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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
afandltu o Relations Safety and Buildings Division INSPECTION REPORT St. Croix
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATIONNE1 ,NEI,sec.23,T29-R1 9,HWY. 12 149236
Permit Holder's Name: ❑ City ❑ Village Ea Town of: State Plan ID No.:
Peggy Moelter Hudson
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
t~OA 020-1060-60-000
/
TANK INFORMATION ELEVATION DATA 12
d
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic l,t)e,5 I3re.C4S Benchmark 3.1 jOd"
Do' Aa-. 6,
Aeration Bldg. Sewer
Holding St/ Inlet $,Oz 9CgoXo
TANK SETBACK INFORMATION St/Outlet ' 7
TANK TO P/ L WELL BLDG. Ventto ROAD [lt-Iat
Air Intake
Septic NA Dt Rnttnm
NA Header-RAvr.- S, rf, X ~
Aeration NA Dist. Pipe 9767'
Holding Bot. System 6. T I
F4
PUMP / SIPHON INFORMATION Final Grade
Manuf rer Demand
Model Number GPM
TDH Lift Friction System Ft
Forcemain Length Dia. Dist. To Well
hi
SOIL ABSORPTION SYSTEM
[ PIT No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
BED /TRENCH Width , Length
DIMENSIONS DIMEN I N
LEACHING nu acturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type Of tf. t , CHAMBER Model Numer:
System: lob ~og OR UNIT
DISTRIBUTION SYSTEM
Headerfgffl T T0tZ 1 Distribution Pipe(s) x Hole size x Hole Spacing Vent To Air intake
1~~
Length _COL Dia. ~ length (p~0 Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center 8 Bed /Trench Edges Topsoil E] Yes F] No El Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
- ► c cl, &d<
irrl~n-n ~mayl; c7
C(
Plan revision required? ❑ Yes No
Use other side for additional information. /Q 9SBD-6710(R 05/91) q Date Inspector'sSignatur Cert. No.
x
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER f(c 'I g ( S A ? TOW~SHIP GI S'621
SECTION _T P? N-R~W
ADDRESS GtJ l ST. CROIX COUNTY, WISCONSIN
(7` 6h f
SUBDIVISION LOT k LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
• 100.0. laX~g ~5r,
far _ ~ ~ I rr
►a
POO ~I
fLw i
INDICATE NORTH ARROW
BENCHMARK:Elevation and description:_ 'f0 ,n 72 / n
Alternate benchmark
SEPTIC TANK:Manufacturer:_&t~WPST lr
0 _t
eU;Liquid Cap. /000
Rings used:_~6_Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front X Side c~
, Rear Ft.
From nearest prop. line:Front , Side k , Rear Ft. a0
I
No. of feet from: Well a S'o , Building:, 19
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
~w
II
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 SYSTEM
Bed: Trench: Seepage Pit:
Width: Length o Number of Lines:__2 Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: /g l/
No. feet from nearest prop. line:Front , Side X , Rear Ft.o2aD
No. feet from well: No. feet from building
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: o~ < PLUMBER ON JOB:
LICENSE NUMBER: 3,231
6/90:cj
•~ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT
#
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ EheJ it revisio~previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
P PE TY OWNER PROPERTY LOCATION
10 i~ S T , N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK~~
S J11 -50
C TY, AATE ZIP & PHONE UMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEARE ROAD ^
❑ State Owned VILLAGE : t7y w d❑ Public 191 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL I R( O a0 - (0 tO / ~ O ~
C
III. BUILDING USE: (If building type is public, check all _ that apply)
v
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. New 2. ❑ Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5.0 Repair of an
ccc 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 M Seepage Bed )Ilk b pacify Type 41 ❑Holdin Tank
b%' 6'I 21 El Mound 30 El S 9
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.) PROPOSE (sq. ft.) (Gals/day/sq. ft.) (Min./inc) ELEVATION
- 1A
to D I S -7 % , Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank Iwo r vi es f-e
-xi- Lift Pump Tank/Si hon Chamber El I L1 El F-I I El 1-1
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plu Signature: (No Stamps) MP T No.: Business Phone Number: lo? olac_~ -4 1 MOA-A l4f I
Plumber's Address (Street, Cl ,State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial
D rmin ion ~f
Advers
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber
S T C - 100
This application form is to be
completed
1
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.
-7--------------------------------------------------
Owner of property
fktt i 1GC` 0 )ki
Location of propertylLF 1/4 4,F 1/4, Section J~ Td /
N-R~W
Township
Mailing address
/ ~C21,
Address of site
subdivision name Lot no.
Other homes on property? j yes No --7- Previous owner of property 1J'
Total size of parcel A o GQ I -
Ie a-tom
Date parcel was created
Are all corners and lot links identifiable? -L-Yes No
Is this property being developed for (spec house)? Yes _No
Volume ~4fiand Page Number as recorded. with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & 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 recorde in the office of the County Register of
Deeds as Document No.~/ ~jj and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the ruction of said system, and the same has been duly
r corded 'n the office of Cou y Register of deeds as Document
o.
I
Signat a app 'cant Co-applicant
Date of Signatu a Date of Signature
W w
f 4
DOCUMENT NO. STATR "19 bT Vnewaim VORM 1-sm TMs epaee 011"1Wi0 Fee
ffiksob
43,'75 y.' REGISTEIce OFFICE
46
d brt nvu S' CROX r
This Deed. made
Michael J. Lund and.Jane.E._Lund_ R
husband and wife . -
t~;,v 151990
..r Grantor. 41 1:50. P.• M
and Peggy Marlene. .Moelter.. and.. .Paul. Wx.lli~t.... ~
.
Gunsallus V
Ib~rolOmi
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration.....
oix. Robert Mudge, Esq.
cones; : to Grantee the following described real state in . C r 110 Second St.
County, sate of Wisconsin: P.O. Box 802
Hudson, WI 54016 a
A parcel of land located in part of the
SE 1/4 of the NE 1/4 and in part of the NE Tax Parcel No:
1/4 of the NE 1/4, all in Section 23, T29N,
R19W, Town of Hudson, St. Croix County,
Wisconsin, described as follows: wa
Commencing at the El/4 corner of said Section 23; thence 7
N00°41'45"W 692.92 faet alorg the east line of said NEl/4
to the point of beginning of this description; thence
continuing NO0°41'45"W 779.81 feet; thence S82°30'23"W
408.19 feet along the southerly right-of-way of U.S.
Highway "12"; thence S00°41'45"E 724.78 feet; thence
S89°44'45"E 405.38 feet to the point of beginning. Containing
7.00 acres and subject to all easements of record.
s 3_M
- rhis homestead property.
-OW (is not)
Tot.•ther with all and singular the hereditaments and appurtenances thereunto belo Igulg; Wt
An,l Michael . J.... Lund. and Jane E. Lund, husband ands wife
warrants that the title is good. indefeasible in fee simple and free and clear of encumbrances except
all easements of record, if any s
and will warrant and defend the same.
!rated this I day of November 1990
(SEAL) _ASEAL)
• Michael. J. Lund
(SEAL,) (SEAL)
• Jane E. Lund
AUTHENTICATION ACKNOWLEDGMENT
Sitmatn-e(s) STATE OF WISCONSIN
•
ss.
.
St.....CLOlX County.
authenticated this ........day of..--....... , 19...... Personally came before me this ................day of '
lbWvi IIIber............1 199Q... the above varied
.Michael...J....:Lund..a.>~d-..Jane-.-E•.;.-Lund,
. _ _ - - husband..azu: wife
TITLE: J1i:V11:1:K STaTF: BAI{ t)F Wl~t'OJTRI V
I If not. ~y
authorized by to my Ltf3g n o be to i;xecuted the
fupr~oin~,In um~• Id klio lcdt;e me.
Mulligan & Bjornnes (JMM) ,p b rn
401 Groveland Avenue rT w 1 0 ~O
T , je
Minneapolis.r " . MN-. 55403-329.2...... Notar•: Public S CIl?f X ~..'Courite, WIS.
, \1 E' rani ,it n t... (i f nor,, jwte expiraioq
(Si:;natnro~ "lay he ;%0hentic,,tc•d or :,,+.now•ledi;ed, Luth lwrntw
ere not nvt(-~rary') dltc•'
•Na,tnnt of Vnrnuaa ,irr.inv, in .n; ratr ,t, 1 L- t.;. prin'.,1 1, th.•ir -.K rat.uc•.
1
:.W AN r)' DI" ;J a+lAfC Ir.\i: 1.1 n t\
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Lzj,:',LX, S' T -
ADDRESS: FIRE NO: ~LOCATION: 1/4, 1/4, SEC. T ~ N-R / WW
TOWN,
OF. ST. CROIX COUNTY-/X-_
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 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 withi_n-----3D--- ys of the three year
expiration date.
SIGN a
DATE : I
99/
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
DFDUST OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
-INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TLOT NO.:BLK. NO.: SUBDIVISION NAME:
NE '/NEB/ 23 /T29N/R19E(or)W HUDSON l!/ lllJ/Jl/ll/lllllll!//
COUNTY: BUYER'S NAME: MAILING ADDRESS:
ST. CROIX EGGY MOELTER/PAUL GUNSALLUS 1411 WI ST. N., MMSON, WI. 54016
USE PHONE 386-7750 DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
®Residence 4 New ❑Replace 110-9-90 10_1190
RATING: S= Site suitable for system U= Site unsuitable for system Burkhardt sandy loam BrC2 p. 58
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
®S ❑U ®S ~U ®S ❑U ~ S ❑U ~ S conventional
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: n /a I Floodplain, indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 102.0 r none > 102, 0 l'Bksl 2.3'Bnsil 1.41ftsl W/ cob 3.8'Bnms.
B- 2 100.8 102.3r none > 100.8 .8'Bksl 2'Bn/Y wit 1'Bnls 4.6Bnms.
B- 3 80,3 100.0 none > 80.3 .8'Bksl 1.3.'Bnsil 1.4'Bnsrl.3,2'Bnms
B_4 86.4 100.6 none -.;,86.4 .7'Bksl .4'Bnsl 1.51Bnssil 1.1'Bnms w/gr 3.5'Bncs.
B- 5 114.0 103.0 none > 114.0 .9'Bksl 1.5'Rdls w/gr 4.3'Bnes 2.8'Bnms.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER I b-5-T- PER INCH
P- 38 none 3 .5
P-
P- 4 46 none 3 greater titan 6 drop during
P_ three min to period.
P- 5 74 none 3
LP_L i d-
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 96.8' Hy 12
,
S_ I SC4E lot! 1 ~ e .
. Li>~e__
fence. I k s BM, j assume 100.0 en
topj ofI metal pipe.:
ti
laoring. ~ r
I t
p
- i I
~ ♦ purvey, stake for SW._c~ar~r~_
t F
_ _ _
a
E
,F 171~
ofi;- E
T
s o - IE1~Zi~fAlt _ _ .
44
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(BUT'
47 i s
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wi onsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
I
NAME (print): ° TESTS WERE COMPLETED ON: F. FMIEWY Licensed Perk Tester & Plumber 1=1Z,gO
ADDRESS: RO @03?33 03289 /ty Heights Road CERTIF7CATT~N NUMBER: PHONE ER (optional):
S, WISCONSIN 54023
BERP o
ne 749-3656 c N
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
fel 11 ire 11tr
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1414E d 3 7'c29 41 R114i l f
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