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032-2032-40-110
Wisconsin bepartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 156 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: Fernandez, Guillermo T. I Somerset, Town of 032 - 2032 -40 -110 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range /Map No: 08.30.19.591 D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht outlet 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 BLDG 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 R No ❑ Yes 0 N]o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 1 Inspection #2: / / Location: 403 165th Avenue Somerset, WI 54025 (NW 1/4 SW 1/4 8 T30N R19W) NA Lo r Parcel No: 08.30.19.591 D 1.) Alt BM Description = i ! to �(p� l a 46M # D(J�d 2.) Bldg sewer length = J - amount of cover = V 4,(Lk. f , 46k Ile F Tinsepc W%, 0.. J� ti / I v Plan revision Required? Yes No L� Use other side for additional information. SBD -6710 (R.3/97) Date 's Si ture Cent. No. County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT p Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road l � Hudson, WI 54016 -7710 (715)386 -4680 Fax(715)386 -4686 Attach complete plans for the system on paper nhiNss than 8-1/2 x 11 inches in size. County Sanitary Permit # 61 0 Check if revision to previous application Application Information - Please Print all Informatio Location: Property Owner Name _/ 3 Gj 114 6014, Sec tpj d c30 N, / R W i Property Owner's Mailing Address NOV Z ' Lot NuPMN Block Number 5 6 03 —' W. � a 4 <U4X CC�Ui 1TY ( �J�/ ) City, State Zip Code PH66 Subdivision Name or CSM Number sy , s839 ��� zo 1 T yp Building: (check one) amity ❑ Village wn of 1S 1 or 2 Family Dwelling - No. of Bedrooms: fQO � ❑ Public /Commercial (describe use): ❑ State -owned Neares o d 1. Type of Permit: (Check only one box on line A. Check box on line B if applicable) LA Parcel Tax Number(s) A) 1 Repair [)<Reconnection 3. ❑Non- plumbing 4. ❑Rejuvenation Sanitation I 1 03Z- 2-032 - - Q B) Permit Number � Date Issued State Sanitary Permit was previously issued f 9 � X78 OG 08 Gal IV. T� POWT System: (Check all that apply) Non pressurized In Arou ❑ Mound 2 24 in. suitable soil ❑ Mound :5 24 in. suitable soil ❑ Mound A +0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating . Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals. /day /sq.ft.) (Min.Anch) Elevation i0OD /Z 66 / 5Z4 Al . S I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks A X410 GbC7 S ❑ ❑ ❑ ❑ S ❑ ❑ ❑ ❑ VII. Responsibility Statement 1, the undersigned, assume responsi ity for repair econnenction /rejuvenation /installation of non - plumbing for the POWTS shown on the attached plans. A license is not required for terralift re it or the inst lation of non - plumbing s Anitation system. Plumber's Name rint lumber' ignature W /MPRS No. Business Phone Number N d r 3c0 Z99- 7 Plumber's Address (Street, City, St ip Code) ezo ) scedCti COO 026 III. County Use Only ` / d Sanitary Permit Fee 77d Issui gent Sig tur s �d" Approved Owner ' en ' jal Adverse 6 /// 111 FD ination IX. Conditions of Approval /Reasons for Disapproval: Rev: 8/05 a 5 p � �/a -�vLfn cz l /ocv — Connec.�i�'� Ce-��, R Fl ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner�et' _ F -- d hfde V ,cr Mailing Address / /( vIC. Property Address 6a olltc (Verification required from Planning & Zoning Department for new construction.) City /State 1 ,s4ftLt, ,. set / Parcel Identification Number LEGAL DESCRIPTION Property Location 4U) I /4 , 5C,0 11 4 d , Sec. O ' T 3 0 N R /f W, Town of — P':6 Subdivision Plat: & , Lot # 3 Certified Survey Map # cgs 8S , Volume �v , Page # /&. Warranty Deed # -5 (before 2007)Volume / 0-39 Page # `/ Spec hous Lot lines identifiabl "yes.e-n� 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. I /we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 1L1�1� NT(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. 09/07) 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 G' C- y -R is e?uT,E S� 9 INDICATE NORTH ARROW ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Property Address City /State Legal Description: Lot - -3_ Block — Subdivision/ 1 /4.— -R t /4, Sec. _ ?, T_ _N Town of PIN # 0 ?-2 2 � —� SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Size ST/PC &wl Setback from: House U , Well �3S P/Lf 7Z' Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: ` ° k l Width Length Number of Trenches -51 Setback from: House Z --T - Well � P/L Vent to fresh air intake ELEVATIONS Description of benchmark 74A /"� �OL.✓A l.r Elevation Description of alternate benchmark Elevation Building Sewer ST/HT Inlet 97, 9 ST Outlet 9 7, g_, PC Inlet 99, .:�8 PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines (/) '7s s' (A 9 2 s'a (3) ,97 .f'/ 97. So Bottom of System f's Final Grade O O ( ) Date of installation P mit number State plan number Plumber's signature License number 3 Date /, —[clo Inspector Complete plot plan WTsbonsin Department of Commerce Count PRIVATE SEWAGE SYSTEM Safety and Buildings Division 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)]. 363825 Permit Holder's Name: ❑ City ❑ Village ❑ Xown of: State Plan ID No.: F ernandez, Guillermo T. Somerset Township CST BM Elev.:- r Insp. BM Elev.: t BM Descriptio Parcel Tax No.: � � , c) 032- 2032 -40 -110 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �1 Benchmark ,`E3 �_p r 9asinq� 2 �-� Alt. BM Aeration Bldg. Sewer Holding St/ Ht Inlet --� TANK SETBAC NFORMATION St/ Ht Outlet tp.o 8, TANK TO P / L WELL BLDG. Air Intake ROAD Septic SD (� r t J NA q)t �B. (a Ct , $3 Dosing O I r _' g � ` � Z NA Header /Man. Aeration NA Dist. Pipe Holding Bot. System to - a t ? 88 -ij PUMP / ON INFORMATION Final Grade Manuf turer mand St cover(e_*�' 8. Model Num er GPM S'�C � ,,, 7-0 qt?-30, TDH Li riction System T Ft ead For main Length Fi ist.Towei SOIL ABSORPTION SYSTEM 1Z� D 9�B�� RENCH ) Width I L ngth , N ..9f renches PIT No. Of Pits Inside Dia. Liquid Depth �!�' `� DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manua SETBACK `dC9.W INFORMATION TypeOf _ CHAMBER MadelNumber'. System: $ �D Sri > ICU 1 OR UNIT �t DISTRIBUTION SYSTEM Header / anifold N Distribution Pi e(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. th ia. pacing 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 #1:04 /ZT Inspection #2: — 1 - i Location: 403 165th Avenue, Somerset, WI 54025 (NW 1/4 SW 1/4 8 T30N R19W) - -Lot 3 1.) Alt BM Description = tV/ 2.) Bldg sewer length = (b • t. ( 0 , a� t 2 . s`{ - amount of cover = ? C��1 z . f 40. t tx- sq �3 ' I Gs 3 I z s� Plan revision required? ❑ Yes �(No Use other side for additional information. OS o L SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i S 4 E c t € 1 S € r E M. # # me e . m w. € i i ... _ z r a a a s 5 � e a „F i 4 s ,.,,...,. 4 ..... . a ..... ,... _ ..._ ...... .,.,,. .,. .,.,, E e E j # j i s E.... � .. ,. ,®®..e t_ . _ .....� _... ,� e .. ., ie 's m � r . .. . sm �r m_ c .mi . . 3 I N*is ; ons i Safety and Buildings Division SANITARY PERMIT APPLICATION 2 1 x ashingtonAvenue n Bo Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less county than 8 1/2 x 11 inches in size. ' • See reverse side for instructions for completing this application State sanitary Permit Number 6 9 S'Z Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Prope Own r Name Property Location _ 114 114, 5 T , N, R E (orYO Property Owner's Mailing Add r s Lot Number Block Number City, S to Zip Code Phone Number Subdiv lion Name or CLM Number ( ) Z Izvo II. TYPE F BUILDING: (check one) El State Owned it Nearest Road ❑ village Public 1 or 2 Famil Dwellin OF - No. of bedrooms Town 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo — - - 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 -------- System Tank Only Existing System 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 g Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill I�i�/�c y VI. AB S YSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation Feet Feet Cap acit y VII TANK in Ca g Total # Of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tank Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ I ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins Ilation of the onsite sewage system shown on the attached plans. Plumber's ame: rint Plum is ure: a p MP /MPRSW No.: Business Phone Number: 1 Plumber's Ad ress (S reet, ity, State, Z' Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) 'AApproved E] Owner Given initial �.- Surcharge Fee) 7V Adverse Determination 2 X. CON ITIOl'i APPROVAL / REASONS FOR DISAPPROVAL: () 4 .w4 ts� dZ,aa xA ---� tx4 ► l AdAt Int SBD -8398 (R. 4199) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, owner, Plumber 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 S. 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. I 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 isto be 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 tine 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. I 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 lank(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 th 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. /d0 a� ®-8 Aerl 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 emu; � „ ��(�,Q�)1�� residence located at: /, _I 1/, Sec. _ T - ?2N, R W, Town of r ` �E"hz,CC r 4 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 Did flow back occur from absorption system? Yes L No-- (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: � �-�— Construction: Pr ab Concret Steel Other Manufacturer (if known) : Age of Tank- if known) : r , (Signature) (Name) Ple se Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baff ) Signature Name ' MP /MPRS i WiscoMsin Department of Commerce SOIL AND SITE EVALUATION Nvision of Safety and Buildings Page _ of Bureau of Integrated Services in accordance with Comm 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 n - " , 'k percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel LID. # APPLICANT INFORMATION - 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 114 1 /4,S T N,R E (or& Property Owner's Mailing Address Loa;,3eJ4 loc # Subd. Name or ,G�#, 8 Cit y Statft Zip Code Phone Number d City Village )� Town Neares Roa ❑ New Construction Use: Residential / Number of bedrooms Addition to existing building 10 Replacement ❑ Public or commercial - Describe: Code derived daily flow 4�gj` gpd Recommended design loading rate bed, gpd/fF _, trench, gpd/ft Absorption area required �-T _ bed, ft ft Maximum design loading rate bed, gpd /ft , ,5 trench, gpd /ft Recommended infiltration surface elevation(s) 1 9.1 . 1 ft (as referred to site plan benchmark) Additional design/site considerations Flood plain elevation, if applicable Parent material ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ,® S❑ U 1 [4 S O U Z S ❑ U 1 YI S E U I [- [M U ❑ s ,M U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 N ,, in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 S' Ground elev. Depth to limiting Q'r factor Remarks: Remarks: Boring # u 9 3 G Ground elev. Depth to limiting factor >4!�__in. Re arks: CST Name (PI a Prin Signature Telephone No. 4 Address bat CST Number '�' fir/ >, SOIL DESCRIPTION REPORT ` PROPERTY OWNER , L 2 Page of PARCEL I.D.# ?V - Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench ... '� Ground 3 elev. Depth to limiting factor ; Remarks: Boring # Ground elev. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles 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. n. Depth to limiting factor in ' Remarks: SBD -8330 (R.9/98) � 1 ,D�', Jka,Aac .Bm 60 �o �8� ST CROIX COUNTY SLID IC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer -ZL " Mailing Address Property Addres -� (Verification required from Planning Department for new construction) City /State Parccl Identification Number =, 2r9�,2 3a .14. ST�I�d LFG AI, DESCRIPTION Property Location JL 'A, '' /a, Sec. _� , T � N -R Town of H, •� � Subdivision Lot # Certified Survey Map # Volume r , Page # Zz- r1 Warranty Deed # - 5 - 2 e, ( n , Volume Page # Spec house 0 yc.r no Lot lines identifiablex O no 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 agrecs to subriui to St. Croix Zoning Department a certification form, signed by the owner and by a m;tsiei plumher, )ourncynian pluniber, resmciC plumhcr ur a Licensed pumper verifying that (1) the on-site wastewater disposa! syvern is in proper operating; condition and or (2) alder inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludgy. 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. Certtficat on stating that your septic system has been m;iinicuncc! must he completed and returned to the St. Croix County Zoning Office within ;0 days of the three car expiration date. r•'/ 1 �� SIGNA F AP NT DATE OWNER CERTIFICATION 1 (we) certify that all statements on this form are tnic to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described ahov , by v rtuc ol' a arranty deed recorded in Register of Deeds Office. / SIGNATUR ; F APP A l' DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department '• "'• •* Include with this application a stanipcd \� arranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed .r .� ., . s . -.. ... -.. . !' T"1• s► ACS RgpgaYaD I" 119CO11DIMe DATA DOCUMENT NO. " STATE BAR OF WISCONSIN FORM 1 -190 ( i WARRANTY DEED f w 50 This Deed, made betwemt ................. Ilsati..I._. vac- �1d. Gtr3( 1.],.. Kctktiohtt ,_i.atixe.._..._........ 'tec'Q�orReoad � I .. ........ fllr✓a_ Cheryl.D.._1( about... husband- sx>slmlfe. .................. .. (' , Grantor , SEP 3 0 1933 j and .... illerm? T. Fernandez and Marx Bratager Fernandez,.. 113 A. �( husband and. vife.......---• ........................••---...... ....- •- .................. .......................... Grantee, Witnesseth That the said Grantor, for a valuable consideration...... –_ -_ — tt{{ conveys to Grantee the following described real estate is - _- St GLOX, _ -• - i! County, State of Wisconsin: I c ! � Tax Parcel No: -y¢- i( Part of the NW1 /4 of SK1 /4 of Section 8o Township 30 North, Range 19 West, St. Croix County, Wisconsin described as follows: Lot 3 of Certified Survey 1 Map filed January 16, 1983 in Vol. 11 6 ", Page 1620, Doc. No. 408585. r p til I EM I( This ........ 1- ................. homestead property. (is) (is not) t i Tt-gether with all and singular the bereditaments and appurtenances thereunto belonging; I� And ---- Dean - I .- Latirsen and Cheryl D. - Rohout. Lain sen f/lc(a- Cive>Y1 D Kohout ' ws °x'anta that the title is Qood, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights - of - dray of record, if any. l i t" and will warrant and defend the same. 11 Dsted this ...._... .................. day of SePtembe.........- ._....... ' % .4 ... . (SEAL)... .. •(SEAL) Jean T. Laursen Che D. Laursen •--- • - •-- • - • - •--- •------ • - -• -- •-------- ... •------ •---- •.•••. .. - - : � fCo (SEAL) •-•-------------------•------• --- --... .(SEAL) y .... ...... ... . ..... .............. ...... .. ................... • AQTSBNTICATION ACSNOWLBDGMBNT Signatures _ Des _ I Lauri! _. c 1X1 STATE OF WISCONSIN D. t Coarsen fa Cheryl as. ........................................ - --- County. authenticated this d y of__ Y....... 19.93 Personally came before me this _........._.. ---day Of ----- -- ---- ---.-_---- --- -._._, 1 19 ........ the above named ....-- - -•... .1 -------- •--------- ------------ - - - - -- .....----- ....•....... � ltristina Oglend ....................•----------- ••--------- _.._.....__ -_ . ..... .......... •- •------- - - - - -• ----------------------- ........._.._..... - ' TITLE: MEMBER STATE BAR OF WISCONSIN •-------------------------------------------------------------------- (It not. ------- ------- - - - - -- .......... ....................... ----....--•----•----•••-•-•-•----•------....__.. _..-- •••- ......-•- °............ authorised by 1 706.06, Wis. State.) to me known to be the person ............ who executed the foregol,lg instrument and acknowledge the same. THIS INSTRUMENT. WAS DRAFTED BY Kristin Ogland ................ ............................................................... = ------------ -_ .... ............................... Attorneyat I,ai+ ....................: ....................................................... ..._...°------••------.... ...................... .•--- -- •-•-•---••--- ------•• -•- Nctary Public .......................................... County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration ' are not necessary.) date: ............ ............................................ 19 ......... rNars.v of persons signing in any eapaeity should be typed or printed be!aw # -::r signatures. it }- r , , IWASAANTT DR= YY:•:POR Slink Co. Ins. M ML WISCONSIN mil..aukoe WY. /919'9 408553 �1�1986 Lo CERTIFIED SURVEY MAP j OINT OF 8EG1 NN 1NG Located in the NW 1/4 of the SW 1/4 of Section 8, T30N, R 19W , Town of Somerset, St. Croix Co. W 1 /4 CORNER Surveyed for: John Walsh, Rt. #1, Somerset, WI SECT 8 _ UNPLATTED LANDS , ' N 89° 54' 36 E 783.53' E I/4 CORNER Q ..L HI ROAD 33 N89 54 36 756.15' A -(� SCALE IN FEET. 1�� -200 1 19 90 RIGHT OF WAY LINE \8 /9. 5.98 ACRES \OO 1 0 1.00 200 300 500 p� F e's 260,356 SQ. FT. LEGEND IC EXCLUDING RIGHT OF WAY r (n io LOT �w COUNTY SECTION.CORNER c �-<°',;? o :'' 51 • 1 PIPE FOUND I 68 ACRES ° c .2 W n 11 11 T 297,258 SQ. FT. '� LV�� O 1 X 24 IRON PIPE WEIGHING � INCLUDING RIGHT OF WAY ', 1.68 LBS. /LI N. FT. SET -n o m o �v 41� N 89 54' 36 E 853.39' ° A �D 4 820.,39 Al ` `C �r ~�t- z + eg o 10.00 ACRES o \z m n /g. 4 0 35 60 ggpp. T \\ c�a m IN i o / g 8• 1N1dLUDING IGHTOFWAY HO USE �1-c 1 z � I � Z � 'O E A � 1 0 I LOT 2 N 10 zrn rn n a I 9.63 ACRES eAr �" �c m 419, 401.56 SO. FT. 1 3 z I EXCLUDING RIGHT OF WAY c 0 1 4 I O \I 896.24 m 33 g 89° 54 36"W 929.24 Om UNPLATTED LANDS_ '� m JAM 141996 o M ST. CROIX COUNTY SW CORNER SECTION 8 D ESCRIPTION PARKS PLANI AND ZONING COMMITTEE A parcel of land located in the NW J/ 4 of the SW 1/4 of Section 8, T 30N, R 19W, Town of Somerset, St. Croix County, Wisconsin, described as follows: Beginning at the W1/4 corner of said Section 8; thence N89 0 54 1 36 "E (assumed bearings referenced to the monumented EAST-WEST 1/4 Section line of said Section 8,bearing N89 "E) 783.53' along said line; thence S 10 °24' 11 "E 869.81' along the West line of that Certified Survey Map recorded in Volume 5, Page 1325; thence S8P54'36 "W 929.24' to the West line of said SW 1/4; thence N0 "W 810.47' along said West line to the point of beginning, containing 732, 858 sq. ft. (16.824 acres), and being subject to town road easement over the Westerly 33 and also subject to a utility easement to provide electrical service; and also subject to any other easements, restrictions and cove- nants of record. I,, James E. Rusch, registered Wisconsin Land Surveyor, do certify that I have surveyed and mapped the above described property; that such plat is a true and correct repre- sentation of the exterior boundaries of the land surveyed; and that I have fully complied with the provisions of Chapter 236.34 of the Wisconsin Statutes and the St. Croix County S �linance the best of my professional knowledge, understanding and belief. A mes E. Rusch Wisconsin Land Surveyor S -1376 �QJ►G�NS� * 5. WX 421 Second Street ��i Hudson, Wisconsin 54016 .DAMES E. I lk RUSCH * z; September 21, 1983 $10 4: Volume 6 Page 1620 1 O LL This Instrument drafted by John Larson ° ��ij�suvk �eee 483 - 43' J Parcel #: 032 - 2032 -40 -110 08/14/2006 10:04 AM PAGE 1 OF 1 Alt. Parcel #: 8.30.19.591 D 032 - TOWN OF SOMERSET Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - FERNANDEZ, G T &MARY BATAGER G T &MARY BATAGER FERNANDEZ 403 165TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 403 165TH AVE SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 6.820 Plat: N/A -NOT AVAILABLE SEC 8 T30 R19W NW SW LOT 3 CSM 6/1620 Block/Condo Bldg: Tract(s): (Sec- Twn -Rng 401/4 1601/4) 08- 30N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 1038/47 WD 07/23/1997 820/389 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.820 67,100 292,300 359,400 NO Totals for 2006: General Property 6.820 67,100 292,300 359,400 Woodland 0.000 0 0 Totals for 2005: General Property 6.820 67,100 292,300 359,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 12/02/2005 Batch #: 05 -56 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 f1 If 0 el 408 i�fi fi�ga 6 CERTIFIED SURVEY MAP DINT OF, 8EG1 NN ING Located in the NW 1/4 of the SW 1 /4 of Section 8, T30N, R 19W , Town of Somerset, St. Croix Co. W 1 /4 CORNER Surveyed for: John Walsh, Rt. #1, Somerset, WI.. T30N,OR19W ' PLATTEO LANDS E 1/4 CORNER 890 I¢ N 54' E . , E . PILL ROAD 33 N89 4` 36 "E 756.15' a -t, SCALE IN FEET I =200` 1 8 90 RIGHT OF WAY LINE - �0 0 0 1.00 200 300 g 5.98 ACRES \0 500 e, 260 35 6 o FT. �r LEGE�D �� w XCLUDING RIGHT OF WAY O LOT 3 �n 11� COUNTY SECTION;CORNER o of • I PIPE FOUND Z ° _ 6.82 ACRES �q W o n �� -o 297,258 SO. FT. '�. N��^ O I X 24 IRON PIPE WEIGHING �> INCLUDING RIGHT OF WAY I , 1.68 LBS. /LI N. `FT. SET I � M � N 89° 54' 36" E 853.39` t^ old 820.39 �, ' N . 8 D _ tk G i� �11 I ;�90� 10.00 ACRES Oo ( �� rn1< cn n m 435 600 z i I o P..FT. 0 D rn n IN I �_ I / . <' IN t RIGHT OF WAY 1-c ,�, I+� l o z 1 ,' 1 � G �f 4 u' Z m O L 2 '" �� M -n I o I� 9.63 ACRES BAS �_ �G D � 419, 401.56 SQ. FT. l c Co M z ,I EXCLUDING RIGHT OF WAY 0 C to O 896.24` Z 33 S 89 54 36 W 929.24 1 o m UNPLATTED LANDS_ ltCn Ln P m JAM 141986 0 - m� ST. CROIX COUNTY SW CORNER SECTION 8 DESCRIPTIQDA PARKS PLANNING AND ZONING COMMITTEE A parcel of land located in the NW 1/4 of the SW 1/4 of Section 8, T30N, R 19W, Town of Somerset, St. Croix County, Wisconsin, described as follows: Beginning at the W 1/4 corner of said Section 8; thence N89 0 54'36 "E (assumed bearings referenced to the. rnonumented EAST -WEST 1/4 Section line of said Section 8;bearing N89 "E) 783.53' along said line; thence S10 "E 869.81' along the West line of that Certified Survey„ Map recorded in Volume 5, Page 1325; thence S89 "W 929.24' to the West line of'`i3aid SW 1/4; thence N0 "W 810.47' along said West line to the point of beginning, containing 732, 858 sq. ft. (16.824 acres), and being subject to town road easement over the Westerly 33 and also subject to a utility easement to provide electrical service; and also subject to any other easements, restrictions and cove- nants of record. '- I, James E. Rusch, registered Wisconsin Land Surveyor, do certify that I have surveyed and mapped the above described property; that such plat is a true and correct repre- sentation of the exterior boundaries of the land surveyed; and that I have fully complied with the provisions of Chapter 236.34 of the Wisconsin Statutes and the St. Croix County SAdivision O inance the best of my professional knowledge, understanding and belief. A mes E. Rusch W Land S urveyor 5 -1376 42 1 Second Street Hudson Wisconsin 54016 • i JAMES E. ,�, 3 RUSCH September 21, 1983 s,9 � O Volume 6 Page 1620 ♦ � � This Instrument drafted by John Larson au 483 -435 °-g' Form S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ��� �/Q a , TOWNSHIP ��� { r S SEC. N -It - W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION �jl �/` LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r � vow f s 5 � r3 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ��, ���Ctc����� % Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: A' Liquid Capacity: /O -co Number of rings used: e _ Tank manhole cover elevation: l�y� Tank Inlet Elevation: - 5 Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side, Rear, 0 /5 feet / From nearest property line : // Front, 0 Side 1 0 Rear, 0 /SO feet Number /of feet from: well A l p , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank), SEE R.RVFRSE RTnE I PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property lines Front, 0 Side, 0 Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: ,�� Len$th: Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, Pt. Number of feet from well: Number of feet from building: (Include s o distanc n of plan). �eot t-7A -0 _ O �� SEEPAGE PIT �' 6 - 4 y '--� �/ Sizes Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, QRear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: i c Inspector: Dated: Plumber on job: License Number: 3/84:mj l ' I ' r INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS p�pp,RTMEN(AN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION LAgOf' '� BUREAU OF PLUMBING ,.ON, WI 53707 P4,St,,S8,T3ON -R19W C ONVENTIONAL 1:1 ALTERNATIVE State Plan l.D.Number (If assigned) Town of S . Somerset ❑ Holding Tank El In-Ground Pressure ❑ Mound 165th Avenue NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA Dean Laursen /Cheryl Kohout 330 South Knowles, "_Iew Richmond, WI 54017 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. J N,me of Plumber: MP /MPRSW No.. County: Sanitary Permit Number: Byron Bird Jr. 3318 St. Croix 119503 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: I = D IN E G LABEL LOCKING COVER D: PROVIDED: OYES ONO I DYES ONO BEDDING: I VENT DIA.: 7TIE. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH ALARM. FEET FROM LINE: AIR INLET: DYES ONO OYES ONO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP /SIPHON MA NUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO OYES ❑NO I DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER DF PROPERTY WELL BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I 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: �y WIDTH. LENGTH I N OF DISTR. PIPE SPACING: COVER INSIDE DIA. . #PITS: LIQUID EL7�fT E TRENCHES- MATERIAL: PIT DEPTH, GRAVEL DEPTH FILL DEPTH DISTR. PI PE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBS O PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER. ELEV. INLET. ELEV. END. PIPES. FEET FROM '' LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES 1:1 NO DYES LINO LEN H OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED: MULCHEDER EDGES. DYES ONO I DYES ❑NO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER. TRENCHES: °I. MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR, JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.. ELEV.. DIA.. ELEV: PIPES. DIA.: 'EI�VpT� ©N L?S`Fii3U"flEll HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED tF13R14A�T IC3N PLANS: OYES ONO OYES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: BF PROPERTY WELL: BUILDING: F EEI LINE: ❑YES 1 NO [:]YES ❑NO ' NfAl#EST � „� 2�( J Sketch System on r Retain in county file for audit. Reverse Side. 40 SIGNATU TITLE: DI LHR SBD 6710 (R. 01/82) . �' Coning Administrator SANITARY PERMIT APPLICATION 4 DIHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY L STATE SANITARY PE IT # —Attach complete plans (to the county copy only) for the system, on paper not less than P I C/��� 8% x 11 inches in size. ❑ Check if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION – PL ASE PRINT ALL INFORMATION. PROPERTY OW R GYM/ ® PROPERTY LOCATION Ay ,G u , r 4 /a %a, S T d, N, R E (or PROPERTY WNER'S MAILING ADD d 1 6T# BLOCK #, u1 (e e /C- a," CITY, STATE ZIP CODE PHONE NUMBER SUBDlVlSlOf4 NAME OR CSM NUMBER /��� o - G irr 11. TYPE OF BUILDING: (Check one) 1 State Owned VI LL AGE ! OTC ` EAREST OAD UL ❑ Public or 2 Fam. Dwelling # of bedrooms PA RCEL TAX N B () 030 III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 El Medical Facility/Nursing Home 10 El 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 in line A. Check line B if applicable) A) 1. � New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 El Specify Type 41 El HoldingTank 12 Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill 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 _Q REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) y 7 /, ELEVATION Feet , Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdina Tank Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's ame (Print): I Plumber's 'nature: (No Stamps) MP /MPRSW No.: Business Phone Number: Plum er' Address (Street, City, tats, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY `{ ❑Disapproved Sanitary Permit Fee ncludes Groundwater ate sssu / I Agent Signature (No S7k _,41_j JLV' / �� Surcharge Fee) �U �� ! I� w A Approved ❑ Owner Given Initial UCIJ, Adverse Determin ti n X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ` 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the 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 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 & Buildings Division, 608 - ?66 -3815. 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 be 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 in 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 in ##1 -7. VII. Tank information. Fill in the capacity f o ever new and /or existi tank list the total gallons, P tY Y 9 g s, number of tanks and manufacturer's name. Indicate retab or site constructed st ucte n tank d a d a k material. P 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% 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, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) + APPLICATION FOR SANITARY PERMIT STC -100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropr deed recording. ----------------- - - - - -- - - - -- .Owner of P ro- pert - - - - -- y V1 Location of property w 1/9 C�� 1/9, Section , T �_ N -R_L _W Township a C Ste. Mailing address 33� �� n0� 9 -S Address of site '/ b .� �� �? Subdivision name Lot number Previous owner of property Total size of parcel D $ Date parcel was . created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes - -No Volume O La ( �) and Page Number .-,22 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. 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 dee a rded in the. Office of the County Register of Deeds as Document No. Est; Z* \ 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 m ncon uction of sai system, and the same a been duly recorded in he Of fice of th County R g er of Deeds, as Docum nt Si ature ot ner Signat a Co Own r ( Applicable) Date f S7natdr4 Date f Signature DOCUMENT NO. , J�J V Q(] Q � STATE BAR OF WISCONSIN — FORM 2 BOOK V2O PA AuE WARRANTY DEED 440GSu i THIS SPACE RESERVED FOR MCOROINO DATA John E. Walsh a single man, REGISTER'S OFFICE ST• CR01X M, W1 1 Recd for Record ........... . conveya,artd warrants to Dean aursen an er o out Air, 1988 as point tenants an not as tenants in common at 8:30 A M tZepNhlr Of Dees Affrum TO the following described real estate In _ St- C rn i Y County, State of Wisconsin: Part of the NW;.- of SW- of Section 8 -30 -19 described as follows: Lot 3 of Certified Survey Tax Key No. Rap filed Januarx 8 6 8 1983 in Vol. "6" , Page 1620, cument No. i SAN SFER FEE ! 'i This is not homestead property. (la) (is not) Exception to warranties easements of record Dated this 16th day of August ,198 (SEAL) ohn Walsh (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGEMENT Signatures authenticated this day of STATE OF k9aOMif MI LANES TA Washington County. Personally came before me, This 16th day of • August 19 _8 L 8 TITLE: MEMBER STATE BAR OF WISCONSIN (If not, the above named authorized by § 706.06, Wis. Stets.) John E. Walsh This instrument was drafted by John E. Walsh, Attorney at Law P.O. Box 142 Stillwater, MN 55082 -0142 to me known to be the person _ who executed the foregoing In- (612) 439 -4695 strums" nd acknowl dged the ame. 1 (Signatures may be authenticated or acknowledged. Both are not necessary.) Grace K. Wakel i n , as in ton Notary Public g Count 4111 •Names of parsons signing In any capacity must be typed or printed below their signatures. y� My Commis !ration date: GRAU 19 .) WARRANTY DEED — STATE BAR OF WISCONSIN, FROM NO.1 1977+ jj STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER ROUTE /BOX NUMBER O n FIRE NO. \ e �� ZIP CITY /STATE `\ V vJ 0 PROPERTY LOCATION: 1/4 S 1/4, Section T N, R 1�_ W, Town of St. Croix County, Subdivision �� W to P, No. 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning 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 (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St. roix County Zoning Office w' in 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address INDUS TIC . OF REPORT ON SOIL BORINGS AND S AFETY &BUILDINGS IAL'DUS�f#Y� DIVISION LABOR AND PERCOLATION TESTS ( MADISON WI 79 HUMAN RELATIONS (ILHR 83.090) & Chapter 145► LOCATION: SECTION: — lwr P/ UNICIPALITY: r OT NO.:BLK. NO.: SUBDIVISION NAME: 1 /4 � IT ; AI I E (o COP T /tppy �4 MAILING ADDRESS: / /� (�HDIjC _¢Qt Gc Y c O ! C o p USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: A TS: Residence .�-�+• New ❑Replace ��� G ��� RATING: S= Site suitable for system U= Site unsuitable for system ' O�TIO � . M� �. �� IN G�� ❑� RE: SYSTEM -IN -F OD ID1 V ING T :RECOMMENDED SYSTEM: (optional) S U ILL SS 6 7 E DESIGN RAT: If Percolation Tests are NOT required DES I If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: Floodplain, indi Flo elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1d yc B- PERCOLATION TESTS TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I AFTER SWELLING INTERVAL -MIN. PE RIOD 1 PERIOD 2 PERIOD PER INCH P- P- P- 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. � �, 1 ,�' �= • r r r SYST M ELEVATION � �' E-( p '67. L f _ i __F -� �I N E 6� G r8�3 — ; — _ A _ a i oe 3 ��. . [ ( a lei 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. 1 NAME print TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): /- O T ✓ I CST SIGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. i DILHR -SBD -6395 (R. 10/83) — OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; B. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over 10 ") BR — Bedrock cob — Cobble (3 - 10 ") SS — Standstone gr — Gravel (under 3 ") LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Precolation Rate med s — Medium Sand W — Well fs — Fine Sand Bldg — Building Is— Loamy Sand — Greater Than 'sl — Loamy Sand — Less Than 'I — Loam Bn — Brown 'sit — Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay fff — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water Six general soil textures BM — Bench Mark for liquid waste disposal VRP — Vertical Reference Point 4N.. TO THE OWNER: This soil test report is the first step in securing a sanitary permit The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. CA 0 P LAN e r�r� 040 tL� ' PROJECT to r en ADDRESS GJ1 /4 1s 1 /4 /S ,7O N /Rl W TOWN a� OUNTY PRS Byron Bird Jr. 3318 DA E BEDROOM CLASS PERC_.Z CONVENTIONAL IN -GR ND PRESSURE CONVENTIONAL LIFT MOUND_ HOLD NG TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE 10 HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE Benchmark V.R.P. Ass me Elevation 100' Location of Benchmark C Borehole Well Scale = Feet O Perc Hole v�� System Elevation a a TYPAR COVERING 2• 12" 3' 142 6' 3' 3' 3' 6' Sewer Rock 18' 12' o &0 .O i pro - a i