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N N Q C Q G CL N G G 0• x N C O CD 67 C D) C CD C � z a m n z a z a ° 3 w ° 3 9 ° ° .� N O S y N D) Q 0 �, N ON 3 O n o v — a CL o o�o _ iy cu 3 'w m CD ° CD o 0 ° � _ .0 3da °- CD m n CD o t7 tn 3 CD �^ o _ c CA) '� 0 0o a o CD CD CD Oq 0 0 0 0 0 0 w 0 o f o Q a RECEIVED S, /O�a� JUN G U ZU07 • EX�����e e/ev� ST. CROIX COUNTY cc /e.'/ $�2Prl.Cn Ft J'aynC f� /SL ,p'r., 60' lots /0e A' oio - /os7 -M - /a0 9y,o' 936 970'. un;:►►�ro ✓e d a ass EXiS4Jr! ``, o � en �Xi;Yfln� /,c0o8w.f, cc;SP /^�. •\ .\ n ` � C.a.,:s6•.� .., /�o y /e,(�P.0 -sus /e c.onn t c.6ed. e-V- c rq�it i�Jtr e/uf. 0, 0"4 /a \ 1 C�i3PclSa{C 7 fir�c C3J C�� S O =97cz >. 979G1� Or"ve 41M 83 Lo � � 1 To o{ S.T DuX � ,feu ! , i p/�e -rt I awn Inc >7 Aol r , e1ty, 10. do' ' r b 3 6 edrov *, 6r: c l' Lox/ jo 0. fest'dence 4. .6. Tco br; �l(u)a/ a6 oe IWS. E14&V - 97 a' .4 /oca.F� -i � 0-( `t.i is ��' %G G�•r( n� �L �Xt S tin C.e. // i I d is h iJtL�cc�o%E' -� i ' SS' 30$1/ �ttadai l7iU�sion I/a�de —r �0'3ri�.S/O e /6e� 303x/ P. v. r— ,c-r-or7 County: St CrOIX Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Sanitary Permit No: 5214 0 Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purpo ses [Privacy y X Law s.15.04 (1)(m)I- Township Parcel Tax No: City village 030 - 1057 -30 -100 Permit Holder's Name: St. Jose h, Town of Holsteen, Stephen SectionlTownlRange /Map No: CST BM Elev: Insp. BM Elev: BM Description: T``i, � / 23.30.19. ?�' 0- L) ELEVATION DATA TANK INFORMATION CAPACITY STATION BS HI FS ELEV. TYPE MANUFACTURER Benchmar S /.$ 98,� 'l 1 •�UWJ Septic T -� _ 0 i Alt. BM Dosing y, ✓D b 1 /�- Bldg. ew C � 11 � Aeration SUHt Inlet Holding a S>� St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD D �7CV" D om Septic Header /Man. i eJ G Dosing /� (� - -� 1 h a � Dist. Pipe � •� [ �►1t .� 3' �b.6 Z Aeration T �� g�J_ p l a< c t) Bot. System �d- Holding F inal G rade ' PUMP /SIPHON INFORMATION Demand St Cover d' Manufacturer �- s 3 9• GPM Model Number { S� /J 3 /o3 TDH Lift Friction Lo System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM S� �PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth BED / TENSIONS RENCH Width 3� Length o. Of Trenches DIM C LAKE /STREAM Ma SETBACK SYSTEM TO P/L BLDG WEL CH MBER R INFORMATION ofof Sy UNIT Typ "7 Model Number: c �5 DISTRIBUTION SYSTEM Air Intake �oC� —ID r 5 I / I� /_ x Hole Siz Y r`'�d x Hole Spacing Ven to HeaderlManifold / / Distribution / , f / t ry_ �i'IQ b^ `� 2 r Length � Dia � t Lengt Dia Spacing J SOIL COVER x Pressure Systems Only xx Mound Or At-Grade x System s Seeded xx Mulched Depth Over xx Depth of Depth Over Topsoil ❑ Yes ❑ No Yes 0 No Bed/Trench Center ) �n�A Bed/Trench Edges Inspection COMMENTS: COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:// -K Parcel No: 23.30.19.2 Location: 1495 North Bay Road Somerset, WI 54025 (Gov't Lot 5 23 T30N R19W) NA Lot 1.) Alt BM Description = /�G I" '(� (l?/1� � S'� ! �.IZ H/� 2.) Bldg sewer length - amount of cover = Plan revision Required? ❑ Yes No Use other side for additional information. y / Insepctors Signature Cert. No. SBD -6710 (R.3197) Date Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. CrA ix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 22 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: Jordan, Doug St. Joseph Township 030 - 1057 -30 -000 CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St(Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG =WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 [W No ❑Yes Fill] No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / ' &� Inspection #2: / / Location: 1495 North Bay Road Somerset, WI 54025 (Government Lot 5 23 T30N R19W) NA Lot 1 ' Parcel No: 23.30.19.201 B 1.) Alt BM Description = �— �-7— 1 - 7 /q p 2.) Bldg sewer length - amount of cover = „ , . l � /( 2- 1 :1 / / 63 if Plan revision Required? Yes ® No FM Use other side for additional information. Date Insepctor's Signature Cart. No. SBD -6710 (R.3/97) trommerce.W1.90V Safety and Buildings Division County 201 W. Washington Ave., P . Box 7162 St. Croix co ns i n Madison, WI 537 62 Sanitary Perini! Number (to be filled in by Co.) Mum M o of rce 5 D 6 (:>I /y Sanitary Permit Application State Transacti� flu �l,�r In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriat vernm Project Address (i different than mailing address) unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned P11 S are submitted to the Department of Commerce. Personal information you provide may be used for se Same purpo in accordance with the Privacy Law, s. 15. 1 m Stats. I. Application Information - Please Print All Information MOVED Property Owner's Name Parcel # Stephen & Jane Holsteen MAY 3 1 2007 030 - 1057 -30 -100 Property Owner's Mailing Address Property Location 1495 North Bay Road ST. CROIX COUNTY / �6 j B l e)) Govt. Lot S City, State Zip Code Phone Number Na '' /s, Na '' /,, Section 23 Somerset, W1 54025 715 441 =3353 (circle one) II. T of Building (check all that apply) Lot # T 30 N; R 19 w i or 2 Family Dwelling - Number of Bedrooms 3 1 Subdivision,, I m Block # / �" 0 Public /Commercial - Describe Use lA Na 0 City of ❑ State Owned - Describe Use CSM Number 0 Vfiiage of Vol. 17 P g . 4585 Town of St. Joseph III. Type of Permit: (Check onl a boa on line A. Complete line B if applicable) A. 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. T f POWTS System/Component/Device: Check all that a 1 on- Pressurized hr- Ground 0 Pressurized In- Ground 0 At -Grade 0 Mound > 24 in. of suitable soil 0 Mound < 24 in. of suitable soil 0 Holding Tank 0 Other Dispersal Component (explain) - 0 Pretreatment Device (explain) V. Dis ersab Treatment Area Informatio 45 Infiltrator W - chambers @ 20.0 sq.ft EISA / chamber + 3 pair end caps 14 S.8 EISA = 917.40 sq. ft. Design Flow (gpd) Design Soil Application RaWgpdst) Dispersal Area Required (st) Dispersal Area Proposed (st) System Elevation 450E 0.5 in -situ soil 900.00 s . ft. 917.40 s . ft. 89.00 VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units _ New Tanks Existing Tanks p ,a3 c a L ? aU � rn iw a Septic or Holding Tank ,00 1 Filter canister X Na I 1 I Wieser Concrete X VII. Res nsibility Statement - 1, the un rsigned, assume sponsibility for ins n of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's gn MP/MPRS Number Business Phone Number James K. Thompson - 5 ---- 30021 715 248 -7767 Plumber's Address (Street, City, State, Zip Code) 340 Paulson Lake Lane, Osceola, W1 54020 -5413 VIII. n /De artment Use Onl &4 roved I 0 Disapproved Permit Fee G � Date suqd 14ding Agent S' o $ ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval G«r 1 , 9f 3 7�k a, d 'ad SYSTEM OWNER: 17 GxAj,UYI fy� �� 1 Septic tank, effluent filter and ee)" -- dispersal cell must all serviced / maintained as per management p provided by plumber. v 2. All setback requir"'119VA"tbl" , t m and submit t o t h e � � t y only an per n � o t than g . it ' cbw in as per applicable code /ordinances. - � E � (` SBD -6398 (R. 01/07) Valid thm 01/09 ` u"` -7v- �X /:5 ! i nq Vance Ko►^i4 /o t I n e ctc /e. -/ st $feP� <� d Sayre ,� /St`PCn Goe 6 - Croi r CA)/. 0 -10 - /os73o -/cam n 9yo 936 92.0 un ';,;6A/•o✓cd aY,<ess �/i Fn L•d([ j► /'S , o G t ��2cJ e 1 • P n Car , . sEe+�. , / /e�Pc - .2 r O indt /� /et: of0 1 k C�i3PClSa�Cc.� 7� e (3) (t- 97.96 ' S a t 0 J = 9�� r. • ` 3 "X a z' a/ � r r� �'• /E-.u.,�, -- - �l �..� �r5/✓oe a l� • 1 43 o a{ S.T �tGX r BfJe-rt /Q�n r . , Assw,ntd ' r �Xi3z�%r�q l � M1 i b 3 6cdroa0.+, BY :CYIVGf� W �g ees :derIct 4:. b, • Top c F 5� mss. _ 9y, of c�t� P °X � 0 1 C is�ii ✓iG CurfG �� 0. Sk—e/irf( � 83/313' /a.ee e lel 79.E ��CQ2/ U O A h� ti "O d 'v N� c 1 J I A e L I n t: —� , WON � LA C E A F \ , � a 'C ■1��, 4 6i fZpr� cr s� < d.TctynC /� /SfPen /s�9Si1• cry oec(. Goi lots 9 C. 2 oO Tos e,O�(, 6E • Cro r 4 o l /��• �o�o /oS7- .3o- /a7 9y.o' 9':5.o' 936 72.o' i 970 EX /S�/19 �� `�� BI . �� \�, w�CS�/ � G / mac /� /CG/ qq /qqC ir7 e44 1 1 I l�i3PclSa�Cc� 7 1i /�c �3l Cam`^ S a,E 9 796, `, P 43 caw„ by -r,�,- •�icnc.�. �fF •-„ f �n ✓e �}rli. � • ` � 6�1� �Q�.Jr1 /!?c n he(c /assu,,ntd , , � jS2 3 bcdroa••+, �'�cY I � '� � n� brr�l�,va/�4 " V /ot 97 oG ,4 /oca.�Er�x -i �� elegy =79. �3ctu/ 2078 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with OWm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8% x 11 inches ins County include, but riot knW to: vertical and horizontal reference ' BM), di and , St. Croix percent slope, scale or dlmernsiorts, north arrow, and location a once to road Parcel J.D. 1057 -30 -100 Please print all information. viewed Date Persmral information you prwi a may be u ad for s.1 N414 (m)). ZL1 Property Owner F roperty Location / Stephen E. & Jane B. Holsteen MAY 1 2007 Lot 5 19 1/4 S 23 T 30 N R 19 W Property Owner's Mailing Address L ot# Block # Subd. Name or CSM# 1495 North Bay Rd ST. CROIX COUNTY 1 CSM Vol. 17, Pg. 4585 City State Z Code Phone Number J City J Village jM Town Nearest Road Somerset I WI 1 54025 1 St.Joseph I North Bay Road J New Construction Use: 16 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD 01 Replacement J Public or commercial - Describe: Parent material Glacial Outwash - Flood p vation, if applicable Na General comments and recomrnendatlonS ble for conventional dispersal ce t 0.5 gpd loading rate. :Reco mended system elevation to be 89.00' ❑Boring # _I Boring Pit Ground Surface elev. 93.65 ft. Depth to limiting factor >96" in. 30l Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Murrell Qu. Sz. cord. Color Gr. Sz. Sh. *Eff#1 *E 1 0 -8 1Oyr3/2 none sil 2fsbk mvfr cs 2fmc 0.6 0.8 2 8 -18 10yr4/3 none sil 2fsbk mfr gs 2fmc 0.6 0.8 3 18 -31 10yr4/6 none sl 2msbk mfr cw 2fm,lc 0.6 1.0 4 31 -56 7.5yr4/6 none strat Is/s 0 sg dl gw 1fm 0.5 1.0 5 56-82 10yr4/6 none strat s 0 sg di aw if 0.5 1.0 6 82 -96 10yr5/4 none s 0 sg dl - - 0.7 1.6 IS contain 1/8"- 1" irregular, discontinuous bands I 4-14 is at 6" - 12 intervals. Loading rate reduced tore aced permlebrlfty of horizon associated with banding. a goring # _ I Boring 16 Pit Ground Surface elev. 93.61 ft. Depth to limiting factor >94" in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I - E f1#2 1 0-8 10yr312 none sil 2fsbk mvfr cs 2fmc 0.6 0.8 2 8 -14 1Oyr413 none sill 2%bk mfr gs 2fmc 0.6 0.8 3 14-32 10yr4/4 none sic] 2fsbk mfr cw 2fm,1 c 0.4 0.6 4 32 -39 7.5yr4/6 none Is 0 sg dl gw lfm 0.7 1.2 5 39 -94 10yr514 none strat s 0 sg dl - if 0.5 1.0 1 7 1 -- H#5 contains 1/8 -1/4" irregular, discontinuous bands 10yr414 Is at 6" -12" intervals. Loading rate reduced to reflect reduced permiability of horizon associated with banding. * Effluent #1 = BOD? 30 220 mg/L ano TSS X30 150 mg/L (fluent #2 a SOD S30 mg/L and TSS 1S mg/L CST Name (Please Print) Signat : CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, W164020 5/21/2007 715 -248 -7767 Property Owner Stephen E. & Jane B. Holsteen Parcel ID # 030 - 1057 -30 -100 Page 2 of 3 a Boring # - Boring Pit Ground Surface elev, 92.73 ft. Depth to limiting factor >91" in. Soil Application Rate Horizon Depth Dominant Color Redox Desc6pton Texture Structure Consistence Boundary Roots GPDtW in. Munsell Qu, Sz. Coat. Color Gr. Sz. Sh. *Eff #1 *Eff#2 1 0-11 10yr3/2 none sil 2fsbk mvfr cs 2fmc 0.6 0.8 2 11 -23 10yr4 /3 none sil 2fsbk mfr gs 2fmc 0.6 0.8 3 7.5 Y r4/6 none scl 2msbk mfr cw 2fm,1c 0.4 0.6 4 35 -50 7.5yr4/6 none gr Is 0 sg dl gw 1fm 0.7 1.2 5 50 -91 10yr5/4 none strat s 0 sg dl - if 0.5 1.0 L coftt&kW1/8"- 1/4" irregular, disconfinuous ba Oyr4/4 Is at 6" -12" intervals. Loading rate reduced to reflect reduced permiabil of horizon F-1 ass with banding. goring # J Boring _I Pit Ground Surface elev. ft. or Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz, Cont. Color Gr. Sz. Sh. *Efr#1 *Eff#b2 F-1 Boring # J Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Sol Applieatim 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. SBD -8330 (x.07/00) A.C.E. SON & Ste H81U8tlons • • EXis�i � �/-a�le ele./!� c-c /Q.'/ Sf <� d saynf � /SfPtn p /s�9si1.,51,V k 9 tiv sec- 23,T.of's�.Tos���(, Al o jo 7_ I 9y.o' 97 0'. canr:.ryeio✓c_d 4yseass oer: 6. oc;3P�s /Y conrrl c46ed. ESE • ° ` , Q✓L/� C/C[f O, o � � 97.9G' 1 � 1 1 33 ��, ✓e 9'9.io' ' t yy 1 1 , CXis�iYlq 1 � � 3 6 c droa.n Br: c k' ' W a!e D wa �8 '1 eSi 6. • Top o F CW-6 97 Q( . `. ")code 0 ,4 /06"-M? Ot I, hi � ✓iG S �" e /'"e 3 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/B�r 5f.c�0/i,% � -�ane /�LS-�ccn Mailing Address 1S/9�r1o•' 6a-y kl/ 6cmet5zt, Z,) /. SP Property Address 54.12 (Verification required from Planning & Zoning Department for new construction.) City /State 5oyr►ey zD/, Parcel Identification Number d 30 - 1057 - 30 leo �2 6/ 3 /U LEGAL DESCRIPTION C"104. /af S Property Location 'r& ; Hr, Sec. 23 , T 3 N R _W, Town of Subdivision C'.5M tV /7, / 4z9 , Lot # �. °�' # 3 5 �X �� i) Certified Survey lv p � ,Volume 1 ,Page # 5 Warranty Deed # - _ 0 1( 6 , Volume '23 I Page # e 3 Spec house s no Lot lines identifiable a X0 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 plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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. I/we 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. Nu of edrooms 3 SIGNATURE OF APPLICANT(S) 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) i 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 S -eole„ residence located at: Section 23 , Town 3o N, Range /_ W, Town of SZ . St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service 7 X407 Did flow back occur from absorption system? Yes r/ / No (if no, skip next line.) Approximate volume or length of time: gallons 3 minutes Capacity: p 1.2&V gd � Steel /°�'� ate - Construction: Prefab Concrete Other Manufacturer (if known): 14 �? f Tank (if known): Gc„k,, 9eE icensed Plumber Signature) (Print Name) (Title) (License Number) /MPRS (Da ) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) V.oL 2394 rVC 635 7 3 6 1 E 1Z STATE BAR OF WISCONSIN FORM 1 - 2000 KATHLEEN H. 41ALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX CO., WI This Deed, made between Roger Douclas Jordan and RECEIVED FOR RECORD Judith A. Jordan, husband and wife -- 08/29/2003 02:10PH Grantor, WARRANTY DEED and Stephen E. Holsteen and Jane B. Holsteen, husband EXEMPT 4 and wife as survivorship marital property REC FEE: TRANS FEE: 1650.00 Grantee. COPY FEE: Grantor, for a valuable consideration, conveys to Grantee the following CC FEE: described real estate in St. Croix County, State of PAGES: 1 Wisconsin (the "Property") (if more space is needed, please attach addendum): Lot 1 of Certified Survey Map recorded in Volume 17 on page 4585 as Document No. 735396 part of Lot 1 or Certified Survey Map recorded in Volume 3 on page Recording Area 861, and part of Government Lot 5 „ Section 23, Name and Return Address Township 30 North, Range 19 West, Town of St. Title One Premier Group, Inc. Joseph, TOGETHER with an access easement to North 706 19th Street South Bay Road. Hudson, Wisconsin 54016 part of 030 - 1057 -30 -000 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This is homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Roadways, Easements, and Restrictions of Record. Dme d this 28 day of August 2003 QVr< 1;6 — - *Ro er Do as J r *Ju 'th A. Jo Qlan AUTHENTICATIO iY P(/ STATE OF WISCONSIN AC KN O WLEDGMENT Signatures) 4 iy > ss. i St. Croix County. ) authenticated this day of Personally came before me this 28th day of August 2003 the above named Roger Douglas Jordan and Judith A. Jordan TITLE: MEMBER STATE BAR OF WISC ����� (If not, to me known to be the person s who executed authorized by §706.06, Wis. Slats.) the fore ins nt owledged the same. THIS INSTRUMENT WAS DRAFTED BY * Michael H. Forecki , Attorney No Public, State of Wisconsin Eau Claire, Wisconsin My Commission is permanent. (If not, state expiration date: Si attires ma be authenticated or acknowledged. Both are not necess December 12 00 *Names of persons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000 ttomey Michael H Forecki 1830 Brackett Ave, Eau Claire WI 54701 -4627 Phone: (715) 835 -3029 Fax: (715) 835 -4112 Title One Premier Group T6796499.ZFX koduxd wah ZI,Fo,,n- by RE F...Net, LLC 18025 Mew MM Road, Clinton Township, Michigan 48035,11W) 363.9805 i 7 3 5 3 9 6 VOL 17 PAGE 4585 KATHLEEN H. WXESR REGISTER OF DEEDS ST. CROIX CO. L NI !{ RECEIVED FOR ECORD Oa/13/2003 10:00AM N n m � CERTIFIED SURVEY MAP r n REC FEE: 13.00 m m - N co PAGESFEE2 3.00 Z my I C m m zm I A .+ O W l BEARINGS ARE REFERENCED TO THE D z NORTH UNE OF SECTION 23 AND IS I G ASSUMED TO BEAR N89 ° 5&WE cx P . c x 1 C) iOj�� m �� A ( w as�"� ml Z� N� I�iinW z ��\ I m ? cFa p (^' to �� n � N 'O V � D C3 m 1 m O /�\ T D Z 1 N \ �' V v D Q VI n a w '{ \` zz / — �➢ � w v w N I m� aC70 m 1 0o t W o 12 [t7 , O v 57< C ' n M j �..� • J mm m Z ( 1� m to < �- m \\ < < cn m Z O m m m I C9 Z 0 7--. y \�'• d w --•- a m `r z 0 m 1 co >< H G� 25 Z 503 °79'S6"W {�Tj` N m +o m ow 51.23 - T B' A cn • m w O 0 1 � v I+ — --pHWM 7p \�1y w '. \ co 0 ZO If ciO m g iN � - cn �Sl• I 00 i0 OOO�n .0 0) i c d 0 C N = Q '\\ m mm m �7 M O t" CA o X m A m �A a r� 2 ZO m O o m O 00 p < x u m + c" p �'-� m rn z o aC c0 m R I �_� z M, mo �o � Z I+ u I �z D m S� pC m gOZ m co$8'Q'OC cn Z T Z O -1 Z A cn cn - Z x m a o �o o me 0 0 D z?� < m r. D O wK o Z C� o �. M zmv�m v m =,z - fl Wm Fn a7 W a z m 0 0 0 --4 a c o, C g m m p7 �p p �Z Z 0 N O t/ m 0 m N o a W �v p O cn 0 a O a O DD � Z Z m SHEET 1 OF 2 SHEETS Vol. 17 Page 4585 I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ( of FILE INFORMATION SYSTEM SPECIFICATIONS Owner f /UL.S Septic Tank Capacity 26v ga l ❑ NA Permit # / Septic Tank Manufacturer G{/fn''_:) ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model Q ❑ NA Number of Public Facility Units /4 Pump Tank Capacity ga l ❑ A Estimated flow (average) gal /day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer NA Soil Application Rate - gal/day/ft' Pump Model ❑ NA Standard Influent /Effluent Quality Monthly avera Pretreatment Unit A Fats, Oil & Grease IF G) <_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand ( 0D <_220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 m [I Disinfecti ❑ Other: Pretreated Effluent Quality nthly average Disper Cell(s) Y1- � � w Biochemical Oxygen Demand (BOD <_30 mg /L - Ground Igravit ❑ In- Groun pressurized) Total Suspended Solids (TSS) <_30 mg /L 4 ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 0 0 1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater an is tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once ever 2 — onth(s) (Maximum 3 ears) ❑ NA p y' ear(s) y Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dis ersa II At least once ever �' ❑ nth(s) (Maximum 3 ears) 11 NA p p Y' ears) y K ean effluent filter At least once every: ear( 1(s) ❑ NA I ect pump, ntrols & alarm At least once every: ❑ monthls) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page 1 of y START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails apdcann 7be repaired the following Igeasures have been, or. must be taken, to provide a code compliant replace�A s t syst / d d tabl e replacement ea has been Iuated and may be utilized for the location of a replacement soil absorption tem. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. A � T Iv� aluat' a o ing ank e ai e fDR- A/6VJ 12U b '�I¢o t8 rr� Ca NST ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS i POWTS INSTALLER POWTS MAINTAINER Name Uyl�� S� Name Phone I �a �.� Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name sue(', L' l b(/ 20AJI Phone Phone — 7/S — 3W(v- g (O SD t 1 This document was drafted in compliance with chapter Comm 83.221211b►11►Idl &If1 and 83.541 1, 12► & (3), Wisconsin Administrative Code. O N O 00 R, d O 3 CD 0 'D f7 - 00 �• • 0 T CD ID CD rt 'S N ` Z O W C_ (n N O D) O N O N ° ° N ° UOi a W W O ICI • V Q 0 CD n N j Z C7 N ' 7 C O I N N c CD p CD Cp CT O V -4 (D Cv 0 co ? N 4 N N Q 0 O O O C CD , 0 O = (O ° W O K O r• y N O Cp N CO . O O p 0 0 Ul CT 0 O O G. O N CL G N N 0 G° a 7 CA N N W S CD 3 ° ° °� °�' O °D o �' V io O i v v 0 0 0 c N W W Cl) co ,!T Q lei 3 3 3 m __0 (n� � < z OIQ 0 E cnai cn� ?� CA ca N� g D m 3 3 CD " CD .. o o CA o (D � m � N 3 r CD N Q D o D co o O ° O a o' CD CD � • m Z7 . CA t�l CD CD N. O O N C CD CD CL W a N a CD a 3 3 to O N O in C :C v O. CL ? 7 0 � -{ N C Z W cn � fD CD W C W CD N 0 .O•. Cp J d CD O. C 7 Vl O_ CD m r _ C o CD CD o a o ° 0 0 o ? CD d o� N) a C 0. T � A n �C 3 = to N CD O• n. Z O 0 CD O O A N p_ 0-0 Cp CD N (n_ N N W qt) O 0 A O O 0 N C Oq N 69 0 0 O r O P CD CD o b O O L O CL ti Parcel #: 030 - 1057 -30 -100 02/24/2005 04:50 PM PAGE 7 OF 7 Alt. Parcel #: 23.30.19.20113-10 030 - TOWN OF SAINT JOSEPH Current I X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " = Current Owner " HOLSTEEN, STEPHEN E & JANE B STEPHEN E & JANE B HOLSTEEN 1495 N BAY RD SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 1495 N BAY RD SC 5432 SCH D OF SOMERSET SP 8040 BASS LAKE REHAB DIST SP 1700 WITC Legal Description: Acres: 4.210 Plat: 1765 -CSM 17 -4585 030/03 SEC 23 T30N R1 9W PT GL 5 LOT 1 OF CSM Block/Condo Bldg: LOT 01 3/861 (4.30AC) NKA CSM 17 -4585 LOT 1 (4.210AC) Tract(s): (Sec- Twn -Rng 401/4 1601/4) 23- 30N -19W Notes: Parcel History: Date Doc # Vol /Page Type 08/29/2003 738160 2394/635 WD 08/13/2003 735396 17/4585 CSM 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 5210 542,200 Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.210 286,700 246,700 533,400 NO Totals for 2004: General Property 4.210 286,700 246,700 533,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount 040 -OTHER ASSM'T SPECIAL ASSESSMENT 731.90 Special Assessments Special Charges Delinquent Charges Total 731.90 0.00 0.00 FOR �n . c S � f�.1 f t A gES O' C pNMBCC �- I C E R T I Fl ED SURVEY MAP ' RapistQr °E weds ~ GOVT LOT 5 SEC 23 T30 N R 19W f It?, W � } ~ UNPLATTED - S66 13' -23 'W S 89 41' -40" E NORTH LINE 73.62' IE S 89 0 - 41- 40 " E 748.69 SEC. 23 \ N.W. COR. 1 317.87' Pl p4, -ST SEC. 23 I" I.P. FD. 6 0 �+�, f Q 24 o - 0 2 ( N S38 -10 W / 1..AN LOT I � Zo L 1 3-10 1 14.1.1 2 2 p, 4.3 ACRES a ` o gg� Z O 0 3g 618.26' �` Ad I 2� -56 0 �� < S880- 13 -14'W o� 218 S 89 -41 -40 E \ b N89 41 =40 'W - -- - 174.61 = -- 0 - -- 106.30' / N 51°-55' -24 "E 511.96' �- ' 0' 67,25' A PRIVATE hi /� 4, /ItI 51°- 55 =24 "E , j S� EASE - <°' ' }, MENT `�// 1 � /,�' ` L 2 °' ti dry. 3.0 ACRES 30 / 6 i 6 — CO 0 _w 159 -5 S89 41' -40 "E 9n B A S S 0 556.62' 13.35' co 115'2- of to rn NO3°- 59' -07"E 93.20, ` 3 -INU of ` ®157° , .58 ! LOT 3 0� _L A - K - E OD to co f - X 1 1 3.0 ACRES o' 0157 0-151_ $p' S 89 41'- 4 0" E S Fio 498.55' u`• �� S63°- 03' -47,'E 120.81 66'PRIVATE r'� % � a , EASEMENT FROM C.T.H. i TO dF� F LOT 4 5 ° � CUL -DE -SAC S32 45' -09 "E 3.0 ACRES 109.44' 0;4 ' 3 PRIVATE \\\ �` l l S � >o0, 68 S 19 30' -50" E EASEMENT . 66 \�� �0 ; 50.38' SOv 65', 1 LEGEND `o- 88.52 N 89 41'- 40" W 505.74' \ �• 1 "X24 "IRON PIPE SET UN PLATTED LAND_ WT. L68 LBS. /LI N. FT. - 'q "�1R0 S SET FT. CURVE I- 2 DATA RADIUS -••=-- 80.0 � N CHORD - - - - -- 108.92' : GENE C. CHORD _ SHAFFER BEARING -- - N18 ° - 44` -55 "VV to S -1325 Q ASSUMED BEARINGS CENTRAL 5 !'HUDSON V ALONG THE NORTH ANGLE---- 85°- 48' -'29" sm LINE OF SEC.. 23 I �► (S89 -41 - 40 E) V .1 20d 150' 100' 50' 0 15 0' APPROVAL NOR SUBDIVIS DOES NOT MEAN APPROVAL FO THIS INSTRUMENT WAS SCALE IN FEET BUILDING SITE OR SEPTIC SYSTE DRAFTED BY GCS M. REFER TO H62.20. dOL . 3 Ptl u;: � 61 �►+. JOB N o. TB -49 SHEET I 0 F 2 CLH'I'IFIr;U .�Uit'J;;Y 1`9IIP;i 5T. CHOIR cuuafY, wI. 0 ST. CR I X COUNTY WI SC O N S I N 2, '+ "' ZONING OFFICE 796 -2239 (HAMMOND) 425 -8363 (RIVER FALLS) HAMMOND, W1 54015 June 13, 1983 Mr. Dennis Christopherson 1116 Laurel Avenue Hudson, Wl 54016 Dear Dennis, I am returning these 115's on Doug Jordan and Sam Miller to you for more information. I need the distance to any adjoining lot line or corner that would better define the position within the lot. Please supply this information and return the 115's to the Zoning Office. Should you have any questions on this, please feel free to contact me. Thomas C. Nelson Assistant Zoning Administrator TCN:inj DEPARTMENT OF REPORT ON SOIL BO ND � �'" ems,r, Y &aDI V° ON P.O. BOX 796 *80 ,R.ISt+Y, p /� R AND PERCOLATION T MADISON W 53709 HUMAN RELATIONS � (H63.0911) & Chart ? .045 � �� �� -_ — �1 ON NAME: LOCATION BL SU �CCTION fOWNSIiIP( >� 'OW 2 - 1T3 1R1% §(-L c N COUNTY OWNI'R'S)BUYER S NAME: / MAILIN D S: f� 0 C - T Orcl 1 c f / sL` p D_ SER q . QNS MADE \ USE _ _ ' J -I E% ION TESTS: NO. BEUIIMS.: COMMERCIAL. DESCRIPTION: - + _- DES New �Ruptt f• ���_ rj _3/ �^ RATING: S - Site suitable for system U= Site unsuitable for system �� 3 fT la l e CONVENTIONAL: MOUNp: IN- GROUNDPRE:SIJRE: SYSTEM -1 -1l -Lii I -DING TANk: flL =COMMENDED SYS - f EM:(optiunat) RK s 0u-1_e s E u ®s EJU _ ns xu l cis Nu t_C9.y��� ?,�.�� X-�-t If Perwlation rusts we NOI' rEl wired I DESIGN RATE If an 1 y poi uuii UI the tested "urea is in the under s.H63 09(b)(b) indicdte. Floo 1plain, u,dicatc Floodplain elevation: PROFI E DESCRIPTIONS BORING TOfAI• ) I' II TO GHOUNOWATIfi J+J+,4.66 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEI'1I-144; ELEVATION OBSERVED ES.HIG TO BLDH IF OBSERVED (SEE ABBRV. ON BACK.) / 0%9 1 e— � 7. S' • S� ! i , l z dh l , !o Bn 3 /� 6 6.1 / s r r f3 s Q t� �' �( (U c[ �-. -- > ��� ' • S _i✓ • 7 9 i ! - &, 3 11 7' B Y t �, 1 y,cl (Z 7 ' r �- l • 3 (�y/ �� , f�n �S Y ! �n s PERCOLATION TESTS TEST DFF - 11 1 WATER IN HOLE TEST TIME DROP IN WA TER I EVFL- INCHES RATE MINUTES NUMBER IINCtit AFTEIi SWELL ING INTERV -M IN. Pe loo pEr pEi�lO`D PER INCH P P- AID P P- - - — PLOT PLAN: Show locations of percolation casts, soil borinbS and the dimensions of Suitable Soil areas. Indicate Scale Ur distances. Describe what are the hori /ontal and vertical elevation reference points and shuw their location on the plot plan. Show the Sulfate elevation at all bminrjs and the direction and percent „f land slope. SYSTEM ELEVATION _ 9 L O e lows Kow-) t 1, the understyned, hereby certify that the Soil tests reported on t lonti were made by like in accord with the procudwas wid methods specified in the Wisconsin Administrative Code, and tt)at the data recorded and the location of the tests are cUrreet to the boss of my knowledge and belief. ' NAME (print) /) O // TE - , - fS WERE CU - EYED ON. l t, ADDRESS / CE H I IFICAT ION NUMBEH: PHONE NUMBER(uptrunal): /t'� / "(�P, CST,'kGN TUBE: DISTRIBUTION: Origtrial aild one copy to Local Authority, Property Owner and Soil I est:a. DILHR SBD -639b (R. 02/82) - OVER - ! County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN �V In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1 1101 Carmichael Road Ato Foo Vp Hudson, WI 54016 -7710 (715)386 -4680 Fax(715)386 -4686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit # ❑ Check if revision to previous application b 22-- 1. Application Information - Please Print all Information // Location: Property Owner Name �C 114 114, Sec .73 v I j Q ~ 1� f 6 N, R , `3 E (or) %T Property Owner's ailing Address p : Loo• ber Block Number I City, State Zip Code Phone Nurier_ ST GFOiX u �' on ame or CSM Number II Type of Building: (check one) "Village Town of 1 or 2 Family Dwelling - No. of Bedrooms: 4� r ❑ Public/Commercial (describe use): ❑ State -owned Nearest Road II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tai umbers) A) 1.❑ Repair 2. ❑ Reconnection 3. ❑Non- plumbing 4).CMejuvenation 0 Sanitation � _ , fi' —��S _ 7 –36 –�� Permit Number Date Issued B) a3, - • ❑ State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) W Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade Cl Aerobic Treatment Unit ❑ Recirculating . ❑ Other V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System levation 7. Final Grade Required Proposed (Gals. /day /sq.ft.) (Min.(nch) j� Q -9N' Elevation c O 9 &101V VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks Oa t! 1 J Una .. ❑ ❑ 11 11 VII. Responsibility Statement I, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationfinstallation of non - plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non - plumbing sanitation system. Plumber's Name (print) Plu er' i lure (no stamps): MP /MPRS No. Business Phone Number plumbeAddre ss S eet, City, State, Zip ode) / & n _ ,' e Only Disapproved Sanitary Permit Fee Date Issued Issu' g Agent Signature (No stamps) d Owner Given Initial Adverse LTO Determination A of Approval /Reasons for Disappro val: A A j n • Wis(.,jnsin Department of Commerce SOLL,;EVALUATION REPORT Page of Division of Safety and Buildings j :' in accordance,wit 61r) 8 1- f'Adm. Code County Attach complete site plan on paper not less than 8 1/4?g1' inche% size. Plan must include, but not limited to: vertical and horizontal refe'en i point (BM), Ow"tiort *� Parcel I.D. percent slope, scale or dimensions, north arrow, and Qcatjon an igtart a `te o nearest road. d. © — a _ C)— 60 Please print all in for '`' I `'W��ry Reviewed by Date . � Personal information you provide may be used for secondary p rp (PfIV 15.04(l 1 ) (m)),` Property _„CO rty Owner -e- Dr �v / perty, Lpdation �Yb U �^ J V (G� t-ot 5 1/4 1/4 Sa3 T 3b N R E (o W T ` Property Own es Mailing Addr ss Lot # Block # Subd. Name or CSM# I a.• City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road �b �r Ljl: 5` o (°715) V 7- 5%6 TC'S'C' o ❑ New Construction Use: Residential / Number of bedrooms J Code derived design flow rate S D GPD ❑ Replacement ❑ Public or commercial - Describe: t�vu�nq,�;e, Parent material 1pe SS by `!tip` O utt- 'S1. -. Flood Plain elevation if applicable ft. General comments $�rG��O`�db� fi0v` POSS• ?1 uVP.va '} a y1 c4>r pr'e•Seh4SySi+2►tt and recommendations: "" -� �. A qS •X07 F$'F. rv+ c�"� G 4 v-. 1 g x .3` e,� Se +Ne- �t 4ii i~ k.. 14 + V �., , �.- A. U 42 - 6 D S - s tGw, c b o ,.3 - t - 1 �S' y �a c� s ©� dt Boring F 1 Boring # q S E] pit Ground surface elev. O0 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 Q D - 7 6 '� ...-- r a0-^$ - 7 , 5 1 i Boring # ❑ Boring ❑ 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 /ft 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 T Name (Please Print) Signatur CST Number I/-- SIZ&7 aa1 y Addr ss CI O Y8 1, ti -L' Date Evaluation Conducted Telephone Number �7 _ CIS- �Y8 -3scS8 SBD -8330 (R07 /00) I Property Owner Parcel ID # Page of F-1 Boring # E] Boring ❑ 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # ❑ Boring ❑ 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # ❑ Boring Ground surface elev. ft. Depth to limiting factor in. El Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz 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 I 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 -8330 (R.07 /00) T3ow R19t O rY) l ! y i PAI a,v, c. a l i i ST CROIX COUNTY SEPTIC TANK MAIN'T'ENANCE AGRBEMENT AND pwNERSHM CERTIFICATION FORM Dwner/Buyer o" v soft Mailing Address property Address J (Verification required from Planning Department for new construction) City/State So h2rS.tl' (/V\ Parcel Identification Number � 1 0� '� LEGAL DESCRIPTION 1 N- Rift-W, Town of S E J 4016 Property Location /4, /•, Sec. I- T 3 Lot # Subdivision Certified Survey Map # 35q S7' , Volume 3 _ ___, . Page # Warranty Deed # 364 --� ZS , Volume X6 6 . Page # a Spec house ❑yes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance o t f your septic system could result in its premature failure to handle wastes. onto hem consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. you Pu 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 masterplumber, journeymanplumber, restricted plumber 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. rds I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system rca with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin 30 stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning days of the three year expiration date. / D DATE F APPLICANT OWNER CERTIFICATION I (we) certify that a ll statements on this form are true to the best of my (our) lmowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds office. S% 01 DATE SI A APPLICANT * * * * ** Any information that is mis- representedmay result is the sanitary permit being revoked by the Zoning Depar- ** Include with this applieation: a stamped warranty deed from the Register of Dads office a copy of the certified survey map if reference is made in the warranty deed VOL j'.� /'QoASE X 24 vs KATHLEEN H. WALSH DocumontNumber Documentmde REGISTER OF DEEDS � ST. CROIX CO., WI L/S'1tY1 -) RC \ v vthG'f"l'0�'1 RECEIVED FOR RECORD J 06-29 -2001 8:00 AN ZONING AFFIDAVIT EXEIWT t CERT COPY FEE: COPY FEE: 3.00 TRANSFER FEE: RECORDING FEE: 12.00' PAGES: 2 Recording Ama Name and Retnrn Address 1?og To rC(CA.V\ Iq 9 S N. i3ay Pood Sorn.e �5 2fi W � . 03o - io< -3o - onn o Pared Idea iSeman Number (PM ?° mwr { r., r! IN F ST CAOX COUNTY i "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT PMOVE" i Thu information MwIft completed by wbmittec: documeu tide. name & renmt address. asd f/N rrf r gdred). Odrer/t wmadon suck as she tnosinl do—, k8d *steps -. ese. gray be plated on thisibw pas, of she doesi mat or maybe placed an addtdonal pages of &e docu mart Note. Use of skis —vrme adds am pate to your document and 52.00 to the neonffnr fee. Wireauin Sraaaes. S9.517 WRDA 2196 Vol 1676PAGF 62' ST. -CROIX COUNTY - WISCONSIN ZONING OFFICE r r «r r ■ less. ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 AFFIDAVIT OF SYSTEM REJUVENATION Property Owner: 1, UJ N J Address: Daytime phone: ( ) Z q 7 - ' ?f O Parcel I. D. # t - -�� a �3b J0 0000 Legal Description of property: P (- A O y' Lo �i 5 �L t A� „ Sec.��, T. N. R L 0+ - I © CS M . A. , Tn. of t , ic Vo l, 3 P 9101 - � St. Croix County, AI As owner of the above described property, I acknowledge that the septic system serving this residence (is /is not) 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: Date: V— Q b LORI A. ROTH NOTARY PUBLIC - MINNESOTA Q My Comm. Expires Jan. 31, 2005 ' 71 5/97 T a'�'0f ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to cprtify that I have inspected the septic tank presently serving the f{ �pr h residence located at: M, %, Sec. T _30 _ N, R W, Town of , 5r. J a0 SR 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 111) /o a Did flow back occur from absorption system? Yes No (if no, skip next line. Approximate volume or length of time: 5Q�2 gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer if known): Age of Tank (if known) : lgna ) (Name) Pldafse Print z�s� -� s,� �n kU%S C J (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) . Name -� _ Signature atlx MP /MPRS 00CUMENT NO. STATE BAR OF WISCONSIN FORM 1--190 THIS fr;rf RlfSRVfG IIO# RtCORO1N0 DATA WARRANTY DEED VOL 66'5 PA-, %12 ?3 QFFIQ I This Deed made between JEROME A.. AN DER SON and ,(, � «. IIYLLIS .I_ ANDERSON. huabaad and wife as jnf,nt tenants WI& r.! th11 26th Granto.•, May rt T9 nd ROGER DOUGLAS JORDAN and J _.,- - WITH A. . 8:30 A rt Iusband and wife as Joint tenants Grantee, IMfb • N WitneSseth, That the said Grantor, for a valuable ceiasideration One Dollar ($1.00) and other good and valuable.considexatian naE; a to Crantee the following described real estate in St. Croix- - R °TURN To (' „t artt ' i • }...fate of Wisconsin: Part of Government Lot "5” of Section 23 -30 -19 described as follows: Lot 1 of the Certified Survey Map filed and recorded in the Office of the Register of Deeds Tax Parcel No for St. Croix County, Wisconsin, on September 6, 1979, in Volume "3 ", page 861, Document 11359518, together with an easement to use the private roadway as shown on said Certified Survey .lap as an access road and for the installation of utility lines. Grantees agree that they will be responsible for road maintenance ,es set forth in a private roadway maintenance agreement dated February 25, 1980 and r1 corded _corded February 29, 1980 in Volume 509 page 63 as Document No. 363035 which a governs all. of the reement e lot s set out ' in the Certified Survey Map referred to above and the costs of maintenance shall be pro rated between all of the lot owners on the basis of the number of lots which have been sold. 1 , 0 .01D �..i Thi% is u o.t ..... homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And JEROW A. ANDERSON and PHYLLIS J. ANDERSON %:uvants that the title is good, indefeasible in fee simple and free and clear of encumbra:i(es except easements and zoning ordinances and building restrictions of record, if any. ..11d will war_ant and defend - he same. f fal- u tills day o May 19 8 3 (SEAL) Jerome A. Anderson. L `� �- (SEAL( Phyllis J. derson AUTHENTIC kTION ACKNOWLEDGMENT Sig�ature(s,) ''Jerome Anderson - - and. - STATE OF WISCONSIN P.hyl_l _I,. " An dersoq .. } - - - -- 3. _County. authepticate this .. -. � _ ......, _ . f of .- - . , 19. 83 Personally came before me this .... day of _._ .. .:_.. -.._. _ _ ...._ - -- __ _ _ .._.. ....., 19........ the above named •_.. Douglas,. Zilz -- - T1TLE: -Nf _IBE STATE BAR OF WkC ONSIN _. (if no . - - - - -- - - -- authorized b y s 70iSA6. Wis. Stats.) to me known to he the person q--• -'1 A-VU Incsn rim -M I CURVE r- Z DATA W WT. 1. 68 Les. / LI N. FT. - V RADIUS ------ 80.0' CHORD - - - - -- 108.92' N CHORR s SHAffM BEARING - - -N 18 ° - 44`- 55" W SS CENTRAL ASSUMED BEARINGS ANGLE---- 85 ° - 48' -'29 ALONG THE NORTH LINE OF SEC- 23 �*4k (S89R- 4i' -40 "E) >O swuR tad l 5d lod 5d 0 15 APPROVAL SUBDIVISWON DOES NOT MEAN APPROVAL FG# THIS INSTRUMENT WAS SCALE IN FEET SUAMNG SITE OR SEPTIC SYSTEM. DRAFTED BY GCS REFER TO H62.20. JOB NO.78 -49 VOL. 3 PA_ir���? SHEET I OF 2 CERTIFIED SURVEY MAPS ST. CROIX COUNTY, WI. ` 1 r , r r AS BUILT SANITARY SYSTEM REPORT OWNER Al � TOWNSHIP SEC. T_N -R W ADDRESS ST. CROIX COUNTY, WISCONSIN. SUBDIVISION 7 -061 . LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements,of H6.3 RING WITHIN 100 FEET OF SYSTEM . 1 7x A 1 rllk 11 � r • v Idiae No thAro SC L = O J , BENCHMARK: (Permanent reference Point) Describe:d 5r,+kF Elevation of vertical reference point: Zoo Slope at site: / SEPTIC TANK: Manufacturer: ( L-S` �— Liquid Capacity: Number of rings on cover : ���— Tank manhole cover elevation: Ile •�T' Tank Inlet Elevation: Tank Outlet Elevation: /os1, z P BER Manufac. er: Number of gallons Number of g ump set for a cycle gallons; total ca y--o distribution lines gallon: size of pump head; gallon per minute horsepower brand name of pump and model number Type of warning device HOLDING TANK: Manufac r of gallons • Elevation of ole cover Ty e o ruing device' SEE IT SIZE: - Number of pits eet iamete _ feet liquid depth seepage pit in e�pipe- elevation bottom of seepage pit E e� vation feet. SEEPAGE BED SIZE: number of lines th length L,tile depth SEEPAGE TRENCH: width length PERCOLATION RATE A REQUIRED G/ REA BU LT INSPECTOR DATED - , r / - PLUMBER ON J.OB LICENSE NUMBER 3,20S— DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 1 BUREAU OF PLUMBING MADISON, WI 53707 EJCONVENTIONAL El ALTERNATIVE State Plan I.D. Number: (If assigned) ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER iINSPECTION DATE: Doug Jordan R #2, Box 315C, Somerset, WI Nayg3 �•� BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. NE NW, Section 23, Lot 1, T30N —R19W, Town of St. Joseph Name of Plumber: MP /MPRSW No Count Sanitary PjrgttSy Tr: Don Schmitt 3205 S Croix 1111 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLE ELEV.: TANK OUTLET E�EV.: WARNING LABEL I L OC OVER PRO IDED: PR QrL I Z b �`� ❑NO YES 1:1 NO BEDDING: VENT DIA.: VENT MAT .: HIGH WATER NUM ROAD: PROPERTY WELL: �r BUIL ING: VENT TO FR ALARM. LINELO •/ ' IAIR INL ❑YES ONO FEET FROM U v (` ❑YES O NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO ❑YES ❑NO ❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL. BUILDING: JVENTTO LE FRESH (DIFFERENCE BETWEEN FEET FROM a "E' AIR I "LET: PUMP ON AND OFF) DYES 0 N NEAREST' SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH. DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH I N - 0 - 0 — F DISTR. PIPE SPACING. COVER J INSIDE DIA.. TS. LIQUID TRENCHES DEPTH TRENCHES AL: — . I �7 9� GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE 1DISTR. PIPE MATERIAL: NO D NUMBER O PROPERTY BUILDING: VENT TO FRESH BELOW C7 ABOVE 0,5R W C-4 ELEV. INLET ELEV. END PIP FEET FROM LIN \( 7�_ I NEAREST' MOUND SYSTEM: Mound site plowed perpendicular to slope f f he f" material or PROVIDE Check the texture o t III ma ROVID ADIAGRAMOFSYSTEM and furrows thrown upslope: mound systems to make ce tain that it ON REVERSE SIDE. SHOW ELEVA- OYES El NO m meets the criteria for me rid. TIONS MEASURED. SOIL COVER TEXTURE ERMANENT MAR OBSERVATION WELLS // ❑Y S ONO DYES ONO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. rDDED J EEDED. MULCHED: CENTER. EDGES: � _,. YES / (NO ❑YES ONO I OYEs ONO PRESSURIZED DISTRIBUTION SYSTEM: f �_ WIDTH: LENGTH. NO. OF LATERAL SPA NG: RAVEL EPTH 7OWPIP1 FILL DEPTH ABOVE COVER: TRENCHES: P�MEISkN'S. °, f. MANIFOLD PUMP MANIFOLD DISTR. PIPE ANI FO LD TER L F STR. DISTR. P E DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.. ELEV.: P IP DIA.: �N ANp ��ON '' HOLE SIZE HOLE SPACING. DRILLED CORRECTLY CO ER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED =t[ obj MAT.ION PLANS I'' . DYES NO 1:1 YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: DYES 1:1 NO DYES El NO NEAREST S� N l �ilb•�� o 23 / s:s � .S3 Sketch System on R ta' in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710 (R. 01/82) 1 1 wlsgonsln APPLICATION FOR SANITARY PERMIT DILHR (PLB 67) I COUNTY UNIFORM SANITARY PERMIT,# inC)USTRV, LRBOR 6 NUTRrI RELRTlOrlS — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /zx 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS R i Box 316 5 G1 - / S' •' ZS u PROPERTY LOCATION CITY: VILLAGE: E1 /4 MIA /4, S 13 , T. N, R _ E (or) TOWN OF: LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER U L TYPE OF BUILDING OR USE SERVED X 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): THIS PERMIT IS FOR A: [C New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. X Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity ' Lift Pump Tank /Siphon Chamber -- Holding Tank capacity _ -- Manufacturer: — 6/C • 5" IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Steel Fib lastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Ch urer. PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 6/ G 1 f1? , X Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MPRSW No Phone Number: Do � o � ( 7151 Plumber's Address: Name of Designer: ll l QO 5 d �% = S �. I d J%'t COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Lbe. Date: Disapproved W M (7 ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: D I LH R - SB D (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. Form - S T C 100 Owner of Property �--� Location of Property ' Section `� ,T YO N R �� W Townghip Mailing Address ':;:Zp e) rn-�)- Subdivision Name � o� (� (J ✓)z l'('J �'l,ti,n/J Lot Number 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 .Other I:egal Document which describes the property 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 recordedin the Office of the County Register of Deeds as Document No. �3S 15 ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recordgd in the Office of the my Register of Deeds, as Document No. s ). SIGNAT OIOWNE SIGNATURE OF CO -OWNER (IF APPLICABLE) 7/ DATE SIGNED DATE SIGNED r I. _. e DOCUMENT N o. STATE BAR OF WISCONSIN FORM __ _ _ 1 -1982 �� THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED VOL •.6 65 'Pat[ 273 W- 05TIOS OFFICk This Deed made between .... . A,.- ANDERSON. and__.__._.__,* Co., wid, P.HYLLIS_.,f, . ANDERSQH, -- huab?id._and-- yJife- as..aoint- _tenants._ - i,,� fhllt 26th f 1 . and --- RAGU -MUJ2 AS_.JORDAX and. JU])1TJ1..A- JORDAN, -- •.....•Grantor, c! ° � May „�A�.�. � Si ........................................ '. 8:30 A .husband..and..wife._as__ joint_. tenants ........ ...... "_._..___._____.. " " -... -- ------------------------------------------------------- - - - - -- ----- - - - - -- ----- ---- "•--•--- •---- -- -- ---- - - - -•- •- - - - - - -• Grantee, K of s Witnesseth That the said Grantor, for a valuable consideration____ -. .One. -Dollar.. 4$1_00)... and_. other__ good. _and..valuab le_ cons iderat - -- conveys to Grantee the following described real estate in -- St_._.Croix............ RETURN TO County, State of Wisconsin: Part of Government Lot "5" of Section 23 -30 -19 described as follows: Lot 1 of the Certified Survey Map filed Tax Parcel No- --- ----------- ----- . - - -__. and recorded in the Office of the Register of Deeds .- for St. Croix County, Wisconsin, on September 6, 1979, in Volume "3", page 861, Document 4359578, together with an easement to use the private roadway as shown on said Certified Survey Map as an access road and for the installation of utility lines. Grantees agree that they will be responsible for road maintenance as set forth in a private roadway maintenance agreement dated February 25, 1980 and recorded February 29, 1980 in Volume "609 ", page 63,as Document No. 363035, which agreement governs all of the lots set out in the Certified Survey Map referred to above and the costs of maintenance shall be pro rated between all of the lot owners on the basis of the number of lots which hai.a been sold. I T 1,.t' ! is a ,. 10.0 T *- s,q, d : J: ,LJI This ------- ia.zi.ot.. homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And....,IF.RQMF�_. .... `II?FrR,$ON_-�nd__PHYLLI ... J_.__ANDERSON--- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements and zoning ordinances and building restrictions of record, if any. and will warrant and defend the same. Dated this ..................... day of May-............. --•• ..... .............. .... •---- ......., 19. .. -- •- ••---- •--- •--- ••--- ....- - -- • ..................(SEAL) ...._.. * --•---•-----•-------•-••--••--••------------------- -•--- ••-- • -• - -- * Jerome A. Anderson --------------------------------------- ------- --- --•--- ---- -- -- - - - - -- (SEAL) - - --- - - -_ - -- SEAL) * ..............................."---- •-- •- •- ••---- •-- •- •---- •• - - -• Fhy1- "i.s...I.. dex -s.oi? AUTHENTICATION ACKNOWLEDGMENT Signatures AndetsQn . ............. STATE OF WISCONSIN . ..... E1_n_. ..... . ... . ..... ss. h _ County. authe ticate this of ... .............. 19 -. Personally came before me this ................ of ......... . .......... ...................... 0 19........ the above rained * ...... Doug as - __ - . Zilz ------------- •---- •----- •--- •--------- • - - - -- ................................... .._ ------------ - - - - -- -•--------------- -• - - -- TITLE: M IBE STATE BAR OF W SCONSIN ... .. ......""""".""" - " " " ". " .................. .....' -•--------•-------•--------------•---......------- ---- .........._...._.......... authorized by § 706.06, Wis. Stats.) ..........•...... " " "' to me known to be the person ............ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY -DOUGLAS .. R... ZILZ,.-. Attaxney -_.at..Law ........ ....... ............................ •.......................................... t . u son,...Wiscs�nsin_ .54016 - - -- - " No - . a tary - • - P - ........................................................ ublic ... - • ---------- - -- - - -------------------- County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: ............... ....................................... , 19.........) *Names of persons signing in any capacity should be typed or printed below their signatures. H.CMillerComp"M STATE BAR OF WISCONSIN Stock NO. �$0�� '" ° »• ......•.. ti�IIl FORM No. 1-1982 FORM N0. 985-A ^ cY CERTI F1 ED SURVEY MAP GOVT LOT 5 SEC 2S T30 N R 19W UNPLATTE_D _ LAND_ Si6°- 13'- 23'11U r 73- 6,2' S89 °- 41' -40"E S89o- 41' -40 ° E 748.69' NORTH LINE. r SEC. 23 N.W. COR. .... .� SEC -23 1317.87' Qio 0 24 "LP. FD. 0�6 S38 NY 1ANp L O T 114.12 4.3 ACRES 0 Ile 618.26' S 89 ° - 41 -40" E • I ,ti ? S88 ° -13 I4 "W `�� N89 41 =40 "W -- 106.30' i 51 65' -24 „ E '311.96' ? \�1 J) 1 A;:Yi'E �” � ,`ec 51 55 =24 "E �''T•.� J� o 0' EASE 'W, : 4, 33.62' cam` �' � to MENT . rb�' y� F LOT 2 9 e °„' ti� �N. 3.0 ACIttS I ' /- , 1 -oo 41 — co ?.w 159P- 26' -56 to \ S89 41' -40 "E 4ii B A S S 40 h «� , o , 55 6.62' 13.35' all 93.2d ti { ..� f LAKE C { LOT 3 0 - - G 3.0 ACRES o f � 015 r j' co SO S 89 41' -40" E � spa ?e 98.55 120.81' �,� Vii o• EASEMENT FROM C.T.H. I TO O* CUL -OE -SAC �B. x d LOT 4 5 S32' „ 3.0 ACRES 4 109 44 I t; , �Q� ��fO ' • �.�,.. PRIVATE 1 10 0 68 � S19 1 k30' -50 "E EASEMENT ,�.� 6 - \^�� - � 0 : 50,38' `O. �'' 65's 1 LE G E N 88.52 N 89 ° - 41 40" W 505.74' t , s ysrFrr cL 8q i I I o ss �U6 A BIB 1 I �L. • /� /� / � ` ��S�E ,hnp7� ,//6 «art) � � � s i &Our# L, /dn 1 , 1 i v e p TY � y I i 7 11 7 11 . 15 y " I � I 1 � p 0 (�l G- , cTOR �Ort - �t/ � � � � i ✓;O�V �G,r� /'x / T T . 1 1 , _ . T i i .. � a t • l I t :. _.. i i.. .. _ .. � � __.. . � � � ��. I _ - _ � _ �I 1 ; _ � � � �� I �I i _.. _ � i r �'� i 4 - � _. .. _ _ I _ 1 �, % �, _{ �, � � 1 � � � �� ,� j� � � �' � � _ _.. � �, � l __ � .. _ � _ � i, j '. i I , � � � � � I � �, . .. _ i .. � � � � � .� � i � _ - � - � - � 1 - � _. _ I � � �'; �, � � � � _ . i _ � - � � � �� i t i '� � f t I ,_ i i _ _ ._ ' � , 1 o -. , . - c a i � i �. 1 - p DL4113 MEN 6F REPORT ON SOIL BO ND xR 8/ TY & B DI IN VISION DI,�`r`RY, � 1, ,LABOR AND PERCOLATION T � P.O. BOX 7969 HUMAN RELATIONS r / 1CIADISON, WI 53707 (H63.09(1) & Chapt 04 LOCATION SECTION: TOWNSHIP/ BL I S U N NA E: ,/ vL 3 /T3�N /R�l�(or S71� ose j ' ..9 Go COUNTY: OWN BUYER'S NAME: / MAI LI NAG s/� C/1�i K�OG� �i �OrQ ,t/ �a i~ ✓��O F c ` s; USE D E NS MADE =' \ NO. BEDRMS.: COMMERCIAL DESCRIPTION: DES . -.74 E1 I N TESTS: .Residence / KNew ❑Rep / yitsq a RATING: S= Site suitable for system U= Site unsuitable for system PQ. .3 q CONVENTIONAL: MOUND: IN- GROUND PRESSURE :SYSTEM -1 ILLH LDINGTANK :RECOMMENDEDSYSTEM:(optional) / ®S ❑ U ©S ❑ U ®S ❑ U ❑ S ®U ❑ S ®U CO.U!/r,�c -7`> O.�tR PQ d If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: I Floodplain, indi Fl elevation: PROFI E DESCRIPTIONS BORING TOTAL• DEPTH TO GROUNDWATER4NG44.ES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH.�PI ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B / Z /o J.`1' it/o,ue— 7 7. S' . S 8l I 1. • !o Btis I •68n lS r X19 9A - B- ,t lcui 7 1 2 , s' . SB I / l 7 gh 1 - 78A 1.5. B S B- 3 �' //D • '1 ` �lo�c 2 7 '1 �' ..�B // .2. o 9,,, S l . 9 d /S . / S 7. s' e�/ l•3 Bh I . �g,► is s B - �s' /a•a' oxe ?s' .s8i /a.o l .3 8 ,h sl.169 s .3 da s B- PERCOLATION TESTS TEST DEPTH' WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER me ' E9 AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIIOD2 PERIOD 3 PER INCH P_ .7•o a 6 W ----3 P- 2 /-5" o ,< d2 .2 a- 3 P- A10 P_ P 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. SYSTEM ELEVATION /46 1 e 6 eAd 4 I 777 1 i �8 A f�sccc. � vo.'o" IWO I a' r�� An E __ _ " I ��S F .! �. � /•l - w ; - 4 - C Ski. f i , _ 610 s ,cgs ,(Cs .d i ' 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WER COMPLETED ON: n S ��i`S2.i/ ICS - t DDRESS: ' � � CERTIFICATION NUMBER: PHONE NUMBER (optional): / 16 c-.-e v'e. � U'��'s S_ v/ / 3dJ' - CST T RE: � ' c IBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. SBD -6395 (R. 02/82) — OVER — 1 INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 63945 Tp ba a cornpletra and accurate soil test, your refsost rnUst•inclurde; r 1. Complete legal description; 2. Wuse section must dearly indicate whether -ihis is a residence or cornnaercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 11. Is this a new or replacement systern; 5. Complete the sintarrili rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SY e EN ARE RULED OUT BASED ON SOIL CONDITIONS; (3. PLEASE use al)€neviations shown We OrvrvKing profile descriptions and completirig the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to We is preferred. A separate sheet cnay be,,krseel if desired; T MAn sweprur berrchrnark and veetic;A Mention telerence point are cloarly shown, and are perrnanerit; 9. Complete an ap1wopriate boxes as ter dates, names, addresses, floorl plain data, percolation test exemp- thib if appropt hae 11 If Ow ,; i nnakni Nu ch as dood pl&n, r =levwion) dons not apply, placz N,A. in the atol i rwiate box; 11 Sign the form and pl r e your current address and your certificathn €wnrlrer; 11 Mae iEacl"e coil m awl distribute as retired. ALL SOIL TESTS MUST BE FILED M ITH THE LOCAL �AUTF#ORITY WITHIN 30 DRYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil SeparaW and Textures, <Other Symbols _ (over 70" ) HR -- B w h o cf; co i.7 - -... Cc, 1)1);e (3- 10 ") SS -_.. sandstarle eIr travel 4un(rer a, "} LS — Li :a mi ��s - sF.,aat HGW — HigIi G ii alai us — & `w rtta po c: — N" tw rate I;, Flo ,` Md F l ic; _ E ie 0� Lawny L„i;d iJZ ..attar r }i, E 1 e � ro i .. Sanely Lo� itn _ L em hat, l Bn R on A! -- £ k Cky r_.at,.t7? y __ fi r'" r ;r.. :;i - - SarwN (D Learn R __ tiNf. . CA s, -- S ra7?�? .Ji N/ .. all " cc -_ € "'se Coy ii: __ tC'n' EiE riCit C; Gay + ►'� ( `.. "a l rf 9_�t'1 sil tit T1'I' I ` : ^? 1-1VVL Six genviral so?l .exnim ciHnn for sp d wane dupdal RM — Chi nai VRP (. Ver ;c } i .,r , r {<nct; P£tin,t i TO THE OWNER: � is sod mot rr wri is [me MY swp in st' utiny d sanitary purr it. The county m the, Department may request ... icm o . -,jf 0s MAI tal in we to! P ifli 10 Ctfrrllit &hwwe. A t om; k �f it set c, }'liars f or the privatr't e S"/ S, io t;; a puny N ,.,Iwal -kno mini he .t °N"Mtted to the f, r ,., �r- local autholity in ordur to bl air at ,[:ii al ho ar tta = rim ftmq b eW ,'=_dell wai ja nta! p0w rJ Me can of any r e,intnmtkni. O / ST ti9