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Id 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
[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 Pe it #/ ❑ Check if revision to previous application
l
1. Application Information - Please Print all Information Location:
Property Owner Name
1/4 1/4, Sec
�y JC 11 r? ,5 cy) T N, 7R E (or) W
Property Owner's Mailing Address Lot Number Block Number
lC �-f. I
FTypeof Zip Code Phone Numer Subdivision Name or CSM Number
4L �l ��� �l -�1� - /��� GSM �g
ilding: (check one) amity []Village own of
amily Dwelling - No. of Bedrooms: Commercial (describe use):
wned Nearest Roa ,_
ermit: (Check only one box on line A. Check box on line B if applicable)�t� -�
Parcel Tax Number(s)
A) 1 1j:1 Repair 1 2. ❑ Reconnection 3. ❑Non - plumbing .10ejuvenation
Sanitation � GLJ ?
Permit Number Date Issued a5� �/�. �7 3
B)
❑ State Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
V 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. /inch) / E evation
I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
Le ' ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement
1I, the undersigned, assume responsibility for repair /reconnenctio re�uvenatio 6tallation 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.
Name (print) Signature (no stamps): MP /MPRS No. Business Phone Number
A '
Plumber's Address (Stree Co e) ► v
III. County Use Only
Disapproved Sanitary Permit Fee D to Issued I suing gent i ature (No stamps)
Approved Owner Given Initial Adverse /
Determination l(7 tw 6
IX. Conditions of A proval /Reasons for Disapproval:
�o alo Whin Ae, rbce- t,) it m W e�( ,
Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
��� See reverse side for instructions for completing this application PO Box 7302
Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Department of'Commeree [Privacy Law, s. 15.04(l)(m)) (Submit completed form to county if not
state owned.
Attach complete plans to the county copy only) for the system, on paper not less than 8 -1 /2 x I 1 inches in size.
Couaw State Sanitary Permit Number ❑ Check if revision to previous application State Plan I. D. Number
I. Application Information - Please Print all Information Location:
Property Owner Name Property Location
h On 114 /4, S N, PJ 2 E or
Property Owner's Mailing Address Lot Number Block Number
9 v o ' 5'1°
City, State Zip Code Phone Number Subdivision Name or CSM Number
,e,y j2 1 �,. ��� 7-1 s ) 6-
I�. Type of Building: (check one) ❑ City
j� 1 or 2 Family Dwelling - No. of Bedrooms : ❑ Village
$Town of
• Public /Commercial (describe use):_
• State -Owned
Nearest Road �
Parcel Tax �Number(s)
III. T ype of Permit: Check only one box on line A. Check box on line B if applicable
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. 6. ❑ Addition to
System System Tank Only /o �/� J� lS old Existing System
B) Permit Number a Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
.rNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
• Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
• At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dis ersal/'I'reatmen
t Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (GalsJday /sq. R.) (Min. /inch) Elevation
yn
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
-o" a /zoa n
- T
VIII. Responsibility Statement
i, the undersigned, assume res onsibility for installation of the POWTS shover on the attached plans. _
Plumber's Name (print) PI is re (no stamps): MP/MPRS No. I Business Phone
Plumber's Address (S t, City, State, Zip
.ten U
IX. County/Department Use Only
El Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
❑ Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination
X. Conditions of Approval /Reasons for Disapproval:
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page --L of
Division of Safety and buildings
in accordance with Comm 85, Wis. Adm. Code �y
County � 1 D i
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. A 5 _ �O�
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. d O
Please print all Information. awed by D e
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.14 (1) (m)). L /�
Property Owner Property Location
M Govt. Lot s E 1/4 N E 1/4 S dS T3/ N R 7 E (or
Property Owner's Mailing Addres, Lot # Block Tu�. Name or CSM#
95 00 fit'.
City State Zip Code Phone Number ❑ City ❑ Village fig Town Nearest Road
5 rri o r
❑ New Construction Use: pi' Residential /Number of bedrooms Code derived design flow rate _ S GPD
❑ Replacement ❑ Public or commercial - Describe:
Parentmato Ifl A:3 4 Flood Plain elevation if applicable ft•
General oomments . 1��� bo r'• r C� o �� FO's p oss; `C r C.l V �"�`� i b1� D F
and recommendations: Ci 6 T
IP ft. se �- r`•�.. t — .. t \6 �' )�0e4 1�.�t� ty is �� � yy vc5� b4�. n OJ:'�h w. �►,F; 1trwt;e
SV,rFA6tL OF gG.1o� /, sy s -} c.o. �S aLrp�rCr+ �Ldylrs 010' -•
ICf ~ •• 4-
Boring # onng
5 ❑ Pit Ground surface elev. _ ft. Depth to limiting factor 7 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
o - � y s : k- ._.,. -. - -Lo
e_ Vj —
"P rky _- --- - 5
S A -3 7. s `+e` LS -- - -
-
� 7r
Boring F
Boring #
❑ Pit Ground surface elev. tt. Depth to limiting factor in. Soil Application 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 '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
CST Name (Please Print) Signature CST Number
Address �,\ S +' Date Evaluation Conducted Telephone Number
7-36 - .2 y$ 358
Q•
a
Property Owner Parcel ID # Page of
F-1 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/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
F1 Boring # ❑ Boring
ace elev. ft. Depth to limiting .
Ground surf P 9 factor in
E] pit - So jlAppllcation 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 'Eff #2
Boring # ❑ Boring
F
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Applicafion 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 'Eff#2
i
Effluent #1 = BOD > 30 1220 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.
SBO -8330 (R.6/00)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
i
AND
OWNERSHIP CERTIFICATION FORM
owner/Buyer
Mailin g Address 1 q�5 q a o 0 S7'
Property Address
(Verification required from Planning Department for new construction)
i
City /State Parcel Identification Number d3r„ - lo<'S - 60 — 0000
LEGAL DESCRIPTION
Property Location L�-E— %<, IV V4, Sec. T_�; [ _N -R L.1— Town of Src r%Tb
Subdivision , Lot #
Certified Survey Map # ice/ 3 , Volume Page #
Warranty Deed # �� G 7 , Volume `'� Page # . _/,_
Spec house ❑ yes ❑ 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
mastorplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
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 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.
00
SIGNATURE OF &PLICANT 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.
— 0; �' c:5 - % �0--'- 9 / g I
SIGNATURE O PLICANT 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
I
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the �° , fin S�r� residence located at:
_ ', , /l l 1 ; , Section T_,d R_Z_) _ W, Town of
STn2�27y� Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced: 74 00
IJ
Did flow back occur from absorption system?
-_ Yes No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity: /&ZIC%
Construction Prefab Concrete Steel Other
Manufacturer: (If known):
Age of Ta f known) : bow 020 c "C-5
l 'VX OZL
(Signatur ) - (Name) Please grint
(Title) (Lidense Number)
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR 83, Wis. Adm. Code (except for
inspection opening over outlet baffle .
Name �/j/1, Z C� . ��, L S ignatur MP /MPRS eOs
Qt1Cl1AfE (1L�, $TAf WC lS�
q1tW �
t�
PACi of ,� x
Vet t l"( ra'S S m n +a; e>ifiatdl � >. ;
341017 _
t� THi� Ce_erl 4r I .
BY ti
h sba A e s o nt tenan g� t r htl� of S7.
P s _3. . _ - 4 _ ..
_�
—
s1vYS18r.g kn_ as Ort3 � 1 * `
_.. _ Ctrartt�r _ d.
Thomeks P. Jo so and Mops Cx. Johnson, t
!� quit - claims to— ,- .., - .. -..�._ _. i
husband__n� ._ oi:nt tenants . '
day
v One an
Grantee _� , far s tafttab�h consideration_
oth good and alu able co - - -»- =-� --
- -
{ the following described reel estate in St • _ CT c,,,tl, state of WiZoasin..
f All that part of the Southeast Quarter (SE 1/4)
jof the Northeast Quarter (NE 1 /4),, Section 25,
,+Township 31, Range 17, lying Easterly of the
Willow River, Tax Key r
This is hetmratead tope ft,
* and Oral Eaierel.
This Deed is executed for no consideration and reforms and confirms a
conveyance previously recorded.
FMWT
{
otde, Wisconsin ,, '7th sap �f J X 77
Executed
SIGNED AND $NAILED IN PRESENCE OF GLC IAL�
Lawrenc Baier _
i�
c l , `
� taEAL3
�{ Oral Baierl
I
j� CM AL)
j � - -- _ tW AL#
Sig,atures of
i
�+ authenticated this day of Y9 —• F-
li 'Cites Member State Bar of •isconsip or eg fti tixF
{! Jkistftorized under Sec. 706.06 Vh .
STATE OF WUWOPfiSTN
Dunn aa. u
1, Personalty c._ a before tae, th.s �tZl , x� = June
Lawrence Baierl ana a " ierl
iI the above named
k ,
to me known to be the perso who executed the foregoing instrument and ac ow the same„ - 3
This insttument was drafted by Robe G. 'r+
ROBER G. : W.LA ER � nzi�
Not Public DU
MY
. 4.
The use of wit owes is egtioaaY. Mp Commission (E n;
. .
�� r
art. •+x;a�. = ... ...
Names of persona a /, cspa. i should be ate t N w tbel� signatures.
!! $SiJ : OF 11'>:SC4NSIN, t
O
CERTIFIED SURVEY N0. 381
A part of the SE of the NE'4 of Section 25, T31N, R17W, Town of Stanton, County
of St. Croix, State of Wisconsin, described in Volume 2 of Certified Survey
Maps, page 381 as Certified Survey 381 .
3. Q3 ) S
NE CORNER, SECTION 25
SC A LE CAST ALUMINUM MONUMENT
FOUND
1
e
0 50 100 150 200 300 400 600 •
0
a
LEGEND UNPLATTED I
4
• 3/4" , 30" ROUND IRON ROD WEIGHING . . N "' -' . S e
_
1.502 LBS /L.F. ....�. • . • . • I 0
N I h
NORTH LINE OF THE SE 1/4 OF
THE NE 1/4 OF SECTION 25 J 33.01 h
N96 °3 4'03 "W I LLo
- X W 27' O
96.30 W \_
N N / � O
I Z
=na DETAIL -A E3 U �`° 66 Fz
~�X P Qi
LL p 2 CONTOUR ABOVE . c i0 ei WF
W ? _ u FLOOD PLAIN CONTOUR •fib ,7 • I
J F ELEVATION 99.0'
to N 0 9 6° \� • •
a / \
r / Q •
W W 1 •
L
~ 0 0 "e '.� w
O e u a W E '\ Q•
W WAG Oy. t 6 jp •
(3 -4 Z �j
�P • \ J • . I
m�N _
LL cr Q�.• i
0
�V�' • B ENCHMA RK RK • W •
t . •
\•� O1 200 14' 06" • U. :
•
Q , I3 S6z 30 15 I
• \2O � Q •
,64 °s �'3 4 ' I d
Z:
2 CONTOUR ABOVE
• /2jOO FLOOD PLAIN CONTOUR LOT 1 I ', •
�� W / • 41, ELEV. 99.0
TIO, 213 50. FT.: I
16.31 ACRES t
• .I • N / •
� e
r+ I . 0
r /46' 204° 26' 28" I
——
/
/ 3 6 6' I
/ h I
/ y P
/ ^ N 156 ?
N IV /
/ O
r �
I y /
QO' 1 56° 40
1'w p'
.0 e N APPROVED
2' CONTOUR ABOVE /) ° �? SOUTH LINE OF THE SE I/4 � /
FLOOD PLAIN CONTOUR ' 5
ELEVATION 99.0 � 0 O OF THE NE I/4 OF SECTION 25
71_' N 9s 529.4Y 3 MAY 18
� r ` 0 z3
S 86 36' 45" E 971
UNPLATTED LANDS
•..... ....• .... ST. CROIX COUNTY
... ... ... I
COMPREHENSIVE ►AUKS PLAHNIN6
AID ZoAmG COMMITTEE
WATER ELEVATION LEGEND
ESTIMATED HIGH WATER 90.8
E61IMA1ED low 'NATER B9B
ArI I VIA It11 Girl +AllIdt tii+A "
AM 1111' (it 1/4' 1 111111 ;
A% INIM AIt11 A.!,I1MI 11 N14l11 "r
N yn' 4y 19" E
i �itllllf.�Ij� ?4.64• s
�`���_ O '♦w/�'�''/� I' 1 FOUND E 1'n
�• I �I N 86' 34' 03" W
r EO 96.30
33.01'
mi, ory e, � A P PR OVAL OF THIS MINOR SUBDI
ow 1S4 0 : DOES NOT MEAN APPROVAL FO.7 SEPTI�ETAIL — A
4 F � I s -) . �0,,'O •�;,,� Cv' TC,� r.
TO 11 • 1 � SHEET10F _SHEETS
SU
J
��4 # C11 R ���� Volume 2 Pace 381
CERTIFIED SURVEY N0. 381
A part of the SE';, of the NE4 of Section 25, 1 R17W, Town of Stanton, County
of St. Croix, State of Wisconsin, described in Volume 2 of Certified Survey
i Maps, page 3S1 as Certified Survey 381 _ .
i
I, Leon R. Herrick, Registered Land Surveyor, hereby certify:
That I have surveyed, divided, and mapped a part of the SE- of the NE-I, of
Section 25, T31N, R17W, Town of Stanton, County of St. Croix, State of Wisconsin,
more particularly described as follows:
Commencing at the Northeast corner of said Section 25;
Thence S 01° 01' 44" W 1,322.13 feet;
Thence N 86° 34' 03" W 33.01 feet to the point of beginning.
Thence continuing N 86° 34' 03" W 96.30 feet to a 3/4" round iron rod being
38 feet more or less East of the water's edge of the Willow River and the beginning
of a Southerly and Westerly meander line.
Thence S 25° 38' 51" W 233.91 feet along said meander line;
Thence S 41° 53' 27" W 405.81 feet along said meander line;
Thence S 62° 07' 33' W 120.30 feet along said meander line;
Thence S 46° 59' 07" W 174.02 feet along said meander line;
1
Thence S 05° 58' 34" E 220.39 feet along said meander line;
Thence S 18° 27' 54" W 226.45 feet along said meander line;
Thence S 04° 51' 50" E 164.21 feet along said meander line to a 3/4" round
' iron rod being 94 feet East of the water's edge of the Willow River and the end
of said Southerly and Westerly meander line;
Thence S 86° 36' 45" E 529.47 feet;
Thence N 28° 53' 38" E 348.54 feet;
Thence N 02° 16' 01" E 1006.68 feet to the point of beginning, including all
land lying between the meander line and the water's edge of the Willow River.
Said parcel contains 710,273 square feet more or less (16.31 acres ±).
That I have made such survey, land division, and plat by the direction of
Thomas Johnson and Lawrence Baierl.
That such plat is a correct representation of all exterior boundaries of
the land surveyed and the subdivision thereof made.
That I have fully complied with the provisions.of Chapter 236 of the
Wisconsin Statutes and the subdivision regulations of the County of St. Croix and
the Town of Stanton in surveying, dividing, 2andmap i ng t Dated this /, 9 day of j j— , 1977
340358
SCONS� 9
IvAb LEON R.. L m F�� j) 1v
w H SR303 K � ,,� 27 1977
MENOMONIE, r M(E(�
WIS. �, moo/ �..y
w .
Volume 2 Pate 381 iftft
Sheet 2 of 2
4