HomeMy WebLinkAbout020-1264-15-000 (2)
RECEIVED T. CROIX COUNTY
JUL 1 ;996 WISCONSIN
ZONING OFFICE
IrrrrN~r~ TCPOIX
(;pUNTY ST. IX COUNTY GOVERNMENT CENTER
19 ZoNtr4G0j:FtCE 1101 Carmichael Road
- y+ Hudson, WI 54016-7710
(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 IR Septic $50.00
❑ Water (Nitrate & Bacteria) 45.00 0 Nitrate & Bacteria
t3 Lead Concentration 21.00 retest $15.00
Owner: 'bNA 4 V l so VIJ Requested by: lam 541Q
Address: Address: N
w ZIP5401CO ZIP
Telephone W°: Telephone N°:
Property address (Fire W & Street) : 500 (6UL -4-rV virw I2G~
Location:_,'-,, Sec. , T _N, R W, Town of l U SO
Realty firm: Lock Box Combo: Closing Date:
02 0-12of - 15-000
a 9.19. /9. saga Cg
TO BE COMPLETED BY PROPERTY OWNER
PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Water sample tap location:
Is the dwelling currently occupied? Yes ❑ No
If vacant, date last occupied: Age of septic system: to L4 ea rS
Septic tank last pumped by: Date: Mpy 23 1944
Previous Owner's Name(s):
Have any of the following been observed?
❑Y NN Slow drainage from house.
❑Y LQN Sewage Back-up into dwelling.
❑Y NN Sewage discharge to ground surface or road ditch.
❑Y &T Foul odors.
Other comments relative to system operation: t1,ev-cr 13e r)
fkny CON Le r VX 5
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:_"
1/94
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
C ar a C-
- -
goy
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? ❑Yes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: ❑Below grd ❑At-Grd ❑Mound
Approx. size 'X ❑Gravity ❑Dose ❑Pressurized
Ft.2 ❑Bed ❑Trench ❑Dry Well
❑Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other ❑Unknown
Septic tank
Setbacks: ❑House ❑Well ❑Prop. line ❑Other
Dose tank
Setbacks: ❑House ❑Well ❑Prop. line ❑Other
❑Locking cover ❑Warning label ❑Pump/Floats
❑Alarm ❑Elec. wiring
Soil Absorption System
Setbacks: ❑House ❑Well ❑Prop. line ❑Other
❑Ponding: ❑Discharge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
N
Inspector
Title
ST. CROIX COUNTY
gyp, WISCONSIN
r~f• 1
4. ZONING OFFICE
p p M p p p p r~~~i ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
July 10, 1996
Tom & Judy Dison
500 Countryview Road
Hudson, WI 54016
RE: Septic inspection at 500 Countryview Road
Dear Mr. & Mrs. Dison:
On July 9, 1996, an inspection of the septic system on the above
referenced property was conducted.
At the time of the inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based on a surface inspection of said system, and did
not involve any excavating or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
Should you have any questions, please contact this office.
Sincerely,
Mar en ns
Assis nt Zoning Administrator
cc: File
C(OPY