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020-1262-30-000
o ~ ~ II ti . p °cn ~ I N h O a i I O O N O I tl C r I ~ I z c c U. o Q I ~ I N I Z W ~ Z I ~ I O C'j M W d m N I- (n O C a U O 2 a c 4) Z a c z N F r O c E v a ~ M I N fy/J C C C y O Oc O Q O N C O a Z co O c z N _ a .y. d n. N 2 N C m I O d ~ y ~ C d' O LO) aa) cO a 0 d p N C U) U) V) E ~e if N S0 a O p Z ~(L aa CL c o o m J U rn rn } O ) a N M° ti:i 4) E a~ m C a N a N N N .0 d Q } (n l0 LO N LO N a 4 O° tl! C E v O ° n o m o o rn o 0 C-4 C? ° r a c a o o r\ ~ ° N o f c 0 v o co v 'yam„ co co c cam' v n in ~ 04 n L of of cl) a ai c d CA -0 0 O N 2 fn co O Z c cn O = E m m a 5 a a • a m E c c r A c°~a2 ,Oaic°~ - t Parcel 020-1262-30-000 01/10/2005 04:55 PM PAGE 1 OF 1 Alt. Parcel 20.29.19.1270 020 - TOWN OF HUDSON Current 0 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * LAFLEUR, CHAD R & VANESSA J CHAD R & VANESSA J LAFLEUR 855 LASSIE LN HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 855 LASSIE LN SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 2.000 Plat: 2319-PINE GROVE HEIGHTS 2ND SEC 20 T29N R19W 2 AC PT SE NE LOT 25 Block/Condo Bldg: LOT 25 PINE GROVE HEIGHTS 2ND ADD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/07/2004 768076 2611/228 WD 02/19/2003 710363 2147/256 WD 07/27/2001 652208 1688/178 WD 01/05/1999 595044 1392/564 mW D 2004 SUMMARY Bill Fair Market Value: Assessed with: 49310 240,300 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 30,000 155,900 185,900 NO Totals for 2004: General Property 2.000 30,000 155,900 185,9000 Woodland 0.000 0 Totals for 2003: General Property 2.000 30,000 155,900 185,9000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 502 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges 00 Delinquent Charges 00 Total 27.00 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT, Sjy,!k,, xw' TOWNSHIP,,' -.u X Say SEC. 2L T O9 N-R1,.W e t° U ADDRESS ~,~5~ stl~J~ KCc ST. CROIX COUNTY,' WISCONSIN L1=lG_ ~ a J T ~o r l (SUBDIVISI'ON? j.LtL LOT _ LOT SIZE ACss2. PLAN 'VIEW + Diitances and dimensions to meet requirements of ILIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM dT/ , i •G'. iC ~$i :k. a ' t yd.'s ,x0,,4 C4 i INDICATE NORTH ARROW • BENCIHIARK: Describe the vertical reference point used arm-C r r Elevation of vertical reference point: I)A' Proposed slope at site: n ' SEPTIC TANK: Manufacturer: 'C eAQ4Z fLiquid Capacity: led, _j~a r~ f rings used i: 'Tank manhole cover elevation: 79 as 40.,..-..Tank Inlet Elevation:' Tank Outlet Elevation: lv pool pa ctai ndg y Number of feet from nearest Road: Front, Side 0Rear, 0 /D0 feet From nearest-property line : Front 10Side ,oRear,0 27" feet Number of feet from: well building: i/~ (Include this information of-the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE I PUMP CHAMBER/- ManufacturersLiquid 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, 0 Side, 0 Rear, © Ft. 'Number of feet from well: Number of feet from building:_ (Include distances on plot plan). SOIL ABSORPTION,SYSTEH Bead: K Trench: Z Area Built:(~:'.Zq Width: Length. 5-Z -Number of Lines: Fill depth to top of pipe: Z Number of feet f. m nearest property line: Front, O Side, Rear, It. ' V_V 0 (Number of feet from well: ? S;D N `er of feet from building: (Include di Lances on plot plan). SEEPAGE PIT A)I,+ Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 00 or distribution box 0 been used on any of the above soil absorbtion sytems? (C"eck one). HOLDING TANK Manufacturer: Capacity: Number of'.rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property lines Front, O Side, O Rear, OFt. Number of feet from well Number of feet from building: Number of feet from nearest road: Alarm Manufacturer Inspector:. Dated: 9 L9Plumber on job: , 44 License Number: /Ne5l~3a ~Z 1 l i 3/84.mj t V -~EPATMErNT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING + DIVISION LABOR & HUMAN RELATIONS P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION X7071 9w State Plan I.D. Number: 41V'r+CY"hL JU~• LN7W (If assigned) Town a6 Hudson CONVENTIONAL ❑ ALTERATIVE Lot #25 Pane Gttove H 019w Ate. ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: R.i.cha&d 0-Stout 1353 Awa tukee Tttait RE ELEV. BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST V. r Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Jahn P. S ko a III 3212 St. U0.4X 135455 SEPTIC TAN o ~l ' MANUFACTUR R: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: 5 / GIJD f ~j, Ci7 / JOS. / YES ❑ NO BEDDING: VENT DIA.:. VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: , r AI ~Er: ❑YES NO fif0 NEAREST-11111- yob DOSING CHAMBER: WARNING MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: PROVIDED: pROVIDED:OVER ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH FEET FROM AIR INLET: (DIFFERENCE BETWEEN PUMP ON AND OFF ❑ YES ❑ NO NEAREST -I LENGTH: DIAMETER: MATERIAL AND MARKING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into ire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH LE GT NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PI ~ S: ABOVE COVER ELEV. INLET ELEV. END: PIPES: FEET FROM LINE: / / AIR INLET: MOUND SYSTE Mound site plowed perpendicular o Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: RENO LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: WIDTH: LENGTH: N TRENCHES: BED/TRENCH DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST ~(,Q~6«, 17 ain in county file for audit. Sketch System on T rLE: Reverse Side. SIGNAT RE: . Zoning Adminizt&atah SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION , ff[LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY • STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than (v /'a .3 - y J~5__ 8% x 11 inches in size. 1161 Check if revision to prevwus 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 .S '/a E'/a, S 20 T27, N, R 1 E (o W PROPERTY OWNER' MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER AAA.s6,4, S"i u I (o 7/5 g4_73) Pwy_ e-v'e. II. TYPE OF BUILDING: (Check one) ❑ State Ow CITY NEAREST ROAD ned VILLAGE s~ ❑ Public ~1 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) L I Z-7 0 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. X New 2.E] Replacement 3. ❑ Replacement of 4.E] Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) r;uq A Sanitary Permit was previously issued. Permit ?a.S 'SL3Cd 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 140 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 ji 5c) Co/ S' zq i 2 feet /6,5- Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Hold! n Tank 60 ukgks i Lift Pump Tank/Si hon Chamber El I F1 I F1 I F1 Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) M PRSW N- Bess Phone Number: -`7~9`f g ~ r (S 5( 3 Plumber's Address (Str , City, State, Zip Code): e-- L Z -757 `8 Z ~a~ :3 _r IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial ri ~urcharge Fee)' O ~G 9L?Z4je' Adverse Determination 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 r' 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; (lose volume; elevation differences friction loss pump Performance curve; pump model and pump manufacturer D) cross section of the soil absorPlion system if requited by y 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. i SBD-6398 (R.11/88) ~ " ' I . i • ~ ~ ; DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1988 THIS IFACa R=VtV= FOR RECORDING DATA j ' WARRANTY DEED. i ~1~ia"`t : - 68Q 'lilt(r 52 JIGE 15n - RMSTERS OFRCR 'j'hiB smahe George J. H. Gies and CROtX 1fVlSw is wff • ST. Jean DorwineGi~ !i Reed Ax•Re00rd IH: 29th Grantor, j' ~y ~=A.a 19 86 . and......lti ck~a>~d.4,...Si 4u _ and_.~anet, P, - Stout i~ 9:30 A. and.,y~ fe„as,-joint-,tenants,-as- to„a„70%„ interest.;..and..._._.. Ij • .Maud..H~..Si:au><..as..Sala..Qxnax..Qf..a..~QX..Ia~taxa$ ;i @@BMW of 911810111 Granteep•'.~ Witnesseth, fihat the said Grantor, for a valuable consideration...... i j RLTYRN:TO._..,---•--.,..__._.._ conveys to Grantee the following described real estate in . tt...QK9..K ~ County, State of Wisconsin: All that paitt of the NEk of the NEk lying Southerly of - the railroad right of way; Tax Parcel No:........ The SEk of the NEk; The NEk of the SEk; All in Section 20, T29N, R19W; I SUBJECT TO all existing highways, platted roads and easements of record. EXCEPTED FROM THIS DEED are all parcels of land previously conveyed in part performance of the land contract referred to below by deeds of record. jl This deed is given in final performance of the land contract originally made by George J. H. Gies and Jean Dorwin Gies, his wife,'as v s and Robert L. VerDugt and Betty Jane VerDugt as purchasers, the purchaser s interest in said contract i; having been assigned to Richard 0. Stout, Janet P. Stout and Maud H. Stout. it The original land contract was recorded in the office of the Register of Deeds for St. Croix County, Wisconsin August 18, 1975 in Volume 52t, Page 271, Document 0328700. The assignment was recorded in the same office on September 30, 1982 in Volume 652, Page 447, Document #380015. TWSFM , This ..:......A,.8 .A Q.t homestead property. rnk Para s. ( (is not) Together with all and singular the hereditainents and appurtenances thereunto belonging; FU- And ..---......(i~4JC8~..>I.e..11<....tzigs-. 4A?4-. jean .1?9.rVA 1..~~:.4$.•.. ),1 f.r r warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except i, easements and protective covenants or restrictions of record, if any; conveyances, liens or interest created by the act or default, if any, of the grantees, and will warrant and defend the same. lot August 86 Dated this day of 19......... (SEAL) (SEAL) ; . . George J. Gies (SEAL) ~f (SEAL) Jean Dorwin Gies AUTHENTICATION ACKNOWLEDGMENT 'T'-"' -Signature (s) George J. H. Gies and Jean STATE OF WISCONSIN Dorwin Gies, his wife as. i ~ August ......................................County. auth ated this Y., &y of 19.86 Personally came before me this ................day of U 19........ the above named • .ohn D. HeVwood TITLE: MEMBER STATE BAR OF WISCONSIN (If not . authorized by 4 708.08, Wis. State.) to me known to be the person who executed the foregoing instrument and acknowledge the same. , THIS INSTRUMENT WAS DRAFTED BY ( Heyw4Qi~•.. .A..gherburne &..Sherbu P. I 0. Box 229, Hudson, WI 54016 • Jotm-v; ' Heywoad...................................................... Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary) date, pds 19.........) *Memo of persons signing in any capacity should be typed or printed below their signatures. STATE BAR OF WISCONSIN J DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSYRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 HUMAN RELATIONS ILHR 83.0911) & Chapter 145) LOCATION: SECTION: OWNSHIP/ UNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION NA E: '261,111- 5 NE'/4 ?0 /TZ"A/RRE (r) W :N COUNTY: j MAILING ADDRESS: t cco r jK_ L Pal t / e5s tom, ; AU /,U 60, 16 USE / 7 DATES OBSERVATIONS MADE NO. B MS.: 1COMMERCIAL DESCRIPTION: 14/4 77474 ESTS: PROFILE DESCRIIPTIONS: Residence New ❑Replace P70 P 6 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: ~N-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:loptional) ZS DU ®SOU NS❑U DSCU OS [MU a" e a R If Percolation Tests are NOT required DESIGN If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indcate: N/T041-- 1 E: I Floodplain, indicate Floodplain elevation:` PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES I HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- /05'x'' h0 t4 > 84 C3'~ 8 t(scV~ 8t 19'A'.S;J /Q `'8e1'V14 cs d-. B- ? $4 /05 h b 4.,,C y 84 .,10l f let so l 1-s B-8 /0~'0'' hbti~ } So 'T 0'.6. sal L41`= v' f. B- B- B- PERCOLATION TESTS TEST DEPTH , WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. -PERIOD 1 PERT D2 PERIODU PER INCH P- P- P- 3/ Y 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. r~siua BA44~_?_ ifs i c ~ / fit. s '0 1► a *41), CC, E i N . - ~N i W 10 RIP, f 3 E R` r~l ~rp~ u•d. I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and meth rRMRMIsconsin 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): TESTS WERE COMPLETED N: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): t Q` f8 t\ W- Z a ^T ~l Z -Z_-1 CST WIGATUERE- DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 1 DILHR-SBD-6395 (R. 10/83) - OVER - J INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 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 number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE 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 LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sI - Loamy Sand - Less Than '1 - Loam Bn - Brown 'sil - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. e f* Gad r C~ -pl6 + C;IZ0 s~vNo~ o~ + I I 1Z~ ~ bed I P {~cu.s I ~ 5:T I Q -mo o o G? ssw...c~.t /6 Lo ol. PI C- s 1 4 r REPORT ON SOIL BORINGS AND SAFETY & BUILDIN S DIVI ON PERCOLATION TESTS (115) MADISON 60 53707 ~ (H63.0911)& Chapter 145.045) L CA I ION: TOWNSHIP/MUNICIPALITY: OT NO.'. LK. NO.: SUBDIVISION NAME. NW 14NW)/ 19 /T25 NIN 7 E GOURMET .A, A. .A. COUNTY: W M CLIFFT ORODNEY GRANGER P.O. BOX 39B, OXNARD, CA. 5891 U DATES OBSERVATIONS MAD C -15 RC IAL PROFILE DE IFTIONS: N: A STS: Np, Q stdence 2 N.A. Now ❑Replace 5/30/82 5/30/82 RATIN S- Site suitable for system U- Site unsuitable for system VS Maoptionall ll VEN 1 NA MOUND: IN-G - -FILL OLDING TANK: RECOMMENDED S TIONS 1111 ®S ❑U ❑S OU 51S 0U I ❑S X SYSTEM IN FI If Percolation sts are NOT required DESIGN RATE: If any portion of the tested area i0l". the under s.H63.09((b), indicate: N.A. Floodplain, indicate F loodplai elevation: N.A. PROFILE DESCRIPTIONS 80RING TOTAL UN WATER-INCHES CHARACTER O SOIL WIT HICKNESS, COLOR, TEXTURE, AND DEPTH NLMABER DEPTH IN. LEVATION OBS V O TO BEDROCK IF OBSERVE ISEE A88RV. ON BACK.) 0-6 8 s, - n me s, B- I 81 9 67' NONE 43 43-81" Y Bri med w/R mot U-7" I is, - n me s, B.2 81 99. ' NONE 49 49-81" Y Bn d s w/R mot B-3 77 99.42' NONE 43 0-7" B1 15 7-43" IS, 43-77" Y Bn med s w/R mot I 8_4 49 99.58' NONE 48 0-6" Bl s, 6-48" Cs, 48-49" Y Bn med s w/R mot 0-6" B Is, 6-47" Bn med s, 13•5 55 99,50' IkPNE 47 ' B- PERCOLA ON TESTS TEST DEPTH WATERIN HOLE EST TIME L V H RAT MINUTES R PER INCH i NUMBER INCHES AFTER SWELLING IN RVAL-MIN. p t P -_,00 2 PER P= 2 P. 2 24 N .66 2.66 2.66 75 P. 4 NO t. 66 2.66 2.66 5 P- P• P- _ PLOT PLAN: Show locations of percolation tests, soil burin d the dimensions of suitable soil areas. Indicate sale or distances. Describe what are the hori- zontal and vertical elevation reference points and show 1 tion on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. ' SYSTEM ELEVATION 98.92 i '285' I 8M = 100.00'•-TOP OF STEEL SURVEY STAKE I 30' LESS THAN lx SL I OPE IN ARE NO SCALE I 9' 80 80 , p3 CP*---- 60' I t N 135' - IB3 18, 4' 6491 ST ° B1,P1 I STREET PROPOSED HOME 75' B41P2 WELL I - - - LBOURNE TERRACE AVENUE - - 1, the undersigned, hereby certify that the soil tests reported on this form were made by mein accord with \pro a 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 kelief, ,S NAME print: TESTS WERE C ED ON: PATRIK L. "NDARKOWSKIVICH 5/30/82 ADDRESS: CERTIFICATION NUM R: PHONE NUMBER(OptionaW 34856 S. LAND DR. CIRCLEVILLE WI. 53421 SS-7 5213 T E: t i DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester. z DILHR-SBD-639S IR. 02/821 - EXAMPLE 28 - j f r 'DI=~R7MENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: SEA, CdE , Sec. 20,T29-R19 L~ (If assigned) Town of Hudson VENTIONAL ❑ ALTERATIVE T ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound J AME •F ER I L ER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Richard Stout 1353 Awatukee Trail, Hudson, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: John Sykora III 3212 St. Croix 135436 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST---* DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES El NO Y: PUM ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) 1 ❑ YES ❑ NO NEAREST 111111- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST 0- MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST----* Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION ~fLHR COUN In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Check`IfreGision to pre ous 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 ( b E'/a)V%,S T2q,N,R C? E(or W .L tA 1), Si7 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # J CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE ; O Lo;ssl a 1_&t40_ ❑ Public X1 or 2 Fam. Dwelling4 of bedrooms .2L PARCEL AX NUMBER(b) III. BUILDING USE: (If building type is public, check all that apply) r 2 `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. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 M Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE 4150 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gal /day/sq. ft.) (Min./inch) ELEVATION / jd/'c 3 f) 0~ Feet J~ • Feet CAPACITY Site Fiber- Plastic Exper. VII. TANK in allons Total # of Prefab. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete structed Con- Steel glass App Tanks Tanks Septic Tank or Holdin Tank 0 o Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) Mk/ SW RN Business Phone Number: se-t Z_ Plumber's Address treet, City, State, Zip Code): Z Kf~ &0 Y, IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination ` 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 ` r 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 116 form; and F) all sizirkg 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) In accord with ILHR 83.05, Wis. Adm. Code COUNTY ,3 1LHR SANITARY PERMIT APPLICATION .a . = I , TE SANITARY PERMIT # 14 -Attach complete plans (to the county copy only) for the system, on paper not less than 57A 8% x 11 inches in size. El Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION '/4 '/4, S T , N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ) ❑ State Owned ❑ VILLAGE ❑ Public CJ 1 or 2 Fam. Dwelling-# of bedrooms PAR EL TAX NUMBER( III. BUILDING USE: (If building type is public, check all that apply) , 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill V1. 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 Feet Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed I Septic Tank or Holdin Tank F] I D_ F1 Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 2, ob, CoZ `t~ -s 1 i z- 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'f2 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 an8 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) s, s ~ 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/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 L- Location of property ,_1/9 1/9, Section T~_N-R-d-W Township :56js.1 Sn A - Nailing address 3 A wc Y' Address of site / P_ ~sc~2~'~cs~.twrll.Scsu uL11~ (o Subdivision name P 0e- a" Ve_ _40.Q6+r_ ~Auck- j adif1AVI Lot number `J Previous owner of property L-0. a p e? Total size of parcel ! Gt,Gf`e_S ~ Date parcel was created ~A - l9 /97 Are all corners and lot lines identifiable? V/ Yes No Is this property being developed for resale (spec house)? es No Volume Z and 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, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. Z//t_1Z'~ -7 ; and that I (We) presently own the proposed site for the sewagee di al system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been it ecorded in the Office of the County Register of Deeds, as Document No. Signature of owner Signature of Co-Owner (If Applicable) 3f~o(ge Date of Signature Date of Signature v I I DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1988 THIS sFAca Rasawso FOR R[cORDINO DATA i i WARRANTY DEED. 4 i ~1 B84X .32%E Fill__ ' - PrOSTERS OFRC@ This ~De d made betWg~1 George J. H. Gies and ST. CROIX QO. WI& Jean DorwR ~i~s, his Me 29th Read for. Rewrd d>tb_ • dayof __Lug. A.a t 9 86 Grantor, tor, li and...... Ai chard. 0,_--Stout. and. Janet. P, .Stout,,. husband„- i, 9:30 A. -And -wif e..as.. joint tenants as to a 70X interest and ~j Maud..H,...S>:QUz..aa..aQle..Qlmix...Q f...4 ..VIAmtrxP$t 'i seema of book i Grantees, I Witnesseth, That the said Grantor, for a valuable consideration...... j~ ii conveys to Grantee the following described real estate in .Att...GK4L.A RETURN TO ( i County, State of Wisconsin: I I~ All that Past cif the NEh of the NEB lying Southerly of - i the railroad right of way; Tax Pared No: The SEk of the NEk• The NE44 of the SEh; i All in Section 20, T29N, R19W; i SUBJECT TO all existing highways, platted roads and easements of record. ii EXCEPTED FROM THIS DEED are all parcels of land previously conveyed in part performance of the land contract referred to below by deeds of record. ~I This deed is given in final performance of the land contract originally made by j George J. H. Gies and Jean Dorwin Gies, his wife, as v sand Robert L. VerDugt and Betty Jane VerDugt as purchasers, the purchasers interest in said contract having been assigned to Richard 0. Stout, Janet P. Stout and Maud H. Stout. The original land contract was recorded in the office of the Register of Deeds for St. Croix County, Wisconsin August 18, 1975 in Volume 52't, Page 271, Document #328700. :The assignment was recorded in the same office on September 30, 1982 in Volume 652, Page 447, Document #380015. 97 or pit T WSFRR._. This A .AIM homestead property. p (is not) 1 to t Together with all and singular the hereditaments and appurtenances thereunto belonging; FEE ! And........... CiJqQx$e_. T.e..e.. GieB-_ and. Jean ilgrwin. Gibs....tiS..wile. A41 that the title is good, indefeasible in fee simple and free and clear of encumbrances except i easements and protective covenants or restrictions of record, if any, conveyances, liens or interest created by the act or default, if any, of the grantees, and will warrant and defend the same. 1St August 86 Dated this day of 19......... ----•-••----.....•........•--••-•-•----•-•-..•--•..(SEAL) (SEAL) George J. Gies - _ SEAL) " Jean Dorwin Gies AUTHENTICATION ACKNOWLEDGMENT " George J. H. Gies and Jean " i Signature(s) STATE OF WISCONSIN Dorwin Gies, his .wife . . ge. County. auth ated this --Y.,l&Y of.... August........., 19.86 Personally came before me this ................day of 44 v , 19........ the above named _ohn D. Heywood TITLE: MEMBER STATE BAR OF WISCONSIN (If not, . authorized by $ 706.06, ~WisState.) - to me known to be•the person who .executed the foregoing instrument and acknowledge the same. i THIS INSTRUMENT WAS DRAFTED BY i HeY3!C444'la..Cais.:Murray Sherburne . P. 0. Box 229, Hudson, WI 546i6............. " John-V;---- 'teywovd•---------•------.........--- Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) pds date:..... 19.........) *xames of persons signing in any capacity should be typed or printed below their signatures. BTATB BAR OF WISCONSIN 1 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWN UYER 5~- ROUTE/BOX NUMBER / 3a 3 24.) Le -E u~c c I FIRE NO. r1 a "t. -+a CITY/STATE &Ar-6, IAJi . ZIP mi ai (o PROPERTY LOCATION:1/9 IVE 1/4, Section, TN, R-6--W, Town of ~S~~t , St. Croix County, Subdivision / ILtP. ~u'~P yp4( 3:sJLot 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 for a MAXIMUM of $3000 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 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 form 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 Department 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. SIGNED IR4 JA DATE 316p19u St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address L ~UEPAFi° MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS NPUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WOI 539069 ` HUMAN RELATIONS f ILHR 83.090) & Chapter 145) LOCATION: SECTION: TOWNSHIP MUNICIPALITY: OT No.: BILK. NO.: SUBDIVISION NAME: ? E'/ NE 1/ ,z0 /T;6N/R19 E z 51-- f Gm MAILING ADDRESS: COUNTY: ,gyp si: GroI WA e- A a/ t `f9z 44r)e lame. 77 ~Sve wt. ~J'~~l (p USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: Residence J/4 New ❑Replace I ESTS: RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMEN ED SYSTEM: (optional) ES [:]U ZS ❑U ®S []U ❑S [JU ❑S ®U C6IAVe141hKQ( If Percolation Tests are NOT required EAS5. IGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: ar i I Floodplain, indicate Floodplain elevation: ►V At PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- /00 a-(o'~~I Sil Ts ~''z9"~I s~l~ Zed`vDoBhC S~ fJ; B- 2 60 /05 /S-4/ 11Ov11 ' l d0 a (91 S41 TS fc`~Z t s zsy/80`'RN C'S.-+sn B- 10.-ja s--J, B- 'St 8 0Z o iv VV E - 3 1',- / - v / ~r~~Cola i Nil `Ts/ 6"2'}" Ba B- PERCOLATION TESTS t TEST DEPTH WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES t NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 PERIOD PER INCH P- P- K A J' a tt,tiM1 Rein, a P 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. 77`/D'y ADz'0 side 9 /0/ `0" 4/te,"AIE(-& 99 o`/ ~ w ~l L E P_Z, s~ -4- 7~ E E suL Ie 1 , i j 1 t _2 0- s i /A L4 i ~04 4 Q" La t I 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 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): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional : #-Z 715 506 --P~4 CS SIG AT DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395, To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must cleacly,indicate whether this is a residence or commercial project; - 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; `5.; Complete the- suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK. ONLY IF ALL OTHER SYSTEMS ARE 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 LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired;, 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; - 11.- -Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. r ABBREVIATIONS FOR CERTIFIED SOIL TESTERS I , Soil. Separates and Texfures Other Symbols st - Stone (over 10") BR - Bedrock SS - Standstone - cob - Cobble (3 - 10") gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate mods Medium Sand W - Well fs' Fine Sand Bldg Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand - Less Than 'I - Loam Bn - Brown Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay ; w/ - with j sic - . Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm Many, Medium m - Muck d - distinct a p - prominent I HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point TO THE OWNER: r This soil test report is the first step in securing a sanitary permit. The county or the Department may request l verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary I. permit must be obtained and posted prior to the start of any construction. i REPORT ON SOIL. BORINGS AND SAFETY & B bl °SI~OI~V ` P.0 SOX 7%9 err , ' txrO~s R 0 A 11 ' STS, (115 } nnA©rso,v, wi 707 r:ar:t ar.3r f ~ VW_TFAWTY: T NQ. SM- UBD VISION ALI` AT'Ef3 OSSERVATIOT4 MADE Now" PRoWoce'll 71 SmSite suitable for system Uft Sits uy►suitable' fot systertr r es" t N L: MOUN 1Kt~ L l N ~A EGOMM o s EE A71:(~spt►tarlet! S S Ot S r4, Cft +tion Tests are NOT required DESIGN RATE:: w ft' any pottfori"ef the tesitet}arifa +3 in Ole l.NR 8~:09(511b),indiCaie: ' 1=fAutdflla?tw'ioiobie Floodf]Wtg sllvmiQA: 4 ~7+gf. ttfiC?Fll,"1ESG`F{t~lii > EL VATId R k f[:;.. S~.t;b1 X AND DEPTH V f a A EI7 ABgk3v. aly eAG V P Or:A~`rt w TUT fMf - RATE MINUTES -IN WATER LEVEL1 Hes DEPTH,_ WATER IN 14OLE "TEST, T INC - ES AFTER 5tli? LIN f f{iI{1L PE i 9 Gii ENs o1gov lbcatiiuts df 416rcolafian tests, tof4 boi)np Mnd the dirrrEnsiorrs of suitable snN areas. fhdicat* scale or disbm4:es.,Dg9&fbe who Ora tM hori- l vdrti. efvvatiort referetree points and show theirbratit7n on, the ;pfoE;plfrt. Show ,the surface elevsttdn at all borings arxf thv,dirwctiot►.and ptrroei~i, X f ~I ~Mp~ro TIM 74 xi" i~~ Iq.. ~p ,I ,I I~++wl~ P } ~ti f t' } 1 f }yam ' ± x eraiprsbif, her~fxy ert+yV th$t the coil cfldSls ieparTeii on th's forrri were triad dy me iri atcoid wKh iht protedutes anti rrttlthor}s specified in ter! ~Afisc_"m stitT Gbkle, rtrtd tfwt thb dita rrcadttif ar%a tfie socetitsss ol`thf tests 9f! t~irmci to the treat n lhy kncivVl3geAtf'ttie# ' PL p oom . IFi @ HONE NU BM W io .MqT A: 54 4 4. 3T40441~b mai arm true icpoV-tq Loot, ~Authon i~r Ov+ +f TfBxer rS tY. betty pet,antr ,I l~ j 1. ad C JJ 3L~y 41 ~t i '16 p ~,4 s ~R It, h ' t IF z } b ~ ;may y n` b r'~l' r h L' 1 t' ~1 T, t yO ~,y y 2V 's cto % 1 W401A z i-,.cA s..,n, 761ZIA. s p S-'7`, C"6( Ca"-J' PIL-)f ~lacw e J:j~- - - 194 pe apa v~ 4 1-4t4d t Grs1jp u! M t' A S> /W J~ dap ct- I ' 1012- C Al L net,! S P~G~. ~~wc~e~~C - ccl( Ot-L al td's ~6• 04e i C6 ~ C-0 A 2. Installation evaluation. Department staff shall randomly check ' 10%, of all alternative private sewage system installations, and a mini- - mum if possible of 5 per county per year to determine if the system was properly constructed. . 3. Continuing inspection. Department staff shall visually check as many alternative private sewage systems as possible during the 5 year control period to check for surfacing of effluent. (c) County monitoring. The county shall visually inspect each alterna- tive private sewage system within their jurisdiction a minimum of once every 2 years. The inspection shall consist of checking for surfacing of effluent around the system, ponding of effluent in the bed or trenches and to check the pump, pumping chamber and septic tank. History: Cr. Register, December, 1980, No. 300, eff. 1-1-81; renum. from H 63.22, Register, June, 1983, No. 330, elf. 7-1-83. ILHR 83.23 Mound systems. (1) SOIL AND SITE REQUIREMENTS. (a) Gen- eral. The soil and site factors which effect the suitability of a site for the installation of a mound, on slowly permeable soils with or without high groundwater, shallow permeable soils over pervious bedrock or permea- ble soils with high groundwater are given in Table 14. The installation of a mound in a floodplain or filled area is prohibited. Removal of the fill material may not make the site suitable. A mound shall not be installed in a compacted area. A mound shall not be installed over a failing con- ventional system. Table 14 SOIL AND SITE FACTORS THAT RESTRICT MOUND SYSTEM INSTALLATION Restricting Factors Soil Group Permeable Soils Permeable Soils Slowly Permeable With Pervious With High Soils Bedrock Groundwater Greater than 60 Percolation rate to 120 min/in 3 to 60 min/in 0 to 60 min/in Depth to pervious rock 24 in. 24 in. 24 in. Depth to high groundwater 24 in. 24 in. 24 in. Depth to impermeable rock strata 60 in. 60 in. 60 in. Depth to 50% by volume rock fragments 24 in. 24 in. 24 in. (b) Soil boring and percolation tests. A minimum of 3 soil borings shall be conducted in accord with s. ILHR 83.09 to determine depth to sea- sonal or permanent soil saturation or bedrock. Identification of a replace- ment system area is not required. 1. Slowly permeable soils with or without high groundwater. Percola- tion tests shall be conducted at a depth of 20 to 24 inches from exiting grade. If a more slowly permeable horizon exists at less than 20 to 24 inches, percolation tests shall be conducted within that horizon. A mound system is suitable for this site condition if the percolation rate is greater than 60 and less than or equal to 120 minutes per inch. - EXAMPLE 24 - Pic' 2) R*Awwv Aa'"V , 3/o/ 9o 1.o`f' Z'~ P~ ke ~,~-azre_ tf eT 2atQ AeR,S,43Z l ~ ~ sa-v► ~1 a~ gip s~ Gv~rTd , C~~~ Plot- -Rtv~ ✓~f PO ~ µ i oxd ve- P`w°~ I J-4 Cra lit b = LAL Cb4r"•e,Lr- In ft L =t2t _S P~CS SDK `C Cb41 -72 " CIF 36`~ AfK 1531 GxoL)u c-;e ~cQ ~96' GWIVIERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ST. CROIX'ZONING' REPORT N04 It 34141/01 RAGE 1 ST. CROIX COUNTY REPORT DATE; 12/22/92 COURTHOUSE DATE RECEIVEDS 12/18/92 HUDSON, WI 54016 ATTN. THOMAS C. NELSON r OWNERS 1st Federal Savings Bank LOCATIONS 855 Lassie Lane, Hudson M COLLECTOR; M. Jenkins DATE COLLECTEDS 12-16-92 4 TIME COLLECTED. 3200pm f 30URCE OF SAMPLES Kitchen faucet f DATE ANALYZED#12-18-92 TIME ANALYZEDSI1S00am COLIFORMS 0 /100 st INTERPRETATIONS Bacteriologically SAFE NITRATE-NS 2 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 ml Nitrate-Nitrogen, mg/L {.a 43 C") 17 . J RESJ 1. -131 : FAX'D OIL: } PHONED LAB TECHNICIANS Pam Gane PHOPHONED ON: CALLER: r R- ~ O,.\NOFOENDEHr WI Approved Lab No. 19 Zs A < Means "LESS THAN" Detectable Level Approved bYS ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY ZONING OFFICE St. Croix County Courthouse 911 4th Street 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. ComRletion 2L this f ornt Essential = #.h0, hS property 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 C (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) S~ eArJi< PROPERTY OWNER'S NAME: /37777 6D~z- ~ ,Jq ~ , l PROP. ADDRESS:. LAS T y CITY Legal Description 1/4 of the 1/4 of Section , T a N-RJL Town of )9 JO S(n Lot Number Subdivision: FIRE NU. ER gZ-~ LOCK I= NUMBBB kE K 0) -0 - /.2 62-3d-a7,,6 Co r of house RAJ Realty sign by house? -'If so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A KhP,i.e,COPY OF PLAT 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 individual re es 'n se ices: ~RUQWE% E,4 --1-Y Telephone Number C~(o~ REPOF T TO BE SEN TO: t-c- ^oz- 1`'t ~o T s CLOSING DATE: Signature ST. CROIX COUNTY WISCONSIN J.. YET ''1t{f' , . ;ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 December 17, 1992 Bill Seiffert Burnet Realty 219 - 2nd St. Hudson, WI 54016 Dear Mr. Seiffert: An inspection of the septic system on the property of First Federal Bank, located at 855 Lassie Lane, Hudson, WI was conducted on Dec. 16, 1992. At' the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon as we receive them back from the laboratory. 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 his office. Sincerely, Mary J.' Jenkins Assistant Zoning Administrator cj NOTE: House has not been lived in for an undetermined amount of time.