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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
b 44 INSPECTION REPORT Sanitary Permit No:
395140 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan t 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:
Belisle, Earl I k'om 032 - 2512 -70 -000
CST BM Elev: Insp. BM Elev: BM Description: n l q Y J � ^
C'O -ar� y I O �Q0/ S f
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Lo (try Benchmark 2.r Z.SZ IoZ.S2 �•6
Dosing Alt. BM
C am,,,, �. �,•,, caw
Aeration Bldg. Sewer
C,-D3
(p .
Holding St/Ht Inlet , q5-
•o }'
' 6. `
TANK SETBACK INFORMATION St/Ht Outlet 9S•S$
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ' f LTO r Dt Bottom
Dosing 12 it Header /Man. -7 $ r
Aeration Dist. Pipe
Af e 4 r
Holding Bot. System S • 7. �° 9 3. ZZ
PUMP /SIPHON INFORMATION Final Grade
3.3b get I6 �
Manufact rer De and St Cover r
GP 2 -qD Cp•tZ
Model Number
TDH Lift Fiction Loss System Head TDH Ft
Forcemain Length Dia. Dist.
SOIL RPTION SYSTEM ( 1�
RENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIM 3 �� C2
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufactyyy�e . `
INFORMATION CHAMBER OR Tv, ?J ^ �1oC9W�
Type Of Sy_ stem: f UNIT Model Nu ber:
�J Z / - -7
DISTRIBUTION SYSTEM
Header /Manifo d Distribution x Hole Size x Hole Spacing Vent to Air Intake
k Pies �
p ( )
Length ia_� Length is Spacing 1
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over j xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center l Bedfrrench Edges Topsoil Yes * No FBI Yes [W No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: 08 ✓/� Inspection
Location: 688 170th Avenue Somerset, WI 54025 (SE 1/4 SE 1/4 3 T301NLR1 W) Q Lot Parcel No: 03.30.19.518A
2.) Bldg
1.) Alt BM Description = NlR
sewer length =
1
Z�
�8
- amount of cover = 34 " - r
3)a��• -� 4 - 10D C— 4- -A -
C7t�" O
—�
Plan revision Required? �� Yes No
Use other side for additional informa ofi n. f ' —
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
Sanitary Permit Application & 13ui1 in8s Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
SCOn n See reverse sick for Instructions for completing this application PO Box 73M
Dapartme�t of t;omm Personal informati you provide may be used for secondary purposes Madison, WI 33707 -7302
(Privacy Law, s. 15.W(i)(m)] (Submit completed form to cotutty if not
state owned.
COMPlete Plans (t Ai the County for __ e system, on = not less than 8 -1/2 x I 1 in G size.
-M tats an t mumber eok trmvtsion to pmv ous on ta0s
��nl� 3
L
PMPN1y owner A Ik tion Info rms 000 - PI Prin All Information Locetlon:
ame Prop" maim
PMPUIY 3 �30,N,I� E
: s
1/4 1/4, S
um
Lot Num
c� tsft �, 1 zip � � I Phone um r SubdMiTon ame or CSM Number
II. Type of Bait ing: (elbeek one) ;
,� . , . ,. _ ...r . -` D City
1 or 2 Family Dwelling - No. of Bedrooms : D C it y
0 Public/Conttaatcial (describe use):_ A§Nwi of
O State -Owned 7
Nomat Road / —�
Parcil Tax NMbv s
Pe of rmit: (Check 4 one box an line A. Check di dine B if le)
A) S Replacem eplacentent 4. ` S. Add m
Tank Onl y Existing System
B
❑ A Sanitsy Permit was 'Dual tt tun r issued `' —`= — UM ISO=
IV, pe OF WOO= (Check all that apply)
- pressurized In- ground 13 Moun4 Cl Sand Filter O Constructed Wetland
Pressurized In- grouad ❑ Holding Tank ❑ Single Pass
❑ At - ❑Drip Lira
grade ❑ Aerobic Treatment Unit ❑ Recirculating O Other:
V. D rsal/Treatment Area Information:
Area 3. ersW Ma 4. Sot a on . Percoleuon
Required Proposed Rate GaisJda /s . ft y7 ev 7, nod onalf
-7 5_✓ ✓ ( Y Q ) (MinJinch)
3 ,� evatlon
VII. Tank CAP acity in Total of Manufacturer Pro Site tee F c
Information Gallons Gallons Tanks Con- Con- glass
ew Crete strutted
Tanks Tanks
S � ❑ v a ❑
VIII. po»ribility Statement L
the undersigned assume responsibility for installation of the Pc?WTS shown on the attached lens.
Pl um s ame of Msf t stamps : o
us nesa rwrA WM— F ) J
s , ✓ G ty State,
IX. County/DepartmeAt Use Only ,
prOV anttary e t
at no u es ater KC ss
Approved O Owner Given Initial Adverse Surcharp F ) a sent i ataotpa
De�ion Z L S O D 3 ZOII
X. tlon / a / o Apprroval / a far Di
1.JItJ��� SE�Je{�S S�tl� / O� k14
Z� e PaJC'e� de6c"4e Dn �ie Q� {i / Auc� Vp1 ���d p�, JD/
e F1"Lr'
( I
OKQ ✓Gs��PnCr %� etC/ 5th Q S ®K e4Q
SBD -6398 (R. 07/00)
PL PLAN
PROJECT Earl Belisle DDRESS 1719 Countv Road I Somerset Wi 54025
SE 1/4 SE 1/4S 3 /T 30 RR 1 W TOWN Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 5/29/01 BEDROOM 3
CONVENTIONAL X)OC IN-GROU4P PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 377 # of chambers 22
BENCHMARK V.R.P. Top of Well ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 93.5/93.0
Alt. BM Bottom of Siding @ 101.4' Well B.M. Existing 3
Alt. Bedroom
Trailer
50' 30'
B -1 T
Vents 0
4% System elevation is
Slope to be set 6'
> Below Grade
B -3
c ° v 35'
B -2 2 -3' X 69' Cells
300' with >3' Spacing
40'
Vents
Plans Designed Using
700 Conventional Powts
Manual Version 2.0
Vent
ALo Sidewinder High
Capacity Leaching
Chamber
6 "
3419 Grade at System Elevation
170th Ave
Witconsin SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County��
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must l•
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. f � / _� /J��
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. (/
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot — „S, 1/41/4 S _ 3 T N R/ E (o W
Property Owner's Mailing Address Lot # [ Block # Subd. Name or CSM#
C ity Sta a Zip Code Phone Number ❑ City ❑ Village JaTown Nearest Road
New Construction Use / Number of bedrooms Code derived design flow rate U GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material fJC.C7�cJGt� , Flood Plain elevation if applicable �l/lTi ft.
General comments L,� �� S c7 �tJ�
and recommendations: %0�,e /� PiVC��(� J /� -�
H are, i s all- C.a 17 r-- /1/0 &4 r; ��o Q L
Boring # Z Boring
9 Pit Ground surface elev.R ft. Depth to limiting facto 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
93. a 2''
Boring #❑-1 Boring
129. 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. I *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
CST Na a (Please Print) i nat C T Number
Address Date Evaluation Conducted Telephone Number
SBD -8330 (R07 /00)
' r
Property Owner Parcel ID # Page of
Boring #
E] Boring
Ja Pit Ground surface elev. ft. Depth to limiting factor 12-4 n.
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
Z S s i , Z.,
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
❑ 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 /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
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)
' Soil Test Plot Plan
Project Name Earl Belisle Sha 4j
Address 1719 County Road I
Somerset Wi 54025 TM #226900
Lot ----- Subdivision ---- - -- Date 5/29/01
SE 1/4 SE 1/4S 3 T 30 N /R W Township Somerset
❑ Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of well
System Elevation 93.5/93.0 *HRP Same as Benchmark
Alt. BM Bottom of Siding @ 101.4' Well * B.M. Existing 3
Alt. Bedroom
Trailer
50'
30'
B -1 25'
4% System elevation is
a Slope 5 to be set 6'
Below Grade
B -3
0
0 5 ,
B -2
300'
40'
99'
700 100'
170th Ave
1
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
OWNERSHIP CERTIFICATION FORM 71
Owner/Buyer
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number cJc -
LEGAL DESCRIPTION
Property Location n /,, %,, Sec. �, T N -R/ .W, Town of- 5
Subdivision Lot ## r
Certified Survey Map # __ __ , Volume Page #
Warranty Deed # 3 ��� �� Volume S. . Page # 7
Spec house ❑ y! Lot lines identif aW.-I�f 0 no
SYSTEM MARUMN — AMEE
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, journeyman plumber, restrictedplumberor 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 bees maintained must be completed and returned to the St. Croix County Zoning Office within 30
days � e three ye 7ti date.
n- / & 1', A
SIGNATURE OF APPLICANT 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 erty describ b ve, b virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE 01T APPLICANT DATE
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
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Eff luent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
Shaun Bir. #226900
i
t:
s
DEED
'41
WHEREAS [ A. F. Yoerg, having been appointed Personal
Representative of the Estate of Josephine Benson, who died
May 11, 1975, a resident of St. Croix County, Wisconsin, and, I
WHEREAS, in my said capacity I have entered into a.
contract for the sale of real estate hereinafter described with
Earl Belisle, Grantee, and, '
WHEREAS, all the conditions of said contract have been
fully performed and the purchase money has been fully paid
according to the terms thereof;
NOW, THEREFORE, 1, A. F. Yoerg, in my capacity of Personal
Representative aforesaid, by virtue of the power and authority
in me vested, and in consideration of the sum of Sixty Thousand
($60,C00.00) Dollars to me in hand paid by the said grantee,
the receipt whereof is hereby acknowledged, do hereby sell anu
convey unto the sa -d grantee, his heirs and assigns, all of the
following described real estate in the County of St. Croix,
State of Wisconsin, to -wit:
Northeast Quarter of Southwest Quarter and
Northwest Quarter of Southeast Quarter and
Southeast Quarter of Southeast Quarter of
Section 3, Township 30 North, Range 19 West,
containing 120 acres, more or less, excepting
therefrom railroad right of way, subject to
50% of all rights in any and all oil, gas and
other minerals in or under the foregoing described
land, with such easement for ingress, egress and
use of service as may be incidental or necessary
to use of such rights.
IN WITNESS WHEREOF, I, A. F. Yoerg, as Personal
Representative aforesaid, have hereunto set my hand and seal.
this .I;Z._ day of May, 1976.
( SEAL)
A. F. Yoe Representative
of Estate of Josephine Benson,
Deceased. tai
r Wd, for tiewre this 17th
& of June A.D. t, �6
df
800 n.
r I
James O'Connell
�.....
ftpAhr' d Ow /__
- Ca a ,te.t gees
-deputy
n
M
IF
VOL lW►37 F1;I
It STATB OF WISCONSIN) i
ss
j ST. CROIX COUNTY )
i
On this /' .4 day of May, 1976, before me personally
appeared A. F. Yoerg, known to me to be the Personal Representative
of the Estate of Josephine Benson, deceased, late of St. Croix
County, wisconsin,mentioned in the within conveyance, and
f
acknowledged that he executed the same an such Personal �
Representative, freely and voluntarily, for the uses and purposes;
therein expressed. i
Hugh F. Gwin, Notary Public i
State of Wisconsin
0 0. My Commission is Permanent
� 1%,This instrument drafted by:
4 .
�M Hugh F. Gwin, Atty.
Hudson, Wisconsin
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ST. CROIX COUNTY
' - 652199
KATHLEEN H. WALSH
AFFIDAVIT REGISTER'OF DEEDS
ST. CROIX CO., WI
FOR ADD -ON PARCELS 'rte T y RECEIVED FOR RECORD
t -
�' >,.:' 07 -27 -041 8:30 AM
PART ONE '� °;�'' p
Rr. CEIVE0 ZONING AFFIDAVIT
EXEMPT D
P" 7 n Recording AS T COPY FEE:
STATE OF WISCONSIN COPY FEES 3.OQ
} S1 % :#
} SS Cp. cC* �!N71' Name and ReQWFEWEL 1E.00
COUNTY OF ST. CROIX } '- �N""'' "'r Fe..� ( QS �e R
% r� Iq c-t zd. L sawfk
Earl M. Belisle a /k /a Earl elisle - Sc r,,.e r$e {' W S4l
Name (Owner) Typed or Printed c3 3 ,2 — a 6).2 — '7 0 — 0 6 o
being duly swom, states under oath that: 0-3 a — Z2 o (a — 30 000
63 — ae ( — doo
Parcel Identification Number (PIN)
1. He /she is the owner /part owner of the following parcel of land located in St. Croix
County, Wisconsin, recorded in Volume S3R Page 571 Document
Number 333641 St. Croix County Register of Deeds Office:
A parcel of land located in the SE '/4 of the sE '/4 of Section 3 ,
T 30 N -R 19 W, Town of Somerset St. Croix County, Wisconsin
described as follows:
All that part of the SE31 lying NE of RR ex cent-
ME I o
2. The above parcel has had added to it the following p 9 I recorded in Volume
583 Page 80 Document Number Z St. Croix County
Register of Deeds Office resulting in a single parcel:
A parcel of land located in the SW '/ of the SE '/ of Section 3 .
T 30 N -R 19 W, Town of St. Croix County, Wisconsin,
described as follows:
All of that part of SWh of the_ ' lyin NEl of the RR
And a parcel of land recorded in Volume 538 Page 571 Document
Number 333641 described as follows:
A pwel of land located in the NW '/• of the SE ' /4 of Section 3
T N -R Town of St. Croix County, Wisconsin,
desc5he� os �'VT p art of the NWh of SE4 lying SE of the prop sed
HWY Deed recorded in Volume Pagr-961 li ucument Number
6 15411 recorded in St Croix Register of D eed s Office
voi.1,688 FACE 82
3. The addition is a transfer exempt from Chapter 18 of the ST. CROIX COUNTY
LAND USE REGULATIONS pursuant to Section 18.05 (A)(3).
4. The purpose of this affidavit is to notify the public of the addition and the
resulting parcel.
Signature * v`
Name (typed or printed) Earl M. Belisle
Signature LA
Name (typed or print d) Suzette J. Belisle
Signature
Name (typed or printed) Michael D. Belisle
Signature
Name (typed or printed) `
ACKNOWLEDGMENT
j" sT cuOA
State of Wisconsin, } '. COUW'
} ss.
sr, C K o Sc County.
Personally came before me, this aS�TJ4 day of J%4 4 )00 k the
above named
to me known to be the person who executed the foregoing instrument and acknowledge the same.
* 'E , hAti •,,
&NNIC J S��ft1V�ITZ Q7 p�aRj' r
Notary Public, State of Wisconsin
Commission Expiration Date ( 0 . aq 130O
t Names of persons signing in any capacity must bd�.f�� ftt,�elow signature.
This instrument was drafted by Earl M. Be
Print or Type -N
L? ..
r ------ 433.84' -
500.00
C.S. I. 128
N 5158
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' 0 3 L - Zo12 - - 1-0 - 600 I
3.3 b. I q . 518A
319.62
- �- LOT I
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S. M. 14/
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AVE NUE � _