HomeMy WebLinkAbout020-1388-05-000 (2)
VibccTsir °uparvnc•`'o1COr°nw'r' PRIVATE SEWAGE SYSTEM ~OUnty SL CrOIX
Safety anc Bu dry Oi': isien
INSPECTION REPORT Sa-.itary Permit No
SAN-2018-190
GENERAL INFORMATION jATTACI i TO PETIT) State P an D Nc
Pcrec',u: nfu -a',c° you f,-:f, do may be sue 'of sccu-idary uu•DOSCS'Privacy Law s.' 5 C4 I lllmjl
Pc'1111IfUlcc, s Na-v City Vili Tomrsnio Pa-xl la'.. No
Tod Carlson TOWN OF HUDSON 020-1388-05-000
CST SM Elev msp BM E.ev. BId Oly, pliar Se::fion+icwr:92&nge'f,noc No
5r v le- P l zx•5~zr S I n 4'-1 14.29.19.2379
TANK INFORMATION ELEVATION DATA
TYPE IOANUFACTURFR CAPACITY STATION HS HI FS FI_EV.
Septic 519 Benchmark
/C,3 Dosing Al 11
-
Aeration Bog. Se er 1 ~6 3?- r
Holding St-Ht In l -
~3,~s
S1:Ht Dille: ' - r
TANK SETBACK INFORMATION
TANK TO P'L WELL BLDG. Vc°cc Air I•,teke ROAD DI In el
D: Bottc-r
Septic
i
t Yl_
Using Headefh1an.
Aerat on Disl Pipe
1
I loldi'lg Bo:. Svstem
Final Grade
PUMPISIPHON INFORMATION
Marl Demand Sf Cover - r
GPM b i 3
PAo. i Ni
TDH Left F -11-t on La.'s Syse'r I Icad DH Ft
Forcema r Lern"r I` a Dist x ;"%el1
SOIL ABSORPTION SYSTEM
BED/TRENCH AfcP' Lcng1° No. of Ircncl•-s PITDIMENSIONS Ne 01='r. rl' cD<: ql.d Depl
DIMENSIONS
SETBACK SYSTFM O L L ,-AKEiSTREAM LEACHING Orlando. ,
INFORMATION oC CI S, CHAMBER '
UNIT Ma ur
DISTRIBUTION SYSTEM
IIca-J, tfa-d:dC Urstnb.1n. II;:b• Sva x F.c a S!a~ r p `Je-,I to Air Intak,
P Oel`'r
Leng!F Dia Lcnyl', _ :i, a~ '!9 _ _
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
I tent- Oeer Dcot•i Over xx ul of xx Scedco: SodoeC IX" Mulc-ed
lir-J+lTench oenler 9ca'Tmnd• Edges Tal I - Yes Nu Yes No
COMMENTS: :.ncluco Coco discrependes, cersons present etc) Inspection a I Z /1 / Inspectio•r 42
Location: Syr SADICS LN ~l 1 C e
C Z „,i 1'wt~ ~z J ~f l
1.) All BM Description =
2.) Bldg sever length = c`F i i Ill mo't` "A
-amOU'11 of GCVef= e/rr r~x•i~u ~0~
Plan revision Requ red? Yes V Nor~ /I1/Z Use other side for additional informali In,eDCtars Sigrnature ature Cer: Na
SBDBr Ia iR 3W?
Jt e t~ uj
u
V
IN I
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514-Zetg-/9Z5
i.,'punty Sanitary Permit Application S-. CROIX COLINTY WISCONSIN
ipa caYd war CnaoBrt S roo: ; rIunh San tart' :Yrdinan-- PLANNING & ZONING DEPARTMENT
ST. OIX C:>UNT" :,0VE°Nf9ENT CEN-ER
Y Personal inf~.Tnation yoc provide rna\ be us c in. cecDria t owposes r-
(Pnvaa Jnw. tb~^W , it X11
Carmichael Road
Hudson l4il SC716-7"p
M1 a-z
f '151386-0F3- Fax ''to 586635
ACact.coxahete plans fo-thc svsiem on panel na: less . V-2 l: 11 inches it sae
County Sahim pe"., ° • G neck r revlslon It p~eviojs aDpii;.aaon /t
5 - Zalss- M .*9S7 JIa~;CS Lp
Application intornation - Please Print all Information Location:
W aOL•RY 'Jw'rlBr Na E
5 1~4 ~ 1!4. SBg
r o ~`'rl' ~--a ~ 1 ✓~0 7 Z'I N. R E or N'
°re:xrh Dwvc', Meiiin0 Address Lot Number RIDS,:. Number
57
~.es
Canc. Slate =1/G COoe Phone Nume: Subowwor Nam- a• "SIJ Numbe•
U 5 0 (-P F'ekI ~CtJ2J~
li Type of Building: (check on, wit\' ❑ \4Lage +ubrn o"
or 2 Fami Dwelhnc . No. D'
~nbllvi..UCIp N~Cia'. (a=scribe U°.EI (a0
State-D~'ec N::aws: Road
I.. Type or Permit IC:Ieck only one oc) or iine p. ::neck nnx nn Ine 6 d appo
?arcel 7 ax Numberi s',
Ai •.❑Rebair Reconne•lioo ?.❑Nor-Diurnoic ❑4e ova-a4n-~ D~ /7G'c2 65
Sanitation J O
r m t NurI .!J D 'DF:e ISS/ it 3/ ! Zb
3} J
S:atE Sani:arv '.crnil was b'eviously issue= . ~5 O 1
R~ TTy/p"f POwT System: (Check all that appry;
J4 rvOn-brB>surrcc Irr-dro:)rrc ❑ Mound _ 24 i•, _.av abk. soil 7 IADJnd s 24 in. sucable sai: ❑ Mound A-0
Sand Fill!- ❑ Co:istructec V%etianc C Peat Filler ❑ Drip Lin-
"ressnr'Sed in-grourd, ❑ Ho.t;ic Tank G Sm9M1 Pass ❑ liner
C Reci•u:atcla Z•a
At-D;adc L] ABre.^.IC Treatment Unit
V. Dispersal Sreatment Area Information:
DBS:;ir 'F IOV• tgpol D:ster a A?:e DISDOfsal Area •4..°.01 Aoplicatlor. ,:ate 'eraotailD`. Rate ~yslern Elevation Final V ade
~Reauved IFranosec ii3a!s.ida.wsp t,, l MIn.Ancni Elevation
Vi. Tank Information ! 3apal_ ) Ir. Gallons Toy l R of Isantrtactu-er Prefac Sae Cs- Stee Fiber- Plastic
Nev; Existing Gallons TanKS Conc-ete strlctEd glass J
'airs Tanks
! I ~ f ❑ G C ❑
IL Responsibility Statement
1, the undersionec assurlc responsiDiiity ix repaciieronnen•tiionrr=)uvenati0niinstaltahnr o' nor-plumbing to- ene POt47S sanvm or, ;he attaCbec plans. A
lic9nse is no: remuiwz fol wuvif. renal' 0;.e ns:a1sa iD nw#-plambing sanilatW FVSiem.
-lumbers Name (pnn',I P unba 'Sip .a. .e 1r siamcsl: td 'ih1~'FS Nr. 5nsnvss Phonc Number
2ZZG6 -715- 766~o~t7
?lumbers Andres (Street. 0i y Stare. -lip '"{o
1676 ;u /~'i (.~L J! DI
Vllt. County Use Only
td 'Saul:dry PL'
P:' v rlTll: Fee :J :e I5?bed IssJln Oei, Si ca- 'F N •aMnsi
~'X ApprOVBd •Jwn VL'f. Irll.VBraB ZZL . C) 2 7 / O
/ JCie.unination J O
D:. Conditions of Approval/Reasons for Disapproval: \
SYSTW OWNW, 11 ~lL~ a r-y ~A o r n J~
1. AsOn W* adkxn' IoM CM 6
d1wilnra C4 rbtwt al Lm"k K
w pw.nw,*Wran! plen yoridlid by p1thri.
2 AI aeNV,k ract.inmenu moot Ire r-. ~u~r k,ed
as per Ioppla"'.1 COI / : ri iUvAll.
Rev siRE
C:ONVr~-,,N IOINAL GOCYAPOMENT DESTGNI
Residential Apnlica'i•^r,
II'MEX AND 7'ITL.c YF.I E
I Iroierr Name: ~
n - - - -
Cwners Yame QQ -
owners Addrtiss:
_fAUZ~
LK.11'11 Description _L - N 4 Y -s- A -T
Tnwnsl,i,^- kns -
5abdivisinn Name
Loi Number
Pafc~l 17- ~-o 66
13 8
Page i _ IrrAF~tancl title
'age 2 Plnt Phan
Page 3 ~Sm g~ Cross Sec San
E'ana n Specs Pz-ge5
k9airrterance !nfnrrna9an
Pane 6 hrtar a z i~'~I plan -
F'ace i SL Croix-Ci~~ S~Iic Tank ?r/iain
'age & _ ten ForM
4hlar:"e De-ai
PA. ' 9 C§ nr Pal,
~'~:.3ChmeWS: Soil Tn..st & I-'ous2 Tars
License NU _
C!_ Phone Numbs
iaf. Anya':fica Lomo
I
ST. CROIX COUNTY ZONING OFFICE
CER'T'IFICATION STATEMENT
FOR [PTJLIZATION OF AN EXISTING SEPTIC TANK
I
This is to certify that .I have inspected Lhe septic tank presently se wing
O
the - 0 ~
residence located at: S K /V
Sec. Ai-, T „ g_N R J W, Town of 'I S Croix
County, Wisconsin- Upon inspection, I certify that I have found the tan and
baffles to be in good conditia and it appears to be functionin
Last time serviced - g properly,
Did flow back occur `rom absorption s
line- ystem. Yes No\ (if no, skip ~ext
Approximate volume or length of time
Capacity: J _ gallons minutes i
Constructin: ' Pre- Concrete
Manufacturer (if known): Sleet Other.
Age of Tank (if known) ; 'fu
(Sign t re - - ~jJ~D~'Ok ~n
(Name-). Please Print
~ (L.ieense Number)
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or
licensed disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic Lank condition, I
certify that the tank, to the best of my
requirements of ILHR 83, knowledge, will conform to the outlet baffle). Wis. Adm. Code (ex ept r inspection opening o er
Name
'j_i3uu1,s aE- Signature
MP/MPRS - -
i
Map
IGpU C~rc~3(~,~ a
4
4s,7 Spbic'S Gpo 4;cdmw
0
y .S S 1
AJO
GPit a Q / ; ~ I ~Jony
ok SeWe;c I,Ne JJJ
t6
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LO
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AND
OWNERSHIP CERTIFICATION FORM
Ov,nerfBuyer-- '~ddQ COL*j
• Mailing Address q57 %01% l(~ KJ050,),Wt ~y
Property Address R'5-7 541 LIJ IOSO.) -Uri
(Vtsificatipn re;tared from pbm=g & zomg Deparonew for new oonsmXtion;
_
CityrState NaD5661 k)L Parcel Werifiiicadon Number &A-139-05-60
LEGAL DESCRIPTION
'Property Location _ 'i< , ~E Sec. T N R W , Town of 05a~
F,to t Lot=
Stiodirisiott
Certified Survey Map f _ Volume Page ;
Warraaty Deed Volume Page
Spec hawse yes ® Lot firm it +e✓b (9 no
sY sma MAI VTENA-NLE AND OWNER CER't 1RiCATION
lmpropa use aod >min~manoe of }roar septic system eatad res2R m its m-awwre ftil= to handle xwtcs- Proar
roamteoanc: mnssts of ptm m* tr-t !he sew trunk every three yeas or Ste. :f needed try a licensed puutpct- What you pat imp
• the system can a` ba the fmtction of due septic teak as a a atcxat stage is the waste disposal system Owner MU0*n3nce
respoonbiliaes ax specified in §CoMM 83.52(11 and in Cbap= 12 - SL Cro~-% County Sanitary Ordinance-
The property owner agsers to ssbaut to S'-Croat County 1r1te®ag &Z= Depart a f~ ~ n_v the
owner and by a ~ plumber, journeymen pfvrrbcc. rm~cted pb bet or a licensed parnpa verifying t 1) the on-sile
wasiew-d= disposal system is in proper opeatg conarbon apss'a (2) after inspection and pmmnpmg (if aecesmy), the serzi` rsk is
less than 173 frill of shsdge-
Uwe, the un,dasigned have read the abev to uremeats and agroe to 11 the Pirate sewW- disposal system With rb^
standards xt fob herein as set by the Depmlmert of Comm = and the Dcpatavt9l of Natural Resources, State of Wisconsa
Cersif><acm strong that your septic system bas been maiomwed rapes be eonit7aed and reamed to the St (}one County Plamtin8 &
Zonmg Deparmtct within 30 days of the three yar emiratioc daoe-
Uwe certify that all smt ernents no this fom are nue to the best of royroor tmowledpa liar aru'ue tar owaffw of tb
property desatbel - vitMe of a warranty teed recorded in Register of Dells Olncc.
Number bedroo
t W OF APPLICr'1_hT(S) DATE
Any that is tt~reprtsemDd tray testt{t in the swRUy IreUw beitg M-Dked by the Pb D1M & Lomng Departaten
- lnchrde with this appbeaum a recorded warranty dttd uam the Regsskr of Dec& Ofd and a copy of the Ce[ti6ed son-e-, trap
:efeteoce is made to the warranty deed.
•
I 9s~ 4 S •
saray,oa Bn~ a~ cONMY
201 W. Washinom Are.. P.O. T1
~ I consin Maddon, a,I 70' _ 7162 - ~`9 Addrow << s
Department of Commerce
Sanitary Permit Application Permit 1, accord wab Comm 8311. Wis. Adm. Cads. prraoml ioforr ocm you portl[. 3R S7-~
1) canes if Revitiom
m be used for :a prrmc Las. M. in 1 r _
I. Application Information - Pkzw Print AN Wormatfm O Stan Plea I.D. Number
46. `
Property Owner's Name 1 N®ber p>O - I - OS^COD
t% .2 . iq.l
Owav's Mailing Addrea Location, -
ST CAM ss AAER; S T NR 13
Code p40mt 11101616 Og9CE Block Number
City. Sue LIP
j- Sabdivsion Nacre CSMNumber
(,1.~-arm G•-~-~ o/~ 7/s ~~X ,
Iy~L Type of Building (check ■B that apph) DCiy _
'A 1 ar 2 Family Dweabg - Number or Bedrooms OviOsge_
n Pub,i co®rreid - Dmrnbe Use *,wethip )_J,
~1 Nwrtx
O Sent Owned
D O o-it}"~ - /t.S ~ • S~il,~3-/1 ~ -
III. Type of Permk: (Check only one box on line A (wmDering sdreme far internal use)- Colnpkte line B If applicable)
A. 1 Nev 2 O Replacement SYaem 3 n Replaczmoa of 6 U AMOCO W Per Comty ox
g Tank System Only Exv;uw. B. 11 CLxk d Semnry Permit Previously hated Permit Number Dam Ismod
IV. Type of Patnit: (Cheek aR that apply)(nombaing schene is for internal nee) Daft
44 g Noa -Pmsmimd to-Gram] 211) Maud 47 n saw Fdeer 5o D Cow Weaud
221) Prewrired In-Groad 41 U Noldw* Tuft 48 U single Pass 51 n Drip Lt*
OS 1) At Grade 46 n Aaobit 71w®ea Orr 49 U Redrald g 30 U Wta ` -2 p s, -y 937Sj
Area Information:
Desi® Flow (gpd) Dispersal Arcs Dispersal Am Sod Application Petrna6oo Rao: SYsoem F2erati,o Fbd Grade
Raluved ProPoaed S3 / ~~-/~s d i- (M;a.arcw y_ / - 9~.3a o'er
,,O0 - j A r-a'9~ - Ry.sz'r
VI. Tank Info Capacity in TOW Numbs Manufacturer Concrete C S., Steel Plastic
Glau
Ganom Galloon a(Tsda
Ncv Fiiaioa -
TWs Tads
lsoudmg Tad 00 tAA~
Doame Caaabo,
pon:$uity Statement- L. U. nndendmed, asame raporrs0Qk7 for of 16e POWIS shove an the mnabed piam. _
VII. Ra
jLjappWppS (prig) Plum6ei :Otgoanue Number -Iksvnesz Phone Number
/s (Strew. City. SEW de)
i VUL ire
Sinlary P CmuI Fee(mIssued amngAgent SrBaa ne (No Sarrys)
7nDZ;l
Apgo county
sn~.r>n Fa) do S Isl
atioo _ _ . - U
f Approval/Reason; I'm Disapprcrral
T05"=,
~~r~E ~6YhL ,r~ y
$'ism(Z a1.F(w ~'-'ttty ~s1 lwwv~u.'/Wril.~S
pvxan iS (~>~,.ns,1214. ~'l' `ilea a.c4l+~ewa/ut ~L sr'rRc~.h
Aaaa.waenh~.oeu~c~.erd»r.ern..yrha.e.r+a:rl~u..an:uw+..k.a.
SBD-6398 (R. 05/01)
.cans Depere+wk of Canxahca PRIVATE SEWAGE SYSTEM County SL Croix
abN and ariwag oiws4on INSPECTION REPORT Sanitary Perms No 395203
GENERAL INFORMATION (ATTACH TO PERMIT) SJal,PlarIDNo:
pmsonel okm ebw you provide may au used w semdary pxpo IPmmcy Law. a is 04 (,Xm)t
Pond Hold.Ks Name Csy Vilape Townwvp Parcel Tex No.
LaCasse Development Hudson Townahi 020-1388-05-000
CST 81.1 1'krv Insp. BM hMV. BM Descro m.
8o r' 6
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic n Benchmark /06
T
Aft
sing - - .BM /./o 99.3
radon mg. Scorer /-y
HPding t IMet s
t Outlet .S % -
TANK SETBACK INFORMATION
TANK TO P/L WL-LL BLDG. VonlIOAnlnake ROAD DtlNet
Septic DI Bottom
7u-
Header/Man.
Aerabon Dist Pipe
z.
H J Bol. System x L /0. 20 0. 2
411 xc~
L
final Grade
PUMPlSIPHON INFORMATION
Manufadtxer _ _ and St Cover x
GPM
Model NUmc
UH 'm Friction Ln.4a -lwn lN:atl H Ft
orcemain LergN Dia. Dist W Wen
501 ORPTION SYSTEM
xnn Lervy^ , OI r PTT txstEitswNS a Rte trade Oia. kluid OeVVIn
oei 3 ' ~ Z
LAKFJSTREAM ING
SETBACK SYSTEM TO P/L BLDG JWLLL
OTl
INFORMATION Typep Sysiam ~ ~ BE T
'ZO ±Z~r
DISTRIBUTION SYSTEM
IIrvrdernArdold Deninueon x Hole Sze x Hoe Spoong Vent 0 Ar Intake Pipe(s) , 4.
/
Lenpmr l< --D _L_ L rgM.LL3 D. iSprinn - L z?
SOIL COVER x Pressure Systams Only xx Mound Or At-Grade systems Only
r pth 0". Depm 0. Depth of u Seede"odded MWdted
6eNTrendr Coma ITodrrrondi Eapes rap" )mf Yea _V~ No rMs Yes I,21 No
COMMENTS: (Include a dlscrepencies, persons present. etc) Inspection s1:4' Inspw;bon p2:
>Ajf S Z1K
Location: 957 II raunty4kindiltHudsom.W1 I 54016 (SE 101 NE 1!414 T2M R19Mf `Feld Haven Ld 5 Parcel No: 1429.19.2378
1.) Alt BM Description = 4" d T S' /ne1.Uf%e Y.
l Aa hA; .
2.) Bldg sewer length = ± ( 4 r S~ Sy S>{Gi.- X18 ✓ rTiTi~k+ U ogee 7>~
- amount of cover = rr
Plan re4ision~'TZepLned? Yes t~ No • I n /-5 Use odgr side for additional mfomna nn. /6J sY~- - -
nsepckrrn Sgnatue .
SFSDiilld lR.:YfJT, S~, 1
r b
I
Y*www Depe rner4 of Conwwrce SOIL EVALUATION REPORT Pap. I a 3
t)iveibn a safety brad Buianps .
in aocadanoe with Comm 85, Wis. Aden Code omro /1
Attach complete silo plan on paper not less than 8112 a 11 inches n sae. Pion must S4. l r
wd*de, but not krAW lo: vertical and hor¢ontel reference paid (BM), daection and Percei 1.0.
percent slope. scab a dirienaons. north snow. and location and distance b nearest road.
Please prhrt cep infwMartion. by Dale c-
P•manal l'amnmaen you poWS mry WU.•d far •aaomrery purpoma(PMetT l.w.+ 1G(M (1)(m)) ~V
Property omner J- Property Location
Govt. La SE 1/4 NE 1/4 S 1~1 T 2,9 N R 19 E(or W
Property Owners Ma kV Address w Al Block a Shod. Name of CSW /
5l3 C A 5 Fleld Nis en - Pd City - zip Code Phone Number O city Elm" ®Tuwn Newest Road Stela 'i4u o1~ (~iS)381-54og
Mc
® New Casbucbm Use: Qi Residential I Windier of bednoans Code dw wW deagn Sow rats Yso /GQ 40 GPO
❑ Repladxrnsnt ❑ Public a conwrerCW - Desvbe:
Pamrtmalensi Ou+waS h Flood Plan abvation if appfiude ~N~ l4 ~r R
Generalcarunenls svsf<m ale V. (oo h•r`ch y2.3o r-oww }r..-c. i~ 41.307Z -
and reewnnlmerdatIDM (4L{.- elev. feQ }re ~v~40.ro0 r-ow }r+..•«. $9. rea lit^
r~Cr/r/~D
~ 1 r
I --i, ^ J P
.000N''Y
8anp a I / Of
®Pit Crasd surface elev. QS. 30 2 Depth to inrft factor
Soo Rate
Monaco Depth Donwmmt Color Rados Description Terbae Sbueture Corsiessm)e Boundaff Root COW
in. Munsea Qu. Sz. Cad. Color Gr. Sc Sh, 'EMN 'Epr2
10 vr Al - I 2 c 2 5 .
D II
. 9
Z a-z )0 I - 5L 2 k C3 I v C -5
3 1 (I _ C. ,rl - - 1.2 rr)5 -7 ti k -
M a °Boring -
® Pit Ground wftw ebv. 9Z. X0 R Depth to rmtrg bcbr in. ~ Apokison Rao
Horizon Depth Oomnent Cofer RMw Description i;Zm Strucene Consistence Boundary Roots GPOW
in. resell Qu. Sz. Cant Color Gr. St. Sh. -EM •EN#2
o-to I S; I 2 CS 2C g
2 lo -a,5 jo~jrqItj SL 2 c5 1 FJ 4
3 35-16 10 - - - m5 -n 1 - - -7 /-Z
• Eflbent s1 _ .>130v<__220 mdyL and TSS >30 < 150 mpM1 • EElArena 82 - BOO 130 n9t and TSS < 30 nV&
CST Nan
Address Dab EvAiabon Co nducked Telephone Number
2)1m L 3 - -O / Z 7-
Property Qaaav LA a S Parcel ID S Page of
I Borip 0 ❑ EwM
® Pit Ground surface elev. 9z. SU R Depth to 6t16 factlr IL(^ in. ~ Applowbon Raft
Hd'¢on Depth DorrwriontGolor Redox Daeteiptiar Tetmae StnrcWe CornidrKe BwdetY Rods GPDIR
n. Munee9 Qu. Sz. Cdr COIN d. Sz Sh 'ew 'ii 2
0-10 Io - 5 1 12ffabk r1, c Z~ 5
2 tp 1 SL 2n-6bk mfr C i:, IvF 9
3 33 I n .S DS JYT I - 1 / 2
F] Bornp tt ❑ BornB
❑ pit Ground surface elev. R Depth b kn&V tact in. Sao (nation Rak
Flor¢arr Depth Damad Color Redox Deavpadu Tedura Stnx4le Conekknoe Bounda7ft&AGPM
n. Munedl Qu. Sz Cont. Cdor F-1 ❑ Budnp
❑ pit Ground auRaoe Mev. R Depth to fnarp hrcbr in
Sol Application Role
Hm= Depth Dwwwd CoW Redd( Description -Tedre Seucdae Conazionce Boundary Rods GPQff
n. Munasa Qu- Sz Carl Cots Dr. Sz SR 'EW 'EIM2
Mani $1= BOD, > 301220 mqL and TSS>30-1150nWL 'E1R1uoMS2= 900,:E 30 nVL and TSS 130 nVA.
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services of
need material in an alternate format, please contact the deparuneri at 609-266.3151 or TTY 609-264-8T71.
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f
PAGE_3__OF-_
NAME 4-CQ X% I OTN jf~L- LEGAL OESCRIM'IONSf ''/NPJ SIN Tao N R /4 E (or)
SCALE:
BM I ELEVATION
BM 1 DFSCRIPTION v~ai 2'6eydfai clay Far +
X
BM 2 ELEVATION- /00. 0
BM 2 DESCRIPTIONS I_ i fH'►3 ~ s ~lol e✓.. L la, N r
SYSTEM ELEVATION b[ 9Z:3o
AI.TFRNATE EI.EVA"ZION ¢t R AoW* r XY•GO
CONTOUR F,LFVATION Zoe f!/•00 fS. Z a
AC.~vtl lot $VWQ2 ti
i 4' 6.Z
K ' p~t~ o^Z
r ~
r
• o
W r w
g';
s •
~V
w ti
Q w
Vi
I
6LS~~ I~I~~IIIII~IIIIIlIIIII~IIII!
JUL 3 0 018
Y
1luaunan Vu:nL ca D+x.unVitt Idle T4 r-
- 1068745
,7L Croix C,OU[11V - BETH PABST
REGISTER OF DEEDS
Accessory Structure Affidavit ST. CROIX CO., WI
//(q) r RECEIVED FOR RECORD
/OCI~~ L~~r[SO^ 07/27/201810:03 AM
EXEMPT
Name - (Owner) Typed or printed REC FEE 30.00
being duly sworn , stares, under oath, that: COPY FEE 2.00
PAGES: 1
I lel~she is the legal owner of the tDllowing parcel of land localvd in tit.
('nri\ County, Wisconsin. recorded in Volume 21907 Pa€e7jY Document
Number 869 / 78 St. Croix County Register of Dcc(ls Office, x a:,a;,.,
being duly described as follows (include lot no. and Subdivi ~ion!CSM or Nxrrd R,l u.\ddress
detailed legal description): ~Oa~ Sd1
~e S d F~i e t~ ~e n 9s7 s,A~s r av e
Pty ~~q~~ , r.u 5•vof c
0. Sat-'. ~•f0~11 40~~ k~•L- Y:ual :d<nti:l,:n!inn Nurnc~r t'rN;
6zo- /388'- 65-atop
As owner of the above described properly, I acknowledge that the Private Onsite Wastewater Treatment System
(POWTS) services both an existing principal dwelling and an accessory building on this lot and is si-ml [or a (•w r(4 )
bcdrm nl home, or a design tlow of 4,C& gpd. If this accessoy building is used as a second residence on this parcel
then the w'astewaler flow may exceed the system design, cause premature failure, and be in violation of the Sanitary
Permit. I acknowledge that I will disclose this information and stipulation to any future parties interested in
purchasing this propcm'. p
Dalcd cus 2 7 d,, ✓ur-`~ ZOI(3
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Sig;:xnucts) _11-It '9/1/S ~i S'iAWOf WISCONSIN I
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♦ . 2 SI. Croix County. I C.
aothrriwated this day of No AR y ; Pmonulk cnmc hctirrc me Ih[ / d:+y of L-
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to me known cc he
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111u1h`uttd by i; 'iU6 06 wi.. S,111:
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"THIS PAGF. IS PART OF -PHIS L/'GAI D(H UMF\'T DO %OI RFTIOV)'"
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St. Doix Counl: 1068745 Face 1 of 1
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