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Parcel 020-1144-20-000 12/06/2005 09:30 AM
PAGE 1 OF 1
Alt. Parcel 17.29.19.751 020 - 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 - RABIDEAUX, JOSH M & ERIN O
JOSH M & ERIN O RABIDEAUX
471 MCCUTCHEON RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 471 MCCUTCHEON RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.650 Plat: 2276-PARK VIEW ESTATES 2ND ADD
SEC 17 T29N R19W PARK VIEW ESTATES 2ND Block/Condo Bldg: LOT 58
ADD LOT 58 _
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
08/10/2005 803047 2863/635 WD
07/23/1997 1070/221 WD
07/23/1997 841/528
07/23/1997 752/338
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 1.650 61,700 198,600 260,300 NO 05
Totals for 2005:
General Property 1.650 61,700 198,600 260,300
Woodland 0.000 0 0
Totals for 2004:
General Property 1.650 31,900 180,500 212,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 136
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
iER i~7 ✓ , TOWNSHIP SEC. 7 T LN, R_ _W
:j. ADDRESS l t, i:14 r , ST. CROIX COUNTY, WISCONSIN.
)DIVISION LOT) LOT SIZE +T"1 61
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
_ SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/,_4
-TIC TANK(S) 'MFGR. CONCRETE STEEL
NO. of rings on cover Depth j" DRY WELL
-'NCHES NO. of width length area
no. of lines width ? length area PV,
depth to top of pipe -
3REGATE
';K RATE , AREA REQUIRED AREA AS BUILT
claimer: The inspection of this system by St. Croix County does not imply complete
aliance with State Administrative Codes. There are other areas that it is not possible
-j
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.
'INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER
ST. CROIX COUNTY
WISCONSIN
1
ZONING OFFICE
: II N 11111,1 II h 1111 - NNr G
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
February 28, 1994 /",I, fd
3-6 o z"3 r.
z'-1 o Heritage Title
502 Second Street
Hudson, WI 54016
RE: Water and VOC results for Robert & Barbara Robinson
Address: 471 McCutcheon Road, Hudson, WI
To whom it may concern:
Enclosed is the original water test and VOC tests results from
Commercial Testing and SERCO Laboratory, Inc. for a water
inspection of the above property. If you have any questions with
regard to said report, please let me know.
Sincerely,
v
Mary Jenkins
Assistant Zoning Administrator
js
Enclosure
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 40612 PAGE 1 of 3
02/25/94
St. Croix County Zoning DATE COLLECTED: 02/16/94
1101 Carmichael DATE RECEIVED: 02/17/94
Hudson, WI 54016 COLLECTED BY : CLIENT
DELIVERED BY : CLIENT
SAMPLE TYPE DRINKING WATER
Attn: Mary J. Jenkins
CLIENT'S ID: Robinson
SERCO SAMPLE NO: 20424
SAMPLE DESCRIPTION: Robinson
Sample
of
ANALYSIS: 02-16-94
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 (Methyl 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, ug/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.
MEMBER
f
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 40612 PAGE 2 of 3
02/25/94
SERCO SAMPLE NO: 20424
SAMPLE DESCRIPTION: Robinson
Sample
of
ANALYSIS: 02-16-94
1,4-Dichlorobenzene, ug/L <1.0
(p-Dichlorobenzene)
Dichlorodifluoromethane, ug/L (Freon 12) <0.5
1,1-Dichloroethane, 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
Isopropylbenzene, ug/L, (Cumene) <1.0
4-Isopropyltoluene, ug/L <0.5
(p-Isopropyltoluene)
Methylene chloride, ug/L <5.0
(Dichloromethane)
Naphthalene, ug/L <1.0
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.
MEMBER
SERCO Laboratories
1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178
LABORATORY ANALYSIS REPORT NO: 40612 PAGE 3 of 3
02/25/94
SERCO SAMPLE NO: 20424
SAMPLE DESCRIPTION: Robinson
Sample
of
ANALYSIS: 02-16-94
1,1,2-Trichloroethane, ug/L <0.1
Trichloroethene, ug/L <0.4
Trichlorofluoromethane, ug/L (Freon 11) <0.7
1,2,3-Trichloropropane, ug/L <0.2
1,2,4-Trimethylbenzene, ug/L <1.0
1,3,5-Trimethylbenzene, ug/L <1.0
(Mesitylene)
Vinyl chloride, ug/L <1.0
Total Xylene, ug/L <1.0
This sample's analytical results ar arc-rrat-below the U.S. EPA's SDWA
Maximum Contaminant Level of 1-30-91 for those requested compounds
which are also on the SDWA MCL List.
Sample received on blue ice.
Temperature of cooler: 18.2 C.
The analytical results in this report pertain only to the items tested.
All analyses were performed using EPA or state approved 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. Anderson
Project Manager
< means "not detected at this level". 1 mg = 1000 ug.
J1
MEMBER
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
CROIX COUNTY ZONING OFFICE REPORT NO.: 57392/01
,:ROIX CTY GOV,CTR REPORT TiATEt 2/18/94
CARMfICHAEL ROAD DATE RECEIVED: 2/17/94
;ATION. 471 McC01 r,.
.LECTOR: Mit Jenk i
'E COLLECTEDS 2-16-'
E CO! LEGTED4 11:Df:;
_1FORMi,MfFCC: 0
E RF'RETAT ION: Rac ter i o i o,3 i s.a i k Sr
5 ppm
ove 10 ppm exceeds the recommended Public
G
r '
f OF.NOEGENOpHT.
O A
id o A
T
PROFESSIONAL LABORATORY SERVICES SINCE 1952
}
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
--~j (715) 386-4680
February 16, 1994
Heritage Title
502 Second Street
Hudson, WI 54016
To whom it may concern:
An inspection of the septic system on the property of Robert and
Barbara Robinson located at 471 McCutcheon Road, Hudson, Wisconsin,
was conducted on February 16, 1994.
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.
Also at the same time, a water sample was taken. Once we receive
the results, we will forward the same on to you.
Should you have any questions, please contact this office.
Sincerely,
/s/ Mary Jenkins
Mary Jenkins
Assistant Zoning Administrator
mz
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.
Water (VOC's) $185.00 Septic $
Water (Nitrate & Bacteria). $Bs-B (Visual inspection)
Owner: r_ A. Requested by: 'oT/rE'L /j7,t E
r
Address: Address: -
City & Sta e: f ~fP r~~l; , tom.- City & St. ~ , 4~
- or Lit Zip Code: ~ L,EZip Code:
Telephone N°: (21! Telephone N°: (7/1,) 0"
Property address (Fire N2 & Street) h 7-41,1S . A:
Location:__;, Sec. , TN, R W, Town of f (iL~ sz' ti'
St. Croix Co., WI. Tax ID N4` '+L;ly'i_'~ Parcel ID NQ I ,rte s"c:'
House color: t Realty firm: / j r Lock Box Combo:
Water sample tap location: E L , r bj
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Is the dwelling currently occupied? 1X Yes ❑ No
If vacant, date last occupied:
Septic system installed by: k A/ L0 Year : ,
Septic tank last serviced by: T/2, c-(-) --^N'7Fl7-10 Date: Su/Y9tl✓ l~ or=
Previous owner's Name (s)
Have any of the following been observed?
❑Y '%1 Slow drainage from house.
❑Y Sewage Back-up into dwelling.
❑Y Sewage discharge to ground surface,
road ditch or body of water.
❑Y Slow drainage from the dwelling.
❑Y ~CN Foul odors.
Other comments relative to system operation:
I certify that the above information is complete---)and true to the
best of my knowledge.
OWNERS SIGNATURE: -,-,.DATE: 4/93
OWNERS DRAWING OF ROUSE & SEPTIC SYSTEM LOCATION
t
IN
e
t.
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 OAt-Grd []Mound
Approx. size 'X OGravity []Dose []Pressurized
Ft.2 []Bed []Trench []Dry Well
[]Holding Tank Ooutfall pipe
OBSERVED DEFICIENCIES []Other []Unknown
Septic tank
Setbacks: OHouse_ []Well []Prop. line i4` []Other
Dose tank
Setbacks: []House ell []Prop. line []other
[]Locking cover []Warning label []Pump/Floats
[]Alarm OE19c. wiring
Soil Absorption System i
Setbacks: ❑House1-) OWell_;L2 OProp. line~~[]Other
OPonding:ti~ ODischarge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
N .
6
4
Inspectors .,!i.;
Title
1-20-94
TRI-COUNTY SERVICES, INC.
507 5th. STREET
HUDSON, WI. 54016
Mrs. Barb Robinson
471 McCutcheon Rd.
Hudson, Wi. 54016
To Whom It May Concern,
My company, Tri-County Sanitation Services, has maintained the
septic tank at 471 McCutcheon Rd. for the past five years. As a
part of that maintainance the first time the septic tank was
pumped the exit line to the drain field was cleaned. Since that
time the septic tank has been pumped every two years, the latest
being the summer of 1993.
incercly,
VINJ
Ben Morgan
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730 cjl:~& 1'tj
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030 r
t{,_L.. _~.t L0t'r iJ- ht ;'Ur' I !"!u
3T.CROIX CTY GOV.CTR REPORT DATE*. 2/18-1
1141 CARMICHAEL ROAD D'J.E
HUDSON. WI
ATTW THOMAS C. NELE-10f-
_t~;ATION; 471 McCukheur, Rd:. Hudsor,
°A_LECTOR: M. 3enkin_
TE COLLECTED4 -1o-5' s
;AE COLLECTED: II+'00a!!?
T.ME ANAL` ZED: :ti-vF:i,
FLiFORMMFCC: G
„J OF `;NDEGENO
t,
/1 2 9(
\IO p ~ \ D 1
,I
L
DC"!=•;: i'ab1.E? Le'V!'i Approved {,7Y!
PROFESSIONAL LABORATORY SERVICES SINCE 1952
-
COMMERCIAL TESTING LABORATORY, INC.
5114 Main Street, P.O. Box 526 ,
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030 C
t10IX CTY GOV.CTR REPORT irATE! 2/V:`
CARMICHAEI- ROAD
r . ,.r ~A;..
ATION1 471 McCu
.:.-ECTOR. M4 jenk ,
L COLLECTED:
f " COLLECTEDI 11:
I~
1
1EORMtMF'CC* 0
A
r Z
JOF.\NDEGENOFN
1
~9m
PROFESSIONAL LABORATORY SERVICES SINCE 1952
- -
0
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
ST. CROIX ZONING REPORT NO.. 06573/01 PAGE 1
ST. CROIX COUNTY REPORT DATE: 6/22/90
COURTHOUSE DATE RECEIVEDt 6/21/90
HUDSON, WI 54016
ATTN2 THOMAS C. NELSON
J I
jj/~,'j ~ r- Zb- jaz
~i / ri,
G 'j
OWNER** RoberDrbarinson
C
Ll"~ I ~~''1LCu
LOCATIONS Hudson, WI
COLLECTORS M. Jenkins
SOURCE OF SAMPLE. Outside Faucet
COLIFORMS 0 /100 mL
INTERPRETATION: Bacteriologically SAFE
NITRATE-NS 35 ppm
Under 10 ppm is safe for human consumption.
I
LAB TECHNICIANS Pam Gane
WI Approved Lab No. 19
Jj!DEPEND
OF E'l'l,`
2 Tm
O A
i? C Means "LESS THAN" Detectable Level Approved byt
01
PROFESSIONAL LABORATORY SERVICES SINCE 1952
eft d wit °+ir ter+ wri4T`; .ii1%~,:: ♦ T
y ~ i !14 1„3.;.3.._
CAA\ 0
ST. CROIX COUNTY ZONING OFFICE
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
n ti,
Telephone - (715)386-4680
1
The St. Croix County Zoning office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
C' =Rlst; on 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 oossib~t._.aftex.-fs~_aiid_ form_ are *'Q~'°~ -
FEE: $ 25.00
i9ATER TESTING
9r nitrates and coliform bacteria)FEE: $175.00
WATER TESTING
(For VOC'S)
SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00
(Determines if system is properly functioning at time of
inspection)
Property owner's name
Property owner's address Ax'_C~~~~rLh'~~
Legal Description 1/4 of the 1/4 of Section T,- N-Rfz
Town of f l!' ;mow'`- Lot Number `5 , Subdivision Name yi/'i.
FIRS NUMBER ;'I _ LOCR_ BOX_ NUHHER
Color of house „yRealty sign by house? A,-" If so, list firm:
PLBABS 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.
Ad/K/22/'4
Firm or individual requesting services:
f -
Telephone Number ' y 17 A>)
REPORT TO BE SENT TO: N "nn
_%:~G;TC EG Yj
Closing date
Signature
._:..,....wr.....rrn,r4we: ..u._ Wvrarrv.actuwvr:. ss'.+-.r ate: n... •-.y u.,1. :
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
Sanitatcy Penm.it-
S,tate Septic
NAME ; Township St. Ctcoix County
Location -z'4 o !-4, Section T N,R -W
SEPTIC TANK
Size gattons. Numbet o6 CompaAtment6
D.i.stance FAom: Wett 120 oA gneatetc zZope 6t
Building 6t. Wettandts S .
H.ighwateA _ 6t.
DISPOSAL SYSTEM
Distance FAOm: Wett it. 12% oA gd.eatetc zZope 6t.
Bu.itding 6t. WetZands Ft.
HighwatvL ~ .
FIELD DIMENSIONS:
Width o6 tAench 6t. Depth o~ tcock below Cite .in.
Length of each tine 6t. Depth o4 Aock oveA Cite in.
NumbeA o6 tines Depth o6 tite below gd.ade in.
Totat tength o~ tines 6t. Stope o6 .tAench in peA 100 bt.
t
Distance between Zine~s 6t. Depth to bedd.ock 6t.
7 Ta al absanb ion atcea ~ 2 Depth to g&oundwateA 6t.
Requi&ed area 6t2
~ y
PIT DIMENSIONS:
NumbeA o6 pits G taveZ atcound p.it,5 yets no
Outside d.iametvL Depth below -inZet it.
2
TotaZ ab.SOAbtion a&ea 5t z
AAea Requited ~t2 rn
I
INSPECTED BY TITLE /
I APPROVED ,,9ATE 197
REJECTED DATE 197
t
i
{i
I
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
I REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: n r-'/4'/a, Section -Q-, TAN, R/7 E (or) W, Township or Municipality-LL e1' 'i
Lot No. S~, Block No. ~r~t 14 /-,z -0 C-~ County
Subdivision Name
Owner's Name: 5,:~ r-- i -
Mailing Address: n/"
TYPE OF OCCUPANCY: Residence t--- No. of Bedrooms 7f7 Other
EFFLUENT DISPOSAL SYSTEM: NEW (ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 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
P 1 1 G
P 3 l t r < < I JI t y7J 7
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)
E 7 y~i
B 72
B 3 ~7 -7 . &'I- y y .~r
L/ 72- 7
PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas ndicate num r of square feet of apsorp on area
needed for building type and occupancy. 1 } ° 4r~tlat ale
or distances. Give horizontal and vertical reference points. Indicate slope.
j 1
. _ .
f
ill I 1 ~ ~ P ~ I I i ~ ( I
- -
I
7tl
t.--+
4
1 i I I l i s/. L(
_j---- h I
r
I ; 3 C I I ~N 1~~ t 1
a ~ i I ( i 11 ~ ~ T I b
a I
I I I Y
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.
Name (print) 141 D x/ k I h /4) . Certification No._~
Address 6-1 t lip ic
Name of installer if known
OPY A - LOCAL AUTHORITY CST Signature,''' - -
J
nt State Permit # 13- _
LB6 7 StateandCou y
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:
B. LOCATION: Section T~ N, R E (or) W Lot# City
Subdivision Name, nearest road, la landmark Blk# Village
Township
R E S- -r-
C. TYPE OF CCUPANCY: *Commercial *qIndustrial *Other (specify) *Variance
Single familOy ~ Duplex No. of Bedrooms 3 No. of Persons
D. TYPE OF APPLIANCES: Dishwasher (s YES NO Food Waste Grinder C.- YES NO # of Bathrooms
/automatic Washer ✓ YES NO Other (specify)
;SEPTIC TANK CAPACITY C) -Total gallons No. of tanks
`Holding tank capacity Total gallons No. of tanks
V'
aw Installation Addition Replacement Prefab Concrete
`Poured in Place Steel Other (specify) _
FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ~52) 3) Total Absorb Area sq. ft.
' w Addition Replacement *Fill System
;epage Trench: No. Lin . Feet _ Width Depth Tile Depth No. of Trenches
Z
.,epage Bed: Length Width Depth Tile Depth No. of Lines
:seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land Distance from critical slope
the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
,1isconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
)y the Certified Soil Tester,
s.AME A (Gh J, 1? D W f' l iy S C.S.T. # and other information
obtained from (owner/builder). _ _ "q /V t7 5
umber's Signature ZRAPIM RSW# ~2 Phone - 3 Z
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Spa Below- F R DEPARTMENT U.SE ONL ~-O
Date of Application Fees aid: State County Dat T~ -
&;L (date) Issuing Agent Name
o Valid# Recd py) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
4. plumber (canary copy)