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Parcel 020-1080-90-000 02J02/2005 10:07 AM
PAGE 1 OF 1
Alt. Parcel 29.29.19.330D 020 - TOWN OF HUDSON
Current X, ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* GROVES, DEAN A & CINDY
DEAN A & CINDY GROVES
796 GHERTY LA
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 796 GHERTY LA
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.010 Plat: N/A-NOT AVAILABLE
SEC 29 T29N R19W NE NW LOT 2 OF CERT Block/Condo Bldg:
SURVEY MAP IN VOL I PAGE 62 ORD & THAT
PT OF LOT 1 OF CSM IN VOL I P66 DESC IN Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
VOL 584 P 116 EXC AS IN VOL 584 13117 ORD 29-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2004 SUMMARY Bill M Fair Market Value: Assessed with:
48275 254,000
Valuations: Last Changed: 06/09/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.010 40,100 156,400 196,500 NO
Totals for 2004:
General Property 2.010 40,100 156,400 196,500
Woodland 0.000 0 0
Totals for 2003:
General Property 2.010 40,100 156,400 196,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 220
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
1
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER DFA /V TOWNSHIP HLe 5 on
SECTION--2 T~N-R W
ADDRESS M 6ha iffi4 La a a_ ST. CROIX COUNTY, WISCONSIN
n tN LAJ
SUBDIVISION _G S M Va~ asp (0G LOT Z LOT SIZE z ,5 hea- 5
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4 Go. IZ o a-c~
ryV Vs
No..~sc•, c P ~
~0 h ~ c 2 &-xs;4i h p/y w45
00 o P
D/iUt Wa~/ I
~ - - - - •P' ~Q'T~~ n- Ribb~~~ T
scald ~~y'=
INDICATE NORTH ARROW
BENCILMARK: Elevation and description: <-k T./
Alternate benchmark19A.
SEPTIC TANK:Manufacturer:(4)e-)scN- Liquid Cap. Oo
Rings used: I Manhole cover elev:(p~Final grade elev: q,
Tank inlet elev.: ,0 Tank outlet elev.: TI 5
No. of feet from nearest road:Front , Side , Rear)( Ft.1-2-1_
i
From nearest prop. line:Front , Side , Rear Y Ft. ll`1'
No. of feet from: Well Cpe , Building: I
(include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
I
PUMP CHAMBER
Manufacturer: ,4/A 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
rench : Seepage Pit:
-
Width:-I'? Length 3b Number of Lines: Area Built o~tglS,'11
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: qo
No. feet from nearest prop. line:Front/k , Side , Rear Ft.(<>5-
No. feet from well: 1_No. feet from building Vol
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
I
Elevation of inlet:
No. feet
from nearest prop. line:Front Side Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
1 INSPECTOR:
DATE : PLUMBER ON JOB:
r
LICENSE NUMBER: /f'f "I y^ 3 Z
6/90:cj
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
State Plan I.D. Number:
S0i 11 S eC. 29-T29-R19 (It assigned)
Town of Hudson Lo, ] 2 CONVENTIONAL ❑ ALTERATIVE
Ghar Lane Hol Ing Tank ❑ In-Ground Pressure ❑ Mound
NAME OF RMIT HOLDER: ADDRESS OF PERMIT HOLDER: i~7 INSPECTION DATE:
Dean & Cindy Groves 796 Gherty Lane Hudson WI REF.P .3 S REF. PT. ELEV
/
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:
Name of Plumber: MP/MPRSW No.:' County: Sanitary Permit Number:
Doug Strohbeen 5432 St nix _ 1 0
0,619 V A--
SEPTIC TANK/ O 9, 3 _ u.-r
11
MANUFACTURER: LIQUID CAPACITY: TANK INLE EV.: TANK OUTLET ELEV.: LABEL LOCKING COVER
r PROVIDED:u,,,K PROVIDED: b~
/Oa? (vim ❑ YES ❑ NO ❑ YES NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: CriVe ~~xPROPERTY WELL, BUILDING: VENT MESH
n ALARM: FEET FROM f y LINE: AIR INLET:
104
~a
❑ YE NO `1 ► A ❑ YES NO NEAREST /0D 6(D
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARN G ABEL LOCKING OVER
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERA MB ER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEE LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: IAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to contin
CONVENTIONAL SYST M: " ' r-r1
WIDTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH TRENCHES: MAT IAL: DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPT DISTR. PIPE DISTR. PIPE DISTR. PIPE MATE AL: NO I TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE CO R' ELEV. INLET ELEV. END: V.IC,, l~.Q PIPES: FEET FROM LINE: r r ( AIR INLET: /
cot jP J_q W, 4, r~ , 4r (t5 ' G NEAREST 7/CI71 ell) 5/S
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 [:1 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: TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL] NO. DISTR. DSTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
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
!X c~~.~.~.rL1 r
o~.r-ei1 tc~-Q-~.~, , c~( yso-~'~►-~ ar, c~.~wX. c.~~ ~ ~a ~ov~ ~7 ~ ~.c~~rr~ ~1
Q
fain in county file for audit.
Sketch System on
Reverse Side. SIGNA RE: TITLE:
SBD-6710 (R. 06/88)
SANITARY PERMIT APPLICATION
ti 'Zt01LHR In accord with ILHR 83.05, Wis. Adm. Code couN
STATE SANITARY PERMIT #6
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑
8% x 11 inches in size. c is n 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
D4.0, 't + C~WJQ ~'/a W%,S Z9' TZN,R 1 4? E re%D
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Z, I
Qi o a,
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
o►^ W T /G c5m o 4 4o
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD {
❑ State Owned 13 VILLAGE : ~0 loti a~-~ L j
~OWN ❑ Public N 1 or 2 Fam. Dwelling- # of bedrooms i PARCEL TAX NUMBER(S) c)(Dd _ td pc ~Q _QQ0
111. BUILDING USE: (If building type is public, check all that apply) 3 p 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. ❑ New 2. LrAj Replacement 3. El Replacement of 4.0 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 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
4t $cj om
(1/51 (o y~ . 7 7- Od Feet 17. Str 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 strutted
Se tic Tank or Holdin Tank OCD Gr)eLift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Si nature: o Stamps) MP/MPRSW No.: Business Phone Number:
Der dL s St Iron L %A& h 3 Z.. z 1(-7 7K Z-
Plum 's Address (Street, City, State, Zip Co
N S '(D
I.X. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Ilsurchegeroun water ate Issued, Issuing gent Si nature (No ) Fee)
Approved El Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
i
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety S 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.
it
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.
11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
Ill. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
Vlll. 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
tans must include the following: A lot drawn to scale or with
p ) p plan, e o 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)
i
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 got resale by
owner/eonttactoc,(spec house), then a second form should be retained and
the
completed when the property is mold and submitted to this office
appropriate deed-recording~------------------------------------------
Owner of property 'Q u
Location of property A1,5-/4 1/4• Section T_9i4_.r"R_Z_L_<j~
Township
Mailing address
Address of site
ldbdlvision nsmo ~ 'e
Lot number
Previous owner of property ~g ~ 1~ r 7 5a LD
Total also of parcels
Date parcel was created l g T3
Ara all cornets and lot lines Identifiable? so __110
Is this property being developed tot resale (spec house)? as 0
Volume 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 PACE 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 Ceitifled 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)
knowledgef 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. 2- - f and that I (We)
presently own the proposed site for the sewage dispo al system (or I (we) have
obtained an easement, to tun with the above described property, for the
construction of sold system, and the same has been duly recorded In the Office
of a County egistat of Deeds# as Document No. J.
Signature of owner Signature of Co-Owner (If Applicable)
///&/9v
Date of signatute Date of Signature
~io
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SEPTIC TANK MAINTENANCE AGREEMENT ~
St. Croix County
w
OWNER/ BUYER D C; 6 J O V
0
Fire Number 794o o
ROUTE /BOX NUMBER tj
CITY/STATE 1t~ dr,o;.~ W= ZIP ~,i 10 0
PROPERTY LOCATION:' Section 'x-9 T 2-7 N. R /9
Town ofSt. Croix County,
Subdivision G5 M Vo I L _PG Lot number Z
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Proper maintenance con-
sists of pumping out the septic tank every three yearn put sooner,
if needed, by a licens'ed' 's'ept'ic tank pumper. What you p
the system can a ect t e function of the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents-may be eligible t grant
a maximum of 60% of the cost of replacement whit 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't'ems 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 oandd licensed mater plmrber,
veri-
journeyman plumber, restricted plumber
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
essary),
sent s apthan 1/3 proximately l 30 of days sludge
to
dc~
Certification septic-.tank
Certification form will be sent approximately 30 days prior to
form c will k be is
three year-expiration. y
0
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 Wisconssi D Tart- Ir
ment of Natural Resources. Certification form must b completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED ~2LAM-_-
DATE 7
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
_ DIVISION
P.O. TESTS (115) . BOX 7969
MADISON, LVI 53707
3707
OLHR 83.090) & Chapter 145)
J 0WNSfHIP/AAUULCIBA4-4-T-Y LOT-7NO.:BLK. NO.: SUBDIVISION NAME:
11/(1 /)E T
Ior) 1,~C3 r~a'nJ 4 / S r} ~cL I ~~(a 6
:r? 3 BUYER'S N AYE MAILING ADDRESS:
t _ •,~.:->v~ 79 r ,1e.e-r.i L~N>r Nv145a ti W +
DATES OBSERVATIONS MADE
41- t 0 1i:iERCIAL DESCRIPTION: PROFILE f I FjIPT10NS: ERCOLATIuiJ TESTS:
CNew Replace / I l c~ ~i - i t i
r
or s;stem U- Site unsuitable for system Igoe
I-%LI I J-GROU D-PRESSURE: SYSTEM-IN-FILL HOLDING TA K: RECOMMENDED SYSTEM: (optional
I L,
.d IiDESIGN RATE: I If any portion of the tested area is in the
C-1LA55 / Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS
ICrJ 0 ` TII 1-0 GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, PdD DEPTH
C'E 5_.RVED_ EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) > 16,
5b &L-r-1
I
l ! i 7 Z /rUr L-r5 2 51L /2rll?r~h~nl' :'.7G1 f'i,l;:•#Gt2.
-
> ~j•5C) 1?_~t LLTS f3'Y~e.,S,~ 4
III; ,r ' > 6'~AL`~(
I
PERCOLATION TESTS
E, ! TEST TIME DROP IN WATER LEVEL-INCHES RAT= MINUTES
111,NTERVAL-MW. PERIOD t PERIOD P Rt. PER INCH
j 3 ?2 >2 > L
! 1'' 1 3 'Z >
71
,:is of pcrco!ation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
:terencr. I>oin[s all
cf show their location on the plot plan. Show the surfacr elevgtion aj_all boring
oo + is and the direction and percent
U ~ . 5~ G r1 l r 1, t i...~ f'r~`•~
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rvo•CU TN
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, 73
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IT
;i`y that the soil tests reported on this form were made by me in accord with the procedures and methods specified in It,,_ 1'Jisconsin
t the cfa[:t recorded and the location of the tests are correct to the best of my knowledge and belief.
TESTS WERE COMPLETED ON:
c Cj.
I J CERTIFICATION NUf41QER PHONE i Ui,-1i;.i3(c;o[ onal►:
CST SI TURE:
. ;n Local Authority, Property Owner and Soil Tester.
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