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020-1184-20-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 572805 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)]. � City Village X Township Parcel Tax No: Permit Holder's Name: 020-1184-20-000 Ka aun, Sue I Hudson, Town o CST BM Elev: r.BM Elev: BM Description: D d N� Section/Town/Range/Map No: /bb G S��� 20.29.19.1161 TANK INFORMATION ELEVATION DATA FDosing MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark . $O l�U G Alt.BM �. ZZ 9 4 .7 g Aeration �� Bldg.Sewer 5 s��t Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Ven Air Intake ROAD birintet—'�,I 6'3 Dt Bottom V 61pd1 ! 1 y •3D l Header/Man. J� •� $$,.f`J Dosing I Z •� Aeration Dist. Pipe / . Bot.System 3 Holding Final Grade PUMP/SIPHON INFORMATION - Manufacturer Demand SLr1overf— !1 1 , 'S3 75, q GPM p 1�' 47 L•. Model Number TDH Lift riction Loss System He Ft Forcemain Length Dia. Dist.to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Dept DIMENSIONS 3 1 46 -T7e.�1J-.-06 SETBACK SYSTEM TO I P/L 113LDG WELL LAKE/STREAM CHAMBER OR Manufacture INFORMATION Type Of System: UNIT Model Number: h DISTRIBUTION SYSTEM Z-- x Hole Size__ x Hole Sp cin� g Vij Air Intake Header/Manifold �( Distribution p��C✓�.. ,L Pipe(s) �. Length Dia T Length Dia pacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Mulched Depth Over \ xx Depth of xx Seeded/Sodded Bed/Trench ch Center 5 Bed/Trench Edges \\ Topsoil 0 No No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: / / Location: 495 Lassie Circle Hul 54016(NE 1/4 SE 1/4 20 T29N R19W) Pinegrove Heights 1st Lot 21 Parcel No: 20.29.19.1161 1.)Alt BM Description= 2.)Bldg sewer length= �5 1� �ad 5 L re -amount of cover= 3 ! Plan revision Required? Ed Yes No b Use other side for additional information. Date Insepctoes Sign re Cert.No. SBD-6710(R.3/97) sac QQiY Q su pa"n prop. • I°•wt� 9 � 93.0' U rl i 4e .1 Propo seal wres cw'c'- Lo 1.21 Id/a 1 o,P,-ne("�e �ikc �' r-' r, i iFflKt t�/,ZS �c l,cmv�.,P. /J�t'�E 45Adotn•, r Ol:- r- • � O„ZQ-af 6,e' if ell acr e3 �i�r �/ Su.r•Fa.ct =91.x" � � �; i' wey �/ ' t�Si d�✓I� � � r r' t /r r ' Gt7.GL7: �/c�Q�•Dl7S sePt✓•��s,,,(/,r1s,,,Co%���•:�.or�'(�,d.=9fg•Sal E,r,�'nc,oG�,ous4./eel,�{,•/tr�:�"re 5ur�ct::9x.38: Mfr 'Ot-- lQt' Q" _JS � �•`� ;�Pro�os�.d d;pe,rs;rnn da..Pre e3nT4r County Safety and Buildings Division St.Croix 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) Madison,WI 53707-7162 rot+Ati (-' V it AppUAii - State Transaction Number In accordance with S1�'E 1s.Adm.Code,submission of this form to the appropriate governmental unit Na is required prior g a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different thin►mailing address) the Department df sty and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(l m,Stats. 495 Lassie Circle I. Application Information-Please Print All Information Property Owner' ame Parcel# Sue Ka aun L.J 020-1184-20-000 Property Owner's Mailing Address Property Location 6 495 Lassie Cr. Govt.Lot City,State Zip code Phone Number N '/., SE'1/4, Section 20 (circle one) Hudson,Wl 54016 715 386-78 T 29 N; R 19 E or W IL Type of Building(check all that apply) Lot# Block# or 2 Family Dwelling-Number of Bedrooms 3 21 Subdivision Name ----_) Plat of Pine Grove Heights, 1 Add n. ❑Public/Commercial-Describe Use a�' tA+�G Na ❑City of —7 ❑S Owned- Use CSM Number ❑Village of ! + /� G Na L9�1 own of Hudson III.Type of Permit: (Check o ne boa on line A. Complete line B if applicable) 26 A- ❑New System 94eplacxinent System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Num and Issued Before Expiration Owner <3 17— IV.2t of POWTS System/Component/Device: (Check all that apply) on-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(explain) ❑Pretreatment Device(explain) V.Dispersalf][7reatifient Area Information: 1 or-Q4 Plus"Standard chambers&c Vend caps,Pol Lok PL-525 effluent filter in new Wieser filter canister Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposeel(sfl System El ev ibtt'-----" 450 Gpd 0.70 Gpd/Sq.Ft. 642.86 sq.ft. 6560 Sq.Ft. ,,// 3 5 a(,j r VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units 0,w'n/ C7 New Tanks Existing Tanks jP Y a 3-0 I a ll � �"U (n vii f Septic or Holding Tank 1,000 1,000 1 Weeks oncrete X Dosing Chamber ' yu / t VIL Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature I MP/MPRS Number Business Phone Number Gary Zappa M[PR.S 222373 715 386-2850 Plumber's Address(Street,City,State,Zip Code) 715 e St.N,Hudson,WI 54016 VIII.Coun /De artment Use Only Approved ❑ rsappeere Per�miit Feee Date Is issuing t Signature tven Reason for Denial $ / 7✓ lD 7 / UL Condit#g��. Reasoos for Disapproval 1:" Septic tank,effluent Mar 3) �Srt GsCi dispersal cell must all be services/maintained ( as per management plan provided by plumber. V"a-ti Yc.`� tt�i+�- d,✓ ' " 2. Aq so6actG oqukements must owMaUftined as per applicable code/or&uirlces. �- Attach to complete plans for the System and submit to#e County only on paper not less than 81/2 z 11 inches in size SBD-6398(R. 11/11) Conventional POWTS Index & Tilte Sheet Project Name: Kapaun 3 Bedroom Replacement Conventional POWTS Owners Name: Sue Kapaun Owner's adress: 495 Lassie Cr.,Hudson,WI 54016 Site address: Same Project Location: Subdivision: Lot 21, 1st Add"n.to Pine Grove Heights Legal Description: NEv4SEv4,Sec.20,T.29N.,R. 19W.,Tn of Hudson,St.Croix Co.,WI. Parcel ID#: 020-1184-20-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Filter tank Cross section Page 8 Esiting Septic Tank Certification Page 9 Parcel map Page 10 Septic Tank Maintenance Agreement Page 11 Waranty Deed Attachments: Soil Evaluation Report Mater Plumber Restricted Service: Gary Zappa,Dept.of SPS Credential#222373 Signature: Date: „_ Page l Of 11 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS,version 2.0 S$D-10705-P(N.01/01) �.SSi2 ei�c/Q Sac Ae: =00 su 4t K4Pa"n?,-Oa t p r scd W res Cc.-,cre-EP Loft P/ o, me"e, Pj c, ' FL-�zS E�5�i.��,uJ¢eks /lcryl S/' Add h. spn`u �� ,ti- D efflke�.tF'/btr G-.c.lVi� �IEyf/3EY�Sec,1o,T1y�(� _9rd o oc. rat-yr y ' ^- • � � � ara � mss:zz V E/c yQan3: L3cG�moFAosc5e5.�1;•+r,: U E,4-�-�d.�ocs�ee�;�{,•/�wG"✓e ���e�9x..38: s a� Q- a� S �, ; ��epose.d d;Jens;rn�oQ.Pre t KAPAUN DISPERSAL CELL SIZING CALCULATIONS 1. (3bedroomsx100 gallons estimated flow)(1.5 design factor)=450.00 Gpd design flow 2. Infiltrative capacity of native soil=0.7 gpd/sq.ft. 3. Absorption area required: 642.86 ag,& 4. Absorption area as proposed:_657.40 4.ft.(326ambers total) Infiltrator"Quick 4 Plus"=20.00 sq.ft.EISA per chamber,"Quick 4 Plus"end cap/pair=5.80 sq.ft.EISA 642.86 sq.ft.—(3 pair end capsx5.80)=625.46 sq.ft. 625.46 sq.ft./20.00=31.28 chambers required Number of trenches: 3-2 Q)11&1 (a7 10=32 chambers total Trench width: 2.83' Trench length: 47.00'.47.00'&43.00' Trench spacing: 9.00'on center Total system area w/9'center spacing: 21.00'xL47.00' Pg.3 of 11 Soil Absorption System Cross Section 9/0'_ ♦_ 6.0' ft f 5. ft 4"Schedule 40 �i$,SDI Final Grade PVC Vent Pipe With Vent Cap 89®Sb'ft 875 � Leaching -► 88•� Chamber t-- .4fft System Elevation ,�•$ ft (o ft ft Soil Absorption System Plan View 1�7; V7�e ,l3 ft 2 83 ft { (� ft Leaching Trench 1 Chambers 4" Dia. Trench 2 Header Vent Or Observation Pipe Trench 3 Leaching Chamber Specifications Manufacturer And Model �Z- 4-&w 10"0-y�"� ,Q/Ia//O AS EISA Rating .2-0.0 sq ft per chamber Soil Application Rate 0.7 gpd/sq ft 4&0 gpd Design Flow- 0.7 Soil Application Rate :- AO-0 EISA= 3.2 Chambers 3 rows of_14,&110 chambers each. lam` Page of Conventional Septic System Management Plan Pursuant to SPS 383.54,Wis.Adm.Code ral The conventional septic system shall be operated in accordance with SPS 382-384 Wis.Adm.Code,and shall be maintained in accordance with component manual SBD-10705-P(N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Questions on the operation or maintenance of the system should be directed to the installing plumber,Gary Zappa at(715)386-2850 or the St.Croix County Zoning Department at (715)386-4680. Septic Tank Septic tank servicing mechanics comply with SPS 383.54(lXe). Septic tank to be located within 150'of service pad,with bottom of tank to be<_ 15'below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113,Wis.Adm.Code,by an individual certified to service septic tanks under s.281.48,Stats. If the contents of the tank are not removed at the time of a biannual assessment,maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank.The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm,the filter shall be serviced if the alarm is activated. Septic tank manholes risers,access risers,and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound,defective,or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33,Wis.Adm.Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce,Safety and Buildings Division. Soil,Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic(other than for vegetative maintenance)over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-March)dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 224mg/L BOD5, 150 MG/L TSS,and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional,more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two-year schedule by use of diversion valve. Effluent to be diverted from new cell to old Drainfield at 3 year anniversary of new system installation. Old drainfield to be utilized for a 1 year period. Effluent dispersal to be alternated between systems on a two year rotating basis thereafter. Qatinaenev Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Pg.5 of 11 Filters PL-525 EFFLUENT FILTER ( J I� 1,.c..kaiF;S54t:z"C`.",rih^...66is5`'.,te •�E'9i` Polylok, Inc is pleased to add its ,_,°.....,.__w � new commercial filter to its existing t line of quality effluent filters.The PL-525 is rated for over 10,000 GPD s Alarm (gallons per day) making t one of Accepts PVC p Y g I accessibility extension handle the largest commercial filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1/16° removed for cleaning, the ball will filtration slots Rated for over float up and temporarily shut off 10,000 GPD the system so the effluent won't I leave the tank. No other filter on the market can make that claim! Accepts 4"& 6" t SCIiD.40 Pipe PL-525 Maintenance: The PL-525 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning. it is recom- mended that the filter be cleaned r every time the tank is pumped or at least every three years. If the installed filter contains an optional § alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be Gas deflector done by a certified septic tank Automatic shut-off M !' pumper or installer. ball when filter is removed 1. Locate the outlet of the t U.S. Patent No;6,015,488 septic tank. 5,871,640 2. Remove tank cover and pump L" tank if necessary. L.-525 installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the tank. Make sure all solids fall 4" or 6" outlet pipe. If the filter is not centered under the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover. 6l. &all 1„ 43� D m� (A D D O O m�-a D I O Z D - I m Z r m D r n O 2" rnAr Dr N0 N �C7 372„ 2„ z m 6„ cl O m r n D = m mD Q o o z O m 18" MIN. < r C m m N A m \ A C � G \ / D 4 r p D r -+ O z 37" 22„ e c a = N + C m m O 'T 0 N m D D Ni D N Z In I r Ln N mN w m ;o D r n 0 m m � 0 ZD O , r m C m m ---I D —i �u D_ r m ,1 (J� O m m D D D z r c— O_ { Z FILTER CANISTER DETAIL SCALE:3/4" = 1' REV NO. DATL \^° MIESER COt1CAETE DRAWN BY:SWT J �z SEPTIC MANUAL W3716 US HWYIO. MAIDEN ROCK, WI 54750 DATE: JANUARY 2008 z REV. JAN. 2008 800-325-8456 FILE:SHEET 13 P� Ewa 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: (Street address) ass Lassie Cr,,Hudson,wi 54016 located at: NE '/a, SE '/4, Section 2 , Town 29 N, Range 19 W, Town of Hudson , 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 SPS. 384.25, and it(they) appear(s)to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No X (if no, skip next line.) Approximate volume or length of time: Na gallons Na minutes Tank Capacity: 1,000 gallon Construction: Prefab Concrete X Steel Other Manufacturer(if known): weeks Concrete Age of Tank(if known): 24 years Permit number(if known) 135337 / J Gary Zappa (Lice be ignature) (Print Name) MPRS MPRS#222373 (Title) (License Number)MP/MPRS September 23,2014 (Date) Form to be completed by licensed plumber(Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 ��, y We s ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Sue Kapaun Mailing Address 495 Lassie Cr., Hudson, WI. 54016 Property Address Same (Verification required from Planning&Zoning Department for new construction.) City/State Parcel Identification Number 020-1184-20-000 LEGAL DESCRIPTION Property Location NE '/4, SE I/4, Sec. 20 ,T 29 N R 19 W,Town of Hudson Subdivision Plat: Pine Grove Heights 1st Addh ,Lot# 21 Certified Survey Map# Na ,Volume Na ,Page# Na Warranty Deed# /J 3 (before 2007)Volume ,Page# Spec house GyesMno Lot lines identifiable Oyes[]no SYSTEM MAINTENANCE An 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 this 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 warranty deed recorded in Register of eeds Office. N ber of bed s 3 GNA LICANT(S) X DATE ***Any information that is misrepresent d 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) 5- 953313 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 03/28/2012 09:01 AM EXEMPT # NA REC FEE: 30.00 TRANS FEE: 302.10 QUITCLAIM DEED PAGES: 1 (the purpose of this deed is to add person to title) Document Number **The above recording information verifies that this document has THIS DEED made between SUSAN L.KAPAUN,a single p , been electronically recorded DEED, UN� erson &returned to the submitter residing at 495 Lassie Circle,Hudson,Wisconsin 54016,Grantor and SUSAN L.KAPAUN,an unmarried woman,and WAYNE A.LIKES, an unmarried man,as joint tenants with rights of survivorship,residing at 495 Lassie Circle,Hudson,Wisconsin 54016,Grantees. GRANTOR quit claims to GRANTEES,the following described real Recordin Area estate in St.Croix County,State of Wisconsin: After Recording Return to: A mar i can -T-,Ile,, I 11C LOT 21,PINE GROVE HEIGHTS,FIRST ADDITION TO THE TOWN PO boX (Oy tO\p OF HUDSON,ST.CROIX COUNTY,WISCONSIN. C)r'-'Orr .r N a- CasI LPq SUBJECT TO ALL MATTERS OF RECORD. Mail Tax Statements To: BEING THE SAME PROPERTY AS CONVEYED TO SUSAN L. Susan L.Kapaun KAPAUN, A SINGLE PERSON BY DEED FROM STEVEN W. Wayne A.Likes KAPAUN, A SINGLE PERSON, RECORDED MARCH 21, 2011 AS 495 Lassie Circle DOCUMENT NUMBER 933780 IN ST.CROIX COUNTY,WISCONSIN. Hudson,WI 54016 PROPERTY ADDRESS: ad 495 Lassie Circle,Hudson,Wisconsin 54016 The legal description was obtained from a previously recorded instrument PARCEL ID NO.(PIN)020-1184-20-000 This property XX is is not homestead property. Dated this day of 20 Personally came before me on '744 this day of nn /I dl) SUSAN L.KAPAUN 20—the above named SUSAN L.KAPAUN,to me known to be the person who executed the foregoing STATE OF WISCONSIN ) ins.WaArn raud.ac knowledged the same. tl COUNTY OF J �� ) Notary Pub c -tit,(L$e¢At�ti�Y-}� My commi -, a is per man t {;#`not,state expiration date) I�ao/13 The preparer did not conduct a title search or examination in connection with this iatrament on the property described herein,and therefore title is neither warranted nor fwnnteed by prepare. The preparer expresm no opinion as to the tide the Grantees)will receive. The preparer has not had any contact with the oreator(s)nor Gtantea(s)nor was any legal advice was given to any party herein Info tiara contained in this insnument was provided to prewar by an agent forssid Grantor audlor Grantee The prepam of this deed makes no mpresentation as to:the status of tba title;property use;any zoning ragutations eoaeenting described property berein conveyed;or say matter except the validity of the form of this inamsent No boundary survey was made at the time of this canveya m PREPARER IS NOT RESPONSIBLE FOR CLOSING,the execution of ibis document,the validity of ray power of attorney,if one is being used,the collection of taxes nor the recording of this instrument Properer not responsible for typed or band written additions made to this instrnmtut after its prepantioa.In some instance,the oomeyana amount was at made available to preparer and was added after the preparation orthis instrument by agent for Grantor.Drafted under am supervision of:John osmga,Esq.13500 W.Capitol Drive,Ste.200,Brookfield,WI 53005 866-755.6300 TANVA K.SEEGER •40TARY PUBLIC TANYA IvG nSEE6Ef� ?; 'S IATE'd WISCONSIN �A r PUBLIC Page 1 of 1 ATE OF WISCO S 1 of 1 52 ,469 SO, T. 52,907 Std, FT, A 1. 20 ACRES � v 1121 ACRES 040 �r S 9►001* :f2"w DRIVEWAY 53,106 SO T. 33.00' EASEMENT v22 ACRES.. to Lis A Of L33100' 20 0 a PSI 89001'32"E +3 10' M ' 0 50, 936 SO, FT. Z' to PONDI 1,17 ACRES co tv +�' ,AS ..wow. �N �E��� -,•«,«. .�.. . "'� JOINT SE Ia1 E Ai fi�DRIVEWAY i-tv 22 OD w 21 "' ru 1. 34 ACRES � ��0 w 61'.x 365 SO�ET _ '79,43' 1.4 1 ACRES ' PONOI LNG EASICIA614T 0 —19. 90, 9" Of* 3 " 1 170. 00' PIN GROVE HEIGHT �. 7 t SE CORNER SECTION 20 SEE COUNTY SURVEY :' ,� 4 o ~ ~ I p p a 0. 0 h N O C I N Z LL C 0 I Q I Cl) \ z N rn W E 6i U) = O Z d a~i N z a m c 0 o z a v ~ a ~ o I f% H r ~ y Z v N (h N ~1 N O O. W N C 4) 0 li .O. 30 C O N O C U 4 Z m o N Z (D E LL ~ E N = lY0 c N L O 0 c a cm co a) a IL ED ca E FL 5, a <n 3 a a a Z a U) a y; g o J U co rn in } rn rn 00 v 0 N = 0 a I ° E co :3 :3 y 0 a ¢ in m b J 0 m y c ~l _ c O C N G C N O a~0 C r. O E C j- l a N 7~ r y C L O N 2 =3 ca 0 E = O Z C U) v~ d E 3 xe a d a • a c r~l c c o L) a. 0 U) N, 5 01/07/2005 03:57 PM w Parcel 020-1184-20-000 PAGE 1 OF 1 Alt. Parcel M 20.29.19.1161 020 - TOWN OF HUDSON ST. CROIX COUNTY, WISCONSIN Current OX Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner KAPAUN, STEVEN W & SUSAN L STEVEN W & SUSAN L KAPAUN 495 LASSIE CIR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 495 LASSIE CIR SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 1.410 Plat: 2328-PINEGROVE HEIGHTS 1ST ADDITION SEC 20 T29N R19W NE SE LOT 21 PINEGROVE Block/Condo Bldg: LOT 21 HEIGHTS 1ST ADDITION TOWN HUDSON Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 20-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1124/396 WD 07/23/1997 886/500 07/2311997 845/302 2004 SUMMARY Bill M Fair Market Value: Assessed with: 49201 222,600 Last Changed: 10/29/2001 Valuations: Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.410 24,100 148,100 172,200 NO Totals for 2004: General Property 1.410 24,100 148,100 172,200 Woodland 0.000 0 0 Totals for 2003: General Property 1.410 24,1000 148,100 172,2000 Woodland 0.000 Lottery Credit: Claim Count: 1 Certification Date: Batch 132 Specials: Amount User Special Code Category 27.00 018-RECYCLING SPECIAL ASSESSMENT Special Assessments Special Charges Delinquent Cha 0 00 Total 27.00 0.00 15 qs� ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 ,26 2q. C I, lllO l May 17 , 1995 l�`� ' 7t , Ms. Lucy Gearhart I� Century 21 706 19th Street South Hudson, Wisconsin 54016 RE: Water Inspection for Jeffrey R. Walker Address: 495 Lassie circle, Hudson, Wisconsin Dear Ms. Gearhart: Enclosed is the original test results from Commercial Testing Laboratory, Inc. for a water inspection of the above property. If you have any questions with regard to said report, please do not hesitate in contacting me. Sincerely, Mary J. Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure I I COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715 - 962 - 3121 800 - 962 - 5227 4:0& FAX - 715 - 962 - 4030 ST, CROIX COUNTY ZONING OFFICE REPORT N04'# 83909/01 PAGE 1 ST.CROIX CTY GOV.CTR REPORT DATE: 5/12/95 1101 CARMICHAEL ROAD DATE RECEIVED; 5/04/95 HUDSON, WI 54016 e� �; ATTN'# THOMAS C. NELSON �O i OWNER', Jeffrey K Walker LOCATION. 495 Lassie Circle, Hudson z COLLECTOR'# M. Jenkins DATE COLLECTED'* 5-03-95 TIME COLLECTED'# 11'#30am SOURCE OF SAMPLE'# Outside faucet DATE ANALYZED25-04-95 TIME ANALYZED'#2'#00pm COLIFORM,MFCC'# 0 /100 mi INTERPRETATION'# Bacteriologically SAFE NITRATE-N'# 3 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 mt Nitrate-Nitrogen, mg/L LAB TECHNICIAN'# Pam Gane WI Approved Lab No. 19 .OFA DEPENOFNr. J t O O0 V Zg A t Means "LESS THAN" Detectable Level Approved by: d !+ PROFESSIONAL LABORATORY SERVICES SINCE 1952 )5-RT . ST. CROIX COUNTY WISCONSIN ZONING OFFICE r r r r r r r n w ■r■�d ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road '__----=� Hudson, WI 54016-7710 (715) 386-4680 May 3 , 1995 Ms. Lucy Gearhart Century 21 706 19th Street South Hudson, Wisconsin 54016 RE: Septic Inspection for Jeffrey K. Walker Address: 495 Lassie Circle, Hudson, Wisconsin Dear Squeak: An inspection of the septic system for Jeffrey K. Walker located at 495 Lassie Circle, Hudson, Wisconsin, was conducted today, May 3 , 1995. 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. Also, water samples were taken. Once we receive the results we will forward the same on to you. Should you have any questions in the meantime, please do not hesitate in contacting this office. Sincerely, C Mary J Jenjins Assistant Zoning Administrator mz i r f OWNERS DRAWING OF HOU & SEPTIC SYSTEM LOCATION r= 1N i 7 r> 4� 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 Mravity ❑Dose ❑Pressurized Ft. ' ❑Bed ❑Trench ❑Dry Well ❑Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES []Other ❑Unknown Septic tank Setbacks: ❑House V ❑Well ✓ ❑Prop. line i/ ❑Other Dose tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover ❑Warning label ❑Pump/Floats ❑Alarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House (i ❑Well V ❑Prop. line ✓ ❑Other ❑Ponding: / e-n. , ❑Discharge: ryto-hem General comments: INSPECTORS SKETCH OF SYSTEM LOCATION d Inspector Title �4 ' S - �- ►�. ST. CROIX COUNTY MT W I SCO ZONIN p' M°°"""" """� ST. CROIX COU RNMEhff CE -- 1101 �-®_ v -_---- -- Hudson, 54016M10 YPA (71 +3$r'-wo/ ` SEPTIC INSPECTION / WATER TEST REQUEST 0:.kM F Please specify desired test(s) & remit appropriat 11��U application. Outside water lines are often turned of uring , , vy winter months, making access to the home necessary. Please make �0 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 e / retest $15. 00 ReqestOwner:/ Ze � ed by: I� Address: ,S //'G e Address: —' ZIP ZIP Telephone NQ: ( ) ,a�l-,�y7�� Telephone N4: ( ) Property address (Fire N2 & Street) : 4P�C�e Location:'„ SF; , Sec. �, T��f N, R /J� W, Town of S Realty firm: Lock Box Combo:_� Closing Date: TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Water sample tap location: 6(AJ[71 k� dQ (��`JE iVAI Is the dwelling currently occupied? Yes ❑ No If vacant, date last occupied: Age of septic system: 4 \( Septic tank last pumped by—1 Date: Previous Owner's Name(s) : Have any of the following been observed? ❑Y Slow drainage from house. ❑Y Sewage Back-up into dwelling. ❑Y Sewage discharge to ground surface or road ditch. ❑Y Foul odors. Other comments relative to system operation: On P V::T .... 4�„^., -.=. �.riyh ;=I certify that the above information_is =completeandtrue,�to-the . above. ._ aata, _best of myknowlekd�tg,.e _ x4MletaWA6s..H3 __._— OWNERS SIGNATU DATE:L 1/94 s. -* HERITAGE TITLE COMPANY A Policy Issuing Agent For Old Republic National ltitle Insurance Company... Tulgren Square r t 502 Second Street Hudson,Wisconsin 54016-1543 sl q (715)386-1073 =! (715)386-1075 FAX April 28, 1995 St. Croix County Zoning Government Center 1101 Carmichael Road Hudson, WI 54016 RE: 495 Lassie Circle, Hudson, WI Dear Sir/Madam: Enclosed is an order for a Septic Inspection and a Water Test for the above mentioned property. The results of the tests are need no later than May 11th, 1995 according to the terms of the sale contract. If further information is needed, please contact me. Enclosed is a check for $95 for payment of the tests. Sincerely, J e Terkelsen t Closer Enclosures Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER iuq lltu~,t5~ TOWNSHIP u1 e.&k SEC. ?_0 TLj_N-R W ADDRESS ' BQK ST. CROIX COUNTY, WISCONSIN ~ t LJ% I ago-//8c:5d1ll61 LOT LOT SIZE 2 Z ctc-b SUBDIVISION / PLAN VIEW Y~ S- L4 Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM L.~ s s; z Ct t ~t,e~ INDICATE NORTH ARROW + sk BENCHMARK: Describe the vertical reference point used ~r~e~.~'F9c. 1X.~ ~%uQ ~p►csCi`O~r~ J ~(y Elevation of vertical reference point: C~Z ? - &3 Z Proposed slope at site: 10~~ SEPTIC TANK: Manufacturer: ~ W~ S Liquid Capacity: ( / fi rI II, Number of rings used: Tank manhole cover elevation: S~ 2 II~ Tank Inlet Elevation: Jr Tank Outlet Elevation: tT O I Number of feet from nearest Road: Front,~Sideo Rear, feet > 1 -From nearest, property line Front 10Side ,@Rear,O feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) *j SEE REVERSE SIDE PUMP CHAMBER IV/~ Manufacturer: Liquid Capacity: " Pump Model: Pump/Siphon Mar.u.,acturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: I~ Trench: Width: Length: sZ Number of Lines: 2 Area Built:4!~2 Fill depth to top of pipe: 3O N__.. I Number of feet from nearest property line: Front, O Side, ® Rear,O Pt. S Number of feet from well: Number of feet from building: / (Include distances on plot plan). SE.SPAGE PIT fi Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK III /4 Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: / ~1 hn Dated : &A? go Plumber on job: S;4" License Number: 3/84:mj 0 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING DIVISION LABOR & HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION P.O. BOX 7969 State Plan I.D. Number: NE " SE WI eC. 20 , T29 -R19 (If assigned) Town of Hudson Lot CONVENTIONAL ❑ ALTERATIVE Lassie Circle Holding Tank ❑ in-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Jim Haut Rt . 4 Box 94 Amery, WI 54001 _ L' 9 ^ - 1.'0G 11 BENCH MARK (Permanent reference paint) DESCRIBE IF DIFFERENT ROM PLAN: tEF. T. E C ST REF. PT. EV.: q5e' :51d' Name of Plumber: MP/MPRSW No.: County: sanitary Permit Number: John P. Sykora III 3212 S C oix SEPTIC TANK To 0 a f C<, 5 MANUFACTURER: LIQUID CAPACITY: TAN INLET LEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER / PROVIDED: PROVIDED: (,c~eel~s 9S/ gY• YES ❑NO 8'fE3$N0 BEDDING: VEi~Y'PoDIA.: MEND-MATL.: HIGH WATER NUMBER OF ROAD P NEPERT WELL: / BUILDING: AER INLET FRESH ~O- n C CJ ALARM: FEET FROM Im3❑ YES 1RfNO Ca~S~ ❑ YES NO NEAREST f LOCKING - DOSING CHAMBER: PROVIDED: ARNING LABEL pROVIDED:OVER MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: W ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST -110, LENGTH: DIAMETER: MATER IALANDMARKING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE 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: DEPTH: BED/TRENCH t TRENCHES: / MATERIAL: DIMENSIONS ~a J? i GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MAT I L: N ISTR. NUMBER OF TP'F OE RTY WELLUILDING: VENT TO FRESH BELOW IPES: AOV//E~O?VEFjr ELEV.INLET: ELEV.END: ~J//~PIPES: FEET FROM NEAI// polo -d .3 7 In 7 NEAREST ~ MOUND SYSTEM: Mound site plowed perpendicular to f 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: N0. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLEDCORRECTLY: 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 7,5 ' in in county file for audit. Sketch System on TITLE: Reverse Side. SIGNA RE: SBD-6710 (R. 06/88) S ~ILHR SANITARY PERMIT APPLICATION cou In accord with ILHR 83.05, Wis. Adm. Code ~ ~mv,r v ~ ~~~aww,~wrsr STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 ~'7 8% x 11 inches in size. cn k revise to pr wous 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 '/a '/a,S TZ ,N,R / E(o W ,01 P PERTY OWNER'S MAILING ADDRESS LOT # , BLOCK # . ! ` ftAi 6 7 /v CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 44 -11 15400 -7 15 d-&54 4'"Ke 44oaL+~ 1 13 ITY II. TYP F BUILDING: (Check One) ❑ State Owned C3 VILLAGE ' NEAREST ROAD kdsov, Lgssre Ci~c~ U M B R( ) ❑ Public 1 1 or 2 Fam. Dwelling-# of bedrooms A ELT AQXFN: III. BUILDING USE: (If building type is public, check all that apply) fC~ / 1 ❑ Apt/Condo 1 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) 1.9 New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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 M 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. ASSORP. 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) 7 le ELEVATION SO is fpZ ,7Z 7 95 7 p4wat 99 /o to, VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank D / btc. Lift Pump Tank/Si hon Chamber NIA- 0+-[:] E] E] 1 0 Vfill. 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 PR W N : Business Phone Number: fig- 3Zt Z ~ 5^ S19~=`~4`~ P, 5;d kb QLJI I - Plumber's Addre treat, City, State, Zip Code) Rl~ Z K '75- 17Z IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signature (No Stamps) WApproved ❑ Owner Given initial Surcharge Fee) Adverse Determination 4 6 '..f I , zz.~ 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 s 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, 6W266-3815. 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. If. 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 - requited 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) loop APPLICATION FOR SANITARY PERMIT 3TC-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 ownet/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property -i..l-J-"4 4412 ij Location of property -NE-1/4 C _1/4, Section ZO , T Zq N-R LC V Township N~ SflY. 9 Mailing address &M go X w~e~r a ~o 0 1 - Address of site L ck s S e C i 'p- cj f u cQ A Bubdlvlsion name BtAe ~~c1bJE 4P-15AN~S i AAaV, +400 Lot number Previous owner of property 1C iC-114 aN'a( Sf O k. Total size of parcel Data parcel was created Are all corners and lot lines identifiable? -Yea No Is this property being developed for resale (spec house)?Yea _ No Volume W and Page Number -1367- as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if' available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Nap shall also be required. PROPERTY OWNER CERTIFICATION I(Ve) certify that all statements on this form are true to the best of my (out) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. _ ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to tun with the above described property, for the construction of said system, and the same has been del recorded in the Office he County Register of Deeds, as Document No. 84nature of owner Signature of Co-ownet (If Applicable) Date f Sig ature Date of Signature I ~.e t NIP . _ Y aK Jut *aft ~*rN1~+Nrt>rw.M wow a ' Tarty ~ , ~ ~ A"Lum to t b* ~M ~~1., Roa~ul 1!N i t Plow >r wilm w, x rat AL" 4 O"lk Po"r of lltto w A1111~1'!1@A110M AflKNOwI! 4~4 : STATE OF %MSCONM - of ce ww: dow of » PwroaMy oinio NMwr wo tltim lit -46 TE S1111 Of 11VMOONStN if om to nu known b M tM . . 40 ~IMttttMMly flrS.~.11aAs. MMO.) t Md h11~ ~ wAt~t'!O S1► t r11* w or pIMNiNI l gem M rCo Mon is ooraiM NY.Y~Y i~ MkNMI~MMl~~I1M M MMIIMU~IIMMM• $NOT •i ~ , r ~~`~a.,Kt`.Os.kc~ic i:"~...t•' u. C, e., - . a3L.Y1,r'sc. ~Jl~i~. . _ w 1 ' STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _17"6-4 p ROUTE/BOX NUMBER 'q so V 9q FIRE NO. CITY/STATE 7` "_44,.r,A u)*, 614016 / ZIP 5800 PROPERTY LOCATION: NE 1/4 S6_/4, Section ZQ , T_a2_N, R19 - W, Town of St. Croix County, Subdivision sr- `OnDte i5(+s dJi-i p , Lot No. Z / Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St oix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 (715) 796-2239 or (715) 425-8363 Sign, Date, and Return to above address EPANTMENT OF REPORT ON SOIL BORINGS AND SAFETY V JUSTRY, HUMAN NDLATIONS PERCOLATION TESTS (115) MADIS. (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ UN CIPALITY: OT NO.:BLK. NO. SUBDIVISION NAME: NE'/ BE'/ Zo /TZ9N/R/9E ( )W hiadsti~r. z 1 N/A P,,Ae C~no-e COUNTY: MAILING ADDRESS: I" a 544. GroiK J7; W 7914H -f 104 K l i4 i. S4 001 USE 5 S DATES O RVATIONS MADE R Residence BEDRMS.: 1COMMERCIAL DESCRIPTION: A IolResidence N/ New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system A41-A+ v~~ a~1Ml Pq.5-C f CONY STlou ONAL: MGK S. ❑u IN G Is ❑1 RE: Sa S 1®UL ❑ JG®TAN u . Rl.0Oµ1/PiW~~DSSYSTEM: (optional) (eIf Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the A~D'/~~ under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: r`r/ ~ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DE NUMBER DEPTH IN, ELEVATION OBSERVED T. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / 80 76-7/` nDole, r! 14`6I sil Ts 1-4,L-31116.1 -s'01, 33`x-$0'/& e B-~ 60 /7-7 IZOoIe- y ~0 11z"Jel %"(T: fZ~~ ~fo`f~H Sr II 314` io'gy CS 5 17-s 6 - 9S -Bh C 5_+5 r, B-3 95 98L4' 116 tA~. y '!(0, 14 B- Af /0 hock 8"Bl zI 17--%$ B- /Z O h b w B- PERCOLATION TESTS 'L' TEST DEPTH . WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES f NUMBER INCHES AFT R SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P_ 3 a P- N P- Z tt i V'W e5' P- / z 1/ P_ d I/ it Of r- /r !r If It ' 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 LEVATION. 9'5 7 " FE _:t , s ro a E /e- (9 r = N - C> Z~F9 _`~~°1 ~ / 1~ E , a ; I 74 I, the undersigned, hereby certify tha he 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: T { Q, - - - - /y /a LT-0 S~' .75 ADDRES CERTIFICATION NUMBER: PHONE NUMBER (o ion Z._7 -715 ^3606847 T GNAT I and one copy to Loca: Authority, Property Owner and Soil Tester. wil. 10/83), -OVEN 'Aa s S/OVS W/5 '969 INSTRUCTIONS FOR COMPLETING FORM 115- SBD - 6395 a complete and accurate soil test, your report must include: iplete legal description; e use section must clearly indicate whether this is a residence or commercial project; AXIMUM number of bedrooms or commercial use planned; s this a new or replacement system; FST3. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; TH 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate meds - Medium Sand W - Well fs - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand - Less Than 'I - Loam Bn - Brown 'sil - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. a QG'~ -::~i VA Aau p f ~clw~ 4416~ f 0 ~.ass~e CirG[(~ ~ ti 1►~~g` s aJl g g-~ ez ~ r Ae g.- L1 2L Rj = 4&M1 s dap o ~r rWJ54 rz` ~ P ~Z~ B-sn ~ .1 w& A 2 `s ~~o o-f Block ~o ache 4L f- ~c 9Z`-7N ted. 3 ge~► Cam.- ZY7 .SP~cs LIS. !Z~ K SZ' d~ra1 cw ~o~l bo"f'~~.c @ 9 5''7 „ ~i (QC(Q Np~.~,,, ~ y X01/ -Ser-+.,ib -A Of lReA 76 /fib' 3~la``c Plot Plan Fundamentals a designer must make, and the most difficult, is the .a. This drawing will show where the private sewage relation to the building it serves. It must readily ,a plot plan on the 115. (ref. ILHR 83.07 (2)) .cs the use of dimensioned plot plans, but great care must be .c all pertinent distances are shown. The main premise to keep in ,at dimensioned drawings must have each point of interest located to two directions. The next (example #4) 115 plot plan is missing ,tons. The CST has made several errors by not showing certain .ances. The completed drawing shows how confused and cluttered a ,mensioned site plan can be. Dimensioning drawings is convenient and therein lies the problem. Remember, the plan reviewer has not been to the site, so all distances must be shown. When using dimensions it is advisable to layout-- e entire site to an approximate scale, maintaining rough proportions. This will lessen the chance of leaving off important data. For example, a six foot distance should not be 1-1/2 inches on the site plan while a 50 foot distance is only 3/4 inches. The completed plot plan for the system just noted would look like example #5. A helpful guideline for system plot plans, especially dimensioned ones, is that, although you are familiar with the site, will someone else get the proper "feel" of it from your drawing? Would a person who's never been to the site be able to use your plot plan like a map and determine where the actual private sewage system will be installed? This should be the goal of your plot plan drawing. The preferred method for drawing plot plans is to use a scale where one inch on the site plan corresponds to multiples of ten feet on the site. For persons unfamiliar with drawing to scale the purchase of an engineer's scale is a good investment. The scale consists of six measuring edges with 10, 20, 30, 40, 50 and 60 scales on it. A reliable scale can be bought for several dollars and is well worth the effort to learn how to use. Since a dimensioned drawing requires complete distancing to all pertinent points, all the necessary data is available for a scaled drawing. This is how the previous site plan looks drawn to scale (example #6). This drawing is much easier to interpret and all important distances can quickly be determined. If you use a scaled site plan, be consistent. Don't scale most of the plot plan and then add some features which are not scaled. The one exception would be extremely long distances which are important to the site plan but cannot be shown due to the size of the paper you are drawing on. If this is the case, draw a broken arrow and indicate the distance to the particular feature. An example would be an 80 acre parcel with the home and private sewage system occupying a small area close to the center. As long as the system can be accurately located, the remainder of the parcel is unimportant. -9-