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Parcel 024-1019-50-000 12/20/2005 04:29
PAGE 1 OF 1
F 1
Alt. Parcel 16.28.17.108B 024 - TOWN OF PLEASANT VALLEY
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 - NELSON, ROLAND D & DEBRA A
ROLAND D & DEBRA A NELSON
1754 30TH AVE
HAMMOND WI 54015
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description " 1754 30TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 4.250 Plat: N/A-NOT AVAILABLE
SEC 16 T28N R17W PT SE SW PART OF LOT 1 Block/Condo Bldg:
CSM 5/1363 & INC COM SE COR SAID LOT
1;TH S 90'E ALNG S LN SE 1/4 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
125.04FT;TH N 01'W 452.35FT TO A PT 16-28N-17W
BEING 100.OOFT DISTANT & PARA TO N LN OF
SD LOT 1; TH S87' W ANLG LN 559.63FT;TH
more...
II~ Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 _ 1176/1 WD
07/23/1997 681053
i
2005 SUMMARY Bill Fair Market Value: Assessed with:
87535 164,900
Valuations: Last Changed: 08/22/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.250 39,000 86,100 125,100 NO
Totals for 2005:
General Property 4.250 39,000 86,100 125,100
Woodland 0.000 0 0
Totals for 2004:
General Property 4.250 39,000 86,100 125,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 122
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
CERTIFIED SURVEY MAP
GLEN WIESE
Part of the Southwest 1/4 of the Southeast 1/4 and the Southeast 1/4 of the Southwest 1/4
of Section 16, Township 28 North, Range 17 West, Town of Pleasant Valley, 3
St. Croix County, Wisconsin.
o Indicates 1" x 24" iron pipe weighing 1.13 lbs./lin. ft. set
UNPLATTTEO LAND
N87° 26' 14"E 432.68' '
0
- u
' w
y
LL
LOT I = 2.722 ACRES n GARAGE
1188562 SO. FT. -
STORAGE -BUILDING r
NET= 2.539ACRES
10,585 SO. FT. 11/2 STORY m
DWELLING W
W
o. a = 3
UNPLATTED LANDS p =
O
n M N LL O
O N O
N
C7 01
ULLPLLATTED LANDS o = z
STORAGE BUILDING o
Z d W
W F
66' TOWN ROAD M
J N
J N
d d
589° 56'00"E 281.13'
SCALE I"= 100'
'd 6
26.20 ' p
2425.16' 196.23 69.97 101 2552.02'
- N90'00'00"W 5243.98'-- SE CDR SEC. 16, T28N,R17W
- (COUNTY SURVEYORS MON.)
SW COR. SEC- 16,T26 N, R17 W, S1/4 COR SEC. 16,728 N,R17W,
(COUNTY SURVEYOR'S MON.1 (COUNTY SURVEYOR'S MON.)
0 50' 100' 200' 300'
.Q.~ ALA T T E 0 L-A DS
DESCRI F"1'I0N :
That certain parcel of land located in the Southwest 1/4 of the :southeast 1/4 and the
Southeast 1/4 of the 'Southwest 1/4 of Section 16, Township 28 North, Range 17 West,
Town of Pleasant Valley, SL. Croix County, Wisconsin, more' fully described as follows;
CONll'<II NCING at the :ioutYr 1/).t corner of said Section 16, the POIN'T' OF 13EG~NNING of the
parcel Lo be herein' described; thence N ~)O' 00' 00" W (asswned bearing on the South
line of said Section 16) a distance of 196.23'; thence N 28, u6' 50I W 371.07';
thence N 87° 26' 14" E 432.6£3' ; therlCe 3 01 ° 27' 30" L 346.74' to the :south line
of said Section 16; thenc« N (a0° 00' 00" W on ,^,aJd line 69.97' to the. POINT Or' BIG-
INNING, containing 2.722 acres, being subject to easements of record and also being
subject to easement over Southerly portions of said parcel for town road purposes
more fully described as follows;
EASEMENT DESCRIPTION:
CON`iIENCING at the South 1/4 corner of said Section 16, thence N 90° 00' 00" W
(assumed bearing on the South line of' said Section 16) a distance of 196.23' ;
thence N 28" 06' 56" W 53.241; thence s 890 56' 00" E 281.13';
thence S 01° 27' 30" E 29.00' to the South line of said Section 16;
thence N 90° 00' 00" W 69°97' to the POINT OF BEGINNING.
State of Wisconsin)
County of Pierce)
I, Laurence W. Murphy, Registered Land '-surveyor, do hereby certify that by direction ~J
of the Owner, Glen Wiese, I have surveyed and divided the lwxids shown hereon `~yu~~uut~i~r
accordance with official records, Chapter 236 of Wisconsin Statutes and th,%%% sc0
Ordinances of St. Croix County; atld that the above map and description arQ~
a true and correct representation thereof.
'LAURENCE-
Dated: 11 October 1983 m W MURPHY °C
C j,✓ S 1713
~'A %RIVER FALLS, . JW
i F WISC. •Q.
Vol. 5 Pa,3e Laurence W. Murphy co
Certified Su?l.-vey Maps Registered Land Surveyor LANID
St. Croix County, Wisconsin
19
PLEASANT VALLEY-RUSH RIVER T 2$ N.R.1 7 W
J Eaw¢cd ✓ i • SEEPAGE 31
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/96~R c.Ef cdMa/o r.6/s In~/Pe~./517_9 PIERCECOUNTY tau Y /Nf
PLEASANT VALLEY TWP. -}--J - 5/ cc°rx o r y, s
RUSH RIVER TWP•
L DRIVE OFFICE 717 MAIN STREET
EAU CLAIRE, WISCONSIN jT. MENOMONIE, WISCONSIN AABY
FEDERAL SAVINGS Business: 273-4945 ® True Value
- AND LOAN ASSOCIATION Residence: 273-4155 REALTOR' Hardware
Car: 792-2732
DAR-RAY Realty
319 EAST GRAND AVENUE Raymond Huppert Authorized PAINTS
EAU CLAIRE, WISCONSIN - Dealers
207 NORTH BRIDGE STREET 372 WEST MAIN STREET 332 West Main Street 698-2377
CHIPPEWA FALLS, WISCONSIN ELLSWORTH, WISCONSIN Ellsworth, Wisconsin 54011
Woodville
t
AS BUILT SANITARY SYSTEM REPORT
TOWNSIIIP S1?C. N-R W
OWNER
ADDRESS- ST. CROIX COUNTY, WI.. CONSI_N .
.T
SUBDIVISION 1..0T LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 1_[63
5. OW EVEIMIIING WITHIN 1.00 FELT OF SYSTEM
I if
~ I e e
S. _
T di_ L n ntth Arrow 1
SCALE
BENCHMARK: (Permanent reference Point,) Descr-i_be:
Elevation of vertical reference point-: Slope at site:
SEPTIC 'L'ANK: Manufac(.urer: w J Liquid Capacity: )~Q 0
Number of rings on coven land manhole cover elevation.
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER • 00
Manut ac r_urer : _~N im car of gallons ( / 4 _
t~urnlaer of gal. puml_) sc t ?or a c yclE gallons; total capacity o
distribution. lines gaI Lon sr oC pump - - - --head;
~!,a l ton per minute Iorsepowe r rand naihe of pum, p
arid model number
c►-eJ~~hw (..v .
1'ype o f.. warning clew l.ce -
HOLDING TANK `I Manufacturer Number of gallons_____
L:1 e vat-ion of manhole cover
('ype of warning device
SI?I,PAG1? PIT SIZE- _ NuiiF oT ptts _ -Teetc iameter
feet liquid depth seepage pit, inlet pipe-elevation
1)ottot7l of seepage pit., elevation feet.
SEL.PAGE BED SIZE: number of lines-width le„gth ti le depth-_
-
Sf:EI'AC;E TRENCH: width lengCi
PI?RCOLA`I'ION RATE ~~EA REQUTRT D ARP AS BUTLT-
INSPt CTOR
l _
DA`l'HD PLUMBER ON JOB ~ _
LICENSE NUMI ER
,RTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BULIDINGS
,OR & HUMAN RELATIONS ALTERNATIVE PRIVATE DIVISION
1. BOX 7669 SEWAGE SYSTEMS BUREAU OF PL UMBING
IADlSON, W,453701 Mound ❑ Pressure Distribution
NAME OF~'ERMIT 0, D ER: ADDRESS OF PERMIT HOLDER: INSPEC ION ATE. PLAN ID NUMBER:
BENCH ARK (Permanent referent\epoint) DESCRIBE IF DIFFERENT FROM PLAN: REF. P . EL V.: CST REF. PT. ELEV.:
SEPTIC TANK:
MANUFACTURE LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.:[Nigi Ik." !PROPERTY LINE: WELL: / BUILDING:
15
DOSING CHAMBER:
MANUFACTURER: LIQUID CAPACITY: PUMP MODEL: PUMP MANUFACTURER: WARNING LABEL LOCKING COVER
r' . PRO IDED: PgOV1DIED
1~~ t~ n()_tn,~ /11 YES ❑NO YES ❑NO
GALLON PER CYCLE P UMP AND CONTROLS OPERATIONAL. Nu(}IG PROPERTY WELL. BUILDING: VENT TO FRESH
DIFFERENCE BETWEEN FEET FRO LINE AIR I"LFr:
PUMP ON AND OFF 1 79 YES ❑ NO INEA : $T--Ttw'
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 the soil is dry enough to continue.)
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM
and furrows thrown upslope: mound systems to make certain that it OF SYSTEM. SHOW
YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF SPACING CENTER LENGTH: DIAMETER: MATERIAL AND MARKING:
61=.E3/RiENCI / ( TREN E TO CENTER:
QItE
MANIFOLD: PUMP: MANIFOLD PIPE MATERIAL AND MARKING. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
e 'A, 0 CIA.: 2_c/ PIPES: - DIA.: ) r
EEs Y,A 13 O 4 3
:HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: DEPTH OF GRAVEL OVER PIPES: VERTICAL LIFT CORRESPONDS TO APPROVED
YES ❑ NO PLANS. ( YES ❑ NO
SOIL COVER:
TEXTURE:
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDLD: SEEDED, MULCHED.
CENTER - / EDGES . j
El YES,NO YES ❑ NO YES ❑ NO
COMMENTS:
I
51 RE: rITLE:
D I LH R-S B D-6227 (R. 05/81)
~7 -
RE:POR'I' OF LNSPHCT 10N I_N1)1V I 1) UA1, SFWAGG SYSTEM
Sanitary Permit
State Septic
AML? 1'0 WNS1111 Q tit. Croix County
&40;-
i. o 1115~ SectIonA/j Lot Subd-ivisloci
51,PT LC rANK
Size gallons Number of compartments
oistance from: Wel]_ Building L2% slope
llighwater
I'UMPINI; i;HAMBER
Size gallons Pump Manufacturer Model Number
TOLD 1 NC 'L'ANK
Sire gallons Number of Compartments
Pumper Alarm System
Distance from: W e I I Building---- l2% slope_.
rf.ighwater
ABSOkPT 10N SLTE
Bed Trench
uistance from: Well. Bui_lding 1.2% s]_ope
Ili ghwa t e r
\iiSURI'T I ON Sl `I'F. D LMENS I ONS
Width of trench ft Required area - ft.
Length of each line ft Depth of rock below the _in.
Number of Lines Depth of rock over tile-- in.
'T'otal. -Length of lines ft Depth of tile below grade --_in.
Distance between lines ft Slope of trench in. per 1.00 ft.
Total absortption area tt 'T'ype of Cover:
I'I'L' DIMENSIONS
Number- of pits CraveI around pits yes no
outside diameter ft Depth he Iow inlet ft
Total absorption area Lt
Area required It
I NSPECTED BY
APPROVED DA'Z'E 198
REJECTED t) ATV' 198.
REASON FOR REJECTION `
State and County State Permit # 47/~7
PL867
Permit Application County Permit # `y/
for Private Domestic Sewage Systems County 111-7
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required ._6 State Plan I.D. # Do/
A. OWNER OF PROPERTY Mailing Address:
PC le Ivielseil 4' ~2
B. LOCATION: '/4 Section T "N, R E (or) Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township !i'$t}n
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance /
Single family _ Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY C3®~) Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete _ K Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber 6V Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM- Percolation Rate Total Absorb Area sq. ft.
New Replacement- X --Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth top) No. of Trenches
rneaYlt,Seepage Bed:_ Length _Width- y Depth it Tile depth (top)No. of Lines
)J1 f."), Seepage Pit:1111111_Inside dmeter Liquid Depth No. of Seepage Pits
SaAJ Percent slope of land 0 `e Distance from critical slope
WATER SUPPLY: Private`' Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester q
NAME A j:jg S 4 M Cf C.S.T. # -5 0'0466 and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# .7 -3 t Phone - Lel%
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
i
,
.
,
s
i
i
il. 41.
s e
i ~
< P._, a , P a me .e m»
1
Do Not Write in SpQace ^1Below FOR COUNTY AND STATE DEPARTMENT E ONLY /
Date of Application O' "ozro Fees Paid: State/~ z-V ounty Da
Permit Issued/Re}ee;ed (date) - / Issuing Agent Name
Inspection Yes No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
6,_ 1
Revised Date 7/1 /78
EH 115 Rev. 9/78
' REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: w Section ,T_N,RJLE (or) N°Township or Municipality
Lot No. , Block No. County
~g~
Subdivision Name
Owner's/Buyers Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence-,-I' No of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW RE~~PJJLACEME NT. ALTERNATE SYSTEM ] ~THE~
DATES OBSERVATIONS MADE: SOIL BORINGS /`14U e It ay~ PERCOLATION TESTS
SOIL MAP SHEET NAME OF SOIL MAP UNIT
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
RATE
NUM- SINCE HOLE HOLE AFTE INTERVAL
MIN/IN
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- n D gh S;
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- o " - e " la le 5 • C, G W G mo?`t C's
B- / rl 111 1111" lsit Q~
B- 60"
C ui
B-
B-
B- S [J e
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the ocation apd square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy vu 5 5 7t' .Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
Poles 1~D k), It
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I, the undersigend, 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 location of test holes are correct to the best of my
knowledge and belief.
Name (print) w y~ ^ Certification No. J M ~V v
Address Q
Name of installer if known
CS Signatu
Copy A - Local Authority re °
PIb.100a 12/78
Detach And Return Upper 6 7 State of Wisconsin
1 DIVISON OF HEALTH
Portion Of This Form Wit SECTION OF PLUMBING
fi 1 AND FIRE PROTECTION SYSTEMS
Any Return Correspond e MAIL ADDRESS: P.O. BOX 309
MADISON, WISCONSIN 53701
O 0 608-266-3815
DATE:
PROJECT:
SE's, Sec,
of
PLAN ID. #
DETACH HERE
PROJECT NAME PLAN ID. #
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
Preliminary review indicates the plan review fee required is $
❑ Plan accepted for review. Fee received is $
Fee is being returned because of ❑ Overpayment ❑ Underpayment.
Providing one of the two catagories above is checked, remit correct fee in one payment.
❑ No fee has been remitted. Plans submitted with no fees will be held in abeyance.
❑ Plans being returned.
❑ Additional information required. SEE BELOW.
1. Plan Submission
❑ Additional information shall be submitted in triplicate unless specifically noted.
❑ Plans not clear, legible or permanent.
❑ All information submitted shall be signed, sealed or stamped in accord with Section H 62.25(2)(a) Wisconsin Administrative Code.
❑ Affidavit enclosed.
11. Alternate sewage Disposal Systems (Mound Systems)
❑ PLB 108 (Application for use of an alternate system).
L~ County onsite required (1 copy). ❑ Design calculations for pressurized distribution
❑ Cross section of mound. ❑ Pipe lateral layout. ❑ Plan view of alternate.
III. Private Sewage Disposal Systems
❑ Ground slope with 2' contours in entire area of soil absorption system extending 25' on all sides.
❑ Elevation of permanent reference point (benchmark).
❑ Location of area suitable for replacement system - provide soil test data.
❑ Plot plan showing lot size and all lateral distances from sewage disposal system or holding tank to bldgs, lot lines, well, watercourse, etc.
❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast.
❑ Construction detail and cross-section of soil absorption system.
❑ Soil boring and percolation test on EH 115 completed by certified soil tester (1 copy).
❑ Complete data relative to anticipated use of bldg. ❑ 3 copies of PLB 60 enclosed.
❑ Deed restriction required (1 copy).
IV. Holding Tanks
❑ Profile of holding tank.
❑ Holding tank agreement signed by owner and local unit of government (sample enclosed).
❑ Reason for installing holding tank soil test or statement from county (1 copy).
V. Lift Pump
❑ Calculations for total lift pump discharge, head and gallons pumped per cycle.
❑ Size, length & depth of force main.
❑ Detail & model of pump or automatic siphons including size, pump curves, drawdown and average flow rate GPM.
❑ Cross section of lift pump tank showing pump(s) or siphon(s).
VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Total area filled (fill to extend 20' beyond edge of trench before side slope begin).
❑ Depth and type of fill.
❑ Copy of onsite report by county or district plumbing supervisor.
_-i Length of time fill has been in place.
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State of Wisconsin Department of Industry, Labor and Human Rela+;-
neply to:
I-- ,,-%rLTY & BUILDINGS DIVISION
--l Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
Plan Identification Number
.__I
Re:
PRIVATE SEWAGE SYSTEM ONLY- \
1~.
sFa -~/MFG
j0N~N~ X98,
The Bureau of Plumbing has reviewed plans, site survey information and installation details for the const fieKive private
sewage system to be installed at the above-mentioned location. The plans and specifications were prepared by
and received for
approval on
The soil and site evaluation was conducted by
The site meets the soil and site requirements specified in chapter H 63, Wisconsin Administrative Code, for the use of
The proposed system is for a
Wastes from the building will discharge to a -gallon capacity septic tank which will discharge to a -gallon capacity
pump chamber from which a pump having a capacity of gallons per minute against a total dynamic head of feet will
discharge through a -inch diameter pipe to the soil absorption system.
It is of utmost importance that the system be installed in complete accord with the plans and installation details and the conditions of
approval contained in this letter. The licensed plumber responsible for the installation shall notify the county inspector when the installation
of the system will commence so that the county inspector shall be able to inspect this installation. The installer shall not deviate from this
approval and shall follow the directions or orders issued by the appropriate local or state authorities.
In accord with ch. 145, Statutes, and ch. H 63, Wis. Adm. Code, the plans and specifications are approved contingent upon compliance with
the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional
engineer, registered designer, owner or plumbing contractor shall keep one set of plans bearing the stamp of approval of this department at
the construction site. If the installation of this system has not commenced within two years from the date of this letter, this approval shall
become void and new application shall be made for approval of these plans before work may commence. In granting this approval, the
Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination oversight,
construction or any damage that may result in or after installation and reserves the right to order changes or additions should conditions
arise making this necessary. This approval is based on ch. H 63, Wis. Adm. Code, requirements. It shall be necessary to obtain and fulfill the
permit requirements of the county in which this installation is to be constructed. Failure to obtain county permits will automatically void
this acceptance.
cc: OWS
County By:
Other
Enclosures
DILHR-SBD-6159 (R. 7/81) ~l9mes Sargent, erector
r
ti
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
• l.~'.4.i:+ 1 L 4 `.i F.i '.f_,' LA`•. i IYi. 1 • d _ .
CROIX COUNTY REPORT DATE: 11/04/91
9IRTHOUSE DATE RECEIVED: 10/3119
.GON, WI 54016
THOMAS r . i~(E -q0t+
/l &
'SCR: Roland Neisar;
iATION: 17554 30th Ave., Hammond
' .iLLECTORi M. Jenk i ps
.'JRCE OF SAMPLE. Kitchen fauce+
2 ppm
,hove 10 ppm exceeds the recommended PubLic
Drinking Water Standard.
I t orm Bacter i al :
OF.\NDEPENOFH _
l
fro
O A
v >
Means "LESS THAN" Deteciab€e Lever Approved by:
o PROFESSIONAL LABORATORY SERVICES SINCE 1952
(,f ST. CROIX COUNTY ZONING OFFICE
A44 St. Croix County Courthouse
1
`0911 4th Street
l• Hudson, WI 54016
C ~
Telephone - (715)386-4680
The St. Croix: County Zoning office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion of this form is essential so that the property can be
located.
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 a S•d
(For nitrates and coliform bacteria)
WATER TESTING FEE: $127.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00 S-CJC~
(Determines if system is properly functioning at time of
inspection) N ~lS
Property owner's name
I I S4~1~
Property owner's address 1~15~ 30 ~e- ' Ltb",► -R
Legal Description 1/4 of the 1/4 of Section ,
Town of P~2u~+Uc~llex.t Lot Number Subdivision Name z
FIRE NUMBER LOCK BOX NUMBER
Color of house Realty sign by house? If so, list firm:
PLEASE INCLUDE, IF AT 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 individual requesting services: ~4v-St
Telephone Number 3Y6 -SS) t (7z°
REPORT TO BE SENT TO: L k-Z- s f (J 0.-t 1 CMaj f)0-4,k IC o6 I-ck-k-CL-j o -1 2- ck
Closing date L1 - 2S 9.1
Signature