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Parcel 020-1163-70-000 12/13/2004 04:42 PM
PAGE 1 OF 1
Alt. Parcel M 7.29.19.954-956 020 - TOWN OF HUDSON
Current XX ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
" JUNCO, WILLIAM D & LINDA K
WILLIAM D & LINDA K JUNCO
1077 RUSCH DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 1077 RUSCH DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.008 Plat: 1929-EDGEWOOD ESTATES
SEC 7 T29N R19W EDGEWOOD ESTATES LOTS Block/Condo Bldg: LOT 24
24, 25, & 26
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
06/18/1998 581305 1333/110 WD
07/23/1997 1087/128 QC
07/23/1997 874/399
07/23/1997 747/239
more...
2004 SUMMARY Bill Fair Market Value: Assessed with:
49027 260,100
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.008 32,200 169,000 201,200 NO
Totals for 2004:
General Property 1.008 32,200 169,000 201,200
Woodland 0.000 0 0
Totals for 2003:
General Property 1.008 32,200 169,000 201,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 305
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
01
pIAL TESTING LABORATORY, INC.
COMMERCIAL
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730 C3:§F kt~
715-962-3121
800 - 962 - 5227
REPORT NO A 04684/01 PAGE 1
ST. CkOIX ZONING
ST. CROIX COUNTY REPORT DATES 5/04/90__.._._..
COURTHOUSE DATE RECEIVE ' 3190
HUDSON, WI 54016
ATTNS THOMAS C. NELSON E 066
OWNERS Brad 6 Shelly Andress 7. 2 lq, q o
LOCATIONS 1077 Rusch Rd., Hudson ~C/y~j~J71Z1~
COLLECTORS M. Jenkins Zy~ ZZ
SOURCE OF SAMPLE! Kitchen faucet
COLIFORM*, 0 /100 ml
INTERPRETATIONS Bacteriologically SAFE
NITRATE-NS 1 ppm
Under 10 ppm is safe for human consumption.
Coliform Bacteria/100 ml
Nitrate-Nitrogen, mg/L
LAB TECHNICIANS Pam Gam
WI Approved Lab No. 19
.OU'\NCEVEOV
~r V
< Means "LESS THAN" Detectable Level Approved by'
® PROFESSIONAL LABORATORY SERVICES SINCE 1952
1-4
r
OIX COUNTY ZONING OFFICE J
ST. CR
St. Croix County Courthouse 3TOAC
911 4th Street . Z~10OUWy
~ ~
Hudson, WI 54016
Telephone - (715)386-4680 he St
~ Croix County Zoning Office offers the service of septic
nd water inspections to Lending Institutions, Realty Firms, and
e<a
rivate individuals.
-s-form is as ty Can be-
.d •
s~t~
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)FEE: $175.00
WATER TESTING
(For VOWS)
SEPTIC SYSTEM INSPECTION-----~---------- FEE: $25.00
(Determines if system is properl functioning at t me of
inspection)
Property owner's name
Property owner's address /0 _S' G h _ N-R
Legal Desc ipt ons_1/4 of the 1/4 of Section ,
Town of Lot Numbera 7Subdivision Nam
RE KtDMIM /6 7-7 ~ PJZ
BOX NUMBER---`
-U= BOX
Color of housef nfita~2, Realty sign by house if so, list firm:
PLEASE INCLUDE, IF A 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 individua requesting services:GA
Telephone Number 9 ~f Gv
U
RE RT TO HE SENT TO C
gneture '
y ~
P
Edina Realty.
Mary M. Narvik
REALTOR®
Mufti-Million Dollar Producer
Bus. (715) 386.8236
Hudson Office Res. (715) 386-2946
700 Second Street T.C. (612) 436.7072
Hudson, WI 54016 ® AKS Q
ST. CROIX COUNTY
WISCONSIN
;Fc i t~ ~ 1tiA .
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
_ z.. _ (715) 386-4680
May 5, 1990
Mary M. Nasvik
Edina Realty
700 2nd St.
Hudson, WI 54016
Dear Ms. Nasvik:
An inspection of the septic system of Brad & Shirley Andress,
located at 1077 Rusch Rd., Edgewood, SE 1/4 of the NE 1/4 of
Section 7, T29N-R19W, Town of Hudson was conducted on May 2,
1990. At the same time I also obtained a water sample for
testing. The results of that test will be sent to you as soon as
we receive it back from the laboratory.
At the time of the inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and
did not involve any 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 is totally dependent upon proper
maintenance of the system.
Should you have any questions regarding this subject, please feel
free to contact this office.
Sincerely,
,
J~
Mary J. enki s
Assistant Zoning Administrator
cj
c
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
. OIKNE`R TOWNSHIP f~Cfur•.,.~K. SEC. TN-R Zfl W
ADDRESS ST. CROIX COUNTY, WISCONSIN
I
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Zd `
' i
3 ~e
j
INDICATE NOIRTH ARROW
t
i
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point:
Proposed slope at site:
SEPTIC TANK: Manufacturer:e Liquid Capacity:
Number of rings used:- Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation: A?'
Number of feet from nearest Road: Front,Q Side o Rear, O "'f &g feet
~
.From nearest property line : Front,0 Side,® Rear, O feet
Number of feet from: well building: /
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
'l SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
A
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: Length: Number of Lines Area Built:.&
Fill depth to top of pipe: y
Number of feet from nearest property line: Front, ® Side, O Rear,0 Ft.1 ~
Number of feet from well:
Number of feet from building: i~
(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:
I
Inspector: -
Dtaed: Plumber on job:
License Number: 9E~
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
MADISON, WI 53707
`PWCONVENTIONAL OALTERNATIVE State Plan I.D. Number:
El Holding Tank D In-Ground Pressure ❑ Mound (1f assigned)
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSPECTION DATE
B & H Development 836 St. Croix St., N. Hudson, WZ _ __04- //,I /1t/
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
SW NW, Section 7, T29N-R19W,Twn. of Hudson, Lot#24, Edgewood Estates
1 /0~ ad
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
William Schumaker 6382 St. Croix 64857
SEPTIC TANK/HOLDING TANK: - 97
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED
11,41 JA /000 6~e DYES ONO DYES ONO
BEDDING: VENT DIA.: Y VENT MA7L: HIGH WATER NUMBER OF ROAD: JPROPERTY WELL: BUILDING: VENT TO FRESH
ALARM FEET FROM LINED / AIR I L T
YES DNO DYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING. LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO OYES ONO OYES ONO
GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) DYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth ofplowing E%OTH 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:
BED/TRENCH WIDTH: LENGTH NO OF IDISTR PIPE SPACING. COVER INSIDE DIA #PITS LIQUID
1,3 JTRENCHEyZ M ERIAL! PIT DEPTH:
DIMENSIONS ~
_ O/` CtAO
GRAVEL DEPTH FILL DEPTH DISTR. PIPE. DISTR PIPE DISTR. PIPE M TERIA L: NO TR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES. ABOVE COVER. ELaa`` E~[~ LET. ELE PIP. FEET FROM LIN/E 5 ~L. AIR L
a~ D 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 O NO meets the criteria for medium sand. TIONS MEASURED.
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 OYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH No OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.: ELEV.. DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: IN UMBFERRO F PROPERTY WELL: BUILDING:
FEET OM LINE:
DYES ONO OYES ONO NEAREST
Sketch System on tain in county file for audit.
Reverse Side.
SI N E: TITLE:
f
DILHR SBD 6710 (R. 01/82)
w~sconsin APPLICATION FOR SANITARY PERMIT
OUNTY
~ D I L H R (PLB 164 64,Z4 --C
- OEPgRTmEnTOF UNIFORM SANITARY PERMIT #
IInDUSTRtO LRBOR 6 MUTgf'I RELRTIDnS e _`/1 F-5, 7
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'%x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
P OPERTY LOCATION q-
G~ 114A1 t,/ 1 /4, S , T: , N, R E (or) TOWN OF':
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
iQ 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify):
THIS PERMIT IS FOR A:
W_ New System ❑ Tank Replacement ❑ Repair
El Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
9 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # ef < issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity ell
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Q 3 / .6- Gl -5'- ZPrivate ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on he attached plans.
Name of Plumber (Print): Signature: /MPRSW No.: Phone Number:
A~i e ZLAA24~ 4 N6 -
(273) S~cF
Plumber's Address: _ Name of Designer:
C~
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee:
Date: ❑ Disapproved
❑ Owner Given Initial
t y ~O Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
f
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 639'8
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
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DLP&R-WNTbF
' REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDIJ.c,"rRY, DIVISION
LABOR AND PERCOLATION TESTS (115) ~AO,so~ WI X3709
HUMAN RELATIONS
(H 911) & Chapter 145.045)
t,o "41'f)ty ST C'fION: O N Y: OT NO.: BLK. NO.: SUBDIVISION NAME-
_5W_ ~l Oll T NCR u o o Z irc*awado a
COUNTY: WNE 's UYER'S AM MAILING ADDHF55:
Ix eat x CX4 "o
USE DATES OBSERVATIONS MA 6E
NO. MERCIAL DESCRIPTION: - A' - TESTS:
IadR,;cidenre 1 1 i New ❑Replace
CO 1+7a ,w« 74--Z
So 11..,S Cup So t L Js ~ ..;rte WS7T
RATING! S= Site suitable for system U= Site unsuitable for system Q 2 Q t.,_ Z~J~ M i A
~ STRU M u S ND: QU IN_G _ S ~u TS ~VL IS TANK: C~ar~M J ~Y' AM (options,) J ' V AL;
N U
If Percolation Tests are NOT required ESSIGN RATE: If any portion of the tested area is in the
under s.1-163.09(5)(b), incifcata~y~~-41-~5~ JI Fioodpiain, indicate FloodPlain elevation:
PROFILE DESCRIPTIONS f~T$ : _A{ZE G-'r2-'~r ~G t t`'J
pptrJ:~ C.KNo~rY-'S
a,a a• t31 S t L, ~ z , &3' S^► i'~1 e:c 5 ~6/ C-r,+e f G ea'
S
B- 0 011 IRE
S,t.T POGK6 TS ' J' S c3' LT. J3 nJ (!Z
g. j ~,o0 ' °>S 4to NONE :J 9,00' 0.80' 43L S; L; 10,70 5" S, L; Z.,?,o' SN is 6 ~ Me~b S;
"Z-0, B N Q1.S w 2
z . So 6,4 M mo S S; 1. tJ a , r_5 r j i-' 4 , :;r)
75., q~.zra , Z, 50, fSnl ME's S ~ fs / 1. 3o' Bev CS ~,jlr t2, 4,7o'
nAi(-r 7S nt eS w
hJ0' LT 8AJ -F5 /Zft`1~ S W~`C j MM IlcstatLuti' n
BlCJ 9,o0' 95s05- NoNe t3,i 114 co S D, 13nJ Also S C'.S re:• 0. 14
090 36,j W:)
S~ Z.QO` C-+Y CS Ca2; 2,30' 8r4 K4mo Sj c Aso' P".J ur/ri
B-
"er PERCOLATION TESTS
Vii"
TEST DEPTH WATER IN HOLE T ST TIME DROP IN WXTER LEVEL-INCHES RATE MINUTES
NUMBER gff*WS AFTERSWELLIN INTERVAL-MIN. PER INCH
P.
°J 5 z 9ia.oZ -c
P. /O z 195-,/7 > < 3 _41 i P w-m
P- T x0Y N.fl 7 +
P-
P.
:'LC f' ,`,.AN. S?oow, locstions of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe 'what are the hor.-
z.ontal 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 ;tope: -
N L_*T 24 Y BmNLN MAVc- IS TOP ,F tR.oN
SYSTEM ELEVATION PISS AT INI t:... caQN~. /vT ?.4 `
ELEY~ Too •v4 aCl
0Q-
76 'P_XCA%/A77qAj/
O TES7' ~ ~EX(ST~'"/N~C7 Sc.bocQ J ~ ` t
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AUDC)N dI
1
i, the undersigned, hereby mortify that the toil tests reported on this form were mape by me in accord w tTi the procedures andmethods specified in a Wisconsin
Administrative Code, and that the data recorded and the location of the tests are cor ct to the best of my knowledge and belief.
_
NAME print : C
JAMES ES~- TS ERE COMPLETED ON: -
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ADORES
CERTIFICATION NUMB
ER: HO E NUMBER Io (optional):
P I
CST ATURE:
i DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. G~
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O..SUX 7969 69, PRIVATE SEWAGE SYSTEMS DIVISION
MADIgON, WI 53707 BUREAU OF PLUMBING
CONVENTIONAL ❑ALTERNATIVE State Plan 1. D. Number:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (Ifaui-ed)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECT N DAZE:
B & H Development 836 St. Croix St., N. Hudson, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: . PT. EV.: CST REF. PT. ELEV.:
SW NW, SeI T29N-R19W, Twn.of Hudson, Lot#24, Edgewood Estates
Name of Plumber: MP/MPRSW No.: Coumy: Sanitary Permit Number:
William Schumaker 6382 St. Croix 58951
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TA OUTLET ELEV.: WARNING LAB LOCKING COVER
PROVIDED:
DYES ❑NO DYES ❑NO
BEDDING: VENTDIA.: VENT MATL.: HIGH WATER NUMBER OF RDA PROPERTY WELL: BU ILDING: (VENT TO FRESH
ALARM FEET FROM LINE: AIR INLET:
DYES ❑NO DYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON ANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ❑NO DYES ❑NO DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR I"LET
PUMP ON AND OFF) DYES ❑NO NEAREST -,1
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (if soil can be rolled into a wire, construction shall cease until
the soil is dry enough to continue.) AIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH NO. OF DISTR PIPE SPACING: COV INSIDE DIA #PITS LIQUID
NCHES. / MATERIAL: PIT DEPTH.
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES. ABOVE COVER. ELEV. INLET. ELEV. END. PIPES FEET FROM
: LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the xture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound syste to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria medium sand. TIONS MEASURED.
DYES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS ]OBSERVATION WELLS.
DYES ❑NO DYES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED: MULCHED.
CENTER. EDGES.
DYES O DYES ONO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BE WIDTH LENGTH NO OF LAT RAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV. . ELEV.: DIA.. ELEV.: PIPES: DIA.:
ELEVATION AND :
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL ERTICAL LIFT CORRESPONDS TO APPROVED
PL NS.
❑Y ❑NO DYES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PR ERTY WELL: BUILDING:
FEET FROM LINE:
❑ YES 1:1 NO ❑ YES ❑ NO NEAREST Ill.
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: DIL
HR SBD 6710 (R. 01/82) T
Wisconsin APPLICATION FOR SANITARY PERMIT -J/-
COUNTY
H R PCB 67
)
DEPRR,rmEnT OF UNIFORM SANITARY PERMIT #
InOU5TR4, LRBOR 6 HUTRrl RELRTIOnS
~8 yS/
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY O NER MAILING ADDRESS
PROPERTY LOCATION CITY:
'"W 114 S , T N, R E (or W OWN
LOT NUMBER BLOCK NUMBE SUBDIVISION NAME NEAREST 'ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
-New System ❑ Tank Replacement ❑ Repair
El Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
V Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity Q
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA [WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
a.I ! , -
S Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: ]mp/MPRSW No.: Phone Number:
r~ (a 7,9)
Plumber's Address: Name of Designer:
Az J.0
R09 S Ac/ ®
COUNTY/DEPARTMENT USE ONLY
Date:
Signature of Issuing Agent: Ei~~
¢ p ❑ Disapproved
~p S ❑ Owner Given Initial
~ ~a4
Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
,
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
APPLICATION FOR SANITARY PERMIT
S T C - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor,("spec
house"), then a second.form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
Owner of Property/ ZL
Location of Property / 3% X34, Section , T N - R W
Township
Mailing Address/
Subdivision Name Lot Number /
Previous Owner of Property Total Size of Parcel 41f
Date Parcel was Created
Are all corners and lot lines identifiable?% Yes No
Is this property being developed for resale (spec house) ? Z1, Yes No
Volume :J and Page Number V % - 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) eehtti,6y that att btatementa on th.ia 6o4m ane tn.u.e to the best o6 my (oun)
knoweedge; that I (we) am (cute) the owneh(b) o6 the ptopenty de6cA bed in th,i,a
in6o4mati,on 6onm, by vi tue o6 a waua.nty deed n Bonded in the 066ice o6 the
County RegiAteA o6 Deeds ab Document No. J q d ; and that I (we)
pneaentey own the pnopoaed .6 to bon the bewage di4po-6-al-4yztem (on I (we) have
obtained an eaAement, to %u.n with the above deben.ibed pnopenty, bon the
conatnuction o6 ea,id bydtem, and the came ha,a been du-0 neeo,%ded in the 066ice
o6 the County Reg.c.aten o6 Deeda, as Document No.
SIGNATURE OF OWN"11 SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
• z
• - y
STC - 105 r
r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
tv
1 9
OWNER/BUYER
ROUTE/BOX NUMBERS Fire Number
CITY/STATE SILL ZIP
PROPERTY LOCATION:,, js✓ 14, ! ~i14, Section T Jj N, R W,
Town of
~d~/'~•,~i St. Croix County,
Subdivision 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
0
• E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin. Depart- b
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED
DATE
ms!
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.
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Ilf l'V1►ITft91 N1 OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INf)t)STFTY,. DIVISION
Q13 AtVD : * PERCOLATION TESTS 115) MADISOP.O. BOX 76
HOMAN RELATIONS
HGM
N WI 3707
(HQ,P90) & Chapter 145.045)
LOr,niiCiN - - SECTION: OWNSY: OT NO.: BLK. NO.: SUBDIVISION NAME:
'/aft Tz N/R /w oeo AS a :o
COUNTY; WNER'S U ER'S NAME: MAI LING AD OR S:
USE DATES OBSERVATIONS MA E
1BEDRW: COMMERCIAL DESR PTION: PROF LE DE IPTIONS
STS:
4" F~ N
ew Replace dr
Kill-7 n
- - V
1
RATING: S= Site suitable for system U= Site unsuitable for system 0~ N Cz.
~O'dV~TlO~NAL: MOUND: o~ IN-OR ~ a~ E:SYST M-INQ-FILLHO~L~pINGTANK: ~~NI~NDSYSTEM: `(optional)
S S U S U ? 0, 62 J~,
If Perrulauon 'Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
- r ~r c s , i _
under s.H63.09(5)Ib) indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS NOTE-, APLE GR IO -0-
' rdor N ei C.KtioE Pt T'S
BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTF# [so, ELEVATION OBSERVED HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
13. j, . I•oo b 8^j SIC. w 6+A•' 2,60' LT, 11-j.MEC S S•Sa
C--'Y e-w GP
J-0 1 „ol PAL Si LJP Z.401 6r.! Migb S r`r FS; 6100' 6
B_Z x.90' y5, 77 NO w Es,e, roa
7. 03 N 0n/'E 7 ¢v 2•00 ' L T.'L3 fC. >j M LKO 6 < grAo% ptott:+7oNy BN YNan
B •Z0' RoB.a t.5;.70'b-4MM S 4CS w/4IL;.40'-ft,o I& -,j Mt'D L,.S~
6 .,r C5 w t2 • 2,10 e,,j rK a I>
B- 4 T_sS' 9-5-.3:5'- O N t=_ > 7• s ~S- 0,50' S I L: l ,so' 2c Bnl i.5 w t5. ~ • oe ' 8nr M u
B - ~w },oa' I~a 1.00' LT. 14w ~Mru S 0.601k4
n S w ~R.• I. 6o' Ga w R xn'6
6 PERCOLATION TESTS
fFtiT r*PTH WATER IN HOLF. i FST TIME DROP AT ER V H RATE MINUT S
NL1MHF.R.'Pic'llFS AF-FERSV•rELLING INl_Efi_VAL-MIN. - 14Q -p1Y~ PER INCH
94,00 X; 3
•c
L_IE
:'LOT "'LAN: S%ovf locations of percoation soil borings and the dimension: of suitable soil areas. Indicate scale or distances. Describe what are the hor:-
:owal 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 :.lope.
ht o It T H t I NE - -'a C44 MprP~.Nc- + ro P ox I;..o nr
SYSTEM ELEVATION 93.00 Z4 Plae AT rat e_ajL- CZ,l..•ar w
_ E.L. E V. /00-00
IJ
s
_ rl
0 Nt P_crat_ATIO.J l EST pU t Tn axLAVA?)ON I I ~
E-Xlr7it,)6 Lee
i'f4pE I
I S A :_Y~10ST ~ % ~ t ~
~ aJ
TN
+
ELEV. 93,00
.YL.id y. Qy~1k:4°yaRXpUE • ~ l_~~ f 1 f
_ 9 G
V, W t
i06..f Vl
.rlt ~y W./...mar r~ • i ~J 2
Ilk
as)
13
tr. / o l -F 1~
HUDSON 0- . u1
I, the undersiclned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wigcon:in
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. i
NAME (prtr•,t) TESTS WERE COMPLETED ON:
ADDRESS
~ CERTIFICATION NUMBER. PHONETJUMBF.R(nptional):
CST_SIGNATURE-
f,.
DISTRIBUTION: Onnlnal and one copy to Local Authotity, Property Owner and Soil Tester.
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