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~Ftsconsin'~apartment of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
' 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
Kinne ,Mar aret Hudson Townshi
CST BM Elev: Insp. BM Elev: BM Description:
C INFORMATION
TYPE MANUFACTURER CAPACITY
Septic
Dosing
Aeration
Holding
~ TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic
Dosing
r
Aeration
Holding
PUMP/SIPHON INFORMATION
TDH Lift Friction Loss System He;
Forcemain Length Dia. Dist, to
SOIL ABSORPTION SYSTEM
I v
Demand
:NATION DATA
County: $t. Cr01X
Sanitary Permit No:
39
State Plan ID No:
Parcel Tax No:
020-1046-30-000
STATION BS HI FS ELEV.
Benchmark
Dt Inlet
Dt Bottyr~n
ist. Pipe
Bot. Syste
Final Grat
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
COMMENTS:_ (I,nclude code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /
~
~
Location~~
ounty Rd A Hudson, WI 54016 (SE 1/4 NW 1/419 T29N R19W) NA Lot
C Parcel No: 19.29.19.17TW
1.) Alt BM Description =
2.) Bldg sewer length =
-amount of cover =
Plan revision Required? ;!, Yes No ~ ~
Use other side for additional information. ~_ ~I~ _ - - -_- '- ~ ~ ~ J
Date Insepctor's Signature Cert. No.
SBD-6710 (R.3/97)
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
BedlTrench Center Bed/Trench Edges Topsoil ~~ Yes ~ No r Yes j J'i No
` ~ Parcel #: 020-1046-30-000 08/24/2006 04:16 PM
PAGE 1 OF 1
Alt. Parcel #: 19.29.19.177W 020 -TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner
O - HOLTZ, MARGARET E
MARGARET E HOLTZ
337 BAER DR
HUDSON WI 54016
Districts: SC =School SP =Special Property Address(es): * =Primary
Type Dist # Description ' 337 BAER DR
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 1.160 Plat: N/A-NOT AVAILABLE
SEC 19 T29N R19W PT SE NW COM INT E LN Block/Condo Bldg:
SE NW&NLNR
'
RR/WSWLYONR/W317.8
TO POB SWLY 200' NLY TO S LN HWY "A" Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
NELY TO PT N OF POB TH S TO POB 498/529 19-29N-19W SE NW
EXC .013 TO CO 650/232 & AS DESC IN
WD-1524/121
Notes: Parcel History:
Date Doc # Vol/Page Type
07/03/2000 625844 1524/121 WD
07/23/1997 883/399
07/23/1997
07/23/1997 498/529
more...
2006 SUMMARY Bill #: Fair Market Value: Assesse with:
0
Valuations: Last Changed: 05/30/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.160 56,800 211,400 268,200 NO 05
Totals for 2006:
General Property 1.160 56,800 211,400 268,200
Woodland 0.000 0 0
Totals for 2005:
General Property 1.160 56,800 175,400 232,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
,~ County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE
Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
G,~ [Privacy Law. S. 15.04(1)(m)) 1101 Carrnichael Road
~
s
+'~ Hudson, WI 54016-7710
~
J (715)386-4680 Fax (715)386-4686
Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
County Sanita Permit # ^ Check if revision to previous application
I. Application Information -Please Print all Information Location:
Property Owner Name
1/4~C
~ 1/4
S
~
,
ec
~~/~t7~~ i /~
~
~
:~ c
W~
.r-
1.~.
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j N, % R E (oi
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Numer Subdivision Name or CSM Number
/~/, 1
II Type of Building: (check one) amity ^ Village Town of
~
,~ 1 or 2 Family Dwelling - No. of Bedrooms: //L
I
"
'~
^ Public/Commercial (describe use): /..
l
-Ui~c
^ State-owned Nearest R d
~
II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) ~~
~ ~`~
^ Repair 2~Reconnection 3
^Non-plumbing . ^Rejuvenation
1 Parcel Tax Number(s)
~9' ~ g' ~' ~y7
.
.
A) ~~C7
«~c~`t~
l' ~3~ ~~'~
Sanitation ,
B) Permit Number Date Issued
State Sanitary Permit was previously issued -3S .3~5 ~ ` ~~' ~ ' `i'~
IV. Type of POWT System: (Check all that apply)
,~ Non-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland
^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line
^ At-grade ^ Aerobic Treatment Unit ^ Recirculating ^ Other
. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals./day/sq.ft.) (Min./inch) ,~ io/, 5th Elevation
-~ ,~ ~~,~, y • ~ ~ ~ ~ac~ ,sue ~ ~ .3c, .
I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
OG~ oOC) / W<c~ ~ ^ ^ ^ ^
^ ^ ^ ^ ^
II. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non-plumbing sanitation system.
Plu rs Name (~p nt) Plumber'~igygature ~avr~p~` / /fMPRS No.
-}MAP Bu!s~iness Phone Numberr~
,
Plumber's Address (Street, City, State, Zip Code)
/5 '~ ~ ~l ~ ~ s ~ ec; ~-~ , ~4/ar~
VIII. County Use Only
Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps)
Approved Owner Given Initial Adverse ~p
Determination ~,5, ~ ~.(~ 2
nditions of ApprovallReasons
for Disapproval:
IX. Co
r
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l - ''~-.
} l
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4~'K Z r~z l ~ ~ ~ M ~,
- ST. CROIX COUNTY ZONING DEPARTIV.~
AS BUILT SANITARY REPORT ~ °,~~, ~''
~';
Owner ~ ~~
Property Address ~ 3 ~ Gb a /-~
City/State ,~/~ s a .J w~ Sx r~ i G
Legal Description:
Lot Block Subdivision/CSM #
S~ 1/4 ~lw '/4, Sec. ~, T~N-R/~W, Town of
number 35325/ State plan number
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer G~ ~ ES ~P Size ST/PC ~ooa / - Setback from: House
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
S.~ ~F'i~~A.trv~
Type of system: 'TrZ~N ~ N Width 3 ~ Length ~~ - ~S Number of Trenches ~
Setback from: House lr ~ , Well /S~' P/L 3S' Vent to fresh air intake ~o ~ ' _
ELEVATIONS:
Description of benchmark 'So~i~€ ~N ~C~? ~pvsr.NS'S~~ ~osi' Elevation -moo'
Description of alternate benchmark ~,~,. s ~ ~xooQ rt-r r~~Pm.~r Doo~P Elevations/3.4 '
Building Sewer /o^~ .9'7 ST/HT Inlet so9. ~5~ ST Outlet /~5' 3/~ PC Inlet
PC Bottom "" Header/Manifold Top of ST/PC Manhole Cover //-?--~~
Distribution Lines (~) l as • ~o (,~) / O ! - `~o ( )
Bottom of System (~) ~0/-~D ~ (-3)
-•so
Well /~ ~ P/L ~G
/ 00 .sa '
( )
Final Grade (~-) /oy~`~ ~ (Q) ~~a 7~ ' ( )
Date of installation i /!a /
Plumber's si ature~~
Inspector
Vent to fresh air intake Water Line
,.~`~' ~ ~~~ 4~E
~~^~
+~.~ rti1~-~!
'~' T C1?Q,X ~°,~
,~NGOFFjG~
~;
number ~/I ~'~ Date/' // / ~`
Complete plot plan ~
NOTICE: Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
LAN VIEW
~Q~ v~c~,4 y. ~ $~
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INDICATE NORTH ARROW
/dav lots StPlic
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,Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division .
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may tie used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: 1 fl City fl Village fl..Town o :
Town of Hudson
ICS~Ivvet7~ Im(p~HC7r I~~np~dC~f ~.1~~tQMI2W1~1
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic ~'b'D
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. vent to
Air Intake ROAD
Septic ~J~~l ~~S-p r 1 ~ ~` NA
Dosing NA
Aeration NA
Holding
PUMP /SIPHON INFORMATION
Manufacturer Demand
Model Number GPM
TDH Lift Lriction System
hi TDH Ft
Forcemain Length Dia. Dist. To Well
SOILABSQRPTION SYSTEM ~ql /rQ...,h,rt pa,~,Qs
N DATA
County:
St. CTO1X
Sanitary Permit No.:
353251
State P a ID No.:
~~~
Parcel Tax No.:
020-1046-30-000
STATION BS HI FS ELEV.
Benchmark 1(0, 13 l b.13r Un • ~
Alt. BM o 3
Bldg. Sewer 5.8~ ~.
St/Ht Inlet (o,?u ~~r~~3
St / Ht Outlet (~ , ~ •
Dt Inlet
Dt Bottom
Header /Man. ~
Dist. Pipe
I • r
/3.13 /02 .OI
/03.00
Bot. System (b' ~~
, ,'~• ~
Final Grade ~(,zo Io .93
St cover 9'~ ! 2
TREN Width r Len th r No. f T nches PIT No. Of Pits Inside Dia. Liquid Depth
DIM N ~' DIM N I N
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manu acturer:
SETBACK
INFORMATION
Type O
,,. ~
f
r
~ CHAMBER
Mo a Num er:
System: 3.5 ~ 1 ~ lSD `~ OR UNIT
DISTRIBUTION SYSTEM
Header / anifold u Distribution Pipe(s) x Hole Size x Ho a Spacing Vent To Air Intake
Length Dia. ~ Leng ia. Spacing jp ~ j ~
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• I2/ ~y/`l9 Inspection #2: / /
Location: 337 County Road A, Hu so , 54016 (SE 1/4 NW 1/4 19 T29N R19W) - 19.29.19.177W
1.) Alt BM Description = ~~ ~
2.) Bldg sewer length = '~ f6.a r
-amount of cover = > 18 r r S~ r~'"'P"r ,
"-' 1"
Plan revision required? ^ Yes ~ No
Use other side for additional information.
SBD-6710 (R.3/97)
Iz. zo qg 1 5 2 fo
Date Inspector's Signature Cert. No.
• ``~~~,,
~~isconsin
• Department of Commerce
SANITARY PERMIT APPLICATION
In accord with IIHR 83.05, Wis. Adm. Code
~--
Safety and BuikGngs Division
201 E. Washington Ave.
P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, {~p`en riot eSs -
`` fount ,.., .
(
than 8 v2 x 11 inches in size. ;-
\ .,~,6,t,
~ ,~j ~
• See reverse side for instructions for coin letin this a licati ~
p 9 pp R
, 11~~'
r~~
- State Sanitary Perini Number
P
f
~
~
`
3 S3 ~!
The information you provide may be used by other government agency progr 3 -
~ f°~,•,.
'-' ` ~
' ^ Check if revision to previous application
[Privacy Laws. 15.04 (1) (m)].
~ ;
; ~
-- ~ ~ ~~
State Pi n LD. Number
~
I. APPLI ATI N INFORMATION -PLEA E PRINT ALL RM ~ I
Property Owner Name
~iyJ IGTY J'~ ~ cation -
S ~'~ _ ia, S," >; T ~ 9 , N, R /9 E (or~
Property Owner's Mailing Address ~ rotlytunber - Block Number
Cit ,State Zip Code Phone Number Subdiw -Ntrrtrgor CSM Number
/-~c~,QSot,/ Gt,t S4/o!~ (?~S),38~-sG4S
F B ILDING: (check one) ^ State Owned
3 ^ !t~ ~
^ Vd age
OSo Nearest Road
D
'4
C
Public 1 or 2 Famil Dwellin - No. of bedrooms
own of r Q ,
o, Ir
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) I ~ _ ?~ ~ t~ • 1~11~
O®2~ -> o~~ ' 3Q - CEO
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 online B, if applicable)
A) 1. ^ New 2. ~ Replacement 3_ ^ Replacement of 4- ^ Reconnection of 5_ ^ Repair of an
______System ________System _____________ Tank Only______________ 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 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank
12~5eepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy
13 ^ Seepage Pit 4 Vault Privy
14 ^ System-In-Fill ~~~ L~iATOl~ Si,OEtr~i.~/,Qc~P
VI. ABSORPTION SYSTEM INFORMATION:
1: Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) lp/• Ste' Elevation ,
~~C7
L~
SOS
~e
'
-
F
t
7.?• • 8 - 8ioo -Sa~eet
SG~• S S
VII. NFORMATION Ca aclt
in gallons
Total
# of
Manufacturer's Name
prefab.
Con-
l
Fiber-
plastic
Exper.
N i
E
i Gallons Tanks concrete stee glass App.
ew x
st
n strutted
Tanks Tank
Septic Tank or Holding Tank dp0 " ~c~0a ~ w.ESE ~ ^ ^ ^ ^ ^
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.
Plum is Name: (Print) Plumb "s Si ature• St p) MP/MPRSW No.: Business Phone Number:
K ~~~' .~2 ~~ .~'I ~~S 3 ~~ .~~5~
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY /DEPARTMENT USE ONLY
^ Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing Agent Signature (No Stamps)
'Approved ^ Owner Given Initial Surcharge Fee)
ZS ~
Z
`
'
'"6 -q ~
~'Z ~
Adverse Determination o
v
i .-
°
X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL:
~0,~ ~ t t/96) DISTftIBtJT10l1: Original to County, One copy To: Safety 8 Buildings Division, Owner, WumDer
LNSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before.the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD-6399) to be.submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(;)must be pumped by a licenserd 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, 608-266-3151.
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 Only.
X. County /Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 1 ]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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S~aFw..JOfR 1-1+aN ~APAcIr~ /~v~OE~
Wisconsin Departrnent of industry, SOIL AND SITE EVALUATION R E P O R T
labor arW Human Relations
• Divislnn of Sa(aN 8 9uildinnA .._ ~ _
Page ~ of
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`~UNTY
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lete site
Plan must include
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not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
9 i 77 W
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dimensioned, north arrow, and location and distance to nearest road. --
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APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R VIEWED Y DATE
~ -d;-•
PROP OWNER:
1 /!rc ~OT'' PROPERTY LOCATION a
GOVT. LOT S fi: 1/4n(f,,J 1I4,S f 9 T Z9 ,N,R ~ 7 E (a) W
PRQ);E,~ OWNER':S LING I~DRESS
J~ LOT # BLOCK # SUED. NAME OR CSM # .
CI'~Y„ STATE
ZIP CODE PHONE NUMBER
' CITY i]V GE OWN NEAREST ROAD r
Av
/,/ N ~! SYJ!/ (~iS)34(~ ^y
45 ~ TW
(J New Construction Use (QQ Residential / Number of bedrooms ~ (J Addition to existing building
~ Replacement (] Public or commeraal describe
Code derived daily flow # v~ gpd Recommended design loading rate a.? bed, gpd/ft2Q~_trench, gpdift2
Absorption area required ,~~, bed, ft2 ~ 3 Vench, ft2 Maximum design loading rate . a.? bed, gpolft2~_Vench, gpd/ft2
Recommended infilUation surface elevation(s) ~~ ~ ~~ ~ ~ ~~ ~ ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material ~f4A11~Y r1~jTW ~ ~ N Flood plain elevation, if applicable ft
$ = Suitable for System
U =Unsuitable for s stem CONVENTIONAL
JQI S^ lJ M UND
S O U ROUND PRESSURE
S O U AT GRADE
^ S U SYSTEM FILL
!~ S~ U HOLDING T
^ S U
SOIL DESCRIPTION REPORT
Boring #
1
Ground
elev.
/~ft
Depth to
limiting
.,
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Boring #
Z
Ground
/ eQ~ft
Depth to
limiting
)f~~.
Horizon Depth Dominant Color Mottles Texture Structure Consistence 8~~, Roots GPD/ft
in. Munsell Du. Sz. Cont Color Gr. Sz. Sh. Bed Trerrh
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Remarks: _ _ .. .:., .. ...
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Remarkc~
PROPERTY OWNER ~iM Copy SOIL DESCRIPTION REPORT
PARCEL I.D. ~
Boring #
Ground
elev.
fL
Depth to
limiting
factor
Page? of..~~
H
i Depth Dominant Color Mottles Texture Structure Consistence BounUar Roots GPD/ft
or
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Remarks:
Boring #
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Remarks:
SBD-8330(8.05/92)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
Mailing Address ~ ~.~ ~ ~ •'~' '~ ~~s~~ ~`~
Property Address ~ ~ '~ ;.~ !
~L (Verification required from Planning Department for new construction)
City/State ! ~ V~ y ~G'y.~ ~ Pazcel Identification Number 424 - f 0 ~ (~ '-"~ D - 67~
LEGAL DESCRIPTION
Property Location ~~ %,, ~ty y., Sec, ~9 • T~`L,N-R >°1 W, Town of _~~,0 S~ti'
Subdivision
Certified Survey Map #
Lot #
Volume ,Page #
Warranty Deed # 7 ~ .313 Volume g ~3 .Page # .3 1 ~r
Spec house O yes (,~1 no
Lot lines identifiable Cd'yes O no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premabue.failuu,r 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
masterplumiber, journeymanplumber, restrictedplurmber or a licensedpumperverifying that (1) the on-site wastewaterdisposal system
is in proper operating condition and/or {2) a8er 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 Natuual 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 exp' date.
f
~-- ~ z- / L / ~ ~W
SIGNATURE O APPLIC DATE
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 described above y._virtue of a warranty deed recorded in Register of Deeds Office.
-----.~
SIGNATURE PLICANT 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
. -•
DOCUMENT NO. ' R'Atl1tA\TY UhF:D t„u ~FACa enaivio Foe eccoeolHO DATA
fTA iE of WISCONSIN-FORM t
463~3C vc: ~;)~PASEt~9 T ,
Transame~cia Financial REGIS ER 5 OFFICE
Tests INDEN'tUItE, Atade by .............................: "......
... ............................................
' ~ CROIX CO., WI
.....Seryces ................_....................-------................---•-.. .. ..
................................-... Rec d for Re,:ord
grantor..... of. -- ............................................................................County, Wisconsin, u~/ 1 ~ 11590
hereby conveys and wuraras to ....Timothy D. Coty and Lorretta d1 10:5 /~. M
D. Coty, husband and wife as survivorship •,___ ~ -~
................... ..................................t .
..marital property . .......... .............................................................................- ~ ~Ati+•.,,~~
.................................................. -- ~' Rfgktfr of Deedf
..._......_......_......_ ........................................_----•---.........-._.......................grantees.... of
--S-t_..-Croix .................................................County, Wisconsin for the sum of
..Dne...IInllar...and...ether...ualuahLe_Cnnsider.ati~an_--.....-_ ~erurtN TC
the following tract of land in.... S.t....CralX ...........................................County,
Wisconsin : ................................................................................................................---
Part of the SE 1/4 of the N6J 1/4 of Section 19, Township 29, Range 19 West,
Town of Hudson, St. Croix county, Wisconsin, described as follows:
Commencing at the intersection of the East ling of the SE 1/4 of the NW
1/4 of said Section 19, with the North line of the right of way of the
Chicago, St. Paul, Minneapolis, and Omaha Railroad; thence Southwesterly
along said North right of way line fcr a distance of 317.08 feet to the
PLACE OF BEGINNING; thence conti:uing Southwesterly along paid North
right of way line 200 feet; thence Northerly and parallel to the East
line of said SE 1/4 of the NW 1/4 ~o the South line of County Trunk
Road A; thence Northeasterly along the South line of said County Trunk A
to a point North of the PLACE OF BEGINNING; thence South, parallel to
the East line of said SE 1/4 of the NW 1/4 to the PLACE OF BEGINNING.
EXCEPT All that part of the above described parcel lying Westerly of the
following described boundary line: Commencing at the SW corner of the
aoove described parcel; thence Easterly along the South line of said
parcel a distance of 20 feet to the Point of Beginning of the boundary
line; thence Northerly to a point 40 feet Westerly of the Northeast
corner of the following described parcel: Commencing at the intersection
of the East line of the SE 1/4 of the SW 1/4 of said Section 19, with
the North line of the right of way of said Railroad; thence Sally along
said North right of way line a distance of 517_8 feet to the PLACE OF
BEGINNING; thence continuing Sally along said North right of way line
for 282.2 feet; thence North to the S line of County Trunk A; thence NEly
along the South line of said County Trunk A to the NW corner of the
above described parcel; thence Southerly parallel to the East line of said
SE 1/4 of the NW 1/4 to the PLACE OF BEGINNING.
And all that part of the above described parcel lying Easterly of the above
described boundary line.
EXCEPT that portion of subject premises conveyed for Highway Purposes in
Deed, dated June 14, 1982, recorded August 10, 1982, in Vol. 650, page 232,
as Doc. No. 379082.
.,~~ '' ,.
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In Witness Whereof the said rantur-..... ha...S.... hereunto set-.._--X31.5_-.,..... ha}i:!-. ; ~d 1.~..-. tha
24th-------------•- day of.....~epteml3er._. - •----, A. D., 1~.y.0... ; TRANSA~I~RICA: Fr~~~~L SF~JIC~ES
SCFf:ED AKD SE 1}, F:D }V PP.F.3E\CE OF
//
Jan -1tiC. Novotn_y___`
~----- --
-( n i ~.; _
..i-.... ._.. ~.-... _....
s;.or~l T,~t.em}~inski
r Y .•---....
_Jam~ , ~~_-$rs'tS1 e F .- c a~- ~ ~ e s ~ d.~ . i-t^ .
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Theresa c'i~_M2fford,__A~' 't. Secretary
_. ._ _ - _.-..... _._.... .....-._......_..... ..(SEAL)
State of Illinois
CQ.OK------------------__-County. ~ Personally came before mc, this_24~~_.- day of.... September A. D., 19-_.90
the above named ..- James__M.. Bran.gle,Vice-Pres.ident_.._--.and-,_..,- _.._. ___ _- __ .___..
--------- - ---- -_ -_._ Theres-a_. A _.Mefford., Ass-istant ,Secretary..,-. -_ _
to me known to be the i erson.:~-wF}ie.-e:~ecvted the k ,tum_a~ an+l.~arknowledf,«l the s1me.
~, -- -f.. -..~._.._,
.._ ~a }~1 No~~otny ,
THIS INS?RIiMENT WAS DRAFTE (~'I'' - rl_ :.~~~ ,.~ .LL...w ~- __ -__. __.._ __. -_- _
2'AY G "'~i+6M~r.~" ' 3 at,FtrJ'h blip- Cook County,
KonnoF}i U Dc~Forc.~n - f3-3[]-92