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032-1049-30-000
/* Wisconsin Department of Commerce y Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count St. Croix INSPECTION REPORT 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)). 370236 Permit Holder's Name: ❑ City ❑ Village ❑ Trwn of: State Plan ID No.: Olson, Katherine Somerset Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: flo ot - a - Z « �t)L 032 - 1049 -30 -000 TANK INFORMATION ELEVATION DATA /� 31, f9, 2 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (,J L Benchmark ( p(, (6a• v Dosing Alt. BM Aeration Bldg. Sewer / �•��� �S, I� Holding St/ Ht Inlet .20. S9 r TANK SETBACK INFORMATION St/ Ht Outlet 7, 3 IT411 � f/ / TANKTO P/L WELL BLDG. Air to I ntake ROAD Dt Inlet ir Septic �' 0� (�S f NA Dt Bottom Dosing NA Header/ Man. 6-12- Aeration NA Dist. Pipe g 0,1 �8 r �• 3 • Holding Bot. System 4- 16 qZ_ 37- PUMP / SIPHON INFORMATION Final Grade - 3.0 °Pty. - 49' Manuf turer Dem d St cover Model Nu er G M TDH I Lift L ction System TD Ft m ead For a in Length Dia. Dist. To well OIL AB RPT10N SYSTEM q + s KV / RENCEP Width i Length No. f T enches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN `3 d 2 DIMENSION f SETBACK SYSTEM TO ` P/ L BLDG WELL LAKE / STREAM LEACHING Manu turer: • _ ` VA / _ INFORMATION Type O I CHAMBER o e Numb System: Co"W, OR UNIT DISTRIBUTION SYSTEM Hea ! anifold V Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Lent Dia. L ia. > $"a SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only 3 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 resent, etc. Ins ect'on o nspectlon _ , Location: 331 Rice Lake Road, Somerset, WI 54U25 (SL li4 . W 1/4 17 T3 IN R19W) - 17.3 1.19.2470 1.) Alt BM Description = - TT ,0 6 tr-du L -Av_- j �"-w.. c� 4&. CTV 2.) Bldg sewer length = Z2- L - amount of cover= 18 + Plan revision required? ❑ Yes WNo �b o Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. dft ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: � � 3 r t � g _ w 1 1 a 1 2 1 i i J E Safety and Buildings Division SAN ITA ATION 201 W. Washington Avenue N* I sconsin P 0 Box 7302 Department of Commerce In ac om .pt a Madison, WI 53707 -7302 • Attach complete plans (to the county copy for ' o of less Count than 8 1/2 x 11 inches in size. ro • See reverse side for instructions for com I t State Sanitary Permit Number Personal information you provide may be used for secon r ses $1 °may E] Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. \` �''"' 101j�� `/ State Plan I.D. Number I. APPLICATION INFORM TI �11- PLEAS ' N ATION Prop rty Owner Name �- Property Location 5 ,C_ 1/4 j yv 1 /4, 5 17 T V , N, R E (or V Property Owner's Mailing Address Lot Number Block Number 't E Cit , State Zip Code Phone Number Subdivision Name or CSM Number E IU /` I S ylli.?- r 11. TYPE OF BUILDING (check one) ❑ State Owned ❑ Cit Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms 2_ Town OF L L D III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 63Z - (04 9- 30- 0vc7 1 ❑ Apartment/ Condo 2 G 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. [K New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------ -------- System Tank Only __ ____ _ ____ __y E stem _- ___- ________ Existing Sy ___ - -_ -_ Exi sting --- - System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Iss d 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 Seepage Trench 22 ❑ In- Ground Pressure , 42 ❑ Pit Privy 13 ❑ Seepage Pit Z X 43 ❑ Vault Privy 14 ❑ System -In -Fill 1w c T VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17 . Final Grade equired (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) ✓ Elevation -3 .8 . 33 Teetj 9 8 Feet VII. TANK Capacity in gallons Total # Of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existing strutted Tanks Tanks eptic Ta "ioJ"*Zank �Q G�/E GO+V ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) P ber's Signature: No t ps) /MPRSW No.: Business Phone Number: P (Street, City, State, Zip Code): SAC A1_ E iE ,f SyQ� s IX. COUNTY / DEP RTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (InciudesGroundwater ate ssued Issuing A ent Signature (No Stamps) [Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination A Z Z S. Od / , /, v 4 1 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: * R W rt5s 5j,, k k6 o 4 ii-e 33r) 6e-- Gonrt1O/t {�r f✓eM oucc / � 4,46� '� ErrCSrer� �,�d� �r S1'ra. c�a �r N•k5 7L .`c �n.57 l /tea✓ Pir`or �o Goh s f.� r;fi anti. a � of r�arw7a�K � SBD - 6398 (R. 4 199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS i 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 5. On sewage systems rnust'be properly maihtained`The septic tank(s) must be pumped byw Iicensec1 P0MlierwFienc 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. • ��= _ 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 on 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. _ - VL. 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 mangfacturer'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.Rroduct 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 1%2 x 1 1. inches must be submitted to county. The plans - must include the folfowiriq :'A) plot plan, drawn to scale with compfete`di06nsions, locat on of holding tank(s), 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 frictioml.oss; 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 1 15 form; aid F) all sizing information. _ GR4UNDWATER'SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges�(fees) fora 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. Mom ■ M■■ ■ MEMO ■ ■ ■ ANN ■ /►_ ■■■r.�r ■SENSE - ■ ':l■ /■ ■ ■ MEMO Q NORM WNU EWER 0 �� f ■■ M ■■ r NONE ■ SEEMS NOME ■M ■ ■■ ON • ■■ ■ ■■ • E■■ ■ rr / /l /.i ■/ ■ ■ ■■ I, '!!! s NONE 'm"T"Samms No : w I �xo ,� o E�vr { t /LA I f ! ! I T _ 1 _ ..A� ; � - -- - - $- - -. -, - -- -- --- ---r -- , i T , , , ! � �vu [�fCwSC t T , I .. : i -i- - - ------ ' -------- : j J A - �7 , f 1 1 s 3 - �rI t 1 1 , _ t t _ I Y i - s 9 i --- i- I , k i , I i 1 S + : i 1 ~ , ! 1 i , i i t , I I Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of 9 Btireau of Integrated Services in accordance with s. ILHR 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 S7� , (�.'e "e percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print alt lniarh7a ; '�, Reviewed by Date Personal information you provide may be used for seconda,�purposes (Pri acy 4T, —f g_ Zt c Property Owner Prop` y Location K Q/ {IdfI.1G' /Sav7 ",', :•,, k '`' i Govt. dot 1/4 /1/ 1/4,S / T 3� ,N,R Property Owner's Mailing Address r' Lot # , Block# Subd. Name or CSM# /►gyp 1* City State Zip Code Phone 1�1(�I9rb�f ! ty ❑ Village [r Town Nearest Road Sc>)•?er -sue 4 S`�/ s' �'�:��j' ,�a�� =s � se- 2�ce LahF �/. ❑ New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow VrV gpd Recommended design loading rate bed, gpd /ft gpd /ft Absorption area required 6OV3 bed, ft trench, ft2 Maximum design loading rate trench, d /tt G g g _ bed, gpd /fi gp Recommended infiltration surface elevation(s) / -? 33 ft (as referred to site plan benchmark) Additional design /site considerations n� Parent material ©41, ewJay /i Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ®S ❑ U ®S ❑ U lii� S ❑ U ®S ❑ U R s ❑ U ❑ S W U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench k Ground S' rh 7 e lev. 7 ft . Depth to limiting An t 42.3-3 factor S/1 t -2 - ( . Remarks: Boring # o? -? 7-y /o �/3 L S �, co C7_/ D s ,b A71 Ground elev. Depth to limiting factor -I /aa in. Remarks: CST Name (Please Print) Signature Telephone No. �1�Imd, .J i S Gryrns' // 7 / s7 '9 � Addres,9 Date CST Number 1� it 11eV t G Ira ' Sc &rse S`Y06 —/? - f 9 /Caf�t? r 61SCH SOIL DESCRIPTION REPORT PROPERTY OWNER Page _-.P— PARCEL I.D.# © -d - /0y 9- S4) Boring Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ve Ground 33- 1.7 , elev. ft. Depth to limiting 5 factor 4/! & -in. Remarks: Boring # ........................... .......................... ........................... .......................... ........................... Ground elev. ft. I 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. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) I , i lot -- - -- , I -I I , I I I yon I I I 4` ® ale I I r. 1 I I I I i i I I I I _ Q/'r _IGJ s' - - -. -- I _ __ r -- .__ _ _ _- t .� _ �; _ - ,, _ _ _ _, _. ,_ _.,� _ _ . - -_ :. _ ___ - _; � i a. ! ! 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R 2q & 21 of the W.tsobnsin L3rtttfotm X veu . Code,` a sotl erosityn �C4ntr4►1 plan needs submitted &-- pproved prior to theissuance of buildln permits #or 1 2 family ziwelbng routs to < hos urts�d�citons where tie foil erosion oontr l pr+i?v xonS f bite l tttfc naa I?welluig C<ad are enforced; .h. Standar4rasion:onir #1 Plan its rsded to assist in mttY' :Llis tiretnent. _ ....::.:........ p.::.. .::. : ; Btiildtn <lris ... rirs: ave:authda .tor ` uest +erasion +coitti�dl tueasuiresIM -9 s ia!M.. r itrM by Code such m ties air ; teemed necessary+ to meet the Code's overall performance standar ;<sf keepin soil . stte, onstrtictlon projects iht disturb snore than S acxes, or are part of a development ihaY disturbs more than 5 Y; ..: ::.::.:.... :::...... .. <:<5 <ti]t1s4 {tt acted to ob;sin a construe;ion $ice s #grnrteri�seharge pentt l�rottt theN�soonsttl :....: .. >....:;:::.;:.;::.:;.. ..:... :;.::::: :< <3�e <taf: <N"aturat Re ources: Applicant: rA TfE/l /NEF 17 L.so' At Z 1 / 7 5207 Name Daytime telephone number 33 Street address, city, zip code Landowner.. L SO N V7 S 90 2 Name Daytime telephone number 32-2 ZA,r& XO- 7 & Street address, city, zip code Location of the budding site (complete as appropriate): quarter of Section /7 . Town 3 N., Range _ R:7 Weer . Lot #A ,, Block AA .. 531 � Ri °C-6 c 4/r,6; 6 M eAs'e Street address Instructions: 1. Complete this plan by filling in requested information, marking (.) appropriate boxes, and completing the site diagram. 2. In completing the site diagram, give consideration to potential erosion that may occur before, during, and after grading. Water runoff patterns can change significantly as a site is reshaped. 3. Chapters ILHR 20 & 21 of the Wisconsin Uniform Dwelling Code, the DNR Wisconsin Construction Site Best Management Handbook, and UW - Extension publication Erosion Control for Home Builders can be referred to for assistance in completing this plan. The Wisconsin Uniform Dwelling Code and the Wisconsin _Construction Site Best Management Handbook are available through State of Wisconsin Document Sales, 608f266 -3358. Erosion Control for Home Builders (GWO001) can be ordered through Cooperative Extension Publications, 608/262 -3346. 4. Submit this plan at the time of building permit application. Check (,V) appropriate boxes below, and complete the site diagram with necessary information: �0V o s CP °� Site Characteristics �I North arrow, scale, and site boundary. Indicate and name adjacent streets or roadways. Q), ❑ Location of existing drainageways, streams, rivers, lakes, wetlands or wells. / ❑_ I� Location of storm sewer inlets. 19 The gradient and direction of slopes before grading operations. �Q The gradient and direction of slopes after final grading operations. 51 Location of existing and proposed buildings and paved areas. ❑ Of Overland runoff (sheet flow) coming onto the site from adjacent areas. Erosion Control Practices Cd ❑ Location of temporary soil storage piles. Note. Although not specifically required by Code, it is recommended that soil storage piles be placed behind a sediment fence or more than 25 feet from any downslope road or dra ina ew g ay . Location of grave{ access drive(s). Note: Recommended gravel drive design is 2 to 3 inch aggregate stone laid at least 7 feet wide and 6 inches thick Drives should extend from the roadway 50 feet or to the house foundation (which ever is less). ® ❑ Location of sediment fences (filter fabric fence, straw bale fence) or vegetative strips that will prevent eroded soil from leaving the site. ❑ �$ Location of sediment barriers around on -size storm sewer inlets. ❑ R! Location of diversions. Note: Althou gh not spe cifically lY e4 Y ci cal r e q uired b Code, it is recommended that c oncentrated fl ow (drainageways) be diverted (redirected) around disturbed areas. Overland runoff`' (sheet flow) from adjacent areas greater than 10,000 sq. ft. should also be diverted around disturbed areas. ❑ Location of practices that will be applied to control erosion on steep slopes (greater than 12% grade). Note: Such practices include maintaining existing vegetation, placement of additional sediment fences, diversions, and re- vegetation by sodding or by seeding with use of erosion control mats. �1 ❑ Location of practices that will control erosion in areas of concentrated runoff flow. Note: Unstabilized drainageways, ditches, diversions, and inlets should be protected from erosion through use of such practices as in- channel fabric or straw bale barriers, erosion control mats, staked sod and rock rip -rap. When used, a given in- channel barrier should not receive drainage from more than two acres of unpaved area, or one acre of paved area. In- channel practices should not be installed in perennial streams. ❑ Location of other planned practices not already noted. Ce / - tv vtLtea;l 6", / � P A a Q J Own q 1 >o6 IT A�Q "L � P/3OP 0 SG O 'JS HO 61 6-1 , i� NoT IO 5� C(vo�raie�6�' tm C MO C,(J -Site Diagram - Note: Any base map of useable scale can be substituted for this sheet. Site Diagram Legend Please indicate north direction PROPERTY SILT by completing the arrow. LINE FENCE EXISTING STRAW ' DRAINAGE BALES I _T TD TEMPORARY fr GRAVEL DIVERSION T FINISHED TREE lv -' DRAINAGE PRESERVATION I LIMITS OF STOCKPILED GRADING TOPSOIL VEGETATION 0 SPECIFICATION Scale: AREA 1 inch = feet Indicate management strategy by checking (.0 the appropriate bow Management Stra!M&s ❑ 10 Temporary stabilization of disturbed areas. Note: Although not specifically required by Coyle, it is recommended that disturbed areas and soil piles left inactive for extended periods of time be stabilized by seeding (between April 1st and September 15th), or by other cover, such as tarping or mulching. to Permanent stabilization of site by re- vegetation or other means as soon as possible- 50 ❑ Use of downspout and/or sump pump outlet extensions. Note: Although not specifically required by Code, it is recommended that flow from downspouts and sump pump outlets be routed to stable areas such as established sod or pavement. ❑ C1 Trapping sediment during dewatering operations. Note: Although not specifically required by Code, it is recommended that sediment -laden discharge water from pumping operations be ponded behind a sediment barrier until most of the sediment settles out. ® Proper disposal of building material waste so that pollutants and debris are not carried off -site. �1 Maintenance of erosion control practices. • Sediment will be removed from behind sediment fences and barriers before it reaches a depth that is equal to half the barrier's height. • Breaks and gaps in sediment fences and barriers will be repaired immediately. Decomposing straw bales will be replaced (typical bale life is three months). • All sediment that moves off -site due to construction activity will be cleaned up before the end of the same workday. • All sediment that moves off -site due to storm events will be cleaned up before the end of the next workday. • Gravel access drives will be maintained throughout construction. • All installed erosion control practices will be maintained until the disturbed areas they protect are stabilized. Agioement: i hereby. certify that T understand the construction site erosion control provisions of the Wisconstn t7nifor X - rig Code, anil that`s accept responsibility for va tying out the above erosion goritrot plan as pproved<by the code eriforcem authority. . Df : Stgnature of app►cant Date A publication of the University of Wisconsin- Extension, Ron Struss, UWEX Water Quality Education Specialist (12192). This publication may be freely duplicated Additional copies are available through the UWEX Environmental Resources Center, 216 Ag Hall, 1450 Linden Drive, Madison, WI, 53706 6081262 -3652 ,i W n� r■■rr r■■■ ■ ■■�■■�■�M■r ■■ r■ r ■■■� r ■ ■ _i 3" h Nam f , } y _ Tfl [ t 4 r oto # { {{ a r f , r . F � , � P s d i f t , , M • f } ; r 1 f 1 I � , , r , y a ; , _ -- - - - - -- I , I , j I � , • r I � ; I 1 -3 6r _ all t I ' I i j : I f , i ' i I I I r I I i • I 7 . i 3 d 727 d 3 � ry 71 27.03 7� �m -�- _ 0 7Z7-o �• � 7zo• � �''� 3 wnu W�l f 1' J i __ -40 . � 1_. I b0 oaf l� w I ' t ro ekS 5 o�(�.25�> --------------- ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1� Tf/�� 0 /0 Mailing, Addremq 33 Property Address E 4 (Verification required from Planning Department for new construction) - Cit T a ty _ �o/�I;E��SF � Gt,1I Sy< zl.S' Parcel Identification Number /7. 31 • l p , �`���. LEGAL DESCMP110N EAlT33S'a ,durst' /l AAtr of w Property Loca %on R _ V4, AI tit _ Y4, Sec. 17 . T L1 N -R Town of ja14 iT3cr 7 , Subdivision Lot # Certified Survey Map # Volume . Page # Warranty Deed # d 3L S ( . Volume -, 17. . Page # S�3f1 S house D es 0 no � Y Lot lines identifiable yes ($ no ffSTEM.MADnMNANCE ImPmpermeandmaiatenanoeof 'c y�ourupti systemoonldresaltm rtspromaturefarTure m handlewastes.Proper consists of pumping out the septic tank every throe years or sooner if needed by a licensed pumper. What you put into system can affect do frmction of dw septic tank a treatment stage in the waste disposalaystem. Tike property owner agrees to submit to St Croix Zoning Department a certification form, signed by dw ovner. fad by a P j Ourne y man p lum bec , restridodplumberoralicensedpumperverifying 9w(1)theon- atewastewater system is in proper operating Condition and/or (2) after inspection and pumping (if necessary), the aeptictanlr is less than 1/3 full o `edge. Uwe, tine Undemigned have read the above requirements and agree to maintain the private sewage disposal system with the set forth. herein. as set by the Department of Commerce and the Department of Natural Rasp mss: state of Wisconsin.. stating that = septic system has been maintained must be completed and rehnaed to the St Croix County Zoning Office 30 days of the dn= year expiration date. 1 / j9 L d22 1 — V APPLICANT DATE OWNER. CERT'InTCATION I (we) certify that all statements on this form arc tress to the best of my (our) knowledge. I (we) am (are) the ow4r(s) of the property described above, b virtue of a warranty deed recorded in Register of Deeds Office. OF APPLICANT DATE « « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department r «« 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 No. 8.1. Warrant Daed— Common Form (STATE OF WISCONSIN) 7 � so& 296.16, Wis. statutes. Perm Na 1 Puhnahed by MR Clam Book ! suuonW7 co. J 305806 This Indenture, Made this 3 day of r'ay , A. D., 19 71 between rlichut.l ZicJ;ae);r:in ;tnd Patricia <<cEach.rai1, husband and �:ifu Catherine E. part i e sof the first part, and `'lson ' part y of the second part MiMtOOM: That the said part i e s of the first part, for and in consideration of the sum of hle tho1.,,11tid r, A no/10(; dol.lurs to U S yin hand paid by the said part y of the second part, the receipt whereof is hereby confessed and, acknowledged, havegiven, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said part y of the second part, heirs and assigns forever, the following described real estate, situated in the county of St. C r o i x and State of Wisconsin, to -wit: East 335 feet of 4 e �, t 1i »1_f rif .�o❑t,:r�.�;t. ��t! rter of i.oh -,':vF: t; ur:rtor �r W of 1;4 of h'i4� o[ ectioi, 1;, ir�ai;�;;i :�l .�orL',, ��tlr;s�c W10 o-b r Zogtt0ft with all and singular the hereditaments and appurtenances thereunto belonging or in anywise appertaining; and all the estate, right, title, interest, claim, or demand whatsoever, of the said part i e s of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained 'premises and their hereditaments and appurtenances. CO I?Ibt c rib t0 1?01b, the said premises as above described with the hereditaments and appurtenances, unto the said part y of the second part, and to her heirs and assigns FOREVER. Aftbt1t$dib Hichael INIn1 lchran lrA Patricia LcEttchr "n, hus} mid .tn(t wife fort h e.m e e 1 v e s , t i, l:- i r heirs, executors and administrators, do convenant, grant, bargain and agree to and with the said party of the second part, her heirs and assigns, that at the time of the ensealing and delivery of these presents they tire well seised of the premises above described, i as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever, .. 'arn that, the Abiii' bar81111iied ptemi** in the gaht and peace ble bn of the said ' part of, the . p s w , 1 k� '` •p k�+ � r y'�+� ;y �. y�� 4 � 1, ��., kw c BOOK 4 73 PA' a538 second part, her heirs and assigns, against all and every person or persons; .lawfully claiming the whole or any part thereof, she will forever; 'WARRANT and DEFEND. In Mftn900 MOMOt, the said parts 9 Of the first part ha hereunto set th eir hand a and seal 9 this 3 day of Alay , A. D., 11W 1 Signed and Sealed in Presence of riichliel iiicLt (Seal) • .»....» �.».. .a!aF:cZ.11�;,,�?�..�t,r!.,,... /••�:•�•.+�•k.'>..�� ,�_� ._._..(Seal) �CEacllr Ye!tric Shirley A. Brinks - - - -- - _ y . ..._. . »..._............ ».._ .................. _. ... . .... »»» ........ .... »... »..._. Jean D. L ars o n %tote of �r #rivN��i�✓ `` t ss. ».._.. _ . .. _.. ........_...._ ........... ... »._ -County. l Personally came before me, this 3 day of tiay , A. D., 1971 , the above namedi' roc. iic'r,:l, :�,,�; i? . r:i.ci,t 1:cL'ac ir.ill, I:ush<'u'1 ;1 :;d Wire to me known to be the persofr' who executed the foregoing instrument and acknowledged the same. . .......�1 �(ir L t L (' ` L'l� Willi iti ' ' Notary Public, wMcNJ6 1 unt iLC ol')i i.ct7 i" ° Minn. Drafted by.. ,v ............. . n rcl, �ic,r,•i,,���', ,� �c;� ,: in MyFp a _........._. » ..._... _»»» . _ . _„ _..» . ,_ ................_.........._. 2 6, 1 (N.H. —Cb. 59 win. State, Pro vides that all instruments to be recorded shall have plainly printed or typewritten thereon the names of the Aran. tors, grantees. witnesses and notary , i o •4 , ! ro 4 w GO JUAN; 04 r A « W `le} • . � c � •4 V b � c �4 O y v M B4 '^ �r4 oaf IF .b t � °Z5i y �. .{X � R *i'"'F,t , $. •�� '% - �yc' � ' 9 A� �V� ' aqi {o d uad -pres agi io rroprsaiW a gtaotad 40- M b a ; al rair aJd a•. l P lm o ,m pajaOon M iNgs -p= 'rasa ;eq n saouerqurnour jje uioij Jaajo pug aaJ aJa auras aril ;aq; put 'ajdrurs aar ar'AW aq; ur aaua;rJaqur ro a;g;sa ajgrseajapar pun a ;n josge 'Wa ;lad darns 'pooa a ;o re 'pagrJOSap asoge saslaraJd aq; ro pazjas jjam a•ze ,Ca,11 s ;uasard asagi ;o A'Jasrjap pug 8urraasua all; pug "IsIq .._.uadpuoaaraq ; -;o _. Ct�d °pftiraq ;� ;t.�pirlr "aT "i3JSa.. ,.. Put urtBJaq ';utJB ';ueuasuoo op '$JO;er;srururpe pue sro;noaxa • sJraq s T ,-, , { j i S NA j A g (11A Of eJin V1I1, pur,r191111 ripl(IO'H" �.I 1'Ta1.I'}1.'t� l' f' uvzcia� {:►rd Ta +(aTI1 Q3���Q3QuYf sa8199e pug sJraq , 1 0 1i o; Pun ' ;Jed puooas ay; ;o ,c Mad ppas aq; o ;un 'saoueua ;Jndde pue s;uaure ;rpaJaq aril ri ; paquosap anoge se sasrward pres ay ; 'Ql ait 03 Qqg jAs$ on •saaueua ;Jndde pue s ;uaura ;rpaJaq Jraq; Put sasraraJd pauja8req asogt aril o; put ur' ;o dfaue;aadxa Jo uorssassod uj Jaq ;ja'.f ;jnba Jo suj ur Jaq ;ja'Mtd ;uy aq; 10 s a T mad prat aq; ro 'rasaos ;eqm puawap Jo 'urje jo ysara ;uj 'ajtp ' ;g8rr 'a ;eua aq; jja pua :8ujujt ;Jaddg arrnsiue uj ro 8uj8uojaq o;unaray; soaueuaundde pun s ;uaara ;jparaq aq, Jtjn$ujr pulp jjt q ;jt U4;;doi r *rY 7 ,IJa.,I u11 i? r 3J /I 1.1O n .I.)• I ?il,) rq.� .; 1 'ursuoisrM ro a ;e ;S pus X 1: c,,17 •fir j o Awnoo aq; u pa ;en;rs'a ;e ;sa jeaJ pagrJasap Bujmojjo1 aq ;'JasaJOI su8rsse pue sJraq ' ;Jed puooas ay; ro X ;Jed pres aq; own urJyuoo pua .fanuoo 'uarje 'aseajar 'asruraJ 'jjas 'ureBraq ';ueJB 'as18 op s;uasard araq ;_Lq pua 'paarsyuO3 pae _ _padasuao 'pauarja'paseajaJ 'pasrcuaJ ' pros - 'paura8.req''pa ;ueJB ''uasj$)Aeq 'pa8pajxoug3e pue passaruoo rigaraq sI ;oaragA' ;draoaJ aq; ' ;red puooas ay; ro 1( ;Jed pres ay; Xq pred puay ur,. en o; s111TIot) ou E >' it pul:snurl� auk ;o urns aq; 3o uoj3traprsuoa ur pug rot ' ;red ;sty aril io s a T ;red pres ay; ;aqj ;� ;li�1W1IDQ ;red puooas sq; ro C uad put Wed ;sJ9 OW /Os o -r utd u o s t ,� • ►� Oil t r a l l iu )f A,jtr+ { ;rlt1 pu�)r {snI{ 4 u'ux1{avr!T3r., r.iara'+11 W"! T ,Uqo E ;,j uaas+;aq IL 6T �•Q •� �� /p lop RM aPOFN %JOUapul qu 90890E 'e0 Amma"Y t *=wm O+PtD . A4 wvmapd t vx m+qR ' - "A V - me (KreNOOBIM 010 7GLYS8) mio,1 uolau'00 18M 4w++ *Y 561529 ray 128 STATE BAR OF WT5OI $1N FORM 2 — \ 0 p WARRANTY DEED .21/7 DOCUMENT NO. y 9 �D � p a -EOLlq o RGIS - .2VY Katherine F. 01snn, n&lq Knt'Fitzrinp 01-qnn.--1 �� TI R:S 01�-FIcr ST CROIX CTY., W1 o " j ti;.��wr conveys and warrants to Daniel R. 01 grin and Mary 01 cnn, JUN 2 19 7 }i sbnnd and wife, 11:00 A Ja a e- 4g( 14 Id fleglsterof DeeUs THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in County, State of Wisconsin: d 9� 4C a on oF' v 32-1049 2-1W-30- S4 - P RCEL IDEN IFICA ION UM jqZ F West 364 feet of SEI '0 of ection 17 , Township 31 North, Range 19 West St. Croix Count Wisconsin. � Ys TOGETHER WITH the right of.ingress and egress over the South b6 feet of theiNorth 164 eet of theEast 296 feet of the W1/2 of SE1 /4 of NW1 /4 of Section 17- 31 -19. 7i y� 98- ANSFER This is homestead property. i (is) (is not) Exception to warranties: Easements, restrictions and rights -of -way of record, if any. I ted this � � day of Ju ne , A.D., 19 �I r (SEAL) (SEAL) K herine E. Olson, a/k /a Katherine n, a a eriiie MENCir an Olson (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT >ignature(s) State of Wisconsin, _ ss. 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