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Parcel 020-1013-90-000 09/27/2006 10:56 AM
PAGE 1 OF 1
Alt. Parcel 11.29.19.598 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - KIRKEVOLD, JAMES & ALYCIA
JAMES & ALYCIA KIRKEVOLD
1006 TANNEY LN
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description " 1006 TANNEY LN
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 6.000 Plat: N/A-NOT AVAILABLE
SEC 11 T29N R1 9W SW SE S 198' OF SW SE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
11-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
01/26/2006 817270 WD
01/26/2006 817269 QC
02/18/2004 754485 2511/218 QC
12/05/1997 569485 1281/076 WD
more...
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 6.000 85,000 166,300 251,300 NO
Totals for 2006:
General Property 6.000 85,000 166,300 251,300
Woodland 0.000 0 0
Totals for 2005:
General Property 6.000 85,000 166,300 251,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 123
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
i Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~ TOWNSHIP
SEC. _ T
_ N R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
r
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Or
~,y,
INDICATE NORTH ARROW
YY
BENCHMARK; Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,o Rear, o
feet
From nearest property line Front,0 Side,0 Rear, O feet
Number of feet from: well
building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
A
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, 0Side, 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: j Length: Number of Lines:_ Area Built:
Fill depth to top of pipe: -
Number of feet from nearest property line: Front, O 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, 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 SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P .b. BOX _/'~69, BUREAU OF PLUMBING
MADISON, WI 53707
C?PeONVENTIONAL ❑ALTERNATIVE S'a,ePI-I.D.N-ber
(lf assigned)
El Holding Tank El In-Ground Pressure ❑ Mound
I
NAME OF PERMIT HOLDER. % ADDRESS OF PERMIT HOLDER: INSPEC O DAT
Daniel Gunsallus R. R. 2, Hudson, WI 91-f r
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV..
SW SE, Section 11, T29N-R19W, Town of Hudson
N-,! of Plumber. MP/MPRSW N,) T~~ix Sanitary Permit Number
Tom Wang 3231 54958
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELE TANK OUTLET ELSE V.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
[-]YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA. VENT MAIL. HIGH WATER ZVAFW-
DOSING BER OF PROPERTY WELL. 1BULDING: JVENT TO FRESH
I ALARM FIR LINE: AIR INLET.
❑YES ❑NO ❑YES CHAMBER:
( I 'I'll PUMP, SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
MANUFACTURER 71INILIQUID CAPAPIU-PAND MP MOD
PROVIDEDPROVIDEDES [!]NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: ONTROLSOPEATIONAL NUMBER OF PROPERTY L BUILDING IVENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENST f JDIAMETER 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 JLENGTH INOOF DISTR. PIPE SPACIN(, COVEN INSIUE CIA =PITS J LIQUID
BED/TRENCH THFNCHES MAT RIA y~ P!T DEPTH
DIMENSIONS I f
GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR PIPE DISTR. PIPE M ERIAL. N DIS ra NUMBER OF PROPE RTV WELL. BUILDING. VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV. INLF E V. END PIPES LINE. AIR INLET:
FEET FROM
NEAREST--p- (J /
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 TEXTURE PERMANENT MARKERS OBSERVATION WELLS
YES ❑NO ❑YES ❑NO
DEPTH OVER THENCH.BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. [ITR P IPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND FLEVELEV.DIAELEV.PIPES A.:
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
❑YES ❑NO ❑YES ❑NO NEAREST
I0.
f7
Sketch System on R tain_in county file for audit.
Reverse Side.
SIGNATURE - TITLE.
DILHR SBD 6710 (R. 01 /82)
wlsconsln APPLICATION FOR SANITARY PERMIT _
~ DILHR COUNTY
(PLB 67)
oEPARTmEnT OF UNIFORM SANITARY PERMIT #
In0l.-STR V, LRBOR 6 HUTRn RELRTIOnS
~y 9s~
-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 ADDRE~
S r, ~ !36 /1 (jf ~ .
PROPERTY LOCATION CITY:
AGE:
.SLt,i /4 S 1/4, S T,7 7'N /
, E (or) W TOWN O
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME REST ROA LAKE 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
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 ❑ 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
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):
7 C~ 1
16 L ~ ~ / Y 5 V Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for install a ion of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signatur / MP/MPRSW No.: Phone Number:
Plumber's Addr s: AS, Nam esigner: ,J
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
y/ •se4 A ❑ Owner Given Initial
~r 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.
Form - S T C 100
Owner of Property 1-;1.Ai C1161 Scd 5
Location of Property Z 4, Section- T2LN R1 W
Township~iC~G`Ge~
~
Mailing Address_~7 /W*5'/ n
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel Was Created
Are all corners identifiable? Yes No
Include with this application one of the following:
.Certified Survey Map
.Deed
.Land Contract, or
.Other Legal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recordedjr the Office of the
County Register of Deeds as Document No. ) J-3 - ; and that I (we)
presently own the proposed site for the sewage 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.
SIGNATUREF OWNER SIGNATURE OF C OWNER (IF APPLICABLE)
DATE SIGNED D TA E SIG ED
/ o 0 5 a cJ ,2i'~a~~~
~ yea ~
H
y
S T C - 105 rr
y
y
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z
d
OWNER/BUYER l ^LL~1 SCi~~ M
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP
PROPERTY LOCATION Section_ T ,2~__N, R_e~ql__W,
Town of L? JC l~ St. Croix County,
Subdivision Lot number
I
Improper use dnd 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
i
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 1,1
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 stems 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- a
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 ,(D'
DATEfa/
St. Croix County Zoning Office
P.O. Box 98,
Hammond, WI 54015
715-796-22_'9 or 715-425-8363
Sign, date•and return to above address.
•r.~..,,_-_ ,..,tea,,,,,
SANITARY PERMIT
,~,,,,,o,,, GROUNDWATER SURCHARGE
[Sanitary ounty
Permit No.
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-
monly 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 Included the creation of
surcharges (fees) for a number of regulated practices which 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.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground-
water, groundwater contamination Investigations and establishment of standards. Groundwater,
it's worth protecting.
Slgnat re of laaulnq Agent; Ground jtater
groundwater Fee: Date; WISCO4aI11'tai
,ILHH SBD-7288 (N. 05/84) buried tCl~&t8Utt1
y e
r
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR A PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN'RE LATIONS \ / MADISON, WI 53707
(H63.090) & Chapter 145.045)
L CATION: SECTION.-_
W SHI MS/NICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
S IJ '/43a /T N/R/'E I. ICY/
COUNTY: 4uoul'S/BUYE 'S NAME: MA LI G ADDRESS:
USE
Residence NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE
PROFILE SC IPTIONS: PER OL TIO TESTS:
❑New 'Replace !~i I~'
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUNDPRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
KS DU f IS ❑UT KS ❑U OS DU EIS 2U 6P U, Fx.5,3 ae s
v.S
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: /
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
51 6
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RIOD 2 PERIOD 3 PER INCH
P f e r
P-
P or 46 2e)
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
M x X. ~K V,
lov'Q. Tod °'Ni✓t gLi~ 15
et4a
1 i 3
E
S la U ~aC ~ N
f O'~ ~~arN,4e
a
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I, the undersigned, hereby certify that the soil tests reported on this form were 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.
NAME (print): TESTS WERE COMPLETE ON"
7
ADDRESS:
1 CERTIFIC TION NU BER PHONE NU BER(optional)
CST G URE:
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