HomeMy WebLinkAbout038-1089-40-000 Wisconsin Department of ommerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
• 399440
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:
Dootan, Fern I Star Prairie Township 0384089 -40 -000_
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark Q y 80
. �
Dosing Alt. BM
J
Aeration Bldg. Sewer
Holding St/Ht Inlet s r
146-20
L. TANK SETBACK INFORMATION St/Ht Outlet c1 S• 9 Z'
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic i �t l Dt Bottom
� 5
Dosing Header /Man.
Aeration Dist. Pipe •o L 2.
6 qy, S(o r
Holding Bot. System 10-4/z /• Tfr
o. v 9t . 16'
Final Grade
PU P /SIPHON INFORMATION
Manu cturer and St Cover
GP Z• 66 �6 �
Model Nu r ok
TDH Pl tion Loss System Head
j 1 W Ft
Forcemain Length Dia.
SOIL A SORPTION SYSTEM
ENCH idth Length No. Of Trenches PIT DIMENSIONS No. Of its Inside Dia. Liquid Depth
DIMENS ONS 1 q3';,5
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufact �re ` $�
INFORMATION CHAMBER OR t . s
Type Of System ' I I _ UNiT Mo el Number.
V �.
, 7
DISTRIE!U SYSTEM
HeMgthej TSl t , Distribution Size x Hole Spacing Vent to Air Intake
v Pip s r
Len Dia Le ngth Dia S
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of eded /Sodded xx Mulched
xx Se
Bedrrrench Center Bed/Trench Edges Topsoil Yes [W No FI Yes No
{
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: ® / � / s Inspection #2:
Location: 2064 County Road C Star Prairie, WI 54026 (SE 1/4 NW 1/4 21 T31 RI 8W) NA Lot NA (` • Parcel No: 21.31.18.364B
1.) Alt BM Description = of AL
2.) Bldg sewer length
- amount of cover = tgf* (•+�i �q� p /
Plan revision Required? ❑ Yes X No ' � n 4 FO
Use other side for additional information. 1
Date Insep or's Signature Cert. No.
SBD -6710 (R.3197)
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
4COnS Personal information you provide may be used for secondary oses u Madison, WI 53707 -7302
p
Department of Commerce [P rivacy Law, s. 15.04(1 m (Submit completed form to county if not
state owned.)
Attach complete plans (to the county copy only) for the'sy do pit r n less than 8 -1/2 x 11 inches in size.
County , State S i P ' Number ❑ Check iP:rdvision to previous; pplication State Plan I. D. Number
I TO
I. Application Information - Please Print all Information Location:
Property Owner Name Property Location
,- `e --,*? z: /t ` 1 1 /4 /��, S T ,N, R 'E (or
Property Owner's Mazling A /' / t� 01-1 X
® / C Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
IL Type of Building: (check one) ❑ City
15 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Village
❑ Public /Commercial (describe use):_ j of
❑ State -Owned
K c� s Nearest Road
Parcel Tax Nwnber(s)
III. Type of Permit: (Ch eck only one box on line A. Che box on line B if applicable) Al. 3 (
A) 1. ❑ New 2. A Replacement 3. ❑ Replacement of 4. 5. 6. ❑Addition to
System System Tank Only Existing System
B) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
0 Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment 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 940 o gIA(Gals. /day /sq. ft.) (Min. /inch) Elevation
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
❑ ❑ ❑ ❑
❑ ❑ F ff- t ❑ ❑
VIII. Responsibility Statement
I, the undersigned, ass responsibility for installation of t he POWTS shown on the attached plans.
Plumber's a (print) Plumber's re (no scam s): MP/MPRS No. Business Phone Number
Pl ber' ddress (Str ity, State, Zip Code) ,
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
X Approved ❑ Owner Given Initial Adverse Surcharge Fee) op
Determination If tl p§1 0 /
X. Conditions of Approval /Reason for Di appr val: L 1 n
�lE' H�'+� ,ou,tiurJ v�.�.�Q_ v�r�xk �e�CC- T�+'�►�- .�--�- � � �r'ecaw►.�t�a�
0
SBD -6398 (R. 07/00)
Sanitary Permit Application Safety & Buildings Division
Washington Ave.
In accord with Comm 83.2 1, Wis. Adm. Code 201 W. PO Box 7302
14 .4consin See reverse side for instructions for completing this application Madison, WI Box 7302
Department of commerce Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m (Submit completed form to county if not
�],__
� state owned.)
Attach complete plans (to the county copy only) for the syVe 4 dn�ppkr,n less than 8 -1/2 x 11 inches in size.
County / State Sanitary P ' Number ❑ Chee$i isign to previ \ Ication State Plan I. D. Number
L Application Information - Please Print all Information Location:
Property Owner Name Property Location
J^ 1 ""�
/Q � - � - .. 1/4 ��p7a, S ' T R `E (or
Property Owner's Mailing Addre y� Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
r
II. Type of Building: (check one) ❑ City
`5 1 or 2 Family Dwelling - No. of Bedrooms : 0 Village
/
❑ Public/Commercial (describe use):_ E7 � own of
❑State -Owned
2 � ��� �� /�� � � %' —t: ✓ � 3 K Nearest Road /�
�'G Tax Nurrrber(s) !fl
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
A) 1. ❑ New 2. A7 Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
$) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV Type of POWT 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:
V. Dispersal/Treat 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 ,(�{¢� gal(GalsJday /sq.It.) (Min. /inch) rr /_ y , Elevation
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
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumbers a (print) Plumbers re (no scam s): MP/MPRS No. Business Phone Number
A
;7
Plulfib5^ddress (Strdft, City, State, Zip Code) r� r
IX. County/Department Use Only
❑ Disapproved Sanitary Pemrit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
X Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination
X. Conditions of Approval n al /Reaso for Di a r val:
_� PP � od Liu- j
SBD -6398 (R 07/00)
/ PLOT PLAN
PROJECT � �r/n G /u� ADDRESS :;7�d
1/4 ff / 1 p?Il /T '�/ N/R jt� , W TOWN � COUNTY
MFRS Byron Bird Jr . 220527 / DATE °? D/ BEDROOM
CONVENTIONAL XXX A - ra CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 6 G
LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA d C # of chambers
IL BENCHMARK V.R.P. /
O , Z�� ASSUME ELEVATION 100 1� >
❑BOREHOLE O WELL *H.R.P.l_
Lenl SYSTEM ELEVATION
12"
dewinder Hi h
Of f g
Cov pacity Leaching
amber with 17.2 y
2 per chambe r
Grade at Systern
Long 34" Elevation
1
r
•o
g el G
Y
o b p
0
yq _ v
t
iq5
9
/ PLOT PLAN '
PROJECT ADDRESS :;
1/4 114S /T/ N/R /z W TOWN . COUNTY
MPRS Byron Bird Jr. 220527 DATE l� BEDROOM y
CONVENTIONAL XXX At- rade CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE /' G' LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE /_ Z ABSORPTION AREA 1 # of chambers
BENCHMARK V.R.P. �-� ` j �J��f�-� ASSUME ELEVATION 100' ��f�n�' /
❑ BOREHOLE O WELL *H.R.P. � r� ,(
A'
�j Lry C
Vent SYSTEM ELEVATION r = y�
AT Sidewinder High
Capacity Leaching
Chamber with 17.2
b" t ^2 per chamber
L ong 34 Elevation
1
r
�
�v
1
(rA i lk z.
he
ob
0 ,
. J !
f
o�
i J,5 0
112 64� - -��
Wisconsin Department of C ce I� IVE� L EVALUATION REPORT Page of
Division of Safety and Buil
� j in rfrd�gw�with Q m 85, Wis. Adm. Code
sin size. Plan must Count
'
Attach complete site plan n per not I Vferenc 1/2 x 1 r' - O
include, but not limited to I and h 1 p hi (BM), direction and Parcel I.D.
percent slope, scale or dim rr�wl�s nc�gpe�tocr nd distance to nearest road.
Ple / vpt_all_i_nfornli i Reviewed by Date
Personal information you provide ma �U J ed�fo y C a D8 0
y p ybe s' � 3 �b �( Wi6rposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location ��ii
F e p Govt. Lot f� 1/4/W/4 SOX f T N R!f E (o
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
f- C- - -
City tate Zip ode Phone Number ❑ City ❑ Village f 'Town Nearest Road
ch't r r v oa (, V d - S/
❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate CJ<25 GPD
$Replacement ❑ Public or commercial - DE�cribe:
Parent material f'ce � k. Flood Plain elevation if applicable ft.
General comments
and recommendations:
S iZ�t U ,
Boring # E] Boring
M R 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 /ft
/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
f /lam /' % '
Qt'•
*.V yb. y
Boring # ❑ Boring
Pit Ground surface elev. �`7 Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
a G .3-
*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 e (Please Print) r Si atuie CST Number
r
A d s Date Evaluation Conducted Telep Numbers
SBD -8330 (R07 /00)
• � ti
Property Owner �r� 60 Parcel ID # Page of
Boring ..
531 Boring # Pit Ground surface elev. ( ` 5 `S ft. Depth to limiting factor >, ' in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
o n 5
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 /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
El Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
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)
Soil Vest Plot Plan
Project Name Fern C. Doolan Byron Bir r.
Address 2064 Cty Rd C 1
Somerset Wi. 54025 CSTM i210527
Lot ---- -- Subdivision ------- Date 6/19/200
S E 1 /4 1/48 Y 31 N /p W Township Prairie
Boring Q Well PL Property Line County S T. CROIX
,BM or VRP Assume Elevation 100 ft topofdoor slab #altBM topofgaragedoor siab100'
System Elevation 91.8 H.R.P. same as BM
Well
2 ,
Driveway
4 bed house
Garage 24'
24' 30'
Ex t
Etc Drainfeild
9 9
5
100
1
94'
B B2
100 300'
175'
' POWTS OWNER'S MANUAL 8Z MAMKU"'Ar i � «.•+•� �'
FILE INFORMATION SYSTEM SPECIFICATIONS
' Owne Septic Tank Capacity 6 o g al ❑ NA
Permit # Septic Tank Manufacturer & /e , f ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturers [3 NA
Number of Bedrooms
❑ NA. Effluent Filter Model 8 0 ❑ NA
Number of Commercial Units I ❑ NA Pump Tank Capacity gal ❑ NA
Estimated flow (average) gal /day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) - 0 gal /day Pump Manufacturer ❑ NA
Soil Application Rate ' a gal /day /ft' Pump Model ❑ NA
Monthly average' Pretreatment Unit ❑ NA
Influent/Effluent Quality Y ❑ Sand /Gravel Filter ❑ Peat Filter
Fats, Oil ez Grease (FOG) :530 mg/L ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BODs) :5220 mg /L ❑ Disinfection ❑ Other:
Total Suspended Solids ( TSS) 5150 mg /L Manufacturer
Pretreated Effluent Quality ❑ NA Monthly average* * Dispersal Cells)
Biochemical Oxygen Demand (BODs) :530 mg/L 'in-ground (gravity) ❑ In- ground (pressurized)
Total Suspended Solids (TSS) _ :30 mg/L ❑ At -grade ❑ Mound
Fecal Coliform (geometric mean) :510 cfu /100mI ❑ Drip -line ❑ Other:
Maximum Effluent Particle Size inch diameter * Values typical for domestic (non - commercial) wastewater and septic
tank effluent.
* * values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Frequency
Service Event
Inspect condition of tank(s) At least once every 2 months ❑ year(s) (Maximum 3 yrs. )
Pump out contents of tank(s) When combined sludge and scum equals one -third (Ys) of tank volume
Inspect dispersal cell(s) At least once every ❑ months ❑ year(s) (Maximum 3 yrs.)
Clean effluent filter At least once every Wmonths ❑ year(s)
Inspect pump, pump controls ez.alarm At least once every ❑ months ❑ year(s) ❑ NA
Flush laterals and pressure test At least once every
❑ months ❑ year(s) ❑ NA
Other: At least once every ❑ months ❑ year(s) ❑ NA
Other: At least once every ❑ months ❑ year(s) ❑ NA
MAINTENANCE INSTRUCTIONS
idual carrying one of the following licenses
inspections of tanks and dispersal cells shall be made by an indiv certifications: Ma
Servicing
Plumber; Master Plumber Restricted Sewer, POWTS Inspector; POWTS Maintainer; Septage vicing Operator. tor. Tank inspectic
must include a visual Inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, as
volume of combined sludge and scum and to check for any back
he observatao ponding
n pipes f and to check for any ponding of effluent or
dispersal cell(s) shall be visually Inspected to check the effluent levels
the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate
notification of the local regulatory authority.
the entire
contents of the tank s
When the combined hall be removed sludge Septage Servicing Operator i and disposed i o in accordance e with ch.
NR 113, Wiscol and scum In any tank
h Y
Administrative Code.
servicing of effluent filters, mechanical or pressurized POWTS components, pretreat
ement componenu,tainer any other
The g
maintenance or monitoring at Intervals of 12 months or less shall be performed by a certified Main
d POWYS
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(() . i high concentrations are detected have the cont( cell(().
that may impede the treatment process and /or damage the
^ r rka ranfr(s't ramovpd by ,% sentage setvirjng opera prior to use.
I
� f
Pate __of...._—
Sys tem start up shall not occur when soil conditions are frown at the Infiltrative surface.
During power outages pump tanks may fill above normal highwatex levels. When power Is natured the excess wastewater will be
discharged to the dispersal cell($) in one large dose, overloading the cell($) and may result In the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank mnovtd by a Sepagt Servicing Operator prior to restorint
power to the effluent pump or contact a Plumber or POWTS Malntalner to assist In manually operating the pump controls to
restore ncrmat levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise diswrb or compact the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may Improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; (at;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
paintlnr croducts: oesticides; sanitary naokins: tamoonsi and water softener brine.
ASANDON EM ENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to Insure that the system is
property and safely abandoned In compliance with ch. Comm 83.33, Wisconsin Administrative Codes
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator,
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another Inert solid material.
CONTINGENCY PLAN
If the POWTS falls and cannot be repaired the following measures have been, Or must be taken, W provide a code compliant
replacement system:
• A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be Infringed upon by
required setbacks from existing and proposed strucwre, lot tines and wells. Fallure to protect the replacement area will
result In the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules In effect at that ame.
• A suitable replacement area. Is not available due to setback and /or soil limitations• barring advancts In POWTS technulop
a holding tank may be installed as a last resort to replace the failed POWTS.
The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POW'TS a soil and site
evaluadon must be performed to locate a suitable replacement area. If no replacement area h available a holding tank may
be installed as a last resort w replace the failed POWTS.
O Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
Inflluative surface- Reconstructions of such systems must.comply with the rules In effect at that time.
< <WARNiNG> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT
OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES.
DEATH MAY RESULT, RESCUE OF A PERSON FROM TKE INTERIOR Of A TANK MAY BE DIFFICULT Olt
IMPMUR1 F.
ADDITIONAL COMMENTS
POWTS INSTAL ER P POWTS MAINTAINER
Name rc �! �s Na rne �' e
Phone /g _— 6e- C Ph one � 6 4
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name 6!? a d' Agoncy ly`- 6 - ' / Co r <<
Phone 7� J lv -hone
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address < </
Property Address
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION �/
�� T i� N -R A
Property Location %a, �� /a, Sec. W, Town of
Subdivision . Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # ..3 ��5 . Volume Page # 2
Spec house 0 yes Jg no Lot lines identifiable .Z yes D no
SYSTEM MAINTENAN
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 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.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
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.
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. rt * * * **
** 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
�
' 7
iT N0. n
"I $ �Avt THIS SPACE
VO 5 MfSE�.
' �• 594 55+0
REGISTERS OFFICE
BY THIS DEED. ELse � +�, _�.Ql liii._!{ S7. for Re CO., WIS.
S. Cook a /a Lorraine Cook,
Rac'd. for Re cord Mli:l 1 th
day of J►e A.D. 19,J6
Grantor conveys and warrants to Leo W. Doo la� and Fern C. Doolan, his at l0s45 Ae , M.
i wife, as joint tenants Jalrea 060on
Grantee._._, AaettJV;t,.;
RET URN TO �
�i fa • valuable consideration
!i
E the following described real estate In St. Croix County, Stateofwisconsia D0atj, Drills Norman $ Bakke
Part of the Southeast One Quarter of the Northwest One Tax Key a
Quarter (SEW411%) of Section Twenty -one (21) , Township Th;s is homestead property. !
j Thirty -One (31) North, Range Eighteen (18) West commencing at the Northeast corner of
said Southeast One Quarter of the Northwest One Quarter (SEk NW4 ;thence Nest 834.0 feet;!
thence South 208.5 feet; thence East 625.5 feet; thence South 208.5 feet; thence East
208.S feet; thence North 417.0 feet to the place of beginning.
1!
!i
�� NSFERR
FED'
Exception to warranties: Easement and rights -of -way, if any, of record
Executed at New Ric hmond . , Wi 3 COtlol :i_.__.this_1_ * �l.i y f - - --__ 19_ 5
SIGNED AND SEALED IN PRESENCE OF i!
(SEAL)
Elmer Cook
_ Witnesses not required i
(SEAL) !{
l Lorraine S. Cook
It
' Gila [.• .1� l_ i
�� (( (SEAL) �E
(SEAL)
j
ii
Signatures of-
authenticated
i;
li
this day of 19_.
f
t
! ! � Title: Member State Bar of Wisconsin or Other Party
Authorized under See. 706.06 via.
:` t1 1' NSnq ) t
I •S County.
i Per �e. this ] 4th day of Jun&
the abov4 C onk
Ji • >, t i3
1 1 to :e kntjl. os- who executed the foregoing instrument and acknowledged the same.
•„ «.. ' i
tv
This instrument was drafted by Cs S. Norma n A
I} George W. Peterson Law Offices St. Croix
BT' lKeirth a -.Imes Notary Public _ Cotmty. Xis.
II Box 184 Balsam Lake, Wisconsin S4001 -
+� The use of witnesses is optional. * my Commission 0n6XU (Is) VArmanant
Names of petsess signing is salt capacity sboutd be typed or printed below thew signatures.
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WARRANTY Ds1�II -irwTt t l b1► f1Q1CONtFDI_ VMM me. 2 1671