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Parcel 020-1167-50-000 02/07/2005 10:01 AM
PAGE 1 OF 1
Alt. Parcel 29.29.19.1036 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): * = Current Owner
* HINES, WALLIS G III & DEBORAH J
WALLIS G III & DEBORAH J HINES
477 COUNTRY VIEW RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 477 COUNTRY VIEW RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.480 Plat: 0211-COUNTRY VIEW
SEC 29 T29N R1 9W W1/2-SE1/4 LOT 5 - PLAT Block/Condo Bldg: LOT 5
OF COUNTRY VIEW
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/23/2004 775119 2661/448 WD
07/23/1997 883/193
07/23/1997 771/33
07/23/1997 745/188
2004 SUMMARY Bill Fair Market Value: Assessed with:
49076 285,000
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.480 32,400 188,100 220,500 NO
Totals for 2004:
General Property 2.480 32,400 188,100 220,500
Woodland 0.000 0 0
Totals for 2003:
General Property 2.480 32,400 188,100 220,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 119
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
l
'RCIAL TESTING LABORATORY, INC.
gain Street, P.O. Box 526
orfiax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
ST. CROIX ZONING REPORT ill.i 10014/01 PAGE 1
ST. CROIX COUNTY REPORT DATE 10 9/11/90
COURTHOUSE DATE RECEIVED: 9/07/90
HUDSONt WI 54016
A THOMAS Co NELSON
21, z407 19. 1034
OWNER', James b fury Dopk i ns
LOCATION#* 477 Country View Rd., Hudson
COLLECTOR: M. Jenkins
SOURCE OF SAMPL.E`. Kitchen faucet
COLIFORMS 0 /100 at
INTERPRETATION*# Oacteriologically SAFE
NITRATE-N: 5 ppm
Under 10 ppm is safe for human consumption.
Coliform Bacteria/100 at
Nitrate-Nitrogen, mg/L
LAB TECHNICIAN. Pam Gane
WI Approved Lab No. 19
oQ.\NDEVENpFMj
J2 ~O
V D
® s i Means "LESS THAN" Detectable Level Approved by.
® PROFESSIONAL LABORATORY SERVICES SINCE 1952
pc~► ST. CROIX COUNTY ZONING OFFICE
RECEIVE0 St. Croix County Courthouse
0 911 4th Street
Hudson, WI 54016
Telephone - (715)386-4680
[C
ix County Zoning Office offers the service of septic
a t 9'nspections to Lending Institutions, Realty Firms, and
priva e 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 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.
WATER TESTING----------------------------FEE: $ 25.00 ✓
(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)
Property owner's nameff
Property owner's address LI 7 1e,t~
Legal Desc~ption 1/4 of the 1/ of Section TN-R
Town of ~d Sm Lot Number Subdivision Name ( A
FIRE NUMBER 7 LOCK BOX NUMBER
Color of house, Realty sign by house?If s, list firm:
ol/
PLEASE INCLUDE, IF AT 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: ~ f'F'LCL /LJ
Telephone Number&/,=,a -
L^EPORT TO BE SENT TO: 5M , NTE2 z-dC c,4-23- /,~S w
7' P4-4 C_ SSi - Ido~
Closing date ro-a-6z, qp
Vsi.gnature
7061
,
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TOP THE HILL
HUDSON, WISCONSIN
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319 East Grand Avenue, P.O. Box 1548, Eau Claire, Wisconsin 54702
j NEW RICHMOND HUDSON ST. CROIX FALLS
251 South Knowles 510 Second Street 134 Washington Street North
1 246-SO 11 386-8808 483-9808
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■
- ` ' ST. CROIX COUNTY
~•'"a ~a f WISCONSIN
pa` s
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
} 911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
Sept. 6, 1990
Jim Stutzman
3M Center, Bldg. 223-6sw-03
St. Paul, MN 55144-1000
Dear Mr. Stutzman:
An inspection of the septic system of the James Dopkins property
located at 477 Country View Rd., Hudson, WI was conducted on
Sept. 6, 1990. At the same time a water sample was obtained for
testing. The results of that testing will be sent to you as soon
as we receive them back from the laboratory.
At the time of 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 excavating or chemical analysis.
Accordingly, there is the possibility of hidden defects in the
system not discoverable by this inspection. This not not in any
way warrant or guarantee the continued proper functioning or
operations 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 me.
Sincerely,
t
C4
i
Mary J. Jenkins
Assistant Zoning Administrator
cj
SERCO Laboratories
1931 West County Road C2 St Paul. Minnesota 55113 (612) 636-7173
LABORATORY ANALYSIS REPORT NO: 2714 PAGE
09/21/90
Commercial Testing Laboratory DATE COLLECTED: 09/11/90
514 Main St. Box 526 DATE PEeEiL'rp: 09/?_ 2/
Coifax, Wi 54730 _ _ 90
0LL ~ TE~ B Y CL ; ~NT
DcLivEPED BY CL.-NT
SAMPLE TYPE WELL WATER
Attn: Pamela Mane
St. Croix ZQnjnq
SERCO SAMPLE NO: 80150
SAMPLE DESCRIPTION: Dopkins
ANALYSIS:
Sromodichloromethane, ug/L <0-2----
Sromoform, ug/L <0._^
Bromomethane, ug/L (Methyl brom de) <1.0
Carbon tetrachloride, ug/L <0.2
C•hlorobenzene, ug/L <1.0
Chioroethane, ug/L (Ethyl chloride) <0.4
2 Chioroethy=vinyl ether, ug/L <0.4
orofor,m,, ug/L
<0.5
Chloromethane, ug/L (Methyl chloride) <0.6
Dibromochloromethane, ug/L <0.4
..,2-Dichlorobenzene, Jg/L <11.0
(o-Dichlorobenzene)
3,3-Dichlorobenzene, ug/L <1.0
(m-Dichlorobenzene)
1,4-D'ichlorobenzene
(fir-D.chiorobenzene)
Dichiorodifluoromethane, ug/L (Freon 12) <0.5
1
-D i r.h l oroe han,e, ug/L 1
1,2-Di hioroethane, ug/L <0.2
(Ethylene dichloride)
-Dich1oroethene, ug/L <0.2
1,2-Dich;oroethene, trans, ug/L <0.1
1,2-Dichloropropane, ug/L <0.
3-D ch'
oropropene , cis, ug/ L ?
1,3-Dichloroprogene, trans, ug/L <0.9
ti
Methylene chloride, ug/L <-5.0
(Dichloromethane)
< means "not detected at this Level". 1 mg -
',000 ug.
Member
SERCO Laboratories
1931 West County Road C2. S1 Paul. Minnesota 55113 (612 636-7173
LABORATORY ANALYSIS REPORT NO: 27 14 GAGE 2
09/2'1/90
SERCO SAMPLE NO: 80150
SAMPLE DESCRIPTION: Dcpk i ns
ANALYSIS:
1,1,2,2-Tetrachioroethane, uglL <0.2
TetrachIoroethene, uc/L <0.
1,1,1-Trichloroethane, ug/L 0.3
1,1,2-TrichIoroet-hane, u /L
g <g.1
Trchlorofluoromethane, ug/L (Freon I?) <0,7
Vinyl chloride, ug/L <1.0
Benzene, ug/L <1.0
Ethylbenzene, ug/L <1.0
Toluene, ug/L <1,
Al' analyses were perfcrmed using EPA or other accepted methodoiogies.
Sampies that may be of an environmentally hazardous nature wilt
returned to you, ether samP !es will be stored for 80 days fro,:, the
date of this report, then disposed of by SERCO LABORATORIES.
Please contact me if other arrangements are needed.
Report submitted by,
Diane J. nder son
Project Manager
e
< means "not detected at this 'evel" 1 r;p = 000 u g.
Member
C
SERCO Laboratories
1931 West County Road C2. St Paul. Minnesota 551 13 16121 636 71 73
LABORATORY ANALYSIS REPORT NO: 2714 PAGE 1
09/21/90
Commercial Testing Laboratory DATE COLLECTED: 09/11/90
514 Main St. Box 526 DATE RECEIVED: 09/12/90
Colfax, WI 54730 COLLECTED BY : CLIENT
DELIVERED BY : CLIENT
SAMPLE TYPE WELL WATER
Attn: Pamela Gane
St. Croix Zoning
SERCO SAMPLE NO: 80150
SAMPLE DESCRIPTION: Dopkins
ANALYSIS:
Bromodichloromethane, ug/L <0.2
Bromoform, ug/L <0.5
Bromomethane, ug/L (Methyl bromide) <1.0
Carbon tetrachloride, ug/L <0.2
Chlorobenzene, ug/L <1.0
Chloroethane, ug/L (Ethyl chloride) <0.4
2 Chloroethylvinyl ether, ug/L <0.4
Chloroform, ug/L <0.5
Chloromethane, ug/L (Methyl chloride) <0.6
Dibromochloromethane, ug/L <0.4
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)
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
1,2-Dichloroethene, trans, ug/L <0.1
1,2-Dichloropropane, ug/L <0,1
1,3-Dichloropropene, cis, ug/L <1.5
1,3-Dichloropropene, trans, ug/L <0.9
Methylene chloride, ug/L <5.0
(Dichloromethane)
< means "not detected at this level". 1 mg = 1000 ug.
Member
SERCO Laboratories
1931 West County Road C2. St Paul. Minnesota 5511316121 636-7173
LABORATORY ANALYSIS REPORT NO: 2714 PAGE 2
09/21/90
SERCO SAMPLE NO: 80150
SAMPLE DESCRIPTION: Dopkins
i
i
ANALYSIS:
1,1,2,2-Tetrachloroethane, ug/L <0.2
Tetrachloroethene, ug/L <0.2
1,1,1-Trichloroethane, ug/L 0.3
1,1,2-Trichloroethane, ug/L <0.1
Trichlorofluoromethane, ug/L (Freon II) <0.7
Vinyl chloride, ug/L <1.0
Benzene, ug/L <1.0
Ethylbenzene, ug/L <1.0
Toluene, ug/L <1.0
i
All analyses were performed using EPA or other accepted methodologies.
l 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.
Report submitted by,
Diane J. nderson
Project Manager
< means "not detected at this level" 1 mg = 1000 ug.
Member
Form-STC- 104
-~G~a-0 ~ , ~,~~AS BUILT SANITARY SYSTEM REPORT
a
OWNER TOWNSHIP SEC. Z % T :27~ N-R ~9 W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION e-o4,,'j/ w LOT LOT SIZE Z e0 14~c Ot r
PLAN VIEW O20~/4,-7
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
31
I~
~ ~ 1 1►1 Bz ~
I 1 , i N s
I O N 7r
0
I ' ,1
S'
a a ~
~5p5Ci rl~d~~/, /DIJ.O
a~ N
° ea-
` INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used h
~ A It a 4" D ifs ~
Elevation of vertical reference point: logo a ~ Proposed slope at site: D-!Z~ 5W
SEPTIC TANK: Manufacturer: Liquid Capacity: / 00 0
Number of rings used: Z Tank manhole cover elevation:
Tank Inlet Elevation:/'j. YS Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,O Rear, feet
,.From nearest property line Front,OSidenRear,O 65 feet
Number of feet from: well , building: a ±
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
II_ SEE REVERSE SIDE
PUMP CHAMBER
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, O Side, O Rear Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: 6c5 n V<-,, i Cj c1 Trench: IV&
i
Width: Z Length: ~i Number of Lines: Area Built:
Fill depth to top of pipe: 410
Number of feet from nearest property line: Front, O Side, O Rear, Ft.Z D"
Number of feet from well: ,
Number of feet from building: s~
(Include distances on plot plan).
SEEPAGE PIT
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, O Rear, 0Ft.
Number of feet from well:
Number of feet from building.:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated:
Plumber on job: License Number : 114 P
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADWQN, YVI 53707
R~FCONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
❑ Holding Tank El In-Ground Pressure El Mound [If assigned)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Sam Miller Rt. 1 Box 282, Hudson WI 54016 ' - /~40
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
SW SE Section 29, T29N-R19 Twn, of Hudson, Lot 5 Country View I
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Doug Strohbeen 5432 St.Croix 88395
SEPTIC TANK/HOLDING TANK: .Sr
MANUFACTURER: LIQUID CA ACITY: TANK INLET ELEV.: TANK y ET ELEV.: IWAINNG ILABEL LOCKING COVER
b~I ~ ~ ~ A 9 PROVIDED: PROVIDED:
w~~~V6CiC/f/ OdGa YES ONO DYES ONO
BEDDING: VENT DIA.: VENT MATL.: HIGH WA ER NUMBER OF ROAD: ROPERTY WELL: BUILDING: VENT TO FRESH
L
R INT.
ALARM FEET FROM /J - LINE: Ial
YES ONO DYES ONO NEAREST P
DOSING CHAMBER:
MANUFACTURER: 7ING
L
IQUID CAPACITYPUMP MODELPUMP/SIPHON MANUFACTURERWARNING LABEL JLOCKING COVER
PROVIDED: PROVIDED:
ES ONO DYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY IWE LL BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) OYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH: DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH: NO. OF DI STg~PIPE SPACING: COV INSIDE DIA. #PITS LIQUID
BED/TRENCH TRENCH PIT DEPTH
DIMENSIONS ~f]tr//]
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR PIPE DISTR. P MATERIAL NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW~/ PIP ABOVE ZER EL INjE7. ELEV PIPESFEET FROM LINE AI INLET, ~
f//~ (!J/ NEAREST-
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 NO meets the criteria for medium sand. TIONS MEASURED.
O
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
DYES ONO DYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED MULCHED
CENTER: EDGES.
DYES ONO DYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH: TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV.: DIA.. ELEV. PIPES. DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY ATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
DYES ONO COVER M PLANS DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
DYES ONO DYES ONO NEAREST
Sketch System on Retain in C unty file for audit.
Reverse Side.
SI NATU E. TITLE.
DILHR SBD 6710 (R. 01/82)
~ SANITARY PERMIT APPLICATION COU1VTY
{L 'DILHR In accord with ILHR 83.05, Wis. Adm. Code
~......~.,,Q. STATE SANITARY PERMIT #
39s
-Attac 1CAmplete plans (to the county copy only) for the system, on paper not less than STATE PLAN Y.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
l~/'/4 ~'/4,Svl T.,~ N,R E(o W
,4M -tv PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
Q 2 2 S'
CITY, TATE ZIP CODE PHONE NUMBERA7Gcj CITY NEAREST R D, LAKE OR LANDMARK
VILLAGE : e
11. 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. ~4 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. 0 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. 14 Seepage Bed b. ❑ seepage Trench c. ❑ seepage 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):
L / j G y ! oe p Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank Wt~ S a f ❑
El ❑ ❑ ❑ ❑ ❑
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: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plum is Address (Street City, State, Zip Code): r Name of Designer:
Vlll. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST # i i -~d li~rso~ 9
(,'-T's ADDRESS (Street, City, State, Zip CO CIA) Phone Number:
///G ,*-c I z- *udsoA laJl~ '716 .30G-57, /
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Surcharge Fee _
X Approved ❑ Owner Given Initial
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBU"PION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT y
APPLICATION
TO THE APPLICANT: ~r
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 b(--,, 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 coocernincu yoo. private sewage syster:i, contact yr: fr 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;
ii. Type of building or use served: Ii 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;
Ili. 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'/s 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 Wiscorisin`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
system or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Rasources. These funks are used for monitoring ground-
water, groundwater contamination investigations and establishment of standards. Groundwater, t
it's worth protecting.
SBD-6398 (R.03/86)
L
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
Location of Property 14 Sections , TAN-R W,
Township .S y
Mailing Address 2
Address of Site ~r~ z (Ili(; ago vrt Lo r, Q.Q
Subdivision Name L~ t, 42-SL Lt
CJL-
Lot Number j
Previous Owner of Property ,s^1 ~ti f
Total Size of Parcel Z. Ae_gi~
Date Parcel was Created (p I g
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume 4-5`7' and Page Numberl..(,_,,_ 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) eeAtisy that att statements on this 6otm ate true to the best os my (out)
knowledge; that 1 (we) am (ate) the ownet (s) o6 the ptopW y des c i.bed in this
.insotmation sotm, by vi tue o6 a wal Aanty deed teeotded in the O s slice o6 the
County Registeh, o6 Deeds as Document No. c 3p- 2; and that I (We) puzentty
own the proposed site sot the sewage d s pos s (ot I (we) have obtained an
easement, to tun with the above descA bed ptopeAty, sot the construction os said
.system, and the same has been duty tecokded in the Ossice os the County Regi.6tet os
Deede, as Document No. ~_2,0 7 Z= )
'A"
SIGNATURE OV.OWNER SIGNATURE OF CO WNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
' z
. cn
. a
STC - 105 r
a
. y
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
cy
OWNER/ BUYER to
ROUTE/BOX NUMBER 1 ,~S'~IC Zg Z Fire Number--"--,,,
.CITY/STATE SOY, ZIP
PROPERTY LOCATION::5w ;&,S_f_~ Section, T _N, R
Town of St. Croix County,
Subdivision(
u~,~~'y 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 pdt 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 z
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.
SIGNE
DATE
a
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
• DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND ,IONS PERCOLATION TESTS (115) MADISOP.O. BOX 76
HUMAN RELAT
N WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWN HIP/ LOT NO.: BLK. NO.: SUBDIVISION NAME:
...5W 11 511 cz /Toz9N/R/9?(0 46.40^• ~ - CgPu4.,~fy U'e_i,,J
COUNTY: OWNER'S S NAME: MAILING ADDRESS:
7~6sc.. .s . Sfo/,6
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATIONTESTS:
XResidence 7 "'ew ❑Replace
J /V y~v B-/I J~_~~•
Ser / f9/9P p X OaL fl
RATING: S= Site suitable for system U= Site unsuitable for system tRECIOMME ti/~j(
ONVENTIONAL: MOUNDNGROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANNDED SYSTEM:(optional)
S ❑U KS ❑U gs ❑U ❑S oU ❑S ®atd~¢,O
If Percolation Tests are NOT required DESIGN RATE: -If any portion the tested area is the 1V/14
under s.H63.09(5) (b), indicate: 14 Floodplain, indicate Floodplain elevation:
PROFI E DESCRIPTIONS
BORING TOTALi
NUMBER DEPTHtW ELEVATION D PTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- y q
~3 On (e- > r . ~Bl/ k o Bn l / B., /s y S S
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PERCOLATION TESTS
TEST DEPTHf WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER +NO' Eg AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIO PER INCH
P_ - 410 a6 L ,2~1 a'
P- Z S..0 /110 6 1e L
P -3 LI /t10 ~o < 3
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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. Saar ts~
SYSTEM El EVATION L/°ftee-
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I, the undersigned, hereby certify that the soil tests reported on this form were mad i ors v~ a"`Tf
by d with the r pote ures a d metho s specs ied in the Wisconsin
Administrative Code, and that the data recorded and the location of the tes rect to the best of my knowledge and belief.
NAME (print): 6 7
n / TESTS WERE COMPLETED ON:
ADDRESS:
CERTIFICATION NUMBER: PHONE NUMBER (optional
l:
tryy /3 CST ATURE:
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DISTRIBUTION: Original and one copy to Local Authority, Prope~ i } ~er.
f DILHR-SBD-6395 (R. 02/82) _ Z R-
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INSTRUCTIONS FOR CON SBD -
r . a c~ --le sail test, yom- red _
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APPLICATION FOR SANITARY PERMIT
STC - 100 j
This application form is to be completed in full and signed by the owner(s) of the i
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
i
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Propertyg-am, -A p h 5
Location of Pro/petty Section a 9 , Td N-R W
Township /yl-et a101)
Nailing Address _ ,e
T
Address of Site '
Subdivision Name (-,r (.0 t/ rte/ r .
Lot Number #t` IT- -
Previous Owner of Property /-7 4 11"lla"'
Total Size of Parcel
Date Parcel was Created y .
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) ceh ti..6y that att .statements on this 6o4m cite true to the but o6 my (ouA)
hnowtedge; that,-1 (we) am (cute) the ownen(a) o6 the pnopehty ducAi.bed in this
.in6o4mation 6dnm, by viAtue o6 a waAAanty deed n conded in the 066.ice o6 the
County Regi,6ten o6 Veedsas Document No. 2'!o - ; and that I (We) pnedentfy
own the pnopoeed 4ite bon the bewage di6po.6 d yb em (on I (we) have obtained an
easement, to nun with the above debehibed pnopehty, bon the eondtnuction o6 ea.id
eydtem, and the dame hae been duQneeonded in the 066.ice o6 the County RegizteA o6
Veedb, as Voeument No. ~a o3 55 1.
a
J00% UZ~
SIGN TURF OFD OWNER SIGNATURE CO- ER ( APPLICABLE)
Ik7
DATE SIGNED DATE SIGNED
S
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