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Parcel 020-1143-40-000 12/06/2005 08:56 AM
PAGE 1 OF 1
Alt. Parcel 17.29.19.743 020 - 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 - SMITH, PHILIP D & JACQUELINE A
PHILIP D & JACQUELINE A SMITH
472 MCCUTCHEON RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 472 MCCUTCHEON RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.360 Plat: 2276-PARK VIEW ESTATES 2ND ADD
SEC 17 T29N R1 9W PARK VIEW ESTATES 2ND Block/Condo Bldg: LOT 50
ADD LOT 50
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
624/477 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.360 55,500 155,600 211,100 NO 05
Totals for 2005:
General Property 1.360 55,500 155,600 211,100
Woodland 0.000 0 0
Totals for 2004:
General Property 1.360 28,500 144,300 172,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 213
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
-
r•~ AS BUILT SANITARY SYSTEM REPORT
q{ER 5 lc t"q I fle TOWNSHIP SEC. aK, R_/ W
0. ADDRESS G , ST. CROIX COUNTY, WISCONSIN. .
'DIVISION ✓ r;✓ ~ ~
LOT -LOT SIZE e 7
PLAN VIE`4
Distances 5 dimensions to meet requirements of H62.20
- ~ f 1
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4-
1- ! i - f--
4~.
` l i/r
~I---'
' ! - i Indicate Nozth' Arrow -
! SCALE:
',PTIC TANK(S) / 1 MFGR._ ? CONCRETE STEEL
NO. of rings on cover` Depth_ 7 DRY WELL
'tLNCHES NO. of width length area
no. of lines_ _ width- J- length area o 6 .
depth to top of pipe '
kGREGATE
?iW, RATE + AREA REQUIRED C' ~i AREA AS BUILT C X
l,sciaimer: The inspection of this system by St. Croix County does not imply complete
'0;pliance with State Administrative Codes. There are otter areas that it is not possible
,Q inspect at this point of construction. St. Croix County assumes no liability for
stem operation. However, if failure is noted the County will make every effort to
~~ermine cause of failure.
TEASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
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`INSPECTOR
DATED PLUMBER ON JOB
LICENSE MIBER/10
REPORT OF INSPLCTION - INDIVIDUAL SELVAGE SYSTLM
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Sava tairrl Pcfl m~
S I a t o Sep-Iic~~l
NAME _ Tawn~shtp - St. Cnotix County
Locatlf' Section 1-7-Lot # Q Subdtivti6 Eon.
SLPTIC TANK
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Size- _gaL_fon.l5 Numbeh o(j compalc.tmen-tA
D.I6xavtee (,n-om: Wo.U Bui d,(" vig 1~0 12% 6. ope.
H-i_gha) a;ten - -
PUMPING CHAM6ER
Size-- --gaeCon-b Dump Manu~aetuflon Modek Numbest
HOLDING TANK
Size gat'Pon's Numbe.n o6 Campan.trne-nt~
AP an m S rI4 T e. rn
"D-L~tance f?iom: LVe~t'
Hi hwa ten.
ADSORPTION SITE
Ded Ttcencli
D4.6,tance ()nom: LVe~F 6 (14f,(U nq 5 12'0'-
I ope.
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It gIt wa.teiT
ADSORPTION SITE "DIMENSIONS
w4 d th of fife vi.e_h 4 h.t Re.q u.t r.v d- area l.S ( t
Lo.vtg h o6 each P6.t Depth o6 tcock beXow
Nurnbe.>z o{ De.p t.h u ~co e h- oven t~. v t-n
- - - - -
ToxaP 61.n_g.th o A Pne6 - - ~.t De.pth o t.t.te below qnadv
11 IVils"tance between tine'15 _ -{;t Sf_ope. a6 Pi-eneh_,~~'~ ~-~_n. pelt 100 f t
To ak- abea~tp"ti_on a~iea 6t Tilpe a( Cove.~t: 'ape. otr AP(wv
PIT DIMENSIONS
Numbers. o{ Gnave-(' aocound pity -Y e,5
n~Out6tide d(,ametee {t Depth befow inlet l
Totat' a_b,~olcptlon anea ~.t
A n e" a n e q u i~t- e. d_ ,l/" t
INSPECTED Dy--L TITLE
/
APPROVED DATE_ ~3f~ IVn
REJECTS"D "DATE /9A
REASON FOR REJECTION
i
REPORT ON INSPECTION OF SANITARY PERMIT #
(1) me a ` ss, of Permit Holder Person/Persons at Site 2 Date of Inspection
ame, ress, icense NO. o ns a Ong Plumber Time of Inspection
x~"
3 INST TION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
(4)BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
W SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
(7)DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO
8 HOLDING TANK: Manufacturer o gallons
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? ❑ YES ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
N0; Wired? ❑YES
Is the warning device installed? ❑ YES ❑ ❑ NO;
Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO
(13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO
DILHR-SBD-6095 N.05/80
Signature of Inspector:
r
State and County State Permit # PLB 67
w Permit Application County Permi #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: 4_)i Y4 01/ Section , T2C' N, RL E (or) W Lot# _ u City
Subdivision Name, 1 nearest road, lake or landmark Blk# Village
Township [ ;z,:.:,•.
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms 3 -No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq
. ft
.
New~Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width 0, ~ Depth ~ '17 ~_Tile depth (top) 36 l No. of Lines -
Seepage Pit: Insidq diameter Liquid Depth No. of Seepage Pits _
Percent slope of land 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, L r _
NAME n 6 ~,1 n r C.S.T. # 1 [ f `and other information
obtained from " (owner/bull r .
_ r`"~:- ,
Plumber's Signature MP/MPRSW# Phone #2f?
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.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application 2~- - ~ Fees Paid: State,~~ , Cz County Date
Permit Issued/Rejeeteel (date) LQe Issuing Agent Name s ri d
Inspection Yes 4__ 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) Revised Date 7/1/78
EH 115 Rea. 9n8
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
Section N,13,44 (orO,,'Township or Muni
County S Y, O/
Lot No. Block No. 6 `
/ subdivision Name Q t~•
Owner's/Buyers Name:
Mailing Address: /'cct oc~ ~d{c~ <<St~l~ vim/
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS- PERCOLATION TESTS
SOIL MAP SHEET S-11? NAME OF SOIL MAP
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
6 ,s
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P-
P- Z 1 VT e_
P-3 5~~ e 14 NO
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES 1
B- l ~J t r t f ~x~ t i it ~5 ,l '4 p :
B- / 9,6 e/
B- 7 ti g. P n d j. S
B- h;p
B_ lkk'
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy/_T_ Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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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) Certification No.
Address'
Name of installer if known
Copy A -Local Authority CST Signature
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