HomeMy WebLinkAbout026-1064-30-100 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
506390 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Forseth, Luke I Richmond, Town of 026- 1064 -30 -100
CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No:
21.30.18.320A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER k CAPACITY STATION BS HI FS ELEV.
Septic - Benchmark
p i •F>l
Dosing l} Alf. BM ,
�1 =: ✓� �) '�, '' Ir. .;:it
Aeration Bld . Sewer
f.
Holding St/Ht Inlet
r
TANK SETBACK INFORMATION St/Ht Outlet 9
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet _-
Septic r,W ' t -•j - Dt Bottom
Dosing Header /Man.
Dist. Pipe
Aeration �.
Holding Bot. System t . ja.y
Final Grade
PUMP /SIPHON INFORMATION 1,
Manufacturer Demand St Cover
GPIV( i; 4 kr
Model Number ,
TDH Lift Friction Loss System Head Ft /
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. ILiquid Depth
DIMENSIONS' S_ ° 1
�r
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR , 1
Type Of System: + UNIT Model Number: f "
a i VA
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipes
Length J Dia ( Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over M Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed /Trench Center -(� Bed/Trench Edges To soil J Yes ['1 No es No
r
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / ° ' / Inspection #2:
Location: 1447 112th Street New Richmond, WI 54017 (NE 1/4 SW 1/4 21 T30N R1 8W) NA Lot 1 Parcel No: 21.30.18.320A
1.) Alt BM Description=
2.) Bldg sewer length
- amount of cover = s
T
Plan revision Required? Yes No y —7
Use other side for additional information.
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
t
CommerCe,yyj„ gov Safety and Buildings Division County
e 201 W. Washington Ave., P.O. Box 7162 (� X
!�+ /'►/�! [ Madison, WI 53707 -7162 Sanitary Permit / Number (to be filled in by Co.)
D� of Camme troe 'V � CJ
Sanitary Permit Application rate Transaction Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to th to governments / /A
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owne are Project Address (if differen thanmailing address)
submitted to the Department of Commerce. Personal information you provide may be used for seconds /1Vg7
p urposes in accordance with the Privacy Law, s. 15.04 (l) m , Stats. / J
1. Application Information - Please Print All Information JV
Property Owner's Name RECEIVED Parcel #
SL"- t, S� ab- 1 30-1 ro
Property Owner's Mailing Address N OV V 7 ZQD] Property Location % 32 o /�
11
LA.,/ (.7
Govt. Lot
City, State Zip Code Phc��?� *JX COUl XZ11-6- /`_�`'!! �° Section
1
l
N ( � T R� rW
II. Type of Building (check all that apply) Lot #
�-f Subdivision Name
2 Family Dwelling- Number of Bedrooms _Z /
be.i n� ove J e > Brock #
❑ Public/Commercial - Describe Use 1 ❑ City of
❑ State Owned - Describe Use C G` CSM Number - 7 75-5- 2 ❑ Village of pp
/ / / Town of /� J
III. Type of Permit: (Check only one box on line A. Complete line B if applica 1
A. ew S stem
y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only Cl Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision Change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date Issued
❑
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that appl
n- Pressurized in- Ground ❑ Pressurized In- Ground ❑ t -Grade ❑ Mound > 24 in. of suitable soil 11 Mound < 24 in of su a soil
11 Holding Tank ❑ Other Dispersal Component (explain) 2 ,Ofr reatment Device (explain) ��//
V. Dis ersabTreatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf) Dis rsal Area Proposed (s System Ele ation
I. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units () E c
New Tanks Existing Tanks e c d ` R
a U rn rn ii. C7 a.
Septic or Holding Tank /Z
Dosing Chamber 11
VII. Responsibility Statement- 1, the undersigned, assume r nsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Si re MP /MPRS Number Business Phone Number
S/ru� ��o Plumber's Address (Street, City, StatgZ i Code)
VIII. ount /De artment Use Onl tj
Approved ❑ Disapproved Permit F� `r � Date Issued �J Issuing Agent 'gna
❑ Owner Given Reason for Denial
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER: Q �� ` � S L t�dl(
1 Septic tank, effluent filter and ]L ?�-� �' C/
dispersal cell must all be serviced / maintained (/ Q
2. All setback requiremen s rriu�' malntaln8 submit to th County only on paper not less than 8 In x l l inches in size
as per applicable code /ordinances
SBD -6398 (R. 01/07) Valid thru 01/09
PLOT PLAN
PROJECT Luke Forseth DDRESS 449 Foxwav New Richmond Wi 54017
A
NE 1/4 SW 1 /4S 21 /T 30 18 W TOWN Richmond COUNTY ST. CROIX
11/7/07 BEDROOM 4
MPRS Shaun Bird 226900 DATE
CONVENTIONAL XXX IN -GR PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44
IL BENCHMARK V.R.P. Top of steel fence post ASSUME ELEVATION 100' Filter BEST Filter
❑BOREHOLE O WELL *H. R. P. Same as Benchmark
Well is to meet all
setbacks required by SYSTEM ELEVATION 91.0/90.8 4.5' below qrade
WDNR
Alternate Benchmark Top of Wood Post @ 98.1'
AL
54' Property Line Scale is 1" = 40'
unless otherwise
noted
Pro 2 Bedroom
House /Being
Plans Designed Using oversized to a
Conventional Powts 4 Bedroom System
Manual Version 2.0
12'
ST
B.M.
1 2 tl.B.M_ 1 5' ,B_
20' 12]3 0'
Vents
150'
B -3 45'
2% Slope Not enough slope to establish contours
2 -3' X 90' Cells with >3' Spacing Vent
>6 „ f : -' Quick4 Standard -W
of Cover Leaching Chamber
with 20.0 ft2 of Area
4' Long
12" 5.8ft ^2 /pair of end ca
34" m Elevation
112th St.
Y
PLOT PLAN
PROJECT Luke Forseth DDRESS 449 Foxwav New Richmond Wi 54017
NE 1/4 SW 1 /4S 21 /T 30 18 W TOWN Richmond COUNTY ST. CROIX
11/7/07 BEDROOM 4
MPRS Shaun Bird 226900 DATE
CONVENTIONAL XXX IN -GR PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44
kk BENCHMARK V.R.P. Top of steel fence post ASSUME ELEVATION 100' Filter BEST Filter
❑ BOREHOLE O • WELL *H. R. P. Same as Benchmark
Well is to meet all
setbacks required by SYSTEM ELEVATION 91.0/90.8 4.5' below grade
WDNR
Alternate Benchmark Top of Wood Post @ 98.1'
AL
Scale is 1" = 40'
54' Property Line
unless otherwise
noted
Pro 2 Bedroom
House /Being
Plans Designed Using oversized to a
Conventional Powts 4 Bedroom System
Manual Version 2.0
12'
ST
�k
B.M.
At1.B.M. 15' B -1
IJL -2
20' 120'
Vents 30'
150'
B -3 45'
2% Slope Not enough slope to establish contours
2 -3' X 90' Cells with >3' Spacing Vent
>6„ M5.8ftA2/pair Standard -W
of Cover g Chamber
0 ft2 of Area
of end ca
4' Long 1219
- a�S -ysC�m Elevation
34"
112th St.
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County �
Attach complete site plan on paper not less than 8 1/2 x 11 incheVWizF..jlan must
include, but not limited to: vertical and horizontal reference point 2
dir ion Parcel I.D. /�
percent slope, scale or dimensions, north arrow, and location an �� -& �o(v y'
Please print all information. Reviewe by Date
Personal information you provide may be used for secondary purposes (Privac / / o - 7
Property Owner rty Lo lion
/—U' 7 is Govt. Lot 114�W 1/4 S T3() N R E ( W
Property Owners Mailing Address 81 # Subd. Name or CSM#
r-- x Cv�
City State Zip a Phone N mber� f✓�t01X sY Village o Nearest Road
New Construction Us Residential / Number of bedrooms Code derived design flow rate �lT� GPD
❑ Replacement ❑ PublicAr commercial - Describe:
Parent material e'L Flood Plain elevation if applicable /v� ft.
and recommendations:
/ s�� � � jJ ✓PJS,�� � � � � ✓�� `�
System Type C.�7 i Syste Elevation / O 0•
l hZ i l z h "
F
Boring # Boring j 3
W ^7
Pit Ground surface elev. �_ ft. Depth to limiting factor in.
Soil Applicalionfate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 ff
•E
® Boring If a Boring
� �� �/D .
1� Pit Ground surface elev. � ' ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. S z. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
1 0 A , 31 z-
2 — - S s . / 4 )VI ,
A� Z/ r ✓ �,
Effluent #1 = BOD > 30 1220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) S' ture CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 7 — e 9 7 715- 246 -4516
T
Property Owner _ Parcel ID # Page of
Boring # ❑ Boring
F3_1 �, Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Descriptign,, - Textore' Structure Consistence Boundary Roots GPD/fF
in. / Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
V�� U � �
�-� 7 L/ G / 7j '�
Z '
Boring # Boring
❑
❑ Pit Ground surface elev. ff. Depth to limiting factor 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
F-1 Boring # ❑ Pit Boring
sur
❑ Ground face elev. ft. Depth to limiting factor in.
Soil ication Rate
Horizon 7epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
• Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mgA_ ' Effluent #2 = BOD < 30 mgll. and TSS < 30 mg1L
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.
SBD46330 (R.6100)
: Soil Test Plot Plan
Project Name Luke Forseth Shaun: $trd r�
Address 449 Foxway
New Richmond Wi 54017 C §T #226900
Lot 1 Subdivision -------- Date`' 11/7/07
NE 1/4 S W 1/4S 21 T 30 N /R18 W Township Richmond
Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Steel Fence Post
System Elevation 91.0/90.8 *HRpSame as Benchmark
Alternate Benchmark Top of Wood Post @ 98.1'
AL
Scale is 1" = 40'
54' Property Line
unless otherwise
noted
B.M.
AtI.B.M.
10' -2 120' B -1
20'
30'
150'
B -3 :: : 4 :
2% Slope Not enough slope to establish contours
112th St.
PMO
Wisconsin Department of SOIL EVALUATION REPORT Page 1 of 3
Division of Safely and Buildings
in accordance with Comm 85, Wis. Adm. Code Cry
St. Croix
Attach complete site plan on paper not less than 8 12 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. Pending
percerd slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please p rinf all information. _
Date
Personal ntmation you provide maybe gs7 jCG ovL 15.04 (1) (m)). � 27 d RPM
Property Owner roperty Location
David Lot NE 1/4 SW 1/4 S 21 T 30 N R 18 E (or)® Property Owner's Mailing Address ot # Block # Subd. Name or CSM#
1912 Ford 1 - Roos I 7i
City State Zip ity []Village ■ own Nearest d
St. Paul MN 5 112th Street
El New Construction UseE] Residential /Number of bedrooms 3 to 4 Code derived design flow rate 450 to 600 GPD
Replacement Public or commercial - Describe:
Parent material Loess over outwash Flood Plain elevation N applicable NA f I
General comments Site suiWde�.fer ayaWmAdditional site evaluation may provide area for a c onventional below grade I �S
and recommendations: N L i -
system. House location is important for this determination' (P �/y
* discontinuous band d& �n�
recommended system contour 101.50' - > ( 2 e 1,9,W
Boring # 11 Boring 3 W' Ai 7 160 `' 8 ti
El Pit Ground surface elev. 99.90 ft. Depth to limiting factor 80 in.
Soil ication Rate
Horizon Depth Dominant Color Redox Description Texture Str Consistence Boundary Roots GPDtlf
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efr#1 'EfN2
1 0-31 10yr3/2 - sil 2msbk mfr cw 2f .6 .8
2 31 -39 1 3/4 sil lmsbk mfr cw if .4 .6
3 39-46 7.5yr4/4 - sl Orn mfi cw _ 2 .6
4 46 -59 7.5yr4/4 - Is Os m"& cw - 7 1.6
5 59-80 7.5yr4/4 - Al 0m mfi cw - .2 .5
6 80-86 10yr5/4 mld5yr5 /8 sil lmsbk mfr - - 4 6
F 2 Boring # a Ong 102.90 28
Q Pit Ground surface elev. ft. Depth to limiting factor in.
Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Str Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eif#'I '01012
1 0 -8 10yr3 /6 - is Osg mvfr as 2f .7 1.6
2 8 -15 1 1 3/4 sl lmsbk mfr cW if .4 .7
3 15 -28 7.5yr5/8 s Osg ml cw _ 7 1.6
6. 4 28-65 10yr5 /6 o2d5yr5 /8 sicl* lmsbk mfi cw - .2 .3
5 65 -90 7.5yr5/8 s Osg ml - - .7 1.6
' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 150 mg1L ' Effluent #2 = mg/L and TSS 1 30 mg/L
CST Name (Passe Print) — — Signature CST Number
Thomas C Nelson ' 227387
Address Date Evaluation Conducted Telephone Number
1432 120th Street, New Richmond, Wl 3/30/04 715 -246 -2454
Property Owner Roos Parcel ID # Pending Page 2 Of 3
Boring
Boring # El Pit Ground surface elev. 101.30 Depth to limiting factor >96
3 R 6 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/iF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 - 0102
1 9A J I 10yr3/3 - sil 2 mfr cW 2f .6 .8
2 '1149
' 1 4/6 - sil lmsbk mfr cam' if .4 .6
3 19 -29 10yr4 /6 - sil lmsbk dh cw _ 6
4 2 - 7.5yr5/6 - s dl - - .7 1.6
F4]Boring # Boring 99.88
Pit Ground surface elev. ft. Depth to limiting factor 47-60
P 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. - 0101 - Eff#2
1 0 -10 10yr3/3 - is Osg mvfr as 2f .7 1.6
2 1 10 -19 is Ose mvfr cw if .7 1.6
3 19-47 1 /6 - cos Osg ml cw _ .7 1.6
4 47-60 10yr5/4 c2d5yr5 /8 sil lmsbk mfr cw - .4 •6
5 60 -104 7.5yr6/4 - s Os ml - - .7 1.6
5
❑ Boring # a Boring Pit Ground surface elev. 99.10 ft >100
Depth to limiting factor in.
Soil Appficatlon Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - E1E#1 - Etf#2
1 0-10 10yr3 /3 - is Osg mvfr as 2f .7 1.6
2 10 -18 Is Osg mvfr cw if .7 1.6
3 18 -35 7.5 5/6 - cos Os ml cw - .7 1.6
4 35 -100 7.5 /4 - s Osg ml - - .7 1.6
* Effluent #1 = BOD, > 30:5 220 mg/L and TSS >30:5 150 mgA. ' 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.
SBD- 8330Tcd0L07l00)
Pro perty Owner RO Os Parcel ID # pending Page 2 of 3
Boring Boring
# Q Pit Ground surface elev. 97.30 ft. Depth to limiting factor 100 in. Soi Application Rate
Horizon Depth Dominant Color Redox Description Texture Sfnxture Consistence Boundary Roots GPDHf
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Ef1#1 *Eff#2
1 0 -12 10yr3/3 - Is Osg mvfr as 2f .7 1.6
2 12 -28 1 4/4 - sil 2msbk mfr cw If ..6 .8
3 28 -35 7.5yr5/6 - Is Osg mvfr Cw if .7 1.6
4 35 -56 10yr5/4 c2d5yr5 /8 sicl lmsbk mfr cw - .2 .3
5 56-100 7.5yr6/4 _ s Osg ml - .7 1.
I 6
Boring # Boring
Pit Ground surface elev. ft. Depth to limiting factor In.
Soil Apolication 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 *EW
❑ Boring # Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Sal Alp fication 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 *Etf#2
* Effluent #1 = BOD, > 30 220 rng/L and TSS >30 < 150 mg/L * Effluent #2 = BOD,, < 30 mg1L and TSS < 30 mg1L
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.
SM- 030red OL07/00)
r
y k.
David Roos
Lot 1
96',
Scale 1"= 30'
BMl top of conduit pipe 100.00'
BM2 Top of conduit pipe 100.33'
8199.90'
B2102.90'
83101.30'
B4 99.88'
B5 99.10'
BS B6 97.30 B2
B6
3% 95'
slope
slope >3M2
98'
105' 4'
- B4 BI
100' 102' 101.80'
recomended system contour ZX SE lot corner
100'
Thomas Nelson
227387
i
Maintenance and Contingency Plan for a Septic System
9 Y P Y
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
ency Plan
Option # . If system.fails, determine cause of failure, use alternate area and install new
e tested replacement area.
Option #2. Install system at a lower elevation, by removing chambers, removing biomat,
and install new system.
Option#3. No adequate area is suitable for replacement area, and system elevation
cannont be lowered. Install holding tank as last resort.
3. Replace any other failing components as needed.
Plumber: Shaun Bird 715- 246 -4516
St. Croix County Zoning 715- 386 -4680
Pumper Tom Mondor 715- 246 -5148
Shaun Bird #226900
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address t` ct
Property Address
(Verification required from Planning & Zoning Department for new construction)
City /State Parcel Identification Number d am- 6 — /D y , -J trO
LEGAL DESCRIPTION
Properly Location /t/� 1 /4. � 1 / a , Sec. Z , T Jy N R 6 W. Town of
Subdivision , Lot # �.
Certified Survey Map # _, Volume Page # /__L
Warranty Deed # / / 6 / , Volume , Page #
Spec house yes no Lot lines identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master phimber, 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.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms Z ->5i a e V 0
/
SIGNATURE OF APPLICANT(S) u�-' Pifer - DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08105)
00' 0 00' 0 00'0 1e�
soBaeya;uanbullaa soBaeya leloadg s;uawssessd leloadg
;unowy AjoBa ;ea apoa leloadg aasn
:sleiaadS
:# Plea :O le(] uol;eol;lpao 0 qunoa wield q pejo AJ811O
0 0 000'0 puelpooM
009'6Z 0 009'6Z 09L'Z AljadOad IeaauaO
:900Z ao; slel0l
0 0 000'0 puelpooM
009'6Z 0 009'6Z 09L'Z AljadOad Ieaau80
:LOOZ J01 s1e ;01
ON 009'6Z 0 009'6Z 09L'Z LEE IVUN341S32J
u0seam a ;e ;g le;ol anoadwi pue saaod ssela uol;dlaosaa
9002/OZ/90 :paBueya Ise-1 : suOljen leA
0
:y;lnn passassy :anlen;aMaeW J1ed :# IHS AbdwwnS L00Z
NSo Zb8b /6L Z999LL b00Z /6Z/60
aM 99Z/089Z 699LZL b00Z /2/01,
(IM 8£96b8 LOOZ /9Z /b0
ads l 0 /1 # 30 0 ale(]
:AJOISIH Iaoaed :sa ;ON
MS 3N M8L
(b /L 09L b/L Ob BuH- UMl -oaS) :(s);oejl
(Od 617 L L 101
LO 101 :BPIS OPU00 ool8 Zb8b NSO MS 3N id M H NO£1 LZ 03S
b0 Zb8b NSO field 6bL'Z :sajod :uol;dinsea IeBa
011M OOL L dS
1S1a 8b'H32J MOIIIM 2J3ddn OZ08 dS
aNONHMJ M3N Z96C DS
1S H1ZL L LbbL . uol;dlaosaa #;slo edA1
tiewud = , :(sa)ssa A:padoad IeloadS = dS IOOUoS = OS :sjopjS1(3
LLOb9 IM aNONHOI2J M3N
b' a2] J.10 ZZ 1
3N(ll 'H13S21O3 - O H13S2�O� 31Ifll
Jaunnp -00 1uaiino _ o 'jaumo juajmo = p :(s) :ssaappy xel
0 00 b00Z /6Z/60
adAl;lwaad #; Iwaad # uol;eollddd eaay sales # deW O MI IeouOMI ale(] uolleaaa
NISNOOSIM 'AiNnoo XIO�Io '1S X ;uaiina
aNONHM] -�O NMOl - 9Z0 V0Z£'8L'0£' LZ :# Iaoaed '
L d0 4 3E)Vd
Nd L£: 40 ZOOZ /804 L 00 l. :# laaaed
BY SIGNING BELOW, Borrower.. accepts an ees to the terms and covenants contained in pages
I through 3 of this Adjustable Rate Rider.
r
( Seal) (Seal)
Luke G Forseth - Borrower - Borrower
r
(
(Seal)
Seal)
- Borrower - Borrower
(Seal) (Seal)
- Borrower - Borrower
MULTISTATE ADJUSTABLE RATE RIDER —ARM 5- 2-- Single Family —
Fannie Mae/Freddie Mae UNIFORM INSTRUMENT
Fannie Mae 4- 2/5 -2/6 -2 ARM Form 3111 1 /01
GrealDocs-
ITEM 2064 L3 (0011) (Page 3 of 3 pages) To Order Call: 1 -800-06&5775
13 0113
x 111111! Ilill dill illll Illll 11111 illl llllll Ills Ilil
* 8 4 9 6 3 8 1
849688
STATE BAR OF WISCONSIN FORM 1 - 2000 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX CO., WI
THIS DEED, made between Robert A. Peterson and Robert W. RECEIVED FOR RECORD
Peterson, Grantor, and Luke Forseth, 0 s //1!/ 05/02/2007 10:30AM
�XQ - WARRANTY DEED
Grantee. EXEMPT N
Grantor, for a valuable consideration, conveys to Grantee the following REC FEE: 11.00
described real estate in St. Croix County, State of Wisconsin (the TRANS FEE: 173.70
" Property "): PAGES: 1
Part of the Northeast Quarter of the Southwest Quarter (NE' /,/SW' /.) of
Section 21, Township 30 North, Range 18 West, St. Croix County,
Wisconsin described as follows: Lot 1 of Certified Survey Map filed
September 29, 2004 in Vol. 19, page 4842, as Doc. No. 775562.
Recording Area t�
Name and Return Address: N
WESTCONSIN CREDIT UNION
PO BOX 269
NEW RICHMOND WI 54017
Together with all appurtenant rights, title and interests. 026 - 1064 -30 -100
Parcel Identification Number (PIN)
This h l, homestead property.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants, and conditions of record.
Dated this day of April, 2007.
* * obert A. Peters /
�y
* * Robert W. Peterson
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
COUNTY ST. CROIX ) ss.
authenticated this Personally came before me thia day of April, 2007 the
above named Robert A. Peterson and Robert W. Peterson to
* me known to be the person(s) who executed the foregoing
instrume t ckn wledged the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.)
s► - nt�s'a M - re
THIS INSTRUMENT WAS DRAFTED BY Notary Pti tc; :,th"te of Wisg6isin
My commission &ppnent �Jf not, state expiration date:
Robert L. Loberg of 71 •
Lober
Law Office a
-�� ��-
g La ]rrt/ cal
(Signatures may be authenticated or acknowledged. Both are not necessary.)
*Names of persons signing in any capacity must be typed or printed below their signature
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. I -2060
1of1
c;
VOL PAGE 4842
KATHLEEN H. VKEq '-
REGISTER OF DEEDS
ST. CROIX CO. MI
RECEIVED FOR fiECORD
69/29/2004 10s60AM
s`
�p I 4 (; � r R lr AST -WEST 1/4 LINE OF SECTION 21 EARINGS ARE REFERENCED TO THE C RE E RTFEE : L3. 0 0 MAP
M AR 2 U�, OP
Y FEE: 3.00
y � SSUMED TO BEAR 089 °54'38 "E PAGES: 2
� S U CO W'," A Y CUL- DE-SAC
_ Sl`r k'cYvEd S PE kGRD EMENT C __IN
12TH ST. NOT IMPROVED // �� VOL_
— 13 PG. 3717 +�
B EYOND CUL -DE -SAC _112 ST
N00 0 23'55 "W 1328.22'
740.22' 196.00• 198.00' L1 14 196.00'
740.36' 196.00' 196.00' A y 195.72'
L EST LINE OF THE NE1 /4 OF THE SW7 /4
S00'23'55 "E 1328.37' L11 18 $
.................................. ............................... .............. SETBACK ............
z z z
co
c c" Op ®� 4
z 198.00 96.00
Z m
m NOO'23'55"W 392.00' 0 02 ° 36'45 "E 1 2.
I 9 16'
m o o O O O .�
2
I
I Oe Z A W N i! W 1
i Oet a g O 0i �l
1 w 1 O W - i W +) _N w _N ( _N 4b
1 E � - y WW �„ m i�
io+ 1 Pm � y
m Op
tC1M� i: v� �y �y r r r r r r r r r r r Z
1(n `a �o r w v rn ~ I m
j W I
�,�.1' �_' �_• vS � �8 7o w it 8ffi7o Fo z
rd
I I k y D 4 C� (7 p n b 8 i�'ii i �'ii 9 '.1 8i i3'i 8i �j q � g 8i �i .�"+ - m �
' y T y T j T T Rl T T T T RI T
(73 Z I O=
I y - i �v I T C
w " w '' w y Fn 1 m O
m m
I
EAST LINE OF THE NE1 /4 OF THE SWt /4
500° '51 "E 1 23.22' —
1
_ Q LANDS
1 � 0
o m _O r m O
z Z� c�c 1TI aNrnoH �tOa� 0-nm
a F, gyp° T ' ` < olrR Z9 Z c z 4Z �C c2 z Z��z
In = r S �p j
ym Cz'f Om0 mm3 ° co z v z �
v C
rn� m Gym me cnc O ? m p �I
^ ���i
M : -4 2 ' ? m
z " m p M O T T` w
SHEET 1 OF 2 SHEETS
Vol 19 Page 4842