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HomeMy WebLinkAbout020-1064-90-000 ti ° a O M 4 I a~ I' ~I I I ~ I 0 © III I! I c ry ~ I V 0 a c F: o I ,6 0 O Z LL c LL C O Q I' M W Z N Z p a o v N a0 co N H Z I I C C7 O z C c U r O m Z ? c to I- r O N o N O 3 ~ N Q h a ~ ~ I RQ z° co z c N E O 0 N ~ 0 l~6 N h m a O Q rn o a a a c Q O O w fn N E E ro a a a a (M~ (n Q M M IMF 7 O to fn J V'', 0 N O O "O } U7 M O ~y O O v 0 0 0 h Q N N_ N 0 O O = .3 E CD N N N C:Ll cn N rn ~ LO ~ O O cm o Y O co 3 00 - to (D co p O O 0 ~ O O O N ❑ rn v o ao a o a o rn o 0 N N N Q pj ~ j _G E E O N o O N c O O O co O ~ O a7 U7 M 0') • Y> C-4 d' C Ch N E E U ® w I (D O. d d a `fir i w ~ U 'c c ~ ~ rr~~ L " 1 A i~ CL o (n o rrs ~ artr QAt,tg4.29.19.20PWNd E+MGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERNUT) Sanitar mit GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI X CST BIVI, lev.: Insp. BM,Elev.: BM Descriptio : fr f Parcel Tax No.: TANK INFORMATION ELEVATId'N DATA A9 163 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark " Septic:, rte! G., Vii, d (~./7I • (0 5 /Gv<~~ Dosing ttG~. J) 14 Aeratio Bldg. Sewer r Holding St/* Inlet "OE Outlet 9733' TANK SETBACK INFORMATION St/ TANK TO PI L WELL BLDG. Ventto ROAD Dt Inlet 97,31 Air Intake ,~~v ~ 7U S'Q- %D ~ ...3. •c Septic 15-' NA Dt Bottom Dosing l NA Header 0 Aeration-- NA Dist. Pipe Holding Bot. System X25 D~ Pump/ S INFORMATION Final Grade Manufacturer Demand Model Number ;2.Cp_'I GPM TDH Lift Friction 6'L System TDH Ft Q Loss I-f Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width -s- i Length i No. Of Trenches PIT No Of Pits- Inside Dia. Liquid Depth DIMENSIONS rx DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of 77 CHAMBER ~ca Lci~ Moe Number: Systems,, OR UNIT j' DISTRIBUTION SYSTEM Header /Manifold „ Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length G/ Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Depth Over Depth Over g xx Depth Of eeded / Sodded xx Mulched Bed /Trench Center -a Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 24.29.19.247B (HWY 12) L~ , r tom}{"/0- 0t C Via( + L G C~ Plan revision required? Yes to Use other side for additional information. U9 1441 1/91 SBD-6710 05/91) Date Inspector'sSignatu Cert. No. ~~"~qZa, STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS a SUBDIVISION / CSM# ~i~~ r /~14v LOT # SECTION. T N-R ZL W, Town of 9&4 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM v P~►"' ~ , ~ P~ 5 tad l r' INDICATE NORTH ARROW Provide setback and elevation information on reverse of this-form. Provide 2 dimensions to Center of septic tank manhole cover. r BENCHMARK: SW of CyrHQr T~:,11 ~/6~~ ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: 1j't Liquid Capacity: I L~'o X64' R .i Setback from: Well -7 Z House Other Pump: Manufacturer Model# e1 k size Float seperation Gallons/cycle: Alarm Location / r W6 y °.t I' 9~~ Fleor /fl~~vm /Y• 3 SOIL ABSORPTION SYSTEM Width: S Length Number of trenches Z Distance & Direction to nearest prop. line: S,,JA Setback from: well: 6~. House 7~' 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 BENCHMARK: W ~01 CcI rKPr Ty~j eT ~/6~/ ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING-.TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well -7-' House Other Pump: Manufacturer (ti c/< Model# efi' Size /-Float seperation Gallons/cycle: Alarm Location 0/1 /fo, 3 SOIL ABSORPTION SYSTEM Width: S Length 1/1, Number of trenches Z Distance & Direction to nearest prop. line: -~vc~ji L.,rco Setback from: well: 6 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: ?.2 eel INSPECTOR: 3/93:jt SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code -S T STATE SATAR # -Attach complete plans (to the county copy only) for the system, on paper not less than /I/ 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 rd lt}'/a x~ F_ %4, S T Z,; N, R (or)~ PROPERTY OWNER'S MAILING A RESS2 LOT # BLOCK # CITY, ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1J o Z 3 x_ Aa(j L.j II. TYPE OF BUILDING: (Check one) El State Owned ❑ ,91' TOWN OF: SA VILLLLAGE NE T ROAD / Z ~ ❑ Public N1 or 2 Fam. Dwelling- # of bedrooms 'PARCEL TAX NU III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo M. g® 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 in line A. Check line B if applicable) A) 1. in New 2. ❑ Replacement 3. El Replacement of 4. ❑ Reconnection of 5. El 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 Pq Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION _9~O 4 16Z. 33 Feet 1617-37 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank i 6Z~a C ' Lift Pump Tank/Si hon Chamber C, F] F1 F1 F1 1 1-1 1 Ej Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb is Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW Np. Business Phone Number: N tdl/ I+KW~ 22 Z Plumber' Address (Street, City, State, Zip Code): ! o 1-11 A-Ue (~t 14~~1 z IX. CO NTY/DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee (Includes Groundwater Date Issued Issuing A nt No mps Approved ❑ Owner Given Initial Surcharge Fee) ,?(j & 71 Adverse Determination u X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a. Sanitary Permit Transfer/P,enewa! Form (SBt) 6399) to be submitted to the county prior to installation. 5. Onsife sewage systems must be properly maintained. The ,;-tic 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 renueStr,(' hn ##1-7 V!l. Tank 15lf,rmation. Fil: ;r1 t`1F capacity of every; new andior exis l.rq tank, :'st the',:tal g dons number of tanks arlcc .lanufacturer's narne. indicate ;prefab or site construct,:id card tank iiaierial. Complete for a/ septic; pwr.pisiphon and holding tanks or this system. Check experimental cAlDpr)va only if tanks received experin ~:ai product app.oval from DILIff. VIII. Respon~ibi;ity statement. installing plumber is to fill in name !ir-c-)se n!!mber imth actorcpriate prefix (e.g. MP, etc-, address and phone number. Plumber must sign application farm. IX. County/Department Use Only. ' X. County/Department Use Only. Complete plam', and soecrf^ations not smaller than 8'h x 11 inches riioA be submittcd to the county. The plans ryml inc!uoe 1?1(,, following: 4) plot ;>`an, draw-. to scale car' .r, ;.')~i,plF n %r !a*.irsn of holdir-tg septi,_ tar,k(s;i or other t e me°~t tanks; bUdding v hate - r ai-- ee service; streams k iai P.s: pum. p or siphon tanks, dhStl'!bLltion LicXeS, 5011 c hLZ 1iP00f) 5yS'HIT-S ro!iki',.wner t system areas. .',e location of the built-1-g) -'e. ''ed; 3) horizG'Ita! an r:ttiC~i ?leuafion '.'F?f?'er E' Qoint:i; C) complete specifications for pumps and controls; doss= volume, elevation difference,; friction loss; pump performance curve; pump model and pump manufa,,-turer; 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. I GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of swct ar,ges (zees) fos a rzclmb,3r of r€,gulated practices which can effect g, oundwater T ,e monies col'ected through these SUrcharges at„ ;;set f lr ;ra ldwater, g cund- water ocntamirwation invest.ioations and establishro.e.n3: o" s~al:f:- f0S, SBD-6398 (R.11/88) ,e, TIMM EXCAVATING JOB SHEET NO. OF Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY E ~M^ DATE 7- .7 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE I I 141-171 L.-.] . . . . --?A A . 174-4 . ,!a T s.. . 4 fq. T .e.q: X. LIJ \ \ t 7' C`... r L 3 P~ ON t` ,o "n.n. lot ON 1 PRODUCT 205-1 ~ Inc.,Groton, Mass. 01471, To Order PHONE TOLL FREE I-800-225$380 JOB TIMM EXCAVATING Route 1 Box 192 SHEET NO. L OF WILSON, WISCONSIN 54027 CALCULATED BY v? +H DATE 1 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE ~I I tl I. y J % F-- y . E l 101,33 L.... f k: it r _ . n s - y PRODUCT 205-1 Inc.,Groton, Mass. 01471. To Order PHONE TOLL FREE I-800-225-6380 PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING LS' FROM DOOR JUNCTION BOX MANHOLE COVER - , ,NC0W OR FRESH ICmIu. IR iWTAKE GRADE I y" MIKJ~ I CONDUIT t8"MIN, PROVIDE I - PROVIDE AIRTIGHT SEAL I` I III i PFR.OVEC JOINT A I III APPROVED JOINTS /C.I. PIPE. I III W/C.I. PIPE :KTENDIKJC• 3' I II ALARM EXTEIJDING 3' ALTO SO!.ID Scl:• B I ( ONTO SOLID SOIL I I I ON c P -fir OFF D CONCRETE BLOCK RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS. SUCH APPROVAL SPECIFICATIONS C AND TANKS MANUFACTURER: ee C rs NUMBER OF DOSES: PER DAy TANK SIZE: gov GALLONS DOSE VOLUME ALARM MANUFACTURER: full Jilydrx INCLUDINGOACK/LOW: f'U`FGALLONS MODEL NUMBER: _ CAPACITIES: A= ,iLdd INC EeOR' ~ GALLONS SWITCH TSPE: - ~ ~ B= _ 2 2 INCHES OR d~,SY GALLONS PUMP MANUFACTURER: o4le✓ C =-G3 INCHES OR • 7 GALLOWS MODEL NUMBER. 2 2 i~ 7- Ds INCHES OR 1..- GALLONS SWITCH TYPE: /dJ-- Dot, ~l~ Uca, bACli NOTE: PUMP AND ALARM ARE TO BE. PUMP DISCHA.RC.E RATE C~ GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE B` ^5?WEEN PUMP OFF AND DISTRIBUTION PIPE.. -11, FEET + MINIMUM NETWORK SUPPLY PRES$LIKTEE✓ . . . . . . . . . . . FEET + 95 FEET OF FORCE MAIN X F/ooFT.FRICTIOU FACTOR.. FEET TOTAL OtJWAMIC HEAD = J FEET WTERNAL DIMEWSIOWS OF TAUK: LEA.IC7TH ail(? l~Jr/~ ;WIDTH ;LIQUID DEPTH SIGIJEDt LICEMSE HUMBER: ~2 DATE: L -117- 9 - PoRw- ,rrPuciPS SECTION: 5.10.260 uct information presented here `0 0991 Z,9ZZZh_q ZZK FM0269 sets conditions time of blication. Consult lt factory regarding o Supersedes iserdepancies or inconsistencies. d 0389 MAIL TO. P.O. BOX 16347 • Louisville,KY 40256-0347 SHIP TO: 3280 Old Millers Lane • Louisville, KY 40216 (502) 778-2731 • FAX (502) 774-3624 HEAD/CAPACITY CURVE SEWAGE and DEWATERING WARNING: Model 293 should not be subjected to less than 15 feet TDN. i TOTAL DYNAMIC NEAOXAPACM PER MINUTE SEWAGE AND DEWATERING SERIES 262 256 267 268 282 284 292 293 294 295 405• Fr. M. Gal LIrs Gal Llrs Gal Llrc Gal 11, c Gil Urc Gal Urc Gal Ltrs Gal 5 1.52 00 341 128 484 128 484 128 484 130 492 180. 681 140 530 196 7 7LI($ Lira Lin Lim Gal 42 Gal 225 852 52 Gal 51 42 400 1514 10 3.05 60 227 89 337 89 337 89 337 95 360 158 508 124 460 181 685 205 776 350 1325 15 4.57 22.5 85 50 180 SO 189 50 189 63 238 135 511 106 401 130 402 165 625 185 700 300 1136 20 6.10 10 38 10 38 10 38 33 125 106 401 88 333 119 450 150 568 168 636 250 046 25 7.62 76 288 68 257 106 401 136 515 153 580 200 757 30 9.14 43 163 47 178 90 340 121 458 140 530 150 568 40 12.19 S 10 50 180 O4 356 115 435 50 1524 60 18 29 58 220 89 337 13 49 SO 223 70 21.34 Lock Valve 18' 25 05 21.5' 21.5' 21.5' 26' 35' 42' S0' 62' 77' 40' W HEAD CAPACITY CURVE 3 MODEL "405" 12 •o 35- 10 W HEAD CAPACITY CURVE o 30 U_ SEWAGE MODELS 8 25- 75 6-20- 22 j 0 ~s- 20 5 'o- 18 0 2 s 55 0 16 U.S. CALLONS 50 100 150 200 750 300 350 400 450 $00 50 WERS 200 400 600 800 1000 1200 1400 1600 1800 0 PLOW PER MINUTE = 14 4,5 v 12 } 0 _J 35- 10 30 8 293 25 6 20 15 282 4 10 284 2 5 262 292 266, 67, 68 p 294 295 U.S. GALLONS 10 20 30 40 50 60 70 80 90 100 110 120 130 140 11,50 160 7018019 200 21 220 2301 - LITERS 0 80 160 240 320 400 480 560 640 720 800 880 'Consult factory for optional impeller performance curves. 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M 0 CL O IN ~h s T 3 ti O ro fD Z b r C 3a- T 3 to b (D 0 CL' f(D~ d ID (D O m to N ~fl< n A) y La 'L7 r 1 ~ m A G E C A -t n C D A ~D m N A I to (D v 1 CD V) Q T9 :3 0eD x ° CIL A/y5 Z N LL O b J h O N jr D 1 d o r n < C~ r N ZO Z) x G ~ ~_j W r n ul O O 0,r ~ o '0 C) 1° 3 J `G t/1 00- O_ v 0 Zlk d- N NZ) ~ I ~ 0 : i ' WEST LIME MW ME I NO-14 WE 433.27' 130.30• EES.E>' - 1 r 1 1 Dp ISO I C It I I 70 u o~ ILA 1 s - - "P i F 1 my I a Y « U1 g R C ~ N I n 1.. ao \ °al w v + I ~ ~ ~m N 1 1 ISO' Sy s•\ lv S, V \`pi«R O ` I ' SO°IS OI'E 36211 r• ~ I Exar LIME nM-x[ b y 3 r r Q w 6 cl, x N v G 6 N (D co O r `0a a k i G. / :3 C, \ Q io / x \ 10/ X V) /0 O G7 U) DD r w Z z o v\ LP frt 0 !9 r(; ` (D C) rij r N s G~ 0i k o Z i'' -7f O m a Cl) L o , 8 FILED 2 JUN 2 21993► JAMES O'CONNELL Register of Deed3 SL Croix CO., WI _QQk CERTIFIED SURVEY MAP LOCATED IN THE NWI/4 OF THE NE 1/4 OF SECTION 24, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN mzzmz mmm v UNPLATTED LANDS I Z= MM M_ a a m 1f m vD, zrn m y< m i WEST LINE NW-NE - n y Z D Z O N0°14 08"W 435.27' 1 _ ° rn o m f N 0o N - o - ' - 150.00' 285.27' - I rn rn o ° cn m I 50' 50' _ -1 O $ ~ rn rn w I m A O O I . C C-) C D z I- I r' W - O N M N W I Q fA PPROVED -4 I 8 w r0 Irn1 p ~a O rn e~ In M O V n ~ m x N JUN 2 2'!31 (n vd y I c c°o O y W 1 z z w Irn OD ,0 I 0 : c St. CROIX COUNtY M Qv' Z : xn~rei+ewsiva P1~rtnir►g to A I p • c ~ :c : r Zara" and Z rants Cofwnittaw► :-o IAA '~'2so - 0 y41 : p It not~eywcevdW s . ~ ~ O ~.rN 4•. Of v I W~7'Oi?/ i ; vrn •0 ~ I app~wal datf y r m m ~ 0 m~ o x Jt~IM1a1't~a[ba W rn m r I . I rno G) 1"A a void :r ° 'D xczi \ ` N ,D m D o~ O O m -I • V) r ^ A O D 2 tq ~s Z Z W WO I A '1 D Nn rn IV tON vN 0 m Q 'n -0 PO -4 (n m m AA M, N `1 `001 0 2 ° m 1 v c m° i i z Q o m N ev I 1 m m rn r rn a rn y ~ ° av z ~ p I ~z rn rn o N IC N 50' 50' Z rrl F 8Q m r o <A x ~o p Iz o t Z A m 2 Nn O 2 -q N ° v oym t-. 11 I x w; 3m T <n r N • m ~ ~ D Z V2 n rn m: iN 7C Z fJ~ • ~ A Ir m ' . 2 C m O Ir p A 85.41' 482.00' I SO°15'01"E T SO015'01 "E 567.41 753.56' rn N EAST LINE NW - NE N _ O UNPLATTED LANDS M Ei m 4 0 ;D -1 0 n ? y w . _ W 0 11 M r, 0. -1 ch M z _s 1 V io r-Z2 't 1 ~m w ~~oo miv~~2°omm ;rri _ D Drn~rn m o M r L) Nm 0- zm ~p i D Z C i N11 CM rAM~ m:0j0-1;D c- x rnc~ H tas G' s f .r, O D b. 3 n~ y A % ZrOm;tnyo Z c e°~sso~~ieev°" s2-3s SHEET I OF .3 VOLUME 9 PAGE 2629 STC-100 This application form is to be completed in full and signed by Ithe 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), thenla 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 Location of* property A)0)114 A)6: 1/4, Section _2~1, TZ _N-R_2 _W Township Mailing address /Ove 46~1 Address of site $'e1 K,NCSwati Kc~ Wrsc Subdivision name K,-J&S Lot no.--. Other homes on property? yes_ OC~N0 Previous owner of property Total size of parcel -5! ,11410_ 1Fc Date parcel -was created 'Are all corners and lot lines identifiable? X~, Yes No a Is this zperty being developed for (spec house)? Yes --',No s-a Volume and. Pa'ge 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 & 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 a~n t 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. Signature of ppli ant Co-applicant J 7- OQ _ I Date of Signature ate o Signature • I S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER- Z~Z-71 ;Ar" ZIADDRESS- /Z FIRE NUMP- BER_ IZ/ wt t CITY/STATE PROPERTY LOCATI/ON : A) 1/4 , A )E 1/4, SECTION- a,'~, T2-2_N-R-/2 W TOWN OF_v St. Croix County, SUBDIVISIONi~~swgy 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 ttie 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/Ile, 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. STATE BAR OF WISCONSIN FORSi 3--1982 THIS SPACE RE,ERVED !Oq RECORDING DATA QUIT CLAIM DEED 4215#57 VN 168 PAGE 52? RECAafto OFCiCE j S.T. C sZom 004 WIS, BOYd---H-.Ki-ng_.and.-Al.i.ce---Ki.ng.,---huaba.nd-and...... Reed. for Recoca N* 22nd Wife As---jo.in-t--tenant-s------- . y of Jan A.D. I9 87 - - quit-claims to B.Urt...R,._.Kin-g.................. 8:30 A AL - . . sio s10«+. the following described real estate in ....$.t -.--0'.03.X_.-._ County, State of Wisconsin: C. L. GAYLORD RETURN To ATTORNEY AT LAW A parcel of land located in the NW; of the NE--, 113 E. EL:.1 ST. of Section 24, T29N, R19W, Town of Hudson, RIVER FALLS, VAS.. 54022 St. Croix County, WIsconsin, described as follows: Commencing 8t the N; corner of said Section 24; thence SO 49'58"W (Assumed Tax Parcel No:------- Bearing) 885.32' along the N-S'k Section line of said Section 24 to the point of beginning; thence N84055142"E 1335.24' along the South right-of-way line of U.S. Highway "12 thence S$0 49104"W 565.33' along the East line of said NW; of the NE;; thence N89 29113"W 1328.33' along the South line of said NW; of the NE;; thence NO049'58'E 435.39' along said N-S; Section line to the point of beginning. Also described as a parcel of land located in the NW; of the NE4 of Section 24, T29N, R19W, Town of Hudson, St. Croix County, WIsconsin, described as follows: All that portion of said NW; of the NE; lying South of U.S. Highway 12 as it is presently traveled. Containing 15.26 acres, more or less 0 Z 0 - ~o f'oy j~0 This -O t._.-_. homestead property. (is) (is not) Dated this - __....._.-16th...........-- day of January... ls.-.87. _ (SEAL) 4677 ..,l..L. 't ...(SEAL) ' - Bold H .Ki.n9..... - -49 _ - .(SEAL) 6Z. ..(SEAL) • Alice King AUTHENTICATION ACKNOWLEDGMENT Signature(s) .--B-QYA-..R.... Ki-ng...an.d STATE OF WISCONSIN ..Alice.-King..... ` =s - --------------County. authe t _ t1d .:ja,nu.ar 19.-.$7 Personally came before me this .----..------day of /ATE 19.------ the above named - - ---CaylQ------ - - TITLE: 3fEMBER BAR OF WISCONSIN (If not, . - - - - - - _ authorized by § 106.06, Wis. Stats.) to me known to be the person . - : who executed the foregoing instrument and acknowledge t_ a same. r-i INSTRUMENT WAS DRAFTED BY _ C.._L.._Gay-l-ordA._At-tor.ney--------- - River. Falla, ..WI-...540.22----. Notarv Public . County, Wis. (Signatures may he authenticated or acknowledged. Both M}- Commission is permanent. I If not, state expiration ,Ir(, riot, rccussary.) ~ date: - •Na- Of prrsnne 34ning in any capacity should he tsped .,r ;,-,ted b,l- !heir = gaa':res. H.GMdlaf Comparq~ Sr% OF FORM K Yo. w1.I n~ax Stock No. 13003 F a - 1•e.+' ~2 ST. CROIX COUNTY WISCONSIN ZONING OFFICE e N n u a N n ■IN11 ST. CROIX COUNTY GOVERNMENT CENTER _ 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 July 27, 1994 r /I~3 Mr. Burt King 881 Kingsway Road Hudson, Wisconsin 54016 RE: Water (VOC) Inspection for Residence Located at 881 Kingsway Road, Hudson, Wisconsin Dear Mr. King: Enclosed is the original test results from SERCO Laboratories for water (VOC) inspection of the above property. If you have any questions with regard to said report, please do not hesitate in contacting me. Sincerely, Mary J. Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure cc: Pat Collins SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 45724 PAGE 1 of 2 07/25/94 St. Croix County Zoning DATE COLLECTED: 07/13/94 1101 Carmichael DATE RECEIVED: 07/14/94 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins CLIENT'S ID: King SERCO SAMPLE NO: 105784 SAMPLE DESCRIPTION: King ANALYSIS: Trichlorofluoromethane, ug/L (Freon 11) <0.7 Dichlorodifluoromethane, ug/L (Freon 12) 2.1 A Tetrachloroethene, ug/L 0.3 Trichloroethene, ug/L 3.3 See Addendum. Vi nt 2 r. < means "not detected at this level". 1 mg = 1000 ug. n , ~2,q~ ST. CROIX COUNTY WISCONSIN - ZONING OFFICE r r r r r r r r r rn' ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM l- ' 1`► 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 'UL arrangements with this office to insure that entry can be gained. ❑ Water (VOC's) $185.00 ❑ Septic $50.00 ❑ Water (Nitrate & Bacteria) 45.00 0 Nitrate & Bacteria w retest $15.00 Owner: Alx7- 9 ifG Requested by: /moo Address: Address: ZI ZIP Telephone N°: / )Telephone N4: Property address (Fire N° & Street) : oy/~n~o~c~J D~`O Location:_-',, Sec. , T _N, R W, To n of Realty firm: Lock Box Combo: Closing Date: TO BE COMPLETED BY PROPERTY OWNER PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: 06 4C14-40--w- Is the dwelling currently occupied? Yes ❑ 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 N Slow drainage from house. ❑Y N Sewage Back-up into dwelling. ❑Y N 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 SIGNATURSy~r~ DATE: 1/94 T OWNERS 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: []Below grd OAt-Grd []Mound Approx. size 'X OGravity ODose OPressurized Ft.2 OBed []Trench ODry Well []Holding Tank OOutfall pipe OBSERVED DEFICIENCIES []Other OUnknown Septic tank Setbacks: OHouse []Well OProp. line []Other Dose tank Setbacks: []House OWell []Prop. line []Other []Locking cover OWarning label []Pump/Floats []Alarm []Elec. wiring Soil Absorption System Setbacks: []House []Well OProp. line []Other OPonding: ODischarge: General comments: I INSPECTORS SKETCH OF SYSTEM LOCATION N I Inspector Title SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 22821 PAGE 1 08/19/92 St. Croix County Zoning DATE COLLECTED: 08/17/92 911 4th Street DATE RECEIVED: 08/17/92 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins SERCO SAMPLE NO: 74562 SAMPLE DESCRIPTION: Sample of 08/17/92 ANALYSIS: King Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 2-Chloroethylvinyl ether, ug/L <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 Dibromochloromethane, ug/L <0.4 (Chlorodibromomethane) 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) <0.5 1,1-Dichloroethane, ug/L 0.1 9 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 N trans-1,2-Dichloroethene, ug/L <0.1 N 1,2-Dichloropropane, ug/L <0.1 cis-1,3-Dichloropropene, ug/L <1.5 0,Z:19 !::j-~ p s' m %4 trans-1,3-Dichloropropene, ug/L <0.9 < means "not detected at this level". 1 mg = 1000ug 'k. Member -Arm SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 22821 PAGE 2 08/19/92 SERCO SAMPLE NO: 74562 SAMPLE DESCRIPTION: Sample of 08/17/92 ANALYSIS: King Methylene chloride, ug/L <5.0 (Dichloromethane) 1,1,2,2-Tetrachloroethane, ug/L <0.2 Tetrachloroethene, ug/L <1.5 1,1,1-Trichloroethane, ug/L <5.0 1,1,2-Trichloroethane, ug/L <0.1 Trichlorofluoromethane, ug/L (Freon 11) 2.0 Vinyl chloride, ug/L <1.0 Benzene, ug/L <1.0 Ethylbenzene, ug/L <1.0 Toluene, ug/L <1.0 Trichloroethene, ug/L 33 buN I? z This sample's analytical results awe-/ re not elow the U.S. EPA's SDWA Maximum Contaminant level of 01/30/91 for those requested compounds which are also on the SDWA MCL list. i I < means "not detected at this leveln 1 mg = 1000 ug. 10 Member 08/19/92 15:40 FAX 612 636 7178 SERCO LAB. S.C. CO CRTHOUSE 12001 SERCO Laboratories St. Paul, Minnesota 1931 West County Road C2 vt St. Paul, Minnesota 55113 a Phone: (612) 636-7173 FAX (612) 636-7178 IlATE : "I Please deliver ; "n,~; ~te1y TO: tvk-("C~ 1 F=m: FRa:M: SF= Laboratories M=bar of Pages (iricludix q cover sheet) Cmalents : VIA , % Yb cat -'U --/tav-f- 4-L Q 6-p ')h c:vnc21'(612)636-7173 J~ r' If you do not receive all of the pages, please as soon as possible. When Quality and Service Count . SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 22821 PAGE 3 08/19/92 All analyses were performed using EPA or other accepted methodologies. Samples that may be of an environmentally hazardous nature will 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, Diane J. derson Project Manager (400j07 t0100,1- 'V ID 41 95 On Jell-MI?Z) < means "not detected at this level". 1 mg = 1000 ug. 0 Member SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 23117 PAGE 1 09/16/92 St. Croix County Zoning DATE COLLECTED: 09/05/92 911 4th Street DATE RECEIVED: 09/08/92 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins SERCO SAMPLE NO: &82642 SAMPLE DESCRIPTION: ANALYSIS: Trichlorofluoromethane, ug/L (Freon 11) Trichloroethene, ug/L 38 All analyses were performed using EPA or other accepted ]methodologies. Samples that may be of an environmentally hazardous nature will 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, Diane J. nderson 8 Project Manager 9 co ti Go rr7 -10 O cz~ ti Z ~ < means not detected at this level". 1 mg = 1000 ug. a,..,„.. MEMBER 08/19/92 15:42 FAX 612 636 7178 SERCO LAB. -*44 S.C. CO CRTHOUSE 2003 SERCO Laboratories 1931 Watt County Road C2. St. Paw. Minnesota 55113 Mwe (612) 836.7173 PAX (612) 838-7118 LABORATORY ANALYSIS REPORT NO: 22821 PAGE 2 08/19/92 SERCO SAMPLE N0: 74562 SAMPLE DESCRIPTION: Sample of 08/17/92 ANALYSIS: King Methylene chloride, ug/L <5.0 (Dichloromethane) 1,1,2,2-Tetrachloroethans, ug/L <0.2 Tetrachloroethene, ug/L <1.5 1,1,1-Trichloroethane, ug/L <5.0 1,1,2-Trichloroethans, ug/L <0.1 Trichlorofluoromethane, ug/L (Freon 11) 2.0 Vinyl chloride, ug/L <1.0 Benzene, ug/L <1.0 Ethylbenzene, ug/L <1.0 Toluene, ug/L <1.0 Trichloroethene, ug/L 33 This sample's analytical results re not slow the U.S. EPA's SDWA Maximum Contaminant level of 01/30/91 for those requested compounds which are also on the SDWA MCL list. e. means "not detected at this level". 1 mg = 1000 ug. Member 08/19/92 15:42 FAX 612 636 7178 SERCO LAB. 444 S.C. CO CRTHOUSE 121004 SERCO Laboratories 1931 West CWmy ftad C2. SG Pout. MiMM12 65113 P=e (612) 6*7173 FAX (612 6367178 LABORATORY ANALYsis REPORT N0: 22821 PAGE 3 08/19/92 All analyses were performed using EPA or other accepted methodologies. samples that may be of an environmentally hazardous nature will 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 re art may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, WW~41~ Diane J. derson Project Manager < means "not detected at this level". 1 mg = 1000 ug. 0 Momtavr 08/19/92 15:41 FAX 612 636 7178 SERCO LAB. 434 S.C. CO CRTHOUSE 002 NERCO Laboratories 7A 1931 Wass County P4ecs C2. U Paul, Mh-*9 1a 551 t~ Ph4ne (612) 876-7773 FAX (&12) 636-7179 LABORATORY ANALYSIS REPORT NO: 22821 PAGE 1 08/19/92 St. Croix County Zoning DATE COLLECTED: 08/17/92 911 4th street DATE RECEIVED: 08/17/92 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE : DRINKING WATER Attn: Mary J. Jenkins SERCO SAMPLE NO: 74562 SAMPLE DESCRIPTION: Sample of 08/17/92 ANALYSIS: King Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 chloroethane, ug/L (Ethyl chloride) <0.4 2-Chloroethylvinyl ether, ug/L <0.4 Chloroform, ug/L <0'5 chloromethane, ug/L (Methyl chloride) <0.6 Dibromochloromethane, ug/L <0.4 (Chlorodibromomethane) 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) <1.0 1,3-Dichlorobenzene, ug/L (m-Dichlorobenzene) 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) <0.5 Dichlorodif luoromethane, ug/L (Freon 12) 0.1 1,1-Dichloroethane, ug/L 1,2-Diohloroethane, ug/L <0.2 (Ethylene dichloride) <0,2 1,1-Dichloroenhene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropans, ug/L <1.5 cis-1,3-Dichloropropens, ug/L trans-1,3-Dichloropropene, ug/L <0•9 < means "not detected at this level". 1 mg = 1000 u90 Member SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7176 LABORATORY ANALYSIS REPORT NO: 33403 PAGE 1 of 3 09/29/93 St. Croix County Zoning DATE COLLECTED: 09/09/93 1101 Carmichael DATE RECEIVED: 09/10/93 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins CLIENT'S ID: B. King SERCO SAMPLE NO: 114443 SAMPLE DESCRIPTION: B. King 8 -Ij ANALYSIS. 40 Benzene u 9/L 1rr° t;; Bromobenzene, ug/L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 \fi 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 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. MEMBER SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 33403 PAGE 2 of 3 09/29/93 SERCO SAMPLE NO: 114443 SAMPLE DESCRIPTION: B. King 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, ug/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 <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. MEMBER SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 33403 PAGE 3 of 3 09/29/93 SERCO SAMPLE NO: 114443 SAMPLE DESCRIPTION: B. King ANALYSIS: 1,1,2-Trichloroethane, ug/L <0.1 Trichloroethene, ug/L 5.0 Trichlorofluoromethane, ug/L (Freon 11) 3.1 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 W--A This sample's analytical results are are not below the U.S. EPA's SDWA Maximum Contaminant Level of 1/30 or those requested compounds which are also on the SDWA MCL list. 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. Re ort submitted by, I Diane J. Anderson Project Manager < means "not detected at this level". 1 mg = 1000 ug. ST. CROIX COUNTY hxk WISCONSIN .r. fi •r Jry~, v a, }^ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 _ (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM 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 a time when entry can be gained. Water (VOC's) $185.00 ❑ Septic $25.00 Water (Nitrate & Bacteria) $35.00 (Visual inspection) Owner: Jj,, f~ ~i=~✓~~,!~ Requested by Address : / 'lG-S V: 3 1SW Address: City & State: ~C `p15,~ City & St. , Zip Code. Zip Code: -a 2 Telephone N°: 3 Telephone N°: ( ) Property address (Fire N2 & Street) Location: A/W Sec. ay , TAN, R ~W, Town of /gyp-S - St. Croix Co., WI. Tax ID N4 Parcel ID N1 Z-4 7- -Z 0 oc 7., House color: Realty firm: Lock B L 9 Or- Vm-bn: Water sample tap location: TO BE COMPLETED BY PROPERTY OWNER, 'PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Is the dwelling currently occupied? ❑ Yes No If vacant, date last occupied: Septic system installed by: Year: 9.3 Septic tank last serviced by: - Date: Previous Owner's Name(s): Have any of the following been observed? ❑Y ON Slow drainage from house. ( 11 ❑Y RN Sewage Back-up into dwelling. ❑Y 9N Sewage discharge to ground surface, Sv road ditch or body of water. ❑Y 'UN Slow drainage from the dwelling. ❑Y FEIN Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. , OWNERS SIGNATURE : DATE: ~1 OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION f IN 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. 2 ❑Bed ❑Trench ❑Dry -Well ❑Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank - Setbacks: ❑House ❑Well ❑Prop. line ❑Other Dose tank Setbacks: ❑House_ ❑Well ❑Prbp.'line- ❑Other ❑Locking cover ❑Warhing label ❑Pump/Floats" ❑Alarm. ❑Elec. wiring Soil Absorption System Setbacks: OHouse ❑Well ❑Prop. line OOther ❑Ponding: ❑Discharge: General comments: INSPECTORS SKETCH OF'SYSTEM LOCATION N Inspector Title