HomeMy WebLinkAbout020-1269-80-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
563853 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Patrick, Craig Hudson, Town of 020-1269-80-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
/LS~ f3 YI/~ ( 21.29.19.1332
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark / Y d /66
Alt. BM
Bldg. Sewer • fN
&60 -5
F,` l o (p
Holding ti- St/Ht Inlet
.9 ~l5• Z
TANK SETBACK INF6.11MATION St/Ht Outlet
TA K T /L WELL BLDG. a to Air Intake ROAD DE inlet D0 Sept
(060 :5'6 / 7Z 33 Dt Botto 1~Ob d i- Ler 9 S . 3
Header/Man. / '
Ding 66 7Z1 . 93 °J V. 7
Aeration Dist. Pipe Q7.
1-7.773.
Holding Bot. System C?-63 97. / 5
Final Grade
PUMP/SIPHON PHON INFORMATION
Manufacturer Demand St Cover
G.O £ C GPM C "°n e.~ ~'-1 S 7
Model Number
TDH Lift / Fricti55onlos ~ System Head TDHz ~Ft
(p& ~ X
Forcemain Length Dia. / Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5 dZ I to L
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR Ov~
Type 0 System: `
G Ja IZ 76 UNIT Model Number: , Pi
ae-
DISTRIBUTION SYSTEM e
Header/Manifold J Distribution 57 x Hole Size x Hole S sing Vent to Air Ek
J
'r17 Pipe(s) / P(~ Sp
Length Dia Length \ Dia Spacing 1 + Q. ~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only re,-,
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
Yes g No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 493 Prairie Lane Hudson, W1 54016 (SW 1/4 NW 1/4 21 T29fN R18W) Jacob's Landing 3rd Addition Lot 39 P el No: 21.29.,19.1332 -7
1.) Alt BM Description= d .0q
[
2.) Bldg sewer length = L-,\,~
- amount of cover G
Plan revision Required? Yes t 13 / Q
Use other side for additional information. (Q
SBD-6710 (R.3/97) Date Insepcto7ature Cert. No.
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
located
(Street address) y 9 3
at: St.,) `/4, Nw 1/4, Section Ai , Town 0-1 N, Range ~W,
Town of ,~1 St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service 3 ` - 3
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: 16 o o
Construction: Prefab Concrete ✓ Steel Other
Manufacturer (if known): W
Age of Tank (if known): /9
9 /
Permit number (if known) /,2 a 7 -7 a.
(Licensed Plumber Signature) (Print Name)
P 6
(Title) (License Number) MP/MPRS
(Date)
Form to be completed by licensed plumber (Dept of Commerce Chapter 5
and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin
Administrative Code)
Rev. 9/2008
9A p. .
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M t~1 i,,4.0 hod o~c PG,
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County
8e4' Safety and Buildings Division
201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.)
a `p S p ='r Madison, WI 53707-7162
3g5S
SK1N~~
Sanitary Permit Applicatio State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit / h~
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if differ t than mailing address)
the Department of Safety and Professional Servies. Personal information you p condary
y{.~tu(pX'' /
purposes in accordance with the Privacy Law, s. 15.04(1 (m , Stats. L. V ~3 I10
I. Application Information - Please Print All Information
Property Owner's Name `n _ ~ ~ Parcel #
_~+J~,~,,, JUL 2 4 2013
00 cs'-T~,
Property Owner*. Mailing Address ST CROIX COUNTY Property Location
ty 113 pl_14~~. 1A~w A
Govt. Lot
City, State Zip Code Phone Number $ W 1/4 /V W 1/,, Section d2 t
~ q (circle one
t4w C.~ 5'yp 1 4~5 41 a. x,25' Q $ s~
T N; RE
LEIH.~Type of Building (check all that apply) _ Lot #
1 or 2 Family Dwelling - Number of Bedrooms " r 3 ~ Subdivision Name
s
YK B10C
❑ Public/Commercial - Describe Use
❑ City of
❑ State Owned `Describe i Use CSM Number ~ El Village Town of of
H~u.o+-++-Crr-+
4. 0
cew III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner 7 T b
IV. Type of POWTS System/Component/Device: Check all that apply)
tKNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (expl ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information: Z
Design Flow (gpd) Design Soil Application Rate dsf) Dispersal Area Required (s Dispersal Area Propose sf) System Elevation
&oo .7 8S? CIC0 47. It
VL Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units
New Tanks Existing Tanks 2
) ffD/L / 6,7 7 o y id
! 5 a U0 05 y cn w c7 a
Septic or Holding Tank a 0 6 v j !0 o u a~ (Q.LL3~~+ A_~_
Dosing Chamber /O o G 60 t~ 6A L 1C_
VIL Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number
LO ALz-C A /14C C N VrLLL_E ~(;t Z ~ l O -vs,- Z`t9
Plumber's Address (Street, City, State, Zip Code) r
VIII. Coun epartmenfUse Only
Approved Disappr c $ Permit Fee Date sued Issuing ent Sign e
iv L~/s. cb
en Reason for Denial 72
DL Cond easons for Disapproval
11. ' tic tank iftftt, MW +ux3 3 Al Pa-0- d(` y y b ~,•t 1 t l c.
siiispersal ceB.must all be se *els I?naltita&tetl P.li 5~tiw~ 1 V (1
ve per management plan provided by plums.
7. AN ae4►ck requkerfit * moat 0 0atlMliW
as pN wic bw Gode for leas:
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inches in size
SBD-6398 (R 11/11)
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: /q;&_aQ r
Owner's Name: P otLt~
Owner's Address: 19 3 P~,o mod. ;r,
6!p
14 S -J c,
Legal Description: S L.N /V
Township:
County: .5 7"
Subdivision Name:
Lot Number: 9
Parcel ID Number: C,
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form 7r,~`"'"p~
Page 8 Warranty Deed"
Page 9 CSM or Plat
Attachments: Soil Test
Designer/Plumber: 02,2 Z License Number: O
Date: 7 - 9-q - 13 Phone Number -715-- 7 *7 - 33,9
Signature
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
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Combination Tank Component Cross Section 9
s
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Approved Manhole Covers With Warning labels
zandl Locking Device 4" Min. Above 'Final Grade
~ i
Weather Proof Junction Box
Electric per NEC 300 & COMI.N.
1.6.28 WAC
~P6
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p~ 3
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Disco ct
9 ai 4 Alternate Outlet Locatiori
a 1 WiApproved 4" Sleeve
F. Approved Force Main Diary
VEffluent 1 x#€r E l R
W
R~,ftl e- i or= to its" 1 f eep Hole or Anti Siphon l)evai,- i
CIS.
iqeftle
1 amcle sip A !
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i B Pump 01f xHlev.
W600'1 X000-NIR
$ W iesez ( f
1 a4. ;Aft. Concrete
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L Bose `Tank Elev. 91. G 9 '
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oni"- Differerss e Between Pump Off and Distribution e
o t
Mirirnurxx Iteq i e-d Supp!.'' 11'ressasze-
$a . of 1 t~, ,liai^= b^SQ F,4-lotion
`!"otai Dynamic Head
Number of Doses- = Per D v Cal.
Volume o Bw. low 11s3 ~~e Q~ . 13.o Gal.
T01-0 ?:dos: volt' rnkr Ga.
Irr' sank f apac';`r _ 1000 1573 s"sS Dimiensicns Inches Gailons
np.
Volane A7 '1l nlh A !5.s !fp57-17'
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9>llinimurn Ois1,ha; ge Rate - -A Cl- GPM A
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Alarm odel d `re~,0o _IQ
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Ala, hczF " G nk as r~,-C. ss4r~ C „ „ >at; ?~ea1 aiat ?t?cv.e5 p~ r C' ) tf i. 83.=t3 8)~g:
; ottp:: Pan, p l ` -m,,Switr-h re i.l:re St e`,'all c4 cuiiS. Coritrels r
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9 PUf,Y1P PERFORMANCE CURVE MODEL
MODEL 98 Beet Meters GaL Liters 37,3 A10 -I
5 1.5 72 273 ass
G 3.0 6 11 231
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~ 5 ~ 4.6 45 170 ~
20 7 25 95
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Shut-off Head: 1 23 ft.(7.0m)
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FL CAN' PER MIR'"TE t-- _
$Kii02
ie t r-al alt mators, for duplex systems, are available and Variable level float switches are available for controlling single
s-Ijp hed with an alarm and three phase systems
Nil chanical aiteriata-)rs, for duplex systems, are available Double piggyback variable level float switches are available for
~ilh or 4 0111etat alarm switches variable level long cycle controls
Refer to FM 1922 and FMO806 for temperatures above 130'F
S Seat Control Selection
~t I lost For j Ptodc A rps Simplex Duplex
_t At, n ~ 4 I ~ 4 '
ct c4 or. 4
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s ,%uto ~ 47 1- 1 4 I A Ea p& d SSeschar e pipe
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hi',"Ijz~i floa; operated riec,hani al switch, no external cc,ntrof required.
r
For ,,itor . ti rs i,g e piggyback variable level float switch or double
( ay?)4 , va i<ab'e leve float switch. Refer to F-M047; .
_ rJ
v -6 for correct model of simplex control panel.
F. r i~ Fr rrri~r. ,;odel of duplex control panel or FM 1663 for a 77 e I t.-, . .0 ~ c pus; L, toy I9-E a`
system
Reduces potential clogging by debris.
eller products refer to catalog on Piggyback Variable Level Replaces rocks or bricks under the pump.
v la._ - -ricai 1a.-. rptor, 1 PA0436; Mechanical Alternator, FrJ10495; Sumpi Made of durable: noncorrosive ABS.
c~ge~ ,s. 1:M) ;7: Since ?rase Simplex Pump Control, FM1596, Alarm Systems; Raises pump 2" off bottom of basin.
Provides the ability to raise intake by adding sections of 11,'2'
F i cnuvlo►a or 2" PVC pipirg.
Attaches securely to pump.
t ov a core v Accommodates sump, dewatering and effluent applications.
e u sh ou. c ire o vl' c NOTE: Make sure float is free from obstruction.
For uimsual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
MAIL TO PC, SOX 16347
Lo is✓'lle KY 405F J ?
Manufacturers o°
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I Y, Lo sEine. KY 40'11 190'
Qvatirv P✓ BPS Sr✓~E
0117 9 JI' 0z) 77-') 9ZB-YU.h1P
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Z- Copyright 2010 Zoeller Co_ All rig its reserved.
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a \O W3716 US HWY70. MAIDEN ROCK. VA 54750 DATE: JANUARY 2008
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1 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 5' of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
v-caA.. Septic Tank Capacity / b o o al ❑ NA
Permit # Septic Tank Manufacturer (,J V ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer P ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Modell ~j ❑ NA
Number of Public Facility Units KNA Pump Tank Capacity /coo al ❑ NA
Estimated flow (average) q00 gal/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) Loo gal/day Pump Manufacturer Z ti ❑ NA
Soil Application Rate +7 gal/day/ftz Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit kkNA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODS) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD5) 530 mg/L 134n-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) :530 mg/L X NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Ys in dia. ❑ NA Other: ❑ NA
Other: fiNA Other:
❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
CK year(s)
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 ears) ❑ NA
K year(s) y
Clean effluent filter At least once every: ❑ month(s) ❑ A
®year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s)
❑year(s) ❑ NA 14 3
Flush laterals and pressure test At least once every: ❑ month(s) 47 ❑ NA
19 year(s)
Other: ❑ month(s)
At least once every: ❑ year(s) ❑ NA
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
START UP AND OPERATION Page (0 of
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name (,J Name L-~ j 1 '
Phone '7tS -'74'9 -33aa Phone 71 s'- 7`F4- 93;1- --7,
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name R~r~ Sti Name Sr
Phone -7 l s'.• 7 q O 1,53 Phone
?1S-38to - 4 619 C)
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY P 7
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer C n~
Mailing Address 1~- M.--~~xs►., yO f°
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City/State 14,, I A-em , CQ r Parcel Identification Number o 1 - 0 ' c d o
LEGAL DESCRIPTION
Property Location Sc.-3 Id LO Sec. oZ~ , T 9 N R J 7 W, Town of
Subdivision Plat: , Lot # 3 9
Certified Survey Map Volume , Page #
Warranty Deed # 5s- B f14 (before 2007)Volume Page # v?J
Spec house ❑ yesX no Lot lines identifiable/' es ❑ no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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 pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on thi form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a w anty deed recorded in Register of Deeds Office.
Number of bedrooms /
SIG TURE OF APPLICANT(S) DATE
* * *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 04/12)
t
STATE BAR OF WISCONSIN FC')Rht 2 - :982
vas' o~Pa~fl3 _
DOCUMENT NO. l
y ti
Jean M. Haves, a sirs&le person,
_
MAY c 1.` 97
conveys anti warrants to _ Craig D. Patrick and Michele L. Patrick rat 10:45 A. ~
hust->And and 6vifet-as survi.vorshi_p marital prgp_erty, -'✓.,at.t !t UJso1.
~ - PHIS SPACE RESERVES FOR HEZORDING DATA
NAME VNU RL 110AN At. ~_}RGSS -
the following described real estate in St. Croix County. River VaUey Abstract & 9Ntle, h? c.
state of Wisconsin: Y.0. DOX 14c9 s 206 2nd Si.
xx.aadsirm IVVI 54016
.9 17 - (0
s
020-1269-80 _
/ PARCEL IDENTIFICATION NUMBER
Lot 39, Jacobs Landing Third Addition to the Town of Hudson, St. Croix
County, Wisconsin.
it
ITA'r INFER
10 6;
s
ti
r
This is homestc:,u prul,.rtiy.
Exception. to warranties: Easements, restrictions and rights-of-way of record, if any.
6th May 97
Dated this day of A.D.. 19
_ (SEAL) (SEAL)
--an M. Haves
V - - (SEAL) -
- (SEAL)
AUTIIEN•I ICATION AC:KNOWLEDGmENT
of . sc
Staic St. Croix
r:. ..all, 'anu I'll", H., 5 t1T day t+1
.,idht•uuc,acd tills__ I I'll", 1~; _
•ji the ..hut r n:unrd
Jean M._ i-1ayes, a s1 n. l c t t
rt rl r nl~Lllsel. ~r:\rr. Il:\I: ~,r IBC ctNti1N ,
Rrc.r+tiu I (ntlilt _
tit not No4:rv Pithl ( -l
io, _ tvht+t
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StiSQt: (lI' VV Itt'l)PVII
u ).Irurni t t.~tl ai 1. n,.,tt! - Ihy-~+.u),r
1-115 INS! HI IMP Nr WAS 01V.rlt RY
Atlorne~ krz.stinz n°.l +nd enda Poulin
Nr:.tn 1'uhlit St__.Gr01x - _ l un).
Hudson WT 54016
natur .mat lti auth.nt.tatr,l 0!' arknr,t~l died ltulh ale nut Att r,.mml._wn is peu).arttnl Ill n. 'la t" daa
11,/1 -.ul, t
~~,Ak.,1 1 , 131.1 n r.,rrt! No 2- 1 +Ield
PORDING
3 E ASE M r ~r;
280 SO FT
2.500 AC-
3
Page l of
Ws. Dept of Safety and Professional Services SOIL EVALUATION REPORT
Division of Safety and Buildings
in accordance with SPS 385, Wis. Adm. Code
County 5 1 C Rp ~
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan n1 . D
include, but not limited to: vertical and horizontal reference point (BM), direction an Parcel I.D. QZ 0 . !Z, (O • 80 • o bo
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. JUL ~ A Revi d by Date
zJ sl
Personal information you provide may be used for secondary purposes (Privac Law W611 5,~004(1
Property Owner PfdM"y Location W
Q
CRRI C 1 Gh E1167 PATR~ ~It Govt Lot .5W 1/4 1 4 S T 2KN R 1 E (o W
Property Owners Mailing Address Lot Block # Subd. Name o CSM#G A~ D/
7 ,~J ~RAtIR~ LN . `3 / JgC•o 13'~
City State Zip Code Phone Number ❑ City ❑ Village KTown Nearest Road
~{u~So'V W 1 5~oilo c7~5 )381-153Y 1490.50 A3 I -OPAI R 11 E- p-
F-1 .
❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate GPD
JA Replacement ❑ Public or commercial - Describen_ I
Parent material <AMD 0 VT WAS k ?~M AV Flood Plain elevation if applicable ft•
General comments r~j N to Ess To Pso(L ~E'p~~CF1~te~T f} P,1=o 1 i le
and recommendations: ~,~~4 C r 7.y
TEST A•tzE~ it Q IE f=op- APD l7 0)~ l TAAJk c
4- WO Ms> p~HP ~ •
Aj Nom
t~J5ROVA(D Ce1V V E,Jrlh-L SW-IF
❑ Boring # n Boring /QQ . 2 > Q''^^
Pit Ground surface elev. ft. Depth to limiting factor I y in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2
o 51 2. n„ nw -FR 2 C / f o 0
o -Zo io yR Z R 01)5E
~i 11 51 L j•~' nn~ ' a..C 00
Z • yL 16Y9 q .1 S• o R C 5
A
Boring # Boring. /o 0
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
z
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
o•fo 10yR5y Ls v, CS 7 r /-CO
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* Effluent #1 = BOD > 30:5 220 mg/L and TSS >3 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Ro?,ERT' u 1 b R t C'k T"- `P6W 1~& 1 2X(037 j
Address Date Evaluation Conducted Telephone Number
gl Z ~o''`'Ave. 5PR1~ V~ Il~y A)I• 57V767 MAI ;Y -.7-013 71 S. -779 • Lf q T z
SBD-83'0 (R11/11)
Property Owner G R.At ?AT R l L Parcel ID # O Z (D • 80 . D Q Page 2 of
3 ❑
Boring # Boring Z a
❑ /o 2, • 5
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
z
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
o- ~oY93 - L5 0,s 5 a,5 .7 /G
2 .5 R 6 S D Q-s
S D
F1 Boring # Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2
❑ Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
F-1 ❑ Pit
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft s
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
SBD-5330(x11/11)
Cf2Aj•C~ I~~TQ~~(~ oza• ~Z~•gD• Doi z 3
Property Owner Parcel ID # (D Page of
❑
Boring # Boring /D Z ' S z
3 pit Ground surface elev. ft. Depth to limiting factor in.
_ Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence 2
Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 " ff#2
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17 A6
3
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. * ff#1 *w?
Boring
Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
❑
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell. Qu. Sz. Cont Color Gr. Sz. Sh. ff#1 * ff#2
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
SBD-8330(R11/11)
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FORM - STC - 104
AS BUILT SANITARY SYSTEH REPORT
OWNER 119•` //ar TOWNSHIP M
SECTION 2 T--N-R W ` ) P
ADDRESS,~~ 2 g Z- ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LpT S91 LOT SIZE z S 04 4 ( .
T - o ds L~ ti • K,
PLAN VIEW 0
?i0 - I lilo~l -LSD -615I~
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
PRAIRIE LAKE
8. M• ~..~o- f N tJ eorHa r
Ef•.~oe.o' I D
R
S
E
W
A
ff, 4Si /
7(
zi(X'2y zQXfo a
9I
zi
N90
I-
• T I\
- - - - fig'
• INDICATE NORTH ARROW
BENCHMARK: Elevation and description: z ~a
Alternate benchmark
~Wa- Sa-f Liquid Cap. .
SEPTIC TANK:Manufacturer:
Rings used:- Manhole cover elevs.L.±_Z-- Final grade elev: '7--10
Tank inlet elev.: q-9S9 Tank outlet elev.:
No. of feet from nearest road:Front.,X , side_,, Rear_Ft. 3
From nearest prop. line:Front Side, Rear ,_Ft. 'gSNo. of feet from: Well 4,-s , Building:_ z
(Include this information in the above plot plan) to se (2 reference dimensions REVERStic tank)
PUMP CRAMER
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
Bedaayya..7;:.~,/ Trench: Seepage Pit:
Width: Length sP, C ' Number of Lines:
-,.3_Area Built `y8's,'7'
Exist. Grade Elev.
Proposed Final Grade Elev. y~
Fill depth to top of pipe: y No. feet from nearest prop. line:Front
Side,, Rear _Ft._
No. feet from well: No. feet from building s
HOLDING TANK
Manufacturer:-/L/-# 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: Wellbuilding-., nearest road _
Alarm Manufacturer:
INSPECTOR:
DATE: PLUMBER ON JOB:'10- 0
LICENSE NUMBER:
6/90:cj
i'
DEPARTMENT 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:
SW 4 , NW 4 , Sec. 21,T29-R1.9 12J CONVENTIONAL ❑ ALTERATIVE (It assigned)
Town of Hudson Lot[:J9H
olding Tank ❑ In-Ground Pressure ❑ Mound
IT HOLDER: ]ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
J~ 41
A ermanent reference point) DESCRIBE I
REF. PT. ELEV.: CST REF. PT. ELEV.~
DIFFERENT PLAIP
E o;<' 4 emu- . ~r 3 ~ / ' S / / • O / Te
Name of Plumber. MP/MPRSW No.: ounty: Sanitary Permit Number:
Doug Strohbeen 5432 St. Croix 128772
SEPTIC TANK/ ~z (e
MANUFACTURER: LIQUID CAPACITY: TANK INLET E I TANK OUTLET EL WARNING LABEL LOCKING COVER
/ / PROVIDP~: PROVIDED:
(1JI'(f ordo , Z -)g PES ❑ NO ❑ YES NO
BEDDING: NE#FDIA.: VENT MATL.: HIGH WATER UMBER OF ROAD: PROPERTY WEL a BUILDING: VENT T F ESH
e p. C ALARM: [FEET FROM LINE: / AIR IN
❑ YES ~NO ❑ YES f1pig NEAREST-► `tt/ps~ 20"
DOSING CHAMBER:
MANUFACTURER: BEDDING: --'t PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
TED YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: N OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FR M- LINE: AIR INLET:
PUMP ON AND OFF) 1 ❑ YES ❑ NO NEAREST::- .
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETE ERIAL 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 SYSTE ,T bof $ eWJ = 9 /
WIDTH: NEUaVF___, ~ NO OF ISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH r p TRENCHES: M IAL:
DIMENSIONS .1 ( C~ G}~ P
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PPE MATER~L NO. ISTR. NUMBER OF PROPERTY WE BUILDING: VENT TO FRESH
BELOW P PES: AB OVER: ELEV. INLET: ELEV. END: If e. PIPES: LINE: / AIR INLET:
~Jj [ Q / FEET FROM / [
LJ NEAREST 7S Ss
MOUND SYSTEM: (o.
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 PERMANENT MARKERS OBSERVATION WELLS;
El YES ❑ NO F1 YES El NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TO SODDED: SEEDED: MULCHED:
CENTER: EDGES:
YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH B W PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DIS IPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA..
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VER L LIFT CORRESPONDS TO
INFORMATION APPRO S
E-1 YES ❑ NO LAMES ❑ NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: iAREST- MBER OF PROPERTY WELL: BUILDING:
FEET FR M LE:
❑ YES ❑ NO ❑ YES ❑ NO
♦
6L[6- olJe_ cz ~ry)0-~l e d 102,10 [moo r?.
r/ ,e rr1
fain in county file for audit.
Sketch System on
Reverse Side. JGA URE : TIT '
SBD-6710 (R. 06/88) 7e__~ 44154-1-
=Qdl LH R SANITARY PERMIT APPLICATION
COON
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than El ~7~~ 2
8% x 11 inches in size. hat if vision o previo s 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
/t2 ' t Lc! '/4 S Z/ T zli , N, R ! E (o W
PROPERTY OWNER'S MAILI DRESS LOT # BLOCK #
v # Z Z S-7
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Hit so S'/D/ 8' Z7l. Ta.t 0 &S LQ.1 i k
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
) 11 State Owned
P2 N 4",j
VILLAGE : DieA / E
❑ Public 1,2 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TA MBE )
-
111. BUILDING USE: (If building type is public, check all that apply) 3 3 Z Gao
1 ❑ Apt/Condo
2 El Assembly Hall 6 El Medical Facility/Nursing Home 10 El 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 90 Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. U1 New 2. ❑ Replacement 3. ❑ Replacement of 4.F] 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 430 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
/ SO C~ l S 4P d. 7 2- --3 9 7. Sb Feet /60- Sa Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks strutted
-M F1 1-1
Septic Tank or Holdin Tank /d CJ Lt/~ a r
Lift Pump Tank/Si hon Chamber F] I El El El EL
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) MP/MPRSW No.: Business Phone Number:
,U~u'lms SRVGc~~ M!~-~~31 ? 3 z3
Plumber's Address (Street, City, State, Zip Code):
(4 f te~, /,4.!&444 7
IX. CO NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued issuing ent Si ature (No S ps)
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Det rmination
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'f 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)
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
114DUSTRY, - DIVISION
HU AN REtT ONS PERCOLATION TESTS (115) P.O. BOX
MADISON, WI 53707
3707
(IL-HR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/Mtft~ffeipm.iO.'BLK.NO.: SUBDIVISION NAME:
N4►'/ /Tz9N/R19 (O W
1J U&sv~ ~ L)4Aj&v A
COUNTY: MAILING ADDRESS:
.~-:>T CP'o,x SAIA M)1_LLtf_ i ~e 1 ekod~'- ]~aat' /~u~45aN W1 s4or6
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: I PROJILE! A E TS:
Residence U NIL , New ❑Replace I( LL f lqb
Vl -sb)LS Sfg • SiQT'Te r' / I
RATING: S- Site suitable for system U- Site unsuitable for system Q s% ~,OIG 1 - Q 61 - &J et
IONA CO ENTEj U . MXS. E]U IN GRXS ~U RE: SOSS -1N[:]-FILLHOLILDING TANK: RECOMMN DEF_DYT3TOE piional
If Percolation Tests are NOT required DESIGN RATE: lW_
If any portion of the tested area is in the -7 1
under s. ILHR 83.09(5)(b), indicate: i.L~CSS Floodplain, indicate Floodplain elevation: I V IV
cC~ PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHZW ELEVATION OBSERVED ESTTTiTM TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 1 g 7S 10 94 ntaN >9.? FsN ~xT l r $qN C 94 '66.,14 S4 i6me
B- ob /oo> b NoN~ > 9,aa 20• $L .1~N '7o"BaN,~.c
B- .0% 6/,7_7 o y .U$ 24•, 18LLT'S z4f gew L 41 "gat c-Yl S1&4~
B- a 9.1-7 /o/. /2 rq.,vLr > l? Zr $LL_'is ! R•v L 7 /17 'S-t 6-V
~o~ e~e-rhS~G~
B- S 92< ~(~,►Z c) > ~2 !9 ligLi-TS rl" - 44.
B-
tyic_f=r PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES
NUMBER bNW;MS AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
P. 6.4 0 r4CNIE > 2 >Z > Z < 3
P. 2 3.10 Nc"s /06,66 > Z > >Z
P. >
P-
P- V #4-r o A'T Q L
P-
PLOT PLAN: Show locations of percol - UIAP~ imensions 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. 97--so
1 ~ 1
A I
,
p
N
8
Qp-2
r r_.
ll
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 WER COMPLETED ON:
N~Qy~Y J~NNSoty JoNfvSae~, `,,u~Ey~NC~c•GUS7 Z /990
ADDRESS: ' I CERTIFI ATION UMBER: PHONE NUMB ER(opt ional):
467coa~f~uri ► S~(Ol6Po~G_g48G
Sr
CST S ATURE: 00
DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester.
L DILHR-SBD-6395 (R. 10/83) - OVER -
SEPTIC TANK MAINTENANCE AGREEIIENT rt
St. Croix County
.r
a
OWNER/ BUYER :S'a,i-ri h~ ; l I ar.
• o
ROUTE/ BOX NUMBER Fire Number p
V
Nc~sev; tom= ZIP Sv/~ 0
CITY/STATE o
PROPERTY LOCATION:'..S /,c:J Section , T 2q N, R /9
Town of ~f St. Croix County,
Subdivision ~~,O ( Lot number.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Prover maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licen's'e~d 'We'Weppt'ic tank pumper. What you put into
the system can affect tTe Funct on or the-septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix Count residents-mom be eligible to recieve a grant for
a maximum of 60K 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 .sys'ttms agree to keep their system properly
maintained.
The property owner agrees to. submit to St.. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
essary), the septic-.tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year-expiration.
H
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with 9
the standards set forth, herein, as..set by the Wisconsin Depart- W
went of Natural Resources. Certification form must be completed .d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date. j
SIG
DATE q()
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
APPLICATION FOR SANITARY PERMIT
8TC-100 owner($) of
This application form Is to be completed in full and signed by theln delays of
the property being developed. Any Inadequacies will only result the permit issuance. -Should this development be intended tot resale by
sold and second submitted r to should this office tttained and
ownet/contcactot#(spec
comp with the
property Is then a
completed when th
appropriate deed recording.
Owner of property -So-ro ' ffQ►l-
Location of property ~ 1/4 lVq)114# Section 2-1 j T_a2__N-R ` Y
Township - HuA k"
Malling address &c -Z.-,
Address of site
Subdivision name- Z~ obz I a
Lot number -_R2
Previous owner of property , l):~ M
Total also of parcel Z cLc~
Date parcel was created
Are all corners and lot lines Identifiable? k _ an o
Is this property being developed for resale taper house)? as
Volume R S and Page Number ~~as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which Includes a DOCUMENT NUMBRR, VOLUME AND PADS NVHBRR, and
the BRAL OF THR 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 Ceitifled Survey Map, the Cettlfled Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
)(ve) certify that all statements on this form are true to the best of my (our)
knowledge= that I (we) am (ate) the ownects) of the property described In
this Information form, by virtue of a warranty deed recorded in the Office of
the County Reglstec of Deeds as Document No. / i and that I (We)
Presently own the proposed site for the savage disposal system tot I (we) have
obtained an easement, to gun with the above described property, for the
construction of said system, and the same has been duly recorded In the Office
of he County egIsteel Deeds, as Document No.
Signature of owner Signature of Co-owner (If Applicable)
Date of signature Date of Signature
nt-1'umrN1 NO WARRANTY DEED n,a 1►#i t ntstnvu, eon •ccnr.t,.aU o.,•
STATE BAIL OF WISCONSIN FORA 2-1002
- ,3 +17 REGISTER'S OFFICE
t Va. ~WME ST. CROIX CO., WI
I J
Recd for Record
~VAr);inia M. Hanson. a sing,.e woman
}
8:00 A M
\ romr~± :uul n..rrntlk U, Sam E. Miller. a single man « n AA
Rh4Nr 91 D"
't
d~ u...:,rn ,n
a
9,.
the folhowiaC drarrihrd real estate in St. CCV I X Lourt},
Tax Parcel No:
r West Half (W')) of Lite Southwest Quarter (SW14) of Section
Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19)
West, St. Croix County, Wisconsin except that part South of the i,ublic
j highway and except Lots S, 6r 7, and 8 of Certified Survey Map n Vol. 6,
! Page 1747, Doc. No. 419479.
That part of the West Half (W'i) of the Northwest Quarter (NWtt:) of Section
Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West,
St. Croix County, Wisconsin lying; South of the right of way of the
Chicago, St. Paul, Minneapolis and Omaha Railway Company.
x
•r~vs~•1~~ 0 ,
This is not
hnimmt.ad pr,.1wrt .
#6tk l is ant) easem•.nts of record and protective covenants and restrictions
of record, if any.
1 s•
hated this day ..r C
88
01
tSEALi ev ' ~ -
Virginia M. Hanson
INEAL►
B t4F,Al.r
s
c
i.
AUTHENTICATION ACKNOWLEDUMENT
Signature(e) +
STATE; OF \t'1SCUh51N 1
I
ss.
` 1 V ~v 'k count,
' authenticated this day of 19 t•erst,n.m fame before me this day or
(YEA IL L- W 88 the above named
3 Virgin-in M. Hanson
TITLE.: MEMBER STATE BAIL nF WISCONSIN
' (If
ant.
f authorized by § iQ(..Qr, Wilt. Stab.)
In tar Lnoan to he the Ler on tvh.r eseruted the
furec2,0 nlment avit) nKiprit•leil r the sidle.
T•,'4 INSTRUMENT WAS DRAFTEo nV
Lois,A. Murra, Ne qod Cart S Murray
229, Hudson, W1 54016 P(Sicnntures n,ny he authenticated or nekn,rcvle,lged. Both Nl,• 1pn U I~ 4A;,i,..w.(if not, state eo. ratio.,
nrr not neressary.)
-Nam" ,•1 p.r.•,n. .Inning In way p...ity •L..r'•1 1.. t}, t r•rr...l 1. rl.•.. r:
WARKANTT Dt:ED STATP. "Aft OF %NCOVf'V N.••. non 1 •x.l ►!h.• •
3 -OIL
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
x x x x x x x■ r~rrf ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
C
February 28, 1994
Jean Hayes
1150 County Rd. A
Hudson, WI 54016
RE: VOC WatetInspection for John Schmelter
Address: 493 Prairie Lane, Hudson, WI
Dear Ms. Hayes:
Enclosed is the original test results from SERCO Laboratory,
Inc. for a VOC water inspection of the above property. If you have
any questions with regard to said report, please let me know.
;,~#cerely,- ,
i
Mary J. Jenkins
Assistant Zoning Administrator
js
Enclosure
r1a
17 SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 40568 PAGE 1 of 3
02/23/94
St. Croix County Zoning DATE COLLECTED: 02/14/94
1101 Carmichael DATE RECEIVED: 02/15/94
Hudson, WI 54016 COLLECTED BY : CLIENT
DELIVERED BY : CLIENT
SAMPLE TYPE DRINKING WATER
Attn: Mary J. Jenkins
CLIENT'S ID: Schmelte
SERCO SAMPLE NO: 19154
SAMPLE DESCRIPTION: Schmelte
Sample
of
ANALYSIS: 02-14-94
Benzene, ug/L <1.0
Bromobenzene, ug/L <0.2
Bromochloromethane, ug/L <0.4
Bromodichloromethane, ug/L <0.2
Bromoform, ug/L <0.5
Bromomethane, ug/L (Methyl bromide) <1.0
n-Butylbenzene, ug/L <0.3
sec-Butylbenzene, ug/L <0.4
tert-Butylbenzene, ug/L <0.5
Carbon tetrachloride, ug/L <0.2
Chlorobenzene, ug/L <1.0
Chloroethane, ug/L (Ethyl chloride) <0.4
Chloroform, ug/L <0.5
Chloromethane, ug/L (Methyl chloride) <0.6
2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2
4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2
Dibromochloromethane, ug/L <0.4
1,2-Dibromo-3-chloropropane, ug/L <1.2
1, 2-Dibromoethane, ug/L <0.2
(Ethylene dibromide) 0 f~
Dibromomethane, ug/L <0.2
1, 2-Dichlorobenzene, ug/L <1.0 WWt'
(o-Dichlorobenzene)
1,3-Dichlorobenzene, ug/L <1.0 GIN;;
(m-Dichlorobenzene) r:
< means "not detected at this level". 1 mg = 1000 ug.
dxa "sY
MEMBER
SERCO Laboratories `
1931 west County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 40568 PAGE 2 of 3
02/23/94
SERCO SAMPLE NO: 19154
SAMPLE DESCRIPTION: Schmelte
Sample
of
ANALYSIS: 02-14-94
1,4-Dichlorobenzene, ug/L <1.0
(p-Dichlorobenzene)
Dichlorodifluoromethane, ug/L (Freon 12) <0.5
1,1-Dichloroethane, ug/L <0.1
1,2-Dichloroethane, ug/L <0.2
(Ethylene dichloride)
1,1-Dichloroethene, ug/L <0.2
cis-1,2-Dichloroethene, ug/L <0.1
trans-1,2-Dichloroethene, ug/L <0.1
1,2-Dichloropropane, ug/L <0.1
1,3-Dichloropropane, ug/L <0.2
2,2-Dichloropropane, ug/L <0.2
1,1-Dichloropropene, ug/L <0.2
cis-1,3-Dichloropropene, ug/L <1.5
trans-1,3-Dichloropropene, ug/L <0.9
Ethylbenzene, uq/L <1.0
Hexachlorobutadiene, ug/L <0.3
Isopropylbenzene, ug/L, (Cumene) <1.0
4-Isopropyltoluene, ug/L <0.5
(p-Isopropyltoluene)
Methylene chloride, ug/L <5.0
(Dichloromethane)
Naphthalene, ug/L <1.0
n-Propylbenzene, ug/L <0.4
Styrene, ug/L <1.0
1,1,2,2-Tetrachloroethane, ug/L <0.2
1,1,1,2-Tetrachloroethane, ug/L <0.1
Tetrachloroethene, ug/L <0.2
Toluene, ug/L <1.0
1,2,3-Trichlorobenzene, ug/L <0.2
1,2,4-Trichlorobenzene, ug/L <0.2
1,1,1-Trichloroethane, ug/L <5.0
< means "not detected at this level". 1 mg = 1000 ug.
MEMBER
,ra
7 SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 40568 PAGE 3 of 3
02/23/94
SERCO SAMPLE NO: 19154
SAMPLE DESCRIPTION: Schmelte
Sample
of
ANALYSIS: 02-14-94
1,1,2-Trichloroethane, ug/L <0.1
Trichloroethene, ug/L <0.4
Trichlorofluoromethane, ug/L (Freon 11) <0.7
1,2,3-Trichloropropane, ug/L <0.2
1,2,4-Trimethylbenzene, ug/L <1.0
1,3,5-Trimethylbenzene, ug/L <1.0
(Mesitylene)
Vinyl chloride, ug/L <1.0
Total Xylene, ug/L <1.0 y
This sample's analytical results are'~~ below the U.S. EPA's
SDWA Maximum Contaminant level of 30-91 for those requested
compounds which are also on the SDWA MCL List.
The analytical results in this report pertain only to the items tested.
All analyses were performed using EPA or state approved methodologies.
Samples that may be of an environmentally hazardous nature may be
returned to you. other samples will be stored for 30 days from the
date of this report, then disposed of by SERCO Laboratories. Please
contact me if other arrangements are needed. This report may not be
reproduced, except in its entirety, without prior written approval
from SERCO Laboratories.
Report submitted by,
'hU~G2,e~
Diane J. Anderson
Project Manager
< means "not detected at this level". 1 mg = 1000 ug.
~{s
MEMBER
-9y
IX COUNTY.
ST. CRO
WISCONSIN
n ZONING OFFICE
+ ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
X Water (VOC's) $185.00 0 Septic $25.00
0 Water (Nitrate & Bacteria) $35.00 (Visual inspection)
Owner: Vo n 5e-kx-e/Ir✓ Requested by:.Tea er
Address: JA Address: V-96 z],,r+&A
City & State: 14udson W;,. „ City & St. 1!,)~ , IJI
Zip code: S%5/D/l,, Zip Code: SLIC14
Telephone N4: (715' )3k6 OS-oq Telephone N4: (7/5 ) 31q627j?Z.
Property address (Fire NO & Street) : ru~yir ~fz.
Location:,5W ~,/Ujj h, Sec. al , T a9 N, R /q W, Town of-/41,0.5-o~c
St. Croix Co., WI. Tax ID N4 Parcel ID If
House color: alvtv,R Realty firm: irtc Lock Box Combo: GvE
Water sample tap location:
TO BE COMPLETED BY PROPERTY OWNER
*PROV A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Is the dwel\i~9currently occupied? ❑ Yes 0 No
If vacant, date` st occupied:
Septic system insta d by: Year:
Septic tank last servic \by: Date:
Previous Owner's Name(s):
Have any of the following been served?
OY ❑N Slow drainage from house.
❑Y ON Sewage Back-up into dwell3.-ng..~:
OY ON Sewage discharge to ground surface,
road ditch..o"r body of water.
❑Y ON Slow drainage from the dwelling. x.
OY ON Foul,-odors. \L 1
Other comments relative to system operation:
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:
e/q3
OWN S DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
t
- IN
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on 'file? OYes ONo
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: OBelow grd OAt-Grd OMound
Approx. size 'X OGravity ODose ❑Pressurized
Ft.: OBed OTrench ODry Well
OHolding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other OUnknown
Septic tank
Setbacks: OHouse OWell ❑Prop. line ❑Other
Dose tank
Setbacks: OHouse OWell ❑Prop. line 00ther
OLocking cover OWarning label ❑Pump/Floats
❑Alarm OElec. wiring
Soil Absorption System
Setbacks: OHouse ❑Well OProp. line OOther
OPonding: ODischarge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
N
Inspector
Title
-
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
"r""~"" ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
February 21, 1994 1~ l 20- Z&j
Ms. Carrie Johnson
Edina Realty 13 ,~3
Second Street
700 Hu
Hudson, Wisconsin 54016
RE: Water Inspection for John Schmelter
Address: 493 Prairie Lane, Hudson, WI
Dear Ms. Johnson:
Enclosed is the original test results from Commercial Testing
Laboratory, Inc. for water inspection of the above property. If
you have any questions with regard to said report, please let me
know.
Sincerely,
/s/ Mary J. Jenkins
Mary J. Jenkins
Assistant Zoning Administrator
mz
Enclosure
e
COMMERCIAL TESTING LABORATORY INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030
ST. CRIIX COUNTY ZONING OFFICE REPORT NO.: 57261/01 PAGE 1
ST.CROIX CTY GOV.CTR REPORT DATE: 2/16/94
1101 CARMICHAEL ROAD DATE RECEIVED: 2/15/94
HUDSON, WI 54016
ATTN: THOMAS C. NELSON
OWNER: John Schmelter
LOCATION: 493 Prairie Lane, Hudson
COLLECTOR: M. Jenkins
DATE COLLECTED: 2-14-94
TIME COLLECTED: 2:00pm
SOURCE OF SAMPLE: Kitchen faucet
DATE ANALYZED:2-15-94
TIME ANALYZED:2:00pm
COL-IFORM,MFCC: 0 /100 ml.
INTERPRETATION: Bacteriologically SAFE
NITRATE-N: 4 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 ml
Nitrate-Nitrogen, mg/L
Ir a
LAB TECHNICIAN: Pam Gang
OF,WOEVENpfNr
sa WI Approved Lab No. 19
O
V ~
is s' ( Means "LESS THAN" Detectable Level Approved by:
PROFESSIONAL LABORATORY SERVICES SINCE 1952
O , ~
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
' - - Hudson, WI 54016-7710
(715) 386-4680
February 28, 1994
Ms. Carrie Johnson
Edina Realty
700 Second Street
Hudson, WI 54016
RE: Septic Inspection for John Schmelter
Address: 493 Prairie Lane, Hudson, WI
Dear Ms. Johnson:
An inspection of the septic system on the property of John
Schmelter located at 493 Prairie Lane, Hudson, WI was conducted on
February 25, 1994.
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.
Z}ncerely,
-.-;"James Thompson
Assistant Zoning Administrator
cc: John Schmelter
ST. CROIX COU
WISCONSIN
ZONING OFFICE
r r e r N N r■• ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
~Q/ ~Y =
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Please specify desired. test(s) & remit appropriate fee with
application. Outside water lines are often turned off during
winter months, making,..access to the home necessary. Please make
arrangements with this office to insure that entry can be gained.
❑ Water (VOC's) $185.00 D( Septic $50.00
t9 Water"-(Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria
retest $15.00
Owner: y01-1/V Requested by:
Address: V, ? z-t l Address:
_r11yVG;V ZIP 16 ZIP
Telephone N4: 3 ~ 4j'y2_ Telephone N4: ( )
Property address (Fire N2 & Street) : ~ /,,7 Z-111/
Location: Sec. , T N, R W, Town of
Realty firm: Lock Box Combo: C Closing Date:
COMPLETED BY P
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Water sample tap location: cF~~
Is the dwelling currently occupied? Yes ❑ No
If vacant, date last occupied:
Age of septic system: 3 'y'Ly4TZ5 r✓r~
Septic tank last pumped by: Na~,v ql i+l-7Date:
Previous Owner's Name(s): Nj~1
Have any of the following been observed?
❑Y JIN Slow drainage from house.
❑Y XN Sewage Back-up into dwelling.
❑YT Sewage discharge to ground surface or road ditch.
❑Y ❑N Foul odors.
Other comments relative to system operation:
I certify that the above informati n ids complete and true to the
best of my knowledge.
OWNERS SIGNATU DATE:
1/94
,A
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
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TO BE COMPLETED BY INSTION AGENCY
System design &/or permit on file? gees ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: []Below grd ❑At-Grd []Mound
Approx. size /8''X510 ' []Gravity []Dose []Pressurized
Ft.2 []Bed []Trench []Dry Well
[]Holding Tank ❑0utfall pipe
OBSERVED DEFICIENCIES []Other []Unknown
Septic tank
Setbacks: 7us0 ,J
❑WellProp. line ~Other
D e tank
e`etbacks: []House []Well []Prop. line []Other
, []Locking cover ❑Warninglabel []Pump/Floats
[]Alarm []Elec. wiring
Soil Absorption System
Setbacks: []M~t s/ ell []Prop. line 00ther
❑Ponding: []Discharge:
General comments : 1, c ( J
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INSPECTORS CH OF SYSTEM LOCATION
N,f R
I pector 9 '
Title r'
U: U3. 94 15:17 Ci►UnTl CI.EkIi VJ l.►!►`L-'! 1.13
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ST CROIX COUNT
WISCONSIN
ZONING OFFICE
k 1 r w ■ ■ • ST, CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 540 1 6-771 0
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEFT FORM
Please specify desired test(s) & remit appropriate fee with
application. outside water lines are often turned off during
winter months, making access to the home necessary. Please make
arrangements with this office to insure that entry can be gained.
Water (VOC's) _ _ _ $185.00 Septic $50.00
Water (Nitrate & Bacteria 45.00 Nitrate & Bacteria
\y retest. $15.00
Owner: ~Ef _~C1`IfYJF2~ Requested by: ce,
Address.- 70
Address:- 0
lfv t?~~6L_ ZIP.-- w--1-- Z I P
Telephone N°: ( _)._.-31 6_--38 _ Telephone N°: (ZC~~-- 3 J,-
6 1...-
cv 1- z - 7 3.5-
Property address (Fire NO & Street)
Location: Sec. T---_--_-N, R___W, Town of
Realty firm: Lock Box Combo: Closing Date: -g---fi
TO__BE_COMPLETED BY_PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM*
Water sample tap location: _
Is the dwelling currently occupied? Ves 0 No
if vacant, date last occupied:_`-_N~/____
Age of septic system.--
Septic tank last pumped by:_____- - - Date:
- -
Previous owner's Name(s) f.ew,~~s..__----------------
Have any of the following been observed?
UY ON Slow drainage from house.
OY ON Sewage Back-up into dwelling.
UY ON Sewage discharge to ground surface or road ditch.
OY ON Foul odors.
Other comments relative to system operation:
I certify that the above information is complete and ':true t4,
best of my knowledge_
OWNERS SIGNATURE:
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OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
IM
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Ho 0.5 C-- 6
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TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? OYes ONo
Soil series per SCS Soil Survey: sheet # ,
Type of soil absorption system: OBelow grd OAt-Grd OMound
Approx. size 'X OGravity ODose OPressurized
Ft.' OBed OTrench ODry Well
OHolding Tank 00utfall pipe
OBSERVED DEFICIENCIES 00ther OUnknown
Septic tank
Setbacks: 011ouse OWell OProp. line 00ther
Dose tank
Setbacks: OHouse OWell OProp. line OOther
OLocking cover OWarning label OPump/Floats
OAlarm OElec. wiring
soil Absorption System
Setbacks: OHouse OWell OProp. line 00ther
OPonding: ODischarge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
N
Inspector
Title