HomeMy WebLinkAbout030-2045-30-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
552365 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Gilbert, Ma & Martha Severson et al St. Joseph, Town of 030-2045-30-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
. 0 0 I® u D T 27.30.20.509C
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
S ptic I IV ~Z ~ Benchmark rb
Dosing ~N o Alt. BM
O
Aeration Bldg. Sewer , S
Holding r" t/ ~~4_x f
TANK SETBACK INFORMATION St/Ht Outlet 92,,9 2
TANK TO P/L WE L BLDG. Vent to Air Intake ROAD Dt net
- d m eoo n)o c $q, X S
Septic Dt Bottom Dosing Header/Man.
'v
Aeration Dist. Pipe Gy I S-n
Holding Bot. System tr
ell Final Grade
PUMP/SIPHON INFORMATION ~*,4- ;d 9.0 - 7.
Manufacturer GP Rand St Cover nk r Q f~j .1 0 I Coq p p
Model Number l T/
7' y 9s `7.01/
TDH Lift Friction Loss System Head TDH Ft ,
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM IS ) /,,(Q App( 00
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Ix Hole Size Ix Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil I FE-1 Yes g No ® Yes FE No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: G / / /-2--- Inspection #2:
Location: 69 County Road E Houlton, WI 54082 (SW 1/4 NE 1/4 27 T30N R20W) metes & bounds Lot Yn~ Parcel No: 2~7.30~.20.509C
D C41A_ C,
1.) Alt BM Description fTo p of ~K s f ('~uvw-) _
2.) Bldg sewer length
- amount of cover = Xu (t/
Plan revision Required? Ful Yes No I n _ ~j
Use other side for additional information.
Date
SBD-6710 (R.3/97) Insepctor's Sig ature Cert. No.
!.+~~'ri Il►`r'y County
,errs Safety and Buildings Division JET ~D/ X
off 9$ A. 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
Madison, WI 53707-7162
Se2 3&
anitary Permit Application State Tr action Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS ""lied to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide in r seco dary
purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. ~xt/Y1'uL
1. Application Information - Please Print All Information
Property Owner's Name Parcel #
A i E2r , D D -ZU~lS D-ODD
Property Owner's Mailing Address V4~ Property
Location
CO 141U 7- `T~ Pio S q't~ t.?I J Govt. Lot ! G J
City, state Zip Code -mulibe
, , Z
_ S /4, N /4, Section
L~Q CJ 2- circle one)
I-IOU 4 ro Al T Q
H. Type of Building (check all that apply) Lot # T N; R Zt~ E ort~
_ti I or 2 Family Dwelling - Number of Bedrooms 1G~ Subdivision Name
Block # VA ❑ Public/Commercial - Describe Use
❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
❑ Town of . S' 7. j c>5 Z -1p III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New System ❑ Replacement System 9 Treatment/Fleiltm' -Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner 3- NM - 9 2 0 ZCZ6
IV. Type of POWTS System/Component/Device: Check all that apply)
❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
VI. Tank Info Capacity in Total # of Manufacturer
«3
Gallons Gallons Units
New Tanks Existing Tanks Y _
o
o. U rn iw C7 0.
Septic or Holding Tank /Z5_0 Z t E 5,',Q N t! /ZfTC
Dosing Chamber SO I !3 ~ Gf~ 200O
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's re MP/MPRS Number Business Phone Number
~~tfN ~utw~ rT i etc ZZ3 76 v 71, -~6D--D x 614
Plumber's Address (Street, City, State, Zip C e)
VIII oun epartment Use Only
Approved ❑ Disapproved Permit Feew Date Issued ssuing Ag t Sign e
❑ Owner Given Reason for Denial $ ( C~~/- .
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER:
1 Septic tank, effluent filter and t~
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
II setback requirements must be maintained
as per applicable for the system and submitito the County on on pa r not less an 81/2 x 11 laklies in size
SBD-6398 (R. 11/11)
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Gilbert Replacement Septic Tank
Owners Name: Mary Gilbert
Owner's Address 69 County Road E
Houlton, WI 54082
Legal Description: SW1/4, NE1/4, S27. T30N, R20 W
Township St. Joseph
County: St. Croix
Subdivision Name: 21 Acre Parcel
Lot Number: NA Block Number NA
Parcel I.D. Number 030-2045-30
Plan Transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 Septic Tank Specifications
Page 4 Effluent Filter Information
Page 5 Dose Tank Cross Section
Page 6 Pump Curve
Page 788 Management and contingency plan
Page 9 Septic Tank Maintenance Agreement
Page 10 Warranty Deed
Page 11-13 Soil Evaluation Report
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 6/2/2012 Phone Number: 715-760-0486
Signature:
In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1 of 13
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\o m W1250-MR MISER COOCAETE DRAWN BY. SME SREV. 1/4'-l'-O" PRE-POUR:
m -q SEPTIC MANUAL DATE: JANUARY 2010 DATE:. LOST-POUR:
~ \z W3716 US HWY 10 MAIDEN ROCK, WI 54750
° REVISED JAN. 2010 800-325-8456 RLE: w129-wt
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County St. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryP1MV:
Personal information you provice may be used for secondary purposes [Privacy Law, s. 1X5.04 (1)(m)l.
PenWIft me: ❑ City ❑ ViIISje jgj0jjrR1s6WriShlp State Plan ID No.:
CST BM Elev.; Insp. BM Elev.: BM Description: Parcel T.2045-30-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ti Sal SOU Benchmark Z '14 'A>
AGO
Dosing JA lGe
Bldg. Sewer
H Ing b Ht Inlet
TANK SETBACK INFORMATION (S-) Ht Outlet p~ 9d.
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom ~(z
Dosing 7 -7 s' y }S/ 5~- 3 r fi~3 o NA Header / Man. ' 3
r
Aeration NA Dist. Pipe /4)
Holdin Bot. System
P MP /SIPHON INFORMATION Final Grade .5- y s- 9 Z
/ y yG 9z
Manufacturer V Demand
Model Number GPM O~
TDH Lift,5- Lriction3 Z L System TDH J,o( Ft k5 ~f ~s p_ Z 7
Forcemain Length Dia. Z'/ Dist. To Well ~~~e✓ 7`3d' p
SOIL ABSORPTION SYSTEM
BED RENO Width Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth
DIMEN I N -7/ ?_'5- Z DIMENSIONS
acturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM EMIT Manuf
INFORMATION Of M o Num er-
System: Z - SP y (Gp DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length 4L Dia. Lengthy-3-!~ Dia. Nq- Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: to / b /(fit Inspection #2:
Location: 69 County Road E, Houlton, WI 54082 (SW 1/4 NE 1/4 27 T30N R20W) - 273020509C
1.) Alt BM Description = D f c o v r r s, o 6 g
2.) Bldg sewer length=
-amount of cover =
3rd C er fv0- "-C" Wes
Plan revision required? ❑ Yes M No
Use other side for additional information. s
vl1"J
SBD-6710 (8.3/97) Da 4 Inspe is Signature Cert. No.
s
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave,
14sconsin See reverse side for instructions for completing this application PO Box 7302
Personal information you provide may be used for secondary purposes Madison. WI 53707-730,
Department of Commerce [Privacy Law, s. 15.04(1 (Submit completed form to county if r
)(m1]_,-
state owner
Attach complete plans (to the count), cop), only) for the stetre: on a er..ndt,les~ han 8-1/2 x 11 inches in size.
County State Sanita Pemit Number ❑ Chge.k, jf revision to previous application State Plan 1. D. Number
I. Application Information - Please Print all Information Location:
Property Owner Name Property Location
e-F. 4- 5V 1/4 &l/4,SX7T N. RAa or
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Ph a N601W / Subdivision Name or CSM Number
OUc o
II Type of Building: (check one) ❑ City
,'A I or 2 Family Dwelling -No. of Bedrooms: ❑ Village
❑ Public/Commercial (describe use): 19 Town of
❑ State-owned S F, O S y
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road _
A) 1. ❑ New System 2. 101 Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Number s)
System Tank Only Existing System 0,3v - o vs-- 3
B) Permit Number Datarlnraed-
❑ A Sanitary Permit was previously issued 21 • '2> o - 20. SG~c-
IV. Type of POWT System: (Check all that apply)
JIINon-pressurized In-ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V Dispersal/Treatment Area Information: eQar E 30 111r1L T A 09 - O /=i L
1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Eleva ton 7. Final Grade
Required Proposed Rate (Gals./day/sq. ft.) (Min./inch) 9/. fo / tw Elevation
0-1 500i s,.I- I/ •76.1 S.9 6
VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
SE T/~ /9-D0 /Sop < n! ❑ ❑ ❑ ❑
AG Soo $00 / rtJ~Et-~ ❑ ❑ ❑ ❑
VII Responsibility Statement
I, the undersigned, assume res onsibilit er installation of the POWTS shown on hed plans.
Plumber's Name (print) P m is Signature (no stamp o /MPRS No. Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
r-d
VIII County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination Z L,- C) d ZD Z o ua
IX. Conditions of Approval /Reasons `for Disapproval:
p
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li~,.~ C~rv~'os. .'S ~ w~rrq~.t6®r.` !n, arrt/ 1l0 6~ etv~e.,.
SBD-6398 (R. 07/00)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt
Attach complete site plan on paper not less than 8'%x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction
and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
Please print all info r- , t!_, R we g y Date
Personal information you provide may be used for se e4Cary ~ (Priv`-' 4'v (m)). f'l "UU
Property Owner CFl~'~l r Location
Gilbert,Mary Severson,Martha CFI-
G SW 1/4 NE 1/4 S 27 T 30 N R 20 W
Property Owner's Mailing Address ~ j Lo Block # Subd. Name or CSM#
69 Cty. Rd. E t 206NA
City State Zil~C" Phone X ity ..jVillage sel Town Nearest Road
CO(1N' Y
Saint Joseph WI 54 Z1)- ZONiNGOFFiCE St.Jose h C . Rd. E
3 New Construction Use: v11 Residen / u n 4 Code derived design flow rate 600 GPD
✓f Replacement .f Public or co I D
Parent material Outwash Plain Flood plain elevation, if applicable NA
General comments
and recommendations: Possible System Elevation 91.90' (high trench) 89.97' (low trench)
Boring # A Boring
ej Pit Ground Surface elev. 95.42 ft. Depth to limiting factor >132 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
1 0-8 - 10yr3/3 none sl 2msbk mfr gw 1m .5 .9-/
2 8-20- 10yr4/4 none sl 2msbk mfr gw if .5 i f ✓
3 20-30- 10yr4/6 none sil 2msbk mfi gw if .5 00,/
4 30-65 10yr4/4 none sit 2msbk mfi gw .5 ✓ „ 8,-
5 65- 7.5yr4/4 none grits Osg ml .7
ers :bra 7. 9otll- ao b
p1, q & zS-,"
Fi~ Boring # --j Boring
l Pit Ground Surface elev. 97.35 ft. Depth to limiting factor >133 , 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
1 0-81 10yr3/3 none sl 2mgr mfr gw im .5 .9
2 8-24, 10yr5/4 none sl lfsbk mfr gw if ~l b
3 24-44 10yr4/6 none sl lmsbk mfi gw if .4
4 44-64- 10yr6/3 none sl imsbk mfi cs .4 ✓ (o
5 64-133 7.5yr4/6 none grl Osg ml .7 ✓ ,
q
r rf
* Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 S30 mg/L and TSS <.30 mg/L
CST Name (Please Print) Signature: CST Number
Thomas J. Schmitt ewe 227429
Address Tom Schmitt Date Evaluation Conducted Telephone Number
Somerset, WI 54025 7/24/00 715-549-6651
~,II
-Property Owner Gilbert,Mary Severson,Martha Parcel ID # Page 2 of 3
F3~ Boring # I Boring
✓l Pit Ground Surface elev. 96.22 ft. Depth to limiting factor >137 ' in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-10, 10yr3/3 none sl 2mgr mfr gw 1m .5 ✓ .9
2 10-24, 10yr5/4 none G 2msbk mfi gw if .5/ .9/
3 24-36- 10yr4/6 none sl imsbk mfi gw if .4 .6-/
4 36-63- 10yr4/4 none sl imsbk mfi Cw A/ .61/
5 64-137. 7.5yr4/6 none g a Osg ml .7 ✓ 1.4
❑ Boring # _.1 Boring
J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ Boring # Boring
A Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 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- nlease contact the denartment at 609-266-3151 or TTY 609-264-R777.
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PAGE OF
PUMP CHAMBER CROS5 SECTION AND SPE.CIFICATIOMS
VCNT CAP
4°C.L. VENT PIPC WCATHER PROOF APPROVED LOCKIMG
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ALARM MIWLJFACTIJftrblk: Ta9rt/ir L~
MODEL WUMBER: CAPACITIES: A ,..E_1AJCNCS OR GALLOUS
SWITCH TJPIi.: , _IYj~/ "z J/ g m _ IN .01cs OR y3• G~LLOAIS
BLIMP MAWUFACTURER: C ■ ....~.,,.twiES OR ..~L1l d WALLOWS
MODEL. NUM6LK:.!8 D 8 IMC11ES OR 19%4, GALLOIJ&
;yWiTCH TLIPE:. /`/E 2C141? kz, AIOfE: PUMP AND ALARM ARf TQ 6C
CPM INSTALLED ORI SEPARATE CIRCUITS
MJJJIMUM DISCI~ARGE RATE
VERTICAL t)IFFEILEUCE DETWEEAJ "PUMP OFF AUD..DISTRIbUTIOU PIPE.. 10 FELT
} MINIJ4UM WETWORK SUPPL.`J PRESSURE . . . . . . . . . . . FE.CT
+ -LM- FEET OF FORCE MAIM X Bfi.FKkCTIOIJ FACYOR.. FEET :
t•
TOTAL. DtINAMIL HLAD = FEET
IIJTCRAiAL DI IJSIOAI Of TANK: LEMCGTH ..........-;WIDTH ;LIQUIO DEPTH ~.rli~.....
91GNE0: LICEQSE MUMBER, - z! 7 !J DATE:`
MEAD CAPACITY CURVE ~'3 7/8 6 4
MODEL "98"
30 f 1~ 4 5/8 --4
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8 i I
25 i !
6 20 3 5/8
a
4~ ) G
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2-
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0 1 1/2-11 112 NPT
U.S. GALLONS 10 20 30 40 50 60 70 BC
LITERS 0 5o 150 240
FLOW PER MENU7E
MODEL 98 60 CYCLE L~.J
1
Feet Gcilons Meters Liters
5 72 1.5 Z73
1
10 61 3.1 231
di j
- I I
15 45 48 17C
12
20 25 6.1 95
Lock valve: 2x _
009971 f 1 I
4 3/16
SK1102
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Electrical alternators, for duplex systems, are available and Variable level float switches are available for controlling single
supplied with an alarm. and three phase systems.
• Mechanical alternators, for duplex systems, are available • Double piggyback variable level float switches are available
with or without alarm switches. for variable level long cycle controls.
SELECTION GUIDE
1, Integral float operated 2 pole mechanical switch, no external control required.
Standard all models - Weight 39 lbs. /2 N.P. 2. Single piggyback variable level float switch or double piggyback variable level,
98 Sari" Control Selection float switch. Refer to FM0477_
Model volts-Ph Mode Amps simplex Duplex 3. Mechanical alternator 10-0072 or 10-0075.
M98 115 1 Auto 9.4 1 or 1 & 7 - 4. See FM0712. for correct model of Electrical Alternator.
N98 115 1 Non 9.4 2 or 2& 6 3 or 4 & 5 5 Control switch 10-0225 used as a control activator, specify duplex (3) or (4)
float system.
D98 230 1 Auto 4.7 1 or 1 & 7 - 6. Four (4) hole J-Pak, junction box, for watertight Connection or wired-in
E98 230 1 Non 41 2 or 2 & 6 3 or 4 & 5 simplex or duplex operation, 10-0002.
7, Two (2) hole J-Pak, for watertight connection or splice.
CAUTION
For information on additional Zoeller products refer to catalog on Piggyback Variable Level Switches, All installation of controls, protection devices and wiring should be done
by a qualified
FM04771EleciricalAlternator,FM0466;Mechanical Alternator, FM0496;SumplSewageBarJns,FM0487; licensed electrician. Ali electrical and safety codes should be followed including the
most
Single Phase Simplex Pump Control, FM1596; Alarm Systems, FM0732. recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
MAIL 7O; PA. BOX 16347 ~ -
Loalsvlfle, KY 40256-0347
Manuiacturersof, .
0 SHIP TO: 3549 Cane Run Roaa
W) 77a 2731-1 {aorai 1 928-PUMP Qvs[/TY PUnsPer ,~iNCE Ia9s1iJ
http:1/www.zoe119r com PUMP LSO. FAX (501) 774-3614
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
rMl 1IT1 r,1 7.ATTnN (lV AN I XT P.TTN(7 SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the 13&WT ^ d,L aeyz-3 residence located at:
LU 1/4, 1/4, Sec. 3 , T -2g) N, R-2-0 W, Town of
Si. '70 STf~ 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- 9-/1-00
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
caPlic ty
Construction: Prefab Concrete- X Steel Other
Manufacurer (if known):
Age of Tank (if known):
o,j AA
( 4 gnatute) P 00*-- Mame plaasi: Fi$F
069
(Title'Llcl~as~ :liur)
®p
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&,V4Qi,v CAoV 1 r~ Signature M ~2
r
Y 5/88
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer //A-,(e y 6113 L=- r
Mailing Address 9 C,7y RD
Property Address G 9 GT Y ®Z D
(Verification required from Planning Department for new construction)-
City/Statev Wj' . Parcel Identification Number _Q 3 0 - _,Q1
-3 D
LEGAL DESCRIPTION
Property Location &W Sec. ,Z? . T_J~_N-R 2_W, Town of S> , o ra o /j
Subdivision Lot # NA
Certified SmVey Map # Volume . Page #
Warranty Deed # Volume . Page #
Spec house ❑ yes IM no Lot lines identifiable 1' yes no
I;MAINIT'.NANCE
LAC+oprraseaadmaiateaanoeofy01Ur:optic:ysbemcouldr+aultinitxpc~emaburefa u~+etohandle wastes.Propermai0mance
consists of; - I ing out the septic task every throe yeas or sooner, if needed by a licensed pamper. What you put into ft system
as affect do ulction of do septic tank as. a. tnat meat stage in the waste disposal.system
j
The pmperty owner agrees to submit to St. Croix Zoning Dot a oartification form, signed by the -owner road by a
P rc;tictedplm imorilicensod dratO1 theon-its diVoWqste&
IS is proper operating condition and/or after inspection and pmmping.(if necessary), the septic-tank-is less than 113 f fi of Andge.
i
s Vwc. due undmigued, have read die above regnir and agree to maindia due private sewage disposal system with the rytadatds
set fordr, hmin,'as set by due DepaMnal of Camma oe cad the Dot of Natural Rawmms; State of Wisconsin.. CaWeafi6n
suing drat your septic system has bocce maintained mnst be completed and returned to due St. Croix County Zoning Office wkBin 30
days- of due dme year ' n date.
SI A OF APPLICANT DATE
OWNER CERTIFICATION
I (we) eec* that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owg9s) of
the property described above, tly vow of a warranty deed recorded in Register of Deeds Office.
SI(i A OF APPL CANT DATE
ss«««« Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department.'""
as Include with this application: a ctmunped wuranty dead from the Register of Dads office
a copy of the certified survey map if reference is made in the warranty deed
f
' ~ IY
STATE BAR OF WISCONSIN FORM 3 - 1998 6 6 2-
QUIT CLAIM DEED KATHLEEN H. WALSH
p REGISTER OF DEEDS
Vn1.1528PAGE104 ST. CROIX CO., WI
Document Number
RECEIVED FOR RECORD
This Deed, made between DONALD R. HOLCOMB 07-20-2000 10:00 Ali
QUIT CLAIM DEED
Grantor. EXEMPT N
CERT COPY FEE:
and MARY M. GILBERT and MARTHA J. SEVERSON, as tenants COPY FEE:
in cotmmon each as to an undivided one-half interest TRANSFER FEE: 600.00
- RECORDING FEE: 12.00
GAGES: 2
Grantee.
Grantor quit claims to Grantee the following described real estate in
St. Croix County. State of Wisconsin:
Name and Return Address
Barry C. Lundeen
(SEE ATTACHED LEGAL DESCRIPTION) MUDGE, PORTER, LUNDEEN & SEGUIN
Post Office Box 469
Hudson, Wisconsin 54016
030-2043-90s . 030-2044-40
030-2044-60; 030-2049-10
030-2050-40; 030-2050-50
Parcel Identification Number (PIN) 030-2045-30
This is homestead property.
(is) (is not)
Together with all appurtenant rights, title and interests.
Dated this 28th day of February 2000
(SEAL) ~u~ C EAL)
* DONALD R. HOLCOMB
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix County.
authenticated this day of Personally came before me this 28th day of
February 2000 , the above named
Donald R. Holcomb
TITLE: MEMBER STATE BAR OF WISCONSIN - - - to
(If not, me known to be the person y who executed the foregoing
authorized by §706.06. Wis. Slats.) instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY -
Attorney Barry C. Lundeen -
MUDGE, PORTER, LUNDEEN & SEGUIN, S. C. ' otary Public. State of 'v lsc~p A
, t, state expiration date:
110 Second Street, Hudson, WI 54016 M9 commission p? t
t
(Signatures may be authenticated or acknowledged. Both are not
necessary.)
Names of persons signing in any capacity must be typed or printed below their signature. VV
STATE BAR OF WISCONSIN "'rn••• Wisconsin Legal Blank Co., Inc.
QUIT CLAIM DEED FORM No. 3 - 1998 Milwaukee, Wis.
Val. 1528P,Gf105
Property Description:
Parcel One:
The NW-1/4 of SW-1 /4 and W-1 /2 of NE-1 /4 of SW-1 /4 of Section 26-30-20. The
E-1/2 of SE-1/4 of Section 27-30-20, except the following, to-wit: Beginning at
an iron pipe monument set at the SW corner of said tract, and running thence E
along the S line of said tract 238.8 feet to the intersection of said S line and the
Wly line of the Hudson and Houlton road; thence NW along said Wly line of said
road to the intersection of said Wly line with the W line of said tract; thence S
along said Wly line 382.9 feet to the point of beginning, containing 1.04 acres,
more or less. All that part of Lot 4 in Section 27-30-20, described as follows:
Beginning at the NE corner of said Lot 4; thence S 20.31 chains to the SE corner
of said Lot 4; thence W along the S line of said Lot 4, 5.88 chains to the line of the
Hudson and Houlton road; thence Nly along the E line of said road to the N line
of said Lot 4; thence E 15.93 chains to the place of beginning. The W-1 /2 of the
SE-1/4 of the NW-1/4 of Section 26-30-20 EXCEPT the North 328.12 feet of the
East 160 feet thereof.
Parcel Two:
The SW-1/4 of NE-1/4 of Section 27-30-20, except the following, to-wit:
Commencing at the NW corner of said SW-1/4 of NE-1/4 of said Section 27;
thence E 26 rods; thence S 47-1/2 rods; thence W 26 rods to W line of said 40;
thence S 3 rods; thence E 28 rods; thence S 29-1/2 rods; thence W 28 rods to the
SW corner of said 40; thence N 80 rods to the place of beginning.