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Wisconsirl Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 430138 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 Par I Tax fop
Green, Dave Star Prairie TownshiU 0
CST BM Elev: Insp. BM Elev: BM Descriptio : Sectionll own /Range /Map No:
/00 - d /00. U *f 5";o7j 09.31.18.1*LL
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic o 6 Bench -mark n , ,
N j/ (JAL,
Dosing Gv Alt. BM
_1
Aeration Bldg. Sewer
H 'n St/Ht In i
olds g et S I
S �• � S
p,
TANK SETBACK INFORMATION St/Ht Outlet 1 t-{
TANK TO P /I WELL BLDG. Vent Air Intake ROAD Dt Inlet _
Septic > -� ! O1 V Dt Bottom
Dosing - - Head /Man.
- -- � X13.7
Aeration Dist. Pipe �3
Holding Bot. System
I - 7 q 2•g
PUMP /SIPHON INFORMATION Fina de 7
Manufac rer _ Demand St Cover Z L
7 �D
Model Number
TDH Lift Fri Loss tem Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM C�i-yl
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pit' Inside Dia. Liquid Depth
DIMENSIONS 9 /
SETBACK SYSTEM TO P/L L JBLDG WELL LAKE /STREA LEACHING Mar urer: f
INFORMATION CHAMBER OR J / d
Typ Of System: / / / UNIT
TT N
, � > I to Model Number:SL ) . A., DISTRIBUTION SYSTEM L l t 4?47 7�n s
Header /M nifold Distribution r x Hole Size x Hole Spacing Vent t itr IIntpke
Pipe(s) J J
Length Dia Length Dia �' "'Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only lfim
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center L,.i Bed /Trench Edges Topsoil -
1 Yes No �' j Yes No
COMMENTS: Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: ! !
Location: 20th Av5, hmond, WI 54017 (SE � /4 SW 114 9 T31 RI 8W) NA Lot D/D Parcel No: 09.31.1
1.) Alt BM Description = R� if 4Z &f of ,�,,_ /�,��
2.) Bldg sewer length = ���� ✓�'l L � &Ak
- amount of cover
Plan revision Required? ,Yes I�) No
I / w
Use other side for additional information. i- - -_L -
SBD -6710 (R.3/97) Date Insepctor's Si ature Cert. No.
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t Safety and Buildings Division Counry�
201 W. Washington Ave., P.O. Box 7162
vi cOnsi i� Madison, WI 53707 - 7162 Sanitary Permit Number (to be fil )ef in by Coo_
Department of Commerce (608) 266 -3151 44 3
Sanitary Permit Application State Plan I.D. Numbber
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Addres (if different than mailing address)
S
1. Application Information - Please Print All Informatio
4� I
re �r
Pr perty Owne ' a me rv.s �(? S�D Parcel Lot # Block # 1.
> r ► _, ; 70
3 03g�
fO 2oAzlix_ s
ProperTy Owner's M ailing ddress operty Location
Pa
5 ) 4 �
}k %,Secdon
City, State i Zip C e Phone Number
circl one)
W T - 2 N; R(((JJJEo W
Type of Building (check all that apply) +/
-eA, OA4 � � Subdivision Name CSM Number
or 2 Family Dwelling - Number of Bedrooms
r^
❑ Public /Commercial - Describe Use _
❑ State Owned -Describe Use 6� CZ +0 S ❑City_ ❑Villag nship of o f cu
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A * ystem ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. El Permit Renewa / l rmit Revision El of Permit Transfer to New List Previous Permit Number and Date Issued
Before Expirati Plumber Owner �30
IV. Type of POWTS System: (Check all that apply) OALA 4X
— 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- ound ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter eachirI Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area ormation: d /
Desi n low (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (so Dis al rea Proposed (sf) S stem Elevatio
3
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site &:eel Fiber Plastic
Gallons Gallons of Units W/ Q lU v Concrete Constructed Glass
New I Existing
Tanks Tanks �--
_ Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, responsibility for installation of the POWTS shown on the attached plans.
Plumber's Na a (Print) Plumber's Si e MP/MP S Numbv Business Phone Numbe
Plumber's Addre ss (S treet, Ci ty, State, Zi e)
VI Count /De artment Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Grou_ ltdwater Issuing Agen Signature ps)
Surcharge Fee) /} U U (d
E) Owner Given Reason for Denial �O —�
IX. Conditiorls of Approval /Reasons for Disapproval
c� c0 d 0),
10,25"
Attach cjApleteylans (to the County only) f the system on aper not less than 91/2 x 11 inches in size
CiT7Tl !7AO iT n+ ran.
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
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.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. / Il eviewed Py Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Property Location C
Govt. Lot 4 r 1 /4 J q)/4 S T 3 / l
N R i E (o W
Property e Z z ��
s M ling Address of Block # Subd. Name or CSM#
City State Zip Code Phone Number ❑ City ❑ Village wn Nearest Road
New Construction use, Residential I Number of bedrooms Code derived design flow rate GPD
❑ Replacement ❑Public 1 7 commercial - Describe:
Parent material Flood Plain elevation if applicable �Af_
General co
and recommendations: t�
/❑ Boring # E] Boring
` A pit Ground surface elev &/ Z' ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Boring # Boring
Z
Pit Ground surface elev ft. 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
/.311 �• -�
• -
•
Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 Effluent #2 - BOD 1 30 n1g/L and TSS < _ 30 mg/L
CST Nettle (Please Print) - - re CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 715- 246 -4516
Property Owner _ Parcel ID # Page of
F Boring # ❑ Boring
pit Ground surface elev. ft. 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
F-1 Boring # C3 Boring
❑ Pit Ground surface elev. ft. 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 J •Eff#2
F-1 Boring # [] Boring
Cl Pit Ground surface elev. ft. 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 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.
SBP6330 (RAM)
Test and System PLOT PLAN
PROJECT Dave Green 4ADDRESS 4 7 220th Ave New Richmond Wi 54017
SE 1/4 SW 1/4S 9 /1 W TOWN Star Prairie COUNTY ST. CROIX
j MPRS Shaun Bird 226900 DATE 7 / 15/03 BEDROOM 3
CONVENTIONAL XXX IN-GROUNVRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 30
IL BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
I
SYSTEM ELEVATION 92.8/92.7
I
Vent Plans Designed Using
Conventional Powts
ALo Standard Biodiffuser Manual Version 2.0
Leaching Chamber
with 31.1 ft2 of Area
Grade at S ystem Elevation
34"
a 2 -3' X 94' Cells with >3' Spacing
30 , B.M.
0 30' B -1 T
20
U�
.� " J
25 Pro 3 Bedroom
50' B -2 Vents House
120'
50' B -3 20 ,
Vents Well
10'
100'
To Share Driveway 660' Prop Line
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Safety and Buildings Division Coun�E; / /J
201 W. Washington Ave., P.O. Box 7162 l �(Q x
Madison, WI 53707 - 7162 Sanitary Permit Number (to be ft W in by Co.)
���On�,�
Department of Commerce (608) 266 -3151 q?O 3$
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, s15.011 M) _•,_., Project Address (if different than mailing address)
I. Application Information - Please Print All Information. ~�
Ai 6- .
Property Owner's Na me' " +, Fy arcel # ✓� Lot # / Block /J
+T
Gv
Property Owne M ailing Address A Pro Location ) K�
Ci ty, P State Zip Code Phone Number
cir
II Type of Building (check all that apply) 014. S T N; R E o
M
C.-
n Subdivision Name CSM Number
or 2 Family Dwelling - Number f Bedroo
El Public /Commercial - Describe Use f ►�
F] State Owned - Describe Use ❑City_ ❑VillageTownship of O¢
III. Typ of Permit: (Check only one box o line A. Complete line B if applicable) b �j$ OLD
A. 1.
ew System lacement System ❑ Treatment/Holding,nk Replacement Only ❑ Other Modification to Existing System
lo
B. ❑ Permit Renewal ❑ Permit Revision of El Permit Transfer to New
List Previous Permit Number an Date Issued
Before Expiration )Ch�ange
er Owner %,
IV. Type of POWTS System: (Check all that apply)
on - Pressurized In- Ground ❑ Mound > 24 in. of suitablev Mound < 24 in. of suitable soi t -G d ingle Pass Sand Filter
❑Constructed Wetland 11 Pressurized In- Ground ❑
Hold ❑ P
eat Filter ❑Aerobic Treatm nit ❑Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter Leaching Chambg# ❑ Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Info mation:
Design Flow (gpd) Design Soil Appbcat te(gpdsf) Dispersal Are equired (sf) Dispe i� a Proposed (sf) ystem Elevation '
J-D , `7 0 3 S
VI. Tank Info Capacity in Total Number ufacturer Prefab Site S•.eel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
0
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, theindeigned, assume responsibility for installation of the OWTS shown on the attached plans.
PI u ber's Na me (Print) in Si gnature MP /MPRS Number Business Phone Number
Plumber's Addre ss (Street, City, State, Z Code)
VIII. Count /De artment Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I ui Agent Signa e: (No Stamps)
Surcharge Fee) � 225 ,
❑ Owner Given Reason for Denial
1X. CondiQons of Approval /Reasons for Disapproval - /1
Z . Q.a..o_ na �v�,6 c�e� ��Li dl �+�,^ i4 ►, cl vet, f " A9 �6+� .
w t om• 90 4 •� D n ,
,no � 8-11 � 120 .E C t �ciK
Attaeh complete pla s (to the County only) for the system on paper not less than 81/2 x 11 inches in size
PLOT PLAN
PROJECT Dave Green DDRESS 1047 220th Ave New Richmond Wi 54017
SE' 11 4�SW 1 /4S 9 /T 31 R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 6/25/03 BEDROOM 3
CONVENTIONAL XXX IN -GROUN RESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 30
BENCHMARK V.R.P. Top of nail in power pole ASSUME ELEVATION 100, Filter Zabel A -100
❑ BOREHOLE O WELL sH.R.P. Same as Benchmark
SYSTEM ELEVATION 95.4'
Alt. BM Top of 2 Pipe t7a 98.0
AL Vent Plans Designed Using
Conventional Powts
>6" Standard Biodiffuser Manual Version 2.0
?6'Lonfg Leaching Chamber
with 31.1 ft2 of Area
0 v I
34' Grade at System Elevation t
Survey was not complete at (,V -a'
the time testing was done ,
Ul
3 Bedroom
House
a d
w
Tested are has �`� 25'
0% Slope and
thus no contours
X 4 Cells with >3 Spacing
30'
B -3
Well
Vents
ents / J20'
Ut 30'
70 ' B -2 45'
6d Id
ad
AC 45' -1 90'
0 20 *B.M.
Alt
td .M.
To Share Driveway 660' Prop Line
PLOT PLAN
PROJECT pave Green DDRESS 1047 220th Ave New Richmond Wi 54017
SE 1/4 SW 1/4S 9 /T 31 R 18 W TOWN Star Prairie COUNTY ST. CROI:X
MPRS Shaun Bird 226900 _. DATE 6/25/03 BEDROOM 3
CONVENTIONAL X)OC IN -GROUN RESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 30
IL BENCHMARK V.R.P. Top of nail in power pole ASSUME ELEVATION 100° Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION 95.4'
Alt. BM Top of 2" Pipe @ 98.0'
Vent Plans Designed Using
Conventional Powts
ALong Standard Biodiffuser Manual Version 2.0
Leaching Chamber
1 "
with 3 1. 1 ft2 of Area
34" Grade at System Elevation
Survey was not complete at
the time testing was done
Pro 3 Bedroom
House
1~
a�
a
0
0
M Tested are has 25'
0% Slope and
thus no contours T
2 -3' X 94' Cells with >3' Spacing 30'
B -3
Well
Vents Vents •
20'
70' B -2 30' 45'
Id
AC 45' TA 90'
0' . t.
.
To Share Driveway 660' Property Line
FROM :,COTTOR FAX NO. : 755 -3501 Jun. 12 2003 09:43RM P2
ORIGINAL
Wisconsin Deperlmentof Commerce SOIL EVALUATION REPORT Page
Division of Safety and Buildings
in accordance tNiM Comm 85, Ws, Adm. Cede -�!^
t:ounh
eutaGl complete site plan on paper not less than a 112 : 11 inches in size. Plan must
include, but not limited m; vertical and horizontal reference and Parcel I.D.
percent slope. scale or dimensions, noAh ow, app b
pV/S"nae lu eareal road.
Please print ! lntormaliort i
. v A_
y
personal nrlormatial ym tra.iea may to uead seaondwy �n fRiva taw, s.
Properly v arty t.oeation
Q � p � Lot 1 /4.e• N S T N R E (--(2
Property t3wtter's f itolg Address <<; n:1 N(- 0 F F I C'i L ft g �1an or J
` State Zip Gale Phone Number ❑ City [ivillage OTo ?St
!J` Road
S
Q New Cano"A tin Use: esidontlal / NnanbPr of b.*wns � es
_ Code denved design flaw rate Y J!J GPD
Replaaareant ❑ Pu6lic or °�tiffi.- Oe9aibe
Parent trmterial Rend PUin etevatwn if applicable
General corrinw-ft
and recarnmengla
/ ► ��
/eov� $ lvw
s Bonng Q /�'
1 «.1 Pit , . s%una sw?ace elev. it Dd* ro Ong factor ey c! in..
Zoll Appkgdon Rate
t Wriwn Lin ' Dominant t 6l . " Rad6z Des6ocn Texnae Structure Gong Wenae • BouWary ROM P
Muns" ... .. 10u. Sz. Cont. Color 6r. 8z. Sh. 1 -ew OEM
3 .z
+o s Botie+q
Pit Ground taut alev. ft. Depol to lirfidng facto in_
Sell Application Rate
Hortim Depth Dominant color Radar Description Texure Structure Consistence Boundary Roots GPOR
in. Mumtell Qu. Sr Cont. Color Gr. Sz. Sh. 'Eff01 'Effl12
r C7 1 Z t• �" ~�. .�
' EAluarrt nOrt s 800 ao 5 220 mall - and T5S a3o c 150 ill = Bt3D 30 mgtl and 1%8 mgA..
CST Nerve 0%3" PMO CST Nui nber
Bird Plumbing, Inc, - Shaun Bird 226900
Address ate Evaluation Go ucled Telephone Number
1008 192nd Ave, New Richmond, WI 54017 715- 246 -4516
FROM :,COTTOR FAX NO. 755 -3501 Jun. 12 2003 09:44AM P4
Property Owner _ Parcel ID # page ..-.— -- of
n ems Borin (r
l J .�• Pit �+d surface etev- 1 11 ft. Depth w Umbi tg factor in. S rc�fiorr Rare
Hwb)vn Depth Dminant Cola Redo: Description Texture Sbucture Car istence Boundary Pas GPDIM
in. Munsell Qu_ Sz. Cant, Caton Gr. SL Sh. 'Eff#1 - EM2
Aoo
D pit Ground suBace etev. it Depth to limiting factor im Soo Appl ication Rate
Horiten Depth 'j i — vir�lrR Clor Reclax Dasaiprien Twus 3trudwe ConmzWkshmae Botadary Roos GPDO
In. mun"I du. Sa Cent Castor or. Sz. Sh. TW 'Ef a
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The Department of Commercc is an equal oltpuriuni(y service 1),ovitler and employer. if" you need assisiunce to aeCess 4erv;(:05 n,
reed matcrial in an alleriime irttnVt!. PIa SC C4tlt1Cl tlu derarlrnrnt ;rl c,p4;_2ti6 -31 x1 ur 'I - t'Y t f)8.2b4 -8777,
sjw -m ?'n (R r qgp
FROM COTTOR FAX NO. : 755 -3501 Jun. 12 2003 09:43AM P3
Soil Test Plot Plate
Project Name Dave Green Shaun
Address 1047 220th Ave
New Richmond WI 54017 CV .#226900
__ - - -_ e 5/5103
- Date Lot Subdivision _
SE 1/4 S W 1/4S 9 T 31 N /14 W Township Star Prairie
n Boring Q Well PL Property Line County ST. CROIX
' ' p ower p ole-
System Elevation 95.4
Assume Elevation '1 ft. = Top of nail in p p
� � BM or VRP -
* s Be nchmark
HRPSame a Be
Alt. BM Top of 2" Pipe @ 98.0
Survey was not complete at
the time testing was done
c
a
c, •
0
Tested are has
0% Slope and
thus no contours
B.
Well
30'
20'
70' B- 45'
90
0
2 *13 M.
.M.
To Slim Driveway 660' Property Line
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
St. Croix County Zoning 715 - 386 -4680
Pumper Tom Mondor 715 -246 -5148
Shaun Bird #226900
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer r ,
Mailing Address /' _ / o C r c � A
Property Address Z 2
(Verification required from Planning Department for new construction)
Ci ty /State Parcel Identification Number I n — ae " cc D ( •
� E �j w 039- /0-V 6Z 0a0�. /b �
LEGAL DESCRIPTION 0 O 000 �• /(v h f
Property Location V,,�1. I / <, Sec t T N -R (_ W. Town of c
1 04 2 s 12 --�'� � Ar/t�e4/_�
Subdivision 710 ar Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed ## Volume 2 , Page # a S 4
Spec house O yes no Lot lines identifiabl )dyes O 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 frill 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.
' C Js/ 0-t
SIGNA'WRE 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 des 'bed 4ove, by virtue of a warranty deed recorded in Register of Deeds Office.
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
APR. 1 .2003 3: 17PM WBS JERRY C /BILL. E N0.363 P. 2/2
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04/21/03 MON 16:22 C /RX N 77131
nOCUMENT Wo. WARRArf 9 1 DUD w T"Is IPACS "UNVIIO I" 1110ce"I Ie DATA
STATS BAR OF WISCONSIN FORM It —UN
«fir
90011 t t 2 nc 2 _ REGISTERS OFFiC!
ST. CROIX CO., WM
Ethel Halvorson f a /k /a Ethel Halverson, Wd 1br Record !Ns 23rd
a .. alid. ........................................................ ............................... ..
... of !!!rch A.0. 14
amv*ya and warrants ta. D. avict..L,....Gwen..and..Chriati ne..J...
..GreeiL,..husband.. and..wj.fe... as- •mar.ital.- property.,..
..vith..rights..of.. survivorship ............... ............................... w
1
...................... .........................'-.--I ........................................................--
.................................................................................................................
.................................................................................. ............................... RSTURN TY
.................................................................................. ...............................
... ............................................................................... ...............................
tM following oescribd real estate In ........ St.... C ..................County.
State of Wisconsin:
Tai Parcel No: ..... .. .... _ .................
The East Half of the Southwest Quarter E e st
a west Quar er SEIt of NWh) of Section Nine (9),
Township Thirty -one (31) North, of Range Eighteen (18) West.
$ '2 00
FM
This conveyance is given in satisfaction of that certain land contract
between the parties, dated December 31, 1986 and recorded February S,
1987 in Volume "768 ", page 129, Document No. 422088.
This ..... 1 .................. homestead property.
(is) (is not)
Exception to warranties:
Dated this ....._..._.:�._.......... day of Mach........- . 19_...$.7..
li (SEAL) ............................ ......... (SEAL)
- - - -•. . -- •---- •--- --••---- -•- ..- .. -. -._
' Ethel- Halvorsomi ------------------- .........
f .......•...._.(SEAL) .... ............................... .........................(SEAL)
' ......... ......................................................... ---•.----...._....... ............................................
} AUTHHNTICATION ACHNOWLRDGMSNT
Signattsrs(s) ............................. ..... .....•-----.._....._...._. STATE OF WISCONSIN
.................... __ ..... _ ... __. .... • ..st -- cr ....County. '
authenticated this -------- day of ........................... i>t...... Personally cause before me this .. . —....... day of
- - - - -.- Mar- ch .................... i9...27 the above named
Eth-e1_.iialyorac� .............. .................
---------------•-----------.....---•----....... .......-- •--- ......-- •- •. - - - - -- --.........------•---------....-----•--•-•-------.._..------•------•........--•-
TITLE: MEMBER STATE BAR OF WISCONSIN
(Ii not. .- - .... ...................................................... .. - - -- ° - - - -- --- - - -- - �s � °•..
E authorized by; 1 06.06 , Wie.Stats.) -- �� �..'
f to me own to be the person .....:._ -•
i for T inatmment an no ti;q;aR�e.y o
THIS INSTRUMENT WAG DRAFTED BY Q: e
j JEeIA1 1��a..... - 4n .. I? Y- k...�..>;(c�S�lzatil....Sr.G. A ,7o n ! a '�,
t AP - _Richmgad r - . . T_.. _540 7 ............ ........... .. ............ - - Cio x �+���j�•.
Notary Public ....... .... ......... o
t
( Signatur es may be authenticated or acknowledged. Both My Commission perm nent. (If not, a��'�2n''
{ 1111 date: ...... -- -.1 .[. D ..................... 18.......
) I
sNo so of person sigains is any eapset4 should be typed or printed below their signatures. '
STATS BAR r e a ISCO al '' Stock NO. 13002
-
U 2 2 8 8 P 3 12 727331
V
KATHLEEN H. MALSH
STATE BAR OF WISCONSIN FORM 3 - 1999 REGISTER OF DEEDS
Document Number
ST. CROIX Co., MI
RECEIVED FOR RECORD
This Deed, trade between David L. Green and Christine J. Green, 06/25/208'3 04 :15PM
husband and wife
QUIT CLAIM DEED
EXEMPT # 8
Grantor, and Jesse Joseph Green, a single person REC FEE: 11.00
TRANS FEE:
COPY FEE: 2.80
CC FEE:
PAGES: 1
Grantee.
Grantor quit claims to Grantee the following described real estate in
St. Croix County, State of Wisconsin (if more space is
needed, please attach addendum):
Recording Area
W % of NF. VA of SW A SQ i-4w G 1 ••v p( S W `l � Name and Return Address
W '/� of SE '/, of SW '/. Jesse Joseph Green
ection 9, Township 31N, Range 18 W, Town of Star Prairie, St. Croix County 1047 220th Ave
Wisconsin. New Richmond, WI 54017
Sellers shall retain the right to receive all CRP payments attached to the subject
property.
c.(0 KS
038- 1039 -60 -000, 038- 1040 -20 -000
Parcel Identification Number
This is not homestead property.
(9) (is not)
Together with all appurtenant rights, title and interests.
Dated this a day of June , 2003
* * Dav id � L. G reen
(
* * Christine J. Green
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
ss.
.Cr l X County )
authenticated this day of y
' Personally came before me this day of
June , 2003 the above named
David L. Green and Christine J. Green, husband and wife
TITLE: MEMBER STATE BAR OF W
(if not, = NDA M. to me known to be the person(s) who executed the foregoing
instrument and acknowledged the same.
Im FA
authorized by § 706.06, Wis. Stats.
THIS INSTRUMENT WAS DRAF� R�
Attorney Kristina Ogland 'yi Notary Public, State of Wisconsin
Hudson, WI 54016 My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) q_aS — b •)
* Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals company, Fond du Lac, M
STATE BAR OF WISCONSIN 800s5s-2021
QUIT CLAIM DEED FORM No. 3 - 1999
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