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HomeMy WebLinkAbout020-1055-60-100` Wiscorvsin 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 ^ Tffiwn of: Miller, Sam Hudson Township CST BM EI~ ~ Insp. BM Elev.: BM Description: SANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ z S~ Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septic ®~ -~ aq r NA Dosing NA Aeration NA Holding PUMP / S PHON INFORMATION Manufacturer nd Model Number GPM TDH Lift , ___ Ion System DH Ft Forcemain I Length I Dia. ( Dist. To Well SOIL ABSORPTION SYSTEM(Iz~~ ~ ti..__ ~,~.s ~~ ~P .G,~ .. ~ ~.._ $6$ TRENCH Width i Leng ~ No. O Tre ches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN ~~ DIMEN I N SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: to 0 FFt.LS6r INFORMATION TypeO SU ~ ~--' CHAMBER OR UNIT Mo elNurr>~er: ~ ~ ( System: p ,6 yn, DISTRIBUTION SYSTEM ~ ~ Header / ifold u Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Lengt ~ Dia. ~ Le Dia. Spacing ~~ 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:OS/oZ/ o~Inspection #L: ~- Location: 539 Stage Coach Trail, H~ud/so~n,~01,¢ (NW 1/4 SW 1/4 21 T29N R19W) - 21.29.19. Raider Estates -Lot 2 1.) Alt BM Description = -~ ~ o'.'~ e'"- 2.) Bldg sewer length = 29 ~~ -amount of cover = ~ f~ Plan revision required? ^ Yes ~], No ~ Use other side for additional information. Or oZ C5b ~(~ SBD-6710 (R.3/97) Date Inspector's Signature Cert. No- ELEVATION DATA County: St. Croix Sanitary Permit No.: 353307 State Plan ID No.: Parcel Tax No.: pending STATION BS HI FS ELEV. Benchmark ~, ~ oS•~ I C~ •~ r Alt. BM d ~ oS'. 03 Bldg. Sewer St/Ht Inlet b,o3 r St / Ht Outlet (a, ~~ qq• 33 r -- Dt Inlet ~ Dt Bottom -~~ Header /Man. ~~''~' g• p r Dist. Pipe r 5 r 9.63 Bot. System 4:5'3 qb. ZSl Final Grade '- ~ . O ~ bo . St cover a_ S`( I ~~ • 2 ~- r ADDITIONAL COMMENTS AND SKETCH Wisconsin Department of Commerce 7~53~ 5~"',.y~a~.-True/ SANITARY PERMIT APPLICATION In accord with Comm 83.05, Wis. Adm. Code ~~ L- + ,~ ~ ~ ~°~-Safety and Buildings Division ` ~/ 201 W. Washington Avenue P O Box 7162 Madison, WI 53707-7162 • Attach complete plans (to the county copy only) for the system, on paper not less county than 8 vi x 11 inches in size. See reverse side for instructions for completing this application ~ state sam ary Permit Nymber 3533~~ Personal information you provide may be used for secondary purposes Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)J. fate Plan Review Transaction Number I. APPLI ATIO.N INF RMATION -PLEASE PRINT ALL INF RMATION Propert Owner N ~,~, ~ Property Location (,~i45 ~11a, S T Z, N, R j E (o Prop rty Ows Mailin Address Lot Number Z~ Block Number -------_.. City, to / ~ Zip Code syo/G Phone Number (3 ~ > z7l Sub bisi Name or CSM N tuber Y` E ! y a s i 11. PE B ILDING: (check one) ^ State Owned ~ itr Vil age Nearest Road ` / ~ Public 1 or 2 Famil Dwellin - No. of bedrooms Town OF l~ J W ~ !/ III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 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 4. ^ Reconnection of 5, ^ Repair of an ______S~stem________System_____________TankOnly______________ Existing System _________Existin~System B) A Sanitary Permit was previously issued. Permit Number 3 S''j 3 d ~ Date Issued o?-l S ZGd'b V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 Seepage Trench {.~ 14~" 22 ^ In-Ground Pressure / 42 ^ Pit Privy ~A -cJ 2 Z ~ 3~ 7 ~ 43 ^ Vault Privy 13 ]Seepage Pit ~ ~~"~f ~ . 14 ^ System-In-Fill 3 ~ •'~ SQ, ~ ' /b 1 Q. ~` K S 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/da /sq. ft.) (Min./inch) Q ~ Elevation ~ ~ ~ ~ ` ~ ' ,Q 7 p ~. p r Feet d~ ,Q~ Feet t VII. TANK INFORMATION Capaclt in allo s g Total l # of k Manufacturer s Name Prefab. site Con- St l Fiber- Plastic Exper. N E i i Ga lons Tan s Concrete ee glass App ew x st n strutted Tank Tanks Septic Tank or Holding Tank Zsd ~ 2 ^ ^ ^ ^ ^ 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 'nature: (No St ps) ~ MP/MPRSW No.: Business Phone Number: ~ ~ LL- ~ a - z ..r _ lumber's Address (Street, ity, State, Zip Code): ~~D ~ 1d ~ -N~D3o N w( S~f~~~ X. COUNTY DEPARTMENT USE ONLY ^ Disapproved S rtary Permit Fee (indudesGroundwater ate ssue Issuin Agent Signature (No Stamps) proved -~p ~~``"" ^ Owner Given Initial Surcharge Fee) Z Sr-.~D _~~~ ,~ Adverse Determination o n~v1YY~ yr r~rr~~.r n/~, rvw~ ~rr/nwvr+~st,./,/_ ~ C J~~ / ,~ rO~L // II//// _ _~ ~ ~~ e//-T~1S ty~`+~ J~ ~-C~.f/ ` Of_yrJ1Q ,~ ~~ ~ 3 - ~ - SBD-6398 (R. DITTRtBUT10N: Original to County, One copy To: Safety & Buildings Division, Owner, INSTRUCTIONS 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(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years- 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and 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 Ae 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 online 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. VI1. 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 a!I septic, pump/siphon'and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII.. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include.the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/v~ater service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; 8) 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 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 can effect groundwater. The monies collected through these surcharges are used far rnonitoring groundwater contamination investigations and establishment of standards. ``~~~, ~~/isconsin Department of Commerce SANITARY PERMIT APPLICATION In accord with Comm 83.05, Wls. Adm. Code Safety and Buildings Division 201 W. Washington Avenue P O Box 7162 Madison, WI 53707-7162 • Attach complete plans (to the county copy only) for the system, on paper not less County o lx CR ~` than 8 v2 x 11 inches in size. , - * See reverse side for instructions for completing this application state sanitary Permit Number 35 3 30~- -.Personal information you provide may be used for secondary purposes ^ cneck if revision to previous application [Privacy Law, s. 15.04 (1) (m)1- State Plan Review Transaction Number I. APPLI ATION INFORMATI N -PLEASE PRINT ALL INF RMATI N Pro ert Owner Name f ~J 4 (~(.,,~t~.~.,, Property Loc tion lI/1/a ~i/a, S ,Z T Z r N, R I'~ E( W Property Owner's Mailing Address Lot Number Block Number a®~O ~~ ~ City, State Nufls®~c wt Zip Code S ~/~ Phon Number c3~] z G Subdivision Name or CSM Number ~A, Ie... EsT~12S II. YP B IL ~ ING: (check one) ^ State Owned ~ It~ • Vilage p ~ Nearest Road k ~~-L Public 1 or 2 Famil Dwellin - No. of bedrooms .S,o own of f{ t III. BUILDING USE: (If building type is public, check all that apply) arcel Tax Number(s) _„ _ _ /J, ~„ r_ ' ~p_~~ -~ 1 ^ Apartment /Condo w~ e!a ~ 2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Ou door Recreational Facility 3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church J 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. ICS New 2. ^ Replacement 3_ ^ Replacement of 4. ^ Reconnection of 5_ ^ Repair of an ______System ________ System _____________ Tank Only______________ Existing System ________ Existin~System B) ^ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Qther 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 Seepage Trench ~~~~ 22 ^ In-Ground Pressure i 42 ^ Pit Privy ~ 2 ~C 3 lC ?S 43 ^ Vault Privy 13 Seepage Pit ~ /~(,c/LT/c~Al"p2 , 14 ^ System-In-Fill 31 t~ ~Q~ ~/ ,~ w ~ DE/L ~ r3 r~ S 2s/ • ~'p7A~ VI. ABSORPTION SYSTEM INFORMATION: ~,~-~~r 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final ra e Re ulred (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ~~~'- Elevation , d~ ~ - ~"'° Feet ) ~d ~ Feet 'T~ ' " .S® ~ ~e , VII. TANK INFORMATION Ca acct in allo s g Total # of Manufacturer s Name Prefab. Site Con= l S Fiber- Plastic Exper. N E i i Gallons Tanks concrete tee glass App ew x st n strutted T nks Tanks eptic Tank Holding Tank ~ 210 I• ~. ^ ^ ^ ^ ^ 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) Plumbed s Signatur o Sta s MP/MPRSW No.: Business Phone Number: a-. f ~G~ ~ zz~' Plumber's Address (Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved anitary Permit Fee tlncludesGroundwater ate slue. Issuing A 9~entSignature (No Stamps) Approved ^ Owner Given Initial Surcharge Fee) ~ S ~ ~-~ /S~ ~/n , l ,~. /T '~ ~+c..~J^~~+ Adverse Determination o X. CONDITIONS OFAPPROVAL /REASONS FOR DISAPPROVAL: ~~ ~-~'~ ~~~ ; SBD-6398 (R.12199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ` ~~` INSTRUCTIONS t . A sanitary permit is valid for two (2) years. 2. Your sanitary permit may fie 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(s) must be pumped by a licensed pumper whenever ,r~cessary, 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. Tq 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 it 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 a!/ septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete. dimensions, location 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 seEtion of the soil absorption system if required by the county; E) soi! test data on a 115 form; and F) all sizing information. i GROUNDWATER SURCHARGE i 983 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. _ M ~• ~~ `~~ r 1 a a. J V 0 ~.i! tl~ !"qq' -~1 _ , ~'i'c`~ ~5 v~'r>. ti .. /`~0 ~° t-~ X11 ' tax 1, ~-V ~. ~ O .. ~~ _~ ~L ~ ~ ~ r ~.i ~ N ~_.__._.___ j 1 ~. °~~.._.... ~y^ ~~ ~ ~ ~ t0 ~ . _ n u---- ~~ `~ c~ ° a 7 ~a ~\` r~r1 ~/' ~ rCr ~it N ,_~ ~ `x1 ~ ~' _~,. ;~'` "cam ~.. -~ °• ~r 1` / o ~ '. ~ ~ T Q ~ ~ v ~ ~ v ® N? o~'~'~ '~ ~ ,:. ~~ N ~~ ~~ ~ ~. ~ ~- ~ ~~;~ ~ ~ ; ~ ~. ~ ~~ ~ _ ~ ~ °~ ~~ ~~ ~ o ~ -~I ~~n~. t~ i~. L. J ~ ~~ ~ ~ ~ ,~ ~ ~ ti ` m ~ N N -~-- ~-~ ~, Q~ ~ ~ ~l'~ _~"I ..,~ tl~r Departmentof Car-merce SOIL AND SITE EVALUATION Page 1 of 3 Divisioi' of Safety and Buildings in accord with Comm 83.05, W ~. Adm. Code AC.E. Soil & Site Evaluations Attach complete sine plan on paper not less than 8'/: x 11„nc size. Plan must County include, but r-ot Imxted ta: verttcxl anti horizontal referefioe, poi6t~t3~d'krectlar- and St. Croix percent slope, sole or dirrrerr~ia>s, north arr kior--and'dist~tce to nearest road. Parcel I.D.# `~ ~ part of 020-1055-60-000 APPLICANT INFORNIATK?N - P pn ll~far-natron: ~ ~ By Date Personal information you provide may be used ry E~i~r~~;GcY Law s. 15.Q4 (1) (m))• ° __ ,~~~ o2' J.5- Ob ~.. Property Owner Property Location Miller, Sarn _ ~~f~~~ ~ ~ ~°~'~? Goff. Lot NE 1/4 sw 1/a s 21 T 29 N,R 19 w Property Owners Mailing Address °-'~' ' aT CROf?t kof # Btoc:k # Subd. Name or CSM# P,o. Box 151 ~ /'`° ~°~f°N~ ~~f 2 ____~__ Proposed CSM City State Zi Code rPhareNumber ~ `,' ~. :0 City ~ ViklageTown Nearest Road Hurlson WI 54 ~i ~~ 386 2"~ '9 ' ~' Hudson Stagecoach Trail New Constrtlctian Use: ~ Residerttiai u •~ of bedrooms 4 ^Addition to existing building Replacement ~ Public or commercial describe Code Derived daily fkwu 600 gpd Recommended design loading rate •7 bed, gpolff? .8 trench, 9P~ lion area required 857 bed, ftz 750 trench, ftz ~ axi ~u design k>~fing rate .7 bed, gpd/Itz .8 trench, gpd/f~ Recommended infiltration surface e~vation(s) ' 9y . 8 S ~S ft (as referred to site plan berrchmark) Additional design I Site considerations stall trenches using high infiltrators. Parent material Glacial outwash Food ain elevation, if icable NA ft S=Suitable for System Conventional Mound In-Ground Pressure AT-Grade System in Fill Hiding Tank IJ=Unsuitable for System ®S ^ U ®S ^ U ®S ^ U ®S ^ ~ ^ S ®U (] s ® ~ Boring# Ground elev 1l1A 1A A Depth to limiting tac~r >115` 2 Ground etev 100.23 ft Depth to limiting fat~a >112` Depth Dominant Color Mottles- -- - - -- Structure i t C d B Roots ~' Horizon in. Mansell Qu. Sz. Cont. Color Texhlre ~,. ~, ~. en ons s oun ary Bed Trench I 0-7 10yr3l2 None sl 2msbk ds cs 2f 0.5 0.6 2 3 7-12 12-26 IOyr4f3 10yr5/4 None None sl sl 2mp1 lmsbk dsh dsh cs aw 2f if N.P. 0.3 0.4 0.5 4 26-6$ 10yr5f4 None ~ s Osg dl gs if 0.7 0.8 5 68-115 IOyr6/4 qs.~ Nane s Osg dl i - - 0.7 ~ 0.8 a.~8/ oq,68 Remarks: 1 0-$ 10yr3/2 None sl 2msbk ds cs 2f 0.5 0.6 2 8-18 10yr4/3 None sl 2msbk dsh cs 2f 0.5 ~ 0.6 3 18-30 10yr5f4 None Is Osg dl aw If 0.7 i 0.8 4 30-72 10yr5/4 None s Osg dl gs if 0.7 0.8 5 72-112 10yr6/4 None s Osg dl - - 0.7 ~~ 0.8 I,a,tT~ - Remarks: CST Name (Please Print) Su3n ~` _ Telephone No. James K. Thompson `~' ~ e'~ '~ _.~_ 715-248-7767 Address A.C.E. Sod & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceolar VJl 54020 11/5/99 3602 1126 PRf)PERT'Y AYMI~R: Hitler sam `pq~~[ ID.~ >a~ of 020.1055-60-000 3 Ground elev 99.85` fl Depth to limiting factor >115' SOIL DESCRIPTION REPORT ~~~ Page 2 of 3 e (` F Coil ~ C;te Rvaluationq De th Dominant Color Mottles Structure d B Roots GPDIft~ Horizon p in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. sistence ary oun Bed ~ Trench 1 0-10 10yr3l2 None sl 2msbk ds cs 2f 0.5 0.6 2 10-28 10yr4/3 None sl 2msbk dsh cs 2f O.S I 0.6 3 28-36 lOyrS<4 None is Osg dl aw if 0.7 ~ 0.8 4 36-8I 10yr5/4 None s Osg dl gs If 0.7 0.8 5 81-115 10yr6/4 None s Osg dl - - 0.7 ~ 0.8 i 4 Ground efev 98.54' ft Depth to limiting factor >102" 5 Ground efev 99.08` ft Kemartcs: nancun rrw a ~ wicwu~ a}ij~cvn...,.~ ...,.,.,... ~...., ~..,.,... _ ____ -- 1 0-10 10yr3/2 None sl 2msbk ds cs 2f O.S ~ 0.6 2 10-22 IOyr4/3 None st 2thickpl dsh cs 2f N.P. 0.3 3 22-32 lOyrS/4 None sl lmsbk dsh aw if 0.4 '~ 0.5 4 32-41 lOyrS/4 None Is Osg dl gs if 0.7 ~ 0.8 5 41-102 10yr6/4 None s Osg dl - - 0.7 ~ 0.8 KemarKS: 1 0-6 10yr4/2 None sl 2fcr ds cs 2f O.S 0.6 2 6-12 10yr3/2 None sl 2msbk dsh es 2f 0.5 0.6 3 12-18 IOyr4f2 None s1 2thick~ dsh aw if N.P. '~ 0.3 4 18-37 10yr3/4 Nane sl 2msbk dh gs If 0.5 I 0.6 5 37-75 7.Syr4/4 None s&gr. Osg dI gs - 0.7 ~ 0.8 6 75-98 10yr6/4 None s&gr. Osg dl _ - 0.7 0.8 Depth to limiting factor >nQe KemarKS: nvnzvn ff3 ai o wu~aet a~Faua. ~~ ie ww,o a,... ~..,,,.,. Ground efev Depth tc limiting factor '. ^ Soi/ O~S+c/wa,6ror~ P•-~ ~ E/eon ~ ~OrgA. S~a~e. ~~ .• , S~caLe: ~ _ ~D ~ c,-: Sam /~j; //e~ RD.~~s~ ~KdsoY; ~~. s~0/6 ,t,~~~-, ~f z of ~~o~scd CSnI, ~~ a ~Q. /9 cJ., T. Off' f/udsor~ ~ / S~y~ / ~ ~~. / '' ~^ ~ pc ^ / 8~ 5~, ~~ ~CoaC~ ~i'al/ P~. 30'3 E/ear /c~D. ~D.~ ~r P%Pc ~~ see. Elev: 99 ~,~' ~~ ~~~~ ~ es ^ 3~Z'f '4 e~/j8 O ^ V Qp ~V V a ~ ~ ~~ ~"` U ,~ . k 1 ~ N (~ ~ ~~ ~ ~ 1 ~~~ ^~ ~ ~ ~ ~ ~ i~ ~ ~ N 3 ~ ~ ~ ~ ~ a' J ~ ~- 1 ~ __.: . ~ `~ C~. ., .}. . ~, • ~~ ~. .. ~.. ~. ~~ ~ . ~ ,~~_` ~ W W - a O~~ F=- V~ U ~.-` . F 1 v !' _~ ~ ' ~X (9 ~ '' ~ ~"~ ~ C m '~ N ~ m r ~ ~- ~ ~ ~ ~ ~ t ~ C W x N ` r ~ ~ Q cd S. to C T ` ~ (b G y G O ~ ~ ~ ~ H c0 w :~ N :~ .o ~ a ~ 0 ;~ _ ~ ;~ ~ ov o ~ >a rn s' ~i x o a ~~~ n ~ =~~~ a L . ~ ~ .~ N p C U C ' ~ ~ ~ .. p . ,. J ro N L ~ > ~ o ~ N ~ N{L EO °= C~'a a ~ ~ j • • • • ®® .~ a ~~ W ~ , ,~ ~ N y v 0 T V lV W W a`> .`°e U ~^^~w ®® ,~ a ~~ -~ w ~ d ... ... o .~ b O U = • Z ~~ ~ 3 v O~ ~ E • . UJ °~ ~ a ~. ' G v ~ ~ ~~ m a c ~ X_ ;~ ~Y a o n~ _ ~ c. .~ ~ ~ ~I f Cd i '° • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~~C1 / ~~~ l L ~- <~.,. Mailing Address RmX '~ ~ ~~ Property Address ~~ (Verification required from Planning Department for new City/State t1 U ~O ~ ~~ Parcel Identification Number ~ ~ d ` ~ C~ Jr ~° ~ n ' ~ ~ 4 LEGAL DESCRIPTION / / Property Location /~~~ 1/4, ~ ~ %., Sec. 2 ~ . T Z'y N-R~ Town of ~`~`U.~.S~IY Subdivision ~ ~ ~ ~~~- ~S ~~ T~ S .Lot # Z- Certified Survey Map # ~~ ~ ~ y t? ~ ,Volume Page # Warranty Deed # ~o ~ ~ ~ ~ ~S ,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, 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 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 of the three yeaz expiration date. ~ ATURE F APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (aze) the owner(s) of the roperty described a~ve, y virtue of a warranty deed recorded in Register of Deeds Office. Z , ~ ~o~ A 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 !{ i Cocu+.;er,r Nom. Wl.{;ilA`:TY UEED I's':;.:':. RAR~F ;Y'<C'~`,~:w r'o::'.1 2-toed -- -- - --I EXCEPT parcel conveyed to Donald F. Johnson in 'volume 500, page 525; and EXCEPT parcel conveyed to Oc•~ald R. Jordan in VoluR+e 580, page 354; and EXCEPT parcel platted as wel's Fargo Station in Volume 5 of Plats, page 89, as Document N478658, ALL in _rction 21 (21 ), Township Twenty-nine (29) North, Range Nineteen (19) West, Town of Hudson, St. Croic County, Wisconsin. The East Half (E~) of the Southwest Cuarter (5'~) EXCEPT parcel Tat Parcel No: l~D.~/05b-~~ conveyed to Alfred L. Ekblad in '.oiume 498 • • • •~" page 484; and EXCEPT ~Q /D~.-,.6 parcel conveyed to Leslie L. Swrson in Volume 49$ page 504• and 6 1 07 5 ka i FiLEEN H. wai_sH kEGI;iEk OF DEEDS ST. CkOIX CO., wI kECEIVED FOR nECORD 09-22-1999 5:30 AM i~ARRANTT DEED EXEkGi N CERi Cif FEE: CDG'1 FEE: TRANSFER FEE: E17.50 RECORDING FEE: 10.00 FADES: 1 . ........................ ....... ..... R~TUR .......... the folluwin~ described real estate in ......5-ti,,-Croix.... .,.._.r-,..County, -_ Stale of Wiscunsin: Subject to unrecorded agreement sated October 12, 1991 by and between Donald R. Jordan, Cail Gordan, John A, Elbert and Eric J. Lunde~l regarding fu^_ure land transfers and roadway conveyances. Subject to covenants, conditions, ^estrictions =_nd easerents created by preliminary plat of Wells Fargo Station First Addition, Subject to easements, restrict?:^s, reservations, and r~;hts-of-way of record, if any is not Th!s ............................ ~:mtstend pro~ert~;. (YdQ (is not) 1•:xcchtion to wnrrnntics: 45 noted above I)atcd this .. .- 20th .. .............. ...... _ . Jay ,: ........_ .............._.... (ScAL) August......... 99 ..........._ ..................... 19.. HUM8IRD LAND CORPORATION ,.__..-.(SEAL) ' by ~ ~ ,~, ,N~wGI~TI!~ ........ ..... Austin J. Baillon, Its President _ ... ..........................................::... (SEAL) AUTHENTICATION Signntura(s) .................................................... ....... onin^.niicatxd .'us ........; ^~. - • ~ Tf'1'LE: ~tE~t'3IiR S'CAT1; Bait ^E lYl~'~.1`'S,. (If not, ........--•---........ authorized by b ?r - -~~~-.,~-~-~- THIS INSTRUMENT W->~ ;~p•F'E:) 9Y Humbled Land Corporati.cn .......................•----...-... _-....... -t r (Signnture~ may be auto:cnti-a!~_' ack~r,w?~•.?F;.>' are not r,.r..~~. .. i - ACKNOWLEDGMENT STA PE OF 11i06~39~t~iSf1Q M I NNESOT ss. Ransey ...................County. ( rrsr.i.:i;y ,:.,mc bdioa'c me this ..-2Cth.-..•,day o[ august .. .. ........ .. . 1:'39.... the above named Austin J. Baillon PresiCent of `du;nbi.r~ Land..Cocancation.....-' .............~. ................... ................................... :c n;c known to Le !Le person .-.......... who ~:.ecuted the .archaic: ir,arun:ent anc m~i~ww+la%3q~lh.R•R?3uRu~~~ti~.w- Paul. A.. Oa.i 1.'r n.. „ ~ ; . ~~,v COUNTY Washin tore''^s'•'-'•'•'• ?Ip (.onucisson is ne:mnr.ent.(1f r.ot, state espirntion /D~ +. .. '~, fi9 ~~ 2000 • 2 b~~~` ~p~'.~.~a'~ si`~461 ~--~--~ CERTIFIED SURVEY MAP Sam Miller, Don and Gail Jordan Part of the Northeast '/. of the Southwest y, a-~d part ~f the Sor/Iheast '/, of the Southwest f/, of Section 21, Township 29 North, Range 19 West, Trnvn oJHud,o/f, St. Croix C'anr~v, Wisconsin, including part of Lots 2 and 3 of that Certified Surve>> Mup recorded i/t 1%nhlnte 9, Page 2503 of St. Croix Cormty Certified ,Sur-'w M/rp records. ,. , •~, ~ ,~, C T S T, 7•~ I 0 ooc>rrr,r>~c-~r~~oQ~roo~ ,~g oho s `~l ;~, s ; )~)~rll~ ~ .to ~h ~ o • FOUND >t• I~OQd P~8 ~ --- A~ ItB00RD®A8 ~ L=so./o' . ~ ,3' 9~ ~, . ICNa0.09' 90'4~q /C O' J4. B7 r~~2~Z00~ x W S L/NE STAGECOA H TR. ~f-~-i~ p!)~~ ~ l` ` op /N~" 1n... , 2„~ _ qtly. ~ . F,I 7 O O •1hL~T! •t,6~~',f~ „/,~'' 'ris 1'BACXCN ~' ~0/ '-'•CIC/~ 7 (4,f :~, FOUND 2• IIU~T PIPB , c ~ O ql-: ~ S ~i~aq •• ;~ . 9 , ~6.f/,; p ,~INr~G' Q ~ ~ ~ Eq ~ , .. ~. ~. ; ~ , C~ I _ .. „ bie S ~ ~~ A p~ Dr A , h 0 r~ ~ ~ h O Oi ----• ---•- Q SOQ. $ORINC~B C~ I FLOW . b IN 0 t ~ ; n' p' :' ~ ~~ ` ~ ~ " " <_ ~` t ELEY~s ~ V ~j/6_O.OGib' p' q A5 :0~~, h b W~o, ~~ '^ i y '£ NOTE - 97.6 69•oP~2''E a, y8 ~ '~ ~ "' ~ 6 6 k9 SEE SHEET 3 FAR ~; I ~ ~N~ NQ „ ~ 5 S 3 `~ ~; o$ ,gp' ~1 ~, ~op~, ACREAGE DETAILS ~~I o~a/%rase O LET 2 L~T3t ;5~ p CJI EAS1EMfNT p O ON ALL LOTS t.~~ ~ $ ?~~• b ~ aes.so' ~~ Msae~s'or , `i1 ~~; ~ ~- S89.O •2 "W 633.50' „ /3 J ~ , OWNERS ADDRESS - ~~ I-' ~ w ~ ` • ~ acv s O B. AL SIV COR.'LOT/ aD p ~ C„lr~vt_, SAM M/LEER `:~ ~ ELEV.s/00.770'IASSfJMEOI M S30•06'49'~ ~~ ~ --~--•-- P.O. BOX /5/ ~~ t ~ O so. oo' I ~ s HUDSON W/ 540/6 ~; I a `^~ RESERVED FOR ' DON AND GA/L JORDAN 2/.:t~ t a ~i ~~~~~~~~~~~~+l~~yiy~ FUTURE TOWN i ~ '~ 550 C.T.N. UU ~1 ~ $ W~ ~~~,-w` SGONS ~i~ROAD I i •,~N HUDSON, W/ 540/6 c~ i z ti is ~~~ V~~ ,....••...., ~/~/ ~~~ I N `~ \!~ ~ Mf 4iM? ~ ~ •• ,•~ I 166 `OM I :~ 'LAUREN •. s ~ LOT 4 t ~ ~`I vas ~~ ~~/1713 ~~ ~ ~~9~*no ii ~.+t ~ q o ~ tA~F1 ER FALLS,,: • J~ ~ / i _ ~ ~i i~ i r W i ! A N D ~~~.~ / / soo~ap, ' 2 ~~.,,:rt~~~~ ~ to ~~ ~°~y ~°+ a 3 ~•1 ~ i DATED: OCT. /2, /999 E W ~ ~ I ~~. Wes, 406.58 ~ REV/SED: /A NUARY /B, 2000 I ~ a ~ I 4.s•r•; -x-,r- ~ ~ REV/SED /ANU~1 RY 20,1 O $ ~ W" ~~ ~ ~ C~ s e9 °02 z2 w o 2boo i o ff. _, , h 4i ~ h , ~ c i <t / W ti h tit \\ :j / O h ~~ I p ~ `I+ ,7 h N t C~ 1 . 0 /s6' ~ ~Tu i W ~~ 1 o,/''= ~ o T 3 ' I 2 ' 255.74 ~ ,~© ~ `r--~ ° ~ APPROVED SB9°0222 W ~ ~ 'o: ~~ I ST. CROIX COUNTY 2 \~- ~ a 3 h 0 Eli I 4 Plannin n Parks Committee .~ ~ W E, I ~ SCALE /N FEET fl>~7~' ~?~ ~ °pj"~ c; UI ~r.•~ t1R~~iti ~ ^/ 1A1R ~~'v1 ~ O ~ Ql 1 i~ ~~ V L L Jt-~~ VV . ~ 4,, 0 50 /SO 300 60 p A, O `'~ ~~I 3'~ E o' eu/L o/,vs ..F.~TB~cN_L /KE • - o a ~~.-5 22 0 ' -- Ifnot rooorded within 3(Z!~ays of ~ 5p 6 ~ ~ I annnn„~1 elsfn annrnvnl eh~ll ha 0 . ~1 - •7 Q v .- r 1 11 1 i ~In z'. LIIT 19 ~ .. .~ N O _ Q --- 0 Z N ('~ Z O Z Q J N m O U Q - - -~ r i CO O c :. N to . ~W' ~ i 0 ~ W W m N ~ D a ~ O V N Z Y U N Z Q Z X J ~- ~ ~m cn z ?~~ w° o a -p z f:.t v ~ z ~ ~ Z c~w W $i O N N - - W Z -1 ~ z xa5 O = Q ~~ ~ ~ x~3 -a z O U C7 X Z ~ > O U ~ W ~ -= Tn > WELLS FARGO STATION lCii 7 LOT 14 ~ l0T 8