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CROIX COUNTY WISCONSIN PLANNING & DEVELOPMENT PLANNING SOLID WASTE REAL PROPERTY ZONING 715-386-4674 715-386-4623 715-386-4677 715-386-4680 October 25, 1993 John & Vicki Kolasa Prime Mortgage Coon Rapids, MN 55433 To Whom It May Concern: An inspection of the septic system on the property of Robert Johnson, located at 638 Country Side Circle, Hudson, WI was conducted on October 25, 1993. 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 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 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 may be dependent upon proper maintenance of the system. At the time of the inspection, it was observed that the vent cover needs to be replace and 1 of the 3 vent pipes needs to be replace. Sincerely, Thomas Nelson Zoning Administrator js ST. CROIX COUNTY GOVERNMENT CENTER 1 101 CA` Form- S T C - 104 . w AS BUILT SANITARY SYSTEM REPORT SEC. T !~LN-RZj W OWNER TOWNSHIP <cf5o r~ ADDRESSf ST. CROIX COUNTY, WISCONSIN Sim GC~tiS J1" ~b l(o - LOT ~P LOT SIZE SUBDIVISION h r PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f i ~ i r _ ~5 r1 _ I ~U I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used s%sf f6~`Li „c e Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: r: Number of rings used: U Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: / Number of feet from nearest Road: Front,O Side, Rear, /feet From nearest property line Front,OSide,ORear, i7l~P feet Number of feet from: well Z~, building: ~s to (Include this information of the above plot plan)( 2 reference dimensiE SIDE septic tank) SEE REVERS 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, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Lenth: 16-7 Number of Lines: Area Built: Fill depth to top of piper ~f Number of feet from nearest property line: Front, O Side,f Rear, Ft. Number of feet from well: O Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of its: P Diameter. . Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box /a 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, O Ft. 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: 3/84:mj ,DEPARTMENT O`f- INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING P.O. BOX 7969 MADISOK WI 53707 ECONVENTIONAL OALTERNATIVE state Plan l.D. Number: 111 assigned) D Holding Tank D In-Ground Pressure ❑ Mound INSPECTION DATE: rNAME ERMIT HOLDER: ADDRESS OF PERMIT HOLDER: 2 e bert Johnson Rt. 1, Hudson, WI 54016 o REF. PT. ELEV.: J CST REF. PT. ELEV.. RK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. SE, Section 34, T29N-R19W, Townof Hudson,Lot#6,Countryside Vill. tuber MPIMPRSW Nct.. Cn"nlySanitary Permit Numberger Timm 3224 St. Croix 83784 SEPTIC TANK/HOLDING T NK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. PWAR\NINGDLABEL LOCKING OVER ' 71&0 YES ONO OYES %0 R OF PROPERTY WELL BUILDING LAIR INLET FRESH BEDDING: VENT DIA.. VENT MATL HIGH WATER NUM BE ROAD LINE. I. ALARM FEET FROM ~S DYES NO OYES ONO NEAREST__- DOSING C AMBER: MANUFACTUR R. BEDDING LIQUID CAPACITY PUMP MODEL PU rSl HO ANUFACTUREH WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO DYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTRO ER TIO AL NUMBER OF PHOPEHTV WELL BUILDING I VENT TO FRESH LINE AIR INLET. (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) DYE NO _ NEAREST I~IAMF TER MATE HIAL AND MA RKING I r1 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing RCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: LIQUID BED/TRENCH WIDTH. L %,IH NO OF ID11111 PIPE SPACIN(I COVE[ INSIDE )11\ =PITS DEPTH' THE NCMjL,S MAT IAL. PIT DIMENSIONS j` C;F2n`✓CL DCPiH FIL EPTH DISTH P F UISTH PIPE DISTR PIPE. MATERIAL NO DISTH NUMBER OF PROPERTY WELL BUILDING- VENT TO FRESH BELOW PIPES ABOVE COV R E EV LET EL LNG FEET FROM LINE/ AIR IN ET'. f x,.35 Z12~5y -NEAREST-757 7--Z 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- meets the criteria for medium sand. TIONS MEASURED. OYES ONO PF HMANI NT MAHKF HS 013SERVATION WELLS SOIL COVER rexiuRE OYES ONO OYES ONO SEE OFD MULCHED DEPTH OVER TRENCH BED DEPTH OVER TRENCH BEU 111, PTH OF T(1PS(11L S()DOFD CENTER EDGES D NO :NO OYES I_JNO OYES NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER WIDTH'. LENGTH NO.OF LATEHAL SPACING (TRAVEL DEPTH BFLOW PIPE BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH UISTH. PIPE UISTHIBUTION PIPE MATERIAL & MARKING ELEV. ELEV. CIA ELEV. PIPES DIA.'. ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS iU APPROVED INFORMATION HOLE SIZE HOLE SPACING GRILLED COHHECI LV COVER MATERIAL PLANS OYES ONO OYES ONO PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING. COMMENTS: FEET FROM LINE L OYES ONO YES ONO NEAREST- _ 57 7 ~6~ 7 Sketch System on in county file for audit. tE Reverse Side. slcNAr TITLE DILHR SBD 6710 (R. 01/82) SANITARY PERMIT APPLICATION CO7.1- STATE ~ DILHR In accord with ILHR 83.05, Wis. Adm. Code SAPERMIT# .~.~.s F3 IF-4 -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8'/z 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 OW 7 ER PROPERTY LOCATION /WSO S T o29N,R l9 (or) PROPER' AILING ADDRESS LOT NUMBER BLOCK NUMBER I (P TEX SUBDIVISIO NAM4/ (30" t e (1, / /C CITY, ST TEn ZIP CODE PHONE NUM~Ej~A O 0 CITY VILLAGE : k ~U NEAREST f t,~1 D, LAKE We R L'ANDM~ IX TOWN II. TYPE OF BUILDING OR USE SERVED: ~~~~~f ((emu-%~` Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable) 1. a. ® New b. ❑ Replacement c. ❑ Replacement of d. E1 Reconnection of e. E1 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. ❑ 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): ,,led G SS 2 600 10,0,5 s i 5 Feet X 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 12061 El El 1 0 El El ~ ❑ ❑ ❑ ❑ ❑ 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) *WLWE8Sw No.: Business Phone Number: rrr fo ~ &_Ieei~ ~u 3-7-7- /s 772- 3 Z/ Plumb 's Address (Street, City, State, Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION CUtffi Soil Tester (CST Name CST ~r r CST's ADDRESS (Street, Cit te, Zip ode) Phone Number: 3 %ii- •`vcr Qaf s ~z (1915) Y 2S'-'76.3 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) X Approved ❑ Owner Given initial j~ urge Fee Adverse Determination v J['~ 22924:j A or U, V 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 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 system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: Property owner's name and mailing address. Provide the legal description where the system is to be installed; IL 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'Y2 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 - s included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried fseas~jre x, a r ~ I 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. ~ U The monies collected through these surcharges are credited to the groundwater fund adminis- tered' by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Ground>vat=-s, 4`s worth protecting. S8D-6398 (9.03!86) r APPLICATION FOR SANITARY PERMIT STC - 100 i 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/contractgr,("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., - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (honer of Property o' Location of Property Section , T. r N - R W Township Al 1' Malling Address ,Pf, / f1~1C7S`t1 i~ 5g0z Subdivision Name Lot Number Previous Owner of Property ' f 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 ZVa and Page Number Z_,21-_.._ as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1 (We) ee&ti6y that a.?.e..6tatement6 on .thin 6onm ane tAu.e to the but o6 my (ouA) hnow,Cedge; t*a.t 1 (we) am (aae) the owneA(b) o6 the ptopehty de,6cAbed in .th,i.3 .(.J16otona.tion 6oun, by vi tue o6 a wahAanty deed neeonded in the 066ice o6 the County Regi-6teh o6 Dee& ad Document No. and that 1 (we) pne,3e.n1`._y own the pnopoeed bate bon the sewage poz5 by.6tem (oa I (we) have obtained an e" emen t, to nun with the above du cAibed pnopeA ty, bon the con tAu c t%o n o 6 .6 aid b y.6 tem, and the b ame hab been duty neeonded in the 0 6 6.%ce o{l the County RegizteA o6 Deed6, ab Document No, y/a 1 SIGNATURE C~JWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) C- 30- DATE SIGNED DATE SIGNED a z H 9 r STC - 105 t" 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County x 0 9 OWNER/BUYER JCoe°r°d Rr?CI V~#i1tj Jd ~ttSbtil ROUTE/BOX NUMBER Fire Number J' + f sy4/~~a CITY/STATE Z I P PROPERTY LOCATION: NE Section? TAN, RW, Town of l7dU'S'0~ St. Croix County, Subdivislon(70() /((S«t~ Ut z 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 01- 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 pr r I.riy -1-978;- 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 bya master plumber, journeyman,plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-pite 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. E z I/WE, the undersigned, have reaa the above requirements and agree En to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Offkre within 30 days of the three year expiration date. SIG N E D DATE 3300 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. DEPA$TMENI`OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 Job No. 76-665 LOCATION: SECTION: TOWNSHIP/ OT NO.: BLK. NO.: SUBDIVISION NAME: NE 1/4 SW4 33 /T 29N/R 19r) w Hudson 6 lComtryside Village COUNTY: OWNER'S 6 NAME: MAILING ADDRESS: St. Croix Francis H. Ogden 123 E. Elm St., River Falls, Wi. 54022 USE DATES OBSERVATIONS MADE 7EDRMS.: COMMERCIALDESCRIPTI: ITIOFILE NS: PERCOLATION TESTS: ~gResidence 3 N/A C7x New ❑Replace l 819/82 N/A RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) 0 S ❑U ❑ S ❑U ©S ❑U ❑ S aU ❑ S DU Conventional Bed 241x401 If Percolation Tests are NOT required DESIGN RATE: S S5 E O M ELEV. I If any portion of the lot is in the N/A under s.H63.09(5)(b), indicate: 10 O Floodplain, indicate Floodplain elevation: Class 2 PROFILE DESCRIPTIONS Pg. 66 ShC2, BxD2 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. CHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 84 98.7 None 7 84 40, dark Bn sl; 44, light Bn s & gr. B_ 2 78 97.4 None 7 78 24, Bn sl; 54, light Bn s & gr. IUL~ g_ 3 102 99.6 None 7 102 6, dark Bn sl; 96, Bn cs. 9~ ll~ B_ 4 102 98.3 None 7 102 15, Bl sl; 87, Bn cs. ECCNA B- 5 102 98.6 None 7 102 12, Bl sl; 90, Bn cs, So took B- PERCOLATION TESTS" j TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL- CHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERI002 PERIOD3 PER INCH P- P_ P P P- P- PLAN VIEW: 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 slop. SYSTEM ELEVATION 95.0 SCALE 11'=401 : 19$ r _ I - -211,-- .ON " PIPE,--'FOLZP, ~A D-".l i E B-1 F4RING,-SITE R. I 3 s d2 of slop. - - djre~tion an Te" I ' ago ono Z 0 ORI B_ 4 B 3 ? e_ _ A -ALT i 00 24' 24' N 7% w°o c, 0 A' 0 20' ' C d 3% t7% l ' 8! L1.h1E OF LOT _ 6 l ~ a , E 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative 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: Walter J. Gregory Ogden Engineering Co. 8/24/82 ADDRESS: 123 E. Elul Street CERTIFICATION NUMBER: PHONE NUMBER optional): 55-588 715 425-7631 CST SIGN T RE: DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4,17 page-Soil Tester. DILHRSOD-6395 (N. 03/81) j~~ier~ ~dtYx~d~ cos ROHL & TIMM EXCAVATING / OF 2 SHEET NO. 310 Arch Street HUDSON, WIS. 54016 CALCULATED BY G✓ DATE (715) 386-8664 CHECKED BY pq_ /r!P S 3Z25I SCALE ~i 1 r _ J o 432- . 1 D 1A5~ . tic, ~ ~xS/T~y1c ~ ~irsm G.,Je l! 1~ ~t~~ic; SS Lea, ~ ~ oF, 2 ' 1 rv.-► ~ io S~ stern ~ L _ 1.5--, PRODUCT 2041 names Inc., Grown, Mau 01471. JOB 7~CJ / ) ROHL & TIMM EXCAVATING SHEET NO. c~ OF r 310 Arch Street r HUDSON, WIS. 54016 CALCULATED BY ~f" DATE (715) 386-8664 CHECKED BY P7/°K5 -3-F--ay SCALE Cis ~ /rd n Am 4 145 ft4llaY f A1.4 a- 5 -.J 9 -z z _ t at PRODUCT 204-1 E'es Inc., Groton, Mass. 01471. J Parcel 020-1148-40-000 03/07/2006 11:35 AM PAGE IOF 1 Alt. Parcel 33.29.19.792 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - KOLASA, JOHN S & VICKI L JOHN S & VICKI L KOLASA 638 COUNTRYSIDE CIR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 638 COUNTRYSIDE CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.010 Plat: 0215-COUNTRYSIDE VILLAGE SEC 33 T29N R19W COUNTRYSIDE VILLAGE LOT Block/Condo Bldg: LOT 6 6 Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) 33-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1045/307 WD 07/23/1997 742/212 07/23/1997 716/422 2005 SUMMARY Bill Fair Market Value: Assessed with: 92660 331,200 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.010 75,000 262,800 337,800 NO 05 Totals for 2005: General Property 2.010 75,000 262,800 337,800 Woodland 0.000 0 0 Totals for 2004: General Property 2.010 30,100 200,600 230,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 501 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 13- • ST. CROIX COUNTY WISCONSIN ZONING OFFICE r r II _ r ' ST. CROIX COUNTY COURTHOUSE A 0/~/ ~Qr~n ~Q • HUDSON, WI 54016 (7150-86-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM ~t1 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 (VOC's) $185.00 Septic $25.00 X Water (Nitrate & Bacteria) $35.00 Asual inspection) Owner: Requested by: - Address: Address : /,33f IrA City & State: d , City & St. Zip Code: yp Zip Code: Telephone N°: Telephone N°: Property address LFJ a N° & Location: c~,t✓ W Sec 3 , T_2N, R~W, Town of St. Croix Co., Tax - Parcel ID N~ y 3- Z House color:,a Realty firm: A-ww Lock Box Combo: Water sample tap /location:~- Ifk TO BE COMPLETED BY TROPERTY OWNER 'PROVIDE A SKETCH -OF HOUSE & SEPTIC. SYSTEM ON REVERSE- OF THIS FORM* Is the dwelling currently occupied? ❑ Yes No If vacant,.date last-.occupied: /6-Zy 93 Septic system installed-by: Year: Septic tank last serviced by: Date: Previous Owner's Name(s): Ro , S , Have any of the following been observed? ❑Y - - N Slow drainage -from :house. ❑Y 4~LN Sewage Back-up into dwelling. /a0j(7~ ❑Y KN Sewage discharge to ground surface, /d road ditch or body of water. ❑Y Slow drainage from the dwelling. ~3 7 ❑Y SN Foul odors. Other comments relative to system operation: e6~,,_,,e4 Two Cam) Ufi I certify that the above informatio is omplete and true to the best of my knowledge. OWNERS SIGNATURE : DATE • lc 1 ZL! 1 Q3 6~ vtaf ~!v /'~~IdtLts 1jC~tjft op jUA-Wg Y~1~ lti`~~ MiJU d~ / 0 M ~ YjSy/ Yi" > 1, 7lr e i 'U/ L... rtn -h 1 V? . I J - 114 f~\ r" M i-fJli % LYiYI I Lel ~s 12-1 '4-~ - MC(~. ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE Jl,~r=1';r I / • HUDSON, WI 54016 _ , . (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM 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 (VOC's) $185.00 Septic $25.00 Water (Nitrate & Bacteria) $35.00 inspection) Owner: 7~ Requested by: f C ✓j'~69 Address: 3 r,1 C`r2 - Address: /o~ City & State: City & St. f ~.3 Zip Code: y0 Zip Code: Telephone N°: Telephone N°: OZ7 /3~ Property address a N, & Stre t) V Location: Sec.33, TN, R ~'g W' Town of1Sc~,t! _Vw St. Croix Co., Tax ID Parcel ID N2 House color: Realty firm: iLW Lock Box Combo:-' Water sample tap location: J, k t R' 7 TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Is the dwelling currently occupied? ❑ Yes No If vacant, date last occupied: Septic system installed by: Year: Septic tank last serviced by: T Date: I ' =_EZZ Previous Owner's Name(s): fia it Have any of the following been observed? ❑Y ON Slow drainage from house. ❑Y 4N Sewage Back-up into dwelling. ❑Y RN Sewage discharge to ground surface, road ditch or body of water. ❑Y 9:N Slow drainage from the dwelling. ❑Y 1~[N Foul odors. Other comments relative to system operation: I certify that the above informatio is omplete and true to the best of my knowledge. DATE: 1,01,493 OWNERS SIGNATURE: Uf(~fr-t k--v 6A-tU1Ufs-F P16VA 4 vp to Z5MV&F, to 1U4-~ a4 17,/ 34 -T - t OUnd~o~ OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION 3cAlt P TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ONo Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ~Below grd OAt-Grd OMound Approx. size 'X ❑Gravity ODose ❑Pressurized Ft.2 OBed OTrench ❑Dry-Well Molding Tank 00utfall pipe OBSERVED DEFICIENCIES 00ther OUnknown Septic tank Setbacks: ❑House_ ~ OWell 25 f❑Prop. line. ❑Other Dose tank Setbacks: OHouse ❑Well ❑Prop.'line_1 00ther ❑Locking-cover OWarning label OPump/Floats" OAlarm OElec. wiring Soil Absorption System Setbacks: ❑HouseOWell~f OProp.-line OOther OPonding: ODischarge: General comments: 3Rj , AA ",A e4 J Goi INSPECTORS SKETCH OF"SYSTEM LOCATION a~ ~ ~25- a4t o`~~ ~G , pI ~r ~b Qt` Inspecto Title ,.irk 5 V-) Z