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Parcel 020-1143-80-000 12/06/2005 09:08 AM
PAGE 1 OF 1
Alt. Parcel 17.29.19.747 020 - 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): 0 = Current Owner, C = Current Co-Owner
O - LAMB, J WAYNE & JUDITH C
J WAYNE & JUDITH C LAMB
460 MCCUTCHEON LA
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 460 MCCUTCHEON LN
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.230 Plat: 2276-PARK VIEW ESTATES 2ND ADD
SEC 17 T29N R19W PARK VIEW ESTATES 2ND Block/Condo Bldg: LOT 54
ADD LOT 54
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1025/165 WD
07/23/1997 787/40
2005 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 1.230 52,700 195,700 248,400 NO 05
Totals for 2005:
General Property 1.230 52,700 195,700 248,400
Woodland 0.000 0 0
Totals for 2004:
General Property 1.230 27,000 156,700 183,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 121
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
AS BUILT SANITARY SYSTEM REPORT
OWNER
u f, 9 TOWNSHIP SEC.''
ADDRESS - ST. CROIX COUNTY WISCONSIN.
SUBDIVISION LOT
LOT SIZE
Distances & dimensions to meet requirementsWof H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
I di, ate ofthlArrow i
SC AL
SEPTIC TANK(S) ' MFGR. CONCRETE STEEL
N0. oT rings on cover 'i Depth
PUMPING CHAMBER SIZE PUMP MFGR. M D L NO.
GALLONS Per Cycle
TRENCHES NO. of width length area
BED NO. of lines width length c
dept to top o pipe area--.-
dept
OF SEEPAGE PITS Outsi e iameter total pit area
AGGREGATE
PERK RATE r- AREA REQUIRED AREA AS BUILT
Disclaimer: The inspection of this system by St. Croix County does not imply
complete compliance with State Administrative Codes. There are other areas that
it is not possible to inspect at this point of construction. St. Croix County
assumes no liability for system operation. However, if failure is noted the
County will make every effort to determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH IS SYTEM.
INSPECTOR z/ 4 y-
) _ PLUMBER ON JOB
LICENSE NUMBER 71
AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP SEC. T ~ N, R W
ST. CROIX COUNTY, WISCONSIN.
LOT LOT SIZE
" PLAN VIEW
z
.s to meet requirements of H62.20
:o
W EVERYTHING WITHIN 100 FEET OF SYSTEM
-i
I
I
WOW-
Indicate North; Arrow ; i
SCALE : Irv! ;
i
tPTIC TANK(S) MFGR. CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
ANCHES NO. of width length area
no. of lines width length area
depth to top of pipe
aGREGATE
?'Rk'• RATE AREA REQUIRED AREA AS BUILT
I,SCIaimer: The inspection of this system by St. Croix County does not imply complete
.0pliance with State Administrative Codes. There are other ,areas ,that ,it is not possible
,o inspect at this point of construction. St. Croix County assumes no liability for
,Stem operation. However, if failure is noted the County will malce, every e,f,fort to
,Qtermine cause of failure.
ASASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
--INSPECTOR
DATED PLU;fBER ON JOB .
LICENSE NUtiBER
C~OMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
n
CROIX COUNTY FtFr'I?R; TIATF' e
:URTHOUSE
SON, W! 540.1
r ye J,
29
- MfcCufchenr~Lane ausn . CY n +Y~"~7
ECTOR: M. ,lenk i
''CE OF SAMPLE: K i is
.:OLIFORMi: 0 1100 mt
MTERF'RETATION: Bach
7
OF.NDEPENDEH
l
J?(. 7m
O P
s
A
PROFESSIONAL LABORATORY SERVICES SINCE 1952
13c -q(
( ST. CROIX COUNTY ZONING OFFICE
J 911 4th Street
Hudson, WI 54016
Telephone - (715)386-4680
The St. Croix Co. Zoning office offers the service of septic and
water inspection to Lending Institution, 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 CO. ZONING, 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 xx
(For nitrates and coliform bacteria)
WATER TESTING FEE:$175.00 XX oo_
(VOC'S) D /
SEPTIC SYSTEM INSPECTION FEE:$ 25.002Q
PROPERTY OWNERS NAME: Dr. Terrance A. Anderson
**PROPERTY OWNERS ADDRESS: 460 McCutcheon LNCITY: HUDSON
Legal Description 174, 1/4 j , T~_N-R
Town of HUDSON , Lot: No 5' Subdivision- FqP- 145 57~}T£s
FIRE NO. LOCK BOX NO.
Color of house TAN & BRT .K Realty sign? vj,,;3 Firm: Century 21
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 %he
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: Dr. Terrance A. Anderson
Telephone No.
REPORT TO BE SENT TO:-,, nr Tarranrp A Anderson
711 Bnpc-hwond Drive Savannah GA 31419
CLOSING DATE:
Signature:
For access to property, please contact my real estate agent, Mr. Randy Cudd,
Bertelsen-Cudd/CENTURY 21, 706 19th Street South, Hudson, WI TEL: (715) 386-8207.
Parcel 020-1143-80-000 12/07/2009 01:42 PM
PAGE 1 OF 1
Alt. Parcel 17.29.19.747 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Foo wner(s): O = Current Owner, C = Current Co-Owner
J WAYNE & JUDITH C LAMB - LAMB, J WAYNE & JUDITH C
460 MCCUTCHEON LA
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 460 MCCUTCHEON LN
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 1.230 Plat: 04-046-PARK VIEW ESTATES 2ND ADDN
SEC 17 T29N R1 9W PARK VIEW ESTATES 2ND Block/Condo Bldg: LOT 54
ADD LOT 54
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1025/165 WD
07_3/, 919 7 7'40
2009 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.230 52,700 195,700 248,400 NO
Totals for 2009:
General Property 1.230 52,700 195,700 248,400
Woodland 0.000 0 0
Totals for 2008:
General Property 1.230 52,700 195,700 248,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 121
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 020-1143-60-000 12/07/2009 01:42 PM
PAGE 1 OF 1
Alt. Parcel 17.29.19.745 020 - TOWN OF HUDSON
ST. CROIX COUNTY, WISCONSIN
Current X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - ANDERSON, PAUL J & KATHLEEN L
PAUL J & KATHLEEN L ANDERSON
460 MCCUTCHEON RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 460 MCCUTCHEON RD
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 1.290 Plat: 04-046-PARK VIEW ESTATES 2ND ADDN
SEC 17 T29N R1 9W PARK VIEW ESTATES 2ND Block/Condo Bldg: LOT 52
ADDITION LOT 52 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
17-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2009 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.290 54,000 269,300 323,300 NO
Totals for 2009:
General Property 1.290 54,000 269,300 323,3000
Woodland 0.000 0
Totals for 2008:
General Property 1.290 54,000 269,300 323,3000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 206
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
E 3'; Y H 'i t?= Y - < S i E s s f i.~•E ' `D 9' _f 9 FAG- i
-
fv`=t-nmerci a i e5ti n _g Laboratory DATE C1LLEC i E f- 1
..fi 'laiEn s St. o`- _ATE RECFP;c7 is 3. is t1.t
_ustar;, REi =
E_ DL-~L~.LL- ~T L131=i
1s fE sEF%ED .4 . CL i t_itf
L ter _{...tI lr-; F .~YE`= a W!- EF_
Hittn c Pamei a ~o E -L Ee
St. Croiz Count17 Zoning
_ _ _ _ R dszon 'WT 5.4 0.16
=AtI`id''L:`_ i1C.:ltvRI f iON: Hnaer=_.on
119
A ySIS- 460 McCutcheon Lane, Hudson
rromo> i. tihI or omnet 1-1 ane, ug,'
Drot-[?o'form, _sg/L
Bromometha.ne, u.qi L (Metn y l bromide)
= i .
Larhon tetrachi on de, f Q/L
C iiorobenZene, u,g/l.
_nioroet~ ane, ug/L t. i•{1 C iori. _ie i.4
-Cl-hioroethylvinyl ether, ugI/L ;ti y
Chloroform, ug/L
C-hioromethane, uq/L (Methyl chloride) "(1.6
Dibromochioromethane, ug/L
1 , -Vi chl orohenzene, ug/C
(o-Di f--hl orohenzene)
1, -Hichlorohenzene, ug/L_
im-Dichlorobenzene)
1,4-DichlorohenZene, ug/L 1.=
(p-iii. chl orohenZene-E
1%
iofTlorC~cthcne, Ur /L
Drich lorcethane, ug/L:V.
(Ethylene dichloride)
1.1-Dichloroethene, ug/L _E *o `
trans-i,21-Uichloroethene, uq/L 0. f 'a a
1, -uichloropropane, ug/L 1 ._.g 6 o~ ~r 3
ci =_•-i , -%i chl oroproperle, uq/L 1.
tr ans-1 , -?-Di chl oropropene, ug/L
Methylene chloride, ug/L
(Hichlaromethane) tM
means "not detected at this level". 1 mg = 1000 ug.
Member
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
~91
SAMPLE iF-ESCRIPTTON: Anderson
a a '7 s
AN f-LYSICS
i g i 5: X- i etrac`:loroethane, u =--t:~
a i r1=nlor o-thane. _.g/L af.
l y l; ---i =h oroe banes ug/I
-i r-i c?- oroet ene q ugf-11- _}a
(tt ichlorv3luoromethlEne, ug/L `-t-reon l1} '-:iis i
Yinyj chloride, ug"i jaU
etraci:loroethene, ug'L
Ethylbe_fZene, ug/L l=f'
Toluene, uQ /L a Si
This sample's anal°jtical results are below the 5I. S. ;:PF:s
Dta i Maximum Contaminant level of 1 /3.0i c~l for those requested
compouncs whi c are also or-, the S13WA MCL list.
one 0-- three vials was received broken.
< means "not detected at this lever=. i mg = 1000 ug.
Member
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS .".E:-i1RT NO: 907` PAGE
12/02/91
All analyses _ were ppr--.f1.or1Tted 1.-!*=?.!i?' E"s-? Or o=f':eY' accepted ;i1°t'to0o_€_tg' e=.
Samples that may be of an environmentally hazardous nature will be
returned to )IOU. Either samples will he stored for 30 days from the
dote of this report, then disposed of by SE8' CO Laboratories. Please
contact m;= i- other arrangements are needed. This report may not be
reproduced, except in its entirety,
without prior written approval
from j-SERCO Laboratories.
Report submitted by,
~ -'kC C"o c/f -J
Project Manager
means "not detected at this level". 1 Rig = 1000 ug. ~
Member
3
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
- (715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
8 Water (VOC's) $185.00 ❑ Septic $25.00
❑ Water (Nitrate & Bacteria) $35.00 (Visual inspection)
Owner: Requested by:
7 ZR,". Siv~c,~
Address: Address:
City & State: City & St. wr
Zip Code: Zip Code:
Telephone N°: (i (S } Telephone N4: ( ) ' - c>
Property address (Fire W & Street) : ~u(D MCC L Tz ~U-fna,
Location: Sec. , T_7 t N, R Town of
St. Croix Co. WI Tax ID N° Parcel ID N4?=)ir
House color: [~UA'Realty firm: Lc_1,',~1'2-- Lock Box Combo: OUJZ,
Water sample tap location:
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Is the dwelling currently occupied? 0 Yes 0 No
If vacant, date last occupied:
Septic system installed by: Year:
Septic tank last serviced by: Date:
Previous Owner's Name(s):
1.
Have any of the following been observed?
❑Y ❑N Slow drainage from house. ❑Y ❑N Sewage Back-up into dwelling. F,;3
❑Y ❑N Sewage discharge to ground surface,
road ditch or body of water.
❑Y ❑N Slow drainage from the dwelling. G(
'`-per c)E~.,C
❑Y ❑N Foul odors.
Other comments relative to system operation: C/
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:
1 ~A
4/93
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
IN
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? []Yes []No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: []Below grd ❑At-Grd []Mound
Approx. size 'X []Gravity []Dose []Pressurized
Ft.Z []Bed []Trench []Dry Well
[]Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES []Other []Unknown
Septic tank
Setbacks: []House []Well []Prop. line []Other
Dose tank
Setbacks: []House []Well []Prop. line []Other
[]Locking cover []Warning label []Pump/Floats
[]Alarm []Elec. wiring
Soil Absorption System
Setbacks: []House []Well []Prop. line []Other
❑Ponding: []Discharge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
N
II
Inspector
Title
07/29/93 08:39 FAT 612 636 7178 SERCO LAB. 4-*4 S.C. CO CRTHOUSE IJU01
SlEIRCO Laboratories St. Paw. tv?;rig=
a,a
1931 West County Roaa C2
St. Paul, Minnesota 55't 13
Phone: (612) 636-7173 FAX (612) 636.7178
CONFIDENTIALITY NOTICE
This facsimile transmission is intended only for the use of the individual or entity to which it is
addressed, and may contain confidential information belonging ro the sender. If you are not the
intended recipient, you are hereby notified that any disclosure, copying, distribution, or the
taking of any action in reliance on the contents of this information is strictly prohibited. If you
have received this transmission in error, please immediately notify its by telephone to arrange
the return of these documents.
~a?
G .;1 7~ cS.Cta DAM: . Z~3
T0: r~ Please deliver this fax
transmittal ' i a 1
F11M: 34 0
NL=ber of Pages
FROM: (including cover sheet)
SERM Laboratories
cents:
If you do not receive all of the pages, please call (612) 636-7173 as soon as
possible. When Cuatrty and Service Counr
07.29/93 08:40 FAX 612 636 7178 SERCO LAB. -44 S.C. CO CRTHOUSE Z002
SERCO Laboratories
1931 west County Roao C2. St. Paul. MinneWta 5.',113 Phone (812) 636.7173 FAX (fit?) 635.7178
LABORATORY ANALYSIS REPORT NO: 32578 PAGE 1 of 3
07/28/93
St. Croix County Zoning DATE COLLECTED: 07/15/93
911 4th Street DATE RECEIVED: 07/19/93
Hudson, WI 54016 COLLECTED BY : CLIENT
DELIVERED BY : CLIENT
SAMPLE TYPE _ DRINKING WATER
Attn: Mary J. Jenkins
CLIENT'S TD: 79-93
SERCO SAMPLE NO: 89043
SAMPLE DESCRIPTION: Lamb,
Wayne
460 Mc-
ANALYSIS: Cutcheon
Benzene, ug/L <1.0
Bromobenzene, ug/L <0.2
Bromochloromethane, ug/L <0.4
Bromodichloromethane, ug/L <0.2
Bromoform, ug/L <0.5
Bromomethane, ug/L (Diethyl bromide) <1.0
n-Butylbenzene, ug/L <0.3
sec-Butylbenzene, ug/L <0.4
tert-Butylbenzene, ug/L <0.5
Carbon tetrachloride, ug/L <0.2
Chlorobenzene, ug/L <1.0
Chloroethane, ug/L (Ethyl chloride) <0.4
Chloroform, ug/L <0.5
Chloromethane, ug/L (Methyl chloride) {0.6
2-Chlorotoluene, ug/L (o-Chlorotoluene) <0.2
4-Chlorotoluene, ug/L (p-Chlorotoluene) <0.2
Dibromochloromethane, uq/L <0.4
1,2-Dibromo-3-chloropropane, ug/L <1.2
1,2-Dibromoethane, ug/L <0.2
(Ethylene dibromide)
Dibromomethane, ug/L <0.2
1,2-Dichlorobenzene, ug/L <1.0
(o-Dichlorobenzene)
1,3-Dichlorobenzene, ug/L <1.0
(m-Dichlorobenzene)
< means "not detected at this level". 1 mg = 1000 ug.
07/29,,93 08:41 FAX 612 636 7178 SERCO LAB. 44-r S.C. CO CRTHOUSE Z003
SERCO Laboratories
1937 West County Roaa C2. St. Paul. Minno ;ota 55113 Phone (512) 636.7173 FAX (612) 535,7175
LABORATORY ANALYSIS REPORT NO: 32578 PAGE 2 of 3
07/28/93
SERCO SAMPLE NO: 89043
SAMPLE DESCRIPTION: Lamb,
Wayne
460 Mc-
ANALYSTS: Cutcheon
1,4-Dichlorobenzene, ug/L <1.0
(p-Dichlorobenzene)
Dichlorodifluoromethane, ug/L (Freon 12) <0.5
1,1-Dichloroethene, ug/L <0.1
1,2-Dichloroethane, ug/L <0.2
(Ethylene dichloride)
1,1--Dichloroethene, ug/L <0.2
cis-1,2-Dichloroethene, ug/L <0.1
trans-1,2-Dichloroethene, ug/L <0.1
1,2-Dichloropropane, ug/L <0.1
1,3-Dichloropropane, ug/L <0.2
2,2-Dichloropropane, ug/L <0.2
1,1-Dichloropropene, ug/L <0.2
cis-1,3-Dichloropropene, ug/L <1.5
trans-1,3-Dichloropropene, ug/L <0.9
Ethylbenzene, ug/L <1.0
Hexachlorobutadiene, ug/L <0.3
Tsopropylbenzene, ug/L, (Cumene) <1.0
4-Isopropyltoluene, ug/L <0.5
(p-Isopropyltoluene)
Methylene chloride, ug/L <5.0
(Dichloromethane)
Naphthalene, ug/L <0.2
n-Propylbenzene, ug/L <0.4
Styrene, ug/L <1.0
1,1,2,2-Tetrachloroethane, ug/L <0.2
1,1,1,2-Tetrachloroethane, ug/L <0.1
Tetrachloroethene, ug/L <0.2
Toluene, ug/L <1.0
1,2,3-Trichlorobenzene, ug/L <0.2
1,2,4-Trichlorobenzene, ug/L <0.2
1,1,1-Trichloroethane, ug/L <5.0
< means "not detected at this level". 1 mg = 1000 ug.
l
07/29/93 08:41 FAX 612 636 7178 SERCO LAB. 444 S.C. CO CRTHOUSE Z004
SERCO Laboratories
193 t West County R020 C2. St. Paut. Minnewta 5,5113 Pnone (512) 636-7173 FAX (812) 636-7178
LABORATORY ANALYSIS REPORT NO: 32578 PAGE 3 of 3
07/28/93
SERCO SAMPLE NO: 89043
SAMPLE DESCRIPTION: Lamb,
Wayne
460 Mc-
ANALYSIS: Cutcheon
1,1,2-Trichloroethane, ug/L <0.1
Trichloroethene, ug/L <0.4
Trichlorofluoromethane, ug/L (Freon 11) C0.7
1,2,3-Trichloropropane, ug/L <0.2
1,2,4-Trimethylbenzene, ug/L <0.2
1,3,5-Trimethylbenzene, ug/L <0.3
(Mesitylene)
Vinyl chloride, ug/L <1.0
Total Xylene, ug/L <1.0
bsYA 71aff/9-3
This sample's analytical results are below the U.S. EPA's
SDWA Maximum Contaminant Level of /30/91 for those requested
compounds which are also on the SDWA MCL list.
All analyses were performed using EPA or other accepted methodologies.
samples that may be of an environmentally hazardous nature may be
returned to you. other samples will be stored for 30 days from the
date of this report, then disposed of by SERCO Laboratories. Please
contact me if other arrangements are needed. This report may not be
reproduced, except in its entirety, without prior written approval
from SERCO Laboratories.
Report submitted by,
Diane J_ nderson
Project Manager
< means "not detected at this level". 1 mg = 1000 ug. -
„,`h
~~r
1
• r
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.itany Pe/unit )760c1
State Septic d2
NAME rownzh.ip S.t. Cno.ix County
10 L , catioiaSects on _
T n
c' 0 V a S
2
SEPTIC TANK ! ~ ~
Size Q 6 ga.t.ton4. Numbe o6 Compantmentz w
D.iA Lance Fnom: Weft it. 12$ on greaten A tope
6t
Buitd.ing WeVand.6
N.ighwaten 61.
DISPOSAL SYSTEM
D.idtance. Fr..om: Wett it. 12$ on greaten a.tope it.
Bu.i-td.ing it. W et.tand,6 Ft.
Naghwaten 6t•
FIELD DIMENSIONS:
Width o6 trench ;Z--6t. Depth o6 rock be.tow. t.i.tel-i!~.-.in.
z
Length o6 each tine 6.t. Depth o6 rock oven .t.iteZ in.
Numbers o6 tine.6 Depth o6 tiZe be.tow grade J Oin.
Tota.t .length o6 E~.nes~it• S,to pe 06 trench Z in pen 100 it.
DiA Lance between t inez ~r it. Depth .to ' b edno ck 6 t.
Tota.t abz onbt.ion area G a Ate Depth to gnoundwatea 6t.
Requ.in.ed anea 6t2 Type oA Coven: Papers % Straw
PIT DIMENSIONS:
Numbers o?o0&btion--a&ea c. Gnavet. around pit.ar_yed no
Ou" ide Uep,th below in.te.t it.
Tota.t 46 At1 • z
Area equ.ined T 6t2 rn
INSPECTED By
. TITLE
APPROVED DATE Z 19t
REJECTED ,DATE 197
01
d~
State and County State Permit # t ` IS
PLB
67
Permit Application County Permit
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:
/ j
-5 A, t
B. LOCATION: d1r irf/ % 'r %Y4, Section T2- N, Raj E (or) W Lot# ✓*~City
Subdivision Name, nearest road, lake or landmark Blk# Village
t/1 1T t+~"4t/ / 5 'i r'14 Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family V Duplex No. of Bedrooms y 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 l✓ 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. 21/ Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft.- , Vidth epth Tile depth (top) No. of Trenches
Seepage Bed: Length Width L Depth S Tile depth (top) No. of Lines
Seepage Pit: Insi e diameter Liquid Depth No. of Seepage Pits
Percent slope of land- Distance from critical slope
WATER SUPPLY: Private n '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, / _
NAME hrl ? 14A 1± C.S.T. # ~ ~ and other information
obtained from /r/✓ " ! /,h (owner/builde _
7
Plumber's Signature c MP/MPRSW# i~ Phone
Plumber's Address r % o rw < Z u h rri/~ <
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
14
,d 1.~ f'Z ~ Div
- lie
Gar,
l e
ut
~.I
/V1 A,
s 5
Do Not Write in Space Bel FOR COUNTY AND STATE DEPARTMENT USE ON Y
Date of Application ee Paid: State /S County Date S Z
Permit Issued/Rejecpod (date) 0 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) Revised Date 7/1/78
E 1 1 aJ Rev. 9/78
q REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701.
LOCATION:'/a/a, Section TI~'(orTownship or Municipality tl w SC~ti'
u
Lot No. - ~ Block No. 4~ _ J N:2 'f/fJ~a' S` 71 y County ~ `X
Owner's /Buyers Name: Subdivision Name
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms .5 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SH EE fp__? a.
NAME OF SOIL MAP UNIT ~ 1i/~/(~"~/,~
PERCOLATION TESTS
TEST 1 HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
NUM- DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL RATE
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 71 PERIOD 2 PERIOD 3 MIN/IN
P_ N/0
Sec /_`2're
P- v
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- Z Lcl:ct_ el Al
B- _3 7
L
,
B- y 3/ le 5-Z 5-5- 115
B- j ~r< yva,u -7 L-6, " s
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the laruh,9 location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy z' 'In icate scat or d'stances.
Give horizontal and vertic I referencf point InnPicate slope. /
-Zi _
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E
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N
l
02, SA,-, c
c C t ~cacf / - t
.t/cr~les
/ I e
~C L`,ra~tfl/
a
-5
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.
~ c-
Name (print) Certification No.~ Sal
Address
.Name of installer if known
Copy A - Local Authority CST Sign e=,, 4 e