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HomeMy WebLinkAbout020-1031-50-000 CD m o o a 0 � I o I 0 `v I M I I I I � I w I I (n o z° c W c 0 � � I I I I rn w E z :: 0 I I LU a m o o z a c y Z a ° o V) a� z S o 2 M` N O. C m N � c 0 O � a - I 0 o I z c c N ° R tv Lo `6 0 Fa a y Y co _ m o o c a U - N a p fA U) U) a c _ w Z r FL - 3 Z c �N maaa (L _ O o m ' 0 fA J V iI, OOi co Z �l c � (D o N 0 'o N = ap c D I � � p ? U) N M ` I O O !; 0 C O W O E CO O L? p O N Y Cp C m N 0) i t \ _ C H v M � C N c � co co o m O N y N Z °: n N I MH ° N N N CD z Y C � V E a •'� m a CL m E c c r o t A c°� a � oU) L) 1 Parcel #: 020-1031-50-000 03/31/2006 10:02 AM PAGE 1 OF 1 Alt. Parcel#: 17.29.19.143E 020-TOWN OF HUDSON Current LX I ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner JAMES W&CANDICE R TRST MILLER O-MILLER, JAMES W&CANDICE R TRST 970 DAILY RD HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *970 DAILY RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.370 Plat: N/A-NOT AVAILABLE SEC 17 T29N R19W SE NE LOT 4 CERT SURVEY Block/Condo Bldg: MAP IN VOL I PAGE 184 ORD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 12/12/2000 635115 1566/356 QC 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 91612 261,500 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.370 74,200 192,500 266,700 NO 05 Totals for 2005: General Property 3.370 74,200 192,500 266,700 Woodland 0.000 0 0 Totals for 2004: General Property 3.370 43,400 165,700 209,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 307 Specials: User Special Code Category Amount i 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 . , du y Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER �1/l/E� TOWNSHIP / UP-r-V A-' SEC. / T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN csy�l SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -44 CA1,1f • $'E�TiG T�.v,� sEit'v/c�l,.� �Q�/-ti j0�1� G�� � G � l �(�� �fZ• lv ee Oc�r�L, 1' A .� jtG s' l��/ iP jl'/�'f rx oy pAt P42 f 0 <a itgl�' 4V INDICATE NORTH ARROW �✓07�,� fO� LVOOG� BENCHMARK: Describe the vertical reference point used Sw�y�` E�11 five of 1�4"F •Z Elevation of vertical reference point: 1670`0 , Proposed slope at site: 2 ?�q S7 P° ,e�1/STi AI6- /N 004-" O�OE� w/ Qom -F,'8EVSAr S SEPTIC TANK: Manufacturer: 1VoT ,C,VOIv.✓ Liquid Capacity: 16WD Number of rings used: (o Tank manhole cover elevation: /'7- -W �'� �D ' ' Tank Inlet Elevation: Tank Outlet Elevation: 007. 60 Number of feet from nearest Road: Front,©Side0Rear, O oa'-A )-00 , feet 50 - From nearest property line : Front,0 Side kj Rear,O 7S feet i Number of feet from: well ' 7� building: // rT (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE 139900'ON'OilIONJIS309d311V1SNI'NNIHI 'S'Ii'd'W 10MON'Oil d39Wflld N31SVW'SIM ` 1FpJIb91t118390H %M'SIM'Nosam''OU 113N,0 959 '00 VNI9Wtlld 011d3S 311S3WOH :aagmnN asuaoTZ :qor uo aagmnT(I :paleQ :aoloadsul r :aaanloe3nueH maeTy -- :peoa Isaasau moa3 laa3 3o aagmnN :SuTpTTnq moa3 laa; 3o aagmnN :TTaM moa3 laa3 3o aagmnN •13 O •aeag O `OPTS O `luola :auTT Alaadoad lsaaeau moa3 laa3 3o agmnN :39TuT uoTlenaTa :-4uel 3o molloq 3o uoTlenaTa :pasn BuTa 3o aagmnN :AlToedeO :aaanloe3nueyl NMVI 9NIQ70H • (auo Noag0) lsmal�Cs uoTlgaosge TTos anoge aql 3o Cue uo pasn ueaq OXO uoTingTalsTP ao O xoq doap a aaglTa seH :ITTng easy :uoTlen 1Td a$edeas 3o molloq :gldap pTnbTZ t :aalameTQ :s1Td 3o aagmnN :azTS ZId aDvaaSS •(ueTd IOTd uo saouelsTp apnToul) / p/ :SuTPTTnq moa3 laa3 3o aagmnN it Q L Q 0 :TTaM moa3 laa3 3o aagmnN lg O`aeag ® `OPTS O `luoa3 :auTT Alaedoad isaaeau moa3 laa3 3o aagmnN :ad-Ed 3o dol of gldap TTTa :ITTng easy Z :sauT'I 30 aagmnN / O� :gl2uaq / s :g1PTM •-C�l :gouaay :peg I• O L� � _5 'l aZSiS NOIJ.a2IOSgy 'IIOS ' .7 •(ueld lord uo saouelsTP apnToul) :SUTPTTnq moa3 laa3 3o aagmnN I :TTaM moa3 laa; 3o aagmnN •la 0`aEag O `OPTS O `luoag :auTT Alaadoad lsaaeau a3 3aa3 3o aagmnN r +:. :adAl goITMS maeTy :aaanloe3nuvW maeTy :aTDAO aad suOTTeO :uoTlenaTa golTMs 33o dmnd :uoTlenaTa Auel 3o slog :IaTuT 3o uoTlenaTa azTS dmnd :aaan3oe3nuuN uogdTS/dmnd :TapoN dmnd :A3ToedeO PTnbT7 :aaanloe3nuuH 'HHg IMD dRnci i _ ! HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD.,HUDSON,WIS.54016 ROBERT ULBRX?h4T WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. MINN.INSTALLER&DESIGNER LIC.N0.00663 6 V og • TeeNC% it hT> w(l�Past 3A � Ma�K£ A)" ��'� p%ST TAE F C'U p 5 �50 - - - - - - - -� Sfik C - - - - - - - � - - - - - - - -- - - t SySTEr1, oo1� INLE�(30x 11 co vaecrV 110 Z S l9 PfP , / -rL)le N►N c- PV i� r �✓ ueRT RAF Pr. Pgosr r'o•�STRU� +ro,�.� % -7P S"&-7- .v E X 7- T O I C/ow'-1 S �OIE �D� I L'lEV. �top ` w r 3Y M n- : t y `P S c'S O /O d•d I 1 90. i i I plo r P44Aj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number Sow, NE,'-,, S 17,729N-R 19G!ab Hudson Town ❑Holding Tank El In-Ground Pressure El Mound (If assigned) Daita Road NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECT( N DATE: Jim 9 Candace Mitten 970 Daily Road, Hud�san, III 5401G —a 9- ?' 4,3d BENCH MARK(Permanent reference Point)DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF.PT.ELEV. Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: abet�t Utbticht i3307 St. Ckoix 112724 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ❑YES ONO DYES ONO BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD PROPERTY WELL: BUILDING. (VENT TO FRESH ALARM. FEET FRO LINE. AIR INLET DYES ONO DYES ONO N DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. JPUMPIIIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO D YES ❑NO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET ON AND OFF) 1:1 YES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing I LENGTH DIAMETER 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: BED/TRENCH WIDTH LENGTH N6 TRENCHES IDISTR PIPE SPACING HOVER PIT INSIUE DIA ap1T5 DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR PIPE MATERIAL: UMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER ELEV.INLET ELEV.END. EET FROM LINE AIR INLET EAREST--► 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. ❑YES 1:1 NO SOIL COVER TEXTURE PERMANENT MARKERS JOBSIRVATION WELLS 1:1 YES El NO 1:1 YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. DYES ONO DYES ❑NO DYES El NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVEN DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTHIBUTION PIPE MATERIAL&M1IARKING ELEVATION AND ELEV.. ELEV.. DIA. ELEV. PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS 1:1 YES El NO DYES 1-1 NO COMMENTS: PERMANENT MARKERS: OBS ERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING (� FEET FROM 3.� S LINE N / DYES ONO El YES F-1 NO INEAREST___� �v. Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE DILHR SBD 6710(R.0,/a2) Zoning adm.ini6t r-cftotc J 1 EZ -�" SANITARY PERMIT APPLICATION COUNTY DILHR In accord with ILHR 83.05,Wis.Adm. Code STATE SANITARY PERMIT##*1111:ps/ // d -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 ❑YESj4 NO PROPERTY OyVNER PROPERTY LOCATION G A47/4, S /7 T , N, R 7 E (Or PROPERTY OWNER'S MAILING ADD ESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME d L CITY,STATE ZI CODE PHONE NUMBER CITY NE REST ROAD,' "'�`�°' ^"'^""^RK � l ❑ VILLAGE: VSO �/��L-Li& TOWN II. TYPE OF BUILDING OR USE SERVED: dab` 103 1—316 00 6 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. El New b. LbJ Replacement c. El Replacement of d. El Reconnection of e.El 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. aX Conventional 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. ❑ Seepage Bed b. Seepage Trench c70Seejp"age Pit 2. PERCOLATION RATE 3. ABSO PTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): s Yd 0-/. �� Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in aa ons 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 AW NQ ❑❑ 1 ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): I Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: ��-T Zl X 1e / 3307 7 ?J6 -(?I(f ' Plumber's Address(Street,City,State,Zi Code): Name of Designer: S %v e / - �fo,✓ C�15 s�o/� VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name `! 7ES; CST# 655 O'NEIL RD.,HUDSON,WIS.54016 �,Y� CST's ADDRESS(Street,City,State,Zip Code) ',MS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. Phone Number: ,%jiNN iNsTALLER&DESIGNER LIC.NO.00663 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) rchar a Fee �4pproved ❑ Owner Given Initial /2O �,�v 11-1 ^n � Ltn Adverse Determination 1 V O� r X. COMMENTS/REASONS FOR DISAPPROVAL: 1 CL h SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber ` e r ! 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 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; II. 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 bill Ground t r included the creation of surcharges (fees) for a number of regulated practices which Wisco t;w:, a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasur .; is used in your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. 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- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deedrrecording. ------------------------------------------------------------------------------- Owner of property MR • Ales. 1/' Location of property � 1/4 1/4, Section T__�:LN-RjW Township V YOitJ Mailing address 'S ��j L Y �7® ,p}�lLy Ddb V P S O W S :5' Address of site Subdivision name C- m Lot number Previous owner of property V,�tiT y ESA)`Se Total size of parcel 37h cre-5, Date parcel was created `""-1 3 ® l / 6 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes _No Volume 5 and Page Number _!603 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 Map shall also be required. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 1Y3 02, 2-- ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the Count Regis of Deeds, as Document No. Sig ure of Owner Signature Co-Own If Applicable) 0 Date of/§ignatAre Date o Signature g t1■�mom Olt, I whit SL e#„ +... husbaed aed ri .. . iein ♦r..�..t.a Otran� s � �•. I , r t. C..a,..w. P. VrM�•r.+••arra• w.aa. y 7we w ff U"M.ML t,80=860"r� 1 Hrt of ink of of Section 17-29-19 described as Lot 4 of Certified Survey Map filed October 22, 1975 in Vb1 a 1, page 184, in the office of the Register '. E o- of Deeds for St. Croix County, Wisconsin. this deed is executed and recorded solely to correct 1 an error in the description in the conveyance recorded in Vblusts 541, page 605, Document 8335020, in the office ' of the Register of Deeds for St. Croix County, Wisconsin. ` n Receptive to w....cw: 0101118"at Hudson. Wisconsin WL—�__dew of ugnst . �' r s�asso AND ssALaD no Passaws oP Brent J A . ?f. Debbra J. eA Qf C�il J/ �� •k .• FA j W/A oaatteotd ilia Lr a( N_. � , Titles snow Stow am N whw w t ob Orw wt>. 4 AMSwrled oaMr see. M.Oi via. sTATS OP 1 WD It — Ciro'x C ounty• 111 /lL "L Femme f Qya Mhro M.we x.30 day of August ' tro*be"mmd Brent H. Jensen and Debbra J. Jensen. his rife • »�!j t` to me, to M Igo P•omm—A oo KKtited oo/�Mla{batnl�aat a aakala/�d } Fr srt 4 4 rile f�lrarwtt Ou It by J.- twin, Atty.scone n Noy e.wk St. Croix �•�• } � { ff K n1MMdN M gtlaaal. w C�Igoioa(sa/Yoa)(ta) LA win a10t1aP:t�r! !9601"M /M�r�t�N ltNnr IoM alsttataoa. __ _ 5 = sti1:�I 11sfCOIt�M. 1'aa11 ti z • - r , N STC - 105 H� ; SEPTIC TANK MAINTENANCE AGREEMENT ►-� ;.. St . Croix County OWNER/BUYER ,, -/� G� ROUTE/BOX NUMBER �90 Dj (�� /YJ� - .Fire Number ` 79 t CITY/STATE ZIP 5 •4 PROPERTY LOCATION:!!! � , Section / , T�N, R t Town of St . Croix County, ru„ Subdivision Lot. number . Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con.- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you pat into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix. County residents may be eligible to receive a grant for l a maximum of 60% of the cost of replacement of a failing system, which was in oprdration prior to July 1 , 1978 . St . Croix County I accepted this program in August of 1980, with the requirement that j 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , 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. o I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with M i the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Off:Lee wit in 30 days. of the three year expiration date . , SIGNED O f , DATE St . Croix County Zoning Office P.O. Box 98 i Hammond , WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above ve ,., I address . i QEPAIITMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS"INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P�, / �� MADISON WI 53707 HUMAN RELATIONS N REL (H63.09(1)&Chapter 145.045) 2- L ON: TOWNSHIP/M 000WN* FT+�': LOT NO._:BLK.NO.: SUBDIVISION NAME: 5 E y �� tot r.J C N�� R S��NAME:�ik A MAILING ADDRESS:L S' k 17 V�S�/J 9701 G U y w ,s s USE DATES OBSERVATIONS MADE NO.BE : COMMERCIAL DES RI TION: 12q_41 PR M D ON: A TESTS: Residence 3 N ❑New X]Replace 37 , 31—eple RATING:S=Site suitable for system U=Site unsuitable for system ONVEN I L: MOUND: IN-GROUND UR :S STEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) ©S ou EIS ❑u ' ES ou MS ou EIS ©u ��'vvE-c�fiDw fi/ — r, EAeA-eS / o ITT, If Percolation Tests are NOT required TESIGN RATE: I If any portion the tested area is in the under s.H63.09(5)(b),indicate: elf'r s Floodplain, indicate ate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUP DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGWE—ST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) �� S• v,(!&) sy s/t i $,5. st o• pN-yy. 671 B" 1. //• �f!0 7. 3, O UFO{' !'ENlE D/ivF 'fefy PA3aH. �Q�Gy /+dfS (PUDO/ED AFT .O' 3.0 B" 74� u doh S A-j B.2 9.o ' 9/, i� ' > d 0' s' s , s T�� v.�7 es 5 . B.3 9.U ' do9yZ ' a , , �s . N s, 8.79 ' Trfm 11Aj C B- PERCOLATION TESTS TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD ____P9Wr= PER INCH P- '` Z 1�- p_ .t P__ I I I P_ t P. PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicates i2lQistanq&Describe' t the hori- tontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevati .1t AI bgljng t 1e direCt percent of land slope. � '4+t1���C 1t -� SYSTEM ELEVATION F ! 10 tONG o _ ..� .... _ 2' .... icl�'S,7 (1— .�.���w eds lwS�r9l/�( -din ✓�� . I-A CIO ! r'eo y r MY 4& 1 y .. 1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the test§are correct to the best of my knowledge and belief. NAME(print): HOMESITE SEPTIC TESTS WERE COMPLETED ON: 655 O'NEIL RD.,HUDSON,WIS.54018 31 / f dp ? ADDRESS: EE TTIFICATI N NUMBER: PHOI�J,EvNUMB (optional): WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. y 00 y 3a( I MINN. .NO.00663 CST SUGNATURe� KK 'DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. L )ILHR-SBD-6395 IR.02/82) —OVER — r rLo i rLANJ 1E AAIJ- e = ��«ffaE fjiTS Y 30, . a3 J ?3 40 / 30 i z 8Y � 5�6 1 � i 1 � J �Y f I f CvE/� p�E�As�'rAA) y M I • v � 2y , SEPTIC T oo�leT l S9•� j vEor. Per. 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