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HomeMy WebLinkAbout020-1022-20-100 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of =Safe Human Relations Division of safety & Buildrgs in accord with ILHR 83.05, Ws: Adm. Code • COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point ,(IaKl djr aid % of slope; scale or PARCEL I.D. # dimensioned, north arrow, and location and distatSce to b6ateafoad. lOZZ -Zp APPLICANT INFORMATION- PLEASE,PR,tNT ALL NF - ,kRM TI °� REV DATE PROPERTY OWNER: A0 TY LOCATION J tJ� 1!4 S 1/4,S 1 { T ,N,R Lj E PROPERTY OWNER' MAILING ADDRESS ( �� L # LOCK # SUBD. NAME OR CSM # 4 C3 L4 N — CITY, STATE ZIP cow P'F10NF.' R CI ILLAGE ®TOWN NEAREST ROAD pd New Construction Use W Residential / " bf ` ' '3 [ ] Addition to existing building j I Replacement [ I Public or commercial describe Code derived daily flow DSO gpd Recommended design loading rate - bed, gpdM? trench, gpdtft Absorption area required — bed, ft 1 S o trench, ft Maximum design loading rate • S bed, gpd$ ' trench, gpW Recommended infiltration surface elevations) s tag Z' It (as referred to site plan benchmark) Additional design / site considerations ? `C1Zk�ICEf�,3 - te.N S' x - t5' LWX Parent material Lo STS s tAit t S C,1- Rood plain elevation, if applicable N- - ft S = Suitable for system I CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem (� S 11 U ® S O U ER S ❑ U ®S []U O S FEW EIS KI U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure ConsistenCe Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch «€ x ) a -5 ti o`-t�Z- 3 Z — si 1 Z,`�' �n. a, S �.� • s 3l L _ s� 1 Zw► Sbk wn cw - S .L Ground 3 1 4 - 0 o -1 -S 4 1L J 1 y - S l CS m u CS - . . S elev. ° 1.R. I S`-lRS1L _ �S9 y •S'�� y ft � Cl a S - Depth to limiting factor T 9.S Remarks: Boring # - nn o - . .3 Z L Z iYo VT 0 - S .> Zz Z -�y S`�lR 3l� s) Zwrsbk lm�`Fh CS ' vi _ 3 14 99 S `11t y/6 — �s b Sg r� 1 _ • S . i Ground elev. % - 0 ft. Depth to limiting ? Remarks: CST Name: - Please Print Arthur L. We erer Phone 715- 425 -0165 mess: egerer Soil Testing &_Design 'rvice - P.O. Box 74 River Falls,WI 54022 Sgnahue: //, Date: CST Number. M00 5 7 6 PROPERTYOWNER SOIL DESCRIPTION REPORT Page? of 3 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed- .ranch 3 0 -8 1o�t� 3IZ — Z A1L Y►'t'�1� a-S 1 .S Z $ Z � Is `6L 3/ S � e-s�k y/ c S -14 Ground 3 Z3 - S `iR t{ /6 - �S O Sg vvt • S ,� elev. l o�%-S ft. Depth to limiting factor 7 `I w 4 Remarks: Boring # • S 6 0-9 Z 9 -qo lk `'tR 3Ib ZrnSlwk M S . 3 yo -icy S ti� sl y _ s 1 �c� tm u�Qr. 0s •� ; • s Ground g gvs ft. y� RS -1 -5 `1R VIL — `� 0 as Depth to ` limiting factor i Remarks: Boring # .n S Z 6 AS 1.5kR 3!y S) 3 �S_4 StitZyl6 - `�s D S°, m 1 s Ground ' : elev. r ft. Depth to I : limiting factor Remarks: Boring # i Ground elev. ft. Depth to limiting . factor Remarks: SBD- 8330(R.05/92) PLOT P LAN Pa 3 of 3 SCALE C M-1 I ry . Z y '` DAP �'1't Z'1�i'C L`�wfJSl�1 CDse' .> awn s •3 IN ,. �► �0 7.5 vpal'Pt N �l CON S A � 4 _ �Lsh/e!}� S ' �� �ar✓ V.1 Ios•ss LJK" ca^ Ll.�1q y d IbO . b 01,3 SpmLAa 30 ff60�1�, Gl�.�jVhl�j BMNZ sLl ,, °I�•8� o►J SP11Rg 2Z" 1 TtrJ\— gnu VQ g" 1 R rZfet o `t S E lU %E �)-T L-e S'T ZS N0R-T)4 Ur- `n1IeIvCft73 , '�`� 4. 4 ♦ 4 S L MQE Iz-o V�b ZVI — LpT S __ Z Z_ b ( 715 ) 425 -n1 h5 14 00576 CST Signature 6 Date Signed Telephone No. CST # Wisconsin Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor. and Human Relations Division of Safety & tidldinp in accord with ILHR 83.05, wri Adm. Code COUNTY S'T Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (Blot), direction and % of slope; scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. - 0 71 - lOZZ —Z o APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION EWEDBY DATE G �d PROPERTY OWNER: PROPERTY LOCATION 1 ;a��� SAT tJ 1/4 Sq 1 /4,S 1q T Zg ,N,R Lg E PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # I SUBD. NAME OR CSM # y.0 tv • �IV13t ST. �\ — CITY, STATE ZIP CODE PHONE NUMBER []CITY [VILLAGE ®TOWN NEAREST ROAD 1�oeERT5 ki I s Lt OZ-3 (z15) ) q Q' 39 PQ New Construction Use Residential / Number of bedrooms [ J Add"i to existing building [ J Replacement [) Public or commercial describe Code derived daily flow ALSO gpd Recommended design loading rate bed, gpcW trench, gpd/(t Absorption area required — bed, ft - 1 S o trench, ft Maximum design loading rate • S bed, gpd/111 �° trench, gPd* Recommended infiltration surface elevation(s) seE' PftB E 3 ft (as referred to site plan benchmark) Additional design / site considerations - ? S' X 1S' I WX Parent material Lo s a c vtm S 4- Flood plain elevation, if applicable ti • fl - It S = Suitable for system CONVOMONAL I MOUND IN- GROINJD PRESSURE AT -GRADE SYSTEM W FILL HOLDING TAW U= Unsuitable fors tem 0 S ❑ U [O S ❑ U S❑ U ®S ❑ U ❑ S fkrU 0 S Z U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz, Cont Color Texture Gr. Sz. Sh. Bartdary Roots Bed tench n 1 0 -� Io�Itz 31 Z Z — si 1 `� ' a sb1k W� v� • s Z. g -t. tL 3 l L — si S Zrn s bk weti cw - ' s .L Ground 3 Zy -y o . S `t tt_ N l y - S l CS vk rn u iv CS -%4 . S elev. -1 f S `tR SIL _ �S9 1 •S ;•b 9 - 1 4 R S , Depth to limiting factor S Remarks: Boring # 0J. 1b`-iQ 31 Z L Z'� - vb IZ V i4` a- S • S -. S`i1z — SI Zwrsbk yA v�r CS 'PS b Ground elev. 1 08.0 ft. Depth to limiting factor Remarks: CST Narne:— Please Print Arthur L. We erer Phone: 715 - 425 -0165 Tess: egerer Soil Testing &.Design .rvice —P.O. Box 74 River Fa11s,WI 54022 Sgnature• ( //yy �j�i� /y 9 b _ t 1 'l Date: � �� CSTN=b 00 S 7 6 PROPERTY OWNER Bve�1 �`r SOIL DESCRIPTION RIEPORT Page? of PARCEL I.D. # O Z-O — LO Z.Z. - ZO Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxby Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITrench E l 0.8 ti 31z - Z, S�� Y4 ch 2 $ -Z 3 - �.S `ttz 3/y S <-s M \j i� - cs Ground 3 Z3 -90 "�.S `7R tl /6 — �S U S� v+� — • S .�• elev. ) ZZLs ft. Depth to limiting factor 79w s Remarks: _ Boring # O —9 l `l 1L 3 I Z — Z`F slid w�'�F a. s 1 • S , �► � Z 9 -un 1�`1R -3�6 1 L Z►�.S�k Yn��- cS _ -S I Ground 3 c_S �k �n u'Q y. S • �L . S 9 - elev. ft. L4 HR Depth to �. limiting factor Remarks: Boring # S . Z 6 -1S 1.S 3!y s� � a-s�� r, �►� cs - . i .S 3 1S_4 �•S`tR - yl6 `�s D S� vrt 1 •S '•b Ground elev. l ,io ft. ` Depth to limiting factor r >9z" f Remarks: Boring # E�3 ------- 1 i Ground ! elev. ft. Depth to limiting . factor Remarks: SBD- 8330(8.05/92) PLOT PLAN Page -3 of 3 SCALE I" = VO ' Q Lrver W M ` t�clf-'S KNA. S Z `' OwLp -f,?r Z}he (os "v�z - 4 - r��h1 O�ZU f'l wz M z 'T He of ln�S'1'ku- OfV 477 �O B ELga y ( - t�L 1 ; 3 ou SPi%L�a C6 3 0" �6ov@ GR.t vr"p 91.8' of s Pty loll). IV-,a* d �1 N o �cstu� S F _M Z S , &30W OF ` N1e'.r ffjU in _rb L ?i R1zGE R4 'Ptb ( 715 ) 42_ 5 - i;s 14 00576 CST Signature Date Signed Telephone No. CST # Wisconsin Department. a PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 463361 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 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 Parcel Tax No: Rasmussen, Jerem Hudson, Town of 020 - 1022 -20 -100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: UU in^ � GS t 14.29.19.103A10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Z (`�• Benchmark Q.- 111Z. Alt. BM (,a feAf- 11 . Aeration Bldg. Sewer Holding St/Ht Inlet Z -�Z /o°t . TANK SETBACK INFORMATION St/Ht Outlet 3.3 /eq -37 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 7 loo , / -Z 1 Z' Dt Bottom Dosing , �+ Header /Man. . SZ /o$ • Z Aeration Dist. Pipe .5Z ,)Y•Z Holding Bot. System PUMP /SIPHON INFORMATION Final Grade - 54 / 0 rJ • 3 Manufacturer Demand St Cover �/ g GPM r , Model Nu er �1 5"•50 ra TDH Li Friction Loss 1S Head Ft _ --7 A -6 L Forcemain L Dia. Dist. to well F-1 SOIL ABSORPTION SYSTEM BEDITRENCH Width / Length f No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 rZ�do Z ; (_e4v_,NJL6 . �\ SETBACK SYSTEM TO `1 JP /L BLDG WELL LAKE /STREAM LEACHING Manufacturer: 1 INFORMATION CHAMBER OR Type Of System: n / �� �� / PIA /� UNIT Model Number: low i DISTRIBUTION SYSTEM 4-- = 45 Header /Manifold /� Distribution x Hole Size x Hole Spacing Vent to Air Intake I Pipe(s) i t' Length Dia Length Dia Spacing_ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over / Depth Over xx Depth of TS eeded /Sodded xx Mulched Bed/Trench Center ti Bed/Trench • 3Z Bed/Trench Edges N-1 Bed/Trench es No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 776 Holden Lane Hudson, WI 54016 (NE 1/4 SE 1/4 14 T29N R1 9W) metes & bounds Lot 11 Parcel No: 14.29.19.103A10 1.) Alt BM Description = CaV.,c V-_6 e�� CV1�C,o 11j6 4__ ( 0 \I'— 2.) Bldg sewer length = Z7 (�0 - amount of cover = i/ - - -- V Plan revision Re � 2 q � I Yes No ulred . Use other side for additional Information. ___ Date insepcte Cert. No. SBD -6710 (R.3/97) i b 17, �. ti w 201 W. Washington Ave., P.O. Box 7162 `�sconsin Madison, WI Sanitary Pcrmit Number (to be filled in by Co.) ID Department of Commerce ; r" state Plan I.D. Number Sanitary Few _ litcation � In accord w ith y be used oor rposes Code L lens) Y Project Address (if different than mailing address) y L aw. Gp�Nj I. Application Information - Please Print All Iruforma3i ZEN \NG OF 7 .74 *L L.✓ Parcel N Lot u Block a Property Na me Pro Owner's M iling A Property Location �s 3f l3 A jr., 54, _ Si,Secdon City, State Zip Code Phone Number \ (circle o �_ 57— 7 T 2f N; R M — E 1 Il. of Building ( a �that pp ly) Subdivision Name CSM Number or 2 Family Dwelling - Number of Bedrooms ❑ Public /Commercial - Describe Use s ❑ State Owned - Describe Use ❑City ❑Village ©Township of �fu o III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. p'New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. El Permit Renewal 0-Permit Revision ❑ Change of ❑ Permit Transfer to New Liu Previous Permit Number and Date Issued Before Expiration Plumber Owner I // Type of POWTS System: (Check all that appl c - X F i c - z 3 X 8& "on Pressurized In Ground ❑ Mottnd > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Weiland ❑ Pressurized in- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip lane ❑ Gravel -less Pipe ❑ Other (explain) 3 V. Dispersal/Treatment Area Information: S Design F►ow (gpd) Design Soil Appiic�tion Rate(gpdsf) Dispersal Area Required (st) Dispersal Ares yste Ekvati 7 S -2 F ; . VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic GallonsGallons of Units Concrete Constructed red Glass New Exisunffi Tanks Tanks Septic ot -Tank 2 ,S t7 V Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement I, the'undersWied, assume air installation of the POT WS shown on, he attached plans. Plumber's Na me (Print) Plumber's Si g; tune - MP/MPRS Number Business Phone Number Fogerty Plumbing y �, aFit7i-46 #221 Igo Ph'ntb �$el� Mate. Zip Code) Spooner, WI 54807 VIII. C � 9 ifte Only Sanitary Permit Fee Wades Groundwater Date issued Agent Si re (No Stamps) Approved ❑ D" . ppro ved Surcharge Fee) ❑ r " L n Denial IX. Conditions of prow 3) t SYSTEM OWNER; S 1�4 1 Septic tank, effluent filter and 5 , J&tv1 I �_ dispersal cell must all be serviced / maintained - {o as per management plan provided by plumber. �\ Ir2t� 2. All setback requirements must be maintained - as per applicable code /ordinances Attach complete plans (to the county only) for the system on paper not less than 8I I inches in sue 30 - *- Rd. u"35 -9609 G- 377 ���lo►�rrtSc N %�T6) t /03 r i � t 4 CO r } i A*I T OF Cof�cc�iE i t` / E — 1 5X0Z7VG� t� - t F LDT � v F W = woru } 3 k i t i 7. ,Wisconsin Department of Commerce SOIL EVALUATION REPORT Page_ Of 3 Division of Safety and Buildings in accordance with ��S 7 r County Attach complete site plan on r t less aq8 1/2 11 inches in size. Plan must include. but not limited to: verti I r fe M direction and Parcel I.D. percent slope, scale or dimensions, north aiw, �sr�e rest d. 3 .•Ir90 R wed by Date Please print all in atiw. CROiX COON information mation you provide may be used for �r .ria ( ))• .2 S S Property Owner r lion GovL LotXq- 1/4 1/4 'S / T N R E (o;l Pr6perty Owner's/Mailing Address Lot # Block # Subd. Name or CSM# r _r 6 z B l/ � City State Zip Code Phone Number ❑ City ❑ Village (RTown Nearest Road cif! ) 77 7- 93Yr u !� (f]i'New Construction Use: (j' Residential / Number of bedrooms y Code derived design flow rate f6VO GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material ©Cll Gr//Yf -- Flood Plain elevation N applicable General continents and recommendations: C— / R 2S e -Z Av 7S # Q Pi8 t Ground surface elev. / /O,l� R. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f 2 in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 s &Se— .or L s �- ` 0 z/sfi - F2-1 Boring # 0 Boring © Pit Ground surface elev. /A& ft Depth to limiting factor in. Soi! Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fN in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 T -Eff#2 S 0- L ,s - 2• S S s L '- ' .S r Z1/5- S� Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L uent - #2 = BOD < 30 mg/L and TSS < 30 mg/L-- - PST Npw (Please Print) CST Number r Date Evaluation Conducted Telephone Number Address Fogerty Plumbing & Perk T sting f� OS — 7�S �S 9fpi� 28288 McKenzie v - Property Owner � Parcel ID # PAC _ ^�B�"2'�-4 Page - ,I of -� 3]Boring F # � Ground surface elev. f 3. D — ft. Depth to limiting factor 6V Z in. Rate Pit Texture suucoxe Consistence Bourxtary Roots GPDIfF Horizon Depth Dominant Color Redox Description Eff #1 'Eff#2 Gr. Sz- Sh. in. Munsell ou. Sz. Cont. Color . r es L — ❑ Boring # ] Boring -- if Ground surface elev. _ ft. Depth to limiting factor in. Soil ication Rate Pit Texture — structure Consistence Boundary Rook GPD/ff Horizon Depth Dominant Color Redox Destiption Sz. Sh. 'Eif#1 'Eff#2 in. Munsell Qu. Sz. Cont. Color o g factor in. a Boring # Boring ,y Ground surface elev. ti- Depth to limiting Soil plUcation Rate �I Pit G � Te)d re Strudrre Cor>sistertce Boundary Roots Horizon Depth Dominant Color Redox Description •Eff#1 'Eff#2 in. Munsell ou. Sz. Cont. Color Gr. Sz. Sh. Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 150 mg /L ' Effluent #2 BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 60896"-3131 or'[TY 608 -264 -8777. SOD-8330(RAM) j Piumbing .'30 * -n?ie Rd. 54801 ( .L5' 3,30 9609 4 377 pL,E x /6 7. 14 �z K —YL 4197 4-TIVr- r 11 Phi = i7G7. gKf i aOF�o..� Or � / 00.2 f i k i i i✓�� 14T lG�jz/v�R- f • - Fvv ' 4 - r - I V - / /0, 3 i 9 - i -- 4161 &EIV ZA i c warn �� a 00 EO N��. ca 4 N S ` ^ aT y #CO c� o N a� IV NN t 4 n w CD '00000,000000ox 0 i *sue � j' `�\ j �\ .�1 � • • _ i O V V f t L� ` ' r • t P ar • Q. v.• , Q�t Cc cd 9d Ni c� _+• :° ;� 'rr • i �.. • • ry w Q, II II II Q . o =� i a�i m 3 e f % ,? \( -611 W u - bo O M o C'n H � Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ■scois�jn Madison, WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (609) 266-fn) (O 3 3� 1 Sanitary Permit Applicatl n Pin I.D. Number In accord with Comm 83.21. Wis. Adm. Code, personal you provide may be used for secondary purposes Privacy Law, s15. 1Xm) MAR 2 8 2005 P10 Address (if different than mailing address) I. Application Information - Please Print All If0rm2f= ST, CROIX COUNT 7 A6 ZAJ t ' Owners Na me f sit Block M Prope � /034 -/0� Proorty Owner's M 'ling Address Property Location 153S e 457. Z - rt _ - %.sett City, state zip Code Phone Number A SS S/ - 777 -, i 3 (circle _ II. of Building (cheek all that apply) '1' �_ N, R1�E o Subdivision Name CSM Number V1 or 2 Family Dwelling - Number of Bedrooms S . ,/ 11 Public/Commerciai - Describe Use 11 ❑ State Owned - Describe Use ❑City ❑Village Wownship of 0&,b&,j!6Z III. Type of Permit: (Check only am box on line A. Complete line B if applicable) A' I M New System ❑ Replacement System ❑ Tratmendfiolding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previotn Permit Number and Date Issued - Before Expiration Plumber Owner IV. TS of POW System: (Check all that ly) to Non - Pressurized In-Gro ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filer ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter F1 Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: 3 C&ZLl el C7{ I . ' Design Fiow (gpd) Design Soil Application Rate(gpdsfl Area Required (st) Dispersal ArtPr o (s9 System i � ) e -3 P VI. Tank Info Capacity in Total I Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gal bffi of Uttits Concrete Constructed Glass New Existing Tonics Tanks - Squic or Haug -*exk / 15 - 0 1 A4*c: s Aerobic Treatment Unit Dosing Chamber - VII. Responsibility Statement- I, the'imrlersigied, assume respm0x y for installation of the POWTS shown on the attached plans. Plumb er's Na me (Print) Phtmbet's Si gnature - Io)PlMPRS Number Business Phone Number _ Fogerty Plumbing .Zx - 9Lo 1 Plumbar eta &Uft. P ) 7/S - �3.5 = -S e4 Spooner, WI 54801 6Si- vt- a6 VIII. Only 4rl 70 — 7 L Sanitary Permit Fee (includes Groundwater Date Issued Issoing Signature (No Stamps) Approved ❑ P6ppr oved __ Surcharge Fee) 3 -3 00 — �} ❑ Owtter Given Reason for Denial 2 1X. Conditions o pp SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / mainta as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances Attach complete Pig to the County only) for the system on paper not less than 81/2 x 11 inches in size 1N cc - 777 X At A4a4 I I Ado I 2 a s 3e` s.v f•" ox✓f rc, !�'•s ' x = i3oRE y ° � .tsn.t.�, s. T• YV = c.iF_' l G � > ra � FiCaw �.vy �.fR� B f s ytTisaa Syfr�.+r: 71- 103 -s ' O �! 4 c -377 Gs / 777— V V P 1N a - y GiL�t� 4'r Atx,4 I I X � I 6� K � = a _ �' T'� of 9�cls 3b �6ev� ��• s..v �" pr✓f rte /i/.D' ,d *Z .taT• 104'1 X Vol YV = w/. L < < > S - a �ito�• �.Vy ��i�� B s �tTapr� Sysr�r 11CAA 1W A y S' 7` /03.0 ' /s foie' rr�r/ smom ommommmmmmommoommmmmmomm MMMMMMMOMMMMMMMMMMMMMMMMEMMMMM mmmmmmoommmmmmmmmmmomENNEEMENO smommmommommommommommmmoommmm MMEMMMEN Emm momommmmmmommoomm ommmmmmmmmmmmmmmsommmmmmom �■�iCiiiiiiii�iii�isii�i��ii mommmmmoommoommmmmmmmmmoommmmm MMMMMMMMMMMMMMMMMMMMMMMMEMMMMM MMMMMMMMMMMMMMMMMMMMMMMMEMMMMM mmmmmmmmmmmmmmmmmmmmmmmmommmmm mmmmmmmmmmmmmmmmmmmmmmmmommm MOMMOMMMOMMEMOMMEMEMEMEMEMMMMM mmmmmmmmmmmmmmmmmmmmmmmommm mmmmmmmmmmmmmmmmmmmmmmmoommmmm MMMMMMMMMMMMMMMMMMMMMMMMEMM sommmmmommmmmmmmmmommmommommms mmmmmmmmmmmmmmmmommmmmmmommmms =iME iiiiiiiMiiiiiiiiiiiii =iiii iiiiiii�■iiiiiiii ■iiiiiiiiiiiii g 0 Wsconsin Department ofCommerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal referen BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, a ��� �� C- 1 q ta[�ce to nearest road. 0 Z-O - 10 Z.Z � Zv Please print all ' tk�ir►aion. _ ! �: Rev' wed by Date Personal you provide may be used f s dary Pk rivacy Law s. 1 .04 (1) (m)). Z Property Owner .= ',^1k Prop rty Location Govtrt N 1/4 SC1 /4 S I T Z N R 1 E (o W Property Owners Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Numb City E) Village ® Town Nearest Road r• , r v st�Kl w) S� o i (� ), 3 1-�vb s fv ® New Construction Use: ® Residential / Number of bedrooms 3 Code derived design flow rate LJ S O GPD Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft, General comments and recommendations: Z �JJ � Z C� 3 X Cf 3 . - 1 S' Loj G W 1 S V ►J lTS W 6�4 O f`P� L`r S 1 A��1 i�D �R �L�� e1�4 �H �2 SRS R62Q c LC. arr� o)= GP-z:S TD BLz- ►`-i - Sy 4D F-1 Boring # ❑ Boring . ' ?� [2 pit Ground surface elev. b J a l : ft. Depth to limiting factor Q S in. Soil Application Rate � Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 log rz 3t Z - s �) z'Fs biz W1 ass 1 • S 8 , c )01-12316 — S!1 zin.sbk m`F� c_w 3 Zy -�d - 1"SL/R -31 S \CS 6r W1U� CS - — •�l '� y Y o S9 MOTE S l 1� �� t�..V�1't� LAY r %- Rhv N- S- M )S r 2 Tom' Ps�Nr >v . a Boring # ❑ Boring ® Pit Ground surface elev. 8 D ft. Depth to limiting factor 2 48 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I •Eff#2 .1 0- 6 l o �lR 31 z — L �`Fs CL. S 1� • S • e , Z 6 - ��( � •s `t��t - s Zyn s h m J f cS - • s -9 Y, 1 - , s •9 .5 /off so' • Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 _< 150 mg/L • Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) 6 Sign ture CST Number Arthur L. Weger �' `g� 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Hain St. River Falls, UI 54022 715 -425 -0165 • r Property- :Owner 4RR 7 Parcel ID # Ci ZC) - 10 Z. Z — Z () Page Z of 3 3 Boring # [] Boring Grou `1. 21 pit d surface elev. � S ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 a - b IT3'm I L - Z -- L zTsbk mT�_ cu 1-p . s b Z 8 �z,3 7 •S `t2 .�1 s I 1 csbl� m ��,- Cg - • y . 6 3 2,3 O sq m l -S Cl ca( 36 /7Z F9_1 Boring # ❑ Boring ® Pit Ground surface eiev. - Lq • `J ft. Depth to limiting factor 7 S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 r3 -It toKIZ_�t'z L z,` s1b1. m a.3 .1� ,s .8 9 - q0 1p `12 314 — L Z ►n s bk M-0- cs - -s -8 mU Ll V v q g z.s LrfL YLL `F 0 S9 M 1 - S • 9 i Boring # ❑ Boring 5 Ground Pit surface elev. ft. Depth to limiting factor Q Z in. Soil plication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft'' "' in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 1 0_ b of.o 3(. z (p �. v ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608m264-8777.. SBD4330 (R.6100) A PLOT PLAN Page 3 of 3 l Scale L og —` - - , a s I J 13.5 Su ITP�i3l� tPl SZ y / FQ w !r L,9-L Pl1 ID � too _--__ _ ►'� -�'��: ��� U O —► � � 8w1Fr 1 CAS �ZiO�gN u� S Lo PC �U PrLO V 1 S v 17 PrSLI�r m= FuZ FvSruz; c�a-I-L s a= _ 0 8M EL. 100,O'Ott1-- 5 Ptitz.�, _� _ 6 "b►A - . -lizz . 0 16 - b , k - !v LOT LlA/6� 1S_ > J pp' ---- - - - - -- ��; �, ` dt, 7 715- 425 -0165 220254 , �1--� • 1 _ 1 b 3 CST Signature Date Telephone A1o. CS,T No. Job NO. o f CD . �10 l lll i -y. = �. A .-► � . tJ� \ ` ' \'/ CA 0 " a ° . ' ( 2 0" �•� CD IQ CD �i• •'• ��rQQ. hj `� � a - Ilk ''c► Oo qQ -- - - - �� 00 CP P• 0 G O00 C � 3 co II it II �r e � POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner R Septic Tank Capacity zSp al ❑ NA Permit # b 3 3� Septic Tank Manufacturer S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model — /Up ❑ NA Number of Public Facility Units WNA Pump Tank Capacity al A Estimated flow (average) 60 gal/dayy Pump Tank Manufacturer A Design flow (peak), (Estimated x 1.5) OT gal/day Pump Manufacturer A Soil Application Rate D - Sp gal/day/ft' Pump Model RtNA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit / WNA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cells) ❑ NA Biochemical Oxygen Demand (BOD 530 mg/L KIn- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu /1 OOmI ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: A Other: ❑ NA Other: PMA *Values typical for domestic wastewater and septic tank effluent. Other: P =NA MAINTENANCE SCHEDULE Service Event Service Frequency E3 month(s) (Maximum 3 years) 13 NA Inspect condition of tank(s) At least once every: 3 19 y ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: '2 ❑ month(s) lZ earls) (Maximum 3 years) 13 NA Clean effluent filter At least once every: ❑ m 1 ❑ NA Z year(s) ls) Inspect pump, pump controls & alarm At least once every: ❑ month E3 year(s) l A r(s) Flush laterals and p ressure test At least once every: ❑ m year(s) A P ❑ yearlsl Other: ❑ month(s) WNA At least once every: ❑ year(s) Other: ANA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance. with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page Z of 2 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal call(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replacement system: N9 A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. O A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. tj/�' alua ' o ing tank b e a� lZZ0 18 TT�'D fob P_ LpNSTR(Ja'g 0 ! O Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER E me l GAT`( Name ne �-�� (0 3 S ?("0? Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name � Name 15t. G ( bU Z4dl�Cl Phone Phone — ](S— 3g(�_ (p (� This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAWMNANCE AGREEMENT AND OWNPRSHTp CERTIFICATION FORM Ownerlo ye[ `1 Mailing Address Property Address &e 4 2 5 C2 ,`' - (Verification required from PI&Wds peprar x-111 for n& consiW6n•) City/Sttue Pwrael Mentifieation Niwiber , gag - ins 2 - j o LEGAL MCRIPTION property Looadon ,AC t/. , .�. '! , Scc. l e , T Af R - ,,S__ W, TOwc Of /k �1�s l/ Subdivision L f /$ p^OArp -��X g &___ _.. Lot Cetrtiflted Survey Map . , , Volume „ . Page # — _ Ware aauty Deed # 7y o Yy _ Volume z2yfr Page # - .V- R a $peo bows yes 6 Ut..14m idepdfiable a ac 4 acv /9 SYMM MA0MANCE laapmpes use sad Xaitrteasoee of your septic XYMM oadd tetuk in its pa+et=Wt f dwg to handle wastes. Proper matintemmc wwcisuc of Vimping ow.. the'eptie tank every Wee years or sooner. if rsedod by a Iken9ed Pm spa' What YOU Put into the system can agm the tittaa'.dm of an o pw wk as a tteanaent stalpc ia the masse diaapoeal system. Owmer aaaiaoaaaa reapoesibgWft we specieed in # Comm 83.52(1) sad is Chapati 12 - Sr. t roix County Saoitwy Ordata ' no p aparty awam arm w submit to St_ CYoix t UUM Zom" Dept a ceakficshm foam, s*w by the owner and u wa hat th �te de ator dixposst lumbee or a► liareosed P�p'a• �"O'� t (1) die on _ by a is in plu pec. M lin wa pt �` �n Inspection and pumping (if oceasarY}, 6C eepbe aank u lee tbm 1 f3 fall of � is in proper.opeawitg vondiition 'P�n dudgar. , Vvx4 the undasWwd have Bead at above rap4remenft and apm to M tint ft rho PrMa wwaV dispotad tam with dw smadards oat forth, beaeia, ms set by the Deparuoctu of C,onoomm msd the Department Of Natural Rc*uuw +, stare of Wi m, seons CcrdficaWa atf&ft that ym r sepfie system has been mak abKd tou3t tae walPictcd"roamed to the st Crobt Cotmty zoninp pApOnmCtlt wtaln 30 days of the forte year ertpir 000 date. SI Z R E OP APPLICANT DATH . O Uwe amlare dw Owwr(s) of the Vwrs ewtilSr so 211 tuts on tf►fs form are am to the bat of my /o►a IaiwM�• _ Ssaibed above, by virtue of a vat[aory dtrod TOO"" it► PAgrtter of 011iee 4. : ... _��� ' ` ?�- D 5 NATURR OF API LICAN•1' , oning Aa Y information dW is s Lutpresa:nted may result in the aataltaty pemdt befog revoked by the Z Dcperttrrent •••••• •s•.•• Include with this appUeaaiion a stamped warranty deed from the Register of Ikeda Offiee and a copy of the cettilled Sw%'*y taap if mferenco is made in the wwanty dcC4 T•d 990S5V9SlLT 9NIOWn'id A18390.J dfi :a So 10 caj Id Wd8Z:Z0 SOW I0 'Qad TS8Z bSb LOS: 'ON Xdd UN18UW GNU QNf oejdwuD 2m tild: W021d U 2966P 295 i3 748tm4$ STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO.. VI This Deed, made between Michael R. Haley RECEIVED FOR RECORD Grantor, 12/03/2003 10:00AN and Jeremy Rasmussen and Sherry Rasmussen, husband and wife WARRANTY DEED Grantee. E%EWT ; Grantor, for a valuable consideration, conveys and warrants to Grantee REC FEE: 13.00 the following described real estate in St. Croix County, State of Wisconsin TRANS FEE: 306.00 (if more space is needed, please attach addendum): CC See Attached Exhibit "A" PAGES: 2 Recording Area Name and ts% OCl -AND ATTCM; !EY AT LAW P.0 C0X 339 HUDC00A, WI 54016 020-1022-20 -100 Parcel Identification Number (PIN) This is not homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of December 2003 * * NV ( hael R. Haley * AUTHENTICATION ACKNOWLEDGMENT Signature(s) Mi chael R. Haley STATE OF ) _.._._ ._ County ) authenticated this' day of De cember 2003 Personally came before me this _ day of the above named * K ristin Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, _ _ to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina O gland * _ Hu dson, WI 54016 Notary Public, State of My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) * Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co., Fond du Lac, wl STATE BAR OF WISCONSIN 800. 655 -2021 WARRANTY DEED FORM No. 2 - 1999 • U 2466 P 296 EXHIBIT " A " A parcel of land in the NE' /. of the SE' /. of Section 14, Township 29 North, Range 19 West in the Town of Hudson, St. Croix County, Wisconsin described as follows: arcin Commencing at the E% comer of said Section 14; thence South 88 degrees 31 minutes 45 est (t rue bearing) 639.38 feet; thence South 88 degrees 55 minutes West 287.94 feet to the point of beginning; thence South 1 degree 06 minutes 20 seconds East 620.02 feet; thence South 88 degrees 55 minutes 40 seconds West 377.00 feet along the Northerly right -of -way line of a proposed town road; thence North 1 degree 06 minutes 20 seconds West 620.56 feet; thence North 88 degrees 55 minutes East 377.00 feet to the point of beginning. St. Croix County, Wisconsin. ST. CROIX COUNTY SEPTIC TANK IVMAWMNANCE AGRMMPNt' AND OWNERSHIP CERTMCATION FORM Mailing Address F' z /3 T_. "'''Z Property Address 776 #Y - 4 1 42 5 y -- (Verification required from piJv%i4Depar treat for cu eonsttuetlon.) City /State . Parcel Identification Niu Tiber . ?w – im :2 -- -d LEGAL MCRIPTIGN Property Location N.k-�_ V , .eA '/4 , Scc. iy , T ?Z,._ N Rte _ W, Tows of L t�s�vv_ Subdivision lOxp .C 3 7 _..— _...__ Lot # �_ Certified Survey Map ii# _ . , , Volume � Page # Warranty Dad 0 7z& yy _ Volume -- 6 . Page # $pee house yes 69 Lot i4m ideneiable cc / 9 7 3 SYSTEM MAD'ENVANCE Improper use and Maintemwee of your septic sybwm could result m its Premature lgihae to handk wastes. Proper a*ktenance consists of pumping out this septic tank every tbros Yeats or sooner. if mcdod by it limed pwnptx. What you put into the System m affi'oet ills titatcdm of the septic hok as a treatment sbW is the waste disposal system- Owner rnaintemnee esepoositx'tifm are spec83ed in I Comm 83.52(1) sad is Chaptss 12 - St. C mix CojwW Sanituy OrdhUnce. The pooperty owaor agrees w submit to St. CrOM t".utrnty Zvi DcPU== a oetrration foam, signed by the owner and try a Maoist p4tteba, jotmseymm plumps. r+aaictal plumber or a littaoaed pumpa vcd jMg th a (1) dw on-d tc wad -Mict dinpati syskm is in proper openustg voadit M WWQr (2) motes imP Wdon and pttrrtpiry (i f uaessary� the scpae tttutic u tats than 1 n fntl of sludge. Vwe, the undetmigted have read ttte above raptirements and &VMc to mrtiptaW the private sewaF disposal ayate m with 0,e ataadrtrdtt let $bell, beaein, as set by the Dcpartmcat oEC,oun =c end the Depaenuent of Nawtai Rcsumw -% State of Wisconsin. Cau(icabca stating that your septic system hss been main simd roust be c(jniplctcd ante rotumaed to the SL Croix Cotmry Toning Deperto" within 30 days of the deree yaar eapitt►tioo date n 1 r w ,1l 1 0 5 S T O j MB tI:ERTIFICATIQM vane t Wwc dw oamer(s) of the VW9 cWtify that dl gfta m a an tots Oxm are ouc t4 the lest of lay /our knowteQge. _ PC o ygZsmbed above , by vidW of a era Wr!r dcod rtt*Wftd irk Register of [leads Office Z -• 01 7 55 � N OF APJ'LICA 1 'v� 3 D T &' ••+•• -+ Any u formation t o is mssrepresented may result in %bo mmituy permit being revoked by the Zoning Dc➢octment. •ef ••• I=IWc with tWe application a stamped Warranty deed from the Register of Deedr MCC and a copy of the cettilled tsutveY tw reference is made in the Warranty deed. T'd IMSSESSILT 9NIOWnId A18390i di SO iU cad Td Wd8Z : LO 5602 TO 'qaJ T 58Z hSb LOS: 'ON Xdd kiN I dt)W QNki QNnododww 8OW U : 1406d Parcel #: 020 - 1022 -20 -100 04/26/2005 05:02 PM PAGE 7 OF 1 Alt. Parcel #: 14.29.19.103A -10 020 - TOWN OF HUDSON Current X', ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " = Current Owner * JEREMY &SHERRY RASMUSSEN RASMUSSEN, JEREMY & SHERRY 1535 E CTY RD B MAPLEWOOD MN 55109 Districts: SC = School SP = Special Property Address(es): ` = Primary Type Dist # Description " 776 HOLDEN LN SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 5.370 Plat: N/A -NOT AVAILABLE SEC 14 T29N R1 9W PT NE SE PARCEL #11; Block/Condo Bldg: COMM E 1/4 COR; TH S 88'W 639.38; TH S 88'W 287.94FT TO POB; TH S 0VE Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 620.62FT; TH S 88'W 377.00 FT; TH N 1' 14- 29N -19W W 620.56FT; TH N 88'E 377.00FT TO POB Notes: Parcel History: Date Doc # Vol /Page Type 12/03/2003 748048 2466/295 WD 06/05/1998 580527 1329/552 WD 05/29/1998 579917 1327/064 WD 07/23/1997 920/388 more 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 47742 77,800 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.370 60,200 0 60,200 NO Totals for 2004: General Property 5.370 60,200 0 60,200 Woodland 0.000 0 0 Totals for 2003: General Property 5.370 60,200 0 60,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount 001 -WATER SPECIAL ASSESSMENT 0.00 Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 V7 ! iOD i 10D OD o. i ` a Ir 4 a IOD � � C 1 t j _ M a Z a 4 y. 0Z ,9C OD OD `.Z �li I at z Or W Va z u. 7) I— W(4 l 3 , oj5 b/ j3 3N1 _jv 31 .0 S 88 7911 p 7t W It o M U S \. °d p rr) Q .i� s' o 0) cV 3 � c0 _. \ 1' > N to co N Or .a1 o a m t og GLG w x t��,yg I 3 � a�, ( M N O z s � k , 7 c J ntnO 3 'vn C7 r� i c r. � l fl C w N n N wr � cD Q 7 n N � w N Q (p � n u m e _ o N j O N rah O _ (C 7 Q O �_ � O y ° 3 o a i D° > > H 3 ° ° ° N_ N 3 j c A < N vi Z D m D 0 a rn W C onn ° w CL CL j N) o n r to c) N C cn CD .. 3 O C? a Cli Z O T Vl N N r -3 m V O `G N 61 'C O Qo m 3 d ° a CL ? N `\ Z Q 0 D o !Y m O v D 3 O cp -.I • N Z CD p 0 CD C C . N� a a 3 n Z co =r (n -i CO) Q a w U) 3 n O A Z O v y n C 0 W m N A m C c z 0 3 A o cn Z CD A � A � C O Q CL m n_ 0 3 _ 2m y o 0 4 3 N M 0 3 fi � A 7 a A I n C O � N e O, ti O — O fD V CL ZZ m c w CD om ., ti (fl O v A ° CD