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Parcel 020-1025-20-000 06/02/2006 02:38
PAGE 1 OF 1
F 1
Alt. Parcel 15.29.19.110A1 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 - LARSON, MARY L
MARY L LARSON
970 BAKKEN RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 970 BAKKEN RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 5.160 Plat: N/A-NOT AVAILABLE
SEC 15 T29N R19W PT SE NE LOT 1 CSM Block/Condo Bldg:
1/217 Tract(s): (Sec-Twn-Rng 401/4 1601/4)
15-29N-19W SE NE
Notes: Parcel History:
Date Doc # Vol/Page Type
02/01/2000 617731 1487/372 QC
07/23/1997 917/127
07/23/1997 660/66
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.160 87,600 192,300 279,900 NO
Totals for 2006:
General Property 5.160 87,600 192,300 279,900
Woodland 0.000 0 0
Totals for 2005:
General Property 5.160 87,600 192,300 279,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 137
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
,n
SERCO Laboratories ` Q 67 l l 01 =1
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
Amon: LABORATORY ANALYSIS REPORT NO: 835:7--- PAGE I
Commercial Testing Lanoratory DATE COLLECTED: 00/iO/31; 05/11/91
514 Main St. Box 526 DATE RECEIVED: 0%171%
Wifax, w! 54730 COLLECTED 3V : CLIENT
DEnIvERED BY : CLIENT
Pamela Game
S-t`;- Croix Kninq
SAMPLE jgggqn, W1 54016
1094
ANALYSISr
omc& -r _ - 0. -
-__om-i-_k-: _ (Meta v! bromine) A1.0
Carbon tetrachloride, - <0.2
CnIomwethane, Ug/L (Ethyl chloride) <0.4
Chloromethane, ug/L (Methyl chlorine) W.6
wg/L <04
-t--.--tr?_eni-'_?Cry UgiL __z0
-
:5 - x S - - tg NIA,
roe: rre . E
(Ethylene dichloride)
} r _ - -r_ _ - _r- _ _ - -
Methylene chloride, ug/L 15.0
(L =ch1o!rometh ne)
means "not detected a this level". f Mg _ 1000 ' ice .
Member
r
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
ANALYSIS `fir-_- NO: S30-:~ PARE L7
SERCO SAPF~E NO: 105441
s _ _ _2,2 T= - _ - V0.2
-i - -
1 , _ r _ - - . _ - _ - - _ . n e G _ _ - - _ _
Trichlorofluoromethane, Ug/L (Freon 11) <0.7
sry= -.._Fir _1-_ - .1_
Benzene, u- = 1 .
i
EtnVibenzene,
Toluene, Ug/L
This sample's results are below the U.S. -
--"--'mss'-a`-= --'mss of _ _ tn--- requested -
list=
also the _DW-=- VOL report,
All analyses were performeo using EPA or other accepted merMonologies.
Samples that may be of an environmentally nazarcous nature will be
returned to you. Other samples will be stored for TO days iron the
then wisposed of by SERCO LanOratOrlen- Please
date of this
contact me if other arrangements are need=_ a This report may not - -
c_r-d _ - its _ without written approval
.-port =-_,i-.._ 5
n
Diane 0. Anderson
Project Manager
mean- "not detected at this level". 1 mg = 1-000 Ug.
Member
09/27/91 13:11 $715 962 4030 COMM. TEST LAB 444 S.C. CO CRTHOUSE I]002
SERCO Laboratories
1931 ww caumy fiaaw 02, St. Fain, minnmta 66110 Pmns 161R) OU-11?3 FAX J$iZ 6x-7470
=AC3£ i
`r=,BCRA a C1RY ANALYSIS REPORT NO: 31215
?3/24/91
Commercz ai T aw1:i nq Laboratory DATE COLLEC.TED1 09/10/91,* 514 Main St_ Sex 1.26 1DATE RECEIVED: 019/17/91
Coj4ax, Wj X4730 I:OLLE,CTED BY CLIENT
DELIVERED BY I CLIENT
SAMPLE TYPE DR I NK I N5 WATER
Attn: Pamela Gans
.
SERCO SAMPLE N4: 97601 9761,
SAMPLE DEWRIPTION: F~ajc ken U.S.
1094 wont
ANALYSIS:
-
Bromodichlor'omethane, ug/L <0.2 {0.2
Lromoform, ug/L <0.5 <0.5
8romomethans, ug/L (Methyl bromide) <1.0 <1.0
Carron tetrachloride, ug/L x:0.2 0.2
Chlorocenzene, ug/L <1.0 1.0
Chloroethans, ug/L (Etnyl chlorids) <0.4 <064
2-Ch l oroethyl vi nyl ether, ug/L <0.4 -0.4
Chloro4orm, ug/L <0.5 <0.5
Chloromethane, ug/L (Methyl chloride) <0.6 .40.6
Dibromochloromethane, uw/L <0.4 {0.4
192-Dichlorobenzanal ug/L i.+d <1.0
(o-Di ch1 crobenzene )
1,3-Dichlorobenzene, uq/L <1.0 <1.0
{ m-Di Chltlr-abQnz a1lnat)
1,4-Dichlorobanzene, u4/L <1.0 <1.4
(p-Di ch1 Qrobsn~ er~a)
Dichlorvd;fluoromethanev ug/L (Freon 12) {0.5 <0.5
1,1-wDichlorosthane, ug/L 0.1 <061
i,2-Dichlorwethana, ug/L <O.2 <0.2
(Ethylene dichloride)
1,1^-Dichloroethene, ug/L <0.2 <0.2
trane-1,2-Dichlor cethene, ug/L <0.1 <0.1
1,2-,Dichlarapropane, ug/L <0.1 <0.1
cls~1,3-Dichloroprrspen>t:,ug/L X1.5 <1.S
trans-193-Dichlorapropane, ug/L <0.9 -<009
Mathylene Chloride* ug1L .0 <5.0
(Di ch 1 oroamthane)
< means "not detected at this laves,". i mg - 1000 ug.
M.mtt»r
09/27/91 13:11 x$`715 962 4030 COMM, TEST LAB S.C. CO CRTHOUSE
SERC O Laboratories
1631 µwtCouMyft"Q, 3t.PauL mimeem foii3 Ptaft(w2)s*7173 r-Ax(aig)aw•7in
".;ZQR-ATQFkV ANALYSIS NEFORT NO'. 61251 PAGE
u912~r5!
5ERCO SAMFLE NOt '97,boi r'a
SAMPLE DESCRIPTION; Bakken U. S.
1044 West
ANALYSIS:
-
1,1,2,2-Tetrach1ora4thane, ug/L _ <0.i {0.2
Tetrachloroethene, ugrL X1.5 {1.10j,
1,111-Trxchloroa+thane, ~cg14 ~5.~ X5.4
191,2-Trxchioroathanaq ug/L <0.1
Trichlorofluoromethame, uq/L (F&eon 11) x:0.7 X0,7
Vimyl chloride, ug/L <1.0 <1.0
Benzene, ug/L
Ethylbenzenr, ug/L <1.0 <1.0
Toluenes ug/L <1.0 x:1.0
All analysas were era~Frmed using ERA or otner accepted methodologies.
Samples that may 00 v4 an environmentally hazarcous nature will be
returned to you. Ether samples will b• stored for 30 days tram the
date of this' report. then disposad of by SERC4 Laboratories. PIQQSO
contact me ii other arrangermien%w are needed. This retort may not be
reproduced, except in its entirety, without, prior written approval
Pram SERCO Laboratories.
i
Report submitted by,
Diane J. Anderson
ProjeGi Manager
t means "not deter-l-ed at this levol f mg = 1000 ug.
M~fn b0►
CO-MWRCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
f
S 4 CROIX COUNTY REPORT DATE
CMIRTHOUSE DATE RECF7vFn! 9p
-116014, WI
Toss Jody 1~
..-IRCE OF SAMPL.E+ Outside faucet
1FORM: 0 /100 m(
CRPRETATION: Bacteriologically 5
7 ppm
,ave 10 ppm exceeds the
.i? f t.41"II'kll.eli?iYe ~''d1li L^.:: ;r.
.OFA DEPEND F
O A
=d : Means "LESS THAN" Detectab;e Level Approved by:
PROFESSIONAL LABORATORY SERVICES SINCE 1952
ST'. (kGI1 t-OCR 1~~=~1 _?}1I(:L
~k~~ ! 1} ~,h:i
J'JA.}- 1101 1 H~ 1 7 1 5) 3<
isle -r _ _ ~_,,:~+zntSr Gor.zng Office offer
1
ept:i.c. anti water insp~.ct.ions to _-~er;~
>alty Firms, and private individi_zr;
omplet on of
:an be Iocat.e:
lease provide
.ppropriat.e tee made patiable to St. l;roix CoUrlt,:
f t ice , and ma11 a I T) 1V ! th f Tr1l t.0 the abo~ e a(AdrF '
cyst in will be
or-m are re.ceiv,,
F,R TESTING--- -
'r.•'or• nitrates and co? i fol t. :lc t eria;
ER `I ESTING _ 1'E':: ?
For- L~OC' S )
IC; SYS`T'EM INSPi:( '['TCi~_----------FFF:
t ermines , r = l ~.r:
pec-t ion) 2~j/~_~y ~
i- t~ Owner-' , i ~Orw. ► D a i- A K.K~~ ~_JU._~P_uD~~v
e:~'al Des r i--- ' , } t } _
i : 1 ~~till~
own i ~-t'-zd ,1P,li.; r• Slay
FIRE NUMBER 9?Q LOCK BOX NUMBER_ .5U_~____
C_4_ LD_ v~~C,'_4+_1_G 6~-
PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e, COPY OF
PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING
SHEET.
;1::. c.. r " 1._~,r + ...1 ~ rE-, ~ li_~ 1 =,ama~ t
resh. It the home is vacani;, and has been so for
•rle, the water line must be. purge++
several hours before the test. r
TER. TESTING: Many times wager
iii cocks are t.>arned off, making a ii
:E?ceCt.arv fi t' c, v. r, :a 3 SF P 1)ri Pi
iT-. -m~`r _ f - _ - . 111. -
L ~ L,o uJ C. L.l., . , ~''v aG L 2..
[1POR7 'I0 P;r ~L~ ~1__t ( T _Lc~~°_._ _nl0 `
sing ..a?-4l I-{ osq,~
MINNESOTA
n _ o p ^ /A 200
' ~--I' N T 4r •f ~P N I f
a I o o I
to
T 1
; Q s 9 _ 3 3 ( O c -_~1 bD }yam R% ~L 300
~ n s g ^ , - _ ~ n ~ - 1 , Z 1 ~~S ~ - ~ y TILT " ~r~7^^ n n- o-- ^ °a I u~-/ ~ O ~ 1~ o ~ c J f
p
i• i
^ n I 1 I ~ tR ~ ~gl ~ ti
o m I,) an~`~~ 3 gel 4 05
lDVTw GVIYIGIIA!L R1 I~ G1 Rw V_'M CC 1 McDi iLv RD '(RUSTIv RG ^ 400
m n m o _ a~ - I' fiT' Gu - \C TRD11T 1\R.y,.~ O
E! P :7
N G r " " G G 3 n " I SAN TAW Ui GRCFR m wVEN we < i~ q , ~1
j - a i O D ] _ -c ~ ' I (I1~,T'111t 1,I~1~'IIIjI~~RIRRR MORN VIC'/ ~ p a._~ R~~'^ jam, I
_ .r r - - a ~ l~ N D^v-~__ DR TAY `/`1^^ "RG ~"~'S✓ I
- ' o I
[`d, ~r N b• wCRT n.Y O
m ^ m a` 1 0 MCII N D. \ 1 mi?Jo y O A!
o.
ULA; 1C. RD. i;-LA!
]AILT 19. ~1
- o _ - ' I w o II N Z N D I wC D -ID LA.
10
~LARSCH
Onwl" N
v ~ - ~ y - X C1MDil r.3 K1wD ~ .in ~ - N IQ U Ii O ~
^ 3 I I
- 0.1 RRC 1 S
1
YEllr .D.~ I 700
ILA RARDC= RA II _ I /O~
~V f N W V/
^ ~ ~ > KIT
II KINHrT a ~ ~n u. 1
I _ lenuwYR qD ~ I
^ G u 1 RD. i 1 k
R.~eT Rn ; \t I1
I
s T n C I !N N j~ N \ p ~Y]lT
^ ^ I A I i J O I
"m y yplr 1 WARREN TWN. 1 /I III _
d - 0 I'I O O ' O LD O O 1 l~ 1 C
u u v
tT
f
:
IE I 17 I 3
15 I
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20 9 16
1
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19 II 112112 4 ( 2 l~ nS ~N
I 1 r I I I
ST. CROIX COUNTY
' WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
A 19,1919, Pq 14q 911 FOURTH STREET • HUDSON, WI 54016
715 386-4680
Sept. 11, 1991
Bill Sieffert
Coldwell Banker
126 2nd St.
Hudson, WI 54016
Dear Mr. Seiffert:
An inspection of the septic system on the property of Tom &
Jody Bakken located at 970 Bakken Rd., Hudson, WI was conducted
on Sept. 11, 1991. At the same time a water sample was obtained
for testing. The results of that testing will be sent to you as
soon as we receive them back from the laboratory.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and
did not involve any excavating or chemical analysis.
Accordingly, there is the possibility of hidden defects in the
system not discoverable by this inspection. This does not in
any way warrant or guarantee the continued proper functioning or
operation of this system. It is recommended that the system
should be pumped once every three years. Therefore, the
prolonged life of this system may be dependent upon proper
maintenance of the system.
erely,
Mary . Jenkins
Assistant Zoning Administrator
cj
Form - S T C - 104
AS fiUI1 i' SAN LTARY SYSTEM PORT
OWN _ `'OWNS141P SEC. 1 N-R f 7 W
ADDRESS Ii6u~y~__ ST. CROIX COUNTY, WISCONSIN
i S .
SUBDIVISION kt _ i.- 1' 'V'::5-~ E _ 1.OT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
or7" L~ k Qi
~ k ra erg'
~LCi ~ 1,~ - ZG
5y Ste- wti E- V- - l I4~
S y sf K1,~~ (o- ~ S L s ,
loo
c,
y
6- &J
r
~
ua-f
J$ /
(C-t- vl S a- Ta~ G~~ uu '
y
Wrfl
r ~srP~~ pity
v S
INDICATE NORTH A4W
BENCHMAR:: Describe the vertical reference point used ( 4ofp;,o~f~ _
Elevatio i of vtrLical reference point: 61'roposed slope at site:
SEPTIC T.~NK: Manufacturer: Liquid Capacity:
1
Numb,:r of rings used: i - Tank manhole cover elevation:
Tank Inlet Elevation? ` T Tank Outlet Elevation: -L ~Z 4> Ll
Numb(x of feet from nearest Read: Front,0Side,0Rear, feet
From nearest property line Front,0Side Rear, IQG, feet
Number of feet from: well s building: lGj.s 4dJ~/
(Include this informatLou of the above plot plan)( 2 reference dimensions to septic tank)
r
PUMP CHAMBER
Manufacturer: _ , - Liquid Capacity:
Pump Model: _ Pump/Siphon Manufacturer.: Pump Size
Elevation of inlet: _ T Bottom of tank elevation:
Pump oft- switch elevation: Gallons per cycle:
Alarm Manufacturer: _T Alarm Switch Type:
Number of feet from nearest property line: Front, Side, Rear,0 Ft.
Number of feet Crow well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORB'1'-.ON SYSTEM
Tr.endi: 9U~
1
Width: T_ LenCtli:_ Number of Lines: 3 Area Built:(,V~ T
Fill depth to top of pipe:
Number of feet from nearest property litre: front, Side, Rear,(7~p't. 7S
Number of feet from well: -
Number of feet from building: 7
(Include distances on plot plan).
SEEPAGE PIT
Size: Il!►I 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 0
Manufacturer: Capacity:
Number of rinks 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:
u Inspector:
Dated: - Plumber on job
License Number: 14vj
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 s,a,ePlanLD.Npmbe,.
• (lt assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER'. INSPECTION DATE.
Tom Bakken 421 Monnoe, N. Hudson, W1 54016 ~ = .rll
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF, PT. ELEV
SE NE, Sec. 15, T29N-R19W, Lot# lotLE, A) t Bakken zub., Town o~ Hudson
Name of Plumber. IMP/MPRSW No.. jC,m,j,. Sanitary Permit Number.
you tas Stnohbeen 5432 St. ctoix 49444
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OU LET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED'. PROVIDED
DYES ❑NO DYES ❑NO
BEDDING: VENT DIA.7 VENT TIE HIGH WATER NUMBER F ROAD'. PROPERTY WELL: BUILDING. VENT TO FRESH
.
w ( ALARM. FEET FROM LINjd6 1AIR INLET
DYES tNO C/J l'1 DYES NO NEAREST
DOSING CHAMBER:
MANUFACTURER 7ING L IQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED PROVIDEDES ❑NO DYES ❑NO DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTv WELL BUILDING (VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ❑NO INEAREST_
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IL EN(ITH DIAMETER MATERIAL AND MARKING
or excavation. (lf soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH IN O. OF DISTR. PIPE SPACING COVE (2 INSIDE DIA -PITS LIQUID
BED/TRENCH 1 TRENCHES M E IA L. PIT DEPTH
DIMENSIONS C
(;RAVEL DEPTH FILL DEPTH DISTR. Pt F DISTR. PIPE DISTR. PIPE MATERIAL NO. DISTH NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES ABOV tVER IF I EV INL f EL END 7 PIPES. FEET FROM INE~ AIR IfyLET>
2 NEAREST--s
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
D meets the criteria for medium sand. TIONS MEASURED.
YES LINO SOIL COVER TEXTURE JPERMANENT MARKERS OBSERVATION WELLS
DYES ❑NO DYES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH: AEU DEPTH OF TOPSOIL SODDED J_SEEDE MULCHED
CENTER EDGES.
DYES ONO DYES ❑NO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. ]LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV. DIA. ELEV. PIPES DIA.:
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ❑NO DYES ❑NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PR OPERTV WELL: BUILDING:
FEET FROM LINE.
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
t
Sketch System on V Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE.
DILHR SBD 6710 (R. 01/82)) _q
I
wtsconsin 7 APPLICATION FOR SANITARY PERMIT e
'~~DILHR ~COUNTY
(PLB 67) ~ UNIFORM SANITARY PERMIT #
OEPRRTTEnT OF , `
-
InOUSTR Y, LRSOR 6 HUMRn RELRTIOns 9 Al 171 Al
-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
K PROPERTY LOCATION 'G'tr':
_}/--1_LL AG E :
5E_ 1/4 X1/4, S /mar, T_2~1 N, R ---7 If (or W TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
N14 Wit Ea-
TYPE OF BUILDING OR USE SERVED
T+ 1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
XNew 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 Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity nom? 0
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: I& i S e
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):
3 (131 S I-'~' 36 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): Sigr~ ure: MP/MPRSW No.: Phone Number:
Dc' r c
Plfump[ber`e Ad/Id(ress: f1 / ) 9 N/a~mt e of Designer:
/fi..,k 4-' A'f r~'~1y
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
7 du I ❑ Owner Given Initial
b6 ^ . (f LL tJ + f7 Y_`~ H 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/contractQV,("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 lD i"
Location of Property 4Section T Z57 N - R
Township /41017
Mailing Address Y-2/ lnoel-od-~rl I
Subdivision Name t
A' I i
Lot Number T
Previous Owner of Property Art f"a/~Kr /1
Total Size of Parcel ICra-s
Date Parcel was Created IV/ sc~
Are all corners and lot lines identifiable? Yes No
Is this property beine developed for resale (spec house) ? _ Yes No
Volume / and Page Number ? 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTV OWNER CERTIFICATION
I (we) co t i.by that aQY statemen.t6 on this bonm ane tAue to the beat ob my (oun)
knowledge; that I (we) am (ane) the owneJc (a) ob the pnopenty daCAibed in -thiS
inboAnati.on bonm, by viAtue ob a ww tanty deed neconded in tte Obbice ob the
County Regizten ob Deedh as Document No. ?2,e~- ; and that I (we)
Oe,sentty own the paopo4ed bite bon the Isewage pos /system (on I (we) have
obtained an easement, to nun with the above deg cAibed pnopvtty, bon the
eonsfi✓e.uction' ob 4aid 6y6-tem, and the. eame h" been duty neconded in the 066tice
o4 the County Regtis.ten o6 Deeds, az Document No. a~ 5 7 I
SIGNATURE Cy OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
~ - e
DATE SIGNED DATE SIGNED
J 0 8 N0.
SUR E Y MAP
FOR '
l)E'-`-tom P ^P
I1";L.r A{l i V.~ Y Ia.~'Lw. 1 Y,;.
+r. .._^-war. .....F,-_ ...,..r~'~'/
0.8
Rcorr etasa.m.-en'*--r`~ ;
A
CS
' fro'. E
4w ~ j }
41 }}I~
A¢rSU.20
i '
0 INDICATES IRON PIPE STAKE BASED ON A SURVEY MADE /
DATE
SCALE
DRAWN
CHECKED _
-
LO C.
W
. H
y
S T C - 105 r
y
SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County
r7
, H
OWNER/BUY F . It_ 2~ / t j -
ROUTE/BOX NUMBER
C I T Y / ST ATE I~~./ r ~ l(-i 7 'l. III
PROPERTY LOCATION:-'-4, _ `4> Sect ion 1!' a , `1 N, K G-~
Town of St. Croix County,
Subdivision k~ e. S.lXt.~ lye > Lot number /wIf
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 licen_st.d sel,tic tank 1>~imLer. 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 ptj be eligible to receive a grunt for
a maximum of 60% of the cost. of replacement of a failing; system,
which was in operation prior to July 1, 1918. 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 scut approximately 30 days prior to
three year expiration. o
I/WE, the undersigned, have rend the above requirements and agree cn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- w
meat of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning; Office within 30 days
of the thr.... year
S 1 C N L ll - - - -
" ll A'1' E
St. Moix County Zoning; Office
P . O . Sox 96
Hammo`rd, WI 54015
715-7 16-2239 or 715-425-8363
Sign, date and return to above address.
IF I
I'ADUS TMOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY Y, 1 C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON W 7969
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: ) 17 OWNSHIP LOT NO.:BLK. NO.: SUBDIVISION NAME:
.~G 1/N 4 /T),`I Ill V(or ti st.,? I v) E - l1Yf /~11/y~•~ c,s!~y s,sc-s
COUNTY:
OWNER'S/BUYER'S NAME: MAyIILING ADDRESS:
F~. v X. 4 `,fS-'!lUl 10
USE DATES OBSE VATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
I XResidence New ❑Replace L/1 ,2-1 'C,,/
!'3
5"o"P-tolp 14
RATING: S= Site suitable for system U= Site unsuitable for system i d
CONVEcNTIONIAIL: MOUND: IN-GROUNcD-PRESSURE: SYSTEcM-IN-FIILLHOLDIcNG TANK: RECIOMMENDED SYSTEM: (optional)
VV [V ®J ~U I RS ~U ~J ®V ]J [ •U /G.i'G't?~. On1i; />r'.t/
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: /L /
P FI E DESCRIPTIONS
r;
BORING TOTAL/ DEPTH TO GROUNDWATER4*41C+~E-S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH-LPd: ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / 7•~-' - - '
L/ I
B- YY Y' I. sr ,r / C9 S *-2 yi s
B-3 9.s-, jlc Y' t3l` / 1. 3 / t g S rc S ; U fh s
B- 3 ~ S' y c) 1 c aC ~ ~ t s Sr /j ~ S r 3, S'4A S ~
B
PERCOLATION TESTS
TEST DEPTH O WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INeIIE3 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- / . S~' O
L 3
P- 3.x' Alio
P_ .3 0 3
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION Y1, 7'
e G--e j
.1~6~t• - %
s_
~K
~ ~vt
-vp F A- 07-
w _ 0
j j
J SS Me /Vc,
' K d ,r~C
7- =
~
RR4 40 e
w * A 6o r e.5 6
E 4
_a 4/11 1 le
kat- li-AeE u - ' ~d slops S.E.
W t s 1r~k e CP~t•'~tC~~v _
1, 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 COMPLETED ON:
ADDRESS: r CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST NATURE:
i
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D I LH R-SB D-6395 (R. 02/82) -OVER
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