HomeMy WebLinkAbout020-1356-27-000Wisc:nsin Department of Commerce PRIVATE SEWAGE SYSTEM
S2~fety and Buildings Division
INSPECTION REPORT
GENEF#AL INFORMATION (ATTACH TO PERMIT)
Nersonal information you prowce may tie uses for secondary purposes [Privacy Law, s.15.04 (1)(m)j.
Permit Holder's Name: ^ City ^y~ Ila e ^ own off:.
last, Kernon Hudson ownship
CST BM Elev.:- Insp. BM Elev.: BM D scription:
t ~ U ~ U o Sf' ~ .Sf
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic 5 /(~U Z C~
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO P / L W L BLDG. Vent to
Air Intake ROAD
Septic 7 ' ' NA
Dos _ _ _ __ _____._,_~_> NA
Aeration
Holding
PUMP! SIPHON INFORMATION
Manu Demand
Model Number PM
TDH lift Lriction Syste TDH Ft
Forcemain Length Dia. H Dist. TOweu
count~it Croix
Sanitary~~rpyjt NO.:
State33PlJJan IDbbLGNo.:
Parce[,T~~C rl°356-27-000
ELEVATION DATA
STATION BS HI FS ELEV,
Benchmark ~ ~b ~
Alt. BM 3 , ~
Bldg. Sewer
Ht Inlet ~ r Z 9
~Ht Outlet ,~P
D
Header /Man. q rl
Dist. Piper` a µ t 9,, o d'. L of ~~
Bot. System ~ ~c /b.z~2y - ~'a
7
Final Grade M ~~ C ~
St cover ~
z
a.
SOIL ABSORPTION SYSTEM / o ,~ ~_..~_0,.~~ _~,.ti
BED /TRENCH Width Le gth No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N 3 Z. S~ 3 DIMEN I N
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LE Man a urer
SETBACK Y
INFORMATION TypeO ~
~
' ~_ HAM T Mod Number:
j
System: 1.4~. v ~'
, j
• ~ f y i•
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
i
Length ~3-S Dia. ~
Length ~.~ Dia. Spacing
~
~
SOIL COVER x Pressure Systems On{y xx Mound Or At-Grade Systems Only
Depth Over Depth Over kx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No
/9
COMMENTS: (Include code discrepancies, persons present, etc.) lnspect>on ~#f: I / i i / /~i Inspection ~~: / /
Location: 725 Paul Burch Drive, Hudson, WI 54016 (NE 1/4 NW 1/4 14 T29N R1~9W) - 14.29.19.2089 Grass Range Addn.
II -Lot 27 .~,~, 0~ ~~ ~ ~~ wl f~ ~ ~!'~
1.) Alt BM Description = gin.
2.) Bldg sewer length = 2 ~ ~
a
-amou/nt of cover = ' I ~'
7.~ ~ b 5 l r Jv AJrt`o-~- ~o pt ~ i~... 6 7~d ll ~ ! `r..
Plan revision required? ^ Yes (~ No
Use other side for additional information. Z
SBD-6710 (R.3/97) Dat Inspector's Si ature Cert. No.
- t
Safety and Buildings Division County
~ 201 W. Washington Ave., P.O. Box 7162
iseons~n Madison, WI 53707 - 7162 Site Address
De artment of Commerce ~^ G
Sanitary Permit Application sarntary Pernut Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide 'Q Check if Revision
ma be used for seco ses Privac Law, s15. 1 m State pI~ I.D. Number
I. Application Info on -Please Print All Information 3 ~
propeprty Owner's Name Parcel Number
7 ~~ property Loaaon
Protretty Owner's Mailing Address
City, State Zip Code Pho>x Numbec Lot N bet Block N bet
Z _J "--
---
Subdivision Natne CSM Number
.~ `' .-~` 7 7f -
II. Type oP BtWtiing (check all that apply) ~/ - ~ (]City
1 or 2 Family Dwelling -Number of Bedrooms T ~ ~ t ~~ ~~~ ~Vi11a8e
S1 c..+iU.-
^ pnblic/Commercial -Describe Use ` , ownshi
~ ,.' ~UPH~tCvCXl--1C%E Neatest Road
^ State Owned ~ ~ . `. .
6iG
9 tater>~~ ' .Complete line B if applicable)
lII. Type of Permit: (Check o y oai: ox on a ft ' $''~
For County use
A. 1 ~ New 2 ^ Replacement System 3 ^ Replacemem of 6 ^ Addition to
S stem Tank Onl Exis ' S stem
Permit Number Date Issued
B. ^ Chtxk if Sanitary Permit Previously Issued
N. Type of Permit: (Check all that apply)(numbering scheme is for intelRtal use) ' ' ' "
44 ~ Non -Pressurized In-Ground ' 21^ Mourd 47 ^ Sand Filter " SU•O Constructed Wetland
41 ^ Holding Tank 48 ^ Single Pass 51 ^ Drip Line
22 ^ Prestattjzed In-Ground , ,
.~ n .. r•_..,a. 4ti ^ Aerobic Tceatment Unit 49 ^ Recirculating 30 ^ Other
V. D' -- rsal/'I't'eatment Area Information:
Design Flow (gpd) Dispersal Area Dispersal Area
Required Proposed
~ ~vv ~ s'ry. Z
VI. Tank Info Capacity in Total Number
Gallons Gallons of Tanks
New Existing
Tanta Tanks
Septic or Naidert~ ~ ~~ ~. ~ .~'~
v
VII. Responsibility Statement- I, the undersigned, assume respoosib ' [ r instt+llat-°° °f the POWTS shown on thB~as~ h Phone Ntwber
Plumber's Signature #P/MPRS Number
Plumber's Name (Print) r"'--'
Plumbin Et Perk Testin Z ~ ~~ ~~ ~^ ^ 7 ~~~
~ pl~~ddr~~ (Syr~`'L~y• state. zip Code
VIII. Count /De artment Use Onl
t~1 Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
~,+ Approved ^ Disapproved Surcharge Fee)
^ Owner Given Initial Adverse ~~~ ~// I ZOOS ~ d'yvt-
Deteru»rsation
IIC. Conditions of ApprovaUReasons for Disapproval //
'~~, re~is~or. 1,~a5 Sli,6w~ily~~ ~ri N~~~P~'~ lit' ' G``aw'~ ~r~ YO~k 1~o C~~cYr
r ~ aW~ .~'y`ovti ?i ~"/~/k-~e~ ~ ~ ~y~~n,CifiPS,
Attach complete plow (to the Cou°t~ od7) ror the system on paper not lea than Sll2 =11 inches !n size
Soil Application Percolation Rau System Elevation Final Grade
Rate(Gals./DayslSq.F11tJ (Min.Mch) Elevation
/ ' Manufacturer Prefab -te Steel Fiber Plastic
Concrete Constntcted Glass
SBD-6398 (R. OS/O1)
FO~1'~ ~11111~IIL
`~ #221180
28288 McKenzie Rd.
Spooner Wi 54801
(715) 635
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. ~ ' _ . FonrtY Plutebin`
#221180
28288 McKenzie Rd.
Spooner, WI 54801
(715) 635
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1~Visconsin Department of Industry,
Labor and Human Relations
r17.d~in....F C~4nfa A Rnilrlirvyc
SOIL AND SITE EVALUATION REPORT
~+_~_
Page 1 of 3
' ~ ~ ~ COUNTY
but
st include
i
Pl
h
i
11 i
l
h
S 1/2 St. Croix
,
an mu
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ze.
x
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es
ess t
an
Attach complete site plan on paper not
(~J; iregiiorr:4and % of slope, scale or
not limited to vertical and horizontal reference point PARCEL I.D. #
,
dimensioned, north arrow, and location and dist ce~tb 'iae~le`st r4'ad.~,; ~~ 020-1020-90
IN~ORMAT101~
APPLICANT INFORMATION-PLEASE 1~.~~AL RE iEWED BY ~o ;E
~
/~ ". r• r
, 58
~
PROPERTY OWNER: ~,'; ~P OPERTY LOCATION
Kennon Bast ``~' ' t I ~ ~ -G VT. LOT NE 1/4 NW 1/4,S 14 T 29 ,N,R 19 6c(or) W
PROPERTY OWNER':S MAILING ADDRESS !.-~,- ~'~ ~ ~ _
~ '` T # BLOCK # SUBD. NAME OR CSM #
948 LaBArge Rd. ~, ~T `~q~'IX L' .. 27 na Grass Ran e S
CITY, STATE ZIP COD ` ~ -~'P,HG ; '
'
~
~
~'-
,''~ CITY VILLAGE ~]fOWN NEAREST ROAD
d
A
Hudson, WI. 54016 ,.:
(~1~) 38 -
1
,
~ .
rge R
Hudson LaB
~ ] New Construction Use [x] Residential / Num ' ~etlr ~ 4 [ ]Addition to existing building
[ ]Replacement [ ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate ~_bed, gpd/ft2~.trench, gpd/ft2
Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate ~_bed, gpd/ft2~$_trench, gpd/ft2
Recommended infiltration surface elevation(s) area 1=98.7 area 2=97.f~ (as referred to site plan t~enchmark)
Additional design /site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S =Suitable for system CONVENTIONAL
®S ^U MOUND
®S ^U IN-GROUND PRESSURE
®S ^U AT-GRADE
®S ^U SYSTEM IN FILL
®S ^U HOLDING TANK
^S [~U
U=Unsuitable fors stem
SOIL DESCRIPTION REPORT
Baring #
1
Ground
elev.
102.7 ft.
Depth to
limiting
factor
+88"
Boring #
Ground
elev.
102.3ft.
Depth to
limiting
factor
+88"
Depth Dominant Color Mottles T Structure nsistence
C r
Bour>da Roots GPD/ft
Horizon in. Munsell Qu. Sz. Cont. Color exture .
Gr. Sz. Sh. o n Bed Trer>ch
1 0-12 10yr3/3 none 1 2fp1 mfr gw 2f np .3
2 12-37 10yr5/4 none sil M na gw if np .2
3 37-88 7.5yr4/6 none ms Osg ml na na .7 .8
$: o~
Remarks:
1 0-~('~ 10yr3/3 none 1 lcsbk mfr gw 2f .2 .3
2 ~0-30 10yr5/4 none sil lcsbk mfr yw if .2 .3
3 30-40 5yr4/6 none cos Osg ml gw na .7 ` .8
4 40-88 7.5yr4/6 none ms Osg ml na na .7 ~ .8
a~' .a'
Remarks:
PROPERTY OWNER Kernon Bast SOIL DESCRIPTION REPORT
PARCEL I.D. # 020-1020-90
Boring #
...~::::.3..,
~..
Ground
elev.
100 .'R.
Depth to
limiting
factor
+g4"
Boring #
.... 4 ~=
Ground
elev.
101.4t.
Depth to
limiting
factor
+84"
Boring #
5
Ground
elev.
100.2 ft.
Depth to
limiting
factor
+80"
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Page 1 '` of
ri
H Depth Dominant Color Mottles Texture Structure Consistence Ba
rxiary Roots GPD/ft
zon
o in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. . Bed Trerx~
1 0-8 10 r3/3 none 1 2msbk mfr w 2f .5 .6
2 8-18 10yr4/4 none sit lcsbk mfr gw if .2 .3
3 18-8 7.5ry4/6 none ms Osg ml na na .7 .8
~1"
Remarks:
1 0-10 10yr3/3 none 1 2fp1 mfr gw 2f np .3
2 10-3 10yr5/4 none sil lcsbk mfr gw if .2 .3
3 33-48 7.5yr4/4 none cos Osg ml gw na .7 .8
4 48-8 7.5yr4/6 none ms Osg ml na na .7 .8
q
• Q-d~
GS. ~ V `U J~ t!
Remarks:
1 0-8 10yr3/3 none 1 lcsbk mfr gw 2f .2 .3
2 8-28 10yr5/4 none sil lcsbk mfr gw if .2 ~ .3
3 28-38 5yr4/4 none cos Osg ml gw na .7 .8
4 38-80 7.5yr4/6 none ms Osg ml na na .7 .8
Remarks:
Remarks:
SBD-8330(8.05/92)
r
STEEL'S SOIL SERVICE
Gary L. Steel Kernon Bast 1554 200th Ave.
CSTM2298 NE4NW4 si4-T29N-R19w New Richmond, WI 54017
MPRSW-3254 town of Hudson (715) 246-6200
lot #27-Grass Range SEcond Addn.
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. The Location of the test mayor may not be as shown
as permanent lot lines were not established at the time the test was conducted.
N
1"=40'
BM. = t
Alt. F
Gary L. Steel
8-21-98
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer c~f,~,rpl/ ,r~,¢~T
Mailing Address
Property Address
c
Z ~ /~~6r G .8L/,2~ fig
(Verification required from Planning Department for new
City/State /etii ~' yOl~ Parcel Identification Number 020 - /.~J b -27- GMd
LEGAL DESCRIPTION
Property Location,~~ ''/,~k~ '/<, Sec. ~ T ~~ N-R~VV, Town of ~sDlt~~
Subdivisionl~'~SS ~i~f/~E' ?1' ,Lot # ~_.
Certified Survey Map # Volume ,Page #
Warranty Deed # SY80B6 Volume j/9Y ,Page # ~'~d
Spec house O yes ~1 no
Lot lines identifiable ~ yes ^ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix 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 he completed and returned to the St. Croix County Zoning Office within 30
days f the three year expiration date.
f
/1 //
SIGN ,TURF OF ICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this Corm are true to the best of my (our} knowledge. I (we) am (arc) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
~l.Z/!tea
SIGNATURE OF APP CANT DATE
'*'*'• Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. """
~~
" Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
~e ~ - ; 1.
~~ ~ ~`~ `~
~~ DOCUMENT NO. RTATAS~bA~N OfF ~ ~ 16--a~M *~ ~i0a ^~~~p'M ~~~
III ~: a •' `• I~; ~~~~~~~_
:.,
}~ 548}86
A88~g'llOr. whether oar or more. for a •sinabit aonsideratioa, asei~ .
,~~, . l0ecsan , ]~Ilt _ and Doglti~ ! ; A - ~
....
' ~~
.~~et ~ d .
„~~.~. ~ . ~~ 'Y~YQ~ehi3t..~r~tals
whether oar or mote} lM '~ Puxhases'a) iM~:reat iw a l.aad Contract ~~'~
dated the .. 8tti--•-...._....,.dar ,.1......:...lT1~~Y......_ , ld 9~. a:ecntsd by
...
~X. ~-•.. Brrnn!-.sad Bteanore Bt"4++gt...~.~~:~~.~._......
;~ joint tenants ; ~ -.h - -
Y,
--..- _
'p T~fOafas W~i0~• a. ve~or to ~Rt'r110t'1 Bl-mt
,,
,~ ... ......................_ ..._.... .... ~ z~ xoaa
..._..~_..._..aa Pareh.aetr _ .~.
a on lands is ..._.~...... ~... GtO~]C . _...~... Cenat~r, State of ~-iarnaain, V
~ together with (the iadebledneaa therein referred to and} all tha interesE oi: tTto Tix 1?ax'vel 02Q-10~I-00
i Asutpor in the Land Contract and tha lands deecslbed thsreia which Laid Can- ~~~~/~~ ~ ~`~ `.
tract was recorded is tM OQiaa as the Eetister of Deeds el said Coont~, on
~ --------------X. 92 485728
~~ ~TUI IO ................. lf----..... as Doeumcnt Num6ce 4/K,`..'''' '" ems! 4
t~ ( ----- ~ ----- - -------- of (Records)'. S77 S78 y ~ 1. "~~ ~~
~~ ,,,. The Asei~gr oovepana t ~t th~tt~ `- ~~ ~ o>A ~ Oon~ tI~ sacra oi~ ~!* ~~St `~ `r ,~
-snd also iptsrest.at . _....: psr Dent Ps+' annaea from: _ -.-•-.-... .....~ -,- _ . • .
that Assignor is tM owner of the above deacrbed interest in tbs Land tract imd ~baR tPod rift to aattiQr !Ma sane,,
and that the condition of the tills od Assignor's ipterest in the same as t~the tints of raewdieE fife ~ Cesta~aeR
~~ PARAGRAPHS APPLYING IP THIS 1S AN ASSIGNrI[IiNT QIi PU$6HA91!$'$ INTERit3T: ~rlite L dr f,)
` $y acceptin` aaJ reeordla` tkis aaiEnmast; tie Assi=ses aaYrees : .
1. That J-asttwor assumes ` asd a~ to I~-7 tbs, alNipelea uettred ~ Ctrs Lord Contract, to es- .rii~- as ~;
terms and conditions of the Land Contract, and to bold itarmisss and °,
i ~ Asai~ a~ >A the yarforaggl0~- sd ati ~. .
.' .r -'
h obtiptioas, farms and eeaditWna of the I+ar3 Catt:xt. (O3j _ . ~ .
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~~ISCOItS%-.1 SANITARY PERMIT APPLICATION
Department of Commerce In accord with Comm 83.05, Wls. Adm. Code
• Attach complete plans (to the county copy only) for the system, on paper not less
than 81a x 11 inches in size.
• See reverse side for instructions for completing this application
Personal information you provide may be used for secondary purposes
[Privacy Law, s. 15.04 (1) (m)].
Safety and Buildings Division
201 W. Washington Avenue
P O Box 7302
Madison, WI 53707-7302
County
State Sanitary Permit Number
3s3 3~ Z
Q Check if revision to previous application
State Plan I.D. Number
I. APPLI ATION INFORMATI N -PLEASE PRINT ALL INF RMATION ~-
Property Owner Name perty Location
is t ia, 5 T •Z 9, N, R E (o~
Property Owner' Ma ling Address Lot Number Block Number
~ a7
City, fate Zip Code Phone Number Subdivision Name or~3~h4#dwrb~er
_
YPE IL ING: (check one) ^ State Owned
~ ~ Its
~
n Nearest Road
Public 1 or 2 Famil Dwellin - No. of bedrooms OF iC/
Tow ~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~y , ^ d t~ • ^ -~,q
~O l
1 ^ Apartment /Condo r _ ^0~
2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility
3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/BarJDining
4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash
S ^ Hotel /Motet 9 ^ Office /Factory 13 ^ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
q) 1. ~ New 2_ ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5, ^ Repair of an
-_____System _ System _____________ Tank Only______________ Existing System ________ Existing System
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
11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank
12 Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy
1 ^ Seepage Pit T~P~'•k~«ES 43 ^ Vault Privy
14 ^ System-In-Fill ~ ~ s' ~
VI. ABSORPTION SYSTEM INFORMATION: ~~,5
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rae 6. Sya1!em Elev. 7. Final Grade
~ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ~ ~ Elevation
/
~
(~~ ~ • 7 Feet p 2 ~ 3 Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name prefab. Con Fiber- plastic Exper.
N
E
i
ti Gallons Tanks Concrete - Sleet glass App.
ew x
n
s strutted
Tanks Tanks
Septic Tank o~tk ~ ^ ^ ^ ^ ^
Lift Pump Tank/Siphon Chamber ^ ^ ^ ^ ^ ^
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation t e onsite sewage system shown on the attached plans.
Plumber's Name: Print) ~,~ Plu er's Signa No amps) 1t7[P7MPRSW No.: Business Phone Number:
~~
tier's Address (Street, City, State, p lode):
fJ fi'r' D1
IX. COUNTY DEPARTMENT SE ONLY
^ Disapproved S itary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
`Approved ^ Owner Given Initial ~ Surcharge Fee)
~S
3-UUU
~`
Adverse Determination .
YO` N~DITtO~PP~RO~ L REA ONS F R~D~S P O,VA - ~1~~
~~--1~ .~1 ~~ "~
SBD-6398 (R. 4199) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
3
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
S. Onsite sewage systems must be~pr=operly maintained` fihe 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-~rildings Division, 608=266-3151., ~ -- - - • ,
To be complQle and accurate this sanitary permit application must include:
e
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 on line 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. Tank 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 all 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 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 o'f holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacerent 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; frictionioss; pump performance curve; pump model and pump manufacturer, D). cross section
of the soil absorption system if required by the coiJrity; E) soil test data on a 115 form; and F) `all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 4T0'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.
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Parcel #: 020-1356-27-010
01/15/2010 11:11 AM
PAGE 1 OF 1
Alt. Parcel #: 14.29.19.2089A 020 -TOWN OF HUDSON
Current ^X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
01 /21 /2004 00 0
Tax Address: Owner(s): O =Current Owner, C =Current CaOwner
O -STRUEMKE, ANTHONY J & JENNIFER A
ANTHONY J & JENNIFER A STRUEMKE
725 PAUL BURCH DR
HUDSON WI 54016
Districts: SC =School SP =Special Property Address(es): * =Primary
Type Dist # Description " 725 PAUL BURCH DR
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 2.185 Plat: 4689-CSM 18-4689 020-2004
SEC 14 T29N R19W PT NE NW & NW NW GRASS Block/Condo Bldg: LOT 2
'
N LOT 27(2.323AC) NKA CSM
RANGE 2ND ADD
18-4689 LOT 2 (2.185 AC)
Tract(s): (Sec-Twn-Rng
40 1/4 160 1/4)
14-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
01/21/2004 752316 18/4689 CSM
01/19/2004 752077 2494/88 WD
01/23/2002 669046 1820/526 WD
07/29/1999 607627 7/59 PLAT
2009 SUMMARY Bill #: Fair Market Value: Assessed with:
27257
346,200
Valuations:
Description Class
RESIDENTIAL G1
Totals for 2009:
General Property
Woodland
Totals for 2008:
General Property
Woodland
Last Changed: 10/25/2005
Acres Land Improve Total State Reason
2.185 75,700 262,000 337,700 NO
2.185 75,700 262,000 337,700
0.000 0 0
2.185 75,700 262,000 337,700
0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #:
Specials:
User Special Code
Category
Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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REGISTER OF DEEDS
ST. CROIX GO. WI
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