HomeMy WebLinkAbout020-1159-40-000
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Parcel 020-1159-40-000 01/07/2005 03:36 PM
PAGE 1OF1
Alt. Parcel M 20.29.19.901
Current XD 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):
' =Current Owner
STEPHEN E & DEBORAH K LIST " LIST, STEPHEN E & DEBORAH K
492 MAUD CIR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 492 MAUD CIR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.350 Plat: 2318-PINE GROVE HEIGHTS
SEC 20 T29N R1 9W PINEGROVE HEIGHTS ADD Block/Condo Bldg: LOT 08
LOT 8
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 851/262
07/23/1997 770/200
07/23/1997 766/302
2004 SUMMARY Bill M Fair Market Value: Assessed with:
48984 229,300
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.350 23,500 153,900 177,400 NO
Totals for 2004:
General Property 1.350 23,500 153,900 177,400
Woodland 0.000 0 0
Totals for 2003:
General Property 1.350 23,500 153,900 177,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 111
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00
0.00
-COIPERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
ST. CROIX ZONING REPORT NO.: 17756/01
ST. CROIX COUNTY REPORT DATE: 2/06/92 PAGE 1
COURTHOUSE DATE RECEIVED: 2/05/92
HUDSONt WI 54016
ATTN: THOMAS C. NELSON
10
01
Stephen List
LOCATION: 492 Maud Circle, Hudson
i
COLLECTOR: M. Jenkins
DATE COLLECTED: 2-04-92
TIME COLLECTED: 3:30pm
SOURCE OF SAMPLE: Kitchen faucet
DATE ANALYZED:2-05-92
TIME ANALYZED:2:00pm
COLIFORM *4 0 /100 ml.
INTERPRETATION: Bacteriologically SAFE
NITRATE-N: 4 PPm
Above 10 PPm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 ml
Nitrate-Nitrogen, mg/L -
4P P ` ~r
U- V
LAB TECHNICIAN: Pam Gane cy~Q.
WI Approved Lab No. 19
t Means "LESS THAN" Iletectable Level Approved by.
® PROFESSIONAL LABORATORY SERYiCES SINCE 1952
ST. CROIX COUNTY
X WISCONSIN
3
COUNTY BOARD OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
` (715) 386-5581 Ext. 200 6220- 11Sq-q0-6Z1_)J
September 14, 1989 M. Z1. , L 0 1
4
sjt~
Greg Austrum.='Y(l
Edina Reality
700 2ed St.
Hudson, WI 54016
Dear Mr. Austrum:
An inspection of the septic system on the Dunn property located
in the Town of. Hudson was conducted.
At the time of the inspection, the sanitary system appeared to
be functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and
did not involve any excavation or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not dis-
coverable by this inspection. This does not in any way warrant
or guarantee the,continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
is totally dependent upon proper maintenance of the system.
Should you have any questions regarding this subject, please feel
free to contact this office.
Sincerely,
Mary J. Jen in ,
Assistant St. Croix County
Zoning Administrator
cj
• COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
ST. CROIX ZONING REPORT NOA 33611/41 PAGE 1
ST. CROIX COUNTY REPORT DATE* 9/11/89
COURTHOUSE DATE RECEIVED: 9/08/89
HUDSON, WI 54016
ATTNt THOMAS C. NELSON
OWNER# Marvin b Sharon Dunn
LOCATION* Hudson, WI
COLLECTORt St. Croix Zoning
SOURCE OF SAMPLE'. Outside faucet
COLIFORMt 0 /104 ml
INTERPRETATION'. Bacteriologically SAFE
NITRATE-N#* 3 ppm
Under 10 ppm is safe for human consumption.
COLIFORM + NITRATE
LAB TECHNICIAN'. Pam Gane
WI Approved Lab No. 19
oF.\NDEVEHDE.Y
V
{ Means "LESS THAN" Detectable Level
Proved by,
® PROFESSIONAL LABORATORY SERVICES SINCE 1952
ST. CROIX COUNTY ZONING OFFICE
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
Telephone - (715)386-4680
The St. Croix County Zoning Office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion of this form is essential so that :)Iro~erty can be...
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received. /
------FEE: $ 25.00 i/
WATER TESTING----------------------
(For nitrates and coliform bacteria)
WATER TESTING FEE: $175.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION----------------- FEE: $25.00
(Determines if system is properly functioning at time of
inspection) NN
Property owner's name Q
Property owner's address
Legal Description 1/4 of the, 1/4 of Section T N-R
Town of S0,) _Lot Number subdivision Name
FIRE NUMBER LOCK BOX NUMBER
Color of house ~ Realty sign by house?t, If so, list firm:
1
4erz
PLEASE INCLUDE, IF AT A L POSSIBL , A MAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF',T11E LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services: GL. e Q
Telephone Number 715' - Y~ -
REPORT TO BE SENT TO: (J00 _7
V -
Closing dat -
Signature -
Mi 1 35 it ~1 1
RESIDENTIAL AREA 1
39
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JIMM 33 ACRES. GREAT LOCATION AREA OF LOVELY HOMES 3 BEDROOM SUNKEN LROOM.DINING R VAULTED MODEL FINISHED. ASPHALT DRIVEWAY. PARQUET FOYER. ANDERSON WINDOWS
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~8 1AX YR 2N RES SF 1161 OWN Ax 1991 h:A 1~9 i $ 1104 ON'N TAX 1970 YA 1988 N Rt SF 7050
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1 V ELEM HUDSON VI W WELL Y DR 12X10 M B C LEN MlOSON N I BELL Y 11X11.7 M C Y L E P ROCK VIEW PANORA• WELL Y p
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Located in bruuilul doscntown aA~T •
t.e A v ohn6 a1 °oj N.
Hudson, first stop and go light R . ~ f7eQr/ x 4j
Tulgren 13uilding. Information on C. 'tt acrtc/ cn 20 6 ~a
all Western Wisconsin properties.
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and operated.. Z t' r read' s o wtad rlfn~TS h t
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SALES & SERVICE f I'
I
Phone: 386-5155
TOP THE HILL
HUDSON, WISCONSIN
i
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_ Federat!Sa ings
LENDER Ii' -
NEW RICHMOND HUDSON
ST. CROIX FALLS
251 South Knowles 510 Secondl~5,{reet 134 Washington Street North
246-5011 386-884$ 483-9808
43 V
ST. CROIX COUNTY ZONING OFFICE
rim 911 4th Street
Hudson, WI 54016
r~z Telephone
'T~ - (715)386-4680
The St. Croix Co. Zoning Office offers the service of septic and
water inspection to Lending Institution, Realty Firms, and
-qv private individuals.
COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE
LOCATED.
Please provide the following information, enclose appropriate fee
made payable to ST. CROIX CO. ZONING, and mail, along with form
to the above address. Testing will be done as soon as possible
after fee and form are received.
WATER TESTING-------------------------------- FEE:$ 25.00
(For nitrates and coliform bacteria)
WATER TESTING FEE:$175.00
(VOC'S)
SEPTIC SYSTEM INSPECTION--------------------- FEE:$ 25.00
PROPERTY OWNERS NAME : J + p h e v~ j-
PROPERTY OWNERS ADDRESS : I l a Ma~~ C Ir TY : H (AA ovm ( ~To w-A S4 Lp)
Legal Descrip N c_1/4 ,_1/4 , Sec. Zo , T a N-R W,
Town of U Lot No.$_,Subdivision , Gyre At
FIRE NO. LOCK BOX NO. ~°2 D I~ yiT ~b~
Color of house a -Realty sign? NO Firm:
PLEASE INCLUDE, IF Al ALL POSSIBLE, A .MAP, i.e.,, COPY OF PLAT
BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
Telephone No. ga I ~,ev~ L-tSt f- t A-1
REPORT' TO BE SENT TO:
~t v W ,i_ 0 2
CLOSING DATE:
Signature:
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THE EAST LINE OF THE SE 1/4 OF SECTION 20
}
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP _SEC. T N-R W
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ADDRESS ST. CROIX COUNTY, WISCONSIN
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SUBDIVISION P>N~ ~RUU~ LOT LOT SIZE
PLAN VIEW
and dimensions to meet requirements of 11HR 83
Distances
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4
N /000
G cU~c&
~G~ (jEn 66'
►X y 2 i9
3
F z~ V
/00t
f
D
5W C-a su*
97, 57
O ACIc- o~2 97~ yo INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used S T L/-~7
Elevation of vertical reference point: lQ d,(, Proposed slope at site:
SEPTIC TANK: Manufacturer: U/&EE Liquid Capacity: 16/j 0
Number of rings used: Tank manhole cover elevation: /0 1 yB
Tank Inlet Elevation: rd Tank Outlet Elevation: f0 Da 2y
Number of feet from nearest Road: Front,0 Side, (VN Rear, O feet
From nearest property line Front,O Side ,O Rear, ILI ~ feet
Number of feet from: well, building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tar
SEE REVERSE SIDE
J
PUMP CHAMBER r►
ufacturer: Liquid Capacity:
Pump Mode Pump/Siphon Manufacturer:
Pump Size
Elevation of inle Bottom of tank elevation:
Pump off switch elevation. Gallons per e:
Alarm Manufacturer: arm Switch Type:
Number of feet from nearest perty lin Front, O Side, O Rear, 0 Ft.
er of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: L=S Trench:
Width:, _ Length:_s Number of Lines:
Area Built:
, -,,o
Fill depth to top of pipe: 3 G
Number of feet from nearest property line: Front, O Side, O Rear, Ft
Number of feet from well: b/~
Number of feet from building: q ;Z
(Include distances on plot plan).
SEEPAGE PIT
ze: Number of pits: Diameter:
Liqui epth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box or distribution box O been use n any of the above soil
absorbtion sytems? (Check e).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevatio of bottom of tank:
Elevation of inlet:
Number of feet fr nearest property line: Front, Side, O Rear, 0Ft.
Number of feet from well: J
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: -~"l Plumber on job.
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR b HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS SAFETY dE BUILDINGS
P.O. BOX 7989 DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
CONVENTIONAL OALTERNATIVE StetePlsnl.D.Number:
D Holding Tank D In-Ground Pressure D Mound Ilfresigned)
Y
NAME OF PERMIT HOLDER:
ADDq ESS OF PERMIT HOLDER-
Richard StOLtt NSPECTION DATE:
BENCH MARK IPermenenf referencepo DEESCRIBE IF DIFFERENT FROM PLAN Hudson, WI 540'16 /7r p6. /
EF. PT. ELEV.: O CSt REF. PT. ELEV
SE, Section 20, T29N-R19W, Town of Hudson, Lot 8, Pinegrove Heights /UJ
Name of Plumber:
MP/MPRSw NO
Cnunfy
Donavin Schmitt Samfary Permit Number
3205 St. Croix 83853
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
WUCJ{`LILG_ PROVIDED PROVIDED
JJ °/jj l~
BEDDING: VENT DIA.: VENT MATI JHIGH WATER YES ONO OYES YNQ
ALARM NUMBER OF ROAD. PROPERTY WELL BUILDING. VENT TO FRESH
OYES NO C FEET FROM LINE AIR INLET
OYES NO NEAREST (2
DOSING CHAMBER:
MANUFACTURER BEDDING. LIOUIO CAPACITY Pl1MV MDDEL PUMP.SIPHON MANUI AC TIIHEH
WARNING LABEL LOCKING COVER
OYES ONO PROVIDED PROVIDED.
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL OYES ONO OYES ONO
(DIFFERENCE BETWEEN NUMBER OF PROPE HTV WELL BUILDING V N T FRESH
PUMP ON AND OFF) FEET FROM LINE AIR INLET
SOIL ABSORPTION SYSTEM. Check the soil moisture at the❑d pth of plowing NO NEAREST ---ql.
Or excavation. (lf soil can be rolled into a wire, construction shall cease unt9 FORCE nME TER MATE HInT AND MARKING
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO OF BED/TRENCH UISTH PIPE SPACIN(. COVER
DIMENSIONS J y TRENCHES / M11 Q-TEHIAL: IvSIUL (lln PITS LIQUID
PIT DEPTH.
G V L DEPTH FILL D PTH DISTI PIPE Of STH PIPE DISTR. PIPE MATERIAL
BELOW PIPES/// ABOVE COVER FIEV INI.EI Ey~LLLl~~~-EEE~V EN/D/ NO ISiH NUMBER OF WELL BUILDING VENT TE FRESH
/ PIPES PH OPERTV
0/6(1 Z - 77 2 2 c, Z- FEET FROM L'"E AIR INLET
/ NEAREST--w.
MOUND SYSTEM:
Mound site plowed perpendicular to slope
upslope: and furrows thrown rpendi Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
DYES O NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER rexruRE
Pf 14 LANE NT n1ARKf HS OBSERVATION WELLS
DFPTH OVER TRENCH BED DEPTH OVFHTHEN(H 9EU OYES ONO OYES ❑NQ
CENTER EDGES DEPTH OF TOPSOIL )1 1)
' JMULCHED
PRESSURIZED DISTRIBUTION SYSTEM: OYES. ONO OYES ONO OYES ONO
BED/TRENCH WIDTH LENGTH NO TRENOFCH LATEHAL SPACING GR
BED/TRENCH AVEL UEPT11 HE LUWPIP(
DIMENSIONS ES. FILL DEPTH ABOVE COVER
MANIFOLD PUMP MANIF OL1) DISTR. PIPE MANIFOLDMATERIAL NOUISTIT UISTH PIPE U I S T H I I1U II ONPIPEMATE~IAL&MARKING
ELEVATION AND ELEV ELEV OIA ELEV
PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHE CT Ly
COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
COMMENTS: PERMANENT MARKERSERVATION WELLS. ONO
NUMBER OF PROPERTY WELL. BUILDING:
Or ❑ FEET FROM uNE
OYES ONO NEAREST
Sketch System on
Reverse Side. Retain in county file for audit.
SIGNATURE.
TITLE
DILHR SBD 6710 (R. 01/82)
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-Q SANITARY PERMIT APPLICATION COUN
~LHR In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach Amplete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application. rF TITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. R V ARIANCE ❑ YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
j_! ~'/4 sue'/4, S T, N, R E (or W
12
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK
W" ❑ VILLAGE : C/ L
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable)
1. a. New b. E1 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. Vu 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. ❑ 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):
• : tj Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete stCon glass App.
Tanks Tanks
Septic Tank or Holding Tank ~Z- IN
1:1 ❑ ❑ ❑ ❑
Lift Pump Tank/Siphon 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): Plumbe r ignature: (No Stamps) M PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code : jName f esigner:
~ e ,
J? r. flox 9'.5A - %L-%
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST
,7
CST's A DR S (Street, City, State, Zip Code) Phone Number:
S1104 e '12, &jz- &e J nit Cff e -46
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Shame Fee
Adverse Determination
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
a \
INFORMATION & 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 syste ~i, contact ycur 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 name and mailing address. Provide the legal description where the system is to be
installed;
11. 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;
111. 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'/z 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 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 reasure
is used in your building is returned to the gl4oundwater tftfogh your soil absorpt%n
system or the disposal site used by your holding tank pumper.
The ponies collected through these surcharges are credi*ed fo ttte groundwater fund adminis-
ferec by :tie ':department of Natural Resources. These funds are a led for monitoring ground- 1
v-.later, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398 (R.03/86)
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
j "s
Owner of Property 1
Location of Prop erty & ' Section Q , T N-R~ W
J_
Township 17
Mailing Address /i
Address of Site fi, a ffa0
Subdivision Name
Lot Number
Previous Owner of Property 1 ~,Q •i
Total Size of Parcel
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 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) eekti.sy that att Statements on thi6 Sotm ate true to the best o6 my (out)
knowtedg e; that I (we) am (ate) the owneA (s) 06 the ptopeh ty dens c t bed in th i s
insotmation Sotm, by viAtue o6 a wa Aanty deed teeotded in the Ossiee o6 the
County Reg.vstet o6 Deed6a3 Document No. and that I (We) ptaentty
own the ptopobed ~6 to Sot the sewage di6pos SyS em• (ox I (we) have obtained an
easement, to tun with the above de~scx bed ptopexty, Sot the eonstAucti,on o6 said
.aybtem, and the same has been duty tecotded in the OSSiee o6 the County Reg.Ustet o6
Deeds, a6 Document No. 3f(7~''i 1.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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STC-105 a
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SEPTIC TANK MAINTENANCE a
AGREEMENT r
St. Croix County 0
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OWNER/BUYER d
ROUTE/BOX NUMBER_"j, y
Fire Number
.CITY/STATE t-1/3
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PROPERTY LOCATION:,
Section-,t(2 N ~
, R~W
' Town of
St. Croix County,
Subdivision4yr U ~7, Lot number p.
Improper use and maintenance of
its premature failure to Your septic system could result in
handle
sists of pumping out the septic tank every three
mYaeianrtsenoarncse ooner oner
if needed, by a licensed sec
,
the system can affe- c- t the fun onnofRHT theese
What you put into
ment stage in the waste disposal system. Ptic tank as a
treat-
St. Croix.. County residents ma
a ma x_ of -_,Y be eligible to receive a grant was in operation cost of replacement of a failing rant for
accepted this P Prior to July 1, 1978. system,
owners of all program in August to St' Croix County
g 1980, with the requirement that
maintained. keep their systems
properly
The property owner agrees to
certification form submit to St. Croix Count
journeyman , signed by the owner and b Y Zoning a liened plumber, restricted plumber or a y a master plumber,
fying that (1) the on-site wastewater disPosalcsyste
veri-
operatin pumper g condition and (2) after inspection and pumping is (i proper
essary), the septic 'tank is
nec-
Certification form will be sent approximately 1 Pumping (f scum
/3 full of sludge and scum.
three year expiration. 30 days prior to
I/WE, the undersigned
to maintain the , have read the above re o
private sews a qui s and agree
the standards set forth g disposal system in accordance with x
meet of Natural t forth, herein, as set by the Wisconsin De
and r at to the sources. Certification form must Part-
etured St.
Croix Count be completed
of the three year expiration date, Y Zoning Office within 30 days
SIGNED
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.
• 'DEPARTMENT OF
INDUSTRY
LABOR AND REPORT ON SOIL BORINGS AND
HUMAN'RELATIONS SAFETY & BUILDINGS
PERCOLATION
TESTS 115 DIVISION
LO,cgrlav: SECTION- (1-163.09(j) ) P.O. BOX 7969
: ) & Chapter 145.045)
4~ MADISON, WI 53707
dO / u TOWNSHIP
CONY N Lor) w Y: LOT NO.: BLK.
OWNER' BUYER'S N
AME: NO.: SU I VISION NAME:
MAILIN ADDRESS:
USE
Residence NO. BEDRMS.: COMMERCIAL DESCRIPTION:
3 ESCRIPTION: DgTES OBSERVATIONS
PROFILEDESCRIPTIONS: PERCOLATION TESTS:
RATING: S= _ Site suitable for system
CONVENTIONAL M U= Site unsuitable for system
❑'1: OUND:
IN-GROUNDPREUURE: SYSTEM-IN-FILL ❑ HOLDING TANK: RECOMMENDE
u ~ Ds D SYSTEM: (Optional)
If Percolation Tests are NOT required DESIGN J , 4)114
under s.H63.09(5)(b), indicate: RATE:
[Floodplain, f any portion of the tested area is in the
BORING TOTAL I PROFILE indicate Floodplain elevation:
NUMBER ELEVATION DEP H DESCRIPTIONS
T
~1'tPO,
BSERVEDTO GROUNDWgT ESTER-INCHES CHARACTER OF S L WI H T
B- I `f 7H IGH
f '7 , n EST TO BEDROCK IF OBSERVED {S EIABBRV. ON BACK TEXTURE, AND DEPTH
&q- 60 ] S, CO
08 00 A5 6. SJ, -,y e 0. J. 4
13
Min 0 0 (9 J4
(041 An
B- It
Ivn Jr 519 c
TEST DEPTH ATER PERCOLATION TESTS
NUMBER INCHES FTERSWEI1 N TESTTIME
P_ G INTERVAL-MIN. DROP IN WATER LEVEL-INCHES
PERIOD 1
P PERIOD 2
P RI D RATE MINUTES
PER INCH
P-
P-_
P-
P-
PLOT PLAN: Show locations of percolation tests, soil boring s and
zontal and vertical elevation reference
the dimensions of
of land slope. Points and show their location on the Indicate
suitable soil areas. scale
or distances-
plot plan. Show the surface elevation at all
ll borings and theribe what are the hori-
9 - /
SYSTEM ELEVATION ection and percent
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I, the undersigned, hereby certify that the soil tests reported on this form were `
and that the data recorded and the location of the tests are correct to the best of my knowledge
made by me in accord with the procedures and methods specified in the
Wisconsin
and belief.
0DRESS: TESTS WERE COMPLETED ON:
~r CERTIFICATION NUMBER: PHONE NUMBER(optional):
47 z i~
CST SIGNAT R .
STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
LHR-SBD-6395- (R. 02/82)
OVER
-
INSTRUCTIONS FOR COMPLETING FORM 115 - SR - 6395
soil test, yo,jr report must include:
TO be a oompletf G4{
t;
his is a residence car commercial projec
Co€nplete lef
indicate w
2. The use sectif ns or f al use planned;
3. MAXIMUM n€ stem; TALK C}N€ IF ALL
4, is this a net o€ -boxes. A "l i E is SUITABLE J
. Complete tt ED t'9 F-~ iSPU O SOIL t
ampletir~g the plot pion;
OTHES S1' . shown writing prc ile to scale is preferred, A
s. PLEASE cos ' n acct . ting yot,
7 _ i€ shown, and are . r
('ata, percolation te,_ np-
. boxes a,
C A, in the appropriate box;
zs flood plat an) does not a
€ current j yoLE, 1ST BE FILED WITH THE
11. >tribut>ute ip-ed. ALL. TI ` v
12 Ma e 30 D, COMPLETION.
LOCALS r
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! he Department nay request
> cat plans for t' p..;vate
is n r€€
the t
this soil test i e local autI >r to
and a permi to mart of any c n-< .
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t. The sanita,
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