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Wisconsin Department of G°n'merce PRIVATE SEWAGE SYSTEM County:
Safety and BukkW DMsIon INSPECTION REPORT
St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit
Personal information you provice may be used for seoondary purposes [Privacy Law. x.15.04 (1)(m)). 5
Permit H er s Name: City Village ❑ Togtn o : State Plan ID No.:
Mandehr, Richard Springfield Townshi
T SM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.:
034 - 1090 -50 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark O
Dosing Alt. BM
Aeration Bldg. Sewer U
Holding St/ Ht Inlet 9 ?
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P / L WELL BLDG. Air i to ntake ROAD bt Inlet
Air I
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA - Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand cover 0e
Model Number GPM bA 11,11 C ry ffG
TDH I Lift Friction System TDH Ft
oss ko7rcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D IMENSIONS DIMEN I N
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM
LEACHING Manu adurer:
INFORMATION TYPe O CHAMBER Moe Number:
System:
OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole 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 Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑Yes ❑ No ❑Yes C] No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: / / Inspection #2:
Location: 708 Pioneer Rd., Wilson, WI 54027 (SW 1/4 SW 1/4 28 T29N R15W) - 282915583B Village of Hersey -Lot 1
1.) Alt BM Description = <
2.) Bldg sewer length=
f e r i SP e f ` a �� ``" rr� �;�� a <— , J r �tc� r ✓�� {vo;v '� `�
- amount of cover =
Plan revision required? ❑ Yes ❑ No F_
Use other side for additional information.
SBD -6710 (8.3/97)
Date Inspector's Signature Cert. No.
Safety & Buildings Division
201 W. Washington Ave.
I
Sanitary Permit Application PO Box 730 ,
Nviscons In accord with Comm 83.2 1, Wis. Adm. Code Madison, WI 53707 -7302
Department of Commerce Personal informatio I may be used for secondary purposes (Submit completed form to county if not
,\. Av c > r Ys-) 04(l)(m)] state owned.)
Attach com let s to G co onl) fbi,the ` tem, on paper not less than 8 -1/2 x 1 I inches in size.
County ST CROIX it N �n Check if'rt�xision to previous application State Plan 1. D. Number
a ooi�t y
I. Application Information - Ple r qt ill Information Location:
Property Owner Name :__;_ l., Property Location
RICHARD MANDEHR SW 1/4 SWI /4, 528 T29 ,N, R15[/
Property Owner's Mailing Address p -F1C Lot Number Block Number
708 PIONEER ROAD 1,2 & 3 36
City, State Zip Code f one Number Subdivision Name or CSM Number
WILSON WI 54027 ` _ "�- ( 715 ) 772 -3440 Village of Hersey
II Type of Building: (check one) O Cit
O 1 or 2 Family Dwelling- No. of Bedrooms: 2 '� ❑ Village
O Public/Commercial (describe use): IN Town of
❑ State -owned SPRINGFIELD
III Type of P k onl one box on line A. Check box on line B if applicable) Nearest Road
ECON ECT Pioneer Road
A I. ❑New stem a lacement 3. ❑Replacement of 4. ❑ Addition to Parcel Tax Number(s)
y S stem Tank Only Existing System 034- 1090 -50- UUo �'�'
B) Permit Number
A Sanitary Permit was previously issued 289443 7 -18 -97
IV. Type of POWT System: (Check all that apply)
O Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground LN Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate_CG,als. /day /sq. ft.) (Min. /inch) Elevation
300 N/A N/A N/A N/A N/A N/A
VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing Crete structed
Tanks Tanks
EX ❑ ❑ ❑ ❑
2000 2000 VI 1 HUFFCUTT
❑ ❑ ❑ ❑ ❑
VII Responsibility Statement
I the undersigned, assume responsibility for installation of the POWTS shown o the att ached plans.
Plumber's Name (print) Plumb Signature (no stamps): M P/MPRS No. Business Phone Number
BENNIE HELGESON ,.L,� 292 715/772 -3278
Plumber's Address (Street, City, State, Zip Code)
W1229 770TH AVENUE, SPRING VALLEY WI 54 67
VIII County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination / 2 SOD Z 3/ 00
IX. Conditions of Approval [R for // Disapproval:
��UU
lli'Jer �LaG` Sk 6M i Q ajar
Ilurn�er 6 r4
Jietj I g 9 e - K A 0 Sc SCT/�aCy� �5S PS.
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE
Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
G [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
Hudson, WI 54016 -7710
(715)386 -4680 Fax (715)386 -4686
Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
County Sanitary Permit # ❑ Check if revision to previous application
1. Application Information - Please Print all Information Location:
Property Owner Name
1/4 1/4, Sec
N, R E (or) W
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Numer Subdivision Name or CSM Number
It Type of Building: (check one) 03ity ❑ Village []Town of
❑ 1 or 2 Family Dwelling - No. of Bedrooms:
O Public/Commercial (describe use):
F ed Nearest Road
it: (Check only one box on line A. Check box on line B if applicable)
Parcel Tax Number(s)
ir 1 2.0 Reconnection 3. ❑Non- plumbing ❑Rejuvenation
Sanitation
Permit Number Date Issued
Sanita Permit was reviousl issued WT 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
. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals. /day /sq.ft.) (Min.rnch) Elevation
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
❑ ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair /reconnencbon /rejuvenation /installation of non - plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non - plumbing sanitation system.
Plumber's Name (print) Plumber's Signature (no stamps): MP /MPRS No. Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
III. County Use Only
Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps)
❑ Approved Owner Given Initial Adverse
Determination
IX. Conditions of Approval /Reasons for Disapproval:
6 L 1,
lit I OA LE Ectoot,
I
L
YV
��Y
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer RJ Ai d ln& n d e- A e
I
Mailing Address 7 I Oh F? e&a-A' W l- S UJ � q-G a 7
Property Address - 70 8 P,& 16
(Verification required from Planning Department for new construction)
City /State LC/i j -S i Parcel Identification Number 3
LEGAL DESCRIPTION
Property Location SLO 1 /., S4) '/4, Sec. o� �5 , T2N -R f � W, Town of r�
Subdivision V i 1-1-4 e o Lot # �
6 /.0 3 !
Certified Survey Map # , Volume . Page #
Warranty Deed # , Volume . Page #
Spec house ❑ yes 1� no Lot lines identifiable ❑ 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
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 thr year expiration date.
4 elw
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.
A
SIGNATURE 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
♦' r
x 35 339 66 $ 394
,n � PAhE
KATHLEEN H. WALSH REGISTER DEEDS
N u mber Q UIT CLAIM DEED ST. CROIX WI
RECEIVED FOR RECORD
hard P. Mandehr, a single person quit - claims to Richard P. 08 -18 -2000 9:30 AM
Mandehr, a single person, a 40% interest and Susan C. Welke, a
single person, a 60% interest as tenants in common the following QUIT CLAIM DEED
described real estate in St. Croix County, State of Wisconsin: EXEMPT 0
CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 57.00
RECORDING FEE: 10.00
PAGES: 1
Recordinjj Area.
Name and Return Address yy
Robert J. Richardson v
S233 McKay Avenue P.O. Box 399
Spring Valley, WI 54767
034- 1090 -50 -000
(Parcel Identification Number)
Lots One (1), Two (2) and Three (3), Block Thirty -six (36), Village of Hersey, located in
Section Twenty -eight (28), Township Twenty -nine (29) North, Range Fifteen (15) West.
i
F
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSMI
LOT
SECTIONT _��j N_R �-LWj Town of r-r A �
ST. CROIX COUNTY, WISCONSIN
.. _ _
HOW EVERYTHING WITHIN 100 FEET OF SYSTEM
-
no
J7
� 0 Cor
WA
IN ICATE �` H ' ARR
-, f
-� Provide setback and elevation information on revers thi'cm�' ,
Provide 2 dimensions to center of septic tank ma' of a cove I
1
pENCHMARR: bac 0
Ar'A Z� A),E
ALTERNATE BM:
:SEPTIC TANK / PUMP CHAMBER HOLDING TANK INFORMATION
Manufacturer: Cr. Liquid Capacity:
Setback from: Well, - House Other
Pump: Manufacturer :Model size
Float seperation Gallons /cyc e:
Alarm Location �1z�„fZo use
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
.NATIONS
Building Sewer '7 7 ST Inlet• nt _
PC inlet PC bottom Pump Off
Header /Manifold Bottom of system —
Existing Grade Final grade
DATE OF INSTALLATION: f
PLUMBER ON JOB: 10
LICENSE NUMBER: a
INSPECTOR:
3/93:jt
WftcoAln Dbpartment of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division yaT . CROI X
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitasNtrwW:
Personal information you provice may be used for secondary purposes (Privacy w, s.15.04 (1)(m)].
Permit ANDEHR, s RICHARD 9�fti '> m ,6 Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: ParceldaY#0-1090-50 - 000
IOG
TANK INFORMATION E EVATION DATA A9700259
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark D ,
a000 ' 3•
L'
Dosing
Aeration Bldg. Sewer
Holding St / Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
irl
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding 9 g r Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
fii W. Lef.A
TDH Lift Lriction System TDH Ft
oss H ead
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia_ Liquid Depth
D IMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
,
INFORMATION TypeO /b_p,.4 CHAMBER , / Model Number:
System:/J,,% >, OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole 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 Mulched
Bed/ Trench Center Bed /Trench Edges Topsoil C] Yes C] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SPRINGFIELD 28.29.15.583B,SW,SW 708 PIONEER RD LOT 1 -2 -3
Plan revision required? ❑ Yes [:]No
(�
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH Y �`
SANITARY PERMIT NUMBER:
II �
i
i
Safety and Buildings Division
�. SANITARY PERMIT APPLICATION Bureau of Building Water Systems
Q�ri i 201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. ST CROIX
• See reverse side for instructions for completing this application state Sa_niPermit,Nmber
The information you provide may be used by other government a ency programs /� / / heck it iisiio p application
(Privacy Law, s. 15.04 (1) (m)]. :?Lop 10;o z r /'C_V/ St to Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S97 -40714
Property Owner Name Propert Location
RICHARD MANDEHR sw 1/4 S 1/4, S 28 T 29 , N, R 15 919 W
Property Owner's Mailing Address Lot Number Block Number
W1 2879 80TH AVENUE 1, 2 , & 3 1 36
City, State Zip Code Phone Number Subdivision Name or CSM Number
WOODVILLE WI 54028 1 (715 ) 698 -2926 VILLAGE OF HERSEY
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 2 Tow OF SPRINGFIELD PIONEER ROAD
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 E] Apartment/ Condo
C S • , I 5 S 13 01- 1090 -50
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 online B if applicable)
A) 1 ❑ New 2 _ ® Replacement 3. ❑ Replacement of 4, ❑ Reconnection of 5. ❑ Repair of an
______System ________ System___ „_________Tank Only______________ Existing System _________Existing
System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 gf] Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
300 N/A N/A N/A N/A N/A Feet N/A Feet
Capacit
VII I NFORMATION in gallo Total # of Manufacturer's Name Prefab. Con steel Fiber- Plastic Exper.
New Existin Gallons Tanks concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank 2000 2000 1 HUFFCITT ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I I I I ❑ ❑ I ❑ I ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
II I I Plumber's Name: (Print) Plumb 's Signature: (No amps) MP /MPRSW No.: Business Phone Number:
BENNIE HELGESON yam 1220292 715/772 -3278
Plumber's Address (Street, City, State, Zip Code):
W1229 770TH AVENUE, SPRING VALLEY WI 54767
IX. COUNTY / DEPARTMENT USE ONLY
❑Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps)
X Approved ❑ Surcharge Fee) Owner Given Initial ij
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
S8D -6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Ruildings Divr•.ion, Owner, Plumber
INSTRUCTIONS `` X
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
count rior to installation
county
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 -3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one 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.
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 1/2 x 11 inches m submitted p p 8 s ust be sub tted 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.
. a S97 -40714
RECEIVED
,1 U L - 1 1997
Y & `�i_0US "'
INDEX SHEET
SAFET
OWNER: RICHARD MANDEHR
2879 80TH AVENUE
WOODVILLE WI 54028
PROJECT NAME: RICHARD MANDEHR
PROJECT LOCATION: SW 1/4, SW 1/4, S 28, T 29, N, R, 15 W
MUNICIPALITY: TOWNSHIP OF SPRINGFIELD
COUNTY: ST CROIX
CONTENTS
Page 1: Plot Plan
Page 2: Holding Tank Cross - Section & Specifications
Name: Bennie Helgeson SigneiL
Address: W1229 770Th Avenue
Spring Valley, WI 54767
Credential number: 220292 Date: July 1, 1997
P.O.W.T.S.
Conditionally
APPROVED
DEPARTMENT OF CPVMERCf
VtStO TY t3tIt4DINGS
SEE COR PONDENCE
A►uCi�cr��;� SEGJia:.i��( 6�c/�i;S� C.i=
iN L Eli (b gCvr- iCA iA
1 4
� L
C
H V1,1� („' N F\
j,r►�t
a s-d
t
W e j�
HOLDING TANK CROSS - SECTION AND SPECIFICATIONS
Approved Approved Lockin
PF PP g
Vent Cap Weather Proof Manhole Cover
Junction Box with Warning Label
4" C.I. 12" Min
Vent Pipe 4" Min
Final Grade
18" 8 Min pproved Joint
Water Tight
Seal
- - -- - - - High - WSt er
Approved Alarm Switch _.
Joint w/
C.I. Pipe
Extending
3' Onto
Solid Soi
3" BM `
SPECIFICATIONS
TANK Manufacturer :
Tank Size: n 000 Gallons
ALARM Manufacturer: E I -c r ) ��� <1 P., s.
Model Number:
Switch Type:
NUMBER OF BEDROOMS
OWNER'S NAME: C-kgrc A4 /L o, Je-
ADDRESS:
LEGAL DESCRIPTION: Su) 4f ) , Sec. - LL, T _aN, R 1.!LlW
19 9; p y i : /MUNICIPALIT
SIGNED: ,
LICENSE NUMBER: 0,'-
DATE:
Wisconsin Department of Industry, S ITE EVALUATION
Labor, acid Human Relations Page of
Division of Safety and Buildings eue s741 � 3111498911 �J ra a with s: R 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than c Fill 'fie: Plan must
County
include, but not limited to: vertical and horizontaoint a�tJl ,11rection and c Rojy
percent slope, scale or dimensions, north arrow, sand fistancq jq Dearest road. Parcel I.D. #
S7 C�3Ui 16 9p APPLICANT INFORMATION - Please n p�1O n. Reviewed b Date
Personal information you provide may be used for secon19k? .kt (NU).
Property Owner t � -_ , -r pertyLocation
Al CLV j k,,� ' C�aA f^ y - Govt. Lot S�,t1 1/4 sW 1/4,S 2 $ T .-� q ,N,R / S E (oro
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
Ca $? q 8c�) Tk Av e n Q 4
City State Zip Code Phone Number Nearest Road
OCCA \ J ( e- W I S 0Q8 (7/ S ) X ❑ City village Town
B- Her- Le S rig+ �'ttic� onQ er �
❑ New Construction Use: ETResidential It Number of bedrooms Addition to existing building
Replacement ❑ Public or commercial - Describe:
Code derived daily ow
Y -300 Recommended design loading rate _bed, gpd /ft trench, gpd/ft
Absorption area required — (UA_ bed, ft2 trench, ft 2 Maximum design loading rate bed, gpd/ft gpd /ft
Recommended infiltration surface elevation(s) 4 ft (as referred to site plan benchmark)
Additional design /site considerations K Xe
Parent material %i l/ Flood plain elevation, if applicable IVA ft
S = Suitable for system Conventional Mound In- Ground �Prressssure AT- Gra System in Fill Holding Tank
U = Unsuitable for system ❑ S 2 U ❑ S [ U ❑ S LJ U ❑ S I-1 u ❑ g [�U L S ❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
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CST Name (Please Print) r Signature Telephone No.
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M SOIL DESCRIPTION REPORT l
PROPERTY OWNER (C &r 2 r Page Z of '
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Wis(onsin Department ofIndustry, HOLDING TANK AGREEMENT Safety and Buildings Division
Labor and Human Relations Bureau of Buildings and Water Systems
Document No /Plan Identification No This agreement is made between the This space reserved for recording data
governmental unit and holding tank
,- .greement Date owner(5)
County or Local Governmental Unit Holding Tank Owner(s)
SPRINGFIELD TOWNSHIP RICHARD MANDEHR
called Mun icipality bel ow
We acknowledge that application is being made for the installation of (a) holding
tank(s) on the following property: (Provide legal land description)
SW4, SW S 28, T 29, N, R 15 W
At HERSEY IN SPRINGFIELD TOWNSHIP
Return To
o chat continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage.
Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm.
Code, or Ch 145, Stats.
As an inducement to the County of ST CROIX to issue a sanitary permit for the above described property, we agree to do the following:
r it t. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the ovine fails to have the
holding tank proper) serviced in response to orders issued by the municipality to prevent or abate a human health hazard as described in s. 254.59,
Stats., the municipality Y icipality may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing
the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats.
v a
2. The owner agrees, pursuant to s. ILHR 83.18 (10), Wis. Adm. Code, to have installed in a new building or new structure a water meter approved by
II w ith in
i c i
the County and State. The water meter shall be installed by a plumber author by th Sta to c onduct such installat , w t sa d sta llati
complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation,
the municipality to enter the above described p roperty on a r maintenance, and repair of the water meter, and agrees to a llow p y P P Y r basis
to read 9
and /or inspect the water meter.
3 Owner agrees to pay all charges and cost incurred by the municipality for inspection, pumping, hauling, or otherwise servicing and maintaining the
holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The municipality shall notify the owner
of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within
thirty 0 days. the owners specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of
Y(. ) Y P Y 9 _
a human health hazard, and the tax shall be collected as provided by law.
4 The owner, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have
the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality. The owner further agrees to file a copy
of any changes es to the service contract, or a copy of a new service contract, with the municipality within ten (10) business days from the date of
change to the service contract.
5 The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the municipality on a semiannual basis a
for h servicing of th holdin tank. In the case of re gistration under s. 146:20 (3)
re in ac with s. ILHR 83.18 4 a 2. Wis. Adm. Code, o the e 9
Il i epo t O O 9
(d), Stats., the owner shall submit the repoit to the municipality. The municipality may enter upon the property to investigate the condition of the
holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained.
6 This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the
property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be cancelled b executing and recording said certification with reference to this a 9 Y Y 9 g a greement in such manner which will permit the
i existence of the certification to be determined by reference to the property.
7 This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to the
register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be
determined by reference to the property where the holding tank is installed.
Owners) Name Print n Notri d O ner igna re(s)
fe �r N Subscribed and sworn to before me on this date:
l�
l
Notary Public
,jmcipat Official Name - Print Municipal Offical ignat re
e My commission expires: 8'.
C r �Y � J
Municipal Official Title - Print
1 ha ,nlot mot un you provide may be used by other government agency programs (Privacy law, s. 15.04 (1)(m)I
S8D6123(R 04/94) / 4/,
r �1.�16 not 1 >n PAPE 536
Document Number Document Title REGISTERS OFFICE
ST. CROIX CTY., Wl
fNr'Y tar Netx►s
JUN A Q 1997,
P
FloosWof Deeds
Reeordin Area
Name and Return Addtrss
Pstd IdectiSution Namber (PIIM
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"THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE"
M is information =AU eompletod by snbmiuert doemnent Ark, wane & return address, and PAIN (1 f requ ra). odor forawaiart'suuk
as the d+ndn: d- u- , -kjal &- *,don, etc --y b, placed, to A,4 f v pate of Ac do=vsmr.or may Ake placed on adacrendl packs 4e
doew -t;" ore: Use ,ed,h odrrr plc adds one Prue to your doomwm ma $'Lop to the mvn:ff rr fee. Wiseonsfn Sretrats, S9.S17 , , WRDA v 6
HOLDING TANK CERVICING CONTRACT
Contract Date
This contract is made between the
-- — — — — — — — — — — — — — — — — — — — _. — — — — — — — — — — — —
Holding Tank Owner(s) Name(s) and Pumper's Name
RICHARD MANDEHR
i
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
SW- SW- S 28, T 29, N, R 15 W
HERSEY IN SPRINGFIELD TOWNSHIP
-----------------------------------------------
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality ", which
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of ST CROIX
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access an
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all- weather acc
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), 1
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agr
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contr
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municip;
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) _) Ow Si(s)
Ai l) J u °���' � A d, '" r� Su bsc ibed and sworn to befo a me on this date:
i
i o J lQ
i
Pumper's Name (Print) Pumper's Signature ko vc EL VWEE*t
" My commission expires: Of
rf r GMy n_5 �-� w ex SeRO 'Cef
Pump is Registration Number
SBD -7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
r
S T C — loo
s to be completed This application form i in full and signed by the p
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner /contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
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Owner of property RICHARD MANDEHR
Location of property SW 1/4 SW 1/4, Section 28 , T _29 .. N - R 15 W
Township SPRrNNFTFt,n Mailing address
2879 80TH AVENUE, WOODVILLE, WI 54028
Address of site '�CD� RI a tv it ��-
Subdivision name 4k ov"5' -�j Lot no.
Other homes on property? Yes
Previous owner of property � � � �, a� - /� r �" � Y 1 � �r A&
Total size of property lq l g a - 11
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? _Yes No
Is this roperty being developed r (spec house) ? _ Yes No
Volume 1 and Page Number as recorded with the Register
of Deeds.
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INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in t e office of the County Register of
Deeds as Document No. 6 �_6 M � , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signature of Applicant Co- Applicant
flat,- of Sirrnatiira flat,- of Sinnatiir,-
559436 STATE BAR OF WISCONSIN FORM 1 - 1982
WARRANTY DEED
DOCUMENT NO.
This Deed, made between R V. King and L)ja C_ J
Petranovich kXJ km i swuiu
MAY 16 1991
Grantor,
and Richard P. Mandehr, as individt,al property • 9:30 A M
Regiates of Ueeds
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
conveys to Grantee the following described real estate in St. Croix THIS SPACE RESERVED FOR RECORDING DATA
County, State of Wisconsin: NAME AND RETURN ADDRESS
Lots One (1) , Two (2) and Three (3) , Block Richardson Law Office
Thirty (36), Village of Hersey, located in Section P•O. Box 399
Twenty-eight (28), Township Twenty-nine (29) Spring Valley, W1 54767
North, Range Fifteen (15) West.
034-1090-50
PARCEL IDENTIFICATION NUMBER
TRANSF8R
$
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging
And Grantor
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
.= easernents, restrictions and rights of way of record.
and will warrant and defend the same.
Dated this 7 day of May ' 19_27
(SEAL) I (SEAL)
Richard V. King Lyla C. Petranovich
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)-- Richard V. King and Lyla C. State of Wisconsin,
ss,
Petranovich County f
uthe d this z__2:�7_�v of May 1g 97 Personally came before me this — day of
ef:) 19—, the above named
nni Richardson
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by 97(X.06, Wis. Stats.) to me known to be the person who executed the foregoing
instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
JENNIFER A. RICHARDSON
Attorne at Law
Spring Ulpy WI 54767 Notary Public, County, Wis. +)
s may be authenticated or acknowledged. Both are not My C011iinission is permanent. (If not, state expiration date:
aciry should by typed or printed below their signatures.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
Fortn No. 1- 1982 Milwaukee, Wis.
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