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020-1304-40-000
Wig sconsin Department of Commerce safety and E'~ailding Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township Procknow, William Hudson, Town of CST BM Elev: Insp. B_M~levj ~ ~~ BM Description: ~x,~ ~i,-~ ~ ~ ~ ' ~ ~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ ~ ~ (,J~ es~_ ~ ~, r~ ~~ Aeration ~ P ~n. • 7 Holding ~ , /' ~ ~ 1 ~ TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Ov Septic ~iu~ ~~ r ~~ • Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDF; Lift Friction Loss Syste TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Cr01X Sanitary Permit No: 514941 0 State Plan ID No: Parcel Tax No: 020-1304-40-000 Section/Town/Range/Map No: 11.29.19.1512 STATION BS HI FS ELEV. Ben rilark~ ; ~'~~ ~D.? ~ 7~ ~ ~3~ Alt. BM ,~ ,ltd- C>d ,ems. S 3 98. ~ 7 Bldg. Sewer SUHt Inlet ~ St/Ht Outlet q I ~ I 9~+ ~~ Dt Inlet ~-1 ~. Dt Bottom ~~• -~.. Header/Man. q'~ I ~ 7. 9 Dist. Pipe /. / ~3. eot. System 1 ~,J /~. ~ / ~Z` Final Grade `r ~ J ~, ` st co~ 5 3 9S' ~ 7 6~ ~ S ~ z . s ~'3- /• BED/TRENCH Width Length No. Of TrenC~'$.y ' PIT DIMENSIONS No. Of P'rts ~ Inside Dia. Liquid Depth DIMENSIONS ) L, ~ le _ -~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:,,~~ t` ~~ INFORMATION CHAMBER OR r' Type Of System: ` ~ ~ ~ $'~ (~ /l/ UNIT Mod I N b J a Dv~ a ~,l~C~ DISTRIBUTION SYSTEM Header/Manifol ~ / / f ~( Distributior?\ Pipe(s) x Hole Size ~ x Hole Spacing ` Vent tgQir In e ~r J~. Length~_Dia "7' Length Dia_~Spacing~` c.~+v oc ~ SOIL COVER / x Pressure Svstems Onlv xx Mound Or At-Grade Systems Only Depth Over 's $ Depth Over ` xx Depth of xx Seeded/Sodded xx Mulc et Bed/Trench Center . ~ Bed/Trench Edges Topsoil ~ Yes ~ No ~ es [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / 1 Inspection #2: / /. j aJt~ Location: 1066 Mounds Drive Hudson, WI 54/016 (SE 1/4 NE 1/4 11 T29N R19W) Tanney Ridge Special Add Lot 7 Parcel No: 11.29.19.1512 p -~-v~,,~ C~ a ~ t~ Rev; t ~ Dw~s~.. ~ ~ l'o~ : ~.Q, ~ac-~S ~' 1. Alt BM Descri lion = 2. Bld sewer len th = * , ~~ ~+"rj 4 r' ~aJ fj G~~S{~J`A ~uw.t,~.~, ) -amount of cover = 'j~~J' d""i ti. ` Plan revision Required? ^ Yes 0 No ~ ~ ~~ I i Use other side for additional information. ; ~~i ~ ___ _ ____ ~ SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. 5 z e um er: J~ ~~ ' ~,y~,~w Safety and Bui 201 W. WashingtQnA' 1 Qi ~O~ ~~ ~ Madison, V~i~ oil C.omrneroe Sanitary Permit Application In accordance with s. Comm. 83.2!(2), Wis. Adm. Code, submission of thi unit is required prior to obtaining a sanitary permit. Note: Applicetio fom-s~ submitted to the Departrnertt of Commerce. Personal information You provide m ' ses in accordance with the Priv Law a. 1 S. 1 m Stets. r A..nlina4inn Tnfnrm'flnn ... PIeYY! Print All 1Of03711atiolt .L property Owner's Name il.. Type of Bnildin6 (check all that appty) ®.l or 2 Family Dwelling -Number of Bedrooms 3 . ^ Public/Commercial -Describe Use t~(,Q,yW,G~ Q State Owned -Describe Use Z A ; w ~ ~"~ iliox 7162 { ~ ''AC'S/' ; 62 ~ J ~ ~7' ~ (a State Trtauactign~Tumber Lot# tOIX COUNTY ING OFFICE iil. Type of Permit: (Cheek only one boa o line A. Complete lice B if applicable) A• New System Replacemwnt TreatrrmermtlFioldingTenk Replacement Only Odrer Modification to Existing System (~P~~) System Ci~n of Pern-it Transfer to List Previous Permit Number and Date Issued B. Permit Permit Revision ~ New Owner 2 3 3 ~~ S ~ I ~ ~ ` Renewal Before Phrrtdxr iration IV. of POWTS S tstlCo pp~nt/DtYitt:: Chcek all that Marnd > 24 in, of suitable soil Motmd < 24 in. of suitable soil Nan-Pressmrieed tn-Carot~nd Pressurised In~C3round Aid3tade Holding Tank Other Dispersal Componera (explain) ^ Pretreatment T~'iSB,L~sin) - i Fiow (Bpd) Design Solt Ap~pJncatton tcarq 7 S~ ` j 'ank Info Capacity in Gallons Ncw Tankt Fait ar Holding Tank ~ ial Area Requme4 ~' ap Projeet Addross (if diffeMnt then ttmailiog ~ ~ ; /jS(o(Q / ~ /D~~c~`~ Ly Part:el # bZb ~ /3 'y0 - ex.'s 0'l(- ProPeAY 1-°ceh°n / ~~ ~ Z~ C i Govt. Lot ~~ m/S~r' %, section l~ tcn.ea aa.l division Ntune Sub yy Q~iv ~ (~ ~ `!/' ~ City of Village of Town of 1~G't- l Jam, ~„~ nl Arra Pro tar) a ••~~•-~•°., W ~ la~L. ~~ t- Total # of Gallons Units VII, Res s€bili Statement- I, the aodersi$eed, assatae resPoagltNitY ~ ~~ Plumber's Name (Prirrtl Plumber's Signature /~ Ptnmber's Address (Street, City, State, Zip Code) of the POW'1'g en the nttaeYed P~- - /MFRS Number' Business Phone Numt C 1' G~-G' /C-~~~~ / C ~ ~e S'~a ~7f ~~t~ ,,~npp,.mvc~ ,,,,~,N........ - - D~ Owner easo Deaiat s /.1 ~ . Gm6 7 Z g IX. Conditl6YSaf.AI~MNWiRsasons [or Disapproval__!! 3 T t ~~_ ~ p,(`~ SO m ~5 ~',llt-- 1. Septic tank;.effluent filter and C ~ U ~ ~~~, ~ K dispersal cell must all be services /maintained ~~a~-~~ (~,~-i~vv` L/ ~ ~ I \ as per management plan provided by plumber. t ~+~ ~v,µ~ '(7 2. ,AN salbackrtagairements tttust be rrrairtfxilatsd Q `GtJr d[..Q,, ~~~''m''~'~ is ' ~/ M- -,,n Mach M eanpkte Plant far' the system and tuMott to the COVaIy oa19 m pper n~ kw Ihatm a 113 x 11 tneW to tfae r ~ s~~ ~~,,,, ~.~-a~r SBDfi396 (R. 01/07) Valid thru Ol/09 ~t CL ~~, rti-. s~~ ~ ~fr ~. .~ ®(3 ~ r` ~~ d ~~~ u ~- - ,~vo ~~~ d ~~`~ ~ ~,~ ~~ ~r~>/~~~ `~~~p ~ s ll OBU1'd ~ ~ / ~~~. _ ~-- _ 33 ~Lt~e~C. TC ~/ ~ 99 ,,,, /~- -f~~'~,.~ 1GGl~f < ,~ 7U I `ram-„ 1 ~."'' ~~~e~ ~CppY ~ ~ / / /` ~~ ~ 5 ~' ~ Nom' /~ ~~~-~~ ~~ d ~~.~5 ~~~.N~ ~ ~ ~s _'' ~ ~~ ~~ t- __ .~ _ ` _ ,v t.~ ~~ ,. ~,,~ ~ .~~~ 33 vu.~~~ ~ ~'s ~~ `7,y~~u ~~ STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER J,4 // //' ~~ ~ ~-,~ ADDRESS~r O~~ Z~ 2_ ~~~~ R ~~ SUBDIVISION ~ csM~ ~,~,yN,~ f,,. ,2 ~~~ ~~- LOT ~~ SECTION // __T Z 9 N-R / `~ Town of yG _ Q,tJ' ST. CROIX COUNTY, WISCONSIN SHOW EVERYTHING WILTHINI100 FEET OF SYSTEM t'.,.~~ I _~~_ rl-OvSE n i _ {~ - ~L ~~``r•i:~:. ~_, ;~" ~ 5 c . _ __ ~ Dti2 ~Y~ way L, ~ ~ 3S ~r ' ~ 1V 7S' ~~;~ - - - - - - ° g' ~,oPt ~ -------' ~~~;' o 10 ~O~ i. ..~...~. - I --- -- III ~ ~ 7fe ir/,~ TE ,9',E' E ,¢ y1 5~°P z io ' ~o __ _ _ INDI CATS NORTH ARROG~' rLw~ae setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover- 4 BENCHMARK: ~~~ Ot LoT ~/~~ /¢T S~ Lam' lO~t'~~lZ ,~~ -`/G~7,©(~, _ =-~'`' ALTERNATE BM : ~oP agrfovsE ~O~M~ ~Ta~/~/-= ~~ ~' ' EPTIC / PUMP CHAMBER / HOLDING TANK INFORMATION ~_ Manufacturer: '/~/.~/S.~a2~. Liquid Capacity: /ooc~6~L Setback from: Well House Other Pump : Manufacturer ~--------- - Mode 1 # ---.-._._~_. - -~+'"' ..Size Float seperation Gallons/cycle: ~ Alarm Location --------~~ SOIL ABSORPTION SYSTEM ~ / - Width: ~~' Length ~/O Number of trenches -~._ Distance & Direction to nearest prop. line: (~~ d S, fi ~ T ~ ..t fis/~ Setback from: well: House Other s ELEVATIONS _ Building Sewer -_ -- ST Inlet. cj,~-, ST outlet `'.~~ PC inlet -- PC bottom Pump Off -`- ! J i Header/Manifold ~!1 /c-, ~~> Bottom of system ~ ~b .'. Existing Grade ~~ ='-' Final grade >~ ~~,~ ~ ~/C"r ~~' DATE OF INSTALLATION: PLUMBER ON JOB: ~~~ /~~--~~!~~~0 LICENSE NUMBER: /~S ~S-~ INSPECTOR: - b 3/93:jt r LNis~o~sin Department of Industry, ' Labor,~nd Human Relations Safety and Buildings Division " GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Permit Holder's Name: ^ City ^ Village ^ Town of: MILLER, SAM E. X CST BM Elev.: Insp. BM Elev.: BM Description: ~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ -,~ ~ ~ ~- ~ ~ _, , ~:J~2 Aeration HoJ ~ng TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septic ~ ~~~. ~~ ' h ~ ~~ NA Dosing NA Aeration A Holding PUMP /SIPHON INFORMATION Ma cturer Demand Model Number \1GPM TDH Friction Ft L ead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: ST. CROIX Sanitary Permit No.: State Plan o.: Parcel Tax No.: ~:j ?~~`" STATION BS HI FS ELEV. Benchmark ~ ~; ~ ~ /DJ, ~' Bldg. Sewer St/b~ Inlet 3a'' •-~,~%~'"" St/yet Outlet %' Dt Inlet Dt Bottom ~ - Header ~` ' iO,Og f ~ ~,'// , Dist. Pipe .c - ~'"~,~, ,., ~ % ~,~ Bot. System ~~~/ ~ 4~. _~, ~ Final Grade ~, --~ ' 7 ~ ~ ~~ ~~ - %"/ ~ ~~ ,,, ~o ~~*- ~ , S~- BED /TRENCH Width ~ Length ~ , No. Of Trenches PIT No. Of Pits Inside Dia uid Depth DIMEN I N ~ ~ ~ DIMENSI6 SETBACK .SYSTEM TO P/L BLDG WELL LAKE/STREAM LEA Manufacturer: -----_.` INFORMATION Type 0 yt e,u,_ ~ ~c ~ AMBER Mo a Num er: System: 13~,( '-~~a. 35 ~ ~ ~ OR UNIT UI~ I KItiU I IUN SYSTEM Header /~ / len th ~ Di ~ Distribution Pipe(s) „ , ~ ~ ~ ~ x Hole Size x Hole S en it Intake g a. Length Dia. Spacing ~ SOIL COVER x Pressure Systems Only xx Mound Or At-G~Svste my Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mu c ed Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No I.VMMtIV 15: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.11.29.19W, SE, NE, Lvt 7, Mounds Drive _ _: ~ '-F: ~~,~ ~ ~ . ~ ~ Plan revision required? ^ Yes [c~IVo Use other side for additional information. ~ C~ Q ~_ SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ./Q ~nf~ /Nav~/A S ,~?.~'!UE 5~,~/E /ice' = /D ~ ~~ 5`tcN! ~ i.,. ~ ~ ~ ~ Wisconsin DeparUnent of Industry, ~t.abor and Human Relations • Division of Safety & Buildings e ~ SOIL AND SITE EVALUATION REPORT in accord with ILHR 83.05, Wis. Adm. Code 1 inches in size. Plan must include, but lion and % of slope, scale or r Attach complete site plan on paper not less than 8 1 not limited to vertical and horizontal referenc dimensioned, north arrow, and location a i9~ai APPLICANT INFORMATION-PL RI T PR~ERTY OWN R: Jib ~'-'1 ~l L.L ~ ~ `° ~ ,~ , . PROPERTY OWNER':S MAILING ADD ' F, ~ ~ ~. CITY, STATE ~,-,,., /L INF'TION Page f of I.VUN I Y ~7•C~, r x PARCEL I.D. # U 8Y PROPERTY LOCATION p GOVT. LOT 5~ 1/4 N~ 1l4,S /' j T Z9 ,N,R / / E (or) W LOT~# BLOCK# SU Dr.NAME OR CS # / 1 i4AyNE~' t~ f ~~ G [~ New Construction Use Residen ~ [ ~ ~b~r cif ms U tiltt [ j Addition to existing building j [Replacement [ J Public or commercial desaibe Code derived daily flow gpd Recommended design loading rate C~ ,~ bed, gpd/ft2 D ~ trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations five4~-v~ T ~av u~ ~~- T r4 to~P IQdvM~ Parent material Flood plain elevation, if applicable ft S =Suitable for system ~NVENTIONAL 0 ND IN-GROUND PRESSURE AT-GRADE SY TEM IN FILL HOLDING~IK U=Unsuitable for s stem ~ S O U ~S ^ U ~ S ^ U S^ U [~? S O U ^ S LifU Boring # x ~ ,: Ground ,glev. 97.35 fL Depth to lfi~miting > `1`~z. Boring # Ground elev. 9 .79 ft. Depth to limiting > facl~or ~ SOIL DESCRIPTIr~N Rt=DI1RT Horizon Depth in. Dominant Color Munsell Mottles Qu Sz Cont Color Texture Structure G S Consistence Bot.a~ly Roots GPD/ft A o-Z3 ~o~le / . . . -~ L r. z. Sh. z >~sb~ ~- r cw z>"t Bed rer>ctt o,s o.6 3 -113 3 - 5 ~ ~ O ,7 ~ ~' ~ 1 1~ ' nemancs: c a.s a ~ ~, 0-4 ~~ -~4 3 -~ ~~C. ~, s m~ Cw ~-~ . ozo.~ ~Z x-121 >QY 4 '~ ~ 1 S rh l 0 ~7 t~ V nernancs: -Please Print .~ RY~y :o ~~ (tiJ•t s~-o~ b Phone: ~ ~~- ~O ~ a Date: CST Number: IIi/g~ 3~4 PROPERTY¢WNER ~~~ r/~rLLg~- SOIL DESCRIPTION REPORT Page ~of PAIiCELI.D.# ~OT ~ TANN Y ~'~'~ a . Boring # . ~::r.;~,..,:::: k 'i...v v..M1~:i . ~.:~ vM:..::,:.~~<:: ~,.:,..>w..: Ground elev. '~Z•~? ft. Depth to limiting f ctor > ~. ~s Boring # ~,.,v~,.... ~~::ww, •.~. Ground elev. 97.a3ft. Depth to limiting 7~~ Boring # ~ :{ h Ground elev. 9~ft. Depth to li~mit~ing } ~ 'I.7 Boring # :•:~~ Ground elev. ft. Depth to limiting factor H i Depth Dominant Color Mottles ' Texture Structure Consistence Boundary Roots GPD/ft or zon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench A D-13 I Del ~ ~ -- L 2 n? cr n-i r C (.,~ ~ p ,S Q .6 8, 13-44 ~a~i~ 4 3 -- S ;L 1 m s~ ~,~~ c S j- z ~ ~ 4 -f•v7 joy >2 ~ ~- - S m ~ C~.7 0 ~~ o Remarks: A 0-1Z yv° 3 "' ~ 2 n, c ~ r~ ~r w 2 rf1 Q.S p .~ B 4-~~¢ Eby ~ ~ ~ -~ ~- r a: cag Remarks: $, ~-12. L>>ir~ 4 3 -~ ~~L J rti s~~ n.~~ e5 ~ 4:2 p,3 Remarks: Remarks: SBD-8330(R.05/92) ~: ~1 ,, w d V _ • ~ ~~ i • ~ ~ ~•~~ \ \ V 1 ~y ~ ~ r ~ ~ ~ `~ -- ~ ~ `~ ~ Y ~ ~ ~ ~ ,^ P~~~ 3~~3 Ma~uas ~Q-v~ ~ ~~ ~ i ~ l ~ ~~ '' ~ ~ ` , ~w, 4 ~" ~ a' i jDt.~ "~pb. , ' ' E ~,~ ~} ~ F ~ 44 ~lrf A'C -. ft ~ , ~ 7'.~,n ~t ~,~F2 ~i' r i. ~ ~ ,.'' r ' ~f ~'~~M ~ fi t ~ ~~~ ~~ ck~t~ ~ r ~ Sy~ ~ c ~~~ ~ .r r 'tip ,~ ~` ~ ~. = ~~Y . ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer i /'aG ~iva Mailing Address / ~ 6~ {1'l ~~.v~S d //'~~e J~~~l~ l~is~~'d~~/ ~/~' Property Address ~~G~ ~~~~~.5 Q/'i`v~ Soo (Verification required from Planning & Zoning Department for new construction.) City/State yyt~~~' p/y ~j ~ ~ Parcel Identification Number LEGAL DESCRIPTION Property Location ~'/4 ,,~ 1/4 ,Sec. ~, T .2~ N R~W, Town of fir` sl S o-~ Subdivision /~ .l~.~~ Certified Survey Map # Volume ,Page # Warranty Deed # ,Volume ,Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Lot # 7 . 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 yeazs or sooner, if needed, by a licensed pumper. What, you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system, Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Deparment within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms ~~.~ ~ -_ SIGNATURE OF APPLICANT(S) ~ /?~ /~ DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) POWTS OWNER'S II-IANUAL & Mr''~NAGEMENT PLAN Page of Owner rz l'. Permit ~' fAINTENAN_ CE SCHEDULE Service Event inspect condition of tankts} Pump out contents of tankls) Inspect dispersal celtts! Clean effluent filter inspect pump, pump controls & alarm Flush laterals and pressure test other: Other: ~"'_ Septic Tank Capacity Lr©Q al ^ NA Septic Tank Manufacturer ~ C.SG' ^ NA Effluent Filter Manufacturer ~d ry ~. ~~• ^ NA Effluent Filter Model ~~,`..r ^ NA Pump Tank Capacity Q al ^ NA Pump Tank Manufacturer • S2Y• ^ NA Pump Manufacturer ~~ya ~ ^ NA ~ ^ NA Pump Model Pretreatment Unit ^ NA Sand/Gravel Filter ^ Peat Flter ^ Mechanical Aeration ^ Wetland ^ Dsinfectwn ^ Other: Dispersal Cell{s) ^ .NA ^ In-Ground (gravity) ^ In-Ground {pressurized} ^ At-Grade ^ Mound ^ Drip-Line ^ Other: other: ^ NA Other: ^ NA Other: ^ NA Service frequency month{s1 {1Naxlmum 3 yearsl ^ NA At least once every: ~ serfs) bined sludge and scum equals one-third {Y31 of tank volume ^ NA When com ^ month(s) (IIAaxlmum 3 years} ^ NA At least once every:. ~ ~f year{s1 monthts) ^ NA At least once every' ~, ~ ~ y°arlsl ^ month{s1 DNA At least once every: `r"^' ^ yearls) ' ^ month{s) ^ NA At least once every: ^' ^ yearlsl ^ month{s1 ^ NA At least once every: .._.,- ^ year(s) D NA MAINTENANCE INSTRUCTIONS O orator. Tan Inspections of tanks and dispersal cells shall be made by an individual carrying one of the ~pt8gegServ sing orpcert'rficat+on: Master Plumber; Master Plumber Restricted Sewer; POWTS inspector; POWTS Maintainer, inspections must include a visual inspection of the tank{s} to ideck ff r any back up oropond ngof effluent on the ground surface measure the volume of combined sludge and scum and to ch ondir The dispersal celi(s1 shall be visuaQy inspected tof effluent onfthe grounds surface m y~indicate a fail ng c ndihteion andeequires tr of effluent on the ground surface. The pond+ng immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank eq~ alsana ~ Spos~}ofr~~ accordance with chapter NR 11 contents of the tank shall be removed by a Septage Servicing Opera Wisconsin Administrative Code. Als other services, including but not limited to the servicing of effluent filters, mechanical or pressurized aomponer-ts, pretrea me units, and any servicing at intervals of 512 months, shall Ise perforwithin 10 daysiofcom`ptetion of anYeservlce event. A service report shall be provided to the local regulatory suthority '+Values typical for domestic wastewater and septic tan+c eriiuern. Page -_____ of ......__._. START I1P AND OPERATfON For new construction, prior to use of the POWTS`ohiAplf i:rpi~n~~+rlt tl-nllis~ f~rlf high concentratona`i! a daected have the contfmta that may impede the treatment process andlor daiftll a ~i ~r~~Ji Sl~~ii~i, , f of the tankis} removed by a saptage servicing opariil~pl' '~i3t' t` u+~~e• - System Stan up shall not occur when soil candifwna ~'~:'# ~-~ ~ l~ifsiti'I~Ye ~~°' ~C1an power is restored the'excess wastewater will be During power outages pump tanks may fiN above 11Al~til~ ~ ~~?" ~~N~ d may result In the backup. or surface discharge of discharged to the dispersal cetlis) in ons largo dod~i ~~ ~~f3~ ~ ~~ ~ b a ~ptage Servicing Operator prior to restoring t iii) , Y t4ffluent. To avoid this situation have the cOntertt~ ~ ~ ~~ , ti~"iMl' fb assist in rnanuagy operating the pump controls to power to the effluent pump or contact a Plumber ~f . restore Harms) lave#s wthin the pump tank. !fit pip tai°park over, or otherwise disturb or compact, the area Qo not drive or park vehicles over tanks and dispehl~I;:igi~H~, {~' within 1 li feet down slope of any mound or at-grade sIP~1 ~e~ ~~+ rolon the Iifs of the ~~~ ~i Iftii rove the performance and p g Reduction or aiirtt3nation of the following from the ~~j d gre~ars; deirtal floss; diapers; disinfectants; fat: hOWT5: antibiotics; baby wipes; cigarette butts; '~.~~- ° ~~ ~ f grease; herbicides; meet scraps: medications; oil; foundation drain SRUmp pumps vaster; fruit and vs~i~ ~ii~ ~~ , painting products; pesticides; sanitary napkins; ta~~~ ~ih +~~M€' ~` .-~ ne. ABAND011tMENT fal steps shell he taken to insure that the system is When the POWTS #ails and/or is permanently takef~ +~u~ ~$ ~i~~ cif ~ns<n Administrative Coda: properly and safely abandoned in compliance with ol~i~tflr ~i~'~~,~~- ~p All piping to tanks and pits shall be dlaconrN~a~l~ ~tt+.f ~F~~ lil~t+d~~ ~?ipe openings sealed. • The contents of all tanks and pits shall be r~i'tici~-1~ a~ ~rbraikrii+ elfit~ased of by a Septage SarvicM>3 Operator. • After pumping, all tanks and pits shall be [l~'fltiill~ I~i'ii{ ~ti1lt+~vl~I°tlir #hefr covers removed and the void space filled with soli, gravel or another Mart solid material. CONTINQENCY PLAN ~ or must be taken, to provide a code complian+ If the POWTS fails and cannot be repaired the fclili~yVi~~ ~+>lli4~f~s~ hdvfl replacement system: t th® location of a replacement soil aboarptiei pr ~, ~~ . (~ A suitable replacement area has been ev nl~. ~ ~ , ~ d compect~ and ~°uM not be infringed upon b~ system. The replacement area should be {i~~p~+i~ TI'l~rrri +~li}~41ri~h$~ ,;wells. Failure to Protect the repiacem~t area wi' required setbacks from existing and propo>f~;! ~i ~ ~tabfe replacement area. Replaaernent systems mus result in the need for a new soil and site eva~~lt{~i ~ ~~~ ~ ~! .: comply with the rules in effect et that time ~.= ' 4~r~~ aw~~~~ soil limitations. earring advances in POWT' Q A suitable replacement area is not avail~f~li~ t11,-t~ ~~ $~' technology a holding tank may be installed ~~ ~ ~~~ fib. AQ The site as not en evaluated to identlf~~ a atfi~h ' ~~ evaluation be performed to Locate a shit may b ail s a test resort to repiace;:lis ~~!' p Mound and at-grade sail absorption systel~d iP~! 1~1k , fil ties rface Reconstruction8 of such:~#~llf4fi# ~aX failed POWTS• area. Upon failure of the P~WTS a r;<oN end ail If no replacement area is available a holding tan in Lace following removal of the biomat at I~I'd~ P ':afil~l~i'if 11il~th the rules in effect at that Lime. in tra v u < <WARNMI4> > ~ 8E8 ANDlOR iN8UFFICIENT OXYGEN. DO NC SEPTIC, PUMP AND OTHER TREATMENT TANKS Nii~'~ ~ ~ ~ "' TANCEB. DEATH MAY RE811LT. RESCUE OF ENTER A SEPTIC, PUMP OR OTHER TREATMENT 'f : ~; ~ „_ ,', PERSON FROM tHE INTERIOR OF A TANK MAY BS ~~ ~ ADDITIONAL COMMENTS pOYYTB ifiEBTALLER Name ~ ` 1 f+-~ S e,R~'e'~4t~t~: Phone "? / ~' ~- ~ $ 10~ SEPTAQE SERViCINt3 OPERATOR {PUMPER? Name __ ~ Phone ~ _.4~ , This document wee drafted in cornplienc®, with chapter Comm 8~~~4i~~lbilf ( ~ :1~ ~/ S - 3S(o - ~~ ~iJ 1l, i2i & (31. Wisconsin Administrative Code. .. ~ 5~33'~`8 Starr Bar of wiscuvin Form ~ - 1482 ' W [rRANTY DEED ~~)~ ~1~8p~~_ 384 OOGU,19EN7 NO. i _ __,~ E• Mi~Zer.__ a -singie~erson=. ____-- Convc s aatl Rifirrant5 io Awl .lam -~rO~W 8i~~--- _ ~atricia A. Procknow,__tiusl~a an wife, the following descrihr~I real etatc ir. $t. Croilc County, St~tc Df Wisconsin: iIGV j//V--~~,,,GIii)yyr5//~~D//~~i,-r~I~Vr~G V[i~N1 S+V•v •*f Re~'d for Record SEP 5 i99a ~ s: oo a.M ~~~. c.. ! 7H~5 SPACE aESEa vEG iOR RECtaa C~NG GATA ~ NAME AHD aE iURN AOOaESS , // /~~t"G C >=3ila-~ {Parcel tdeatificalion Number) Lot 7, Tanney Ridge Special. Addition to the Town of Hudson, St. Croix County, Wisconsin. This ._ ~.,3~-___ homestead prape»y. }i~(is not) F..xception to warranties: Easements, restrictions, and rights-of-way of record, if any. Dated this ___,___.._-----~-_---- aL_~ ~ day of ~ -._-_..._.~~`~~" .__- ._--, 19.95.... - (SEAL) -----------------_____-.-----._ __ _ (SEAL) ~r"`"J ~^^ _~~~_ + • St3fr! L''. iiiiZEr --- ----- --- ---------- - --- __ ---- --..._ .._. _-.._ (SEAL) ___ _____-_ ---___--- ---- ---- -- ---- ------ ---- _ (SEALS a ~ ~~ AiJTHENTICATION tf ~j Signature(s) . _ _ .- -- -- ___ _ __.__ ...----..- -----._- -- . authenticated this day of ___ _ _- _. _ . ..___-_ ! 4 _ - _ TITLE: MEMI)EK STATL' RAK OP 1ISCONSIN- T (IC not. - - ---- - -- - - authorized by §706.(16, VVic. State.) - - -- ACKNOWLEDGAIENT STATE OF WISCONSIN St. Croix ss. _ .. _ . -. _ County. Personally came before me this .._ __ ~ 5 - _ ~-_ day of --- -- -_-- . _-- - .--------.-._ !9_~S_ the above named __Sam. E.- _Mi11er, a single _pe,rson,_.-_- __-- to r. to b<• th_ person _ _ _. who executed the <-~;. •awii,~~ rcg • 1 inctrumcnt a ~ uaa9ed l c samC. THIS :NSTRUMEN7 WA$ GRAFTED By .+` t~•S ~-IV ~ ~ ~~.- ... f ~,.~ ..........,, S,j,~ - _ - -- - - - _ _ - Kristi-na Ogland <t, .• ~ ~ ~~~ -c~-'`•.i3`5- - . aw~oe- \~eirbst' Attorne at Law "' - ~/'O/ X _ cnDnn~. ~~'is. Y ~c: l,i: c ...~_._ ~ Notary Public ,.- ~-_. _. _ ---• ~- ..,,'y'^Nr~err nr z!!anl.rel~•d_iSot7lerc eo2Z~•_ My commi<cion is prrmancnt. Uf not, ayttere!Ipiratinn drt<: ... ....- tea. ~ _ ~rr Z ~~ •\., m.. ••r pe.r..•r. ..vnmv m ..m , .La.~.. •n~•uld M is Ir~„ga~1l.~,u,•-..un~ la'.\RR \\T! rIt ! 1) "'PVT AT F. AAR QP N-15('Oi51~ ~ lti~sco.a.n 1 .moo :~ DIanA r•., h+r. t'r1R'<t aiA. . - I9N2 L1.Iw.l,.APP «.,c 1! r ~I h ti I! ., ~~ ~,~ ~, ~~ I i I I t7 3 ~ cn 'J N ~ ~ -~ ~ N O m ~ qy S S ` ` O o O ~ n ra 3 3 u, 00 00 C ~ j 7 ~ ~ ~ b ~p N cn N ~ ~ ~ C N O ~p I ° ~- -, ~ ~ I m N I O ~ -D I n p ~ °~ ~ a I ~ ~ O ~ - x N CD I a Z O_ =h I v O_ 4 3 I ~ I `D c I w m I n 3 z CD ~ o ~ I ~ I I I V ~~~ I ~ I ~ a a '' ~ o' ~~ 47 ~ Z 0 I ~ //A`\ ~ (~y \ N 111 ~ 1 I ~ o I ~ m I ~ V o g~ O ~- nv, p ~ vn o d d c d o c ~ > m > ~ ~ 3 ~ ~ ~ ~ m m 3 = 3 ^~ r: N ~ ~ ~ ' N O ~_ ~ ~ ~ O O ' 7 N p 7 N Q> O O O O ~ A O ~ a ~ o. .. n N tb ~ O ~ _ `O CO °- n r v1 c O c O N ~ cn cn o 3 a ~ ~_ M Q ~ N N N ~ ~ V d ~ ~ ~ v v ~ m ~ a ~ ' ~ ~ ~ u = a' 3 °' ~ . ~ ~ .. CD Z W Z n ~ D a ~ a' ~ ~ a N N fD y N a iU C m ~ a o 'P Z ~ C ~ T N . a - _ .Y' ao v m N a 3 ~ Z ' ~i Z o _ o r: ~ m ~ N Z (D ~ W T C 7 a d A U m eC O ~t 0 v ti a :.. STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SA ~!~( ~,~ ~~- L E ~ ADDRESS~OJ(~ Z~ 2-- SUBDIVISION / CSM~ ~~ /~//-/,E f/ /2 ~~~ ~~ LOT ~,~ SECTION /_T / T Z 9 N_R / 9 ~~ Town of ~ yU _; O ~I' ST. CROIX COUNTY, WISCONSIN PLAN VIER SHOW EVERYTHING WITHIN 100 FEET-0F SYSTEM r/ ~+OUSE ~:~ )' ~,~,~ - ~s a E_ ~, _, sC/~L~ ~~~/ 1 ~O i ~s' ------- ~-f~o'_ ~ ` __.. --- ~ ~ D . ,.-- ___. 5oc)TH --- -_ ------ _---- LoT G/~~ w ~~ 0 h ~~ 3 I N D ]CATS NORTH ARROL~' Provide setback and elevation information on reverse of this form- Provide 2 dimensions to center of septic tanF; manhole cover. ~, r BENCHMARK: 7a~ of (o7"t'/~~ /fT S~ Lo'r~a.P/~/~/1 ~/=/rzlov" ~~ ALTERNATE BM : 7of' al~fi`o~sE ~D~NV JET/l~A/.L/= ~~ ~-' -' .EPTIC / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: !NF/,$~~._, Liquid Capacity: ~®~6/~L Setback from: Well House Other Pump: Manufacturer Float separation Model # _S i z e "~J-~- Gallons/cycle• Alarm Location ----~ SOIL ABSORPTION SYSTEM Width: / ~ Length yo Number of trenches ~~~ Distance & Direction to nearest prop. line:_ (~~ ~ rd sa. ~ofi~/iYE Setback from: well: House Other ELEVATIONS Building Sewer --- ST Inlet. c~,4~r' ST outlet ~'.~z- PC inlet -- PC bottom Pump Off Header/Manifold Ala (o,?,> Bottom of system ~ ~6 Existing Grade ~ ~ '- Final grade ~ e$ ~~~~ - DATE OF INSTALLATION: ~ ~ ~ ~~ PLUMBER ON JOB: ~~~ `~~1~~"~JC LICENSE NUMBER: ~/,%~~~.s ~ ~~~~ INSPECTOR: ~ 3/93:jt 1Nisconsin Department of Industry, Labor 0nd Human Relations Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Pe me~: E r s Na^ I L ^ City ^ Village C1 Town of: • ~ ER M L r X CST BM Elev.: Insp. BM Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY p~ i Dosi n Aeration Ha 'ng TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic ~-1~~~. LS ~ ~ / ~ ~ NA Dosing NA Aeration A Holding PUMP /SIPHON INFORMATION Manu#acturer Demand Model Number ~1GPM TDH Lriction ~ Ft Forcemain Length Dia. Dist. To wen SOIL ABSORPTION SYSTEM ELEVATION DATA County: ST. CROIX Sanitary Permit No.: State Plan o.: Parcel Tax No.: F/o 7/~s STATION BS HI FS ELEV. Benchmark 2, ~ /~1~, CU Bldg. Sewer St/b~f Inlet 3~ ~y~~~ St / }eft Outlet 9 7~' ~(~ ` Dt Inlet Dt Bottom Headed », 0,09 93 ~7~ Dist. Pipe :x1- ~~ ~~ ~,~ Ste` Bot. System ~~ ~, ~' Final Grade ro~ --=' ~ 7. ~ ~ fcj ~~ -. , // ~/ ! ~ BED /TRENCH Width ~~ Length `~ r No. Of Trenches PIT No. Of Pits Inside Di uid Depth DIMEN I N ~ DIMENSI SYSTEM TO P / L BLDG WELL LAKE /STREAM LEA Manufacturer: SETBACK INFORMATION Type O >"~ Crx ;f ~ ~ AMBER Model Number: System: iJ~~ "~~,, 3~S` ?~ ; OR UNIT DISTRIBUTION SYSTEM Header l1 ~ i Distribution Pipe(s) , ~ x Hole Size x Hole S en it Intake /~ ~ Length ~,_ Dia. ~ Dia. ~ Spacing CJ Length ~ 7 ~ ~ SOIL COVER x Pressure Systems Only xx Mound Or At-~Syste my Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mu c e Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.Zl 29.19W, SE,~NE, Lot 7, Mounds Drive _~c , ~-~ ,G~ yC. ~ /~~ ~~ ~ ~'=-~' r- -~~' ~ ~„ ~'~" _ y ~ ~ ~~. ~ S ~ Cis n-e' `'~ ~" Plan revision required? ^ Yes [~-bo / Use other side for additional information. ~f ~ Q ~_..- SBD-6710(R 05/91) Date Inspector's Signature Cert. No. ' ~:~~ : SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code • Attach complete plans (to the county copy only) for the system, on paper not less than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application The information you provide may be used by other government agency programs !Privacy Law, s. 15.04 (1) (m)]. Safety and Buildings Division Bureau of Building Water Systen 20T E. Washington Ave. P.O" Box 7969 Madison, WI 53707-7969 County ~. . Cr'Dr State Sanitary Permit N/umber ^ Check t~evlsion t~ evious application State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFO RMATION Property Owner Name S LL.E~. Property Location S~1/4 ~~ va, S~~ Tz , N, R /y E (or Property Owner's Mailing Address Lot Number Block Number Cit ,State Zip Code Phone Number Subdivision Name or CSM Number vosoN ~ ss~o~ (3~~)z~~ ~ ,e o~ II. TYPE OF BUILDING: (check one) [~ State Owned ^ city Nearest Road Public ^ 1 or 2 Famil Dwellin - No. of bedrooms -.3 ~ town OF U~SO Md~ 0 S D2~Y,E III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~Z 0 ~- ~ 3a`{ ~ ~C7 1 ^ Apartment /Condo 2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise:SaleslRepairs 11 ^ RestaurantJBar/Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ~] New 2. ^ Replacement 3. ^ Replacement of 4_ ^ Reconnection of S. ^ Repair of an ' ____T System ________System ________~____ Tank Only______________ Existing System _________Existing5ystem B) ^ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 1 1 ®Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 1 ~ Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^Seepage Pit 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade / / Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft_) (Min./inch) ~ ,i Elevation ` ~~ 3 S ` ~ Feet ~ `/ ~ z O ~ ~, Feet ° 7- VII. TANK Ca acit INFORMATION in gallo s Total # of r Manufacturer s Name Prefab. Site con- l Fiber- Plastic Exper. N E i i Gallons Tanks concrete stee glass App ew x st n strutted Tanks Tanks Septic Tank or Woiding Tank 0 S ~ /r'- ^ ^ ^ ^ ^ Lift Pump Tank !Siphon Chamber ^ ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber' ~ (Print) Plumber's Signature: (No Stam s) MP/MPRSW No.: Business Phone Number: ~t . ~ ~ LL i~'~-~ `~ 25- 3Sno 3 - ~6qL Plumber's. ddress (Street, City, State, Zip Code): ~/ ~~E ~L L N~ /f~vSoN t,~s o/ IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (~"c~udesGroundwater ate slue Issuing Ag t Si nature (No S Approved ^ Owner Given Initial ~}~i Surcharge Fee) ~y~r+] '' ~- // I / ~ [ Adverse Determination ~ ~~ ~4e~~ dd r X. CONDITIONS OFAPPROVAL /REASONS FOR DISAPPROVAL: -~ SBFY639B (R. OS/94) DISTRIBUTION: Original to Cnunty. One copy To: Safety 8 BuilJings Division, Owner, PlumtKr INSTRUCTIONS ,~, ~.~' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a 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. 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. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. TypE~ of permit. Check only one online A. Complete line B if permit is for tank replacement, reconnection, or repair. V. -Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tan4: information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for al! septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. 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. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 1 1 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with corplete dimensions, loca~.ion of holding tank(s), septic tanE:(s) or other treatment tanks, building sewers; wells; water mains/water service; steams and lakes; pump or siphon tams; distribution boxes, soil akasorption systems; replacemen~system areas; and the location of the building served; R) _ ~rizoni~u and vertical ~~lev<, .i _~n reference points; C) compete specificr;tic~; for pumps and controls; dose volume; efevatiorrdifferences; friction lass; pump performance curve; pump model ar,-f pump ±nanufacturer; D) Cross section of the sot! absorption system :f required by the coup qty; [) soil test data on <:~ 1 ? ~ form; anu F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. . sft /!~ ~ ~~ L E2 TA~t/NEf" x'/06 ~ ~ o r..~- 7 •1 D to U /It+ov /VD S 1~~/U~ S~~/E /i~'_ /D " /Lj i'. ,~ `,r ~ ~~ ~' ~~i f" ' j 7; ~ ~ ~, ~ Lil 4 a ~ O W = QN U R~ .. ~ i ~ ~ ~ ~ ~ x i 1 `~ ~~ ~ h ~~'~ ~. ,` ~~J, t ~ 1 ~~~ ~ ~ ~ r',, ~ . ~ r~ -• 1 /'~ - V `,ti ~ \ ~ i v 1) ~ `~ :` Y~• ~ ~ V ~v/''~ ~~ V ~~ M M ~.. wa W ~ S ~ 0.. - is W ~.. d 0 R~ ta! d ~¢ ~ F- ~ X ~ ~' UUU O ~ F- O ~ r0 ~ K ~ •~, z 00 ~ I M I j .. .. ti ~~ U W ~ ~.~ ~ ~~ O _~ O O ~ 2 ~~ w a z 0 w a z z ~ °- ~ a o J W ~1 F \ U U a ~ ~ 3 Z i t ~I :~ ~ Y O .- ~~ w a a ~' ~.. 0 _, ~ U ) / . W ~ ~ ~:t~ W 4 0.. 3 0 w m r `L Q Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page ! of 3 _Labor aixl Human Relations • Divisi~rn of Safety & Buildings __~ .• :.~ ~~ ~ ~r, .,., .,~ ..,:_ . ~_ .._~_ ' NTY COU C '~~ X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size Plan must include but t JT . , not limited to vertical and horizontal referent lion and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location a i 9j,,, r s d. ~~ _~~~ APPLICANT INFORMATION-PLRI T /~L IN ~ TION ,• REVIEWED BY DATE PR~ RTY OWN R: ~ ~ L`,~ 6 :'r : tJ ~ ` PROPERTY LOCATION 9 Z~ ~ J4 ~ / L,L ~ ~ -~ a'/: f ;~_ ~ „ T ,N,R / E (or) W GOVT. LOT ~~ 1/4 N~ 1/4,S ~ PROPERTY OWNER':S MAILING ADD ~;~ ~:lv~~ v LOT # BLOCK # SU D~,NAME OR CS # ~ - ~ CITY, STATE i~;~~ _ UMBER , r • a v f~ ~ ^CITY ^VI GE OWN NEAREST ROAD ~ f~~ ~• ~~ ~ ~ ~Q N ~~y ~~,~ [ ~ New Construction Use [ ~cJ Residen .(J~lrrjt>e~r df~ ms U ~ ~ [ ]Addition to existing building j ]Replacement [ ] Public or commeraal describe Code derived daily flow gpd Recommended design loading rate O.7 bed, gpd/ft2 O ~ trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 Vench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations Ly~4c.-y/t T ia~v ,~~ `°o~e, tact ; /Q ~°~P a~OvMt_ Parent material Flood plain elevation, if applicable ft S =Suitable for system U=Unsuitable for s stem ~NVENTIONAL 9(] S^ U N~10 ND l1~ S^ U IN-GROUND PRESSURE ~ S ^ U AT•GRADE S^ U SYSTEM IN FILL S^ U HOLDING K ^ S U SOIL DESCRIPTION REPORT Boring # `'tea .~. Ground lev. 9~.3s' ft. Depth to limiting ' f~tq[ ~ Boring # . \..~~Y 2. Ground elev. 9~7'~ ft. Depth to limiting factor ~ ,d~ Horizon Depth Dominant Color Mottles Texture Structure Consistence Bax~da Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed Trertd~ A 0-2.3 lOYr~ l L Z lrisb~ n., ~- D,w 2>'h Q.5 (),~ ~~ 3-53 /o`/ 3 ~ - S.L I r~ alOi~ n., ~ ~ w ! 0.2. O, 3 -//~ ~ 3 - S n-t ~ D =~ k Remarks: A 4-Za IC~y 3 ~ ,- L ~ /h s.6k m~r C. w 2 Q.S 4.G Remarks: Name:-Please Print Y~y ~S ~,N I~ t s'f'O) 6 Phone: ~~b_ AD~a Date: /I /// /~~ C; 3~ g¢ PROPERTY~WNER ~~ I'' ~ ~~~~ SOIL DESCRIPTION REPORT Page?-of `PAi'tC'EL•I.~.# ~bT ~ TrANN~Y ~'~~ Boring # `3 ~;> ~~~;<~ }~ k\` V ~j. Ground elev. ~7 SZ ft. Depth to li~mcipng >f`1t7S~ Boring # x«; ~ x 4 :~ Ground elev. 97,g3ft. Depth to limiting ~~ctor~ Boring # ~~ .. w<~ ~~ ~~~~..~ Ground elev. 9~?-ft. Depth to limitti~ng 7 f~c `1~ Boring # .4`,ti •x~~ Ground elev. ft. Depth to limiting factor Depth Dominant Color Mottles ~ T Structure Consistence Boundar Roots GPD/ft Horizon in. Munsell Du. Sz. Cont Color exture Gr. Sz. Sh. y Bed Trerxh A D-13 Ol/~ / -- L 2 r~ cr M r C w Z 0>5 0.6 $, i3-4~ ia~i~e 4 3 -- S ,C. 1 r~ sb ~~-~ c ~ I ~ .2 3 ~ Q -li7 spy 4 4 -- S rh~ O.7 !~~ Remarks: A 0-!Z p~/,~ 3 -' L 2~ c r rh ~r w 2 r>7 O.S 0,~ ~ 4-Il¢ gay 4 Q S n, ~ b~ ag Remarks: Q C~-~ ill°~fZ3 1 -` L Z rncr ~'h~r w Z ,S O.6 Remarks: Remarks: SBD-8330(R.05/92) l i • Y •, . ~ 1~ a~ G~ ~ ~ ~, b m 'b ~ ~ a ~ z ~~ ~ . ~ v r ~` W d ~ - - - ~" Q ~' ~ ~ ~~ ~ ~ ~ b '~ ~~~ , -~ -~ a cN ~ ~ ~ i a O ~ ,~ ~ ~ C7V ~' 1 ~, ~y ~ ' ~ i r ~ ~ , 1 ~ -- `` , ~ ~ V v W vY 1 \~ . o~ ~~ pa~~ 3~~3 Mou,uas ~Q,~/~ ... .~~ ~) Q ~ __ _~ ~-`- ~~ _ ~ R - _- - ~• ~~ _ - _ j3j3 /~ }FI ~$$$• ~ Y~ - - W ~ o ~' _ - - o: W R J .. e i ~0 • O a ~~--- 1 SCtdr~ 3 qm a al -frr •~r 8 ~I _ _ _ I I I ~ byee` i' ~ _~~ 0_ ° ~~ ~ ~ W p ~ )• 7 8 ,a, Q i• '~! 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F ~ Q 00'011 ZL'18b M OZ £0 005 / 2~ / nj !i1 ~ 10 Q !Q aaI I h 1~ r ~ ,Ll'I7t dl NI •n_ y w ~9 /0 11.1 G ~ ~' S ./~ /1p / / I LI.I bb 4052 .zvs71 ~ _ ° r 'O / I b 380 fn a M O O % I N 4Z 0 Z ~••7i• ~ {1 / ~~ N I r nl x, s ~1n N /-~~__Ti - vi N JI ~ W C p ~ I 8 t ^0` - r / / / ~ii OI O _ J~ ~ .J1 " ~ m z ~ RA RN w /, /,"'// plg ~ w g o1 W J i Z J ~ < cA • ~ s~ 1i f ~ `. r • OI ~ \ Q R 1J_ f.w ». a a i ~ RI ~ I ~ wl p ~ SI~~ m JI " -JI - i i `~ -1 kl W M SS 7f In '^ al 71 .._..~_,,,,.,...... .................._.......... ~...........~.........._.J ~ I ~~ JI fill 0 \o r \ 1 \ ~` ~ (,tl ~ \ ~ w ~- -HinOS-OrOa3Nt tuCNnOW~- p1J \ .. t~8 0 ~ / ~ ~Il9fld / ron ce OOt 031tgp3 -- ~ ~ ` -'~'~. 7D y I ~ ~~~ --~ _ ., " b ' ,~ I ~ t ~ ~ CI `I ~`: ~! ' • ~. „ ,.... I ~ J ~ $~TQ' ~ $~ ~ f- ~~' ~ yRl y ~ o ~ 4 ~ ~, o ~ 8 ~~,tLY07 • J M'f0[ K~ 1 n N011~77 ~M7M 7N1 A M77 7NL l0 7N1, 167.1 ~ ~ sanr, c_! ! r,dt:n ,. - ~ .~ STC- I05 SEPTIC TANK MACNTCNANCE AGREEMENT St. Croix County OWNER/BUYER SAM /VI I L L ~,'~ MAILING ADDRESS QOX ~ 2b L f~uD SO 1y 4~.L r`l~l~ PROPERTY ADDRESS ~9(a (~ MOU ALD 3 1~ 1~1V~ (location of septic system) Please obtain from tlic Planning Dept. CITY/STATE µ U t~S U 1~•1 W I SyO 1 So PROPERTY LOCATION S ~ 1/4, ~\ ~ _ f/4, Section (~ "I' Z 9 N-R y~' TOWN OF ~ u 1 S O ST. CROIX COUNTY, WI SUBDIVISION ~~ h~ ~ }' ~10 (o~ LOT NUMBER ~___ CERTIFIEDSURVEY MAI'~~~C1-~, VOLUME ,PAGE ,LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect tl~e 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 rllaximum of 60% of tl~e cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix Count} accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater 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. I/V/e, 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 DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date ~._J slc~NeD: -_-- _-- DATE: ~ _ ~ `~ / __ St. Croix County Zoning Office Government Center 1101 Carmichael Road I~udson, \VI S401G ll/`~~ sTC-ioo .. - .~ 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 _5 A M M ~ L L ~ ~ Location of property 5~ 1/41/4 , Section _L_, TAN-R~ Township ~-~ U 17 S c~ 1J Mailing address BOX ~Z 8 Z- ~+ y D s o ~~, ~,~~ ~ S~ o~~ Address of site~p(~(o M~vND S DRIvE Nu~Sota w~ Syry/~ Subdivision name _'1'~4N KY 121A ~E. Lot no. ~_ Other homes on property? X Yes No Previous owner of property ~ANI~~I~L 5 y,~~,~ Total size of property Z, 0 3 r4L, Total size of parcel 2, 0 3 , Date parcel was created q- / - Are all corners and lot lines identifiable? _~Yes No Is this property being developed for (spec house)? k Yes No Volume ~0 31 and Page Number yS~ as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. SO ~ S S S and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. So'f S S'S S tune of Applicant Co-Applicant ~~'~~~ Date of Sicrnature n~t.P of SianatnrP • ,. w _ •~ DOCUMENT NO. STATE BA F WISCONSI ORJ4 1-1983 T"~s ar~cc RcscsvcD row RscoRO~"a DATA • ~ ~ ARRANTY D D y so~sss ~o~ ~~3i-~~f 456 This Deed, made between .-.--- .--------------------------------.•--------.--_-. .-, Randall W. Synan and Patricia E. Synan, . husband. _and- wife-- _-_-_ _ - . --- - •---------•-- ----- -------• -....---•--- --- - •- - -- ----------------- ----------• Grantor. and.... Sam..E.~...M~ 1_~er-'-• a---s-~-n~1e---person ............................... -----• .................•------•-•---------•-----•-•--------...--•-••--•----.....----------------• Grantee. Wit~168Seth, 'I hat the said Grantor, tqr a valuable rnnsideration...... Randall W. SXnaa and Patrlcia E. Synan conveys to Grantee the following described real ?!!tste i~ ...St . C~ Oix County, State of Wiaconein: r _CJST~4'S OF7C~ RtTURN TO '. ~; Ta: Parcel `lo- -----------------•------•---------- The SE1/4 of NE1/4 of Section 11; the SW1/4 of NW1/4, the N1/2 of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of NW1/4 except the East 74 feet thereof, all in Section 12; all in Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. FF~ AND ~~-~' A parcel of land located in part of the NE1/4 of SE1/4 of Sectio`~ 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1/4 corner of said Section 11; thence 889 30'00"W, along the North line of the SEl/4 of said Section, 1212.32 feet to the point of :,eginning; thence continuing S89 30'00"W, along said North line, 66.00 feet; thence 800 28'03"E, 500.00 feet; thence N89 30'00"E, along the North line of Certified Survey Map filed in Vol. "3", Page 722, 38.08 feet; thence N00 11'33"W, 150.00 feet; thence N03 58'34"E, 351.07 feet to the point of beginning. Jai This .-------..f.~_-n42t.-. homestead property. (is) (is not) Together with all sad singular the hereditaments and appurtenances thereunto belonging; '- Ana.....R~nda~]__ W_,___Synan_. and--Patr,leis..-E-.-_-Syna_n_____________________ _ _ _ _ ___ _ _ _____ __ __ warrants that the title is good. indefeasible in fee simple and free and clear of encumbrance except •„ easements, restrictions and rights-of-way of record, if any. ' and will warrant and defeend the same. Dated this .............~-•=•-••---------------........ day of --------.._---PAIiJUSt----................-------•• ---•- -- • 19..3.. .- ---• GirN~~_K/, ~ ~!S!!~...(SEAL) .SGQfLF.ec~v.E..!~ !~t/....---•-•• .. .............(SEAL) , Randall•W. Synan ~ Patricia Synan ----------------------------------••------°•------••----------• ----(SEAL) i AIITHBNTICATION authenticated this --.-----day o1---------------•°.-.-----• 19_--.-- t-•--•---------------------------------------------- •------------- TITLE: MEMBER STATE BAB OF WISCONSIN (If not- ------ ---- -------•-- - - --------°-----•-------- anthoriud by Q 706.06, Wis. Ststa.) THIS INSTRUMENT WAS DRAFTED BV Kristine Ogland ---•---------At-cBrnep--at..ta W ----•------•-•----•-•---------- (Signatures may be authenticated or acknowledgeZ. Both ACHNOWL$DOMSNT STATE OF WISCONSIN aa. St. Croix _ Couaty. Pe;aonally came before me ~ _.._....day of August --------------------•---., 19. _ the above named Randall W. Synan, Patricia E. ------ Synan _ ------------- -----------------------•----..... A~e_ X07.... --- - to me known to be the person . ~._..._.Nz~~ he going inatru nt and a n wle~~e~ !WA Alice Joy onihors Note-y Public ------------•--•-----•--------------------County, Wis. My Commission is permanent. Sjf not, state ezpXation r _ . ,',~X 40.. ~'U9 ^,ec'~ ~ Reoad - SrP 1' 1993 ~t 10:45 O n :.M Q' w'r.+-~c~. j R-~IS`e- ,I Oea~