HomeMy WebLinkAbout030-2094-20-000 ozo a O TCt— W - oov z 9, 3a i 4, 78s
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' ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner Y1 4 0 A6 M C
Property Add ess y
City /State o d
Legal Description: I
Lot � t Block Subdivision/CSM # / 1d n J
%a ' / a, Sec. , TAN -RI�W, Town f Si p i PIN # 03� - 2o9`f - Zd - en
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer � f � S7Siz ST , d 16'56' Setback from House v�� Well �d P /L
Pump manufacturer Model CGS
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
i
Type of system:( Width Length Number of Trenches
Setback from: House -�;50 ' Well `5'0' P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark � el 0 ✓? ��' Elevation
Description of alternate benchmark *0 7o �2 Fe tu e y 41 Elevation 9 l
Building Sewer l ST/HT Inlet l ST Outlet PC Inlet
PC Bottom U �� Header/Manifold Top of ST/PC Manhole Cover ° 106
Distribution Lines
Bottom of System
Final Grade
Date of installation /c�'� /UGPermit number 3�°2 ! State plan number
Plumber's si nature 1 a License number G M9 Date 1� /o
Inspector ►J
Complete plot plan e
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
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INDICATE NORTH ARROW
Wisconsin Department of Commerce
Safety and Buildings Division . PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. 370214
Permit Holder's Name: [ ❑ Village ❑ jown of: State Plan ID No.:
L ari gness. Dion I St. Joseph Township
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
100. o IM. o r '1 = csr Q l 030 - 2094 -20 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic C 6 5� Benchmark 3,�p 16-21 ,0'
Dosing - Alt. BM `{� `u. •�{o
Aeration "" Bldg. Sewer 7/, p
Holding St/ Ht Inlet �Z.�}o
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ve Intake ROAD Dt Inlet
Septic > 5-t NA Dt Bottom J 6, o ��•8
Dosing i NA Header / Man. cj�, 35 /
Aeration NA Dist. Pipe
'f 9� •3S�
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand �'. o
S St cover Q S. Z a
Model Number S (� GPM
TDH Lift c6.� Lriction 3} Syetem ® TD H 3 j�ft ad
oss
' Forcemain Length $p Dia. F z Dist. To Well
SOIL ABSORPTION SYSTEM 304.4 -tc o.a Y P A,4
BED/TRENCH Width ength,� No f renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION `�` DIMENSION
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Ma n f ure :
INFORMATION Type Of r CHAMBER Model Number
System:, O ^ '�`t ! ) OR UNIT
��
DISTRIBUTION SYSTEM
Header / Mo Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
i
Length Dia Length paa p
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No E] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 0 e / / Inspection #2: -- r - -
Location: 461 Highland Vi Houltorl, 5408 ( 1/4 SW 114 29 T30N R Highland Hills I - 11
1.) Alt BM Description=
4 1
, r , � • '�
2.) Bldg sewer length= 23
- amount of cover = 3
Plan ) r Islon required? ❑ Yes ®, No
Use other side for additional information. ° l 2 O3
i I _U
SBD -6710 (R.3/97) `Y ate N cmQ�`S Inspector Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W Washington Avenue
Visconsin P O Box 7162
Department of Commerce In accord with Comm 83.05, Wis Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the syst pap r not ounty
than 81a x 11 inches in size. A '
• See reverse side for instructions for completing this appli r _' n 1`���Ew� � Sanitary Permit Numb r
Personal information you provide may be used for secondary purposes "; j ut) k it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
ST CAD X StM9 P lan Review Transaction Number
I. APPLICATION INFORMATION -PLEASE PRINT AL 'kt1 RM
Propert y� QQ wner Nam �' oca
L
V PS S T ?U , N, R/� E (o&
Property Own is M'illn Ad es of r Block Number
City, State Zip Code Phone Number Subdivisio Na e r CSM umber �` n
K
11. TYPE OF Byl DING: (chec one) ❑ State Owned It� Nearest Road
Public 1 or 2 Famil Dwelling- No. of bedrooms Town of !� �' P 1 �O. h . 4
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers)
1 ❑ Apartment / Condo 63 a Y- - -?0 ®aG� rJr
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1 New 2. ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
---- -------- System_ __Tank Only ______________ExistingSystem Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 10 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 E] Seepage Pit �'-) 3 X 91 .7-S C Cg s 3 V ult Pri y
14
L
j 3' k , S' 10 = 3�,
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
J Requi ed (sq. ft.) Proposed (sq. ft.) (Gal /sq. ft.) (Min. /inch) E tion
T
2.5 e e . C4 Feet
VII. TANK Cap acity in g allons Total # of r Prefab. Site
g Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
Tanks Tanks
New Existin strutted
Septic Tank or Holding Tank U� r ® ❑ ❑ ❑ E] 1:1 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ I ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sews shown on the attached plans.
Wtier's Name: (Print) Plu ignature: ( o to ps) M PR �Lo Business Phone N tuber:
do
luntber's�d �"3e (Stre+, St t Zip Code):
��
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved s anitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
*4pproved E] Owner Given Initial
(�/� surcharge Fee) �
Adverse Determination ��S 0 �b(�
X CONDITION�_O APPROVA / REASONS FO DIS PR VAL:
vw C. e z a °`ti`cQ QS S (mac i S C - ,ts
SBD -6398 (R.12/99) DISTRIBUTION: Original to County, One copy Tol Safety & Buildings Division, Owner, Plumber �
r
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608 - 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to oe installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the'following:, A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks, distribution boxes; soil absorption systems; replacement system areas and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
-- ---- - - ----- ----- ----- - ------------ --- - ---------- - --------- ----- - -- --- ------------ ---------- ------ ---
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Combination Sepric;Tank and
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS ' PAGE OF
•VEKIT CAP WEATHER PKOOF
JUWCTIOW 80X
4'C.I. VENT PIPE APPROVED LOCKING
�:- 10' FROM DOOR. MANHOLE COVER s4JI11{
'iIMDOW OR FRESH '"ARIVlA16 LNSEL
AL_IiJTAKE S couputr
S S t I
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IAILET W /y1 C� PROVIDE
AIRTIGHT SEAL I 'I
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Approved A ��► Approved
joint w/• Tank construction
PVC pipe shall comply with I III joint w/
.ALARM PVC pipe
ILHR. ;3.15 and 83.20 rs I 11
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C I I o►�
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LLEY, b`6 `i FT - -�
PUMP �
OFF
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COMCKETE
iZeu. 86 -o0' pLOCK
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RISER EXIT PERIiIT(ED Ot,ILy ►J
IF TAK MAAIUFACTURER HAS SUCH APPROVAL 3"APPQo'rl:p
8>:p01 NQ,
SEPTIC F SPEC,IFICATIOUS
DOSE
TAki!r MAULIFACTURER bIAJL p1 3 T WuJl%BER OF DOSES: 3• y
TAMK 51ZE : �u00 `65U PER DA.
GAI- L01.1S DOSE VOLUME z '
ALARM MAWUFACTLIRER; S.S. �LE'�T72Q SLfS jt�-tS !WCLUDIAJG 6ACKFLDW: GALLONS
MODEL AIUMBER: — Q HIAJ CAPACITIES: A- - 606
SWITCH TtIPE: �N1ZC.UP�( - 1MCHE5 OR GALLOWS
PUMP MAIJUFACTUREK: GoUL_t, S B ' _ Z IUCHES'OR 2 G(LLOAJS
3 C= IUCHESOR 1S3 GALLOWS
MODEL IJUMBER: �0 S.
D` INCHES OR 153 GALLOWS
SWITCH TYPE: Wl � MOTE: PUMP AMD ALAf -r RC - TO 6L�
MIAIIMUM DISCHARGE RATE 35.) GPM INSTALLED OIJ 5EPARATE CIRCUITS
VERTICAL DIFFERENCE DETWCEW PUMP OFF AMD..DI5TRIBUTIOAI PIPE.. NZ-1S
+ Mt►JIMUM AJETWORK SUPPLY PRESSURE ^"'EYS�e ^a�cei
+ t q 5 FEET OF FORCE MAIM ?`�3 oFtFRICTIOU FACTOR_. 3'SZ FEET
TOTAL 0!JMAMIC. HEAD = `_ 8 FEET
As per manufacturer 11.0 gal /in. Liquid depth 38ti
Wisconsin Department of Ind st e `- - �I ✓� ��� 6� �� r e t S - - " LZ—`f ��
Labor and Human Relattions Ft ATI �� - Q r `1 � Page Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and S;( - ., )c
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Rev' ed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). P /� 1
Property Owner Property Location U
L a, o n e-,; S Govt. Lot S'L 1/4 S LJ1 /4,S Z T 36 ,N,R E (or 6
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
City State Zip Code Phone Number ❑ a
` ty ❑Village VTown Nearest Road
New Construction Use: ❑ Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow y 0 gpd /� ` Recommended design loading rate i bed, gpd/ft L trench, gpd /ft
Absorption area required 0 U bed, ft 2 _I L1 trench, ft 2 Maximum design loading rate ' 3 bed, gpd/ft �) trench, gpd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material -
Flood plain elevation, if applicable ft
S = Suitable for system C nventional 5M nd In -Gr nd Pressure T rade System in 'll Holding Tan
U = Unsuitable for system S❑ U S❑ U 's IN S U S t] U ❑$ AU ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
CLA)
Ground
elev.
Depth to 4 _�
limiting
factor
"e in.
Remarks:
Boring # 04( I 0 �, S 1 - e� r4 r
Ground
elev. - -
,�
" a6 VINf
Depth to
limiting 3�
factor
"ta in. Remarks:
CST Name (Please Print) '' Signature Telephone No.
I' h 0 r k 5 C ( - 71)- 2yL-,;tZS
Address t � \ 1 Date ' CST Nu mber 22
� 1 v.i R
SOIL DESCRIPTION REPORT ,
PROPERTY OWNER Page of
PARCEL I.D.#
Boren # Horizon Depth Dominant Color Mottles Structure 2
Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
2 -
Ground
p elev.
Depth to 3 ( — X14 • �fi
limiting ;
factor
k 1
Remarks:
Boring #
I m56 K r �(,� •, �,-�
Ground
Depth to
limiting
factor
+qZ in.
Remarks:
Horizon Depth Dominant Color Moftles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
...........................
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW -8330 (R. 08/95)
N BY D
1432 120 'h STREET, NEW RICHMOND, WISCONSIN
715- 246 -2454
PROJECT NAME: HighLand Hills Phase 2
DESCRIPTION: SEA/, SW/4, SECTION 29 „T 30 N, R19W
TOWNSHIP: St, Joseph COUNTY: ST.CROIX
LOT
j nn
,2 2 cuc re-' 3
0
a U
� y �
SCALE 1 " =40' Tom Nelson
BM 1 Top Of Phone Pedistal Elevation 100' cstmo2605
BM 2 Top of Power Box 95.61'
Wisconsin Departmen! of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
' Latx+4and Human Relations
,eniv�s i of Safety & Buildings d
in accord with ILHR 83.05, Wis. Adm. Coe
w COUNTY
St. Croix
Attach complete site plan on paper not less te�8 1ti a Plan must inclu de, but not limited to vertical and horizontal referencirectio °/ slope, scale or PARCEL
I.D. #
dimensioned, north arrow, and location and earroad. APPLICANT INFORMATION - PLEASE ; .�ATIO R VIEWED BY DATE
-2c
PROPERTY OWNER: �� as : j rvr: PERTY LOCATION
Jo Ann Persico /Bruce Peters T Gp . LOT SE 1/4 SW 1i4,S 29 T 30 N,R 19 2 (or) W
PROPERTY OWNERS MAILING ADDRESS # BLOCK # SUBD. NAME OR CSM #
#328 Co. Rd. #F ,j,xy;o;,; 4 t r 11 na Highland Hills phase II
CITY, STATE ZIP CODE BERa CITY ❑VILLAGE [MOWN NEAREST ROAD
Hudson, WI. 54016 ( �. ` St. Jose h Co. Rd. #E
Ic] New Construction Use [x] Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate ' 4 bed, gpd/ft2 .5 trench, gpd/ft
Absorption area required 375 bed, ft2 375 trench, ft Maximum design loading rate • _ 4 bed, gpd/ft2 - 5 trench, gpd/ft
Recommended infiltration surface elevation(s) 101.90 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash over till Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL I HOLDING TANK
U = Unsuitable for s stem ❑ S :F ® S ❑ U ❑ S 13 [I IOU [I Y1 U ❑ S ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourtday Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ranch
1 0 -10 10yr4 /2 none sl 2mgr mvfr cs 2f .5 .6
2 10 -2 10yr4/3 none sl lmsbk rw r gw if .4 .5
Ground 3 26 -82 7.5yr4/4 none sl lmsbk mfi na na .4 .5
elev.
100 ft.
Depth to
limiting
factor
+8 2 11
Remarks:
Boring #
<� 1 0 -13 10 r4 2 none sl 2mcfr mfr cs 2f .5 `•..6
k +
2 2 13 -26 10yr4/3 none sl lmsbk mvfr gw if .4 �.5
3 26 -41 7.5yr4/6 none scl 2msbk mfr gW na .4 .5
Ground c p yr
elev. 4 4_ 8 7.5yr4/6 7.5 r5/8 scl 2msbk mfr na na .4 .5
99. ft.
Depth to
limiting
WWI`
41"
Remarks:
CST Name:— Please Print Gary L. Steel Phone' 715- 246 -6200
Address: 1554 200 , Ave., New ichmond, WI. 54017
Signature: Date: CST Number:
6 -22 -94 cstm 2298
PROPERTYOWNER Persico /Petereon SOIL DESCRIPTION REPORT Page 2., ofd
PARCEL I.D. # N .
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ITrer&
L:3 1 0 -10 10yr4 /2 none sl 2mgr mfr cs 2f .5 .6
2 10 -32 10yr4 /3 none sl 2mgr mvfr gw 1f .6
.6
Ground 3 32 -80 10yr4 /4 none is Osg mvfr na na .7 .8
elev.
100. 901t.
Depth to
limiting
factor
+ 80"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
.:...............
Ground
elev.
ft.
I
Depth to
limiting
factor
I
Remarks: _
SBD- 8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Highland Hills phase II 1554 200th Ave.
CSTM2298 lot #11 New Richmond, WI 54017
MPRSW 3254 SE4SW4 529— T 30N -R19w (715) 246 -6200
town of St. Joseph
�N
-/ =40'
` top of Nw lot stake at el. 100'
A q0
lo. ,
c r�
--
Gary L. Steel
6 -22 -94
r ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer &
g
Mailing Address
Property Address / r
(Verification required 4om Planning Department for new construction) / -
City /State Parcel Identification Number
Na, pbh
LEGAL DESCRIPTION c,
Property Location �� ' /4, ly ' / <, Sec. T zG ) N -R_ Town of
Subdivision S C' Lot #
Certified Survey Map # ! , Volume . Page #
Warranty Deed # �J / / . Volume , Page #�
/34
�2
Spec house 0 yes Q no r Z 3 Lot lines identifiable Pk yes 0 no 9
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, joumeyman 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.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
day , three year expiration date.
SIGNATURE OF A-PPLftANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the er�y descr" ed above, by virtue of a warranty deed recorded in Register of Deeds Office.
7"
SI NATURE OF AfPLICANT DATE
I
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
i
• 591.234
-0
VOL ',37�.PAU 429
DOCUMENT NO. I I WARRANTY DEED
STATE BAR OF WISCONSIN FORM 2 -1982
A 1MYWtITLE OF STILLWAT R ST. I L C o ., 1835 NORTHWESTERN AVENUE WI
STILLWATER, MN 55082 kdr, d !�eCOrd
NOV 1 0 1998
TAX PARCEL N0. 9=30 gm
04j",
Qf ,4eds
IU 4 7 dw&V,0V �L
Rod ox and Sherrie L. Cox Husband and wife conveys and warrants �� o bi -o
an mess
a
single a son g the following described real estate in
,County, to of Wisconsin:
Lot 11, Highland Hills First Addition to the Town of St. Joseph, St. Croix County,
Wisconsin.
YRA�SFER
This no�c
S
homestead property
(is is n
Exceptions to warranties:
-- ted: October 16. 1998
Rod a B. Cox
o� Y
She "ie L. Cox
ACKNOWLEDGEMENT
STATE OF MINNESOTA )
) ss.
COUNTY OF WASHINGTON )
Personally came before me on October 16. 1998 the above named Rodney B. Cox and
Sherrie L. Cox, Husband and wife to me known to be the person(s) who executed the
f"org<yin instrumen knowledge the same.
'
JUDITH A . SIDEW .
.
NOTARY PUBLIC — MINNESOT
Ub is N EXPI 1-31 -2000
NOTARY MY COMMISSIO
This instrument was drafted by:
Attorney's Title of Stillwater, 1835 Northwestern Avenue, Stillwater, MN 55082
591233 WARRANTY DEED
Document Number VOL 1375 PAu14 -28
REG,IS�ER'S OMat
ST. CROIX CO., WI
Rac'd !:.- R•aord
Return Address NOV 1 01998
ATTORNEY'S TITLE OF STILLWATER 9 3O
1835 NORTHWESTERN AVENUE
STILLWATER, MN 55082 +w 0,005
Parcel I.D. Number: 030 - 2094 -20
Highland Hills, a Partnership, conveys and warrants to Rodney R. Cox and Sherrie L. Cox, husband and
wife, the following described real estate in St. Croix County, State of Wisconsin:
Lot 11, lat- of Highland- Hills- in. the- Township- of St.. Joseph, St. Croix County_,. Wisconsin.
This deed is give in fulfillment of that certain Land Contract between the ptirties hereto dated June 15th
1996, recorded my 17, 1996 in Vol. 1190 Page 331 as Doc. No.
546914
This is not homestead prop
Exception to warranties: Easements, restri ions and rights -of -way of record, if any.
Dated this day of O ober, 1995 -
Highland Hills, a Partners ' \
JoAnn Persico, indivi ly and as Power of Attorney
for Bruce Peterson d Roger Ruelin
ACKNOWLEDGMENT
STATE OF SCONSIN )
) ss
Or (moo +A COUNTY )
Personally came before me this j& of October, 19A the above named JoAun Persico,
individually 'and j s Power of Attorney for Bruce Peterson and Roger Ruelin, to me known to be the
P erso n s who .�hA74ted the foregoing instrument and acknowledge the same.
�)
Notarl ,t);etli1ic.•'' County, WI
My co expires I l — l5 ^�
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristin Ogland
Hudson, WI 54016