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HomeMy WebLinkAbout036-1030-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 463049 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Johnston, Howard Stanton Township 036- 1030 -80 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 13.31.17.195A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /a 04 Benchmark 15M2_ �•r6 goy. roe -Z Dosing _ Aj cr ?-2 Aeration BI Sewer 6.55 - 5 7.5� Holding t Inlet -7 3 :� TANK SETBACK INFORMATION St/Ht outlet 7 �� 9 4 Y9 TANK TO P/L WELL BLDG. [Vent to Air Intake ROAD Dt Inlet Septic 1Z/ _ Dt Bottom Dosing Header /Man. w 7,F3 z C, 7 .�ite g(,. Aeration Dist. Pipe Holding Bot. System C :05 q S Z ° .L. 9 Final Grade PUMP /SIPHON INFORMATION Manuf cturer Demand St Cover Z to I. GPM Model Num TDH L' Frictio ss System Head TDH Ft rcemain Length Dia. I SOIL ABSORPTION SYSTEM - 7 9 7 - �� 3� BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 1 Y3.7 3 SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR =h 1 Y s Type Of System: UNIT > 15 7 �O�J N/� Model Number. DISTRIBUTION SYSTEM abs vek -°h�a Z� Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake f Pipe(s) 1 Length__, E j_7 Ll 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 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ° t / 27 / a Inspection #2: Location: 1978 210th Avenue New Richmond, WI 54017 (SW 1/4 SE 1/441133 T31N R17W) NA Lot Parcel No: 13.31.17.195A 1.) Alt BM Description = WE corWe Y 2.) Bldg sewer length - amount of cover = 173 - .3( Plan i revis Use otherside for additional Yes No Re informal n. — SBD -6710 (R.3/97) Date In epctoe's Signature Cert. No. i Safe and ' s rvtsaoii County 201 W. W hin on Ave., P.O. Box 7082 t visconsin �~ Mad son, t I.31707; -0 t `` Sanitary Permit Number (to be filled in by Co.) De artment of Commerce (608)��I 6 n(� 0 4 54`6 k Sanitary Permit Appli atib ` ' State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal in ut r o cwirjc '" �—' may be used for secondary purposes Privacy Law, s I5.04(I)(m) Project Address (if different than mailing address) I. Application Information - Please Print All Information Property Owner's i me Parcel # I Lot # Block # Property Owner's Mailin dre� Property Location Iq Q ay..L TVJ' %., Section I City, State Zip Code Phone Number 7�0 -21 (circle e) 7 T 3 N; 11 7 E ZO IL Type of Building (check all that apply) - e3ivf I'tumbet El �e 1 or 2 Family Dwelling - Number of Bedrooms _ � ❑ Public/Commercial - Describe Use A a ❑ State Owned - Describe Use Z I ❑Ci ❑Villa Township of L C a'7o n III. Type of Permit: (Check only one box on line line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B, List Previous Permit Number and Date Issued ❑ Permit Renewal ❑Permit Revision El Change of El Permit Transfer to New Before Expiration Plumber Owner IV. Type of PO WTS S stem: Check all that appl 06 Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Inf6rm ation: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation /so . 7 y Z VI. Tank Info Capacity in Total Number anufacturer, Prefab Site Steel Fiber Plastic Gallons Gallons of Units L �64 4-400 C t 1 Concrete Constructed Glass New Existing t /fir' J Tanks Tanks ptic Holding Tank /0O 0 — /coo / Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for install f the POWTS shown on the attached plans. Plumber's Name (Print) Pl is Signature MPQfRS umber Business Phone Number ZZ Z / T . 7ts- - .? 4437 Plumber's Address (Street, City, State, Zip Code) �s2 l elo U �;T VIII. County /De artmen Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Reason for Denial �� y s �QD IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: �X Gip 1 Septic tank, effluent filter and r�.� Cod 1 tn21�6Qa dispersal cell must all Ike serviced / maintained 1 as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 91/2 x 11 inches in sift SBD -6398 (R. 08/02) I". yo' '� 3 n 7 7 AZ 4 (N e f) yo -� P � 2 ' cn 3 G T G q9 SIc i / -Dose— Q c 0 Ti E 3 .� _ en scit Al-1 (Ahr) 4u., %.,.4j � �4 icya Th S , 4# ! 1 ,t,r► /® A. 2 7 y� �Q.totr2 14 e 6.t" V (j Lo .I &wtt/ � 99. 3 4 q9 / S.tc i r 1 A��� *)97g Wisconsin Department of Commerce OIL EVALUATION REPORT Page of Division of Safety and Buildings in accords - th Comm 85, Wis. Adm. Code County Attach P on complete site Ian paper not less than 8 1/2 x 11 inches in size. Plan must P P include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Pro go ty Owner ion w+h #),Q_ A- Che r o 11 45 E 1/4 S T BI N R E (or Property Owner's KTailing Addre Lot # BI do # I Subd. Name or CSM# — 11 JR SID t SEP 12004 city State Zip Code Phone umber ❑ City l Village [Town Nearest Ro d �• YDI ( 1 �y UNT`! J P' 1'T -T0 °� p /1 Ave-, ❑ New Construction User Residential / Number of bedrooms Code derived design flow rate GIRD Replacement ❑ Public or commercial - Describe: Parent material I b G 45n %3e-v- ou"tw e4-S Flood Plain elevation if applicable ft. General comments „ S u 5 S G.S - r 3- S ti e r - f T r e h L� .S e .7) Fo - and recommendations: A 1 1 3 � R-•i � e. S �-F �, �- 9 S, a b � �' Un K„ n w n i F l; Ft t/. � S�p� !4 6 �R L •R Boring # ❑ Boring ` ��.0 7/ �/5 Pit Ground surface elev. J 9 31, ft. Depth to limiting facto in. Soil A Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 bY{2 S; L a�St�k. CI 5 ►� CZ Lo .2 F L a -1 1)0 i F P t, h C F 3 l a -I D%i A sl q F P L Cw I , y . 10 - 7- ao Yd L , Boring # Boring 4 1 ® Pit Ground surface elev. 7 4.3(� ft. Depth to limiting factor /00 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-1 b�1R S: CP S-b Qt,5 C L 1 -11 1 DYkM Y Si L (F P h Cw 1 wl 4 .16 3 / •38 ?,S YA y 1 N .7 q 3$490 73YQ Y -� -- ...�...�, �, 5 !a L 1, * Effluent #1 = BOD > 30 5 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD 5 30 mg/L and TSS < 30 mg/L Name (Please Print Signature CST N umber Jl.a! yJ61 Address a D .t �.{.� ate valuation Conducted Telephone Number a �a -Y 7 S -a y� -3Sg � Y0 } �Dwar•� tC�'iQr�/L Property Owner -� U h11$ ``Q n� Parcel ID # Page __a of F-31 Boring # ❑ Boring n ®. Pit Ground surface elev. 7 9.L ft. Depth to limiting factor /0 0 in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 F PL. Vin 3 Y- 7,5 y --- -- 5t- FSLV- Join CL, I jF , Y .7 '7 /1 iv Q � F Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 F-1 Boring # ❑ Boring El Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SBD -8330 (R.07 /00) s / SE / y Sec.. 13 -r 3i IN k � 7� �D» n 44 , 54w-r� �? 54-46 C - 11 P"=%' %' Aa e -� p ar I70tR e.1�Gr �PGC —l.Jb Si aG. + �o \ "C O P , e 4 � s s Nous� LZ � r Two ♦ s 4 cis C11 E � c� c� r 4Cl lip p.�Tl. p ;roc Private Onsite Wastewater Treatment System, Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. ..The approved plans and permits for system are on file at the county zoning or health department. This ,management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567 -P (R.6/99). _ Table 1: System D esi n S ecifications San itary Permit Nu mber 3 D Number of Bedrooms Design Flow - Peak d S!SC� Estimated Flow - Average d 3cad Septic Tank Ca acifi al MO Soil Absorption Com oner 3 Type of Wastewater. Domestic Table 2: Soil Abso tion Compo - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Desi Flow - .Peal<- (gpd) - . - /C+o 0 - S'. 3 Maximum Influent Particle Size in NA 1/ Maximum BOD (m 91L) NA 220 Maximum TSS m LL NA 150 Maxim FOG NA 30 Ta ble 3: Main tenance Sc hedul e S Tank Inspect and/or service once every 3 years Out Filter Should inspect once a year and clean once every 3 years Soil Absorption, Component Inspect once eve 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR. 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter sha11 be assessed at least once every 3 years by inspection.. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may ;_lough off the filter when removed from its enclosure. If the filter is equipped with an alarm, U filter shall be serviced if the alarm is activated continuously. intermittent filter alarms may indicate surge fiows or an impending continuous alarm. The septic tank shall have its contents removed when th'e'volurne - of scum and sludge ill the exceeds 1/3 the liquid volume of the tank. if the contents of the tank are not removed at the time of an 191'lC►I 1" tiF.it 190 t1PERATIt7t11 [star aatave• autar�rrurstlo�Ca,. laa'I ©{� xis jasetc,eaf tkit�.�1r433li1736 fi r!I•ta>arcagrlYrAt'rrveni: kstalflafl for the pr[rsanrrro a� aslt:stiirr page_, ctrrsx rrrtayr iisayae�nits lJXr3 i t t as r rn8ps xtrrd7ar dAlrtal g laradUF4V or aflus iXeictf nt 16tui 9;aaaitc get tins rllazparerY$ rseaQb •. !i' frrp}h nn »rtr fivatttnrs6 girls ctst'Hurb tdAh aver it, Crr3' rc�rtrr3v�n,3 Iay.a asaairtagto- ssatt�((rslrs.}� �+raerraxrar rntlaar •r<ca sera„ $ys>alrt5 �aCBtt up ssi�itiat saxsti arrisur wtr�,rdrs sail acaridlxTetsss wsrus X117 Bra rur VII ifrl'ift altfive aasur!<acsra. Z3urirrg ps�'�tra+r asi'�ragetsa iatrrrtia 7lsrsksr• rrwy+ 714[l sal�cs�tti inmrriacsa .iatpla+,sreitpi•'iaaArcnit2. WFamia ,p>:itrs!aer id a'esatcsrettf xfxra +asrsserrsf r IasxFasprg ad irn ti'law rliulstnrasl raliTs} its s rsB latl atu d+aae, a V'0rlc'8dtixJ1l'1,'126 rselllacl axrsil armry rasult In Ttle, hrlukup rrC :gut ttca . Y axm>i 01 ti, als�'lltrtlttat f "is asrsrTcf This atsr�allttin 6 the talrAW20 tip' DTO l,� ullip nle Irsai vodi by �t #6rr�a> t41�rs �tarutcrirt�ry �?ptr�l8'Gmr ii1l � arltrl Yts cs Xst;vsrar to cf�let I'irsdY9 Vill[np or co as l lurrs�aa�� a ar 'C?1lf!?! Ntmiraiallr:ar icr asstir3 bra ars>araurfflty +aC►ar6tf lt1( tlx,t 17 P r, i fir s resxprsr airtrr,:tat lrstrrals satJP.l'lIF1 Tkt$tirx)� ariiv, (,�Ct t'lizl 4lt3ua .rrr ��rrfc vt�l7�tatrat3 cvar xaxtir� artr! , tlrralvmzeral �crlIsc» ors rls�t �trisrei ar park pVrSl;� ur caxl9prwrise d7aesarla aa►' at�mpr�ui arrr�t W1t1111a 1 9 ful at down ejups of shy rci(atanai or am ,grado 1?2g gfl�gniV0r3jj rireriw 1�Fyc�sa[Yti �7 °s car �llrrr[ersclrat� of thu fta1I4019 frcm lass W'tstilwaTior .a£, uAin may Irn;W -Ova thin porfarrr an u and groloNg TU ; i? 1 17,' r art�il��taflu�, t�aC�y virY o&: rt? arr l� a butts; taand'oa'ttsl; Got= Taut abir. dagrolaserrs; d'51""f RI floss; .tdlnpnrat I1ialltaitfs9 �.�I; i wrsclstiari tlralrx fatlrrala 11t %T11a) wafter; frur tarts vegetable pueilit�aa; yaaaullr�pl l3>�watea; F1nrlltalt[riss; raleeii aoral�s; rxtaadlcaa uYI, 1'aUslntlrt larr cit3rrt3; tlrith[lolrlsr,; esri3tsti its lcSra,$F kpta7tirsnte; carl VM. tv kni'l emer'Wria„ A'BATiDONMIN T WIT" Thm l TS fa7ttr salarlfdr Is taken ciut ai` tic5tatitatr'Char Fr3tbGiurrlrs> } plops slxatl i is Tattk�ara to it7asuri s llssgi Tfrta : rs Ic farral't�riy erid saerl'etty a[rrcarttleatta+�t trt tesaantatlassrses trUIU1a s 1"Vtor COMM 83.33, Wlfturtallra AcdmInIstradve Cader All 011,I to tanks Wd PILO shoo ho d1'S'2lrtt3erot d ttrad the #1band arlud Fs pe raparilrigst maisled. • The CouL011a:s Of fill T a nku an ielrrt¢ shelf be rarawvmd uti4 yaropetrry[• dyCpQSFarl & hV la SepUgia Ser t>°lraing 0 "► AFfmir pwriptrr+p, all tank& 4MG1 VIXG WWII be excavatmd and i rsstarrvms� Or 9 iatair WOMB rrtatrova>rrJ< wind the m trend e�taaa3ei W11, mull, gravel aar s nothar rntaex sscild r.QutMrletJ» CONTINGENCY PLAN 11' ales it't' VVTS falls and aiattna t, be raspalrerd •Mara fallowthU rrtm,asurfAu .1%ava bwQri, car ><aru sp be Ink L11, to ;arsaviedta s aetdcar s infer r6plgafaucrmant; aty�sttatrr; 1:2 A stttlLUUtes iseplr�csOrrserrt Areas sans I,aamrs svfirweia d egad t ray .or cai iia tgci for The isxaaoifars QP at rmlpluagrtstarsi: sGil raS tyri sYst=7x 'lgnm 114la113trtaerrtanso shliutd b a prratulaeE Ftucls,rllst,ua`taarersaet grid 4scr Tipauffrin and �elUlli.l��ti�S a ma 9 I jhff rgpo `day ra4'td'ired sr�'rbtjmk fl -all, aarlatIng at�stl l; lVp uaied latrWrra`Ct ha, list fillet; mad want. IcaalIurs to protai t - The reploualnont ro Will, Ira 'film 'Tur sa� ei'1hr ,anti ar rl , C t"tta atiui3i taavt�rtrt 4ta lssipllilrxSs r3 arulttafeCe r~sprIasrsrrtrarsx sermaw Flcapta estauany raMa tr f. rararrilsl�t W11 ?'hea rules Irk 10 ati a�rl; tiger t,�hno. !:I A. attlrralalu ra plauf4alaanx area Is rain: eviallables latm '4 e�a7llerrcrlc >�rts�l'rai israSl litril�siitartta., Sa rrIng aduenaadi s rn TS S xngl'sWc rjuy a h arrlPstg ilitilt ana,•y Ike irtsi:aUmd stem a shot ruVwri; to rasrel[1c�as the ZaTted l�flMl"!'�a '1"lira >s7tra to a twat b lln &WIlUa leld to Waratiflr to oulrgSs1s lspiausaall•[arat 01 Upott fiffl are of Tba >aOVS S a:t ,gall Its ra�vatltrert�lisn must he parfDtrm ad To IDuarte a sellable arras. If no rattletrtrrcttanx arh3rr Fu evadlasble a I1137d all army be Insta[torg as a Iaeis rtasart to ae> r'arasa 1118'i failed kaClSJ &"S„ l lfilltat�rar3 aict4� at -wradu Mail abaal °Marl €eya erns May Etta room rstri�aite � tl kts #7aory •Fb llaysrita rtarnrrr,'ral ayt ra 1s7� llsilitra T� a �7 '!li77 lr[a ,lac, x a gt rl'aula, i muonetrtzcrEPraises cal Such te+Jpus Tim rrsttatt rssal ply 'w th. the ruf as In affect at that 'iMe. < <.WA1INlN% >> VNIT PUMP AND iiTHl3l�! T(jg M>81ti111" 7 "Ali S ] WAY S:�JRTAIN UITl'+l'a' L 40A S$ES ANDIOR INSUFFICIEttT C)XVrCIEU. Xr l G llt7'8t A S81sTiiM'� FUNIF OR ClUg t'h"Sl ATMENT TAN UM111St ANY OIJRDUWSTANrgS. pS *A°i'H MAY REi UIx React A 1SFll l ihx la> CSlltl 'I'l+lt! iN'1"AtalltrR OP A, TASK MAY ]aS I llipj SC1LT t'81R In11Prj&S[gLZ,. �' lfif S I S'T' LEl3 PQ Mill m IR - -- I� It, % /1 � � /� fO •- 3.. .....�.. —...., 1ui9cahq a PTAl2 >�lti�t ca W 111.111 INV Ia:�t t1 .10 fT IVern'ssx �17l7J'9La ... .`....._..._.,_......__.... -... 7; 1't�lrc crcl" ""14tisa; zn a* *i'l'rasel In ursta Orstlraavdlt4 rylaswur fi.taratrn 13 2 . 22 01ttli'lliri Wa'), and W040), i2} &dam. IM IM ' At'It#1YrrT$7:l7sttfr+e Cwde. ST CROIX COUNTS SEPTIC TANK MAINTENANCE A GREEMENT AND OWNER HIP CERTIFICATIO! �1 FORM Owner/Buyer Mailing Address 71 r��A U`E , Property Address (Verification required from Planning Department for new + ;onstruction) City /State Parcel Identification Nu fiber LEGAL DESCRIPTION Property Location C t /4, Q %, Sec., T _ - 31 N-R (g)rown of Subdivision , Lot # Certified Survey Map # --- " ,Volume Page # Warranty eed # Volume Pa age # Spec house ❑ yes ❑ no Lot lines identii iable ❑ yes ❑ no SYS M MAINTENANCE Improper use and maintenance of your septic system could result in its pr! mature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed b)I a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste dispo ,A system. The property owner agrees to submit to St. Croix Zoning Department i certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verj lying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if neces cary), the septic tank is less than 1/3 full of sludge. Uwe, 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 N r=.tural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and return -d to the St. Croix County Zoning Office within 30 days of the three year expiration date. q SIGNATURE OF AP CANT DATE OWNER I CERTIF CATION I (we) certify that all statements on this form are true to the best of my lour) 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. 3�� LLL�� 9- SIGNATURE OF AOLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permii 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 referent ; is made in the warranty deed X60 0 0 St. Croix County Property Report Page 1 of 1 .. LISTING UPDATED ON: 9/15/2004 9:06:01 AM Location Information Tax & Assessment 2002 2003 Information I L 11 1 PIN: 036 - 1030 -80 -000 Status: — �1 1 1 Mapping Number: 71 13.31.17.195A Assessed Acreage: 1139 39 Municipality: Town of Stanton IFTotal Land Value: 11 $17,500.00 1$14,000.00 Site Address: 1978 210TH AVE Total Improved 1 $93,900.00 $103,300.00 Section: 113 Total Value: 1$111,400.00 $117,300.00 Township: 131 Fair Market Value: $119,800.00 $124,600.00 Range: 17W Fair Market Ratio: 110.93 0.9417 Quarter- Section: Original / Net Tax: $1,836.65 $1,802.58 Quarter- Quarter: Special Assessment $0.00 $0.00 Plat Block: Special Charge 1 $0.00 $0.00 Lot Number H Delinquent Utilities: 11$0.00 1 1$0.00 Woodland 1$0.00 1 1$0.00 Managed Forest: 11$0.00 $0.00 Ownership Information Private Fo rest: 1$0.00 1 1$0.00 Primary Owner Name: HOWARD B & CHERYL JOHNSTON Total Amount $1,836.65 $1,802.58 Secondary Owner Name: Total Lottery Credit: $64.77 :] 1$70.89 Billing Address: 1978 210TH AVE . ..... .... Total Amount P 1$1,836.65 $1,802.58 NEW RICHMOND WI 54017 Balance Due: –� $0.00 1 1$0.00 Document Nu 11 Interest: 11$0.00 :1 $0.00 Volume: 11 Penalty: 11$0.00 $0.00 Page: 11 Total Due: 11$0.00 11$0.00 If you are paying taxes based on this report, please print & attach with your payment. Legal Description SEC 13 T31N R17W 39A SW SE EXC 2 RDS ACROSS S SD , v n Z J - \ IV C "1 http: //69.58. 147.26 /website /pasystem /pro /final_report.asp ?IDValue= 036 - 1030 -80 -000 9/15/2004