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020-1240-30-000
~o ~~ll~ ~~~~ ~ ll August 7, 2007 Terry Fossler 831 Harbor View Rd. Hudson, WI 54016 RE: Remodeling/addition, Town of Hudson, St. Croix County Code Administration Lot 22 Jacobs Landing Subdivision 715-386-4680 Parcel # 020-1240-30-000 -Computer #21.29.19.1244 Land Information ~ Dear Mr. Fossler: Planning 715-386-4674 You have requested the Zoning Office review your remodeling/addition project for Real Property compliance with the state sanitary code (COMM 83). When remodeling or adding 715-386-4677 onto a dwelling, you are required to examine whether or not the planned modifications involve an increase in design wastewater flows to the Private On-site Wastewater Recycling Treatment System (POWYS). 715-386-4675 I have reviewed your remodeling plans for the above residence. The project involves construction of an addition that includes two new bedrooms, combined with the existing finished bedrooms within the structure. This project will result in a total of four (4) finished bedrooms. The existing POWYS was designed and installed based on wastewater flow for three (3) bedrooms with a maximum occupancy of six (6) persons. Technically the POWYS will be undersized for the number of bedrooms within the residence; however, current occupancy does not exceed the design wastewater flow for the POWYS. An Occupancy Affidavit is required to disclose the disparity between number of bedrooms and septic system sizing to any future owner(s) of the residence. The affidavit has been submitted to the St. Croix County Register of Deeds office for recording against the deed prior to issuance of a building permit from the Town of Hudson. ~~in~/.T ~ ~'S ~ ~ 3 y The original system was installed in July 1989 by Douglas Strohbeen. In November 2001 a replacement POWYS was installed with a valve to alternate distribution areas; both installations were inspected by zoning staff. The system(s) were found to be code compliant at the time of installation. Inspection reports and sanitary permit documents are on file with the zoning department. To prolong the POWYS lifespan, the septic tank should be pumped at least once every three years or when the tank becomes 1/3 full of sludge and scum. The effluent filter on POWYS installed after April 2000 should be backwashed as needed to prevent clogging of the septic tank outlet. In addition, water conservation measures are recommended, such as repair/replacement of leaking plumbing fixtures, reducing shower time, running the dishwasher only when full, avoid using a garbage disposal, using a wash machine with asuds-saver feature, etc. ST. CROIX COUNTY GOVERNMENT CENTER 1 1 O 1 CARMICHAEL ROAD. HUDSON. Wl 54016 715-386-4686 FAx „~~„-r, ~ ~ ,,,,T.-~,,,,, ,,,, , ,~ The long-term function of your POWTS is dependent upon proper maintenance of the system. If this POWTS should fail at any time in the future, the system will be need to be inspected by a licensed plumber or POWTS maintainer to determine if it requires replacement according to state code requirements in effect at that time. The proposed remodeling and room addition project must comply with all applicable building codes. Please contact the Building Inspector for the Town of Hudson to obtain a building permit. Should you have any questions, please contact this office. Sincer , Pamela Quinn Zoning Specialist Cc: Brian Wert, Building Inspector ~--~G ~ o~~iG~ file ST. CRO/X COUNTY GOVERNMENT CENTER 7 lO 1 CARMICHAEL ROAD, HUDSON, Wl 54O 16 775-386-4686 F,v~ Title St. Croix County Occupancy Affidavit Name - ( Her) Typed or printed being duly sworn ,states, underoath, that: 1. He/she is the owner/part owner of the following parcel of land located in St. Croix unty Wisconsin, recorded in Volume Page Document Numbe St. Croix County Register of Deeds Office: A parcel of land located in rhe~11_ f %, of th ~5'c.~1~/, of Section ~~~ T~~ N - R ~ W, Town of ~~, ~ s ~ ,~ St. Croix County, Wisconsin, being duly described as follows (include lot no. and subdivision/CSM or de led legal des tion) ~ f iiiii~ ii~ii iiiii iriii ii~ii «iii iii iii~i~ iii iii * 8 5 7 1 3 4 1 ~5~14 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 08(07/2007 10;30AM AFFIDAVIT EXEMPT 1 REC FEE: 11.00 COPY FEE: 2.00 PAGES: 1 Naa and Return A~ddclcess Paroel _,..1,~_ .~, As owner of the above described property, 1 acknowledge that the septic system serving this residence is sized for a ~ bedroom home. or a design flow of ~/S'a gpd. The design flow is calculated by assuming 150 gpd for 2 thdividuals per bedroom. There are currently ~ occupants living in this residence; ~ occupants are permitted based on the design flow. Therefore the septic system serving this residence is code compliant. However, t understand that if there are intentions to exceed the number of permitted occupants, the system will need to be modified to atxomodate any increased wastewater flows and/or contaminant loads. I also acknowledge that I wiA make this information available to any future parties interested in purchasing this property. Dated this ~ day of ~ o/ a y_S ~ . , ~ , ,* "•. 4 ~ ~! ® ~ ~. ., k • ~^ ~ i.a~ ~ . AUTHENTICATION Signature(s) authenitcated this day of rv,u~y~~a.c mcn ~ •~ ra , ~. STATE OF WISCONSIN ` t, ,~,,;# . ,•.~~ ~~! °r ,-. ~. ~yi St. Croix County. )~~~~~' ~~ l~' ~, ;~`~ , Personatiy came before me this "'+ y d(,~~~~5 the above named :.+A,' . J TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. StatsJ Instrument and acknowledge a same. Tests a~srRtna>=tJr was oRA~o sY r Notary Public, State of Wisconsin -~y~ (Signatures may be authenticated a acknowledged_ Both are not My Commission is t. ff not, ate expiration date: rY•) Date: f~ ~ ~ l /~oo~ "THIS PAGE IS PART OF THtS LEGAL t?oCUMENT- 00 NOT REMOVE" This hfl~rmatbn must be oorr{pleted by submRter. nt ~idg, Lame 6 return address. and ~l (~regauhed). Otherhlormation such as the grarr~rg louses. /saga/ despiption, etc. may be placed on tlfs Hirst page of ens docraner>< ormay be placed on addtlonaf pages of ttre docwnel. ~ Use of this oorerpage adds orre page to your dodxneat and ;x.00 to the ngoordlna fee. t~soonsM StaGdes, 59.517. ~ c~ fA O c~ N O ':I ~ v c) C7 I ~ d~ ~ ~ m f 'I ~ ~ c ~ ~ m ~~ ~ ', I n A v C~ i `~ ~ ~ ~ '~° `~ ~ v `~° •'• 'a m 3'k c m ': 3 ^~ _ 3 ^' _ ~ '.< ~ ... t .. .. ~ ~ ~' o_ o co 0 0 ..w. a Cn ~ o m -, us ` 3 i Oo c Z ~ U3 N O ca N R + a ro _ 7 _ ~ N w ~ p A . Q~ 0 m m N I o o N N 3 ~ O ~ N ~ 0~~ C 0 0 ~ 7 7 ~~ CD h fD ~ 7 O CD n O '~ '. ~ O A O Oo A 3 O o ~ ~ ~ y j . .. o ° ~ 1 1 I m ~ ~ ~ H+ c = d l i o C R ~ ~ ~ m mo . ~ a ~ '' ~ 1 I r r ~ D d. j i . •C D ~ o ` m ~~;, a v, a t, , N `~ a G ' w~ ~° W ~ ~ I W o o ~ M _ = O o~ Z ~ ~ ~ m rn N Q 1 o ~ N ~ 0 0~ N O O 7 '~: y 0 C ~ C C I (D c0 C 3. .. ~ ~ -' < 1 ( ~ a O_ ~ ~ A O i p Z - ~ ~ 0 ~ _~ ~ ~ ~ ~ 0 ~ ~ ~ 'P ~ ~ C 0 C C C (n ~_ O O ' N ~ N d O_ ~ ~ UJ ~ fA O N N N .i n N ° cr N E G G Vt Q Q O B O G ! Q 1 m 0 .« ~ 61 'O O O ~ d 'O y 1 O ID ~ O I ~ Ip f'D ~ 01 1 (D `~ 41 p M ~ ONt T ~~. ~. 7 1 1 N .~ ~ _ C ;, I Z I °. Z D ao o o zD ~ o y t I 3 ~ ' D c ~ ~ N ' 3 C D f N . j m ~ N ~ ro ~ ~ N w , I E ~ rn m ~ ~ ~ n 3 ~~ i 3 ~ I ° N ~ D o I N ~ o .r ~' Z ~ I ~ d a !i A ~ 7 ~ ' Z ~ N W I W~ Ir" a I ~ a ~ I 3 a ~ ~ 3 a z ~ ~ ~ w w ~ ~ A N O Q Q ~ S Q O ~ ~ _ C~ ~' (p ~" ~ K N N A = 7 a ~ N C ~~• fl7 C I ~' a~ z o. I .~.m z n, ~ o ~ o O ~ ~ N N ~ N ~ ~ ~ ~~~ N N G `Z _ _ r. ~` '.,I ~~ O T y A O O i xD~N n S ~ 7 ~ ~. d N __. J ~ ~ ~ O ~ O m3~ a ' O y N ~ = I N ~ O O. j V O ~ ~ A ~ b I m I m ~ ~. I Ea O ~ ~» O ~ ~ ~. A ~ I i O L ~ Q i ~ ~'+ y O . +.. i.1 Parcel #: 020-1240-30-000 os/osi2oo7 03:25 PM PAGE 1 OF 1 Alt. Parcel #: 21.29.19.1244 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 -RASMUS, JOHN E & ROSE MARIE JOHN E & ROSE MARIE RASMUS 831 HARBOR VIEW RD HUDSON WI 54016 Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description ~ 831 HARBOR VIEW RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.473 Plat: 2131-JACOBS LAND 2ND ADDITION SEC 21 T29N R19W NW1/4 OF SW1/4 & SW1/4 Block/Condo Bldg: LOT 22 OF NW1/4 LOT 22 JACOBS LANDING SECOND ADDITION Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 7/23/1997/ ~,(~ ,/' ~ ~8~4I/6/28 ~ ~9,',/J /~ /`'~y/,]y,1U 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.473 76,900 158,800 235,700 NO Totals for 2007: General Property 2.473 76,900 158,800 235,700 Woodland 0.000 0 0 Totals for 2006: General Property 2.473 76,900 158,800 235,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 131 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT ~'EU..To~ft/ iE~}S.tiUS ~ ~IiPS . /~oS~ Owner /~i~S~ U S Address ___ ~~,~ f_~'/~D~ U /~- w City/State (ID.lOi/ ~/S • SAD/(,o ~~G" ~/`3d Legal Description: Lot ZZ Block Subdiv"sion/CSM # S~r'O~-S L~'V~~'~ ~ ~~ ~~D%T. '/, ~Sdi/, Sec.Z•/ , T Z~N-R /9W, Town of fjLU~.S'O~v,. PIN # Q1~' /Z yd '.~D • aa~ SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: /D~ ~ Tank manufacturer ~~EJ~/Z° ~ • Size ST/PC / Setback from: House ~~Well ~~ P/L y TS Pump manufacturer Model /" Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width `3 Length (O 9 Number of Trenches Setback from: House > ~O Well ~/~ P/L 80 , Vent to fresh air intake > ~'o ' ELEVATIONS: fo ~~sr z,~s,~u~o,~ Descri tion of benchmark TOf~ of .SEj j7•~' %~,v~,f ~~ll~! • C~ p Elevation Description of alternate benchmark TOp Of' /OZyES % DDS ~- 5~~~ Elevation /DD• yU ~- Building Sewer N/'~ ST/HT Inlet ~~'~ ST Outlet ~" ~ `s PC Inlet /~ PC Bottom ~ Header/Manifold Distribution Lines ( ) Bottom of System ( ) Final Grade ( ) . N//~ Top of ST/PC Manhole Cover •'~RIGINA~ Na,,, ~"o; ~~ 2 9ysd~ Date of installation ~~ / r Permit number 3 State plan number dumber s stgnnture License number J Date 1 1 YD~ l Inspector A~ HIV ,C~J ~' / ~ f Z !~•D ,` Complete plot plan ~* ~'~ ~ U ~ ~ 'a c w~a ~~ ~ ~ ~ ~ ~ ~ ~ ~OmS ~' ~y p.~~ o S ~, n ~ ~ ~G o o m~~ 0 o J N~ ~ ~ " 0 Y ~ ~~ ~, ~ "~ ~ sov~ LoT ~ ~ ~ ~ o d o ~ ~ 0 b I ~ ~o ~ o~ li I' W °~ ~ I O W I I ~ ~ ~ ~~ U~ ~ ~ ?c 0 - ~ i ~" 1 I c ~~ C ~, a~ ~- ~n , ~ I I 1 1 ~~ ~o~ ~' . loi w ~ ~~ ~ -~ ~l H 1r - - ~ --~ ~ W rn 0 ~i ~ N ,.il~-,~ ~ ~ • d1 \-~ ~, ~ w ~~ ~ o _ .., ~~ N u w N __~ __, ~ ` 1 ~~' ~ .,~.. _ __0-.--- - - O_ ~ © I w w ./~ ~ 1 ~~ M _.- ~-J ~~) ~; ~_ 0 C I~ ~ z ~ } 1~ 0 ~. L M _ h ~ ~ Cy ~ N ti H ~ _ s ~, ~ ~ ~ ;~ ~~,~~ ~ Q~ ~ N ~~ ~~~ ~ G ~ ~. ~ c c~ ~ ~ ~ ~ ~ ~ k Wisconsin Department 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 Rasmus, Rev. John ~ Hudson Townshi - CST BM Elev: Insp. BM Elev: ». BM escription: l u ~ , ~. Teak iti~nQiueTtnti ~i t=veTlnlnl neTe TYPE MANUFACTURER CAPACITY Septic / ~ S i!1a~~5 ~ / / l l Ov C~ Dosing ~~- Aeration w~' Holding TANK SETBACK INFORMATION PUMP/SIPHON INFORMATION t Loss Forcemairf' (Length (Dia. SOIL ABSORPTION SYSTEM BED/TRENCH Width Leng1 DIMENSIONS ~ / SETBACK SYSTEM TO INFORMATION Type Of System: ffiti~J DISTRIBUTION SYSTEM to '/L BLDG WELL ~ 2bl ~~'~ ~ ' lGd / County: .St. CirOIX Sanitary Permit No: 399581 0 State Plan ID No: Parcel Tax No: 020-1240-30-000 STATION BS HI FS ELEV. Benchmark z. ~' z_ Alt. BM Bldg. Sewer ~_ S Ht Inlet ~kr` ~ t Outlet . 3~ 9 y. Inlet ~ttoa~ ~ ~ ~ 3 - ~ Header/Man. Dist. Pipe, ~ V. y q ~(/. 9 °! 2, L Bot. System t, ~~, QS ~(7, ~; t0 Final Grade ~ 3 ~3,~~ St Cover T: 92.s 7 Dia. OR Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake i ~. Length Dia Pipe(s) / Length,1Q~,5'~ Dia ~ Spacing Z ' / / i 7 C/ " SOIL COVER x Pressure Svstems ~nlv xx Mound Or At-Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil n Yes ~ No [] Yes [~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~_/~_/~ Inspection #2: / / Location: 831 Harbor View Hudson, WI 54016 (Unknown 21 Unknown) Jacobs Landing Lot 22 Parcel No: 21.29.19.1244 1.) Alt BM Description = o~ / Cs SF ~ew f ~ 2.) Bldg sewer length = n, sr ~ /~ - amount of cover = V~" J` 3 ~ o `.Se r V q ~:a.~ v ~o ~~v~~, `~` i h.S ~it,~Pn]~ '~ ~- Z~ Plan revision a red . ^ Yes I] o ~ Use other side for additional information. ~ ~- ( ~ ~. ~ ~ ~ SBD-6710 (R.3/97) Date Insepctor's Si ature Cert. No. ~' TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 7 ~~ , ~' ~ ~' 3 y i Dosing Aeration olding ~.! 1/-i5_.vi .~ l1~n L v_"`cG r• Safety and Buildings Division County 5 ~ C2 0 ~` ~ 201 W. Washington Ave., P.O. Box 7162 ~seons~n Madison, WI '53707 - 7162 Site Address ~~ /~ Department of Commerce ~Q,fo-rJ SYD/ w • • Sanitary Permit Application Sanitary Permit Number , In accord with Comm 83.21, Wis. Adm. Code, persottai information you provide 3 ~ ~ s¢ ~ ^ Check if Rev Sion ma be used for seco ses Privac Law, a15. 1 m L Application InfotYrtation -Please Print All Information ~ State Plsn 1.D. Number N/~ Property Owner's Name ~~ . ~ o t-f-~ ~~q-S~cvS Parcel Number z~ ~ Q 19-~2 !r ~F o,20 • /~ YO.3 0 • o~~ Prop(e~rty Owner's Mail~injg/A~ddtess Property Location 9 City, State Zip Code Phone Number Lot Number Z Z Block Number i '" y ~(~~St7~ ~(/ ~. SL~~/~ r~,~ ~~j~O Subdivision Name t~~ ,~.5~;;~=!._ _~.1~A~ ~s~ ~i4~/~S G~,vDi.~G~- .z~-for T. II. Type of Building (check all that apply) %~ Z ~ ~ \ ~ ` ^City 1 or 2 Family Dwelling -Number of Bedrooms ~ _ ~~ _ f (Village ^ Public/Commercial -Describe Use ' '-' QSaN T hi ~ owns p ^ State Owned ~' ~w'~ X Nearest Road III. Type of Permit: o line A (numb the b e . omplete line B if applicable) l A' 1 ^ New 2 ~Repiacement System 3 Replacemeet o 6 ~it(n `~' ~~ County use ~ S stcm = aek Onl S s `• B • ^ Check if San usiy Issued Permtt Number Date Issued IV. T e of Permit: (Check all that apply)(numbering scheme is for internal use) N 44 on -Pressurized In-Ground 21^ Mound 47 ^ Sand Filter SO ^ Constructed Wetland 22 ^ Pressurized In-Ground 41 ^ Holding Tafik 48 ^ Single Pass 51 ~ Drip Line 45 ^ At-Grade 46 ^ Aerobic Treatment Unit 49 ^ Recirculating 30 ^ Other V. Dis ersal/Treatment Area Informat ion: Design Flow (gpd) Dispersal Area i d R Dispersal Area P d Soil Application Percolation Rate System Elevating ' ~ Final Grade O ~r / re equ ropose ) } Rate(Gals.iDayslSq.Ft.) (Min./Inch) /. ~ s.Q~ ~ Q, Elevation VI. Tank Info Capacity in .Total Number Maztufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constntcted Glass f ~(i5 ~I/~ ~ New Existing // '` ~ Tanks Tanks nn ~C./~ ~~ Septitor do _~ /~ ~~ / ~~ ~ ` l~t-}p.Ct~amber VII. Responsibility Statement- I, the tmderslgtted, assnmie respoasibWty for Installation o[ We POW'T3 shown on the attached plans. Plumber's Name (Print) PI tier's Signature b4P/MPRS Number Business Phone Number R , ~ tb ~I~~,7- zz~3~s . ~~s~~~~ ~d'~~s Plumber's Address (Street, City, State, Zip Code) IpSS O ' /ver`L ~~' f~1~So.J Lc>/, S Yv/CP VIII. Count /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signahtro (No Stam s p ) ^ Owner Given Initial Adverse . Surcharge Fee) 7 O ~ Z ' ~ Determination C Z.S. ~ ~ .~. v//onan/tons of Approva//uxeasons ror/Dt/sap/proval _/ ,~ / ~ /~ ~r J L~~ ~ ~( T"~~ iK %~G/9 ~G4.9~ i'l~-Q., ~h. ! 4~~ ea` ~P ~ /M-aty ~ ~ tc~ C~ k ~r PY S trP C a cyl the ComtT orrl~) for the t,~stem on paper not less th.n ltl/2 x SBDy6398 (R. OS/Ol) m C Oi RU ~'~ <3~~ ~N m~ w ~~O at ~~ > ~a of 0 h ~' '~ 0 0 ~~ ~~ ~~ N 1~ •I ~, ? ~ 0 .~ ~ ~ , ~ 0 ~y ~ ~ ~ ~ ~ OJT ~ ~ ~~ ~ v .~ N v ~ ~ ,~ ~ ~ ~ ~ ~~ ~~ ~ ~ SD ~~~ ~N~q~ ~ ~~ ~~ ~ ~~ ~ ~~1 -~ Hl aC 3 ~ ~, 4 M ~ h ~(' _ "~ .~ W } ~ i . , ...... . _ ~, ~ ~~ M '' ~ - - - - - - - - - -- -I .~ , '"~ \ ~ . j ~ ~~~ ~, ~ W ~~~~ ,~ ~ 3 ~ ~ ,q r~ ~ ~ , i .~ p ~ i ~ o~ ~1 I ~ p V1 ~~ 1 ~ 1 ~ 11~ ~ 11 ~~, , , ~° ~ ~ `~; S ~a ~ ~ ~° ~ I M ~` -, '' ~ ~- ~ , ~i ~ -Q . _._._._._.._._~... _. _w__.___.._~_._.____..._~_.. ,_ _... _... QC ~ `~ ~ \ ~ ? ~ 0 m o w ~ 0 ~ Q\ ~ ~~ ~ a m. ~ v i ~ Z -I o ~ ~a~ox M ~ ~ ~ J N ~~ h ~ q ~ ~ ~~ ~.; ~ ~ h ~ ~~ ~ ~ ~~~ '~- h ~, 4 ~ ~ ~ ~ ~S t~ ~~ ~- - -___ r_ M ~ M ~ ' `` ~ (~ ~ -- i ~ Y - ~ ~ ZS X~ZI O I ~3 r - - - - ~ V1' - Hl~ I -- 3 U.~=. N ~ -M , cfl ~ 1 ~ ~ ~~~ ~ w 1 ~ `cl~ nl 4 h ~ ~~ ' i ~ ~ 1 ~nl I ~ ~k , ~ 1 ~ ~ ~ ~ ~ --~--- a ~ ~ ~ _ v~ ~ `~ - ~ ~ ~ ~ ~ ~ ~ ~ ~ ~° ~ -, ~, ~ -, ~ ~ ~ ~ o ~ ~ ~ ~ w -~ ~~ v~ ~, o ~ ~ .5 V .~ 3 Qo J ~, ti. ~, {.~ V ~~. 1~ M 2 ~~ .~ Q~ ~ ~ Q .~ ~\o ~ ~ ~ ~ ~ ~~ ~ ~ O ~ ~. ~ .~~~~,~ ~~Q~~ ~ ~ ~ v J ~ ~ l:. ~ ~ ~ ,V ~ v ~ ~ o~ O ~ a, Q O ~ z . ~ I~Ii ~II ~, ~. .~ ~ 0 { • • ~ I~ - . M g~ ~~T~ ~ ~~ s ~ ~ ~~P ,~l U,v iv..s~l ~c T/ov ~ /~ p ~ sc~. Qo °A' ,~ , w 9/r ~f~L ,~ 9' --1- - r. _ ~~ _ _ ~ L ~ ~~ L ~E'~ ~t'~ D 7-iti° t~t~Y.~, ~r.~ ~ S ~./s TAM , . .. Cho ~~ S~~cTio~ off" T~~-~uc~s :~ ~`~~-~ c~~~</~r y w i~ 1?.~ S Q. F T ; 7-v T~9 C... /~-~iz S ~-o Tia,v --~--- , ,~.1iv. , 2 -, ,~~, ~Pp~U~~ v~ti 7- c,4/n U,v ~,vsp~c T~ov ~/~ t/r/ sc~.Qo I p 1, - - - ' ~j ~. _ 9~~v~- 3 ~ Teti ~ ~ ~~~ •~ ~ ~ _. ~ • . J ~.~ It U za~t Z ~Nisconsin Department of Commerce SOIL EVALUA ,i TON REP / vtsi ORT on of Sale an ty d Buildings Page of in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County sT Gr~~i~ Y ` Include, but not limited to: vertical and horizontal reference point (BM), direction and ,\ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel LD. ~ D~ . ~~ y~ , 3~ , ~h j Please print all Information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner k U ~ Property Location /~j l~EV, ~©~~ ? ~os~ ~~-SUS Govt. Lol /Ufj 1/4 ~~1/4 S~"` T Z! g Property Owner's Mailing Address N R~! @(or) W B ~ ~ ~~ d ~O ~ ~ ~_, _ ) Lot ~ Block # Subd. Name ore91v1# /t ~ ~'t/ 2 Tr~lcof~'s ~NDtvt~-Z~yQ ~DD. City( State Zip Code Phone Number `/ U~~~9~ ~ S O (~ ^ City ^ Village ~ Town Nearest Road ` /. y ~ (~~s,3~1 • /moo ~}vos'o ~ ~T o/~ ~i~LcJ ^ New Construction User Residential / Number of bedrooms _2-3 Code derived design flow rate _ ys O GPD Replacement ^ Public or commercial -Describe: Parent material Flood Plain elevation if applicable ft General comments ~ and recommendations: ~X/.ST/jv(j ~/fiGI~V~ D~/t~jf~~`/~~L~ Cl~2X sZ ~~S ~,j~/ Boring # ^ Boring Q ~ /L Pit Ground surface elev. ~ ~~ ~ ft. Depth to limiting factor }/` J~ in. Horizon Depth Dominant Color Redox Descri lion Soil Application Rate P Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ~ ~ ' ~n ~nYR ~/~ 1 SG 'Eff#1 'Eff#2 2 /o • Y3 ? S yr2 /y~ C ~s~k ~.~~ cs z f , y , G .~ ~ ~Z ~' a On ~ q S ~o III ti Boring # c^~r Boring R C, ~O ~~ !'Sl. Pit Ground surface elev. J ft. tk4 tp tip 4J ctor ~ ~~~ in. Horizon Depth Dominant Color Soil Application Rale Redox Description Texture Structure Consistence Boundary Roots GPD/its In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. / ~ ~ _ ~ ~~~~ S 'Eft#1 'Eff#2 Z - • y~ ~.syr~ , s. o, s 3 . yD•/io ioye s~ s ~~ cs ~ . ~ i. Z~ o~ ~-~ . 7 ., ~ z ~~ , -, 'Effluent #1 = BODs > 30 < 220 mg/L and TSS >30 _< 150 mg/L (Please Print) Signatur /2o/3~T Zl/d,~i'~T- ' Effluent #2 = BOD. < 30 Date Evaluation Conducted ~v -i~•~/ and TSS < 30 mg/L CST Number ~2~ 3 ~ S Telephone Number 7!S ~ 3 ~~ • d'1~S Private Sewage Consultants 655 A'Neil Rd. Hudson, Wis. 54016 . Property Owner ~ ~ ~~Q-SUS Parcel ID # ~ ZQ . ` 2 ~~ • ~ Q ~ Z Page of a Boring # ^ Boring ~ 3.7f~ ~ Q (y Pit Ground surface elev. ft. Depth to limiting factor ~ / d in. Horizon Depth i Dominant Color Redox bescription Texture Structure Consistence Boundary Roots Soil Application Rale GpD/f<= n. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eft#1 'Eff#2 y ~ ~ •3lv ~o y - S~~ /fsh~ v~ a s /~ . Z ~ .3 ~~ o s S. ~, S . 7 ~. " 9L. •~ I I Boring # U Boring u ^ pit Ground surface elev. tt. Depth to limilina tarter :~ Horizon Depth I Dominant Color Redox Description Texlure Structure Consistence Boundary Roots Soil Application Rate GPD/ft~ n. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eft#~ 'Etf#2 ^ Boring # ^ Boring n pst Ground surface elev. K. Deoth to limilina tarfr,r s., Horizon Depth in Dominant Color M Redox Description Texlure Structure . Consistence Boundary RoolS Soil Application Rate GPD/ttz . unsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 =BODY < 30 mg/L and TSS < 30 mg/l. The Department of Commerce is an equal opportunity service provider end employer. If you need assistance to access services or need material in an alternate format, please contact the department at G08-2GG-3151 or TTY 608-2G4-8777. r ~ ~. w _`\n`~ 0 O C ~° d k ~ ~Q O~ ''S ~ ~ I 1~ °0 ~ v 'Y ~ `~~+~ ~~ 'J7 -~ 4 ~~ c.,, ~ i ~\~' ` ` ~~ I' ~ ~ ~ 'I W ~' ' ; x. ~ i ~ ~i ~ ~~ L~ 5 0 w 0 l~ ~~ ~` 1 ~~ ~ ~ r z~ X s z' r3-~ ----I °: ~ ~ w~' ~ _ ~: ~D , Go 7-- L . `~ •, ~,, c ~' b .~ I~ I ~ ~ ~ i~ y ~ a `~ N ~ `~ ~ `~ o~ c a, t Q ~ `n II v, `~, o ~ ~~ ~ ~ ~ ~~~ W ti ~ ti g~ 0 ~' c„ N !1G~ ~ ~ ,~ w W ,~ --.---- 0 c pS N ~, N y . N_ 1~ e~roc ~.w<~ ti; ST. CROID~` ~Ot~N:T'~ ZONING OFFICE CERTIFICATION STATEMENT A FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the .septic tank presently serving the ` ~j residence located at: ~_1%9, `~~ 1/4, Sec . ~ l T / N, R~W, ,Town. of ~~SD'J Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. 5~~~, ~,G~ ~a Last time serviced / Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: ~~~ ~r~x- Construction: Prefab Concrete ~ Steel Other Manufacurer ( i f known) : ~~ E.S ~~ ~~ ~-( 1`~ Age of Tank ( i f known) : rlj~ Q/ (Signature) (Title) (Date) (Name) Please Print (License Number) Form to be completed by licensed plumber (x.195.06, 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_ ~ ~iif/~~vGt/ Signature -Mf~,/MPRS ~~~ ~~S 5/88 /~IJ~ • ~~ ~~ / ' ~l Uwner/Buyer ~d Mailing Address ST CTtUIX COUN'T'Y 5EP1'IC 'TANK MAINTENANCE AGREEMENT ..._...~,- AND UWNERSIiIP CERTIFICATION FORM ~~ ~~ ~ ~3 / r y's 3 ~G - ~~~ e a~ lei-~'-~- Property Address ' `'4'`1'e' (Verification required from Planning Department for new construction) City/State 6( y~fy "~ ~~ ~ Parcel Identification Number ~ 2"~ ~ ~~' ~ ~ ~~ ~ ~~~ LEGAL DESCRTf, jTION Property Location r `~' '/, ~~ y~ Sec. 2 ` T Z~ N-R I~ W Tow o ~V O`s~ ~ , n f Subdivision ~~,1,3 S G~'~Cl~l~V ~ 2NYiC._ ~~~ ,Lot # ?'Z: Certified Survey Map # ~~ ,Volume ~ ,Page # ~ ~/ Q ~ Warranty Deed # ~7 ~74 Z.. ,Volume ~Y~ ,Page # ~'y Spec house ^ yes CTno Lot lines identifiable C'~ yes ^ no SYS'T'EM 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) the on-site wastewaterdisposal system is in proper operating condition and/or (2) alter inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, 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 drat your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days f the three y expiration date. SI N 7URE OF APPLICANT DATE UWNER CERTIFICATION • I (we) certi that all statements on this form are true to the best of my (our) knowledge. I (we) Am (are) the owner(s) oC th roperty de cri a above, by virtue of a warranty deed recorded in Register of Deeds Office. IGNATURE OF APPLICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a cony of the certified survey map if reference is made in the warranty deed PAGE b REVERSE SIDE OWNER's MAINTAINCE OF SEPTIC SYSTEM POWTS (landowner) is reponsible for proper operation and maintenance of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of this syste~t. The owner is required by code to submit all necessary maintenance/inspection reports to the controlling authorities. SPECIFIC CONTACT AGENTS G ~i/ ST~ (~or~ K 7 * Governmental authority/ inspectors: ~~~(~.~ ~'~/`'~ ~ 3~C~~ yGga *.Licensed installer, responsible for providing an operation/ maintenance "Users" manual: ~~ ~~~~~~~ 3~G~ gibs ,y~~s ~z~3~ s * Licensed servwce / inspection agent other than installer: ~ ~ , ~ ~ ~ S~ti,~ T~~o~ 3 ~~ ~ 2l3 a * Electrician, for pump, electric controls, wiring units: IMPORTANT OWNER MAINTENANCE RE UIREMENTS 1. Winter traffic (sledding, shove ring, etc.) across the area shall not be permitted, or frost can/will penetrate into the cell, freezing up the system. Discontinuos use in the winter (a vacaction trip, resulting in no water use) can also lead to freeze ups. 2. Water conservation needs to be exercised! Or system can be hydrolically overloaded and destroyed. This sys(Cem was designed for a maximum wastewater flow of y5'"v gals. daily. 3. POWTS ar.e not designed to accomodate wastes from a garbage disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. 'i 9. If a power outage occurs, or a pump fails, it may result in a temporary overload of effluent being pumped into the ~ cell, which may adversely impact the cell (leakage). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts. Consult your installer immediately for advice. 5. Neglect of the vegetative cover (the cells insulation & erosion preventive) can lead to failure. Compaction or heavy traffic also can destroy t he system. It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER A SYSTEM!! Effluent in the system beneath IS NOT sufficient alone t0 maintain a grass cover. ~` ___ ~~~ ~~ -. 1~ ;~ i DC+CUMENT NO. STATE BAB Ot WISCONSIN YOBS 1-1Mt ~~ TM1e ea/Ce RffeR~'m rO1 "~1°"'e °ATA 449'T02 ~ ~ ~AC~._ na ThiB Deed, made between _ Sam: E. Miller, a single man ,~----. JohD- • B.. - ~@1Pt?4_. ~Dd...itose.. Marie.. ~AlelAUi ... bu~ab~aad.,aad..._ ....Wife - as • autv~y_or$~l~,p. malcita~,_-plcage>;t}t.---•.- --••---.....---•--........ .................................................................•--------................------ -• Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... conveys to Grantee the following described real estate in ......St_..Cioix......_.__ County, State of Wisconsin: Lot 22, Jacobs Landing Second Addition in the Town of Budson, St. Croix County, Wisconsin. REGISTER'S OFFICE ~ sr. caoac oa, an Rs~d for R+wtao~d ~~ JUL 1 ?1989 I °f io:3o A. M II~ * ~~d0~ ,~ RsTU~N To Ta: Parcd' No: rx s ees This .......i$..110~.-...-... homestead property. (is not) Together with ali and singular the hereditaments and appurtenances thereunto belonging; And..-...._..Srantors.. S~l1_ E,-..~'1,1.~~.a~--•----••------•-••----•----•--••---...----••--•-----•-----•--•-----•--• ........................... warrants that the title is Qood, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and will warrant >,uld defend the same. Dated this .-----------•---•--/.Y..~'---------------- day of ---------- --°------Jul)t--------------------=------------------, 1989.--.. .._(SEAL) ~~~C_~~_ "'-- ~ ~!~"'........-..(SEAL) ii Sam E. Mi11e f , ` -•----••-----•-•----•----•--------•--•-----•-----------•----•------..(SEAL) i i AIITHBNTICATION 8ignatnru(s) authenticated this __._....day of ........................... 19..._.. TITLE: YEl[BEIi STATE BAB OF WISCONSIN •-•- • -----....---• .......:..........•-••-----------.....-....---.(SEAL) ACSNOWLBDG)ldBNT STATE OF WISCONSIN St. Croix ~' ------------------------------------- - County. Personally came before me this ... l~th ....day of --...--°•----...--..ruLy..__..--.-•.--. 19.$9._. the above named ------- • .........................Sam.. F.--MilJes..... ---•----.. _.... (It not- ------------------•----...-----•---------'•~'~ -•--------- ~' ----....---•---•----••-----...-----•-----•---•---------------•---•----------- aathorized by ~ ?t-8.06, Wis. Stats.) ; .. ~ me known to be the . c` S A ~ ~ • person --.-----.... who ezecuted the ,~,~ lpregoing instrument and ackn ge the same. THIa I~~STRUMENt WA9 DRAFTED BY w • ~ • I G ~~. `~ HEYWOOD and CARI ...~-~-.. '-'*~!---------------- r //}}~~ -•--....P,0.-•Box-X29-,--Ilt+d oa,--b1L-----• !df -~5~~ - '~lotarv Public ---------------------•---.----------------County WiR_ s O Z N h O 3 • f- N Z ~ ~ Q s ~ = Q W ; ~ H W ` t > ` W ~ t } ~_ Z ~ J ~ 1~ O i ~ V r-~ 1 ~ I 0 1 N' Q I JI GI WI F- HI Q J al z ~) `~ N w N OI ~ O O m O N N G1 O O O m m m ~i W a ~ o Q O O ~ O e~f ~~ ~~ ~~ ~./ o ~ ~// o/i ~~ . BS' t9E M ~~/ 1 ~ ~ ~98 I ~ HN IO IO WZ , 3 ~ ~3 ~ I W F_ r ~ ci a ~ 4~i-'~ N O Oyu (~ O ~ F- Wo h M N N N ~ GOO ~ ~ m Z \ O n I ~ aWC 3 ~ '" m W N ~ IL N WWQ 3 z= a ~ -- ; .00'ZdE N N_i N a+ 3.6T.Ot.68 N I ~ I z o o O ~ ZWZ - ~ Q20~ • W.N p m J!- O I ~ Z W ' NQ O~ - O m ~ N . EZ ' SLd N m N N ---' BZ' ST =~ ~ tp ~ h h O N 1~ f~ O 3 W e QI ~ ~ ~ V .00'Z~6 0 0 3.6t.OT.69 N 2 N I ~ i= • O ~ • O ov O N< H V ~ A • • ,•~,, • ~j N~ (A Q O I C ~ N N O M ~ ~ 0~ ti N ~ 't m , 9 9 r N r ~ o= r W xW r ,;~ ~I ~ ~ • W - 1 ~_ 1 .~' .00'ZbE 3.6T.Ot~68 N .00' - I_ •~ ~Nd~ 3blddd 133!!18 • .00'ZfE M,6t.OT.68 S I .00' ~ _ ~ Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~ ~/~ ~j~L/~ TOWNSHIP ~ ~~ ~ SEC. ~_ T ~N-R ADDRESS ~~y~ ~~Z ST. CROIX COUNTY, WLSCONSIN SUBDIVISION ~a.C ~0 ~ ~<~'~1 ' `"' LOT Z 2 LOT SIZE ~ . 2 S ~~~' '" ..PLAN VIEW Distances and dimensions to meet requirements of ZIaI~R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM d 1 ~~S I'y, I ~ 79 v r a ~~o 9 _--..--~ S "~ J `~ I ~~ ~~~~ { i ~~ '~ ~ ~ ~ ~ ~ l~ ,~ '.;y,~ C C ~ ` INDICATE NORTH ARROW ~~ ~y BENCHMARK: Describe the vertical reference point used / ~c~/ ~~~~ S (,J ~~~ ~o/h.~v .Elevation of vertical reference point: S,~D_ (Qd_l~ Proposed slope at site: S'% S E ------- __ _._ -- -- ~ ---- ~o =~ /w A C-t,t~ l ~ f '~ ~ No ~, ; ~ -----, / / ~/M9~ a ~ r y~ G: '~` . Pi]MP CHAMBER I~ianufacturer: ~~ ~ .Liquid Capacity: ~ Pump Model: Pump./Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: .Number of feet from nearest property line: Front, O Side, O Rear, © Ft. Number of feet from well: Number of feet. from building: (Include :distances on plot plan). SOIL ABSORPTION SYSTEM Bed: C~7 v~fi~~o-~. Q ~ Trench: ~_, Width: /g ' Length: 3 G ~ Number of Lines: -.3 Area Built: ~o ys Fill depth to top of pipe: ~/p ~~ Number of feet from nearest .property .line: Front, O Side, Rear,O Pt. Number of feet from well: ~l s' Number of feet. from building: ~9 (Include distances on plot plan). SEEPAGE PIT ,~ Size: / ~ ~ Number of pits: Diameter: y .Liquid depths Bottom of seepage pit elevation:. Area Built: Ha§ either a drop box O or .distribution box O been used on any of the above soil ab'sorbtion sytems? (Check one). HOLDING TANK Manufacturers ~ TI Capacity: Number of rings used: Elevation of bottom: of tank:. Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well:' Number. of feet from building: Number of feet. from nearest road: Alarm Manufacturer: ~EPARTNIENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION p.0. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 I~I[~- S~~ S._1 29. ~.-?~19:'T Sf at sPgned) 'Number: `"' ..`"' ~ 'm >`T ~ CONVENTIONAL ^ ALTERATIVE Town of Iiudson T _~ ~~ T_..,.,~,. T .,_a;~.^._J~Ioldina~Iank ^ In-Ground Pressure ^ Mound NAME OF PERMIT HOLDER: Sam Tliller ADDRESS OF PERMIT HOLDER: ' Box ?.Q2 LIudson G]I 54016 INSPECTION DFyTE: /~~~ ~ l/I/~_ ~ ~ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: RE . PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Dovg Strohbeen 5432 St. Croix 119423 EPTIC TANK/HOLDING TANK: AANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER / '~ •`~ l~iL~/tl~-I~ V ~DO~ ~r ~~ l9 ~/ ~ W ~J PROVIDED: S ^ NO PROVIDED: ^ YES NO tEDDING: VENT DIA.: VENT MATL.: HIGH WA TER NUMBE R OF R OAD: PROPERT Y WELL: BUILD ING: VENT TO FRESH ~ YES ~ NO C Z ALARM: ^ YES ~ NO FEET FROM NEAREST ~~ c`~I ~ LINE ~ ~? O ~S 3 "'~ AIR INLET: DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ^ YES ^ NO ^ YES ^ NO ^ YES ^ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ^ YES ^ NO NEAREST ~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CANVFNTIANOL SVSTEM~ BED/TRENCH DIMENSIONS WIDTH: r1 ~./ LENGTH: _,~ NO. OF TRENCHES -- : DISTR. PIPE SPACING: ~I COVER MATERIAL: PIT INSIDE DIA.: {~ PITS: LIQUID DEPTH: GRAVEL DEPTH BE OW PIPES: t t FILL DE ABO E COVER: ~O DI R. PE LEV. INLET: ~ 3~ DISTR. PIPE ELEV. END: ~ ~' ~~ DISTR. PIPE MATERIAL: ^ ~`~ ~ tT NO. DISTR. PIP ~ NUMBER OF FEET FROM NEAREST ~ PROPERTY LINE: ~~~ WELL: (~5 BUILDING: ~~ VENT TO FRESH AIR INLET: ~~ '~" MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ^ YES ^ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ^ YES ^ NO ^ YES ^ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ^ YES ^ NO ^ YES ^ NO ^ YES ^ NO PRESSURIZED DISTRIBU TION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING : GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL 8 MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND D ISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ^ YES ^ NO ^ YES ^ NO COMMENTS: PERMANENT MARKERS: OBSER VATION WELLS: NUMBER OF PROPERTY LINE WELL: BUILDING: FEET FROM : ; ^ YES ^ NO ~ ^ YES ^ NO NEAREST ~~ _ ~~ `~ ~ ~~ :~ , , '~ - - f J 1 ~ f k ! 'J , ~°, , ~7~ Sketch System on Retain in county file for audit. Reverse Side. sIGNATU TITLE: c ~+ ~~~~ Zaning Administrator SBD-6710 (R. 06/88) ~ l.. sANlTARY PERMIT APPLICATION °OS~ - ~ j~ II DILHR 0 ~ Adm Code Wis ith ILHR 83 05 I d . . , n accor w . ~~ ° ~,..,..,.~..,~,. STATE SANITARY PERMIT # 1 / 9 ~3 -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8'h x 11 inches in size. -See reverse side for instructions for completing this application. PETITION S ~ No ^ I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. YE FoR VARIANCE PROPERTY OWNER PROPERTY LOCATION ,~ ' ~L/' ~/a 5 cv'/a, S 2 / T 2 9 , N, R / E (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAMEn CITY, ST TE SO ~Z ZIP~CIODE ~7e3 /(P PHONE NUMBER .~Fl~ Z769' ITY NEAREST ROAD, LAKE R LANDM/ARK O VILLAGE : 4~.SON ai brjr it 4> ~om.U II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family --3 OR ^ Public (Specify): 111. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable) 1. a. ~ New b. ^ Replacement c. ^ Replacement of d. ^ Reconnection of e. ^ Repair of an System System Septic Tank Only an Existing System Existing System 2. ^ A Sanitary Permit was previously issued. Permit # Date Issued 3. ^ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ^ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.: IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2} 1. a. ~ Conventional b. ^ Alternative c. ^ Experimental 2. a. ^ System- b. ^ Holding c. ^ Pit Privy d. ^ Vault Privy e. ^ Mound f. ^ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. See a e Bed b. ^ See a e Trench c. ^ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ~ ,3 ~ ~ ~'S^" g Feet ~ Private ^ Joint ^ Public VI. TANK CAPACITY in allons Total # of m N f t ' M Prefab. Site Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks s e anu urer a ac Concrete glass App Tanks Tanks structed Se tic Tank or Holdin Tank Do0 ~ L/a% fGf ^ Lift Pum Tank/Si hon Chamber VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: o 'r e {. ~ Ps- ~ ~. Z ~ 7 32-3 Plumbe 's Address (Street, City, State, Zip Code): Name of Designer: 2-~ .~ .. ~ ~. o s Dom. ~~ k b VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # ~~y ;S ~~ ,~~ ~ CST's ADDRESS (Street, City, State, Zi Code) Phone Number: r~ ~ k oh. vac ~i,~ 3~6 - sss~ IX. C LINTY/DEPARTMENT U E ONLY ^ Disapproved itary Permit Fee n Sa Groundwater ate Issuing Agent Signature (No Sta s) Approved ^ OwnerGivenlnitial , ,,YY ,yam ~^~ oa ``++1N~ v S~ch~s v(' ~ _ ~~~ l ~ ~ ' S Adverse Determination , ~j C t ~~1 ' ~ X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03!86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber 1NFORMATiON & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained.--The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; lll. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project , is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DiLHR; VII. 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. Fifl in designer name if applicable; Vllt. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'h 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; dosing or pumping chambers; 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 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground star -- included the creation of surcharges (fees) for a number of regulated practices which Wisco in's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure is used in your building is returned to the groundwater through your soil absorption o l system or the disposal site used by your holding tank pumper. G The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- f water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) APPLICATION FOR SANITARY PERMIT This application form is to be the property being developed. the permit issuance. Should owner/contractor,(spec house), completed when the property appropriate deed recording. ------------------------------- STC- 100 completed in full and signed by the owne=(s) of Any inadequacies will only result in delays of this development be intended fat resale by then a second form should be retained and is sold and submitted to this office with the Owner of property s~ ~l ~•~~~t/'" Location of pro/p'erty ~1/9 s ~ 1/4, Section Z~ , T~N-R~ Township _y~d'S®~y Mailing address tS°'~al''~~ 8'2-- ,~/df~Sc~•-t h.,/.~ ,~ ~CJ/~~ Address of site ~a ~ o b s ~rk~aa ~,-,.~.~~~ ~~ bs ~ Yd~./ ~~Gt9` .Subdivision name__~s.Gc~~s La~.~.'.r~ c~ir.t ~~~V .Lot number * Z 2.. ;Previous owner of property ~i~/a ~ n ~`Q. /~- ~~ ~' 6's ti Total size of parcel Z . ~ 73 /~!a-rS Date parcel was created ~~Zg /$'S~ Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house)? ~ Yes No Volume O S and Page Number yG Z. as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGB NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ---------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. .Sl3 S'// 7~ ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Req's er of Deeds, as Document No. 'y3 S~/ / 7 ) . Signature of Owner Signature of Co-Owner (If Annlicablel f1000M[N1 rvo WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-1982 43 ;417 z:. ~(~r,~c~ Virginia M. Hanson, a single woman conveys ami ~c,:rrant: to Sam E. Miller, a. single man St. Croix tfie folh~winR descrihcd real estate in ... .. .. _ _l;uulay, ~tatc of R•i3consin: iH18 SIAt.C RES[RVED FAA RCCi1RO1N(i UAIA REGISTER'S OFFICE . SRsc'rtdafor Record ~ M~~ ~~ tae ~ 8:00 A M I+! 1111+N Ip Taz Parcel No: West Half (Wlg) of the Southwest Quarter (SW'-~) of Section Twenty-one (21), Township Twenty-nine (29) Nortir, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of the I+ublic highway and except Lots S, 6, 7, and 8 of Certified Survey Map n Vol. 6, Page 1747, Doc. No. 419479. That part of the West Half (W'~) of the Northwest Quarter (NWT} of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolis and Omaha Railway Company. $~-~-~ Q FEF This i8 ROt homcvtrad prr+pcrt;:. #p{~C (is not) F:xcri+!ian t.. ~i•arranties: easem%nts of record and protective covenants and restrictions of record, if any. S~ lrntcd thix ~' day of ~ ~ r ~ ~ l9 $$ ( E A 1.1 ~.l~sG.G;~ij~t.C.QJi// i'~~'/L1Lid~" -C/ t S E A 1, r Virginia M. Hanson (sF:A[.1 AUTHENTICATION Signature(s) authenticated this .... day of ......_ _. 13 • ................ ....r ......_ ... _ _ ___.... T1Tt,F: !1fF,MBER STATE BAR OF \VI«'f)NSt\ (If not. .._ . _ .. _ _._.. _.. authorized by § 700.06, Wis. Slats,) T 4'S INSTRUMENT WAS DRAFTED BV Loi_s_ A,_ rturray,._Neywood_,._Cari & Murray P.Q.._BRx..229, Hudson,..WI___54016. 1tiF;A1.1 ACKNOWLEDGMENT STATE OF WlSCUNS4N ( ~ ss. ..~~ \. r ~ `ac.. County. I'ersonall}• come before me this .- ~' day of M to ~ c.. f--.... 1 J 8~ .. the above named Virginia M. Hanson _. to me knoi~n to he the rer;on tehn oxecuted the forei;oin • ' trument not) ai'knowlcd~:e the same. U' 3TC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _~ %!'7 ~~~I/`,-° _ _ -- - -_ ROUTE/BOX NUMBER ~X ~ Z- ~ 2.. FIRE N0. r---- CITY/STATE /~~~ ca ~i G/~ ZIP S'~~/~ PROPERTY LOCATION: ~1/9 S G[/ 1/9, Section 2./ , T~N, R_1L1J~/ Town of h`~~/SOLr , St. Croix County, /~ Z~ ~K~/ Subdivision Ta~o~ S Ler~.,t~,'~~•L~d6 , Lot No. ~ Z~ Improper use and maintenance of your septic syst/em 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the. owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1> .the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED s DATE 3 '~ ~ St. Croix County Zoning Office St. Croix County Courthouse 911 9th Street Hudson, WI 54016 (715) 386-9680 Sign, Date, and Return to above address DEPARTMENT OF INDUSTRY, ~ •LABOR,AND HUMAN RELATIONS ~~ w '/a ~'/ s r. r~~ esidence REPORT ON SOIL BORINGS AND PEROOL.ATION TESTS (115) IH63.09(1) & Chapter 145.045) TOWNSHIP/•hftfiC7CtP~tt-iT`f: LOT NO.: BLK. NO.: S ~~R19~11 ~~u~s~~ .~z - T SAFETY & BUILDIN( DIVISIC P.O. BOX 791 MADISON, Wl 5371 1~~.r I /~~-c~cs,'~ ~rOcy~ ~d, f j~k-4S ~~lt~,5. S'~vl6 DATES OBSERVATION MADE MMERCIAL D SCRIPTION: (PROFILE DESCRIPTIONS~ERC LA ION TESTS: New ^Replace ~ ~//,. ~J~ I 3 ~/_ 1'1q S ~+ Nr ~fj° S,(Q lO~1 V RATING; S= Site suitable for system U= Site unsuitable for system. P(r S`~ SA- `/ rG /G/7~/~ CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:loprional) ~I ' ~CS2' If Percolation Tests are NOT required DESFGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: ~/~ Floorlplain_indicate Floodplain elevation: _ ~./~ PROFI(~E DESCRIPTIONS -~'- - 'BOWING TOTALf O U PTH TO GROUN DWATER= CHARACTER OF SOIL WITH THICKNESS COLOR, TEXTtURE, AND DEPT( NUMBER DEPTH Lid ELEVATI N OBSERVED ES'T. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B ~ ~'~' ~ ~v+ I ok ~- / /• .~' / p . ~ ~~ , 7 ~iy s~ ~ 6 B r .S~ . ~ ~vs b rlsr S B- ~ . S ~ ~ ~ Kdr~[i' ~ ~• ~~ ~ , .~ /~ . ~ It ~ S~ .f, ~. CS • 3 .t r B- , tJ ~ l V V . 4 r /Kd~,c,(~ ~ ~ C~ , r 1 ,~ S~ . Z ~ s ~ Bn B-S" ~' . b' vu~ 7 ~ , V ' J T nl b 1,2.9 .• L1 6^f B- PERCOLATION TESTS TEST DEPTHr WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER -" ~ AFTER SWELLING INTERVAL-MIN. pE I D PERIOD Ri D PER INCH P_ ~ 3% n Z ~ ~ ~ ~- .3 p. 2 , Z' p 2 ~ ~- 3 P. 3 ~ a z ~ ~ 3 P- __ L --- - PLOT PLA zontal and of land slo SYSTI N: S verti ~e. M ~. ~! ~I I~ s 0 'v t how locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the h cal elevation reference points and show their location on the plot plan.. Show the. surface elevation at all borings and the direction and perc ELEVATION 9-~ ~ ~ ~sr./rl/~, l "= Ya'~ ~ e G et~-~ ~~ ~r~ rc.,~t -~3 01 .1 ~ ~ ~--~ ~C " I : ~ , f ~ ~J I~ ~rw4t~ ~ for ~ ~- , ~f o~x~ /Q~ F ' ~r G,q ~ .xs ` t~ ~ .s, t/ • e/d f Ce1e-..r ~., ' so ,-..-a ~ ~ '- o o,~ r~P _ A f •~ ~~ t,l~~-~, ~ ~;, i ~~Pr P3~I ~ ~-gss~M~~ ~~. = fdo.~` ~? ~~ 3 ~- ~o~~f- CB.~~ ~o~~ ""' % u j is ~ ~s r_ / _ S t~ ~' ~ ~' -. --- 'i ~' Sou r~ kJ~ S'`7o sl~Pc. ~. ~. J, the undersigned, hereby certify *.hat the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wiscon Administrative Code, and that the data recorded and the Location of the tests are correct to the best of my knowledge and belief, ' S~r» rn~lldto .JG.CO b's Lan: n~ 2n/ A~/S; f,'o.- Hof ~ Z Z 6a~afc r', v ,` wa ~! as~XZ~1' ...~.~.._.. ___~_a _ _____ ! No4 5~ ~S~X S/S/ ' ~ $ f4 ~ <ct z s' so'~~ ~~ ~ BL ~' 30' _ _. L~~~~a a ~3,M• ; s -r H.. v~.,t + /~o~l z R~.~ '~p',~-1' a'4 ~k~ S.W. ~o'c c~~ha.~c eti flop o~ ~ ~" dot Q~P~.. , ~- A~5 K m~ d ENV. _ ~Do.o ~ - SoJQ s L~~~k t.o~.1 p _ 'P a r c S (~'.. st ~01t o w~ E 1 • _ °15 ,. ~ ~ per{~ ~~ ~~~s~~~ _ 2DO ._ _. _.. ._... _ _ __ _ ____ Z~ 2s_ 5a a'y/ /o'f /.'A s... 3 y 2 ' ~/Va Sc4 ~a / N r /70r /9S ~ /70~ I ,. ~ ' ~.. ~...• 'I .. M d ~: '. o- ,.: ~ y la- f c ° +- .~ . .': ~' H u- H ~ . ,- ~ d a . ~.: J ., .'. J ~.~ r .. ~~~ ,'• k~. ~ •~ ~. . , ~ ' . .:.; . ;~ .... ' tia"s. •:' ~~ ~ ~'v1 C ~ (,~~ ~% 0 v 1 7 . ~~-~ ,O 0 d o . a ~- 4 J . ~ . ~ ~as 4~~ o .' d •. . ;o~ ; ~ V ~ ~ o • ~ . J T J ' : H . ~ i i .T}! ~~. _ I , ~ ~ ~ ~ ~ , ~ ~- ; ,. ~ ~ ~ a ~ s y , d o ~ ~ ~ I -0 -r a 7 ~ : _ M u- A ~i ~ , t d ~, ~ ~ ; ~ . AJ 3 ~ ~ d N ~ c9 ' ~ '~ j -6' d ~ ', M J 7 d ~• ' ~ '? ;' • ~ 0 ~~ T =~ d ~ ... .. N ~ r N ~ ~~