HomeMy WebLinkAbout040-1232-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
515029 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Knuteson, Daniel Troy, Town of 040- 1232 -80 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No:
Job 6 M I 65 �r 03.28.19.1154
TANK INFORMATION n4 ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
t
Septic 'L 2 `75C> Benchmark
J.l J01.1 lacy
Alt. BM
S, 0 9G, • ,%
Aeration Bldg. Sewer
G 3
Holding St/Ht Inlet
- -7, )`J
TANK SETBACK INFORMATION St/Ht Outlet `0'
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Z 7 7Z I i 15 / — Dt Bottom
-- -
Dosing Header /Man.
Aeration Dist. Pipe 7 V5 i -
/0.6 0 . ">
Holding Bot. System /0. - � 4 G , Z
/1.73 Tj. -.f % r
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM J ✓' �, � -Q � S. U �J (c 1
Model Number _`j
TDH Lift Friction Loss Systern-H6_J'tk,, TDH Ft
Forcemain Length - ]a. Dist. to Well
SOIL AB SORPTION SYSTEM [ ,J "5
BED /TRENCH Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Z/ . L �-- �-
SETBACK SYSTEM TO lfJ P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR -V'�t • [ �'�'F Q �_
Type f System: r / 1 UNIT Model Number:
�r1,�J�✓is� -' /G 30 / 72 Nts � -�
DISTRIBUTION SYSTEM ( a-- (. _— �Z
Header /Manifol Distribution ` x Hole Size x Hole Spacing Vent to Air Intake
Pipes) ` �.. �O <'
Length T Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over i Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed/Trench Edges N I-1 Topsoil ` as E] No N K . Yes [] No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / /
Location: 525 Trillium Lane H dson, WI 54016 (SW 1/4 SE 1/4 3 T28N R19W) Country Wood Lot 18 Parcel No: 03.28.19.1154
-1-:, e4--
1.) Alt BM Description =
2.) Bldg sewer length = ��
- amount of cover =
side , - -- - - — j— - -- --
Plan revision Required? Yes No
Use othe r side for additional information.
SBD -6710 (R.3/97) Date �, Ins4dor's $fgnature Cert. No.
T
Safety and Building4vision County T
` 201 W. Washington Ave., P. bx' 7162 `. C Qa`�`i(
i sconsin Madison, WI 5370 7 2 Sanitary Permit Number (to be filled in by Co.)
'Department of Commerce (608) 266 -315
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide / "
may be used for secondary purposes Privacy Law, s15.04(1 xm) Project Address4ff different than mailing address)
I. Application Information - Please Print All Information RECE
6(��
Property Owner's Name Pai el # Lot # Block #
fl Z.EL - teat , 3 KUOTE30M NOV 2 6 2008 v lo- ig33 -go -00 s
Property Owner's Mailing Address Prc perty Location
ST CRUIXCUUNTY �^
�N ZONING OFFICE �LL y, �C y Section
City, State , ` 9 � � ('� - , � ` + Zii`p(C Phone Number
Code Q Q
HL) Vv� J [��O 11S' 30! `�J T �I N; R l(c Eor�
II. Type of Building (check all that apply)
k I or 2 Family Dwelling - Number of Bedr s `►1��0- Subdivision Name CSM Number
iR
ntaT B6 A ND Cor I
❑
Public /Commercial — Describe Use � t-
❑ State Owned — Describe Use N a City_ ❑Village Township of
6
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. 15 -New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that apply)
0 d
K Non — Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑Pressurized n- ound ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filterr1 ❑ y
Recirculating Synthetic Media Filter ching Chamber ❑ Drip Line rav 1 -1 Pi El Other (e lain) CA' _2 � . a
V. Dispersal/Treatment Area In orm ion: 2.
Design Flow (gpd) Design Soil Application Rate(gpds A rea Requir Disp Area Proposed (sf) Syst Elevation 0 5, i o t? � Disp � # sr.�
aq 9. A l
VI. Tank Info Capacity in Total Number anuf Prefab Site I Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank 757 tL7 75c, ! W tL. W Z C e t - I�C.I
Aerobic Treatment Unit [ J l
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plu is S' lure I MP/MPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
W L).S , �W Y c) M Rock S� 7Sd
VIII. Coun /De artment Use Onl
11 Approved 11 Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing ent Signa o Stamps)
Surcharge Fee) / // lb I „ „
❑ Owner Given Reason for Denial 'J �/�
IX. Conditions of Approval/Reasons for Disapprov 3 ou / )�� � *�� n _�
SYSTEM OWNER: n / - � f l tlGt� l0 / z9 l Dom'
1 Septic tank, effluent filter and -'�'-"�-
dispersal cell must all be serviced / maintained
- .
as per management plan provided by plumber. �2. Acabl Code /o ina aiRt l ed /J/( as per ap I' able code /ordinances.
Attach complete pleas (to County only) for the system o t 1 the 1/2 z 11 ' r in s' Yy
6X -0 iikd
SBD -6398 (R. 01/03)
SANITARY PLOT PLAN
scale 1"m
OWNERS NAME SANITARY PERMIT NO.
A,y �a1 ®F
BENCH MARK( ®� #1 I(/! V 6 SEPTIC TANK 4t
#2 PUMP TANK Aj
SYSTEM ELEV . A ' C�'�'> EXISTING TANKS
B WELL NOR H
C — ' PROPERTY LINES
NOTES- REPLACEMENT AREA
Lo7 L i hJL
tike (
I�
;I
6,40
a� 3 g
W Ll�IE
O F
R q�g
>s
py
� 1
MFRS - o.� q q 647 -4682
PLUMBERS SIGNATURE LISCENSE NO. PHONE DATE
SANITARY PLOT PLAN
V* 'i� VG
OWNERS NAME Stale SANITARY PERMIT NO.
80T. � TA D G
ARAG SEPTIC TANK LL
BENCH MARK( ®� #1 �!/f/r� 6 s
#2 PUMP TANK A)_
SYSTEM ELEV . A EXISTING TANKS
B \ WELL NORrH
C — ' PROPERTY LINES
NOTES- REPLACEMENT AREA
I '
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.O!?
rfIf
I
,
I
S'
i
6hM6f-
WP L/ o F F
N
s7�t 91Z
3 >s
C MFRS 647 -4682 [ �
PLUMBERS SIGNATURE LISCENSE NO. PHONE DATE
The flAN - .RTK) Kk) I F-5CW
Quick4® Standard
Chamber
X2.1 G�
The Quick4 Standard Chamber
C f 2 �
ON
IS Ell
g= s
34" 48..
(EFFECTIVE LENGTH)
MultiPart End Cap
�r R
34'
FRONT YI�W �' r' $IPE VIEW "'TOP VIEW
Quick4 Standard Chamber Specificatio
Size (W x L x H) ........34" x 53" x 12" (86 cm x 135 cm x 31 cm) Louver Height . .............................8" (20 cm)
Effective Length .......................... ............................48" (122 cm) Invert Height ................................ 8" (20 cm)
14lT-" (-ZMTtUE S( -AWF- M CKAM9ER -- 9D, S4 FT
p2opt)5 EAC-0 6 Cmm; LCAA (Ay
lq So Fi dD y tb,7 CAM E95 ti;zb�D Cad
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0 0 3`x aqi o
1
7 3
Wisconsin Department of Commerce �IL VA ON REPORT Page of2
Division of Safety and Buildings
in accordance with Co
omm 85, Wi A ode
County S
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. P n / . -
include, but not limited to: vertical and horizontal reference point (BM), directl a Parcel I.D�. )��) //� �J
percent slope, scale or dimensions, north arrow, and I ar ad. (/ %7/ /Ol�v7 'V — O d d -
Pease print all fori�r►EMVE viewed Date
Personal information you provide may be used fors condary purposes (Privacy Law, S.1 04 (1) (m)).
Property Owner NOV Proderty Location
D aol 1 r) S Gov Lot S� 1/4S�1/4 S 3 To?� N R� E (or
Property Owner's ailing ddress Lot Block # Subd. Name or CSM
, / ZONING OFFICE #
_ ck � �
l /v
City State Zip Code Phone Number ❑ City ❑ Village 0 Town Near est Road
Ing
New Construction Use: P' Residential / Number of bedrooms Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material s7 rlpaw lerc4ce / Flood Plain elevation if applicable a o ft.
General comments 7e-v''(/ arm, sv� lTab / �j C/ / p� C ell
� and recommendations: "C T �n � �Uv� ah SD ��{ '
vse leach b C17c'4,e,9 3,1, e
c all 114 - � � �'j � ems► F !,( I. '4r - -
ca A
9 / t
®
F/-1 Boring # Boring
❑pit Ground surface elev. 7�i(� ft. Depth to limiting factor �O � 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
S /7 r ml l ttl
4 r. W r /
Boring I.J Boring
T g ®, 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. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
mv (--r s
11961W '0� - -
/ -S -, s m -
Cos
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 rint) Signature CST Number
Address Date Evaluation Conducted Telephone Number
SBD -8330 (R07 /00)
a
Property Owner �17(J�.S�17 Parcel ID #
Boring # ❑ Boring L�/! Page d of
Pit Ground surface elev. , ft, .�
Depth to limiting factor _ in.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil G I ff Rate
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
'Eff#1 •Eff#2
O
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
Boring #
Boring
❑ Pit Ground surface elev, ft. Depth to limiting factor in.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil A on Rate
GP licati
ati
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.
sub -8330 (R.07100)
PLOT PLAN
OWNER SCALE 1"= - 40FT . PAGE of
BORING ELEVATIONS BENCHMARK ELEVATIONS
B -1 _� ' BM #1 DESCRIPTION OF #1 AO
B -2 ��� BM #2 DESCRIPTION OF #2
B -3 OA
B - — LEGEND 1 = BM (BENCHMARK)
_ Q * SOIL BORINGS
S
®= WELL NORTH
NOTES: '
�a 7
j I
Yep
cc
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y ,
V7
1710 22148 715 -647 -4682
CSITMG SIGNATURE CSTMO# CREDINTIAL## TELEPHONE ## DATE
POWTS OWNER'S MANUAL & MANAGEMENT PLAN - -
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner � d Septic Tank Capacity a l ❑ NA
Permit # O Septic Tank Manufacturer e S r ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 1 I ❑ NA
Number of Bedrooms( ❑ NA Effluent Filter Model J !' , 4 7,r ❑ NA
Number of Commercial Units A Pump Tank Capacity gal 9 NA
Estimated flow (average) fTA gal /day Pump Tank Manufacturer ® NA
Design flow (peak), (Estimated x 1.5) I S-0 gal /day Pump Manufacturer I? NA
Soil Application Rate 0 gal/day/ft' Pump Model K NA
Influent /Effluent Quality Monthly average* Pretreatment Unit R NA
Fats, Oil & Grease (FOG) <30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD <220 mg /L ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids ) 5150 mg /L ❑ Disinfection ❑ Other:
11 Manufacturer
Pretreated Effluent Quality L10K NA Monthly average" * Dispersal Cell(s)
Biochemical Oxygen Deman D 530 mg /L JR In- ground (gravity) ❑ In- ground (pressurized)
Total Suspended Solids (TSS) <30 mg /L ❑ At -grade ❑ Mound
Fecal Coliform (geometric mean) <10 cfu /100m1 1 ❑ Drip - line ❑ Other:
Maximum Effluent Particle Size Y, inch diameter
* Values typical for domestic (non- commercial) wastewater and
septic tank effluent.
* * Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every ❑ months 9 year(s) (Maximum 3 yrs.)
Pump out contents of tank(s) When combined sludge and scum equals one - third ( % of tank volume
Inspect dispersal cell(s) At least once every ❑ months 5a year(s) (Maximum 3 yrs.)
Clean effluent filter At least once every ❑ months ® year(s)
Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) 1K NA
Flush laterals and pressure test At least once every ❑ months ❑ year(s) E1 NA
Other: At least once every ❑ months ❑ year(s) 0 NA
Other: At least once every ❑ months ❑ year(s) 61 NA
MAINTENANCE INSTRUCTIONS: Inspections of tanks and dispersal cells shall be made by an individual carrying one of
the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS
Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any
missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check
for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the
effluent levels in the observation pipes and to check for any ponding of effluent on 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.
When the combined accumulation of sludge and scum in any tank equals one -third (% or more of the tank volume, the
entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR
113, Wisconsin Administrative Code. _
The servicing of effl I ters, mechanical or pressurized P TS co nents, pretreatement components, and any
other maintenan or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer.
A service report sha to the local re ulator aut 10 days of completion of any service event.
START UP AND OPERATION: For new construction, prior to use of the POWTS check treatment tank(s),for the presence
of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high
concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System
start up shall not occur when soil conditions are frozen at the infiltrative surface.
Pace e ) - of exces
During power outages pump tanks may fill above normal overload lvels. When power is
and may result in os surface d scha
be discharged to the dispersal cell(s) in one large
of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to
restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump
controls to restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb 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 d improve the performance and p rolong diapers; t he life
l
of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; greas e; dental fl oss; herbicides; meat
disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline, g
scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONEMENT: When the POWTS fails an o f
service the Comm 83f313 Wns onspn Admin istrative to stes shall be taken
insure that the system is properly and s afel y abandoned in compliance with
Code:
• 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 properly 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 fails and cannot be repaired the following measures have been, or must be taken,
to provi a code compliant replacement system:
to
suitable replacement area has been evalua from d sturbanae and compact on not be soil b raged o upor
system. The replacement area should be pro tected
required setbacks from existing and s ite e evaluation to establish a
p roposed able replacemen area relacement area
wi ll will result in the need for a new soil
must comply with the rules in effect at that time. if
❑ A suitable replacement area is not available due ue to setback sort to replace so the faalednPOWTSng advances in POWTS
technology a holding tank may be installed
and site
❑ The site has not been evaluated to identify a suitable replacement
ment area. lf no peplacementfarea s able a tank
evaluation must be performed to locate a suit able replacement
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems systems y be reconstructed comply with th ou in effect at t meomat at the
infiltrative surface. Reconstructions of such
< < WARNING > >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY NOTAN UNDER ANYSCIRCUMSTANCES FDEATH MAY
DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATM
RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS:
POWTS MAINTAINER
POWTS IN P_T7'a?T36- EEE LER Name
F
Phone
LOCAL REGULATORY AUTHORITY
SEP SERVICING OPERAT R (PUMPER) Agency �T • G� v
Name N,yzd
Phone
Phone mees
This document was drafted by the staffs of the Green Lake, M
54(1112) & 131, Wisconsin in
Administrative t e
Code.Use of this docume t
the minimum requirements of ch. Comm 83.22(2)(b)(1)1d) &Ifl a
tho r,arfnrmgnce of the POINTS.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer �Mt Y-4-�K kN N o I p- "�o/i
Mailing Address Jc�J� TRH,u.4- Cklit Ic il- �d 6
Property Address St
(Verification required from Planning & Zoning Department for new construction.)
City /State HU �� Parcel Identification Number I '
LEGAL DESCRIPTION �q 6
Property Location 1 /4 , 5k- 1 /4 , Sec. , T N R-1-7 W, Town of
Subdivision Lot # l 0
Certified Surve ap # , Volume , Page #
Waanty Deed # 7 3 - 7 5 2 , Volume Z 3 , Page #
Spec house yes no Lot lines identifiable no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & 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.
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 Planning &
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
K0 AC_ V IVOT 11 �Sw��LL //��
Number ot —I- B S�GUL�L L�✓1��D l2 y
y / t/a/ og
SIGNATURE OF APPLICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
73�56�
it c� KATHLEEN H. WALSH
VOL �C1 PA GGE N REGISTER OF DEEDS a
2 3 90 ST. CROIX CO.. MI
RECEIVED FOR RECORD
08/26/2003 01:16PM
QUIT CLAIM DEED
EXEIPT i 3
REC FEE: 11.60
TRANS FEE:
COPY FEE:
CC FEE:
PAGES: 1
�A3a - oo0
(above space for recording use only)
QUIT CLAIM DEED
DANIEL KNUTESON AND ERIN KNUTESON, HUSBAND AND WIFE, Grantor,
whether one or more, in consideration of and other valuable consideration, receipt of the
which is hereby acknowledged, conveys to DANIEL KNUTESON AND ERIN
KNUTESON, HUSBAND AND WIFE, AS JOINT TENANTS, Grantee, the following
described real estate in the County of SAINT CROIX, State of WI.
Lot 18, Plat of Country Wood, and part of the Southwest Quarter of the Southeast Quarter (SW '/4 of SE ' /4)
Section 3, Township 28 North, Range 19 West, Town of Troy, being part of Lot 19, Country Wood
Addition, further described as follows: Commencing at the South Quarter comer of Section 3; thence
North 89 Degrees 38 Minutes 39 Seconds East, along the South line of the Southeast Quarter, 564.91 feet
to the Easterly line of Lot 18 of Country Wood Addition; thence North 27 Degrees 37 Minutes 12 Seconds
East, along said Easterly line, 588.56 feet to the Southerly right of way line of a Trillium Lane; thence
North 62 Degrees 22 Minutes 48 Seconds West, along said right of way line, 66.00 feet to the Northeast
comer of Lot 19 of said plat being the point of beginning; thence continuing North 62 Degrees 22 Minutes
48 Seconds West, along said right of way, 251.20 feet; thence South 01 Degrees 11 Minutes 46 Seconds
East, 259.17 feet to the South line of said Lot 19; thence North 89 Degrees 38 Minutes 39 Seconds East,
along said South line, 142.99 feet to the Southeast comer of said Lot 19; thence North 27 Degrees 37
Minutes 12 Seconds East, along the Easterly line of said Lot 19, 160.00 feet to the point of beginning.
To have and to hold the above described premises unto the said grantee and to grantee's
heirs and assigns forever so that neither the said grantor, nor any person in his, her or
their name and behalf, shall or will hereafter claim or demand any right or title to said
premises or any part thereof, but they and every one of them shall be these presents be
excluded and forever barred.
=,
DA IkL ANVTESON ERIN KNUTESON
STATE OF WI ) i2 E �t �`
MO INFORMATION SER INC.
) ss 2126 NORTH 117th AVE
COUNTY OF SAINT CROIX ) OMAHA. NEBRASKA 68164
I hereby certify that on this day, before me, an officer duly authorized in the State of
aforesaid and in the County aforesaid to take acknowledgements, personally appeared
DANIEL KNUTESON AND ERIN KNUTESON, HUSBAND AND WIFE, to me known to
be the person(s) described in and who executed the foregoing instrument and
acknowledged before me that they executed the same for the purpose therein expressed.
Witness my hand and official seal in the County and State aforesaid this —5 day of
uGuS i , 2003.
0 . )
NOT
Notary signature (notary sea /) „ 9
p - O
My commission expires: /o / P? / 0.3 o
Prepared By: Jessica /838807 Mortgage Information Services, Inc.� �iz.`SCONS�N
2126 N. 117 Ave., Omaha, NE 68164
Daniel and Erin Knuteson
525 Trillium Lane, Hudson, WI 54016
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ST. CROIX COUNTY PERMIT APPLICATION CHECKLIST
The following lest must be completed prior to the submttal of all sanitary permit
applications.
it A COMPLETED SANITARY PERMIT (COMPLETENESS IS ESSENTIAL!!!!)
• MUST HAVE LICENSED PLUMBER'S SIGNATURE
• ATTACH STATE APPROVED PLANS (IF DESIGNED AS A MOUND SYSTEM, AT-
GRADE SYSTEM, IN- GROUND PRESSURE SYSTEM, HOLDING TANKS AND
EXPERIMENTAL SYSTEMS)
❑ DETAILED PLOT PLAN
• ABSORPTION SYSTEMS: BOTH PRIMARY AND REPLACEMENT SYSTEM
LOCATIONS
• NORTH ARROW AND LEGEND
• LOCATE AND DESCRIBE THE BENCHMARKS
• IDENTIFY ALL SETBACKS DISTANCES FROM THE SYSTEM TO LAKES, STREAMS,
BUILDINGS, PROPERTY LINES /EASEMENTS, CRITICAL SLOPES, ETC...
• LOCATE DWELLING /BUILDING THAT IS SERVING THE SEPTIC SYSTEM
• IDENTIFY ANY SETBACKS ISSUES ON ADJOINING PROPERTY
❑ MANAGEMENT /CONTINGENCY PLAN
IF ORIGINAL SOIL REPORT (PLEASE INCLUDE THE DATE THE SOIL REPORT WAS
COMPLETED AND THE ORIGINAL SOIL TESTER'S NAME)
IF A COMPLETED MAINTENANCE AND OWNERSHIP AGREEMENT FORM (MUST BE
SIGNED BY THE OWNERS, ORIGINAL SIGNATURES ONLY, FAXED COPIES CANNOT
BE ACCEPTED)
it COPY OF THE WARRANTY DEED (REGISTER OF DEEDS)
it COPY OF THE CERTIFIED SURVEYOR MAP (CSM) OR COPY OF THE LOTFROMTHE
RECORDED SUBDIVISION PLAT (REGISTER OF DEEDS)
IF COMPLETE SET OF HOUSE PLANS (NOT REQUIRED FOR REPLACEMENT SITES)
❑ APPLICABLE FEES
Incomplete applications will be placed in a "hold" file until they are completed.
The workload and number of permits we receive necessitate that we handle only
complete applications and that we obtain cooperation from the plumbers
regarding the submittal of COMPLETE permits! REMEMBER: WE REVIEW ALL
SANITARY PERMITS ON MONDAYS. YOUR COOPERATION WILL IMPROVE THE
SERVICE WE PROVIDE.
s .. ST. CR. OIX .COUNTY .
WISCONSIN
= - - ZONING OFFICE -
s r r ■ ST. CROIX COUNTY GOVERNMENT CENTER
Hr
1101 Carmichael Road
Hudson, WI 54016 -771 o
(715) 386 -4680
Nfovember 16, 1998
Dan Knuteson
525 Trillium lane
Hudson, WI 54016
I �
RE: Existing septic system inspection
Legal SW K, SE %, Sec. 3, T28N -R19W, Town of Troy, St. Croix County
Dear Mr. Knuteson:
On November 16, 1998, an inspection of the septic system on your property, located at 525 Trillium Lane,
was conducted. At the time of the inspection, the septic system appeared to be functioning properly. No
ponding of septic effluent was observed in the drain field vents. The dwelling was occupied at the time of
the inspection.
The septic system serving the property was installed on May 23, 1997, and was sized for a three bedroom
house. A Weeks 1000 gallon septic tank discharges to a trench type drain field — two - 5 foot by 57 foot
trenches. The system was inspected by staff from this office, and was installed as a code compliant system.
To prolong the life of the system, remember to have the septic tank pumped once every three years or when
the tank becomes % full of sludge and scum. Other efforts to prolong the life of the system could be as simple
as fixing or replacing plumbing fixtures with water conserving fixtures, reducing shower time, washing dishes
when the dish washer is full, avoid using a garbage disposal, using a wash machine with a suds saver feature,
etc. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system.
This inspection of this sewage disposal system was based on a surface inspection of said system, and did not
involve any excavation or chemical analysis. Accordingly, there is the possibility of hidden defects in the
system not discoverable by this inspection. This does not in any way warrant or guarantee the continued
proper functioning or operation of this system.
Should you have any questions, please contact this office.
Sincerely,
P066 aW
Rod Eslinger
Assistant Zoning Administrator
ST. CROIX COUNTY
WISCONSIN
- ZONING OFFICE
r r r r A r r r 0 ■r��i ST. CROIX COUNTY GOVERNMENT CENTER
,;.. 1101 Carmichael Road
= - =-'- -- Hudson, WI 54016 -7710
(715) 386 -4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Please specify desired test(s) & remit appropriate fee with
application. Outside water lines are often turned off during
winter months, making access to the home necessary. Please make
arrangements with this office to insure that entry can be gained.
0 Water (VOC's) $185.00 � Septic $50.00
Water (Nitrate & Bacteria) 45.00 0 Nitrate & Bacteria
t) Water (Lead Con cen ration) 21.00 retest $15.00
Owner: Requested by:
Address: Est' ; /(;.- j Address:
F(.g ZIP ,S'y0(6 ZIP
Telephone W: ( r ) 3 gl.- 25 -21 Telephone W: 3.0- z- p.Sj
Property address ( Fire W & Street) : F Aw ?
Location : , , , , Sec. , T Z E N, R / j_ W, Town of
Realty firm: t 0- Lock Box Combo: Closing Date: ll' AV.
- I o f `m..A. OqC - Iz 32,-
TO BE COMPLETED BY PROPERTY OWNER
* PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM*
Water sample tap location:
Is the dwelling currently occupied? cC Yes 0 No
If vacant, date last occupied:
Age of septic system: Aw
Septic tank last pumped by: �,.,,,,, Date
Previous Owner's Name(s): ,J
Have any of the following been observed?
DY k,N Slow drainage from house.
DY QN Sewage Back -up into dwelling.
❑Y PT Sewage discharge to ground surface or road ditch.
DY R1 Foul odors.
Other comments relative to system operation:
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:
1/94
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOC ION
1N
(,j j s
,
#A
.I
P
TO BE COMPLETED BY INSPECTION AGENCY
System design & /or permit on file? ❑Yes ONo
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: ❑Below grd OAt -Grd OMound
Approx. size _T_'X_=Fj' (c)) OGravi --ty// ODose ❑Pressurized
^' Ft.' / OBed MTrench ❑Dry Well
Molding Tank 00utfall pipe
OBSERVED DEFICIENCIES 00ther OUnknown
Septic tank
Setbacks: OHouse OWell OProp. line 00ther
Dose tank
Setbacks: OHouse OWell OProp. line 00ther
OLocking cover OWarning label OPump /Floats
❑Alarm OElec. wiring
Soil Absorption System
Setbacks: OHouse ❑Well OProp. line 00ther
OPonding: 'Di s harge•
General comments: p
- �- �►�w.
INSPECTORS SK CH OF SYSTE ATION
N
l�
Inspector
Title
r
ST. CROIX COUNTY
WISCONSIN
k ZONING OFFICE
r r r r r r r■ ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
November 16, 1998
Dan Knuteson
525 Trillium lane
Hudson, WI 54016
i
RE: Existing septic system inspection
Legal SW A, SE Ya, Sec. 3, T28N -R19W, Town of Troy, St. Croix County
Dear Mr. Knuteson:
On November 16, 1998, an inspection of the septic system on your property, located at 525 Trillium Lane,
was conducted. At the time of the inspection, the septic system appeared to be functioning properly. No
ponding of septic effluent was observed in the drain field vents. The dwelling was occupied at the time of
the inspection.
The septic system serving the property was installed on May 23, 1997, and was sized for a three bedroom
house. A Weeks 1000 gallon septic tank discharges to a trench type drain field — two - 5 foot by 57 foot
trenches. The system was inspected by staff from this office, and was installed as a code compliant system.
To prolong the life of the system, remember to have the septic tank pumped once every three years or when
the tank becomes 1 /s full of sludge and scum. Otherefforts to prolong the life of the system could be as simple
as fixing or replacing plumbing fixtures with water conserving fixtures, reducing shower time, washing dishes
when the dish washer is full, avoid using a garbage disposal, using a wash machine with a suds saver feature,
etc. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system.
This inspection of this sewage disposal system was based on a surface inspection of said system, and did not
involve any excavation or chemical analysis. Accordingly, there is the possibility of hidden defects in the
system not discoverable by this inspection. This does not in any way warrant or guarantee the continued
proper functioning or operation of this system.
Should you have any questions, please contact this office.
Sincerely,
Rod Eslinger
Assistant Zoning Administrator
I
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS G"9 �/ RIL
SUBDIVISION / CSM# Co"Atr2V L ooQ LOT #
SECTION T g g R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
CL: /bv. 0
C` /610c) Gt.
5!' CEZ /.► L
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
E
fl
z
s
3
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
�4
The information you provide may be used b other government agency programs Check it revision to previous Y Y 9 9 Y P 9 ❑ P application
(Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Q ner Name Property Location
42AAatEL 6" O 1/4 S ` c 1/4, S 3 T , N, R i I E (or)(9
Propert Owner's Mailing Address Lot Number Block Number
S « LA
City, Stale, Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road
❑ Village
Public Qj 1 or 2 Family Dwelling - No. of bedrooms 3 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. New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
-----------------------------------------------------------------------------------------------
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
12 K Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1- Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min- /inch) Elevation
S� 6 O ,O Feet ,Q Feet
Capacity VIL TANK in g allon s Total # of Prefab. Site Fiber- Ex p er-
INFORMATION g Gallons Tanks Manufacturer's Name Concrete co" steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank X �� ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ I ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) = re: (No Stamps M W Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
5"�4 W e�W cue �'-
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing A a e l ragtps)_,.
Ap Surcharge Fee) - �j ..✓ ..L�
pp ❑Owner Given Initial /'� - !
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASON F R DISAPPROVAL:
SBD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
. i
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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 sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
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, 608 - 266 -3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing 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.
III. 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 v
y p to s recei ed experimental product approval from
pp y p p pP m o
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.
Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tanks) 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 loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
36"
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page? of 3
Labor aril Human Relations
Divisioroof Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
PVIEWEDBYIJ ,\
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ' x
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road. pending
A
DAT
APPLIC NT INFORMATION- PLEASE PRINT ALL INFORMATION
PROPERTY OWNER: PROPERTY LOCATION
Richard Stout ZCVILLAGE4FOWN REST SW 1/4 SE 1, Mor) W
PROPERTY OWNER':S MAILING ADDRESS OCK # SUBD. NA
1353 Awatukee Trl. na Country E
CITY, STATE ZIP CODE PHONE NUMBE ROAD
r
Hudson, WI. 54016 (715)549 -6731 Troy Tower Rd.
(x] New Construction Use: J Residential / Number of bedrooms 3 ( ] Addition to existing building
L ] Replacement (J Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/ft
Absorption area required 643 bed, ft2 563 trench, ft Maximum design loading rate • 7 bed, gpd/ft -8 trench, gpd/ft
Recommended infiltration surface elevation(s) 96.00 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material stream terrace Flood plain elevation, if applicable na It
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for system E] S ❑ U f3 S ❑ U ®S ❑ U ®S ❑ U CIS ®U ❑ S In U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles p
Boring # Horizon De Texture Structure Consistence lBartdary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerctt
1 0 -8 10yr3/3 none 1 2msbk mfr gw if .5 .6
2 8 -31 10yr4 /4 none sicl lfsbk mfr gw if .2 .3
Ground 3 31 -82 7.5 r4/6 none is osg mvfr na na .7 .8
99 e195 ft.
Depth to
limiting
factor
+82
Remarks:
Boring #
v 1 0 -8 10yr3 /3 none 1 2msbk mfr cs if .5 .6
2 2 8 -14 10yr4 /4 none sicl 2msbk mfr gw if .4 .5
3 14 -22 7.5yr4/4 none sl 2mgr mvfr na .5..6
Ground
9 4 122-80 10 r5/4 none cos osg ml na na .7 .8
Depth to
limiting
f Off
Remarks:
CST Name:— Please Print Phone:
Gary L. Ste el 715 - 246 -6200
Address: 1554 200th Ave. New Richmond 11 -26 -95 cstMO2298
Signature: Date: CST Number:
PROPERTY OWNER Ric Stout SOIL DESCRIPTION REPORT Page? of 3
PARCEL I.D. A lending
Depth ominant Color I Mottles I Structure I GPD /ft
Boring # Horiz Texture Consistence Roots
gin. A/funsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed iTrench
3
1 0 - 14 r /3 none 1 2msbk mfr gw if .5 ;.6
2 9 -20 lbyr4 4 none sicl 2msbk mfr if .4 j .5
Ground 3 . 20Q -36 7:5yr3/4 none sl 2mgr mvfr gw
99. na .5 i .6
5 ft.' 4 36 -84, 10yr5 /4 none cos osg ml na na .7' .8
Depth to
limiting
fac%
Remarks:
Boring #
..��...... », 1 0 -12 10yr3 /3 none 1 2msbk mfr gw if .5 .6
2 12 -37 10yr4 /4 none sicl lfsbk mfr gw if .2.3
Ground 3 37 -80 7.5' r4 4 none is OSQ mvfr na na .7 .8
elev.
99. ft.
Depth to
limiting
+80
Remarks:
Boring #
�::::::;: 1 0 -7 10yr3 /3 none 1 2msbk mfr cs if .5 .6
5
2 7 -16 10yr4 /4 none sicl 2msbk mfr gw if .4 !.5
3 16 -80 10yr5 /4 none s osg ml na na .7 .8
Ground
glgv. l Q.
Depth to
limiting
factor
+80
Remarks:
Boring #
.................
Ground
elev. j
ft. �
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Richard Stout 1554 200th Ave.
CSTM2298 SW4SE4 S3 T28N - R19W New Richmond, WI 54017
MPRSW 3254 town of Troy (715) 246 - 6200
lot #55- Country Wood
1"=40
Ip�
BM. =top of l" steel pipe C el. 100'
Alt. Bm.= top of steel fence post @ el. 103.6'
r3 �4 �/
13 r
� 6
Gary L. Steel
11 -26 -95
O
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N 40
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LA
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8 T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner /contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
-------------------------------------------------------------------
Owner of property 0 AUI-c ( k_ .Aes :,
Location of propert l /4 _ - S r, 1/4, Section 3 T N-R _/ y W
Towns /hip Mailingaddress
Address of site 54
Subdivis ion name C o u ry rrL Y Lot no . _
Other homes on property? Yes JC' No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes X No
Volume and Page Number J W as recorded with the Register
of Deeds. � 3 -
-------------------------------------------------------------------
INCLUDE WITH
THIS APPLICATION THE FOLLOWING.
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. Ift .1 t L %!ZW2,,T , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the Count Register of Deeds as
Y Document No .
g
Signatu e of Applicant Co- Applicant
Date of Signature Date of Signature
STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER I7AN/E[_ 1 9rj. QAJ
MAILING ADDRESS 57 41 L 14u a G A
PROPERTY ADDRESS a, 5_ Z— 41 " 4A
(location of septic system) Please obtain from the Planning Dept.
CITY /STATE iLQ 10
PROPERTY LOCATION S ay 1/4, SL-= 1/4, Section _ 3 T A_ N- R ___Z7__ W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION C 0 "Azr1? ie ILIOoAQ LOT NUMBER
CERTIFIEDSURVEY MAP , VOLUME , PAGE , LOT NUMBER
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
VOL 3? n 3n?
STATE BAR OF WISCONS:N FORM 1 — 1982
55 0075 WARRANTY DEED
DOCUMENT NO. REGISTER'S OFFICE
ST CPOIX Co W1
This Deed made between Richard O tout PaddbrPAwd
SEP 2 6 1996
Grantor, at 1:30 P. M
and Daniel A. Kau son and Tina M Knuteson, -- XaQ...'4k IJAaL
husband and wif R891RQrrctDO*&
Grantee,
Witnesseth, That the said ctantor, br a vakow
Richard O. St out THIS SPACE RESERVED FOR RECORDING DATA
conveys to Grantee the follows ng described real estate in S t. C roix
County State of Wisconsin: NAME AND RETURN ADDRESS
Wood Town of Troy, b �
Lot 18, Plat of Coun ,
`�
St. Croix County, Wisconsin. a
This deed is given in full and final satis-
faction of that land contract between a _
O.
Stout out and
Daniel A. Knuteson and
R ichard PARCEL IDENTIFICATION Nutreot
Tina M. Knuteson dated November 13, 1995, 1
and recorded July 18, 1996, in the Office
of the Register of Deeds of St. Croix County in Vol. 1190,
page 588 as Document # 547027.
*4F:
This is not homestead property.
(is) (is trot)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And RichArd 0. Stout
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions, rights -of -way and covenants of record, if any.
and will warrant and defend the same.
Dated this 24th day of September ,19 96
2! (SEAL) (SEAL)
Richard O. Stout
(SEAL) — (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
State of Wisconsin,
Signature(s) ss.
St. Croix
authenticaad this day of ' 19 — Personally cum before me this 2 4 h d" of
September , 19 .the above rtatrrd
Richard O. Stout
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, , �arrcn
authorized by 1706.06, Wis. Slats.) plane M io me ltnown to be the person who executed the fore9*9
Notary Public ;rtn and acknowledge the carne.
THIS INSTRUMENT WAS DRAFTED BY State Of W j$ °O risu�
Janet P. Stout
Hudson, Wi. 54016 NotaryPttbl�ic, ` S� CreriC CountKWis
(Signatures may be authenticated or acknowledged- Both as not My commission is permanent. (If not, s �e qPrad �on� date.
necessary.)
• Names of persor signing in any capacity should by typed or printed below their sismatures.
Vftwaio am* Co
STATE RAR OF WISCONSIN Low ' y
WARRANTY DEED \ Forst No. 1 — 1982