/95 St. Croix County Zoning DATE COLLECTED: 05/22/95 1101 Carmichael DATE RECEIVED: 05/23/95 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE WELL WATER Attn: Mary J. Jenkins SERCO SAMPLE NO: 60805 SAMPLE DESCRIPTION: Youderia i.' " ,95 ANALYSIS: v Benzene, ug/L <1.0 d, Coi< 0.2 ,~ITY Bromobenzene, ug/L ZON*4OM4CE Bromochloromethane, ug/L <0.4 / Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 i 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 Dibromochloromethane, ug/L <0.4 1,2-Dibromo-3-chloropropane, ug/L <1.2 1,2-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. A~W SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 51848 PAGE 2 of 3 06/14/95 SERCO SAMPLE NO: 60805 SAMPLE DESCRIPTION: Youderia ANALYSIS: 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) <0.5 1,1-Dichloroethane, ug/L <0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-1,3-Dichloropropene, ug/L <0.9 Ethylbenzene, uq/L <1.0 Hexachlorobutadiene, ug/L <0.3 Isopropylbenzene, ug/L, (Cumene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isopropyltoluene) Methylene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L, (volatile method) <1.0 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ug/L <0.1 Tetrachloroethene, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichlorobenzene, ug/L <0.2 1,2,4-Trichlorobenzene, ug/L <0.2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. d.re ira 7 SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 51848 PAGE 3 of 3 06/14/95 SERCO SAMPLE NO: 60805 SAMPLE DESCRIPTION: Youderia ANALYSIS: 1,1,2-Trichloroethane, ug/L <0.1 Trichloroethene, ug/L <0.4 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <1.0 1,3,5-Trimethylbenzene, ug/L <1.0 (Mesitylene) Vinyl chloride,.ug/L <1.0 Total Xylene, ug/L <1.0 The analytical results in this report pertain only to the items tested. All analyses were performed using EPA or state approved methodologies. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, Carol A. Davy Project Manager < means "not detected at this level 1 mg 1000 ug. d 4 as -~s y ~ 91 ST. CROIX COUNTY WISCONSIN \ ~`a j► ZONING OFFICE r r a r r w■ a r ``1' CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 ,.r SEPTIC INS EST 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 ❑ Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria retest $15.00 Owner. OM t-,Bceelja~ ~p~ ei~k~Requested by: ~ ~ Address: lho( Tangy eu t,,a~e Address • 4 udSovN W-( Z I P 5--ta (o -ZIP Telephone NQ: -7115) 38(,,- 75-S Telephone N4: ( ) Property address (Fire N° & Street) : f o ci( -Tn n n e a L, cL o e Location: /L AZF Sec. 1,41_, T _27_N, R /q W, Town of ~urlsnr~ Realty firm:_ Lock Box Combo: Closing Date: DU415'Je waAev\ klve5 a4`q 4"Cvlej O \ TO BE COMPLETED BY PROPERTY OWNER PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: Is the dwelling currently occupied? ❑ Yes a No If vacant, date last occupied: Age of septic system:_ Septic tank last pumped by: Date: _ Previous Owner's Name(s): Have any of the following been observed? ❑Y ON Slow drainage from house. ❑Y ❑N Sewage Back-up into dwelling. ❑Y ON Sewage discharge to ground surface or road ditch. ❑Y ❑N 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: ~ t DATE: S-(I- 95 1/94 rOWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? []Yes ONo Soil series per SCS Soil Survey: _ sheet # Type of soil absorption system: OBelow grd OAt-Grd []Mound Approx. size 'X OGravity []Dose OPressurized Ft.2 OBed OTrench ODry Well []Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES []Other []Unknown Septic tank Setbacks: []House 0We11 ❑Prop. line []Other Dose tank Setbacks: OHouse []Well ❑Prop. line []Other []Locking cover ❑Warninglabel []Pump/Floats []Alarm OElec. wiring Soil Absorption System Setbacks: ❑House []Well ❑Prop. line _❑Other OPonding: []Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title