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020-1100-30-000
c > > 0 = P d 0 .. u F = CA r �1 m O w O O) p C A N `C • m 0 3 l m m 7 • 3 7 m m o 3 co m o R Q fl' N 0 fi n., N O C " - D N O m...., ION N LA cT a, O_ 3 7 B. N Q 7 O 7 0 3 O o o lo. W 5 7 p C .- A O O C (1) V A O 7 f A7 3 7 3 c > H o 0o owe !i 0S+ c w I �+ 0 m C.D. Z cn Z D C / ) Z G) Z D < D . te a. 1 1 co O D c� D W c= D D W a a CD 0 c c 0_ ° m m c :IL _ hit = ° o c I ° c c 3 O O O O v N 1 "4...4 a O y O h A A N .O•. C !V 3 c z O O O O� I . �• z z OOOa,1 C C o C C A 1 < N Z /am E co c d) co co > V 4 cu d w 3 m m o) a a o a c 0 Q O CO ' O co W A 5i 0 4 � CR N N ; W \�V` Z Z O o Z q Z O D -4 o ✓ O a O o 1 7 N fD O H h• 0 0 0 C llV1 C C C W ( D co @ ? a I n 3 a. 3 o 7 co Z = z d a A Z n o N o N 3 c I ^ , co o v m a A z o ?. 5 Z N A z a - o TT i Z 3 ` F! 1 m c co A W N co N 0. 0 O 0 O Q 0) CD O O O 0 d O CD � ' i1 < N'O ma --0.o. <.v i 0.-0.0 0) oDS 0.o' . ? 5 r^ 0;C CL . ,�+ 7 - o A O N � O O 7 - 7 A O N -. O C A l i O i < O N 7 i N .•< O N 7 o CO S N 03 13 Z O N S , Z d CD CD SD 0 CD V co,., O O O o o N O 0) O 0 0 N 0 N N N Cl) Q) N a N (O S _ (O S _ a3 O O O < 0. 3 o o a0 p 0 a C O_ p co O. c O_ o o O q A ` . ' . . r O N F ,�.. -, O N N 0 oD 0 _ . < . y < N 7 � A N .P co 3 (a a - • d 3 6 N V C 3 �°o ma * 2 3 3�� al 2 3 A 0) O o 0 N y 0. y 0 o 0 CO y a C f co 7 7- c 0 0 0 0 0 c N 0 ti CO o. aao • O) y CO °. aao < (D 0 C W y (D 0 C ` CD ti 3� @<< o ''c 3 m o 0 7 K* 0 0 7 . g 0 ti) xa) x xsa x Et K o A 0 ! � ) $ 0 0 o o 0 1 CO a N W o o 0 o O a W 'i Parcel #: 020 - 1100 -30 -000 01/31/2005 04:31 PM PAGE 1 OF 1 Alt. Parcel #: 34.29.19.402G 020 - TOWN OF HUDSON Current I X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * HOLM, SCOTT J & THERESA J SCOTT J & THERESA J HOLM 694 BAKER RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 694 BAKER RD SC 2611 SCH D OF HUDSON SP 1700 WITC egal Description: Acres\ ' .020 Plat: 0335 -CSM 06 -1673 SEC 34 T29N R19W NE NE 3.02AC LOT 2 CSM Block/Condo Bldg: LOT 02 6/1673 REPLAT OF LOT 13 CSM 1/94 & P402B Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 34- 29N -19W NE NE Notes: Parcel History: Date Doc # Vol /Page Type 12/26/2003 750134 2481/193 WD 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 48410 268,200 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.020 46,100 161,400 207,500 NO Totals for 2004: General Property 3.020 46,100 161,400 207,500 Woodland 0.000 0 0 Totals for 2003: General Property 3.020 46,100 161,400 207,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 113 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 Wisconsin Department of Commerce County PRIVATE SEWAGE SYSTEM St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 463057 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal inIIrmation you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Holm, Scott Hudson Township 020 - 1100 -30 -000 CST M E Insp. B BM Description: Section/Town /Range /Map No: � l / Oe) /Qt 13 v 1 (8 \ 34.29.19.402g TANK INFORMATION ELEVATION DATA TYPE MANUFACTUFEP,- jam,, / / C ACITY STATION BS HI FS ELEV. J i e1/`� \, Septic j / 0 Q d IUI �� /n � mark L C / IZ / ', 7/60 Dosing C ,�: �✓V� -e�C l/lJU Alf. BM — via �� i 1 1 • C S - Q - 6 J a� ' Aeration R. � Bldg. Sewer�/i !9Q FT H Holding ® Inlet ��/�/� v , , ✓� i ff TANK SETBACK INFORMATION t Outle 'A ' ainjr- TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 7 - Dt Bottom ( 40 ' sD 3° !'� Dosing Head /f 7 81 • . Aeration Dist. Pipe 0.1 gq.3 Holding /-----' Bot. System 13 r B 7 . Final Grade PUMP /SIPHON INFORMATION 5 . 7 96 - 3 Manufacturer Demand St Cover -M ( f/ --P-,A I. S 9 Model Number s r e a l n 74'. TDH (Lift Friction Loss Head TDH Ft 0 _ t L /.1 ' r Forcemain Len th Dia. Dist. to Well g / / 0 _ q&, i SOIL ABSORPTION SYSTEM / 67151 6 BED /TRENCH Width , Length / 'No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 7S (Di< 7 - - ire,". r... \ N ' � r SETBACK SYSTEM TO � P/L BLDG ` WELL LAKE /STREAM LEACHING Manufactur�ry / J ] iodesV C'�%�li ^✓rt ( � INFORMATION CHAMBER OR / r Ty Of System: /yam// (_ili ,, / / ∎ 1 /� ( 'An4 trn" r �� t /A/ L' (426 S i 1J 1'f UNIT Model Number: DISTRIBUTION SYSTEM 1 Header /Manifol$1 . / Distribution x Hole Size x Hole Spacing V ent to Air Intake Pipe(s) ` Length Dia Length Dia ` Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over i Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center � (� �/ Bed/Trench Edges \ Topsoil ' ..., , es [] No Yes No l COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 10/ / 0y Inspection #2: / / Location: 694 Baker Rd Hudson, WI 54016 (NE 1/4 NE 1/4 34 T29N R19W) NA Lot 2 v to Parcel No: 34.29.19.402g 1.) Alt BM Description = 5 , ,- GAA. / 1 L � I ���� ��' � m ' / 2.) Bldg sewer length = � . C mo w • �.", $ � � - 5 j ! - /j / (� / / t1 / �� t c �" v �- t> r I r - a of cover = ■ ZS3'i 1,--o Plan revision Required? Yes p, No Use other side for additional informs on. _ _j 1____ 3 Date Insepctor's Si./ - Cert. No. SBD -6710 (R.3/97) 1 . 7 • Safety and Bu Division CountyF 201 W. Washington Ave., P.O. Box 7162 / , Madison, WI 53707 - 7162 Permit Sanitary Pe Number (to be filled in by Co.) NS (608) 266 -3151 .1a , - Department of Commerce ( ) Z A , 3 of s t State Plan I.D. Number Sanitary Per it Appl' ati - In accord with Comm 83.21, Wis. A 444e, personal in ormation you provide„ , c\ \ may be used for secondary rposes Pn cy Law, 15.04(1)(r )? ' i (, \Project Address (if different than mailing address) G t . Application Information - Please Print All Information ( ,,,,,,_ Property Owner's Na e 2.. \ Parcel G C / 80-4--‘_ � � # t # Bloc /e 5 hI d - - 520- 10o -36' ooa(•q02 &) 2 - l Property Owner's Mailing Address Property Location 3 LJ L� � 1 rue,. N5, Section 3 V City, State / / Zip a Phone Number .. 1. '.e' -' " "-. e__E 5 b 7/5 ' 3 C)(' - 5737 T i !N; R /t c er W e) II. Type of Building (check all that apply) Subdi ision Name CS / M ' Number jit 1 or 2 Family Dwelling - Number of Bedrooms / 1 o 2 l// '9/6, ❑ Public/Commercial - Describe Use , f/ 3 /] � / t e ❑ ity ❑Village Township of !'T`'■ ❑ State �. ^?rd - Describe Use _- — - III. Type of Permit: (Check only one box on line A. Complete line B if applicable) /9._ — / (...., L 7, A ' ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New Before Expiration Plumber Owner I IV. T of POWTS S stem: Check all that a ..1 &jr' A i 011 - l �'"'' �''`' . Non -Pressurized In-Ground ❑ Mound >24 in. of suitable soil ❑ Mound <24 in. of suitable soil 1 ■ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter '' -∎ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) 61 V. Dispersal/TreatmentArea Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Pro.. (s tem Elevation (( 3 VI. Tank Info Capacity in Total Number Manufacturer Prefa. '' i - Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks --_ Septic or Holding Tank 0 bC _ /Q 00 WAI K1111 Aerobic Treatment Unit .■■ Dosing Chanter �■�� VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Pluuj er' Name (Print) Plum Si ture CMPRS Number Business Phone Number Plumber's Address (Street, City, State Zip Code) � • / �' /� 2"--' Z - Y (1) C) III. County /Department Use Only Sanitary Permit Fee includes Groundwater Date Issued suing gent .r . Sign. (No (No Stamps) i g Approved ❑ Disapproved Surcharge Fee) v ❑ Owner Given Reason for Denial 25 — _Al • t 2t l) . . _ % ! 1 1 IX. Conditions of Approval/Reasons for Disapproval 3) \ n r'f, _ 1 _ V� t"" ' ctr`V p ■ ) - 4 SYSTEM OWNER: t' /� 1 Septic tank, effluent filter and k,..4 (12!z- tz. .` • t .r S -S dispersal cell must all b %sgrviced i laintained (� � - t `` as per management plan provided by plumber. G l-�+�-'�� ) D . 2. All setback requirements must be maintained f eLLI � � . S , J as per applicable code /ordinances. f Attach complete plans (to the County only) for the system on paper not less than 81f! x 11 inches in ' L ' SBD -6398 (R. 01/03) t / C . ! , to ' t'A r :, , /a° z` r @ ,(A-4-0)-P Al 3y q -y do-6-Q.. / 1 g 0: /silk .=- 3 r(i-- % 7" �y T 3hic 7 owl 4 0 6 4c ' D 'III t p ) ) / V V 3 9 - ot_ 55/ r '', i f/ e 0 t_o ,5- 0-0.uzi, A J3 -3 4 4 �� Oil LI V" ____ II 1 - 6--, _,-- . c o1I , ,4 M w O'l 1 1 3- e2-el li --A aJ) 1 r! cii_,L, 1 - r6 1 9 4 yci fu / 2: vc - 17 1 /000 ,d, 144,:_s_ .4- , I D cr 0 3-g9 11 --- i t ) ;‹ 1==J 15 - i!=::;,," 0 A /3-3 ------ OA D 1 1111111111 1 - / - f \ # 3) 6357 r rir ♦ 1445 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Steel's Soil Service Inc. County Attach complete site plan on paper not less than 8%x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. 020 -1100- 30-000 Please print all information, a • we�i By Date 1 ( � yl Personal information you u.•� , t ? .� ' ,Jw. (Priv Law, s. 15.04 (1) (m))• 5fs9 T (T,Th 1 Property Owner R E C F R f E C Property Location Holm, Scott I ( Govt. Lot na NE 1/4 NE 1/4 S, 34 T 29 N R 19 W Property Owner's Mailing Address '2004 Lot # Block # Subd. Name o L 694 Baker Rd s i ' ? - 2 na a T 1 1 O' City tate . 4ip,CgIp P,hpne, Number I j City A Village iti Town Nearest Road Hudson 1 ! W I i 64084 ( ' Hudson 1 Baker Rd j New Construction Use: lifj Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD igi Replacement , j Public or commercial - Describe:na Parent material Pitted outwash plains and Stream Terraces Flood plain elevation, if applicable na General comments and recommendations: Conventional system, system elevation 93.40ft. Trenches spaced and depth to code 3.75ft below grade. 1 Boring # j Boring el Pit Ground Surface elev. 97.45 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color _ Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 - 12 10yr3/1 none sil 2msbk mfr cs lvf .6 .8 2 12 -30 10yr4/4 none sl 2msbk mfr cs na .6 1.0 3 30-100 7.5yr4/6 none ms osg ml na na .7 1.6 I 2 Boring # J Boring If Pit Ground Surface elev. 97.15 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft° in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/1 none sil 2msbk mfr cs lvf .6 .8 2 10 -22 10yr4/4 none sl 2msbk mfr cs na .4 t 3 22 -30 7.5yr4/4 none scl 2msbk mfr cs na .4 .6 4 30 -100 7.5yr4/6 none ms osg ml na na .7 1.6 * Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS <30 mg/L CST Name (Please Print) Si. r . ture: ' CST Number David J. Steel ` 248956 Address Steel's Soil Service Inc. 411111111."-- — Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, WI 54017 7/1/2004 715 246 Property Owner Holm, Scott Parcel ID # 020 - 1100 - 30 Page 2 of 3 3 Boring # Boring ill Pit Ground Surface elev. 96.05 ft. Depth to limiting factor 100 in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft in. Munsell Qu. Sz. Conk Color Gr. Sz. Sh. `Eff#1 *Eff#2 1 0 - 12 10yr3/1 none sil 2msbk mfr cs 1vf .6 .8 2 12 -34 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 34 -100 7.5yr4/6 none ms osg ml na na .7 1.6 Boring # j Boring ,, Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring # J Boring Pit Ground Surface elev. ft. Depth to limiting factor in. SoN Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD <30 mg/L and TSS <30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. Page3of3 STEEL'S SOIL SERVICE INC. David J. Steel 994 200 th St CST -POWTS Scott Holm Baldwin,W1 54002 Lie. #248956 NE1 /4,NE1 /4,S34,T29N,R19W Bus.(715) 684- 5680 Town of Hudson, St Croix Co. Fax (715) 684-3449 Lot ,2 Legend e l"=. 40' ()It enchmark Ele. 100.00ft f 3/4" PVC Pi eV_ Benchmark Ele. 99.80ft f 3/4" PVCPipe --- El =Borings Boring Elevations B1= 97.45ft B2 = 97.15ft B3 = 96.05ft B4 = 00.00ft N 0 1 oo sySi -e-r- 1 lal 4'5.e- Q T' P /vt / 46 f / i Sr-- �_ i t 3�' t �t' � y " ►_ s-�-e, — w1e1I Ai llierA l' x ci6, 66-F7.- ■ r,1 (. Yr i'l J ll i . • 3f { � 0 . 77 __..,--) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity pc4,14.,\.... c4,14.,\.... i /aoo gal ❑ NA - Permit # 4/6 3 0SR- Septic Tank Manufacturer 0 � ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ? CCCC "` ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model )L _// I n ❑ NA - Number of Public Facility Units — ❑ NA Pump Tank Capacity ga l ❑ NA Estimated flow (average) 300 gal /day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) 4/57 gal /day Pump Manufacturer ❑ NA Soil Application Rate ga /day /ft2 Pump Model • ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit y0A, Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L "(In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 5530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size 3/ in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ months) A'year(s) years) (Maximum 3 ears) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: a AI yearl 1(s1 (Maximum 3 years) ❑ NA Clean effluent filter At least once every: months) ❑ NA i / 4 earls) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) ❑ NA At least once every: ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. I � Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. tifi - alua '• . •• • . . a o • ing tank •. be'. . • . . . • ..•rm s'•e el e' - •,• • 1 Roi418T1E2 . rot -AiaV aNS`l uic.TI. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the such systems must comply infiltrative surface. Reconstructions of s sy P Y with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name 4/ Name () p Phone 7 Phone SEPTAGE SERVICING OPERA R (PUMPER) LOCAL REGULATORY AUTHORITY Name Name s"fj' C4?/ <ovtd 2oAl1 Phone Phone 7 /s— 3 (A— q(pO 0 This document as drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &1f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C'LRTIFICA T ION FORM Owner/Buyer 5 5o 0 L*7 Mailing Address 6 9 6 7 /` /1 [/CAv4..), (.l; • SVC'l6' Property Address $4M (Verification required from Planning Department for new construction) City /State / i6t;4cw, �J, Parcel Identification Number Ot-) Q — /16 e) — LEGAL DESCRIPTION 0 2 ) C. Property Location tiE v4, /U,L= y, Sec. 3 �� , T (. 9 N -R I l W, Town of / Subdivision , Lot # a Certified Survey Map # T/ � 4 / 0 4 Ao , Volume ( / ° , Page # J (a 1 . Warranty Deed # 7 So f 3 / , Volume 0( Y ' / , Page # / Spec house ❑ yes tgl,no Lot lines identifiable P31 yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 g of the three year expiration date. A Gi :I 11.(I 7 / /x,oy SIGNA i .I, OF APPLICANT DATE OWNER CERTTFICATTON I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the p� , erty described a.•ve, by virtue of a warranty deed recorded in Register of Deeds Office. i '7 Oy S • 6fF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U 2981P 193 /( S f+ STATE BAR OF WISCONSIN FORM 2 - 2000 KATHLEEN H. WALSH • Document Number WARRANTY DEED ST. CROIX CO. 111 RECEIVED FOR RECORD This Deed, made between James K. Holm and Sherry A. Holm, husband and wife Grantor, and Scott J. Holm and Theresa J. Holm, 12/26/2003 10:15AM husband and wife as survivorship marital property Grantee. WARRANTY DEED Grantor, for a valuable consideration, conveys and warrants to Grantee EXEMPT # the following described real estate in St. Croix County, State of Wisconsin (if REC FEE: 11.00 more space is needed, please attach addendum): TRANS FEE: 705.00 Part of the NE 1/4 of NE 1/4 of Section 34, Township 29 N Range 19 COPY FEE: West, St. Croix County, Wisconsin described as follow of 2 o 'Certified CC FEE: Survey Map filed July 2, 1986 in Vol. 6 1673, Do . • .. • 14046. PAGES: 1 Recording Area +iur.v wed Raum Address Mr. Robert Casey WESTconsin Credit Union P. O. Box 308 River Falls, WI 54022 -0308 02 -- fly 30 — • a. P :6 titification Number (PIN) hIL°24 This is homestead property. Jl (is) (is not) Exceptions to warranties: easements, restrictions and rights of way of record, if any. Dated this ' II day of December, 2003. �!{/ W /y/y / * * ' James K. Holm * * Sherry A. 'Holm AUTHENTICATION ACKNO EDGMENT Signature(s) STATE OF iti0f) �- ss. ST-,-CSIOIX. I !gullet County. ) authenticated this day of r Personally came before me this day of December • 2003 the above named James K. Holm and Sherry A. Holm * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the persons) who executed the foregoing authorized by 5706.06. Wis. Stats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Joseph D. Boles - Attorney at Law /,a7; n River Falls, WI 54022 +6 . 1 1 � . 1_ riC , 77 J . Issjq �. • sr, ' i on' { X , ot, • .te expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) PJrOS • ,) ' Names of persons signing in any capacity must be typed or printed below their signature. INFO - PRO (800 " oprofonns.com STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 2000 I :°' N89 ° 58'W 57735' 1 1 351 .25' 226.21' 1 - M 4 \ N I C1 O . 6 61 1n O • O LOT 2 0 4 N ¢ p 3. 0 2 Acres+ N r . - cC 1 31 , 66E S . F. _ F. 0o LL c4 N• r 0 uj • 1 I a ' Y 9 U m N 89 ° 58'W 571.00 -ro cn '' IL o r t''' W 4 . o ¢z ... i Ic kgId • f FORM NO. 985-A • r Stock No. 26273 � FILED 2, 41. 404 f J an o 1986 ewes a COMM ispb..r of oosds 5 odb Croix Ce, CERTIFIED SURVEY MAP wbo $ LOCATED IN THE NE1 /4 OF THE NE1 /4 OF SECTION 34, T29N, R19W, S v TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN �i. NE CORNER SECTION 34 T29N, R19W ^ ao 0; CT' S I EET POINT OF M ° .. N z BEGINNING Tie" z 0' 100' 200' CU CO w = S, F- cc \A o , 5 APPROVED OCT 0 51983 .. Q`, ooc -ts— ST. CROIX COUNTY i� X N V.- . � 6 3 IN � 00 1 COMPAEHENSIVE PARKS PUNNG 's• ` \ �� O AND ZONING COMMITTER IA hO 13 N. N. e� a`! ,5'3 N \ of t ------ LOT 1 0 �\ \ > 3.46 Acres± \ \ /� 1 50, 765 S.F. ± \` 1 ' N 89° 58' W 577. 35' g \ 1 351.25' 226.21' NI 1 n, o' 1 N N I Z o; 1 6 6' a ; al o � JI 0 LOT 2 ° C] o r" Q ¢ J . 02 Acres+ e'•, O • NI N3c 31,668 S •± ; - . -oo wI 11 c4 0 1 ^ 03 O w c o o H I I � c; ' .- N 1 z 1. =M N89 °58'W 571.00' < 1 ¢I -. V I J 1 "' Fe O 4 a • M 1 I O IA Z 1 O I °C w ._I 'shed' 1 W I LOT 3 I✓ I I driveway I u.1 3.58 Acres± ~I ▪ ao ° _ 155,814 S.F.± J 1 Q c.?:, N �) 3 M I z 11. 1 CO -c rn z I tV ■ 1 1 33' 33' N 87 °25' 30 "W 429.20' X y NORTHERLY RIGHT -OF -WAY LINE OF COUNTY 142. 80' TRUNK HIGHWAY "N" This instrument drafted by James T. Swanson. Vo 1 Ian e 6 P.a.. /4.7 3 . 1 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER jern �`1 „1. TOWNSHIP / 47.1/d1'eA/ SEC. Y T .Z'j N -R 11W ADDRESS Gc?, ri,- Al i T 7 ST. CROIX COUNTY, WISCONSIN SUBDIVISION r , #/4, LOT j, LOT SIZE . 2 ,f- a..G....jza:. PLAN VIEW /'r LUT C$1 IA V Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I-7o 1 A ,N - . 7 A Di i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ,sri yx e 4 S / / S Elevation of vertical reference point: Af , ” Proposed slope at site: 76 SEPTIC TANK: Manufacturer: j � t. ..,_ Liquid Capacity: J 25c5 Number of rings used: g Tank manhole cover elevation: I Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side Rear, O .2 7/ ' feet From nearest property line : Front,OSide,ORear, O ,e ' feet 1 Number of feet from: well GO , building: /5 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) l SEE REVERSE SIDE thig PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, °Side, O Rear,Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: )< Trench: Width: /:2 Length: ‘ Number of Lines: 2 Area Built: 8 a Fill depth to top of pipe: 4.2 " Number of feet from nearest property line: Front, Q Side, ® Rear,Vt . Number of feet from well: '?Y Number of feet from building: �9 (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: ' ' ":;- Plumber on job: / �.,, License Number: ~... 'c „,, 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION B P.O. BOX 7969 UREAU OF PLUMSION MfADtSON!WI 53707 NE %,NE 4, S34 ,T29N -R19W XI CONVENTIONAL ❑ ALTERNATIVE (If Number: Town of Hudson, Lot 2 ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound • CTY N WI B�ID (Jr173 NAME OF PERMIT H ER. A PERMIT HQ INSPECT( Rolm CTY TRKNRoute 1, Hudson, Wl 54016 N ATE: BENCH MARK (Permanent reference point/ DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: William Schumaker 6382 St. Croix 92499 SEPTIC TANK /HOLDING TANK: - MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER , / P ROVIDED: PROVIDED: 9 /1G`( 9/,4/0 OYES ONO OYES ONO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT FRESH ALARM: FEET FROM LINE: AIR INLETO T . LI VES ONO ❑YES ❑NO NEAREST ) - - DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: 'PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH , (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES LI NO NEAREST —» SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH: DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDT : LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA. #PITS. LIQUID BED /TRENCH / 7 TR�uC� ES ( " Mn RIAL: PIT DEPTH , DIMENSIONS / lP GRAVEL DEPTH FILL DEPTH DISTR PI IDISTR. PIPE !DISTR. PIPE MATERIAL: NO. DIST NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH BELOW PIPES i ABOVE COVER: ELEV. INLET EL 1 , V E PIPES. FEET FROM LI /� /9 AIR}N L L T L4'1% ( s , is I VS. L . -1 - 7 2" (7 2... NEAREST - -► 7 7 ,) \/[/, T • MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. EVES ONO 'OIL COVER (TEXTURE PERMANENT MARKERS. OBSERVATION WELLS LI VES ONO OYES ONO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED. SEEDED MULCHED CENTER: EDGES: OYES ONO OYES ENO _ OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER • BED /TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL' NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.: ELEV.: DIA.: ELEV.: PIPES DIA.: ELEVATION AND DISTRIBUTION H OLE SIZE HOLE S PACING: DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS OYES ONO ❑YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: (� LI VES ONO OYES ONO NEAREST > t \ / r 87r. ( 4- s \- ft � � n . q '� �a r p , °. X 3.44 1 (DII 7 Sketch System on . ` ��'�o Retain in county file for audit. \ Reverse Side. VC q1), 1" _ " �+. 1111 " -.1iVam TITLE • DILHR SBD 6710 (R. 01/82) �` Zoning Administrator . , ■ CILH SANITARY PERMIT APPLICATION COUNTY , C /'U/ k In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # 9a' II —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8 %% x 11 inches in size. —See reverse side for instructions for completing this application. PETITION �I I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. FOR VARIANCE I I YES NO PROPERTY OWNER �� PROPERTY LOCATION (? ja.. ,,,Ps Na Z AI Ale xai "4--,4,s2 9 Tal , N, R /1 E (or)(�/ PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME Y.,� A- le .1/ t/ At;-'16" i v ‘,../ i A- CITY, STA7 Z IP CODE PHONE NUMBER ❑ CITY : NEAREST ROAD, LAKE OR LANDMARK !r.S -41J 01 , rr, /r ( _- ) , N ® TOW O /i, F: G.wi eo. mil/ II. TYPE OF BUILDING OR USE SERVED: ,4 /Ui. U 0 1 0 — /J40 , Number of Bedrooms if 1 or 2 Family 8 OR Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable) 1. a. ►.� New b. ❑ Replacement c. ❑ Replacement of d. I i Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. X Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. W_ Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 2 e / - C/,s e '7 eel Feet Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in gallons Total ## of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New Existing Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holding Tank P( Jf I / C✓` 1t.. _ _ 0 1111 Lift Pump Tank /Siphon Chamber [ _ El s .J El VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system show on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) P MPRSW No.: Business Phone Number: hii It 1 A rr, Sc A u, *It 414V , /_ ' . _. _ i ,r.. — ( 2 F ) e/ 2 t Plumber's Address (Street, City, State, Zip Code): Name of Designer: — L e --- £ 1 ' Lt/. // ...sL. .mac A u Irs..,.drestA • VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # 15 3`r�y' T's AD SS reet, City, State, Zip Code) Phone Number: If 2 .5.7 , e d.i- 17 1 ' ). -So,/ /i`/ /r .1 (3 gr6) sic rO IX. COUNTY /DEPARTMENT USE ONLY �q ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) ,�V Approved ❑ Owner Given Initial ' i�� . Oa S c Feee Qp' /,//�/�/,,, //�• ' " �� Adverse Determination �17 w /�~ r ' "fJ"'� `h/ X. COMMENTS /REASONS FOR DISAPPROVAL: L SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new • criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed • pumper whenever necessary, usually every 2 to•3 years; 6 If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owners name and mailing address. Provide the legal description where the system is to be installed; I!. Type of building or use served: If public is checked, ndicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1-6; VI. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County /Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 forrn. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground included the creation of surcharges (fees) for a number or regulated practices which Wisco can effect groundwater. The surcharge took effect on July 1, 1984. Ali of the water that burled reasure is used in your building is returned tr; the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are cred'ted to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground water , groundwater contamination investigations and establishment of standards. Groundwat , it's wort`: protecting. 6 . 037 +313) A APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, ( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property m,er Location of Property Ay S- 1, Section may, T 0Z9 N -R l9 W Township Z�GG 6/.' ' • Mailing Address j 2 sa,4 -5` ' ' / Address of Site ,f / /'L I $' r/ 4,1-` 53</y,.‘ Subdivision Name SS /77a--$ • Lot Number Previous Owner of Property Total Sine of Parcel Date Parcel was Created .j1 ,,2/ / /9 73 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes OC No Volume ..74/f and Page Number 6; as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1 (We) ce that a statements on th.iA 6okm cute .t&ue to the but o6 my (our) hnowtedge; that I (we) am (cute) the owner(4) o6 the property de4c ,bed in this £n6atmati.on 6orm, by v.ihtue o6 a walvcanty deed recorded in the 066ice o6 the County Register o6 Deed4as Document No. 5',9 5'9 ; and that I (We) pneeen.tty own the proposed 4Lte bon the sewage dispo.saC system (or I (we) have obtained an easement, to run with the above dedck bed property, bon the cons,t ruction o6 da.id system, and the same has been duty recorded to the Office 06 the County Register o6 Deeds, as Document No. '/ 9 a g '' ) . /IK SI OIL OWNER S ATURE OF CO -OWNER (IF APPLICABLE) /7,,,? DATE SIGNED . DATE SIGNED CrJ') • DOCUMENT NO. r _ ""� i MORTGAGE —To Corporation—Short Form \ Insurance, Option and Tax Clause t 3 1 (] ] (� r 9 _, STATE OF WISCONSIN —FORM 20 a7 c7 , THIS SPACE RESERVED FOR RECORDING DATA . REGISTERS OFFICE KNOW ALL MEN, That 'TAMPS K- a ___A.- 13o.1mr •ST. CROIX CO., WIS. husband and wife Rec'd for Record this let mortgagor.$, of St. Croix County, Wisconsin, hereby mortgage Ito day of November A.D.1973 The State Bank of Hudson f. • t _ , a Corporation duly organized and existing under and by virtue of the laws of the State of � o • G ' ` Wisconsin, located at Hudson Wisconsin, Reg stet of O e for the sum of Ten Thousand and no /100 ($10.000.00) -rTollars, RETURN TO the following tract of land in St. Cro iX County, State of Wisconsin: SEE ATTACHMENT This mortgage is given to secure the following indebtedness: Ten Thousand and no /100 ($10,000.00) Dollars payable from date hereof with interest thereon until paid, at the rate of per cent. per annum, payable semiannually, according to the conditions of certain promissory note _ bearing even date herewith, executed by the said mortgagor to the said mortgagee. The mortgagor agree to pay all taxes and assessments of every kind, ordinary or extraordinary, which may be assessed or levied upon or against said described premises, or upon this mortgage, or the note thereby secured, or upon the mortgage interest in said premises created by this instrument. The mortgagor agree to cause said premises to be assessed as unincumbered real estate (and so long as the indebtedness mentioned herein, or any part thereof, remains unpaid; to cause the building located upon said described premises to be insured in some solvent fire insurance companies, selected by said mortgagee, its successors or assigns, in the sum of full insurable value Dollars, and the policy or policies of insurance issued thereon made payable to and deposited with said mortgagee, its successors or assigns;) and in case of the non - performance of any of the agreements herein contained, by said mortgagor to be kept and performed, then it shall be lawful for said mortgagee, its successors or assigns, to expend any sum of money necessary to preserve the lien of said mortgagee upon said premises, in payment of taxes, (insurance money,) or otherwise, and said mortgagee, its successors or assigns, are hereby authorized in the event of the non - performance of any of the above agreements, to grant, bargain, sell and convey said real estate at public auction, and make all needful deeds of conveyance to the purchaser thereof, pursuant to the statutes in such case made and provided, and out of the proceeds arising from said sale to reimburse itself for all costs, charges, taxes and insurance moneys, which it shall have expended in and about the preservation of said premises, or of any suit to foreclose this mortgage, together with a reasonable sum of money as solicitor's fees. It is understood and agreed by the said mortgagor , that the agreements contained herein shall not be construed to in any wise abrogate or abridge any of the rights and remedies given to a mortgagee under section 2209 of the Statutes of Wisconsin, of 1898, and that this instrument shall have all of the force of an instrument drawn in the form set forth in said section. IN WITNESS WHEREOF, the said mortgagor S ha ve hereunto set their hand S and seal Ste_ this 31st day of October , A. D., 197.x— . SIGN$D AND SEALE a IN PRESENCE OF �� l/ / (SEAL) •A ' /J � � rs_ _ / . ames K. Holm ,� . Dar � .. _ 1 . _ . C " (SEAL) o S -err A. Holm M A E ��fl��� 4 , 1 I. / % ' 4.-----' (SEAL) Paul W. Hamblin (SEAL) STATE OF WISCONSIN, 1 ss. St. Croix County. Personally came before me, this 31st day of October A. 11, 19 73 the above named James K. and Sherry A. Holm, husband and wife • to me known to be the person s who executed th l . regs • g in furpent and acknowledg- . - m I \\ NV NOT •• • . Donald M Johnson o • CA C ( BENL • 4. "'. This instrument drafted by A ' � e L. t C; • - Notary Public S t . Croix County, Wis. The State Bank of Hudson �.,' . ... . :; ± My Commission (Expires) (Is) 2 -8 -76 0 (Section 59.51 (1) of the Wisconsin Statutes provides that all instruments to be recorded shall have plainly printed or typewritten thereon the names of the grantors, grantees, witnesses and notary). \ Mr,RT(SAelr —RTATF CIF W TS(ymsSTN FO RM MC 9n mint . 11 1 11 PAN Ell , eoog 5Q& rt,t6 2 Parcel, #14 - A parcel of land located in the Northeast Quarter of the Northeast Quarter (NE4 of NE4) of Section Thirty -four (34), Township • Twenty -nine (29)- North, Range Nineteen (19) West, Town of'Hudson, des ry. as follows: Commencing at the Northeast (NE) corner of said Section 34= :# thence.SO ° 08'W (.true bearing) 884.76 feet along the East line of said No6theast.Quarter (NE4) of Section 34 to the point of beginning; thence i' SO 08'W.403.12 feet along said East line; thence N84 ° 21 1 10 "W 142.80 feet along - the North right -of -way line of the Present County Highway "N "; thence thence•N87 ° 25 1 3 0 "W 429.20 feet along said North right -of -way line; thence • NO °08'E 369.75 feet; thence S89 ° 58'E 570.25 feet to the point of beginning. Also a roadway easement 66 feet in width located in the North one -half (N1) of the Northeast Quarter .(NE') of Section 34, Township 29 North, Range 19 West, -being all lands lying 33 feet radially and at right angles each side of the described centerline of roadway: Commencing at the North Quarter (N4) corner of said Section 34; thence S0 ° 08'W (true bearing) 1290.81 feet along the West line of said Northeast Quarter (NE4) of Section 34; thence S89 °49'35 "E 610.47 feet along the North right -of -way line of the present County Highway "N" to the point of beginning; thence N0 ° 08'E 466.29 feet; thence Northeasterly whose chord bears N along � a 233 foot radius curve concave South easterly 45 05 E 329.22 feet; thence S89 ° 58'E 954.00 feet; thence Southeasterly along a 233 foot radius curve concave South- westerly whose chord bears S44 ° 55'E 329.80 feet; thence SO 08'W 432.52 feet more or less to the North right -of -way line of the present County Highway • • • • • • 9 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ty a H OWNER /BUYER Qy ROUTE /BOX NUMBER rr / 14. aSe 41; Fire Number CITY /STATE /4c_Jc,,✓ are` ZIP ,j af' G'l‘ PROPERTY LOCATION: 1/4, %, Section y' , T a f N, R /f W, Town of ./.( dsi,,J , St . Croix County, Subdivision S r , Lot number . • Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ' ment stage in the waste disposal system. 1 St. Croix. County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 I /WE, the undersigned,, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SICNED / / DATE yr/Li' /7 St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715- 796 -2239 or 715- 425 -8363 Sign, date and return to above address. . DEPARTMENT O - RE PORT ON SOIL BORINGS AND SAFETY at BUILDINGS DIVISION INDUSTRY, PERCOLATION TESTS (115) MADISON WBOX I LAOR AND HUMAN RELATIONS (H63.09(1T& Chapter 145.045) LOCATION:N SEC ION: - - MUNICIPALITY: LOT NO.: BLK. NO. SUBDIVISION NAME: 14 I 1 L 1 1 N /R/ (oWJ ubso'l Z - cerriFach Sut2vle /SAP O HER' UYER'S NAME: 1 A' s - . COUNTY: � N / I 1 r � �� STCeo1X .�AMc H oL0 CTY 1 Rk. Iv P-7 1 du ) USE DATES OBSERVATIONS MADE NO. BEORMS.: COMMERCIAL DESCRIPTION: A p FkrResidence (,INlt -_ --- K PROFILE D PERCOLATION TESTS: New ❑Replace D /QA 7 QIL / iisc) Qp 8 ell /1,117 Q RATING: Sm Site suitable for system U- Site unsuitable for system C0N ENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM-IN-FILL HOLDING TA K: RECOMMENDED SYSTEM:(o tional) ►.I S DU EIS DU NS DU ®S DU OS IO U caNVEr/T1c>\1 gE If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the 1 under s,H63.09(511b), indicate: CL4K,S Floodplain, indicate Floodplain elevation: NA `c PROFILE DESCRIPTIONS BORINGI TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR. TEXTURE, AND DEPTH NUMBER DEPTH$ ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 / /.2c 9c.c 1,101.1c >//.2' /3 " %Ls,Lis Z3y$RNSrI 97' c '1 St6Q B- 2 //. cA gS 79 1 \ 1 0 - Nt. > /to , "ISieNSL / /d' $ tN S' 6R E1-3 12. = 94.x' _ NoN >/2.33 ze;stLL-rs /l`BQ.,►Stl. z6 9/ " ep., Si4,,Ie B -4 /6 ?.3 9.49 Non: >/0. /a 8cLr� it "bte.. teitr4 516* 96 B- < // 06 9(.3o nlo�t >8.0 /z "e?LtT irt.4$eN ti6 sc- 46(e4d'Et.seK3 e t$R. StG* B- - PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL- INCHES RATE MINUTES NUMBER nneFfn AFTER SWELLING INTERVAL -MIN. PERIOD 1 - pE91OD 2 _ 3 PER INCH P- /. / 7 V //0116 I ,6& 3 }z _ — >Z <? P- - 7,I1 NaNt 9411 3 >Z _ _ >2 < P- 3 6, • T NJG 1 i4 '73 3 '.4. ,. > G 1 .• P l_._ ____ - ... _, la.t,JgTtphi AT Vt_ _ I _._ LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent f land slope. No`s a S rES-tr= 4 Recou r.ENZsS (6)0v1,4 t, l'H I WSTEM ELEVATION 8780 SY ‹T EPA As T'Ae To TNG as— As Possa it:f . c � c O — / CO - — 1 ----t----- . T ; , 1c A ` a r\j &_ Z 73/ - — — -- /00 -- / / _ $ -1 . P -1 • a 6 Q • P -z J "r P -' I TN I 3 44' Le q T teNwr— wJ rR PLC: q 4 /2' / L ON . / O () B -S ` 1 /04'- - .- )JaTE• ; Alaimo, 6.4 4T)oN o{' foP oP BcAy.-r., 84sEf►tefvr 99. SG 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 1 Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. (NAME (print): TESTS WERE COMPLETED ON: .fAC Yv n/� ise7 b' ll! �O +i kC11�'J /MI�'> �N TI �IQIL _ IADDRESS: / CERTIFICATION NUMBER: PHONE NUMBER (optional): j , 1YV/ 484 38G- oact CST I NATURE: „/ - �� , i • a'ISTRIBUTION: Original and one copy to Loral t..rhrvity, PropFrtv Owner ;awl Soil Tester. ' fill FM) -' , !N. (17/R7) - OVER - - 1 •74 leoS el i w ii W7 w/4 . . •INti AVMH911-1 )1Nnui. A.LN1103 dO 3N1 1 'AVM-d0-.I.H0121 47211H.1.10N), 108 'VI I. MO It I.Z 0 sOZ . 6Z14 MOE iSZoLO N 1 E £ IEE 1c t., r / kiX . . • I z 1. NJ n.) 0 Z > I r I CAI r .... IA 0 X ...... w 'VI 0 ■ T - 'A s tl Lii 'SS I. ...0 • Tsa-13V 8S -£ Aeman!..ip I-1 ,,..-----). 1m £ 101 r m 7) I 0 I PetIsi - > 0 1 I . 0 i z x z v) p. , 1 ., 0 1r cl 1> 1 r w x ..../ 1 i NIIIIS 068 N z 100 • US > ... -• > 0 I . vi mei Pc I F3 I 0 - 0 a 14 efii (6 I •••I ex' ' I Iv) 0 2 .4 I m zg "tt .4: • A • S 899' 1.£ I. 0 > • I 0 Kt 14 .T.S9.13v . • Z 101 tft 0,.. tn 9 9 • CO ma i-----2t--- ---3 , 1.0 i 'Y to ICA I1V9ZZ ;2.1 (Itt I z it, it I utt. V' 0 i I I isz • ISE \ o m 0 68 N A, 0 • I SE LLS • \ \ I It ..- -----\ \ (v . W PY/4 i T. •A • s S9L 'OS I \ \ • s 5., .., T.semov 9ir 1 .----------/ \ ci. X l .101 / - ------------ - N‘..X9 \ • he N. N sO a 0 1,‘ (N ot -•-•••••'. 6 0%4 ...... r% • - . • , ...we . Vy; , ,v, t ...,; 1 A0 , • , ,..I y/ rt ,t (1".., • 1 ...q/n9 ,../...,.•//!' filt k g 011 ' :11411 11 k '.. / ,.... PIP11104 N f- T. ■ ,.,..i. IVY': ' /ft, '4' • ' No r_v 7 , , /ANAIMIIIIIIIIIm iv° g • ,...., ,„v • ....1 ,,,, c-1 A .. -""TANIMEIIM2.1111".";1' .." • os• 1 .... - -.• I •?..," . ' O/S. , I , -17A IJI,,,,,,, .: ' ''' . * \, 1/1""W ' • ' ' • . / , , p./////./1,/ • 0, ' ' 'ir ,.. , ,......, • 0 rifg 2, r • , v ....1., ...., __ • •V . p sill." • • • 0 . 3/13P fa AWN& W F g 9- 1 , e . , , 11P 111111 I i ; Y 1,...• It tl .7 f 4 d i lliNglialri ■ a./ _ °II //05,1/./////./w GM/ - r pp SIAAorr,c. , • cc, iv,VlOrn j. I, r DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INDUSTRY, P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 HUNI,AN RELATIONS (H63.09(1 Chapter 145.045) ti • LOCATION: SECTION: TOWNSHI UNICIPALITY: LOT NO.: BM NO.: SUBDIVIS ON NAME: N L. 1 /4 " 14 Tz9 N /R/ (4W) ubso4 Z — ceenr Ids sc>12vc> 1`14e COUNTY: OVYNER NAME: MAILING ADDRESS: 1 SrCeo)x .)AMirs HOLM CTY , Rx. Al k P 1 ubSoN W► S46. It USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence uNIE -- New ❑Replace / QAQIL 7 !9$7 ApRfl 6 /9t7 n RATING: Sm Site suitable for system U= Site unsuitable for system C ENTIONAL: ❑U f s I S DU : M I. IN G E: S® D D S M- IN-FILLHOGeiU CoN JEArT O N A K: ( 1r, S 16€11, • If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the 1 under s.H63.0915)(b), indicate: C. L4SS j L Floodplain, indicate Floodplain elevation: b./ 4 bcGCT PROFILE DESCRIPTIONS NUMBER DE TOTAL H1$ ELEVATION DEPTH O SERVED HIGHEST T TO BEDROCK IF OBSERVED H (SEE ABBRV. ON BACK EXTURE, AND DEPTH TEXTURE, 8- I !/ ZS 9 ►JoniL > / /•2( 13"gLS, cm Zeg R., S.l IV C-'1 St64t B- 2 / o 9S 79 Noi\J > / /.O iS g " teNS - / /O Stdr • B- 3 rz. _,-. 14,1 NoNi. > /2.33 2c�"' SLt- /1'Bf ?.ESL Z6'4YS,t/(S, 9/ "�BeN B- 4 /b 33 9 .4 NoNi c >/o. 3 3 /a" "BC t. T":.. rebv. eikr. S16# 96. ea Srr< &A B- < / / 00 9( 30 JJonit >//.0 /Z "e_.i_LT = /1 "D4 getNSt..46t tiCtkusi6e63 ET$['Ns.t&R B- bC. `_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL- INCHES RATE MINUTES NUMBER ti S AFTER SWELLING INTERVAL -MIN. ' PERIOD 1 I _PERIOD 2 poi= 3 PER INCH • p_ / - ?5r 1 6 1 40N 4 9s.48 3 >2 >2 <2 p_ Z 7.1/ NQnlr 99 3 >2 >2 tZ P- 3 .91 ea , 94.7/ > 2 > Z ( P- •.LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- r,ntal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent -f land slope. Nom y 'SO Cr£S1Y_ RECOYM r.ENDS !'toVI G, TN ;YSTEM ELEVATION 87.80 SY�,T,E M as Fie To TNT 1rf 6s-r As Pow oT Lt g -I /' • p - • a 6Q ■ P. 2 , n M P• ' N 47 , S� • ♦ _ tcsAt R m.. (. 7,P , Kt. , N ----�' 1 _• ..- . _ _ _--- __. ____ 3 q4 sw ALT ieNore I`© �wlr� �t�' q4�i / AgNE Gkooki - ' w i■/aTE ; 1 RUPdstb ELt\,4T1ON of MP pfi ikeF.v, imscil eto : 99. so 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 the location of the tests are correct to the best of my knowledge and belief. !NAME (pr int): TESTS WERE COMPLETED ON: 1 / -, , t / , O � � n IS �N Pt ,C11 6N` / OP _ 8 /se7 iADDRESS: 4 467 <r;, r, rJ /■ -. 0^I 1n4) �4�34 3eG — 080 CST 1 NATURE: • ! 3tSTRIfUTIf1N OtiiEVial and one copy to Local Aia:irxit i, Property Ownar and Soil Tester, ,Ill NR '! " > 4- 95 (R. O7 /ft ) — OVER - CERTIFICATION NUMBER: PHONE N MBER(optional): T'i4 ,k#J B ^nt / v W Pi w/4 �11Nf1OD dO 3N11 • " AVMNJIH )1N11211 e08 'Zfi l AVM- �U- 1NO12i .i?213H12iON X MO 1.112 ∎OZ'6Zh MOEISZoLB I ££ la: lc N Iz to p ✓N N 7 JS l8'SS l 1 +saa3y 8S'£ rn I-1 �( ea�aniap�� I -i £ 1O1 I Y Y fri z N O 'v I > �� ,,, 100 • ICS 1%85°68 N A � �D i 1-1 o Lv�ch/ L ✓/l � I � Im 2 +' A•S 899'1£l 7 **4 stn G ^' +saADV ZO '£ O r • w c b•rd s.r a -< , ft r a Z 10'1q a v Ir ,0 . ! _ ch 5. t -ix �- _ _ ___._ 0 w r i I ILL•9ZZ 4SZ' LS£ l 1 0 - G IS£ 'LLS M N •I, \ • �,o// x WI \ �� +'A'S 59L '05 l / J + sal 9h '£ ��� X l 101 — --' \ �� a n �aP \ 4\ he NI • �,, 09 . a tk d5 . . ., - i 'vile , ' 4 . c. r ■ 1 F, , t 7/ ow M ��i 7wn ❑ 4 ■ 4.0 Irei it . mil ON uW,y ✓)V:.ruts. /roiiaq ✓Tdlurrr 2 )N/ , ,Y /�iY f r ` /ff 1 o,a n a/r ! . 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