HomeMy WebLinkAbout020-1010-70-000
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Document Number Document Title
940885
BETH PABST
St. Croix County
REGISTER OF DEEDS
Occupancy Affidavit ST. CROIX CO., WI
RECEIVED FOR RECORD
08/31/20111:06 PM
RIAn K~eerv'
EXEMPT
Na e - (Owner) Typed or printed
REC FEE: 30.00
being duly sworn, states, under oath, that:
PAGES: 1
3
1. He/she is the owner/part owner of the followin parcel of land located in St.
Croix Coup,.Wiysconsin, recorded in Volume Page(j Document
Number (C St. Croix County Register of Deeds Office: 3 Recordi Area
Name and Return Address
A parcel of land located in the Y, of the E of Section _ ~n Cyy~,~ 1J~CK
ad ~1~,~~ P1QcQ
TLEN - R _ W, Town of 6L IrAlcpr~k St Croix 1"81
t County, )&`isconsin, being duly described as follows (include lot no. and G
subdivision/CSM or detailed legal description): I U aq
19M 02-0 - I6 0--70-(-W
s
Parcel Identification Number (PIN)
i
As owner of the above described property, I acknowledge that the septic system serving this residence is sized for a
~
3 bedroom home, or a design flow of &!;50 gpd. The design flow is calculated by a suming 150 gpd for 2
Individuals per bedroom. There are currently occupants living in this residence; occupants are permitted s.
based on the design flow. Therefore the septic system serving this residence is code compliant. However, I
understand that if there are intentions to exceed the number of permitted occupants, the system will need to be F
modified to accomodate any increased wastewater fl ows and/or contaminant loads. I also acknowledge that I will make
this information available to any future parties interested in purchasing this property.
Dated this 3 _ day of i
V
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1A eer X,
t
f
ACKNOWLEDGMENT
Signature(s) AUTHENTICATION STATE OF WISCONSIN)
authenticated this day of St. Croix County. )
j Personalty came before me this day of
E the above na
TITLE: MEMBER STATE BAR OF WISCONSIN i
(If not, to me known to be the person(s) who executed ft foregoing
autliaized by § 706.06, Wis. Stats.) instrument and acknowledge the same.
s
THIS INSTRUMENT WAS DRAFrED BY I
f
Notary Public, State of Wisconsin
(Signatures may be authenticated or acknomMedged. Bo rd Commission is permanent. If not, state expiration date:
necessary.)
"THIS PAGE IS P NT - DO NOT REMOVE"
This k*MU M must be completed by submNer. and PIN_ (irequIred). Other intbansUon such as the 4
etc. may be or may be placed on addlkvW pages of fie
!8 mss' wsconsln Stat<des, 59.517.
document. Use of this mverpage adds one
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Parcel 020-1010-70-000 03/09/2006 03:36 PM
PAGE 1 OF 1
Alt. Parcel 10.29.19.44E 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 - COOK, ROBERT D & KATHRYN S
ROBERT D & KATHRYN S COOK
681 OLD HOPKINS PL
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 681 OLD HOPKINS PL
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.048 Plat: 3793-CSM 14/3793
SEC 10 T29N R19W PT NE SE BEING CSM Block/Condo Bldg: LOT 3
14/3793 LOT 3
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
10-29N-19W NE SE
Notes: Parcel History:
Date Doc # Vol/Page Type
03/07/2002 672843 1848/502 WD
06/24/1999 605568 1436/516 WD
07/23/1997 737/25
07/23/1997 582/60
2005 SUMMARY Bill Fair Market Value: Assessed with:
91421 183,300
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.048 75,200 111,700 186,900 NO 05
Totals for 2005:
General Property 2.048 75,200 111,700 186,900
Woodland 0.000 0 0
Totals for 2004:
General Property 2.048 44,100 93,500 137,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
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
:WER TOWNSHIP=I1tSEC. T No R/% W
0. ADDLES ST. CROIX COUNTY, WISCONSIN. '
'DIVISION LOT LOT SIZE
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
A
~-TIC TANK(S) ~ MFGR. CONCRETE Z
NO. of rings on cover L Depth DRY WELL
WCHES NO. of width length area
no. of lines width , length - area
depth to top of pipe a
REGATE
,L. RATE AREA REQUIRED AREA AS BUILT f ~
;claimer: The inspection of this system by St. Croix County does not imply complete j
:pliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
:tem operation. However, if failure is noted the County will make every effort to
..ermine cause of failure.
_ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
'INSPECT'OR
DATED PLUMBER* ON JOB
LICENSE NUMBER
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
SanitaAy Pe&mi tjo,2
State Septic /,won
NAME yr ry Township ~2 ~j -1-1(_~ -St. C&oix County
Location,~&% oQ, 1-4, Section// T~jZN,RX1W
SEPTIC TANK
Size gattonts. Number. oCompaAtment/s
Distance Ftcom: wets 12% on gtceate,'t stope it
Buy 2ding it. Wettands
High.waten it.
DISPOSAL SYSTEM` 11
`Distance Ftc.om: Wett it. 12% otc gtceatetc slope it.
Buitding_~,L it. Wettand,5 Ft.
Highwate& it.
FIELD DIMENSIONS:
Wid=th o6 tkench fit. Depth o6 tcoch below tite in.
Length of each tine it. Depth of tc.ock oven tite ~ in.
I
Numbet o6 tines Depth o6 tite betow gtcade c yin.
Totat .length o6 t nes L {t. Stope of ttcench in pets 100 it.
ff.~. Distance between tines it. Depth to bed&ock.
otat ab,s otcbtion atcea ,'`.C. 4t2 Depth to gtoundwateA
V, 4 2
Requited atcea it
f.
PIT DIMENSIONS: 1
Numbet o6 pit,5 G4 avet atcound pits yeas no
Outside diametet it. n th betow intet it.
2
Totat ab,s otbtion atcea it z
A
Atcea tequ ,iced 6t2 rn
,fr a
C
INSPECTED BY TITLE APPROVED DATE 19 7
REJECTED DATE 197
-t
n
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION:-VL'/4, A-ii,'/4, Section Wit-, T,2-7N, R L2 E (or) W, Township or Municipality
Lot No. , Block No. A r i r L County f5 ct J X
Su division Name
Owner's Name:y L
Mailing Address: / 5f n', ill e' W.5 n
TYPE OF OCCUPANCY: Residence ' No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW Z/ ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS / J 263 PERCOLATION TESTS
SOIL MAP SHEET _ SOIL TYPE
~
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MI
P-1
P-)
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
R 2-
PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of sui abl ar Indicate number square feet of absprotion area
needed for building type and occupancy. / } e` ti!idiCat cale
" 57 or distances. Give horizontal and vertical reference of s. Indicate slope. -
f
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f N
16
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f t t
LILL
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 location of test holes are correct
to the best of my knowledge and belief.
N (print) ~ •`--o~ \ ~ Certification No. / ~ / f
144,
e of installer if known
CSTSign
LOCAL AUTHORITY ature
State and County/ State Permit # /yt
PL867 Permit Application County Per t
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:
~m L VY~ 5
B. L CATION: <7 at/ i c Section T.~ N, R 7~ E (or) W Lot# _ City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township r-le c r t
c. TYPE OF OCCUPANCY: `Commercial `Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons_
D. TYPE OF APPLIANCES: Dishwasher YES L-- NO Food Waste Grinder YES c- MO # of Bathrooms-L
Automatic Washer t ~fES NO Other (specify)
E. SEPTIC TANK CAPACITY i Total gallons No. of tanks
'Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement Prefab Concrete C_-.
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1)1$__ 2), 5 3) . j Total Absorb Area :2 sq. ft.
New y Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length 5_ , Width 1,~ ' Depth 3 X„ Tile Depth 9 y No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land ._,S g/B Distance from critical slope
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 Cert/if' d Soil Tester,
NAME C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature n_ fcY Gc % z Phone #JY
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
Do Not Write in Space Below - FOR DEPARTMENT USE ONLY
Q Date - - / ry
Date of Application -~7 c5 Fees Paid: State J , C, o Cour -71- y
q c> /17
Permit Issued/Utjwft:d (date) -Issuing Agent Name _4--,,
Inspection YesNo Valid# Date Recd
17
1. county (wh
to 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 6/1/76