HomeMy WebLinkAbout040-1291-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
463256 0
GENERAL INFORMATION (AT,j TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes (Pri`44 Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Hickok, Cline & Diane I Troy Township 040 - 1291 -90 -000
CST BM Elev: Insp. BM Elev: BM Description: 1� SectionlrowniRange /Map No:
% - (; It, 24.28.20.1666
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
15 l0'S Z •� /�2.� l�
Iri'ti �a (o Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet 7. & `75.5t�
TANK SETBACK INFORMATION St1HtOutlet .7� 6 c75-
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet �
'JOJA
Septic Z 24 ! Z L! ! Dt Bottom 1
7 ��
Dosing Header /Man.
$ 95 `t,3.
Aeration Dist. Pipe 1-95013,'97
Holding Bot. System
Final Grade O - I � •p
PUMP /SIPHON INFORMATION ( • - I O
Manufacturer Demand St Covert
G M '
Model Nu - n
V 7Z
TDH L' Friction Loss System Head T Ft
/o • 3
Forcemain Length Dist. to Well Q Z.. 5
SOIL ABSORPTION SYSTEM r
BED/TRENCH Width j Length No Of Trenches IT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 (4� 14
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: �-
INFORMATION CHAMBER OR
Type Of System: C � t UNIT Model Number:
Co J `
DISTRIBUTION SYSTEM L,-
Header /Manifold !/ Distribution ole Size Hole Spacing Fen)) to Air In ke
! P x H
Pipe(s) �� ` JQ v,1
Length Dia [ Length x Dia �\ Spacing Q
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only ev�d$
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center / b 7 Bed /Trench Edges Topsoil 1 Yes No Yes No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /
Location: 315 Lindsay Road Hudson, WWII X 5 , 4016 (SE 1/4 SE 1/4 24 T28N R20W) Troy Village 5th Addition Lot 138 Parcel No: 24.28.20.1666
1.) Alt BM Description
2.) Bldg sewer length = 35
- amount of cover =
(v OJPJk.
Plan revision Yes
Use other side for additional information. ' o
Re
Date Insepctor' Signat a Cart. No.
SBD -6710 (R.3/97)
Safety and Buildings Division _ County _
, a „ 201 W. Washingto rp rovide x 7162
M 11lEf�
a
e I nitary Permit Number (to be 1`11W ed in by Co.)
DLL
D rtment of Commerce 0 3 2S
Sanitary pp Permit A Rea i 6 2004
I r
to Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal informa
maybe used for secondary purposes Privacy Law, s15. COUNTY rolect Address (if differen t than mailing address)
I. Application Information - Please Print All Information
Property Owner's Na me - __. Parcel M ;4 Illock M
Property
�r Owner's M Address \ Property Location
City, State 'Lip Code Phone Number - A, 1 nt,SCClII)n
II. Type of Building (check all that apply) ea PQr S w« - 1'_ N; R'�
Dwelling Number of Bedrooms SuNfivision Name -:7N f rL'
1 or 2 Famil
Y g _ _
❑ Public /Commercial - Describe Ilse ! r - 6 4, i(. f.. ACS
❑State Owned - Describe Use I ICiry_) IVilluge Township of j e2 , Z _
`
III. Type of Permit: (Check only one box on line A. Complete line 11 if ap plicabl e)
A. New System r) Replacement System L I '1'reahnenl /I loldin I llllk 11c llaeciliCnt On I I Other Modification to Existing 5
� v P v g" l v s stem •'v
B. ❑ Permit Renewal ), Permit Revision { I Change of I I Pernnit Tra nsft r w New List Previous Permit Number and Date Issued
Before Expiration Number Ow11er
IV. Type of POWTS System: (Check all that appl
N 9 Non - Pressurized In- Ground ❑ Mound > 24 in, of suitable soil L.I Mound < 24 in. oi' suitable soil I I At- Grade ❑ Single Pass Sand Fitter
❑ Constructed Wetland ❑ Pressurized In- Ground [I Holding Tank L_I Peat Filter I I Aerobic Treatalent Unit I { Recirculating u
❑ Recirculating Synthetic Media Filter Leaching Chamber 11 Drip Line I) Gravel -less Pipe ) Other (explain)
V. Dispersal/Treatment Area Information: 5-
Design Flow (gpd) Design Soil Application Ratc(l; W) Dispersal Area Required (s ?ispersal Areif Proposed (sf) tel i
VI. Tank Info Capacity in Total Number Manufacturer PreGih -- IC
Gallons Gallons of IJolts Concrete Constructed Glass
New Existing
'fankx 'I'aukn
Septic or Itolding •rank -
Aura 1 e 'rrenunenl [Ink
I�?
Moing Chamber r
VII: Responsibility Statement- 1, the undersign assu111e respooslblllly f o r hts or t h e 1 shown on the all ached plan _
Plumber's Na me (Print) Plumber's Si gnature . MP /MFRS Number Business Phone Number ^
/ 1i_7
f�.
Plumber's Addre ss (Street, City, State, Zip Code)
\ r
VIII. County/Department Use Only_
Approved, ❑ Dis prov Sanitary Permit 17T cludes Groundwater v Dale Issued 1881111 g Agent Signanire (No Slannps)
Surcharge Fee) Own a ial _
IX. Conditions o prov 1 3) Nees ox�dt ' p
SYSTEM OWNER: �`Sr���an Cb tN Q tsta
1 Septic tank, effluent filter and
dispersal cell must all be serviced I maintained , t1
as per management plan provided by plumber. Q` S u
2. All setback requirements must be maintained
as per applicable code /ordinances t S �,, t i � ,�-� t <�`•�
Attach complete plans (to the County only) for the s : n, on paper not less than 81/2 x 1l inches in size
SBD -6398 (R. 01/03)
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LOT 136
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WEBSTER EXCAVATING, INC. -
- N5815 770th St.
Ellsworth, Wl 54011
(715) 273 -3430 "
POWTS Index Sheet Page 1 of 4
5
Conventional System for a Bedroom
Residence
Property Owner/Proiect Name Lot 138 — Troy Village
Town of Troy, St. Croix County, WI
Done for Wooddale Builders, Inc.
Contents
Page 1 of 4 Title Page
Page 2 of 4 Sketch
Page 3 of 4 Drainfield Area Detail
Page 4 of 4 Septic Tank & Filter Detail
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Wisconsin Department of commerce SOIL EVALUATION REPORT Pag --- ( of 3
Dlulsion of Safety and Buildings
In accordance with Comm 85, Wis. Adm. Code
Attach complete she plan on paper not less than 8 112 x t 1 Inches In size. Plan must y
lnciude, but not limited to: vertical and horizontal reference point (8M), direction and Parcel I.D.
percent slope, scats or dimensions, north arrow, and location mid distance to nearest road. D yd _ 17- 9 l - q o - 0 o O
Please print 811 Information. Reviewed by Date
Pomonet Information you provide may be used for seconder/ purposes (Privacy law, s. 15.040)
Property t7 +ner Property Location
ON L- UT,� d1-LDP/Y\ CC) K P, SE 1/4 SE 114 S Zy T 2- Y N R
Praparty Owner's Melling Address Lot It Blocs 0 Subd. Nara or CSlutdl
I I g 0 !Q 0 P ,' L. L� � - t � t r 1 1 3$ -- 1 A 1 ADVAJ ,
State Z10 Code phone Number (] City ❑ Vlitege Town Nearest Road
L� 1,1� MiJ S 4 4 9 1 (7(- 57 7549
New Construction use: Residential / Number of Wed des flow rate .. ._ GPD
0 Replacement Public or commercial - Destxi - - -• --
Parent malaria! _ 0 (Al dl S 11 Flood PIT "�?n U Ilcacle _�_ _ .. fl•
General comments Q 0 1 .
andrecommendstlons: 0DjVUt_:ArT10MAL - iR�NC+1b �XCO�N-"
ST. GRO O FFICE
ZON
a
Boring
❑ Bori
T� Pit Ground surface atev. _ g 9 Z . ft. Depth to Ilmitlrtg factor 4s tn. SoG Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
In. Munsell Qu. Sz. Cont. Color Gr. Sz..Sh. 'E"1 *F"2
ID (tt — ! ll -L I�r LLb S p
z -7 )0 `Ir2. --- rv\ i 0.b v�- 0,3 0
3 r7• -rz. 1,01V ti — 0� s o I,z
- 10 M 3 5
DW t<5 0 NT
1t .o�1I p Bolin
Pit Ground surface elev. 4 3 •q ft. Depth to 1lmitl tailor Soli icatiort Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Ert#2
l - C -Lae mqs y- 0.5 - n 0, D,3
Z 1 1 3/
D,-7 1,21
tibltl 1Z So M - tol3t:5 5
Effluent dt1 ■ BCD > 30 _ 220 mall. and TSS >30 =150 nvtL ' Effluent 02 BOD 30 np/L and TSS < 30 mWL
CST Na (Plaere Pant) nature CST Number
Nam
3o H l.1 STF o ZZ
Acidness Date Evaluation Conducted Telephone Number
W98 ?S e'�� *h AV�• RItIE fAU-5 WS 5 d9 -OZ —OZ X15 y2b-1�7S
C� faS� oy0_ 1291- 9 0 -o0d
Property Owner CotrI; AL- VCA)T-- Parcel ID Page z or 3
# ❑ Boring
Pit Ground surface elav, _ gq Z R. Depth to limiting factor _ in. �cpp Acatlon Rate
Florizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOlff
In. Mumell Qu. Sz. Cont, Color Gr. Sz. Sh. •Eff#t •Etl#2
Z r Si l -m0.b d5 3� F +r'n1 iJ 5 0,8
Z
4- 0 t2 z� l m - � sb1 . 2v - � , Z- 0
ic. ��y �• 5c1 rrt i
5 LI a, 0,D
t {
i - 2z iD tz' S (�S 0.5 i
S z z- 24 10 >? 3J
_b
Z-14 o 0 1 t, ti m
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❑ � m L L a-1 Ole?
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��� # factor In,
❑
Pit Ground surface elev. � ft. Depth to Ilntlllnq Soil (cation Rata
Horizon Depth Dominant Color Redox Desalptlon Texture
Structure Consistence boundary Roots GPORf
i In. Munsep Qu. 5z. Cont. Color
Gr. Sz. Sh. 'Ef#1 'Eft #2
Boring # Boring
❑ Pit Ground surface elev. _ _ _____ ft. Depth to limiting factor In.
Sop cation Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDRf
In. Munseil Ou. SL Cont. Color Gr. Sz. Sh, `091 'Eff#2
•
Effluent tit = BOO, a 30 220 mgt and TSS >30 ^ 150 molt. ' Effl #2 = 000, < 30 mWL and TSS 30 mgtL
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.
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Wisconsin Department of Industry SOIL AND SITE E V A L U 1Q -3V REPORT Pa l of . 3
tat 1 and Human Relations g _
I)Ms�3rmof Safety & Buildings
in accord with ILHR 83 Wis. Adm.,Code
A ,._.� COUNTY
Attach complete site plan on paper not less than a 112 x 11 inches ?n e. Plan must include, but
ST ' 0AZ-0
not limited to vertical and horizontal reference point (BM), direction ar�,76�of slopq „scale or PARCEL I.D. # pip L#u r
dimensioned, north arrow, and location and distance to nearest road.;
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMA't;ION R IEWEDBY _ DATE
PROPERTY OWNER: PROPERTY LOCATION
1/4,S T Z$ ,N,R 0 E ( W
PROPERTY OWNER':S MAILING ADDRESS • LOT # BLO!] SUBD. NAME OR CSM #
\Z301 OFhirn t pmt Q- . -, 1Z� - U b .
CITY, STATE ZIP CODE PHONE NUMBER EICITY []VILLAGE [TOWN ' NEAREST ROAD
SS g1114 ( ) �'Q-OY LEI” I Srm k
[ New Construction Use 14 Residential / Number of bedrooms 4 [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow (3 t-Np gpd Recommended design loading rate bed, gpd/11 - 7 trench, gpd /ft
Absorption area required 9 S 8' bed, ft - 1S 1 3 trench, ft Maximum design loading rate - bed, gpd /ft - trench, gpd /ft
Recommended infiltration surface elevation(s) 2s8 -.a Cart► - hk� � ft (as referred to site plan benchmark)
Additional design/ site considerations _S 1yuT� Iry STh - t_t_� Gry i6 3
Parent material LD 15s oueZ G uN e ftt. OvTwt! 311 Flood plain elevation, if applicable
S = Suitable for system CONVENTIONAL MOUND I IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ®S I]U I ®S ❑U 9S OU IRS ❑U [&S ❑U OS ®U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles I Structure GPD /ft
B ring # Horizon Texture Consistence Botndaryr Roots
\ in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. B�a rem
IQ
MY 1 0 -Lb lb� -LR sl4 lm �Lsl1 cg
2 1D-3Z �:S 31
Ground 3 Z -il 3 l S CJSg m 1
elev.
3g o tt
Depth to
limiting
factor
Remarks:
Borfn #
10'1tt-.31Z — Sl� 16vt0.UlZ cQ�� O
cLJ •1 -S3
Ground 3 � -6 -ily � • S x-12 j 1 Y � S� Gh O 3g ri1 � .- -'� . B
elev.
€ e4.t n
Depth to
limiting
factor
�
Remarks:
CST Name:— Please Print Phone:
Arthur L. We erer 715 -425 -0165
egerer Soil Testing & Design Service —P.O. Box 74 River Falls,WI 54022 '
Signature cl _ Z 9 - 7 _ �Z,� Date: 1 � 3 0 `� 4 CST Number:, 220254 (��.
PROPEM OWNER COhMQQk`� Vt b�Zy . SOIL DESCRIPTION REPORT Page? of
PARCEL I.D. # _ 'F. is xjz)j Iy G .
Bori # Horizon Depth Dominant Color Mottles Texture Structure h.
in. Consistence Roots
�j Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 13ou1y Bed Trench
Z t6 -4t7 101 31 sr 3612 GQ
Ground - ) -S'-12 31 y
elev.
894 � ft.
Depth to
limiting
factor
> 1Ze
Remarks:
B r #
S i l 1 M J S
'..,.�� z �� 33 �•sY�.�rb 1`Fs l�sb►� r�v`fy. ckJ ~ .s �.b
33 -rZ0
Ground 3 •S `riZ 3 1 Y S 6l. S9 >� — •7 .
elev.
2 8R.1 it.
Depth to -
limiting
factor
> \Zp
Remarks:
BQr ne
r:. ► 0 -4 �o��z zCz Sz 1 1 sbh m`F; cs Z .
3 33 -�
Ground l0`1 513 � -S11i S!$ S Q) tesbh MT ,r -1
c
elev, y) -120 1.g �1R31y - S �t Ga DS
M.
Depth to
limiting
factor
> 1.ZO'
Remarks:
3oring #
around
,lev. _
ft.
)epth to
imiling
actor
Remarks: �_
Ok PL P LAN Page 3 of 3
SCALE 1 "= S0 '
e
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CST Signature Date Signed Telephone No. CST #
r , S hdge p oi°
iltitiitgdYi,alit dtid iatliirtdtflk11e of .thin bysteci 'Is c titii ai to its proice
o�Nidtfdtt a rt d lungtVity.. 1110 dygtp fii.tc a tier InUdt bit ptovided vith a .
Vnidpletti sfet of pinirs including the dlclnhgelderlt dectidn,
GCHEKAL
h tapdt l"Utictl:iccilh of dh t
G y
deh endr tit ype or on -giLe V didpobgl s� d tdr, is
bhp, the am of vater eciteelhb tilt! gygteM dnd the g Udlit
Of thU'gdtdr� The l bvet the volume of pater gild the lover tile 1pvely
bf cdhtatnitibttt9l `tile mote efficielit gild loitger ldbt — Dig, the system
gill b��
fiybiedl gydtdm LOtapdilefits ific lude d .1hotic 'tank to gettlp out fi
bkook ddVh 9`01ldb, ti affltl'bnt filter dt tltd septic eittl b out f d t
�iittit ,dtlt 131ii�il phrticicdi o
d pump tltnk uittil an t: .pun►>> gild
t:tlittftiid diid lit flbdorptibit cell to d1dpdbd't r the vgta I n a manner
ifiticli tali ptdtaet the groutidvdter dtid public health.
k LCUI.1.t1.�NlyA l l UtdS
vdtttr 'dsV'lltg 'de'vicds vhcit aid vil$j possible.
2. It ltnik .fitly VALVE leaky db bud,, as pti dg ibla,
nEiE;.pdur'gtkgged olio, chpmiaais such an I or pelnt
Eltifilligs ilttd,,thb gyti.ti!hi,:
' xt ytiG havU '.n gdtbd9d 'dispodnl, u,40 i.t filldk
5, be b
but tllg db d! filly d ier
• dy � y : h ( produlttd other than t ttito tilt' '
�� i'l to nut3id C.�tccisvivb [l ot" ut' vatd l it bhort li'riods of tt.mt!,
Ilt.ltrtdit;g: t ldthbs vgdhin throut;lioui: tbs vook it, rdcomlhenddcl,
NA I11TERANd ,'
'xhd skip E "ie tdtik'sliould be inshctcted by n licensed cUq� ever
titYda a;tiril��ar id sg g it irecejdaty td t pWove l solids y
hnd d't ?llM,.
?� fiii dilUdtit CiIIC mint bq c10 6116d periodically tic remove any
bdCUhiGlAtad drtitled, It bhould be Wdghed back into the s
tit WH ihtdt o or: a 9 nccommendatlull,
at Plot thtl mnttuffi�turar.'if
' htsE 'bd1r�. iddbpctiott9 ', tile; bbsdrVatl pipdd aboGld be made b
tl►� 'bwti� ttl ddtdk'�ide it atny pdridittg i takitig piset ii tits y
dbA,dt.p•fifili @ll Algti tir0clt for dijy noblidgp to the ground sUtldce:
1 `� fl�i:dtpltt lfbnfliryg tik sfat)cagp is fidtCd, d lli'ptta plumber
Jlib ?" bN Ccb Nitir:tt! 1. . oi �. ipxl , bdtiCy;r(t1 air � t
Rich httlgt bd intti
dlldd ' Oil H keparate
Eli b,d eidrrd gati�btes, nfinlfalze vatet use
tilt
I. iMblddigtplyr
C �fYC1 Ci. �
H old ELI ritt� tf+t ilft[''vo till d!`Eludnt tit!
it pti �ip,vuiep, Hdhittif itg nfuUt 'b� dau��rl��yalidefirar. h @glary
Cot CvHk nj,� , CI Y, PUmpJ.•tig dod disppbifdl dF. ttnstuw�tprtb seii ce ngr3dtg
utl6ip�� tud�y+`bp A e�asfidry + tinialydid and rdrdird drd mddH,
' c
i �'dildd ft,tluNt aytit @latl Idol+ t "U"ed t dld(JVdl •gild did(Iddel dt the
d�F:LbE` @>tHd fill; n tin replfacicig it i rteW sa ar •instdlilitg
t
lilt gdrti>ii` �rbYtttlatMent (snit t d t4 dded or e1 i
ti tlifl<ra� key ba. ( >itbllehb� li natd tiny c
Z, #t1- lfitiiilid fidil dblibrptioh d y #Ebma ae at- grille dyfiteMd Mdy tequite
Elie itigtctilutldu d.t all uprbble pttytr.df giant licciE
of tits ylftNl4, Additltruel giLP and soil dti diueti ufisrm4dypdpddmCot
bti dot +� NHtI ddditiottbl pidnd Mdy ndad to bd ,pratififed and
ti . 1 kttudtj bji Hid safety dhd huildiligit bit:ididtc of, the btipdt•tmetlt
ti 'dtife6lLkrd r
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Ur.v- vv = ?004I -, m , PH PM OWATONNA CLINIC OBGYN FAX NQ, 9523450544 N0. 039 P. 2. 02102
ST, CROIX COUNTY
SEPTIC TANX MAINTENANCE AGREEMENT
AND
/
OWNERSHIP CERTIFICATION FORM
Ownerftyer ( i A G i a►rt s7� i �G b
MailingAddMe $O'1 4ke.r ?tavin LFnv SS'O60
(Variftcason required Vom planning rpP" Men? for now const ueClon.)
City /Stage .. AVd -4O/I bat Parcel idcotifioaaon Numb 0 0 - / 4 11 10 0 00
.Ibbi�}
LEGAL CRIPno
DN
Property Location f V4 , - L '14 '/4 , Soo. �, `t , T . L<� N R W, Town of ro ,
Subdivision �.r� �','�,�a /� �►y►� 1/.'!/.►. �. . Lot dl ! 34t
Certified Survey Map # - Sec 4'�-4 e.14.L. Volume , , Page #
Warranty Dead # c c ��H« J. 13
Volume Page # 4 140's—
Spec
hour rt yt Lot lines identifiableXes U no
SY57'�M M,►Ytvt�:1y�NCE
lmpropar use and maintenance of your septic fiyfitetq Could MWt in its premature failure to handle wsat". Proper
maintenance tourists otpumping out the septic tank evcry throe years or sooner, ift►eeded by a licensed pumper. What you put into
the system can affect 1139 ltmotion of the septic tank at it treatment stage in Cho waste disposal system,
The property owner agrees to submit to St. Croix County Zoning Department a oortifleation 10M signed by the owner and
by a mrater plumbs, journeyman plumber, restrlctod plumber or a liOn pumper vetif*q that (1) the on -site wastewater di sposa l
'"'On is In proper operating condition endior (Z) aMr inapcotlon and pumping (if neoeasary), the septic tank is lest than 1/3 toll a
sludge.
Uwe, the undersigned have toad the above requitetnentr and agree to maintain the private sewage disposal system with the
standards set forth, h'KWG, ae sot by the Departrttent of Commerce sand the Department of atural Rooureea, State of Wisconsin,
Cattifiowon stating that your septic system has been maintained must be cots pleted and remmod to the St Croix County zoldng
Department within 30 days of the throe year expiration date.
SIGNATURE OF CANT DATE
Uwe
Certify Chat aD sRatemertts On this f OTM afro true to the bast ofmy /our knowledge. I o an/arc the mmer(s) of the
property dosoribed bone, by virtue of a ty dead recorded in Rgitter ofDeeds office,
SIGINA7UM OF APPLICANT L DATE
Any inlbrmation that is miareptesentad may result in the raeitery paemlt being revoked by the zoning Departmmt * * *w **
Tneludo with this application a ttamped watranV deed fmyn the Resistor of Dada Af tee end a copy of Cho eerCificd survey nrp if
reference is made in the warrmny deed.
78ii -4
U. 2 7 0 4 P 4 6 5 KATHLEEN H. WALSH
R OF DEED
STATE BAR OF WISCONSIN FORM 2 - 1998 ST. CROIX Go., WI
WARRANTY DEED
RECEIVED FOR RECORD
r -
Document Number 11/29/2@04 @2:00PK
,
i
( This Deed, made between WARRANTY DEED
E)(EWT •
Troy Development Corporation, a Minnesota Cor ration
Grantor, TRARS 5390
and one G. H i ck ok and Dianne R. Hickok COPY FEE:
H usband and Wife as joint tenants CC FEE:
�1
PAGES-
Grantee.
for valuable consideradon, conveys and warrants to the following
1 desc ibed real es a In St. Croix County, State of Wisconsin:
it Rcoorm,,g Are:.
'i Lot 138 of the Plat of Troy Village Fi fth -.. :.. ...- .. --
Name and Return Address
Addi on n the Town of Troy, St. Croix County, Vi llage
Wisconsin. 2550 niversity Avenue W.
ii
Subject to Declarations of Covenants, Conditions and Suite 214N
Restrictions for Troy Village, recorded in Vol. 1241, St. Pau}, MN 55114
Page 256, as Doc. No. 559964, and the Declaration of
Golf Course, Covenants, Conditions and Easements. -
recorded in Vol. 1241, Page 301, as Doc. No. 559969,
040- 1291 - 90- +
all as appearing in the office of the Register of Deeds
for St. Croix County, Wisconsin, and such other Parcel Identification Number ("M
easements, restrictions and reservations of record, This is not homestead property.
or in use, and the "Buyer" obligations contained in (is) (is not)
the Purchase Agreement for this lot.
`i
RETURN
Village Title S n,ke. ;a..t Company
255G Unveil• i!- :re West i
SuRe 214 hic:
Saint Pare:
Exceptions to warranties:
Dated this 18th day of November 2004
S I.
(SEAL) _ (SEAL)
Charles S. Cook, President !•
Troy Development Corporation
(SEAL) — (SEAL)
ii
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Minnesota
State of W+acorts .
ss.
Anoka County. i
authenticated this day o!' p� ersonally came before me this 18th day of I+
y --�' N ovember _� � 0 04 , the above named ;`
Charles S. Cook, President '
Troy Develorxe t Corporation II
I
TITLE: MEMBER STATE BAR OF WISCONSIN to
(If trot, me known to be the person who executed live foregoing
authorized by §706.06, Wis. Stats.) instrument and acknowledge the same..
C1 QJ . Q XLrz� ii
' THIS INSTRUMENT WAS DRAFTED BY
C a rr► e Q. C� brej
TROY DEVELOPMENT CORPORATION / � (+
Notary Public, Srailwef- Wiseewau►Anoka County, Minn. 'I
Charles S. Cook, President My commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not 1 i3 f , 2i00.) +`
necessary.) ++
i
Nsmes orpersons signing in enY capecity must be Typed or printed below their slgnstum
STATE BAR WISCONSIN wnconaln legsl B lank — Co.. Inc.
ii
' WARRANTY DEED FORM Nn. n. 2 - 1898 MUwauaoe, Wis.
CARRIE A. ALBR£CHT
NOTARY PUBLIC - MINNESOTA
0 MY COMMISSION EXPIRES
JANUARY 31. 2005
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OUTLOT 1., '��•
' _ TROY VKLACE '
4 Is ^ � !P TROYTLOCAG'If
TOP OF 2 1/2•
, .1i.. N..........._ar�E.� •Efll11 PARK.
ELEYATpM.SSSAS 1 � ` - \�•{�,� /� � , �•E
- ` -' - III \\ •\ \ �,_ ?t■a�1�\
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A l J' +`. 135\ \% it �NNa1- t1- ; SCALE IN FEET
, '• •. 1.1012 MME
119 �ry 132 • '� �, \,!�" ��
1.042 AM 134 • 7 ( \ \
4 y , 0 •0 770 240
$' `
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t bb \ \ \ 11 % I M4 = M/T I STMT I
�•R ve� 1 N RIVER FALLS, WIlCd161N 64022 ' lX/TLt
' OATEO TWOS 11TH DAY OF Molm. 2002. 1 w IJY l
{ \ IIEVIS[O THIS 11TH DAY OF IM C", 2002. I
Z�� 1
of
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KCTQN 24 i S�% OF SECTION 24 •�: s
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address $v9 ��t�.e ��� d wa- fo•Ar� , M�/V s'�D�id
Property Address L: 0 % 01 $& 7 ,0 RAd I N u d Se h , %k1% .SNO / 4
(Verification required from Planning Department for new construction)
City /State - H&Ad" h . wZ Parcel Identification Number 640' I ?9 J • 90'
I.FC.AT. DRI RIPTION
Property Location S C ' /a, -SG 'A, Sec. 2_ 1 , T_.N -R a W, Town of
Subdivision • 444 7isy 13"'0045 y: I '1!�C Lot # 1 3g
Certified Survey Map # S« 0 ^ 64 A%4 4L , Volume , Page #
Warranty Deed # sec A/ j'%-4 -C. Volume Page #
Spec house 0 yes)�no
CYSTRM MAINTFNANCR
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master
plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in
proper operating condition and /or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
44.'e 4. 40 ;)� z
SIGNATURE OF APPLICANT DATE
OWNFR C ERTMC ATTON
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
prope described a ve b irtue of a warranty deed recorded in Register of Deeds Office.
04
SIGNATU OF APPLICANT DATE A01
* * * * ** Any information that is mis -represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
* * Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
e
DEC -06 -2004 13136. VILLAGE TITLE 6516462134 P.02•
Sr STATE BAR OF WISCONSIN FORM 2 , 1998
!R WARRANTY DEED
Mtl y � •_.. :• ,. tkx)unont Numbs ...
3 >�� This Deed, made between
A Troy D--velopoent Corporation, a nnesota CoYPOxat on
II Grantor,
• �' and - ne c o an D„�,e t:
US d e 5 o is
I) Grantee,
! Grantor, fora valuable condderanon, conveys and warrants W Grantee t following
described rani estam in St. Cr County, State of Wisconsin:
{ 138 Of the Plat of Troy Village Fifth `� •.- vim..., -.m,.. ,.�,
I. Addition in the Town of Troy, 5t. Cx'Cix Cottnty, Nuns end RoWnAdores*
Wisetinsin: Village Title
.'2550 University Avenue W.
Subject to Declarations of Coy'enanta, Conditions and Suite 214N
Restrictions for Troy village, recorded in Vol. 1241, St. Paul, 'MN 55114
Page 256, ae Doc. No. 559964 and the Declaration of
Golf:Courae Oovenantsr Conditions and Basements, :. •.•..•.I
I , re= 404 11 Vol, 1241, Page 302, Doc. No. 559969, 040- 1291 - 000
All as appearing in the office of the Register of Deeds
for St. Croix County Wisconsin,, and such of peloel klendSatston Numbar PH
I easawnts, restriotions and reservations of record, This — not ' homestead property,
Cr in Use, and the "Mayer" obligations Contained in (Is) (is not)
the P"chass Agreement for this lot.
1
,i
I�
RETURN DOvUMIEtd:•R'To:
UBtags Trite t& Ahr'r.•trt Gon"hy +I
2590 UNve::etly ALi;ltlte VdElit j
ttufa 214 MIth 1
aaird Paul. tu_vmw<rhs55114 H
'4a
,
lxceptlons to warranties: !f
DRted this 18th day o f Novem 2004 u
(sEAW
• .•Charles S. Cook, President
Troy De"lopment Corporation & b
(SSW (%AAW �I r
r ,
AUTHENTICATION
ACKNOWLEDGMENT
111
up,
Signmura(s) Minnesota
State of VAICO rs$rr, 1
f i r i
Anoka Co„aq - 1
authenticated this _ da of p arsnrwtl came before me this 1 tlh de of q .
y Novemer 2004 , the above named
Charles S . Cook, President
Troy Deveiotxnent Qgrtx>ratian -
TnIM M4MBER STATE DAR OF WISCONSIN to j 5
at not,,,,, me known to be the person —who executed the foregoing .
authorized by $706.06, %s, Scats,) Ins and acknowledge the ss
y � THIS INSTRUMENT WAS DRAFTED BY
Yi TR T 10r=PMENP CORPORATIO ^ « C g I-, e.
Notary PutrAc, StetweGWleeortartAnoka County, Minn.
pttarles S. Cook,. President My commission is pen } tanent. (tf not, *race expiration date: q
!� (9rgnatorna rruty be audtanucuad or ackrwwledpd, Both are not / 3! 2,Q�5a U
nacasrarg) .. -7� 1=
„ tt
!� �Nal,w.orpgo, ■•tgitlry In aqq cryheur -1 b+"dol• pemUd WOW %h* rigANww .• :',
STATE IIAR Op WISCONSIN - YNwa1Nt1 }J
WARRANTY PSED FORM Na, a teas t ''M Wyq, wd t ._
CARAIEA ALBRBCHT
NOTARY PUBLIC MINNE60T1`
pOMMISSION Q(PIREB °.
TOTAL P.02
Pl*NEER M91 neerzng
Mendota Heights Office Coon Rapids Office
2422 Enterprise Drive CIVIL ENGINEERS LAND PLANNERS LAND SURVEYORS LANDSCAPE ARCHITECTS 201 85th Avenue N.W.
Mendota Heights, MN 55120. Coon Rapids, MN 55433
(651) 681 1914 Fax:6819488 Mendota Heights Office (763) 783 1880 Fax:783 1883
F
Certificate of Survey for WOODDALE BUILDERS
TROY, WISCONSIN
40 ,
O 886.
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�IV 886.5
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(VACANT)
883.
138
883.9
884:1 92,5 x 893.8 895
893.4
0 90.6 / O ���. i / �� ' 89p.fi'/ . O
��� / 999 ♦�\ i �� 900. 900.2
Q �P O/ O ,��•, �'oIi DRAINAGE AND UTILITY
L� �� `�� `�.� EASEMENT PER PLAT
892.4
x 893.8 l�
891.4 92.8 ,. I OQ Jcw h� 900.3 / 1
• /1
R90 p � � ` ^�`�• Q Id � � � °� a� � �� ? A°
0 894,0/ �I I I ' 1
S 99.1
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00 6 894.1 6 S .9 1 1 ti
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898.0 �
i�I I II�N \tom /J
° 697.8 /
901.0
897.1
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(VACANT) o8 \ ®0 899.6
899.9 , CpO
896.3/ Q
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897.3 96. Q
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?AirrIAL- ^ , PROPOSED HOUSE ELEVATION
NOTE: PROPOSED GRADES SHOWN PERVGRADING PLAN BY: b (7DCN ENV I N6EQINCy 0 f 4��
/ LOWEST FLOOR ELEVATION:
NOTE: BUILDING DIMENSIONS SHOWN ARE FOR HORIZONTAL AND VERTICAL LOCATION ..... •
OF STRUCTURES ONLY. SEE ARCHITECTURAL PLANS FOR BUILDING AND TOP OF BLOCK ELEVATION: -� i� C" -
FOUNDATION DIMENSIONS. , , PETER J.
HAWKINSON GARAGE SLAB ELEVATION:
NOTE: NO SPECIFIC SOILS INVESTIGATION HAS BEEN COMPLETED ON THIS LOT BY THE 2493 F
SURVEYOR. THE SUITABILITY OF SOILS TO SUPPORT THE SPECIFIC HOUSE
PROPOSED IS NOT THE RESPONSIBILITY OF THE SURVEYOR. BURNSVILLE,
�. 1 �T.
NOTE: THIS CERTIFICATE DOES NOT PURPORT TO SHOW EASEMENTS OTHER THAN '�,•�, MN %rti X 000.00 DENOTES EXISTING ELEVATION
THOSE SHOWN ON THE RECORDED PLAT. 41 ��. ( 000.00) DENOTES PROPOSED ELEVATION
NOTE: CONTRACTOR MUST VERIFY DRIVEWAY DESIGN. * U v - - - DENOTES DRAINAGE AND UTILITY EASEMENT DENOTES DRAINAGE FLOW DIRECTION
-�-
NOTE: BEARINGS SHOWN ARE BASED ON AN ASSUMED DATUM -A DENOTES SPIKE
-@- DENOTES OFFSET HUB
WE HEREBY CERTIFY TO WOODDALE BUILDERS THAT THIS IS A TRUE AND CORRECT REPRESENTATION OF A
SURVEY, OF THE BOUNDARIES OF:
LOT 138, TROY VILLAGE FIFTH ADDITION `
ST.CROIX COUNTY, WISCONSIN
IT DOES NOT PURPORT TO SHOW IMPROVEMENTS OR ENCROACHMENTS, EXCEPT AS. SHOWN, AS SURVEYED BY ME OR
UNDER MY DIRECT SUPERVISION THIS 17TH DAY OF NOVEMBER, 2004.
SIGNED: IO E R ENGINEERING, P.A.
SCALE : 1 INCH = 40 FEET REVISED 11- 30 -04 STAKED
ItiIZ�n�I BY:
3643 104308000 RWDX2 Peter J. H wkinson License No. 2493