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020-1171-60-000
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N 'O _d Q z CA >- w M Q z 0 � w M w e d Q z to Co v� co 7 a� co M y H Cl)w c N E E c y v E V CO O p c O c N C O c .O N € c c a� Co o y c co c O N � y ti CY z ° v y C7 z °: v' ao a°'i c`$ y oi co a� v c (D ~ O N V O r O y N O t6 U O y N O U O O O y O U •O ' o O 2 m 0 2 LL F- N z CL F- g L Z Z N E I U c €a d i � I M CL m d d• a m .2 0 d E 0 c 2 c`Ai c� �1 A cia2 o I (aU 0v� v I Parcel #: 020-1171-60-000 12/13/2004 04:05 PM PAGE 1 OF 1 Alt. Parcel#: 7.29.19.1071 020-TOWN OF HUDSON Current ❑X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner *GORSEGNER, KENNETH R&CYNTHIA A KENNETH R&CYNTHIA A GORSEGNER 334 EDGEWOOD DR HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *332 EDGEWOOD DR SC 2611 SCH D OF HUDSON SP 1700 W ITC I� Legal Description: Acres: 1.170 Plat: 1932-EDGEWOOD ESTATES III g p a SEC 7 T29N R19W LOTS 112&113 EDGEWOOD Block/Condo Bldg: LOT 112 ESTATES Ill. Tract(s): (Sec-Twn-Rng 401/4 1601/4) 07-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 1198/640 WD 07/23/1997 821/315 07/23/1997 807/210 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 49112 215,600 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.170 29,200 137,600 166,800 NO Totals for 2004: General Property 1.170 29,200 137,600 166,800 Woodland 0.000 0 0 Totals for 2003: General Property 1.170 29,200 121,400 150,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 123 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 .OUSTRY, INSPFr REPORT FOR SAFETY&BUILDINGS DEP16FITMECif`IJ RELATIONS VATE SEWAGE SYSTEMS DIVISION LABOR&�� BUREAU OF PLUMBING P.O.BN WI 53707 re NA -R19W AX]CONVENTIONAL ❑ALTERNATIVE Stassiganl.D.Number: (11 assigned) ,own 17i Hud�san ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 112-113 Edo t. aad E.6 es NAME OF PERMIT HOLUI° ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Dennis 91otn6tad 296 Edg ewaad DA. v eis Hud6on W1 54016 BENCH MARK T rmanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Nis of Plumber MP/MPRSW No.: County: Sanitary Permit Number: OUZUam Schuma 382 St. Ct oix 112758 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: ITANKOUTLIT ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. 1:1 YES El No DYES ONO BEDDING: VENT DIA.. VENT MATL.. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: JIUILUIN, VENT TO FRESH ALARM. LINE. AIR INLET FEET FROM EYES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. DYES ❑NO DYES ONO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL'. NUMBER OF PROPERTY WELL BUILDING VENTTOFHESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES El NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH lit_11ME I E H MATEHIAL AND MARKING or excavation. (if soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH' LENGTH. NO.OF DISTR.PIPE SPACING COVER INSIDE CIA it P1T5 LIQUID BED/TRENCH L3 TRENCHES MATERIAL! PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR NUMBER OF PROPERTY WELL BUILDING VENT TO FEtE 5/1 BELOW PIPES ABUVE COVER ELEV INLET ELEV.END'. PIPES FEET FROM LINE AIR INLET NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO SOILCOVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS : YES ONO DYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES ❑YES : NO DYES NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO.OF LATERAL SPACING JGRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR UISTR.PIPE DIST141BOTION PIPE MATERIAL&MARKIN(; ELEV.. ELEV.. CIA.. ELEV.. PIPES DIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANSCAL LIFT CORRESPONDS TO APPROVED DYES ❑NO El YES 1:1 NO COMMENTS PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF PROPERTY WELL: BUILDING W FEET FROM LINE: ru I t ❑YES ❑NO YES EINO NEAREST ��•`I���-------------. _� ICI- 1 lD 5 t o '�3 .3 ► !� .�� 4 Sketch System on ,L� Retain in county file for audit. Reverse Side. SIGNATURE. TITLE Zoning Admin L6tw-tvtc DILHR SBD 6710(R.01/82) � I SANITARY PERMIT APPLICATION COUNTY ILHR In accord with ILHR 83.05,Wis.Adm.Code PO/ Lac .� ST/1SAN�TARY PE�F MIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION may E PRINT ALL INFORMATION. FOR VARIANCE ❑YES L?`M NO O N PLE A S PROPERTY OWNER n PROPERTY LOC TION ,LQ�J Y�i/S � X $/�'/4�(/�1/4,S T , N, R / E(or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME it Cj CITY,STATE ZIP CODE PHONE NUMBER CITY NEAR T ROAD,LAKE OR LANDMARK VILLAGE: i 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. Z�New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. 4A Sanitary Permit was previously issued. Permit# in ye(.0 Date Issued 27D_ � 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. RIConventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.El Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): O. � -5 F?r Feet �Private El Joint ❑ Public VI. TANK CAPACITY Prefab. Site Fiber- Exper. in allons Total #of Manufacturer's Name Concrete Con- Steel glass Plastic App INFORMATION New xisting Gallons Tanks structed Tanks Tanks Septic Tank or Holding Tank / �`' Lift Pump Tank/Siphon Chamber ❑ ❑ ::;r Lj I Lj VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage sy m shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MPRSW No.: Business Phone Number: 'u h Gc.sna R Plumber's Address(Street,City,State,Zip Code): / Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# �`- Phone Number: CST's ADDRESS(Street,City,State,Zip Code) 4/, Sc IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issu"ng Agent Signature(No Stamps) Surcharge Fee LN Approved Owner Given Initial > l d Aj Adverse Determination ` X. COMM TS/REASONS FOR DISAPPROVAL: Plah 7,Aow"a C. SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanita'ry'Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years-of steady negotiation and public debate. The groundwater bifl Ground I~ included the creation of surcharges (fees) for a number of regulated practices which Wisco tn'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried r a i Ur'E3 is used in your building is returned to the groundwater through your soil absorption o system or the disposal site Used by y our holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- f water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) / ��d✓ G � ci ,� o !�' %_ �b 76 _ ,a 15, v o" 3 � © a/°�a0a i.rti'AR It rmtto W. TY & BUILDINGS INDUSTRY, IIrLf yr If V1� 'if aitiiF r"fsltinr DIVISION LABOR AND p P.O.BOX 7969 HUMAN RELATIONS ■ E�OLATIQN TESTS (115) MADISON,WI 53707 (H63.09(1)&Chapter 145.045) SECTION: OWN HI MUNICIPALITY: OT NO. NO.: SUBDIVISION - 5E y"_� / ZR N/Ri19 (or so NZ_ii3 FS COUNTY: NAME: MA ING ADDRESS: -ST G ©IX� F-61NI S A -Z9 f. one / u USE DATES 09SERVATION8 MADE CIAL Residence N —.—. T ATNew ❑Replace AU/_ -z 9 1%Ts Au61 z s /9R 0 SOI i<' s - ��'lw r-r RATING:S-Site suitable for systefn U-Site unsuitaw for system Cz T/A4 rQ"ENTIO S ouLMO ►IS.❑u IN -----S ❑u Tars u al G TA K: CONVNDED SYSTEM:(optional)#I L J If Percolat ion.Tests are NOT required DESIGN RATE: If any portion of the tested area is in the �/ under s.H63.09(5)(b),indicate: �/J4SS Floodplain,indicate Floodplain elevation: AJA C PROFILE DESCRIPTIONS BORING TOTAL B AT -INCHES F SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER ELEVATION V TO BEDROCK IF OBSERVED SEE ABBRV.ON BACK.) 22"$1e.i-Y S 1 9"a R>✓S.L Y B- $.qZ g Z-SO :c M. MaT i0 �Srr_-rS 29*6w,4 tL. zG Fco& 4x NI or B- � 9.1� q Z.3� /� � .oa ��"1?�8 MS aiZ � iz..B��i-s �SnBRNsII. �S�a�rh5 6B" d �n.DEviM B- 3 iz.':�3 I r-o,I e. o*'3 14 efl F-Ih le - q5 Eau B- A )-z.$3 9,6-35' ,- > 12 f$3 15"BL.LTS S. 94.3s,L G"R&MS'it4A 'Rb -MS B- .3� L 4 .Z� o t` > `a.33 9"&DTs M a St 1. 9"'R&f,* g*4e Zc Ra'9au Ms B- C 9. 1-7 9).Z1 1Jo�JIC >9.l7 W'BLC DE,Fr PERCOLATION TESTS TEST P NUMBER KEPT -AFTERSVYELLING INTERVAL-MIN. .� RAPER NC S P. 1 .10 `VON is 4 .Ao 10 d P P- I I IEI-svAm AT tR C P- e P- PLOT PLAN: Show locatioi is 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 tip alstrface levation at all borings and the direction and percent of land slope. 6 Y SYSTEM ELEVATION 88.5L2 1 a vt e-6 1 � SCALLr • / �3D Q $camMAf-\c- TaA ar WIEU- - Q EL-EvATlory 1,the undersigned, hereby ce ify that t e soil test reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Coda,and the the data he location of the tests are correct to the best of my knowledge and belief. B-► NAME(print): TESTS WERE COMPLETED ON: I�AQ\dF Y 36/4 AJ So ti • K CSC L4 A\(C, /Aj A('14u';r ZS O x"t 'CERTIFICATION NUMBER: P ONE NU BERr(o`ptional): L q.�` + l CJ-t'sl3 e'V ) �'t d 1 Z. :aA C% I � / CST SIGN URE! N�TN: 1 lS -S da DISTRIBUTION:Original and one copy In Local Authrn ily,Ptmlo-rty Owner and Soil Tesler. DILIAR•SBD-6395 (R.02/8?) OVER - DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABO i&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 SE4,NW4,S7,T29N—R19W [;CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: (If.ss gnadl Town of Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 112-113 Ed ewood Estate III NAME OF PERMIT HOLDER: ADDRESS OF PERMIT.HOLDER: INSPECTION DATE: Dennis Bjornstad 1 296 Edizewood Dr. Hudson WI 5401 BENCH MARK(Permanent reference Pomt)DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT.ELEV.: CST REF.PT.ELEV. Name of Plumber. MP/MPRSW No.: County'. Samtary Permit Number: William Schumaker 6382 St. Croix 102866 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY'. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ❑YES ONO ❑YES ❑NO BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD PROPERTY WELL. BUILDING. IVENTTOF RE SH ALARM FEET FROM LINE AIR INLET EYES ONO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY JIU-1 MODEL PUMP/SIPHON MANUFACTURER W LOCKING COVER PROVIDED. PROVIDED: DYES ONO OYES ❑NO ❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPER ATIONAL'. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH JUIAME I U MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH-. LENGTH NO.OF DISTR.PIPE SPACING. COVER j0F1 DIA -PITS LIQUID BED/TRENCH TRENCHES MATERIAL! PI DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH JIIITR PIPF DISTR,PIPE DISTR.PIPE MATERIAL. NO.DISTR NUMBER PROPERTY WELL BUILDING VENT TO FHESII BELOW PIPES ABOVE COVER. ELEV INLET ELEV END. PIPES FEET FRLINEAIR INLET NEARES MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES El NO SOIL COVER TEx TURE PERMANENT MARKERS JOIIIEHVATIONWIIIS ❑YES NO ❑YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. 1:1 YES El NO OYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTHIBUTION PIPE MATERIAL&MAHKIN(, ELEV. ELEV.. DIA. ELEV.'. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANICAL LIFT CORRESPONDS TO APPROVED DYES ONO DYES 1:1 NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. NUMBER OF LINEERTV WELL: BUILDING FEET FROM El YES 1:1 NO OYES ONO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE Zoning Administrator DILHR SBD 6710(R.01/82) f SANITARY PERMIT APPLICATION COUNTY � DILHR In accord with ILHR 83.05,Wis.Adm. Code - 0 STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES L�a NO PROPERTY OWNER PROPERTY LOCATION lZd'/a, S �7 T N, R /9 E (or PROPERTY OWNER'S M ILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER Q CITY NEAREtf ROAD,LAKE OR LANDMARK O VILLAGE : d w ` S II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. L&NeW b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. V4Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. X seepage Bed b. ❑seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): c� —1 �T //,,267 11.2,6— Feet ;RtPrivate ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pum Tank/Si hon Chamber L ❑ ❑ :E ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print):: Plumber's Signature:(No S,t+ammps) P PRSW No.: Businepss Phone Number: Plumber's Address(Street,City,State,Zip Code): Name of D�e,signer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST Name CST# a CST's ADDR (Str ,City,State, ip Code Phone Number: IX. COUNTY/DEPARTMENT USE ONLY IH Disapproved Sapitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved Owner Given Initial V*tP rcharge Fee Adverse Determination / X. COMMENTS/RE,ASSONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION s TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; li. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; - VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 81/2 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; dosing or pumping chambers; 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. ------------------------------------------------------------------------------------------------------------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground�atef included the creation of surcharges (fees) for a number of regulated practices which WiscoriS;in'S can effect groundwater The surcharge took effect on July 1, ',984. All of the water that buried rea5Ure j is used in your building is returned t: the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. a The ,�-ionies collected through these s-.rciiarges are credited to the groundwater fund admini.; tered by the Department of Natural P-sources.r These funds are used for monitoring grOUn:d- t Aier gro ndwater contamination !r# �stigal',)n and est: _,lishm='.rit of standards. ,..-s vvorti, protecting. 3D 01,865) APPLICATION FOR SANITARY PERMIT STC - 100 i This application form is to be completed in full and signed by the owner(s) of the pruperty bring 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.. - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - owner of Property Ca.4 i 27r,4 Lucat iuu of Property $E^k- XaJ k, Section 7 , T �9 N - R W Tuwuship 11VIL6A/.. , - Malllnb Address iv-119etyo6d 7),-,A Subdivision Name �94ct1�dt! ,�T�ir24 Lot Number // Previous Owner of Property Tutal Size of Parcel lae-rr. hate Parcel was Created 4el Are all curners and lot lines identifiable? �-, Yes No 15 Lhiti property being developed for resale (spec house) ? X_ Yes No Vultune C/o S and Page Number S• as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 1. Land Contract J. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1 (We) eeAti.6y tJua.t aU atatemen.ta on th ,a. 6ova ane tAu.e to the beet 06 my (uun) k►iuwtedge; tJLat 1 (we) am lane.) the owneM,6) o6 the nnopeh ty de cA bed in VaA tn6ulu►w.tiun 6onm, by viAtue o6 a waatan.ty deed neeonded in .the.066.iee o6 the Cuu►i ty Reg-i.e,ten o6 Deeda as Document No. 39a y 0 and that I (we) pneee.►►fixy own fine.pnopoeed a•ite bon the sewage poa system (on I (we) have ubtailted an eaaement, to nun with the above deaen.i.bed pnopenty, boa the eoiotAueti.un o6 said 6yatem, and the came haaa been duty %eean in n the 066-iae u6 .tile County RegiA ten 06 Deeds, ae Document No. 39-4t/-2o 1 SIGNATURE OWNER J SIGNATURE OF CO-OWNER (IF APPLICABLE) IS DATE SIGNED DATE SIGNED t � ,�v �•,.I :. >. ��'a"T.e;,, afar.&Teas atOtoatttn testa aano..wa�saa ! Vu WRIT R OFFICE r4 ? I ro CWM 00.1 VM y: 5� I W&for Record m_I l th {o1q■tisr", I of A r A.D. 19_64 zwe 11:30 A ,M. . • , �;;;,,', �..w .......: ("llrstl4�'. sir w se staa)• , Yasis stlllw to 1* ww tV MM0 aM t a Pm- ra�Mr► (as 4dw"~F r"Pw7 )I ads bt b fd Wb*=d tt tsruart VOGMUM Kam: At FORM R ; v7r 81911, EXCBPT the P O. eooc M S% of S1ldem M1 54016 J All that t 900' S>Zic�of >8�it of Section 12, Tart tend N&.................................. P+4r T2911, 140Kr 1 , �bsriy of State Trunk South 32 rods thereoan aced.'U ng Pl1t lyi sou ly d 1Ms�jLe�l , prly right-of-my line St C! .TQr, III laaa&WAt foc ingress and ogress over a portion of the S!�'' ''-c9-'*eatUw 12-29-20, Town of Rndson, awe fully described s'"` Cewslmtlrcing at the Bast quarter-oorner of said Section 121 , oGR60060"N 1,332.81 feet to the Ely right-of-way of S.T.T. •3��r"t a ?• a2 42005 637.14 feet along said Bly right-of-way of 8.T.H, � ' ` ,~q < N 1�1r 'Q! the Ps�opestY deeded to Asthur F. windolff aced �' Kin4oUf, as recorded in Vol. 519, page 25, Doc. No. 325163 iA-t3sre_tWjiee of the St. Croix county Register of Deeds, being ' .:! '=_..._ sir• D>PSCR.I-OTI0 , OQNTINUED ON ADDENDU e�rec*snn� t�reebe ysr s>»arohm as, and to par to vender, at aio;�g{etp>rr~sis�nos ace' Fsx written ' tbasut e:: �•" °•,•,••••x•'••10•••"... h the tdlowia� twanNrt (a) i.}�!t.Q�••�.pL��r OD 71i1t�,_ at the execution et thiii c staid anfd (b) flee balance of =.84,.395.00"........... ..:,topther with interest from date f �� �lll ► •i tbt 1 al•tB1�..�IQ�....................... per gent per annum ssW ptIJL�i . ArllrUal installments of $10,000.00 each, plus accrued interest, on or before the first and second anniversaries of this Oontract, and the entire balance, plus accrued interest, on or before the third anniversary of this Contract. See attached ALYIEMU for provisions for release of logs and application of payments da eto. Estimated Aenl. Estate Taxes for 1984, payable in 1985, have been prorated at closing; Purchaser shall thus pay the entire 1984 Tawas and subsequent years as due. Pruvided, however, the entire outstanding balance &hall be paid in full on or before the . . 23.rd . ._.. .. day of feJw.iary. ... .... .. ... ........ 11687.... ( the amarity date). Following any default in payment, interest shr9 accrue at the rate of...l.U.. :v per annum on the entire amount in default Iwhwb shall include, without limitation, delinquent interest and, upon accelerrt ,rrt or maturity, the entire principal balance). f urel.aser. agrees to pay JUrLiannual taxes,speew asseeanwats,fire and required insurance premiums when due.ZKXli@CMl@r1 —1 and furnish copies of receipts on Vendor's written request. Payments A" be applied first to interest on the unpaid balance at the rate specified and then to principal. Any amount may be prepaid without premium or fee upon principal at any time IF In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long a+ the mpaid balance of principal,and interest land in JtUCjL case accruing Interest from month to month +hall I,e treatec: u .np,ud pflrelpall is less than the amount that said indobteduess would have been had the monthly payments been !.jade as .°.rst specified move; provided that monthly payments shall be continued in the event of credit of any proceeds in•ural.cv or condemnation, the condemned premises being thereafter excluded herefront. 1'u!,11•„r<•r -tau-.i tv it t'urrhu:.r is satisfied with the title as shown by the title evidence submated to Purchaser for ,'.•..n1,at,l,n cxrept: Within six (6) months hvic-after, Vendor shall record 3 ct.•rtified c(-T)y 4f uln_ (s.,.,tt► certificate of Willimn F. Marty, and release of inl-eritawe tax liens in •t,' r.0.tr•r of th- E,:tatlr ref Wi l l i,uo F. Marty, u.) the satisfaction of Purchaser's attorwy. 1. 1 ,..� ,.'rrr- I , u,. .,t .,r lilt rl ;.�., .•i., I UL_r rY I r ,• .a :n t', ,.I , ul, r,l t•.,rt, 'f .Ial: ,• L,r,j,.l .I,. r !. t.1.. ,y I,. ,. 1.:, I. If!! �,lt-;.i 1:. ! 11'. tl• .. ! 1"t .` ltT'�.``161; Y tiI a., !. ,nt 1 t, r 4.As.: ` >owl a tMr�4 AIIte!� La.� ova MIMM/a le / , • � • "'ill" r .n .�='1/ dumb the daalf>td bww? �1 ttnitl� r'4 of betd���itwe M fop" aai � �► -111 --ft feasible. Paasha w nit b oiardt asr Wash b be seatnNtiwl Qt!ir. '# is gr•d Mw 16 an it in W r+sir �P10010 �!t�MI�M`1r b eaat'iary�wkY W 1sw� lilltl�wr a� f do a m be I �� St eye iii is Idea 0> a>im spewfiA Vander ds r! 6 the Parci ear,a� . i. in�4100 POPMe !area Me d d my Her K anaa • R anal =$" ' 4wa! !. .. w.......... .�..... ...tw........ .................. ni�...w. ...i'sa!�•attd�rd >pt�ii......'.i -Nf•!•''�'_ • .s!/MME. M.. ♦.... FM. N N..w..MN.r• .. :... w ., ,. wan. ' •. ...............N.•NNw.wwNN..Hww Nw � PUrehaaer aptM!l awe there b N sad (a) be the atatwt of a dltllM&is tie Pi iwwlt ant illilr> +err Mlerat wbkb otnibM for a paled of -4101 talkWh!s UM 08dOW daa,� A�Ak f ltrt b tlllti of olbw.ablix tian of 1pum Lases wlddw��sw�dnw ter a• at uiMlia atdira Nan tuna iaMria,ongapir dme yplysbk is at w% )o Kim wt aKieo. ltrdtWr iwip wsivoa).anal Vender,"aleo haw the following rights seed ramodies (066" to OW 11100 "000 Imoetdsd law) � additiow to these by law or in dale t : (1) Vendor nay. at bi totr has"tlrila-40WAIMS and saaaaaaw r�i#1, , this and one do Property W renewer the Prepsrtlr s"f wtfi swigr at wnpt on to a eaaditisad "pan rurclukewo full pw.ees or the entire ln.ew itttMllren� the date of default at the rate In effect on such dateadeiharam ay"d wrwndar. whkhawntailMSentts paid �r Purchaser, *0 he ferefeited a lkaidated daa+ases for (silvans to ft" evow M and sr tK the Property it purehaser fails to rodseat): or (h) Vendor may an for spWle porforaeacrof 9 1 Ceskud to a ipel immediate and toil payment of the entire eutsfandiwtg baleuroa. with haerest tbsraw at an raw is duet one''fits dude at default and other amaanis der hereunder,In which event the Property shall be aaetMaad at}tdhW safe sad Parebaooe shell be liable for say detkMny•or IHi) Vendor stay sue at law for the oewtiro tmpW pare>attN�Irt K May a thereof;K (h) Yonder my dsair"ibis Ceattact at an cad and remove d& Coatrastaaaind new h►a artioa If the o"itable Mionat of Parch oor le inaleaiflesat; and (w) Vender stay have Pardow 40"_W poesersios of the Pro sad bare a row � to collect any Hats. imUa or prslfta,dmrirtg awr pa- demo of any aetloa Undo D. (H or (IV abovo.Notwitliat rAng any oral or written statemMmh or sytisna of V�as election of any Of the�srsesine vet aball ody be bindq(��g upon Vendor if and when pwmW In Mantles sad ea4r led espe ad nee fedmdhwg toaasanbis adereop feu of Voor Incurred to edaree any remedy oa beadsr (wbrwar abated or not the one bmt not probibked by law and oapsttsne of title evidence shall be added to pe tipai#aO�.Jwld by Psnehow. to ia- crn!sd,and shag be hedaded Is any Jodgmsnt Upon tbo asntmaeswneat w during the pendenti of any action of fwrdown of'#*d0er ?arehaser osmssat� to tbo appointment of o rreelve of the Property. iselud,n ilaaestead interwtl.M eMMat floe rtmt+r„ sad of the pity dairise the of stab action.and such rents,issues.and peel is wbsn ce aolheW Mall he eMwd applied is On awt ibaq id rset. Purchaser shall set transfer. sell or convey any IeRal or table interest in tM Property (by assignment of say o • of Pa s rights mwtdar tW Contract K by option,long-term k�aae or w w • ago""of•indae tiwtla>r,,dflst,Iba o �ewtsttar py * conveyed is a plefte K mlenment of rchaser's interest under this Contraet solely as security for an indebtedness of e Pureheaer. In Uw event of any such transfer,sale or conveyance without VoWer s writles con conk the entire am-,--ding • balance payable uMo ors Contraet shall became immediately due and paysitle to ftt%at•Veside'eptlea without notice. Vender %Wj aw Ao all pa;r.m nta wt on due under a.ar eaten 2MV c=-�-zalile QW..0--t.fro !�.:y an wua date of this Contract (osyewae�pet for soy mortgage tiranted by Purchaser) or under any seta MOUred tbariy.�wplrovided Ya"hossir Krttraxop It Yonder nib to do Una allies otents so nm de y Purrhaisor purchaser, " be neenisideRrM pa n1s tme&on this Contract Vendor may waive any default without waiving any other subsettueat or prior default of Pardmer. All tertus of this Can*" shall be bhadhgr upon and inure to Lis benefits-of der heirs heal raptrawtsdw, snoeessom and �{� of Yonder and pureboaer. (if not an owner of the Peoportp tie sposb o?Mee N a rsiwrable ceneldcratian Join) min to td , haasst-1, righu in the sub/oet Property and ae!rass to Join Is do almentlw of the dood to be undo to feMoopt horeeLl limited thli .23rd day of February . ttl 84 • B. iL H, LLNMDR4 , INC-. (PurdWMr) C� Iw�,G. lj l u LLt'e (SEAL.) By: Li (SEAL) Anita P. Marty (%*ndor) E'• B ,.1tx+esitient n : �!! L'• -' (SEAL) Ad �+�+n• tSfilAl.l'' i William C. lrlatt�tell,, Sect'etarJi: �' a1 % • . •., � . Ant AUTURNTICATION ACUNOWLSDOUSN Signaturels.) of Anita P. Marty, a single STATE OF WISCONSIN ? se. .� «I. i" r ..... ST. CROIX Count ;. authen 'catod this 23 dqy of ry. ,:.•.. , 1884 1'ersonully come beforc me this 23rd, day of FetinkrY....... 19 84 the aboc named Donald E. B jornatad, 'Pretaidertt, , . Robert F. Wall WillidmC ec 0 said TITLE: 11F NIRFit SPATE: BAR OF 111. tbrporat:ion,• %ho aG�GtX]W ItZ1at `;`.�. P executed thi's fiistivoif awes 9u* li of'fio=ra :wlL..n°.d i.y ;or.ul;, tCls: Stata.) Of d t7c�r itit�fl ► its"w t�lriU, and a. nie nuwa e w .. esetu the fu of �•r►ytumw �elCMwl�,thf/wnc. Willi;vn .1. (;ilt,ert, Atty. William J. lbert MLIX : s i�11�i�:r Croix P.O. 144.)x 321, IiU.L•:�•wl Wl .,I �.• Notury Puhlie Counte. Win. ., t . .t..! !,rvncle.11.�l. C.•t! %I% 0,111110-anion Mollaft /.1y GJAY.UafiJn is i�afrrwtaferll t �',h ..•\IaA. 1 InA...drtl • U+ r N•-rowdw. r...N.. 11—Iff: f^ 711 , ,��� .� ; � . ' • ADD Peve a CONT="Tx= Or RNWRTY DsSCRIPTIONt . the•Miy line of the South 32 rods of said Wk Of UM of ;MetL6M.I i-W2O1 thence M90'00•00"i along said Nly line.of said Win"M; !!sr 349.49 feet to the centerline and Point of of AM,uLde easement, being deecribed along said centerline as 011008.80 bay► *12055'004V 199.43 feett t1ance My on a our" coeeare ego • a radius of 99.45 feet* whose chord bears 946.OSIOVW 108.02 400ti thence 979015120ON 111.S4 feet, yore or less, to the Ely right *ir qi i.S.R. •350 and the Pout of seMination of said easesMat. (M*Jth8 sirposes of'this description, all bearings are referenced to the',i�i�t�Meet quarter-section line of Section 12-29-20, assu"d M90•04100`W) SUBJECT TO recorded easements for e.ectric and tslephosw';4 ees.. ' SUBDIVISION AND. RELEASE Or LOTS: Vendor agrees that Purchaser may subdivide said Prcpertr.; tlth all costs associated therewith to be paid by Purchaser, and that Vredfr V111 join in execution of any plat(*) , certified survey map(s) aad' other instruments necessary. for such subdivision, except that Vendor's intemot shall aft be subordinated to any indebtedness incurred by Purchases.- Purchaser may develop, improve and sell subdivided., loW':-Vit.h or..witbout buildings being constructed thereon by Purchaser. release such lots upon sale thereof by Purchaser, by V ndds' a execution of Warranty Deeds thereto to Purchaser; Purchaser shall prepare and fur- nish at Purchaser's expense all such Warranty Deeds and the associated Real Estate Transfer Returns, except the f , Return conveying the remaining part of said Property ieh shall be at Vendor's expense. Upon such release and coaveyaaoet, e:►*he. value of each •,released .lot .4"11, .,Qr, ca cMJ&tion of , b&by rounding off the acreage of the lot(s) rel000e4 to tht aeem=sst even number and multiplying same by $1,500.00 per aeret the transfer fee shall be paid by Vendor. Upon conveyance of the remaining part of said Property, the balance of, the transfer fee not paid upon lot relGaMs shall then be paid by Vendor regardless of the acreage of such reaaiaLng. pert. Upon Vendor's release of lot(s) as aforesaid,,.Purebaser shall have paid or shall then pay to Vendor an amount equal to 500 of the selling price paid to Purchaser for such lot(*) released; provided, howev #a-that the $10,000.00 annual payments due on the first and second anniversari0f of this Contract shall be deemed advance payment toward such release-payments, thus entitling Purchasers to release of lot(s) for sales up to $20,0OO.,QO- for each such annual payment, and Purchaser shall be obligated only :to pay 501 of the selling prices that exceeds $20,000.00 aggregate with rispeot to such credit for each annual payment. All payments received shall ',be.:applied first to interest and then to principal . The $10,000.00 down paysrent paid at the execution of this Contract shall not be applied to any release of lots, , but instead shall be deemed to be advance payment toward vendor's release and joinder in the dedication of public roads and of any parkland or similar areas which Purchaser may be required to dedicate pursuant to the subdivision of said Property. It is the belief of the parties that such $10,000.00 down payment, applied to release and dedication of lands' to the Town of Hudson for public use, is exempt from real estatte transfer fee pursuant to Sec. 77.25(2) , Wis. $tats. , and that transfer fees will thus be due only upon $84, 395.00, to be paid by Vendor as provided above-,.. Nothwithstandinq the aforsaid method of oalaulating the MONSt to be paid to vendor for release of lots, Purchaser shall be obligated to psi such, additional amount, if any, for lot releases to assure tbst tie MIG"ing acreage not theretofore released as lots or dedicated to t a public. if multiplied by il,Soo.00 per &are, does not excised the remaiaiaq balance due under this Contract. The foregoing provisions shall be deemed to modify any conflicting term this Contract which prohibits or restricts transfer or conveyance of id Property, to the extent necegsary to give full force and effect to the foregoing provisions. O , 4 Y _ � U) S T C lU r • y - I SEPTIC TANK MAINTENA CE ACKEEMENT o St . Croix guilty > 0WNEk/BUYEK , �£NNrs d2Ns7AD �._ � KOUTE/BOX NUMBER GdjiWd e. —_Wire Number CITY/STATE eydoti &J,#4, Zit, SyOL___ _ PKUPEKTY LUCATIUN : 5E k. NAI k, Sect ion , T _a 9 N , k._/9, .._W • Town of, LgtjZ) _ , S • t:ruix County , Subd$viaioo Lot tiuinbe r A2-//S i improper use, and maintenance of your septic cyst .-w could result in I its premature failure to handle wastes . Pruner maintenance run- bibts u [ pumping out the septic tank every Cikrcc years or suoiter , it needed , by a licensed se tic tank pu!!V r , Whin you put into the system can affect the function of- wia s-optic tank as a creat - went stage in the waste disposal system. St . Croix County residents MliEX be eligible Cu receive a grant lur a lfi.,xiukum of 60% of the cost of replacement of a failing system. which was in operation privc , `. _4t . Cruix County accepted this program in August, o'f 1980, witt► the reyiiiremeut ttIat owners of all new systems agree to keep their systems properly maintained. .------- 'i'he property owner agrees to submit to St . Croix Cuunty loving a certification form, signed by the owner and by a master pluu►ber , journeyman plumber , restricted plumber or a licensed pumper veri - fying that (1) the on-pit4 wastewater disposal system is in proper uperating condition and (2) after inspection and pu►nping ( it nec - essary) , the septic 'tank 1s less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 0 C I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with M the standards set Forth, herein, as set by the Wisconsin Depart- 19 ment of Natural Resources. Certification form must be completed and returned to the St. Croix Country Zoning Offk a within 30 days of the three y4ar expiration date . SIGNED DATE ° St . Croix_ County Zoning Office P. O. Box 98 Hammond , WI 54015 715-796-2239 or 715425-8363 Sign , date and return, to above uddress . DEPARTMENT OF REPORT ON SOIL BORINGS AND , SAFETY& BUILDINGS INDUSTRY L� �� � DIVISION ILUMAN "° PERCOLATION TESTS (115) MADISON,WI 53707 � IrIUMAN RELATIONS (1-163.090M Chapter 145.045) [LOCATION:q E TON: O HI UNICIPALITY: T NO.:BLK.NO,: SUBDIVISION NAME: sE �4 1/4 __2_4T N/R E(or)W SI5 rooz,111 I Et,4LW06& G.-rorES 7zt COUNTY: ER' UXXER'S AM AI LING ADDRESS: ' / STCI�O`ik IS oQh1STn� 1296 Aiatwook � Nu� Y1/SQN I S4 16 USE DATES OBSERVATIONS MADE NO.BEORMS : CO MMERCIAL DESCRIPTION: R S: A STS: Residence New ❑Replace � Fes 29 /9S8 Mole �itcS LTyor ;AGE` `'9 `JbILS- Js - 3E% V-T RATING:S-Site suitable for system U-Site unsuitable for system SnC-L-SANT I Ali O O N-G N :[RS N-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) � � s �� 0 S OR --rQ4.nrcN Sy-,;u', If Percolation Tests are NOT required DESIGN RATE If any portion of the tested area is in the under s.H63.09(5)Ib),indicate: C��dSS Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL D P U AT INCH ARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,AND DEPTH NUMBER OEPTHIX, ELEVATION QB V TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) MS 6 Kati MS B- Z Q T7 99.6? oN� > 8.17 i 3 gt,t.TS Z6 szeger.4 MS B- 8.�U 9�,/Ls NoN > �•Sb n Q st b i�' e LtTS 2 BaN Co Cs$ n,Ms 3 S R p gQ•1 MS g. 4 PAZ 9?X9 oNr_ > $.qZ z"It tTS 41" kw&#kMs B- < 9.9-Z /01.77 >9.9Z "13t.�T=♦ B- PERCOLATION TESTS T DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. p l p I PER INCH P. / S•SO 100.1 30 ® 3 3 P. 5,00 E 3� I ' I l 4 24 P. 3 3.co o •Z a P- _ LIEJATIOw AT F;Rc P. P. PLOT PLAN: Show locations of percolation tests, soil boring and the dimensions of suitable soil areas. Indicate scale or distances. Describe wha are the horl. '°�ontal end vertical elevation r and show their ocation on the plot plan. Show the surface elevation at all borings and the directio r and percent ,..f land slope. SYSTEM ELEVATION 110 I p I RI ) g-S - 3Z' 30 �NCNfh4♦Ztt— —TbP dF L'M'P Ct)LVl`RT• E�J'./OO•t7b ^ 1,the undersigned, hereby certify that the soil tests reported on this form were m 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 corrlcct to the best of my knowledge and belief. NAME print : I i TESTS WERE COMPLETED ON: 4e\16--1 Jou Soh/ -� xN SudeJ�Y�N4 �Ne /Vla�ecN 2 / k ,ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(opt ional): 407 Stc:�NA -- u�sl, Wr S9o16 34 Z+ 386-4OgU CST SIG ATURE: DISTRIBUTION: omlinal will ono cnliy In 1 ocal Aulhotoy,Plnliel ty Uwnr., anll;foil resua. DILHR-SRD-6395 (R.02/89) — OVFII 6,J , -4l �d B 14,46d NO K