HomeMy WebLinkAbout020-1168-10-000
t
c ca 0 l c co 3 m o d v1
or c
CD
eo
3
0 CD n
3 -
y, O
0 A~1 O O N O (A O o p1 O O U) O 00 O c N No •
=r :3 c w OD ~ C P. 0 N
CD CD
N v S 0
CL CD CD :Z ((DA N S N CL A Z CD
n
o
eoo :3
CD M K) - CL
100. c m o ? (D o p~ Oy
? °o Ln co CL
0 C)
C)
C
C)
o
o v>zD o a U) D o a
(O D U, a p l co (D
CL o
CD
CCDD (W CCDD o
C o c
CL :3
3 3
Q °D F Q N N
CD ? 0 0 L A O
0 0 ~l
O 00
00 N 00 00 co
O) 0 (n C !r
'I CD fD .Z~. cr` 111
z 00 <c 0Sc,~ 0S y z 0C 0C 0C O y y y 7 N
O
CD -u 'p 'D G G G j
c 3 CO) ul to ai N ',i N 3
o v - cr v v v o
o w CD A y 0 CD
e'D m cn g
7 CD C CAD o m o 01• m j 00
N < 3 Of CD
N 7 3 N a
CL Q N
z z
0 Q a Q n
0 =r =r cn "A
_ m w m CD w
N
CD Cn CD
CD w c CD w c
co Io -
N N
I C (D CD C CD CD
w a w a
a 3 7 I a 3 7
z CD c6 z CD fO -1 cA
in N o" r_ ;u
0_ a v n A 3
0 0
(WD ~ W ~ m m rv
CL a z
3 A
00 :r 00 ^ N
3 O
N z M z
CD CD
Ca ~ (a ~ A
i
7 w w n D _ CA 00 7 N D
O p_ N CD N gn CD OD a C O a
7
w r. - a s 0 v -4 Cnn o
7 m Co CD
a CD 1 0 0 v T CD N c O S w c
C
C.0 CD
CD 005' CL
acD a -'c w o a rn° o o
~3 D w w so» m
CD NCr w y o 3 ~ aN m y f
m oo3 ~0) CD CD o
3_CD 'o 0 CD P w ( co
~ 0. O 0) ? 0 ter.
N A Oo Z ~ ~ ~ A
~ww.CDy 0~oy e
to N O N O p 27
C 3 CD 3. 0 c O•
Qy m 0 a -3
O S .O = A
0 Co CD O 0 N `OG D w
w O
c°aCm C>>' o
w
tv
0 CD ((1) CL n ~ ~ CD
mom. ~o BCD o
*
rn m w 3 co A
CO. a a
0 0
CD CD
do a
o0 o 0
o a o a
s
I
0
rn
i
n
'tJ
x co 43
S 04 u-, W N
o
41 o
d 3 1 U ^'o w .o
C/) o : 3 W 00
N
(Y r-I n M
W ra I
rn ON 4
111 co H O
F- . cv t a
uo
'C3
N
00
r~
z ~ \ H
ND
CL4
a
PL-
U 3 S x `n 0
d w o cc
34 H
U 3 ra O
J x 1J G 4J
9 n
a a Q)
z' U)
o
° O x
saB~eya;uanbullaa ssBje4a leloadS s uawssassd leloadS WWI
0012 1N31NSS3SS`d I`d103dS ONI-IOA032J-860
;unou V iG0681e3 epoa leloadS jasn
:siepedS
ZZ6 43;e8 :oleo u01;eol;lva0 6 :;uno0 ualel0 ;}Ipaa~ /(J81101
0 0 000'0 puelpooM
0017'617Z 000'861• 0017'65 05£'E A:pedoJd leJaua0
~1700Z ao; sle;ol
0 0 000'0 puelpooM
OOZ'S££ 008'09Z 0017'17L 05£'E A:pedoad IeJaua0
:500Z Jo; sle;ol
50 ON 00Z'9EE 008'09Z 0017'171 09E'£ 60 WUN30IS32J
uoseaa a;e;s Ie;ol emidwl pue-l saJOV SSela uol;dljasaa
5002/5Z/0 I, :peBue40;set :SUOI}enlen
0OL'8ZE 698Z6
:41Inn passasSV :amenWPM aled Ilia AbdwwnS 5002
89E/617L L66 UEZ/LO
edA.L aBed/lon # ooa a;ea
:tio;slH IaaJed :sa;oN
M0Z-N6Z-Z 6
(17/6 096 17/6 017 Bu2i-um1-09s) :(s);oejl
400MH0N`d2J
Z'86 lOl :BpIS opuoaploole / iVId Z'8 6 SlOI 3N 3S MM3 N6Z1 Z6 03S
a00MH0N"-Z9EZ Wld 05£'£ :saaoy :uol;dljasea 1eBa-i
011M OOL 6 dS
NOSanH JO 0 HOS I, M OS
HCI QOOMNO1100 17906 x uol;dinsea #;s!a 9dA1
tiewud = :(se)sse ippy AvedOJd leloadS = dS I00y3S = OS :s;ouisla
960175 IM NOSanH
MJ QOOMN01100 17906
MdHIIOOH V H11a2ib" 81 dIIIHd
V H-LIMJV 81 d1IIHd 'MdHI-100H - O
aaumo-oo juaiino = o 'iaumo juai.ino = 0 :(s)JauMO :ss83ppy xel
0 00
adA 1 }Iw-18d #;!uaaad # uol;eollddd eater sales # deW a;ea 1BOPO;s11-1 oleo uoneejo
NISNOOSIM '.11Nf100 xioHo '1S X' ;uenna
NOSanH 30 NMOl - OZO 6E06'0Z'6Z'Z6 laoaed 1IV
LAO 6 399
wd 170:o 6 900WO/zo 000-0 t--89I. -OZO IaOaed
00.0 00.0 001Z 1elol
soBje4a;uenbullea soBae4a leloadg s;uawssessV leloadg
001Z 1N3WSS388d 1d103dS ON110AO0 ]2 -860
;unowV tioBe;ea opoO leloadg -jasn
:slehadS
8£6 431e8 :a;ea uol;eol;ll6+a3 I. :;unoa wiel0 :}Ipa.lo A.la}}O-i
0 0 000.0 puelpooM
006'£L6 008`6£6 00£`£E 9L01 A:padoJd IeJ8u89
:VOOZ jo; sle;ol
0 0 000.0 PuelPooM
OOb` 6£Z 009`£86 008`Lb 9L01 Apec!O-ld IeJaua9
:BOOZ ao; SIMI
90 ON 00V`6£Z 009`£86 008`Lb 9L01 6J 1VI1N3a1SMa
uoseem a;e;g le;ol anoidwi puel saaob ssela uoi;dl.iosea
SOOZ/9Z/0 6 :pa6ue4a Ise-1 : suOljell leA
006'9ZZ 90£Z6
:44im passasSv :enlen;ailJEW pled Ilia ANvwWns 5002
slow
99/1.99 L66 6/EZ/L0
aM 6Z0/L£Z 6 L66 6/EZ/L0
aM ZZ6/9091. 9LE6b9 6002/LZ/£0
(IM 8ZZILLLZ 86E66L SOOZ/b0/tI0 x
edA1 aBed/10A # ooa o;ea -V /
:tio;s!H laoJed ~~~JJ :sa;oN
MOZ-N6Z-Z 6 AA
(v/6 096 b/6 Oti hub-unnl-oaS) :(s);oejl
:Bp18 opuoapiool8 WSO M01, 101 3N 3S M23 N6Zl Z6 03S
318d11VAV lON-b'/N :1e1d 6 U :saaay :uol;duosea IeBal
011M OOL 6 dS
NOSanH MO a HOS 6 M OS
ba o0OM3Ja3 69Z . uoi;dliosea #;sia edA1
tiewud = * :(sa)ssajppV ApedoJd IeloedS = dS IoouoS = OS : ouisla
960bS IM NOSanH
as a00M30(13 68Z
S213W3018 0 Al JVIN
J )12i`dW `Sa311\13018 - O
jaump-oo juann0 = 0 'jaump;uann0 = 0 :(s).iaum0 :SSajppy xel
0 00
adAl;lw.'ad # 31=88 # uoi;ealiddb eater sales # deW a;ea Ieolao;siH a;ea uoi;eaaa
NISNOOSIM '.11Nnoo XI02l0 1S X ;uenna
NOSaf1H MO NMO1- OZO 009t,•OZ•6Z•Z6 laoaed 'IIH
I• d0 6 39Vd
VYV 69:60 900MO/Zo 000-ZO- ~ ~ ~ VON 1a3aed
O Si f o y 0 3 o d
c d f c o tD
3 r
CD 0 -0 0
0 C
eD 9 'I
U) Z Z o aD 0
N ~C •
N O N w O d y O 00 O Q N
o.*
7 O A .p co
Q (D N CD
K3 a co
N ra O ? A O O O O ' C 1
3 N Q 3 O_ -I 9
COD ? °o oo0 S W O O
.0 V1 0 C: E 7 W p W
N N = W 'O I, ° 00
a N !D ? Of O rn !r
r t `
m a D N fx a p 1 m ~p
N co o° n ~i
:3 0
W o co
C: CD CD
p ao\D f 3 ° N ° ~y
O
CD CD
a A a
Z
co co
V p Cl) c c 00 CO m 1 rn V, CD
o rn l y
3 a
v
"a M -0 C
o g CL rr "AA
Z OOOa, Z OOOo
o 0
0 =r ca ca 0) o' w I3a
m -0 (3 ID O o' CD N)
C -
f~D N O 0 A I.. O lr
N 3 = r. - rn
N
D 3
CL ° M a 7
3 z
DWO 1 Z~Z O
m a ? D a
O ~r
o s co o. v N
CD (A CD
CCDD w a c
0 M. CD w o CD N ca c CD m
m w a
Q
z CD
(D z CD N o A z m
v c
CL
w a A
o 0
cn --I
W CD
o. (D N m Z N
c 3 o 3 z~
Z N
0
y H
Z
Z
W W A
O N~ Q O C =U) 00 :3 D
CL 0) m
D) a p G O N +y
= M U) CD -4 C?
fD ld 0 0° C :3 m N C 0
7. N
O T
N M~ 7 O--"-?• v C
7 Q
arc m o co~ j o a CL
CD t2 (n I m N v
CD CCD oo CD
'COD C L 'COD
CD I
t
*4 W 29 N Z
vi CO 'O .N.. O .O O 01 a,
G N 0 N O
~ o
C 3
ON c
N r g~ a = a
o
vCD CD~ T CCDD K N S' A
-01 R~ C :D' o
0 (D CD (n S.ca
U) CL _0 (D
S' (D
v~ C m
° o
(A o
n a ti
(OD Qa b
c* o p ti b
CD *
° a °o i
ti
Parcel 020-1168-10-000 02/01/2005 04:49 PM
PAGE 1 OF 1
Alt. Parcel 12.29.20.1039 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
* HOOLIHAN, PHILIP T & ARDITH A
PHILIP T & ARDITH A HOOLIHAN
1064 COTTONWOOD RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1064 COTTONWOOD DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 3.350 Plat: 2362-RANCHWOOD
SEC 12 T29N R20W SE NE LOTS 1 & 2 PLAT / Block/Condo Bldg: LOT 1 &2
RANCHWOOD
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
12-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 749/368
2004 SUMMARY Bill Fair Market Value: Assessed with:
49079 322,400
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.350 51,400 198,000 249,400 NO
Totals for 2004:
General Property 3.350 51,400 198,000 249,400
Woodland 0.000 0 0
Totals for 2003:
General Property 3.350 51,400 198,000 249,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 122
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
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~ ~,;,rst
TOWNSHIP SEC.- N-R_;2,~ W
ADDRESS l,Sl7 5~~1- ST. CROIX COUNTY, WISCONSIN
ijr7~fZt 1
/a~ d
SUBDIVISION LOT Z„ LOT SIZE 626:z(d -16-0.rc)
/PLAN VIEW 2t-~ 10 31f
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1
s~ ~ 1
1
any t
t
INDICATE NORTH ARROW
~'N,us _ 9s:c3'
BENCHMARK: Describe the vertical reference point used,
Elevation of vertical reference point: J Proposed slope at site:
SEPTIC TANK: Manufacturer: 1-6A' S ~~~/-_Li uid Capacity:
Number of rings used: _ Tank manhole cover elevation: < Y
Tank Inlet Elevation: ;2S; Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side, Rear, Ofeet
From nearest property line Front,OSide,ORear,~ feet
Number of feet from: well /
building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
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: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, Side, O Rear,O Ft.;
Number of feet from well:
Number of feet from building:
(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: ~.J
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LAB sFi, ,4CMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.0LBOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE Stale Plan ID N-1-
(11 a55igntt1l
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. I7;A72 Phiti Ho
rJtihan 957 St. Cuix N. Huctson W1 54016 m
BENCH MARK (Permanent reference pmml DESCRIBE IF DIFFERENT FROM PLAN. RE K PT./ELEV. : CST HEI PT ELEV
SF NW, Section 12, T29N-R20W, Town v{j Hudson
Name nl PI.-h- . JMPIMPRSW N... County- Sanitary P-a N-1-
Cat Poweus Jn. 1563 St. cuix 83832 J1
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV IWARNING)LABEL LOCKING COVER
PROVIDEVIUED
D0_~ 195-99 9S.S~ YES ONO C YES XNO
BEDDING VENT DIA. VENT MATL. IHIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING VENT TO FHFSH
ALARM FEET FROZ-/L) LINE ~ IAIH INLET
❑YES %NO ❑YES ❑NO N~;
DOSING CHAMBER:
MANUFACTURER JBEDDING LIQUID CAPACITY PUMP MODEL PUMP. SIPHON MANUTACTLIIIFH WARNING LABEL LOCKING COVER
PROVIDED PROVIDED
❑YES ❑NO ❑YES ONO ❑YES LJNO
GA LLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL. NUMBER OF PHOPF HIV WELL Itil UIN(I (VENT III IIII SR
(DIFFERENCE BETWEEN FEET FROM LINE AIR IN(F I
PUMP ON AND OFF) ❑YES ❑NO NEAREST 30
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LFN(,T1/ JI)IA111111+ 111AIII11,11 AND MAIIKINI,
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 LENC INO OF IIISTR PIPE SPACING COVER INSIUI OIA =PITS LIOUIO
BED/TRENCH THENHES NIAr TAU PIT OFP711
DIMENSIONS
GHAVFL DEPTH FILL DEPTH UISII( 11'I UISTH PIPE DISTR. PIPE MATE HIAL NO DI„ H NUMBER OF rY WELL HUILOING VFNT TO 7f III y:
IBF LOW PIPES AHOVE COVEN 1 f V INI I I ELEV I NO PIPFS !PLIHN(7VEH
AIH INLE i
/ r` (0 - ~j - FEET FROM
e" " v I NEAREST-s > f~ ti v-«
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-
❑YES ❑ NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TFXl UHE PFHMANf Nr MAHKI HS c11;SI I/Vn 1111N WI I Is
❑YES ❑NO -YES LINO
jLF[PTHR)VFH tHINCII BFIJ DEPTH OVIR TRENCH BED DEPTH OF TOPSOIL Hf D
CENTEEDGES
❑YES ❑NO ❑YES ❑NO ❑YES NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LF NC;7/1 NO. OF LATERAL SPACING ('~HAVEL Uf PT11 HI LOW PIVI-- f II L OF P1H nH()VI (:UVI H
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANII (7LU MA iE111nL NO OISTH I:ISTH PIPF )1STIiIIMIV1NP1I'( NIP, Hlnl &MAHKIN(.
ELEVATION AND ELEV FLEV DIA ELEV. PIPFS DIA
DISTRIBUTION
INFORMATION HOLE SIZF HOLE SPACING UI+ILLEU CUHHF CII V COVFN MA iE HInL VFIItwAt I IF T COHHI SPUNDS 10 APPImVI 17
Plnn~s
FEETT
❑YES ONO DYES NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL BUILDING
LINE
tij I ❑YES ❑NO ❑YES ❑NO NEARESOM _ I -
t
I'
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURETITLE
DILHR SBD 6710 (R. 01/82) %7-~"
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LA$OR &OUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.q. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
:
xICONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
Ilf assigned)
O Holding Tank O In-Ground Pressure D Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Philip T. Hoolihan 957 St. Croix N. Hudson WI 54016
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: TrP CS T REF. PT. ELEV.SE NW, Section 12, T29N-R19W, Town of Hudson, Lot#l Ed ewood Est.
Name of Plumbr: MP/MPRSW No.County: Samlaermit Number.
Cal Powers 1563 St. Croix 88447
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY' TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
OYES ONO OYES ONO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: JVENT TO FRESH
ALARM FEET FROM LINE: AIR INLET.
OYES ONO OYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO DYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF ~PROPERTY WELL BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) OYES ONO 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 DISTR. PIPE SPACING: COVER JINSIDE DIA. #PITS LIQUID
BED/TRENCH TRENCHES MATERIAL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPES. ABOVE COVER. ELE V. IN LET. ELEV. END' PIPES: FEET FROM LINE. AIR INLET.
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-
O meets the criteria for medium sand. TIONS MEASURED.
YES ONO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
OYES ONO OYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL- SODDED. SEEDED MULCHED
CENTER: EDGES:
OYES ONO OYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH TRENCHENO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL: NO. DISTR. fSTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV.. DIA.'. ELEV.: PIPES A.:
'
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY JCOVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
OYES ONO OYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE:
O YES ❑ NO ❑ YES ❑ NO INEAREST-
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE.
DILHR SBD 6710 IR.01/821
IL R SANITARY PERMIT AP0C7 T~11 COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
E: H
STATE SANITARY PERMIT #
-Attach complete 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.
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PETITION
FOR VARIANCE ❑ YES ❑ NO
PRO ERTY OWNER PROPERTY LOCATION
4S , N, R ,::o E (or) W
PRO ER OWNER'S MAILING AD ESS LOT NUMBER BLOCK UMBER SUBDIVISION NAME
-1
CIT , STATE ZIP CODE PHONE NUMBER JZCITY NEAREST ROAD, LAKE OR LANDMARK
VILLAGE
TOWNOF
11. TYPE OF BUILDING OR USE SERVED:
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. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Onl n an Existing System Existing System
2. A Sanitary Permit was previously issued. Permit # 1 d 3 Z Date Issued e-l y -G b
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. M Conventional b. ❑ Alternative C. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. E1 Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. 9 Seepage Bed b. ❑ seepage Trench c. ❑ seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes p r inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Feet [0 Private ❑ Joint ❑ Public
VI. TANK CAPACITY
in allons Total # of Prefab. Site
INFORMATION Fiber- Exper.
New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank a ❑ ❑ ❑
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): Plu Per's Signatur . No
S) rMP/MPRSW No.: Business Phone Number:
3
Plu ber's Address (Street ity, State, Zip Code): Name of Design
er:
Vlll. SOIL TEST INFORMATION
Certii 'ed it Tester ST) Name CST #
,(s
C T's ADDR SS treet, Cit , State, Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
X❑ Disapproved Sanitary Permit Fee Groundwater Date Issuin Agent Signature (No Stamps)
Approved ❑ owner Given Initial S rcharge Fee p
Adverse Determination 0/0z)- /0~ S O e!45 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
i
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 systei i, contact your kcal code adniin strav-,)r or U_ie
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owners name and mailing address Provide the legal description where the system is tc 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'/2 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 Wiscor~,~n's e
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that
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.
Ti-,e monies collected through these !=uircllarges are ~_ied,ted '':o the groundwater fund adminis-
tered by the Department of Natural R, source Thlese funds are used for monitoring ground- 41~.
water, groundwater contamination in vest Jati ins and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398 (8.03;86)
4110 //)4W
II
"-®r ~,ar
PAGE OF
Fresh Air Inlets And Observation Plpe
[J/ Approved Vent Cap
Minimum 12" Above
Final Grade
20- 42" Above Pipe _4" Cost Iron
To Final Grade Vent Pipe
Harsh May Or Synthetic Covering
min. 2" Aggragals
Ols Over Pipe
Mon 0 0 0 0 Tee
Pips
6" Aggregate
8enealb Pipe o --Parlwr-leJ Pipe 8sl:'s
Garbling Terminating At
I.-
Bottom Of System
PruPoSeD T'inal `9rH~~c ~
~~tJ•.l' ton
SOIL FILL
DISTKIBU71016.1 PIPE
APPROVED S4kt •iETIC COVER
' -sMATEM4- OR 11" OF STRAW
Z"OFtbGREGAIE OR MARSH 14Ay
(o OF 12-2i!2 AGGREGATE 41
tL E V. OF FEET
DIS"TRIfj~JTI0kJ PIPE TO BE AT LEAST _ INCHES BELOW ORIGINAL GRADE
AUU AT LEAST20 INCHES BUT 1.10 MORE THAN H2 IAICNES BELOW FIAIAL GRADE
MAXIMUM DEPTH OF ElAeAVAT160 FRoM ORIGINAL 6KAoE WILL BE _ INCHES
M1N1MUM 9EPTM OF EXCAVAT101M fR0M'GIKI(0JAL CRAPE WILL BE ~ INCHES
SIGHED:
LICEMSE IJUMBER:
DATE:, 041- 42- c?eo
J _ _ 110
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INbUS~TFZ.*, c DIVISION
LABOR ADD PERCOLATION TESTS (115) P.O. BOX 76
( MADISON WI 53707
HUMAN RELATIONS H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNS IP/MU ICIPALITY: LOT NO.:BLK. O.: SUBDIVISION NAME:
COUNTY: OWN R' BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIA DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence IMNew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system - /
CONVE:N I ZONAL: MOUND: IN-GROUND-PRESSURE: SYSTEccM-I -FILLffF
LDIING TTAnANK: RECOMMENDED SYSTEM: (optional)
YS ~U ®S EA ~S DU 0 J
If Percolation Tests are NOT required DESIG RATE: I If an
L y portion of the tested area is in the
Ender s.H63.09(5)(b), indicate: J Floodplain, indicate Floodplain elevation: 411-4
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH 1~0, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B-
B- A10AII-C >
B-
s
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. PERT D 1 PERIO 2 PERIO PER INCH
P-J0 /1. 9
P-
P y
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
#
1 E
s I
#
3
r
'4/ E
i
3
i # 3~ (
ry
E
h?
I, the undersigned, hereby certify that the soil tests reported on this form wer 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.
NAM (pri TESTS WERE COMPLETED ON:
ADD S: CERTIFICATION NUMBER: PHONE NUMBER'
C IG TUR
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DI LHR-SBD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPI. -TING F-.-M 116 - SBD - 6396
To be a complete anc' curate soil test, you
1. Complete legal descr.,.__.....,
2. The use section must clearly indicate whether this is or commercial project;
3. M \XIMUM numl of bedre commercial use pla
4. N :E
n - stT~° OR A )I _ TANK ONLY I ALL
_IC
6 I completing the
7, scale is prc A
flood pl, rcolation to temp-
1 Q. 1 th c ' 'ate box;
11.
12 ES- BE FI WITH THE
IT _
`N`EVI TI N FOR CERTIFIED SOIL TESTERS
I Textures ois
10") RR
g ,
m ed
f _
I
S,
P.
e Point
i
OT I
to
t ..'J
I
f
ST. CROIX COUNTY
r WISCONSIN
s T z~y ZONING OFFICE
796-2239 (HAMMOND)
.425-8363 (RIVER FALLS)
S HAMMOND, WI 54015
i
I
December 4, 1986
Ms. Carolyn Haag <1'
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Carolyn,
Permit 483832, issued 8-14-86, is being rescinded as the system area
was relocated. The plumber was unable to obtain that permit.
Permit 4488447 has been issued for the installation of the system.
Should you have any questions, please feel free to contact this
office.
Sincerely,
Mary J. Jenkins
4~j
St. Croix County Zoning Office
Parcel 020-1168-10-000 12/14/2004 08:28 AM
PAGE 1 OF 1
Alt. Parcel 12.29.20.1039 020 - TOWN OF HUDSON
Current IXI ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* HOOLIHAN, PHILIP T & ARDITH A
PHILIP T & ARDITH A HOOLIHAN
1064 COTTONWOOD RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1064 COTTONWOOD DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 3.350 Plat: 2362-RANCHWOOD
SEC 12 T29N R20W SE NE LOTS 1 & 2 PLAT / Block/Condo Bldg: LOT 1 &2
RANCHWOOD
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
12-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 749/368
2004 SUMMARY Bill Fair Market Value: Assessed with:
49079 322,400
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.350 51,400 198,000 249,400 NO
Totals for 2004:
General Property 3.350 51,400 198,000 249,400
Woodland 0.000 0 0
Totals for 2003:
General Property 3.350 51,400 198,000 249,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 122
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
1
0 !A p 3-0 n d
C .dr F C Of O
3 ? 3 3 A.
lti,
•
(D
3
ID \ 1
_ Q
C/) z 0 co
O 07 O (a O C.) 0 C N N •
CD 3 (D f"C CO O a N F"" ~C 11
:
QO- C tD Z c, Vs to N_ 7
A O N N O0 co
CL 0
o ,D S ° o rJ. Q
O1 3 eD m co O R
y C O
~v a °
o t~1
, n
CD
m w CL
c°
N
3 N co
0 0*
a 0 Q
CL 0.
0 r- cn
o
o 000 °Y `•tii
SSS SSc
N C 3 N I N O N N
3 Q u aa!R o
y v rn
CD
I ~ w a
CL
oZ 3
ca3Z
n x a ~
o o v, U
=r CD
CD y
X W C
0
C v N
w d
Z fD --I cn
a 3
O ~ ~ A Z N
=i
0 n A z
O
j
m M m N N
CL z
3 A
p * Z N
y 0
Z
C
w
I
a
I ~ ~ I
o -
Z a
0
fD
N i
I I y
fi
I y
I . b
I ~
o-
A
I ~
I
ti
I °
0
~ A
o b ?o
(D
oro w
cfl O
ON
o C
ILH MOMS SANITARY PERMIT APPLICATION COU TY -
In accord with ILHR 83.05, Wis. Adm. Code
TATE SANITARY PERMIT
-Attach complete;plans (to the county copy only) for the system, on paper not less than d Z~l
STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application.
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PETITION
FOR VARIANCE ❑ YES ❑ NO
PRO ERTY,OWNER PROPERTY LOCATION
Y"tho %a, S , N, E (or&
PROPERTY OWNER'S MAILING ADD ESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
21
CITY, STATE ZIP CODE PHONE NUMBER 71 CITY : k a$i NEAR T ROAD, LAKE OR LANDMARK
T` ❑ VILLAGE:
~T
y.
II. TYPE OF BUILDING OR USE SERVED: Im. rJ~~ `CQ '10 -OO 0
Number of Bedrooms if 1 or 2 Family_ OR ❑ Public (Specify):
Ill. PURPOSE OF APPLICATION: (Check only one in #1. Check 2,3 or 4, if applicable)
1. a. Z 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. 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. 9 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):
Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total 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 - ❑ ❑
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation a vate s wage system shown on the attached plans.
Plumber'p Name Print): Plu er's Signa re: (No tamps) MP/MPRSW No.: Business Phone Number:
J
Plu er's Addres (Street, C' y, tate, Zip Code): Name of Designe
& 7
VIII. SOIL TEST INFORMATION
Cert' 'ed S it Tester (CST) Name CST
CST' ADD ESS Street, City tate, Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater
Date Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial 0 qi7 Sypharge Fee p
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
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION r
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 syster:,, 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 name and mailing address. Provide the legal description where the system is to be
installed;
ll. 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;
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% 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.
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 a
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that burocd treas<jre
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 nnon;es collected' through these surcharges are credited to the groundwater fund adminis-
tered by he Department of Natural Reso:_.rces. These funds are used for monitoring ground ape,
water, groundwater contamination in< est.gati-ons and establishment of standards. Groundwate,-,
it's worth protecting.
SBD-6398 (8.03/86)
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property Section , T,~ N-R W
Township ~i~ t1C~r~i~J,1
Mailing Address
A)
Address of Site
Subdivision Name Lot Number
i
Previous Owner of Property
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) ce ti6y that att Statement/s on thi-6 bocm ahe tAue to the best o6 my (oun)
knowledge; that I (we) am (ake) the ownex(,s) ob the pnopeAty duch,%bed in thi.6
in6o,mati,on 6on,m, by viAtue o6 a waftanty deed 4ecohded in the 066ice o6 the
County RegisteA o6 Deeds ass Document No. and that I (We) pnesentty
own the phoposed site {on the sewage dis poz system (on I (we) have obtained an
easement, to nun with the above deschi.bed pnopenty, 6o& the convstnucti.on o6 said
ay6tem, and the .same has been duty neconded in the 046ice o6 the County Registeh o6
Deeds, ad Document No.
r
SIGNA(T/[\URE/y F yOWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
V (A ~Jj
DATE SIGNED DATE SIGNED
y H
' z
H
• a
• STC-105 r
r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
ty
~ H
OWNER/BUYER Pj, / 4
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP 44
PROPERTY LOCATION: .x'14, Section, T. N, R_W,
Town ofSt. Croix Count
Subdivision LJLa~'~QC2L'~ 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. H
E
I/WE, the undersigned, have read the above requirements and agree Ln
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.
l'
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 REPORT ON SOIL BORINGS AND Af L 1a, (
IN DIVISION
DUSI:R Y,
7969
LABOR
HUMA ANt+ PT- RCOLATION TESTS (115) MADISON, WI HUMAN RELATIONS , WI 53707
3707
(H63.09(1) & Chapter 145.045)
L 'AT N: / SECTIO % / 4W11 S W/M ICIPALITY: LOT NO.:BLKSUBDIVISION NAME:
T _V11
C NTY: OVVNER'SIBUYER'S NAME: A G ADDRESS:
/ DATES OBSERVATIONS MADE
USE
0. BEDRMS.: COMMERCI S RIPTI0 : r~1 P- ROFIC~DE8JC 'TIONS P I_A I N TESTS: I,
FixIResidence .Q [ANew ❑Replace
Al 4L
RATING: S= Site suitable for system' U- Site unsuitable for system
ONVENTIONAL: MOUND: ?-GROPND-PFESSURE: S STEMIN--FIILLI_ OLDING A . RECO MENDED YSTEM:(optional) EAU DSM
ros ou i ms Eju EIS U ,12
If Percolation Tests are NOT required DE~!GN RI`;TE: If any portion of the tested area is in the 1
un.ler s.Fi..i3.091G;(L1, indiceir: fL r' I Floodplain, indicate Floooplaw elevation:
PROFILE DESCRIPTIONS
r
5 1 BORING TOTA DEPTH T R U D ATER-INCITES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH, ELEVATION OBSERVED EST. H S TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) I
s y I
' .tea
Ile
fir, Sf' {
A6AI
, y:
' j. PERCOLATION TESTS
DEPTH. WATER IN HOLE TEST TIME O WATER L I H S RATE MINUTES
Q, I
TFST
° hIUMBER FPJBfft!>s AFTER SWELLING INTERVAL-MIN. P PER INCH
y~ i fP.-tti 't' : -
A4rAZ
AIX
{ r '
06
s t, M
` akOT PLAtnI: Shd14- locetiona' of perColetlon tZlats, loll bbringt end the dimensions of suitable loll areas, Indicate scale or distances. Describe;what are the hori• i
,~xdrtet and vertiad elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
ttf land slope. a
SYSTEM E~LEVATI N 9T
-
I
G ;
-
t
I
} ` j I
- -
ti
.
l I
1
!C; I 1
~21
A __1
1, the undersigned, hereby certify that the soil tests reported on or Ire made by me In accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the ion of tt~-tel s are correct to the best of my knowledge and belief.
NA rin TESTS WERE COMPLETED ON:
ADD S: CERTIFICATION NUMBER: PHONE NUMBER (optional):
4[
` w
14,
CST; 5NAT RE:
- DISTRIBUTION. Original and one copy to Local Authority, Property Owner and Soil'Tester,
'OILHR-SBD-639518.02/821 -OVER::
A(.
95 Ss
fl~u~ 1~~ sib 40,.T
t; f~i t7~G 'OW
s 7
✓,a~,l~~df fit/
i
1 s' ,
6 /t~<'LrI*y
a~Eref ~ _ -
r
• PAGE OF
a ~
C.roSS See~'lon Ot~ A Ze J t
p ys er" ~
Y-57 Fresh Air Inlets And Observation Pips
1/ ) C-,~-Approved Vent Cop
Minimum 12" Above
` Final Grade
1
20- 42" Above Pipe _ 4" Cost Iron
To Final Grade Vent Pipe
Marsh May Or Synthetic Covering
Min. 2" Aggregate
Over pipe
0161. button
Pipe o 0 --o o - Tea
i
6" Aggregate
! Beneath Pipe o Perforated Pipe Below
o Coupling Terminating At
Bottom Of System
i
' PI`uPo3et~ ina~ gracl<
IrLif-0J Ion I
.
SOIL FILL
DISTRIBUTIOK.) PIPE
APPROVED S4WIETIC COVER
2"oF1~6GR~GATE c " MATER14 OR 9" OF STRAW
OR MARSH HA,13
A
Z G G R E GAT E
V. of 0 F12'2i/
ELE
tk FEES'-,
{
DISTR113UTIO U PIPE TO BE AT LEAST INCHES BELOW ORIGINAL GRADE
ANU AT LEAST20 INCHES BUT 1.10 MORE THAN 42 IAICNES BELOW FINAL GRADE
MAXUr►l1M DEPTH OF EXCAVAT160 FROM OKI&V+aL 6RADR WILL BE INCHES
PUNiMUM 9V "H of E'ACAVAT1®N FRoM 00,1141MAL (,9i4PE WILL BE INCHES
' i
t
f
SIGNEO:
{
I
LICENSE ►UUMBER:
DATE: