HomeMy WebLinkAbout161-1060-70-000
o cn o r. -0 n C7
o co
o m F c ' 0
F
~ Q
z C) -4 CO <
7 y m c p
3 co
m 3' o CD J M.
cn m
Q Z Q_ N Cn CC CD O
' 7 W 7 O O O O
Nfl-= o N o O
ZN O
O 0 7 Q CD O O
° C CD n = 2 O
Ul 3 :3- CD
N 2 O O
c c p
P. w i o H,
U) CD D C s
(p N
N W a n
O P) G iv d (D
a
C cn H - ~ o X
3 O s
l~
~ ((DD ~ rtt n CD ^ ° j a
Z
N• co cD 0, 'i o r Cn
O w n 00 =7- N cnn L I o c
Sy O d c
-0 -0 m CA
Z Z O O O 0
~
En N -V
cD Vi F- rt o ~o N N li O 3
r- CD
0" I3 C)o cp
v v C_n .1 N cZ2
0 v CD
Z CD (D CD Q
~ ~ ~ N C H
L ' C3D III N
7
r o
CD a = ` ~1
d N z 00 O
Ul a 7
m
r~ Ul 3 CD CD
•
N
C H cn v N
j N• N L~J c C
CD D CD
00 ~ a
St I n ~ ~
47 O N Z (n A Z
i-h O C/) N Oc
(D n Q A Z O
P~ Z C) v O
c1 rt
w x o :D
G W -0 m w
CD m Z
UJ ?
0 -r- 0 ;w y Z
o m o
CD
W
ID
O CL
7 CL
CD T
d O7 C
7
o z a
o 0
'o CD
CD N
s I
CL
CD
CD
v
7 s
O
C
o w
m D ti
o
_ ON
o
A
o
= A O
Di O
W
r~ O 00
O (D c b
s.
Parcel 161-1060-70-000 06/23/2006 03:51 PM
PAGE 1 OF 1
Alt. Parcel 13.29.20.526H 161 - VILLAGE OF NORTH 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 - SPRINGER, DON C
DON C SPRINGER
1531 INDUSTRIAL RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 711 GALAHAD RD N
SC 2611 SCH D OF HUDSON Ci~ ~Q~ ~j,(s~f(~
SP 1700 WITC CC
Legal Description: Acres: 0.000 Plat: 0055-VIL OF N H ASSESSORS PLAT
N 100' OF S 920' OF OL 85 AS DESC IN VOL Block/Condo Bldg:
573 PAGE 324 VIL NH
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
13-29N-20W
Notes: / Parcel History:
3 Date Doc # - V0VPage, Type
JJ 07/23/1997 723/357 )
~y~l3z
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/20/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 331,500 316,100 647,600 NO
Totals for 2006:
General Property 0.000 331,500 316,100 647,600
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 331,500 316,100 647,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 114
Specials:
User Special Code Category Amount
SIC ~ ~
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 161-2065-70-000 06/23/2006 03:53 PM
PAGE 1 OF 1
Alt. Parcel 13.29.20.2161 161 - VILLAGE OF NORTH 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
DON C SPRINGER O - SPRINGER, DON C
PO BOX 448
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 202 GALAHAD PL N
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 06/67-GALAHAD LANDING 1996
SEC 13 T29N R20W PT OL 86 LOT 7 GALAHAD Block/Condo Bldg:
LANDING 202 GALAHAD PL OR 706 GALAHAD RD
N Tract(s): (Sec-Twn-Rng 401/4 1601/4)
13-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1200/91 WD
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/23/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 80,000 0 80,000 NO
Totals for 2006:
General Property 0.000 80,000 0 80,000
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 80,000 0 80,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00
0.00
Parcel 161-2065-10-000 06/23/2006 03:53 PM
PAGE 1 OF 1
Alt. Parcel 13.29.20.2155 161 - VILLAGE OF NORTH 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
DON C SPRINGER O - SPRINGER, DON C
PO BOX 448
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 203 GALAHAD PL N OR 712
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 06/67-GALAHAD LANDING 1996
SEC 13 T29N R20W PT OL 88&86 LOT 1 Block/Condo Bldg:
GALAHAD LANDING 203 GALAHAD PL OR 712
GALAHAD RD N Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
13-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/31/1997 567738 1273/501 WD
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/23/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 96,000 0 96,000 NO
Totals for 2006:
General Property 0.000 96,000 0 96,000
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 96,000 0 96,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
t
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
- -T-OWNgHIg SEC. T N-R W
ADDRESS C!,
= ✓ ST. CROIX COUNTY, WISCONSIN
1985
Ux
SUBDIVISION LOT - LOT SIZE
i
PLAN VIEW;
Distances and dimensions to meet requirements of ILH,R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3~,
I
i
Imo. ,
~ I' 13~ ~ ~ LASr ~oPLi,sY
G/JRA GE - i -6-A ~ /
I
I
/ahICSNG /an~A ~
S9 3~ a
-rro f J C 6
- S -
-WrAi-) STACit G/JL.dI✓Ar
RIO /el"
V1~G~ CC
f
Ortz„a wAy
/3.I'~, =f l✓ ~/ZOP~rtrY Jo.+7N Z=,r
Co/ZNt2 ~p~ /=L V_ =11~b -
a
INDICATE NORTH ARROW
/VC .('CAL L
BENCHMARK: Describe the vertical reference point used
r
Elevation of vertical reference point: Proposed slope at site:_
SEPTIC TANK: Manufacturer: ~F Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side,O Rear,
feet
.From nearest property line : Front, 0Side ,0Rear, 0 '9,9 feet
Number of feet from: well
building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
f
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:
C 1
Width: Length: Number of Lines: Area Built: Uf)
Fill depth to top of pipe:
Number of feet from nearest property line: Front, (2) Side, O Rear,0 Ft .2L-
Number of feet from well:
t~
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, O Ft.
Number of feet from well: _
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
G
Plumber on job:
Dated: License Number: 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
CONVENTIONAL ❑ALTERNATIVE state PlanLD N mbe,.
~ Ilf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE. r
Don Springer 721 St. Croix Street, Hudson, WI 54016 - / 1 5 - mil /~J
BENCH MARK (Permanent ref--ce point) DESCRIBE IF DIFFERENT FROM PLAN R F. PT. ELEV.: CST HEF PT. ELEV
SE NE, Section 14, T29N-R20W, Village of N. Hudson
Name M Pl-E- jMP/MPRSW N,, C,i ii t San ary Permit N-h,,
Gar Za a 3300 St. Croix 74975
SEPTIC TANK/HOLDING TANK:
IMANU FAC TURER. • LIOJID CAPACITY TANK INLET /T, LANK OU7;1,; TE~ WARNING LABEL LOCKING COVER
47 PRGVIDE D. PROVIDED
"r ES ❑NO ❑YES O
BEDDING- VENT CIA VENTM 'i H WATER ~MB ROF ROAD PROPERIV WELL BUILDING TO FRESH
' r C ALAHM1I I / LINE f r~ ~ / IAVIENT
FEET FROM
❑YES O ❑YE a N NEAREST-
-
DOSING CH BER:
M A N U F ACT Li R FH BEDDING IT IIAU I[) CAPA(:I T, PUMP MI)1)F L "W,'iP Sli'l il)h VANU( AI HHE H RNING LABEL LOCKING COVER
OVIDED PROVIDED
❑YES ❑NO ,YES ❑NO L_ ❑NO
YES
HOP 4 WELL BUILDING VENT TO FRESH
GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL NUMBER OF !
qL1+T J I
AIR INLET
(DIFFERENCE BETWEEN FEET FROM/
PUMP ON AND OFF) YES ❑NO _ NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing nn+l a ATI HIAL ANU to KIN(,
or excavation. Of soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue) MAIN
CONVENTIONAL SYSTEM:
WIDTH JLENGTH 1N() or UISiH PIVt .PACT^.(. COVER PSI,JF UTA -PITS LIQUID
BED/TRENCH to THENL151 ITEHIII PIT DEPTH
DIMENSIONS 0 4 tt
GRAVEL DEPTH FILL DEPTH DIST fi IPF DISTH PIPE DISTR. PIPE MATERIAL NO DI' H NUMBER OF PR OP ER TV WELL BUILDING VENT TO FRESH
BFLnwPIPES ! AeovcovER EIEV "II I _ OINI PIPES FEET FROM uNF AIR-INLET
~-j ~j
r ( NEAREST- / - t"► -J
MOUND
M 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.
YES ❑NO
SOIL COVER TEXTURE PI IintnNl NT MARKERS jC1I11E1\/ATI0NV4iLLS
DYES ❑NO _❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER 7H.FNCH HF f) TH Of if)PS~)IL St 'I)Pf O SEE UFII
MULCHED
J
!:ENTER EDGES
I❑YES. L1N0 ❑YES C_!NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LAT EaAt SPACING GRAVEL IT PT Ei HFL()W PII'I FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MAN( OL. PUMP MANIFOLD DISTR PIPE MANIFOLD MATE HIAL NO UISTH I:ISTH PIPE DISTHIBU710N PIPE MATERIAL & MARKING
ELEVATION AND FLFV ELEV. PIA ELEV PIPES [)IA
DISTRIBUTION
INFORMATION " zE oLESPncNG n LLDC01HFCllV coVEHMATEHIAL VERTICAL IF rcoRRESPONDS TO APPROVED
PL nnls
❑ ES ❑NO ❑YES ❑NO
COMMENTS: RMANENT MARKERS OBSERVATION WELLS NUMBER OF PROPERTY WELL BUILDING
FEET FROM LINE
❑YES ❑ ❑YES C_1 NO NEAREST
~ P
Sketch System on _ Retain in county file for audit.
Reverse Side.
ti
SIGNATURE TITLE nL''
DILHR SBD 6710 (R. 01/82) el v
Wisconsin APPLICATION FOR SANITARY PERMIT
COUNTY
DILHR
1111(~~ OEPRRTTEnT OF
(PLB 67) UNIFORM SANITARY PERMIT #
~ InOUSTRY, LRBOR 6 HUTRn RELRTIOns ~ ~ ? /~S-
-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 OWNER MAILING ADDRESS
PROPERTY LOCATION.;
VILLAGE:
S-9 1/4 /NE 1/4, S J , T2 , N, R ~,O E (or )(D /vo~TfJ .Po
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
? Liv
TYPE OF BUILDING OR USE SERVED
0 1 or 2 Family Number of Bedrooms:, ❑ Public (Specify):
THIS PERMIT IS FOR A:
N New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
® Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny Tank
l System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued -
El 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 \ Ef
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: L,,/_T_ on,
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 (SScuare Feet):
z /Q 0 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: /MPRSW No.: Phone Number:
o 0 (fir ).?d peso
Plumber' Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
' ❑ Owner Given Initial
die,/ /A~ 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 Q,y
Location of Property 4 -4, Section, T N - R Z4 W
Township +
Mailing Address
Subdivision Name /t/, A
~zv~' ~s
,rte
ell
Lot Number
Previous Owner of Property i3yy'S ~~W7'42F Zq
Total Size of Parcel t 7
74
Date Parcel was Created
Are all corners and lot lines identifiable? c/ Yes No
Is this property being developed for resale (spec house) ? Yes No
S ~J
Volume and Page Number .,sag,_ as recorded w'th the Register of Deeds
X57
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
I (We) eeAti6y that aU atatements on the 6otm ane VLue to the best o6 my (ould
knowtedge; that I (we) am (aAe) the owneh(,s) ob the pnopoity dacAibed in this
Cnsorcmation Ao cm, by vi4t:ue, ob a waiiAanty deed neconded in the 06{ice ob the
County RegisteA o~ Deeds u Document No. zo &v 2a and that 1 (we)
pneseyWy own the proposed bite {ion the 6ewage dispoba 6y6tem (oA 1 (we) have
obtained an easement, to nun with the above dmcAibed pnopeAty, bon the
co"thucti.on o6 4aid /s ystem, and the same has been duty neconded in the 066ice
o6 to County Register o6 Deeds, a~5 Document No. _ -i,2- es
u
Ace
SIGNATURE OF OWNS SIC ATURE OF 0-OWNE IF APPLICABLE)
07
x Q 2-3 /OS
DATE SIGNED DATE SIGNED
I~
H
y
S T C - 105 r
r
SEP'T'IC TANK MAINTENANCE AGREEMENT ry
St. Croix County /Oz--
OWNER/BUYER~1~
rn
ROUTE/BOX NUMBER Fire Number_
C I T Y/ S T A T E
_ L 1 P Spa r~
PROPER'T'Y LOCATION: 4, Section, T Z N, R
Town of St. Croiy, 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 seJ~tic tank pumper. What you put into
the system can affect the function of the septic rank Lis a Lreat - ~
ment stage in the waste disposal system.
St. Croix County residents m~41 be t,Ifgi1)1e to receive a y,raI It Iur
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
0
I/WE, the undersigned, have read the above requirements and agree
cn
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County 'Lon Office within„30 days
of the three year expiration date. ,
SIGNED
DATE_
---L~ ~/-S/ - -
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.
v
iv ? N y N
00 3 O
N m O m n n 'CD j cm 3 ;3
~ r N
z =r c 3 ro om
cmm-"o-
m m a n p- CD ~ (D
4 f mCD ° 7r ~ W p~ i
w w cD ' m cn N Q
(D CD (gyp (D N
o 3 a
o~°~fDw
om con~oC°
:3 = Err > o
o c l c c m
Z~ co l< a, 3 6* 0
~ o
0
C: =r
:3 CD
CD w OD -0 -0
< m m Wa-
o
o ° CD
o 0 3 o D
c ? O a =
a w (MD O a Q 7 0
°
~m NON ~cDw~MZ
m ° CD
w =r m o -►n m
am0 3omm~a a a
mCCDD oE; ° m
tea= -w A = a
a m~?aco
a c
0 CD
CO CD 0 ic
CD cr 0)
° -~a N.o ~ a
a w m
4 u o m oco O' m
ui
91) 0 vi °a of WC:cc~w CL 0)
w m w aaam (4 ° fl1
a m a
c G) CO lc<r s m ti
M. U) 0 G) CD 3
m n C ° v, . n m o
a o :3 o cp a c cD v s
a c
4q OL
ro a 3 0 o 0 3 m
w am 'o~ vl3
CD U) 3 a O0
1R z
o
c
INDUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
LABOR AND P.O. BOX 7969
PERCOLATION TESTS (115) DIVISION
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045) MADISON, WI 53707
All 3707
/4). /00 ' S. 9-2 D O/L P .S. o
LOCATION AME:
: SECTION: T6bVfd3fiIAUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION N
S~ ~4 '/4 /T'q N/R20 E (o Nom NupS.7N cc~s 's!' ~i. vo/ 5 3, r~'. 3i y
CsyNTY: OWNER'S/BUYER'S NAME MAILING ADDRESS:
S `l 0 r JC i~~ T PI r 7D-) S4. ll /',y S'T • Mo R d~ ~I UD s'o ~J w i'S
USE i_` •
DATES OBSERVATIONS MADE
NO. BE RMS.: EREI1,^ L C PROF] - DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 /New ❑Replace
(l/ fi S l .~-d~s
J
RATING: S= Site suitable for system ~1}~.Site u 't~ble f tyst
CONVENTIONAL: MOUND: =GiOUND RESSURE: S M-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
MS ❑u zS ❑u ~ ❑u , S ®u ❑S au 6uuEA-)Tt;0,l 4R- s~-
If Percolation Tests are NOT required DESI
C G~SS ~ [Ffloodplain, any portion of the tested area is in the
under s.H63.09(5)(b), indicate: indicate Floodplain elevation:
PROFILE DESCRIPTIONS iN 17ECiNtv?S F~~T.
BORING TOTAL DEPTH TO GROUNDWATER-INS " CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
S/ .O .u.
/ Sr t7 N
B 5 r /pO.L~~ ~i1~~ ' /.33 a
r
B 2- P. S /00.16 - 5• " /1 10 1 Al 8N. N- N.
44 6: le . w~ Celr
B- J 7 /oo yo " P TO S , 3 3 ,
C S 16t4
S w co (r 5 ''ice - a,, cs 3 iQ • w e-p-& Z s s
B-5 33
s G- w i d~ cvfr .
13-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IN F7. AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ ( 7r~_ e Z " DiPiti'UE
P-
P- Z Z !P
P-
zz:
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 ELEVATIO ~0 ? ° = 9 . p • aE~r • ~P~F Pr .'s To~ ~ All
oA,3 (acv F ,gloomy Sa• to? Al
No. Gor L • C Ff/?R)/ L,3~1~/w(r /~~tiNk E [,L f . = /DO, p fr.
~Jc Si TES 3 ~y •..p So . ~Tf -
x~
1 [ SYS>fM 7`o
" D
l3 - I31- J33 I. / oo
I Sp' ~j Zs SD b iDE 13
J) Icy 1 S A TERN. AJeE r 3
;'Thsest Site APPA0 w
i s canrrentionat septic system. S'O ' 13s
30,
30'
I t
. r
~i
R•M ,
V• R~ ~ So. 1. 0r I- ;N ~
E. p
~1 ~ l~ARo~~ 2. ~~•ti.~,e~~ . ~ 'tom,; is~~-, ~1~~ .
I, the undersigned, hereby certify that the soil tests reported on this form were made by me 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.
NAME (print): TESTS WERE COMPLETED ON:
HOMESITE SEPTIC PLUMBING CO. I2 / J~f~s~e_
ADDRESS: ROBERT ULBRICHT iCERTIFic$KTION NUMBER: PHONE NUMBER (optional):
WIS. MASTER PLU I NO 3,10711111l S s _0) 3 P 6- fle S
MINN. INSTALLER & DESIGNER LIC. NO. D0663 CST SIGNATURE
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
,Ji A H ,,VU f uT n; cO !)E ` O0 O' n, 0
`:'1F.
A L C i'w L : C€3~E,~~S?1 accurate'/ loi i,'-ny ci,,)=
~i
,t :01 ,"Vn, and 11e p Ein
.P..'{ ~a ~,f
7i[ , w tu, fi. ;fit-. ~ , _
over 3,1 i
~ s
3ai 3
Chi si~Li b"€ra .._e 3
L i{a-;
LE+
S 1~.1 C.{'sFi~
iXIAI~ d
I
a x°10 pin CZo _s
1
VSLZ,CG~ 0l= /V.~✓u4C~..~
ST Clzcr_£-C , Co.
1
J
r ~
rk&-iL 13LDC S'twE& Ls~e i
U>-b_'~zQ/CIVt waY
GA R A G E To a)-" 2htiPWLATE/J
H~ / -/dU 0 6AL SEPTIC SLopL
0~ 7/o~vlC _
{
ALT. I
6 6 36 AAJ~A
/C1=SZ~kNGL-' ~
kJCZN(~ A VFti~ STACIE
ArLEA
~-30 Id,
/.,)O rcA
ea
yo
~nvaosE~ ~iL-~ ~S
/sv
'o/Tor'.E'R7 Y Con,,,,E/L niP6 T6uT/.! PnopEnTy t=NE GALAIJA~ 2D i2ZGl rT
FLV.= JDo.oc, 0l IvA`/
_ n -y-- I
Sax 1 7umr,& Q
/~n[~z7 UL13rL-IGx7
~~--iC?PP.riDVED vFrv CAP
!S/LS✓rn JZ SSGn ED
FS NA G/%A/
L.ZC Fn.tC~
C~A-rF 10_/
~Axx, urn JJ
T I~e=NA L 6nADE
/ /AlU.4 IA-1 b>ZSyJcv~Th_l-nc CD,.EruNG
/ lTla oC r' Aacn EGr9-1
L>v r_-/L IOYpE
0='rr X13a72o-~
P=PE 0 0 0 0 0 0 F- T
r1~~A7~N a~~ rJ o
3---YT-r- A(L b-TL /~GGnEG.~7TE
T o/ o /~R~~apTD /zPE ~flv.•
~P.~ o
CooA zrvL~ /t2mI~vFTZ, G faT
/I T7urh OF
f Y! t /n
ntn0 3vn d r_
r Q m
m = 0"1 3
a) CD
CDi
n
3
to
ID 7 O (o (p -4 N d N ICI
CL fD Z d N W N (OD
Zl CD - n
M N d N 3 to 0. 0 0 v
H 11 a\o
0) > p_ CD 0
m (D (D (fl (D (n G (D 0
N W -V
3 d = ~ 0 -
c 0
0 O V
z CD (O ~ n o c
o ccnn (°Dn a
Z O O O
v a N N Vi N rn m
v v v v i W o
N r
(D
0 -
C N W CD
d N
Z z
z W z _
O a`J~ c
N
0 m
E a N li vU
d v CD CD
W 3 W
n CD
CD (n
Z (o z z m (D
CD- A z j
1
a) v NJ W_ LI)
CL z W J
0 3 A
CN
N .n C ~J
(CD
W ~
ID
CL C
V V 0 T~ v
0 a i. 1
N
~v
a,
a
11
kj~
Nr'
OO
a
0 A
b
v
dQ
O O tA ~v.
ti V
O (D
yby J~ /
O L "i
0 cn 0 -0 0 d _1
1
~o
0 0 m w 0 o CO c = w 0)
~C
m
~ 3 o c 4D m m m i.)
a z a m N w CO
ID CD O
~ CD o o
a v Z cn
cn 3 °o
O
v a o O
v C w a ~
m n (n a m i
m c
3 a
0 = c°
3 o
"ftooK
L J A CD N
z co co = 0 ~ C
c00n v~
a ~ ty
o Z v v v z Nh.
0
17
~I v a 3 v v v 0 0'
CD
co
c R ° v m v m
O
cn n
m -1, a
H TJ TJ CD
CL rn D
v oz `v
W z co z O
D a m N
'Zi n fTl 0 (n N
F rn x -a (n
H (D N
CD ~ V4
N ci ' W a
trJ rv a 3 _
P Z Z N
C7 ~ I O 0 I A ZCD
oc, ~ c I ~ A
w ° a A G)
i r- r- cc cn a•
a m C.0
z
00 ? . o 1 3
o z O A
~n 3 ; o
0 .
b z 3
C7 IV
C Q~ W 0
CL
A W t~ z 3
a C
7J O. _
N ~ C
O - ~
z o
c~ m
I i
' z
i A
ft
m
w
N
O
O
ON
A
0 b
CD bQ O
ti
en 0
O S* ~
O N a
O L a
Parcel 161-1060-70-000 06/23/2006 11:08 AM
PAGE 1 OF 1
Alt. Parcel 13.29.20.526H 161 - VILLAGE OF NORTH 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 - SPRINGER, DON C
DON C SPRINGER
1531 INDUSTRIAL RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 711 GALAHAD RD N
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 0055-VIL OF N H ASSESSORS PLAT
N 100' OF S 920' OF OL 85 AS DESC IN VOL Block/Condo Bldg:
573 PAGE 324 VIL NH
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
13-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 723/357
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/20/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 331,500 316,100 647,600 NO
Totals for 2006:
General Property 0.000 331,500 316,100 647,6000
Woodland 0.000 0
Totals for 2005:
General Property 0.000 331,500 316,100 647,6000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 114
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
00
Total 0.00 0.00
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNERJA`i w..". Ctacr"c *=u~sra~t ~i TOWNSHIP kmosc:r- t SEC. T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•LHR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
N U
B~ , W~ st.
d
s
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used l~~TaLr~~ a ~s~ cst~ ~z Pve_~N
Elevation of vertical reference point: 1(~ Proposed slope at site:
Liquid Capacity: 13()0 4LALtt) "
SEPTIC TANK: Manufacturer:
Number of rings used: Q Tank manhole cover elevation: q4•/ o
Tank Inlet Elevation: q3-40 Tank Outlet Elevation: 5 r`!!-
Number of feet from nearest Road: Front,O Side 0 Rear, 1^ feet
From nearest property line Front,O Side,O Rear, ® feet
Number of feet from: well N Q , building: is 4-d.
(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: PAX $,j Trench:
Width: i ~~..~as ~ » ze
Length: 5.3- a Number of Lines: Area Built: 7$
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,O Pt.
Number of feet from well: ~i1q
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, 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,OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
[4YCONVENTIONAL ❑ALTERNATIVE ST ate PIao I.D. Number:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound ula-gr,ed)
NAME OF hERMIT HOLDER. - lr
ADDRESS OF PERMIT HOLDER INSPECTION DATE
MU. Eugene G"ta6san 711 Galahad Rd., N. Hudson, W1 54016
BENCH MARK (Permanent re tence poinrl DESCRIBE IF DIFFE T FR
REF. P7. ELEV. : CST HEE PT. ELEV
Section 14, T29N-R20W, Vi .06 N. Hudson, Lot I-6, Uk 2-3,Plat a6
N.iine of Plumber
MP'MPHSW N,, T~Cuix --.ate:5td~e NumberPaul Cudd 2739 69673
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY TANK INLET ELEV TANK OUTLET ELEV WARNING LABEL LOCKING COVER
C~'d' PROVIDED PROVIDED
BIDDING ~Tp ❑YES ❑NO ❑YES ❑NO
ENT MAll GH W ATER BER OF RROPERTY WELL BUILDING TO FRESH
ALARM NE
YES FEET FROM - IAVIERNITNLET
CiYES L ~NO NEAREST DOSING CHAMBER: -
~MANUFACTURER BEDDING LIOUID CAPACI TV PUMP M(1DEI
FJ ".~P. SI Pl~c)N MANLIE i.r:l OF{E H WARNING LABEL LOCKING COVER
❑YES ❑NO PROVIDED PROVIDeo
GALLONS PER CYCLE: PUMP AND covrHOLS OPERATIONAL ~ ~ YES ❑ NO YES ❑ NO
(DIFFERENCE BETWEEN NUMBER OF Pfi)PERrv wELL BUILDINa~vENTTOFRESH
FEET FROM "F AIR INLET
PUMP ON AND OFF) ❑YES DNOLF _ NEAREST-~
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing
or excavation, (if soil can be rolled into a wire, construction shall cease until RCETE^.1AT1RAL AND MAHKIN(l
the soil is dry enough to continue.) IN
CONVENTIONAL SYSTEM: -
wIDTH LENGTH D
NrT r1F
BED/TRENCH ID it =IF- ,P,V.Inr o~-FH LIQUID
,n;t nIn =Firs
TRFN.~+FS ;tn IL. QUID
DIMENSIONS TEH
U PIT DEPTH
F'1VE L. DEPTk1 FILL DEPTH DISTR PIP( DISTR PIPF DISTR PIPE MATERIAL NO UIST Il NUMBER OF WELL BUILDING
FLOVJ PIPES ABOVE COVER EIFV INLET ELEV ENU PROPERTY
VENT TO FRESH
SH
PIf ES FEET FROM LINE AIR INLET
r c
NEAREST-i..
MOUND SYSTEM:
Mound site plowed perpendicular to slope
and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑YES ❑ NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TLxTURE -
Pf ItMANFNT NIAHIFHS OIiSEFIVATION WELLS
DEPTH OVER THENCH RED DEPTH OVF R THE NCH HEU YES ❑NO EYES ❑NO
CENTER DE PTH OF i/)PS(11L S(TI)DEI> SFE DEI)
EDC~ ,ES ti1ULCHED
OYES LINO ❑YES ENO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH wlDn+ EN n+ TNRoENofCHES LATEHALSCnaNG, (;RAVEL DEPTH 3eiwPlNf FILL DEPTH Aeove covEH
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIF OLf) MATERIAL
EIEv EL EV DIn NO DI STH L'ISTR PIPE UISTH IBU.ION PIPE MAT EHIAL $ MARKING
ELEVATION AND ELEV PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING, DO LLLD CoHHecTI Y
COVER MAT EH IAL VERTICAL L IF T CORRESPONDS TO APPROVED
PLAn'S
COMMENTS: PERMAVENTMARKERSDYES ❑NO ❑YES ❑NO
OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING.
FEET FROM LINE'
❑YES ❑NO ❑YES ❑NO NEAREST-
1
Sketch System on ~
>
Reverse Side. Retain in county file for audit.
SIGNATURE FTF
DILHR SBD 6710 (R. 01/82)
wls4onsln APPLICATION FOR SANITARY PERMIT
DILHR 2t.
67 Croix COUNTY
OEPggTTEnT OF
I(PLB n OUSTRy, LABOR 6 Humgn RELRTIOnS
UNIFORM SANITARY PERMIT #
/6 / 1,
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER
:r s • u-ene Gustafson MAILING ADDRESS
rPROP;EERR:TY LOCATION 1 711 Galahad R d . , N O . Hudson , c~ i 54016
4 1/4, S4
T 29N, R 2 0E It 0 W VILLAGE: j or. t.h iiudson
MBER BLO NUMBER SUBDIVISION NAME X~F.
NEAREST ROAD, LAKE OR LANDMARK
STATE PLAN I.D. NUMBER
Plat of Lakeside r
TYPE OF BUILDING OR USE SERVED
E2 1 or 2 Family Number of Bedrooms.
❑
Public (Specify):
T=AAlteernnaatee Elk orption System _J❑ Tank Replacement ❑ Repair
I Revision F-1 Privy
Reconnection El Petition for Modi fication
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
FX1 Seepaye Bed ED Seepage Trench
System -In - Fill ❑ Seepage Pit ❑ Holding Tank
❑ In-Ground Pressure ❑ Vault Privy
❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit #
El An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. issued
Total # of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass
Septic Tank Capacity Plastic
lOn0 L r
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: a Leser L .---cr'eue Products
" IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound
❑ In-Ground Pressure
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): ABSORPTION AREA WATER SUPPLY:
PROPOS ED~ (Square Feet):
Vi~..I,sS 2 945 ;75/,
H' ® 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):
R Signatur .
maul R . Cudd P/MPRSW No.: Phone Number:
Plumber's Address: l _1 -,;;2'739 (715) X25-204
t R. 5, BOX -River Name of Designer:
364, labs, ,I 54022
~ tirthur ;rde _ erer 6
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent:
Fee: Date:
J ` ~ ❑ Disapproved
IJ ~Jy~~.~ ❑ Owner Given Initial
Reason for Disapproval: Approved Adverse Determination
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
1
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
Snecessary t to of W scoly every 2 to 3 years. If you have questions concerning
must be properly maintained. Have a licensed pumper clean your septic tank whenever
your system, contact your local code administrator or the Bureau of Plumbing,
G ,Per of Property tt l
Location. of Property __4 Section N K Z, W
.:F-e » z-S-I i p G Cnce Xey-v(7/, Z e
c_iin A ddress
e- j t
~ubdivisior. ?game
Lot Number r-
Previous Owner of Property l/?-.R,. i' /k/,
Total Size of Parcel > < l?
Date Parcel V.as Created
Are all corners identifiable? Yes No
Include with this application one of the follokin~!:
.Certified Survey Map
.Deed
.Land Contract, or
.Other I:egal Document which describes the property
PROPERTY OWNER CERTIFICATION
Vve) certify that all statements on this form are true to the best of my (our)
a.nowiedqe; that I (we) am (are) the owner(s) of the property described in this
inforrnation form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. -2,15/9 ; and that I (we)
p-esently own the proposed site for the savage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No._____
SIGNATURE (0) C;iNER SiaNATuRE of CDOwNEK (IF APPLICAaL-E)
/tea/~', _
DA7 SIGNED DATE SIGNED
T C - 105 r
y
ti
SEY'I IC 'i ANK MAINTENANCE A(;k1:EMEN'1'
G
St. Croix County
(iWNER/BUYE,I: FFF---iii----
ROUTE'/SOX NUMBER Fire Number
C i `I' Y/ ';TA I' L t'ti1 L-~ ~ t r. 4 c n_ Z 111 '540
i
P1, 11E1,TY f.UCATJON: >4y 4> Section P ~L N, It W,
C---AltLSt Croix County,
'1 awn o ~ . ,
-
Subdivision Lot ti umbif r
Improper use and maintenance of your st-:ptic 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, j
er. What you put into
if needed, by a licensed septic tank )um L)
the system can affect the function of the septic tank a5 a treat-
ment stage in the waste disposal system.
St. Croix County residents mad be eligible to receive a pram f.or
a maximum of 607 of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program fit August of 1980, with the requirement that
owners of all new SV_sten:s at,r~e to keel) their cyst<ns 11170perly
maintained.
The property owner agrees to submit to St. Croix Count) l,01_1111 it
certification form, sigued 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.
1/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with
H
the standards set forth, lierein, as set by the Wisconsin Depart- b
ment of Natural hesources. Certification Iorm must be completed
and returned to the St. Croix County Zoiiing Office within 30 days
of the three year expiration date.
S I C N E ll(~ - - 1-s`a
DATES - -
St. Croix County `Lon:-ng Office
P.O. fox 98
11ammor d , W1 521015
7 15 - 7~ 6- 2 2 3 9 or 715-425-8363
Sign, date and return to above address
o
>o M
E. EO o co Env asc
CL O O a> > L V O C
U co L d c0 O Z' O j N F- Ol O C 10
O
p U N
c S 0` U i N T C m C7 O N
U .y N«r Oct 0-0 ('}3~
3 D
cc O O
'D L
Ul 0 -0 a E cco \
O y O C Ol 7 O N "lam
4u >,.ic
G L H N d Ca = C) C 'a E G
f0 co N N O d L
N 3 U 7-0 c0 N
a N cc C~ C U N O CD N L
v cc
- as :3 -0 C
Q O U O 3 L ..7- N
Oi O
Q Q 'O L L U U N d y r S
Z Q L- 3 4j 3 y N~ C q~
3
N O
Q Z N ~ O a« c O1 N
'
N cc c C v c`d i
O 3 0-0 U a t O'-
O 0 U E Q 0O N N
C O L cm a N N N>
`tea) OCc
Q 0- CL 000 N o
Y
- CD c c O N
in i0 m y r ca ~
c ; c~ T~ cmZ c
O-COE5O :3E
N C 7 T O O~
p~ c c «L. C c
t fd o O O
O) N O cl) U O E U
00 0 Y «L.. c U ca .0+ C
(n 4) CL O co .
_61 V 0'0 0-,0) o03N a
co ~
ONi w O ca U C O Q N
0) C
CL O i
-co z O N d N'a O d« 7 a al O
T Y N 1) 0 O ? O>~ M co
't Ca 0 -0 _0
E a 3. s Ir
g ,Za2= 8, a C4
C O y c L« O N . m
I II O E N N N .t-. F- 3 N
O
a =
N J_
O
l