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020-1033-00-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 569592 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: Labore, Caul. &Yvonne Hudson, Town of 020-1033-00-000 CST BM Elev: Insp.BM Elev:� BM Description: Section/Town/Range/Map No: 6 �d rtdM d ; 17.29.19.146E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic mi p i Benchmark �t/--• •/�..�... z.s / Z 5 /OZ.5 hero -7 .tP7 Dosing Alt. BM I. �ee�� SQS r Lo 1 t '45 /oo 7 V•7 Bldg. Se 16 4- Holding St/Ht Inlet G • 0 9�.5 �a .17 TANK SETBACK INFORMATION St/Ht Outlet (e• %5 762 97 TANK TO P/L WELL BLDG. en to Air take ROAD Dt Inlet Septic J 7, 15.5 7a !7 5 '91 / g d., Dt Bottom � ! Header/Man. N• � 1�4t o � ✓ �f Aeration Dist. Pipe Holding Bot.System PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Number �•.S / T a� z •3 fro. -'7 TDH Lift Friction Loss System Head TDH Ft Forcemain Length to well �0♦< , ^ . er SOIL ABSORPTION SYSTEM J /v ,. BED/TRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold IDistribution :]fftems x Hole Sp g Vent to Air Intake Pipes) length Dia Length Dia Spacing SOIL COVER x Pressure Sys s Only xx Moue Sys Only Depth Over Depth Over re—path of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil >� Yes � No � Yes COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1:_:�7 /A _/ Inspection#2: / / Location: 963 Trout Brook Rd. udson,WWII Parcel No: 17.29.19.146r- 1.) 54016(SW 1/4 NW 1/4 17 T29N R19W) metes&bounds Lot Alt BM Description= ` ' C6,/� ea ie�s i 2.)Bldg sewer length= tJ..4 -amount of cover= � J a�� �0��� 4 Let,.,� (o•5 Joh -71.5 - V3_ (_lo_`7 �, (o('► �r Plan revision Required? � Yes No L� ?1� Use other side for additional information. — ns - --- SBD-6710(R.3/97) Date Insep or s Si lure Cert. o. PLOT PLAN PROJECT Yvonne Labore ADDRESS 963 Trout B k Road Hudson Wi 54016 SW 1/4 NW 1/4S 17 /T 29 N/R 19 W TOWN dson COUNTY ST.CROIX SYSTEM ELEVATION Existing f 4 BEDROOM r CONVENTIONAL AT-GRADE C ENT IONAL LIFT XXXX HOLDING TANK MOUND SEPTIC TANK SIZE 1256) DOSE TANK SIZE existing HOLDING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. same as benchmark Willow River Trout Brook Road 45' New Huffcutt ST 150' "5 Existing 4 Bedroom � 35' House OFE 45' , 259 d Well L vE � M s. �n 120 -�vvd places-' . 2-5' X 70' Cells Distribution Box Vents 48' Private Road ST. CR O I X L NTY Land Use Planning&Land Information t.5( <�/2�S't/l Resource Management Community Development Department Monday, July 14, 2014 Leonard J. &Yvonne Labore 963 Trout Brook Rd. Hudson, WI 54016 Regarding septic inspection for Leonard J. &Yvonne Labore. Location of Property in St. Croix County: Municipality: Hudson, Town of Subdivision or Plat: metes & bounds Certified Survey Map: Lot: Address: 963 Trout Brook Rd. Dear Applicant: A septic inspection of the above reference property was conducted on July 14,2014. This property is located in the SW 1/4 NW 1/4 of Section 17, T29N R19W, metes& bounds (Lot ), Hudson, Town of, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a 4 bedroom home. Additional Notes: Steel tank re-used in 1989 was abandoned and new building sewer to Huffcutt 1250 gal. concrete tank installed. It will have a sealed manhole cover due to being below the BFE of 704-706' MSL for the Willow River—45' away. Flood proofed for dose tank vent pipe to 713 which is 2'above new Base Flood Elevation of 711. If you have any questions regarding this, please contact our office at 715.386.4680. Sincerely, lot/ Ryan Yarri ton Zoning S cialist cc: file Phone 715.386.4680 Government Center, 1101 Carmichael Road, Hudson, W154016 Fax 715.386.4686 www.sccwi.us/cdd www.facebook.com/stcroixcountywi cdd @co.saint-Croix.wi.us dauan' r `, County .01 Safety and Buildings Division )C, };. 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) -\NT a,� .( M��j W� —7162 _ Q terry Permit App ' n State Transaction ltl NIA In accordance witfi`�W (21 Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address if ditlaent than mailing address) the Departmrnt and Professional Sernm Personal information you provide may be used for sewndary mooses is accnordance with the Privacy Law S.15. 1 m Stats. G L A cation Information-Please Print All Information Property Owner's Name / Pared# Property Owner's Mailing Address 22 Property Location /`7 U K )a Govt Lot City,State Zip Code Phone Number ,> 'V,ZI.12%, Section Z2 Tz�—N; R W Type of Building(check all that apply) Lot# 2 Family Dwelling-Number of Bedrooms Subdivision Name Block# ❑Public/Commercial-Describe Use ❑City of of ❑State Owned-Des CSM Number ❑ Village Describe Use Tows of III.Type of Permit: (Check only one box on line A Com le line B if applicable) A. ❑New System ❑Replacement System Tank Replacement Only ❑Other Modification to Existing System(explain) B. ❑Permit Rwewsl ❑Permit Revision ❑Change of Phmnber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Ow /� - VV16121 N. of POWTS S stem/Com nent/Device: Check all that apply) Non-Prass�aized In-Grouad ❑Pressnriwd In-Ground 0 Al-GCrade Mcnmdd 124 in.of suitable soil ❑Mound<24 in.of suitable soil ❑Holding Tads ❑Oiber Dispersal Component(explain) C� >n�� 6" ❑P �Device(explain) V.Dis ai/T reatment Area Information: Desi Flow(gpd) Design Soil Application Rate(g&o Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation r � VL Tank Info Capacity G Gallons Unmt New Tanks FEE Tanks; S rs rn rn iZ E5 a Septic or Holdins Tank LZ Dog ! ou VII,Responsibility Statement-I,the undersigaZassame a' 'ty for iostallaMm of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Si MPJtvIPRS Number Business Phone Number Plumber's Address( City,State,Zip Co C a,<Q VIII.Conn /Ae ent Use onix �;G Issuing Agent I App�� P ee d e �� � S 7 z ❑Owner G ven Ream for Dna S' �. DL Conditions of ApprovaMeasons for Disapproval T,/A� � / � Z �1, .z� U� SYSTEM OWNER: 1.Septic tank,effluent filter and fluff eeUc� dispersal cell must tZp_servig /maintained r/ /� 1 as per management plan provided by plumber. / 7. a h 7 S�� 2 All setback requirements Must hp maintainod } for the system and satrmit to the Comty oony on paper not less than na:l l iaehes m . as per applicablQl�ft . 1 � 7� - nom- >/�"-�,,/Zit✓ a f/wNj � Q�`�° elD-6398(R.i l/11) 7e /MI5 Z- Cover Page g Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 6/11/14 Owner: Yvonne Labore Location: SW 1/4 NW 1/4 S17 T29 N,R19W 963 Trout Brook Road HudsonSystem type: In-ground absorbtion system(conventional) Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3-5. Maintanance and Contingency Plan 6. Filter Specifications Sheet Signature License num #226900 PLOT PLAN PROJECT Yvonne Labore ADDRESS 963 Trout p k Road Hudson Wi 54016 SW , 1/4 NW 1/4S 17 /T 29 N/R 19 W TOWN dson LL COUNTY ST.CROIX SYSTEM ELEVATION Existing BEDROOM 4 CONVENTIONAL AT-GRADE C ENTIONAL LIFT XXX HOLDING TANK MOUND SEPTIC TANK SIZE 1255 DOSE TANK SIZE existing HOLDING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. sameasbenchmark Willow River Trout Brook Road 45' New Huffcutt ST 150' 5' 15' Existing 4 Bedroom 35' House B.M.* 45' 25' Well 120' 2-5' X 70' Cells Distribution Box Vents 48' Private Road It SNOUV130SSV 3138ONO3 1SV338d NISNOOSIM 8 1VN08VN g-W I uo�'}}n�83nymtAm r IIIL-E2L (SIL) XVJ 2Old33631NI 3SV3 dO d0 838W3w 9I9I-426 (008) 964E-E2L (SIL) O U 1 313 V 0 0 0 (g) 9NI010H '3Ild3S 'dwnd oj Q4 33I3ONd AO-1 '-lVD OSZ'I °0 62LK IM 'Slltl3 VA3ddIH3 ,1,1 n n H iNV1d 031311833 �y OWN o 133KS p-AE21 69117 :133f Oad ICI ----- C U-) I d w F-N Z W ww a > r p F- �i w0J Li QV w = oi5 ca W w ww J I OY =� w o Q � ° LJ o .. W N � Q I W pq Lj- J � Y I =O Q � I v I I I I io ---------------------J d 0 CL U d' r Z N w a 0 13 L� J L� Q W Q Z O Z n r W a J Q d M Fi r w 0 Q — o J Q � n W v i m l F ~ w J O 19'001 1901 ,211 55' _ 47' 8' 3' 44' d 5.75' 2' y A. UI ru N m N W A D 20' 2' N m ? z O+ t0 9 r 7 ❑ < I � e = ty ty L J a 13 D D m z D m D N Od D £oo-0 vj ccm rrl ID m l7 E3 ��= D 0 0 P Z 111 ,II II N � m � ❑D C1 m N Wo W N A G) TI f!'I D A.Z. VN01 Z7 O D 3 C 00 m 00 L-1 < rri DDO� m n m - rZZ C"1D r rn A ca❑ - ❑m z zz ❑z m mr ❑ m - a D Dm � A m r r (4� a zo ❑ rm*I a a mA mm ti I m m u w w r dty zm m m ;a -i m m mE rnd M r', A ❑ r r a.. m 45' 10' =a A A A CE)42' �m rn < e A as m-zi dA ❑y C7 m n Vl m Z C3 C3 m m D A L1 r 2' ❑ E p .r. ti y o0 r---- ----- z -, m m cm w -- Gi o o rn m - o� ti o Dm 0 ro v E m I6 0 A M N mGZ1 C3 N m r p d -i m Z -H < b �Z Z N a ❑O❑ D M r I'-, ;az d ❑ v M d m Ao n me o m VD D Z t7 D M N r z Z W --I W ;u me r m v� r C d ❑ C3 Ar ;a v m c, m A r D M m Z m A m -i Cl :L7 PROJECT, 4154 123rd STREET o N.P.C.A. CERTIFIED PLANT HUFFCUTT CHIPPEWA FALLS, WI 54729 0 1,250 GAL, LOW PROFILE PUMP, SEPTIC, HOLDING, (715) 723-7446 w (800) 924-1516 MEMBER OF: OR GREASE INTERCEPTOR C 0 n C R E T E. in C FAX (715) 723-7111 . www.huffcutt.COM rz r NATIONAL&WISCONSIN PRECAST CONCRETE ASSOCIATIONS ST. CROIX COUNT,! ' SEPTIC TANK MAINTENANCE AGREEMENT AND . OWNERSHIP CERTIFICATION FORM Owner/Buyer V 2., .�Q.� Mailing Address Property Address (Verification required from Planning&Z.oniug Department for new construction.) City/State _ Parcel Identification Nuiaber U `a/Q 3� -/rD—=Q LEGAL DESCRIPTION Property Location Y,AA.A2/4 , Sec.! 7, T Z57N RZ1 W, Town of Subdivision , Lot# Certified Survey Map# , Volume ,Page#_ Warranty Deed# j �✓ Volume , Page# Spec house yes no lot lines identifiabl yes 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§Comm. 83.52(1)and in Chapter 12-St.Croix Coimty Sanitary Ordinance. The property owner agrees to submit to St.Croix County Planning&Zowng 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. Uwe,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 Commerce 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. l/we certify that all statements on this form are true to the best of my/our k.aowledge. Uwe an✓are the owners)of the property described above,by virtue of a warranty deed recorded in Register of UY k is Office. Number of bedrooms 7 IGNATURE OF APPLICANTS) E�- DAT ***Any information that is misrepresented may result in the sanitary permit being rovoked 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.08/05 POWTS OWNER'S MANUAL $ MANAGEMENT PLAN Page Of FILE INFORMATION SYSTEM SPECIFICATIO S Owner o. Tank Manufacturer 0 NA Permit# ASeptic O Dose 0 Holding Volumgr/2��� (gal) Tank Manufacturer Ict�j ❑ NA DESIGN PARAMETERS ' . Vvb11" Number d Bedrooms' 0 NA 0 Septic 0 Dose 0 Holding ume: t9�) Number of Public Facility Units: ANA Vertical Distance Tank Bottom(s)to Service Pad: 1 (ft) Estimated(average)Flow: 416 0 (gauday) Horizontal Distance Tank(s)to Service Pad: Specillc Design Flow estimated x 1.5: (gal/day) servicing mechanics must be provided If vertical Is>16 feat or g (per) ( ) (f r (g Y if horizontal is>150 feet. Specift instrudkxe to be provided an back. In Situ Soil Application Rate: (galldayme) Effluent Filter Manufacturer sg/'Z.. 0 NA Standard(Domestic)Influent/Effluent Monthly average.. Effluent.Filter Model: Fats,ON&Greece (FOG) s30-mglt_ Pump Manufacturer: &..,j S�j n ❑ NA Biochemical Oxygen Demand (BOD9) s220 mg/L 0 NA Tsai SuqwxW Solkis SS 's150 Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg(L Manufacturer. ..��NN (BODs) >220 mg& 0 NA 0 Mechanical Aeration 0 Peet Filter ; 'A 3S >150 0 Disinfection 0 Wetland Pretreated Effluent Monthly average ❑S"Gravel Filter 0 Other: (BODE) 00 mglL Soil Absorption System (TSS) s30�mgIL ❑ NA nd(gravity) 0 In-Ground(pressure) Fecal CoNform(geometric mean s10 0 At;d 0 Mound ❑ NA Maximum Effluent Particle Size 36 in d ia.. 0 NA 0 orb-Une 0 Other Other: ❑NA [Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) en combined sludge and scum equals one-third(')S)of tank volume 0 When the high water alarm is activated Inspect condition of tanks) •At least once every: 8)(s) (Msxifntun 3 years) O NA Inspect dispersal call(s) At least once every: month(s) (Maxhnum 3 years) 0 NA Gean effluent filter At least once every: month(s) 0 NA s) Inspect pump,pump controls&alarm At least once every: mor h(s) 0 NA Flush laterals and pressure test 'At least once every:. morrth(s) 0 NA 0 yWs) Other: At least once every: 0 month's) 0 NA Other: 0 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an Individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware,Identify any tracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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 treatment tank equals one-third(%)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator(pumper)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 fortified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-006(02/05) Page of START UP AND OPERATION For new construction, prior to use of the POWTS chadc treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment-process and/or damage the soil absorption system. If high conoentratkms are detected have the contents of the tank(s)removed I y a Septage Servicing Operator(pumper)prior to use. Pump tanks may 01 above normal highwater Ieve13 prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended,as the excess wastewater will b&-discharged to the sod absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent.and damage'to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator(pumper)prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when sod conditions are frozen at the intrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not.drive or park over, or otherwise disturb or compact, the are@ within 15 feet down ski of any mound or at-grade soil absorption arm. Reduction or elimination of the following from the wastewater stream may impr6ve the performance and prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes,-dgsrstWbutts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats,foundation drain(surnp pump)(dscharge,frult bpd vegetable peelings, gasoline, greases. herbicides, meat scraps,medications,cis,painting products,pesticides,saniNy napkins,solvents,tampons,'and water softener brine discharge. 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 safety abandoned in Compliance with s.Comm 83.33,Wisconsin Administrative Coder; a All piping to tanks,pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator(pumper). e 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 sod 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 eff ect at the time of their permit Issuance. I.A suitable replacement area is not available due to setback and/or soil limitations. If the sod absorption system cannot be abithated and barring advances in POWTS technology,a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area Upon failure of the POWTS a sod and site evaluation must be performed to locate a suitable replacement area. if no replacement area is available a holding tank may be installed.as a last resort to replace the failed POWTS. ❑ Mound and at-Wade 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 TREATMENT TANKS., .PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN UFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE ADDITIONAL INSTRUCTIONS: POWTS INSTALLER 4 POWTS MAINTAINER. Name Name Phone —- -�f` Phone SEPTAGE SERVICING OPERAT PUMPER LOCAL REGULATORY AUTHORITY Name Names- �- Phone ?J= -- Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance vft sections Comm 83.22(2)(b)(IXd)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. APPLICATION FOR THE II I I `IIII I ( I TERMINATION OF DECEDENT'S INTEREST lIIIIlllllil�llllltllhllllllll AND CONFIRMATION OF APPLICANT'S INTEREST IN PROPERTY 8025845 TX:4018555 DECEDENT'S NAME DATE OF DEATH 935233 LABORE, Leonard John January 4, 2011 BETH PABST aka Leonard J LaBore ADDRESS OF DECEDENT AT DATE OF DEATH CITY ST ZIP REGISTER OF DEEDS 963 TROUT BROOK RD HUDSON WI 54016 ST. CROIX CO., WI RECEIVED FOR RECORD PRESENTATION OF DEATH CERTIFICATE 04/21/2011 11:57 AM I certify that I have viewed a certified copy of the decedent's death EXEMPT #: ctifc te. � REC FEE: 30 .00 i � PAGES: 7 G - TER OF DEEDS SIGNATUf A E Recording area THE INTEREST OF THE DECEDENT IN THE PROPERTY NOTED HEREIN Name and return address: IS HEREBY TERMINATED/CONFIRMED UNDER THE FOLLOWING STATUTE (please check appropriate statute) Yvonne R LaBore Ig s. 867.045 which pertains to real property in which the decedent was a joint 963 Trout Brook Rd tenant, had a vendor's or mortgagee's interest, or had a life estate. (You must Hudson, WI provide a copy of the document establishing interest in the real property.) 54016 ® s. 857.046 which pertains to property of a decedent specified in a marital property agreement; survivorship marital property; or a third party confirmation; or 236-0006-02-030/020-1033-00-000 a nonprobate transfer on death as described in s.705.10(1). (You must provide a copy of the document establishing interest in property.) Parcel Identification Number Presentation of recorded document establishing interest in real estate. SEND TAX STATEMENT TO: DOCUMENT# VOLUME/REEL PAGE/IMAGE RECORDS/DEEDS 963 Trout Brook Rd 772491 2643 0051 Hudson WI 376247 0643 0033 54016 Description of the real estate. ® See Attached Description of personal property(if any)being transferred. You may fist savings accounts, checking accounts and securities on attached pages. Indicate person(s) receiving property. DECLARATION: I(We) declare that this document is, to the best of my(our) knowledge and belief, true, correct and complete and is in conformity with the provisions and limitations of the Wisconsin Statutes. Name and Address Applicant's Applicant Signature (List all remaindermen/ Interest in Property (Notarized) Date beneficiaries. if more space is (is; spouse, remainderman, (print or type name below signature) needed, attach ages. beneficiary) Yvonne R LaBore spouse 963 Trout Brook Rd 0 Q � ` 1�� d�� Hudson WI 54016 7 c Yvonne R LaBore ,Rxu. This document was drafted STATE OF WISCONSIN, County of �,` .••••••. ti by:(print or type name below) Subscribed and sworn to before me on: a f �D '.• YO Yvonne R LaBore by the above named person(s): l/ • " NOTE: SEE DIRECTIONS. Signature of Notary or other person t Wisconsin Register of Deeds authorized to administer an oath (as per Association Form HT-110 s 706.06, 706.07) •t Website version 05/2010 Print or type nann '•, •, .••.• • .• 5 D—a 7S'eTitle: c^ l hxpi r•es: B Q Ice- THIS • a. IS A STANDARD FORM. ANY MODIFICA IONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. 1 of 7 Parcel 020-1033-00-000 02/22/2006 10:46 AM PAGE 1 OF 1 Alt. Parcel M 17.29.19.146E 020 - TOWN OF HUDSON Current LX] ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner LEONARD J & YVONNE R LABORE O - LABORE, LEONARD J & YVONNE R 963 TROUT BROOK RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 963 TROUT BROOK RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.300 Plat: N/A-NOT AVAILABLE SEC 17 T29N R19W PARCEL IN SW NW FROM SW Block/Condo Bldg: COR GO E 392' N780' TO POB TH S61 DEGW 327'N20 DEGW ALG RD 90 FT N23DEG E 221' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) S66DEG E33' TH N63DEG E118.9' S28DEG E 17-29N-19W 192' POB Notes: Parcel History: Date Doc # Vol/Page Type 08/24/2004 772491 2643/51 WD 07/23/1997 1145/315 QC 07/23/1997 864/439 07/23/1997 705/159 2005 SUMMARY Bill M Fair Market Value: Assessed with: 91623 253,900 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.300 89,700 169,300 259,000 NO 05 Totals for 2005: General Property 1.300 89,700 169,300 259,000 Woodland 0.000 0 0 Totals for 2004: General Property 1.300 46,600 145,700 192,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 211 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 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT A 2 OWNER v J ANSEIMD TOWNSHIP UySo~ SEC. T N-R I W ADDRESS ~~03 7iPbvT~~''~ ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83Ft SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM o. ?Y Sol DoT I TtE L ~iNK I i~spEcz .,/mar E ~ . D 150 WAS Ire fo,~D K v Ar INDICATE NORTH ARROW 3oTlo r-t ED(~t of BENCHMARK: Describe the vertical reference point used AT s,W , HOUSE' e(WA1E)L .Elevation of vertical reference point: /00" Proposed slope at site: 9O /~uEa o ' a' T3~ 'f i3E 'Pb Skr a 2a- SEPTIC TANK: Manufacturer: S'tE+_~L T'44< Liquid Capacity: ~l S0 D r s~ Number of rings used: ~ y Tank manhole cover elevation: X Tank Inlet Elevation: ? Tank Outlet Elevation: 3 ' Number of feet from nearest Road: Front O Side-0 Rear, O > '/O O feet . , From nearest- property line Front .0Side .0Rear ,O ys / feet Number of feet from: well > s / building: I (Include this information of,the above plot plan)( 2 reference dimensions to septic tank) SRR REV_FRSF. STDR ST. CROIX COUNTY ZONING OFFICE ' 8 ,� St . Croix County Courthouse yid UUU 911 4th Street C� Hudson, WI 59016 L'E � Telephone ( 715 ) 386-4680 The St . Croix County Zoning office offers the ervice of septic s'�v and water inspections to Lending Institutions, Realty Firms, and private individuals . Completion of this form is essential so that the property can be 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: $ 25. 00 XX (For nitrates and coliform bacteria)FEE: $127 . 00 WATER TESTING (For VOC' S ) SEPTIC SYSTEM INSPECTION-----------------FEE: $25. 00 (Determines if system is properly functioning at time of inspection) Property owner 's name Michael and Cynthia Anselmo 963 Trout Brook Road, Hudson, Wi 54016 Property owner ' s address 2 19 Legal Description SW 1/4 of the NW 1/4 of Section 17 , T 9 N-R Town of Lot Number Subdivision Name FIRE NUMBER LOCK BOX NUMBER Color of house Realty sign by house?no If so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, 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 reguestinqq services : First National Bank of Hudson Telephone Number 715/386-6614+ , REPORT TO BE SENT TO• The First National Bank of Hudson 307 2nd Street, Hudson, Wi 54016 Closing da January 19"990 as soon as possible Signature COLMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715 - 962 - 3121 800 - 962 - 5227 t ST. CROIX ZONING REPORT NO.. 00340/01 PAGE 1 ST. CROIX COUNTY REPORT DATE' 1/10/90 +i COURTHOUSE DATE RECEIVED' 1/09/90 HUDSON, WI 54016 ' ATTN' THOMAS C. NELSON Z G�- /0 3 3 ]963 chael 6 Cindy Anselmo OWNER: 4 LOCATION. Trout Brook Rd., Hudson COLLECTOR' . Croix Zoning y E SOURCE OF SAMPLE' Kitchen faucet COLIFORM' 0 /100 ml INTERPRETATION: Bacteriologically SAFE NITRATE-N' 5 ppm Under 10 ppm is safe for human consumption. Conform Bacteria/100 ml Nitrate-Nitrogen: mg/L i i i 1 LAB TECHNICIAN' Pam Gai* WI Approved Lab No. 19 0�A DECENa 7 A N D A� < Means "LESS THAN" Detectable Level Approved by. T SA ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 l PUMP CHAMBER GUEtk-S CON r onvcTS Manufacturer: Liquid Capacity: Pump Model: / Pump/Siphon Manufacturer: 2ot~~~n Pump Size Elevation of inlet: ! S S Bottom of tank elevation: V, d'S r /6, Pump off switch elevation: ~ ~y3 Gallons per cycle: Alarm Manufacturer: 'P L t vE L A ln'vi ?AEA (0 R k ~ 10 1- 4rr~ Alarm Switch Type: l Number of feet from nearest property line: Front, O Side, ® Rear, © Ft. / r Number of feet from well: C-7 S Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM 2 Li,v S Bed: Trench: X 2 3 s~ Width: Length: ~ O Number of Lines: Area Built: Fill depth to top of pipe: ;21/ + G 36 " Number of feet from nearest property line: Front, O Side, O Rear,O It 33 Number of feet from well: Q ~ Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: umber of pits: Diameter: Liquid depth: Bottom of seepage pit eleva on: Area Built: Has either a drop box O or distribut on box been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Cap ity: Number of r/nearest Elevation of bott of tank: Elevation oNumber of fproperty line: Front, O Si O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: I ° r C Inspector i! plumber on job: Dated: License Number: PO NIESITE SEPTIC PLUMBING CO. 6bS C'NEIL RD., HUDSON, WIS. 54016 3/84:mj ROBERT ULBRIGHT .R.S. M.P LIC. N0.3307 WIS. M°STER PLUMBER T9NN d`STALLER & DESIGNER LIC. NO. 00663 . 1 4s $ ¢EEL SE/~ • s~~r~ °~Ry~~% I^yt~ F~lsfi~lr, ~E.~1~FD. C/E~I~E1~ P, Ly 1-7. POP C'BhFFLE$ Fovap. zaTrlcT , 3 e S SPECS ,i ° TkE.v a4,0,5 lmiiE (y ~o .i M EOI~ M . i NM 81' of w4SAiep 3/qu /4NSE(~-~o 4" Scl~• 2?Z-q ~~ST2i(3. P%~ES, 40 J1 Afppftoei> -N p*p- S yotWi c- Fit Q to . 31 • Soo-t, Cx p pca • as p&- ' or Woo pv~P g i . 1AJ 11 III 11 $Wi{[.~. ~ ~ D F F 'REF- P ► . Ej.CV Tloa = y~ ` y3 DERr tc,Troh EDW si pia~r' OF 00 \ ; f q 7,x'3 Pi p~ ry 5 'A70sysr~H 5~c70 - S y sre.~ of , ~R~cnsr co~r„12~~- 9P.y5 6~0 Top of 7Rop Qox w~`N-`~1~ pip,- ~ry cs. wSp~cr~o~ PL-V 1 G ~~UAT10~ OF '~oRC~ MAW l0Ler 33' I ~ ~s ds- ;uAo- Rep' SEpr~c SyS T~~ 145- I,3 U/Z- 7- PG07- Otis-14i~~,v DEPAR-I MENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING • DIVISION bABOR % HUMAN RELATIONS P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: ss~gned) SW., NW, 17, 29, 19W jg CONVENTIONAL El ALTERATIVE tlN A Town of I-ludson ] Holding Tank E] In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECT N ATE: Michael & Cind Anselmo 963 Trout Brook Rd. 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: Robert Ulbricht 3307 St. Croix 119482 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: ARVIN OVIDED:G LOCKIDED:OVER ❑ YES ❑ NO ❑ YES ❑ K1- BEDDING : VENT 12 IA.: 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 CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING OVER PROVIDED ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO FRESH GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: AVENT IR INLET: (DIFFERENCE BETWEEN FEET FROM LINE: PUMP ON AND OFF ❑ YES ❑ NO NEAREST 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: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH ~I TREN~ES: MATjIIAL: PIT DEPTH: DIMENSIONS Z'f / 3 `✓1~ 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 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: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. 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 PERTY WELL: BUILDING: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF F COMMENTS: FEET FROM E: YES ❑ NO ❑ YES NO NEAREST-~ O . 0~ 1 I2_gL 1 V ~ ~ "ter 5 ,tip Retain in county file for audit. Sketch System on Reverse Side. SIGNATURE: TITLE: Zoning Administrator SBD-6710 (R. 06/88) Thomas C. NTe son E Z ®ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code c ~~TM. mime STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 4 yr), 83~x 11 inches in size. El ZZ re/vis on 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 i PROPERTY LOCATION ,m1cH.t,L ' C%~Dy ~~vsE~iyo / SW'/aS 17 T N,R E(or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ' & 3 "TRov T 13,foox PP - CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER UM) 7Q& 13 ?0 CITY NEAREST RO II. TYPE OF BUILDING: Check one ( ) State Owned VILLAGE : I Vofov -Tt7Dffj' 0, ❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms - PAREL TAX NUMBER() /G III. BUILDING USE: (If building type is public, check all that apply) l -f ( - E cao- to 3 :,a) --UQ - Q Qo 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 40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Chonly one in line A. Check line B if applicable) A) 1. El New 27Replacement 3. ❑ 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 EAej x _ W 04 166)( 011"// ~ 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/ y I. ft.) (Min./inch) a?, o / ELEVATION D O 0 • [ f Feet jCd Feet VII. TANK CAPACITY Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Siphon Chamber, Fj K WEE~I T-71 El Vill. RESPONSIBILITY STATEMENT ,ug(,~ R~`Lj~lij j2 4015 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: Roi T 2[/~G,7' ace-e-1 Plumer'~ Address (Street, City, State, ZipCod - DJQ A,115 S 0 'N~ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved San? Permit fee (Includes Groundwater Date Issued Issuing Agent Signature No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determinati n oC 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 INSTRUCTIONS ' .'r 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. Vil. 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 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) " 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. r Owner of property /a C/"'10y`i✓sG'l Location of property S 1/9 Ww 1/4, Section /7 , T N-R Township _ 1+1_)J2 So Mailing address ~F6 3 Address of site s~ Subdivision name Lot number Cp Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes +N0 Volumeo S and Page Number l as recorded with the Register of Deeds. r 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 reco ed in the Office of the County Register of Deeds as Document No. ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the 4natU ction of said system, and the same has been duly recorded in the Office th County Regist r of Deeds, as Document No. f Owner Signatur of Co-own Applicable) Date of Signature to of Signature LIg x -•r-- g is s 5~`3' 9'~ i " iF r~ }i.sk 1~ r f Mal" ''t.,........r. flo Pttrsfi~rtie, spw tir 1M~Mt l1>~ 11~-1l~.rct+aeer. the r tes~11ww#t11M a Ietasou (an edlsd dw4 County. at"* at 1lsettesis: and Cart ' fir:. '.ya 21 TIN fftvd 1 Of 1. atlWSs`47), carted iA Bombast pre ter at M A$* $I IAN tw Totiwttip U (29) , 100ft-R 11" as s # e Bout ist QoecWW of asie 4 lif1,/4) 96 due ael/t a diatanos of 392.0. Of I "M-0 'fsest>'*D rho Point at bsginniritq far the P Qet t tbi ci sou Eh 61002' Mast a disc =e of 327.0 fast, ~ 90*3g of the dd read a disbum of 90.0 'feat; °t 4101V thlk Ckmtwline of the e public road a distasloe of 221.0 owt' ' Sim a dlstainoe of 33.0 feet ca a meeinder line along the of k 6 63! J East a dif l*", CC 13$.9 fret on a meander 13>>te~, tt>Neiloe at distame of 192.0 feet,- to point of beginning, together with NOWAUr Line ad the olantift of Iitillop River and also an r zcd* WOW 4 *2 4 of lmd 30 feet in width lying imnediatyaly adiaoiiit>it bo 9 l atild extending westerly to aoalltect to the existing pt$;1i# 1 (m) (is nett) . hftWtead ptoprtty. Lstnrebaaseari++b potekaoe the p'relbetty and to pay to Vendor at et tidri In the following manner: (a) $19, a30Qr• 'M + Castfati asst (b) the balance of a87.a70Q. a4- tom bMawt tboMt"0'i4,i 9 tee the Ubm" we N%' *NMIPUxobaoft-s oatotlmdtt g hm Um to time at the rate of.-ell:IlCA-._(JU----. per cent agras tD asstsne Veendors r ' Loan 601162 x allaloen, and hold Vendors harmless foe". "le 00, to ' 1d antlerest hereof on the balanoe outstat g from tiv a bf r, of 4:1444IR lpal and,_ pmt per araaa until paid in full jjWd .1 `rx .1a~lterest at the rate of $742.$2 ~aencfngf ~l.esdli i~oat6i:theeifber and including March 1, 1967, rat P" 0 shell be imriesssi .00 qxAca, the per month, to a total of 1. IM, am ~h~.my be pre-paid for 12-month periods on Marc > . the entiroaa v tatsdimg balance shall be paid in full on or befowthe..__lst--_- ~ ...019 .(tbe Nabirity date). p qty default is 1S F Payutent, interest shall accrue at the rate of X per saunas on the eath+rile"rerrtt; r * ; (whist ahaN hxdnd% wlthcwt Halation, delinquent interest and, upon acceleration of maturity; too j11Mp 2 I)~ Furebaue, • INS esxtwod by Vatdor, agrees to pay monthly to Vendor amounts sufficient to Pay reaseM j . ePWW aseenments, fire and required insurance premiums when due. To the wheat get, red WV . Wftd" bms 89"" b apply Pia to these obligations when due. Such amounts received by the Ver fee am-0, a and i~saraace will be, deposited into an escrow fund or trustee account, but shalt not bil~r AF&ft et#aewLe required by law. l 101111 "Is SW be aPPlied first to interest on the unpaid balance at the rate specified and the to Pr ` "4y be propaid without Premium or `ee upon principal at any time)I0ID is the at'ent Of any prepayment, this contract shall not be treated as in default with rq tat do W&PIdd balance of principal. and interest (and in such ease accruing interest from month to month shW ji iZ4 NS =Vmd principal is left than the amount that said indebtedness would have hem had the monthly pa 'aMMka " first gwilisd above; provided thnt monthly payments shall be continued in thil e. nt of credit of e ' 'af iaao''amee er tOftilemnation, the condemned premises being thereafter excluded hereProat. ? Purchases states that Purchaser is satiolled with the title as shown by the title evidence aub>blttfa t te powho 2W "20i"" t°° `00W:easements, reservations, restrictions and rights-•of-wMy of Parchaser, *Pow to pay the cost of future title evidence. I,, title eviJStuw is in i~e,lbe+Ee et as 6e,"040 i by Vead* until th* full purchase price Is paid. 7!arehaoer oiublt beeWtIod to take o b~► P seeion of the Property on:... l,E'b1iL1t' i sle- z ~1r~tr ~y OF istsrOVNr d'. , 3 ~ ~ %y"±t•.' , M*~AFC. f ~ tyre ~ ~ i} I ~wrsbl she snow wt b4 ibm b" SUZ fr' r U i F ~ tlet ~'t!rderttr. - Bii ~ ~ : dip ip neat 1K(~ Qttlt lntseest rya " ; Yo tlattts anal! 1s ! eMeiiiad. Vender oft'' w owl • , free and sire et, aB a!al ti a/m~ dki 44 a< dshldr st Purcjmw, and 409*PL. 110001014^04" r. . . 910" is of the DaDeaee and (a) in the event of a bfault in tie #a7t a,yaefed of drys followiai the SPWfled dim date at 04 107I1 of Pambamar which continues for a period of rriAll~ly at alsiied blr asrufled mail), the scum -12'm' sa e d psf*li fa tall, at Vendor's option and wAbou! i4m ' VsrRi~rr a>tie tdle.►i,K rWts and remediee (sW, met to i s In oqm*: (i) 'header way, at hie o term i aa" Won" and recover the Property thnouph trtrict p~rcberer's full psYment of the entire outatand' babasett+re with dradalt at lrata in effectoawe4 datearedotberammntaduehemundar(i~tr tai;s t~DSltidiDd a~s 0 (1i WatVed r>tml ea for faiiuro to fulfill this , tract . NOW U'ssntofdie may we for specific Parfet aastsy hf arctlne estattwdllm balance, with interest Oereoa t1 #40 ~i r eft asl.llle blinmoder, in whkb event the Property sbaH wow d Illfleisaey• sr (iris Vssdor mW one at law for is the emire~ f +ime sle lids CDetract at an end and remove this C ale ~rsrt ~t rAftbagir $nsissificmnt; and is (v) Vgrdsr_n~ay sob" -Now jklm to collect any rents . isauee or profits a! any oral or written atateaseats or darism,ty . ' actl m eg 9 . r+f~V ei►aa Vendor it sod when purmoed in lidrait"Ky ~0". Sam !aw and Dec eeiDAt to enform any remoedy hereunder (wlretisr aisi~i belodsd is aq jnLdtie evidence shall be added to princ K ipal eked paid b et any action of torealpsnre of thin mseftdi" homestead interest, to Calk" Ibis awta. { of #eh'aM oa. and rents, iseuea, and prolks when Mt r♦~ low or eanv 'y any IKai or .xwitable ink i. the ~ at M .rptisy Isria~ term lease of In odor ~tt stsuec'ia~e payable under this Cdaet is tint pW ice or: I f;: s rle i under this Contract safely as security !Dr eDaveyatue wh et Veudws wrk 1'.irllsaia due and. > pia tail, at Vdya mit oej Nod by ==i - - snow a"* an eDenreri II IMItt thDU alte r under" Co p M!MK to b no and all paymemb so made by Purchases . NOW waft $ie emy dkfrtidt w waivittPrsny other subsequent or peke detiumtt 4 AnNaenr. - 9u An *no v jied K 4aa! ahaB be bmdfnp upon and Inure to tie a min of a* 60% ~sa~ty 1 i (If net an owner of tie Property the 0W* am m ape~e0 of OMiK A riphte is tM Mse+eoL1 anbfaet Property +t "n to 3•i& i. the tlds aM d r _ err of te- f .,...v...-- SEAL) , ~ • ( _AID /=ylBEAL) Wff AUT8sNTICATION ACKNOW16111 D®1[slE? STATE OF WISCONSIN meted t6 St. Croix _ daY of 19....-- Personally came before me th I ist ..._....itil F1F'bYt]dIY . it Elmer W, Kirchoff Lorraa'- 4 Michael AnBelmo, Cr........... "TLE MEMBER STAT£ BAIL OF WISCONSIN Yrathi~ (If not. ' authorite$ by S 7tM,,(IB, R'' St . tx. at. to me known 'W be.the'Terson 4 forecning instruwtont`ind a '~elNSTRUMEtrT=,1hr,yg 6RAp'TEO BY Kfm M Kenrm A W,4: Notary: Public St. Pfn 7C. h)} egtfie~ytica4ed or aeknowiedgPd. Both MY Commi-4sion is permanent. Of date : ftbruary N " - . r iMil4ka! ~ ~ P ' } aR+sdli ~ ~471~d err artnt.J illtiv tUrir.lRfrty,;•e. ;rah -a,+'~g, r STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ✓ C~~~`° ? `/~~L ROUTE/BOX NUMBER . 6 7;00 OF ' 1,10 K• 19d FIRE NO. CITY/STATE 11 r/50 A.1 4olS ZIP F dc~" 0l PROPERTY LOCATION:` 1/4 ,✓6 1/4, Section ? , T L( N, R-Lf-W, Town of 1-f up s0 A,/ , St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result in its premature failfire 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 i 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 ounty Zoning Office within 30 days of the three year expiration date. SIGNED + DATE St. Croix County Zoning Office St. Croix County Courthouse 911 9th Street Hudson, WI 59016 (715) 386-4680 Sign, Date, and Return to above address I 1NGS ANU 7Hr C 1 T Ol DUI LLIII N INDUSTRY, DIVISION P.O. BOX 7969 LABOR AND, PERCOLATION TESTS (115) MADISO N WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) { LOCATION, ION, SECTION: TOWNSHIP/ LOT NO.: BLK. NO.: F68 DIVISION NAME: 5w / / 17 /T4 N/R[ E (or ff u 0s o A-) COUNTY: OWNERS BUYER'S NAME: MAILING ADDRESS: Sf ~oi~' Mle~~t~ / c-;ap, Avs,/,,,o -11~3 -rRovT 'BQack k~0 lfvl~faN G)i. syoi USE - 70 3 60 DATES OBSERVATIONS MADE -LE IPERCOLATION NO. BEDRMS.: COMMERCIAL DESCRIPTION: R I DESCRIPTIONS: ESTS: ` Residence A1.4 ❑New Replace M k r) ~p~D'1 1 RATING: S= Site suitable for system U- Site unsuitable for system ONVENTIONAL: MOUND: IN- dROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) S ❑U ®S []U J ®S ❑U ❑ S R ICRI El S OU DESIGN RATE: _ If Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: GG/tSS Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION O SERVED EST. I IGHES TO BEDROCK IF OBSERVED (SEE ABBR . ON BACK.) B- ~ 7,0 1 J7. `/e ~ y 3 ~ 7 • ~ r /s - so~w~►il s'~- ~r -3 B-Z f'0 /00,36)-4~ 4 r 0, OR Z'e:'0Y es B-3 l •0 03, 6. o It,- B. D f /00-70 r > 0 ' 1,2 S ' ~~,f s . 7 S ' -InA age/ er , B- B- PERCOLATION TESTS IN Ufip K TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD RI D PER INCH P- 3.X 4 Z 6 4 r P_ 23 P- P_ P-S, 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 Zowfk 7A E.A.)c k - t f ` I I i f . for APp. n r E'? rte { } ' I I I SEE ~L_D 1 ,J TN S7Vi~'fiTf~ 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- fi C.-N TE SEPTIC SON. wlsW. G CO. 54016 1411,417 . / F go JF 6r,• ADDRESS: ROBERT ULBRIGHT CERTIFI A I N NUMBER: JPHONENUMBE(optional(: 19 MBER LIC. NO.3307 M.P.R.S. / MINN. ijISTALLER & GF.SIGNt LI CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBO.6395 (R• 10/83) - OVER - l ' E,/i ST/,~J f ~~P~c~tS T S ~/c T/ G T + Y5' ,gssv~+v T~ ~aoo , 106- ~i fir ffoM E7- 13 A i- i4 D FAA411Y J E✓i t7/u r ' r P 2 test s~tc als itic SYS- i cooVeOtl01 r c r~ V 70 f qoi ~d z_ i HOMESITE SEPTIC PLUMBING CO. 6513 O'NEIL RD., USON, WIS. 54016 G - Z Q ROBERT ULBRIGHT 0ST 1 y~ VVIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. aISTALLER & [;ESIGNCR LIC. NO. CM ,r3,9cK ~/a~ f30if'ivGS / y X PCB G S TES )iFcf pr 30 Ti oNI eiP?L-F o~ 4000, s'pi v~ //3aoe- l~v~~>•~,~ = Gov • o /~G dT" ~i/~o cJ /Fi llf~ c~£ckEO FOP, CODE CO.~PIiAA)CA To gF QE-Asvp E✓i STi,~ f 1~eE fS T Shia Ti T. SSVA D Tv lip / 00 S 5 s (-F p0.'l Pu-ipep- - Pioki•-'s cpdyc w'p) PAt 40A)0f12SAT"roJ) MAY 10 -I f e1 U o is 3 13Epip'l-A - oMF i ~ ono 1 po To .~il~~p tNtET O FhMI~y ~~N ~ p oL)TLE7 l5 " 13 O tw y N Pv,,,f G, foie Fv?vRr boo Gv®E~' /~.poe7'S ' U'vpE- P/ ~rr,er ,Pei .w I v foD I f a U ! -----o J o 10 o - - 01 Sys?E~r = o 'Bit • iNLEr A 70 ' BOY, V =9 s° I F/ev~1T ! 40 J HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., USON, WIS. 54016 ROBER i ULBRIGHT ' S7- yr Z VMS. MASTER PLUMBER LIC. NO. 33o7 M.P.R.S. H 0NN. B ISTALLER 5 DESIGNER LIC. NO. 00663 X PC,~G ~ TES 30roAl eP,+E a~ ~ao0 f© v~r ,J CA) Y Fresh Air Inlets And Observation Pipe -Approved Vent Cap Minimum 12" Above Final Grade A ' t 102'.0 4" Cast Iron Above Pipe Vent Pipe' -to Final Grade Me, sh Hay Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution 2-2- Tee pipe 0 0 0 0 0 " Aggregate 0 Perforated Pipe Below Beneath Pipe 3y pock- to Coupling Terminating At Bottom Of System P11C P1-UM~NG CO NOMEgITE N, WIS. 54016 65S C NE►pLpBEP ( UOS GNP 33d7 c M.P.R•S n P~uMB~R u. No. C1C: No. o%6 ,1.. ~npS. MASTE ~ ~ Gc`SIGNr V Fresh Air Inlets And Observation Pipe h Approved Vent Cap Minimum 12" Above s Final Grade ` ~~'V ~'s f{ t'`, r /L/ O , o Above Pipe _ 4" Cast Iron 1•o Final Grade Vent Pipe' Ma ynthetic Covering Min. 2" Aggregate Over Pipe Distribution 2?.x j Tee Pipe 0 0 0 0 0 Aggregate 0 Perforated Pipe Below 3Beneath ~ 0 Coupling Terminating At Bottom Of System ~ 17 D' I 1 PAGE OF PUMP CHAMBER CROSS SECTION AAlD SPECIFICATIONS Z. VEWT CAP 'i C.Z. VENT PIPE WEATHER PROOF APPROVED LOCKING; JUIJCTIOIJ BOX MANHOLE COVER 25 FROM DOOR, 12"MIU. WINOOW OR FRESH I 1 GeAIR INTAKE I y'' 7/~~DE Z GRADE COWDUIT \ _ - IB"MIN. ~O PROVIDE I I 9 INLET AIRTIGHT SEAL i III /l III APPROVEDJOINTS APPROVED JOINT A I I I i W/C.I. PIPE { w/C.I. PIPE EXTEWDIWG 3' II I II ONTO SOLID SOIL LXTENDIAIG 3' ALARM ONTO SOLID SOIL, B I I ON j LLEV. FT. INg D y O PUMP OFF h I r~~K COIJCKETE BLOCK , RISER EXIT PERMITTED GIJL~i IF TANK MANUFACTURER HAS SUCH APPROVAL t 1, S P E C. I F I'CAT I DKI.S GOD SEPTIC E DOSE CC S `tJ-JG.Q'~lQ ~Q _ - TAIJKS M AM U FAC T U R. I- R CUMBER OF DOSES: PER DAM TAWK SIZE: /C GALLOIJS DOSE VOLUME -GALLONS /,h -off INCL ALARM MANUFACTURER: CTL MODEL 1JUMBER: UOIMG BACKFLOW: UL CAPACITIES: A=22 INCHES OR GALLOW5 Alyt7"~ B = INCHES OR 3 GALLOWS SWITCH TYPE,: C = 9' 02 WCHES OR -•GALLO►JS PUMP MANUFACTURER: l MODEL NUMBER: 2 D= v" d IN CHES OR GALLOWS SWITCH TYPE R~~R T/,ojfS NOTE: PUMP A►JD ALARM ARE TO BE : ~ INSTALLED ON SEPARATE CIRCUITS t'\IMIMUPI DISCHARGE RATE GPM VERTICAL DIFFERENCE DETWEEIJ PUMP OFF AND DISTRIBUTION PIPE.. / FEET 1~ ms`s + MI►JIMUM . IJE1'WORK SUPPLY PRESSURE . . . . . . . . . . . FEET + 100 FEET OF FORCE MAIN X _0 F~oFr.FRICTIOM FACTOR.. LAO FEET TOTAL. OtWAMIC. HEAD = " 3 FEET Q lQQ • Orr ~o u~vv 77 y -;WIDTH - ;LIQUID DEPTH INTERIJAL DIMEIJSIONS OF TAIJK: LICLOSE AIUMBER: DATE: S_IGt..IE D: ' f jo M-41 E - /6 • 0 1 AM /9i. j 116 iD 5 ~ -dam, l ss 6 HEADI 34 4 11s CAPACITY 111111 I-V Ai" 32 105 - - - CURVE ~ S0 100 - - - 95 - I 26 t - 80 26 t 85 - - EFFLUENT 24 80 MODEL and Q 75 MODEL 189 _ DEWATERING = 22 70 X65 V 20 65- Q 2 t8 60 - 55 J 16 50 MODEL O 163 MODEL F- 14 45 188 12 40- 35 - - - - - - 10 MODEL 30 137,139 - MODEL 185 SEWAGE and 6 25 - DEWATERING 6 - 20 - - - - MODEL 15 MODEL 161 4 - 97 H W 2 MODEL - - - 5 53, 55, W ~ 57, 59 i 0 GALLONS 10 20 30 40 50 601 70 80 1 90 -100 1110 24 80 - - IT 75 LITERS 0 80 ISO 240 320 400 22 FLOW PER MINUTE 70 20 ~ MODEL--- G 18 -so-- - - - - - 295 \ - Z 16 55 - - - - - V 50 - Q 14 05 MODEL Z - - - - - 294 p 12 40- - J 35 MODEL - - H--? 1 p 293 _ f r- O 30 I MODEL F- I 1 284 - _ _-r 8 25 1 l MODEL 6 20- y82.__ ;a - - , t - - ZZ MODEL Z 2 267,268 ZAZZ a 3280 Old Millers Lane GALLONS 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 P.O. Box 16347 Louisville, Kentucky 40216 LITERS 0 so 160 240 320 400 480 560 640 720 (502) 778-2731 FLOW PER MINUTE . i HEAD CAPACITY cast iron Series UNITS/MIN Feel Melers Gat Llrs. • AtllonlatiC Or Non-Automatic. 5 1,52 57 216 • H.P., 1 Ph- 115V or 230V. 10 3.05 51 193 r • Non-clogging vortex impeller design. 15 4.57 43 163 20 6.10 27 104 • Passes ' solids (sphere). Lock valve 24 s is 1 NPT discharge. f n. • Float operated submersible (Nema 6) mech- anlcal switch. i ' d' 97 Series listed sc-2225 • Automatic reset thermal overload protection. • Stainless steel screws, guard, handle and arm and seal assembly • Watertight neoprene "I I' ring between motor and c. a tilA da as pump housing. C A,-i, Approval avAilaLit N97, non-automatic. available packaged with a piggyback mercury float swilch. L