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Parcel #: 020-1158-80-000 01/07/2005 01:10
PAGE 1 OF F 1 1
Alt.Parcel#: 20.29.19.895 020-TOWN OF HUDSON
Current ❑ ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): *=Current Owner
*KLIPFEL, KENNETH E&CHERYL E
KENNETH E&CHERYL E KLIPFEL
839 MAUD RD
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *839 MAUD RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.410 Plat: 2329-PINEGROVE HEIGHTS ADD
SEC 20 T29N R19W PINEGROVE HEIGHTS ADD Block/Condo Bldg: LOT 02
LOT 2
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 1237/432 W D
07/23/1997 846/512
07/23/1997 817/305
2004 SUMMARY Bill M Fair Market Value: Assessed with:
48978 206,400
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.410 24,100 135,600 159,700 NO
r
Totals for 2004:
General Property 1.410 24,100 135,600 159,700
Woodland 0.000 0 0
Totals for 2003:
General Property 1.410 24,100 135,600 159,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 214
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
1 ~ ,
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T 9�N-R�W
ADDRESS & ST. CROIX COUNTY, WISCONSIN
SUBDIVISION R k,P 1//w,�LOT L LOT SIZE —�-
PLAN VIEW
Distances and dimensions to meet requirements of I'ZHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/ 1
Sz
�LC
�'._r6
' Y
I
li
i
y 7
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 3 j�^/yl f
Elevation of vertical reference point: AV'r ' Proposed slope at site:
SEPTIC TANK: Manufacturer: Gf/e.rt Liquid Capacity:
Number of rings used: _ Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,0 Rear, O'�� feet
From nearest propert� line Front,0 Side,0 Rear,� feet
Number of feet from: well building: zg- �
(Include this information of tie above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
r
' 1
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 Ft. `
+ �... k
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: /L� Length: S'-y Number of Lines: 2.. Area Built: 704P
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, &ear,0 Pt ./�_
Number of feet from well:
Number of feet from building: 7
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
License Number: 3��
3/84:mj
36 c
ST. CROIX C UNTY
„
WISCONSIN
ZONING OFFICE
ST.CROIX COUNTY COURTHOUSE
• HUDSON,WI 54016
(715)386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
1 r
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
O_Water (VOC's) $185. 00 0 Septic $25.00
Z Water (Nitrate & Bacteria) . $35. 00 (Visual inspection)
owner: /'/Wk IA,/ /Z O L/j Requested by:
Address: 5?3 u7 m fL.0 Rp Address:
City & State: Iy�Dsv.✓ , �� r City & St. ,
Zip Code: Zip Code
Telephone N4: (°7/5) 3s�;�, -��,s�% Telephone N4: ( )
Property address (Fire If & Street) : 'S
�/� Tr'IZ�-✓�
Location: ;, ;, Sec. 00 , T_Z�LN, R__0 W, Town of
St. Croix Co. , WI. Tax ID N2 Parcel ID N4
ova
House color: Realty firm: Lock Box Combo:
Water sample tap location: ou-t5;to FRa, R - yl<
TO BE COMPLETED BY -PROPERTY OWNER , .
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE_ OF THIS FORM*
Is the dwelling currently occupied? Yes ❑ No
If vacant, date last. occupied:
Septic system installed by:
Septic tank last serviced by:
Previous Owner's Name(s) :
} �''
Have any of the following been observed? lc�'.p
OY ON Slow drainage from house.: r-
f.�
❑Y ON Sewage Back-up into dwelling. `;
OY ON Sewage discharge to
g g ground su �iti, '7
road. ditch or body of water. �Ge r a ter t
❑Y ON Slow drainage from the dwelling`t.-d �-
❑Y ON Foul odors.
$T
Other comments relative to system operation:
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: �� /�6 DATE: ///1/ 9.3
OWNERS DRAWING OF HOUSE & SEPTICSYSTEM LOCATION
t
IN
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 ❑Gravity ❑Dose ❑Pressurized
Ft.2 ❑Bed ❑Trench 0Dry -Wel1
Molding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other ❑Unknown
Septic tank
Setbacks: ❑House_, _ ❑Well ❑Prop._ line ❑Other
Dose tank
Setbacks: ❑House : .❑Well . . ` -❑P-rop. 'line _ ❑Other
❑L�ocking.cover ❑Warning label ❑Pump/Floats "
❑Alarm ❑Elec. wiring
Soil Absorption System
Setbacks:.__❑House. .0Well ❑Prop. line ❑Other
❑Ponding: ❑Discharge:
General comments:
INSPECTORS SKETCH OF 'SYSTEM LOCATION
N
Inspector
Title
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715 - 962 - 3121
800 - 962 - 5227
FAX - 715 - 962 - 4030
ST, CROIX COUNTY GOVERNMENT REPORT M04: 52536/01 PAGE 1
CENTER REPORT DATE: 11/12/93
1101 CARMICHAEL ROAD DATE RECEIVED: 11/10/93
HUDSON, WI 54016
ATTN: THOMAS c. NELSON
OWNER.' Mark Koib
LOCATION!** 829 Maud Rd., Hudson
COLLECTOR*# M. Jenkins
DATE COLLECTED: 11-08-93
TIME COLLECTED: 1:30pm
SOURCE OF SAMPLE: Ouiside faucet
DATE ANALYZED:11-10-93
TIME ANALYZED:2:00pm
COLIFORM,WCC: 0 /100 st
INTERPRETATION: Bacteriologically SAFE
NITRATE-N: 4 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
� 2
Coliform Bacteria/100 ml -
Nitrate-Nitrogen, mg/L
LAB TECHNICIAN: Pam Gam
.0.\NOfVENpfHI. � L
`9p WI Approved Lab No. 19
d 5A { Means "LESS THAN" Detectable Level
Approved by.
PROFESSIONAL LABORATORY SERVICES SINCE 1952
r
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
NE, ,SE, ,S20,T29N-R19W CONVENTIONAL Ell ALTERNATIVE (Ifaassigned)D.Number
.
Town o� Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound
Lot 2 Pine Gnave He,% W
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Tom Hanson 9_ q —3
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:
David B. FogvLty i3289 St. ctoix 112723
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED. �q-
/2 40 — , — [$CYES ONO DYES f AVO
BEDDING. VENT DIP VENT MATL. HIGH WATER NUMBER OF IROAD: PROPERTY WELL: BUILDING. VENT TO FRESH li
II 1` ALARM FEET FRO LI" � �D y (AIR II ET
❑YES O �� DYES O NI
DOSING CHAMBER:
MANUFACTURER BEDDING'. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED PROVIDED.
❑YES ❑NO YE ❑NO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PR OPE V [Vj� 1BUILDING JVENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing I LENGTH IDIAMETERNTe AL ND 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 LENGTN NO.OF DISTR.PIPE SPACING COVER IN SIDE CIA &PITS LIQUID
BED/TRENCH TRENCHES 1 MATERIAL PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL. O DI NUMBER OF PROPE RTV WELL BUILOIryG V NT TO FRESH
BELOW PIPES ABOVE COVER. LfE_V.I LLEET ELLEV.ENDD'q ^� PIP FEET FROM LINE
ID t) ,',"_ V +W -I�,V—I d' NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
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 ONO
OIL COVER TEXTURE PERMANENT MARKERS TATIONWFLLS
❑YES ❑NO YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED IMULC.EU
CENTER EDGES.
DYES ❑NO ❑YES ONO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEV.. ELEV.. DIA.. ELEV.. PIPES DIA.'.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING.
LINE
❑YES ONO DYES ❑NO NEAREST FEET FROM
11 !
r— 7
L4� I i
Sketch System on Retain in county file for audit.
Reverse Side.
SIG ATU TITLE
DI LHR SBD 6710(R.01/82) A�+, Zoning
COLO .
c71LHR SANITARY PERMIT APPLICATION COUNTY ' ��D/
In accord with ILHR 83.05,Wis.Adm.Code 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'h x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION �j
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES 119 NO
PROPERTY OWNER PROPERTY TION
'/4 '/4, S �r7 T , N, R E (or
,ow zilkte.�.twl PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
3 Z
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROA
LiILLAGE: p
,r EW II. TYPE OF BUILDING OR USE SERVED: d
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. LI!1 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. Dy 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 c. ❑ See age 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): 9,s' J/
7
❑
Feet �rivate Joint F-1 Public
CAPACITY
VI. TANK Site
in allons 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 Holdina Tank ls(, ❑ ❑
Lift Pump Tank/Siphon Chamber ❑ El I L ❑
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) 44P/MPRSW No.: Business Phone Number:
Plumber's Address treet,City, tate,Zip de): Name of Designer:
t^ w^
Ill. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
G t
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
, d ccl ^c o 40 7 �1.oa
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial fiWrcharge Fee a
Adverse Determination 120'Ww
X. COMMENTS/REASONS FOR DISAPPROVAL:
- J
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
F
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 Cod will be applicable;
3. All revisions to this permit must be approv y the permit issuing authority. A new permit may be needed
if there is a change in your building plans, sy em location, estimated wastewater Clow (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 4cerised
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. Prcperty owners 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
YP 9 P YP ( ,
P
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 hone number. Plumber must sign application form. Fill in designer name if
P 9 PP 9
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''h 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�St4t
included the creation of surcharges (fees) for a number of regulated practices which wiscoriuth S .
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reas.&6,-
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 purnper.
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)
4
APPLICATION FOR SANITARY PERMIT
S T C - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor, (spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
--------------------- - -------------------------------------------------------
Owner of property Q A�
Location of property 1/4 -5,F /4, Section �n , T_2!�YN-R /9 W
Township
Mailing address �� (� �6 U e- N
Address of site Arwz! 6�epUFz
Subdivision name ZeAv,-
Lot number Z /
Previous owner of property
_2
Total size of parcel Ito 1
Date parcel was created
Are all corners and lot lines identifiable? P/ Yes No
Is this property being developed or resale (spec house)? L,-'Yes No
136
Volume 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 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, de d re orded in the Office of
the County Register of Deeds as Document No."- �.� 1_� ; 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
onstruction of said system, and the same has beef} r ly corded in the Office
of the C m y Register of Deeds, as Document No.
\A t Al�, , -
Si4ABfure—or Owner Signature of Co-Owner (If Applicable)
1/ 2 (/
�-'j IN
Date of Signature Date of Signature
�L
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
439711
BOOK 817 r ,,
� REGISTER'S OFFICE
RICHARD 0. STOUT , JANET P. STOUT and ST. CROIX CO., WI
MAUD H. 6TUUT Rec'd for Record
J 1a L 92 1996
conveys and warrants to THOMAS W. HANS ON
of 8.30 AM
Register of Deeds
RETURN TO
the following described real estate in 6t . r o ix County,
State of Wisconsin:
Lot 2 , Pinegrove Heights in the Town of Tax Parcel No:
Hudson located in the Northeast Quarter of the
Southeast Quarter of Section 20, Township 29 North, Range 19 West.
This i not homestead property.
(is) (is not)
Exception to Warranties:
Dated this 1 9th day of July , 1s 88
+ `'��` (SEAL) •, �c (SEAL)
Richard 0. Stout Maud H. Stout by Richard 0. Stou ,
_ �,y� _ Power o Attorney t/`� (SEAL) (SEAL)
Janet P. Stout ,
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
St. Croix
County.
authenticated this day of =, 19 Personally came before me this 19th day of
/ duly _19 RR the above named
Hichard 0. Stout and janut
P. 6tout
TITLE:MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person Iq who executed the
authorized by§706.06,Wis.Stats.) foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Notary Public County,Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date: ,19 .)
'Names of persons signing in any capacity should be typed or printed below their signatures. NTF 2280
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms,P.O.Box 1075,Green Bay,WI 54305-1075
Form No.2—1982
L
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 1)
ROUTE/BOX NUMBER FIRE NO..�
CITY/STATE t� ZIP SC�z >--
PROPERTY LOCATION: V1/4 ,je 1/4, Section _9 T_22_N, R1 W,
Town of GIDjB/(/ , St. Croix County,
Subdivision Lot No.
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St. 1 Count Zoning Office within
30 days of the three year expiration date.
SIGNED ,,
DATE t�
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DEPARTMENT OF REPORT ON $OIL, BORINGS AND SAFETY& BU DI
INDUSTRY, IVISION
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNS HIP/Mbll`+2FPfctF;Y: LOT NO.:BLK.NO.: SUBDIVISION NAME:
AlIF as a r) /T,,, N/R E (o �— I — I er=
COUNTY: OWNER'S MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: ��/ PROFILE DESCRIPTIONS:1PERCOLATION TESTS
:
Q�Residence l _ LJ New ❑Replace
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL:IMOUND:( �` IN-G(ROOU-N�`D-PRESSURE: SYST1EIM-I(N�FILLHOLDIINGTANK: RECOMMENDED SYSTEM:(optional)
If Percolation Tests are NOT required iD ESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- l /11)9 Z X
B-
B-
B-
PERCOLATION TESTS
EPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE M
NUMBER I TERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD NCH
P-
P-
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 ,
E
E
I
r
F x
I I I I
.._ 4--
A
� r
,
L
INSTRUCTIONS FOR COMPLETING FORM 115 - SB - 6395
To be a complete and accurate soil test,your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacerrient system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for w,iting profile descriptions and completing the plot plan;
7- MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
B. Mal<e so,e your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp-
tion, if appropriate;
10. tf thie nforrnation (s,rch as flood plain,elevation)does riot apply, place N.A.in the appropriate box;
11, Skin the form and place your current address and your certification number;
32. Make legible copies and distribute as rerluired. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS
Soil Separates and Textures Other Symbols
st — Stone, (over 10") BR — Bedrock
cob Col:rble (3- 10") SS — Sandstone
gr -- Gravel (under 3") LS Lirnestone
s Sand HGW — High Groundwater
c:; - Coa3°se Sand Pere Percolation Bats=
Ineci s _- medium, Sand W -- Well
fs — Eire Sarni Bldg -- Building
Is — Loamy Sand Greater Than
sJ Sandy Loam < Less Than
"E Loam Bn - Brown
Silt Loam BI Black
1s Sill
°v` — r.3 r a",
Clay Loam Y Yellow
sc7 __ Sandy (clay Loam R — Red
siel Silty Clay Loat mot Mot 1 e
w Sandy Clay wi - vvirh
�L _. Silty Clay fff — [(w,fire, faint
xc -- t;iay cc -- ("Ornnlur�,coarse
01 - Peat mm -- Many, medium
r11 — !rv'luck d — distinct
p prornineno
HVVL - Hiqh vvator level,
Six.€lcneral soil 'textures V�—Itar
for liquid waste disposal `01 �a+ J
T'q(I dF REPORT ON S BORINGS AND SAFETY&BUILDINGS
INDUS
INDUSTRY,, ' DIVISION
LABOR AND P.O. BOX 76
HUMAN RELATIONS PERCOLATION'TESTS (115) MADISON WI 537907 9 53707
(1-163.090)&Chapter 145.045)
SECTION: T OT NO.:BLK.NO.: SUBDI VISION NAME:
NE 114SE�74 20 /T29 N/R19 or)W Hudson IL2 n/a I Pine Grove
COUNTY: OWNER'S AME: MAILIN DR S:
�i
St. Croix Dan Schneckenberg R.R.#1, Clear Lake, Wi. 54005
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE S: ERCOLATAON STS:
Residence 3 n/a ®New ❑Replace
5-6-87 n/a
}
RATING:S-Site suitable for system U-Site unsuitable for system
ONVENTI NAL: MOUND: IN-GROUND•PR T M- N-FILL rEls OLDING TANK:RECOMMENDED SYSTEM:(optional)
®S ❑U ®S ❑U IL]S ❑U • ❑S ®U OV conventional
If Percolation Tests are NOT recl6ired DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Class 1 Floodplain,indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOI H I SS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTHM ELEVATION OBSERVED HE TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
B- 1 6.92 100.45 none >6.92 .67b1:1. 1.33 bn.sil. .42bn.l.s. 4.50bn.c.s.&gr.
B- 2 7.00 100.25 none >7.00 .67bl.1. 1.08bn.sil. .33bn.s.1. 4.92bn.c.s.&gr. `
B- 3 7.42 100.83 none >7.42 .92bl.1. 1.25bn.sil. .42bn.l.s. 4.83bn.c.s.&gr.
B- 4 7.17 102.23 none >7.17 .83bl.1. 1.25bn.sil. .42bn.l.s. 4.67bn.c.s.&gr.
• B- 5 6.83 101.94 none >6.83 .83bl.1. 1.08bn.sil. .42bn.l.s. 4.50bn.c.s.&gr.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD I PERIOD2 PERIOD 3 PER INCH
P-
P-
P-
P-.
i
P-
P- f
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 96.95
— u
_.
j 5L �
- Fe
Al
t _ _
x
I,the undersigned,hereby certify that the soil tests re p!ed on thi m were by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data rec)rded and the yI OA of the test s,a r ct to the best of my knowledge and belief.
NAME(print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
I 2298 715-p6-6200
CST SIGNAT
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER—
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