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HomeMy WebLinkAbout020-1353-39-000 5/JiSconstf`Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. 363847 Permit Holder's Name: ❑ City ❑ Village ❑ Tgwn of: State Plan ID No.: • Jameson, Scott ( Hudson Township CST BM Elev.:- ! Insp. BM Elev.: ., BM Description: Parcel Tax No.: Ic7V M ;- . i ;� i'o 020- 1353 -39 -000 TANK INFORMATION IJciil ELEVATION DATA /(lptic TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ` ( Se N V FFz- grit g41) /GrO Benchmark (1. 1 /vet/ fo p Dosing / Alt. BM { ' • / / 2 Aeration Bldg. Sewer la 3 (' 7 j Se Holding • St/ Ht Inlet IO,7b ' ' . y' TANK SETBACK INFORMATION St / Ht Outlet 1 l• / e7 2j TA K TO P/ L WELL BLDG. VAirentto lntake ROAD Dt Inlet eptic 4.//4 f 5 • NA Dt Bottom Dosing NA Header / Man. ( ( ' 5E Aeration NA Dist. Pipe Low 11 :7 q2. WI- - 2-. Holding Bot. System (-Ow fa..00 -�' I.I 1 .-740 . PUMP / SI' - • N INFORMATION Final Grade $•36 9S Zr Manufacturer • emand St cover G - 'Pr it 92 - � Model Number GPM p ea vAw.loe 1 1. 5" 42. t _ TDH Lift Fricti • • • em TDH Ft • - .. Forcemain Length Dia. Dist. To Well SOIL • : • RPTION SYSTEM BED CM Width 1 Length / No. Of Trenches PIT N_p Of Pitt I a Li DIME , • 1 � a _ DIMENSIONS n fa Ma SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM E ACHING In 4 11ra f y.• INFORMATION Type O 3 , CHAMBER Model juumber: . Systeto 3 r NA_ -- OR NIT jit C CepeAl DISTRIBUTION SYSTEM Header / Manif Id Distribution Pipes) w ‘ r x Hole Size x Hole Spacing 1 Vent To Ai Intake ee Length e 1• Dia. u"I , I Length .7 a Sic. ;J.; Spacing _ I I — l 39 SOIL COVER T x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over I xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ o Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: S / I spection #2: / / Location: 649 Hillary Farm Road, Hudson, WI 54016 (NW 1/4 NW 1/4 36 T29N R19W) - 36.29.19.2039 Cottonwood Ridge - Lot 39 5 j We (no{ i «i-o(g)Inca ec-i - rSrj , 1 . ) Alt BM Description = (ob, • 1 S � 'a.4 lD ui lol i St.✓•►� 2.) Bldg sewer length = 15 ^ - G �- -amount of cover = -1'�-11..1 d G6 ►'' `j��� n wuS a ' u' r Weo 4w,t, M . a (Se le- ` tr V 1 ow& et, a iP, 3) (�e,,,fRGP (�' V wi Si'be. b • Lae Sduutlti� r �- � r�,.a r 1 -4 �---- „„4 8)515 -1 Was 64.5 43 fl . 1' -►'1 t, A Twt /k Ck G 4— ` ' � �b ft / n M!!A u I 3 "�'Y Plan revision required? E] Yes ❑ No Use other side for additional information. C 2 OC IIIN X i SBD -6710 (R.3/97) Date Inspector's nature Cert. No ADDITIONAL COMMENTS AND SKETCH `` SANITARY PERMIT NUMBER: p . � r^ a i-a # ,- .�:.�. fie. . ....«..� t ..«««« I I 8 . i ; S , i t I Ht i S ci, .4 p . . 1 i 1 ,.,...... 4 km.. � �‘ I 1 a ..... . _,4 , . _,,,,,, . 4. . ___ • i i 4- .. rr , , , , , , I ii,,,,, , , . . 1 . 0 , . , , , i. + , : , , . , , kii.„,....t..,.. MI • - ' 111 Ina 111 kik IV" • • f _ A I ,,,,4_ . I . II dmmaiii i I use= I o lix.„:4 . - ,,,K r , _. _.,...e_ • . 1110 . . al • I RO In 1 : , ....4 m I € mil aimas Ullirer" 1111 lir giassrp E I I s 3 ► , k leg- ,dial. impom I . 0 3 Ilk MI AI � ..� I • 1 I } 1 ._.., 1 _ _1_,..., ....._..,,,Hrn i _f_ 1 . 1 .,..• _._ .. _.„:._ al • min al L. wet F I iii . i a, g, . mai —1- i tf . .e r ov , : . 4_,._ . SCALE m _ AL _i � � ,.. . i_ I . Safety and Buildings Division 1 4k--6 Htt_LAe_y 5L14( 4. no ' SANITARY PERMIT APPLICATION 201 W. Washington Avenue sconsin P O Box 7162 Department of Commerce In accord with Comm 83.05, Wis: Adis. Code -- Madison, WI 53707 - 7162 ' • Attach complete plans (to the county copy only) for the systent,d wer no • ss' , County nn than 8 1(2 x 11 inches in size. , , � . ` r0 i �L • S reverse side for instructions for completing this app t o Sanitary Permit Number r0 363S43- Personal information you provide may be used for secondary purposes i -- t" 2 ( III heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 1 ''' r /L 4 Op - Plan Review Transaction Number I. APPLICATION INFORMATION - PLEASE PRINT A , FORM ' Property Owner Name c— J J 0 � -s _ ) ( t { r , Z, ' 1/ 4 e ty L , 3 T 2 7, N, R / 4 7 E (o6DN Property Owner'sM?ilhng d ss S �� ds u of Block / Number GG�� ) [city, State_ ri „ � c Zitle g hone Number Subdivision ame or CSM Number I I. TYPE OF B UI / LDI check one) State Owned ✓ ❑ City N earest d ( ) ❑ ❑Village e.trz,1„dio4y1;,,ti ❑ Public or 2 Family Dwelling - No. of bedrooms S 7egown OF %c, i _ I III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number([) ■' 1S S ' 31-44 3. 24_: 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility • 3 ❑ Campground 7 ❑ Merchandise: Sales / Repairs 11 ❑ Restaurant / Bar / Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office / Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) -N 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 1 eepage Trench 22 ❑ In- Ground Pressure ✓ 42 ❑ Pit Privy 13 ❑ Seepage Pit 4� V Privy ■ 14 ❑ System -In -Fill 2- 3 )e 9y / e..--R- ,��+t SO e- n-�J�p /n d1> VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Pr7s1frq. ft.) (Gals/day /sq. ft.) (Min. /inch) q E vation 75 0 237 , 8 '� / Feet 7 5. ( Feet TANK Capacity VII. INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber Plastic Exper- New Existing Gallons Tank Concret strutted glass App Tanks Tanks Septic Tank or Holding Tank S .. / 650 / — 1 e, j / — ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb ' ignature: ( mps) MP /MPRSW No.: Business Phone Number: 5 1---a Pe 546 99, 7/s - `- S b Plumber's Address (Street, Ci State, Zi C de): C OI ? IX. COUNTY/ DEPARTMENT USE ONLY 0 Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued_ Issuing Agent Signature (No Stamps) Surcharge Fee) cgtApproved ❑ Owner Given Initial 1 I »-'`^^- Adverse Determination olaS. S- / P �..._ X. ON S _ OF A • VAL REASONS FOR DISAPPROVAL. .� trv^.l R SS. o I SBD -6398 (R.12/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS { • 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a 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. 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. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 - 3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to oe installed. - II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. 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. IX. County/ Department Use Only. X. County / Department Use Only. • Complete plans and specifications not smaller than 8 1/2 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; pump or siphon tanks; 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 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. 1'. • , PLOT PLAN . PROJECT Scott Jameson ADDRESS 9740 S. Autumnwood Place Hiahlands Ranch CO 80126 NW 1/4 NW 1/4S 36 /T !AI /R 19 TOWN Hudson COUNTY ST. CROIX MPRS Shaun Bird 226900 /I':a DATE /25/00 BEDROOM 5 i CONVENTIONAL XXX IN- erND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1650 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .8 ABSORPTION AREA 954 # of chambers 30 BENCHMARK V.R.P. Top of Nail in Poplar ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 91.80 op Vent >12" I Sidewinder High of Cover Capacity Leaching Chamber with 31.8 ft ^2 per chamber 6' Long 16" 3 4" Grade at System Elevation 1 40 Property Line A Pro 5 Bedroom House 0 ST, please note: using a two 15' . Alt. chambered septic F-. ' , :.M, tank, with baffles in both '8 A� 1 ' sections, please remeber o to pump both sections. .1 B 80' 10 . ST ' Vents i► 0' Vents C 4 0' , • 2 -3' X 94' 20' B Trenches with 6' Spacing B -4 • 80' Please note: the dimensions of this plot 6% plan are based upon the soil test, of Slope which, no scale was established, a V educated guess assumed the scale to be 1" = 80' 60' ,II Property Line 1 � PROPERTY OWNER SIC:50 of SOIL DESCRIPTION REPOR Pag 3 PARCEL I.D.# Boring # Horizon De Dominant Color Mottles Structure G D /ft g Texture Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench 3 1 0 1 O» r 313 — SL_ 11 nQbk m C. S -C . L- 1 ' . 5 Z Iz -L5 1 p y ,- LIN LS I ms9 l t-rr ceS _ ,1 : R Ground 3 211c iOyr cIke elev. m$ OSg mI C$ • g ff. Depth to limiting factor o in. Ili .4 14.4 Remarks: Boring # .., 1 h- 0 3/ l- sa. 1T- 5 ii 2k,46 l l7 yr r •1; 1 1 c+5-119 Inyr Like mS O 3 ml CS -' g Ground elev. ( Wok Depth to limiting , factor II in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 0-9 lbw-3123 __, S L 1 rreAlic Ynt'r C5 l 4 ' . S RZATKr ijg 5 2- 9-94, 3 - LI /`I L S 1 rnSc mfr LS — • —1 : • :a6741 3 % -17s, 1 OyrLi /te m3 Ogg m1 e s — -1 ; • g Ground elev. - Qr:$Oft. Depth to . limiting 0 `I' ' factor _ tan. Remarks: Boring # u' Ground elev. Depth to , limiting factor 'n ' Remarks: SBD -8330 (R. 07/96) 'Wisconsin Department of Commerce SOIL ANDS EVALUATION I ' Divisionsof Safety and Buildings � 'i-� ." Page f of • Bureau of Integrated Services in accordanc t t s ;'OQ. Wis. Adm. Code • ', County Attach complete site plan on paper not less than 8 1/2 x 11 in es in size. 7n must a �. include, but not limited to: vertical and horizontal reference p int (BM) direction and ,t7 i ` X percent slope, scale or dimensions, north arrow, and locatio d distnpe, to nearest road. ('arcel I.D. # APPLICANT INFORMATION - Please print all tnformatio ; 1 �r). ' ,r eviewed by Date � �( .rnd ) Personal information you provide may be used for secondary purposes (Privacy 114,v tVQ (m)) �.., �' , i e. /w� i tl /R Property Owner - P r o p e r t y L9Ca)i 1 l Eftt rd Sc:)k..1_4- f Gaut. ',( 1/4 4 1/4,S a ce T 0 ,N,R 1 et E (or)(19 Property Owner's Mailing Address "'Lod # Block# Subd. Name or CSM# 1 35 - ' 2 -) A .- -Lake e � . 39 CakAon t ..0 ocr City State Zip Code Phone Number ❑ City Village �- Town Nearest Road \ ©n 1 1540ND 1 n ) :3yq -(0161 i ( icA, ►'.) 1 rOkir.,r1 LA-1cs c.)a +►-. Fr -New Construction Use: VrPresidential / Number of bedrooms 3 4 Addition to existing building ❑ Replacement J El Public or commercial - Describe: WO Code derived daily flow O gpd Recommended design loading rate • bed, gpd /ft • g trench, gpd /ft Absorption area required 5.-1 7 bed, ft 2 {5Q trench, ft 2 Maximum design loading rate • 7 bed, gpd /ft - C trench, gpd /ft Recommended infiltration surface elevation(s) q/- 8 d ft (as referred to site plan benchmark) Additional design /site considerations dr.4/� . )f/- q/. 0 d L- u w a r 9Ci • 06 Parent material ka.(: KNA OLiAL Flood plain elevation, if applicable -/'W ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system 2❑ u ` ❑ u ❑ u ErS ❑ u ❑ s Eli ❑ S E tJ SOIL DESCRIPTION REPORT Borin # H Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o - Z4 Ii fy .:31 — 5t_ I rna mfr c 5 I f - LF .. 5 Z 24-3(0 16 yr t-tki I.-. 1 m55 (IA Tr c..5 — - ; . Ff Ground 3 .(o -12,4 IO yr 4'c� _____ r' o ri i"r�t C j . ' • 2 elev. J q. Depth to ' limiting factor ' 124 in. 0 116, ' Remarks: Boring # - I 6 - 13 ID yr 3/3 _____ SL 1 mark rrr r c s I C . q ; .5 2 Z )3 -31 ►t'1yr 'AM L,5 I msc . mfr c 5 `1 ', . g 3 31-17 to jr till — _ rrys O .5 11.-11 1 -S — . --L g Ground elev. U Zoft. ' Depth to , limiting factor IZ.t in. Remarks: CST Name (Please Print) Signature Telephone No. Adam Schu maker i Gf:__ — � `115-2- f - 1-- (lpo4 Address Date CST Number - IDS CeAer S1-. 4t `f ScrnerC -i-, Lv ( 5'4025 4 -t 5-99 2,53 - 09 SOIL DESCRIPTION REPORT 3 PROPERTY OWNER S() I Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure (20 ,-,, f+ 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench I 0 -12 10yr 3/3 — 3L mabk rat- C `5 zf .5 2 1 [byr cllct — LS I n,s5 11 'r C.% ` ,�1 • $ Ground 3 zy_iu, 1O Like mS l7Sg Prtt CS — • tJ elev. _Oft. • Depth to limiting factor 11(n in. • 1'. Remarks: Boring # 1 0 10 If 3/3 SL_ I POCAL* m CS . 5 2- 24,-u5 fe.) 1. mss r �r c s — • `I $ -119 16 ti /cam m5 mt — '1 $ Ground elev. qz(A. Depth to limiting factor II in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ( ©'9 t1 i r 3 / 3 SL t rnO.hK yer CS 1 C y . 5 5 Z 9 y(p 10yr ti /y — L S t rr )c3 . m rr C_g -- t • % -i2g IQ' /rc-! Ie i1 — , Ground elev. - Q.C, hOft. Depth to limiting factor 1 " - "' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) I'Azc 3o 3 .5"00+- Go 3 c Cc) - w o e', e . —L -. 1 / t nk t‘ I ;Sao: Pce — /3A. e t a , / AC'i I ' $ "I 1301Z cl ttJ. t(lG. U N $,y e,v, ..e d . q/, $ a 7 6 u / 'erg Q(, Ov r¢Lf. Cl. J . t o ,v-.-r 4 w _ 0 per, ti tsar` A C At er p* L. I.— L, I 47 Z I • 0 OS- pnmary 6 V C I Au s wa s ,,rle., 412.. tA, - ,rare,. CiAS-a j o,A P.D` Y '0 5�� CST: s: uA .e,- c a j fr-.e_ ems.- s - 3 - 2.eo0 + 1.14_ - dcr,.fg, a , 1 go = 80.0 / , e^'�e ,e4 P�' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer a. � esboti Mailing Address ( 4 1 7 , 40 - •• LA . ••._ • GQ-tg , (�R*t.4kS �(Zvbr3C�'t' Co � /- r t Pro a Address 1 - ,/ P rtY (Verification required from Planning Department for new co. truction) City /State tiGt0gLIY1 L Parcel Identification Number CO 110 3 — RZ? LEGAL DESCRIPTION / Property Location / - / Sec. X , T 09 N -R2W, Town of 1 > Subdivision n itritddel4 746' ,F . , Lot # 37. ,------ Certified Survey Map # , Volume , Page # - Warranty Deed # 7 70 g , Volume // 0 7 , Page # 3 _6_/ Spec house ❑ yes a no Lot lines identifiable`0yes ❑ 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. Croi K County Zoning Office within 30 days of . three year expiration date. I - ' 9 0 /1.4,04,t9. _1 SIGNATURE OF i LICANT ATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (arc) the owner(s) of the pro, described above, by virtue of a warranty deed recorded in Register of Deeds Office. V 1,9 /O • f vi ATURE OF ve PLICANT DATE '•••'' Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. t* Include with this application: a stamped warranty deed from the Register of Deeds office a cove of the certified survey map if reference is made in the warranty deed STATE BAR OF WISCONSIN FORM 1 - 1982 r 61'77 WARRANTY DEED KATHLEEN H. WALSH �j •r� ] 2 REGISTER OF DEEDS DOCUMENT NO. � 87 PAGE 3 J J ST. CR]IX CO., WI _ - -- RECEIVED FOR RECORD This Deed, made between RTr HARE (1 STnUT and 02- 01-i!000 10:00 AM JANET P. STOUT. husband and Wife, NARRAN'Y DEED EXEMPT N , Grantor, CERT COPY FEE: and SCOTT M, .TAMESON and ANN E JAMESnIg, COPY FIE: husband and wife, REC 10300 PAGES: 1 Grantee, Witnesseth, That the saki Grantor, fora valuable consideration — • conveys to Grantee the following described real estate in St _ Crn1Y THIS SPACE RESERVED OR RECORDING DATA County, State of Wisconsin: : NAME AND RETURN ADDRESS Lot 39, Plat of Cottonwood Ridge, Town of ✓�� Hudson, St. Croix County, Wisconsin. 020_11 na -8f' PARCEL IDENTIFICATION NUMBER • • • This i S not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And Richard 0. Stout and Janet P. Stout warrants that the tide is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions, rights -of -way and covenants of record, and will warrant and defend the same, Dated this 31st day of January Jebtt900l. n(Rit -hard n_ (�� Stnnt �,, �� (SEAL) J abet P . stout (SEAL) (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. authenticated this day of , 19......... Personally came before me this .I at day of 7 amt a ry xJ02.0.CL0 the above named Richard 0. Stunt and ,TanPt P_ Stunt TITLE: MEMBER STATE BAR OF WISCONSIN NOTARY P11F ;I IC (If not STATE OF WISCONSIN authorized by 1706.06, Wis. Stars.) to me kno , be tIK(4515ABertted the foregoing instru • >• • ' - • owledge the same. THIS INSTRUMENT WAS DRAFTED BY 7 Janet P. Stout 1353 Awatukee Tr. Notary bli County, Wis. tit ■dson Wi 54016 ry (Signatures may be authenticated or acknowledged. Both are not My to miss'. is�rmanent. (If not, state expirati da : necessary) - • Names of persons signing in any uupuiiy should by typed or printed below their signatures. STATE BAR OF WISCONSIN WiaconsIn La9al Oar* C 9,199 . 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Code 201 W. Washington Ave. � See reverse side for instructions for completing this application Per PO Box 7302 NVIsconsin Personal information ma provide rov ou be used for secondary purposes p Madison, WI 53707 -7302 Department of Commerce y p may (Submit completed form to county if not [Privacy Law, s. 15.04(1)(m)] state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 - 1/2 x 11 ' ches in size. County ,, Sanitary Permit Number CI Check if revision to previous application State P n I. D. Number 15 .36 3sY2 I. Application Info ‘ i ation - Please Print all Information , cation: Property Owner Name 'roperty Location ' SC. st u)1 /4ti[,tA /4, S3,�T,2y,N, l (or Property Owner's ailing Add , 6-I /-7/, 7/_ Lot Number Blockivumbe`1' City, state ip Code Phone Number Subdivision Name or CSM Number G 1 /44/ IL Type of Building: (check one) ❑ City 1 or 2 Family Dwelling - No. of Bedro , ' s : ❑ Village ❑ Public /Commercial (describe use):_ Town of ❑ State -Owned A Newest Road . /J _ , /7 .1 i.09-e. / /irk, &� n� P arce l T ax N _ l3 -S3 ?9 —cr�n r/ . `.� P s . yr, III. ype of Permit (Check only one box on ride heck be on line B if applicable) A) 1. ❑ New 2. , ❑ Replacement 3. ❑ Re, .ce nt of 4. 5. 6. rW A to System System Tank 0 Existing System B) P . ' 't Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ❑ Non - pressurized In- ground r. Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground • Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatme Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Informatio 1. Design Flow (gpd) 2. Dispersal Area 3. ' spersal Area 4. Soil Applicatio 5. Percolation Rate 6. System Elevation 7. Final Grade Required ' s posed Rate (Gals. /day /sq. (Min. /inch) Elevation VII. Tank Capacity ' Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallo Gallons Tanks Con- Con- glass New ' isting crete structed Tanks Tanks ■ ❑ ❑ ❑ ❑ ■ ❑ ❑ ❑ ❑ VIII. Responsibility St ement I, the undersigned, ass me responsibility for instal att /f f the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Si! ( stamps): MP/MPRS No. Business Phone Number Plumber's Address (Street, City, State, Zip c /b .' 2 /9 �,..�. ��-i l ' / � ' ‘ S 7 . IX. County/Department Use Only .. ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Iss ' g Agent Signature (No stamps) ❑ Approved ❑ Owner Given Initial Adverse Surcharge Fee) ■ Determination X. Conditions of Approval /Reasons for Disapproval: c tr��� iv �'° 4,e ((Ae 4L RV-Aye lAel 7 atiwi AI it 1 ` - ex 44 % 4, sly SBD -6398 (R. 07/00) • PLOT PLAN 1ROJECT Scott Jameson ADDRESS 9740 S. Autumnwood Place Hiahlands Ranch CO 80126 NW 1/4 NW 1 /4S 36 /T 29 ■ /R 19 W TOWN Hudson COUNTY ST. CROIX MPRS Shaun Bird 226900 i DATE9/16/00 BEDROOM 5 CONVENTIONAL )00( IN -GRO 1 P SSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1650 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .8 ABSORPTION AREA 954 # of chambers 30 IL BENCHMARK V.R. Top of Nail in Poplar ASSUME ELEVATION 100' ❑ BOREHOLE O W . *H.R.P. Same as Benchmark / SYSTEM ELEVATION 91.8 I ,' Pro.. Line G.. '.e is for residential and per al useo ■ , Garage 75' : ilding Sewer • Garage with no living Cleanou quarters, a toilet and • sink only 75' Pro 5 Bedroom • House 50 4 20' ST, please note: ing a two 15' t. L , chambered septic E-. k : M. tank, with baffles in .. th ' , A, 30' sections, please reme.: °' 0 to pump both sections. 10' 80' B-5 E, _ FT Vents V ents 0 Vents —■ 2 -3' X 94' ,,, 40' B -3 Trenches with 6' 20' Spacing B -4 N 80 6% 0 , Slope 60' - Property Line ■ 10/06/2000 15:34 715- 634 -5150 HAY SAFETY AND BLDGS PAGE 01 � 4 : `•' SAFETY AND BUILDINGS DIVISION 10541N Ranch Rd - sconsrn C,�• <+•'` � FAX E� �;�I ��T Department of Commerce Hayward wl 54543 Date Sent: /0 -04, -2 oc;lo • , Paget Sent (excluding this cover): TO Sr. C +i,.f C.. 20.1/#4 FROhll.: D4110K ' FAX #: 7/ S' - a = _ - = (� s F'AX:#: (715) 634 = 515• PHONE: '•RHQ Special Instructions: 4 nom Aoh✓ - P. oR ;.. Scorr A1•7611'00v • w:' If there were any problems with the transmission or not all pages were raCpl'ad • > c'oil'ltict sender Immediately at sender's telephone number above. SBD -8170 (R.02/91) • • _ • i• `h1 1 •.. , u.i'. . 10/ @6/2000 15:34 715- 634 -5150 HAY SAFETY AND BLDGS PAGE 02 • Safety and Buildings • 10541N RANCH ROAD . >' HAYWARD WI 54843 N TDD #: (608) 264 � r ry„yyy.cpmmerCe.state.Wi.us SCO nSI Tommy G. Thompson, Governor Department of Commerce Brenda J. Blanchard, Secretary October 06, 2000 CUST ID No.226900 : :'::'..: ::A77N: POWTS INSPECTOR . ' ZONING OFFICE ,' SHAUN R BI' • ' > ' '.: ST CROLX COUNTY -PIA 1008 192 ND A > 1101 CARMIC - • RD NEW RICHMOND , 54017 f? ', HUDSON WI 5 ■ 16 RE: CONDITIONAL A "ROYAL. Identification Numbers PLAN APPROVAL EXP : 10 asactioe ID No. 438318 ' Site ID No. 199677 Please refer to both identification numbers, SITE Site 1D: 199677, SCOTT SAME ` � above is all comes • •adence with the _enc . ST CROIX County, Town of HUDS • ; COTTON W':; WOOD ' • IL; HUDSON 54016 NW 1/4, NW 1/4, S36, T29N, R19W FOR: Description: Existing Nonpressurized.In -Gr• .'•;10 • Object Type: POWT System 1.egulated'Obj '' ' "•::.76;4 The submittal described above has been conditio - ,. y • , eoved•,'as it b in compliance with existing (prior to July 1, 2000) applicable Wisconsin Administrative C • • .compA and • nsin Statutes. The owner, as defined m chapter 101.01(10), Wisconsin Statutes, is responsibl- or ," "1 w 'h� all' code requirements• The following conditions shall be met d , . •. g.cons'tiiictionpr 'Nation and prior to occupancy or use: • The connection of the water c and lavatory'pIu`mbia'$ tem Installed in the unoccupied garage to the existing POWTS is accep . le. No additlonal,d Is'-ezp - • ed to occur as the plumbing fixtures are for the private use of occu , nts of the five b'edroom`,home. • No State review is requir • for a gravity PIMS, 4» orless;an dia 11 ter. • All plumbing shall be i' ccord with chaptera Co* „82 & 84 of th :- isconsia Administrative Code. A copy of the this letter s , :11 be on -site during co nstri c t oTl an lopen to inspect'' ' by authorized representatives of the Department, which • ay include local inspectors; :, Alf' ,» ..0, e • uired b • _,1 m . 1 'ci , all sh .11 • e o• tained •riort. co mencem • •, c_c•.:.. ,:ts''` q , ration. Inquiries cone ' g this correspondence may be made to;;me a telephone number 1is. • below, or at the address on this letterhe; . ;L ,, `` Sincez °' " ': DATE RECEIV • • 09/20/2000 . FEE REQUIRED S 175.00 .' . 3 ',. FEE RECEIVED S 175.00 Tti• • S E DEVEREAUX , PLUMB G /,P0 S'R1 EWER II BALANCE DUES NQ.00 I grated Services :',....'1.. a 15)634 -3026 , 7:45 AM - 4:45 PM MON: - FRI.: ; . `'' : • EVEREAUX ®COMMERCE. STATE.WI.US . '; , ` : WiSMART code: 7633 cc: BIRD PLUMBING SHAUN BIRD SCOTT JAMESONA f ' ,' ,',.. .. : :: j : ''',.;r::1.:.