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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 plot plan).
SOIL ABSORPTION SYSTEM
Bed: Gov! Udurt ovtc? Trench:
Width: 145 Length: E!�. Number of Lines: �, Area Built: T'
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,®Pt . �
Number of feet from well: CD
i
Number of feet from building: �9
(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: 1P45
License Number: /11`I /' �^ Q 3 17-
3/84:mj
A! .
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP �t�s��,-� SEC. T �N-R
ADDRESS PiS Z-- ST. CROIX COUNTY, WISCONSIN _.
ific�SoM GcJ,` , �—SID IG
SUBDIVI ION�j, ;��J�, j� LOT Z'" LOT SIZE ( 3 #Cir K S
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
�Q. k V,,,cW I-T -'- S Z
sv st E I. - 97.o '
S. w, c,r Ka r
,
tr V)
Uj to,
Gel-
10
�
------------------------
Q\
_ INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used L'4;fi Po Su! 4ce/if 4t Y,
Elevation of vertical reference point: O _ Proposed slope at site:
SEPTIC ANK: Manufacturer: S t r Liquid Capacity: looe q 4 A
Number of rings used: Q Tank manhole cover elevation: Qp
Tan Inlet Elevation: 0 Tank Outlet Elevation:
Number of feet from nearest Road: Front
,O Side, Rear, O //O feet
i
From nearest property line Front,OSide,®Rear,O gam' feet
Number of feet from: well cpD/ , building: 1 Z d- o96 ��ioYr, Saco✓►1a✓
(Includ this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
DEPARTMENT OF I DUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN R ELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MAD N
ISO ,,Wt 5370
NW1,4,SE%,S17, 29N-R19W MCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number:
(lf assigned)
Town of Huds n ❑Holding Tank ❑In-Ground Pressure ❑Mound
Lot 92 Parkv ew Estates IV
NAME OF PERMIT HOLDER ADDRESS Of PERMIT HOLDER: INSPECTION DATE:
Sam Miller Route 1, Box 282, Hudson, WI 54016
BENCH MARK(Permanent ref rence point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Douglas Str hbeen i3432 St. Croix 92549
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
t�L�1 1 -1• i `F 1 '� P AYES ONO PR❑IYES O
BEDDING: V NT DIA.: VENT MATL.: HIGH WA ER NUMBER OF ROAD: PR ERTV WELL: BUILDING: VENT O FRESH
1� ALARM: FEET FROM LI /Z AIR IN�LET�w
DYES NO \ ' ❑YES O INEAREST V �Q
DOSING CHAMBER:
MANUFACTURER: B DDING: LIQUID CAPACITY. PUMP MODE L. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
YES ❑NO ❑YES ❑NO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: SACT2 PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN LINE AIR INLET
PUMP ON AND OFF ❑YES ❑NO
SOIL ABSORPTION YSTEM.Check the soil moisture at the depth of plowing LENGTH: DIAMETER MATERIAL AND MARKING
or excavation. (If soi can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough o continue.) MAIN
CONVENTIONAL SY STEM:
W DTH: ```��� LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA. *PITS LIQUID
BED/TRENCH I TRENCHES: F MA L: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH Fl L DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL. BUILDING. V NT TO FRESH
BELOW PIPE 1 r Al OV COVER EV.INLET.ELEV.END PIPES-. FEET FROM LI I re A ET
•� �? NEAREST------*-
MOUND SYSTEM:
Mound site plo ed 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.
1:1 Y ES ❑NO
OIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ❑NO OYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER: EDGES:
❑YES E:1 NO DYES ONO DYES ❑NO
PRESSURIZED DIST 31BUTION SYSTEM:
BED/TRENCH W DTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
DIMENSIONS
M NIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL'. NO.DISTR. DISTR.PIPE
ELEVATION AND DISTRIBUTION PIPE MATERIAL&MARKING
ELEV, ELEV.: DIA.. ELEV.: PIPES DIA..
DISTRIBUTION
INFORMATION H LE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
OYES El NO ❑YES 1:1 NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
rt FEET FROM LINE:
�G
OYES ❑NO ❑YES ❑N NEAREST
�(i! t 10'
a� 07
Sketch System on ' in county file for audit.
Reverse Side.
SIGNATURE: TITLE.
_J
Zoning Administrator
DILHR SBD 6710(R.01/82)
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed- . - -
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owners 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;
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'/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 ate[--
included the creation of surcharges (fees) for a number of regulated practices which Wisco in`$
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reaSof6.
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumpeY.
a
The monies collected through these surcharges are credited to the groundwater fund admi.nis- ,
tered by the Department of Natural Resources. These funds are used for monitoring ground- f
water, groundwater contamination investigations and establishment of standards. Groundwater, f
it's worth protecting.
SBD-6398(R.03/86)
(-� "`°° SANITARY PERMIT APPLICATION COUNTY
l7] DIL R In accord with ILHR 83.05,Wis.Adm.Code , (f X
.......% "'°" STATE SANITARY PERMIT##
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches ir size.
—See reverse sidE for instructions for completing this application. PETITION
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO
PROPERTY OWNER PROPERTY LOCATION
W/a %' S T.29, N, R E(Or
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER S BDIVISION NAME
R SO 2. 2—ZIP Z
CITY,STATE CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
❑ VILLAGE : iw
A �
II. TYPE OF BUIL ING OR USE SERVED:
Number of Bedro ms if 1 or 2 Family .3 OR ❑ Public(Specify):
III. PURPOSE OF PPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. 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 Sanit ry Permit was previously issued. Permit## Date Issued
3. ❑ An Exis ing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The Sys tem 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. FConv ntional b. ❑Alternative c. ❑ Experimental
2. a. ❑Syste - b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fil Tank
V. ABSORPTION 3,YSTEM INFORMATION: (Check one)
1. a. V seepage Bed b. ❑Seepage Trench c. ❑ Seepacie Pit
2. PER66LATIOt I RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per nch): REQUIRED(Square Feet): PROPOSED(Square Feet), 9
(s§ S it ( 7- Feet Private [--]joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xistin Gallons Tanks Concrete structed glass App.
Tanks I Tanks
Septic Tank or Holding Tank 0 ❑
Lift Pump Tank/Siphon Chamber ❑ ❑ ❑
VII. RESPONSIBI ITY 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:
ioou �4s 5t � 0 � �- � 3 �
Plumber's Address(St eet,City,State,Zip Code): Name gf Designer:
if 45 ao�
Vlll. SOIL TEST IN ORMATION
Certified Soil Tester(C T)Name �} CST##
CST's ADDRESS(Stre ,City,State,Zip Code) Phone Number:
IX. COUNTY/DEP RTMENT USE ONLY
❑ D sapproved Sanitary Permit Fee Groundwater ate Issuin Agent Signature(No Stamps)
Approved ❑ O ner Given Initial / rcharge Fee
A verse Determination 1 •0'6 �� ( �r 2 _ r
X. COMMENTS/ ASONS FOR DISAPPROVAL:
C1
SBD-6398(formerly Plb- 7)(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. Should this development be intended for resale by owner/contractor; ("spec
house"), then & 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 �cr. /yj ��r
Location of Prop erty _ (,� ,Ix, Section , T_!aj N-R�
Township �.
Mailing Addres s
Address of Site �. �� ; f ,E,, tfl9�
Subdivision Name Q /� (J, kJ ex te l%e --r-
; Lot Number �..
Previous Owner of Property
Total Size of Parcel ' r i/ i C rl
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number �_ 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 Re ister 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 a.0 6 to temenza on this for are true to the best o6 my (our)
know.tedge; that I (we) am (are) the owner(s the pnopeh ty dens cA i.bed in thi.6
in6o4mati,on 6o km, by vi tue o6 a waAAanty deed Aeeohded in the 066ice o6 the
County Regi6tept o6 Veeds as Voeument No. 2 'Z._ ; and that I (We) phesentty
own the ptopod d Aite bon the .sewage d4pozat bys em (o& I (we) have obtained an
easement, to Aun with the above de cA bed ptopehty, bon the construction o6 said
system, and the same has been duty Aeeoaded to the 066ice o6 the County Re9.i6teA o6
Heeds, as Vo ent No.
SIGNATURE 011. 0 MER SIGNATURE OF CO-OWNER (IF APPLICABLE)
13 ' T-7
DATE SIGNED DATE SIGNED
3,
SURNMOSS CERTITMATZ:,
1.Amu&-Z.ltuaeh.Ragdslrrod Wiseeasis Laad Suzvayorg haxeby certify to the
beet of nay prefo*ateatl krwwledje, nndarots,odtng and belief-
That I bwro trtrwy 4, divsd94 wA roapp4d Park View£atstes;Fourth Addition,.
located is the NZ1 14 at the SW 114 and the 11M.114 of the 52114 of Section 17, T29.4,
It 191p. Towwof Hodson. St. Croix Conaty. Wisceasia:
That 1 have tssydo ouch survey, land dlyinion aad plat by the dlsaction of Darrel E.
Wartand'Revrzly.A.Wert.owner•of said land, described as(allows:
Commasclag wAtba El/4 coraar of said Section 17;thosee S89eW.""W (assotsed
bmxU4 s to the woonameated 1;A3T f E3T 1/4 Section.11ss ci'Section 17.
bassist aa*uuaed S89'22'06•'ilf)(recorded as 3$y'21'40"7lt on that Cara .04 Srzvy plop
reaew&A tat Veiraa*1.Page 184). 1332.98'along saki EAST-W ZST'114 Section Ha*,
these*t0'tt6130•tf`227.77 to the pole(of h.8ia.iws: he t x89'5240"Y 412.009;thence..
NO"Oba36"S 212.004 to tie Southerly right-of-way Use of Crean.UJU Lea*;thence
MIr 52444-If 6,6.008 al" said rJ�yhl.41-opy Had; thence S4'04a3O"W 231.401;thence
:579"261S2"W"194.359;thence 389115114"W 216.741;thenc*:47S'S7%S"M /42.171:thence
SW1S't4-W 536-00s.-thence NV06130"L 104.009.;thrice 3WIP14-V 3t4.DWt thence ,
N0'!vt30"E'.156,009;thence 389'15114"M 66.0I81 th*sse SO'Ob9SO"V MAW;tbeaco-.
:SWISS 14"W"151.008;thaaea N0137t31"W 54.1!8;-Uwsce 589'22'09'"2'141..10';these•
30'06sS0"ti!204.488;tbasae NWIS914"X 13+1.00+;these*30 GMS0"M 31L 971;thence
Nd9'1Ss14!'L 150.00�•th*aes Soatheastarly 66.232 aloud the era-of&:381.909 radius
t.srvs<oncst�Morth+aetsrlp whoa*chord boars 34'S01S0"E thomam:184'15914"C
s7,0l1;Mason 3otz;ttdst*r1T_136.561 alone the ato of s 317.004'radise curve cootave t
Nostbashtesl1pp wboa*chord booze 924 03102"E M.511;thoae*'s36 23130^_' 143.141;
the"dt;(71'36130"1: 160.461;tbanee Nal15114"1;243.000;thence S0t061MIW 10x.001; `
these•+53.;36'30"ff 259.161;wane SoutheasterlT 96.141 al t6o arc d a 217.001
radisva nsa vs.tneaeave warth000torly-witoso Chord boars 378'0�lb'S 9S.3rd9:thence
1(89!t'V14M 920.048;these*Merdwastezly 91.214 alone the szw'.of a.306.006 radius.
r's
ca 4041i►�rs Nerthmmeleziy whose abord bear*NW32'40"X99.85871 t6exs'.*North..
weewst r 91;4487 along the era of a 309.00'mdtu*cvrv*concave No"hoaaturl y whose
chord barer•MV3702611W 91.091:thous*NO.061300E 150.009;thence NWl5r14 ..
478.052;thane x0'06030"14;$34.561 to the paba of hegiasing.,
The*samlb plot is.o correct repr*soslatios of all the wdeeies bouodeaios of the i
trial a r 9 Ford mad the eabdiviatoe thereof aade, aid
e.�,��That I have tally eernpiled with the provieloss of Chapter 136 of the Yf ieeoasla {
SUAVC*o. the iebdtvlsLs'I and Zonis Re tans of St. Crcls Count --_. -
' g Xalat y, the 'owe ul ,
1ladeon 9ubdivtefea Ordinance.and the City of Hudson.5nbdivislos►ad Pist;:is{Or4i-
_ nice.,is navaying.Olvidisg sad mapping the same.
- Dated thla' 4 day at , 1984
i
RAvised WjhlSth do of April, 1984,
uses >!. sac - •�.:�:-I3iS NAM
421 1kzoM Street 11 M
i Hodson.Wisconsin 54016 Oft*
COUNTT 711ZASUREit'S CERTIFICATE
5TA7Z Or WISCONXM S3
ST, CROIX COUNTY )
1. Moat'Seas Livermore, bola#duly elected, qualified and seeing Irraasurer of
St,.Croix Ca way p do hereby certify that thr raoords in my office show to unr*d*amed
tan sales and no unpaid tn.xae or opeciet asseoemente se of /-t-
s/fecting titer lands included in the Plat of Park View;Ceuta• Fourth Addti,on.
jr.pf MO
Date Holy Treasures
7.ON1NC COlA?.t TTZE RESOLUTION
TMs plat is hereby approved by the St. Croix County Comprobansive Parks,
PlsnelaM and ZouinR Commit(,,..
Usia Glui"T'A 7
Q4_
.a
Date A --
Administrstor
w.
F,
tfalSTEk'S !4i'ti�,� ,
-__1 _A__
PARK \y IEW ESTATES FOURTH ADDITION I �
A n-3•RAL %WV) ION LOCATED lIV THE hL-*.Sw14 a NWNs-SE*,SECTION IT, T29R, R19 W. �
TOWN CP.HU)SCV.,ST C90X COUNTY' Yb'isc iStN �
CS2TI1iCAT OT TowTzrAsnrR
STATZ OF-9
t'3'. C3OI7f C liiKT7 ,
I'. Bever Fly A.3cbaseii.bodat the,"y elected, qualified'aW actIzg Tuw%TTeasurar
o!the Sown o iludaoa, do lyrepY csrtily that in se:cordaacs r oorda in my office,
t3e:e air ao peid taxes or sryaelal assassrasAts sa of •r oa any lats8
irtaladet la t Plat of Park view Latatas Fourth Fddttien. •'
Beverly.
JohnsoW lowst 'reasurrr
TOWN BOARD R:SOLUTION
RESOLVED, thst the Plat of Park View E+tates)Fourth Addition in the Town of
Hudson, Carr 1 E. Wert and Baysplmy A. Wart, owners, is hereby approved by the t
'fowl .S.A d,
r• ,+ Y
s • p roved own rman
D ig ed own l nacrmAn I
t aarabv eertliy that the forrtoing 19 a copy of a resolution adopted by the Town II
Board of the 7 own of tludac.n.
—Z—Ate Town Clark I
i
OW,'4ZR31 CLI1 TIFICATE OF DEDICATION
As o-ne rs, we hereby certifr that we caused the land described on thi: Plat to be
su ,rveynd, d:• led, mappad and ds fisted as re?re%ented on this Plat. W4 :.Iso certify
tbAt t:.is Fiat I r required by S. 236.10 or S. 236.12 to be submitted to tiie foiluwing for
approvsl or ob action:
Ospa:t of e.f Development i
liegart nt of Industry, Labor and Human Relatio•ts,
Town of tudson. City of Hudson and St, Croix Co..nty.
W;TNES the hand sod real of said owners this
day of "-
In�rrre
IaIJ rral r-. er ri
r7
t
r1 i
Beverly A. Waif
STATE OF W CONSIN) SS
ST. CROIX C UN'f Y
Personal y carna before me this day of /� / •• _^the above 1'
nar4e4 Darrel . Wert and Beverly A. Wert, to me known to be the parsons who executed
the foregoing instrument and acknowledged the same. I
Notary P blle�'�',_r�l. •?„�, , Wisconsin My commission expires'_el
b1aryRisch, Votary Public 1
i
-:CERTIFICATE OF TOWN CLERK- �
.sTA'L1:OF WISCONSIN)
ST; CROIX COUNTY ) i
I. Rita;ior e, being the duly appointed, qualified and acting Town Clark of the
'Town of M dso , do horebi Ca.�f i!pp that topic of this Plat were forwarded as
t required by a. 236.12 on thee- day of� 1994, and that within
the 20-day lim t set by a. 236;12 (3)(no objecti nob to the plat have been filed)
(all ah)rrinns o•ha -,)at have been met).
Dace AitX Horne, Town Clerk
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JAMES E. RUSCH
SURVEYING & }MAPPING
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HUPSONt WISCONSIN
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
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OWNER/ UYER:!�cz `l / /t !fir'/ 4-le, M
ROUTE/ IOX NUMBER K x � oA' $�� Fire Number
CITY/S ATE #&Le1 4rk11t , 'I. IP
PROPERTY LOCATION : A K/ 14, .`.� 14, Section, T C ' N , R
Town of &tii Ase"j St . Croix County ,
Subdivision& Y 0,4C tj Lot number 9 Z.
Improp r use and maintenance of your septic system could result in
its pr mature failure to handle wastes . Proper maintenance con-
sists 3f pumping out the septic tank every three years or sooner ,
if nee ed , by a licensed septic tank pumper . What you put into I[
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 .
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I/WE, the undersigned,, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth , herein , as set by the Wisconsin Depart- v
ment cf 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 .
SIGNED �.�
DATE "
St . C oix County Zoning Office
P. O. fox 98
Hammo d , WI 54015
715-7S6-223S) or 715-425-8363
Sign , date and return to above address .
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6595 `
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;
S. MAXIMUM number of bedrooms or commercial use planned;
4. is this a new or replacement 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;
b. PLEASE rise the abbreviations shown here for writing 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 rased.if desired;
8. Male sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
0. Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp-
tion, if appropriate;
10, If the hifurr-nation (such as flood plain,elevation)does not apply, place Nl A.in the appropriate box;
11. Sign the form and piece your current address and your certification number;
12. Make legible copies and distribute as required. 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
cola - Cobble (3- 10") SS - Sandstone
gr. - Gravel (under 3") LS - Limestone
s - Sand HGW - High GIOUndwater
£as - Coarse Sand Per - Percolation Rate
rued s - Medium Sand W - VVrrll
fs - Fine Sand Bidg - Building
I; - Loamy Sanrl Greater Than
sl - Sandy Loam < - Less Than
`i - Loarn Bn Brovvn
sil Silt Loam BI Brach
Si Silt °:3y
ci - Clay Loarn Y Yel,ouu
sc,l ._ Sandy Clay Loam R - Red
sicl - Silty Clay Loarn mot - Mottles
w -- Sandy Clay vv/ - with
sic - Silty Clay fif fev"', fine,faint
k'r _ Clay cc - cOITIni an, coarse
III - Peat nnrn - Many, medium
r;; Muck d - distinct
p - prorninent
HWL -- High water level,
Six general soil textures surface, water
for liquid waste disposal BM - Bench Mark
VRP Vertical Reference Point
TO THE OlNNER:
1#?is swl test repo,t is the, °irst der) ;rt a sanitary pcnmht The county orthe Department rnayreguest
,f'c;3°, on rst' hds -od Test w j:I"o field prior to pti,!rnit issuance. A cot-nplete- Si?t of piano for the private
.SEi CyS1_`'IYt w--d a } '?f nw a,sla.waE,.)n rmist he suhn3itted to the erpoi c't)' ale local in order to
r'e 3�',:il;°` t t',r4;" t1..."o be t}I.tloin:d and `j?C)titF'd p�I()t.t�;) the start£'3f rir(V�'e.C)t�sirllCti`.)n.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969
HUMAN RELATIO )S 1 / MADISON,WI 53707
(H63.090)& Chapter 145.045)
LOCATION: • SE TION: OWNSHIP/ LOT NO.:BLK.NO.: SUBDIVISION NAME:
W '/aE '/a 17 /Ta9 N/RI �(o sd,u 9,2 * Jl�
COU TY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS:1PERCOLATION TESTS:
Residence I New ❑Replace I Cl I^ V 7 Q D
O /1 ' / / O
RATING:S=Site suite le for system U=Site unsuitable for system �j . uh k 0// s_9.d /10/Jt�
CONVENTIONAL: MOUND IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:
S au s ❑u IS ou o s gu a s au �� - 36>
If Percolation Tests are NOT required DESIGN RATE` an y portion of the tested area is in the
/under s.H63.09(5)(b),i dicate: Floodplain,indicate Floodplain elevation:
PROFI E DESCRIPTIONS
BORING TOTAL/ DEPTH TO GROUNDWATER4494" CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPT EVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- l _d' /.3' 9,d /. Bbl/ /. �/ . /s .f:o
ko 0 1 .2. 4 0 Al/S. IK 7 X"t e-J
B-3 �,0' �616f d 7 v 4 Y 015'1 7 last S/, .'y Am It-151 ..4 9 Ai frS
Bn e S
0/,1 dtit� 7 d' �ls�� 1. ,F 6/+e., ^,'s. )rIf F*'// . 7 B•rst
ty. S At: AS /s s .2-7 At Ire-1 s
Xs S1, IS AeJ_9
B-
PERCOLATION TESTS
TEST DEPTH/ ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER FTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERT D PER INCH
P- I 5l.3 07- (V 6 e--3
P_ 3 .O' o Z L�
P-_
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions`Q ,s4fibi bl SQ eas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the pfo#;elan. ow the r ce elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 77. '
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I,the undersigned, here y 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,anc that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(print): / TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST URE:
DISTRIBUTION:Origin I and one copy to Local Authority,Property Owner and Soil Tester.
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