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~ o °~' ° °~' ° I N y I M d9 I N N Oq +~ a ~ I I ~ ! I I O L Ol ~ I I d q I I ~ I oyi a I I h ~ I I ayi ~ 0 I z ayi U Z o I ~ Z I i , ~ c ~ c I t L I u . 3 ~ •~ I c 3 ¢w I ~ a I I ~ I M ' ~o ~ ~ I ~ I m I ~ w z ~ I I ~ I I ~ v I o I ~~ I ,, ~ ~ a m II € m I '~~ I o I o Z~ c ~ v f ~ r > w > ~ I Y w o I in H r ', ~ ~ m ~ n ~ z I ~ I U ~ ~ ~ .p M N ~ ' N O1 ~ co m ~ I ~ _ ~ ~ y N y f N ~ ~ N O "~ z°mz I z° cZ N - y z I .. ~ °' I .. m E ~ I N in R E O 1p ~ ? LLJ ai ~ .. N a~ w ~ ~ ~ .. N I a '~ .`. •°. y I ~ ~n ~ ` ~' $ I ' ` ~ °' ~ o o a > c o a j o N ~ J~~ V'~lJ a~ vr~v~Vr> 1O ~ ~ n' u~ I corNtovr> ° ~ °' °° o ~ 3 3 °aaa I 3 3 ~aaa Z o • r ~ ~ f ~ ~ ~ I ~ I ~ •o I .'.. J >> ? 0 0 y C O O O O . N y 2 fA V '. C~~ y ` ~ N = N N } p ~p 0 ~~~ ~~~' A N N !C 2 ~ p Z~ 0 N O = O CD O w •= ~ ~ ~~ CO p 0 0 0 C 7 E N ~ N o I m y } C ~ y I Ql m ~ C A ~ ~ ~p d ~ Q (/~ ~ d fn Q m '', a~i y y I ~ H y ~ I '~ p O ~ V! C . ~ H = O ~ M N ~ i O ~ I ~ ~ ~ a 0 0 1 ~' ~ ~ ~ ~ ! `~° ~ ~ ~ ~ ~ ~ ~ ~ M I V w ~ O ~ ~ ~ i d OOD y ~ ~ w ~ CO n 1~ N ~ M ~ ~ CO y w ~ ~ ~ M ad+ N > I ~ L l0 I • o ~ 2 '', ~ ~ N Z ~ 2 I o M o Z ~ Y ~ fA r ~ xt ~` ~ a E v dt a L I i~ a ~, I :: a ~, I `Iv ~ E ~ '~ c :: ~ 3 ' I r t A vat ',Ov~icv I ~ o owv r - ~~ ~,a~~,~ ~/ - q3 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. Water (VOC's) $185.00 ^ Septic $25.00 ^ Water('(~Nitrate~& Bacteria) $35.00 (Visual inspection) Owner: I~"E-i'- ~,.JO L.~J " ~ C~ei~~ Requested by: i ~"'~~exc~. ~~~osse Address : q '? 1 h! CtZT R Address : a,nd ~ City & State: ~uc~QS© /~I , WI City & St. ~4,~ds~~ w ~ , Zip Code :'540 / (, Zip Code : s~lo~to Telephone N°: ("CIS) 38t=- 65zz Telephone N°: ( )n Property address (Fire N4 & Street) : 9-l l L~L~2-T 2t1J Location: ',, ~, Sec. 17 , T Z~_N, RAW, Town of t-Iu Sct~! St. Croix Co. , WI. Tax 3D N4 Parcel TD N4 L.~7T''~ 69 od0-I,~I~-3o House color:~2oW1~1 Realty firm: ---' Lock Box Combo: water sample tap location: [-3y ~iZ~NT 1Joc2 EAST~"v~C,lw~4~ LyAt.L . TO BE COMPLETED BY :PROPERTY. OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE. OF THIS FORM Is the dwel-ling currently occupied? ~ Yes ^ No If vacant, date last. occupied: _ Septic system installed by: Year: Septic tank last serviced by: Date: Previous Owner's Name (s) : --~ -- ,-__ i' •~~ Have any of the following been observed? ,. ~"~ `` ~ ~ `~ ^Y ^N Slow drainage from house . P ~ Y' .~ . ^Y ON Sewage Back-up into dwelling. ~ s;•,',:~'~`-' ~ ^Y ON Sewage discharge to ground surfa e.~ ~`` ~ ., ',''~~ ~ ~ . ,;- '' road ditch or body of water. ~~ ~1~`'~. %- V ^Y ^N Slow drainage from the dwelling. ~ ' .~~?~; ~ ^Y ^N Foul odors. ~;,' ~~'~`~~;-,<' /,~ Other comments relative to system operation: y~ ~ •`c~"~ . ~ I certify that the above information is complete and true to the best of my knowledge. ~) OWNERS SIGNATURE: ~~}kac,t~~, C~=_~~ DATE: "'~~a~i3 ~9v 1~~w-+~A~ `1-s~a-a' ~ ~~9.~~. 3 0 ~4` . 1•-4..t~ ~w1~..5 ~ OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION 4 I~ TO BE COMPLETED BY INSPECTION AGENCY. System design &/or permit on file? ^Yes ^No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ^Below grd ^At-Grd ^Mound Approx. size 'X ^Gravity ^Dose OPressurized Ft.2 ^Bed ^Trench ^Dry We11 ^Holding Tank ^Outfall pipe OBSERVED DEFICIENCIES ^Other ^Unknown Septic tank Setbacks: ^House ^We•11 ^Prop. line ^Other Dose tank Setbacks: ^House.. ^Well ^Prbp.~line ^Other ^Locking-cover ^Warning label ^Pump/Floats" ^Alarm ^Elec. wiring Soil Absorption System Setbacks: OHouse ^Well ^Prop. line OOther ^Pondings ^Discharge: General comments: SERCO Laboratories 1931 West County Road C2. St. Paut. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 32756 08/13/93 St. Croix County Zoning 1101 Carmichael Hudson,- WI 54016 Attn: Mary J. Jenkins ' SERCO SAMPLE NO: SAMPLE DESCRIPTION: ANALYSIS: DATE COLLECTED: .DATE RECEIVED: COLLECTED BY DELIVERED BY SAMPLE TYPE 95013 DOLD VOC Benzene, ug/L <1.0 Bromobenzene, ug/L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L'(Methyl-bromide) <1.0 n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon. tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl-chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 4-Chlorotoluene, ug/L-(p-Chlorotoluene) <0.2 Dibromochloromethane,`ug/L' <0.4 1,2-Dibromo-3-chloropropane, ug/L <1.2 1,2-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L (m-Dichlorobenzene) < means "not detected at this level". <1.0 <1.0 1 mg = 1000 ug. ~ ~ ~~ / ,, r w d,Wgorvorn i~~To 08/13/93 PAGE 1 of 3 07/28/93 07/29/93 CLIENT. CLIENT DRINKING WATER J ~o R~~~ 1993 1 o' ~~ 5~ ~r ~~ Z~ PAGE 2 of 3 SERCO SAMPLE NO: ~~~~~ SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 32756 08/13/93 SERCO SAMPLE NO: 95013 SAMPLE DESCRIPTION: DOLD VOC ANALYSIS: ----------------------- 1,1,2-Trichloroethane, ----------------- ug/L -------- <0.1 Trichloroethene, ug/L 34 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <0.2 1,3,5-Trimethylbenzene, ug/L <0.3 (Mesitylene) Vinyl chloride., ug/L <1.0 Total Xylene, ug/L <1.0 PAGE 3 of 3 D'37~8/i~/~~, This sample's analytical results ,~r~/ are n°e ~ below the U.S. EPA's SDWA Maximum Contaminant level of 1/30/91 for those requested compounds. which are also on the SDWA MCL list. The analytical results in this report pertain only to the items tested. All analyses were performed using EPA or state approved methodologies. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 dais from the date,of this .report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reprocluced, except in its entirety, without prior written approval from `SERCO` Laboratories. Report submitted by, Diane J. A derson Project Manager < means "not detected at this level". 1 mg = 1000 ug. a 4 ~yL ~ ~Y ST. CR®!X CClJiVTI' W6SCO~S6i~ PLANNfNG & DEVELOPMENT PLANNING SOLID WASTE REAL PROPERTY ZONING 715-386-4674 715-386-4623 715-386-4677 715-386-4680 August 18, 1993 Mr. & Mrs. Peter Dold 971 Wert Road Hudson, WI 54016 Dear Mr. & Mrs. Dold: Enclosed you will find the results of the laboratory testing on a water sample which was taken from the property located at 971 Wert Road, Hudson, WI. There are some unusually high readings noted-1,1,1-Trichloroethane, ug/L and Trichloroethene, ug/L. Unfortunately, the Zoning office is not familiar enough about this type analysis to give you any specifics. Please contact Pat Collins at the Department of Natural Resources, 990 Hillcrest Street, Baldwin, WI (715)684-2914 with any questions you may have. Sincerely, Mary Jenkins Assistant Zoning Administrator mij Enc: ST. CROIX COUNTY GOVERNMENT CENTER • 1 101 CARMICHAEL ROAD • HUDSON, WI 54016 Wisconsin Department of Commerce PRIVATE SEWAGE 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)(m)], Permit Holder's Name: ^ City ^ Village ^~own of: old Pe er M Hudson Township CST BM Elev.: Insp. BM Elev.: BM Description: TANK INFORMATION S LEVATION DATA TYPE MANUFACTURER CAPACITY Septic ~ t; Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septic > ZS ~ ~ Flo' NA Dosing ~ NA Aeration NA Halding PUMP /SIPHON INFORMATION ~- Manufacturer ~ Demand Model Number GPM TDH Li Lriction SYS TDH Ft Fo cemain Length Dia. H Dist. Toweu SOIL ~SO.~PTION SYSTEM ~Z J,,,.~ ~ County: St. Croix Sanitary Permit No.: 363880 State Plan ID No.: Parcel Tax No.: 020-1145-30-000 ~~•Z9•~9i '11oZ. STATION BS HI FS ELEV. Benchmark a?•~ uZ-`BI DO , O ~ Alt. BM Bldg. Sewer St/Ht Inlet St / Ht Outlet ~. Z(vr ~ ` Dt Inlet - - Dt Bottom Header! Man ' ~2 9 `~ a9i Dist. Pipe ~ © O •~ t c~ off, r Bot. System !O' (° 4a. ~-! ` al Grade 3. (0 1 ,ZD St cover -3 `~ ~ o~ TRENCH Width i Le h ~. r No Of T nches PIT No. Of Pits Inside Dia. Liquid Depth DIME DIMEN I N SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manu rer: S~~ v SETBACK c ~ INFORMATION Type O ~ r CHAMBER Model Numbed: System: >~s 3D "' b I - OR UNIT 1i.4-: ~ Qu DISTRIBUTION SYSTEM ~-"" fq') ~ U Header /AAanifold N / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Qi Dia. ~ Leng Spacing r SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: D(o/0~/ aU Inspection #2: / / Location: 971 Wert Road, Huds nq „WI 54016 (SW 1/4 NE 114 17 T29N R19W) - 17.29.19.762 Parkview Estates -Lot 69 1.) Alt BM Description = /~O"`~- -~~. , 2.) Bldg sewer length = '• S~ ; ,yc~s' -amount of cover = ~ Z Plan revision required? ^ Yes ~ No Use other side for additional information. SBD-6710 (R.3/97) ~KD D~ o} w ~ ~ S Date Inspector's Signature Cert. No. SANITARY PERMIT APP `~ Safety and Buildings Division ngton Avenue P o x 7 SC011S%11 ~ r f ` ~ Bo 302 Department of Commerce In accord with Comm 83.05, - ~ ' Madison, WI 53707-7302 ~ • Attach complete plans (to the county copy only) for the sys n p 4f; ' ss Couftty ~ than 8 1/2 x 11 inches in size. ~~ -~CtJ r~:-L-- C ~ • See reverse side for instructions for completing this applic ti~i q r tr R ' State Sanitary Permit Number ~~ ~ ~ t ~( ~ i~w _ ~ ~~ Personal information you provide may be used: for secondary purposes ~~~ t ST C~iX ^Ghedk if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. -'`~ ' ` (~CJlff'i~Y ce Ian LD. Number ..~ . I. APPLICATION INFORMATION -PLEA E PRINT ALL I ~~~ --° `` P y Owner Na a ~ L ~ .= 1~ o /¢ ~i/ N R E (or~ /7' T ~ C v j , ` , ProtZerty Owner's Mailing Add ~~ Lot Nu ~ ~ Block Number City, SUte ` ~, Z~C~~ ~ Phone Number - ' (• - Subdivisi Name or CSM Numl~r d~ ~~ ) ~ II. TYPE F B ILDING: (check one) ^ State Owned ~ ^ Ity ^ Vll age Nearest Road , ~ 1 ~ Public 1 or 2 Famil Dwellin - No. of bedrooms Town OF ~) III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) I ~ • ~~ ' `q • ~ ~~ l ~ 1 ^ Apartment /Condo ~ ~-' ~ - ~'!'?~7 y~ ~ 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) q) 1 _ ^ New 2.~ Replacement 3. ^ Replacement of 4. ^ Reconnection of S_ ^ Repair of an ______System _____-__System_____________TankOnly______ ___-____ Existing system ____-____Existingsystem 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 ^ Moun _______ 30 ^ Specify T pe 41 ^ Holding Tank ~ 12~,Seepage Tre Z2 ^ In-Grgand Pressure 13 ^ See a e t tS~IN 1/ 'I ~ i N TANK 1 QO0 5'~~ 6 w _ 42 ^ Pit Privy I x ~~' ~ 43 ^ Vault Priv p g . ~ k . . y 14 ^ System-I Fill ~wSfid~j/N A ~ Uv y„~ ~Qp, N'~'~ VI. ABSORPTIO 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade ~ Requ a (sq. ft.) ~ Pro os~d (sq. ft.) (Gals/day/sq. ft.) (Min./inch) E levation ~ ~ . a-~ Feet ,~~ Feet VII. TANK INFORMATION Capactt in altos Total Gallons # of Tanks Manufacturer s Name Prefab. concrete Site steel Fiber- glass Plastic Exper. App New Existin strutted Septic Tank or Holding Tank ~ f V~ o ~S 1~ ^ ^ ^ ^ ^ 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 Na Print) Plumber's Si nature: (No Stamps) MP/MPRSW No.: Business Phone Number: -NI .. , ~t%1.~~.>-~n I~ ~ .;.__ ~.,,.,,, p~~. _J'I :7~1~',~.L ~1~~i _ ~,4~i_.._ ~f~~~°ri^, Plumber"s Address,(S reet, City, State, Z Code): ` I IX. COUNTY /DEPARTMENT USE O ^ Disapproved ,Approved ^ Owner Given Initial 7/'v' Adverse Determination X. CONDITIONS _AP ROVA~/ RE ~ ~ ~° is Std. Sanitary Permit Fee (Includes Groundwater ate ssued Issuing Agent Signature (No Stamps) ~j Surcharge Fee) r -SONS FOR DIS/APPROVAL: _ n ~ ~ ~~ Si!r ~ ~-~ t5 S t~c~- ~ °`- n .. n_ . __ __ t. _ •~ (R. 499) 'J ' '- DISTRIBUTION: Original to Cd~nty, One copy To: Safety 8 Buiktings Division, Owner, Plumber 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 toinstallation - 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a Ciceri"sedpumper vJhenever 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 Di-visioc~, 60&266-3151. ~ - - - - - - - - - - - ~ - To be complete-and accurate. this sanitary permit application must include: !. 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 6 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, ete.}, 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 follovving:`A) plot plan, drawn to scale"or with complete dimensions, location of holding tank(, 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 s8ction of the soil absorption system if required by the county"`F) soil test data on a 115 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 cari effect groundwater. _ The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ----- ---------------- - • _ _PR, . 7 Ti• - AI, ia anct Si cle_.i.0 h6ciars_. a ' ' iI I a i i // I // _ . PY iti a�J • . A 41, .1! sir As n, - 1 V I% ! ' V g EX,StJNS V SyS�fr. ? a J -nJs-'el) Bun RAN VA)ve r 8 poo a _ 2 l.Ian,.r I tip 8-3 04,ell a,) 3 PPck p TRD 3x 75 Ba r 00 1ioJ.t r / (DS' to Le I I Fio n, 51 s` e O= ( 1:01) Roles 13.euci. 17IAek QeitoYll of 5;4;Ny ,I-9v- )vu. U • JN III Iliiiiliiiluom I�N� s II I liiiiilllulv'I'I 9a. d5 111'1111IllhiiiiiIffl riNp► GRp� a) as ro al plip iiililll L 6 . a) cp .�n� , 111IIIIiiOIIIIIIllII__ `� �" Illliiiiiii A E �-- 01 IIIII� � � Zo c ►- ® ill •�Ilr�illilli�l,�l i cSI��1111i Iill U E W1•11. I ! III 1111CI I 0 3 aiQEav l lliili�iil� • 412` 3 0 f IMMO o , _��IIlilli�i,/l M oo1 — I ��IIIIIIiII w cn .� -no a. W -� illy illlllllll 7 a _ NQ ( I , i ai t! ! fl as U -J �� _c ) L >, N t c 2) o) _c /� c0 `a v n o)5 Q.0) 2 I N (� 0) V♦U = ``vaoaoav��vP o J u 0 = cn N (n `IT ' a . . . • ~, Wisconsin Department of Commerce ~ Division of Safety and Buildings SOIL AND SIT ,~~~T`ION in accord with Com 8 ~; Wis. A~n. Code Page 1 of 3 A.C.E. Soil & Site Evaluations r,,~f"°: eC' Attach complete site plan ~ paper not less than 8%z x 11 inches in size. P `st , : _r,; ~.: ~~ f~ ~ ` ' ~ County and include, but not limited to: vertical arxf horizont~ t~erence point (BAA), di ~ St. Croix pert~nt slope, scale a dimemsia~s, north arrow, and location and dis i road• ~~, ~, Parcel I.D.# r --,__ a=~ PLICANT INFORMATION ` ~ 6 020-1145-30 ID# 17.29.19. 7~2 ~ , ~ AP - p/ease print all inform A. T ~-~+' '" Date d B R h ~ Personal information you provide may t~ used for secondary purposes (Privacy La s,.~5.04 (1) (~N* y evi we t ; y Property Owner ~`+,pe~Y Lora ,':.~` -;r---- Peter Dold 9t~"-- _ _ __K• 3/ NE 1/4 S 17 T 29 N,R 19 W Property Owner's Mailing Address Lot I # ubd. Name or CSM# 971 Wert Road 69 Parkview Estates City State Zip Code PhoneNumber ~ City ~ Village ~7own Nearest Road Hudson WI 54016 715-386-6522 Hudson ~ Wert Road ~ Residential / Number of bedrooms 4 ^Addition to existing building ^ New Construction Use: ® Replacement [] Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate •7 bed, gpd/ftz •8 ~~, 9l Absorption area required 857 bed, ft2 750 trench, ft2 Maximum design loading rate .7 bed, gpd/ftz •8 trench, 9pd~ Recommended infiltration surface elevation(s) 92.2x. ft (as referred to site plan benchmark) Additional design /Site eonsiderationS ~~ trenches using high capacity infiltrators. htstall Bull run valve to albw future use of existing hydrolically Parent material Glacial outwash ~ ~ Fkxxf lain elevation, ff a ble NA 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 SOIL CESCRIPTION KCPUK 1 Boring# 1 Ground elev 98.56' ft Depth to limiting factor ,,,~" 2 Ground elev 99.21' ft Depth to limiting factor 123" Depth Dominant Color Mottles Structure n C i t t3ounda Roots ~~~ Horizon in. MunseO Qu. Sz. Cont. Color Texture ~. Sz. Sh. ons s e ry ged ~, Trench 1 0-10 10yr2/1 None sl 2fsbk mvfr as 2f,lm 0.5 ~ 0.6 2 10-26 10yr3/4 None is Osg ml cs 2f,lm 0.7 0.8 3 26-84 10yr5/4 None s Osg dl gs - 0.7 ~ 0.8 4 84-119 10yr6/4 None s Osg dl - - 0.7 0.8 Rz•ZS ~5.~z ltl.~Z, Remarks: 1 0-10 10yr2/1 None sl 2fsbk mvfr as 2flm 0.5 0.6 2 10-25 10yr3/4 None Is Osg ml cs 2flm 0.7 ~~ 0.8 3 25-91 10yr5/4 None s Osg dl gs - 0.7 0.8 4 91-126 10yr6/4 None s Osg dl - - 0.7 0.8 . SZ- It I.~Z Remarks: CST Name (Please Print) Signatu ~ Telephone No. James K. Thompson s 715-248-7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, 54020 4/24/00 3602 1209 w PROPERTY OWNER: Peter Dold PARCEL I.D.# 020-1145-30 IA# 17.29.19 3 Ground efev 98.87' ft Depth to limiting factor 121' SOIL DESCRIPTION REPORT Honzon Depth in. Dominant Color Muns~ MotOes Qu. Sz Cant. Color Structure Tex41re Gr. Sz Sh. ce Boundary Rods GPOVttz - - - -T - - -- Bed ~ Trench 1 0-8 IOyr2/1 None sl 2fsbk mvfr as 2f,lm 0.5 ~ 0.6 2 8-21 10yr3/4 None is Osg ml cs 2f,lm 0.7 ~, 0.8 3 21-80 10yr5/4 None s Osg dl gs - 0.7 ~ 0.8 4 80-121 10yr6/4 None s Osg dl - - 0.7 ~ 0.8 '~~Y ris. rtemancs: Ground efev Depth to limiting factor Ground elev Depth to Limiting factor Ground efev 12~ Page 2 of 3 A C F Cnil Rc Cite F.valuatinnc Depth to limiting factor . ~ __ ^ 50;1 C~b~e~c~-~~ p, ~ ~ Ele~afoh a~ QX~S~:ng grade II~ v JSCLi~C: ~ ~= ~~ w,e~~ l~d 3y0. Gd ~~ z~~= ~Wne~: P~-- ~~ 9 7/ rve~~ ~~! sya/G 3s<O.~' Loco-~ on Cod (09, Ru~S'd~e~ Es~afe: SwS'ynEyy, See. i7,T.19~1., SE, C~oir co., ~~ ~~. 3oF3 ~8o~.n o~ s;d; ~. ~. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the z -Q,~- ~c ~~ reside``n~~ce located at: i ~,~_~, Sec. 1? , T a ~ N, R ( W, Town of N u DSON , St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good c ndition, and it appears to be functioning properly. Last time serviced ~~ ~ a I ~ UU Did flow back occur from absorption system? Yes No (if no, skip next line. Approximate volume or length of time: Capacity: (~ (~ ~1 p ~ Construction: Prefa~ Concrete ~/ Manufacturer ( i f known) : ~ ~ 3 e ~'i- Age of Tank ( if known) : ~ ~ ~~~.~ (Sigrn~ature) 1 (Title) ~ ~b~0 (Date) ~ ~• ~c~ ~a r~-ecs ~ ~ f? (Name) Please Print a as ~v,y~ (License Number) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet,~baffle). Name .~ 1~^ ~c+ ~;r~ e ~ S~-t,~(, S ignature ,~~'~ a ,~ MP/MPRS ~, a G` gallons minutes Steel Other ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer I°~ r _T~. Mailing Address t' ~~ ~ ~-= ~~ ~ ~ Properly Address ~ ~ ~ ~~ ~'~`[- ~C~ ~~,. (Verification required from Planning Department for new construction) City/State t-d-UCH ,. L~ ~ Parcel Identification Number ~ ~ ~ _ i l ~~ - 3 0 LEGAL DESCRL~ON Property Location ~ Lam' '/s, ~C '/,, Sec. ~ `1 . T ~ ~ N-R ~ `~ W, Town of I '~ 5~~~ Subdivision n~ 2K U i G Ly ~ S ~~-T~S ,Lot # ~ `~ Certified Survey Map # __ / "~~ Volume .Page # Warranty Deed # ~ `l'~. to Volume g Page # --~j~~,_ Spec house ^ yes ^ no Lot lines identifiable ^ yes ^ no :,~ S_ ~_ '~1~ MAINTENANCE Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Pmper msintenaace 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 fon~, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licxnsed pumper verifying that (1) the on-site wastewaterdiaposal system is in proper operating condition andlor (2) after inspection and pumping (if necessary), the septic tank is less. than 1/3 titll of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with tlta standards set forth, hereiq as set by the Department ofCommerce snd the Department of Natural Resources, State of Wisco~in. Certification stating that your septic system has been maiwtained must be completed and returned to the St. Croix County Zoning Office within 30 o e e y expire ' n date. .5 ~.~ ~ Zoe SIGNATURE OF IC DATB OWNER CERTIF>[rATION we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners} of 'bed b v of a'warrauty deed recorded in Register of Deeds Office. pJ t5/~~ SI TURE OF ICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Deparhnent. ****** ** 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 ~, } " DOCUMENT 1V0. ~ STATE BAIL OF WISCONSID', FORM 1-ia8! WARRANTY DEED s Thi$ Deed, made between --Donald J. S*_eph2ns sad Lori. -3.--Stephens,-•husband and wife -•-•.•••.--,.-•---• -•, - , --............ ......... ........-•---•-••--•--•--...., Grantor, and......Peter-M.,-Dold--and.-Patric ia..K...Dold-,.-husband--and-•--••- wife,as_~oigt.• tenants.. _ . ......... ............... ...• - •---..........._.._. • ........................._ ..........................._•-.-°-...............----•-•-••-•---•--., Grantee, Witnesseth, That the said Grantor, for a valuabI~ consideratioa...._. conveys to Grantee the following described :•. al estate in ..._.~t,-. CrOi;X-•, County, State of Wisconsin: TNIa \-A<a 11[KIIYL!1 IOa IItC01101M7 DATA ~~~ ~f~ Rac'd, f;;r ~~cord fi?s 25th day of May A. D. 19 84 at_12:30 P _~, TO Lot 69, Park View Estates Second Addition to the Town of Hudson, St . Croix County, Wisconsin. Ta: Parcel No: ~' This _......_i$_._-----___. homestead property. (is) (iscxa~ Together with all and angular the hereditamenta and appurtenances thereunto belonging; And-......---Donald - J ..- Ste-phens .anti. Lori _J ..,-Stephens___.__-.- warrants that the title is gvod, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and will warrant and defend the same. Da*.ed this -_ ............._2,5th.-------------.-... day of (SEAL k . - - _. --- - - ----- - -- ---- - - -(SEAL AUTHENTICATION ...- - May -- - --- ---- --- - -----_.......------., 1984..... / .._. D /~ _..uG:O~.y!~~ ~ ...... . .. .......(SEALS DONALD J. STEPHENS . -... _-./)n` 'J ~~ •,(~.~.---".. _.- . -- -(SEAL) LORI J. STCPHE_NS Signature(s) _.__Donald_..1..__°iephens._and.i.o_ti. J. Stephens authenticated thi~.~3. a• ; .,._.:~Iay ............. l9.$4.. ~.~ ~i~ AMU EL CAR I TIT E: bIBER STATE BAR OF WISCONSIN (IP not- -- ------ ------- ----------- ----------------- --------- - at~thorized b~• ~ 106.06, Wis. Stats.) ?NIS LN 37RUMEN7 WAS DRAFTED BY HE`fW00D, CARI & ^!L`RRAY by Sanuel R. Cari P.O. BOX 2Z9~ HadSC~,..1.i-I----~+Ql~?•--•-------~----------------------------- ACBNOW LEDCiMENT STATE OF WISCONSIN -• ' ss. - { ......................•---•------.County. Personally came before me this ................day of ---.~_.•-•---.•.-•-------------------------- 19........ the above named to Ime known ±o he the person ._. _....._. who executed the fvr~ doing in.~trurrent and acknowle~lge the same. Votary Public -.-.__.-----.•--•---•--------------•----County, Wis. %~. ~ ~ e lJ .~ F ~s~ O Q. M) OO ~ O o ~, o fh 0 z 62 1.71 ACRES O O 0 t° o o ~ O N Z 61 1.72 ACRES 2~'So O6 , ~ SS,. 15 ~, 248.92' I 300.00' ~o WERT 828.84' N 89°52'40"W ® ~ - - - 829.27' S 89° 52' 40" E ~ ~ ~0 200.00' 200.00' 200.( a ~OQ' ~ / ~ ~n~ 24.19 ~ ~ , ^,~ / ~ ~ ~ 3 M O ~/ / 6 8 tC o S~ 1.56 ACRES ~ M ® 134°S3'05~~ z 6' 6' ~'~ ~~ M z ~~ gd,~g~ 2 2 5.0 0 ti ~ ° 9 W ~ 9F e 69 1.56 ACRES 200.00' ~ 3 ~ ,o,, I I I ~ 3 ~ o ~, I q M ~ .o ~o ~; 2 i 3 ~ o ~ -- J O M I Z ,` I 0 3~ ~6 I 6 s' 9° I I I -- 6 6.00~~ NORTHERLY RIGHT-OF-wAY SINE OF G 9° 15 14 E - - _, ______!_GREEN _____. LANDS O ~ 70 0 M 1.56 ACRES 200.00' 1050.00' O ° 71 ~ 1.56 AC M ~ 200.0 S 89°52~ 40" E 1 I I I ~~ ~ ~ ~` ~ 4 I 5 ~ -- I -- I I I 1 I I REEN MILL LANE ~p MILL `D ~~ z REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM SanL any PenmLt• - " . . State Septic_ NAME Township L7' ��%e St. Cno.ix County . Location Section SEPTIC TANK , 6 9 { t,, Size moo gattonb . Numbers ofi Compan.tment4 / Distance Fnom: Wett `1 12% on greaten 4.tope �t • Bu.i.Cd.ing j{.'; WeUQanda _ 6t. H.ighwa.ten DISPOSAL SYSTEM - Distance Fnom: WeLl 6t. . 12% on greaten ..Lope - 6t. Bu.i 2d ing; ( st. W etLandd Ft. • H.ighwaten St. FIELD DIMENSIONS: Width off' trench St. Depth ofi /Lock below t.i.Ce / ,- in. Length ofi each tine '! fit. Depth ofi /Lock oven z.ite [) .in. Numbers, ofi tines ,' Depth of t.iLe below grade •Jr / ,.in. Total Zeng.h o .tined (7 .:/ 6t. Slope o6 tneneh „4 4: in pen 100 lit. Distance between tines ' bt. Depth to bedrock " " fit. Total abdonbt.ion anew 1.- '! fit2 Depth to gnoundwaten fit. Requited anea is �. ict2 Type ofi Coven: ;Papers on S.naw PIT DIMENSIONS: Numbers ofi pits ) Gnavet around pi-CA yes no Outside d.iame c n I 6 . Depth below .Ln.eet 2 Tota.Z abdonb .ion anea / 6t A Area nequ.in' d fit2 m INSPECTED BYxj,,,,,,e/ ;. TITLE APPROVED • XIV 4, DATE • 7,C57 19 . REJECTED ,DATE 19 7 . 115 Rev.9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES .. P.O. BOX 309,MADISON,WISCONSIN 53701 LOCATIONs it,'14,!`T 4 /4,Section ,T2%N,R// R(or)�y�/'Township or Municipality A/Ce JS`i"l Lot No. / Block No. f '` �``t C`` S"�'��S County s j' C���cX , , Subdivision Name Owner's/Buyers Name: S/}M /4 ct//Ct- Mailing Address: -Fr"ci-1 I3r c 4- /?(I, /icc S6',J 6e'�f . S U/ TYPE OF OCCUPANCY: Residence k No.of Bedrooms -3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHERS 7-DATES OBSERVATIONS MADE: SOIL BORINGS `�C 77 PERCOLATION TESTS 9'`,2_L+ _ ?7 SOIL MAP SHEET -- cf NAME OF SOIL MAP UNIT /)A /4 �fiAC/A 41'9it'l PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM- INCHES THICKNESS IN SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIIOD 2 PERIOD 3 P / Y�" cC e_ Pore_ a/`}/4 ' A o _3 SC k .3- P- 3 Yt c cc %sere 4h '/j— A/c 3 (c G 6 • P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- / N " ,lo„Al c_ 7 ' `. /e"./-5 /_3 S 4, .7,3"S B- Z ?N" Alo,- C Y6" /c'"/s, /9•' 5.Z 6- 7"-s B- 3 ?e." AkAi4-- 7re:" /C"„ s Vic;" - 2-, 6. 5. B- Y " Vow %�" /C rs, /f'' S/ 6 '' _s. B- S' f�'' it/viu 7 Y /0'`7`S, Z y" `"-S B- 6, 7 " plo,,.e > ., /0 /C, ,26 sic C.:(;-_s PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on theIan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy.zp t�/ .,7� 5e 4"' •Indicate sc le or distances- Give horizontal and vertical reference points. Indica a sloe. T� ,S-/-<• 4A, /phr,) i ctr S' s}e/:-, -F-A,,`'4,tec.�e..7 /O cC,�/t- _ p,5 14/it,.'s /4S. Tit t cie'er;l`Pel 1.01- S'I/t-/(e e� �kit EV� Sc N Ao aSe"1 c vie,,Ak\b \.� '' \ t REs (eme fcem /4(( /mac'- ya la;� 101 r Q /9rte0 3 V ��N� /////P e�42-- /////� \ N s. tp' p y ores in _3`�t.-' .-s=h N)/,/ ® Pr pcs c G1 l�' 2- /iv CY s ,',..- "9/-04 N r Xo G "9-7 ,',��1 3 'cc' I,the undersigend,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct to the best of my knowledge and belief.Name (print) P '/i ,S r/Pi4574)/4/Se'c/ Certification No. -57-C _/---C-C/ Address J// 49te re 7 46'e, N ce I seA.i (-0r S. S /C/,6 Name of installer if known A—Local Authority CST Signature �1L-r...>''ff:177--- Copy tY 7iit-A„,-11,3-5*, ,n. yO B State and CountyState Permit # Fd Permit A lication County Permit # 1 Pp' -- ',,040 - (" for Private Domestic Sewage Systems County 4-t` U- %/ *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I-D- # A. OWNER OF PROPERTY Mailing Address: _S ,et. inA f ( l/ j� r� 5 -1 %-i-/ , B. LOCATION: CS --' '/ ' ,-L 1/4, Section L 7 , T 24 N, R i f E (or) W Lot# 4 City �} Subdivision Name, �nearest road, lake or landmark Blk# Village t el r�� V �-� 5 7L / Township 1-1- K�5 G it � r (,r/ C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family _ ✓ Duplex No. of Bedrooms ) No. of Persons --- D- SEPTIC TANK CAPACITY / .. Total gallons No. of tanks I. HOLDING TANK CAP ,.CITY Total gallons No. of tanks Prefab concrete ,/ Poured-in-Place Steel Fiberglass Other (specify) New Installation t/ Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate ' ti Total Absorb Area C / C sq.ft. New V Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft._ _ Width Depth Tile depth (top) No.of Trenches Seepage Bed: t,/ Length 7 . Width t =--- Depth T�i Tile depth (top) 3 0 No. of Lines 2--- Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits Percent slope of land�/~7 Distance from critical slope WATER SUPPLY: Private F. Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester,, NAME o1(34Ar, z.-. A /t{sj`e/,heny91 / S of C.S.T. # �� , and other information obtained from 5" a AI M i(e n (own &4.__— 5- 3y Plumber's Signature 00, e MP/MPRSW# Phone #2.¢7— 3 2- 3 i Plumber's Address f #- 1- ' e /t t c ,41 �'(.-t LA.-, , . + >i�+ PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors -, property. If well has not been drilled please indicate. , 3 I- © ' (. , -t:. , ,,,,, ,„._ , , ,._,,,..„ _r_ ,. t ,_......1,...,.... 3, � E , i ,,. ,,,,,,,,_±.,,,,,.,,,,, , 4-- -4:- -- ; -i, , ,,-. ' k , , , ! , , 1 01 -— -- it' '! e IV fi • t 1 I EHH 3 e a I ? 1 iam i ® r---.1 _.-- m_., ._�,.. n�d�,..-..._ y....m .... . .. ...... tee.-. 3......,, .... - Do Not Write in Space -Below. - FOR COUNTY AND STATE DEPARTMENT USE QNLY, Date of Application/ %, J. -j�� i Fees. Paid: State County , ' - ' Date Ir /)--c'/� Permit Issued/:..:,�•,r': /(date) _ Issuing Agent Name _ i Inspection Yes . No State Valid# Date Rec'd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 AS BUILT SANITARY SYSTEM REPORT y., OWI~EA• ~~~ ~ :.~ ~ ~,~ TOWNSHIP j~ ~; ~I ~~'•~n SEC. T N, R ~ ~ W ADDRESS ~ ~~: ST. CROIX COUNTY WISCONSIN. '+ SUBDIVISIQN ~~,,,~ ~ ,,,~, ~- t~ 1`•2; LOT~_ LOT SIZE s ~> PLAN VIEW Distances & ~lmen~ans to meet requirements of H62.20 Pf1A~1 li~i~w~e.r.~.._ - _ a nvw ~v GtcY Tx 1NG WI THI N 1 00 FEET O F SYSTEM 1 ~ ~y fi 5 ~ ~ ~ 7 ~ e, ~ ~~ ~ ea °,lI ~~~ ~ ~ %J ~. I di, a e or th Ar ro w ~ '.: ~ SCAL ~ '~ i 0 SEPTIC TANK(S)/ " I ~`~' MFGR. L+/r ~ y A.~ CONCRETE " ~ STEEL N0. o~ rings on cover Depth PUMPING CHAMBER SIZE PUMP MFGR. --~L NO. GALLONS Per Cycle TRENCHES N0. of wi tc3`Ti -' r length area BED N0. of lines width length ~' ~ Brea G dept to top o pipe ~ c' ' NUMBER OF SEEPAGE PITS Outs3ae diameter total pit area AGGREGATE PERK RATE ~ ~ QUIRED ( / 5 AREA AS $UILfi G^ ~ ~' Disclaimer: The inspect~of this system by St. Croix County does not imply complete compliance with Stdte Administrative Codes. There are other areas that it is not possible to aspect at this point of construction. `St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure.': GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. DATED INSPECTOR ~~11 PLUMBER ON JOB rXJ ~-r-~~~-_- `~-~ LICENSE NUMBER /LI- ~ - ~^ ~ 3 :2_.