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HomeMy WebLinkAbout030-2024-30-000 4. o ~ o kn p ug, C O C f6 O N 3 'O vi lV U O - N O d N G U 0 O '67 O 3mm~ > N_ C x C N C r6 i ~ In C U m M 1' O.L M "O N N O N O 6 N C cn (p ~ N ~ O) U C C Z O C N C O 7 (6 U COO U. CO O) w O C O C O a~i ~tt--23 x N - N E Q N L N C U (D Lr) n ~ m w iii > LLl Z O O w O Z d d O W Ali, C. m N F- Z O O l d c U =3 o d Z` 0) Q Z r r C O -0 CD ! N (0 O ch I y~~] N O_ O N C • Aa U O C V O Z H Z p N Z E N - E 7 O N N O O L d O Lo W otj 4 y .r N N C O d 47 Q y D O C. E N E o F H F a co N N O Z O ~ = a a a u, I a C N T co M W V O rn N N ~ ~I 3 rn w ~ i I, O m ~ I C N C33 O I 3 O L" w O o c Co w c 3 E o E M ~ O E C "6 N N N O N C 5 O C u) co C, i N 0) 0 cu F-- o N y Eo E ~x cLi • s~' o in d o H cn O ~ III' w I E m I v v~ m -m~!, La ttww L it `~1 A 0 CL 2 II 0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Je L~Q~2~~ ~ ~ ~ / AMAK Pa-tR434J 14`77 d&~ ADDRESS Hw% 3.~ NuO.SON sr S ~ fJ~ SUBDIVISION / CSM# LOT SECTION. I a T 4 N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 5 Bgw2oo- Homk It ~urj JA 70 l ~ ~Mn Ru ti U~lv~ a' y? o -1 96 0 '4 rte t-tc N I i F--- A~~1t~fi IN ICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center, of septic tank manhole cover. BENCHMARK: To rte 3A5Q 711-911 L.J 1 NC u , S',', , ID~ . - O U O ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING-TANK INFORMATION USed Card Manufacturer: Wec~S Liquid Capacity: 800 _ ~op4 T 5p~ oid ~oo0 4~ ~ Setback from: Well OV iz House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location (z~N VAIV' SOIL ABSORPTION SYSTEM old syp'` width: S Lengthy Number of trenches gaa~ ► Distance & Direction to nearest prop. line: (S NQw syr~~ri Setback from: well: House Other ELEVATIONS pld talk ZNIe fi 9a.sa o~T~e fi -~a. d 8 89 37 $9.6 Building Sewer ST Inlet; ST outlet y 7 Q overt PC inlet PC bottom Pump Off - Y'~ b - Cov ' H',yh Iner88.0 ~(~.U Header/Manifold Bottom of system MAD +Lov'' -0,7,00 Nepptn ~iJb I r ga•3U H"I Existing Grade ~al grade 41.3o rw;p+-low vg DATE OF INSTALLATION: 10 1 y I ~U ~1a•~cr~ PLUMBER ON JOB: Qo~-' LICENSE NUMBER: 3'A y INSPECTOR: 3/93:jt LQ "jVApart%'rrtofT 'VH 12.29.2PRIafr SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) sanitar rmit GENERAL INFORMATION Permit Holder's Name: ❑ City Village i Town of: State Plan I o.: -M r_ P .4 lev.: nsp. Bi~tt Elev.~ Description: Parcel Tax No.: Z/ /C L 030-2024-30 nnn ~ TANK INFORMATION ELEVATION DATA A9300287/0 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 3 t"- r r G1 l,! G~f•-" ~i'~ - /(Jd , G~ Dosing Aeration 7/1 } a7 Bldg. Sewer Holdin /,Ot Inlet Z~ 9173 TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic' SD ws NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 0,50 Manufacturer Demand 17, ) Vi c: 5.99 Model Number GPM ? Friction S stem 197 TDH Lift L Ft x Forcemai n Length a. Dist. T, Zl- SOIL ABSORPTION SYSTEM BED / TRENCH Width Length t No. Of enches PI No. Of Pits Inside Dia. Liquid Depth S I S DIEN I N DIMENSION LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM INFORMATION Typeo >5~, CHAMBER o e Number: System: Cad: ^-//J OR UNIFT DISTRIBUTION SYSTEM Header / Meti4eiW t( Distribution Pipe(s), x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. `f- Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over / Depth Over d „ J xx Depth Of xx Seeded/ S xx Mulched It I YTrench Center _-2-3 ' b SgeW Trench Edges c:,~)~ Topsoil ❑-Y.es' ❑ No ❑"Yes, ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 12.29.20.4340 (r e/ ' / (804)95' 16,63' Plan revision required? ❑ Yes ®'No Use other side for additional information. /,!I / SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ~_A ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STA282 STiY,tfjM -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ 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. ARTY OWNER PROPERTY LOCATION A1,F '/a ,C'/4, S Tai, N, R 40 E (or W PROPERTY OWNER'S AILING ADD ESS LOT # BLOCK # a j7 CITY, T TE ZIP DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER M/ A-152W (71.T D (~a II. TYPE OF BUILDING: ( heck one) ❑ State Owned O VILLLLAGE : NEAREST ROA V'i of o.~ ❑ Public or 2 Fam. Dwelling of bedrooms ROM MBER(s) III. BUILDING USE: (If building type is public, check all that apply) o - 6 -00 0 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 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. ❑ New 2.E] Replacement 3. ONeplacement of 411 Reconnection of 5.0 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 ❑ eepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 W Seepage Trenc 220 In-Ground 42 ❑ Pit Privy 1130 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill , 14 f3 9,6, /D r 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 ~y REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 66'.0 ELEVATION 93v / C0 , Feet Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed 77 Septic Tank or Holdin Tank S,06 1.,660 /ffo0 - --cowcrei4e Li 2 Z 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 Si nature: (No Sta ps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State' Zi Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ' ary Permit Fee (includes Groundwater ate Issued issuing ent Si tam W pproved ❑ Owner Given Initial Surcharge Fee) / A verse D ermin i n X. CONDITIONS OF APPROVAL/REASONS 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/Renewal Form (SM) 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The s^, tank(s) must be pun p:d ~)y a-licensed pumper whenever necessary, usually every 2 to c', 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. It. 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 requester; in #1-7. VII. Tank information Fill in the capa~_ity of every new and/or ex si;,! , talk, list the total gallon number of tanks and manufacturer's name. indicate prefab or site constrrl_-t~:d art. tank material. Cornpler?e for all septic, pump/siphon and holding tanks for this system. Check F x >erimentai F pproval only if tanks received experimental product approval from DILtiR. VIII Responsibility statement. Installing plumber is to fill in name, iirense 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 specification-- not smaller than 8Y2 11 inches nru.rzt be submitted to the county. The plans must include the following A) plot {clan, drawn to scale ^r with complete dimen;;kw,s location of holding tank(s), septic tank(s) or then treatment larks, %..;SG,~ r l ~r ±s; Waler rni?i avater service; streams and lakes, purnrp-or siphon tanks; distrlbut orR box-9 systems rrt it system areas, and the location of the building served; a) h:m7ontal ~ tk- elevation rat-rerr• :4irl's; C) complete specifications for pumps and controls; dose volum-e elevation differences; fi .`,rurr 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. - - - - - - - - - - - - - - - - - GROUNDWATEM SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The rrlonres collected Through these surcharges are ose(; f,), ~s~ ink vr,j .7-,dwFaler, reund- water contamination invesiigaiions aM establishment-cif staff r;atds: - - I SBD-6398 (R.11/88) o rr, w ow . _ rn i r V _ ~ O O~ y ~ I N~ o\~ b L ~ oV m ~ ~ ~ , spy , ti ~ U1 v~ all 00 r d ti r ~O, d' To Ry ~ L b fi ~ g ~s ~ b v sc c A -v Ri N Approved Veal Cap Minimum 12' Above Final Grade q ~~Etic~ y~ +0 9 3. a 3Ca "Above Pipe -41, C a it lion 'to final Grade Vol fIpe' Synthetic covering win. 2' Aggregale Over Pipe Distribution Tee Plp, 0 0 0 0 0 /a a Aggregate 0 pulkeled Pipe Below Baneolk Pips Coupling Tertnlaeling At • 6yS7E.A4 Bottom Of 11.16160 Fresh Air Inlets And Observation Pipe Q.--- Approved Veal Cap Minimum 12f Above Final Grade 'Nils //&0 ele4pr 7'~E'~E.o c ~f y a +o ~ 34 *Above Pipe _ Cost Iron 4'' ~"t X' 1o float Grade Veal Synthetic Covering min. 2' Aggregate Over Pipe Oi:lribullon - Too pipe 0 0 0 0 0 iL Aggregate Beneath Plpe o Pertimaled P1,96 Below 0 "'-Coupling Termineling At .SyST 2_~'' Bottom Of Sy31so :'6, o Fresh Air Inlets And Observation Pipe Approved Veal. gop TitnE~V C f7L ' /r Minimum 12" Above C~ Final Grade L, 4o *Above Pipe _ 4' Cost Iron /,A to final Grade Vent Plpi Synthetic Covering min. 2" Aggregate Over Pipe Distribution Toe Pipe '1 -0 0 0 0 0 0 /2 ' Aggregate o Perforated Pipe ,Below Beneath Pipe o _Coupling Terminal hig,:AI ; 4 Bottom Of syslbm.~, 5 y5 rE.~-r 2/7 (7 , . , ....Nrr:•ySqt,~efi~o'x+b•W++M+"i++~aiw.y... , ,;.-v►•.».ryw:'d~y+idQ~r.v......tn?+wtc:.rsr.,war.+nr:, Zo o //U.tiBo~T- ~lvc • se svi /4-- io At L FST~tE Sv,~,oo/e T` S t,P(// « 5 lo Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT 5S v,3/ Page of 3 Labor and Human Relations Division of Safety a Buildings in accord with ILHR 83.05, WS. Adm. Code ceuNnr ST clPolX Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.0./ dimensioned, north arrow, and location and distance to nearest road. U30 - CO0 0 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTYt R: JVf ,e PROPERTYLOCATION St FF 3 C HE RyL HOL ME S GOVT. LOT NC 1/4 A/F1/4,S/Z T 2 ( N,R z U E (qr) W PROPERTY OWNER':S MAILING ADDRESS LOT t BLOCK t SUBO. NAME OR CSM C /0 77 ooy Hwy 3 S CITY, STATE ZIP CODE PHONE NUMBER ~CfTY (YLLAGE [f N NEARFST ROAD /il v D.St,../ G,v/S S y0/G ( 7!5 ) 3 006 - /O// s r ' v SC P /f- 049 /~w y 33 New Construction Use Residential / Number of bedrooms S [ [ Addition to existing building (~Replaoement Pudic or commercial describe Code derived dally flow 950 gpd Recommended design loading rate gibed, gpoltt2 trench, gpW Absorption area required NP bed, 112 trench, 112 Maximum design loading rate bed, gpdm2 ' G trench, gpollt2 Recommended infiltration surface elevation(s) %tE P , 3 R (as referred lo site plan !+@ndtfttark) uT~o-y Additional design I site considerations A(St TiP£-vG~, S o y4r !✓iS~h Z Po, /3 o,r U iST/' 14 Parent material _61C S Flood plain elevation:, d applicabk /V+ It Ov [tJ .v tU= Ultabl@ for system CONVIINIT10N.11 MOUND INN--G D PRESSURE AT-GRADEr / SYSTEM W Fly. HOLDING T nsu itable for Stem CC'S ❑ U ❑ 5 CAS ❑ U ❑ S L~t1 ❑ S ICU S SOIL DESCRIPTION REPORT eU.41J,e&z)Y- Boring # Horizon Depti, Dominant Color Mottles Texture Structure CoInsistwce Bartdary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. BPd 1r O'/-~ y 3 Z cd.aPif~r~`'~// f5/~& 44, f/ C'S /1-7c ^3P Ground /.3 z 101x Y/2- J-1 fk 5 1.2- -"3 elev. C,S 3S- y~ n~ f/t . S • ~ yob It 133 /o YA s/y S/ -1:f, D@pU1 aD C s -y~ /o 0, MA k ~ - 7 • limiting factor Remarks: Boring # d frU1 /1,,l 5 - E-v C /3 i*, syn S/y S/ 3,4M Sh& (WA +Ia S .G Ground 2 elev. C y~ l~ /o yt? Sti2 ~ Depth to Is tes site PROVE limiting --far-a-GenvaFganal *01, • fac>~ , Remark-.: p CST Name:--Please Print T /6rt / C GrJ-' Phone: 71S - 3 ?6 ress: & S J Alp ~1 [IpSO~v LU/. Sya/G 1- /0- ~ 3 c S rM Z 2 - Sgnahue: h6•'v"'i Date: CST Ntmber: ?Z~ # NDTE TD ~~S f/)~I /p - BE6,1USE OF RA 0I'C~9 L C 1I A Nd-`S % •u 5 d i L 5 t i2 UC t o p& h= PO M P i v P i AND L: c-.4 u5L c; f.. 5 T/P a u~_ 13,+VP1,0 G- c !J/ T /PE~v7- TEA 7 v I2t S ve l d t 't"l-k P! JS 1)0 ti, o T v S E- A 13 E U. s r T- l/ XiS`rt-9Vi FoQ MAxiAfU-t1 p£ w4 ~ e AM 1, A ~I'LI•r<y y /Vt NIG,F 5 a-v z y T p,' f f~'~-~v~ I" t/.1 r o ~v - 1 v J4,_-E-v T Tv Ike -f t 1•// :0 G- 6y57_6,-7 L"'_ 133) 100,6- COPE co-y~ ;t T /"v i R E' /U w S S7E~ r . 0 L V S y.5 7~ ,ti> C~,v . • . PROPERTYOMR - SOIL DESCRIPTION REPORT Pape Z 013 PAACB. I.D. # Depth Dominant Color Mottles Texture Structure cons seoe Bouridary Roo ~ GPO/ttBoring Horizon In. Munsell oi. Sz. Cast. Odor Gr. Sz. Sh. Bed ouch ~O y 51.Z si f, 5- hl( f2 s 2-f , ~y/ , s Ground 36 7 s ye 5/6 fi, 5 R nKv f IR S S G r z yu v . . ~ 36- y~ 7.5 yX S/~ CS . y S-I ;L 9 Depths G-GD 75y~ y/~ /'~~vEo fs D,f /mvf2 lftng " S `/R 3~ ~fo,P/zoo S/ f 9ie nM fi~ Q .C , S • Co laclor C a o //O /0 Ile s S s~ . 5+. Remarks: Boring # j r Ground elev. fL _ ` Depth lo limiting tads Remarks: Boring # i Ground elev. Depth ID kniling faclor _ L Remarks: - Boring # Ground elev. K Depth b liimiling facts Remarks: eon 0013n,o nc,n1% -ro jU 71 4 TC 71Pt'.vG(~ 7- Pt7~e s%STE--ys ,(Egv.,~o~-- Z-lSi~v6- x M/t 55Rt5A1E- i3t O-L li V-1-, i) t'.STP03uTio~j ~fpi o U/A)6- OFF fL xCtss v rn Z4 N n o n L -p V1 to IC) i N rrr~ • Rj W I V j r V - O ~ U 61 ~o w b k 3 'T ~ R C r Z ~ dU ~►F~ ~ p y ~ c N ~ N I 3 y LIJ o 0 R, ILHR 83.08 (2 ) - Eire 6s m Tom" st.", ° r S~iP /CAS F?2oo ,~U,•,eocr- tae . So . Sc/~fE-/o / , ~1.:vv~.~~o /~'s ~ ~1i%vv . 5'S y3 / PROJECT INDEY SHEET Owner J't F ~ C t ; )e y L ft (M E 5 7i53 PG 10-77 OLO Hwy 35 '34 U Oso J, t c.~ I'S 5 y 0 /G Address Site Location y~ NE 5,eC, i 2 ST ost-p H- P~~e«G 201~ - 30-000 c GoUA.)T Project Description S 7 ~01X Y 441 i--c i:STi c)L 4- 13~fJ.?•M . him E- %S Rci:v cr- S E,&v£D ~1~D~,e - s, zEo ~ 3 6~~RH p~P~1•;v r~, ~ o s ysr~-•-y St~f6s oF ~G~t,•~; ~V- ye~oE s~~f, c ~ir~~" y fie 5 13Cr0,*5 115 ! ya 5 N~zu ?0"0 . 5&10fiL ~~}-✓K ~~~~~'S CD-JGzf e_ ~/~ODUGTS) w~// 6 ~ P I- Jf4 3 _,F /1F/ tll DS Sim D/D 1>,PAiv Fit[-D 5 '~/l /~C LCf-T 10,1 iti Coti,tJ E-C t Eo /0 / U~ Page 1. Plot Plan & SYSTEM Plan View Page 2. Cross Sec-ion of Soil Absorption System C(OPY PLUMBER : e~~G1~oIVy°° ROBERT W. ULBRICHT ' Ile D1160 NWSOK °DsN~~ Date: Signature ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently T. serving the lL~~V\ C3j"~ residence located at: 1/4,1/41 Sec. , T(~ ! N, R' 0 W, Town of Upon inspection, I certify that I have found the tank and baffles, to be in goo condition, and it appears to be functioning properly. Q Last time serviced Did flow back occur from absorption system? Yes No (if no, skip Approximate volume or length of time: next line) ~9allons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer (if known): Age of Ank (if nown): (S' nature) (Name) Please Print s e~ ~'l 3y dY (Title) (License Number) (Date) 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 o ening over outlet baffle). Name m 30(AyAtf~NC Signature P/MPRS 5/88 SEPTIC 'T'ANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER I ADDRESS: le) 7-7 FIRE NO: LOCATION: 1/4, 1/4, SEC. T I N-RW, TOWN OF: J/ 2~~ ST. CROIX COUNTY SUBDIVISION: LOT NO. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system: St. Croix County residents may be eligible to receive a grant to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification from will be sent approximately 30 days prier to three year expiration. 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 Wisccnsin DNR. Certification form must be completed and returned to the St. CroiX Count Zoning Officer within 3 days of the th e ~year _ expirc,tion date. SIGNED: 3U Y DATE: St. Croix C o ~.nky 'Zoning Office 911 4y`1 St. Hudson, W1 54016 f 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 wi].7 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 ~ V Location of property A,,6114 /U-~'1/4, Section /a To2-::/~' N-R--90 W Township J%` 14ailing address A,4 djo Address of site Subdivision name Lot no. Other homes on property? yes No Previous owner of property Total size of parcel 4-1 Q.-C1, Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ~No volume5"and Page Number S3~ 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 th office of the County Register of Deeds as Document No. ~~and that I (we) own the proposed site for the sewage disposal systemorpresently 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 o County Register of deeds as Document No. n re applicant Co-app l cant 9~3C; _ r Date of Signature Date of S gnature 1300 Parkwood Circle Suite 200 tlanta, GA 30339 'Prudential Relocation Management v= A 404 612-6000 TO WHOM IT MAY CONCERN: I HEREBY AUTHORIZE TO ACT AS AGENT IN BEHALF OF PRUDENTIAL RELOCATION MANAGEMENT AT THE l i CLOSING OF PROPERTY LOCATED THIS INCLUDES AUTHORITY TO SIGN ALL RELATED DOCUMENTS, INCLUDING THE I.R.S. 1099 FORM REQUIRED. THE ABOVE IS AUTHORIZED TO SIGN ALL DOCUMENTS PREVALENT TO THIS MATTER. PRUDENTIAL RELOCATION MANAGEMENT RELOCATION CLOSER ~33 3 , wwwtwn rr ulcwu j DOCUMENT NO. f STATE or WlscoNsm-FORM S ; 3 4 0 8 2 5 VOL 55 5 PA"E 537 I THIS SPACE RESERVED FOR RECORDING DATA i . , ..e rr ~ ~t...Q.0j.dr.1..azlS THIS 11VDB1V'I'URB, "Made by .IEi~,....... REGISTERS OFFICE ~ f husband and f ..14 a 1t .,q ST. CROIX Co., WIS.. Rec'd. for Record this 16th grantors.. of..:.. „St. Croix ............................County, Wisconsin, day of hereby conveys,and warrants to. Z41CIt1as Y•..so ..ad........................ ---_A.D, 19_7 823 Deborah ;,E. Petersen,.:)I ..ond ..tr a- i ..1Q ,C3 at • tenants t I t1 ~ Rrapbfw of Duds ! j 1 .............grantee.$.... of I • ` County Wisconsin for the sum of .Good. ar Valuable t. RETURN TO one. Dolly J 1_.00)., and other ~Qorii3 c eratior~:. _ . _ the following tract of land in........ ..~?x......._ tY, Wisconsin: .......................................a:. t 4A parcel of land located in NE 1/4 1/4 bf Section 12-29-20, Tb n of St. Joseph described as follows: Owmencing at the NE corner of said Section 12; thence S880511W ji 1139.65' more or less along the N line of said NE 1/4 of NE 1/4 to the intersection of the N line of said NE 1/4 of NE 1/4 and the Wly right-of-way line of present State Highway "35"; thence S14012'E 773.83' along said right-of-way line to a point of curvature; thence Sly 31.10' along said right-of way line of a 1810.08' radius curve concave Wly to. the point of beginning, said point of beginning being S13°44'E 31.10' from the above mentioned point of curvature; thence Sly along said Wly right-of-way line to the S line; of said NE 1/4 of NE 1/4; thence W along said S line of NE 1/4 of NE 1/4 to the Ely line of Town Road; thence Nly along said Ely line of Town Road to a point S79D30'W 298.77' from the point of beginning; thence N19D30'E 298.77' to the point of beginning.', Zhis is to correct the deed dated May 10, 1977 and recorded at the Register of Deeds Office for St. Croix County in Volume 1155411, page 262, as document #340161. This is ri{!I to oorrect the marital stgtius of the grantors. I FEE F` #3 Mampt # 3 . EXEMPT Signatures of Michael A. Guldan and Ollie H. Guldan,. authenticated thus i~ 15th.day of-4une, 1977. Robert F. Wall, Member State Bar of Wisconsin. IA W tress Whereof, the said grantor.s.. ha..va__ hereunto set...... t1'rfair............. hands-.. and seaLs. this ' day of A. D., 19... ? l ! BI(INffiD AND sAA7.>QD`I: PRZIMNOE of (SEAL) Michael A. C;uydan • i `,yL wl e z •--........(SEAL) Ollie H. Coil dance (I t `~•P..~....t..../.r,l-?K~` .(SEAL) »(SEAL) I j State 61 *isconsin, ....County. Personally came before me; this.... day of............ A: D. ' the abovenamed ....1e..,As-- C~il.dan, arid, Ollie H. Guidanr husband. and wife as joint I teTlaTltS. I r ! to me known to be the person.$.. who executed the foregoing instrument and acknowledged the same. I .i`. z THIS INSTRUMENT WAG DRAFTED BY - r NOTARY Notary Public, ......COUnty, lX/ts 1 RIC RD6 & WAhL My commission (expires) (is) . (Sedloo 39.71 (1) Of the Wisconsin Statutes prevides that all instruments to be recorded shall have plainly printed or typewritten thereon the names oI the 4motors, Srantees, witnesses and notary. Section 39.513 similarly requires that the name of the person who, or govern. •t -el ~ rnrnfal ore" ws-n dT•A "0, ln.f--n• +1111 M Mlntrel. Iv1•r••vrirrrr. srvnf•e•rl ~r ~•ri•r•n ther-n in a Ir(;i1+ir mrn~N.1 L ~ ~EST~tT~ Svodo/e T S t,PvicES , 8200 /~~,ti,Bo~r- ipa~=. se . svirF io i w'-0 Departrnentoflndustry, SOIL AND SITE EVALUATION REPORT SSy3/ Page of 3 Labor and Human Relations Oivision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must iockide, but ST CipG~ X not limited to vertical and horizontal reference point (glut), drection and % of slope, scale or PARCEL I.D. dimensioned, north arrow, and location and distance to nearest road. 030 - 2-0-77 ` 30 - C7o O APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTYOR: avyE,p PROPERTY LOCATION ,je f'F D C HE RyL HOL MES GOVT. LOT Ne- 1/4 AIC114,S/z- T Z `l N,R L O E (0') W PROPERRTYY OWNER`. MA~yAD`D3R~ LOT # BLOq(s SUBD. NAME OR CSM # /0 77 CITY, STATE ZIP CODE PHONE NUMBER ❑CfTY C)VILLAGE BrOWN NEAREST ROAD //vD,sOAi 6v/S SyoiG (7(5 )36'1011 sr. S~S~ ~~O rYwy 33 (j New Consh6on Use ('f Residential / Number of bedrooms S [ ] Addition to existing building t~'1~Replaoerttertt [ J Public or cornntteraal describe Code derived da)lbw '75 0 gpd Recommended design loading rate .gibed, gpcW 1! , gPd/112 Absorption area required NP bed, ft2 trench, g2 Maximum design baring rate N/7 bed, t ' G trench, gpd1ft2 Recommended infilration surface elevation(s) SEE Fj ' 3 R (as referred b site plan bendtn" Additional design / site considerations *-St rfe iA t.% o•v41 wig l~iPojn 3 OX l7isr,P iii Parent rrlate W -'4S f9 1),v ,,4 &P i /k_ - Flood plaint elevation, d W icable it OUT W N Tu~y S - Suitable for U a Unsuitable f~ WSW 31 ❑ UU O MOUND I j N -WOUND U ~ AT-WADE S ~ 0 SS Id lJ 0S C SOIL DESCRIPTION REPORT ea-,►,,dje v r- Boring # Horizon Depth Dominant Color Mottles Texture Structure Qom Boundary Roots D/ftZ in. M nsell Qu. Sz. Cont. Color Gr. Sz. Sh.. Bed lends 4 /-L y 3 Z coyPifc rb p f S/✓.~ r~ fi eS lvf X1 P w) l /v ye 312 /)m f ► CS Al f N Ground /32 z ~s /aye z S/ f Sort s . Z. .3 elev. it 33 as- y~ /o y,~ spy s/ z, f, s~ ~s - •s . G Depth to c S ~y9 YX limiting Remarks: Boring # d /1 f iP~ ~o~ /1,15 13 E.v c vj .P ~vo o-l y 1.15 ye y 1s ,,m, e S S z /32 jy. / S yR s/y s/ 3, ss f a , s . G Ground elev. C V, 9e /.0 ye 51,F s 0.1 , s m...-k- 7 1? g~ ft. Depth to Thi test site APP OWE factor - non sep c sy tem U H I bil if ISM Co Remarks: yC5 Marna:--. ooze Pried Zllbl?/G 14 Phone: -715-3 ress: SS U it1~ i'L ~G~ LIPJ4914-1 zu/. S5b/G 93 F CS _te; Signature: ~z5 Date: 1} / [.lam`:. i NOTE TD /tiS-rA//ER 13 EC-U$E 0F RA0I'CA L C A v ~ ! N i 56t'L StRucrups f->2DM Pt-~ 'Fo P1-1 ► AvD 13EC4 uSE 0f.. OF V/' ~f 7PE~vT rE.A -'u 12E5 W Ict'-&fit ! 1)0 Aj ~ ~ S~ o T v5 ~ A 13&L.-) , ZNS-tfv► Fc,P, MAAiti U-'-1 s lD&w-4// pe-RMiA 61'c1'yy ~~/9101 /V~l" V6w roe-,vcGFS avZ-y 4-T p/'f-r"6>u - F/-V'tr,oN S 5011s ~V S~4c E-v T Tv 7%-P f, =v G- 5 ~s TE 133) AMA C OPE- co-y/ II A U 7- rO > 3 ' g jj /OW S l/ S7E--fr . O GV S ys T ~ tii C~j,v , • . 13E ~'E' • 2rs~ o . ~ o UE ~P E a ~vy~ /,times PROPRIry4 SOIL DESCRIPTION REPORT POP' d VHS PAFM D.i Texture Structure ConsMgnoe 8outday GPI orfzon Dominant Color Moves Car. Sz. Sh. Roots Bed Win. Munsen O AL Sz. Cont. Color A d-~~. ioy,•2 s/~ - S/ f, 5hl( AM 7W s 2-f , y . S 75 si i, f, sbk f,e s • y .s GwW /3 z 36- y(P 7 5 Y,p s/4 - S/ f, `lie r►M f c5 i . y 5 Depth 61 G- Go -7 s yie lg f 'p fs o, f, 'YiO o i~o Ie 5ly~ S v, f, s ' S Cz Boring A E3 Ground elev. ft Depth b imi5ng factor Remarks: Boring # E3 Ground elev. tL Depth b g faGor Remarks: Boring # NEW LMj Ground elev. it Depth ID M*M facto F1 I Remarks: can ooon,o ncK+" ~o iv ST~t/l~n < ~ 02~~-~e ~ S, T vet TE T~~ SyST~-y ~l£~/~tT/ovS i.l sys~-~5 Sh~Y/ /~c o~-~T' `s~-~ 3~ . s,•r~- w,~/ us~ti~x 77e,tSSRt5~7~- ~plp~ad-- o l~ C~5 ~~.v,'~G- oFF ~ xC'fss lee ~ i'•~ovi%0(r S,4-,(-12r 3i" 1,E Up j 3 ° Z4 0 m n c o - 'fl IN, o - m cn N ~ Z R► C~ Rj W N ~ O~ ~ r _ v 1 O C O► O C` \ w N En CAN n ~c o W el zc~' ~ I ► ~141, 3h To f~ 0 I 14~ m ~~e N N n y p 0 R► S£// ,PS - ~O.~ f~~ T t'so.~ - ,Prp,PES u r v ,Q/ I LHR 8 3.08 (2 ) IMF tL ~sT~ r °~owe r SHIP alez ?2-00 110.1/,6047 1U-e . SO Sc~iY,-- /p D _ --PROJECT INDE): SFIEET - . - Owner Tt r F i, C H C ►e y L Ito I A-+ E 5 7/ 6 3 P6 10-77 01-0 HWY 3S 14 u PSo,.j , I i' S 5 ~O/G Address Site Location NZc JX C. i Z 7- Z O U.,, 7-04c "A.; o~ T. T oStp H- R1-i~Pc~L p ~ 030 _ 2D iy , 30 _ a S oo Project Description 577, Cf0l')C e"00.07,1 441 exiSTiv(r 5 l3 DR•y. hoME is !3£i:v& SK,c°'uft~ ,9•,c~ 7,f~,~~,2 s, zEO 3 ~,yz 5 , r4 N eu Bt~U ~-es.Q . S~~fiL f~},v1~ ~wEE~'S CD-~IGc,el~2 ' ieOPOCTS) 6 3 _ /f~-/~ ~os sI oiD ~IP~I,v ~I~o still /fit iti T.~c T Ca v,~ c L: /v -e ~v c c~ ~.4.cJk v /:4 ~4 13 u /l IM l[/ Ole ~~'s n V J'~U,~J 60Y C s~-e S oI L po/e T Page 1. Plot Plaza F SYSTEM Plan View Page 2. Cross Sec.-ion of Soil Absorption S.irstem PLUMBER: G0 ~,y e~~fr"...,•~ri~ ism • foam W. s uusalcHT D1160 V~3 Wis. Date: • wM,....,.r'f y► o Q► o000 ~~'S 1 GNP oe • . •,trrrr~*~~ SignatzrP: i -o n to VO O _ m Q W 41 rn L w " rn fi 3 \ Ijj W N 44 Ol °O °0 C 0 b % Vl ~ oQ O p NG' ~o~ 1 ore 1n a - . ~ ~ S m CIO Z m o -p 14Z A QQ ~i t 4 o 74 31 'd I 3~ O ~ m p ~ Irv" ~ L b LA T- ~O 1 11 N n ~ o an W -n + Approved Vent Cop • Minimum 12' Above Final Grade T,PENc~ z4 y~ to 93. a 04 3(fo 'Above Pipe 4' Cost Iron - Vol fl o /dGv4~P' :,^I* Final Grade Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Toe pipe . 0 0 0 0 0 112- ' Aggregate o PerfbroUl Pipe Beier Beneath Pipe 0 -'Coupling Terminoling At 5yS7,6 ! Bottom Of S.ystenl Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12" Above Final Grade 7iP~~V ~ ff ~ y~, ~o 36, 'Above Pipe _ 4" Cast Iron • - 'to Final Grade Vent "t ' Synthetic Covering Min. 2" Aggregate Over Pipe Distribution - Tee pipe 0 0 0 0 0 12 ' Aggregate o PufOraled Pipe 8dor Beneath Pipe 0 -'Coupling Terminating At -sy$T1 Z__~- Bottom Of System 6,0 Fresh Air Inlets And Observation Pipe Approved Veata Cop Minimum 12" Above Final Grade `ice 4o A0 ' Above Pips El- 4' Cast Iron, -to Final Grads Vent Pli; Synthetic Covering min. 2" Aggregate Over Pipe Distribution -Tee pipe 0 0 0 0 0 /Z ' Aggregate o Perforated Pipe Below Beneath Pipe -Coupling Terminating At o Bottom Of System 5S/STE.H ~~-T • ~S U L 0105INCI B1101,g3- Plea sc d© ivo t A'cW ST. CROIX COUNTY PiClc.. f~/s C'Q/~ WISCONSIN t~iKY ZONING OFFICE ' .GMs' A 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 inspe Owner: A'udyl j0_1 14019006,v Requested by : ,J~O~ 0/.50z) Address: /300 PHkkwcod ji t/eAddress: defilufy -a/ City & State: Alafitr. City & St. /fZIA'SO~ ,kLI_ Zip Code: . 0_x Zip code: O/W Telephone N°: O (~/at-GcUO(~ Telephone N°: (7/5 ) ~0-. ay'7 /e77 Property add ess (Fire N° & Street) : JQ~!rl-lwg 3T Al Location: Sec. , T 2(' N, R Za W, Town of ST-i JZTF7/-l St. Croix Co., WI. Tax ID N2 Parcel ID N4 U3U- 3Q (D 61z House color: fQA/ Realty firm: &)&irz4o2j Lock Box Combo: M51Y W TO BE COMPLETED BY PROPERTY OWNER PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Is the dwelling currently occupied? ❑ Yes XNo If vacant, date last occupied: Septic system installed by: Year: _ Septic tank last serviced by: / 6 Date: y/ 3 CS~Ar/~~ Previous Owner's Name (s) : 7OM Dc-) Pete 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, y road ditch or body of water. ❑Y ❑N Slow drainage from the dwelling. ❑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: DATE: i OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION t IN I 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: PIS-elow grd ❑At-Grd ❑Mound Approx. size /&~'X-3!v ? G]Eravity ODose OPressurized Ft.: 7 @Bed ❑Trench ODry Well " ❑Holding Tank ❑Outfall pipe OBSERVED nk'I U~ ther OUnknown Septic tank? ` Setbacks: ❑House ❑Well OProp. line ❑Other ose tank Setbacks: ❑House OWell ❑Prop. line ❑Other OLocking cover OWarning label ❑Pump/Floats OAlarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House ❑Wel1OProp. line OOther OPonding: Ve6 ODischarge: General comment : _ - M Z Uri INSPECTO KETCH LFISYSTEM LOCATI N N r O' l 05 Inspector s^ Title ~k Li rp-- ? AUG 0. 190. -Tau) add (15) 4Y8-2048 .1 Vft Ucen§e. i &PEtSW 2T3s s S "Ing care o your sewer syt ^ s Da* I 4 ag 3. Y { s = ~a Petersarz r - - Add+es 1077' Old .H• 35 )udsan L-- - 7.-- - - - " We're your.. LENZY* U der s DATE Description AMOUNT 12/3 -,a new t' ~"tra man TOTAL Oct Tome- OUe on receipt 112% interest per month ant unpaid balance 'TbqWi1c Yout ra 19059 t S ` g f CeAuiF- Premier Group 70619th Street South Hudson, Wisconsin 54016 (715) 386-8207 (612) 436-8433 PARADISE! Addr Old H 35 L# Ci Hu son Fire # Dist Ol Gorgeous wooded 4 acre setting and lovely % 1/1 Sec Twsp S Joseph C St Croix landscaped grounds create a peaceful private site Ext Cedar Brick Yr Blt 1977 Ht Nat GasFPI Style ranch for this spacious family home. The comfortable. Lot Size SMFL TFF Tax Yr 19-92- floor plan features gracious living areas and 4.0 Acres 2216 3300 $3,031.20 lovely decor with three + bedrooms and three L C D Approx Rm Size 3 # Baths ] WT Sch Hudson - baths. Deluxe DREAM kitchen offers incomparable LR 1 C D 16x12.1 (AMB iK]BB custom oak cabinetry snack counter, and butcher DR 1 W 19.5x12. 4 ()1 Dwshr Disp. H20•:test on file block island. A brick Wilkening fireplace warms kit 1 V 24. Rekig [ R&0 ( )Yes ( )No the living room. Main floor family room with two FR 1 W 21.6x18. WS R ( ] 0 Avg Ht $ skylights and french doors that lead to sunny MB 1 C B 14.5x12.8 [ C. Wtr [ ] C. Swr. Avg Util $ porch. Lower level craft room and office. BR 1 C B 11. [ Well K ] Septic Poss Date N ot. Triple garage. BR 1 C B 11x10.3 Frplcs :K I C. Air Bsmt BR L C C 13.2x10.1 X)q Gar 3 K ] GDO ( Deck [ ] Patio N-287R BR L C B 13.2x11.2 ()J Rec Rm Ldr UFFI I I Y [ ] N I ] UKN Legal/Disclosure New Nat gas furn & central air 1992 Craft room L 19.50.3 Laundry L 9.4x8.5 9-/-B-/C 2.8% Lister Jenny Olson Ph 386-2554 PRICE: $173,900.00 Brkr Centu 21 Premier Group # 230 Ph 386-8207 DIRECTIONS: Hwy 35N, through North Hudson. West on old Hwy 35. Information is considered accurate but we accept no liability for error. Listing may be changed or withdrawn without notice. ..........E Ot►ORTUNITT Each Office Is Independently Owned And Operated REALTOR' N 88051'E 32.18' POINT -OF BEGINNING 33.92' PARCEL N120121 E 77.82' S880 51'W 1139.65' 102.65' • NORTH LINE OF NE CORNER NE 1/4 OF NE I/4 / W N 1: SECTIO co P/ M 3 0 , o 'w ~.t v 3 a o u m '0 N 04 Z N ° N 8023'W 136.87' 0 FARCE L I N POINT OF CURVATU E r N 2°42'w 10 0. 0 0' _M 4.0 ACRES M SI°07'W POINT OF BEGINNING 0.00' PARCEL 2 s 5 298,77, 4 S13044'E 31,10' tD 33.31' y 3c _tn ►il o °N PARCEL 2 ? to J • 4.0 ACRES o I 00 cr N W ±i z V w 0 3 0 o v1 0 N F- N1 M M M t ST. CROIX COUNTY WISCONSIN r,.,, , r'^u a ZONING OFFICE.__ %sr 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: Requested by: Address: Address: City & State: , City & St. , Zip Code: Zip Code: Telephone N°: ( - ) Telephone N°: ( ) Property address (Fire N° & Street) : Location: Sec. , T _N, R W, Town of St. Croix Co., WI. Tax ID N4 Parcel ID N2 House color: Realty firm: Lock Box Combo: 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: 71QYl 3 J977 Septic system installed by: year Septic tank last serviced by: C Date: Io(3 i9 Previous Owner's Name(s) : --rip + t&A, P-9-~L,-,- O Have any of the following been observed? ❑Y XN Slow drainage from house. ❑Y & Sewage Back-up into dwelling. ❑Y 9N Sewage discharge to ground surface, road ditch or body of water. ❑Y IAN Slow drainage from the dwelling. ❑Y IZN Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. o OWNERS SIGNATURE: DATE: /II(3 kXA-fhC)1LC CA-0 W a1 ST. CROIX COUNTY t WISCONSIN 4y1i~'xx,~ 7 ZONING OFFICE . ba r T _}f• ST. CROIX COUNTY COURTHOUSE 'r - 1101 Carmichael Road Hudson, WI 5401( _ (715) 386-4680 August 16, 1993 Jenny Olson C/O C-21 Real Estate Hudson, WI 54016 Dear Ms. Olson: An inspection of the septic system serving the former Tom & Deb Peterson home, located at 1077 Hwy. 35 N, was conducted on August 13, 1993. This inspection was based upon a surface inspection of said system and did not involve any excavating or chemical analysis. Accordingly there may be hidden defects in the system not discoverable by this inspection. Our records do not date back to the time this system was installed, so it is impossible to determine exactly what the system consists of or how many square feet of drainage area there may be. At the time of inspection, the septic system appeared to be functioning, but not at full capacity. I noted that sewage effluent was ponded within the drainfield,'which is typically an indication that the system is approaching failure. As the house has been vacant since 7/28/93, and there is still sewage effluent standing in the drainfield, it appears that failure may be near. It is very difficult to estimate the useful life remaining in any septic system. I cannot guarantee or warrant that this system will continue to function properly in the future. I cannot predict how long this system will continue to accept sewage effluent nor how soon the system will reach complete failure. In an effort.to prolong the system's life, I recommend that steps be taken to minimize the wastewater flow from the house which enters the system. For example, repair any leaking water fixtures and/or replace them with water conserving fixtures, reduce time spent in the shower, wash clothes and dishes only when there is a full load, use a washing machine with a suds saver feature, etc. I would also recommend that you have the septic tank pumped at a minimum of once every three years. Should have any questions or concerns that I can clarify, can be ach at this office between 8:00 am.- 5:00 pm., Monday - Friday. Sincer ly, J es Th m so ssistant Zoning Administrator