HomeMy WebLinkAbout161-1094-20-000 �� �oS roc, -J� g (�(� 73-
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE---:
r
^' ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386 -4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
❑ Water (VOC's) $185.00 V Septic $25.00
g Water (Nitrate & Bacteria) $35.00 (Visual inspection)
Owner: R&ZA KPONa Requested by: 3E rJ
Address: dtn -;L nun`, CiR(c.E NO Address: - )D_ o Ictrn 5f. So
City & State: {{�� , ,-�j , SLK)j City & St. Ifi►p5C�, 1 1 fA4a L
Zip Code: Zip Code
Telephone N°: ( ) 36(o - g5L4I 5 Telephone N°: (1I5_) - :�Lq(p -8'L'7
Property address (Fire N & Street) : a(aa 1 - c3
Location: ;, ,, Sec. , T N, R W, Town of HuosOn9
St. Croix Co., WI. Tax ID N Parcel ID N° I(DI - Cq( - 6" 0
House color:'BI0 -t Realty firm: (2 -2-j Lock Box Combo: 3AS.
Water sample tap location:
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH :OF HOUSE & SEPTIC - SYSTEM ON REVERSE OF THIS FORM*
Is the dwelling currently occupied? )(Yes ❑ No
If vacant, date last occupied: -
Septic system installed by: - j>_ )es6i- 1cN0 Year_:
Septic tank last serviced by: i RA too - Da 25
Previous Owner's Name(s):
Have any of the following been observed? � c�
❑Y ITN Slow drainage from house.�`
❑Y IRN Sewage Back -up into dwelling.
❑Y CAN Sewage discharge to ground surfa;
road ditch or body of water.
❑Y 13"N Slow drainage from the dwelling.. ...
❑Y 13N Foul odors. c
Other comments relative to system operation: SEPn fit'
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:
►�C,2 t�cto+ -X= era �� flay lq .
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
t
I N
TO BE COMPLETED BY INSPECTION AGENCY
System design & /or permit on file? ❑Yes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system P11elow grd ❑At -Grd ❑Mound
Approx. size 'X 0 QGr - avity ❑Dose ❑Pressurized
Ft. ❑Bed, ❑Trench ❑Dry;Well
Molding Tank ❑Outfall -pipe
OBSERVED DEFICIENCIES ❑Other ❑Unknown
Septic tank
` "' . ❑Prop . line C`' - ' ❑Other
_ Setbacks: ❑House ❑Well '� 1
Dose tank
Setbacks: ❑House DWell ❑Prop.'l ❑Other
❑Locking cover ❑Warning label ❑Pump /Floats
❑Alarm ❑Elec. wiring
Soil Absorption System
Setbacks : House Dwell c- y: ❑Prop .`--1 ine O! ❑Other
❑Pondings �}' ?.o ❑Discharge: LU >
General comments
INSPECTORS SKETCH OF SYSTEM LOCATION
Inspector h L4 r I
Title i" c
COMMERCIAL TESTING LABORATORY
4 514 Main Street, P.O. Box 526 k1�
Colfax, Wisconsin 54730
715 - 962 - 3121
800 -962- 5227
FAX - 715 - 962 -4030 j
ST. CROIX COUNTY GOVERNMENT
CENTER
1101 CARMICHAEL ROAD
HUDSON, WI 54016
ATTN. THOMAS C. NELSON
OWNER** Ronda Hanne
LOCATION** 262 Station Circle N., Hudson
COLLECTOR** M. Jenkins
DATE COLLECTED. 6 -28 -93
TIME COLLECTED. 1 :30pm
SOURCE OF SAMPLE: Outside faucet
DATE ANALYZED **6 -29 -93
TIME ANALYZED.2.00pm
COLIFORM** 0 /100 ml
INTERPRETATION. Bacteriologically SAFE
NITRATE -N** 4 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria /100 mL
Nitrate - Nitrogen, mg/L
4.
LAB TECHNICIAN: Pam Gane
DfA DFC(N � Q
t WI Approved Lab No. 19
O
A
Z A < Means "LESS THAN" Detectable Level Approved by.
0
PROFESSIONAL LABORATORY SERVICES SINCE 1952
. - = ST. CROIX COUNTY
r WISCONSIN
ZONING OFFICE
n =.•.'.E•','' ST. CROIX COUNTY COURTHOUSE
Pt W Fq 1101 Carmichael Road • Hudson, WI 54016
1 - (715) 386 -4680
June 29, 1993
Jenny Olson
Century 21
706 - 19th St. South
Hudson, WI 54016
Dear Ms. Olson:
An inspection of the septic system on the property of Ronda Kanne,
located at 262 Station Circle No, Hudson, WI was conducted on June
28, 1993. At the same time a water sample was obtained for
testing. The results of that testing will be sent to you as soon
as we receive them back from the laboratory.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and did
not involve any excavating or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
Should you have any questions, please contact this office.
Sincerely,
Mary J. Jenkins
Assistant Zoning Administrator
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Wisconswn Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Buildigg Division
INSPECTION REPORT Sanitary Permit No
463234 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 X Village Township Parcel Tax No:
Soltis, Gayle I Village of North Hudson 161- 1094 -20 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
(QQ- 0 po. a <J , -n5L 13.29.20.745
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic t /000 Bench
2.33 lo2.3 l v
L ai& �oO Alt. BM /
Aeration Vyi�UL�� Yt - /' Bfdg. Sewer 4 . �O
Holding S IAjt
TANK SETBACK INFORMATION St/Ht Outlet 3
TANK TO P WELL BLDG. Vent to Air Intake ROAD Dt Inlet Q
Septic / f > 25 / Dt Bottom
DosingHead Man.
Aeration Dist. Pipe S `
Holding Bot. S st
� � � ® / a
PUMP /SIPHON INFORMATION Final Grade of G('-IC.0 0 3 5 /
Manufacturer Demand St Cover t/
GPM % 3+0
Model Number
TDH Lift Friction Loss Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width / Length No. Of Trench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Ty Of System: n � J / 1 UNIT Model Number:
DI T SYSTEM FX.Q VV, 1 411 N _ -
Head anifold Distribution y / ole Size x Hole king Vent Air Intake
/ Pipe(s) LJ 7
Length Dia Length T Dia Spacing_
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
Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 262 Station Circle North Hudson, WI 54016 (SW 1/4 SW 1/4 1 T29N St. Croix Station Lot 21 Parcel No: 1,3.2299.200.7,4,5L
1.) Alt BM Description = a a pu
2.) Bldg sewer length = -- ?Ub VZ&4e-
- amount of cover
Plan side for additional in Yes No
Use other
revision formation.
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
M A, Safety and Buildings Division County
* 201 W. Washington Ave., P.O. Box 7162
Mad WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.)
266 -3151 3 2 3
Department of Commerce
Sanitary Permit W046�
EIVED State Plan I.D. Number r
In accord with Comm 83.21, Wis. Adm. C provide
may be used for secondary p 0 3 Project Address (if different than mailing address)
1. Application Information — Please Print A ation
Si'. CRO1X CO UNTV
�
Property O Name Sa / �, C OFFICE
V Q Block #
1,. J !bl- o ?y -7o --0 C .771
Property Owner's Mailing Add y� t Property Location
yJ �U.. 1 [, • L [ r 4 tV ®s � %, Section 3
City, State r Zip Code Phone Number
14 L,L d So n t S y o b 71 f (circle one)
T _2_a N; RLri or(5
II. Type of Building (check all that apply)
�( Subdivision Name 66hLAlrrasltar.
K I or 2 Family Dwelling — Number of Bedrooms
❑ Public/Commercial — Describe Use �4. lro ►1 �,t�t�c0
❑ State Owned — Describe Use ❑CitY_011age ❑Township of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A, ❑ New System J( Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. T e of POWTS System: Check all that appl
VNon — Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ 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 XLeaching C ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dis ersaVTreatment Area Inforration: C
Design Flow (gpd) Design Soil Application Rate( Dispersal Area Required (sf) Dispersal Area Proposed (sf) Sys em Elevatio
1 7 r .7 /071, /088. �' C1.2.
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank B� 1 O e D 1
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement - I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number
Plumber's Address ' (Street, City, State, Zip Code) D L�
VIII. Coun /De artment Use Onl
Sanitary Permit Fee (' cludes Groundwater Date Issued Issui g Agent Signaui (No Stamps)
4pproved ❑ Di ppro ved Surcharge Fee) ?Q)
❑
Ongfeyen Reason fo nial O
IX. Conditions Approval/ assem fe. BilwilipTooff
SYSTE ER:
1 Septic tank, effluent filter and ll AMC` y
dispersal cell must all be serviced) maintained (S —� •
as per management plan provided by plumber.
2. All setback requirements must be maintained g E U�L- 9_U_A) \JA 6
as per applicable code /ordinances.�� _p,T
Attach complete plans (to the County only) for the system on paper not toss than Sr/2 x I inches in size
SBD -6398 (R. 01/03) J v
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations
Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must County St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
161 - 1094 -20 -000
Please print all inflon�nation. �y
Personal information , tuation you provide may secondary purposes (Privacy Law, s. 1504 (1) (m)). a Date O
Property Owner " Property Location � \J
Gayle D. Sords `; ' CoA. Lot 19 19 S 13 T 29 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
262 Station Cr. ` `i _ 21 St. Croix Station
City State ZipiCode Phone Number J City re Village J Town Nearest Road
Hudson I WI 1540161 0715 - 381 -0308 North Hudson 1 262 Station Circle
New Construction Use: 0 Residential / Number of bedrooms 5 Code derived design flow rate 750 GPD
Replacement I Public or commercial - Describe:
Parent material Glacial outwash Flood plain elevation, if applicable na
General comments
and recommendations: Install five trenches at elevation = 92.50' using 35 leaching chambers. 550 gallons additional septic tank
capacity must be added to make system code compliant.
a Boring # Boring
16 Pit Ground Surface elev. 97.30 ft. Depth to limiting factor >97" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
1 0-6 10yr4/2 none gr all fill 2fsbk ds as 2fm,1c 0.6 1.0
2 6 -22 10yr2/1 none sl 2fsbk ds cs 2fmc 0.6 1.0
3 22-40 10yr4/4 none sl 2fsbk ds cW 2fm 0.6 1.0
4 40-62 10yr4/4 none gr Is 0 sg dl gs 1fm 0.7 1.6
5 62 -97 10yr5/6 none s & gr 0 sg dl - 1vf 0.7 1.6
9 - Sy
H#4 contains approx. 30% gravel & cobbles. H#5 contains approx. 10% gravel & cobbles.
Boring # _j Boring
t/ Pit Ground Surface elev. 96.74 ft. Depth to limiting factor >94 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
1 0 -12 10yr32 none all 2fsbk ds as 3fm,2c 0.6 1.0
2 12 -18 10yr4/4 none sl 2fsbk ds cs 3fm,1c 0.6 1.0
3 18 -30 10yr4/4 none gr Is 0 sg ds cW 2fm 0.7 1.6
4 30-41 5yr4/6 none gr Is 0 sg dl gs 1fm 0.7 1.6
5 41 -94 10yr5/6 none s & gr 0 sg dl - - 0.7 1.6
H#3 contains approx. 50% grave cobbles. H#4 Aftntains approx. 30% gravel & cobbles. H#5 contains approx. 10% gravel & cobbles.
' Effluent #1 = BOD ? 30 < 220 mg/L a TSS >30 < 1 mg/L ' E nt #2 = BOD < 30 mg/L and TSS <-N mg/L
CST Name (Please Print) NSignatu X. CST Number
James K. Thompson 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, O WI 54020 7/162004 715 - 248 -7767
P Owner Ga yle D. Solbs 161 - 1094 -20 -000 Page 2 of 3
Propert YI Parcel ID #
3] Boring # .) Boring
Pit Ground Surface elev. 96.77 ft. Depth to limiting factor >95" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2
1 0 -7 10yr42 none gr sl fill 2fsbk ds as 2vf,fm 0.6 1.0
2 7 -20 10yr2/1 none sl 2fsbk ds cs 2fm,1c 0.6 1.0
3 20 -28 10yr4/4 none sl 2fsbk ds cw 3f,2m 0.6 1.0
4 28-49 10yr4/4 none gr Is 0 sg dl cw 1fm 0.7 1.6
5 49 -95 10yr5/6 none s & gr 0 sg dl - 1vf 0.7 1.6
H#4 contains approx. 50% gravel & cobbles. H #5 contains approx. 20% gravel & cobbles.
F—I Boring # Boring
J Pit Ground Surface elev. ft. Depth to limiting factor in. F Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2
❑ Boring # J Boring
Pit
J Ground Surface elev. ft. Depth to limiting factor in. F Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
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.
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3 or 3
Private Onsite Wastewater Treatment System Management Plan ,
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
'his management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Desig -Spe ' icatlons
Sanitary Permit Number
Number of Bedrooms
Desi n =f=low - Peak (gpd) 7
Estimated Flow - Average (gpd) o0
Septic Tank Capacity (gal) o00 4- 8 = l8ep
Soil Absorption Component Size (fV) / 8 `
F-_ Type of Wastewater Domestic
Table 2: Soil /absorption Component - Limits of Reliable Operation
Septic Tank Com onent Soil Absorption Component
Design Flow - Peak (gpd) '7 Irm 7 0 /8
Maximum Influent Particle Size (in) 220
Maximum BOD (mg/L 150
Maximum TSS (mg/L)
Table 3: Maintenance Schedule
Septic Tank Ins ect and /or service once every 3 years Z aA,-A R
Outlet Fitter p 3
Inspect once a year and clean at least once every years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be rem oved unless P rovisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next. service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to. the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously,
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next.service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
. The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
I
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
f
qb - 7 Yc2-3
A
- 71 q9 33a�.
-7L5 - 7y9
3
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer—
Mailing Address o CP CLh C b
Property Address PK�% m !S G 1
(Verification required from Planning Department for new constriction) \
City/State /��
Parcel Identification Number
LEGAL DESCRIPTION V
' 3, T z j N -R2—W, of N o 2TH �Sd�/
Property Location /., /4, Sec.
Subdivision
�`, (`J�o� -�. `a Lot #
Certified Survey Map # . Volume , Page #
-wervent5 Due # 2 S 20 36 } Volume , Page # 51
Spec house ❑ yes ®, no Lot lines identifiable 18L 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
tnasterplumber, journeymanplumber, restrictedplumber 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.
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.
'�L rL / L
SIGN OF APPLICANT
DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
—A
SfG OF APPLICANT DATE
* * * * **
« « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Departm ent.
** 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 2 4 9 3 P 5 8 7 75aID3is
KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., MI
Document Number QUITCLAIM DEED RECEIVED FOR RECORD
01/16/2004 03:30PK
Grantor(s), GAIL D. SOLTIS (a married person), for valuable QUIT CLAIM DEED
consideration quit claims to Grantee(s), GAIL D. SOLTIS & THOMAS H. EXERT # !M
SOLTIS (wife & husband), as Joint Tenants with the ng t o survtvors ,
following described real estate in St. Croix County, State of Wisconsin, REC FEE: 13.00
described as follows: TRANS FEE:
COPY FEE:
CC FEE:
Legal Description PAGES: 2
OT 21, T. CROIX STATION IN THE VILLAGE OF NORTH
N, ST. CROIX COUNTY, WISCONSIN.
PARCEL #: 161 -1094- 20-000
COMMONLY KNOWN AS 262 STATION CIRCLE N, HUDSON, WI,
54016
Recording Area
N ape en d Re Address:
1 'K51
aw
The purpose of this deed is to add Nf^1 4 5 h • 56 / 11 ' 3ithe legal title to the property.
This 9 /is not homestead property.
Date this day of D 1 2003.
GAIL D. SOLTIS
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF )
) ss.
ANOKA COUNTY )
Authenticated this day of
, 2003
Personally came before me this J S�_ day of
2003 the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
GAIL D. SOLTIS (a married person)
This instrument was drafted by Spiro S. Nicolet
& Patrick W. Walsh, P.C., Attorneys at Law
to me known to be the person(s) who executed the
foregoing Instrument and acknowledged the same.
Notary lic, tat
My commission is iration
Signatures may be authenticated or acknowledged. : q " NOTAR Mroot�a
Both are not necessary.
2003
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SOUTH LINE OF THE SW 1/4
UNPLATTED LANDS - --
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COUNV( SECTION CORNER MON FOUND, BERNTSEN CAP
1-1/4 PIPE WEIGHING 2.27► /LINEAL FT. FOUND
c,
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Z X 30 IRON PIPE WEIGHING 8.65.M /LINEAL FT. SET Tl,ere ere t, I , ; r. ; u '• t w rh r.: x:e t: 5• 216 1 �
ALL OTHER LOT CORNERS : TAKED WITH I X24' IRON PIPE 2,.6.16, 7 i ,r ± i?(.11 r.) cnd 1 1V`s ;Icts, H 33 c d =-
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WHICH ARE 1 X 3d IRON PIPE WEIGHING 1.6B.M /LINEAL FT
I'X 24" IRON PIPE WEIGHING I.6a1M/ UNEOL FT. 19 77
SET ON LINE • �?�� }, 7 '_
- UTILITY EASEMENT, WIDTH SHOWN. .;•-
STONE MONUMENT, FOUND Deportment of low! HNaI. 1 J•wbprnwA 1
Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Bvaildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 289314
Permit Holder's Name: ❑ City ❑ Village Rg Town of: State Plan ID No.:
LEIFELD, MARTIN HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
161- 1094 -20 -000
TANK INFORMATION ELEVATION DATA A9700134
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Air to
i ntake ROAD Dt Inlet
ir
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia Length Dia. Spacing
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 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.12.29.20,SW,SW 262 STATION LANE LOT 2
Plan revision required? ❑ Yes ❑ No (�
Use other side for additional information. I
SBD -6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I,
I
�• =I`., SANITARY PERMIT APPLICATION S afety and Building S
•� ■ � Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. S$ C, c Z,
• See reverse side for instructions for completing this application State Sanitary Permit Number
aOO931 �
The information you provide may be used by other government agency programs [:]Check it revision to previous application
(Privacy Law, s. 15.04 (1) (m)]. 2_122 o 0 11 /� /
uc c 3 t � • f r, � V State Plan I.D. Number
I. AP PLICATION INFORMATION - P LEASE PRINT ALL INFORMATION
Property Owner Name Property Location 1%5p O
h c L : — e e 1,,/I/ 5 al / S /'L T Zq, N, R ZG, (or)
Property Owner's Mailing Address Lot Number Block Number
Cit , State Zip Code Phone Number Subdivision Name or CSM Number
S''t01 ( ? , C f c5 S A - C.. "l i •a
II. TYPE OF BUILDING: (check one) ❑ State Owned o (- Ity Nearest Road
Public 1 or 2 Family Dwe lling - No. of bedrooms Z_ X To w a n OF
111. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) Iq nc • a -
1 E] Apartment/ Condo Co I ' CD q 4 , -z tJ
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 online B, if applicable)
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 Wepair of an
_____System ________System _____________Tank Only______________ Existing System ___
B) 1 ± Sanitary Permit was previously issued. Permit Number -6b q Date Issued fj S 3
V. TYPE OF SYSTEM: (Check only one)
.Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 eepage Bed 21 ❑ Mound 30 [J Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
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
El zr
Required (sq. ft.) Rfepasee(sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
Feet 4" 1. 4 6 Feet
Capacit
VII. TANK in Ca g Total # Of Prefab. Site Fiber- plastic Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- . Steel glass App.
New Existing strutted
Tanks Tanks
e tic Ta r Holding Tank pq> ocia ❑ ❑ ❑ ❑ ❑
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.
s Name: (Print) "s Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
earl s Address (Streie , City, State, Zip Code):
4.
I COUNT / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issue Issuing Agent Si mps)
Surcharge Fee) Go
Approved ❑ Owner Given Initial 1
Adverse Determination TI
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divi ion, 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 -3815.
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 be 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-
VIL. 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 into 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.
ST. CROIX COUNTY
ti WISCONSIN
ZONING OFFICE
/NNNNNNN■
rrrri
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
- (715) 386 -4680
AFFIDAVIT OF SYSTEM REJUVENATION
Property Owner:
Address a S kc,� �o.a I,.G..�.
W�-
Day time phone: ( ) .. � rj � 3 C)
Parcel I . D. # /(V/• ZQ!r 1-;I a
Legal Description of property: S(„I ; SW ;, Sec. / - Z , T. N. ,
R. W., Tn. of
St. Croix County, WI
As owner of the above described propert acknowledge that the
septic system serving this residence 4141s) undersized by
current code standards. I understand that the issuance of a
sanitary permit to allow the attempted rejuvenation of the septic
system does not imply that the system meets current code sizing
requirements, nor does it imply that the proposed procedure will be
successful. I also acknowledge that I will make this information
available to any future parties interested in purchasing this
property.
Signature: ��,_• ` 5 1
Date: - 2 , �
5/97
r
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the r(1 cs,1 �', �� 1. e, residence located at: S LJ /, ':5
Sec. /'Z. , T R Town of I St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced -1 q 6
Did flow back occur from absorption system? Yes Nom (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known) e k�
Age of Tank ( if known) : L4
(Signature) (Name) Please P int
Vn
(Title) (License Number)
S- ) � I on
(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 tank condition, I
certify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over
outlet baffle).
Name Signature
MP /MPRS
Wisconsin Department of Industry SOIL AND SITE EVALUATION / Z
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County .�•
include, but not limited to: vertical and horizontal reference point (BM), direction and s / ' C zotx
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
/(o/ • /Q 17 2 O
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner // Property Location
/ l4*T f v %F,eLL) Govt. Lot .SG) ) �i 1/4 5 0/4,S �Z T . ,N,R .20 E (o W
Property Owner's Mailing Address Lot # I Block# Subd. Name or CSM#
:�42_ 51'fT GN • Z l ST ciPo�x sT•�y -tJ
City Stat Zip Code Phone Number Nearest Road
L, ��s�
//. S(/O�� ( El city El Village eTown SrdT_440 GW
❑ New Construction Use: (3 Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: !¢ S SO L,9 /AI /¢` /L / f
Code derived daily flow �� gpd Recommended design loading rate bed, gpd/fe Q g trench, gpd/ft
Absorption area required L bed, ft ft Maximum design loading rate 7 bed, gpd/ff • (i trench, gpd/ft
Aeeemn ended infiltration surface elevation � �/, IaKi �' ft (as referred to site plan benchmark)
Additional design/site considerations � ST/.u�' SyST /S '..� , A /
Parent material _ s �" Flood plain elevation, if applicable V I A ft
S = Suitable for system Conventional Mound In- Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system ❑ U ❑ ❑ U ❑'S� ❑ U L/�'S ❑ U ❑ S ❑ S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /f12
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
/ -/B 16W a/ 2— LS / S S 3 •7 •8
JO /0 VVe Ground �' • '2 , 8
p elev.
7 ,.44—ft.
Depth to
limiting
factor
Remarks: E- 6F Sr T /
Boring #
13
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) zze j Signature Telephone No.
Ulbricht & Associates 7/5 306 -0(9 3 -9
Address Pr, ons
u an ate swaps Date CST Number
655 O'Neill Rd. ,1 Z C 5'.q 6 Z�
Wis. 54016 7 S
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Borin # Horizon Depth Dominant Color Mottles Structure 2
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground
elev.
ft. ,
Depth to
limiting
factor
in. '
Remarks:
Boring #
M
>iF
Ground
elev.
ft.
Depth to
limiting
factor
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 #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
F
a ,
Ground
elev.
ft. ,
Depth to
limiting
factor
' Remarks:
SBDW -8330 (R. 08/95)
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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
Location of property 1 /4 51V 1/4, Section 6Z - R Zc W
Township _ � ; Mailing address
Address of site
Subdivision name } ro"�x Lot no.
Other homes on property? Yes _ No
Previous owner of property
Total size of property , p
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for (spec house) ? Yes _ CX No
Volume 1235' and Page Number �t(, 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
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. � Jq , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signatu o Applicant Co- Applicant
Date of Signature Date of Signature
STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER -b
MAILING ADDRESS ���. �� o •.\ I,.�. t
se
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY /STATE vA_bo ^i
PROPERTY LOCATION 6 1/49 f 7t-/ 1/4, Section 12, , T Z q N -R ZO W
TOWN OF �. +L 5 c� r.1 ST. CROIX COUNTY, WI
SUBDIVISION S (' c o , , j LOT NUMBER a
CERTIFIED SURVEY MAP , VOLUME =`PAGE � 6 , LOT NUMBER
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
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 system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
W 1?35PACf'?f 7
WARRANTY DEED
Document Number _
REGISTER'S C' E
558514 ST CROIX CT•t., vii
Return Address -►-►K / ` APR Z 8
l9(,1
1 1 :20 ti.
cJ!
sra� 1 4'j-' r .,
�� I flbylSt6rurDaa�;
�y
Parcel I.D. Number: 161 - 1094 -20 -000
Martin F. Leifeld and Wendy Leifeld, husband and wife, conveys and warrants to Gail D. Soltis, a
married person, the following described real estate in St. Croix County, State of
Wisconsin:
Lot 21, St. Croix Station in the Village of North Hudson, St. Croix County, Wisconsin.
This is homestead property.
Exception to warranties: Easements, restrictions and rights- of-way of record, if any.
Dated this 25th day of April. 1997.
(SEAL) (SEAL)
Martin F. Leife d Wendy Leif Id
ACKNOWLEDGMENT
TRANSF=ER
STATE OF Illinois ) � -- 76
�� )�
�f. ( XX l COUNTY )
Personally came before me this 0 06- day of Ap d
1997, the above name
Mart F. Leifeld to me known to be the person(s) who executed the foregoing instrument and
acknowledge the same.
*
eq OFFICIAL SEAL
No Public Il linois JOYCE ANN BERKEL
q [My OTARY PUBLIC, STATE ,cs: io/24 9
My commission expires Q 4 ) COMMIS3ICN `
ACKNOWLEDGMENT
STATE OF California )
)ss
JA2 AMLl%4t6 COUNTY )
Personally came before me this a� day of April 1997, the above named
Wendy Leifeld to me known to be the person(s) who executed the foregoing instrument and
acknowledge the same.
( MICHELLE Y. JAUkE
\ �o Public 1 1 c COMM. 11088211
-i
1 o is
1 F NOTARY Pl19la 440ORNIA
My commission expires 3 U ' Los A rAm COUNTY
Co
w . Is, M
THIS INSTRUMENT WAS DRAFTED BY:
Attorney ristina O land
Y g
Hudson, WI 54016
i
a '
AS BUILT SANITARY SYSTEM REPORT
OWNER all ��%c CZ/ �) T-86 ��� ; �' SEC . /2 TZYN -R ZU
ADDRESS j ST. CROIX COUNTY, WISCONSIN.
Vb
SUBDIVISION �_��, ( �x c� «c�T /?1? LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -
AA I
r
J
— I
f - --
G
r'
All
jffl . 1. 1 1 Z) I di at N h rr w
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: /0 " Slope at site: 0 —
SEPTIC TANK: Manufacturer: ���L3 Liquid Capacity: IC:UO
Number of rings on cover : /' Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle gallons; Total capacity of
distribution lines gallon: size of pump head;
gallon per minute horsepower ;brand name of pump
and model number ;
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover ;
Type of warning device
SEEPAGE PIT SIZE; Number of pits feet diameter
feet liquid depth seepage pit inlet pipe - elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines width � length - 3,& tile depth
SEEPAGE TRENCH: width length
PERCOLATION RATE _ e ` AREA REQUIRED x(5 AREA AS BUILT
INSPECTOR
DATED PLUMBER O JOB .. 'f'�
LICENSE NUMBER
DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HYIMAIV RELATIONS PRIVATE SEWAGE SYSTEMS olvlslo
P.O. BOX 7959 BUREAU OF PLUMBING
MADISON, WI 53707
IN CONVENTIONAL 1:1 ALTERNATIVE [tate Plan l.D.Number:
assigned)
El Tank ❑ In- Ground Pressure 1:1 Mound
NAME OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Charles dd Co. Plaza 94 t��0�
t BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
SE SW SW, Sec 12, T29N —R20W, Lot 21,ST.Croix Station,Villag
of N_ Hiirigon
Name of Plumber: MP /MPRSW No.: County Sanitary Permit Number:
Ro er Timm I 3224 St. Croix 38549
SEPTIC TANK /HOLDING TANK:
MANUFACTURER: LIQUID CAPA� TANK INLET ELEV.: TANK OUTTT EV.. WA kNING LABEL LWIG OV
5 (7 PRD P ❑ O NO
BEDDING: VENT IA. VENT TL HIGH WA R NVMBE VF .ROAD: PROP TV ELL' BUILDING: VENT TO FRESH
ALARM FEE,r, FROM LINE. AIR INLET:
❑YES NO DYES ONO NEAREST
DOSING CH MBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. P NUFA ER. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES ONO DYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA BER.GIF PROPERTY WELL BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN ' FROM LINE AIR INLET.
PUMP ON AND OFF) ❑YES ❑ O N' EST
.SOIL ABSORPTION .SYSTEM. Check the soil moisture at the depth Of plowing L TH DIAMETER. MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORGE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH ILENGTH . I NO.OF DISTR. PIPE SPACING. COVER INSIUE DIA.: #PITS. 100ID�
L? 6 IBEO QA IENC TRENCH E MATERIAL: gl DEPTH:
GRAVEL DEPTH.. FILL DEPTH DISTR. PIPF ISTR. PIPE DISTR. PIPE MATEEE�1AL NO. D R NUMBER OF PROPERTY WELL: BUILDING: V NTTO FRESH
BELOW PI S. [ AB C ER. ELEV iNLE E V. ND: PIPE FEET FROM Lop;
/ / 7` 7` NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTJ
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHO EVA-
DYES
meets the criteria for me um TIONS MEASURED
❑NO
SOIL COVER I TEXTURE P MARKERS: O VATION WELLS
/B YES ONO ❑YES NO
DEPTH OVER TRENCHED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED S MULCHED.
CENTER. EDGES.
❑Y S El NO ONO ❑YES El NO
PRESSU D ISTRIBUTION SYSTEM:
r�
WIDTH: LENGTH - . NO. OF ATE AL SPACING: GRAVEL EPTH BELOW PIPE. FILL DEPTH ABOVE COVER:
OtTflE H TRENCHES:
nA 1 .
MANIFOLD PUMP MANIFO DISTR. PIPE J MANII`i! MATERIA NO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
�I���IITiI�IN Afil ELEV.: ELEV.. DIA.. ELEV.: PIPES: DIA.:
°
°TBTIN HOLE SIZE HOLE SPACING: DRV CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS:
❑YES ONO I DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NlBER'C ERTY WELL: BUILDING:
❑YES ❑NO ❑YES ❑NO N IFFEST
Sketch System on R I n county file for audit.
Reverse Side. A
SIGNATUR TITLE:
DILHR SBD 6710 (R. 01/82) C
DEPARTMENT OF APPLICATION S AFETY & BUILDINGS
" INDUSTRY FOR SANITARY A DIVISION
Lo*6R AtNt� PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8' /z x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property caner. Mailing Address:
D -
Property Locat
- K : 6ilq; Vi1�cL ip: County:
''' OS Tc ! N/R -20 K (or) 4 A 4
of Number: Blk No : Subdivision Name: Nearest oad,_ or Landmark: State Plan I.D. Number:
WA ` s ue , I ` C �, 6 / �� C�1 ✓�i t (If assigned)
T YPE O F BUILDING
Number of
(� Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family * State Approval Required. 3
TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY 160<j
HOLDING TANK CAPACITY
LIFT PUMP TANK /SIPHON CHAMBER
MANUFACTURER: 1 �{
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
j / ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: 7 Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the-attached plans.
Na Plumber: Signature: / MP /MPRSW No.: Phone Number:
r 2 (71 :5rOM6 8�
Plumber' ddress: y Name of Designer.
f. I - - / y 14 Pi
COUNTY /DEPARTMENT USE ONLY
Signatu of Issuing Agent: Fe Date: , El APPROVED San' ary Permit Number:
1/ ' fL ^' ❑ DISAPPRO
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber
DILHR -SBD -6398 (R.07/81)
Form - S T C 100
Owner of Propert P Y �. 4 A 5
Location of Property / k 14 Section = ,T =`;. R �) W
Townshi
Mailing Address FP A-M A ¢
Ij
Subdivision Name - r . � kin ly
Lot.Number 2 I
Previous Owner of Property
Total Size of. Parcel
Date Parcel Was Created
Are all corners identifiable? Yes No
Include with this application one of the following
.Certified Survey Map
.Deed
.Land Contract, or
.Qther Legal Document which describes the property '
Certificate of Property Owner's Agent
I, James E. Rusch, Certified Soil Tester, hereby certify that all statements on
this form are true to the best of my professional knowledge, understanding and
belief; that the above stated is owner by virtue of the following legal document
recorded in the Register of Deeds Office as Vo L-
V4
instrument document number
568 Date
:James E. Rusch, C.S.T.
I
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SAFETY ,& H DIVISION
SIOIV
t %uSTRY,
�1BOR AND + PERCOLATION TEST'S (115) pAADISO . BO 96 7969
JNiAN RELATIONS
(H63 .09(1) & Chapter 145.045)
,LOCATION: SECTION: OWNSHIP/ UNICIPALITY: OT NO.: BLK_ NO.: SUBDIVISION NAME:
5= sw' / 4 1 N/R zQ E (o ► v � s o �/ 2 ( — ' -r. Gna t,( S r-r,-M 0A1
COUNTY: OWNER_' BUYER'S NAME: MAILING ADDRESS:
�7•lRcrY fNAe- L.avS�•'� jet_ - Zr 1 ��{- }tvis� >>.• S I 0
U SE DAT ES OBSERVATIONS MADE
� NO.BEORMS.: COMMERCIAL DESCRIPTION: PROFILE DE�TI NS: `OC' N TESTS.
W Residence � 3 New ❑Re lace
'E�K_ {
R S- Site suitable for system U- Site unsuitable for system
N
OVE NTI MOUJVD: ❑� IN- GFtOl1NdQ R : S - IN�FILL O S TA : RECOMMENDED SYSTEM: (optional)
( _ ' u j ®_S S U ( J , ( V_ N7 J ) c it
�dVtJTl ^?J. t— lG X SZ' t -j7
!tf Percolation Tests are NOT required DESIGN RATE: It any portion of the tested area is in the
under s.Hfi3.09(5)(b), indicate: i t • 1 1 Floodplain, indicate Fl elevati
L�GI MA, L_ PROFILE DESCRIPTIONS
_ Fri
PORING TOTAL DEPTH TO GR UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPT14
�'. �ti!BER DEPfH ELEVATION BSERV ED EST. IGH S TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) .
1.10' 5L V 5 w -kG NN IC-. rA A;T a: � P afw d1.S
X00, 5Z NoN w GR Cos; 1 MmSw GP_ i Co a • 4.4�5'sN65 w16, r-
1.4Z' bL SlL 1 1.00' Cirvi of S w/ tos+. € tun; I. o' N VW1 &A tColki
B - t? 9,4Z- /00,7 0 Aj en > 9 . 4•z /.,7o SN mate 5 w /(r a fb81 Sod' 3N GS ti•!�C -, s CQr3
1.17' 2L L; 1 .3 3' 13 �/ v S L. G ►�• ; I • S ta m $wl g;
�- a �•o o /00,37 Alan/E } Q j.0 O
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r
0ee-lMAL_ PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES:
NUMBER - r� AFTER SWELLING INTERVAL -MIN. p p p E A 1 D PER INCH
P_ ¢..t A 17 e 7 7 �
1 0_
LP
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or "distances. Describe what are the hori
zontal 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
of land slope. ZOZ J� 5 a2 . FT U (
SYSTEM. ELEVAT • 2 5' - E G
_ r.►c t-E
f -f - r-I ti �z► I -- - - -.. - -- -
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` 1 the undersigned, hereby certify that the soil repo d on this form ere made by me in accord with the procedures and methods specified in the Wisconsin
rninistrative Code, and that the data recorded and t cation of the tests are correct to the best of my knowledge and belief.
'SIAPAE (print): TESTS WERE COMPLETED ON:
eSS: CERTIFICATION NUNISER: PHONE NUMBER(oplional).
!,
44 _ ,�. �• = : /l �r�_� - -�_G7
' CS `' GNATURE
D'STRIBUTION: Or.Rioal an9 n-- Copy t0 . t_r>ral Auth Prope. ty Owner and Soil Testa,, - _
r JOB l �['L Ay t C,.1/
ROHL & TIMM EXCAVATIN SHEET No. % of Z
310 Arch Street - , .-
HUDSON, WIS. 54016 CALCULATED BY \ Qc:�k7 ` ✓ l✓l DJZe � Z
(715) 386 -8664 ti .I
CHECKED BY— �3 t l 1241 }�1: L E_ _ / — S�
SCALE
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