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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
404956 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information 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:
Stoner, Raymond Hudson Township 020 - 1353 - 22-000
CST BM Elev: Insp. BM Elev: BM Descri tion:
I Ott I ou N Cor I .a:e_ - 1 �►• -.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic /benchmark it ;
5 Y tos-. ea .
Dosing Al pM i
Aeration Bld Sewer
Lt A t¢ -- 7. (08 q7. - 7
Holding St(Ft Inlet
" St/Ht Outlet
TANK SETBACK INFORMATION 8. 1 6 t Z. 3
TANK TO P/L W ELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic J I g T 0 / / Dt Botto
Dosing � C Header /Man. q • L
Aeration Di ipgT ( �' K C q ---
__
Holding , . 0. System •— 1 (2.0 c '
__ • - •
Final Grad
PUMP /SIPHON INFORMATION ,5775 ctr• 6C
Manufacturer Demand 'gt Cover 3 • 1 -
Writ
Model Num.: /
TDH'Lift Fri ', L.. 'System Head TDH Ft
Forcemaigtif Dia. .
SOIL ABSORPTION SYSTEM
BED /TRENCH Width 2 l Length No. Of Trenches PIT DIMENSI NS No. Of Pits Inside Dia. Liquid Dept
DIMENSIONS n �l ,---
SETBACK SYSTEM TO P/L BLDG WE [ LAKE /STREAM LEACHING Ma cure
INFORMATION ! HAMBER- �L rs
YP Y
T e f S stem:
' 1
t)
( ll Model Number:
N
f
DISTRIBU ION SYST M (
Header /Manifo a 13 •istributio 4 . y W# _ 1 . 1 "" r, / x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) 1 [ /p� ,/
Length , Dia � �� Length 7 Dia � h � Sfiaci � 3s
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
9 I' l Yes I w i No Ifs' Yes 11 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: (e / 20/ 6- Inspection #2: / /
Location: 664 Hillary Farm Rd Hudson, Hudson, WI 5 ,, 40116 (NE 1/4 NW 1/4 36 T29N R19W) Cottonwood Ridge Lot 22 Parcel No: 36.29.19.2022
a
1.) Alt BM Description = ' "L f lt �"" 4 Cl? - ! / p� � ��y yth/
2.) Bldg sewer length = t I tJ��,. 0 ► ^ � k �n' i frb d b"--- 0 11
- amount of cover = i
P..W - 4,445w & i /, ez
Plan revision Required? Y es �� 0 if/ �v~
Use other side for additional information , tv
i ' & 4- -C-6
Date �_ Insepctors Si n 6 / a v
lure 0--2 Cert. No.
SBD -6710 (R.3/97) L / /tl
' •
Satety and Buildings urvtsron -- "my ,
201 W. Washington Ave., P.O. Box 7162 5 �
NYeisc'
on
O resin Madison, WI 53707 - 7162 Site Address
Department of Commerce 4 6 /vz- S73/ V g/ (t/ Wi u_Ai y /v i7
Permit App 'cation Sanitary Permit Number
Sanitary ' go y
In accord with Comm 83.21, Wis. Adm. Cade. personal information you provide tl [bfCheck if Revision q,Ns
may be used for secondary purposes Privacy Law, st5.04(1 C C i v r D State Plan I D. Number
L Application Information - Please Print All Information
/ Y
Property_Owner's Name JUN ] 1 2002 Parcel Number
a- S / Div - /363 — 22 —6O0
Prope Owner's Mailing Address 5 I . CFZOIX COUNTY property Location
9 b I ZONING OFFICE � / S 3.� ?13 !4 T)/N,R
City, Stan Zip Code Phone Number Lo r Block N r ^
vZ-- , N 03 a`-'
_ ' isio CSM Number
I ,
1 h , of Building (check all that apply) / , , OC;t
% . 2 F amily Dwelling - Number of Bedrooms ✓ ` , r�� EtV�l la
0 Public/Commercial - Describe Use S + 'r • 1Township � c
0 State Owned 1
°L `� , 3'( 4(' )S & -tsi ./A.e N l ! l d � re,..„ �C�r �
III. Type of Permit: (Check only one box on line A (numbering . , a for internal use). Complete line
A. 0 Replacement I Tank Only Replacement of I Existing ��m i For Count'. use � I 2
B. 0 Check if Sanitary Pen7rit Previously Issued 1 Permit Number Date Issued
IV. of Permit: (Check all that apply)(nnmbering scheme is for internal use) de ��- �t 3 a '
N on - Pressurized In- Ground 210 Mound 47 0 Sand Filter 50 0 Constructed et 114 � I /
22 0 Pressurized In- Ground 41 0 Holding Tank 48 0 Single Pass 51 0 Drip Line - 3/./ � -
45 0 At -Grade 46 0 Aerobic Treatment Unit 49 0 .... :. ._ ) 30 0 Other
V. Area Information: `� 0 :1 1 o
Design Flow (gpd) Dispersal Area / .Dispersal Area Soil Application Percolation Rate System Etevatiay' Final Grade
/
Required Proposed / Rate(Ga1s./Days/Sq.y. (Min./Inch) f3.0/ 0 Elevation
v
Od . 7s
7 33 9/11 7(,a
VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Construe Glass
T n i1 i I i tipl
Tanks Tanks
Septic or Holding Tank ./......, - r Z La / ( A. J ,X
Dosing Chamber 1 1 1
VII. Responsibility Statement I, the urn :1 ...>, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name Plumber / it MP/MPRS Number Business Phone Number
5 I z- z b 9 a 7 /..r zyI yer /.1
Plumber's Address (Street, City, state, ✓) L-0 s ki ^ / ? Zvi 47P( • Ne_LiAtjj
ty�partment Use Only
Sanitary Permit Fee (includes Groundwater Date Issued - ".r Signature (No Stamps)
Approved 0 Disapproved Snrcbarge Fee) � �
0 Owner Given Initial Adverse — A /, /
Determination - � • >.� /
IX. Conditions of Approval/Reasons for Disapproval - r �" n C�� �> �" CPI- A 0 _
P �� owe v� c (�t °�`r vks. _ W ` -
�'�,�� -�,Q, c�d� -� 1 per' r� .�
- { cozy -
- Vii t w
co mpiele Plant (to the County only) for the system on paper not less than 81/2 x 11 inches In sire
SBD -6398 (R. 05/01)
PLOT PLAN
PROJECT Ravmond' Stoner ADDRESS 799 hwv 64 New Richmond Wi 54017
NE 1/4 NW 1 /4S 36 /T 29 N/R 19 TOWN = On COUNTY ST. CROIX
/ 6/7/02 4
MPRS Shaun Bird 226900 DATE BEDROOM
CONVENTIONAL )00( IN- GROUND P' CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE / DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 933 v of chambers 30
■ BENCHMARK V.R.P. Top of Flo ndatiew- — ASSUME ELEVATI 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H,R Same as Benchmark
SYSTEM ELEVATION 93.0/91.1
200' Property Line
•
500' property lin -
Vent
4ip
>12" Sidewinder High
of Cover Capacity Leaching
Chamber
6' Long 16"
34" Grade at System Elevation
B -2
Set at 3.5' Below Grade 20% 'Vents
} Slope
Vents B -1 G 1 '
50' iiiii
LAG. ,1 40
3, D B -3
B.M */ 151.
0
10
g ' T 2 -3' X 94' Cells with >3' Spacing X
Pro 4 Bedroom House
^ Plans Designed Using
iEly Conventional Powts
Manual Version 2.0
Cottonwood Trail/Hillary farm road
r -
visconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of '
)ivision of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must i �� I
include. but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. - (LW / 3S J-D- --az
Please print aB information. Reviewed y Date
Personal information be used for secondary (Privacy Law. s. 15.04 (1) (m)). / ` W ..2..... provide may ry Purposes
. operty Owner Property v� GC�iYVr 0
�y , � - O 4 Govt. Lot A/ F 1/4,1/ s 3.kT ' YN R / E (or e
operty Owner's•Mailing Address Lot # Block # Subd. Name or CSM#
ty S - g Tip • • - Phone Number ❑ City ❑ Vili •• • Nearest d
Nc.e� , e.. Q -1 Q 115# 0 l 1I ( ) mot/? r✓ 16:� �- /e
Construction ential / Number of bedrooms , -) Code derived design flow rate �....rb GPD
1Replacement P is or commercial - Describe:
Trent material 0),(76.41 Flood Plain elevation if applicable it/ /4 ft.
metal comments e. 1,& D /
d rerecommendations: !. - ?
C'r- -C=/l, CC . , S- /5 /67,c) 6 rctc—gzi
Boring # ❑ Boring
pit Ground surface elev. / Oft. Depth to limiting factor / /
in. -
Soil Application Rate
orizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *EMI " Eff#2
1 0 0 16 y> z)�. f/ 2,,- 1 ...1 - 02.4-- , s - O
7- 0212_ /-5/1 4/" /. .s-d/( ,A' / .C' - a . -.
' b ..- DS- !1 ' A.- ,
■
Borin # ❑ Boring J
Ground surface elef ft. Depth to limiting factor /f in.
Pit Soil Application Rate
orizon 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 D -10 - '/ // . �,--- , - -
2 0- 44./ . a . 3
of
A y /
* Effluent #1 = BOO > 30 < 220 mg/L and TSS > • ►1 50 mg/L ' Effluent #2 = BOO < 30 mg/L and TSS < 30 mg/L
N (Please Prim} - ` /` � Signature CST Number ��f
A I./ LGi St '17 - c /J / — at 2- b 9 VV
kddress Date Evaluation Conducted Telephone Number
/fie) d'( ?) rilo).d !mil /i,_C 7 tJ - OL 76 - 7- /t —. 0(107 -)
Property Owner Parcel ID # Page uP
I Boring # ❑ Boring G)'
j lElpit Ground surface elev. i 1 ft Depth to limiting factor / 2 - 0 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
1/43 2- 7V . g 1/:
3 (5:j ( 7 /
M- q3 6; ,/,
s 1�. „L”
•
I I Boring # El Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Sal 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
I (Boring # El 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. 'Etf#i *Eff#2
• Effluent #1 = BO; > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BO; < 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.
ssn -8330 (Rmroo)
12' TYP. •
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3.001 ACRES ; c 22 i i
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130.744 SQ.FT. ! ' ,� !
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1 1� 3.036 ACRES 1 io 3.014 ACRES i ; n 3.011
�� 132.236 SQ.FT. 11 10 131,286 SQ.FT. � u 131,1
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MATCH LINE
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
• 404956 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
. Personal information 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:
Stoner, Raymond Hudson Township 020 - 1353 -22 -000
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
. Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
•
•
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding • Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH 1Lift Friction Loss System Head ITDH Ft '
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER Systems Only
x Pressure Systems Only xx Mound Or At-Grade y y
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
. ❑ Yes DK No 0 Yes [; No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /
Location: 664 Hillary Farm Rd Hudson, WI 54016 (NE 1/4 NW 1/4 36 T29N R19W) Cottonwood Ridge Lot 22 Parcel No: 36.29.19.2022
1.) Alt BM Description =
2.) Bldg sewer length =
• - amount of cover =
Plan revision Required? Yes „ No 1 I I
Use other side for additional information. '` _— L. _ L -
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division
N w ir„ , - . , ; 20 W. Washington Ave., P.O. Box 7162 Coun "� / , fl Pc
VI sconsin Madison, WI 53707 - 7162 �I- -t- Address
Department of Commerce Oz. D/ /L 8 6 —t C.6 �i t- Y Pekem Y Permi
Sanitary Application Sanitary Perrmt 9
PP lication o stp
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ , - k if Revision
may be used for secondary purposes Privacy Law, s15.04(1)(m) -�
I. Application Information - Please Print All Information ; vE b State 'Ian I.D. Number •
Property Owner's Name Parcel umber 00 d
.. i...... �. . _�1 r 5 71 4'2 a 1 53- 21
Property Owner's M • • . : Address `
sr R O spperty . . don e l C
C IX GO
C P / S T • c' G OFF ' t/. ;S .3.6T2' Lt
City, State Zip • .e Phone _R' Lot Number Block Number
� Subdivision Name ^ umber
II Type of Building (check all that apply) «%s r • s '
� � • ❑City
or 2 Family Dwelling - Number of Bedrooms ❑Village
❑ Public /Commercial - Describe Use : ,whip// Z n s
❑ State Owned Nearest Ro
C2) 3 t x q -7C' -�eAAJ LQ S (= -� ,. U.,, ' 4 i � -
III. Type of Permit: (Check only one box on line A ( numbe , i, : ■ u. a for internal use). •. plete line B if a' ' 11
A. F, ai use 1
w 2 ❑ Replacement System 3 ❑ Replaceme, of 6 ■ lion to
y a m Tank Only Exis' System ,
B. ❑ Check if Sanitary Permit Previously Issued Permit Nu r Date Issued
IV. Type of Permit: (Check all that apply)(numbering heme is for inte , , e) * .. 4—tot EFF. PLTeL
n - Pressurized In- Ground 210 Mound 47 ❑ Sand Filte 50 ❑ Constructed Wetland
❑ In- Ground 41 ❑ Holding Ti : 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerobic T '„ent Unit 49 ❑ irculating 30 ❑ Other .J 13e I trt� �'('�2�g,
V. Dispersal /Treatment Area Information: O . "pe/ /R - 5++ /
Design Flow (gpd) Dispersal Area Dispersal So Application Pe • tion Rate System Elevation Final Grade
Required Proposed Rate(Gals./Days /Sq.Ft.) (Min. 1 h) Elevation
'- /1
6 0 5 0 51 i �� / .3. ,2,s- �,
VI. Tank Info Capacity in Total , umber Manufacturer Pr- •b he Steel Fiber Plastic
Gallons Gallons of Tanks Cone Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank K. - / Z60 1 t v Q,4�
Dosing Chamber L
VII. Responsibility Statement- I, the undersign ., -, ,, ;e responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Si •. , . H� M P/MPRS Number Business Phone Number 9 0 (7 7 , ,--,....- a 2 / 1 ciy/ 4
Plumber's Address ( Stree City, State, Zip • .
7/ / 7z,--2-(")4?' -c__ f ` \e -(-t) f e-4-- i- L/ (A) ) 3-1 o ( 7
VIII. County/Department Use Only
Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved ❑Disapproved
Surcharge Fee)
❑ Owner Given Initial Adverse $ � � r w 21, �
Determination YVt� -� w'1i,..
IX. Conditions of Approval/Reasons for Disa rov ' . t`
.X " rirpanr� t S r b _ ok,. d- ,�„�.,,�.. , I Z s•� • Q ems over
g N.R li, r C-kw.. J t Cor)?i(mildC
t,6- A-ll 5•0. ,a-c -s . 6 - ,,ku � . L r
Attach com • - • • (to the County • • j • • e em on , , 'r not less • • 8112 x 11 inches In size
cpe• Pk t - t 1 tsu -S .
SBD -6398 (R. 05/01)
PLOT P • N
PRO„ ECT Raymond Stoner Al? , ,s 799 hwv 64 New Richmond Wi 54017
NE 1/4 NW 1 /4S 36 /T 29 N/ y1 • TOWN Hudson COUNTY ST. CROIX
MPRS Shaun Bird 226900 � DATE3 /13/02 BEDROOM 4
CONVENTIONAL )00( IN- GROUND f ' ' SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 514 # of chambers 30 •
■ BENCHMARK V.R.P. Top of Nail in 6c1 $"-Poplar � (i ItA
ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL •H.R.P. Same as Benchmark
SYSTEM ELEVATION 93.0/92.5
200' P 40'
wn#"Z De sc.�r r ev " . .
. 8n p r
O.
h�
120' 500' property line
2 -3' X 94' Cells with >3' S
B.M. #2 8%
0'
B-4 Slope
15' • 40'
40'
B.M. #1 Vents
Spacing 40' 40'
P g 1 —Q
Vents
1 1
A new soil test and
revision will be done 20'
• 30' A 0' 5
on this site. B B -1
2% Slope
Pro 4
Bedroom
House
Vent
>12" I Sidewinder High
of Cover Capacity Leaching
Chamber Plans Designed Using
6' Long 16 Conventional Powts
Grade at System Elevation Manual Version 2.0
34"
Cottonwood Trail/Hillary farm road
' • . ' • PLOT PL N
PROJECT Ravmond•Stoner ADD S 799 hwv 64 New Richmond Wi 54017
NE 1/ 4 NW 114S 36 /T 29 N/13/19' / TOWN Hudson COUNTY ST. CROIX
3/13/02 4
MPRS Shaun Bird 226900 DATE BEDROOM
CONVENTIONAL XXX IN- GROUND 3 SSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1260 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 514 # of chambers 30
■ BENCHMARK V.R.P. Top en -Poplar 4 - 1
P of Nail in l g � �/ ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL •H.R.P. Same as Benchmark
SYSTEM ELEVATION 93.0/92.5
200' P 4 , 40'
Da
\ /
120' 500' property line
B.M. #2 8%
B -4 Slope
15'
40' •
40'
30'
B.M. #1 40' 40' Vents
2 -3' X 94' Cells with >3' Spacing • .0
Vents 1
A new soil test and
revision will be done 20'
• 30' • 0'
on this site. B B -1 5
2% Slope
Pro 4
Bedroom
House
Vent
>12" I Sidewinder High
of Cover Capacity Leaching
Chamber Plans Designed Using
6' Long 16" Conventional Powts
Grade at System Elevation Manual Version 2.0
34"
Cottonwood Trail/Hillary farm road
J
Wisconsin Department of Commerce SOIL AND.. EVALUATION
1 3
Division of SAfety and Buildings , Page of
Bureau of Integrated Ser''rces in accordance; s. ILHR 8 yis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inctes in 'size. P n halt, -• n '. County Q
include, but not limited to: vertical and horizontal reference p r1t'(BM), direction and t,t 1 , Crl�1 �(
percent slope, scale or dimensions, north arrow, and location d ro
fi istap pto n "arest ad. , P rcel LD # J �
APPLICANT INFORMATION - Please print all in or natioon co oly; .� ' , viewed by Date CQp
,�
Personal information you provide may be used for secondary purposes (P La
acy w, `s: 1 6
Y 6Jij.Kfif M, �� i�/�pp/( U 6 , // / /
Pro P rtY Owner , ' �j�
�, , Property'hot;�d
`�-_ _ bt:.L 1/4 j 1/4,S T 2 et ,N,R 1 ct E (or )CI
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
/3 53 Awa-iit kc Tv . 2 C- 2 - +Iar t.do r /• /�
ti(4e_)
City State Zip Code Phone Number ��
❑ City ❑Village h, Town Nearest Road
1 + 1 -4 AOC\ 1 I 5 on 1 (115) 5Aq- col .N t4 u d m - 1 ecrHo , s A.re» c1 4-r.
4New Construction Use: S- Residential / Number of bedrooms 2- 7 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 6, Or) gpd Recommended design loading rate • 7 bed, gpd /ft . 8 trench, gpd /ft
Absorption area required g,5 bed, ft -- 7 c trench, ft 2 Maximum design loading rate • ? bed, gpd /ft • trench, gpd /ft
Recommended infiltration surface elevation(s) R Z..4 0 ft (as referred to site plan benchmark)
Additional design /site considerations V pp , ( - q 3, 00 Lou,, e r- ?O .On
Parent material (71 ( Q 0.10. (' ()Di u,)aSti Flood plain elevation, if applicable - 14Z 0 ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system g'( ❑ u El' ❑ u E ❑ u [ ❑ u ❑ s E 1-ti ❑ 5 B-tf
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
.._ 1 o--IL l0 yr3 / Sl, lrw k m r LS 1-P .'{ ..5
2, IL-46 /Q y r L / 4 L5 l rns9 rn) c 5 _ • - 1 ., 8
Ground 3 44) `T1 /O y r 4 ii, mS 0 I(Y11 c - • ', • 8
elev.
Depth to - -
limiting
factor in. (p
Remarks:
Boring #
1 O -IZ 0yr3I2 SL- 1Mc bK M-("r CS 1C . L A ; • 5
Z )4-21 /0yr — L5 Im.55 m1 CS — . - 1 ,.8
3 Z 1.40) 10V r 4I() -- mS oSi ►Yl 1 C S '� ; • Z
Ground
elev.
Depth to ,
limiting
factor
/(39 in. Remarks:
CST Name (Please Print) Signature Telephone No.
Pei air S.chu mr4 ICer (7)6 .47 - , 40 d £s'
Address Date CST Number
` (leder 1 S60-/ erse4 CJ1 5' -02,s /s -`r/ z330 5'
1
•
PROPERTY OWNER ;ICU f SOIL DESCRIPTION REPORT Page '-
PARCEL I.D.#
Boring # H orizon Depth Dominant Color Mottles Structure G D /ft 2
g Texture Consistence Boundary Roots P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
3 0-1Z /6 y - 3) SL I MGbL. ry- - c s I -4 . � ' . 5
2 /z-1 l0 yr• `4114. ' LS I msy rr CS •
Ground 3 (6 "iZ6 /0 yr m5 Qs5 r l ( LS —
elev.
76.COft.
Depth to
limiting
factor �l
t ro in. 2 1
Remarks:
Boring #
I 6-440 /Cyr.3 /Z (rlabk rrrFr C.S I . l . 5
Z 4-2d /U yr �/AI LS 1 m55 YYl l 5 — 8
3 20 -1. /0yr Hilo I115 os5 m I c...5 Z. $�
Ground
elev.
gz.7oft.
Depth to
limiting
factor
/30 in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /fie
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring# / p, /Oyr3 /Z SL in-14 bk m''r C ic •'
S Z 8 - L 2 i - - yly L5 I rn5 . 5 ml C. 5 -- . 1 • $'
3 22 -13 lbyr y lk m5 o5r rnI « — .
Ground
elev. -
9t.yoft.
Depth to `
limiting JO/ ,
factor
±3k Remarks:
Boring #
..........................
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
Vale_ 3 �- 3
Seat -e. / '� 8*0 tc"
AG rI ;n(
QAA e(eu. Ioc). o
no I t \ " poppC4
3w► Z .e( • iov .
s Veit 9 Z, 9
UrP y 3,00
112-t. e(t.u, Govrerg0,
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II
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715- 246 -4516
71,r- Y` d - P L1
57 6.5 --. 'fi
7
Shaun Bird #226900 "�
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT c
AND n t -f 3 - � 1
OWNERSHIP CERTIFICATION FORM
Owner/Buyer /62 /po AA d s Tv Are- t-
Mailing Address 7 9q ,ly e, ` LI N-e Le, are, l/f yo /y "j w , S
Property Address , , , , / , ■• , -
(Verification required from Planning Department for new constructio ,'��
City /State Parcel Identification Number
2 0 Z 0 - 13 5 3-2 -
LEGAL DESCRIPTION �ep j t
Property Location 1 / 4 W ) ' / 4 , S , T N -R \ 1 \ W, Town of r - .
4.Z
Subdivision , Lot # ,
Certified Survey Map # , Volume , Page # .
Warranty 6 D eed # e, s'2-3 1 1 , Volume I b k6 q , Page # S - 5 7 .
Spec house 0 yes` ',3 no Lot lines identifiablaa yes 0 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 wastewater disposal 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.
Uwe, 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
days of the three year expiration date. 4. 9-1. /.0)S4 .._
SIG '1 JRE OF APPLICANT DATE
OWNER CERTIFICATION
1 (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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGTURE OF 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
•
STATE BAR OF WISCONSIN FORM t= 4168 [/
R t WARRANTY DEET 65291
KATHLEEN H. WALSH
REGISTER OF DEEDS
Document Number u +i 1.689 FpL: 539 ST. CROIX CO., WI
-, RECEIVED FOR RECORD
This Deed, made between tlC ', f - '.i(� i • - n
RI_rHnRn O STOUT and JANET P. STOUT, 07-30-2001 8:45 AM
husband and wife, WARRANTY DEED
Grantor. EXEMPT N
and RAYMONf) W _ STONRT a cincjla persor� CERT COPY FEE:
COPY FEE:
— - - -�� TRANSFER FEE: 157.20
_ RECORDING FEE: 10.00
, Grantee. PAGES: 1
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St. Croix County, State of Wisconsin:
Lo WI Plat of Cottonwood Ridge, Town of N ame and Return Address
Hudson, St. Croix County, Wisconsin. The First National Bank of Hudson
;307 Second Street
Grantee, its successors and assigns, hereby Hudson WI 54016 -1507 •
agree that a single family residence only will
be constructed on the subject premises.
020- 1353 -22 -000
Parcel Identification Number (PIN)
This i s not homestead property.
(is) (is not)
Exceptions to warrantees: easements, restrictions, rights -of -way and covenants
of record.
Dated this o� day of _ VOA Y 2001 .
R %Q _ a 51 4 —.
t b -Z (SEAL) / . (SEAL)
* Richard O. Stout Janet P. Stout
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
State of Wisconsin,
55.
St. Croix County. �f
authenticated this day of Personally came before me this D-`J 1 4 ...,__ day of
July 2001 , the above named
Richard h_ Si and Janet __......
P_ Stout
TITLE: MEMBER STATE BAR OF WISCONSIN �� ` to
(If not, me known to be to toot7�q r' V (executed the foregoing
authorized by §706.06, Wis. Stats.) instrument an cQIWISCONSIN
KERNON J. BAST
THIS INSTRUMENT WAS DRAFTED BY "4%
Janet P. Stout
.1353 Awatukee Tr. •
Hudson, WI 5401 6 Notary ' blic, State of Wisa1'
My c- misslloy Is perman• t. (If not, state expiatio dte:
(Signatures may be authenticated or acknowledged. Both are not �0� .._— f/�.)
necessary.)
Nantes of persons signing in any capacity must be typed or primed below their signature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
WARRANTY DEED FORM No. 2 - 1998 Milwaukee. Wis.