HomeMy WebLinkAbout040-1262-20-000 R Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
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)]. 353316
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plan ID No.:
Miller, Sam I Troy Township
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
e'O o I s0 . p T (Z - 5t %,kk * 1 pending
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic f Z Benchmark (Q ( 5 (10.6s I C , p'
Dosing lt. BM
9 D, 90 1 - S
Aeration Bldg. Sewer
Holding St/ Ht Inlet S q
t
8•� �f o '
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet —�
Air Intake
Septic 2O' yr�p� ' NA Dt Bottom ��---
Dosing NA Header/ Man.
fo �
Aeration NA Dist. Pipe
Holding Bot. System
E o
PUMP/ SIPHON INFORMATION Final Grade
o.
Manufacturer mand St cover
Model Number GPM
F ' n stem
TDH Lift TDH Ft
— 1 oss
Force n Length Dia. Dist. To Well
SOIL AB PTION SYSTEM
B&D-O RENCV , Width r Length _ r No O Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN 3 Zf-� a I DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufa rer: _
a,
SETBACK CHAMBER ��–
INFORMATION Type O c i M el Number:
System: 33 6 — 1240 OR UNIT _ – au
DISTRIBUTION SYSTEM
Header / Manifold 4 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
�
Length >OLf— It Dia r I ia. cing -I;p 0-0
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 ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l: "Z( epInspection #2: f
Location: 543 Cambronne Streg, u
td n, r�I X4016 (NW 1/4 SW 1/4 5 T28N R19W) - 5.28.19. Frontier -Lot 2
1.) Alt BM Description = Iu�`e�.
2.) Bldg sewer length = 2,6'
� Cover.
- amount of cover — > IS " So i
Plan revision required? ❑ Yes CK No
Use other side for additional information. L ) 8 A
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
� � I
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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�� ety and Buildings Division
V iscons i n SANITARY PERMIT APPLICATION I �� 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. 5/ ('g9
• See reverse side for instructions for completing this application State sanitary Permit Number
Personal information you provide may be used for secondary purposes heck if rLsvision to previous application
[Privacy Law, s. 15.04 (1) (m)).
fate an Review Transaction Nu mber
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner N m Pr pe y Lo ation
f /4 &,0 1/4, 5 T N,R If E W
P[gperty Or's Mails Address Lot Number Block Number
" r.W
Cit , Stan Zip Coe Phon Numb r Su ivision Name or CSM Number
e Li ( ) 2
II. F BUILDING: (check one) ❑ State Owned It l est Road
vil nn
Public 1 or 2 Family Dwelling - No. of bedrooms Tow g e Ne r OF
III. BUILDI G 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 online A. Check box on line B, if applicable)
A) 1, kfNew 2 E] Replacement 3_ E] Replacement of 4_ C] Reconnection of 5. E] Repair of an
_System __ _________
System _____________ Tank Only_____ Existing System ________ Existing System
B) KA Sanitary Permit was previously issued. Permit Number 3 5 :3 Date Issued 3 — 20"
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
12Weepage Trench I„ G f{ 22 ❑ In- Ground Pressure 1# s 42 ❑ Pit Privy
13 ❑ Seepage Pit - r/l0 7 Q - 3 k 7S 43 ❑ Vault Privy
14 ❑ System -In -Fill Z -70T#4,,
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System El v. 17 Final Grade
/ ,, Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
Q 7 , 9 9; t17a Feet ,Feet
VII. TANK capacit g allo ns Total # of Prefab. Site
g Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tankst Tank
eptic Tank r Holding Tank ..a ❑ ❑ ❑ ❑ ❑
ump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's ame: (Print) Plumber's 5i ture: ( Stamps) MP /MPRSW No.: Business Phone Number:
—x ' o " I AOF Zzs'a 3
lumber's Address (Stre t City, State, Zip C de): "
IX COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
`
Wpproved ❑Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIO �OFPR OV AL / RE SONS FOR DISAPPROVAL: /&l%4
s�►�s .ap-s 3— - ,�,,.�
SB 6398 (R.12/99) DISTRIBUTION: original to County, One copy To: Safety & Buildings Division, Owner, Plumber
__ —
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit 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 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 -3151.
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.
IL 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 received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. NIP, 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 1/2 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
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 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 off regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
.ice
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tb A sconsin Safety and Buildings Division
SANITARY PERMIT APPLICAT 201 W. Washinngt n Avenue Box 7162
Department of Commerce In accord with Comm 83.05, Wis Cod$ 1 Madison, WI 53707 -7162
• Attach complete plans (to the county copy only) for the syst bv(papeWt Iess County.
than 8 112 x 11 inches in size. �� R CFI � 1J Cro
• See reverse side for instructions for completing this applic t* State Sanitary Permit NuTber
`'t 3,S'3 /6
Personal information you provide may be used for secondary purposes ty : ` ❑h;fi it revision t X 3 previous application
[Privacy Law, s. 15.04 (1) (m)]. Sy3 �( S7 GIX Stpte$ n Review Transaction Number
I. APPLICATION INFORMATI N - PLEASE PRINT ALL I FIDE `
Property Owner NarDe I Prert y Loc�ai ' T N, R E (o W
Prop y Owner's Mailing Address Block Number
45 OX ad S` / Z-
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDIN : (check one) ❑ State Owned �, j itr Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms L__ ° rown of C i O Z% ,.
111 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
___ystem ________System _____________ Tank -- -- ____________ Existing System ________ Exlstin 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 CEOeepage TrenchLEArGW 22 ❑ In- Ground Pressure 42 [] Pit Privy
13 ❑ Seepage Pit in iNG /c �'4A r & - 43 ❑ Vault Privy
14 ❑System -In -Fill �SQP-r- ,a c(_ x-,04 b .6.,A
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area . 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
no 7s 7 4 1 Feet /
Capacit
VII. TANK in Ca allo Total # of r Prefab. Site Fiber- E p er.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic A p p
New Existing strutt
Tanks Tanks
e tic Tan X I O lJt� ❑ ❑ ❑ 11 ❑
er ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No tamps) MP /MPRS�W^Noo.: / Business ) Phone Number:
Z Z J G/ S GP p ,.
Plu ber's Address (Street, City, State, Zip Code):
D I
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issuing Agent Si nature (No Stamps)
KApproved ❑ Owner Given Initial /� Surcharge Fee)
Adverse Determination 4 Z'Z S vd
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: ���p� zee C
SBD -6398 (R.12199) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS .0
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 / Reriewal'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 - 3151.
To be complete and accurate this sanitary permit application must include:
i
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.
ll. Type of building being served. Check only one and complete # of bedrooms i 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.
i
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 dotal 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 numb�r 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 1/2 x 11 inches must be submitted to the cokinty. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains /wate� service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system area¢; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specificaltions 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';1 15 form; and F) all sizing information.
----------------------------------------------------------------- �----------------------------- - - - - --
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number olf regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord With Comm 83.05, Wis. Adm. Code
AC.E. Soil &Site Evaluations
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County
include, taut not k ri ted to: vertical and horizontal refererm point (B", direction and St. Croix
percent slope, scale or dimensions, north arrow, aoix" distance to nest road. parcel I.D.#
APPLICANT INFORMATION - P� . per al► Ihfoni mtfon. Prt of 040 - 1022 -10 & 040 -1021 AO
Personal information you provide maybe us %!b{ 406ndary j poses (Privacy Law, s. 15.04 (1) (m)). BY Date
Z L
Property Owner �'�u� .I Property Location
Miller, Sam Govt. Lot NW 1/4 SW 1/4 S 5 T 28 N,R 19 W
Property Owner's Mailing Address _? t Y 2 1 j Lot # Block # Subd. Name or CSM#
P.O. Box 151 2 Plat Of Frontier
City S ip Code ebxvWWber ❑ City " ❑ Village ®Town Nearest Road
Hudson W $X401 d 1769L,/ Troy Tower Road
® New Construction Use: ti8 `` rooms 4 ❑Addition to existing building
El Replacement ❑ Publlc _' describe
Code Derived daily flow 600 gpd Recommended design loading rate 7 bed, gpd/ft 8 tench,gp
Absorption rea required 857 bed, ft 750 trench, ft' Maximum design loading rate .7 bed, gpolft .8 trench, gpd/ftz
Recommended infiltration surface elevation(s) 100.00 ft (as referred to site plan benchmark)
Additional design I site considerations Install trenches using high capacity infiltrators.
Parent material Glacial outwash Flood plain elevation, if applicable NA ft
S--Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system NS ❑ U ® S❑ U ® S U ® S❑ U El S® U
L ❑ S ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPDIft
Ho►izon Texture Consistence Boundary Roots
BodrQ# in. Munseti Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ;Trench
1 1 0 -8 10yr3 /2 None sl 2msbk mvfr as 2f 0.5 0.6
Qr;
, 2 8 -19 10yr5/4 None sil 2msbk mvfr aw if 0.5 0.6
Ground 3 19 -23 10yr4 /6 None is Osg ml cw - 0.7 0.8
elev
103.48 ft 4 23 -74 10yr5 /4 None S Osg dl gs - 0.7 0.8
Depth to 5 74 -121 10yr6/4 None S Osg dl - - 0.7 0.8
limiting "
factor '� g
>121'
Remarks:
2 1 0 -16 10yr3 /2 None sl 2msbk mvfr as 2f 0.5 0.6
2 16 -22 10yr4/4 None sl 2msbk mvfr aw if 0.5 0.6
Ground 3 22 -27 1Oyr4/6 None Is Osg ml cw - 0.7 0.8
elev
105.97 ft 4 27 -70 10yr5 / None s Osg dl gs - 0.7 0.8
Depth 5 70 -124 10yr6 /4 None s Osg dl - - 0.7 0.8
limiting
factor
>124' I� '
Remarks:
CST Name (Please Print) Signature: 7- Telephone No.
James K Thompson 715 248 -7767
Address A.C.E. Soul & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, Wi 54020 1250/1999 3602 1150
PRDPERI'1r Mina, Sam SOIL DESCRIPTION REPORT + +so Page 2 of 3
`PARCEL LDS Pct of040- 1022 -10 & 040- 1021 -90 A.C.E. Soil & Site Evaluations
Depth Dominant Color Mottles Structure C411V
hlorizort in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. ��w Boundary Roots Bed ; Trench
3 1 0 -6 10yr3 /2 None A 2msbk mvfr as 2f 0.5 0.6
G D 2 6 -18 10yr4 /4 None is Osg ml gs if 0.7 0.8
elev 3 18 -24 10yr4 /6 None s Osg ml cw - 0.7 0.8
104.14 ft 4 24 -79 10yr5 /4 None s Osg dl gs - 0.7 0.8
Depth to 5 79 -123 1 Oyr6 /4 None s Osg dl - - 0.7 0.8
limiting
factor
gS
Remarks:
4 1 0 -9 12yr3/2 None sl 2msbk mvfr as 2f 0.5 0.6
2 9 -18 10yr5/4 None sil 2msbk mvfr aw if 0.5 0.6
Ground
elev 3 18 -24 1Oyr4/6 None Is Osg ml cw - 0.7 0.8
104.17 ft 4 24 -65 10yr5 /4 None s Osg d1 gs - 0.7 0.8
Depth to 5 65 -118 10yr6 /4 None s Osg dl - - 0.7 0.8
limiting
factor
>118'
Remarks:
5 1 0 -12 10yr3 /2 None sl 2msbk mvfr as 2f 0.5 0.6
2 12 -18 10yr4 /4 None is Osg ml gw if 0.7 0.8
Ground
elev 3 18 -68 10yr5 /4 None s Osg dl gs - 0.7 0.8
102.47 It 4 68 -115 1 Oyr6 /4 None s Osg dl - - 0.7 0.8
Depth to
limiting
factor
>115'
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
�i�o ,Poao�
-� 3/7.57 "
' Tap air /'ot_Srfc+Af.
A656tmed a le+f a "
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 5. � ��� 1 - --
Mailing Address
property Address L13
(Verification required from Planning Department for new construction) ._..t r•
City /State HL ' N be— Parcel Identification Number
LEGAL DESCRIPTION
N -R
�1'j' ' 24 G Town of L!
Property Location /s /. Sec. T V,
Subdivision E kC MT/ �F, k-- . Lot # �-
Certified Survey Map # ('Q Volume #
Warranty Deed # � Volume , Page #
Spec house 0( yes ❑ no Lot lines identifiable )� yes ❑ no
SSys= MAINTENANCE
Improper use and maintenance of your septic system could result in its Premature' failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
a certification form, signed by the owner and by a
The property owner agrees to submit to St. Croix Zoning Department
masterplumber, journeymanplumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
1/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
of the, y ar iration date.
GNA 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
p rty desc 'bed a by virtue of a warranty deed recorded in Register of Deeds Office.
S ATURE PLICANT DATE
I �
ssrsss
*'�• *• Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Departmen t.
•« Include with this application: a stamped wananty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
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vn1.1442 42
STATE BAR OF WISCONSIN FORM 2. 1998 606 641
KATHLEEN H. WALSH
REGISTER OF DEEDS
This Deed, [Wade between Kat rvn B, Tuieren, and Ferris — ST. CROIX CO., WI
R_ Ti_ i��n w4fg n d 1. , b� .r RECEIVED FOR RECORD
Grantor, conveys and warrants to 07- 14-1999 11:00 II
Sam E Miller, a Aik2le person WWRWTY
E)0:lw• IT DEED
Grantee. CERT COPY FEE:
Grantor, for a valuable consideration, conveys and warrants to Grantee
C OPY
Grantor, 2225.10
the following described real estate in St. Croix County, State of RECORDING FEE: 12.00
Wisconsin (The "Property "): MS: 2
Recordi Arm
Name and Return Address
040 - 1022 -I0; 001022-30'.040-1021-ft
040-1029 - 20.000. 1028 -70
Parcel Identification Number (PIN)
This ism homestead property.
(See Attached Exhibit "A ")
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any
Dated this 13th day of July, 1999.
4 -Pn B. ulgrcn
• ' [ Ferris R. Tulgren
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) $a.
authenticated this _ day of St. Croix County )
Personally came before me this ] day
of July, 1999, the above named Kathrm B. Tnlaren•
and Ferris R. Tulgren, wife mid to
Tf17.E: MEMBER STATE BAR OF WISCONSIN
(If not, [awn to
me the s) who executed the foregoing
authorized by ¢ 706.06, Wis. Stats.) instru and ackno ge the same.
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristin& Ogland
Hudson, WI 54016 N hilt, State of Wisconsin
(Sigumtes may be authenticated enria
ted or acknowledged. Both are not My coommissio is�pc rent. if not, slue expiration date:
OeCQ Brenda Poulin f r d0
Notary Public
State of Wisconsin
-Names of perswn signing In any capacity should be typed or printed below their signatures
WARRANTY ONSD ZrATR MR of WISCONSIN
a'PRM !1►. r • HIa
PIFORMAfl0/1 r WE=0WLa C0AV MY FORD PV LAC. YA adP-0a6M71
Z
' y yfii.1442PAGE 43
EXHIBIT "A"
That certain pa r cel o an f land located in the NE % of SE'/ of Section 6 and in the NW' /,
of SW '/, and the NE % of SW % of Section 5, ALL in Township 28 North, Range 19
West, Town of Troy, St. Croix County, Wisconsin more fully described as follows:
Beginning at the West quarter comer of said Section 5; thence N87 0 51'08 "E
(recorded bearing on the East -West quarter line of said Section 5) a distance of
2342.24 feet; thence S00 0 13'24 "E, 854.00 feet: thence N87 0 51'08 "E, 288.00 feet to a
point on the East line of said NE 1 /4 of SW' /.; thence along said East line,
S00 3'24"E, 466.08 feet to the BE corner of said NE % of SW Y,; thence along the
South line of said NE % of SW'/, and the South line of said NW'/, of SW'/,,
S87 9 54'54 "W, 2372.41 feet; thence N00 0 30'28 "E, 170.48 feet; thence 887 0 54'54 "W,
273.91 feet to the monumented West line of said NW'/, of SW A thence along said
West line, N00 °30'28 "E (recorded as N01 0 3236 "E), 941.26 feet; thence
N64 0 57'47 "W (recorded as N63 0 54'50 0 W), 458.40 feet to the North line of said NE Y,
of SE' /. of Section 6; thence along said North line, N88 °20'1 3 "E (recorded as
S88 °40'1 9 "E and N89 °24'42 "E), 416.69 feet (recorded as 25'/. rods) to the Point of
Beginning.
1101 Carmichael Road
Hudson, Wl 54016
Phone: (715) 386 -4680 St. Croix County
Fax: (715) 386 -4686 Zoning Department
Fm
To: Tammi From: Shawna Moe
Fax: 386 -9281 Date: August 18, 2000
Phone: 381 -5000 Pages:
Re: Septic Verification — 543 Cambronne St. CC:
❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
•Comments:
I
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
" " " " " " "� -- ■•.� ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, W{ 54016 -7710
(715) 386 -4680 Fax (715) 386 -4686
August 18, 2000
First Federal
Attn: Tammi
201 S. Second Street
Hudson, WI 54016
RE: Septic Inspection for Sam Miller located at 543 Cambronne Street, Frontier
(Lot 2), Troy Township, St. Croix County, Wisconsin
Dear Tammi:
A septic inspection of the above referenced property was conducted on May 2, 2000. This
property is located in the NW 1/4 SW 1/4 of Section 5, T28N R1 9W, Frontier (Lot 2), Troy
Township, St. Croix County, Wisconsin. At the time of the inspection, this septic system
was found to be code compliant for a four (4) bedroom home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
Sincerely,
6�atjA_,
Kevin Grabau
Zoning staff
sm
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