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AS BUILT SANITARY SYSTEM REPORT
OWNER Af-,~ f~1 Sc~~ TOWNSHIP
SECTIONT,N_R f W
t
ADDRESS e'> ST.-;-CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE/=
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF.SYSTEM
1~ ~1~Zo G~ (`'}A x n S t'' L
l ZtD c~ G Pl'L S Ti
2 + tao.
- A4 . 7
(j i.
I ~
I 7 I lT~`
P12 ~ INDICATE NORTH ARROW
BENCHKARK:Elevation and description:
Alternate benchmark
SEPTIC T_kMK:Mantfactt3rcr:
Rings used:_~_Manhole cover elev: rF Final grade elev: 02,Z-
Tank inlet elev.: iff -Tank outlet elev.: 9G. I,/ Z.
No. of feet from nearest road:Front , Side
Rear Ft.
From nearest.prop. line:Front , Side L,1, Rear Ft. f3~
No. -of --feet---from: Well, Building:
(Inglude this information in the above plot plan)
(Z reference dimensions to septic tank)
$EE REVERSE SIDE
PUMP CHAMER
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 SYSTEK
Bed: 1 Trench: Seepage Pit:
Width: ength ! Nu.2ber of Lines:-/--Area Built
Exist. Grade Elev. e5 Proposed Final Grade Elev. I~
Fill depth to top of pipe: ;?Z;? "
No. feet from nearest prop. line:Front , Side , Rear Ft.7
No. feet from well:-Zj~_.-No. feet from building 410
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: r.," . ezt -T Jr~ S
DATE : PLUMBER ON JOB: ~
ter ' LICENSE NUMBER -
6/90:cj
LOCATION: HUDSON 18.29.19.160A,NE,NW,CASPERSON, LOT 2
Wi~consin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Ftuman Relations INSPECTION REPORT
Safety andj3uildings,Division ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 149326
Permit Holder's Name: ❑ City ❑ Village)] Town of: State Plan ID No.:
BLASIER JEFFERY HUDSON
CST BM Elev.: Insp BM Elev.: BM Description: Parcel Tax No.:
1~"~ 020103790000
TANK INFORMATION ELEVATION DATA A9200172
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ! Benchmark
Dosing,;
Aeration Bldg. Sewer
Holding St/Ht Inlet d q
TANK SETBACK INFORMATION St/ Ht Outlet D r1g4"~
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic j 5a a(o ` ' L NA Dt Bottom
Dosing NA Header / Man.
,d~O /
Aeration NA Dist. Pipe
Holding Bot. System / Q'7 QF
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss H
Forcemain Length Dia. Dist. To Well /
SOIL ABSORPTION SYSTEM q
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION y L-1 L) / DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Moe Number:
System: W OR UNIT
DISTRIBUTION SYSTEM
Header/Man fold Distribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake
r-t
'
length Dia. Length Dia. ! Spacing tb
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed / Trench Edges ~D Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) `
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.{
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: .
m
III
~HR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
~.w-,rnv~
Zaol
STATE SANI Y PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ check if re~ls~ sous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER P g4rJ RTY TION
/a, S T2-1), N, R E W
PROPERTY OWNER' MAILING ADDRESS LOT # BLOCK #
1-20 2, CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
C~ .
II. TYPE OF UILDING: (Check one) El State Owned ; VILLLLAGE : NEAREST ROAD
56 /J
❑ Public ~1 or 2 Fam. Dwelling-# of bedrooms AR EL TAX N BER( )
III. BUILDING USE: (If building type is public, check all that apply) D d oe)U
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 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. I New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq ft.) (Min./inch) ELEVATION
, r 9A60 v c~;7_ Feet 3 Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New dating Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank /m J,
Lift Pump Tank/Siphon Chamber E
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) / PRSW No.: Business Phone Number:
r),7 cyt S
Plum is Address (Street, City, State, Zip C e
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued issuin gent Signature (No Stamps)
® Approved El O
Adverse wner Given Initial Determination j surcharge Fee)
l~
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety& Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years. '
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
A
S T c in
This application form is to be completed in full and signed by
the owner(s) of the property being developed. Any inadequacies
will only result in delays of the permit issuance. should this
development be intended for resale by owner/contractor,(spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
owner of property _ ✓e--4r-.Z A, DA-wn
Location of property V~ 1/4 At W 1/4, Section' 1 , T_ILN-R I_,_W
.Township vj sa h
Hailing address 77-7 6e-rA,,' ch.-a / Rd,
Jd Soh S o l 6 '
Address of site 33 Ca-sPerSon 'Pr.
Subdivision name Lot no. Z
Other homes on property? yes___X_-_No
Previous owner of property bu r' C t/•So~
Total size of parcel 3 • 7 0 Rlw
Date parcel was created j -1 Are all corners and lot lines identifiable? _ x Yes __No
is thia property being developed for (spec house)? Yes • CHO
Volume D and Page Number Z-S,S as recorded, with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING;
A 19Atuuvt'1'Y DLED which includes a DOCURENT NURDER, VOLUME AND PAGE
1Iumui R & 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 ny (our) knowledge that I (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded in the office of the county Register of
Deeds as Document No. ` 3O q3 , and that I (we)
oo:n the proposed site for the sewage disposal system orreI (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.
Si t ge of la co-applicant-
S- TL
Date of signature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
483043
Val REGISTER'S OFFICE
ST. CROIX CO., WI
I b v r C a s P. r s o n 5,41/1 tea : Reed for Record
2 1l s7h sr. uwy 63 MAYO G 1992
Cvn,bj,- rlwn L D✓~ 5-gg21 dfi 12:15 P.M
conveys and warrants to
3'4~ rtv Q' 6/ 1's~ r
D A-Wti M . I S~ F Register of Deeds
RETURN TO
the following described real estate in STr C Kd$ X County, I
State of Wisconsin:
Tax Parcel No:
S~Ltlron ~g TZ9
~ N ~ R 19 w , Towh o.f- 14ud son ~
St, C(LO!X Cd✓It -''Y~ ~n/I~SGOks/`J1 . /JGttn.f /Ot Z A-064-
~Vy~
D C e r fi'4 ,)i S v r v L y M d P V o S f "C. ?_3 S'S..
I QPq
This !'S homestead property.
(is) (is net) pL ► a
Exception to Warranties:
I ~ q
Dated this ~h day of MAY 19 / 0_.
(SEAL) ~f/~ PILL (SEAL)
• w t L4 k R. C>4S roc-_So K
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ss.
~2ROh County.
authenticated this day of 19 Personally came before me this 6~ l day of
fMIAY , 19the above named
W l t_ IS t.t k- CA S PCCR,S o h
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the p P rson who executed the
authorized by § 706.06, Wis. Stats.) fore i str t a knowledge the same.
THIS INSTRUMENT WAS DRAFTED BY ii'
t K
-Mr kae
•NOTAR • Notary Public Q o
e County, Wis.
r*now
(S u e ;ay be authenticated p g.Both; My Commission is permanent. (If not, state expiration
are not necessary.) )
date: 19
°'•°'°Cl B LIG
Names of persons signing in any capacity should oe oeG( Iae ignatures. SB2 NTF 0021
Wit ~i AR OF WISCONSIN
WARRANTY DEED Nelco Tar Forms, P.O. Box 10208, Green Bay, WI 54307-0208
~ Form No 2 - 14Ai
a
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~rt- y A ~ .0- /V) . a, i`S- h
ADDRESS: 331 C a.sp-YSo rn Dr. FIRE NO:
LOCATION: 1/4, NW 1/4, SEC. 18 T?-`q N-R l 9 W 1604
TOWN OF: I-~ ✓ So n ST. • CROIX COUNTY
SUBDIVISION: LOT NO- _2_
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:
L./ r
DATE :
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
•
IN1XJ TiTN' i WARTMENT REPORT ON SOIL BORINGS AND
INDlUSTRY SAFETY & BUILDINGS
LABOR AND P.O. BOX 7969
HUMAN`RELATIONS
PERCOLATION TESTS (115) DIVISION
(H63.09(1) & Chapter 145.045) MADISON, WI 53707
L CATION: SECTION: T UN CIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
T V44 M/R~ E (o
QQ,, N yyyER'S N ME:
c h ILIN DDRESS:
USE
N B RMS.: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE lG
Residence 7PROFIL DES RLIT S: ER AT ON T TS:
New ❑ Replace
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOM ND E D SYSTEM::(O:P:t ional) ~
~s❑u Isou,®s❑u osru ❑sau te E;
If P ercolation Tests are NOT required DESIGN RATE:
under s.H63.09(51(b), indicate: If any portion of the tested area is in the
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL D PT
NUMBER H TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 46
~ao,~ cry ,0 d- s 6 kq vc8
B-
d-11 hCd. t . ~5
B- 3 10 s
_171 60 li ' y 5d Gr
LB_
PERCOLATION TESTS
R WATER IN HLE TESTTIME DROP IN WATER LEVEL-INCHES
AFTERSWELLING INTERVAL-MIRATE MINUTES
PERIOD 1 PE
PER INCH
a
~
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
I ~R1
E /Yl P
W
E ,
r~e
3
~o
10~o ppjtp~~
;
I '
.r
I
d +
,
tt t I
w
r } -
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the pr r s~ ~-c 1
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge antljqds ecified in the Wisconsin
NAME (print
/6 ~ G( TESTS WERE COMPLETED O
ADDRESS: 3
c) f v do-J~~, GJ CERTI FI) Y ION BE PHONE NUMBE
~ptionall:
CST SIGNA C/ S J
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
s
CTIONS FOR COMPLETING FORM 115 SRC1 6395
To be a cr curate soil test, your report must include:
i, Compl- ' dal d _ 'ption; commercial project;
2. The, u e on must clearly indicate wheth, its is a or
3_ MAXIMUM number of bedrooms or comrT use pli
4. Is this a r, c rnent system;
S SUITABLE FOR A HOLDING TANK ONLY IF ALL
5. Comp rating boxes. A SF,
OTHER JLED OUT BASED ON SOIL CONDITIONS;
B. PLEASE u. here for writing profile descriptions and completing the plot plan;
y. "kKE n accurately locating your test locations. Drawing to scale is preferred. A
sh desired;
sure yr vertical elevation it point are c ly shown, and are permanent;
e all -ria° Dxes as to dates, names, -_:ldresses, flood h, data, percol. '4 "xernp-
ppropri x;
1 formation (such as flood plain, -tion) does not apply, place N.A. in tI
l fog -1 and place =rl-_rr current t=~ and your certification number;
)pics al' aistribUte ar r cluired, ALL SOIL TESTS MUST BE FILED WITH THE
')RITY' IN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERI : . ) SOIL TESTERS
Soil ,n- and Textures Other Symbols
st ver 10") BR Bedrock
cob C (3 - 10") SS Sandstone
gr _ ( (under 3") L- - Limestone
y,s & - High Groundwater
rand - Percolation Rata
Sand - Well
m« _
1d Bldq Build
Lc my Sand ~ &-a
y Loam Les"
L m Bn Brow
-ilt Loarn BI Black
Silt. Gy Gray
*cl May Loam Y - Yellow
Sandy Clay Loam R - Rest
- Silty Clay Loam mot - Mottles
Sandy Clay wl - with
- Silty Clay fff f.
Clay cc - earl
C'
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CERTIFIED SURVEY' MAP
LOCATED IN THE NEVI OF THE NW4 OF SECTION 18, T29N,
R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN.
Being Lot 2 of Certified Survey Map vol. 6, pg. 1729..
IN CORNER
SECTION 18 N88057103"E N1 CORNER
North n• o the NN SECTION 18 DETAIL
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o ' Tree ocucupies corner.
Ito1 Iron pipe is 3.51 South as
l.G established by Art Nola.
Iron pipe is 8.861 south of
c N8805313911E 1418.141 462.12 protracted line.
South line of.the N of )188°5313!"E
the I of Section 8.
REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 2
07/09/9.2 08:34 REQUESTS FOR INSPECTION WORK SHEETS FOR: 7/ 9/92 AREA: MJ
Activity: A9200172 7/ 9/92 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON 18.29.19.160A,NE,NW,CASPERSON, LOT 2
Parcel: 020-1037-90-000 Occ: Use:
Description: 149326
Applicant: BLAISER, JEFFERY Phone:
Owner: BLASIER, JEFFERY Phone:
Contractor: MYERS, LYLE Phone:
Inspection Request Information.....
Requestor: LYLE MYERS Phone:
Req Time: 15:07 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION ~}5
Inspection History.....
Item: 00012 FINAL INSPECTION
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COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227 4:1:Fr
FAX - 715 - 962 4030
ST. CROIX COUNTY GOVERNMENT REPORT NO.S 53242/01 PAGE 1
CENTER REPORT DATE: 11/29/93
1101 CARMICHAEL ROAD DATE RECEIVED: 11/18/93
HUDSON, WI 54016
ATTNS THOMAS C. NELSON
OWNERS Jeff Dawn Btaiser
LOCATIONS 331 Casperson Dr. No., Hudson
COLLECTORS Jim Thompson
DATE COLLECTED. 11-17-93
TIME COLLECTEDS 3200pm
SOURCE OF SAMPLE: Kitchen faucet
r DATE ANALYZED41I1-18-93
TIME ANALYZE7;2200pm
COLIFORM,MFCCS 0 ,/100 mi
INTERPRETATIONS Bacteriologically SAFE
NITRATE-NS ( 1 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Conform Bacteria/100 ml /
Nitrate-Nitrogen, mg/- y a
CD
LAB TECHNICIAN'# Ram Gay* RESULTS: { ~y
oF•\NDEVENpFHj. FAX'D ON. p
i~. pl.'I F.QY1~ rrn r~K l-lL~,i,r~
WI Approved Lab No. 19 PHONED Ohl: i~f ci
s a CALLER:
a 5~ C Means "LESS THAN" Detectable Level Approved by!
o
PROFESSIONAL LABORATORY SERVICES SINCE 1952
I
. CROIX CO N
WISCONSIN
ZONING OFFICE
Jl
?ST. CROIX COUNTY COURTHOUSE
• HUDSON, WI 54016
- - - (715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
4 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) Septic $25 00~
Water (Nitrate & Bacteria) $35.00 ? Visual inspec ion
Owner: ee r., GaSe-f- Requested by:..
Address: 33 (IaspeEs r; , Address: P.0-5m-861?.
City & State: 5,,~ City & St.~-{r _
, Zip Code: 87401(, Zip. Cade ! ice, ~n
Telephone N4: ( IIS) - saa9 Telephone N°: (`715) 39 - VA T
Property address (Fire N4 & Street) : 3 3 1 a5A.Q sue,
Location: ME Sec. ~g T°I N, R__gLW, Town of GSM Lz'fa
St. Croix Co., WI. Tax 3D N2 Parcel ID N4 von P~
House color: Realty firm: Lock Box Combo:
Water sample taplocation:
C TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH 'OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM
Is the dwelling currently occupied? Yes ❑ No
Q If vacant, date last.occupied:
Septic system installed by: McYtr's fly,. 1, ii -5Year: 72
Septic tank last serviced by: Date:
Previous Owner's Name(s):
Have any of the following been observed?
❑Y 9N Slow drainage from house.
❑Y QN Sewage Back-up into dwelling.
❑Y 9N Sewage discharge to ground surface,
road ditch or body of water.
❑Y ITN Slow drainage from the dwelling.
❑Y W 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: Mal
DATE: )1-~y-q3 poll
~f
at*`
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
4
tfo~s~
IN
(,AtLA6C
pra:hG~cl~
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? ❑Yes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: ❑Below grd ❑At-Grd ❑Mound
Approx. size. 'X ❑Gravity ❑Dose ❑Pressurized
Ft.,. ❑Bed. ❑Trench ❑Dry Well
❑Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other ❑Unknown
Septic tank
Setbacks: ❑House ❑Well ❑Prop. line ❑Other
Dose tank
Setbacks: ❑House ❑Well ❑Prbp.'line; ❑Other
❑Locking.cover ❑Warning label ❑Pump/Floats"
❑Alarm ❑Elec. wiring
Soil Absorption System
Setbacks:_OHouse ❑Well ❑Prop. line ❑Other
❑Ponding: ❑Discharge:
General comments:
INSPECT RS SKET H OF*SYSTEM LOCATION
N I J'/
Gam'
.r
S"
3
0
Inspector
Title
ur~~
i
AS BUILT SANITARY SYSTEH REPORT
OWNER ~j.. ~i`.C f~ / SCE Z TOWNSHIP/./
SECTION-f=Tr' N_R I _W
ADDRESS-I'/ ST.^ CROIX COUNTY, WISCONSIN
SUBDIVISION LOT L I,OT SIZE S/= /1
PLAN VIEW:.
SHOW EVERYTHING WITHIN 10'0, FEET OF A.)( STEM
S CJ4 r-
~r`tz /-~,ptns z~
lLca~G rfz S ,T,
_ A,4L ,7
0z yxyD j i
I
r~INDICATE NORTH ARROW
BENCHKARKO.Elevation and descriptiop:- / Z:,
Alternate benchmark 7~3 c~ ~~)L
SEPTIC TANK Manufacturer:4t ft-r&400 Li Li ~
quid Cap. ,r)&
Rings used:-I.-Manhole cover elevs~dL%,?Final grade a oZ,-
1ev. ~
Tank inlet 'elev.:- i~,. Tank o~;tlet elev.: 9jj. ,~Z
No. of feet from nearest road: Front , Side , Rear L Ft.~
From nearest prop. line:Front , Side L-1, Rear Ft._ e!5=->
No. -of-feet-from: Welly
Building:.
(Inplude this information in the above plot plan)
(2 reference dimensions to septic tank)
qEE REVERSE SIDE
.
ST. CROIX COUNTY
WISCONSIN
N N p p N N p • ZONING OFFICE
p i rrrri
ST. CROIX COUNTY GOVERNMENT CENTER
• 1101 Carmichael Road
Hudson, WI 540 1 6-771 0
- (715) 386-4680
November 18, 1993
Landmark Bank
PO Box 808
Hudson, WI 54016
An inspection of the septic system on the property of Jeff and
Donna Blaiser, located at 331 Casperson Drive N., Hudson, was
conducted on November 17, 1993.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and did
not involve any excavating or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
Should you have any questions, please contact this office.
Sincerely,
James Thompson
Assistant Zoning Administrator
mij
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 22282 PAGE 1
07/20/92
St. Croix County Zoning DATE COLLECTED: 07/10/92
911 4th Street DATE RECEIVED: 07/14/92
Hudson, WI 54016 COLLECTED BY : CLIENT
DELIVERED BY : CLIENT
SAMPLE TYPE DRINKING WATER
Attn: Mary J. Jenkins
SERCO SAMPLE NO: 61782
SAMPLE DESCRIPTION: Blaiser
Sample
4- "
ANALYSIS: 7/10/92 $ 9"
y,:^
Bromodichloromethane, ug/L <0.2
Bromoform, ug/L <0.5
Bromomethane, ug/L (Methyl bromide) <1.0 p".`, N G
Carbon tetrachloride, ug/L <0.2 `0i
Chlorobenzene, ug/L <1.0 s' n"
m N
Chloroethane, ug/L (Ethyl chloride) <0.4 ~s V
2-Chloroethylvinyl ether, ug/L <0.4
Chloroform, ug/L <0.5
Chloromethane, ug/L (Methyl chloride) <0.6
Dibromochloromethane, ug/L <0.4
(Chlorodibromomethane)
192-Dichlorobenzene, ug/L <1.0
(o-Dichlorobenzene)
1,3-Dichlorobenzene, ug/L <1.0
(m-Dichlorobenzene)
1,4-Dichlorobenzene, ug/L <1.0
(p-Dichlorobenzene)
Dichlorodifluoromethane, ug/L (Freon 12) <0.5
191-Dichloroethane, ug/L <0.1
1,2-Dichloroethane, ug/L <0.2
(Ethylene dichloride)
1,1-Dichloroethene, ug/L <0.2
trans-192-Dichloroethene, ug/L <0.1
1,2-Dichloropropene, ug/L <0.1
cis-113-Dichloropropene, ug/L <1.5
trans-1,3-Dichloropropene, ug/L <0.9
< means "not detected at this level". i mg 1000 ug.
Member
i
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 22282 PAVE 2
07/20/92
SERCO SAMPLE NO: 61782
SAMPLE DESCRIPTION: Blaiser
Sample
7/10/92
ANALYSIS:
Methylene chloride, ug/L <5.0
(Dichloromethane)
1,192,2-Tetrachloroethane, ug/L <0.2
Tetrachloroethene, ug/L <1.5
1,1,1-Trichloroethane, ug/L <5.0
1,1,2-Trichloroethane, ug/L <0.1
Trichlorofluoromethane, ug/L (Freon 11) <0.7
Vinyl chloride, ug/L <1.0
Benzene, ug/L <1.0
Ethylbenzene, ug/L <1.0
Toluene, ug/L <1.0
Trichloroethene, ug/L <0.4
This sample's analytical results are ISM,7A!ice, below the U.S. EPA's
SDWA Maximum Contaminant level ofe30/91 for those requested
compounds which are also on the SDWA MCL list.
< means not detected at this level". 1 mg = 1000 ug.
Member
Ar.~
7J SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 22282 PAVE 3
07/20/92
All analyses were performed using EPA or other accepted methodologies.
Samples that may be of an environmentally hazardous nature will be
returned to you. Other samples will be stored for 30 days from the
date of this report, then disposed of by SERCO Laboratories. Please
contact me if other arrangements are needed. This report may not be
reproduced, except in its entirety, without prior written approval
from SERCO Laboratories.
Report submitted by,
Diane J. Anderson
Project Manager
< means "not detected at this level". I mg = 1000 ug.
Member
ST. CROIX COUNTY ZONING OFFICE
St. Croix County Courthouse
911 4th Street
rt,~ Hudson, WI 54016
Telephone - (715)386-4680
The St. Croix County Zoning Office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion g1 this form ja essential z-Q that g property can ka
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING-------------------------- -FEE: $ 35.00
(For nitrates and coliform bacteria) /
WATER TESTING FEE: $185.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION FEE:. $25.00
(Determines if system is properly functioning at.-time of
inspection)
PROPERTY OWNER'S NAME:,
PROP. ADDRESS: CITY
,.Snn Lr -
Legal Description 1/4 f the 1/4 of Section 8, T Z N-R_/j
Town of Lot Number -'~-Subdivision
n2G-~D~~-9p
-
0_1 - L517
FIRE ER
DD
Color of house (A,V) _Realty sign by house? If so, list firm:
PLEASE INCLUDE, IF AT ALL POSSIBLE, A NAP, i.e,COPY OF PrAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individuals uesti services:
Telephone Number
REPORT TO BE SENT TO: P
CLOSING DAT :
Signature
h00 c
L