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Wisconsin Department of Commerce p ATE EWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(mll.
Permit Holder's Name:
Hoff, Randy & Kathleen ^ City ^ Village ^ Town of:
Hudson Township
CST BM Elev.:- Insp. BM Elev.: BM Description:
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic _~~~~ ~0
Dosing
Aeration
Holding ~
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. vent to
Air Intake ROAD
Septic Z ~ NA
Dosing NA
Aeration NA
Holding
PUMP /SIPHON INFORMATION
Manu , r errand
Model Number GPM
TDH Lift Fr~ ~ n Sys H Ft
Force Length Dia. Fi Dist. To well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County
St. Croix
SanitarX eerlpj~-~Vo.:
StateState Plan ID No.:
Parcel Tax No.:
020-1129-90-000
/7.29/9. ~/~/
STATION BS HI FS ELEV.
Benchmark 3,~ •Yfi pp.~
Alt. BM
Bldg. Sewer
St/ Ht Inlet
St/ Ht Outlet I'L.t'a q/,Z$ ~
Dt Inlet
Dt Bottom
Header J Man.
Dist. Pipe
Bot. System
Final Grade
St cover ~ , ~~ ~~ ~~ ~ ~
Lla~•kZ /.1 12-b2 v. r
r _ ~I~ I Z . ~ ~'~'~ O 1, wi_ 1
BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN 1 N DIMEN 1 N
SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
SETBACK
INFORMATION
Type O CHAMBER
Mo a Num er:
System: OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
pepth Over Depth Over xx Depth Of xx Seeded I Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No
C~~M~NTS' (4 cl code~i re e , r o t) ill'N`'~~.,...,~..C,~~,1 ~ ~ -- ...~Y,,.,~-~~~ .-
location: 447 ~artk~ane, Hu~sorQ~ Ss4~[6s ~r17~~~e1~4 17 T29N R19W) - 17.29.19.614 Park View Estates Addn. VI -
Lot 33
1.) Alt BM Description =
2.) Bldg sewer length = ~ ~ ~~ ~k~~ ti
-amount of cover = ~i~ e ~ ~y5~"''`~ 1~~,~ ~ ~ ~•
Plan revision required? ^ Yes ~ No
Use other side for additional information. «0 (3 00
SBD-6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
~li~~ i'~ie~
v~^a.nr,t SANITARY PERMIT.- ]~'TIaON
h f-
Inaccord with ILHR 8 5,"`UVI -Crid~_=",
~~ ,: ~.
• Attach complete plans (to the county copy only) forth '~' em, orA~~g~t less
than 8 1/2 x 11 inches in size. ~
r
• See reverse side for instructions for completing this a R~' 'ation4 ~ ~~ ~~,
The information you provide may be used by other government agency y'~ims ~~ ~'~~`
(Privacy Law, s. 15.04 (1) (m)]. ~~
Safety and Buildings Division
Bureau of Building. Water System
201 E. Washington Ave.
P.O. Box 7969
Madison, WI 53707-7969
~"~. C-'o1 K.
,,mate Sanitary Permit Number
f 3~Z
Check if revision to previous application
tate Plan 1.D. Number
L APPLICATION INFORMATION -PLEASE PRINT AL INFO MATT
Property Owner Name {;`,
n d a, h 1 ~.e.~ /=/a'~-fir -'PrU'p~rfy ion
~.ir4 s. _ 1/4, S / 7 T .29 . N, R 1 q,(or) W
Property O ner's Mailing Address Lot Number 3~ Block Number
City, State t
/-~a.dS~t*. taa. Zip Code
d'yvs(o Phone Number
(7i~>~Sb93oB Subdivision Name or CSM Number
a1-~'C V.'G~ 57~'a~'e5
II. TYPE OF BUILDING: (check one) ^ State Owned ^ ity
^ Vll age Nearest Road
~ L
~
^ Public 1 or 2 Famil Dwellin - No. of bedrooms Town of /~f dL
l
el.~
lll. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
~/
~ ~~ °~ 9 ~ ~ 9 . ~! T ~'`~j~ ~ ~~v~~
1 ^ Apartment /Condo
2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility
3 ^ Campground 7 ^ Merchandise: Sales/ Repairs 11 ^ Restaurant/ Bar/ Dining
4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash
5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable}
A) 1 _ ^ New 2- ^ Replacement 3. ~ Replacement of q_ ^ Reconnection of 5. Repair of an
i
~
xlst
ngSystem
______System ________System _____________ TankOnly______________ ExistingSystem_______
Date Issued
B) ^ A Sanitary Permit was previously issued. Permit Number ~~A,
~,,/~
/,
V. TYPE OF SYSTEM: (Check only one) ~ x ttoS = y9~ r r I'e.Ct'K~~--~t s~G~s(t~Q-S tx~r-" -
Y
Other
Non-Pressurized Distribution Pressurized Distribution Experimental
11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank
12 ^ Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy
~GXI
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l
~~
,S
A
t Privy
r 43 Q Vau
c
13 Seepage Pit P.'fs , ~`.~...~ -p -~/~ts~+N
14 ^System-In-Fill. ~' uY~S I ro5'~,oar rol-~ ~ $~~~~' ,
VI. ABSORPTION SYSTEM INFORMATION• ~~,b~~
1. Gallons Per Day 2. Absorp. Area 3. Abs 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Igs~'ws-~ .Elevation
D o ;Z (.~s-~~4 , ,~ ,g,~ .. ~O ~j Q-, S t . 7 s Feet Feet
VII. TANK
INFORMATION C pacity
in gallons
TOtal
l
# Of
k
Manufacturer's Name
Prefab.
Site
Con-
Steel
Fiber-
plastic
Exper.
i
i Ga
lons Tan
s concrete glass App.
New Ex
n
st strutted
Tanks Tanks
Septic Tank or Holding Tank pc~ o / O a-o ~ „~,d„p~-, ^ ^ ^ ^ ^
Lift Pump Tank /Siphon Chamber ^ ^ ^ ^ ^ ^
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name:{Print) Plumber's Signature: (No Stamps) MP/MPRSWNo.: Business Phone Number:
w a l+e ~- llle.e. ~ ~ : `/e, (~ aa7 Zt o z<s'- z - ~a a ~.
Plumber's Addres~ treet, City, State, Zi ~Co~ ~ ~ ~ 7 ~oZ
tt
oo
7
A
RT N
USE ONLY
IX. COUNTY /DEP
T
^ Disapproved S itary Permit Fee (~ndudes Groundwater ate Issue Issuing Agent Signature (NO Stamps)
,Approved
^ Owner Given Initial
' Surcharge Fee)
~
~~
l ~~
1
Adverse Determination ~
X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL:
SBD-6394 (H. OS/y4) DISTxIBUTION: Original to County, One copy To: Safety & &iilJings Divrion, Owner, Dlumber
.., ..,
w
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be property-maintained. The septic tank(s) must be pumped bya Ficensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-38,15. _ __
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one 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 Oniy~ ..~
X. County /Department Use Only.
Complete plans and specifications not smaller than 8 i/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 of 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; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 1 15 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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GVisconsin Department of Industry,
Labor and Human Relations
Division of Safety and Buildings
SOIL AND SITE EVALUATION
in accordance with s. ILHR 83.09, Wis.
Page ` of ?`
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must """"`y
include, but not limited to: vertical and horizontal reference point (BM), direction and ~~ Gi~D~•x
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
Dzo • //z 9 • y'O • ~av
APPLICANT INFORMATION -Please print all information. Re 'awed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ ~~ z_ Zf~
Property Owner r Property Location I'
%Q~I/VfJY ~ /~ ~T I ~'t.~~E/V /~Q~F Govt. Lot S~ 1/4N~ 1/4,S ~ 7 T 2~ ,N,R ~9 E (o W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
7 Pr~iPK GN • 33 1~~ ~ f'/%~"~ ~"s~,g?~S SST pD~T
City State Zip Code Phone N~u?mpb/er ,~ Nearest Road
NUD,JD~ ~ ~~ ~ Sys/(v ~ ~ 7!S Ddb ' X30 8 ^ City t~ ^ flag' ~ ~' Town ~ ~~Ipl~ L/V .
^ New Construction Use: Residential / Number of bedrooms ~ Addition to existing bpilding
^ Replacement ^ Public or commercial -Describe: /iL- / G E'T.s
~ -KEPht R of S~E~TtG T~l~k ovT~e•7'
Code derived daily flow ~~_ gpd Recommended design loading rate ~~ bed, gpdfft2 ~ trench, gpd/ft2
Ab~s'o~r~ption area required bed, ft2 ~ trench, ft2 Maximum design loading rate s bed, gpd/ft2 ' ~ trench, gpd/ft2
-F~ederht~ r~nfiltration surface elevation(s) ~/• 7.l ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material ~OESS DU~ .S/~'N f~ ~VTwi'I-SLt~ Flood plain elevation, if applicable N~f~- ft
S = Suitable for system Conventional M~ound/ In-Ground Pressure AT-Grade Syste 'n Fill Holdir
u = unsuitable for system ~ ^ u Ll~ ^ u 0~~^ u C~'~~^ u s r ^ u ^ S
SOIL DESCRIPTION REPORT
Boring #
/'
Ground
elev.
95.x°-ft.
Depth to
limiting
factor
~~.o
~ Boring #
.......E
Ground
elev.
ft.
Depth to
limiting
factor
in.
Horizon Depth Dominant Color Mottles T
t Structure i
c
C
t B
nda Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color ex
ure Gr. Sz. Sh. en
ons
s
e ou
ry Bed ,Trench
D•i ioy2 3/y L•~ /~,, ~ ~a~ w zf . 7 ~ •8
/D C2 '~° Sic- !~ ~ ~. -- . z; • 3
/O art ,~ C - •
7
r b I ~ i ^
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D d~ ~ ~ 's '
CST Name (Please Print) Signature Telephone No.
Ro[3et?T' ~~bJPicG~-r- 7/S• 38~' S/85
Address Ulbricht ~ Assoclatea %~ Date CST Number
Private Sawag® Consultants Q ' ~. ~~ 2ZC13 ~.S
Remarks:
PROPERTY OWNER
PARCEL I.D.#
Boring #
Ground
elev.
tt.
Depth to
limiting
factor
in.
Boring #
SOIL DESCRIPTION REPORT
Page of
Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench
Remarks:
,n
Ground
elev.
tt.
Depth to
limiting
factor
in.
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Boring #
Ground
elev.
ft.
Depth to
limiting
Horizon Depth Dominant Color Mottles T
t Structure isten
C B
da R
t GPD/ftz
in. Munsell Qu. Sz. Cont. Color ure
ex Gr. Sz. Sh. ons
ce ry
oun oo
s Bed ,Trench
Remarks:
factor
'n' Remarks:
SBDW-8330 (R. 08/95)
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ST CROIX COUN'T`Y
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
Mailing Address ',I N "~ ~a r^ k L-.ct ~ ~
Property Address 1-1 ~a ~„~ f-, ~ 1 n~
(Verification required from Planning Department for new construction)
City/State ,~~~~~;~-,s,y ~ ~ ~ Parcel Identification Number _ f ~ ~ ~ 19 ~f
LEGAL DESCRIPTION
Property Location '/., '/~, Sec. . T N-R W, Town of ~ .~'~-~-~~s.
a~.Qt., y ,ice-~.~ ~ ..oJ-~.o~.r~,4 ~-~ Q..~,~-~-~-- .Lot # 3~
Subdivision
Certified Survey Map # Volume _ ,Page #
Warranty Deed # ~ ~- 3 ~ ~ °~- .Volume ~ ~ ~ .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
masterplumber, journeyman plumber, restricted plumber or a licensed pumper 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
of the a year expirati n te.
/ /
A OF L C DATE
OWNER CERTIFICATION ~ ___-- ---
I (we) certify the ' 1 s is on t ' are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
operty crib a o a warranty deed recorded in Register of Deeds Oflce.
/ /
n_wr ~ err m n w nr r~ trr DA
/ ******
****** Any infonnat' n is mis-repr ented may result in the sanitary permit being revoked by the Zoning Department.
** Include with this n: 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. CROIX COUNTS ZONING OFFICE
CERTIFTCATIO~'( STATEMENT
'FOR UTILIZATION OF AN EXISTING SEPTIC TANK
~';rt ;'This is to cer_tify_that I.have inspected the septic tank presently
~r serving the ~ ~ ~ residence located at:
E~~
' ~ ~~ ; s ~ ~t , ~_ ; ~, Section ~ , T~N, R~W, Town of
M ~' 3 ~3 . lQct,~R- y-+~'~ ~e ~-IUpon inspection, I certify that I have found
`~~ the-tank and baffles to be in gooc; condition, and it appears to be
~ ~~ `functioning properly.
Last time serviced: /
-Did flow back occur from absorpti=:}n system?
Yes No (If nc.>, skip next line)
Approximate volume or length of ti,~e: gallons
Capacity:
Construction: Prefab Concrete_~__ Steel Other
Manufacturer: (If known) : (~ ~~ti `d-a® Qe.~
`~ a
{' ` Age of Tank (I f known) : 1 4 7 ,~1 2
~~, t
~.: -
,~ ~ ~
` ~~- (Signature )
,x~, ~~~~
,_
-(Title)
r ~~: = Date
•
minutes
(Name) Please print
(License Number)
.Form to be completed by licenser plumber. (s. 145.06, Wisconsin
~:. Statutes) or Licensed Disposer (}~~R 113 Wisconsin Administrative
. , ° Code) '
~, Plumber (applying for sanitary pex:mit) Certification:
~.
~~ 'In accepting the above statement regarding existing septic t~k
.condition, I certify that the tank to the best of my knowledge wi"11
conform to the requirements of ILA-i~2 83, Wis. Adm. Code (except fors
inspection opening -'over outlet ba~:fle) .
r,:
~~r;, Name l~ q,l ~'e.~- ~ ~ C.~~ ; l f e Signa~tu~•e~Q~R,..r~figP/MPRS ~ ~~ ~ l ~
,rv
~~
f
\~.
- -- ------ro~a
V~l..~.S~,OPAGC ~JS
EXISTING SEPTIC
SYSTEM AFFIDAVIT
Document Number
Name & Return Addre s ~~
w ~T 3 N .~.e ~ vYI ~- p/v~~
r--
/ - d
02o•~/z y• 90.0 i~.2g.iq.~ty
Computer I.D. Number Parcel I.D. Number
624597
KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
06-09-2400 2:00 PM
AFFIDAVIT
EXEMPT q
CERT COPY FEE:
COPY FEE: 2.00
TRANSFER FEE:
PA~DING FEE: 10.00
~ ~~-.~
The existing septic system which serves the dwelling being added on to must be verified by
an acceptable soil report or be inspected by a licensed soil tester for compliance with
high groundwater and/or bedrock separation requirements as set forth in s. COMM Chapter
83.10 (2) WI. Adm. Code. The results of that inspection must be made available to this
office. If the existing septic system meets these minimum requirements, and is properly
functioning, an addition may be added to the dwelling without updating that system. This
addition must not, however, encroach upon the required septic system setbacks as set forth
in s. COMM 83.10 (1).
Property Owner(s)
Property
`~
`~
O~ Property
~~Nv y ~~~~.~. h~~~
y~f7 l~~,P~ ~,v .
Mailing Address: ffyDSa'y ~(J~...S' sy0! `"~
Legal Description: Lot # ~~ ~SubdiV1S10n ~~/G+l U~~~ ~ST~TTE~
sTff D17~"f=
Sc~ ~s, ' " ~~s, Sec. ~ ` , T Z / N-R~W, Town of /~LI~.S~^~
Comments: The existing septic system was sized and installed for a three bedroom dwelling.
The repair project involves replacing a broken pipe between the two existing dry-wells with
an approved plumbing pipe. A soil test conducted by Robert Ulbricht, revealed t.ha;. c.._
existing septic system had 3-feet of suitable soil beneath the existing system. T'he septic
system was originally designed for a three-bedroom home, since that installation a fourth
bedroom was added, thus making the septic system undersized according to Comm 83.055.
I, as the owner of the above described property, hereby affirm that the septic system
serving this dwelling meets the above referenced state private sewage system codes.
realize that the previous addition of a fourth bedroom caused the existing seot;,:• s~,s~~r~ '
become undersized according to the State Private Sewage Code (Comm83). I will make tri:~
information available to any future parties interested in purchasing this property.
Signed:
Date: („ 1 `'1 I O 0
Zoning Dep ~ent F
Approval:
Date: Q
Notary public Subscribed and
sworn to before me on this date:
Un ~~-----------___
commission expires:
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EXISTING SEPTIC
SYSTEM AFFIDAVIT
Document Number
Name & Return Addre" ~s ~S'
GtJ LT s N /~-C G U~// '' P~U~.
~ - d
Computer I.D. Number
Mailing
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4Y~ Pte- ~"''~
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The existing septic system which serves the dwelling being added on to must be verified by
an acceptable soil report or be inspected by a licensed soil tester for compliance with
high groundwater and/or bedrock separation requirements as set forth in s. COMM Chapter
83.10 (2) WI. Adm. Code. The results of that inspection must be made available to this
office. If the existing septic system meets these minimum requirements, and is properly
functioning, an addition may be added to the dwelling without updating that system. This
addition must not, however, encroach upon the required septic system setbacks as set forth
in s. COMM 83.10 (1).
Property Owner(s)
Q~
'Property
`~
`~
O~ Property
r~.2q. ~q .qty
Parcel I.D. Number
y~f 7 ~,L~~iP~ GN • ,' n
Address: ~! V ~S ~'v K! ~-~ - s~~~ `-~
Legal Description: Lot # 33 ta3M~Subaivision ~~/~~l ~/~~~ ~ST~TES
~j ST f~0l~rT
SeJ '~, ~~'~, Sec. ~ ~ , T 2 / N-R~W, Town of ~Vv.S~~
Comments: The existing septic system was sized and installed for a three bedroom dwelling.
The repair project involves replacing a broken pipe between the two existing dry-wells with
an approved plumbing pipe. A soil test conducted by Robert Ulbricht, revealed that t~:~~
existing septic system had 3-feet of suitable soil beneath the existing system. The septic
system was originally designed for a three-bedroom home, since that installation a fourth
bedroom was added, thus making the septic system undersized according to Comm 83.055.
I, as the owner of the above described property, hereby affirm that the septic system
serving this dwelling meets the above referenced state private sewage system codes.
realize that the previous addition of a fourth bedroom caused the existing serr.i;~ ys!_e_r~~.
become undersized according to the State Private Sewage Code (Comm83). I will make this
information available to any future parties interested in purchasing this property.
Signed:
Date : ~`~ 1 0 0
Zoning Dep ~ent ti
Approval: ~~~_-~~j7~' /~
Date : 'I
Notary Public Subscribed and
sworn to before me on this date:
~~~T acx~__________ .
My~1ommission expires:
~o1~G~
^ ~~~~~~~11TTE W~~~i
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ttTATE B/13_41 gWISCONSiN ><.Uyry~ ! - lifll
14~ l (~ P6"f ~ { t
„~_~~~~,_.W*_ JOHd~;SON.-and.-SHERYL...K.. JOHNSONR_ ___.
...x11i1~~14d~1S'~...~5~,. M~ ~`it.. A~...~Q ~:D ~.. ~gnan~:s ~ .......................
.......G~~n~srx~.......... ••-- --..
a^~rcya sad warrants a ...FZA.N~iX_.~t2~')?'..~tiSI;..K~T.~~~r~N..x4F:?+'.~....
.........husband..and..>~ct ~,...as..aurvlx~rsr~.. ma~i.~~......
..----.Gran.lesa* ........................................................ _..._.... .......
tM toUowins dsserlbed teat esaa ta .......5~....Cx'G~)f. ...................Conn4.
aaa oc Whsoasin:
Lot 33, Park View L~tates First Addition
to the Town of Hudson..
('~,cri
is
This ............................ homestead property.
(Is) (~ ~)
REGISTERS OF~C!
ST. CRt~iX LO., WiS~
R~'Id. l+or R~aord t~Ib~ 17th
t _nn_p . w
nm,Rn -ro
Tsa: Past No : ..............................
Ezception to warranties: Subject to easements, reservations, -
restrictions and rights-of-way of record, if any.
Dated. this ................................................ day o! .......-.---------•----------._...------ -......................... 19...87..
---------------(SEAL) ......... _. ...._................(SEAL)
• ...............................................................•-- • _, Richard W.:..........nson
---•--.. (SEAL) ..~~2.'.~.".'.. ~ ................................. (SEAL)
Sheryl K. Johnson
•IIT8>iNTIOATION
Si~natnre (r)
anthmtieated this _~.~_.dq a~______________•-_-.__.._, Iti....--
TITLTS: YE1[BE$ STATE BAR 0! WISCONSIN
(u~t, ----------•---------------------------•-----....------------
aathorissd b7 ~ 90A.OQ. Wis. Stata.I
TMIa INfTRUMENT WAf DRA/T[D aY
,__,___ Robert. W._ Mudge_s__ Attornex_ _ _
,______.IiUDSONr __WI 54016
a(8ei ~ a~•be authenticated or acknowledged. Both
ACSNOWLaDGI[liNT
STATE OP WISCONSIN
... St:.__~roix ____.._.... Coanty.
~~
personally came before me this .._/~_~.....aay of
----._._~~~ ............... 1>t.$~.._ the above named
Richard W. Johnson and
_Shery_1__K,__Johnson,___his wife
to me known to bs the person ~._...._... who executed the
foregoing went d acknowled~t~ the lame.
_ ~ .. ~ . ,~ i::'Y ice, a.
d ' .+M l!NG~„x•,' YiA i; ~.~y 4j
Notary Public -----St.--_CroiX---------•----.County, Wis.
My Commission is permane~ntj,(If not, state ezpi on
date:.-~?_G.~~+--.~Y=.....----•-------•- -+ 1s..)
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