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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety = and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 353349
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plan ID No.:
H eintz, John I Star Prairie Township
CST BM Elev.:- Insp. BM Elev.: 7BM Description: Parcel Tax No.:
0 6 p -) /' 038- 1184 -30 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic r'� . 7/ U C) v Benchmark
Dosing e d U Alt. BM `�. D U
eration Bldg. Sewer
Holding (am / Ht Inlet Z q 3
TANK SETBACK INFORMATION
TANK TO P/ L WELL BLDG. Air I to ntake ROAD
Air
Septic ,)A ( 31 NA Dt Bottom /3� ?b. 3
Dosing yZ / A/A 1 1 1 NA Header / Man. 3 y q.s
A _ NA Dist. Pipe
Holding--- Bot. System T2 o Z I I S
PUMP / SIPHON INFORMATION Final Grade
Manufacturer �d r�IS Demand St cover
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length q ft Dia. 2 Dist. To well N
SOIL ABSORPTION SYSTEM
BED/" Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME . Z 5 Z— DIMENSION
SETBACK SYSTEM TO P / L I BLDG WELL LAKE/STREAM
LEAC Manu acturer:
C MBER
INFORMATION Sys 1 q-3 1 VA O Model mb r.
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length (b Dia. Length S�- 2 -�S_D,a. �i / 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 El No
COMMENTS: (Include code discrepancies, persons present, etc.) Ins ction #1: 3 /3 4 Inspection #2:
Location: 2110 Cook Drive, Somerset, I 54025 (SE 1/4 NW 1/4 21 T31N R18W) - 21.31.18.930 Circle "C" -Lot 13
1.) Alt BM Description
2.) Bldg sewer length=
Ir
- amount of cover= 7 3G
y) a C��r stS 4QA��r' (�t�d �0 �r (,�at
Plan revision require Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
t
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner 1 /L/ A
Property Address
City /State a
Legal Description:
Lot /,3 Block -- Subdivision/CSM #
5L '/4 + -lt /4, Sec. T�N -RZEW, Town of I PIN # b 4=3 r 3 d
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer I Size ST/PC IOW 1614V Setback from: House - 13 Well `-- P/L
Pump manufacturer Model o.�7
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: /�- /a Width 3 Length Number of Trenches
Setback from: House LI-3 Well P%I, Vent to fresh air intake
ELEVATIONS
Description of benchmark w Elevation X 100
Description of alternate benchm Elevation 9%,52
Building Sewer ? ST/HT Inlet 9 �i ST Outlet '—' PC Inlet
PC Bottom IDS 3 7 Header/Manifold _ Top of ST/PC Manhole Cover
Distribution Lines
G r �
Bottom of System () / �' -IQ () ��' -2 ( )
Final Grade () () ( )
Date of installation 3 /V/ Permit number 3,5 3 3'1 State plan number
Plumber's signature G;�-- License number hl ad D Date 1 160
Inspector �lJ�
Complete plot plan �
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
�1
INDICATE NORTH ARROW
I
' Ul^'llr YC\�t it7ruc �:v�v� V IT cz— b cF 6
�_=.uulds
Subm:arslbl e
j ,
} Effluent Pump
3871 EPO4
EP05
I�
APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron
Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer,
following uses: • Capable of running lubrication and efficient strength, and durability.
• Effluent systems dry without damage to heat transfer. ■.Motor Cover: Thermoplas-
components. tic cover with integral handle
•Homes Motor: Available for automatic and and float switch attachment
• Farms manual operation. Automatic
• Heavy duty sump • EPO4 Single phase: 0.4 HP, models include Mechanical points.
• Water transfer 115 or 230 V, 60 Hz, 1550 Float Switch assembled and m Power Cable: Severe duty
• Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant.
automatic reset. ■ Bearings: Upper and lower
SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing
115 V, 60 Hz, 1550 RPM, construction.
Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo-
• Solids handling capability: automatic reset. plastic Semi -open design
3 /4" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING
• Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SA Canadian Standards Association
• Total heads: up to 24 feet. with three prong grounding -
• Discharge size: 1 NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- (CSA listed model numbers
• Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in "F" or "AC.)
rotary/ceramic- stationary, three prong grounding plug improved performance.
BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged
• Temperature: thermoplastic design provides
104 °F (40 °C) continuous superior strength and
140 °F (60 °C) intermittent. corrosion resistance.
• Fasteners: 300 series METERS FEET
stainless steel. 10 I i
• Capable of running
dry without damage to s 3 0' — 1 -- - .�. - GPM
components. I i
Pump: EP05 6
• Solids handling capability: o 7 25
3 /4 " maximum. w
• Capacities: up to 60 GPM. _
• Total heads: up to 31 feet. 6 2°
• Discharge size: 1 NPT. z 5 - — i
• Mechanical seal: carbon- > i
rotary/ceramic- stationary, a 4
BUNA -N elastomers. o EPOS
• Temperature: ~ 3 10 =
104 °F (40 °C) continuous EPO4
140 °F (60 °C) intermittent. 2 -- j
5, I
1
0 0
0 10 20 30 40 50 GPM
L _L L �
0 2 4 6 8 10 12 m� /h
CAPACITY
0 1995 Goulds Pumps. Inc. Effective May. 1995
gKOSS SECTION AND SPECIFICATIONS
4" CI VENT PIPE I2" MiN. ABOVE GRADE E WEATHER PROOF
:25' FROH DOOR, WINDOW OR JUNCTION BOX APPROVED
FRESH AIR INTAKE WITH CONDUIT MANHOLE c
FINISHED GRADE 4 CI RISER W/ PAOLO(
7
6" MIN. WARNING L
---- A80VE G ADE — �_v�� MIT
18" IN. 6" MAX.
off
INLET
WATER TIGHT SEALS GAS -
TIGHT
CI PIPE A SEAL
BAFFLE �- APPR OY ED
3' ONTO B LM JOINTS W/
PIPE 3' 0
SOLID — r - � ON SOLID S0I
SOIL C � '
PUMP OFF ELLV . - FT. -+- OFF ** RISER
D PERMITTrD
IF TANK
MANUFACTUI
3" APPROVED BEDDING UNDER TANK HAS APPRO'
SPECIFICATIONS CONCRETE PAD
+EPTIC / DOSE k
TANK MANUFACTURER: _�LAi NUMBER DOSES PER DAY.
TANK SEPTIC - -��
GAL. DOSE VOLIINE INCLUDING
DOSE l- GAL. FLOWBACK: / S��
�? GAL.
ALARM MANUFACTURER: f��, (/° CAPACITIES: A z
MODEL NUMBER: _RLL3NCHES
SWITCH TYPE:
e = INCHES
LUMP MANUFACTURER:
MODEL NUMBER: — a � C , G IINCHLS = ��
SWITCH TYPE: D
�' INCHES =�
REQUIRED DISCHARGE RATE �_ GPM PUMP 6 ALARM WIRING AS PER ILHR ' 16.23
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE � /
+ KZNIMUM NETWORK SUPPLY PRESSURE FEET
• S'.S '� FEET FORCE1iAIN X S V FT/ 100 FT. FRICTION FACTOR - - - - � FEET
TOTAL DYNAMIC HEAD _ FEET
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH{ 'S'
WIDTH FEE
; DIAMETER
LIQUID DEPTH
IGNED: _ LICENSE NUMBER:
n �.ww.
Safety and Buildings Division
NVI sconsi n SANITARY PERMIT APPLICATION 201 W Washington Avenue
P O Box 7162
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the system, on paper not less County ,
than 81/2 x 11 inches in size. 45 Tr Cat -t -eAl
• See reverse side for instructions for completing this application State Sanitary Permit Number
353 3 "
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)). State Plan Review Transaction Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Prope wn r Nam Property Location
3,r 1/4 Nq,� 1/4, S a� T
e 3/ , N, R/B '(orto
Property Owner's Mailing Ad r ss Lot Number Block Number
T L5 L
City, State Zip Code Phone Number bdiv" ion Na r CSM Number
(/SS r It L
11. E F BUILDING: (check one) ❑ State Owned , Nearest Roa
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑Apartment/ Condo
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 on line B, if applicable)
A) 1, pf New 2 ❑ Replacement 3 ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an
- _____System ________System _____________Tank On[�______________ Existing -ystem ________ Existtng5yste
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 ❑ Holding Tank
12MSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill - A 5 _T/. S
VI. ABSORPTION SYSTEM INFORMATION: J-
9
b C
. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate s em Elev e
Required (sq. ft.) Proposed (sq. ft. (Gals/day /sq. ft.) (Min. /inch) Elevation
wo J , Y Feet Feet
Cap acit y
VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete st Con Steel glass Plastic App
T nks Tank
Septic Tank or Holding Tank 1000 -- ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb is Name: (Print) Plum is Si ature: ( o tamps) P PRSW No.: Business Phone Number:
Plum be_A dress (Street, Ci y, Sta Zip Code):
v
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps)
Approved Owner Given Initial 6p Surcharge Fee)
u Adverse Determination
X. CONDITIONS OF APP OVAL / REASONS FOR DISH R VAL: .
J
SBD -6398 (R.12/99) STRIBUTIQ riginal to Count , One c uildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary peerfiit 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
county prior to installation
5. Onsite sek*,ragt systems must be pY -operly rrmiAlained.. The septic tank(s) must be pumped by a ticertserd pumperwhenever
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,-4W-2W 151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's naive anclmaijing 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.
111. 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.
I
Complete plans apOpecifications not smaller than 8 1/2 x 11 inches musj be submitted to-the county. The playas must
include the folIci iH g: A) plot pi an, drawn Lo scaI6 - or with cor`tlplete 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,joss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required bythre -eo ty; E•) soil test�data 6na.115 form; and'F) all sizing information.
----------------------------------------------------------- --------------------------------------
GR04NDWATER SQRCHARGE
!, 1983 Wisconsin Act-410 included the creation of surcharges ( fees) for a number of regulated 0a't&es vvfii can A ' s `
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
if GL LOT# 13, LEGAL DESCRIPTION - 1 I4 A W/SS c T k c N R I ff E or
SCALE: I"= (OO
BM I ELEVATIO (CJO .
BM 1 ESCRIPTION 1 "oue.. p;"
BM 2 ELEVATION QK.70
BM 2 DESCRIPTION h p a t (` PyG _
\ ' / SYSTEM ELEVATION
A LTERNATE ELEVATION ' �/ �f, d 0
CONTOUR ELEVATION NIV--►
lam° Y
s � 9y• so
3
t woil �91Gx
� 1
v
3
8�
�nZ
�v
SIGNATURE DATE
I
_
Wisconsin Department of Commerce SOIL AND SITE EVALU ATION fGks`'"� I
Division of Safety and Buildings , icy Page ( of
Bureau of Integrated Services in accordance with Comm Wis. Adm. Code ��
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and S I C U ,
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
03B - I l8`{
APPLICANT INFORMATION - Please print all information. Rev,' wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).� , 3 _Z - Ztor
Property Owner Property Location
-I- ) (bU C Govt. Lot = 1/4 w 1/4,S Z I T 3 I ,N,R I g E (or) e
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
765 c J� E 13 C ; .r c l�
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
t-�- n w .-volt ( -7f5 ) 5 "(q -S1 77 1 s rcA ,\r , e___ c�v
® New Construction Use: [� Residential / Number of bedrooms 3 -1 4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow (00 6 gpd Recommended design loading rate _ bed, gpd/ft gpd/ft
Absorption area required r 6 ? bed, ft trench, ft Maximum design loading rate _ bed, gpcl$ . g trench, gpd/ft
Recommended infiltration surface elevation(s) qy • !�_ ft (as referred to site plan benchmark)
Additional design /site considerations y `� . UU A(_4-. o I-c.. ,
Parent material w C"s f^ Flood plain elevation, if applicable /U/a ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system ®S ❑ u W S ❑ u [A S❑ U � S ❑ u ❑ S 0 U ❑ S IR U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
0 -10 IU 1Z SL 1015 mfr L s y . 5
Ground 3 1$ -170 10 `/ 1 -- GUS 659 r n I S S
elev.
q .
Depth to
limiting
factor
i Zd in. ,
Remarks:
Boring #
1 d -1 10 r 312 SL l yn b rrrrr
-�6 -IM 10 Yr y 10 rn 1 GS 7
Ground
elev.
q�,w ft.
Depth to
limiting
fact r
11 in. Remarks:
CST Name (Please Print) Signat a Telephone No.
0 S C_- �j ,L -e "7� S - -Zy7 60
Address Date CST Number
/ o �' �e F I UZ� 3 _ _0 3 3U
PROPERTY OWNER �' d ( U� SOIL DESCRIPTION REPORT page of
PARCEL I.D.#
Boren # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
3 a -r /v 312 — S� Imsbk Mm V- CS Iv f y
2 �3-+S IU r `I �y — m S S rY1 i c S - . �:• 8
Ground 3 /, -11j Id r `f (� COS n S C S 1
elev.
y14Qft.
Depth to
limiting 9 1 131-
factor
121 in. I 34.9/W
nsz
Remarks:
Boring #
1 a- 10 4r 312 5L ( YYI 10 (Y) J V LI 5
oll 4 Z -W r `f 1 m 1 ►�I �S •� '
3 W -JI I r `t lu co S nq M
Ground
elev.
Y 7. oo ft.
Depth to ° �.n �3. �" Y Z
limiting
factor
1 I In in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # J O -8 lo "r <S i f y
Ground
elev. s� 3.
� ft.
Depth to
limiting
factor
I Z(.c Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in ' Remarks:
SBD -8330 (R.9/98)
PAGE 3 OF
NAME 0y Uc LOT# ► 3 LEGAL DESCRIPTIONSG '/4 uO /4,S Z(T 9 (,N,R1 k E (or)�V�
SCALE: I "= &)
BM 1 ELEVATIO ► (>O d
BM I ESCRIPTION {ooT�.
BM 2 ELEVATION 8
BM 2�DESCRIPTION p of Pyc P' e_
SYSTEM ELEVATION Qy,St�
ALTERNATE ELEVATION f Y, d 0
CONTOUR ELEVATIO
t�e /
L �
smz
SIGNATURE G DATE —w
Wisconsin Depahment of Commerce / S IL-ANp SITE EVALUATION
Division of Safety and Buildings Page of
Bur Intr grated Services in ordance with s, HR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 'ak 11 in Planrmus County
include, but not limited to: vertical and horizon ref ence point" ction ands
percent slope, scale or dimensions, north arrow floc i and distance to nearest ad.
o� ��� Parcel I.D. #
APPLICANT INFORMATION - Please hall in LReiewed by Date
Personal information you provide may be used for second stlNG*PR{F 15.04 (1) (m)). `
3 -2Z ZOfJ�
Properly ner x-_ Property Location
2
ir Govt. Lot 1/4 1 /4,S T ,N,R j�(or)�
enll_x) ZL , Property Owner's Mailing Address Lot # Bloc S ame o CSM# r
Az 113 r 2
Cl Stag Zip Code Phone Number El City ❑ vill i
e ® Town Nearest Road
v
New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow — gpd Recommended design loading rate bed, gpd/f1 gpd/Ft
Absorption area required _ Z:�Lf bed, ft . S� /3 ttr/r��ench, ft Maximum design loading rate �� bed, gpd/ft _ trench, gpd/ft
Recommended infiltration surface elevation 7
s) ,70 ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system VI S ❑ U Ms [__3U 0 S ❑ U I ff] S ❑ U I Cl S ® U ❑ S RT U
SOIL DESCRIPTION REPORT
Bonin # Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
�. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1, ?
Ground L
Depth to
limiting
factor
} in.
Remarks:
Boring # ,
1 r
_ L �
Ground 2 a -
elev.
Depth to
limiting
factor
$min. Remarks:
CST Name lease rint Signat e / _ Telephone No.
_Xk, L_ , d I - -
Q�'
Address Date CST Number
el 2
I
•
Structure
..
Dominant Color Mottles
Munsell
_�
MM
MIS - �r�l�1�1� ► -�
Dominant Color Mottles
• . �r_� � i _ ��I �I �/i'JFi•���� i
�i
}
Ie
SaD -� -7 A le
0
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer John N. Heintz / P. C. Collova Builders, Inc.
Mailing Address 905 County Road H, New Richmond, WI 54017
Property Address 2110 Cook Drive Somers
(Verification required from Planning Department for new construction)
City/State Star Prairie, WI Parcel Identification Number
LEGAL DESCRIPTION d 3 s r l l$ q 30
Property Location S E %., NW j., Sec. 21 , '1' 31 N -R 18 W, Town of S t a r P r a i r i e
Subdivision circ c Lot # 13
Certified Survey Map # Volume -- ,, Page #
Warranty Deed # 5 5 0 5 21 Volume 120 , Page # 234
Spec house ® yes ❑ no Lot lines identifiable ® yes ❑ no
SYSTEM MAUMNANCE
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 if necessary the
s tic tank
P�Pmg ( s eptic 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.
.)I 09&2/n 3 / 6/ oo
SP9NATURE 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 aboebbyi e of a warranty deed recorded in Register of Deeds Office. =�r x 5 /,6/00
SI TORE OF APPLIC DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * ** * **
ss 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
t 0
State Bar of Wisconsin Form 2 -- 1982
WARRANTY DEED
DOCUMENT NO. '''j VOL �_ �ST C , �1l
PACE._.34 .,
James Barnett, a married -ma — - - -_ - OCTO. O A. it
I,
_ � l'JI
John N. Heintz and Patricia J. P "f�!ed
conveys and warrants to __- H tz Pa
- - -_ -- --_ -.
Heintz, husband and wife as survivorship marital _
Qroperty_ - --
ii - - -- - - --- - - - -- -- -- __ -- -- - - - -- - - - -- - - - -- TH SPACE RESERVED FOR RECORDING DATA
:I NAME AND RE TURN ADDRESS If
REINSTRA & VAN DYK, S.C.
- I, 201 South Knowles Avenue
the following described real estate m __ St. Croix __ _ __ New Richmond, Wisconsin 54017
County, State of Wisconsin: II
l
I! 038- 1088 - 30;_ 038 - 1 _80;__ - __
(Parcel Identification Number) 038 - 1089 -30
and 038 - 1089 -30- 10
SEE ATTACHED SHEET Ge""
i
$ IRAN §FER
E 4; l
I ��C
i II
I�
I I
l
I
is
This __. _ is_no t.._ _.,_ _.. homestead property.
(is) (is not
Exception to warranties: Subject to all easements, restrictions and covenants of record.
ii
Dated this _._ - 2nd day of _ October 19 96
'I - i .
� �e. - -- (SEAL) _._ _ ..... -- -- - - -- (SEAL) Barnett
II ---- - - - - -- ------ - - - - -- (SEAL)
(SEAL)
l '
AUTHENTICATION ACKNOWLEDGMENT i
Signature(s) James - - Barnett _ _ STATE OF WISCONSIN 1 j
authen S is�p v ted this 2nd ( o f - October 19 9.6 Personally came before me this _._ _ - -_. day of
19 the above named
Hendrik W. Van Dyk
TITLE: MEMBER STA "IT BAR OP WISCONSIN __-
(if not
.
authorized by §706.06, Wis. Slats.) to me known to be the person _.___.. who executed the
foregoing inslrunu•nt and acknowledge the same.
i. THIS INSTRUMENF WAS DRAFTED BY
REINSTRA & VAN DYK, S.C. - -- - - -- -
201 South Knowles Avenue - - - - - -- New Richmond, Wisconsin 54017
Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not• state expiration dale:
necessary.) .19 )
•Nome. or Ik•nonv .ipninp in., c.q,,61 y should he aped nr printed bdow Ihcir cipnnlures.
1AARRANII OEEO srATB BAR OF WISCONSIN - Wisconsin L"M Runk Co.. Inc.
FORM Nn. 2 — 1982 Milwaukee. Wis.
ST. CROIX COUNTY
l WISCONSIN
ZONING OFFICE
�, 1 r x r r u r r • -- M�.�� ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
'� • " Hudson, WI 54016 -7710
r (715) 386 -4680 Fax(715)386 -4686
May 30, 2000
P.C. Collova Builders
Attn: Pat Collova
705 County Trunk E
Hudson, WI 54016
RE: Septic Inspection for John Heintz located at 2110 Cook Drive,
Circle "C ", Lot 13, Town of Star Prairie, St. Croix County, Wisconsin
Dear Laurie:
A septic inspection of the above referenced property was conducted on March 31, 2000.
This property is located in the SE' /4 of the NW' /4 of Section 21, T31 N -R1 8W,
Circle "C ", Lot 13, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the
inspection, this septic system was found to be code compliant for a three (3) bedroom
home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
J n Sonn tag
Zoning Technician
/sm
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