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Home My WebLink About020-1165-66-000 MEN" t O Cl) a m C c 3 to CD xc ~ n Q a~ 00 O d o m vN o o c o `C j• CD ° vi v ! N ~l z a o c° C: CD 00 (n CL l o° C o ° CD CD C: ID a l o Q O) O A N p co y o o O co (n co x .~1. p = W O CD 0 C 3 O N p 10 ID w y N r C c co co a) 0) N 3 :7 Q ° v "4• 0 cn !J a r N N A Vt d a- a- 0, 3- =t O _G ° RL W < 61 O CD 0 y N A N _z N U N ° zzmo O O a v CD m Cl) CD m c t~l c m N* OIQ CA) a z CD V! ~ T M a p z b W (D a 3 z °o y m z C CA) o a v o a -n _ c o a 0 N N a o N fi I n ti I m N (D W k-j co °o a ~ ~0 H o o0 o m ~ b I ~ a 0 , ST. CROIX COUNTY WISCONSIN ZONING OFFICE tl Y M N M M M M r~rrf ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 May 10, 1994 Mr. Jim Henry l / lP S-_ f Edina Realty 1~5~ D! "Zi 700 Second Street Hudson, Wisconsin 54016 RE: Water (VOC) Inspection for John and Rose d Address: 454 Brookwood Drive, Hudson, Wisconsin Dear Mr. Henry: Enclosed is the original test results from SERCO Laboratories for water (VOC) inspection of the above property. If you have any questions with regard to said report, please let me know. Sincerely, /s/ Mary J. Jenkins Mary J. Jenkins Assistant Zoning Administrator mz Enclosure cc: Pat Collins SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 44416 PAGE 1 05/06/94 St. Croix County Zoning DATE COLLECTED: 04/21/94 1101 Carmichael DATE RECEIVED: 04/22/94 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE WELL WATER Attn: Mary J. Jenkins SERCO SAMPLE NO: 57224 SAMPLE DESCRIPTION: HAND ANALYSIS: Benzene, ug/L <1.0 Bromobenzene, ug/L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 Dibromochloromethane, ug/L <0.4 11 2-Dibromo-3-chloropropane, ug/L <1.2 112-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. a~od r~.r6 MEMBER Z LA 1 SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 44416 PAGE 2 05/06/94 SERCO SAMPLE NO: 57224 SAMPLE DESCRIPTION: HAND ANALYSIS: Dichlorodifluoromethane, ug/L (Freon 12) <0.5 1,1-Dichloroethane, ug/L <0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-1,3-Dichloropropene, ug/L <0.9 Ethylbenzene, uq/L <1.0 Hexachlorobutadiene, ug/L <0.3 Isopropylbenzene, ug/L, (Cumene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isopropyltoluene) Methylene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L <1.0 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ug/L <0.1 Tetrachloroethene, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichlorobenzene, ug/L <0.2 1,2,4-Trichlorobenzene, ug/L <0.2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. I 0~12'- MEMBER Arm - I 7 SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 44416 PAGE 3 05/06/94 SERCO SAMPLE NO: 57224 SAMPLE DESCRIPTION: HAND ANALYSIS: 1,1,2-Trichloroethane, ug/L <0.1 Trichloroethene, ug/L 0.4 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <1.0 1,3,5-Trimethylbenzene, ug/L <1.0 (Mesitylene) Vinyl chloride, ug/L <1.0 Total Xylene, ug/L <1.0 ZIA This sample's analytical results aarr /a re not-below the U.S. EPA's SDWA Maximum contaminant level of"'T/30/91 for those requested com- pounds which are also on the SDWA MCL list. All analyses were performed using EPA or other accepted methodologies. Samples that may be of an environmentally hazardous nature will be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, Diane J. nderson Project Manager < means "not detected at this level". 1 mg = 1000 ug. d MEMBER f 1 ST. CROIX COUNTY / WISCONSIN OFFIC ZONING r r w r r Ileum NTIE ST. CROIX COUNTY GOVERNMENE 1101 Carmichael Road Hudson, WI 54016-7710 ~y (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make 1 arrangements with this office to insure that entry can be gained. Water (VOC's) $185.00 ❑ Septic $50.00 ❑ Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria retest $15.00 Owner: JOHN a- QaSB HAj\)b Requested by : _j IM ,HEN 12Y Address: eq&q j P_C>Z> j022Q DQ, Address: 'app 2A21 St 1-, cUbsocy , w 1 ZIP d1 f-IuD9t~n~ 0 L01 ZIP 5ti0lfo Telephone W: Telephone N°: (-7/,;)'3Z(,,- 223 Property address (Fire N2 & Street) : -q5-e/ B2oo/GWOOD Dle - Location:n)F- suJ;, Sec. 117_, T_Zc~_N, R 9-i W, Town of~yf_1DSON Realty firm: Epi,y,4 Lock Box Combo: J D N Closing Date: 5-!'3-014J TO BE COMPLETED BY PROPERTY OWNER PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: Is the dwelling currently occupied? ❑ Yes ❑ No If vacant, date last occupied: Age of septic system: Septic tank last pumped by: Date: Previous Owner's Name(s): Have any of the following been observed? ❑Y ❑N Slow drainage from house. q~7 2 ❑Y ❑N Sewage Bac k-up into dwelling❑Y ❑N Sewage discharge to ground surface it ❑Y ❑N Foul odors. Other comments relative to system operation: I certify that the above information is comp a 6 •t`6 the best of my knowledge. 9 OWNERS SIGNATURE: DATE: 1/94 L OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet # Type of sail absorption system: ❑Below grd ❑At-Grd ❑Mound Approx. size 'X ❑Gravity ❑Dose ❑Pressurized Ft.2 ❑Bed ❑Trench ❑Dry Well ❑Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other Dose tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover ❑Warning label ❑Pump/Floats ❑Alarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Ponding: ❑Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector_ Title to 0 -0 0 O f 3 O 7 = 14- I p lD 'O ~ A CD ~ Cf) _ O - C1 O O C V N °C • ~ W Z O Co 7 3 CL jV O O (D CD N C n N V Oy O ►nj~ r- z cn 0) N O O ID O ? f OOj O O T, = N p A~ I O (~r1 y (A W > cn CD (D (n A (r rt H Cp IW CL O CD 9) -ti O 3 O N- p rt - (D (D m N CD Wft1 o to CO 2 0 r to O B 00 00 c Ch F. I~-I 0) O) N I 3 C z W O L=J =t (71T~ N FA- co ca ca 0 o Q ~vv~ is Cl) 0) P- D ICD C . C o a_ m ~w7 C 3 Cl) a CD V z 40i'• y S o _ N N i/ FO O D co M < O CD 'CIO) N rt I ro v c cl. Z i c CD LTJ ca O a ro m z ro (D 0 :3 w .0, CD x H rt - c 0 :3 r O O' A O v7 z --l (D t3d a z x 3 rt oo r A H o H z Q C A I W a Q 0 0- v n c o z a o ro N I a i CCDD CL O o ~ ~ o Q, ~ z < o m v v A CD ~ ~ O ti ro 40 w O * . O CL ~ ~ 'a ti Parcel 020-1165-66-000 10/07/2005 11:51 AM PAGE 1 OF 1 Alt. Parcel 17.29.19.1012 Current j X ! 020 -TOWN OF HUDSON 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 CHRISTOPHER P & JANE L DRIGANS O - DRIGANS, CHRISTOPHER P & JANE L 454 BROOKWOOD DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 454 BROOKWOOD DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.021 Plat: 2284-PARK VIEW ESTATES 4TH ADD SEC 17 T29N R19W PARK VIEW ESTATES 4TH Block/Condo Bldg: LOT 95 ADD LOT 95 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1080/178 WD 07/23/1997 768/513 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.021 24,500 163,100 187,600 NO Totals for 2005: General Property 1.021 24,500 163,100 187,600 Woodland 0.000 0 0 Totals for 2004: General Property 1.021 24,500 163,100 187,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 109 Specials: User Special Code Category Amount Total Special Assessments Special Charges Delinquent Charges 0.00 0.00 0.00 y 1 orm - S T C - 104 _ AS BUILT SANITARY SYSTEM REPOR OWNER TOWNSHIP SEC. T N-RI J_ ADDRESS ST. CROIX COUNTY, WISCONSIN ~j , y SUBDIVISION S ~G tu) LOT- LOT SIZE S O ' er ' PLAN VIEW Distances and dimensions to meet requirements of I"ZHR, 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 9 7, i ti s W&'' 6aia5y, Ho uScs~2` 190- .2 g v 0 V )L x Sa --So - - - - _ zo' 55 o INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used _Z ~~/of Ii ~a stf S. ~or/1 ~r Elevation of vertical reference point: Proposed slope at site: 0/0 S. F SEPTIC TANK: Manufacturer: Lei's z-y Liquid Capacity: Number of rings used: Tank manhole cover elevation: Z ey Tank Inlet Elevation: ,Q Qy'z`Tank Outlet Elevation:. Number of feet from nearest toad: Front,O Side Rear, ® feet From nearest properAy line Front, Side Rear, 0 feet V Number of feet from: well :77,, building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Jd Manufacturer: 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, Q Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: ~/¢n~/ t7a4 Trench Width: lr6'1 Length: Number of Lines: Area Built: ~yBSy~! Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,f Mt. 2 Number of feet from well: Number of feet from building: S O (Include distances on plot plan).91--v° SEEPAGE PIT q~'ZS 0 Z0 Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: { Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, 0 Rear, Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on j obi License Number : c' F r 3/84:mj ST. CROIX COUNTY WISCONSIN `tixF„ ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, W154016 - (715) 386-4680 "J\/ SEPTIC INSPECTION / WATER TEST REQUEST FORM V ~ Specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. Water (VOCIs) $185.00 u Septic $25.00 ❑ Water (Nitrate & Bacteria) $35.00 (Visual inspection) owner: J OHA-) q- ,y'9&)Fp Requested by: J / M H E- n> l~~l Address: yam/ c3,2~~,~,/a>DOL~ cif' Address : 7bC> ZF- . City & State: ,yu~~r'~n , cuZ City & St. 1--Ic U , s.J~ Zip Code: Zip Code: Telephone N°: ( S) -z7 ,~r7c Telephone N4: ) M7,C=, 3~a Property address (Fire NO & Street) : tZ o z~ Location: h, Sec. 1-1 , T N, R W, Town of -Iuz - olQ St. Croix Co., WI. Tax ID NO Parcel ID NO 02-0-11 7O7- House color: rzown,Realty firm: r~jNlGl Lock Box Combo: J pfd Water sample tap location: N/dy);~2 TO BE COMPLETED BY PROPERTY OWNER APR E A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS Is the dwell' currently occupied? 0 Yes 0 No p6 If vacant, date st occupied: !~a p~ ~ Septic system instal by: Year: O Septic tank last service Date:_ Previous Owner's Name(s): -Rai 111f Have any of the following been rved? Cj A OY ON Slow drainage fr house. OY ❑N Sewage Back- into dwellin EQ, ❑Y ON Sewage di arge to ground sur ce, co Qltp 2 Lq road d' ch or body of water. S~ 199: l~s OY ON Slo drainage from the dwelling. <Lb OY ❑N ul odors. VGw Other c ments relative to system operation: I certify that the above informatio 'scomlet and true to the best of my knowledge. ` OWNERS SIGNATU ,G` DATE: -.27 4/93 V OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION t IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ❑Below grd ❑At-Grd ❑Mound Approx. size 'X ❑Gravity ❑Dose ❑Pressurized Ft.2 ❑Bed ❑Trench ❑Dry Well ❑Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other Dose tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover ❑Warning label ❑Pump/Floats ❑Alarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Ponding: ❑Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title Ira 7 SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 33872 PAGE 1 of 3 10/28/93 St. Croix County Zoning 1101 Carmichael DATE RECEIVED: 10/13/93 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE DRINKING WATER Attn: Mary J. Jenkins SERCO SAMPLE NO: 131453 SAMPLE DESCRIPTION: John Hand ANALYSIS: Benzene, ug/L <1.0 Bromobenzene, ug/L <0.2 Bromochloromethane, ug/L <0.4 Bromodichloromethane, ug/L <0.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 n-Butylbenzene, ug/L <0.3 sec-Butylbenzene, ug/L <0.4 tert-Butylbenzene, ug/L <0.5 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L <1.0 Chloroethane, ug/L (Ethyl chloride) <0.4 Chloroform, ug/L <0.5 Chloromethane, ug/L (Methyl chloride) <0.6 2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2 4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2 Dibromochloromethane, ug/L <0.4 1,2-Dibromo-3-chloropropane, ug/L <1.2 1,2-Dibromoethane, ug/L <0.2 (Ethylene dibromide) Dibromomethane, ug/L <0.2 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) < means "not detected at this level". 1 mg = 1000 ug. MEMBER SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 33872 PAGE 2 of 3 10/28/93 SERCO SAMPLE NO: 131453 SAMPLE DESCRIPTION: John Hand ANALYSIS: 1,4-Dichlorobenzene, ug/L <1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) <0.5 1,1-Dichloroethane, ug/L <0.1 1,2-Dichloroethane, ug/L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 cis-1,2-Dichloroethene, ug/L <0.1 trans-1,2-Dichloroethene, ug/L <0.1 1,2-Dichloropropane, ug/L <0.1 1,3-Dichloropropane, ug/L <0.2 2,2-Dichloropropane, ug/L <0.2 1,1-Dichloropropene, ug/L <0.2 cis-1,3-Dichloropropene, ug/L <1.5 trans-1,3-Dichloropropene, ug/L <0.9 Ethylbenzene, uq/L <1.0 Hexachlorobutadiene, ug/L <0.3 Isopropylbenzene, ug/L, (Cumene) <1.0 4-Isopropyltoluene, ug/L <0.5 (p-Isopropyltoluene) Methylene chloride, ug/L <5.0 (Dichloromethane) Naphthalene, ug/L <1.0 n-Propylbenzene, ug/L <0.4 Styrene, ug/L <1.0 1,1,2,2-Tetrachloroethane, ug/L <0.2 1,1,1,2-Tetrachloroethane, ug/L <0.1 Tetrachloroethene, ug/L <0.2 Toluene, ug/L <1.0 1,2,3-Trichlorobenzene, ug/L <0.2 1,2,4-Trichlorobenzene, ug/L <0.2 1,1,1-Trichloroethane, ug/L <5.0 < means "not detected at this level". 1 mg = 1000 ug. MEMBER 4 Arm SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 33872 PAGE 3 of 3 10/28/93 SERCO SAMPLE NO: 131453 SAMPLE DESCRIPTION: John Hand ANALYSIS: 1,1,2-Trichloroethane, ug/L <0.1 Trichloroethene, ug/L 0.4 Trichlorofluoromethane, ug/L (Freon 11) <0.7 1,2,3-Trichloropropane, ug/L <0.2 1,2,4-Trimethylbenzene, ug/L <1.0 1,3,5-Trimethylbenzene, ug/L <1.0 (Mesitylene) Vinyl chloride, ug/L <1.0 Total Xylene, ug/L <1.0 This sample's analytical results ;are? elow the U.S. EPA's SDWA maximum contaminant level of 1/30 for those requested compounds which are also on the SDWA MCL list. The analytical results in this report pertain only to the items tested. All analyses were performed using EPA or state approved methodologies. Samples that may be of an environmentally hazardous nature may be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, Diane J. erson Project Manager < means "not detected at this level". 1 mg = 1000 ug. r, MEMBER . bEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX f960 BUREAU OF PLUMBING MADISON, WI 53707 L ONVENTIONAL ❑ALTERNATIVE state Plan'I .N-t- III assigneril El Holding Tank. El In-Ground Pressure E Mound NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. L" / ~E 3 ~qT s "Vmot 6 INSPECTION DATE Sam Miller . RAT- i , DUX 2°'vz;-z dJson/, WI 5401^6' 1.2 ,ol'749 1-030 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.. ICST1111. PT. ELEV NW SE, Section 17, T29N-R19W,Twn. of Hudson. Lot#95. Park View Est.IV Na),. of Plumtw, IMP/MPRSVV No.. County Sanitary Pe,mit N.mHer: Douelas Strohbeen 5432 St. Croix 83807 SEPTIC TANK/HOLDING TANK: 7VI /60 MANUFACTURER. I LIQUID CAPACITY TANK INLET EL V. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER PROVIDED PROVIDED YES DNO DYES ONO BEDDING. VENT DIA. VENT MAT L.. 11116H WATER NUMB F ROAD'. PROPERTY WELL BUILDING VENT TO FRESH N ALARM FEET FROM { LINE _j- AIR INLET X YES DNO UYES ONO NEAREST----)N- DOSING CHAMBER: MANUFACTURER JBEDDING 11-1111111) CAPACITY JPUMP MODEL JPUMP: SIPHON MANUF ACTUHEH WARNING LABEL TL.O.CK:NG COVER PROVIDED. VDED. DYES ONO DYES ONO OYES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHOPFHTV JWILL BUILDING, IVENT-LOFFUSH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ONO NEAREST SOI L ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH JIIIAMF TE H MATT 111,11 AND MARKING or excavation. Of soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH JNO,01 DISTR. PIPE SPACING COVER INSIUf DIA =NI Tti LIQUID BED/TRENCH / l7 3 T11 s L: PIT DEPTH DIMENSIONS SCCII''JJSS GRAVFL DEPTH FILL DEPTH IIISTIi PIP( DISTR PIPE DISTR. PIPE MATERIAL NO. DISTH NUMBER OF PR OPEHTV WELL BUILDING VENT TO FHF SH 1HF LOW PIPE~2 ABOVE CpVEH f I V INI.F i ELEV END PIPES LINE AIH NLE T /j FEET FROM q U NEAREST OW MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TF XT UHF PEWANT NT MAHKF HS 11111,11 HVA I ION WI I I S _ DYES ONO D YES _ ONO DEPTH OVER TRENCH HEO DEPTH OVER TRENCH BED T TH OF TOPSOIL S()D1)1 D SEF DFU LCHf D MU CENTEH EDGES DYES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF LATERAL SPACING GRAVEL DFPTH BE LOW PIP! FILL DEPTH ABOVE COVE H BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MAT Ef71AL NO DISTH BISTH PIPE UISTHIBU I ION PIPE MAIf HIAL & MAHKIN(, ELEV ELEV. DIA. ELEV. PIPES CIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DHILLEO COHHFCT I.V 1COVIR MATERIAL VEHTICAt 1-11 T CORRESPONDS TO APPHOVE D PLANS DYES ONO _ DYES ONO COMMENTS: PERMANENTMARKERS. OBSERVATION WELLS. NUMBER OF PROPERTY WELL BUILDING FEET FROM LINE _y~~ EYES ❑ O DYES O NEAREST Sketch System on ounty file for audit. Reverse Side. SIGNAT ~ TITLE DILHR SBD 6710 (R. 01/82) I SANITARY PERMIT APPLICATION COUNT CILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITA-Attach-complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inchcrs in size. -See reverse side for instructions for completing this application. PETITION I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER PROPERTY LOCATION E , (,v'/4 $E %a, S / Ta , N, R / E (or W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME Z S _J;' CITY, STATE T ZIP CODE PHONE NUMBER CITY : NEAREST ROAD, LAKE OR LANDMARK f~l 7 i5 VILLAGE : 90-0016 WO ri, ✓*i _jS1&-,274f U TOWN OR II. TYPE OF BUILDING OR USE SERVED: yLe!) . 6 . jl~~ 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. Seepage Bed b. ❑ seepage 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): Z_ - 3 / S 5 T- (0 8 S ~T . 8 Feet O Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank OGt~ i 5 t/ ❑ i 1:1 ❑ ❑ Lift Pump 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: ( o Stamps) MP/MPRSW No.: Business Phone Number: t s 32 a~ SZ 33 Plumbe 's Address (Street, City, State, Zip Code): Name of Designer: ILQIr at.J /l,-cl7 oh O/7 CVO VIII. SOIL TEST INFORMATION Certi ed Soil Tester (CST) Name CST # 10 & l,, ~er`s~~ jS"9'9 I* r CST's ADDRESS (Street, City, State, Zip Code) Phone Number: aG Qi w r>1 / Alle - S0,7. 3 / 6 - 3` IX. COUNTY/DEPARTMENT USE ONLY X❑ Disapproved Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Su Approved ❑ Owner Given Initial ~ charge Fee Adverse Determination ;7V5 1 r a- _j 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 r INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT ' APPLICATION TO THE APPLICANT: y 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 systei i, 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: 1. Property owner's narne 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 ?ype of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms it building is a one or two family dwelling; III. 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. Fill in designer name if applicable; VIII. 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 1 result of over 2 years of steady negotiation and public debate. The groundwater bill " (groundwater - ` included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried teas-are ~ 11, ~ is used in your building is returned to. the groundwater through your soil absorption! t system or•the disposal site used by your 'holding tank pumper- The monies .oliected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) . t Form - S T C 100 r Owner of Property Location of Property /V A/ Section-~ 7 T~N R~ Township Mailing Address ~X•Zt~L Subdivision Name L j Lot Number# q31- Previous Owner of Property Total Size of Parcel /6 D Z / Q cam s Date Parcel Was Created S~3 ~gc/ Are all corners identifiable? 1/ ! *t 57 Yes N o c S p ~a 1 Z Y~ ~~C 0~d C r Include with this a lication one &h~eSfollo~wi~0~ W Dvi 1~ "tn : V .Certified Survey Map 4``~ Sdr„ S`v .D .Deed Land Contract ~~..r _ - .Other regal Document which describes the property 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. ~q 5i-rL ; 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 Register of Deeds, as Document No.fsZ 1. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SI N DATE SIGNED z En S T C - 105.- . p; r. r ~F~',-/► j j 9 H co/ SEPTIC TANK MAINTENANCE AGREEMENT o 71 St. Croix County i1 z oinci 9 OWNER/BUYER ECts.A.) ROUTE/BOX NUMBER Fire Number Z IP (p CITY/STATE b(c PROPERTY LOCATION: Section , Tc N, Rl W Town of ►y-Uj_s0\, St. Croix County, Subdivision Lot number Impt'%per use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into II the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. Ho E I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- ro ment 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. FL~.4) SIGNED D A'I' E c y ~ St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. y.+... v A ] Pnl/ CD Z 7' ~n g X987 ZC 1'i3t`f'{~ APPLICATION FOR SANITARY PERMIT OI'Rff i S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property RA w o,K A L a- Location of Property 14, Section 17 , T a N-R / W Township Gt p Mailing Address 1<n vo UA- cam, Address of Site P_ s # ~ .gam %Y"~ l./t✓ ~ ~ Gv Subdivision Name =-tat c Lot Number Previous Owner of Property ,T)ez.j V_Q_ ( (.()a Total Size of Parcel t c Q_V- Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes ? No Volume 3Y and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) eenti.6y that a t statements on this 6o&m ane tAue to the best o6 my (ouA) hnowtedge; that I (we) am (a&e) the owner (s) o6 the pnopW y du cA i.bed in th.i a in6ormat on 6orm, by vi tue o6 a watAanty deed ke orded to the 066ice o6 the County Reg.e,ater o6 Deeds as Document No. ; and that I (We) preaentty own the proposed site bon the sewage dibpos s ys em (on I (we) have obtained an easement, to nun with the above deAcAbed property, bon the con.4.tAucti.on o6 said zystem, and the same has been duty recorded in the 066.tce o6 the County Register o6 Deeds, ab Document No. / Sl ) SIGNATURE O P OWNER SIGNATURE OF CO-OWNER_(.I APP ABLE) ~.4_7_ ~s ~ -7 / (~~7 - - DATE SIGNED DATE SIGNED I H z fA H a ST C- 105 r' • r a SEPTIC TANK MAINTENANCE AGREEMENT H 0 St. Croix County z d a OWNER/BUYER ROUTE/BOX NUMBER e,e-7~'/ Fire Number CITY/STATEt9 A--, &/'r ZIP~1j/G PROPERTY LOCATION:&2Z 14, 5E 14, Section 7 , T~N, R Z W Town of ~I Z O`l , St. Croix County, Subdivision ei,e/,'e&&r, ,c5 , Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists 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 treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. 0 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b ment 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 DATE ! ~J (J St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015' 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOF) AAID PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN FTELATIONS \ / MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION:TT.~~ pp TOWNSHIP/ , LOT BLK~NO.; SAI ♦ 91407 1/ •~~N,1rtt/ ~{or COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: USE DATES OBSER ATIONS MADE NO. BEDRMS.: COMMERCIA} DESCRIPTION: PROFI E DESCRIPTIONS: PERCOLATION TESTS: Residence xlew ❑ Replace .21 'PK RATING: S= Site suitable for system U= Site unsuitable for system r~ / SS_e _ PP ~&a CONVENTIONAL: MOUND: ' 1 IN-GROUND-PRESSUR_E: SYSTEM-IN-FI OLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U ~S ❑U RS ❑U El S .RU Cl S ..®U If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PR FIL DESCRIPTIONS BORING TOTALI DEPTH TO GROUNDWATER'.+W:R-6 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH LEVATION OBSERVED ST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- d r oo / 1 Q,cct~ 7 / r • /~S/ . 7 D%/ -s~ S S'+ B- oZ , 0 ~ 11 .0 ' 'ool B- 0 ' 0.2. / ~ ~ > 0 r ~~S d t Bn.SI ~a ~ir S ~Zg ~°S B r 6 d~•~ ` /~6~C~ ~ t ~ r s ~ ,Pl~~ Bh ~ / . /l .S ~i oZ B- PERCOLATION TESTS TEST DEPTH' WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 0WIleS AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- / o a2 .c P-.2- q, 9 r a eZ 6 L P- ' 02 P P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 9 7• r~' - - P(e F 4 YL 9 i; s~ ~ = r~d,_O K " , LS, 10 re 5 2-0 t W ~T 7,~ + i B . 3 ~f 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): o/Lt X06 / CST SI TU E: j DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - _ i h ,tPB,..G 8 1n[s^re 7°s "15--r )o e~ 1 O 3. 4, -p- B t TH THE. r r _ p ~ ~ v ' -tom ~ , ® N LSJ ~ r P Iz P L, u LA s .~J ~ Ctl P m 1T1 4 o 9~ 1 s Ilk r ~ ~ A I N 4 0 G 4 ~ s I ~ tr) i i i i S o~ c• • o ~Al - w Its LIS Z 0 41 S T C - 105 r t SEPTIC TANK MAINTENANCE AGREEMENT `-S`\-~~ to St. Croix County 1•~~~~~ ; z ,C t~ t7 OWNER/BUYER ~1p y\ > (4 QL. 14, ROUTE/BOX NUMBER Fire Number CITY/STATE&dLC9V\ ZIP 540 c PROPERTY LOCATION: L Section, T~ N, R/9 W, Town of at Lp~, St. Croix County, Subdivision-paj,~ V~,jW/ Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists 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 treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. ti 0 E 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 Depart- d ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zonin Office within 30 days of the three year expiration date. SIGN DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. rt r t APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property SD k Location of Property , Section N-R Township T L" CJ-I/-,- Nailing Address 2,~ ~j l g CL o.\ UW 3-- Address of Site &2A rr Subdivision NameU .Lot Number Previous Owner of Property DG f y-¢ I W Q✓7t- Total Size of Parcel ) - j/ . Date Parcel was Created f 2 Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number s ` as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 (We) centti6y that aU stactement6 on this 6onm ahe true to the but o6 my (oun) hnowtedge; that I (we) am (ane) the owneh.(s) o6 the pnopehty desClti.bed in this .in6onmation 6onm, by vi tue o6 a waAAanty deed neconded in the 066.ice o6 the County Register o6 Veed.6 ah Vocument No. to Z Z 303; and that I (We) phes ewtCy own the proposed .bite bon the sewage a4Apos system (on I (we) have obtained an easement, to nun with the above ducAibed pnopenty, bon the eon.6tnuction o6 said eystem, and the same hat6 been duty neconded .in the O66.tce o6 the County Reg-i.6teA 06 Deed, a6 Docment No. ~,/2230~'~ 1. SI URE Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) b DATE S GNED DATE SIGNED