HomeMy WebLinkAbout030-1015-90-000 }
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPO RECEIVED
Owner P4 7 - 5 iJ.v 4 �29M
4A4tc ^ S i Q MAR 0 1 2004
City:;State ST. CROACOUNTY
ZONING OFFICE
Legal Description: 3 y5 ,010 - 1/0 Z
Lot Block Subdivision/CSM #
% -�L'A NV 0 Sec , TAN -R II W, Town of _ 5 OS E`Rlti PIN # 0 30 - /O /,s' JO.Oa
SEPTIC 'TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
W I5 7'i N G- I 0 S - ( PORC k) �Sa
ank manufacturer Size ST/PC / Setback from: House g Well P/L _
Pump manufacturer Model
Alarm location
(ttOLDING WANKS ONLY)
Setbacks: Service road N Z Vent to fresh air intake Water Line
Meter location
Alarm location
SO IL ABSORI' HON SYSTEM
Type of system: t�E� S Width . 3 Length � Number of Trenches �-
Setback from: House Y5 ' Well > /20 P/L, > 50' Vent to fresh air intake > SO
,col?
ELEVATIONS ,
8'4S E•YE,07 - /o 9 // ,g /�,c,:�,� /'00.0 O
w P O O R Si
Description of benchmark Elevation
Description of alternate benchmark To OF 1149Al - V&,v T C h4 P O N Elevation /6
Building Sewer Nl + STINT Inlet A ST Outlet 7 PC Inlet �
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines ( ) S Ems" ( f Lje 7 P&A
Bottom of System( () ( )
Final Grade O ( ) ( )
NO
bate of installation I / Permit number y' � State plan number
Plumber's signature J License number Date
Inspector
Complete plot plan
c 6 /?if - 734 2 Ulbricht & Associates q
Private Sewage Consultants
2812 10th Ave.
Spring Valley, WI 54767
THIS POVV'T SYSTEM SHALL N07Tt 5z r1 7-.4 ff CUSS
INCORPORATE PER COMM.
83.44(2)c A PROPER ZABEL
FILTER MODEL # /90V /
1 PR1'oR -� rr'o A-3 .
ly`' x /g"
AL
• H�� _rOP 0 w
o � A ,vvM
POOR Sill
/0 D.0 z
9
Ulbricht & Associates
Consultants
Private Sewage
2812 10thAve.
, W 1 54767
Spring ,r
V�
OV k � 2(0 ST
f�g �e u'f L'eT" SE
(,ewsa) -ro )e f N
G
L��' DE .
106 .14
° f v o
3Y
• i - - - -- New 13ull UA)�V&
I p l ion I TO R E 'xSE
6 �/f iL i �c7 G-
i
I i ( ;P vAJ0 &-v)
VE7A CAP
1 1 M � I
��� I �,I T °r S s,
Gv DODS
N
s Mr 5 y5rE� � • = G�
50 ' fo Ens r r L�
THIS POWT SYSTEM SHALL
INCORPORATE PER COMM.
83.44(2)c A PROPER ZABE
FILTER MODEL # e . / L�
13 6 FL- T P(A AJ
t
Wisconsin Departmentbf Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Buildinb Division
INSPECTION REPORT Sanitary Permit No: 430478 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:
Sandom, Einar & Pat I St. Joseph Township 030 - 1015 -90 -000
CST BM Elev: / Insp. BM Elev: BM Description: Section/Town /Range /Map No:
( .-D �j .� C Sr F3 VA 1 04.29.19.65E
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic Benchmark
Ec51��rc a`f I aD .v
Dosing Alt. BM
Aeration Bldg. Sewer _
t
Holding St/Ht Inlet ^
St/Ht Outlet
TANK SETBACK INFORMATION �• 8 .OZ�
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic >� 5 ' y 5-Z' t Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe �`, .O
D �
Holding Bot. System 1 3
.3b 9 2.-SO
Final Grade
PUMP /SIPHON INFORMATION vac X�
Manufacturer Demand St Cover - AA--
GPM a
Model Number � aj S ` a- V
TDH Lift ric Loss System Head T Ft , 81 Ib • 93
Forcernale Length Dia. ::L— Dist. to Well
SOIL ABSORPTION SYSTEM / ( cA C 14 -ef
BED/TRENCH Width 1 Length I No. Qf Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 6$ • �• Cz3
SETBACK SYSTEM TO T, /L BLDG IWELL LAKE /STREAM LEACHING Manufactuperl
INFORMATION CHAMBER OR
Type Of System: S � I 1 � 1 UNIT Model Number: t r
1h.lf
DISTRIBUTIONS TEM -�•�— '2��• t h c �`t `�s.90
Header /Mai Id Distribution x Hole Size x Ho ang en to Air Intake
Pip s)
Length Dia Lengt D' cing
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
Bedrrrench Center Bed/Trench Edges Topsoil /- Yes [j No Yes [] No
COMMEE TS l�d
4 (in�e cod #1:/\ screpencies, persons present, etc.) Inspection #1: D& / ZW ,3 Inspection #2: T T —
ocation: 44 XX��
L 538 River Road Hudson, WI 54016 (SE 1/4 NW 1/4 4 T29N R19W) NA tot 1 Parcel No: 04.29.19.65E
1.) Alt BM Description = N/A
2.) Bldg sewer length '- (,� 1 • - 1 c
amount of cover - v ` la q- a � t� . _p„ C_ _ �.c T .�- • �d�-
Plan revision Required? E. Yes XNo t�(o3
Use other side for additional in tion. � �`''^ ^ '�"' "' �- L_.__._.
SBD -6710 (R.3/97) Date Insepctor's Signature Cerl. 0
�js - Its C-E -1_e-c tn� o l� 2v��•
r
Safety and Buildings Division County !+;- G ./���
201 W. Washington Ave., P.O. Box 7162 5 IICC
1 *6c�nsin Madison, WI 53707 - 7162 Sanitary Permit Number (to filled in by Co.)
Department of Commerce (608) 266 -3151
Sanitary Permit Application State Pl n I.D. Number
In accord with Cgmm 83.21, Wis. Adm. Code, personal information you pro '� I I✓
may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address)
I. Application Information - Please Print All Information R E -- V E -..D_
- 5;� -
I
Property Owner's Na me r Parcel # of # Block #
s�4,V00� 1 t- s 2.0 3 1 0 3 64 Ot
Property Owner's M ailing Address L � _Zc _______._ ,_ T " G; i Property Location
9 3,? R/ 1 A • M � = r 5 4� , k, A I N ,Section
City, State Zip Code Phone Number
lV aosa'o w/. 3 �� • 3�3 /Q (circle QRQ
II. Type of Building (check all that apply) T N; R // E W
llk or 2 Family Dwelling - Number of Bedrooms �t�� CSM Num r
11 Public /Commercial - Describe Use 1/01. Z pg • 3 y S �i o
❑State Owned - Describe Use S 1 C, _ ❑Village ownship of 5 T'
D
III. Type of Permit: (Check o line A. Comp ete line B if applicable)
A ' ❑ New System 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
i
IV. Type of POWTS System: (Check all that apply)
9 Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Fil
El Constructed Wetland 11 Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter El Aerobic Treatment Unit El Recirculating Sand F' t
El Recirculating Synthetic Media Filter El Leaching Chamber El Drip Line El Gravel-less Pi ❑ Other (expl in) a
V. Dispersal/Treatment Area Information: - ! 3
Design Flow (gpd) Design Soil Application Rate( sf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) 5 stem levation
ysa • 7 �V3 ( s� (� �N�
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
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 Na me (Print) um nature ber's P /MPRS Number Business Phone Number
R•2r /h/?r'44 2_'�!-&3Z S 7/S •? - 7a • 3 fZ
Plumber's Addre ss (Street, City, State, Zip Code)
:2,91 /D P-�- 511e llu G- U10`
VIII. County Department Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issu' g )Lgent Signature (& Stamps)
Surcharge Fee) r�
❑ Owner Given Reason for Denial Z
IX. Conditions of Approval /Reasons for Disapproval
SYSTEM OWNER,
/ 1 Septic tank, effluent filter and
i dispersal cell must all be serviced / maintained l /P
as per management plan provided by plumber.
2. All setback requirements must be maintained �
as per applicable code /ordinances. ��� 1
�. ~ Z
Attach complete plans (to the County only) for the cyst on paper not less thhn 81/2 x 11 iq£hes in s ize
SBD -6398 (R. 01/03)'
r °p
OW E
V.44
O R
/00' 20
Ulbricht & Associates
Private Sewage COnsultants
2812 10th Ave. �.... �N:_.._.:. ......�r_�..a.......�...- -..r�.
gpring Valley, W1 5476
N E W
sip-
A)
619 /i
ia�
, tQ fh tl° Dot PRA
y 0 .
r -- 1
- - - - -! ✓ N ECU 13 v!l UA /v e
i t I I I I 7
� I
I
1
fo � X ' 5 T j,v lr—
60 I I J3ev
5 V:5 rem
r
tray c p
q bi
�I
I i
Id
400 OP
5z
1 2.0 p _
�1 11 d 6 tl of - e/9
s `� sit o3,¢G�l P/7
,D
930 Q
cop
THIS POWT SYSTEM SHAL
INCORPORATE PER COMM.
3.44( )MODEA PROPER ZABE O V ii
/� ' /goo l l
7 N Z AJ l
ULBRICHT & ASSOCIATES CO.
655 O'Neil Road • Hudson, Wl 54016 Reg. r esigners of Engineering Systen
715- 386 -8185 Private Sewage Consuitants
PROJECT INDEX
PLAN ID # 'All"t " DATE �G � 13
� y
OWNER ; r A47— 4 1 ( �,0D� PHONE 7i.5 3 boo - S p
d
ADDRESS S3 .0 /3/ Vt
LEGAL DESCRIPTION L -s/�'1 ,3 LI S4 /O U��• Z— p� • 'S c 3 S
S
TOWN OF ST T0SzFP4, ST e^Ao1�
COUNTY
csTM �• Zl�OZ-
LOCAL AUTHORITY/ SUPERVISION GjPDiX C. / • Zw AjeA3
PROJECT DESCRIPTION!
AA) �x�sr�tiG 3
�3O// 1 ltl t ,
C /
.0z 70
THIS POWT SYSTEM SHALL Ulbricht & Associates
INCORPORATE PER COMM. Private Sewage Consultants
83.44(2)c A PROPER ZABEL 2812 1 Oth Ave.
FILTER
MODEL
14- Spring Valley, WI 54767
4 X 4 ?111
Pg.l INFILTRATOR SIZING WORKSHEET
Pg .2 SYSTEM PLOT PLAN
Pg.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS.
Pg . 4 to It is n F1 or
Pg.-!) OWNER MANAGEMENT PLANS & ZABEL FILTER SPECS
P .6 OPT
g (OPTIONAL) L CROSS SECTION AND SPECS FOR DOSING TANK.
PG.7 (OPTIONAL) PUMP PERFORMANCE SPECS.
The attached plans and specifications are based on °In- Ground
Absorption Component Manual For Private Onsite Wastewater
Treatment Systems. (Version 2.0) SBD- 1075- P(NO1 /01.
m
a y
N
��
L
l Ln
o r
o y
W Top 0 t`' „UV -I s i Il
dooR ,
/,00.0 r 2
Ulbricht & Associates
Private Sewage Consultants
2812 10th Ave.
Spring Valley, W l 54767
rl v6- 3
-
N t /'�'��
ge e
T — - - --
✓NEw r3v// U-4 / V
lol I 'O' i • - - - t To RE ,xs�
'A.; G--
1 1 1 1 I
,x 1 , s T/N !r- f/f
rl �� Rep
I ' s s 5Fa . yo
I i
y rF
I
13 CA P
q b'
C..--
S
52,
�•) rl d
THIS POWT SYSTEM SHALL
INCORPORATE PER COMM.
83.44(2)c A PROPER ZABE
FILTER MODEL # 4 , �gf�d !� '�X 10
PZZ T P�A A
ivSp�c ii�� e'r9'�' 9 ��
ANSI E -- 7 / ®,v p /A_(" ! /( Div. i �
Z- k � L k4rlt1> T r&w "Z� 5 � T��
y
C�Po S� Sic io�1 0�" TAPf�v�s
lr{► c �Ac r �/ ''SiD r> ;Z° ,�D� L 3 X G a2 L o v
w 'A 31- / 5Q. jr rfa�.'vvj c,,rlcr �,c. S�E� Ti'a A-
101 2 .,
Iff
3C�
OVER, See Backside For Inspection Pip Vent Details
P P
PAGE 6 REVERSE SIDE
OWNER'S MAINTAINCE OF SEPTIC SYSTEM
POWTS (landowner) is reponsible for proper operation and
maintenance of this system. Regular periodic inspections and
servicing is necessary for the safe healthy operation of this
system. The owner is required by code to submit all necessary
maintenance /inspection reports to the controlling authorities.
SPECIFIC CONTACT AGENTS
* Governmental authority/ inspectors: A.15
3�( •y�80
*.Licensed installer, responsible for providing an operation/
maintenance "Users" manual:
* Licensed servnce / inspection agent other than installer:
OCR • 3 a
* Electrician, for pump, electric controls, wiring units:
IMPORTANT OWNER MAINTENANCE REQUIREMENTS
1. Winter traffic (sledding, shovetring, etc.) across the
area shall not be permitted, or frost can /will penetrate into
the cell, freezing up the system.'Discontinuos use in the
winter (a vacaction trip, resulting in no water use) can also
lead to freeze ups.
2. Water conservation needs to be exercised! Or system can be
hydrolically overloaded and destroyed. This system was
designed for a maximum wastewater flow of
V5 gals. daily.
3. POWTS are not designed to accomodate wastes from a garbage
disposal unit, or any other unnatural sources of waste.
Any introduction of such waste materials will overload and
destroy this system.
4. If a power outage occurs, or a pump fails, it may result
in a temporary overload of effluent being pumped into the '
cell, which may adversely impact the cell (leakage). It is
recommended that a licensed pumper empty the dosing tank,
allowing the pump to return to dosing the correct amounts.
Consult your installer immediately for advice.
5. Neglect of the vegetative cover (the Gells insulation &
erosion preventive) can lead to failure. Compaction or heavy
traffic also can destroy t he system- It IS NECESSARY TO
REGULARLY WATER THE VEGETATION OVER A SYSTEM!! Effluent in
the system beneath IS NOT sufficient alone tO maintain a
grass cover.
6. Periodic inspections by the owner, or his agents, is
necessary. Inspection pipes and ports have been incorporated
into the system: on the mound basal area (effluent level
Inspection pipes), cleanout terminals on the pressurized
laterals, at each tip - for flushing and cleaning the laterals
out. The filter system in the tanks (via a locked above
ground cover /manhole). Only a licensed properly qualiOied
person should
be
performing xng this work which
a severe safety risks. Evidence of effluent pondingsinetheh
system's treatment cell shall also be regularly inspected.
s
Wisconsin Department of Commerce SOIL EVALUATION REPORT �� � of `
Division of Safety and Buildings
in accordance with Comm 85. Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must /
Include, but not limited to: vertical and horizontal reference point (BM), direction and Pam i.D• 0 3 ® �! o !.J '
Percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. wed by Date
Persona! information You Provide may be used for seconCary purpom (may Low, s.15.e4 (1) (m)). � Z J 102
Property Owner Property t.ocatoon
1Ni}12 ? �/� r/Q/ G/ /�- J fEN/74M Govt. Lot s r 1/4 N 14 S 7 T 2 7 N R �/ E (or) W
Property Owner's Malting Address Lot # I Block # Subd. Name or CSM#
s 3 F 0V--t Ro / CS 4 3 Y 57,P/ o , 1 " 0 / . z-, r 53
( %Y State Z+p Code Phone Number Q City [} Village IdTown Nearest Road
vDSo r/ Gv /• syail� ( 7� 5 3 �l •3�3 / 57 1 X D .
0 New Constructim Use: In Residential / Number of bedrooms Code derived design flow rate ✓ GPD
0 1.Repiacernent 0 Public or commercial - Describe:
Parent material D U.0,_ -rAA D!)�lfJ �A Flood Plain elevation it a pplicable
—_ /QES S TX /ter aPPi ft.
Y
General corrrneitts
and recom iendations: • �x/'S T'�'ivG- v� yST� / s /'v
PI' T) dvye 44,
2 7*lt� nee • uS2
B,M # 0 6
j a Pit Ground surface elev. �' ft. Depth to uniting factor at.
Soil ft Rate
Horton Depth Dominant Cokid Redox Description Texture Structure Consistence
Boundary Roots GPDff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#•l 'Eff#2
O YA 3/ 4" fShK dS4 4- , s .
•av /b Y d4 6Z / Z • 3
•37 7•S S 0 S C • '7 (• Z
• /D /D ty S S D . 7 1 • Z-
r� q�
`f -S-Z S • s z--
Gy Pit Ground surface elev. ft. Depth to limiting factor in.
Horizon Dominant . Redox Description Soft Rate
ption Texture Structure Consistence Boundary Roots GPt>M
in. Munsefl ou. Sz. Coat. Color Gr. Sz. Sh. 'Etf#1 "Eff#2
/ o •/p /o Y/R aG / 4 a S 3 - - . � • �
b • /o S/L .Sly /c. dA 0.5 -f- • - Z-1
• 3
7 •5 ve Y l , , - , r _.V --
/o Ille s s ,e
- Lllt�—o
2 -•S.1
Effluent a'i 1 = BOD > 30 220 SS >30!: 150 mgA- ' Effluent #2 = BOD < 30 rragA and TSS < 30 trigiL
CST Nam P lease Pri<tt} Signature CSTMunt w
Z1-1h A / ZZ S
Add Date Evaluation CorKlu ted Telephone Number
4 • 1Y his• • 77' • 3 YY
-- W rIcht & Associates
Private Sewage Consultants
2812 10th Ave.
Spring Valley, WI 54767
5
�,�
� Z 3
Property Owner Parcel id # Page of
Boring 0 Bv � F 3 - 1 # �Plt Ground surface etev. �" • ` fl. Depth to liming factor in. Sal AppkaWn Rate
Horizon Depth Dominant Color Redox description Texture Structure Consistence Boundary Roots GPDRg
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Efr#1 'E4f#2
o �aYie 31tl -- Sz- / IS dX W IS w
•�. /b
51L- Ifs
v cc f • Z •3
(0 2
Boring # r�-1 Boring
�J Q Pit Ground surface plev. ft. Depth to limiting factor . in.
Sod Wication Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPM
in. Munsell Qu. Sz. Copt Color Gr. Sz Sh. 'Etf#1 'Eff#2
El
Boring # t ❑t---tt ��
t_3 Pit Gnculrx4 surface elev. ft. depth to factor In.
Sod Application Rate
Horizon Depth Dominant Color Redox Description_ Texture Consistence Boundary Roots
GMW
in. Munsell Qu. Sz. Cont Color . Sz. Sh. TIM 'EfT#2
SDoing # Boring
iJ Pit Ground surface elev. �_ ft. Depth to RniWV factor in.
� Sod Rate
Fiontzon Depth Dominant Color Redox Texture Structi" Consistence Boundary Roots GPDM
in. MunseN Qu. Sz Cont Cafes Gr. Sz Sh. 'Eff#1 'Ett#2
i
" Effluent #1 = BOD, > 30 220 mg& and TSS >30 150 mglL ' Effluent #2 = BOD < 30 mg& 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.
SADl330 (R&UO)
i
H , r °p O w�---
13 �
� a A
1'
S
J9 o ,
0.
' 29
Ulbricht & Associates
Private Sewag e
2812 10th Ave.
P
$ ring Valley, WI 54767
g,�7X i s 7 3
fib PeR� -fir, SSE ..
(ieA SE�3� -r p l e
E
A)� I �' C�flE 4 A-I T
b ► /�F
3
- - -i To RE �tSE'
T /N G f,4 iL N G--
vp ' , ; ��' ) 19
s v5 7e Al !� - • ---
--�. O
- -- h
:
1 v VE-A3T C�
1 14 �'t P
/ o /, i4/'
Io
S `-
,lZ N
/ I/-=
Ga 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 4 -SAN1'20, residence located at:
SCE 1/4, IUW 1/4, Sec. , T N, R I f W, Town- of
�'"• - J'OS "A-- Upon inspection, I certify that I have found the
tank and baffles to b//,,e in good condition, and it appears to be /�
functioning properly. ti- 7/f/ G ;",Y Sflc�i
Last time service
Did flaw back occur from absorption system? _Yes X No (if no, skip
�2 next line)
Approximate volume or length of time: T gallons minutes
Capacity: 16 EIQ .
Construction: Prefab Concrete Steel Other
Manufacurer (if known) : LU%�`Se7e ��6r�,e7(t `'d
Age of Tank ( if known) :
(Signature) (Name) Please Print
(Title) (License 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 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).
tame `R .211 g(11(t _ Signature_A.�1- — MP-/MPRS
Ulbricht & Associates
Private Sewage Consultants
2812 10th Ave.
Spring Valley, WI 54767
r
• ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT _.._.
AND
OWNERS111P CERTIFICATION FORM
owner /13uyer GItl4R Si 41 0M 3 ?6 '3 _
Mailing Address S ��' U�t. kA - //Varo,J S z/D/ ("
Property Address
(Verifica(ion required from Planning Department for new construction)
City /State! Parcel Identification Number 0 30 - Q
LEGAL llESCRIP*floN , . 1
Property Location S� 1 /1, /V L ' /a' See_ � , T ?/ N -R � / W Town of
Subdivision , Lot #
Certified Sul Map # 3 y S S>1 , Volume 2- Page #
I � g
Warranty Deed # 3 1 �S , Volume 5�� 3 ,page #
Spec !rouse L1 yes El no Lot lines identifiable O yes 0 no
I
SYST MAIN'T'ENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintena
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the sysi
can affect the function of the septic tank as a treatment stage in (lie waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and b
master plumber, Journeyman plumber, teslricted plumber or a licensedpumper vetifying that (1) the on -site wastewaterdisposal syst
Is in proper operating condition and/or (2) a[tet inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludi
i /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standa
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certificat
stating that your septic system has been maintained must be completed and returned to the St. Croix Count Zoning Office within
days of the ihre a expiration date. y g
e
IGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to tine best of my (out) knowledge. I (we) (are) the ownet(a)
the roperty deseti e, by virtue of a warranty deed recorded in Register of Deeds Office.
c
IGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- tepresented may result in fete sanitary permit being revoked by the Zoning Department. * * *'
*' include with this application- a stamped warranty deed from the Register of Deeds once
a copy of the certified survey map if reference is made in the warranty deed
DOCUrAcVr NO. `, � STATE DAR O. WISCONNIN -FORM s
4 �j 5 .!r'( WAUN:�.�fT 3) 1. P.D
♦; �l V v�l_ [J�' " . v
0 ACC FOR AacuKU NG o r•
h x
I
,.' 7 )11S �)l'CIJ� ..,a, ?� hriw,...I ^;, `r2Y2 (: t h, .�. ��u a:_'1' .... .. -.... - - ___ _... ,. � •s•
> I ,
(
..
ti .r _.. _. •, ,
28 th
c
•' _..., ....... ........, Crantut .J :y �:, QQj Ltu" A.D. 1 77
' and ..: CGYtt(1 :.�.':2 :ri l- :;1 «2'L.0 +1- I�CLtI. ✓!irl �QIR�....13. �jJ121............
.. tanant.t, . not—z5, J1.lnt `3 _izL. C.'.71 ]n .... ........ .......................
....._.
... ................_......_....... ._ ..... .............., Grantee,
s Witneacth Thar: the said Gt utt , r f„r a va'uahle a ,is !cntio y..�Y1B..C�O.L.Z(LX' Rsylt ul ONda
(,1.00) and othar gvod and valuable consi��ea•atzon
_ ............ ....... ......
on,cys I. Grint_r thr i 11.,+ +i.,� Ics.ribcd re.rl cstalc in a.tA .CrQZx......... County
A[TV AN TO
Stale of Wisconsin:
Part of the Southeast Quarter of the Northwest Quarter
(SE4 of NA) of Section 4, Township 29 North, Rarge 19
" West, ToLn of St. Joseph, St. Croix County, Wisconsin, Tax Key tr ............... ...............................
further described as follows: Commencing at the North Z14 This is .................. homestead property.
corner of said Section 4, thence S 01 -00 -32 West along the
East lit.? of the NW 114 of said Section 4, 1686.89 feet to the. point of beginning
of this description; thence continuing S 01 -00 -32 West, 327.80 feet;thence N 89 -Z3 -29
;Jest, 510.84 feet; thence N 05 -10 -01 East, 327.49 feet; thence S 89 -22 -30 East, 487.10
feat to the point of beginning containing 3.75 acres; together with an easement for
roadway purposes 66 feet in width from the above described parcel to the Town Road
to the South as now traveled.
f /
5 --
�1.
FEE
Together with all and sing the .,.rc l:ta ;ncnts and ai 1�urtcnanr+s d,ecunt, l eloo ing cr in any wise appertaining:
And ........... Kermet ... J. . Bauer .. ...... - -- ......._ .... .. ................ . -- ._... _......... ...................... ................. ..................
........ ....- .... - -- .... . . .
warrants that the title is good, indrfctsihle in fee simple and free an! clear of enc;u^: - es e`' ept— ........ ..................... .......................
... - ............_.........- ..__........_ ................. .. 1-- - -. - -- ..................... --° - ....... ........... — .............................. ......... I.......
_ ..................
... _......................... .I. ........- ................ -- ................ ... I....................................................
and will warrant .and d the same.
Executed at....i�. +L1 L CYl.ii.. �G:.a. > -e .c.�t. :t........ :his....- ..1...1.- da, of October ..... .... ....... 19 ..
�...
,;IGNED AND ,SEALED IN Or•' - ' , � _ (SEAL)
.... ...t .,- .- .- ;;— F )... .. mo w.:....... :�..:......_
.._.._ fi••r.. 4 fit:- Yt./.. =:�. �. �' -.0 ?�?.t -c./' .. .. ............. ..... �
. ... ...... . . .. .. --------- ...... ....---..(SEAL)
Ten 4. Kramer � Einar_&andom
............ -- (SEAL)
=atricia Ann 5andom
Genevie M. darner
_ -..... .... .. - -- ........ . .............. _...... ...... (SEAL)
I
ignatures ............._......... . .. ... ......._.. ._....._....... _.....
.... ........ . .... . .-. .. ...
authen *. cated this . .............. _........._- .__...._._ d:ay „f_ ... ..... .... . ............................... -- ---- --.... 19..........
Title: Member State Bar of Wisconsin or Other Parry
Authorized under Sec. 706.06 viz ....................... ...............................
STATE OF WISCONSIN
ss.
........ S.t- Cho. x .. .. ...... ..............aunty. f�
came before me, th s ....... ....... / °- day of...... OCt ......
Personally _................. 19..., . .._,
Y J -• - ° °- Y
the above named ............ ......
Kel�neth J...... Bauer .................................. ...............................
.... _.
............................... ................. ...................................... .._ .................................... ............................................
to me known to be the person ........ who executed the foregoing instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED DV ......... ..... r � ...... • -{.� :4 = �' - �+A•�• rr / / i�
B. Dean Fisk 'D E Kramer ' ,; •; � `� •• �rt�
1296 Hudson Road, St. Paul Minn. 55106
Th e use of witnesses is optional. Notary Public, ............ .................... I .................... ......., Cp�t
My commission (expires) (is) ..... „ „,w `tcpitt:.�,.�.::lle.•'�
Names of persons signing in any capacity should be typed or printed below their signatures.
i
STATV BAS OF Wl-ACONSLY Wisconsin Lekal Blank Company
WARRANTY DEED FORM No. 1 -• 1071 Milwaukee, %Via t Job 32620)
• 34581
troy y z2
JAN 5 197F >N
345810 ° �`E« w
t w T.�••.r, � +o
CERTIFIED SURVEY MAP s
SE 1/4- NW I/4 - SEC. 4 , T -29 -N, R -19 -W
S 8 13' -29 "E NI /4
NORTH LINE -NW 1/4 SEC.4
3 COR. MON.
150' 100' 50' 0 150' iv `F —EAST LINE -NW 1/4
o C g.M PPGF' �98, 1 2D SEC. 4
SCALE= 1 "- 15-0= 0 ' S 89 22-30" E
9.35 N
9 p o 487.10' �g
iL
0-
W
W 't LOT I M
LEGEND ° ti
p
N 3.75 ACRES N p
I M M BEARINGS REFERENCEI
• - 1 IRON PIPE FOUND o o TO THE NORTH LINE -
0- 1 "x 24" IRON PIPE SET p N NW 1/4 - SEC. 4
WT. 1.68 LBS. /LIN. FT. I Z t ` %
J $�' 510.84' `0 /'
I I N 89 13'- 29" W
THIS INSTRUMENT
5 DRAFTED BY ( G.C. S)
c S - P?G� 40
77-34
SURVEYORS CERTIFICATE
I, Gene C. Shaffer, Registered Land Surveyor, hereby certify that in full compliance
with the provisions of Chapter 236.34 of the Wisconsin Statutes and Section 5.4.2 of
the St. Croix County Zoning Ordinance and under the direction of Kenneth Bauer,
owner of said land, I have surveyed, divided, and mapped said parcel of land, that
such survey correctly represents all exterior boundaries and the subdivision of the
land surveyed and that this land is located in the SE 1/4 of the NW 1/4 of Section 4,
T -29 -N, R -19 -W9 Town of St. Joseph, St. Croix County, Wisconsin, further described
as follows:
Commencing at the N 1/4 corner of said Sec. 4, thence S 01 -00 -32 W along the East
line of the NW 1/4 of said .Sec. 4, 1686 .89 feet to the point of beginning of this
description; thence continuing S 01 -00 -32 W, 327.80 feet; thence N 89 -13 -29 W,
510.84 feet; thence N 05 -10 -01 E, 327.48 feet; thence S 89 -22 -30 E, 487.10 feet
to the point of beginning. Above described parcel contains 3.75 acres.
��IiNtlypF'' CERTIFICATE OF TOWN OF ST. JOSEPH
I, Carolyn Barrette, being the duly elected, qualified
GENE C. and acting Town Clerk of the Town of St. Joseph, do
SHAFFER hereby certify that this Certified Survey Ma.p has been
S -1325 q approved by t Town Board of T wn of St. Joseph
HUDSON• 1 / this day of 1977
WI
0 �� , c �
UT0 •
qNG S � APPROVED Carolyn Barre e, Town Clerk
NOV 04 1977 APPROVAL OF THIS MINOR SUBDIVISION
DOES NOT MEAN APPROVAL FOR
VOL. 2 PAGE 535 ST. CROIX COU -Ty BUILDING SITE OR SEPTIC SY:.TEM.
CERTIFIED SURVEY MAPS COMPREHENSIVE PARKS PLANNING REFER TO H62
ST. CROIX COUNTY, WI. AND ZONING COMMITTEE
l .'