HomeMy WebLinkAbout034-1056-90-000 r
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
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)]• 370273
Permit Holder's Name: ❑ City []Village ❑ 1Xwn of: State Plan ID No.:
Johnson, Gerald Springfield Township
CST BM E ev.: Insp_ BM Elev.: BM Description: Parcel Tax No.:
wv p o o 034- 1056 -90 -000
i
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_
Septic / ; � t e) Benchmark 7) f6
Dosing 6 ,ro Alt. BM 3 S 3
Bldg. Sewer
Ing &Ht Inlet "e 20. 3
TANK SETBACK INFORMATION
TANKTO P/L WELL BLDG. Ventto ROAD
Air Intake
Septic ?(Q U ' �� �� ` L 2LI NA Dt Bottom Z
Dosi ng }- a y 16 I NA Header / Man.
e NA Dist. Pipe
Ing Bat. System
PUMP/ SIPHON INFORMATION ` Final Grade
Manufacturer / emand St cover
Model Number 2 �. GPM r 0 /0 Z
TDH Lift Lrictio - S ste TDH �t Ft #�_ f ' Z,®
Forcemain Length Dia. - 2_ (( Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Lengt i No. Of Tren hes PIT No. Of Pits Inside Dia. -- th
DIMENSIONS f
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACH - anu acturer:
INFORMATION Type 0_ b j- &C ( CHAMBER M r:
System: (66 > / O}i`UNIT
DISTRIBUTION SYSTEM
Header/Manifold 1n Distribution Pipes) I x Hole Size x Hole Spacing Vent To Air Intake
Length Did. Length Did. /� Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over TBed th Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center /Tr ench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: // Q00 Inspection #2:e /15
Location: 3259 75th Avenue, Knapp, WI 54579 (NW 1/4 E 1/4 25 T29N R15W) - 25.29.15.398 /
1.) Alt BM Description = - top o �lo� d �� = J 4 w , « Iv av o,�. vxd
2.) Bldg sewer length=
- amount of covert l l s{ ecr
yy 3.) contour= P.
Plan0ev�isi9�requ ri ed ? e � , `� a dco `�� rr
Use other side for additional information.
SBD - 6710 (R.3/97) r / / r Dat Inspector's Sig ture Cert. No
61 5 iEtti —) .7.) ) �QW �S (ors ily �( �C e .I.Je ' / ` 0 2 i7
f I kw. Iar. r cv.1
d,3? tivc fwv�Y � i'� x - - - —
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
P ( I
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lip + L T
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 Box Washington Avenue
Visconsi
Department of Commerce In accord with tLHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the syste , piq pbe�o lesS Count d
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this app 'c F n tate Sanitarry Permit Nu1nl5er
Personal information ou provide may be used for seconda`` t 3 � 0 � 7
Y P Y ry purposes heck if revision to previous applica Ion
(Privacy Law, s. 15.04 (1) (m)). { .. j it�
i t to Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT i L-U ` ,INF
Prop ert ner Nam at
! F� T o-._j r N, R E*W W
Property Owner's Mailing Address Lot Number y,� Block Number
Lo AA
CAA State Zi Cod Phone Number ionName or CS Number
j� ( 1
II. TYPE OF B IL ING: (check one) ❑ State Owned ❑ It Nearest Roa
Village Y � —
Public 1 or 2 Family Dwelling - No. of bedrooms Town of � (-1
111 BUILDING USE (If building type is public, check all t a y ) , L o , I Tax Numbe (s)
► b A
1 ❑ Apartment/ Condo Q 3q'" v5
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: x on line A. Check box on line B, if applicable)
A) 1. ❑ New 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 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill Coninoy 9q--7
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
Required (sq. ft.) Proposed (sq. ft.) (Gals/da A ft.) (Min. /inch) E tion
5`l S o °�"' !(�•C.t
Feet o Feet
Capacity
VII TANK Ca in gallo Total # of Prefab. site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
eptic Tank r�FleMirteF»nk ' ,t >t .1E.� ❑ ❑ ❑ ❑ ❑
Lift Pu= Tank T t El ❑ 11 El 1:1
VW. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the o site sewage system shown on the attached plans.
P eras Name: (Print) P 's Signature: Im ) iMRP /MPRSW No.: Business Phone Number:
C
PI mber's Address (Str t, City, State, Zip to op.):
Rp,g
IX. COUNTY / DEPART NT USE ONLY
❑ Disapproked Sanitary Permit Fee (Includes Groundwater I D ate Issued IISF Signature (No Stamps)
®,Approved ❑ Owner Given Initial C Surcharge Fee) 1 4 1 Adverse Determination � O � 1 "e4
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
-,I o cows (o �i?n.. �_
A. �,�,m*VoUhfibQ- �' P �j
SBD- 6398 (R.11 /97) DISTRIBUTION: Original to County. One copy To: Safety & BuildikoDivision, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is vat 4oclwo (2) years.
k - ,
2. Your sanitary ` perm it may be renewed before the expiration date, and at a time of renewal any new criteria in the
WisconsirrAdministrative 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 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.
.To be complete and accurate this sanitary permit application Ast 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.
IL 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. 14•
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.
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
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 contamination investigations
and establishment of standards.
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Safety and Buildings
' 10541 N RANCH ROAD
HAYWARD WI 54843
� TDD #: (608) 264 -8777
,�cOI�sI www.commerce.state.wi.us
Department of Commerce Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
June 01, 2000
CUST ID No.220728 ATTN: POWTS INSPECTOR
ZONING OFFICE
CLARENCE L GLOTFELTY ST CROIX COUNTY SPIA
N4955 SUNNY HILL RD 1101 CARMICHAEL RD
WEYERHAEUSER WI 54895 HUDSON WI 54016
RE: CONDITIONAL APPROVAL —
PLAN APPROVAL EXPIRES: 06/01/2002 Identification Numbers
Transaction ID No. 318231
Site ID No. 192776
SITE: Please refer to both identification numbers,
Site ID: 192776, GERALD JOHNSON above, in all correspondence with the ag ency.
ST CROIX County, Town of SPRINGFIELD; 75TH AVE
NWI /4, SE1 /4, S25, T29N, R15W
FOR: MOUND, REPLACEMENT, 450 GPD
Object Type: POWT System Regulated Object ID No.: 665046
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
The following conditions shall be met during construction or installation and prior to occupancy or use:
1. This plan action is subject to designer comments on the plan. k ! t
2. The orientation of the mound system must be such that the mound's longest dimension is perpendicular
to the direction of maximum slope.
3. Vehicular traffic is prohibited in the area 25' beyond the down slope edge of the mound. �` L
4. Abandon failing system per COMM 83.03(2). Gam" G
5. Maintain well and waterline set backs per COMM 83.10(1) and 83.14(4)(a).
6. The downslope width ( "I") calculates to a minimum 20'.
CAUTION: Wis.stats 145.135(2)(b) indicates that the approval of a sanitary permit is based on
regulations in force on the date of approval.
The effective date of COMM 83 revisions is expected to be July 1, 2000.
Thus depending on the type of system and your design, this plan approval may not be
eligible for sanitary permit approval if submitted to the issuing agency on or after July 1,
2000.
Note: There is a otp ential for a law suit that may delay the effective date of the code so this status
may or may not change.
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
-
' - CLARENCE L GLOTFELTY Page 2 6/1/00
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Since DATE RECEIVED 05/19/2000
FEE REQUIRED $ 180.00
FEE RECEIVED $ 180.00
PATRICIA L SHANDORF , POWTS PLAN REVIEWER BALANCE DUE $ 0.00
Integrated Services
(715) 634 -7810, FAX: (715) 634-5150, M -F 7:45 AM - 4:30 PM
PSHANDORF @COMMERCE.STATE.WI.US WiSMART code: 7633
cc: GERALD JOHNSON
r
Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page I of 3
Divis, ,jn of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Certified Soil Testing
Attach comp s OPs s than 6 x 11 inches in size. Plan must Count
include, but n orizontal reference point (BM), direction and y St. Croix
percent slope, e , h arrow, and location and distance to nearest road.
ParceII.D.# 034 - 1056 -90
APPLICANT INFORMATION - Please print all information.
Personal information you provide may be used for secondary purposes (Priyggt.Law, s. 15.04 (1) (m)). Reviewed By Date
t
Property Owner Property Location
Johnson, Gerald �' Govt. Lot NW 1/4 SE 1/4 S 25' T 29 N 15 W
Prope Owner's Mailing Address ° ' Lot # Block # Subd, Name or CSM#
S 52 CTHW AA
City State Zi C - Phoneber [ City ❑Villa a ®Town Nearest Road
Durand W1 5W73 715- 684 -4472 Springfield 75Th Ave.
New Construction Reside orlornme t/ Nurrl;rfrvOOms 3 ❑Addition to existing building
Use: ���r .
X Replacement Public rcial descnbe "
Code Derived daily flow 450 9Pd �` Re6ornt design loading rate 4 bed, gpd /ft2 .5 trench, gpd /ft
Absorption area required 1125 bed, ft 900 trench, Maximum design loading rate .5 bed, gpd /ft2 .6 t rench, gpd /ft
Recommended infiltration surface elevation(s) 95.7 ft (as referred to site plan benchmar
Additional design / site consideration install 5' x 75' rock bed mound on 94.7 contour as upslope edge of rock w/ 1' sand fill
Parent material tilt Flood plain elevation, if applicable NA It
S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system ❑ ® U N S❑ U ❑ S NU ❑ S N U ❑ S ®U ❑ S N U
Bonn Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD 1ft2
9# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
' 1 1 0 -7 1OYR 3/2 - sit 2 m gr mvfr cs if /m .5 .6
2 7 -16 l OYR 4/4 - st 2 m sbk mfr cs lm .5 .6
Ground 3 16 -30 IOYR 4/4 - scl 2 f -m sbk mfr cs If .4 .5
elev
94.7 ft 4 30 -67 l OYR 4/4 f2p 7.5YR 5/8, 5/3 scl 0 m mvfi - - NP NP
Depth to
limiting
factor
30"
Remarks: horizon 3 has some stratified LS gr; horizon 4 is generally resistant to penetration
2
1 0 -6 IOYR 3/2 - sit 2 m gr mvfr cs If/m .5 .6
2 6 -26 l OYR 4/4 - sl 2 m sbk mfr cs l m .5 .6
Ground 3 26 -32 10YR 4/4 - sl 0 m mfr cs if .3 .4
elev
93.3 ft 4 32 -36 7.5YR 4/4 7.5YR 4/6 scl 0 m mfi cs - NP 0.2
Depth to 5 36 -43 7.5R 2.5/1 f3p 5YR 5/8 scl 0 m mfr cs - NP 0.2
limiting 6 43+ LSBR NP NP
factor
32'
Remarks:
CST Name (Please Print) Signature: Telephone No.
Henry F. Grote _ 715- 665 -2681
Address C ertified of r esting D t CST Number Ref #
P.O Box 57, Knapp, WI 54749 1/f 1999 222774 1015
PROPERTY OWNER Johnson, Gerald SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.# 034 - 1056 -90 Certified Soil .. e
Depth Dominant Color Mottles Structure GPD /ft
i Horizon Texture onsistence Boundary Roots
in. Munsell Qu, Sz, Cont. Color Gr, Sz. Sh. Bed Trench
s_sek 1 0 -3 10YR 3/2 -
sil 2 m gr mvfr cs 1 f/m .5 .6
3 ;
2 3 -7 1 OYR 4/4 - s1 2 f sbk mvfr cs if .5 .6
Ground
elev 3 7 -21 10YR 4/6 - sl 2 m sbk mvfr cs lm .5 .6
91.8 ft 4 21 -28 10YR 3/4 - A 1 m sbk mvfr cs - .4 .5
Depth to 5 28 -34 10YR 3/4 f2d 7.5YR 5/3 sl 1 m sbk mvfr cs - .4 .5
limiting
factor 6 34+ LSBR
28"
Remarks:
A�
Ground
elev
Depth to
limiting
factor
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
Ground
elev
Depth to
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Remarks:
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Wisconsin Department of Corty�r� SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildin in accord with Comm 83.05, Wis. Adm. Code Certified Soil Testing
Attach complete site plan on paper not less than 8' /x x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimemsions, north arrow, and to atioa ap distance to nearest road.
Parcel LD.# 034 - 1056 -90
APPLICANT INFORMATION - Plea ,prir> t W information.
Personal information you provide may be used for T d$ry purposePrtvacy Law, s: 15.04 (1) (m)). Reyjewed By Date
Property Owner Property Location �(
Johnson, Gerald Govt. Lot NW 1/4 SE 1/4 S 25 T 29 N R 15 W
Pro Owners Mailing Address Lot # Block # Subd. Name or CSM#
S 52 CTHW AA
city State 3� - fie P td her City [ ] Villa e ®Town Nearest Road
Durand W1 5�, 13 ! Pringf9eld 75Th Ave.
Use.
New Construction Resi 'at / Nttr>lber of b oms 3 ❑Addition to existing building
eplacemen Public or com escribe
Code Derived daily flow 450 gpd Recommended design loading rate .4 bed, gpd /ftZ .5 trench, gpd /ftZ
Absorption area required 1125 bed, ftZ 900 trench, ft' Maximum design loading rate .5 bed, gpd /ftz .6 t rench, gpd /ftZ
Recommended infiltration surface elevation(s) 95.7 ft (as referred to site plan benchmar
Additional design / site consideration install Y x 75' rock bed mound on 94.7 contour as upslope edge of rock w/ V sand fill
Parent material till Flood plain elevation, if applicable NA ft
S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system ❑ ® U ® S ❑ U ❑ S ®U ❑ S ® U ❑ S ®U [Is ® U
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary oots GPD /ftZ
Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. rY Bed Trench
1 1 0 -7 10YR 3/2 - sil 2 m gr mvfr cs If/m .5 .6
2 7 -16 10YR 4/4 - sl 2 m sbk mfr cs 1 m .5 .6
Ground 3 16 -30 IOYR 4/4 - scl 2 f -m sbk mfr cs if .4 .5
elev
94.7 ft 4 30 -67 1 OYR 4/4 f2p 7.5YR 5/8, 5/3 scl 0 m mvfr - - NP NP
Depth to
limiting
factor
30"
Remarks: horizon 3 has some stratified LS gr; horizon 4 is generally resistant to penetration
1 0 -6 10YR 3/2 - sit 2 m gr mvfr cs If/m .5 .6
. _ 2 6 -26 IOYR 4/4 - sl 2 m sbk mfr cs lm .5 .6
Ground 3 26 -32 1 OYR 4/4 - sl 0 m mfr cs 1 f .3 .4
elev
93.3 ft 4 32 -36 7.5YR 4/4 7.5YR 4/6 scl 0 m mfi cs - NP 0.2
Depth to 5 36 -43 7.5R 2.5/1 f3p 5YR 5/8 scl 0 m mfr cs - NP 0.2
limiting 6 43+ LSBR NP NP
factor
32"
Remarks:
CST Name (Please Print) Signature: Telephone No.
Henry F. Grote _ 715- 665 -2681
Address C ertif ied Soil Testing pate CST Number Ref #
P.O Box 57, Knapp, WI 54749 11/2/1999 222774 1015
PROPERTY OWNER: Johnson, Gerald SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.# 034 - 1056 -90 Certified Soit e'iesting
Depth Dominant Color Mottles Structure GPD /ftz
onsistence Bounda
Horizon Texture ry Roots
in, Munseil Qu. Sz. Cont. Color Gr. Sz. Sh.
Bed Tr ench
3 1 0 -3 l OYR 3/2 - sil 2 m gr mvfr cs 1 f/m .5 .6
4
i
2 3 -7 l OYR 4/4 - s1 2 f sbk mvfr cs 1 f
.5 .6
Ground
elev 3 7 -21 10YR 4/6 - sl 2 m sbk mvfr cs lm .5 .6
91.8 ft 4 21 -28 10YR 3/4 - sl 1 m sbk mvfr cs - .4 .5
Depth to 5 28 -34 10YR 3/4 f2d 7.5YR 5/3 sl 1 m sbk mvfr cs - .4 .5
limiting
factor 6 34+ LSBR
28"
Remarks:
4 .
Ground N
elev
Depth to
limiting
factor
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer � D , —�eL' , y G eez)
Mailing Address �y
Property Address
(Verification required from Planning Department for new construction) /
City /State Jde W f L Parcel Identification Number
LEGAL DESCRIPTION
Property Location _)VU1414, k `/4, Sec. ;,-6' T_ -R �� W, Town of , /Zr�- it'�P..l -�
Subdivision . Lot #
Certified Survey Map # , Volume ^ - . Page #
Warranty Deed # , 12 i f 7 , Volume 2 Page #
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
SYSTEM — ANCE
Improper use and aintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, 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 113 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 year expiration date.
SIGNA4URE 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. , d�-
r
SiGNk11JRE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
00C-UMFNT NO. .T. \TE GaK OF WISCONSIN FORM 5 - 198E THIS so.. waa[11Vr° Pole w[rnwmno asp.
PERSONAL REPRESENTATIVE'S DEED
� s
51248 � 062►AGf 547.
REGISTER'S OFFIC
Janice L. Fleming ...... R�ofd
Ree'd for
..-•----... •.. ............. ........... -
--
.......----- ••.......... JAN 31 1994
as Personal Representative of the estate of -
.3
0 M
Frank Johnson �
I1
�- ... . ..
----... ..............._............... a.
( "Decedent
Gerald D '
- 4
for a valuable consideration conveys, Without warranty, to .............................
Johnson, a single person ...... .......
........... ..•-•-•----•--..........._.. ......•..................... - -- ..__._._... Grantee, afM'WT°NA+M+na. olW Of HUDSON
the following described real estate in ------- St . _ - .... Cr Croi ---• . ........ - ...._ county, jgsp liTfl SL .......
State a; Wisconsin (hereinafter called the "Property ") : Bap�
Tax Parcel No ............................... i
North Half of Southeast Quarter (Nh of SE's) of Section Twenty -five
(25), Township Twenty -nine (29) North, Range Fifteen (15) West.
One third of the above- described premises is being trar3ferred
by descent, and is exempt from fee pursuant to Section 77.25(11)1
and two - thirds of the above- described premises is being sold by
_ the estate to grantee.
i
y S
d
F
i
Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which
e Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which
the the
i Personal Representative since acquired. �^
Dated this .._.._._.a7 I' vp • -__ •--- •- - - - -•,
................... °-.-••_. -- day of .
I
(SEAL) x_- - -.- (SEAL)
. anice Fleming ...............
_ . .....-- •••- •......._ evres--•-
:. .srsonal Bepresentativa Personal Rpreseo4tira
4�
AUTHENTICATION ACSNOWLBDOMBNT
I
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. STATE OF WISCONSIN
j --- ....................................... ................•_.......... G Conntq
authenticated this ........day of ................... •.• -• -. . 19- - - -.- Personally came before we this ....... dsy of
wl/ary✓' 19 .. 4. the above named
•-- ................. .... .......... •- •- •..... ....... --- ............-- - - - - -- a1? e- . L.__Flemin
r`r ... ... Q.. -
' ! TITLE: MEMBER STATE BAR OF WISCONSIN - --
(If not, .•.•_.- -•-•- --- -•-•--- ----- -- -•- ---•-• - -- --- --- ---- --- --• ............. --••-•-••-- -......- -- ._........... ........ ..........
authorized by 1 ?08.08, Win. Stats.) to me known to be^hq, person ---- -_ who ex ted the
foregoing instr , u3pIpt and ac[#ypwled the as
•:n ! THIS INSTRUMENT WAS DRAIrT£D BY "_ " " "e tr"� C=. .._ "..._" ................. ...
Thomas A. McCormack
........... ----- •---- •-- •- ••--- •----- •- •• - -• -- ---- • - - -•-
Baldwin, WI 54002
No tary publin! + / -ewilk , Wis.
.......... . ... ...• -• .............
...... i
My Cisgi +{ rylarIq t jIfr not, state expiration
(Signatures may be authenticated or acknowledged. Both s �� .,�
are not necessary) date ._ ., F - -- -- -...., 19 ........)
-
A - oWasses of persons siring in any eapxeity should be typed or printed below their si¢nafuzea.
STATE. BAR OF w1SCONSIY Wisconsin Leasl Blank Co. Inc.
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