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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count St. Croix
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarxMpo.:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)j.
Permit Holder's Name: - ❑ City ❑ Vi age ❑ To of: State Plan ID No.:
Emerson, Jeff omersettownship
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
� 032 - 1043 -95 -000
TANK INFORMATION ELEVAT116N DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Alt. BM
Aerat' Bldg. Sewer
Holding (3V Ht Inlet -
TANK SETBACK INFORMATION / Ht Outlet 2
TANKTO P/L WELL BLDG. Air to
I ntake ROAD
Air
Septic > 6 b l j p r NA
NA Header / Man. / 3.4
Aeration Dist. Pipe cM) r z . s / ? -z
ht I H oT& ng Bot. System �� Ti
PUMP / SIPHON INFORMATION Final Grade �4 , 3
rer Demand St cover ` , 2-
Model Number G ON
TDH Lift Friction stem TDH
oss
Fo main Length Dia. Dist. To
SOIL ABSORPTION SYSTEM 0 c
BED / RENCIfI Width ( Len th / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME 3 2• J DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LE Man ICI r:
SETBACK AM
INFORMATION T ype 0 CH BER
+ / / / r ` � M e Num er:
System: v ! 7 (e 1 1 etc,
DISTRIBUTION SYSTEM
' Header Pi e(s)/ q x Hole Size x Hole Spacing Vent To Air Intake
Length '2 � Dia. Length � Dia. � Spacing s r N 7 ��U '
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over I xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/Tr nch Center Bed /Trench Edges Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) Inspection #l: ? / /Oylns - p ��0�
Location: 2148 60th Street, Somerset, WI 54025 (NE 1/4 SE 1/4 15 T3 1N R1 9W) - 153119220 /
1.) Alt BM Description= S c 7� �r•
2.) Bldg sewer length=
- amount of cover = !
Z,� � �> r p , e S f 4v- " C /_ 5 - /.A ld
41 L i W e M
Plan revision required? E] Yes a4o Use other side for additional information. Cc �(,c he
SBD -6710 (R.3197) Date Inspector's Signature Cert. No. G I r`r f
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave.
NVIsconsin See reverse side for instructions for completing this application PO Box 7302
Personal information you provide ma ondary purposes Madison, WI 53707 -7302
Department of Commerce [Privacy Law . 1,5 1 (t�i)9 � , (Submit completed form to county if not
state owned.
Attach complete plans to the coup co o e s tem, on paWrof Xss than 8 -1/2 x 11 inches in size.
Co un State Sanitary Permit Number ' heck i ; o previo Lion State Plan I. D. Number
I. A plication Information - Please Print all Informat on- ' Location:
Property Owner Name O .� Property Location
r r , vim 1/4 ,E 1 /4,S S T N,
P roperty Owner's Mailing Address C? J OG Lot Number Block Number
.7 V �0 S l 10
City, State Zip Code bdivision Name or CSM Number
XXV 7 1 /A97
II. Type of Buildi g: (check one) C ' t y w
�I 1 or 2 Family Dwelling - No. of Bedrooms : Village
/❑ Public /Commercial (describe use):_ Town of
❑ State -Owned L
� ^ � S � ✓ Neazest
y x 6L. Parcel TaxNu 2
III. 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. 5. 6. ❑ Addition to
System System Tank Only Existing System
B) Permit Number
anita s revious tssued
IV. Type of POWT System: (Check all that apply)
Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information: b m
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area . Soil Application 5. P olation Rate 6. System Elevation 7. Final Grade
Required 5� Proposed 5 I�•Z'� Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation
40 5F-7-7 F . s P3$ .7 z. o ' s
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
WC 42- vd 10,fil'•l' W
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersigned, assume responsibility for installation of the S shown on the attached plans.
Plu er's Name (print) Plum is Sig nature (n os s) A�1ivIPRS No. Business Phone Number IVA
bees Address (Street, City, $tate, Zip Code)
1, 7 0' D 4 Y— 1
IX. County/Departine Use Only
❑ Disapproved Sanitary Permit F e (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
pproved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination 1 °Z°ZS• /0 —26W
X. Conditions of Approval /Reasons for Disapproval:
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Affisconsia. Department of Industry SOIL AND SITE EVALUATION REPORT Page -/- of s�
Labor and Human Relations
Division of Safety & Buildings in accord with I LH R 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but - C AgMC
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 2 --
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION VIEWED BY DATE
4 - ZED
PROPERTY OWNER: PROPERTY LOCATION
r"
ZXK
[ E—Al t GOVT. LOT 1/4 1/4,S ST N,R E (o
OPERTY OW R':S MA116JNG ADDRESS LOT # I BLOCK # I SUBD. NAME OR CSM #
.7 gi �1 r _
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE VtOWN NEAREST ROAD
Ym ( V _ 7107 a
[ I New Construction Use [/J Residential / Number of bedrooms y [ J Addition to existing building
kj Replacement [ ] Public or commercial describe
Code derived daily flow Oda gpd Recommended design loading rate .1 bed, gpd/ft . f trench, gpd/ft
Absorption area required X,58 bed, ft 75U trench, ft Maximum design loading rate 7 bed, gpd /ft j_ trench, gpd/ft
Recommended infiltration surface elevation(s) � ft (as referred to site plan benchmark)
Additional design / site considerations L
Parent material c #.crK, -g2A4g&AZ& �� - .� .1,o FI plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL I HOLDING
U= Unsuitable I PS ❑ U PS ❑ U S❑ U 17S ❑ U ❑ S QJU ❑ S IQ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
of I I • S
Ground ,3 2 S� L
elev. _
X.9 ft. 2 — .9 — S Of S 66 M L
Depth to
limiting
factor
5�•r;�43 • v
Remarks:
Boring #
::.:, >• : >: 10- i2- /0 2 L s s -of v s
`ti : :
4 'Gro nd
Depth to
limiting
factor
T_
Remarks:
CST Name: Print Ae lva Phone:
es
A ddress: Q_ 3a b jt vZ ,3
Signature:: Date: CST Number:
PROPERTY OWNER '.�'/� ` SOIL DESCRIPTION REPORT Page .Z.. of .S ,
PARCEL I.D.# 03.2 (DV?
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
G s 3 F
4 1�r6dnd ' 3 _ 0 7. - Fs +S
elev.
ALL
Depth to
limiting
factor 4 . z 8s • Z
Remarks:
Boring #
Ground x
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
4ti
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
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ST. CROIX COUNTY
L
WISCONSIN
sr ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
1101 Carmichael Road
Hudson, WI 54016
715/386 -4680
EXISTING SEPTIC SYSTEM AFFIDAVIT
The existing septic system which serves the dwelling being added on
to must be inspected by a licensed soil tester for compliance with
high ground water and /or bedrock seperation requirements as set
forth in s. ILHR Chapter 83.10(2) WI. ADM. CODE. The results of
that inspection must be made available to this office. If the
existing septic system meets these minimum requirements, and is
properly functioning, an addition may be added to the dwelling
without updating that system. This addition must not, however,
encroach upon the required septic system setbacks as setforth in s.
ILHR Chapter 83.10(1).
Property Owner (s) , '
Property Mailing Address:
Property Legal Description: Lot CSM /Subdivision
4 _ 1/4 1 1/4, Sec. /.; , T. .Z/N. , R.W. , Tn. of �WrE
I, as the owner of the above described property, hereby affirm that
the septic system serving this dwelling meets the above referenced
state private sewage system codes. I realize that this addition
may cause the existing septic system to become undersized for a
dwelling of the resulting size, and I will make this information
available to any future parties interested in purchasing this
property.
Notary Public
Subscribed and sworn to
before me on this date:
Signed: � � ���
A, p oO O
I T
Date:
My commission expires:
Count ..�^1
A p p roval: V
Y PP CD `
��
Date: Z ��
JUDY K. TAK
NER
Notary public -State of Y�isconsin
SEPrc 7 a'� jai `��..rk Clca �
gor
.s yD 13
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Ownera*)W -
Mailing Address 21 !yj �D��T p eC ,P- 1k—� w� J�i✓D�S
Property Address �W&4fE _
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number 03 Z — /D
LEGAL DESCRIPTION
Property Location &&Z ' /4, SST 1 / a, Sec. /5 . TAN- R_Z_f 1AT, Town of
Subdivision , Lot #
Certified Survey Map # , Volume `----. Page # ^----
Warranty Deed # y/0(e/� , Volume ; Page # 170
Spec house ❑ yes X- no Lot lines identifiable f Z yes ❑ 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 agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, 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 Zoning Office within 30
days of the three expiration date.
a ll '1.�U ►'� ' 2 / /
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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APP ICANT 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
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 residence located at: %, %,
Sec. , T N, R W, Town of , 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 No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known) :
Age of Tank (if known) :
(Signature) (Name) Please 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 t condition, I
certify that the tank, to the best of my knowledge, wil conform to the
requirements of ILHR 83, Wis. Adm. Code (except for inspec ion opening over
outlet baffle) .
Name � �� f 0 Signature
MP /MPRS D'
VV
"! $'1'Jk JWA or f f Ial lPt l 1 *r w �aftm ell as" +.
J. 00 CUMEW WARRAWIV V
4A .036PME 170
RmTwofflcl
mods between 2!�.......a, cha ,, .. wa. 1€or +.m?d L li! 4th
d _ ! �1: . : :.. :.. :. :... ' . : : : : .............. " : :: do ms !'ril D. t 'PIG
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- - . f raator. at a—.. . :JVA ..: U.
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._...Jaaes Q'Connell
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._.... .. ........... .. . . .... . ...... .. '...... :...............
.. . ............................... Oren N
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W b That tM ran De u
PmMft said G for, for ♦alusbi eonaidrration_..... P t7
and outer valuable consideration - -
.......................•---•--•-•-- •--- ••••- ••••............,... _..•..........._ .
conveys to Grantee the followintr described real estate in ....... t...J '0_iC- -__.___- 1141 ' To
Century 21, Indiainhead Realty
ronntr, state of W isconsin: New Ric um Wiscons 54017
TaxParcel N. ...............................
i
The North 209 feet of the East 209 feet of the NEk of the SEk
of Section 15- 31 -19.
1€
Subject to recorded easements, reservations, and rights of way.
SCMD
FEE
is
This _......... homestead property.
�.' . ot)
(L) not)
Together with an and singular the hereditaments and appurtenances thereunto belonging; �
AndS:Q � .. . .......... .......... ..... ... ... ..... ... .- - -_. --- -------------- -__. ......._...._........_......._. i
warrants that the title is good, indefeasible in fee simple and free and clear of entumbrances except
no _exceptions
ii
---._._ .L. _.... day of ..._...... Mw , 1!_ 8
and will warrant and defend the same.
Dated this .- -•- ._.• --- _
ti !) �
------- .-------------------- ..... ...............•...._........._ .....(SEAL) ..
j'
Marcella Schaar
(k
-- ---- (SEAL) .... .....(SEAL) �.
I` •
AUTHENTICATION ACHNOWLBD(iMBNT
)� $ignat�ue(a) - ---------------------------------------------------------- STATE OF WISCONSIN
------------- -------------------------- ........................................ .. .... t. -Croix ..............Cooney. / T t
{` authenticated this __ __--__day of. .... _.................... 19 ------ P p lla ally came before we 31........_day of
r
t,
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Scflaaz' ____. __ . 19______.. the above named
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€� ......................_.._......._.__.......------ •- -- -- -•-- ---.......- --• -- - - -- Marce
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1
i TITLE: MEMBER STATE BAR OF WISCONSIN
........................................... ....................................
(If not, -----°--..._..._-• --- - °- --- _.....-- ••..._--• -••-- i
authorised by 1 708.06. Wis. Stats.)
to me known to be the !
,? person __.._._.._._ who executed the
foregoing instrum t and acknowledge the
t - '
I
Eric J. .....11 Box 157
••. ........ ...
THIS INSTRUMENT WAS DRAFTED BY
.
--ic ..................... - J. _-__.______________ 1 ohn D. Wals4,��i� � W��y,,
New Ricticmnd Wisconsin 54017 .
...... ... ... . ..
1 .... '---- - -•••. - --••-......•-•-- -- --•- -- -- Nota Public ......... nt Win.
(Signatures r-ay be authenticated or acknowledged. Both My Commission is permanent• JJ4irA� pi ion
i
are not necessary.)
•N&mes of perwns sieefcit in and capacity ehould be tTVed or Drinta! blow !heir sbrutu�� � _...__
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ST ATB Bat or wrecoNSIN
..... F�� roam No. i —It" 3001
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BANK HOURS
BANK OF SOMERSET SOM Monday- Thursday 8:00 a.m. -4:00 p.m.
Friday 8:00 a.m. -5:30 p.m, ,
Est. 1910 r2m Saturday 8:30 a.m. - 12:00 noon
aff SOMERSET OFFICE OSCEOLA OFFICE Drive up . Mon -Thurs 7:30 a.m. -5:30 p.m.
Friday 7:30 a.m. -6:00. p.m.
110 Spring Street 409 Cascade ® Saturday 8:30 a.m.-12:00 noon
PO Box 220 PO Box 578 OSCEOLA
INSTANT CASH Lobby and Monday- Thursday 8:00 a.m.-5:00 p.m.
Somerset, WI 54025 Osceola, WI 54020
MACHINE Drive Up Friday 8:00 a.m. -6:00 P.M.
(715) 247 -3348 (715) 294 -4200 OPEN 24 HOURS
56 EVERY DAY Saturday 8:30 a.m. -11:30 a.m.
ST. CROIX COUNTY
J* 0 4 * WISCONSIN
ZONING OFFICE
F•s
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680 Fax (715) 386 -4686
October 31, 2000
REMAX Team 1 Realty
Attn: Jo Hinz
103 Main Street
Somerset, WI 54025
RE: Septic Inspection for Jeff Emerson located at 2148 60th Street,
Somerset Township, St. Croix County, Wisconsin
Dear Ms. Hinz:
A septic inspection of the above referenced property was conducted on 07/02/2000. This
property is located in the NE 1/4 SE 1/4 of Section 15, T31 N R1 9W, Somerset Township,
St. Croix County, Wisconsin. At the time of the inspection, this septic system was found
to be code compliant for a three (3) bedroom home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincer
J n Sonnentag
Zoning Technician
/sm
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Parcel #: 032- 1043 -95 -000 12/05/2005 07:53 AM
PAGE 1 OF 1
Alt. Parcel #: 15.31.19.220A 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 - LANGE, LYLE & HONG
LYLE & HONG LANGE C - LANGE SUSAN T
LANGE SUSAN T
2148 60TH ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 2148 60TH ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 1.000 Plat: N/A -NOT AVAILABLE
SEC 15 T31 N R1 9W 1A IN NE SE N 209' OF E Block/Condo Bldg:
209' OF NE SE
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
15 -31 N-1 9W
Notes: Parcel History:
LEFT SUSAN'S NAME ON. LAST RECORDED Date Doc # Vol /Page Type
DEED 1560 -69 SHOWS HER AS A 10/05/2005 808589 2903/245 WD
LANGE -- NOTHING RECORDED SHOWING NAME 11/16/2000 633842 1560/69 WD
CHANGE FROM LANGE TO GREEN - - -- CALLED 07/23/1997 736/170
FOUR SEASONS TITLE & THEY WILL DO A
more...
2005 SUMMARY Bill M Fair Market Value: Assessed with:
76955 129,600
Valuations: Last Changed: 07/23/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 16,000 88,300 104,300 NO
Totals for 2005:
General Property 1.000 16,000 88,300 104,300
Woodland 0.000 0 0
Totals for 2004:
General Property 1.000 16,000 88,300 104,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 307
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00