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Wisconsin Department of CommerCz PRIVATE SEWAGE SYSTEM
Safety and Building Divii ion
t . ~ 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
Kerr, Brad Hudson Townshi
CST BM Elev:
~~ Insp. BM Elev: BM Description:
~
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TANK INFORMATION
` ELEVATION DATA
TYPE MANUFACTURER CAPACITY
Septic
`GSe/
I ~
Dosing
Aeration
ding
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic ~ ~(/~ ~ ~- / ______
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
PM
Dia. IDsst. to
SOIL ABSO RPTION SYSTEM ( ~
BED/TRENCH Width ~ Length No. Of Trenchi
DIMENSIONS ~ Q 3.35 '~.
SETBACK SYSTEM TO P/L BLDG
INFORMATION Type Of System:
~
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t
~~..~ (~U ~4 -
DISTRIBUT ION SYSTEM
county: St. Croix
Sanitary Permit No:
395241
State Plan ID No:
Parcel Tax No:
020-1376-61-000
STATION BS HI FS ELEV.
Benchmark
3.z
3,z
Zoa
Alt. BM Z.os z
Bldg. Sewer
/~~ y
/ . ~
S t Inlet
/z_ 6
10~. v
S t Outlet. yt' ~, /oO- 3~
D
Header/Man. 4(~ ~~, ~~ Q6, flZ
Dist. Pipe ~ 3 •'1
2. QS O/
t!!-
Bot. System rr ~. y, ~ Q3 - (s
Final Grade ~
%U. 3v
9 ,
St Cover ~
~. ~.~ pp
Q• ~~
Q- ~ m
Of Pits
OR
HeaderlManifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
A.
Length~_Dia y Pipe(s) r ~
Length 3-~~ Dia /Spacing
~~
'r ~
60
SOIL COVER x Prescur~ Systems Dnly xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx SeededlSodded xx Mulched
Bedlrrench Center Bed/Trench Edges Topsoil ~ Yes ~ No ~ Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Q /r' ~ / ~I Inspection #2: / /
Location: 890 Fraser Lane Hu(d'soln, WI 54016 (SW 1/4 SW 1/414 T29N R19W) Swte/et Grass Farm L ~ f ,~, Parcel No: 14.29.19.2322
1.) Alt BM Description =`~ dT ^~'ugP ~~'~'+~`+`Gw I ~, k9 (.UQ ~~ G/~/ ' ~~
2.) Bldg sewer length = j ~ ~ ~~, Svs'~C,yt, t p(~.}~ ~,,/I~,,,f~~ ~Gt!~° if
\ - a//mount of cover = 7 S ~ ~ ~ ; / ~tsf `1~ ~Q~ ~rr//~`~~ ~ d3 ~~
~~) rlbStrV ~or~pe5 JH.ST~.I~~ ~r. ~ ~(0-l
Plan re~slo" ° n"Requl~ed Ye~ No
Use other side for additional information.
Date Insepctor's Signature Cert. No.
SBD-8710 (R.3/97)
~ ~~D99~
~ Safety and Buildings Division C~tY `
S
. 201 W. Washington Ave., P.O. Box 7162
~
~
s
n Madison, Wl 53707 - 7162 dress
Site
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Department of Commerce
Sanitary Permit Application Sanitary Perwt Number
3 9S~2~f ~
In accord with Comm 83.21, Wis. Adm. Code, persoffil infortnation you provide Check if Rev lion
m
ma be used for Seto ses Privac Law, s15. 1
_
I. Application Information -Please Print All Information - Number
r----
Property Owner's Name Parcel Number /(f , ~Q ~ ! ~ ~. .Z a.
,~ ~ ~'~ O O - l3? - -oo
Owner s Mailing Address
Prope Property Locaa~
~ q
City, State Zip Code Phone Number Lot umber Block Number
Subdivision Name CSM Number
~ syo~~ ~s- ~g-~ s~ ~- ~
/
II. Type of Building (check all that apply) ^City
~
~1 or 2 Family Dwelling -Number of Bedrooms ^Villago
^ Public/Commercial -Describe Use 'Township
^ State Owned
a - s ~~.-~-~ - Nearest Road
D
- Qo
III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A
1 New
2 ^ Replacement System
3 ^ Replacemem of
6 ^ Addition to For County use
S stem Tank Onl Exis ' stem
B. ~ Check if Sanitary Permit Previously Issued Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use)
44 ~ Non -Pressurized In-Ground 21^ Mound 47 ^ Sand Filter 50 ^ Constructed Wedand
22 ^ pressurized In-Ground 41 ^ Holding Tank 48 ^ Single Pass 51 ^ Drip Line
45 ^ At-Grade 46 ^ Aerobic Treatment Unit 49 ^ Reti=culating 30 ^ Other
V. D" ersal/'IYeatment Area Informati on:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required Proposed ltate(Gats./Days/Sq.Ft.) (Min./Inch) ~ Elevation
3
9
SOD sDo s/ ~ ~
s
e ~ ~
VI. Tank Info Capacity in .Total Number
Gallons Gallons of Tanks Manufacturer Prefab Site Steel Fiber Plastic
Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank a $ ...~• ~ a
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibt'fity for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plum 's Si tare RS Number Business Phone Number
~ ~lG~~D o 3s 7 , - ~ Sys
Plumber's Address (Street, City, fate, Zi e)
D ~ ~~ sYoo
VIII. Count /De artment Use Oni
Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater
Date Issued Issti Agent Signature (No Stamps)
Surcharge Fee)
^ Owner Given Initial Adverse ~ ~ . ~ Z~
Determination
1X. Conditions of ApprovaUReasons for Disapproval
- Ail ~~ Ste- ~ ~t4 _ ~~'^^,~ .
Attach complete plans (to the County ouly) for the system ou paper not less than 8112 x 11 Inches m she
SBD-6398 (R. OS/O1)
DILHR
SANITARY PERMIT
TRANSFER/RENEWAL
(PLB 67-T)
UNI M PERMIT # 't`'"_
PERMIT ENtE AL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PL I.D, NUMBER:
/°t~~ ll - v? 003 ~ P~2.I [.. ~ ~ - aoc t -~3~$3~1~z~-'
PROPERTY LOCATION: CITY:
VILLAGE
/U (,f.( '/a LL1'/a,S ,3,T p~ yN,R
~OI') : l'
TOWN OF: }I tJDSm~
LOT NUMBER: BLOCK NUMBER: SU
B
DIVISAME: NE
REST ROAD, LAKE OR LANDMARK:
A
<
, r
'
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGEDI:
SANITARY PERMIT TRANSFERRED TO;
NAME: SIGNA UR
r
~ NAME:
~C PHONE NUMBER:
~~i.~~ ~
~~ 5
ADDRE S: PHONE NUMBER:
-
- ADDRESS:
~`
`
~as
~ ~ aoo c~-t
5?
. S /h
~'.~//~
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
property.
PLU ER'S GNATUR PREVIOUS PLUMBER'S NAME (IF CHANGED):
PLUMBER'S fDRE S' PREVIOUS PL//UMBER'S ADDRES~ ~
f.
P PRSW NUMBER: PHONE NUMBER: P PRSW NUMBER: PHONE NUMBER:
0 3s (~s-~ a~ S ~ ~9yS` o (is~ 3 ~ ~3 ~?
_,
SIGNATURE OF ISSUING AGENT: DATE APPROVED: DISTRIBUTION: Original -County
Copy -Bureau of Plumbing
Copy -Owner
DILHR-SBD-6399 IR. 5/82) Copy -Plumber
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Wisconsin Department of Commerce
Division of Safety and Buildings
SOIL EVALUATION REPORT
Page _ ~ _ of 3
m accoroance w¢n Comm rso, vvis. Aam. was
County
th
'
must
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Pl
~~ ~ -" St. CrOlX
I
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an 8 1/2
Attach complete site plan on paper not less
include, but not limited to: vertical and horizontal re "g Q1nH(;dirg~etion and Parcel LD.
percent slope, scale or dimensions, north arrow attddis`tafte"~ fa~tearest road. ~ -. -
''~` ~ '
Please print al ~&3matio ~'
n
,,~ `~~~ Reviewed by Date
Personal information you provide may be used f endary purpos ~~
e ' Law, s. 15.0 (t) (m)).
Property Owner -=y '-~ , ~ Propert~Location
Brady Kerr v--,~ ~ 1~ Govt. L ~t NG~1 1/4 NW 1/4 S 23 T 29 N R 19 f(or) W
Property Owner's Mailing Address ,~,~+ ~~~~_~ ~~
~ Lot # Block # Subd. Name or CSM#
9250 Old Cedar Ave. S, a °'"
19'~~. 61~ na SweetGrass
City State Zip Code Number ~ ~ity ^ Village ®Town Nearest Road
Bloomington NIlV 55425 (6 6,~- 1 ~~,~ '~ '' Hudson Florence Ln
~ New Construdion User Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
^ Replacement ^ Public or commercial -Describe:
Parent material OutWaSh Flood Plain elevation if applicable a ft.
General comments
and recommendations:
trenches @ el. 94.70', spaced to code 4.00' below grade
^ Boring # ^ Boring 98.70
~] pit Ground surface elev. ft. Depth to limiting factor 110 in.
Soil licetion Rate
H
i D
th t C
l
D
i tion
Redox Descri Texture Structure Consistence Boundary Roots GPD/fg
or
zon ep
in. o
or
om
nan
Munsell p
Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2
1 0-7 10yr3/3 none L 2msbk mfr cs 2f
2 7-14 10yr5/4 none sil 1csbk mfr
3 14-48 7.5ry4/4 none cos Os ml
4 48-11 7.5 4/6 none ms
Boring # ~ Boring 97.70
Pit Ground surface elev. _ ft. Depth to limiting factor 110 in. Soil A lication Rate
H
i D
th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlft'
or
zon ep
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
1 0-12 10yr3/3 none sl 2mgr mvfr 2f .5 .9
2 12-23 10 4/4 none cos Os ml
3 23-45 7.5yr4/4 none ms Os ml
4 45-11 7.5yr4/6 none ms Os ml na na .7 1 2
'Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L t uem ~z = rsv ~ ov rnyi~ anu ~ ~~ _ ~.. ,,,y,~
CST Name (Please Print) Signature ~J • CST Number
Gar L. Steel ~'", 02298
Address Date Eva anon Conducted Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 8-21-2001 715-246-6200
Property Owner BraDY Kerr
Parcel ID # ~ z0 " ~ 3 ~CO~Ia/~OGd Page 2 of 3
3 Boring # ~ Boring
®Pit Ground surface elev. 90.40 ft. Depth to limrbng factor 1 00 in. Soil lication Rate
.Horizon Depth Dominant Color Redox Description Texture Stnx~ure Consistence Boundary Roots GP D/fE
in. Munsell Qu. Sz Cont Color Gr. Sz Sh. 'Eff#1 'Etf#2
1 0-12 10yr3/3 none L 2msbk mfr cs 2f .5 .8
2 12-29 10yr5/4 none sil 1csbk mfr 1f .2 .3
3 29-49 7.5ry4/6 none /cos Os ml na 7 1
4 49-10 7.5yr4/ none ms Os ml na na .7 1.2
4 Bori # ~ Boring
~ X^ pit Ground surface elev,90.40 ft. Depth to limiting factor 1 00 in
Soil Ap lication Rate
Horizon Depth Dominant Colo Redox Description Texture Structure Consistence Boundary Roots GP D/ff
in. Munsell Qu. Sz Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2
1 0-9 10yr3J3 none sl 2msbk mfr 2f 5
2 9-26 75.ry4/4 none cos Os ml 1f
3 26-45 7.5yr4/4 none /cos Os ml
4 45-10 7
Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
Pit Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft=
in. Munsell Qu. Sz Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2
'Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mglL and TSS < 30 mglL
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 608-264-8777.
SBD-8330 (R6I00)
..
STEEL'S SOIL SERVICE
Gary L. Steel
Brady Kerr
MP SW-3254 NW4NW4 S23-T29N-R19w
town of Hudson
lot #61-Sweet Grass
N
1"=40'
BM.= top of 1" pvc pipe @ el. 100.00'
alt. BM.= top of 1" pvc pipe @ el. 90.80'
a'~
19~
1554 200th Ave.
New Richmond, WI 54017
(715) 246-6200
Gary L., St
8-21-2001
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer {S y"a~ ~/ ~Gc y r
Mailing Address _ _ ~~ (~ • Q~~ ~ l ~ ~ I ~ vc! 5~ 4~ f,tJ=' S y O 1 ~
Property Address
0 ~
~_Li~~l ~ 1 ~ Y~ v ~ V
syv~~
(Verification required from Planning Department for new construction) ,
City/State ~UdS®v~ w~' Pazcel Identification Number ~ ~~~ ~ 17"b~ _(JLV
LEGAL DESCRIPTION
Property Location N ~ %a, N tt.( '/<, Sec. ,~~, T v2 ~( N-R~W, Town of ~I tr 5~~ ~
Subdivision
Lot # L ~
Certified Survey Map # _ , Vohune ,Page #
Warranty Deed # C~J`~O 7 g 3 ,Volume ~~?~ ,Page # f
Spec house ^ yes f~ no
Lot lines identifiable ~ yes ^ no
/5 F ~~s5,
/ ' /l~~l ~
~~~~~
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 fonm, signed by the owner and by a
masterplumber, journeymanplumber, restrictedplumber or a licensedpumperverifying that (1) the on-site wastewaterdisposal 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 standazds
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 Zoning Office within 30
days of the three year expiratio date.
./ /f,
SIGNA OF I ANT DATE V
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property desc ' ed above, virtue of a warranty deed recorded in Register of Deeds Office.
/ /®
SIGNATURE OF ICANT DA'C'E
****** 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
ST>'~TE BAR QF WISCONSIN FORM 2 - 1998
WARRANTY DEED
Document Number ,vq~ ~~i78r~r>f ~2
This Deed, made between , _
RICHARD O. STOUT and TANFT .D_ STO[[Tf__
~1u5 a[Ld and w; fP~ __
---- -- -_- -_._, Grantor.
and BRADY J. KERR, ADAM M KFRR and .TAMES T~ _
CARTER III
t~ust~rTCI~TS~if~,
- -- -- --- Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate In _ St . CroiX County, Stale of Wisconsin:
Lot 61, Plat of Sweet Grass Farm, Town of
Hudson, St. Croix County, Wisconsin.
650753
'r,AT;~LEEN H. WALSH
REGISTER OF DEEDS
iT.. E'RDIX L"G., WI
kECEIUED FOk kECORD
07-10-2001 1:30 RM
WARkAHTY DEED
EXEHRT q
CERT COPY FEE:
COPY FEE:
TkAHSFER FEE: 163.50
kECORDIHO FEE: 10.00
F'RGEB: 1
t;._.rt~.._ .
Name antl Relurn Address
' ~~r S"'~!T ~P
Lc'i~r".i,rr .
9e>.,: rsr t~ //tea' n7~S ~/i1
f ~ 7S /car/7~/_3
020-1376-61-000
Parcel ItlentilicaUOn Number (PIN)
Thts 1S nOt homestead property
(is) (is not)
Exceptions towarrancies: easements, restrictions, rights-of-way and covenants
of record.
Dated this 20t(h~ djay,_o_f -}-- June . 2001~I
~~~X Ss ~'ti...~~1 (SEAL) ~~1/W1./~ ~ ~".~" .. (SEAL)
Richard O. Stout Janet P Stout
(SEAL) __ (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) __._ ____
State of Wisconsin, lI
} ss.
St. ('rO1X -County. JI
authenticated this _ day o(_ Personally came before me this _? 0th _ day of
_ JUn~,2.4_~_ ,the above named
_, Richard O. Stout and Ja__net _
P. Stout
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stats.)
THIS INSTRUMENT WAS GRAFTED 8Y
Janet P. Stout
_ 1353 Awatukee Tr.
Hudson, WI 54016
---_--' -. to
me known to b~'+ e CC i'~~Glt..tkritrcuted the foregoing
instrument and ~~Q~ ?~16CONSIN
NQN J. BAST
_,_~
Notar Public. State of consln J
My ommissio is permanent. (If not, state expiration d tc:
~! -- -- ')
(Signatures may be authenticated or acknowledged. Both are not
necessary)
' Names of persons signing in any capacity most be typed or printed below their signanrrc.
WARRANTY DEED STATE 8AR OF WISCONSIN Wisconsin Logai Bia~k Co.. e,c
FORM No. 2 - 1998 M Ewa kea, wrs.
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Vkisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GE,~VERAf. INFORMATION (ATTACH TO PERMIT)
'er al information you provice may oe usea ror seconaary purposes ~rnvacy Law, ~i5.u4 li)(m)].
~~r~_ o~~s,4lan,e: ^ city ^ vfl+~~~orp~nship
:ST BM EI Y~~C Insp. BM Elev.: BM Description:
TANK IN F RMATION
TYPE MANUFACTURER CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORI~-TION
TANK TO P/L WELL BLDG. vent to
Air Intake ROAD
Septic NA
Dosing NA
Aeration NA
Holding
ELEVATION DATA
STATION BS HI FS ELEV.
Benchmark
Bldg. Sewer
St/ Ht Inlet
St/ Ht Outlet
Dt Inlet
Dt Bott
Hea /Man.
D' .Pipe
Bot. System
Final Grade
cover
PUMP /SIPHON INFORMATION ,,
Manufacturer em d
Model Number GPM
TDH Lift Lriction System
hi T t
Forcemain Length Dia. Dist weu
SAIL ABSORPTION SYSTEM ~
BED /TRENCH Width Length No. Of Trenches IT No. Ot Pits Inside Dia. Liquid Depth
I EN I MEN I N
SETBACK SYSTEM TO P/ L BLDG WELL LA /STREAM
LEACHING
Manufacturer:
INFORMATION TypeO CHAMBER Mo a Num er:
System: OR UNIT
r11GTRIRI ITIif1Al CVtTFI~
Header /Manifold Distribution Pipe(s) x ole Size x Hole Spacing Vent To Air Intake
Length Dia. length Dia. Spacing
SOIL COVER ® x Pressure Systems Only xx Mound Or At~ade Systems Only
Depth Over Depth Over xx Depth Of x Seeded /Sodded xx Mulched
Bed /Trench Cen r Bed /Trench Edges Topsoil Yes ^ No ^ Yes ^ No
COMME 5: (Include code discrepancies, persons present, etc.~nspection #1:
Loca ' n: 890 Fraser Lane, Hudson, WI 54016 (SW 1/4 SW 1/4 14 T29N
Grass rm -Lot 61
1.) t BM Description =
2. Idg sewer length =
-amount of cover =
Plan revision required? ^ Yes ^ No
Use other side for additional information-
SBD-6710 (R.3/97) Date Inspector's Signature
.Inspection #2: / /
- 1429192322 Sweet
Cert. No
~. ~ D ~q.~~ Safety & Buildings Division
Sanitary Permit Application 201 W W ~ ~
3oi
~S`~n~R In aceard with Comm 83.21, Wis. Adm. Code
' ~
Madison, Wl 53701-7302
Department of COmm(3rCe Personaf
infotmation you provide secondary purposes (Submit Completed form t0 county if not
[Privacy .:s:,~15~p!~( ...
~ st~eowned.)
Attach co lets lens to the c 'the to o'b.
of kss than 8-1/2 x 11 inches in size.
County State Sani Permit N "~"~ ion to pplication
, State Flan I. D. Number
ST'~ GYc~ i may' 4,~, ~-~
2 O ~ ~,
I. A lication I ormation -Please Print all Inform ~ ~" nt', , Location:
Property Ouvner Name t ~ ~ }'roperty S K b~
2! ~e : ~ ~ ` .~ C ,t.,t II4 /4, : 'Io'n ~ ,N, or
Propert. ~ s Malting r~ :k ~ . ~
. 1 I,ot Nam Block Number
,
City. State ?.ip Code ::;; ~uAi~ ~5 '~ ;~ S lion NAU-e or CSM Number
ad G~ ` `
r76 ~ ~~`
~S
lrJG~1-' tc s'S
II Type of Building: (check one) u~ p•1-s ~~ Ciry
^ 1 oc 2 Family Dwelling - No. of 13 :~~ Inw.~.tYe. •M.s . ~ vrliage
own of
t7 Public/Commercial (describe use):
o Stau-owned G~
III Type of Permit: (Check only one box line A. Check box on line B if applicable) Nearest Road
a.i seY
A) 1. New System 2. ^ Replacem 3. ^ Replacement of 4. O A on to Parcel Tax Number(s)
system Tank Onl )rxis ' S stem t77ib ~ l 3 ~73D
$) Permit Number mete Issued
^ A Sanitary Permit was viousf issued ' ~ ~i
IY. Type of POWT System: (Check a!I that apply) fit' 14--IUD •
.
Non-pressurized In-gound ^
C] Sand Fiita ^ Constructed Wetland
Pressurized In-ground ^ Ho ~ g Tank ^ Single Pass ^ Drip Line
^ At-grade l „~I Aerob Tt+eatment Unit ^ Recu~culating ^ Outer:
93 • ~"
cQ,v,;~
2 x
V t Area Information: ars ~,•uS
1 (i8+d) 2. Di lArea 3. Dispersal Area
4~. ~ f~ itattt 8_;8~atatp "k;;l~irprrl t3ratb
~},
R~~~~ 5 (~'t' ' /sq. fl.) ('Min.lurch) ~ wit
~:~~ 8,5-7 ~5~ g3.9S~
VI Tank Capacity in Total # of Man aRurer Prefab Site Stoat Fiber- Plastic
information Gallons Gallons Tanks Con- Con- glass
New Existing crate strttctod
Tanks Tanks
_ ^ ^ ^ ^
.,? ~c r
^ ^ ^ ^ ^
Vil Responsibility Statement
the tutdersi assume r ~bilit for ins 'on of the POWTS sho the attar lens.
Pltanlrcr's Name (print) Plumber's Si lure (no stamps): S No. Busvress 1'hoae Number
~J,~i~,'µm s ~r v ~~' ~~ Qd rs- ~~- ~~
Plumber's Address (Street, City, State. Zip Code)
/~74 ~. a t~ o,a/ GJ ~ ` G
VIII Connty/Department tJse Only
^ Disapproved Sanitary Pernril Pee (Includes Groundwater Date Issued Issuing Agent Si tore (No stamps)
,Approved ^ Owner Given I ' al Adverse S e Fax) d0
~"
~ ~ ~ 2
.
Determination 22,5:
IX. Conditions of Approve{ eaiOAS for DiaapprOVaf: ~ ~_ ~ ~
s~ S.~'~t-v(-S n~
~bM,tQAUrinel is
~s pw IMO~wr*~
,.;
~~
ww,r->~xtltrll 6e,r 5 { Ic, 4~ ~~ aMO~ aiC( v~ ~lt~I t ~ f ,~..,. ~ .
t~ 1~r ~ ~~f~;~-~~l.a.. ~u- ~- -~(1 ~~ - cQ~ ~tllea
.r S Arc. cwM. b-tis .
S bc~r;rt~,t~.Hrt:.S tntiat.8 be tK-r't E
Of CfH.~t~~-' (,e G ~ tn,(7~,t,
~r i nt.
S~ t
i~,,~.s~~'~
s S-I~ r~ st~t~tt .
~~ re- ~~ ~~~~ b~.G,
~~ ~~
~ W Per v~~
_ ~,
~ sLv
i {:~.~lj~v~ ~~ ; ~ e Y ,yly1~Y../~v %y L oT ~ l Sic ter" l~-d-n s s /~u/.d d/~ if/~.~! s.~..v(~
S«~~ ~ .•=/dam:
a ~~'
~/ 6~8'a J Qnr.
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e ~ ~~ • ~3ir
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I
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings
Bureau of Integrated Services in accordance wit ®, Wis. Adm. Code
Page ~ of /
^~ ~ ~" ~ e d e` `'ti
Attach complete site plan on paper not less than 8 1/2 x 11 inches ' si~~ Plan my~, `' `Founty
include, but not limited to: vertical and horizontal reference point N~;tlirecti ~~~°~~~ 1, S"'~ LRO . X
percent slope, scale or dimensions, north arrow, and location an~ds~nce to asst t'oakl. Pa el LD. #
~.-~ a T
... .~a
APPLICANT INFORMATION -Please print all infdrfiation. _ _ Rev7e ed by Date
Personal information you provide may be used for secondary purposes (Pnvac`y Law, s. 15.04 (4j ~,jj,+ e
Property Owner e L aUCh., "„
".~.~A~ p .T ~,~ - n• Govt._Lat" '` ~~ 1/~~ 1/4,S~ Tz~ ,N,R l~ E(or 1V
Property Owner's Mailing Address ~ `tbt'# # Subd. Name or CSM#
l3 ~ ~~ k sz--e ~.-r-a ~' i ~ I Sc~-esz~-- (g r~ s S
City State Zip Code Phone Number ^ City ^ Village ®Town Nearest Road
(-~v cP~ ~ ~cl C .~ ~U ~ b (~ r .~ )s ~/~- ~ 7 3/ ~ rQ s o ~ ~i-~ z-ti r- l ` ~" -~
New Construction Use: [`~ Residential /Number of bedrooms ~ Addition to existing building
^ Replacement ^ Public or commercial -Describe:
Code derived daily flow s~ gpd Recommended design loading rate ~ ~ bed, gpd/f12~_ trench, gpd/fi2
Absorption area required ~S7 bed, ft2 ?-~ trench, ft2
~ Maximum design loading rate ~ bed, gpd/fl2 ~ ~ trench, gpd/ft2
Recommended infiltration surface elevation(s) ~ 3' ~ s ft (as referred to site plan benchmark)
Additional design/site considerations ~~~ r ~~ ~2 ' ~ ~ G° ~' `~ ~G ~ S
Parent material ~ U-~ W ~ ~ (~ Flood plain elevation, if applicable /~ ~ ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system ®S ^ U ~'S ^ U ~ S ^ U [~S ^ U ^ S (~ U ^ S (~U
If
CAII r1CC/`DIDTIAAI DCDART In .. r~.NO _ _' ~ (~
Boring #
Ground
elev.
q`i.~Sft.
Depth to
limiting
~ctor
~ in.
Boring #
Z
Ground
elev.
9~ 2 Sft.
Depth to
limiting
factor
~`~ in. Remarks:
CST Name (Please Print) Sin ure Telephone No.
~-G(a n^ ~~ Gi.~wt a l~-i-- ~~~----~~~ _- err - 2 y 7~ G/vaSr
Address Date CST Number
at l ~ ~ ~ t~ Sf< ~~ ~- s~ ~- ~~ ~ _ SGI~ z ~` - S'- y-oa zs` 3 3G~
Horizon Depth Dominant Color Mottles Structure i d
B R
t GPD/ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Cons
stence ary
oun oo
s Bed ,Trench
3 y3 to ice, 6 -~.,~ c5 - ~ ; ~
Remarks:
~ e-io 0 3 ~ -~ ~i 1 was 6k rR ~s ~ ~ ~ y ' ~
.Z
0 R - '^ S 1 CS '~' Z ' ~'
'
wFR3.`tS I '
-~-
39• t~ ~s: c, ,
S ~ ~ SOIL DESCRIPTION REPORT
PROPERTY OWNER
PARCEL I.D.#
Boring #
~~
Ground
elev.
~/J~"L~
Depth to
limiting
factor
CSC in.
Boring #
Ground
elev.
X1595 ft.
Depth to
limiting
factor
chin.
Boring #
1
Ground
elev.
y~, SSft.
Depth to
limiting
factor
min.
Boring #
Ground
elev.
ft.
Page ~- of
t
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed , Tren
1 6..6 io ,~ 3 -- Sr, 1 ~ - ~ I v~= y ~ .
Z ~ -~ ~ - I^1 O s a,.,.- ~-5 - tS
Fs- io -- n5 ~,..,. L5 - ~ g
Remarks:
~ o-fs to ~ 3~2 SL, ~~ ~~~- y ~
Z - +n / ns or.,~ C "' >~ ; is
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
-b l0 3 Z ~~ 5 ~ w.5 b~ v~t'rL CS ~ v i- ~ S
3 z ~ ~ ,,,,. - ~- ;
Remarks:
Depth to
limiting
factor
'n' Remarks:
SBD-8330 (R.9/98)
•. ~'.
PAGE~OF~
NAME ~S-b~ ~' LOT# C9 ~ LEGAL DESCRIPTION,fKJ'/,GCtP/4,S Z~TLa ,N,R ~ ~1 E (or)
t
crnr F• ~~~_ /C:~U
BM 1 ELEVATION ~ ~ , Z._rj
BM 1 DESCRIPTION'fnD o~ ?~~~v~DiOr? ~crf~t w/P~a J
BM 2 ELEVATION !GD ~ U
BM 2 DESCRIPTION ~p n ~ ~~ yL ~; D.p . ~u f l~ ~/ h ~a y
SYSTEM ELEVATION ~ 3 , ~ ~
ALTERNATE ELEVATION 9Z ~ /~n,~ Lowtr' ~y' ~ ~
CONTOUR ELEVATION d/~Y'~
C
l
l°
a
t
t
o ~
~ ~ 4Z PriMpry 65
a
n
~ ~.w•~~
X
I
-i-
f
la,~z
Fra t
X33 •
•
d~ I~~{.
3'~
~~
DATE y y
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In-Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWYS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
Table 1: System Desian Specifications
Sanitary Permit Number - 2~
Number of Bedrooms
Design Flow -Peak (gpd) ov
Estimated Flow -Average (gpd) btu
Septic Tank Capacity (gal) ~~
Soil Absorption Component Size (ft2) ~
Type of Wastewater omestic
Table 2: Soil Absorption Component -Limits of Reliable Operation
4
{ ~
Septic Tank Component Soil Absorption Component
Design Flow -Peak (gpd) '- Z - i~
Maximum Influent Particle Size (in) 1/8
Maximum BODS (mg/L) 220
Maximum TSS (mg/L) 150
~XX~taw c
Tab le 3: Maintenance 5cnedu~e
Septic Tank Inspect and/or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the se tic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
w
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
freatment of holding tank may confain lethal gases, and rescue of a
person from the interior of the tank maybe difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
• ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer !~~-,va/e fie`
Mailing Address ~a~(s ~.~/ /~ i ~ ..5' ~'o l ~ /
4 O ~/
Property Address ~~ `.s_...",~_L~ ~ ~ g ~4 S~.r' Q h ~,
u,. ~-.-- ~.,.z
(Verification required from Planning Department for new
City/State
Parcel Identification Number ~p?/_~ ~37G --~ l-a'~
LEGAL DESCRIPTION !
Property Locations'/., ~ '/., Sec. ~?~3 ,
T 29 N-RAW, Town of ~,!/~.~sa,.~/
Subdivision ~ ~ ~ ~ ~ ~~yu- ~s ,Lot # ~.
Certified Survey Map # ,Volume .Page #
Warranty Deed # G ~~ S~~ ,Volume /~Gj' f ,Page #
Spec house yes ^ 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
mastorplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdisposal 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 Zoning Office within 30
days f the three year exp' 'on date.
f / /~~
SIGN TURF OF APPLICANT ATE
OWNER CERTIFICATION
(we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the .rop rty described above, virtue of a warranty deed recorded in Register of Deeds Office.
SIGNA OF APPLICANT 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
STATE BAR OF WISCONSIN FORM 2 - 1998
WARRANTY DEED
Document Number
uo~ 1609P~Gf 484
This Deed, made between
-__.~$.~.., em_o~o..rrrm .-~-o~.:T~r~-mac mnrrm
h~i c h rT rT r i-fb-r-.
-------•---- - -------. Grantor.
and rurvnizc v,_,Teon_EAPdSTHHErfFBPi, F-F7E.
--- - __.__ _- Grantee. ',
Grantor, for a valuable consideration, conveys and warrants to Gtanlee [he following ',
described real estate in $7; C;r6}y __ County, State of Wisconsin: '.
Lot 61, Plat of Sweet Grass Farm, Town of
Hudson, St. Croix County, Wisconsin.
Parcel I enti6calion Ntxnber (PIN)
This ;;~r,t homestead property.
(is) (ls not) -
Exceptlons[owarranties: easements, restrictions, rights-of-way and covenants
of record.
Dated this ~•9th dray of __ ..L~Zrrh 2/00]1 ' _ I ~J ~ J`'
c ~. a~ (SEAL) / It 'emu--~ ~ _,/~-" "~- (SEAL)
C.
Richard O. Stout ~ Janet P. Stout
AUTHENTICATION
Signature (s)
authenticated this day of
(SEAL)
TITLE: MEMBER STATE BAR OF WISCONSIN -Q~~~q le,
(1f not, c~ ~ `"h
authorized by §706.06, WIS. Stats.)
THIS INSTRUMENT WAS DRAFTED BY ~. Q SON
Janet P. Stout
,•
1353_Awatukee Tr. .~,~_~.,.... '
__ to
to be the person ~ who executed the foregoing
and acknowledge the same,
L . b l..s~~l
HudSOn, WI 5401 6 `~.~, ru ., ~~,,,.~N'ot y P blic, State of Wisconsin
My o mission is permanent. p(If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not __- 6 -~ ~ .~- U~.)
necessary)
• Names of persons signing in any capacity must be typed or primed helaw their signature.
STATE BAR OF WISCONSIN Wisconsin Lepai &enk Cc.. Inc.
WARRANTY DEED FORM No. 2 - 1998 Mnwaukee. wis.
6+41582
KA7ul c, r.,.i H. WALSH
RF"LISTER OF DEEDS
!T. C6'OIX CO. ~ WI
P,ECEIVED FOR RECDRD
?~-?^-?001 8:50 AM
UARRPNTY DEED
EXE".PT R
CERT COPY FEE:
CDPY FEE:
?RA1vSFER FEE: 157.20
F.'ECCkDIRG FEE: 10.00
PAGESt . 1
F+•;r.c:nLng Araa
Name and Return Address
5 5 urn rrs ~G /=/c--GQ Lr /~L' /Lr•
/~vDSOr-, r [...~T. 55/6
ACKNOWLEDGMENT
(SEAL)
Stale of Wisconsin,
ss.
St, Croix County.
Personally came before me this ~9 th day of
~~.~~ , ~giD-~, the above named
D~~t,=.-aa.~-r~t~-t and Janet P.
'" LV I ~y eLEV. -999.0 ~ ti w
I ~- - 2.99 wcRES ~ + ~
11999s So f r ~ ~ ~
I' ~ ~ :
~~ 25• I : O
I I $
I ~ ~ N89'49~x0"E ae9.x4~
I ~ + I ;
I 7 j
" ~ a
~I $
-~- , : LOT 60
I I _ 2.90 /1~CRE8
113472 8~ FT
I C29 ~,~' .--
' ~ ~ ~\ •. m
•• 1 ~~
• ~~ ~ ~ • • N89'49'xti"E x92.30'
• \ 2x8.38' 312.92'
• ~ ~ ~ ~
• ~ w~ ~ a-.
•' \~ \ ••. Z N N
• ~ ~~ .• _ LOT 61 ~ LOT 62 ~>
. ~ ~ ~, ~ ~"' 2.01 ACRES
. ~ ~ ~ ~ 87947 8G Fr "
. \ ~ • ~~ 2.19 ACRES ~ ~~
. p ~ 93888 SQ FT ~p • ~. ~ •
~~ .• ~,i
•• \~•~ ~ ~ MIN BUILDING ~.
. ,,,~ ~* ELEV. =900.0 ~
H.W.L. =899.0 •• \" ~ ~••. ~. ~ / ~ /~
" ~~~ ~ ~~"
~ ~~ ~'~ /
• \ o ~~ ~
. ~~ ~
MIN BUILDING ~ ~ G'~ ~ N~~, ,t~9~/ ~ .
ELEV. - 900 O ~ ~g`/ , " .
•
~ ~.
i ~
• ,. N~ /~
r ~ .
~ ~,
~"
C8 ~=~~~ •
Z,4 ~ ~ .
i
~ ~+
'?~~. '...•t'•~
V s
N ~~ ~
+
MIN BUILDING fA
ELEV. =897.0 ~ LOT 25 O
~ a.oo n-~cRES ~
BUILDING 180880 8G FT `I
45 R
V. =897.0 +
M I r1T nc m