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020-1120-10-000
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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 O-FILIPIAK,TIMOTHY S&MARY JO TIMOTF Y S&MARY JO FILIPIAK 416 BR OKWOOD DR HUDSO WI 54016 District : SC=School SP=Special Property Address(es): "=Primary Type DIst# Description 416 BROOKWOOD DR SC 2611 HUDSON SP i 700 WITC Legal Description: Acres: 1.920 Plat: 2553-TROUT BROOK WOODS ADDITION SEC 17,& 18 T29N R19W TROUT BROOK WOODS Block/Condo Bldg: LOT 15 ADDITION LOT 15 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 773/506 07/23/1997 763/587 2006 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.920 75,100 211,900 287,000 NO Total s for 2006: General Property 1.920 75,100 211,900 287,000 Woodland 0.000 0 0 Totals for 2005: General Property 1.920 75,100 211,900 287,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 136 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ` ST. CROI X COUNTY W I S C O N S I N CIVIL DEFENSE OFFICE 796-2239 - HAMMOND, WI 54015 January 30, 1987 Ms , arolyn Haag Bureau of Plumbing P. 0 Box 7969 Madi on, WI 53707 Dear Carolyn, Perm t#88456, issued 12-23-86 to Carl Thompson has been rescinded, due to a change in the system elevation. Permit #88470 has been issued for the installation of the system. The plumber was unable to obtain the original permit card. Should you have any questions regarding this subject , please feel free to contact this office. Sinc rely,, } st�� Mary J. Jenkins Assi taut Zoning Administrator . j 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: Number of feet from building: (Include distances on p y�31an) H'tpn ITW SOIL ABSORPTION SYSTEM 4-1�J Ci � y 70)g5 So_ END 9��5a Bed: Trench: �'yJ Bec /-/ R Width: I $ Lenth: 3 W Number of Lines: 3 Area Built: y y a., Fill depth to top of pipe: Number of feet from nearest property line: Fronts O Side, O Rear,0 Pt . Number of feet from well: N N Number of feet from building: (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: 2 � Dated: / Y7 Plumber on job: License Number: 7� 3/84:mj Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ( 4OWNSHIP lA UaSON SEC. T N W fti ADDRESS ST. CROIX COUNTY, WISCONSIN _1 Ul a o t'. SUBDIVIS ON OU -R—UO LOT J LOT SIZE WWVS PLAN VIEW Distances and dimensions to meet requirements of 111iR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 BedRaorn Nome 0 38 �� QED N T yof t INDICATE NORTH ARROW BENC : Describe the vertical reference point used � a Elevation of vertical reference point: 100 - 0 Proposed slope at site: �a SEPTIC TANK: Manufacturer: ���5 Liquid Capacity: (MO Num)er of rings used: Tank manhole cover elevation: do, �9 Tan c Inlet ..Elevation: Tank Outlet Elevation: 99A Number of feet from ,nearest- Road.: Front;O Sideo Rear, O feet From 'Rearest, property line Front 10 Side,0 Rear,0 feet Num er of feet from: well N O IN , building: (Includ this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR& 7969 RELATIONS P.O.'BdX 7969 PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING MADISOW WI 5370 ❑CONVENTIONAL ❑ALTERNATIVE State Planl.D.Number: I (11 assigned) ❑Holding Tank ❑In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Carl Thompsoa 458 Burlington Rd. St. Paul, Mn. 55119 l—_� —Q BENCH MARK(Permanent ref rence point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: NW—Se 4 Sect on 17 T29N R19W Town of Hudson Troutbrook Woods Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:--I p R. Hopkins 1059 St. Croix "0�- g8y70 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIOUID CAPBCITy; T K LET E EV.: TANK OUTLET ELEV.: ING LAB L LOCKING COVk) Q,f U��1/Vlt Uy//k t 9 �WA.F OED: PROVIDED: BEDDING: V NT DIA.: ENT MATL.: HIGH WA ER IN / �" YES NO ❑YES NO UMB R OF ROAD:/� IPROPER-(Y/ WELL: IBUILDIN IVEPT TO FRESH ALARM. FEET FROM l: -\ LOW:_/ y AIR INLET. DYES O DYE S ❑NO NEAREST r.1Lra�l1 .nv)/Jvfl� / DOSING CHAMBER: MANUFACTURER. BE DING: LIQUID CAPACITY: PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ❑NO OYES ❑NO DYES NO GALLONS PER CYC f— AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ONO NEAREST SOIL ABSORPTIONS STEM.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 t continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WI TH: LENGTH IN..OF DISTR.PIPE SPACING COVER IINSIUE DIA -PITS ILIOUID j! TRENCHES / M ERIAL: PIT DEPTH DIMENSIONS �. ( J GRAVEL DEPTH FI DEPTH �SFTV-�Lt P DISTR.PIPE _ DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL 9UI ING: V NT TO FR BELOW PIPES: / AB C9 ER END. PIPES FEET FROM LIn �/-fit lY °' 2_ J NEAREST—i —'V -✓ 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- ❑YES ONO meets the criteria for medium sand. TIONS MEASURED. OIL COVER TEXTURE 1PERMANENT MARKERS OBSEHVA TION WELLS ❑YES ❑NO ❑ (ES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER ITRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER: EDGES. ❑YES ❑NO OYES ONO DYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE JMANIIOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND EL .. ELEV.: DIA.: ELEV.. PIPES DISTRIBUTION INFORMATION Ho'E SIZE HOLE SPACING DRILLED CORRECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. OYES 1:1 NO El YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES 1:1 NO OYES 1:1 NO NEAREST Sc Sketch System on R ain in county file for audit. Reverse Side. SIGNAT ,^ TITLE. DI LHR SBD 6710(R.0'/82) / 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 sanitar y p ermit a pp licaJon must include. I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; 11. 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; 111. 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:l.aw-This legislation is more commonly known as the groundwater, protection law. Th►s,tbange in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Groundw�a(te[ -- included the creation of surcharges (fees) for a number of regulated practices which Wiscor4in`15 can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried r asure. is used in your biiiding is returned t, the groundwater though your soil absorption u system or the disposal site used by your holding tank puriper. a The niorl.;es collected through, these surcharges are credited to the groundwater fund adminis- tere,� by he Department of Natural Resources. These funds are used for monJoring ground- T water, gr(.)undwater contamination investigations and est<<blishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) SANITARY PERMIT APPLICATION C"? C12o1' In accord with ILHR 83.05,Wis.Adm.Code ■��^M � STATE SANITARY PERMIT# 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 iii size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES OKI NO PROPERTY OWNER �% PROPERTY LOCATION Q r /U 4)1/4 51& /4, S T-1f, N, R E(or W PROPERTY OW MAISNG ADORES V DSO� LOT NUMBER BLOCK NUMBER SUBDIVISION aZoot / O Ov,.5 CITY,STATE l ZIP ODE PHO E NUMBER El VILLAGE: U©SQ� NEAREST ROAD, K DSo-J S ?3 7410 v r BROO ,P II. TYPE OF BUIL ING OR USE SERVED: Number of Bedro mS 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. Nys e b.El Replacement c. ❑ Replacement of d.❑ Reconnection of e.El Repair of an N m System Septic Tank Onl an Existing System Existing System 2/CJ A Sanit ry Permit was previously issued. Permit## y Date Issued 3. ❑ An Exi ting 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 SYS EM: (Check only one in#1 and only one in#2) 1. a. Con entional b. El Alternative C. ❑ Experimental 2. a. ❑Syst m- 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. ❑Seepage Pit 2. PEF(coLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes pei inch): (REQUIRED(Square Feet): P/ROPOSE (Square Fe t): �j� (p (9 �� /4 .1�3V r � '- Feet rivals El joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATIO New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin 1 Tank ❑ ❑ Lift Pump Tank/Siphoi Chamber T1 ❑ ❑ VII. RESPONSIBI ITY STATEMENT 1,the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Pri Plumber's Signature:(No Stamps) PRSW No.: Business Phone Number: PJC,1A tft)PKf 4S Plumber's Address(S reet,City,State,Zip Code): Name of Designer: w S , VIII. SOIL TEST IF IFORMATION HUMESITE SEPTIC PLUMBING Certified Soil Tester( ST)Name RT, 3 VNEIL RD.; HUDSON: MS. 54016 CST# u �j ROBERT ULBRICHT 2, l d CST's ADDRESS(Stre at,City,State,Zip Code) Phone Number: MINN. INSTALLER&DESIGNER LIC. NO. 00663 IX. COUNTY/DEF ARTMENT USE ONLY ❑ isapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ wner Given Initial n Surcharge Fee I/W—f Averse Determination (J S 71 L X. COMMENTS/F EASONS FOR DISAPPROVAL: SBD-6398(formerly PI 7)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber W:,DYER T�sT ro.v iio,�S sa.v.�,y, 3s F, fT"-J�iP'o�`T", DEPAWNENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS DIVISION INDUSTRY, ��U151�/J P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115 -T� Re p MADISON,WI 53707 HU;nAN RELATIONS (H63.090)&Chapter 145.045) o f 11.-I C,- I I Ap LOCATION: , ECTION: OWNSHIP/74AILINAD : �T O••BLK-NO•: SUB Div ISIONNAME: NW ��4 �4 �� �T29 N �9 E (o )w TiPO r �ip00,� WOO, $' COUNTY: BUYER'S NAME: S:/t�o/X ST Jf U12SO• ) J �o USE DATES OBSERVATIONS MADE NO.BEDR COMM R A DES RIPTION: G STS: PROFILE . Residence IN U, ❑Replace ���{ � �S 6 Sc5 S'8 ,f3u�,E�h�tRDT! RATING:S=Site suitable for system U-Site unsuitable for system ONVENTI NAL: UUND: I I GROUND PRESSURE: SYSTEM-IN•FILL OLDING TANK:RECOMMENDED SYSTEM:loptional) r t]S ❑U ©S ❑U OS ❑U ©S ❑U ❑S DU �a,�vE">o,vh c_ If Percolation Tests ire NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5►(b ,indicate: CG�S Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS jp 9ECi#iAt. T-T-- BORING TOTAL P H TO R UNDWATER INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION pgSERVED T-HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) • / 7 9 O J. 40, Qv . ,S',; 46 • 8.r.�o lam, 7,oo G `cy B- l /oo• (0 B.Z �v /aovy 7�t o 9 0 'mss°b 40. J,/ /J& • Zu. 4-1V 4-47' 74A* oar 8.3 �9 , /00. ).0 - > �� ' io' -Q^' s,' , .2•O vr. dW . ,j-.'/ i,�s • X3,0 J^,/, G.a. 'T.ra vl!;.y B-141 c5j6-R • r B-✓ Q. /o D, 3 '?pro- y a 51,E -f 0 y ue Cs G e- PERCOLATION TESTS k�n1 5 Fr, C, t� IS - TEST DEPTH WATER IN HOLE TEST TIME DROP WATER R L V L- INCHES RAPER INCH MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. —PERIOD 1 01 P- 2 P- P. ... P- ;74 '0 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 o levation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent SCALE : 1 " 3 • of land slope. SYSTEM E LEVATION Jr- _ ,fp � E ` ie E r l . 1 ae Of T I 3� I T H .. - , • I - o , Atc � e fRo✓r pRon+� �' w6,.V� sA� 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 Coc e,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED,ON: RT. 3O'NEIL RD_.:HUDSON,WIS,W161 `Z� /9 8 7 ADDRESS: CERTIFI TION NUMBER: PHO NUMB ( tional): WIS.MASTER PLUMBER_ LIC. NO.3307 M.P.R.S. .2,yj2--- .3a a " � CST SIGNATU E: DISTRIBUTION: r i,inal and one copy:o Local Authoi ity,Property Owner and Soil Tester. 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, 608-266-381:5. To be complete and accurate this sanitary permit application must include: I. Property owners 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; 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'/i 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; close 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 y 4 PT[.-� included the creation of surcharges (tees) for a number of regulated practices which Wisco ir3'� can effect groundwater. The surcharge: took effect on July 1, 1984. All of the water that buried recasure is used in your building is returned t,. the groundwater through your soil absorption u ; system or the disposal site used by your holding tank pu riper. 11 he nonies collected through these surcharges are credited to tha groundwater fund adminis rr.-ec= by the Department of Natural Resources These funds a.e used for monitoring ground- t � water, groundwater contamination investigations and establishment of standards GroundwatE ; s worth protecting. 0-6398(x.0186) SANITARY PERMIT APPLICATION r-Oubwv 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 D. 8%X 11 Inches I size. STATE PLAN I.D.NUMBER —See reverse Sid a for instructions for completing this application. 1. APPLICANT IN ORMATION—PLEASE PRINT ALL INFORMATION. PETITION FOR VARIANCE ]YES ❑ NO PROtr1 TY O7ER `'�'',G� WAIA ERTY LOQ6TION / �) M 64 A/ Sh %, S / 7 T��, N, R 8 E (or W PROPERTY¢WNE LIJVG�DDRS� LOT I�U�y1R BLOCK NUMBER �� AME6 C T ,S,v("TE8 �,IP CODE PHONE NUMBER CIITYYfs N EST L� LJ VILLAGE: 11. TYPE OF BUILDING OR USE SERVED: Number of Bedro ms if 1 or 2 Family OR ❑ Public(Specify): �Q eJ N ! &Xl e III. PURPOSE OF APPLICATION: (Check only one in##1. Check#2,3 or 4,if applicable) 1. a.ANew b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an Syst am 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 Sy tem 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. )(Conv Britional b. ❑Alternative C. ❑ Experimental 2. a. ❑Syst - b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fil Tank V. ABSORPTION YYTEM INFORMATION: (Check one) 1. a. Seep,i a Bed b. ❑seepage Trench c. ❑ seepage Pit 2. PERCO ATIO RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minute per nch): REQUIRED(Square Feet): PROPOSED �,(S uare Feet): ��5 rJ / �� 0 Feet 'Private ❑Joint ❑ Public VI. TANK CAPACITY Site INFORMATION Manufacturer's in lions Total #of Prefab. Fiber- Exper. New xistin Gallons Tanks Ms Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding ank Lift Pump Tank/Siphon hamber LJ ❑ VII. RESPONSIBIL TY STATEMENT I,the undersigned,a 5sume responsibility for installation of the private sewage system shown on the attached plans. Plu ber's Name(Print) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: Plum is Add r ss(Astr t,City,S ,Zip ode): , f Na f Deal er: _ Vol . � 5 o !� VIII. SOIL TEST IN ORMATION Certifi oil ester(C T)Nam CST## ak CS 's D ESS(Stree Cit , o de) Phone Number: IX. C UNTY/DEP TMENT USE ONLY ❑ Di approved Sanitary Permit Fee Groundwater ate Issuing Agent gnature(No Stamps) Approved ❑ O ner Given Initial �j Surcharge Fee Ad erse Determination � X. COMMENTS/RE SONS FOR DISAPPROVAL: SBD-6398(formerly Plb-6 )(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber APPLICATION FOR SANITARY PERMIT STC - 100 This applicati n 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. Sho ld 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 , d S O a ay� e � � Location of Property S ' Co 14, Section j T :L9 N N-IR W Township aj o s �•-- 0 ��� Hailing Addres s U y/,- >oll e� � - S?: 5 Address of Sit �';�, sD N !d/y e Subdivision N e �'ep "--t -yam . Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Z Z L8�, Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes _ — No Volume and Page Number 6'9 7 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deel 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 (We) cexti6y that atC 4tatement6 on this for an e #lcue to the befit o m owc 6 ( 1 hnowtedge; th 1 (we) am (an.e) the owner(4 the phopenty densc i.bed inyth.iA .in6oAmatti.on 6o km, by vivtue o6 a waAAawty gged tecMded in the 066ice o6 the County Reg.,6# o 6 Deeds a6 Document No. V Z 0 5T 3 ; and that 1 (we) p to en tey own the phopos d sate bon the sewage di,6poa eys em (on I (we) have obtained an easement, to ILLn with the above deAcAi.bed to p pehty, bon the eon.6.tJcucti.on o6 datd ays#em, and th same ha6 Peen dut recorded in the 066ice o6 the County Regi,6ten o6 Heeds, ad Vocu ment No. Z 6r3- ) . SIGNATURE OV,OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) -a- 2 8 z5 DATE SIGNED DATE SIGNED DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA II � 'WARRANTY DEED '!05 B60X i 63-K-E587 -REC4811M Offia This Deed, made between ...Eeter E... . To..........W............ ................ ST. CRM CQ*WIS. ................... ......••..•... .............................................................................. Roe& iDr Ra6c v6 ............ ------ --------------------- .......................•..........•..... ....... ---------------------- ...................................... -----------------------------------------------------------I Grantor, clay of -C.- D. 19.tf. and-------_C I-RioiTP_s_orx..d/`b/`a ------------------- at ------------------- -- ----------- ----------------_-- ----------- --- --------------------------------------- .---------- - ------ --- ..................................................---............ ------------------ ------- A. rid (vim L ------------------- ----------------_----- -------------------------------- ------------------- Grantee, Withesseth, That the said Grantor, for a valuable consideration____-- ----------Grantor---------------------- - ----------------------------------------------------------------- RETURN TO conveys to Grantee the following described real estate in ------St—_CrQiX---------- County, StatE of Wisconsin: Tax Parcel No: ----------------------------------- Lot 15, Trout Brook Woods Addition, Town of Hudson, St. Croix County, Wisconsin. 11", SM 0 This ---------i.S.-flot------- homestead property. (is) (is not) Togeth(r with all and singular the hereditaments and appurtenances thereunto belonging; And---- .--Grantor----------------------------------------------------------------------------------------------------------------------------------- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights—of—way of record, if any. and will warrint and defend the same. 19th December 86 Datedthis _ ----•------------------------------------•-- day of --------------------------------------------------------------------- 19--------- ----------------------- -----------------------------------------(SEAL) ------'0�4-ol; ell (SEAL) ------------ Peter E. Todd -------------- --------------------------------- ------------ -------------------------------------------- ------------------- -------------------- ---------------------- ------------ ------------(SEAL) ------- ------------------------------------------------------------(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) ---------Peter E. Todd-11 ----------------------------------- -------- STATE OF WISCONSIN Ss. ------------------- ------------------------------------------------------------ 19 December 86 --------------------------------------County. authenticated this -----day of------------ -------- 19...._. Personally came before me this ----------------day of - _ _ ---- ------------ --- ---_-------_---- 19------.. the above named --------------------- ------ ------------------------------------ .....•.. * Kristina Ogland Lundeen -------------- --------------------------------------------------------------- -------------- --------- -------------------------------------------------- --------------------- ------------------------------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN -------------------------------------------------------------------------------- (If not- ----------- -------------- authori2ed by § 706.06, Wis. Stats.) to me known to be the person ------------ who executed the foregoing instrument and acknowledge the same. THIS lNsrRUMENT WAS DRAFTED BY Kris ina 0--land Lundeen ------------------ ---------------------------------- ------------------- ------ ------ ------------------------------------------------- --------- Atto,ney at Law *-------------------------------- --------------------------------------------- - ----------------------------------------=------------- - -- - - 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. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leval Blank Co. Inc. Alil, e, FORM No. I—1932 nuke W is. cn y Y S T C - 105 r , Y S1iPTIC TANK MAINTLNANCL AG ItEHMLN'1' r� 0 5t . Croix County s d OWN I R/BUYER �'� 4 �SD �"� rn ROM E/BOX NUMBER-#-n P3 4YII T�53-) � Fire Number C IT) /STATE_ (4 ZIP PIt0REItTY L0CATION 4 , S. uI �, Sectio,il��, Town of &'R Lo St . Croix County , S u b d i v i s i o n7"4T 15 Mal UJ06�4 Lot number_ 1 L. Improper use and maintenance of your , septic system could result".'iii its premature failu:re . to handle wastes . Pruper maintenance can gists of pumping out the _sepCic.' tank every three years , o.r' sooner7, K if' needed by a licensed ,suLtic ` tank Bumper . What you piit into the system can affect. 'the function of 0 1 U septic: tank;. as 'a . tr:eat= inent stage. In the waste disposal system . �Y P St: Croix, County residents maw be eligible to receiVe a g,raat� foFr , k a inaxI'u►um "of 607. of- ,the, cost of - replace Ili ent of a ._failing system, vi which: was . in operation , prior to .July• 1 , 19 78 :` St ('r°oix Gount,- . Aw ri a IMMI cc.ept'ed this prugram in Auiust 'o(':1980, 'witli the rcc U: r;e iii ell t :that L i4 uwner.s of all new systems agree -to keep ~thus r sys'teuisz'pxoperly _ J Ili i'nta-ined - as � 1'he property owner ,agrees t^o submit to St . Cruix Couti Zoain� a,.,. certification form . signod : by the own�L,r "and by a ,n►uster - plumber ,'• '" journeyman plumber ,;-. restricted plumber::or a licensed ,pumper v.eri" f y i n g `that ,(1) the . on site wastewate'r ' dispusiil systeui' � s `in propex . oper• t'ing c'�Ondition' and (2) ' after , inspection and pumping (lf ,"nec essary) , the septic:- tank is less than I/3 Lull of sludge: and ; 'sc um. ' Certification form;,,will; be sent approxi�iiately 30 'days;` prior t.o three year expiration . H 0 I/WE , the undersigned ,. have read the above requirements .:and agree '. N to maintain the private sewage disposal system in acc'orda'nce with x the- tandards set forth, tie rein , as 'set. by the Wisconsin Uepart,- ro } ment of Natural Resources . Certification form must be completed and to thePr -St Croix " County; Zoning ' Office within'"'30. =days of t e three::yea•r expiration date SIGNED DATE St . tjoix Cziunty Zoning Of f ice P.- O. f-ox 98 - Hamm rd , W1 54015 715-74'6-2239 or 715-425-8363 Sign , date and return to above address ...,-....a W-407i ST - S�v ay, 3f DPri: NIENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, OW'j DIVISION 6ABOR AND PERCOLATION TESTS (115) QUIT" MADISON WI 53707 HUMAN RUKATION I1-163.090)& Chapter 145.045) LOCATION: SECTION: OWNSHIP/MbIftetPAtITY: OT NO.:BLK.NO.: SUBDIVISION NAME: N0 1/4 1/ i /Tz9 ON E to ►W wso,.� is 7x&4p r e-vea& woo p r COUNTY: BU;ER.S NAME:�G!�i!" M/ILIN AD�fl S,T LI UDSO.J , 40 f S. : c/�o , f n- �J r1 USE DATES OBSERVATIONS MADE O.BEDRMS.: COMMERCIAL DESCRIPTION: II R F I S: t TESTS: Residence New ❑Replace L�� , s — UGC•I S - 0 �o Sc S S8 41RDT- RATING:S=Site suitable for system U=Site unsuitable for system Bukoh,11 ONVENTIONAL: MOUND IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) S ❑U S ❑U ]S ❑U ©S ❑U 11 S DU �a v v�•v�i'o v�l L If Percolation Tests are OT required DESIGN/RATE: I If any portion of the tested area is in the •�� under s.H63.09(5)(b),i dicate: N4 S < Floodplain,indicate Floodplain elevation: I� PROFILE DESCRIPTIONS jp li�£CPiAl_ T-1_- BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.fl I GFE—ST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) o' OC do• S",/ 40 ' 8.0• /o l y 7.4 " ;rW AZVY • Q-- 7 /•O D•C Q a, S./ C� ' 4ou Or/i4 G.6 7' A4,0 OW B- CS Z- v /a v y l-R 7 , ,7s . AV'dd . ,r,/ A 7s ' R0 s,/, 4,j, '-r4--J v44r B-y 97 /o/. Dy csj6-R . r /o' pf- Qa• Si , 3.o W. Qo. 1 •p a Qa . B. / D. � � o • / s f; - 0 L2 3 T y ue c5 G B- PERCOLATION TESTS TEST DEPTH ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES FTER SWELLING INTERVAL-MIN. PERIOD 1 PER I PER INCH 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 eleva ion 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. S GALE • 1 " 30' SYSTEM ELE' ATION • _ gc�r�lo� P•Ts t � � r 6ro ?4to _ ,---�— p .---,--•-� ._ - Su Iliac- C, i T- cr o I t r_� . ._ ._, _ _r... --sue ;__`�iY• __ - - �--3�--_� .- _.-_ �_- .-._ ;__-_ 1•r� dp��1 C-1; � .ie 0' `1� 7 IN V$ FIO� L c� T s i P , hr test sitli coin_-6njQC� � d�E v le �cc � �v�• IAA �� � __. ! four pRacK 1J�010 cl OVL- l S�Ir.. 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,an that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED O (� RT. 3 O'NEIL RD.:HUDSON: MS. 54016 �QG' 15 - I q 6`i' ADDRESS: ROBERT CERTIFI TION NUMBER: PHO NUMB ( tional): 1115. MASTER PLUMBER UC NO. 3307 M,P.R.S. Z y 2_ 3 a – / CST SIGNATU E: DISTRIBUTION: Origi al and one copy to Local Authority,Property Owner and Soil Tester. DILI-lI3-SBD-5395 (R. /82) —OVER — L. r I 0 S ,; C. T I I\l PROJECT R- W NAME r./ - ]'h �at't---= N A M E L 0 C A I ON ,u t. __ 1Qod5 1r- 1 C E NIS E =. ►Q. _ PLO 1 a 3 RejK00M s;l i S► x: 1 o 1006 toyf ` 'F a .1Aph A• t �8x3� B3 a X= KC 5tt5 F;. Bed 3 ru t , t i+s C 1£v 100 0 L' f 71 -i ffl t P 145 Ac. s FRESH AIR INLETS AND OBSERVATION PIPE CnO7S SECTION *, [_ Approved Vent Cap FPtia } 9 Final b , �� ` � Minimum 12" Above ra �,. - �._._ --- 106.5 .j yr,Ax r 4" Cast Iron as t't Above Pipe\, \ Vent Pipe - To Final .Grad 1. Marsh Hay Or Synthetic Covering Min. 2" Aggrccj a►. (� Over Pipe istribution� I Tee Pipe _......__.. Cp (J Aggregate Perforated Pipe Below ".. L Beneath Pipe Coupling Terminating At Bottom o f System �u ., -- - _— ....._ _._.... ------ �.._ 67 LOT ANF) OSS SE CTl ICI y N A M E_ r....1__. _ h_ ion---- _NAME L; 0 C AT 10 _� J00d5 1- I C E N _ E - r PLO I MAP YeaKoor, y�4+. BIOME 0 1400 _ ;; 4 6m k6t Pits . QQ I?03 w S 3 �B3 x= RKC .p c 1 Pipe At 5 Y S� C(st1 oil �CNek a c leV. - 100.0 yl , [� Te1e Pc C FRESH AIR INLETS AND OBSERVATION PIPE CI:OSS SECTION R I Approved Vent Cap r Minimum 12" Above Final Qr.a de _� -- 100.5v p r riY 4 " Cast Iron s � Above Pipe Vent Pipe } To Final .Grad " Harsh Hay Or Synthetic Cover.i.ng s+' -- -- Min. 2" Aggreg 11 0 r Over Pipe 1` M istribut Tee Pipe Aggregate Perforated Pipe Below Beneath Pipe Coupling Terminating At 8,#0M - __""_� . . �_.._.. .. .._ . Bottom of System