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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER vin Vln',1\ V TOWNSHIP c, v%.- SEC. / T�N-R/ W
ADDRESS F le f o X 2 g Z ST. CROIX COUNTY, WISCONSIN
SUBDIVISION-�,, E LOT LOT SIZE . D9 c Q✓ g
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4/7/ ZZ GZ
tl 4,1
e
� I I
I l I
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SG Kfi �L LO� I� 41� I
8, Wt• ,l`
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 0 5 coma
Elevation of vertical reference point: Proposed slope at site: %
SEPTIC TANK: Manufacturer: W e ; S Q✓ Liquid Capacity: to 0o s a
Number of rings used: �_ Tank manhole cover elevation: 7. /Z
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: FrontP Side, Rear, O 1 feet
From nearest property line Front,0Side,®Rear,0 (o ( � feet
Number of feet from: well 2, building: a, -� 3S�i0— Ss Grua✓e� a�s�
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
t„
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: 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,0 Ft.
Number of feet from well: t
Number of feet from building:
(Include distances on plot plan) .
SOIL ABSORPTION SYSTEM
Bed: ea Trench:
Width: l Length: 3 Number of Lines: 3 Area Built:-(o`�$5
Fill depth to top of pipe: �T
i
Number of feet from nearest property line: Front, O Side, O Rear,aVt .1�
i
Number of feet from well: g/
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: k4— 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 �/f
Manufacturer: /7/ 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•
Dated: Plumber on job:
License Number: 5 2-
3/84:mj
014
ST. CROIX COUNTY
WISCONSIN
- - ZONING OFFICE
N r x a�,x■". ""„i ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
A� /aZdbz.
June 17 , 1994 tZ 6— 11�--7–
Mr. Doug Torgerson
Century 21
706 19th Street
Hudson, Wisconsin 54016
RE: Water Inspection for Jeff Alden
Address: 473 Greenmill Lane, Hudson, Wisconsin
Dear Mr. Torgerson:
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 let me
know.
Sincerely,
Mary Y. Jenkins
Assistant Zoning Administrator
mz
Enclosure
s
COMMERCIAL TESTING LABORATORY, INC.
514 Matn Street, P.O. Box 526
Colfax, Wisconsin 54730
715 - 962 - 3121
800 - 962 - 5227
FAX - 715 - 962 - 4030
ST. CROIX COUNTY ZONING OFFICE kTPORT NO.S 64228101 PAGE 1
ST.CROIX CTY W).CTR REPORT DA1E'# 6/15/94
1101 CARMICHAEL ROAD DATE RECEIVED'# 6/09/94
HUDSON, WI 54016
ATTN'# THOMAS C. NELSON
OWNERS Jeff Alden
LOCATIONS 473 Greenmill Lane, Hudson
COLLECTOR'# M. Jenkins Z
DATE COLLECTED'# 6-08-94
TIME COLLECTED'# 114'30am
t faucet
SOURCE OF SAMPLES Ou side f ace ,
DATE ANALYZED'#6-09-94 :: I
TIME ANALYZED'#2'#44pm
COLIFORM,MFCC'# 0 /100 mt
INTERPRETATION'# Bacteriologically SAFE
NITRATE-N'# 8 ppm
Above 10 ppm exceeds the recommended Public
f Drinking Water Standard.
I
Coliform Bacteria/100 ml
Nitrate-•Nitrogen, mg/L
I
LAB TECHNICIANS Pam Gane
r
.. �. WI Approved Lab No. 19
< Means "LESS THAN" Detectable Level Approved by'#
dam, ® •`'
O
PROFESSIONAL LABORATORY SERVICES SINCE 1952
ST. CROIX COUNTY
WISCONSIN
-- --- ZONING OFFICE
N M N N N■ „�■„� ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
June 8, 1994
Mr. Doug Torgerson
Century 21
706 19th Street
Hudson, Wisconsin 54016
RE: Septic Inspection for Residence located at
473 Greenmill Lane, Hudson, Wisconsin
Dear Mr. Torgerson:
An inspection of the septic system of the Jeff Alden property
located at 473 Greenmill Lane, Hudson, Wisconsin, was conducted
today, June 8, 1994 .
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,
please do not hesitate in contacting this office.
Sincerely,
Mary J. enkins
Assistant Zoning Administrator
mz
ST. CROIX COUNTY �5!
WISCONSIN
-- ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
rF. 1101 Carmichael Road
, ,. . Hudson, WI 54016-7710(715) 386-4680
/�� PTIIC INSP CTICV / WATER TEST REQUEST FORM
ase spe f,,� fired tj,�t(s) & remit appropriate fee with
�a lication. ti elAtside;'water lines are often turned off during
winter months, " king access to the home necessary. Please make
arrangements with this office to insure that entry can be gained.
0 Water (VOC's) $185. 00 Septic $50. 00
t Water (Nitrate & Bacteria) 45. 00 Nitrate & Bacteria
flL_b_XA1 retest $15. 00
Owner: JEFF Requested by 14C�f'.
Address: Address: aa-
s ,y ZIP1i; ZIP
Telephone N4: A,j Telephone : E.0 t 7 i
Property ad r ss (Fire N4 & Street) • �1 j RA-viELJ ESTRTESJ
Location: ; , ; , Sec._ , T. N, R___a Town of
Realty firm:LE ? Lock Box Combo: Closing Date:
TO BE COMPLETED BY OPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM*
Water sample tap location:�,lc4e., ,S°v, /I
Is the dwelling currently occupied? N- Yes 0 No
If vacant, date last occupied:
Age of septic system: 4 vef.
Septic tank last pumped by. Tj; C',,,,44 5,,, J,,t j04 Date:
Previous Owner's Name(s) :
Have any of the following been observed?
DY 01r Slow drainage from house.
DY Bit- Sewage Back-up into dwelling.
DY PR' Sewage discharge to ground surface or road ditch.
DY B<—Foul odors.
Other comments relative to system operation: zVo
�,ey�.� . �,.. .�^-s ;.-, .. .. . •. `� ? 1..,_ `• ,.•., ..i,w *yin::;�i.h! 7u.t�a!l��.q f�4•.:'�p'+.+tF ��i^1'vi
I--- that the above--information-Lis -66- mpleteand true tothe
�
bests of,myknowledge�
' 'a'z��.a;.'xsy � titi7dsr..a,eA:zo ,wi.l•,r.G.xiai:..,.xa,..m.w&.:s:G,. 'gdS: .���,f� .w...
OWNERS SIGNATURE: DATE:
1/94
r .-.,y !.7 n^• i
zr'
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
x r
v
as
"''- Irk TQn It��'��►�,p;�q sole ) �
i,
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 OGravity ODose ❑Pressurized
Ft. 2 ❑Bed ❑Trench ODry Well
OHolding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other OUnknown
Septic tank
Setbacks: ❑House ✓ []Well ❑Prop. line ' []Other '
Dose tank
Setbacks: ❑House ❑Well �,_Upro< l ine OOther
0 king cover --OWarninglabel ❑Pump/Floats
Alarm ❑Elec. wiring
. Soil Absorption System
Setbacks: ❑House V ❑Well �' OProp. line []Other
OPonding: '71.6'h(„/ C, ❑Discharge:
General comments:
INSPECTORS KETCH OF SYSTEM LOCATION
N
Inspector
Title
Parcel #: 020-1157-30-000 12/06/2005 10:29 AM
PAGE 1 OF 1
Alt.Parcel#: 17.29.19.880 020-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): O=Current Owner, C=Current Co-Owner
JEROME L&PATRICIA A GERMAN O-GERMAN,JEROME L&PATRICIA A
473 GREEN MILL LA
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *473 GREEN MILL LA
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.002 Plat: 2277-PARK VIEW ESTATES 3RD
SEC 17 T29N R19W PY NW SE PARK VIEW Block/Condo Bldg: LOT 86
ESTATES 3RD ADD'N LOT 86
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 1085/554 WD
07/23/1997 826/382
2005 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.002 47,700 251,400 299,100 NO 05
Totals for 2005:
General Property 1.002 47,700 251,400 299,100
Woodland 0.000 0 0
Totals for 2004:
General Property 1.002 24,300 223,400 247,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 128
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
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
*LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
NW14, SEA, S17,T29N-R19W CONVENTIONAL ❑ALTERNATIVE (If aual^naliD.Number:
Town of Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound
Lot 86 Parkview Estates
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Sam Miller Route 1 Box 282 Hudson WI 54016 10, JO I b-Dg-<,&R
BENCH MARK(Permanent reference Pointl DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF,PT.ELEV.
Name of Plumber MP/MPRSW No.: County Sanitary Permit Number:
Doug Strohbeen I5432 St. Croix 102862
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
^ PROVIDED. PROVIDED.
DYES ONO DYES ONO
BEDDING. VENT DIA. VENT MATL. HIGH WATER NUMBER OF ROAO' PROPERTY WELL. BUILDING. VENT TO FRESH
ALARM. FEET FROM LINE. AIR INLET'
DYES ❑NO DYES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY JPUMP MODEL. JPUMPISIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ONO ❑YES ONO [—]YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING IVENTTOFRIS"
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing 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:
WIDTH: LENGTH NO OF DISTR.PIPE SPACING COVER JINSIDE DIA -PITS LIQUID
BED/TRENCH ^ TRENCHES MATERIAL: IT DEPTH
DIMENSIONS 0.
GRAVEL DEPTH FILL DEPTH DISTR PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FHESH
BELOW PIPES ABOVE 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.
❑YES ❑NO
SOIL COVER ITEXTURE PERMANENT MARKERS 10111111VATIONVIIIIS
OYES ❑NO 1:1 YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER. EDGES.
DYES El NO 1-1 YES ENO OYES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIT FILL DEPTH ABOVE COVEH
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL IN DISTR DISTR.PIPE DISTHIBUTION PIPE MATE HIAL&M HKING
ELEVATION AND
ELEV.. ELEV.. DIA. ELEV.. PIPES DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS
LIFT CORRESPONDS TO APPROVED
DYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PR OPERTY WELL. BUILDING
FEET FROM LINE
V u ❑YES 1:1 NO DYES ONO NEAREST
a
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE
DILHR SBD 6710(R.01/82) Zoning Administrator
=ML SANITARY PERMIT APPLICATION COUNTY C��v� x
ZZ In accord with ILHR 83.05,Wis.Adm.Code STATE�SANITARY PERMIT#
�c� a
—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 2 NO
PROPERTY OWNER PROPERTY LOCATION
%a- '/4, S T , N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
,e-,el z z V o 1 U;.fj A D Z
CITY,S ATE ZIP CODE PHONE NUMBER CITY �AREST ROAD,LAKE OR LANDMARK CACJS Q�f, 7�-� ('176 9 VILLAGE : vh !J i ![ 1,
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 3: OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. A 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. Conventional b. ❑Alternative C. ❑ Experimental
2. a. El System- b. 1-1 Holding c.❑ Pit Privy d. ❑ Vault Privy e. 1:1 Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. JZ 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 :
3 (p 1.S �T e, PT� 77 9s 7 Feet X Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total #of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete strr cted Steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank El 1 ❑
Lift Pump Tank/Siphon Chamber El ❑
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 Stamps) MP/MPRSW No.: Business Phone Number:
4 s�rc wt Lys 3233
lumb is Address(Street,City,State,Zip Code): IF
Name of Designer: `
/Z e t W WK 0�•b�'/� L�,7 •l' 70�-7 ,l�O�. J[ /C R Gd X
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST Name tt CST
i C 0 7d✓5
ST's ADDRESS(Street,City,State,Zip C de) Phone Number:
4 I./ . Sao/4-
X. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial S rcharge Fee —
Adverse Determination 12d Co 9S.Sjrcharge Fee
Adverse Determinationi �' 12d no XT
X. COMMENTS/REASONS FOR DISAPPROVAL:
log 77-A66-?&O fi/ye Svc
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 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
I. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
ll. 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;
Ill. 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'/z 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
included the creation of surcharges (fees) for a number of regulated practices which Wjsco
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried resure
is used in your building is returned to the groundwater through your soil absorption u
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- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, 1 C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON W 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION:, SECTION: OWNSHIP/ LOTNO.:BLK-NO.: SUBDIVISION NAME:
(•�J �/E�/ /7 /Tn N/R/71( o �� �" r� 's�L
COUNTY: OW`ER'S BUYER'S NAME: MAILING ADDRESS::]
S i J Ie�� tYl J.
i
f, rS.
USE DATES OBSE VATIONS MADE
NO.BEDRMS.:ICOMMERCI A L DESCRIPTION: I PROFILE DES RIPTIONS: FI OLATIO TESTS:
�esidence XNew ❑Replace
Sv.' Mn �L
RATING:S=Site suitable for system U=Site unsuitable for system G 114
CONVENTIONAL:, MOUND: IN-GROUND-PRESSURE: SYSTEM-IN ILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
CAS DU S DU XS DU DS ®U DS XU C tl 6'
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain, indicateFloodplain elevation: All
P FI E DESCRIPTIONS
BORING TOTAL$ ELEVATION
DEPTH TO GROUNDWATER i?F6N�E CHARACTER OF SOIL WITH THICKNESS,COLOR-,TEXTURE, AND DEPTH
NUMBER DEPTH 4#r OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBIBRV.ON BACK.))
B- /(}a,d1 0•tt '� �i Q' • ��5� • n S i 4 d S� J� A6 S
�Y �•� s/, . �'/?-t Errs, • 7 B� /sue
B- v' S,3
> ,O �7 81 S/� , S 1".0, . e Bh rSI, .Z o �n�rSJ
B- •c� •u S
B-
PERCOLATION TESTS
TEST DEPTH# WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 444rolIE$ AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
3
P Y 3' L-3
P- 43
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION �S• 7' _
J
I
t
/d �r%oe
tN
4 es
f P
}
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I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belie.
NAME(print): TESTS WERE COMPLETED ON:
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ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER(optional):
CST SI TURE: ...
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DISTRIBUTION: Original and one copy to Local Authority,Property Ovdner and Soil Tester.
DIL! <D-6395 (R.02/82) --OVER -- i
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APPLICATION FOR SANITARY PERMIT
STC - 100
I,this application form is to be completed in full and signed b the owner(s) of the
PP P g Y
property being developed. Any inadequacies will only result in delays of the permit
(issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
Owner of Property ^� y ,0,/Z
Location of Property /f/1,0 —Ic Section 17 , T �9 N-R�
Township
Nailing Address / „ ®X 2 t( Z
4 AV
Address of Site /¢y 4r— ear r T7la.-t t Ar T,,6
Subdivision Name
Lot Number f �
Previous Owner of Property "f--
Total Size of Parcel Z
Date Parcel was Created -s-O-6- $-/
Are all corners and lot lines identifiable? /'_ Yes No
Is this property being developed for resale (spec house) ? _ Yes No
Volume _ S and Page Number 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (Wel cVLU6y that dtt e.tatemente on thus 6onm ane tAue to the beAt o6 my (ou,%)
hnowtedge; that I (we) am (ahe.) .the ownen(e o6 the pnopeAty deecA,i.bed in thjA
in6onmati.on 6onm, by v.iA_tue o6 a waAAanty deed neconded in the 066.ice 06 the
Cotut,t RepAteA o6 Deeds ad Document No. /3�SZ and that I (We) pneAentty
Run .the pnoposed e•i.te bon the -Sewage WApod dye em (on I (we) have obtained an
eaaemen.t, to nun with the above d"cA bed pnopeJrty, bon the eonetnuction o6 aa.id
ayatu++, and the name has been duty neconded .tn the 066.ice o6 the County Reg.ieten o6
veedd, ab VOCament No.
SIGNATURE Op OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED
. DATE SIGNED
PARK V11EW ESTATES FOURTH: ADDITION !
A 11PAt .9-6DMSICN LOCATED IN THE;v*SwWEkNWIAaSEI4,SEC77CN IT. T29R, R19%N., t
! 'I'CNN:CF.FBI,.ST. CRCfX CAUNTY, VVISC4,ON
C=T27ICATE OT TOMN T7tl/iS[1xZR
STATZ OF VF1SCCN3Lr)SS";,! .• : .•.
S-r. C7totZ COIN-4y
I'. Beyesly A.John
mm*-being t!e daly alact«I,qua=*&and acting TLVwa Treasurer '
of ttta To—n of Hudson, do Uereby certify that in aceerda"o r rde Is any office,
these are no unpeld taxes or spaolal assessments as of „�on say land
lAsia da.t In the Plat of Ark Viees Estates Fourth Addition.
• Haverty. +ohnso Towa 3 seasarsr i
TOWN BOARD RESOLUTION
RYSOLVED, that the Plat of park view Estates Fourth Addition In the Town of i
Hudson, Darrel E. Wert and Bave A. Wort,
Town B rd.1 owners, to hereby approved by the
/�
' i
a •Approved
own anon
D ignad owe C;%&irmae�
A hereby certify that the foregoing
board at the Town of Hudson, is a copy of a resolution adopted by the Town I
I
Dot• own Clark
OWNERS'CL-RTIFICATE OF DEDICATION
As o*nor3, we hrraby certify that we caused the land described on thi: Plat to be
surveyed, d!-A:I*d# rrapped and dodteated es r-0ors.ented an this Plat. W4 4180 certify
tAet ::-is Plat la required by S. Z36.10 OT S. 21--0.12 to be submitted to tiie following for
approval or objection:
Depart: at t.l Dayslopgteat
liepertmeru of Industry, Labor and Human Relations, I
Town of Fludson. City of Hudson and St. Croix Co..nty. I.
W;TNES3 the haul end seal of said owners this_/_ a day of - + --
In mil
a esance of:
artal _
`% `/-J,,� - .Pal/IR f , h• '�/..
Bev erl A. 1
Wes
STATE OF WISCONSIN) SS
ST. CROIX COUNT Y ) I
Personally came before rote this day of //.. P ••• the above
amn4 Darrel E. `Mort end Beverly A. Wort, to Inv :mown to be the persons who executed
n '
the foregoing Instrument sad acknowledged the tams.
Notary Public r'r' i..,, •?„[, Wisconsin My commisston explres G/J9/BT
t
• /�/icy a�aa,+fi, "! I
Mary K411nsch, ?rotary Atbllc !
1
CERTIFICATE OE'TOWN CLERK
STATE OF WISCONSIN) j
ST; CROIX COUNTY )
I. Rita'.brne, belag the duty appointed, quatlflad end acting Town Clark of the
'Town of U-Moron, do hereby c, if that copie of this Plat were forwsrded as
required by x. .176.12 on t o-11 day of� . 1984. and that within
the 20•dsy limit vat Fy e. 216:12(3)(no object! na to the plat have boon filed)
(all jhj..cnons to he slat have born met).
G L21 Y±4
Date ART Ho
Town Clerk
JAMES E. HUSCH
SURVEYING & MAPPING
HUDSON, WISCONSIN
,:, �•: THIS IPIST11WCNT CRAFTED 91
i
3U3tVX.TO1%e3 CZRTU MATS.,
1.trams S.Rusak.RojdsUmod Wtsceasia Lars Surveyor, buteby certify to the
boot*f my peol*osiowat knowledge. underetaodaAS asd bets.[:
Tbwa2 haav earvoyslo divided sad roapp4d Ark View£ststes.lourth Addition..
104ateA in the NS1/4 W gibe SW 114 seed the N W314 of the SEI14 of 3eesioa IT. T29N.
R 19Y. Tow of Helena.9t. Croix County. W4seossia;
That I bore m&4* such survey. land di-rWos sad plat by the 4136as7los of Darrel C.
Warta"lieverly.A. Mart. owsore 01 said lard, described as follows:
COiaste39dag at,the ZI/4 comer of said Section 17;theta•Si9•L:bg"w (►seam*
600,1113950 Taiwan*"to the niowumentod lyd3T 9 CST I/4 3ectiow Use,si'3ecdoa 17.
bw *"9 asanssed SWU'011'!W)(recorded as 341ir21140'"M on tb"C*wM-%d Survey Map
recorded is Volwas 1�,Pago 1414). 1332.948 sloag swtd EA3T-WZ,31'1 14 Ucues ltAel
4, 1 SV G64`WW-227.TJ$to the polar of boomaisgs tbeno*N411l5284411Y 412.001.thoaso.. .
NO"06830"L 232.00+to Ike 5"aborly rtgkt-of-way Also of CrO+a UJU Lobes tksou
IMP52144-W 64.008 along raid rt kt-efw.11y lire:these*SVO48301W 231.004.thence
379"261SVIV 194.351;thooco SUP 15814"W 236.714;&house:N73'37805"W /42.174:theaea _
3419"JYet4ww 5541008;.ihsaco NPO6130"Z 104.0041 tb**"SW15414"W 3f4.OW;theme
NOr!s830'sE 155,004:td►e.oe S49"1313411W 64.011t that**f0r0i83 1W 316.434;thosce •
SWIS834"W'151.00+;tbsuce NO'37851"W 54.124:theaee 3i9'224'1"'A 341..9061 theses
30 M*Pff.204.44181 thmw.N4y'13 914"Z 150.004;thence St►ON301W 312.97';thocce
N4!'l5814"3C 130.00f1•th.ae*Jootkoasts:ly 66.2371 al"th*araof s 3413.908 radius
eurno'eommt ro tortheraterty whose chord hears 54504501174 64,17'1 them.:41"015414"L �
57.0181 theae*'3009hewseerly.336.541 alone%ke tiro of a 317.004 radio•carve eoeeave
Northeasterly wbo*r chord beam 324 03702"S 13x.51 e;thee.*336'231301°.' 143.141:
tboane 14Tr361S0">:'140.961;thew*WS9'15'14"L243.OW;theaca Sd06131-V 104.002;
tb«aeo;b31'3036'W..239.348;theae*Southeasterly 96.344 d tern are of a 217.00'
radtsi orvs.asoeays NorthaastorlY wli ore chord Doris 87P03416"E 95.351;thence
17SAM.4714"=MAW;them"Northoastorly 91.210 along the nos'of s 30VJOI mdiva.
ees+iso39a4w HertMmoterly wbose'ebord beare 34414t'32840"L90.8ft tbesao North-.
"doeiril'.'44rgong tbo are of s 309.008 radius curve sanative Honheactnrl r�.hora
chord boars N41o3'T/26wW 91.098;thence N0104130 02 150.008:tboace N419/15s14
4741.05AI dean..PW*683009 434.568 te.the point of beginning.. t
Tbew sash plat Is s correct r*psosoatstioa sf all th*wdevior boeadsaiea of the
I&"aIt.9 Y04 sad the subdivie"m thereof=ad*, sad 1
Tiles I have tally compiled with the provisions of Chapter 236 of the MflseoosLi 1
statabe* the l0,6divislaft WA ZOMng ReXalulens of 3t. Croix Cauaty, the:own of
ltedsee 7lub4ivist"Ordiaoaeo,wad the City of Hudson Snbdlvlstas sad Ssletuis.s Or41-
AaACso,in swrraying.tt9vidlsg and stsapping the same, y,
Dated thls 01-16 ' dsy of Nett , 1984
1 RAv{ ,l5th d0, .�t�i, 1914.
&tea 3C.It osahM Les, 1776 ��
421 be:oad Dtrwt
.. litidsoa.Mlscossia 54016 �'' d� t; `:
COUKTT TIMAM TUR13 CZRTITICATZ '�►�
STA7r Or WISCONsim At1��
Si
ST.C3t017[COUNTY )
I. IJtuty Jess Livermore, bat"duly elected,qualified and sating I rsssurer of
3t..Croix Cooney, de hereby certify that the rocorde in my attic 0 show 0,r suredeemed
tas sales sad no oupald taxes er special sssos*msats as of Z!��-J/
aHeetlag the Isads inalt.ded is the Plat of Park View Xstwtes Yourth Addvlan.
" Dais linty Trd.%~or
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:fie •,. t.�,k �
7ON1NG CO24).f1TTZZ RrsoLUTION
This plat 1e hereby approved by the St. Croix County Comprehensive Perks,
i IAWas sad 7oAlnX Committee.
11 s
I3sto CI►�I>'lt.a
Dsto Administrator
.IESISTE3YS r'�`l�.( ?
;1 M619 al.!t0. .� • '1\. ,
• iw.w...•Y flews'�.•.-1
4� 774111, .._A*.ww� i
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St . Croix County z
cy
a
/ter H
OWNER/BUYER .—�4►�'/ ��/. �
ROUTE/BOX f
NUMBEReje° z .rao,r IF Fire Number
CITY/ST ATE 06or! �� Z I /,6
PROPERTY LOCATION :& 14, Section T .;�,l N , R�
Town of St . Croix County ,
Subdivision r a'1
�,�°�C c��s f � � L o t n u m b e r_.
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 put 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
a maximum of 60% 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 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 . H
0
E
z
I/WE, the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with H
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 Office within 30 days
of the three year expiration date .
S I G N
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 .