HomeMy WebLinkAbout032-2051-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
' INSPECTION REPORT Sanitary Permit No:
420564 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal infornfation 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:
Schaeffer, Mar Somerset Township 032-2051-30-000
CST BM Elev: Insp. BM Elev: IBM Description: •
I LV-s I ICD D 6
TANK INFORMATION V ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
nu � - 3'� ►o �.3 far' o •
Dosing _ Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
I r
TANK SETBACK INFORMATION St/Ht Outlet l i'.3 3 90 • o l
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic `SV f ' (00 z �� Dt Bottom
Dosing Header /Man. �• 3
Aeration Dist. Pipe I I
tz 8R• 3`f
Holding Bot. System
. 12 .441
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer - ' _ Demand �St Cover
GPM ( cjy - �1
Model Numbe
TDH Lift iction Loss System Head TDH Ft
Forcemain length ell
SOIL ABSORPTION SYSTEM �S
BED /TRENCH Width Length f No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 93 '+� Z
SETBACK SYSTEM TO 1 P/L JBLDG IWELL LAKE /STREAM LEACHING Manufactu r. rIr
INFORMATION CHAMBER OR ' I�T� aJ
Type Of System: ,� S� (DD I UNIT Model Number: I
it
DISTRIBUTION SYSTEM
Header /Manifold IDistribution ole Size x Hole Spacing Vent to Air Intake
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 Mulc ed
Bed/Trench Center Bed/Trench Edges Topsoil
Yes D11 No Fw] Yes F
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: . dL Inspection #2:
Location: 784 150th Street New Richmond, WI 54017 (SE 114 SE 1/4 14 T30N R 4 13W) NA Lot Parcel No: 1 .30.19.688K
1.) Alt BM Description= wSe_ 5 T_ Nw, Q der
2.) Bldg sewer length = 2(o r
- amount of cover = � (. It
Plan 3) .�b•�Q. �- -Its �:
revision Required? Yes No
Use other information.
side for additional
SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No.
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
`Nvirsco Personal information you provide may be used for second purposes Madison, WI 53707 -7302
Department of Commerce P (Submit completed form to county if not
rivacy Law, s. 15.04(1)(m)j
``� •' �` 3 a3 state owned.)
Attach c omp l ete plans (to the county cop only) for the system, on paper not less than 8 -1/2 x 11 inches in size.
County State Sanit4ry Permit Number ❑ Check if revision to previous application State Plan I. D. Number
i5/ -d - X
I. Application Informati - Please Print all Infor ifiation Location: - 7 , 91 S'p
Property OwnerNam� Property Locattiio-n /�-.�
Z , 1/4 G�1/4, S�' d,N, I (or
Property Owner's Mailing Address L-► V Lot Number Block Number
, 5 - 4 _ / b 7Ll7 Caw,` LO-T ( ' /&
City, State Zip Code hone !" er 1 1, Y U t Subdivision Name or CSN Number 3:1-4
II. Type of Building: (check one) i ❑ City
❑ Village
V or 2 Family Dwelling - No. of Bedrooms :_�)CI S?1� own of
❑ Public /Commercial (describe use):_
❑ State -Owned
Nearest Road S?� 73
Parcel Tax Numbers
III. Type of Perm (C heck o ly one box on line A. C heck box on line B if app icable)
A) 1. ❑ New 2. 9KReplacement 3. ❑ Replacement of 4. 5. 6 ❑ Addition to
System System Tank Only Existing System
$)
13 Permit Number Date Iss ed
A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply) �y� j
on- pressurized In- ground ❑ Mound ❑ San Filter / Con� d 3 / / f
Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
g P
❑ At -grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: 2 W h
V. Dispersal/Treatment Area Information: "g S
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area }, 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed 33 �t' Rate (Gals. /day /sq. ft.) (Min. /inch) 71 _ /c ` 0 Elevation
/I o
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New I Existing crete structed
Tanks Tanks /
e
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Y!ltmp ame (print) Plumber' ignature (no stamps): MP/MPRS No. Business Phone Number
Plum e ' A dress (Street, City, State, Zip Code
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssued Isg6iing Ag Signal ure stamps)
U Approved 11 Owner Given Initial Adverse Surcharge Fee) n Uv Q
Determination 2 /
X. C nditions of Approval /Reasons for Disapproval: .33
SBD -6398 (R. 07/00)
PLOT PLAN
PROJECT mar Schaeffer ADDRESS 784 150th ave NewRichmon WE 540 17
SE 174 SE 1/4S 14 /T 3 � N /R 19 W TOWN S Somerset COUNTY ST. CROI
11 -11 -02
MFRS Byron Bird Jr. 2205 DATE BEDROOM
CONVENTIONAL XXXX rade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gal LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RAT 5 ABSORPTION AREA 900 # of chambers 30
BENCHMARK V.R.P base of sideing ASSUME ELEVATION 100'
❑ BOREHOLE O WELL •H.R.P. same as Bm
j2T, ent SYSTEM ELEVATION T- 1 = 88 .4T -2 =87.8
S�i�ind�Iigh
eapaeity Leaching Chamber with 17.2 d 3 1 . (
t ^2 ch per amber
16, Grade at System
Long 34" Elevation
150th ave
way
3 bed house
garge q15 46'
ell
st
40' V 40' 2
Failed s p 'c
3 3 1
�Yt
94 Li
' O /
91' 100' P,'
> 100' to PL
B3 B
O ob pipe
>1 ♦ �rdA�S,►2
aila1.....7..
PLOT PLAN
PROJECT mary Schaeffer ADDRESS 784 150th ave NewRichmond Wi. 54017
SE 1/4 SE 1/4S 14 /T 30 N/R 19 W TOWN S. Somerset COUNTY ST. CROI
' 11 -11 -02 BEDROOM
MPRS Byron Bird Jr. 22052-- DATE
CONVENTIONAL XXXX rade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gal LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE E3 LOAD RAT 5 ABSORPTION AREA 900 # of chambers 30
hk BENCHMARK V.R.P base of sideing ASSUME ELEVATION 100'
❑ BOREHOLE u WELL *H.R.P. ,same as Bm
Vent SYSTEM ELEVATION T- 1= 88. 4T -2 =87.8
> 12" v�h�iigh
O f
C ov aeity Leaching
Ce Chamber with 17.2 �0� 31. l �{- Z /C,�il�✓�
6" t ^2 per chamber
Long 349 Elevation
150th ave
ri way
3 bed house
garge 9 46'
ell 7
50 90'
st
40' 40' 2
Failed spp�ic
3C' 3 ' 1 O �L� �j�
94'
91' 100' Y3- 3 3
> 100' to PL
B3 B
O ob pipe
> 100f %� y ♦ ��� �
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings
in accordance with Comm 85,Wis. Adm. Code
/) 1 x
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must County ,sT' C1'C-
include, but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D.
percent slope,scale or dimensions,north arrow,and location and distance to nearest road. 3,2 —,2475/_ 3o__.cv-,
Please print all information./fr2-°..D 1 3 tG4)j,,A3 Re .y Date p
Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). I I�//0/1'?�
Property Owner P Locatio
/0 a y f Cl'J E' ,�1 ��" Govt. Lot 1/4��1/4 S A/ T.2 N R / 7 E(o ;'
Property Owner's Mailing Addres/ Lot# Block# Subd. Name or C M#
&7% ram._
City Stat, Zip Code Phone Number ❑City ❑Village �('Toown Nearest Road
/1, At rlJk>'2r"/ I '_S ✓71 (7Z5 ),. 9e O/":2 .`fie iv,e�_ >/�e' A I /J� 4.r" ..
I] New Construction Use:R'Residential/Number of bedrooms Code • gywpie //_L, GPD
replacement ❑ Public or commercial-Describe: Ra--GI1"'
Parent material ec>G applicable
�s Flood 4in elevation if a ft.
General comments �� / $ t / NO\I 1. 1 2O02
and recommendations:
7 2_ '5'7 / ST.CROIX000NTr
3,
ZONING OFFICE
c
/ Boring# ❑ Boring �y L
jg pit Ground surface elev. /1(ft. Depth to limiting factor2,7 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2
e)'''' - ,V;-vAr._. 03 67.7 ./,7/ ,d," /1,74 010 A.7 _
LO-7--? K ii
'1 Boring# El Boring
Pit Ground surface elev. / f ft. Depth to limiting factor Z4 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu.Sz. Cont.Color Gr. Sz. Sh. *Eff#1 *Eff#2
el,—0 /3 _,.(---,;,....1 ,),,,,,,yi
_ ,� � / al/* /� / G /� -s--
ii A97e / / / ' ��/ /�fJ// • z...„„5- /7— r '.
, 1,0 (Y'il /
Li Zit-2e/
*Effluent#1 =BOD5>30<220 mg/L and TSS>30< 150 mg/L *Effluent#2=BOD5<30 mg/L and TSS<30 mg/L
CST Na lease Print) o / Signature CST Number
V i" -,c'/ 1 , .,-O2/`'
Address
ate valuation Conducted Telephone Number
7, - Ge t. e— 441/',t- ` //s-//d )2/- i'/6/6
SBD-8330(R07/00)
Property Owner ' - ✓`"'L Parcel ID # Page y of
Boring # El Kring
R Pit Ground surface elev. ft. Depth to limiting factor y� in.
Soil Application Rate
Horizon Depth I Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
42, =
F-1 Boring # E] Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ Boring
F1 Boring # Ground surface elev. ft. Depth to limiting factor in.
El pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
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)
I
Soil Test Plot Plan 3/3
Project Name Mary Schaeffer Byron Bir Jr.
Address 784150th ave NewRichmond Wi.
5 4 0 1 7
CSTM 220527
Lot -- --- Subdivision ----- -- Date 11/1112002 County CROIX
S E 1 /4 1/4S 1 4 T 30 N /R W Townshi S. Some
Boring O Well PL Property Line# Alt. BM
,BM or VRP Assume Elevation 100 ft.Base of sideing
System Elv. T- 1 =88.9T-2=87.8 H.R.P. Same as Bm
150th ave
W ay
3 bed house
gage 9 46'
well 7
909
40' 40'
2' Failed septic
30 30 B O
91' 100'
> 100' to PL
B3 U B2
> 100' to PL
Wetlands
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page L of 71
FILE INFORMATION SYSTEM SPECIFICATIONS
F F ; n Septic Tank Capacity �v a l ❑ NA
# O 5- Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer K ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) gal /day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) 3 e9V9 gal /day Pump Manufacturer ❑ NA
Soil Application Rate - 6—gal /day /ft2 Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) <30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODd :_220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD :_30 mg /L In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :530 mg /L , NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 5 ° /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
* Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ earls) s) (Maximum 3 years) NA
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ nth(s) (Maximum 3 years) NA
[i r rear(s)
Clean effluent filter S �� At least once every: ❑ m th(s) ❑ NA 1 Z / j ear(s)
Inspect pump, pump controls & alarm At least once every: ❑ mo ❑ year(s) ) ❑ NA
❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: At least once every: ❑ month(s) ❑ year(s) ❑ NA
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of S12 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
Page v f
. START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another. inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
• A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
• A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLEP, POWTS MAINTAINER
Name ro ) < Name r r
Phone �� l� Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Dd'z j Name � G ro /� 4 f o h 11 a-r
Phone 5� Phone ��- to "W f-E
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST CROW COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
ovmer/Buyer /
Mailing Addresses
Property Address c r 1
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location Sec. T - N -W 'W, Town of �n
Subdivision + . A��°
Certified Survey Map # �t` . Volume — , .Page #
Warranty Deed # ; j . Volume f . Page #
4
Spec house ❑ yes jZno Lot lines identifiable yes ❑ no
SXBTEM 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 thesyst n
can affect the function of the septic tank as a treatment stage in the waste disposal system.
'The properly owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masWplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wasbewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than W, fidl of sludge -
Vwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal systepi with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.' Cadficetion
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three y
�
expiration date."
6
S1 41A F APP "IJ ATE
Y
OWNER CERTIFICATION
I (we) certify that all statements on this foam are true to the best, Of my (our) knowledge. I (we) ain d ! die oamet{s�f
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. ,
'2:. Kit
SIGNA OF LICANT DATBw M
« « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning bepartm
«« Include with this application: a stamped warranty deed fmm the Ngister of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
DOCUMENT NO. STATE BAR OF WISCONSIN -FORM 3
356 6 3'7 VOL 593 ' Ci � QUIT CLAIM R
»� TMs$ SPACE RESERVED FOR RECORDING DATA
REGISTERS OFFICE
Marvin Wirth and B a rice R. Wirth, his wife, ST. CROIX CO., WIS.
of N A w Richmond, Wisconsin 4t
_ Rec'd. for Record this
quitclaims to Gordgn Schaeffer and H ry Schaeffer, his day of M,%y A.D. 19 - 79
wife, of NewRichmond. Wisconsin at 9!3n A
the following described real.estate in St Croix County,
State of Wisconsin: RETURN TO
Township Thirty (30) North, Range Nineteen (19)._
West, Fourth Principal Meridian: In section fourteen
(14), that part of Gov't. Lot one (1) described as
ti follows: BEGINNING at a point on the south line of
said Gov't. Lot one (1) N. 89 ° 13'08 ", 613.90 feet from Us Vey No.
the southeast corner thereof; thence N. 1 ° 06'04" W., 482.29
feet; thence S. 88 ° 12'35" W., 421.98 feet; thence S. 1 ° 41'15"
E., 45.72 feet; thence S. 29 ° 13'08" E., 363.43 feet; thence S. 0
46'52" W., 417.43 feet to a point on the south line of said
Gov't Lot one (1) thence with said south line S. 89 ° 13'08" E., 72.00
r feet to the Point of BEGINNING, containing 1.16 acres, more or less.
i
This deed is given to correct an error in the description in a prior
If deed.
i
d
is not
This homestead property.
(is) (is not)
Dated this day of 19 �+
(SEAL) Marv Wirth
(SEAL)
(SEAL) Beatrice R. Wirth
) _(SEAL)
ti
r ,
AUTHENTICATION ACKNOWLEDGMENT
I Signatures authenticated this _day of STATE OF WISCONSIN '►
, 19 _ p/ . as.
County.�.
Personally came before me, this day of
the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(if
not,
authorized by § 706.06, Wis. Stats.)
This instrument was drafted by
I E.F. Shuda, Jr., U.S. Fish to me knowif fo the erson executed e
P ,.L w th e fore-
; and Wildlife Service going instrument{aind acknowledged the same.
Federal Building, Fort Snelling
Twin Cities- Minnesota 55111 Y "
(Signatures may be authenticated or acknowledged. Both NaaQLz*I1efAkk nty, Wis.
are not necessary.) My ,Commissiott is per mane f not, state expiration
date."
QUIT CLAOI DZZD —STATx BAR OF WISCONSIN, FORM NO. 3 -1977
• `U'''� w.rti� M�
a a �"�° r r { s a,.k tY 'i •? Y ,
P 56 87"10 TERMINATIONOF ECINT'S ,
PROPERTY INTEREST
DCCEDENT.i NAME
Gordon Thomas Schaeffer a /k /a Gordon Schaeffer
AOORESSOFOECEOENTAT DATE OFDEATM cm STATE LIP REGISTER'S O FFICE
784 150th Ave. New Richmond WI 54017 ST, CRtJIX CO rd WI nor tt;roN
DATE OF DEATH SOGAT SECURITY NUMBER NOV 2 0 1997
June 26, 1996 471 -32 -3397
PRESENTATION OF DEATH CERTIFICATE'
I certify that I hAve vi,;wed a certified copy Of 'he decedent's death certificate. L R g fw rt Q=
q,1re Nov. 19, 1997
REGISTER OF DEED'S SIGNATURE DATE
Interest In property is terminated under (please check appropriate statute): .Recording area
Name and return address:
x s. 867.045 which pertains to property in which the decedent was a joint;tenant' Mary Schaeffer
had a vendor's or mortgagee's interest, or had a file estate. '(You must provide a copy 784 150th Ave.
of the document establishing joint tenancy of Ile estate.)
New Richmond, WI 54011
s. 867.046 winch pertains to (1) property of a decedent specified in a marital
property agreement, and also to (2) survivorship mat ital property. (You must provide
a copy of the document establishing survivorship marital property.)
Presentation of recorded document establishing joint tenancy, III* estate,
survivorship marital property, vendor Interest, or mortgagee Interest In real estate. 032-2-51 PAICr►raNruMeFn
This document number is 2966 10 454 452
page 192 of (check one) Records X'-: .Deeds
3 - ZT — X
Description of the real estate.
Include on& the extent of cwaeabb !or vendor ormortaacee s Interest) to land at the time of the decedents death If th'64kerit of 6d is exactty
the same as on the document a copy of that document may be attachad to describe the real estate. The legal description of the property and the
persons receiving the pmpcity are as foAlows: (#more space is needed, attach pages.) � =4
SEE ATTACHED
Description of personal property (if any) baing transferred.
You may list savbVs accounts, checking accounts and securities on attachedpages. Indicate person(s) receiving property.
DECLARATION: I. we declare that this document is, to the best of my (our) knowledge and belief, true, correct and complete and is in confor-
mity with the provisions and limitations of the Wisconsin Statutes. (If more space is needed, attach pages.) `
Nanw and Address of Person RocolvhV Property Relationship to Daeedent Signature No Date
Mary Schaeffer
784. 150th Ave. Spouse Kam r, A+(2� 11/19/97
New Richmond WI 54017
STATE OF WISCONSIN, County of St. Croix
This document was drafted by: '
(print or type name below) C � Signed and sworn to before moon 11/19/97 by the above named person(s).
Mary Schaeffer il S t horiz e ed t of o admin notary is ter an other person \
� authoriz
to o �tft - � • lw )!(
)� (as per s. 706.06, 706.07) —�
•' ti
NOTE: SEE DIRECTIONS ON REVERSE Sa $T (`� Print or type name Kathleen H. Walsh
Wac-sk ReOW at Do@& Amedulm Form HT- no(IIAW Title Notary Date commission expires 12 /13/98
z+s Is p I/9il
4 31et° "psF
i
f..y�y 9 � yf a'd Sq „R" ,� {.. 9 tea. ?•f+�{ . }•
• VOL P79PA00
A parcel of land in Section 14-30-19. described " follows: Commencing at the Southeast corner
of the Southeast Quarter of the Southeast Quarter (SE o f szj) o! said Section 14; thence West
an the South line of said Southeast Quarter of the Southeast Quartet (SEk of S10 for 665-9 fee'
to the place of beginning; thence Worth for 417.43 feet; thence South for 417.43 feet to the
center of the Town Road; thence East for 417.43 feet to the place of beginning. Containing 4
acres. AND:Township Thirty (30) North, Range Nineteen (:9) West, fourth Principal meridian:
In section fourteen (14) that part of Gov't. Lot one described as follows: Beginning at
A point on the south line o said Gov't. Lot one (1) N89 13'08", 613.90 feet from the southeast
4. feet; thence s
corner thereof; thence N1 C6 AN,682.29 ft; then 88 12'35"W, 421.96 feet; thence si 41'15
45.72 feet • thence S29 0 o 4 0
13'08"E,363.43 feet, thence So 652"W, 41?.4 feet to a point on the so
i line sog 13 08"1.72,00 feet to the point
line of a& d Gov'!- Lot one ( 1) thence with said south i
Beginning. containing 1.16 acres, more or less. EXCEPT: Township Thirty (30) North, Range
Nineteen ( 19) West, Fourth Principal Meridian: In section fourteen ( 14) that part of the Gov't
Lot one ( 1) described as follows: Beginning at a point on the south UnicS said
N39 13,06" West 1.031.33 feet from the southeast cornet chareoft thence 0 41f 15"WAILS:
feet; thence N8; 13 54.00 feet; thence SO 46'52"V, 417.43 feet go a point an tb*•
south litA of said Gov't. Lot one (1) thence with said south line $89 11 72-06 Sort
T .
to the Point of Beginning. containing .60 acres more or less.
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4 �� 1� #. � •`,"$•! �jt r ��'�� %#! t :`,�''�f�E. �@�".�4Sar� "�"'it � i � Al
Wisconsin Department of Health and Sooial Services
P1b. X67 10/69 Division of Health
M
w PERMIT APPLICATION
for
PRIVATE DOMESTIC SEWAGE SYSTEMS
A. OWNER OF PROP TYPE OR USE BLACK INK
Nam g 1 / Address (Street ity, Zip Code)
County
B. LOC ATIO N OF P -:RE SYST$ti WI LC E CONS TRUCT ED , ALTERED Ott FXTF:NDLD
Cheak One:
CITY VILLAGE LEGAL DESCRIPTION: _
V
TOWNSHIP—
' / i
C. IS LOCAL PEMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY �'i 1, Gallons NEW INSTALLATION REPLACEMEM ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUi3FR OF TANKS TO BE '_NSTALLED: y
E. TYPE OF OCCUPANCY r
Check One: One or Two Family Residence / Commeroial Industrial Other
( Specify)
Number of Persons to be Accommodated <' Number of Bedrooms
F. APi>LIANCES, ETCs Food Waste Grinder YES NO Automatic Clothes Washer /i. YES NO
Dishwasher _ YES NO Automatic Potato Peeler YES � NO
Other (Specify)
G d EFFLUEFIT DISPOSAL SYSTEM NEW - EXTENSION ADDITION REPLACEMENT
Tile Size r NO.Lin.Feet / o d — Trenoh Width 3 Depth Z ` Number of Lines
'gage Bed= Length Width Depth Tile Size No. Lines
• Seepage Pita Inside diameter ^ Liquid Depth .,�..
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level I nches ;Sinutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to ILAst To Fall
1st Wetted Overni ht in M!rnites Last Period. Last Peri o<j Period One Inch
Fy:npls
P— 0 36" Top Soil 10" Clay 26" 25 as or no 30 1/2 j 1/2 1/2 60
RECORD DATA FROM r OF 3 TEST HOLES
C ompute eize of absorption area in accord with H 62.20 Wis. Adninistretive Code. I
S O I L B 0 R I N G S— Minimum 36 Below Prop osad Absorpt System _
oring Total Depth Depth to Ground Water Depth to Bedrock
i
umber Inc hes Osserved Estimated Observed Estimated Character of Soil with Thickness in In ches
xample
— 0 72 72" Blaok Top Soil 12 "• Clay 18 "• Sand 18 24"
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE GrHER SIDE
I, tha undersigned, hereby certify that tree percolation tests reported on this form were made by me
or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and that, the data recorded and location of test holes are oorrect to
the best of my knowledge and belief.
NAB 1. - J / ; y TITLE
v (Type or Print)
REGISTRATION NO. or MASTER PLUr"u3ER LICENSE No.
ADDRESS 1,_�• � _� It'r�i ��C�I /ii' /i� �J� �
DATE SIGNATURE
MASTER PLUTT3ER MAKING APPLICATION ,
MP
Signatures C License Numbers
rip RSW
(To be Complete Eby Issuing Agent)
Date of Application J /. •`% Fee Paid
1
Permit Issued (da e) Permit Number
Agent (name i, ! "r j �' <_ _r; For_
Town, Village, City, County, etc.
` (Specify)
Notes The application cannot be considered for filing until all of the above questions are answered
and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the
Permit (yellow copy) to the Division of Health. Checks and money orders should be made
payable to the Division of Health.
Do not write in space below — FOR DEPARTPIENT USE ONLY
DATE RECEIVED ` - - ACCEPTED BY RETURNED r
• (Initials) (Date) see Corres./
�.�
FEE RECEIVED VALID. N0. 0 j � `-�� PEFB'lIT N0.
(Yes or No)
REVIEWED BY `�/ J APPROVED DATE
(Initials) (Yes or No)
COMMENTS;