HomeMy WebLinkAbout020-1166-22-000
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AS BUILT SANITARY SYSTEM REPORT
OWNER~J 417 ~S Eft ~IWAe,6-it1 TOWNSHIP 0,A/
SECTION /7 T-?!2_N-R /9 W
ADDRESS 9's/S GJERT /P~_ ST. CROIX COUNTY, WISCONSIN
t~,OS off! 6j, S--VOA:i
SUBDIVISION&~(1~/L-l~ EST. ~ ~AW, LOT /O LOT SIZE
PLAN VIEW
h
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Alo-f TI! PIpoAEr7Y .CiNE
Esr
410, 1 6 335' -
S'
a Fx.sn
G'
5` ofx-S E cE
w mew sOR 3C 3 Effu4E.urL4#j c
.46
Ex /STAN(,
JET QQifi411`if(O I JVcc✓ 5c.~~/J ~FFu46AT~i ~i5'Ti~/!m
fD/vLeElP ✓ltc vF
so(A rli 0 oz?rr A/ C- INDICATE NORTH ARROW
0 5c.ttE
B CHIMARK:Elevatian and description:5;<oP o~ ExiSTi.V~ At4y)44~ -ovAf
Al ernate benchmark /w. 0.0'
~iciST.r--VSEPTIC TANK: Manufacturer: Liquid Cap. /OoO 4-
-Manhole cover elev: /oo ov' Final grade elev: /OCR. 6,9'
Rings used:-17
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front Side , Rear Ft.
From nearest prop. line:Front , Side , Rear Ft.
No. of feet from: Well , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front_, Side_, Rear_Ft.
Distance from: Well Building
SOIL ABSORPTION SYST
Bed: Trench -00 Seepage Pit:
G
3 a< Width: S' Length 6~O~ Number of Lines:-~_Area Built loo sq.,-f, TAL
Exist. Grade Elev. W. if.?' -Proposed Final Grade Elev. ~~01
Fill depth to top of pipe: 3-~
No. feet from nearest prop. line:Front , Side , Rear +/Ft.Z4_`
No. feet from well: 9 L No. feet from building 33-5`
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front Side Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: -4~ PLUMBER ON JOB:- c
LICENSE NUMBER: /vIP~S 3555"
6/90:cj
i
I~4'3+'rlTartrrl~str7.29.19.1~,At~F~,A"S~WERT RD. County:
Libor and Human Relations INSPECTION REPORT
Safety and 3uildings Division ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: 186533
❑ City ❑ Village Ekrown of: State Plan ID No.:
~Rffffe-F-H-A-r-_E7-N Insp. ev.: WBMFMDnV HUDSON
escription: Parcel Tax No.:
J C~ ~ ~a .~4--- 020-1166- 2-000
TANK INFORMATION ELEVATION DATA A9200416
Q/ 11 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark mil] aj-'
osi n , 121, 2.59 of , 5-5
Aeration Bldg. Sewer
Holding St/ Inlet GCazC~r'
TANK SETBACK INFORMATION St 1,10( Outlet
Vent
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt_JnIAt
Septic >ZS Cap ` Zp't NA
NA Header.
Aeration NA Dist. Pipe ~Z
Holding Bot. System /o. /
/v.
,o
PUMP / SIPHON INFORMATION Final Grade _
b . ' 9
aG.ur•
anufacturer Demand S.T. ICL
Model Number GPM
TDH Lift F
Loss i riction Syeste DH Ft
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width 6/ Length No. Of Trenches P f Pits Inside Dia. Liquid Depth
DITEN I N
DIMENSIONS
LEACHI Manu acturer:
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM
INFORMATION Type O &,M , CHAMBER el z
um er:
72 OR UNIT
System: 9z
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 (2) Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
laed /Trench Center 1~39BA;g /Trench Edges . 9-_5P Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 17.29.11~9.1021,NE,SW, LOT 104, WERT
1zn d G ima n~c
C2
Plan rvisl~on er d? z p
Yes
Use other side f:J /dditional information. 12 ;Z7- 9Z.
Sr
SBD-6710 (R 05/91) Date Inspector's Signature Cert - No.
r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
®ILI'll~ SANITARY PERMIT APPLICATION
)
In accord with ILHR 83.05, Wis. Adm. Code 7W7
Mumma STATE SA TARY R IT #
-Attach complete plans (to the county copy only) for the system, on paper not less than L3S 8% x 11 inches in size. cif revision TO 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
J 5 S'T~PfEN EN Jll,,r'/a S l9 T o)q , N, R /Q E (o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
Cf5/s L-c>E/~T D . /D4~
CITY, ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
;0A1 LcJSyo/~ 7/5 b+93,ly Ae ✓i-- L., ~ LLv.
7-1 II. TYPE OF BUILDING: (Check one) El State Owned O VILLLLAGE : NEAREST ROAD
10 =N QF: 7-
❑ Public 1 or 2 Fam. Dwellin O~c~ ~✓E Q
g~# of bedrooms 3 PARCEL TAX NUMBER( S)
14,1
III. BUILDING USE: (If building type is public, check all that apply) a 2 U /a 21Z
1 ❑ Apt/Condo
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.E1 New 2.,K Replacement 3.E1 Replacement of 4. ❑ 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12,n 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. _64 ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
/-/.,50 ~ Z Ss-C fr ~ 00 s?- . r 9s 0,
Feet F7- s 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
Septic Tank or Holdin Tank I/ 0C) /ooo / GJ.ESE L1 F]
Lift Pump Tank/Siphon Chamber I El [I F1 El 1 0. 1 F-1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumberigna re: (No SjAWpqV MP/MPRSW No.: Business Phone Number:
.0'eS 339 i 5' .SM - .?V~o
~ili4 Atu ~jLre. ZA 1
Plumber's Address (Street, City, State, Zip Code):
~/S GTy Sr N 0Sa1 C..~r . SYo/,6
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S tary Permit (Includes Groundwater a e ssue Issuing gent i
Approved ❑ Owner Given Initial Surcharge Fee) 41
Adverse Determin tion ~ W)
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 (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, 618-266-3815.
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.
Ill. 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 DIIHR.
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-6399 (R.11/88)
STC-100
This application form is to be completed in full and the OWnez(s) Of the property being developed. Any inade ua 'by
will only result in delays of the permit issuance. Should this
development be intended for resale
by house), then a second form should be reaiowntractor,spec
nedrand n ompleted(when
the property is sold and submitted to this office with the
appropriate deed recording.
-
Owner of property acrn S i . .l
e
Location of property/ -1/4 S),l 1/4, Section_
~ T-,2y N-R_Zy _W
Township p -
Mailing address ~ A r
J^`~~l(o
Address of site 9 e_r•+
cM LU.j
Subdivision name 0.r k 2~ Ec a~-e g11114~ &11NLot no.
Other homes on property? yes_
_ No
Previous owner of property S
am l
Total size of parcel ' X Q y '
Date parcel was created
Are all corners and lot lines identifiable?
Yes No
Is this property being developed for (spec house)?__Yes X
No
volume 1 to and page Number 6 6q as recorded, with the Register
of Deed-s.
INCLUDE WITH THIS APPLICATION THE FOLLOWING: -
A WARIUVITY DEED which includes a DOCUMENT NUItBER, VOLUME AND PAGP.
NUMBER & TILE SEAL OF THE REGISTER OF DEEDS.
certified survey, if available; ;would be helpful I o asdtoiovoid
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()
the property described in this information form, by virtue sofoa
warranty deed recorded in the office of the county Register of
Decd, as Document No. y~;3(.7 0
oun the proposed site-To-r--the sewage di p salt system) orr I e(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.
signs ur o a ¢lica t
Co-appl ant
s
Date of Signature il- a3 ~ a
Date of Signature
STATS BAR OF wtl MUSIN VOW 2'. 1 ~v
-low" "16FAst 561~
M
Sas• C. Nil er," a sinale • erson
. it"d
4. . .
is
s warrants to .James--.E." Stef-fenhgen an4...............
Y
+ :t~.#e.nha=ea,...husband...a.ad...ic~..
as...~oin:t._.tens!4t.~
asrustR 7e
a.
tits toibwint described real estate- in ...........County.
~4. ;SIh11►~Sf 1Atieoelisin:
Tat Pared Not
Lot 1O4,.Park View Estates Fourth Addition r
in the Township of Hudson, according to a.
plat recorded in the office of the Register
of Deeds, St. Croix County, Wisconsin.
'
- _i
k a
j
This J$- _n Q.t:. - - homestead property. k A.,
rQ Yfsk'(is not)..
t x $ieeiiiion to warranties Existing highways, easements , right 8 af' r . *>4
restrictions of record.
. Mme. ~ ~ T
v
Dslt,thie' 3. _ day of
- (SEAL.)
• Slm E. Miller..
s
y (SEAL)
AUVIN i<MTtCA?ION ACR1fOWLNipiit: l
- STATE OF WISCONSIN
(s)
ti•-.-•- _ S t Croix _ .......Cottitx. .
If ltti fed this ........day of.,_--.--. 19...... Personally same before the
t r + y r~ 6 .tire
I...... Sam E. Miller, a ~singlt gt _
~t
e<
Y16NBER STATE BAR OF WISCONSIN
.
-ur Trot.......
atrtkoritred by 706.06. Wis. SUta.) to me known to be the persoa - .,;r..t.
k
or acknook ,
Tk 11sf raTRUMtN T, WAS ORr "OD ev'
r
1Jk>rN Y... D-o.m !.0 rev n...
Notirp PuNk
K (81enatures tgi►F be authenticated or acknowledged. Both' Dty Coittnifsioi
aft'aet necessary.) date:
' 4rrt it po%ft. SM84 s in any eapnelky h_M be typed to Vr+nt.d 61it,W taeir iiReaWnM. ~ ~
ST. CROIX COUNTY ZONING OFSieE
CERTIFICATIO9 STATE14E14T
A
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have Inspected the septic tank presently
serving the - JlalES residence located at:
/l 1/4, :5U 1/4, Sec. /2 , TAN, R /_~_W, Town of
iLr00S / Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes-No no,.,iktp.
next line)
Approximate volume or length of time: //=gallons minutes
Capacity: /
Construction: Prefab Concrete V Steel - - Other
Manufacurer ( if known) : /~/=ESE2 CovcRtTt
Age of Tank (if known) : ~'>-eAAX
(Sign r / (TtVame) Plea rint
/2 .CT/1 .v% F iOrJl1 /J * i .yE/J r 1. it .~.~0 17..
(Title) a, IV (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 LLHR=83, iis. Adm. Code (except for
inspection opening over outlet baffle).
n
Name Glyz?we SIgnatar
5/88
SEPTIC TANK NAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER a C s' E. J 2 ind L. S 1- QJ_ Q r\ a
ADDRESS: 945 \Al2c+ kA ktA so,, U,~f S4616FIRE NO:_ q ~S
LOCATION : /,/t LL 1/411, .S'l✓ 1/4, SEC. 1 T~N-R~_W,
TOWN OF:_ 1T uds on ST. CROIX COUNTY
SUBDIVISION: Pat- k y i e w ies 141h411 LOT NO. /d
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 prior 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 Wisconsin DNR.
Certification form must be completed and returned to the St.
Croix County Zoning officer within 30 days of the three year
expiration date.
SIGNED. 4
I.
DATE : / I - 13~ a
d
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of
Labor and Human Relations
DiKision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
. COUNTY
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.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
C-
J~MCS r- F=t'~r~Nd4EN GOVT. LOT NC 1/4 W 1/4,S ~7 T N,R E (or) W
PROPERTY NER':S M~ILI/NGL ADDRESS /OOT~ BOCK # BD. NAME OR CSM # ^ T14 d~~N
OQ . "t
CSi
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY qVILLAGE JVOWN NEAREST RO,
ljJ ~Sa►J VII ( ) NU~znvw ~r 1Cd,41
[ ] New Construction Use Residential / Number of bedrooms 7 (j Addition to existing building
Replacement Public or commercial describe
Code derived daily flow SO gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required G4S bed, ft2 S&S trench, ft2 Maximum design loading rate a--j bed, gpd/ft2Q.$ trench, gpd/ft2
Recommended infiltration surface elevation(s) q-5. clo ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE YSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem 23S ❑ U 4S ❑ LI KS ❑ U OS ❑ U S❑ U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
i o S
-9' oi~23 - ~L 4 1 n~►1 c z 4
~.va `?`s? fit s ~oy Z S L Y► i h1' I~ l o.4
Ground D (,AS y 3/4 sL ~ SkK ^1~Tr / (04 .SJ
elev.
/ ft. /b " OY Q- X15 n~ O -7
Depth to
limiting
factor
7 IR 9Z
Remarks:
Boring # n
S c. r.~ O 4 a 5
4L4
Ground "s4 3 SL Ct-- f 0.4 O.S
elev. /6 S 4 ►~s 7
9 Uft.
Depth to
limiting
factor
%4,i 7
Remarks:
CST N -Pjease Pr_igt Phone:
r o N S~ i~J 3~s -~O
Address: l~%u~Sa ~ S~}a 1
Date: / Z CST Number: 3k,
Signature
t2_ LQJ" 2d_;k~4
PROPERTYOWNER~ ~fj~N~dGE~J SOIL DESCRIPTION REPORT
Page L of
PARCH. I.D. # '
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxlary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
A b 16Y~4 4 S ) C 0.4 O.S
Ground "-47 4 _ ~.~►,QbKrh~~f C 0.4 o.S
elev.
927-1 ft.
Depth to
limiting
j
~ factor,
Remarks:
Boring #
\k
h,
44
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
SU4!!. ~ = 20
A'p
ANT 40
I 1
IT 4-
~ ~F1J4ln+k1QL' - 1 ~
A~PRok,rnrrcc 1~ ~~Ts d~ o
( o~~ Svs?Eta Ov EkiST ►r►4 SEA
• lljoe- N
P/I'oO~2%Y PLB 87
I PLOT & CROSS SECTION PLANS
EAPPA BROS. EXCAVATING INC
Wes-, PLUMBING UNIT
Pia&If PROJECT
5 Si Ef/E~11 fAG E~
A P L ee vUAir S s M
OF Sot/
5/O' g 3y ST ~iPv x ~ou.vT
m~o fxiSTiw~
Q ~1rS S' ~jA.I
41
A.f<T--AAffz5 Aj 1.
♦ g-? //o' c ~~cc
IJEw S Q!~ 35 Ovc T i ~F~ k.tvt.~K
~ffue,FNr ~.~VE TPor- MAN~o<<COve?
i,90.00I
r - - - - - - IVEw ScM~O EFf~ILe~c/T.~iN
~xiSTiNI~
Qipii/ill 1cEL 4 MV
JE~ L -
+NO
s SCALE
FRESH AIR INLET AND OBSERVATION PIPE
APPROVED VENT CAP
MAXIMUM 12'
ABOVE FINAL GRADE i
I
Ir1----r- 4' CAST IRON VENT PIPE
MAXIMUM OF 42• ABOVE PIPE TO FINAL GRADE 1
SIGNED:
MARSH HAY OR SYNTHETIC COVERING I I LICENSE: /VS 33 qs
MINIMUM 2' AGGREGATE I ( i DATE: _
OVER PIPE 1%,Lr~
DISTRIBUTION PIPE I
1, TEE
SOIL TESTING BY:
ELEVATIO14 BED 6' AGGREGATE •
BOTTOM PER SOIL,,, BENEATH PIPE PERFORATED PIPE BELOW
TEST IS • COUPLING TERMINATING
!?S FT. AT BOTTOM OF SYSTEM
C.
REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1
11,/30/92 10:30 REQUESTS FOR INSPECTION WORK SHEETS FOR: 12/ 1/92 AREA: JT
Activity: A9200416 12/ 1/92 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 17.29.19.1021,NE,SW, LOT 104, WERT RD.
Parcel: 020-1166-22-000 Occ: Use:
Description: 186533
Applicant: STEFFENHAGEN, JAMES E & WENDY L Phone:
Owner: STEFFENHAGEN, JAMES E & WENDY L Phone:
Contractor: STAHNKE, MARK E. Phone: 715-386-2850
Inspection Request Information.....
Requestor: ZAPPA, GARY Phone:
Req Time: 13:12 Comments: /1J6
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Z TOWNSHIP {AS c~ i > SEC. !'7 T Zy_N-R12_Q
ADDRESS E) Z ` ST. CROIX COUNTY, WISCONSIN
SUBDIVISIONP,' ~Jmu; LOT LOT SIZE LQ t ,
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
R
t
1
I ( L:.~s'.t E
z•~x3~
b
a
7F
; - - t o
B:rn_
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used , L,i 5 LJ s1` ~
Elevation of vertical reference point: A Ll Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: / Tank manhole cover elevation: /014e
Tank Inlet Elevation: Tank Outlet Elevation:
n i
Number of feet from nearest Road: Front,V Side,O Rear, (D ~s feet
From nearest property line Front 10 Side,~Rear,0 Z feet
11 `y Number of feet from: well `-70 building: Z3 1V(0Ccr.iov ~'owW;.ti~e~e►.S.►~~.,,~.
►clude this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE STDE
PUMP CHAMBER
V
Manufacturer: VV Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
n
Bed: 0-1ct Trench:
Width: Length: Number of Lines: Area Built: 6gFj7'7-
Fill depth to top of pipe: = 2
Number of feet from nearest property line: Front, O Side, Rear,O Ft . M
p+
Number of feet from well:
Number of feet from building: S
(Include distances on plot plan).
SEEPAGE PIT
a
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet fro% building:
Number of feet from nearest road:
Alarm Manufacturer:
f
Inspector. ~ /(~Jj G7
/t- ~
Dated: -s -2- 3 5 Plumber on job:
y License Number : 14A
3/84:mj
DEP OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
❑CONVENTIONAL ❑ALTERNATIVE State Plan l.D. Number:
+ (It assigned)
El Holding Tank El In-Ground Pressure E] Mound '
NAME O ERMIT HOLDER: f ADDRESS OF PERMIT HOLDER
' q INSP~E(CTI DAT
'a 6
ZrV V
B H MARK ermanent reference point) DESCRIBE IF DIFFERENT FROM PL N: RE ELEV.: CST REF. PT. ELEV.:
Na a of Plumber: MP/MPRSW No. County: Sanitary Permit Number:
SEPTIC TA K/HOLDING TANK: 0-i 11. i G `
MANUFACT RER. LIQUID CAPACITY : TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
/ I PROVIDED: PROVIDED:
C-'~f-i t(~, ~~LL( d YES ONO DYES ONO
BEDDING: VENT DIA.: VENT MATL. HIGH WATER 'NUMBER OF ROAD: PROPERTY WELL BUILDING: JVENTTOFRESH
A LARM. LINE: AIR INLET:
FEET F~ Z
DYES ONO DYES ONO INEARE R
STOM 61
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY JPUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO DYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL. BUILDING AIR NT INLET: RESH
(DIFFERENCE BETWEEN FEET FROM LINE
PUMP ON AND OFF) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing It IN,,TH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH INOOF DISTR. PIPE SPACING. COVER INSIDE DIA.. #PITS. LIQUID
BED/TRENCH J_ TRENCH MAMFjtA~-. PIT DEPTH:
DIMENSIONS (T' tJ /ja ( i'
GRAVEL DEPTH FILL DEPTH DI STR PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW ,P IOP 'S ABOVE COVER. D GINLE EL PIPES LINE: J Al Fj FEET FROM NEAREST- ~G ~5~
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ONO DYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED:
CENTER. EDGES.
DYES ONO OYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. JNO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.'
ELEVATION AND ELEV.. ELEV.. DIA.. ELEV.: PIPES. DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
DYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
DYES ONO DYES ONO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SrNT'ij : T ITLE. "
DI LHR SBD 6710 (R. 01 /82)
f~
tT" n APPL ICATION FOR SANITARY PERMIT
L•HR 11~ COUNTY
EnT OF
(PLB 67) UNIFORM SANITARY PERMIT #
1-1.1 InDUSTRV, LR8 6MUTRn RELRTIOnS ~ D
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPEL Y OWNER j~r dLING ADDRESS
PROPERTY LOCATION SITY:
1/454/1/4, S/ , TZ , N, RE (Dr6P OWN of X/'-/50" &J"-5
LO/T NUMBER JBS BGDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
trT
1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
,XJ THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity D b
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
C ('1_5- l;_- Z/6 % Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature- Qy~ ~JB MP/MPRSW No.: Phone Number:
l/0 4 5T"' b 14 3- 11) (117) 1,1 Plumb 's Address: Name of Designer:
R2yNQ; K w~S S v~
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
~7 ~y ❑ Owner Given Initial
3- Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
Y
• • ' T
Y ,
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractgx,("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 SX m /a; Z~kp-
Location of Property 14-5-4/ k, Section / 7 , T N - R
Township
Mailing Address kZ g- Z
/T 1-.5 w.'s ~y~ isQ
Subdivision Name a4- ccJ 2.s77a-Ar 5
Lot Number ~O ee
Previous Owner of Property _F.
Total Size of Parcels g
Date Parcel was Created f Z- 21-a/
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number / as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed._...._._
2. Land Contract
3. Other recordings filed with the Register of Deeds Office
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 the Certified Survey Map shall also be required.
PROPERTV OWNER CERTIFICATION
I (We) ce4ti.6y that at statements on this ~onm ahe tAue to the belt o6 my (ouA)
hnowtedge; that I (we) am (aAe) the owneA,(s) o6 the pnopenty de.6c ibed in .th"
injonmation Sonm, by vi4tue o6 a wak&anty deed neconded in the 066ice of the
County Reg-c.sten o6 Deeds as Document No. 3 Sz- ; and that I (we)
p4es enttey own the pao pos ed site j on the sewage pos ads ys tem (o& I (we) have
obtained an easement, to nun with the above descA bed pnopexty, bon the
constcucti.on o6 said 6 stem and thesame has been duty n o
~ ec nded in the O "c
e
o6 the Count Re yo ~~ti
~ y g.c~sten 6 Deeds as Document No. ,3 Z ) .
Y
J1, t
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
5-4-6s
DATE SIGNED DATE SIGNED
o Ma '
i a OOCr<JNENT PIO. 1 WAMiJM Om 1111111111114111 spa= onawss no oneemm
STATS SAIL OF WISCONSIN FOM 2-aryl!
401551 i l
711►AGf R.?
40019M orm
ST. Cam co, WIL.
E.... Wwr t
.a>c}c~ 84verlY A, Wert,
' . ~ husband
4►4 „ ed for Reoord b
.~►i.fe.....Alkle..~~);~.]...~!i~r.~..~}a.. Beverly. Wert.. day of April AA 19 SS p
at 1:45 P
1
conveys and warrants to ....SaH..P....~il1StZp...a..-aingle-m 1.......
.......I
116TNRN TO
.
the following dewribod real estaq in .........St. Croix ....County.
state of Wisconsin:
Tat Parcel No:
1
Lot 104, Parkview Estates Pourth Addition to the Town of Hudson
TOGETHER WITH and SUBJECT TO easements, covenants, reservations or
restrictions of record, if any, but this shall not be deemed to
extend any such recorded encumbrances beyond the term established
by law therefor.
TRANSFFA
3&00
FM .
This . ......i8 not honestead property.
(is) (is not)
Exception to warranties:
Uateu Ills a 16d1 day of Aplll ]9. 85
_ .(SEAT.) (SEAI,i
• Darrel E. Wert
_ .
.(SEAL) ly (SEAL)
Beverly Wert
AUTHENTICATION ACKNOWLEDGMENT
94flature(a) ...Q. ..~d =1- E.,..W2It .And STATE (OP WiSC'ONSIN
Ar" everly A. Wert
...................y.........................................
County.
au6i8tieated th,1~5th a f.... - rl1 lg 35 Personally came before me this day of
_ 19...... the above named
_ Y.~...
•...uQh.. F....... in
N/A
TITLE: MEMBER STATE LAR OF WISCONSIN
(If not
authorized by ! 706.06. W+s. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
T4!S INSTRUMENT WAS DRAFTED BY
Gwin & Gwin
43() Second St., Hudson, WI 54016
Nota-y Puhtic County, Wis.
(Signatures may be authenticated or acknowledged. Both %I%' Commission is permanent. (if not, state expiration
are not necessar^.) duce: 19
•4t.mr of persons .iralax in any capacity .h..u:d be lypwl or t,.nt.d L. L.w u,.,r eiQnawn•.
M.GWM~GanPl,® STATE
FORM NO 2 - 1462 BAR OF -WISCONSIN Stock No. 13002
H
r U]
a
ST C- 105 9
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z"
d
a
/ H
OWNER/BUYERS#YL7
ROUTE/BOX NUMBER t&4 -;;r ZR 3 Fire Number
CITY/STATE AJ-Smh (4-)i ZIP_Lr S-
PROPERTY LOCATION: #E 5(~ k, Section 7 , TZ7 N, R I w
Town of~{u~_a , St. Croix County,
SubdivisionA/j~K-g0_)F~t&s.V, Lot number/de/
I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists 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 treat-
ment 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 systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
0
three year expiration. H
E
I/WE, the undersigned, have read the above requirements and agree cn
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart- IV
ment of Natural Resources. Certification form must be completed
and returned to.the St. Croix County Zoning Office within 30 days
of the three year expiration date. A
S I G I I~,
DATE /y'~
St. Croix County Zoning Office
P.O. Box 98.
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
1
3URYYS08i'13CERTIFICATE-:
1. awn" S. Bassi., Re- stewed Wtsesasia. Lead Surveyor, hsxsby certify to the
boot of P9910"W"I f knntsledge, andsretsadsng and belsof:
Tbsi1I bee essvwfw4. dindod wad roappod Park View Estates Jrourth Addition,,
located is the NZ114 eat the SW 1/4 a" the N`N1/ 4 of the 51314 of Section' 17, T2911,
It 19M. Towwof.Hadnon. 9t. Croix County. Wisconsin;
That I have mode such survey. IarA division and plat by the di2malon of Darrel E.
Mart and'BavestT R. Wort. owners m said laud, described as follows:
Comaeancing as the SI/4 corner of said Section 17; thence S8912~W (assamod
be►sbW relaresced to the wownew sited SAS? :W EST 1 /4 Section. llaa t'd Section 17.
boazift aaastaod S89s22101"W) (record" as 3W21146"W os tiat Certxt~d: Surrey Uap
reoesdeltaYeinme 1, Pa 184). 1332.986 along saki EAST-WZST-114 Station lint
thelew~-227.795taths pains sit beginning. thence N8f324WW 412.008; thence..
NO`061301M 222.004 is the Sawtherxly right-of-way line of Orton Mill. Lane; thence
H34e5240'w 68.004 at" said right-01-pay use; thsnee W04930"w 251.001; Uisret ~
5rr26152-"V8 194.354,- thmms 88 '13114"W 236.761; thence N7r57%5"W :42,172; thence
S89elSSi4 W thence M006830"Z 204.901.1 tbesee 3891IS,14"11 *#.0011 them&
XWw..X30"3 253.001; thee" S89'15,14"W 66.0itt theses SO' 6,30"V 316,3.31; thence . '
'WI3834"1 '131.006; tbance M0137t31"W 54.13'; these. 889'22109" W 142..',2011 thence
SWO65MOW 204.481; them* N4y'2S114"E 150.0017 those. 321'06430"11.312.971; thence
N89"ISs24" 134.04 themes. Southeasterly 66.251 along the aro-of w3a3.002 radius
cnrver eor.eswe: Mer[hessterl7 whose chord bears .34'501i0"E 66.17,: them a N W 15114"t:
,',7.0111 thopoe South-tsstorly.136.58, ale»g tits are of s 317.01!4 radios carv* coscave
o"boa tewl}ypwhose chord bears 324 03tOt"K M.511; thence 336e23t30" 143.141:
ihofwe tf7r3ds'f0"S 160.96-1; thence N89*15114"E243.001; thence SWO613Y"M 108.002;
themes SW3030"W 2".161; thence Southeasterly 14, aloe= the are of a 217.001
r*i6wFetttrvs.e~+toetva Iios!>se►stodX wfiass eMid'batis 378'031. 16"E 9S.3S1i thane
KslFI4~16"lE: 920.001; tthsace Mortboasterty 91.21a along am sra t+f s- 300.,)71 radius
es::1i sasenw tilorthwoetorly weose atwrd bears jt80.32246M 90.85Aytbw:%" North-
arestowir 91.44' along thf are of a 300.006 radius curve conserver Narthseanrl -whose
chart bww* N0137126"19 92.091: tbeaee N000030wE 1+30.001; thence NW15"4
470.05111Issnce 1Wy06630" t 634.562 to.tba point of beginning.
Thus coak pUt is a correct repreass wion ad all the exterior boamdaaies of the
Land snsvey" fad the asbdfvteion thereof wads, "A
That I have fatly oaraptiod with the provieWas of Cb4ptsr 136 of the Wtseonetn
S*attaeaao, tb* S"41+t,si6o and Zoning ReXal"WrA Of St. Cfcl: County, the ?'awn u1
Mochas Subdivision. Ordinance, avA the City of Hvdeon _%ibtlivlsioo and ?Wring Ordi-
nenoa., is sarvaying. dividing and mapping the same.
- 1 I
Dated this i1} dry of &RC& , 1934
Ri~'rsnad__ 11th ds of April. 1984. 7
. tnas S. Ausch E ,tllEle L
AL" am I
42I Seaoad Street ?2
Hodsos. Wisconsin 54016
COUNTY TREASURERtS CERTIFICATE
STATE 01' W11CONSM)
ST.-CROM COUNTY )
1. MoLvy Seen Livermore, b@ing duly elected, qualified and ac"ns Treasurer of
St. Croix County, do borsby cartily that the records in my office show no uarodoemod
tan sales and be aupaid taxes or special assetanwerts as of
affecting &be lands included is the Plat of Park View Estates Fourth Addtion.
Data only Treasurer
i
ZOM134G COZ2T.t1T'. X1' Ill'•SOLUTION
This pist is hereby approved by the St. Croix County Cornpreh*nsive Parks,
Pa "ing and Zoning Committ.e,
h
, t
Date Chair'fra►
13 44
Date Admial strator
v .w
h.
.
.
I ,
_ d
f
AR ~;'il:7W ESTATES F(DURTH ADDITION
R AG SUMYISION r-COATED IN THE %-ZA+-mowaNWWSE-V4,. ECTTCN. 17, T29N., Pig-IN,
t CON CF-. H[ 4.. ST CROX COUNTY, 'Ad SGOWN
- i
CE' TT41iCATE OF TO` N T'IMASUIM
SLATY OS -9=CN3=
I, Damlp A. 3ohasoe. belay ike daiq siscied, qualifiad7and acting Town Treasurer !
Of the Town of Hudson, do hwreby certify tbac in acaordanca rda to nay office,
tsaza are to unpaid taxes or spseisl as6essrnsets as of r on any larsd
inolaled !a the 1viat of Park Viees,Letatas Fourth Addition.
Bewrly . .+ehns owes raurrr
TOWN BOARD RZSOLUTION
ItZSOLYED, that the Plat of Park View Estates Fourth Addition in the Town of
Hudson, rarrel E. Wart and Beve A. Wert, owners, is hereby approved by the
Town S"-A. 1 /
r ; Y, iY
i34-
Oats Appr+d(L own rman
D fined own t.~arrman f/
i aareby es-tiiy that the foregoing a a copy of a resolution adopted by the Town
Board of chs To--% of Hudwn. f
Ddte Town Clerk '
i
OWNZRSt CCiTI.ICATE OF DEDICATION
As ov %vrn, we hereby certify that we caused the land described on thi: Plat to be
curvsynd, di•Aded, mapped and da eated as r"renent..d on this Plat. We also certify
that this F9st is required by S. Z36.10 or S. 236.12 to be submitted to the following for
approval or objection:
Dspartmeet of Development
Uarxrtrnant of Industry, Labor and Human Rolatie-is,
Town of Hudson, City of Hudson and St, Croix County.
W,;TN+=SS the hand and seal of said owners this day of _~/.~ry%•%••''"'
In presence of:
L)arr erY ~
Cleverly A, Wait
STATE OF WISCONSIN) SS
ST. CROIX COUNTY )
Personally came before me this day of the above
naraed Darrel E. Wert And Beverly A. Wert, to me known to be the persons who executed
the foregoing instrument and acknowledged the sane.
i
Notary Public (Z, Wisconsin My commission expires'
biarvrsch Notary Ptiblic
CERTIFICATE OF TOWN CLERK
STATE OF WISCONSIN)
)SS
ST', CROIX COUNTY )
I, Rita;iDrne, being the duty appointed, qualified and acting To%vn Clark of the
Town of ff^dzon, do harthi. certify that copies of this Plat were forwarded as
required by .1. 236. 12 on the day of , 1984, and that within
the 20-t!37 lirnit art cy s, 236; 12 (3) (no objects nn to the plat have been filed)
(all ::hj„c:inns to •hi :)at have been met),
Date flit Horne, Town Clerk
A
JAMES E. RUSCH
SURVEYING & MAPPING
HUDSON, WISCONSIN
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DEPARTMENT OF SAFETY & BUILDINGS
INDUSTRY, REPORT ON SOIL BORIN
LABOR ANA DIVISION
P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS 15, MADISON, WI 53707
(H63.090) & Chapter 145.0451 _ j 67
c~ ,
LOC
rf ~qq q
At 6 V/ SC7O/ 7 °C / N/R' / I(or TOW NS IP/MUAM4&N V" NO. ION NAM:
94a jxO PRtffit: T, ly SB I E ~
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
Si- Croi-K S
USE DATES V TIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILED SCRIPTIONS: 1PERCOLATION TESTS:
RResidence -KNew ❑Replace I _ /O _ BJS IUIA t 46
O 7 ~ a(^
RATING: S= Site suitable for system U= Site unsuitable for system Ste. (r. S P r 11(4144 d,#I k Jj9kd
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-Fl LL HOLDING TANK: RECOMMENDED SYSTEM:(optional
®S ❑U NS ❑U (~1 S ❑U ❑ S .®U ❑ S ®U e0A1 L
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the /
under s.H63.09(5)(b), indicate: ~V Floodplain, indicate Floodplain elevation:
PR FI E DESCRIPTIONS
BORING TOTALr DEPTH TO GROUNDWATER :4449 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH+po' ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / ,0' we- , .D Bl S/ /H/s 3,1 ,617 A e1S , 07S
B-~ Dr 10/.0, a e 7/0, ~.3v15 ~ r n 1 r( L"S r. 3,ffNnS
B-3 O,0' /o/•7I xAue- 74r0r /rZ6/s ra ,S 0 'go, Y!y /1&7,oj -5-
Z
O r0 ' /02, 7 Or 3 / s/ 3 ,eh ~ med S.
B-
PERCOLATION TESTS
TEST DEPTH' WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 011401 fi AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- I q,/' A10 A3
P- 3. o S 3% 3 3 a
P- A& 3 -3 31 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.
SYSTEM ELEVATION I7• ~e ea d
T
71
1._ xer! 1..~ ism
o
47-
:
&3
41-0
I I f =L;,~ ~jo(~ '
( t i i 3 ~ I P
I, the undersigned, hereby erti y hat the soil t~,ts reporte on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): 11 ~ TESTS WERE COMPLETED ON:
' t C:f~w:s ~94txea 41-11-
ADDRESS: ADDRESS: ` / CERTIFICATION NUMBER: PHONE NUMBER (optional):
/A~ 97 41.!5_ 7/.s'
rP/! ~r 6,t.I cask, sy,
CST S TUBE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) OVER
-
I
I
INSTRUCTIONS FOR COMPLETING FORM 115 - SBO - 6395
To be a complete and accurate soil test, your report must include:
1. Complete legal description;
2, The use section must clearly indicate whether this is a residence or commercial project;
3, MAXIMUM numb of bedrooms or commercial use planned;
4. Is this a new or acement system;
5. Complete the -J, ity rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS RE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LE -'L diagram accurately locating your test locations. Drawing to scale is preferred. A
separate she ' is .d it desired;
8, Make sure ym ,.mark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all _ >priate boxes as to dates, names, addresses, flood plain data, percolation best exemp-
tion, if approt ?e;
I 103 If the infc ich as tlood plain, elevation} does not apply, place N,A. in the appropriate box;
11. Sign the form your current address and your certification number;
12. Make legible col . ad distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHOI '-Y WITHIN 30 DAYS OF COMPLETION,
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Sail Separates and Textures Other Symbols
st ne (over 10") BR s'-o^':
col) C )ble (3 - 10") SS , one
gr ravel (under 3") LS - L stone
*s - is and HGW - High Groundwater
cs irse Sand Perc - Percolation Pate
med s=? dium Sand W - Well
fs ine Sand Bldg Building
Is - Loamy Sand > - t n n
Sandy Loam ~l an
Loam Bn - Frown
- Silt Loam BI Black
- Silt: Gy - Gray
1-cl - Clay Loam y - Yellow
sci - Sandy Clay Loam R - I_
sicl - Silty Clay Loam mot r,"' *!e=
sr: - Sanely Clay w/
-
sic - Silty Clay ftf I'l faint
"c - Clay cc; pinion, coarse
Pt - Peat ruin iy, medium
ru - Muck d - inci_
p - prominent
HWL - High vva.~
Six gene) tu; es Surface,
for liqui i~ disposal BM - Bench Mark
VRP - Vertical Ri
t
TO THE 0
;t r ;i in scua Ali y m . m+ie county c, _ne Dc,,,, i mer 'ay request
x, private
itted t_ rfpr to
T' r nd post
4
U y
d~ r m
0
M
6
v
J J ~
'f
v- ! v
,O
4 SA OA, VIA', 1 <o n sT
v:,., F st•Q1~ z .U lat y
-S it ~,,N 1V. ~ T c-
A 8.tA. 15 -}k~ V441f [TV JI'2 ~QF \CI Nt
cit Lofi coy h4 ati~ C~ ~P cF
a fats ~P~ (Assc~w%mLE 1 = loo.a')
3 2--
O
~c
6a.a5~
iyX3Z
I
s4 VIA I
' }(ouSL $
sy` B3 `bo
Ri
r
ZO - z
{
l~~r~rty Si~~ 34"
fln~l~
ST. CROI X COUNTY
TYfn' .
WISCONSIN
t-
ZONING OFFICE
796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
May 28, 1985
Mr. Sam Miller
R. R. 1, Box 282
Hudson, WI 54016
Dear Mr. Miller:
The septic system on your property located in the NE14 of the SE14
of Section 17, T29N-R19W, Town of Hudson, Lot# 104, Park View Es-
tates IV, was installed and inspected by this office on May 23, 1985.
The system that was installed is adequate for a three (3) bedroom
home.
Should you have any questions regarding this subject, please feel
free to contact this office.
Sinc rely,
a I~~
Harold C. Barber
Zoning Administrator
mj
V C) C --es + r\ e e e a -~o r e t via he i ri-0 Q ~-o c( 0 r f_
rya L CQ~ T~t.~ ~3, ~qg3 ,
ST. CROIX COUNTY
WISCONSIN 77
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
nw- (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.
3K Water (VOC's) $185.00 0 Septic $25.00
❑ Water (Nitrate & Bacteria) $35.00 (Visual inspection)
Owner: -`-Q-~ ev~~aa P., Requested by: F%(s-~- 2~4rcc1 - vo CC 4?-,
Address: f145 We,-A- KA 'A Address: 6 I S "A
City & State: ,N Wr City & St. so ,
Zip Code: 54 01 Zip Code: 5-4 p I (o
Telephone N°: (115) 386- 7344 Telephone KI-: (-715) 3&`6 - g30~1
Daytime ekore 715.-S" - t~ ;Lo I CWeA Sfe~_re"t,"40.)
Property address (Fire NQ & Street) :_94 Location: sec. T~1LN, R~W, Town of 4,x Sorg
St. Croix Co., WI. Tax ID N20ao-ii4&-aaParcel ID N4 17. A9. /J. /0~.1
parKv~ew Es+&4es 44,Add Lo+ Ioy
House color: B rowan Realty firm: Lock Box Combo:
Water sample tap location: ps%Ae. ;,A. a}ev- ~cef hem C a1pnr. rns'jde.
Coca o+~ rs retutrej, lease cct(I So Lug ca.. arrak, e kouse c eh .
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE O HIS FORM*
Is the dwelling currently occupied? 0 Yes 0 N Z
If vacant, date last occupied:
Septic system installed by: Year•.
Septic tank last serviced by: te:
Previous Owner's Name(s):
Have any of the following been observed?
❑Y ❑N Slow drainage from house. zy ra
❑Y ❑N Sewage Back-up into dwelling. j•,~i
❑Y ❑N Sewage discharge to ground surfac~
road ditch or body of water.
❑Y ON Slow drainage from the dwelling.
s:k1;
❑Y ON Foul odors.
o° M yj.
Other comments relative to system operation:
I certify that the above information is comp ete and true to the
best of my knowledge. z
OWNERS SIGNATU a Air. J, DATE: QV~J
,
R
A
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
4
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.Z ❑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 ❑Prop.'line ❑Other
❑Locking cover ❑Warning label ❑Pump/Floats "
❑Alarm ❑Elec. wiring
Soil Absorption System
Setbacks: OHouse ❑Well ❑Prop. line ❑Other
❑Ponding: ❑Discharge:
General comments:
INSPECTORS SKETCH OF'SYSTEM LOCATION
N
Inspector
Title
08/02/93 15:08 FAX 612 636 7178 SERCO LAB. -*44 S.C. CO CRTHOUSE 121002
Post-ItIm brand fax transmittal memo 7671 # of pages ►
TOOE~ From
Co. Cob , .
SERCO Eaborator
Dept. Phone #
1931 West County Fbao C2. St. Qaul. Minnesota Ui t3 Phoft (8121636.7173 FAX (612 Fax ~ v Fax I, D
LABORATORY ANALYSIS REPORT NO: 32519 PAGE 1 of 3
08/02/93
St. Croix County zoning DATE COLLECTED: 07/14/93
911 4th street DATE RECEIVED: 07/15/93
Hudson, WI 54016 COLLECTED BY : CLIENT
DELIVERED BY : CLIENT
Attn: Mary J. Jenkins SAMPLE TYPE : DRINKING WATER
SERCO SAMPLE NO: 86833
SAMPLE DESCRIPTION: Steffen
q
ANALYSIS:
Benzene, ug/L <1.0
Bromobenzene, ug/L <0,2
Bromochloromethane, ug/L <0.4
Bromodichloromethane, ut2/L <0.2
Bromoform, ug/L <0.5
Bromomethane, uq/L (Methyl bromide) «,0
n-Butylbenzene, ug/I, <0.3
sec-Butylbenzene, uq/L <0.4
tart-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, uq/L (Methyl chloride) <0.6
2-Chlorotoluene, uq/L (o-Chlorotoluene) <0.2
4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2
Dibromochloromethane, ug/L 40.4
1,2-Dibromc-3-chloropropane, ug/L ¢1.2
1,2-Dibromoethans, ug/L X0,2
(Ethylene dibromide)
Dibromomethane, ug/L <0.2
1,2-Dichlorobenzene, ug/L <1.0
(o-Dichlorobenzene)
1,3-Dichlorobenzene, ug/L <1.0
(m-Dichlorobenzena)
< means "not detected at this level". 1 mg = 1000 ug.
~r
I
08/02/93 15:09 FAX 612 636 7178 SERCO LAB. 444 S.C. CO CRTHOUSE Z003
SERCO Laboratories
1931 West Counry Road 02, St, Paw. M1nnews 58i 13 Phone (612) 636.7173 FAX (612) 638-7178
LABORATORY ANALYSIS REPORT NO: 32519 PAGE 2 of 3
08/02/93
SERCO SAMPLE NO: 86833
SAMPLE DESCRIPTION: Steffen
ANALYSIS:
1,4-Dichlorobenzene, ug/L <1.0
(p-Dichlorobenzene)
Dichlorodifluoromethane, ug/L (Freon 12) <0.5
1,1-Dichloroethane, ug/L <0.1
112-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 <011
1,3-Dichloropropane, ug/L <0.2
2,2-Dichloropropane, ug/L <0.2
1,1-Dichloropropene, ug/L X0.2
cis-1,3-Dichloropropene, ug/L <1.5
trans-1,3-Dichloropropene, ug/L <0.9
Ethylbenzene, uCj/L <1.0
xexachlorobutadiene, ug/L <0.3
Isopropylbenzene, ug/L, (Cunene) <1.0
4-Isopropyltoluene, ug/L <0.5
(p-Isopropyltol.uene)
Methylene chloride, ug/L 6.1 A
(Dichloromethane)
Naphthalene, ug/L <0.2
n-Propylbenzene, ug/L <0.4
Styrene, ug/L <1.0
1,1,2,2-Tetrachloroathane, ug/L <0.2
1,1,112-Tetrachloroethans, 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 'snot detected at this levelff. 1 mg ~ 1000 ug.
08/02/93 15:10 FAX 612 636 7178 SERCO LAB. 444 S.C. CO CRTHOUSE [1004
Arm
SERCO Laboratories
1931 West County Ams C2. St. Paul Minnesota 55113 P1+one m a1 es6-7173 PAX (612) M7178
LAaORATORY ANALYSIS REPORT NO: 32519 PAGE 3 of 3
08/02/93
SERCO SAMPLE NO: 86833
SAMPLE DESCRIPTION: Steffen
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 e-0.2
1,2,4-Trimethylbenzene, ug/L <0.2
1,3,5-Trimethylbenzene, ug/L <0,3
(Mesitylene)
Vinyl chloride, ug/L <1,0
Total Xylene, ug/L <1,0
hm S/z-lR3
This sample's analytical results( below the U.S. EPAfs SDWA
Maximum Contaminant level of 1/30 1 for those requested compounds
which are also on the SDWA MCL list.
A: This compound was observedin the laboratory blank at a
concentration of 16 ug/L,
All analyses were performed using EPA or other accepted 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,
Diane J. derson
Project manager
< means "not detected at this level". 1 mg = 1000 ug.
08/02/93 15:11 FAX 612 636 7178 SERCO LAB. -*44 S.G. CO CRTHOUSE 01005
~c
SERCO Laboratories
ANALYSIS RiOUEST FORM
Si. Paul. Minnesota
DIANE J. ANDERSON TOE FOLLOWING INFORMATION IS REQUIRED TO
PtO"'~' .PROPERLY PROCESS YOUR SAMPLES. COMPLETE
AND RETURN WITH SAMPLE=.
+931 west County Aaad C2. St. Paw, t.unnesm 55113 PLEASE P R I N T .
18121 676.7173 Pax 18t2F oWn7e
DUE DATE:
Z STANDARD: CLIENT NAME ~~'rroo I IL Uyl PRIORITY:
CLIENT ADDRESS: IADVANCE NOTICE REQUIRED)
.1'` rvu Q
AM
_ r16 TIME CQLLEC*#0 : OCR M
ATTN: I eq,~~{,i y Is 4ATE COLLECTED~14 -c13
CLIENT PHONE NO. 2 -7I S- 3 S (-Lf 6Y,~0 NAME Of SAMPLER YIS
SAMPLE TYPISXCIRCLE AT LEAST ONE)
CLIENT ORDER MO.:T~ WASTE WATER SLUDGE
GROUND WATER SOIL
INVOICE TO: Gd_.~O SURFACE WATER SOLID WASTE
Ll PATE _ HAZARDOUS WASTE
GRAB COMPOSITE
OTHER:
PLEASE LIST TESTS REQUIRED FOR EACH SAMPLE. ONE SAMPLE PER BOX.
PLEASE MOTE SPECIFIC DETECTION LIMITS REQUIRED OR APPLICABLE REGULATION.
AMPLE IDENTIFICATION ~ i c ~ r e n' - . . . . . . . . . _ . _ _ _ , . _
7 LETTERS PER LIME, . . . . . . . . _ . . . . _ _ _ . . _ _ . . _ _ _ _
ONE SOX PER SAMPLE) . . . . . . . . . . _ . . . . . . _ . . _ _ . . _ _ _ .
-ANALYSIS,
V
N -OF BOTTLES/S111
SPECIAL INSTRUCTIONS AR UNUSUAL' CONDITIONS:
08/02/93 15:08 FAX 612 636 7178 SERCO LAB. 444 S.C. CO CRTHOUSE Q001
SERCO- Laboratories St, Paul. Minnesota
1931 West County Road C2
St. Paul, Minnesota 55113
Phone: (612) 636-7173 FAX (612) 636.7178
CONFIDENTIALITY NOTICE
This facsimile transmission is intended only for the use of the individual or entity to which it is
addressed, and may contain confidential information belonging to the sender. If you are not the
intended recipient, you are hereby notified that any disclosure, copying, distribution, or the
taking of any action in reliance on the contents of this information is strictly prohibited. If you
have received this transmission in error, please immediately notify us by telephone to arrange
the return of these documents.
DATE:
Please deliver this fax
transmittal im odiately
r
FIJI:
t Number of Pages
(ineludiix cover sheet)
FRCK: A. SII~00 Laboratories
Com cents:
v~
If you do not receive all of the pages, please call (612) 636-7173 as soot, as
Possible. When Quality and Service Count