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042-1053-40-000
V ,NisCOnsin fie artment of Commerce p PRIVATE SEWAGE SYSTEM county: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 479206 0 GENERAL INFORMATIO11 (ATTACH TO PERMIT) State Plan ID Npr` Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. A Permit Holder's Name: City Village X Township Parcel Tax No: Polen, Gary Warren, Town of 042 - 1053 -40 -000 CST BM Elev Insp. BM Elev: BM Description: , Section/Town /Range /Map No: - ; .: 19.29.18.303A ,_}c, I<J rat - ; TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchma { , Dosing ` Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dosing ea er /Man. Aeration Dist. Pipe Holding Bot. System L • L 9 PUMP /SIPHON INFORMATION Final Grade r Manufadlyrer Demand St Cover i , - GPM t ,� t r �S .C,•:ie Model Numb TDH Lift tion Loss System Head TDH Ft T5 T y4i a+til4. C.►�A..�� Forcemain Length Dia: Dist. to Well say, ct �'_�.. SOIL ABSORPTION SYSTEM °> tr�. Ifta"ENCH Width Length ~' No. Of Trenches PIT DIMENSIONS No. Of its Inside a. DIMENSIONS , a. SETBACK SYSTEM TO I P/L BLDG WELL LAKE /STREAM LEACHIN Manufactu r: INFORMATION CHAMBER R bi ` Type Of System: r U Model Number. DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake j, Pipe(s) Length `- Dia Length Dia Spacing __j VE 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 Cent r Bed/Trench Edges Topsoil I I Yes No L Yes ] No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: h F- <a ; .' v -` Inspection #2: 7 / Location: 979 80th Avenue Roberts, WI 54023 (SW 1/4 SE 1/4 19 T29N R18W)NA Lot Parcel No: 19.29.18.303A 1.) Alt BM Description = t,E' 't' w v 2.) Bldg sewer length= �3�yfit� i 1 - _ - -_ –._. _ ._.— — _._. _ _.____.._ _. _.. - -- 4 Plan revs j Yes o (/ J Use other side for additional information. L Date pctor's Signature Cart. No. SBD -6710 (R.3/97) 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 - 7162 ��� Sanitary Permit Number be filled in by Co.) (608) 266 -3151 a- V De artment of Commerce State Plan I.D. Number - Sanitary P pli V t A In accord with Comm 93.21, Wis. Project Address (if di than mailing address) may be used for secondary 5.04(lXm) I. Application Information - Paeans Print All Informati ? r7 V . '� Parcel A Lot q Block # Property-Ownees Na me .7� -r"�� 6*f.R oGam' Property Location 303 Property O 's M ailing Address � 0 ' 2 yt, / City, State Zip Code Phone Number S C/ S tc �� trcC) - II. Type of ding (check all that aPPIy) P p ��/ 3 8� Subdivision N me CSM Number &f or 2 Family Dwelling - Number of Bedrooms ❑ public/Commercial - Describe Use [I State Owned - Describe Use ❑City ❑Village ©'township of Gr/M t/2o- III. Type of Permit-- (Check only one box on line A. Complete line B if applicable) A - ®Flew S 'ystem eplacement System ❑ Treatmtmt/Holding Tank Replacement Only 11 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 alt that all 10 ol WNon Press raund ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter El Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Chamber 11 Drip Lune El Gravel4ess Pipe ❑ Other (explain) V. Dis reatment Area Information: .2 C- - f h f + Design Soil Applicatitnt Rate(gpdsf) Dispersal Area Required (sf) Dispal ATE' (sl) S Elevation 6 - r eY. y Design Plow (gpd) !,n ers C- Z ?4 9 od 7 e5 7./ se's VI. Tanta Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing L Y6Y� G Tanks Tanks Septic or %eldhig�anit ,45-P 2 Aerobic Treatment Unit Dosing Chamber VII. Responsibility Stateme Y, the - utid, sigued, ammo respoa for insWlation of the POWTS shown on the attached plaas- Plwn4 er's Na me (Print) Plumber's Si gnature Number Easiness Phone Number - Fogerty Plumbing , .zx 7 /-i - 3s- 9�0 Phtmbrgte� Jtate. Zip ) 7 1S Spooner, WI 54801 VIII. Only- 4r Sanitary Permit Fee (includes Groundwater Date Issued Sigireture tamps) Approved 0 Disapproved Surcharge Fee) 3 CV !/3 i Q&_ �2 ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval YS �^ OWNS filter and aV 3 3 3 _ 1 Septic tank, effluent y' dispersal cell must all be serviced / mailuber. as per management plan provided by p m 2. All setback li able code requiremen ts must bes. m aintained as per app Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in size Fogerty ph mbhg 1 _ :"221180 r 2R2C. 3 McKenzie Rd. spcomr, Wl 54801 (71..,35 -9� ot 41 BAS /* 30 ' s=LQ N ' 1 7,0 . X ell �p.u• �,c�i*� `�'l/ Cam. � N C 3 6� d #L '� d #/ _ $ih, rah f , lF.y'74 F7.4 ` x L,gnG,s �aX ,�'60�i�' 7kt a I i ^ am li 0 e ( o e W r . 1' RK it s s _ a ♦ \ _ 1 , = t� ♦. UQ sy CD CL CD oi &i : / = a co CY CL Jll _ trj a ! -.. y lid O y A ! vo N o d i "0 � ►�+-� 1 � v m N V • ��� ODC jnOt O 9 ;D R f gyp'= Xv ` Z Fogedy rk mbMg 221180 282Eg "cKenae Rd. speor?r, Wl 54801 (715) C-3035-9609 X oD AX Ss� • � �' - CSl'vt i • ZO ell c, Z _� 's' x'C� • , '� z >AV � d g7.q \ tl,�i =•ter a� . F� ✓: c -� 9= v F7.4 G - 2- - wE P6.9 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Bnger ,po�.t/ - - • 1 Mailing Address fg 7 9 "Jov. ,r i ll -2 — S� Property Address 9 7 f (Verification require (Tfrom Planning Department for new construction.) City /State ? /3/� com- T*13 Parcel Identification Number yZ ' 3 — LEGAL DESCRIPTION Property Location 5 ct l % a , S � � % a , Sec. /f , T Lf N R / W, Town of Grt,�, �'•�/ /� Subdivision Lot # Certified Survey Map # !— S3 3 , Volume �--- , Page # 3 f Warranty Deed # 7v 2 9 2 , Volume Page # ,S 'e1 7 Spec house yes Lot lines identifiable (yes no SYSTEM 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. 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 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 Zoning D ent within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE, OWNER CERTIFICATION I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the described abov a of a warranty deed recorded in Register of Deeds Office SIGNATURE OF APPLICANT DATE * * * * ** Any information that is misrepresented 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 and a copy of the certified survey map if reference is made in the warranty deed. ALE INFORMATION SYSTEM SPEt�HCA77� ESeptic Tank Capacity Z s-� NA ❑ _ r f d (� Septic Tank Manufacturer E- ❑ NA Effluent Filter MalwfacUK4 ❑ NA DESIGN PARAMETERS Number of Bedrooms p NA Effluent Model ❑ NA Number of Public Facility Units : XNA PUMP Tank C al rl Estimated flow (average) OQ aUd Pump Tank Manufacturer A ay Design flow (peak), (Estimated x 1.5) Pump Manufacturer Np` Soil Application Rate al/dayne l Pump Mode •� Standard Influent/Effluent Quality Monthly average* Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg1L ❑ Sand /Gravel Filter ❑ Peat Filter - Biochemical Oxygen Demand (600 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (M) <750 mg1L 13 Disinfection [I = Monthly ag e r (sl ❑ NA Pre_ treated Effluent Quality y [3 b1 -Gramd (pressurized) Biochemical Oxygen Demand (BOD S30 mg/L XNA (gravity) Total Suspended Solids (TSS) <_30 m9A_ ❑Mound - - Fecal Cokform (geometric mean) < -1 1 OOmI [3 Other. � ❑ NA Maximum Effluent Particle Size Ye in die. ❑ NA Other: ❑ NA ❑ NA Other. ❑ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequ 0cy ❑ monihts) (Maximum 3 years) 0 NA Inspect condition of tank(s) At least mice every: earls) Pump out contents of tank(s) When combined sludge and scum equals one -third %) of tank volute ❑ NA ❑ VnOrythts) NA Inspect dispersal cell($) At least once every: 3 years) l 3 years) ❑ ❑ month(s) ❑ NA C &t-� At least once every: ,' years) ❑ month(s) aNA Inspect pump. Pump controls & alarm At least once every: ❑ y ear(s) ❑ month(s) Q NA Flush laterals and pressure test At least once every: ❑ year(s) Other.- At least once every: El y � d (sl _ j L NA tither. n.,NA MAINTENANCE INSTRUCTIONS one of the following or certifications: Inspections of tanks and dispersal cells shag be I ual carrying Operator. Tank POWTS Master Plumber: Master Plumber Restricted Sewer; or; POWTS Maintainer: Sep. S operator. or leaks, inspections must include a vis motion tion of the tanks) to identify any irwsin9 or broken hardwarere, ► anY measure the volume of combined sludge and scum and to check for any back up P9 of effluent on the ground surface. m eel to check the effluent levels in the observation pipes and to check for any ponding The dispersal cell(s) shag be visually sPect indicate a falling cmtdwOn and requires the of effluent on the ground surface. The pmrdiing of effluent on the groglnd surface may immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septaga Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not rffnited to the servicing of effluent filters, mechanical or pressurized components, pretreatment tainer units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Main . A service report shall be provided to the local regulatory authority within days of completion of any service event. .PAT UP AND OPERATION oducts or other chemicals For new construction, prior to use of the POWTS check t reatmen t tank(s) for the presence of painting pr that may impede the Ueattnent process and /or damage the dispersal call fs)• If high co ncentrations 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 and conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal call(s) in one large dose, overloading the cell(sl and may result in the backup or surface discharge of effluent. To avoid this situation the contents of the pump tank remo r ved by a Septage Se fWmg 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 d'rspmgl 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 improve the performance , d prolong disinfectants; the Gfe the life oof f far POWTS: antibiotics; baby wipes, cigarette butts; condoms, cotton swabs; degreasers, dental foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. - ABANDONMENT manently taken out of service the following steps shall be taken to insure that the system is When the POWTS fails and /or is per I � properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative 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 provide a code compliant replace ystem: t St:' far nerft area has been evaluated and may be bdized for the lo cation of a replacement W absorption sys�em. The replacement area should be pmtected from duswrbartce and � artd should not be infringed upon by structure, lot lines and wells. FaGure to protect the replacement area will required setbacks from existing and proposed �. �t systems must result in the need for a new sort ar►d site evakiation to establish a suitable replant comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POV 0/*aly site as t been ev to identify a replacement ar Upon failure of the POWTS a soil and site luatio be perfo ed to ate a su' le repla ant are f no re t is av ' b!e_a holding tank c cuxnen be in ailed a 1 resort to re a failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL DES. DE A TH INSUFFICIENT LT. RESCUE OF A HATER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY FIST PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ` #221180 - _ c n (715) 635 -9609 j POWTS INSTALLER POWTS Ot t v Name Name R Phone Phone SEPTAGE SERVICING OPERATOR (PUNIPER) LOCAL RE131LATORY AUTHORITY Name Name l7' 1 G� X 0 t-tJvp�, � l Phone phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54{11, (2) & (3), Wmonsin dative Code. yllsconsfn Department of commerce SOIL EVALUATION REPORT T�'�s•�'Bi�A�y' Page of 3 Division of Safety and Buildings 4-VA 4� in accordance with Comm 85. Wiis. Adm. Code . .. C Attach complete site plan on paper not less than 812 z 11 itches in size. Plan nvAA include. but not ('soiled to: vertical and horizontal reference point (BM), d'irecdon and Parcel I.D. percent slope. scale or d' , north arrow. and location and distance to nearest road. y — S' 3 O Date �T e riot all for IV D 31 US' personal bd miation vau provfd�aY for (''■poses (racy Law. s Is. fw (1) Uri - Property owner I '- , _ 0 0 5 Gay Lot Gt/ 1M rC 1/4 'S T N R E Coley pv4cAl Block's property er's Mailing Address N OF "ri a Subd. Name CSIN# O ZONW ; =i. 7 60 Vill own Nearest Number city ❑ �Y State Zip Code Phone tY d t >-) 7 ( New Construction Use: UkAesiaen U ms al / Number of bedroom Z/ Code derived design Qar rate ` ❑ Replacement ❑ Public or commercial - Describe: ft. d applicable Parent material �,� %� Flood Plain e levation General comments and recommendations: M Bftrutg # 0 Pit h surface elev. .L R Depth to g fagot � -- m- Soil Application Rat Texhue St Consistence Boundary GPD/f* tiorizaf Depth Dommnant Color Redox Description � •Eff#1 •Efffit2 in. Nkssell Ou. Sz. Cont Color Gr. Sz- Sh. I ve- ttt . to IF s S •s Z& J S s 2 _� y d L IV P] Boring 0 [a p 8rrr9 Ground surface elev. 93• y n. Depth to limiting farmer > o tlr Sol gpp8pdor, Rao Horizon Depth Dorrrnarut Color R� De P� Texture Shuck" Cartistertoe Bofada y Roots GPD/IP in. Munsell Qu. Sz. Cont. Color Gt. Sz Sh. 'EffB1 'Efi#2 z — F 41V .P q. LS S -� • s • uent_ 02 = BoD s — < 30 mg1L and TSS < 30 mgk - • Effluent #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 mglL CST Number CST NOW (Please Print) r Date Evaluation conducted Telephone Number Address Fogerty Plumbing & Perk Testing _ 49rjz25 77S = 28288 McKenzie Rd. I 1 Page Of 3 -- Parcel ID # y Property Owner El going # ❑ Pit d Groun surface elev. _ 7 ft. Depth to Wn&V factor n. Sol Rate GPDlffl` V Pit Texture Struck Core Bar>Aaty Roo1S 1 091 'Etf#2 Horim Depth Dominant Redox Gr. Sz. Sh. in Munsell Qu. Sz Cord. Color — o a JZ 2 J` S hf S S� do IL El 0 Pit • • M — in. Sol lion Rate Dept to tag # Ground surface elev. _ ---- ft. � Roots GPDIff Texture Structr3ce •Eff #1 'Etf#2 Horizon Depth Dominant Redox Description Gr. Sz. Sh. in Munsell Qu. Sz. Cord. Color Depth S # gocr)9 elev. ft. to 19 factor — n• oo - ' Rate Pit D B n( G roun d surface _ GPOIf� y� � wry Roois Redox Desatption Texture Structure - F-01 'Etf#2 Horizon Depth Do minant Gr. Sz. Sh. in. Munsell () Sz. Cant Color Effluent #1 = BOD > 30 < 220 mglL and TSS >30 <_ 150 mglL •Effluent #2 =• f3OD, _< 30 mglL and TSS _< 30 mg The De artment of Commerce is an equal opportunity service provide and e If you neor`�Ytance to acces . services or need material in an alternate format, p depa tease contact the SOD•6330 (R.6000) f Fogerty Plumbing #222180 2p2£g McKenzie Rd. Spec rt r, WI 54801 (715) 1 535 -9609 �.� eA szt9 3 X3.0 • �9y� p. roo' Lcr 4,? \ ' � �J STi'ti :rp , 1 7-v - - 7 (! = G*,Q 4-*fi Parcel #: 042- 1053 -40 -000 05/31/2005 10:46 AM PAGE 1 OF 1 Alt. Parcel M 19.29.18.303A 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * GARY P & RHONDA M POLEN POLEN, GARY P & RHONDA M ' 967 80TH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 979 80TH AVE SC 2422 ST CROIX CENTRAL � >—� SP 1700 WITC `X � Legal Description: Acres: 6.230 Plat: N/A -NOT AVAILABLE SEC 19 T29N R18W PT-, SE LOT 1 Block/Condo Bldg: CSM 7/2063 INC P (341 042- 1054 -50) LOT 3 CSM 11/3041 6.23AC Tract(s): (Sec - Twn -Rng 40 1/4 160 1/4) 19- 29N -18W Notes: Parcel History: Date Doc # Vol /Page Type 12/19/2002 702929 2085/547 PR 07/23/1997 1157/181 LC 07/23/1997 1076/406 TI 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations Last Changed: 10/22/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.230 52,600 42,500 95,100 NO Totals for 2005: General Property 6.230 52,600 42,500 95,100 Woodland 0.000 0 0 Totals for 2004: General Property 6.230 52,600 42,500 95,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 J 2 0 0 4 7 7 KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 5 — 2000 REGISTER OF DEEDS PERSONAL REPRESENTATIVE'S ST. CROIX CO., WI Document Number DEED RECEIVED FOR RECORD JUDY NICCUM 12/19/2002 99:39AN EXEMPT # 17 as Personal Representative of the estate of FLORENCE K. POLEN REC FEE: 11.00 TRANS FEE: COPY FEE: ( "Decedent "), CERT COPY FEE: for a valuable consideration conveys, without warranty, to PAGES: 1 GARY P. POLEN AND RHONDA M. POLEN, HUSBAND AND WIFE Grantee, the following described real estate in _ ST. CROIX County, State of Wisconsin (The "Property ") (if more space is needed, please attach addendum): parcel of land in the SW-4 of SEj4 and in theSE4 of SEk of Name and Return Address Section 19, Township 29 North, Range 18 West, in the Town of GARY AND RHONDA POLEN ;Warren, described as follows: 967 80TH AVENUE I ROBERTS, WI 54023 of 3 of a Certified Survey Map dated November 7, 1995 and recorded January 5, 1996 in Volume 11 of Certified Survey aps, at Page 3041, Document Number 538231, in the Office iof the Register of Deeds for St. Croix County, Wisconsin. 42- 1053 -40 Parcel Identif on Number (PIN T OGETHER WITH AND SUBJECT TO any other easements, covenants, reservations or restrictions of record, if any, but this shall not be deemed to extend any such other recorded encumbrances b eyond the term established by law therefor. This Deed is given in fulfillment of the Land Contract between Florence Polen, a /k /a Florenc Polen and Gary P. Polen and Rhonda M. Polen, dated January 9, 1996, recorded January 10, 1996, in Volume 1157, page 181, as subsequently amended by Amendment to Land Contract dated January 6, 1999, and Recorded January 7, 1999, in Vol. 1393, Page 359, Doc. No. 595194. Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. Dated this �' Z day of August 2002 (SEAL) (SEAL) hdy N ccum j Personal Representative Personal Representative AUTHENTICATION ACKNOWLEDGMENT Signature(s) M104 ds t Gyh. State of Wisconsin, ss. I j authenticated this Z Z -i I ZAa z - County. Personally came before me this day of the above named ' * �I►ttla A/G TITLE: MEMBER STA WISCONSIN (If not, to me known to be the person who executed the foregoing authorized by §706.06, Wis. Stats.) instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY s S amuel R. Cari, Heywood Cari & Anderson, S. C Notary Public, State of Wisconsin 1 200 Hosford Street, 41106, Hudson, WI 540 16 My commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) • Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. PERSONAL REPRESENTATIVE'S DEED FORM No. 5 — 2000 Milwaukee. Wis. ;� r JAN - 5 /ggs _m_ su�v� s�n►ri► CERTIFIED SURVEY MAP LOCATED IN THE SW 1/4 OF THE SE 1/4 AND IN THE SE 1/4 OF THE SE 1/4 OF SECTION 19, T29N, R 18W, TOWN OF WARREN, ST. CRO I X CO., WI. NOTE: BEARINGS ARE PREPARED FOR FLORENCE POLEN REFERENCED TO THE SOUTH L INE OF THE SE 114. Z (RECORD BEARING). UNPLATTED LANDS 0 QT .................... "APPROX EAST ......... 1 LINE OF THE . 800 07 o _ 33g 40 7. 1 w 3 39. 03 • \ , CA cn 33 2 I q • 37.40 3� x •. I •S'� � FENCE 1 ® x A �� N: z HOUSE IN S 07 34' 59" W Z: O LOT 2 269. 77' a: 0 2 , J� o $ 7.67 ACRES $ sHE�lm W: (333,943 SO. FT.) $ GARAG (0 7.41 AC. EXC. R/W _ a• ( 322, 754 SO. FT.) w J o� ao • a: 0 , O W BARN LOT 3 (b o: w 6.23 ACRES (271,328 SO. FT. ) 3 J� 5.97 AC. EXC. FTRiW ) (260, 014 S0. . N W; �o _j O Z' FENCE x I X 7 20' 2T 334. 00' 282. 4 I ' ! 304. 79 S89 °44 1 0 "E LI—X — X — N 89 0 44' 10 "W 616.41'_ 0 _ N89� /On W I S 114 CORNER OF SEC. SOUTH LINE OF THE SE 114 FENCE 19. ( COUNTY MONUMENT SE CORNER OF SEC. 19. FOUND). UNPLATTED LANDS FOUND )Y MONUMENT .......................N DS NOTE: THIS MAP IS A SUBDIVISION OF LOT I OF THE C.S.M. REC. IN VOL. 7, PAGE 2063. 0 SET I' X 24' IRON PIPE ���� `�° �,.v ^.,�; .�.;;'•',�.. WE I GH I NG 1. 13L BS PER L I NEAR m "a�' ''s e;• n ► FOOT. JAMES Fit. �` `'• • - I" IRON PIPE FOUND. ° S' r WELD —M ° dom� S • 1804 9 SPRING VALLEY Via: 200 0 200 400 600 . GRAPHIC SCALE - FEET -- ��`��= f*3 JAMES M. WEBER S -1804 NELSEN -WEBER LAND SURVEYING 95 -145 THIS INSTRUMENT DRAFTED BY JIM WEBER DATED TH 1 S VT— DAY O F'— • 1 995. 1 `r o ii P, ,30 `� 1 444477 CERTIFIED S URVEY MAP LOCATED IN THE SWI /4 OF THE SE I/4 AND IN THE SE I/4 OF THE SEI /4 OF SECTION 19, T29N, R18W, TOWN OF WARREN, ST.CROIX CO., WI. OWNED BY: NELSON POLEN R T. I ROBERTS, WI 54023 UNPL ATT ED' LANDS • I. rEAST LINE OF THE D� i Illrrr SWI 14 OF THE SE Alt S8 00 0 7 .� w 2 w JP a co 7.40 �" wv 4 \ 5L( Q � 0 drlve :N 0: N cw, Z• house a ' QUIT -CLAIM DEED Z w Q • -_ VOL. 797, PG. 59 tu -�' - f` S 7 °34' 59 W w iO ' shed garage " : LL �o 269.77 (REC. AS 269.79') w w m shed w ur 0 m It a w W, N (/�• x k 0. LL 2 Z' 2 ~ • barn a' c Q . � Q• — to m Z W E .x Z• o LO T 1 3 �. �I� S • - z 13.90 ACRES W. Zy (605,271 SQ. FT.) � N 13. 38 AC. TO R.O.W. LINE (582, 770 SO. FT.) 0 J o a N Z - D' 27L* ' 70 1 .. 0 A N89 "W S89 10 "E ITS_ N89 °44' 10 W 616.41 r�� 1304.79'. C3 O �_ SI /4 CORNER OF SECTION 19, SOUTH LINE OF THE SE 1/4 SE CORNER SEC. 19 T29N,R18W. (1" IRON PIPE T29N, RIBW. (COUNTY FOUND). MONUMENT FOUND). UNPLATTED LANDS . .... . . .. .. . . ... . . . ...( JAMES M. + WEBER +�. 8-1804 SPRING VALLEY O = SET I "x 24" IRON PIPE WEIGHING WIS. /�, 1.; 3 LBS. PER LINEAL FOOT. p� aP�,�� �G�+%� ®,� 0 = I IRON PIPE FOUND. !AP _ " ".? �� ® S Rv V I N SCALE 1 " - 200' JAK I � V8 iAM S M. WEBER S -1804 �a caa,►1x D A TED du • �. , �48g _ 0� 100' 200' 400' SHEET I OF 2 88 -210 THIS INSTRUMENT DRAFTED BY X'mAzr—V VOL 7 PAGE 2063 0 _N 0 n N 5; T O r1 O •� d O ` 1 � � (D � � (D �j (D 'p A� • T T W A 3 FT 3 `� �• CD CD N N G p O 7 O r.y cn N G7 O CO (D :3 z W Ui O n N N Q O 3 y o O ° .4 d O O ° O c n CD n 7 D 6 w 3 Vl O 0 1 S N 4 O C Z O Ot m o m m co a a o C.0 m D N a a D N N a D p Co (D W < N " C N C °O i N ° p ` (D �y O O O O N V v� 0 O c 0) cn � Co Co w .Q z C 0 00 C 0 Ln 00 0 C 0 O T NO z �� G G < W z �f CD N y N W ? 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C: 'D �a 3�.( � mm CD - CD CD EL _ o o _ g m m CD a? a o i CD CD m o v> O O " r� ° :E ' ° :� o a CD CD o a ° o n G O N o b't ! 3 G —1 M ' m 1 d Z o I m o 0 m o o m oo m� • c. a m m N m 7 a m N N? m f0 �' o m Q N 0 co C A O_ n 7 G M 1 0 O v 01 D b y go� 3 a w to j O c C =r a cn D W S. s 0 A N a m m m a 0o m -0 y W D 00 CL $,m a 0 co° c o � A m o ° o m -4 - 4 °Q o rto to y m m N» � 3 T 000$' Z OOO�i� 0 0 o w m e o <wz m 3 N N N s 3 N N N w o D v v m m o' m W_ m m < °: m :: w w CD CL Z N ZM Z Z O O D 0 O D a CD Co ( = C (D � C C 3 cDD C m N N * fD CL C.J m a m Z m C' o A Z C CD N C =_ n a ;; CL a �' Q M 0 m c�N0 m CL 3 a r z a X ° o °o m c y Z f a G m m A V =r -U •o 0 0 D 14 rn m D m o' 9• m a CL N ai = - oo ; N C �• O t 7 N C .I cio�iwy o 4 ' ID o a , a m o a m a � sp N (� J � N0 00 c�a °mod cn 3 g 3 m ` O �a fu w N w CD o -mom 4rn coo 0) U ) w o a W W 7 m (CD N A C O. 0 y CL a vC � O O m O. m 3 v O 00 = O_ A fD Q '•C^ CD CL m m 7 to 7 CD m _ � j 3 N O CD O m OO ? po y x A N N O O N I, EA 0 b9 0 'v p CD CD 0 C� ti Parcel #: 042 - 1053 -40 -000 07/19/2005 02:05 PM PAGE 1 OF 1 Alt. Parcel #: 19.29.18.303A 042 - TOWN OF WARREN Current I X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " = Current Owner GARY P & RHONDA M POLEN ' POLEN, GARY P & RHONDA M 967 80TH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): "= Primary Type Dist # Description ' 979 80TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 6.230 Plat: N/A -NOT AVAILABLE SEC 19 T29N R18W PT SW SE & SE SE LOT 1 Block/Condo Bldg: CSM 7/2063 INC P3041(042- 1054 -50) NKA LOT 3 CSM 11/3041 6.23AC Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 19- 29N -18W Notes: Parcel History: Date Doc # Vol /Page Type 12/19/2002 702929 2085/547 PR 07/23/1997 1157/181 LC 07/23/1997 1076/406 TI 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/22/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.230 52,600 54,000 106,600 NO Totals for 2005: General Property 6.230 52,600 54,000 106,600 Woodland 0.000 0 0 Totals for 2004: General Property 6.230 52,600 42,500 95,100 Woodland 0.000 0 0 Lottery Credit: Claim Count 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 i ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER �: - -- 1101 Carmichael Road Hudson, WI 54016 -7710 } (715) 386 -4680 r Fax (715) 386 -4686 May 23, 2005 File 05LU0011 Gary and Rhonda Polen 967 80"' Avenue Roberts, WI 54023 Re: Temporary Occupancy Land Use Permit, Parc # 19.29.18.303 Town of Warren Dear Mr. and Mrs. Polen: q q to " &-#_ - This letter confirms zoning approval according to the plans you have submitted to temporarily live in an existing home on your property in the Town of Warren while you construct your new house pursuant to Section 17.70(3)(c)3 of the St. Croix County Zoning Ordinance.. Staff finds that the proposed temporary occupancy request meets the spirit and intent of the St. Croix County Zoning Ordinance with the following findings: 1. The existing house to be temporarily occupied is connected to an existmg septic system. 2. The existing house and existing septic system will be removed upon completion of the construction of the new house and septic system. 3. The approval of this project meets the intent and purpose of the Ordinance and will not affect the public health, safety and welfare of County residents. Approval of the land use permit is subject to the following conditions: I . Prior to beginning construction, the applicants shall secure a building permit for the new house from the Town of Warren and a sanitary permit from St. Croix County. 2. The applicants shall contact the Planning and Zoning Department prior to commencing site preparation and when all construction is completed. 3. Prior to commencing construction, the applicants shall implement Best Management Practices for erosion and sediment control as outlined in the enclosed document, Erosion Control for Home Builders.. 4. Immediately upon completion of the construction of the new house, the existing house shall be removed from the site or demolished. All materials resulting from the removal or demolition shall be removed from the site within six months. These materials shall be disposed of in accordance with all local, State, and federal regulations. The areas shall also be restored with per manent g round cover as near and practicable to the original conditions. 5. Immediately upon completion of the construction of the new house and installation of the new septic system, the old septic system shall be abandoned in accordance with Wisconsin Administrative Code Comm 83.33. 6. Upon completion of the construction and removal of the existing house, the applicants shall submit to the Planning and Zoning Department an as -built drawing and photos of the completed project. 7. The applicants shall have one (1) year from the issuance of this land use permit to complete construction of the new home and remove or demolish the existing home. The applicants may request an extension of up to six months from the Zoning Administrator prior to one -year deadline. If the land use permit expires, the applicant will be required to secure a new land use permit. I I This approval does not allow for any construction beyond the limits of this request. Your information will remain on file in the St. Croix County Planning and Zoning Department. Please contact the Town of Warren to obtain the necessary building permits and the St. Croix County Planning and Zoning Department to obtain the necessary sanitary permit for the proposed construction. It is your responsibility to ensure compliance with any other local, State, or federal rules or regulations. If you have any questions, please do not hesitate to call. Sincerely, Jenny Shillcox Zoning Specialist Cc: Deina Shirmer, Clerk, Town of Warren Jennifer Emmerich, St. Croix County Code Enforcement Specialist Kevin Grabau/Pam Quinn, St. Croix County Sanitary Specialist FW Bob Bezek, St. Croix County Code Administrator L cc FL ui y � _ y N O i i pS 0 C d V o (A c CL 0o O y o oC y w� d • E MW CJ O cc V 4) Z - CL v � , cis y y y m X � �+ y cc S .o m 0 cc d F- _ v c E c Z 0 o � O o ea E L to m z o a o � o � d , JAN -5 1996 CERTIFIED SURVEY MAP LOCATED IN THE SW 1/4 OF THE SE 1/4 AND IN THE SE 1/4 OF THE SE 1/4 OF SEdTION 19, T29N, R 18W, TOWN OF WARREN, ST. CRO I X CO., W1. NOTE: BEARINGS ARE PREPARED FOR: FLORENCE POLEN REFERENCED TO THE SOUTH 6 LINE OF THE SE 1 i4. z (RECORD BEARING). UNPL�ITTED , LANDS `APPROX EAST SW –SEOF THE • S 80 ° 07 2O ! p 3 39. p 4 07. w 339. O cn 30 •.,• 2 S 1 37 . 40 lb x FENCE X x \ \ HOUSE N S 07 34' 59" W z. 2x9.77 $ LOT 2 C,7 Q: z , _j: e n p; 7.67 ACRES $ SHEt� I W; co (333,943 SO. FT.) O BARAG Q � 7.41 AC. EXC. R/W J; (322,754 SO. FT.) w +; N w BARN. LOT 3 Q w 6.23 ACRES ' Q' (271,328 SO. FT.), 3 J: 5.97 AC. EXC. RiW G; (260,014 S0. FT.) N W; th �• e J: O fL' o Z: FENCE x 1 X 7 27 1 334. 00' 282.4 !' I304. 79 S89 44 ' 10"E L' � - i - X — N 89 10"W 616. 41'_ x _ X _ o_ N89�44' 10'W S 114 CORNER OF SEC. SOUTH LINE OF THE SE 114 FENCE SE CORNER OF SEC. 19. 19. (COUNTY MONUMENT ( COUNTY MONUMENT FOUND) UNPLATTED LANDS .................... FOUND) NOTE: THIS MAP IS A SUBDIVISION OF LOT I OF THE C.S.M. REC. IN VOL. 7, PAGE 2063. O SET I" X 24' IRON PIPE z��` • a ^'; WEIGHING I. 13LBS PER LINEAR �,e."+��� '� • ^,yJ".rr FOOT. JMOrEs M. • • 1' IRON PIPE FOUND. = WFoE:R d S • 1804 —� SPRING VALLEY 200 0 200 400 600 `°•9 9 Wis. •• ,,.r�f ��"��� b.� GRAPHIC SCALE - FEET -- ��-- -� ►��� -� �-�- � JAMES M. WEBER S -1804 NELSEN –WEBER LAND SURVEYING 95-145 THIS INSTRUMENT DRAFTED BY JIM WEBER DATED THIS DAY O F'% • 1995. 1 JLf yo� 11 3a �Q Parcel #: 042 - 1053 -40 -000 05/24/2005 10:30 AM PAGE 1 OF 1 Alt. Parcel #: 19.29.18.303A 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * GARY P & RHONDA M POLEN POLEN, GARY P & RHONDA M 967 80TH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 979 80TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 6.230 Plat: N/A -NOT AVAILABLE SEC 19 T29N R1 8W PT SW SE & SE SE LOT 1 Block/Condo Bldg: CSM 7/2063 INC P3041(042- 1054 -50) NKA LOT 3 CSM 11/3041 6.23AC Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 19- 29N -18W Notes: Parcel History: Date Doc # Vol /Page Type 12/19/2002 702929 2085/547 PR 07/23/1997 1157/181 LC 07/23/1997 1076/406 Ti 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/22/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.230 52,600 42,500 95,100 NO Totals for 2005: General Property 6.230 52,600 42,500 95,100 Woodland 0.000 0 0 Totals for 2004: General Property 6.230 52,600 42,500 95,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 1 444477 CERTIFIED SURVEY MAP LOCATED IN THE SWI /4 OF THE SE I/4 AND IN THE SE I/4 OF THE SEI /4 OF SECTION 19 T29N, RISW, TOWN OF WARREN, ST.CROIX CO., WI. OWNEQ BY: NELSON POLEN R T. 1 ROBERTS, WI 54023 UNPLATTED' LANDS EAST LINE OF THE V', M __ SWI /4 OF THEE A 1� Seoo0 E i 4 0 7 .0 in S8p7'2o E Of 4p1 ' 44 ' % `�� z ° JA�'� 1989• W . ®� = W 7: 4 0' ( fi Vim' 00 �, � A 4 \ E SL W �' 1- : � co ^ ` V C O ' � drive •N � O N z• O hou : QUIT -CLAIM DEED Z W Q • (� VOL. 797, PG. 59 a � "� • - � S 7 59" W W w ' shed garage LL co 269. 77 ' (REC. AS 269.79') W , W m shed w'" o' m Q W W • N cn' Z LLO ~ • a . Darn Q Ld Q • to ...� . W E m = Z. ° LOT I o. w� O 3 13.90 ACRES = W. zy (605,271 SO. FT.) N S �.. 13. 38 AC. TO R.O.W. LINE (582, 770 SO. FT.1 �t o �. O W a• z - D• 27_'� .71.20 N89.44'10 "W S89 10 "E N89 10" W 616. 41 rt 1304.79' -17'1 C3p'• SI /4 CORNER OF SECTION 19, SOUTH LINE OF THE SE 114 SE CORNER SEC. 19 T29N (I" IRON PIPE T29N, R18W. (COUNTY FOUND J. MONUMENT FOUND). 1610G 0L�,'�' UNPLATTED LANDS . . • ... . .. . . . . ... . . . ... JAMES M. ' WEBER w 8-1804 SPRING VALLEY s v 0 =SET I "x 24" IRON PIPE WEIGHING WIS, Arc 1.13 LSS. PER LINEAL FOOT. 50--a -Ir �� �Q e e 1" IRON PIPE FOUND. i U �io�0 S " ' AK' t °`'s JAMES M. WEBER S -1804 SCALE I n 200 � clsi ipp DATED • �. , \E8 . 0� 100' 200' 400' A� SHEET I OF 2 98 -210 THIS INSTRUMENT DRAFTED 8Y AA"X1nAZt6mV VOL 7 PAGE 2063 • AS BUILT SANITARY SYSTEM REPORT "'ER �� 4Q E S / f�„d/ TOWNSHIP SEC. 1 T PN R ADDRESS , ST. CROIX COUNTY, WISCONSIN. ?DIVISION rWb a( LOT LOT SIZE PLAN VIEW 1(tS -Distances & dimensions to meet requirements of H62.20 _ �,�, go SHOO, EVERYTHING WITHIN 100 FEET OF SYSTEM FT F Aq � � n I J E I • I I I � a I � � I i , ► i I ! - N i f e� � f >'TIC TANK(S) 4 �FGR Indicate No)Lth Arnow _ �.( C ONCRETE S cat e .i NO. f rings on cov De th a DRY WELL -' -NCHES NO. of Width length area no. of lines '� width length area d pt�h to top of pipe G CATE �� RATE AREA REQUIRED AREA AS BUILT 8 )� ;r_iaimer: The inspection of this system by St. Croix County does not imply complete _:reliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for ;tem operation. However, if failure is noted the County will make every effort to '.::ermine cause .of failure. "ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYS t `INSPECTO . t,,, . f4t, DATED PLU:MER ON JOB LICENSE NUMBER REPORT OF IIISPECTIO ?l-- II- MVIDUAL SEWAGE DISPOSA7, SYSTEM Sanitary Permit r State Septic .,Al 1.� P TOWNSHIP CC� . • St. Croi- County SEPTIC TA' ?K . JIQ gallons. , `umber of Compartments Distance From: !-jell w „S'� ft, 12% or greater slope - , f1. Building' ft. Wetlands """ f Itighwater ft. DISPOSAL SYSTE:1 — Y Tile Field or Seepage Pit(s) -• Distance From: Well. 9S t. 12 %.or €rester s l ope ft Building; ft. Wetlands f :; FIFLn `raiFLiwater ft Total ` length of lines ft. N umber of line Length of .3, each line . ` ft. Distance between lines ft. Width of the t ft. Total absorption area _ , ft. Depth {� sq. De P � of rock below file �in, D,-pth of rock over the �' i n.. Cover � k . roc,, Q.t�> Depth of tide below S L � grade �loPe of .- trench Z in ?per 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS :Number of pits tsi a dia j er ft. Depth below inlet ft. Gravel a pi :, no. Total absorption area s q. f t . .Square feet oZ epage trench bottom area required :square feet oepa�:e p' r required • Inspected Ti Title':. ' i Approved , .Date 197 , Rejected Date 197 , EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES s DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOAC 309 MADISON, WISCONSIN 53701 g REPORT ON�SOIL BORINGS AND PERCOLATION T`E.ST / LOCATION: /4, SC' /4, Section!!!! , 1 %;4, R/Q I+ (or)�Township or Municipality Wg/ rC,✓ Lot No. , Block.No. County e o 0 ���/ Subdivision Name Owner's Name: Mailing Address: / / v f` f S O 3 TYPE OF OCCUPANCY: Residence — No. of Bedrooms 2 1 Other d 7 O� - — XS� EFFLUENT DISPOSAL SYSTEM: NEW —ADDITION REPLACEMENT p DATES OBSERVATIONS MADE: SOIL BORINGS / I�- , �] / PERCOLATION TESTS SOIL MAP SHEET �/ SOIL TYPE Ah J02 ^,,-7 e PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P_ 1 68 Sew , ► ®gam ��- A y/I y I P - 6801 See 490re- D.l�/0 �Y 10 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B- / A1 ; 76'f �, 7s, is " , 36 , S , 1/0" M e s 21 .100e, - 7,96" s'4 6" ens B- 3 f( „ owe 7�6' B- S� Fd (1 F "M S 6 " ,�C�- 7 6" a " t5 /o ".0 �Z-2 -r/- 12-4 ,�. C++G � "/ PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square yet f suitab_1Q areas. Indicate number f square feet of absorption area needed for building type and occupancy. • 0y0 tf IAL. % A-6 Indicate scale or distances. Give horizontal and vertical r f r nc50Vt�lndicate slope. Sy` P'�^ �- e?� e. A# nn pra tLu J to, I / a r l tN es. i ce o � u f 0r- YS ' I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and-belief . / Name (print) 1h�/� h 4 ^' Certification No. --� �' 145 Address &Z6 49"1_ Name of installer if known CST Signature COPY A — LOCAL AUTHORITY r State and County State Permit # �� PLB6 Count Per ' # Permit Application Y �� for Private Domestic Sewage Systems Count * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Ae &w -1 ©e � 4�i�� w�11. a~ 3 6. LOCATION: Sr aJ '/ Y4, Section ��, TR'9 N, R 4V (or) Lot* City _ Subdivision Name, nearest road, lake or landmark Blk# Village Township 6 4A� OreW C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms Z No. of Persons �-- D. TYPE OF APPLIANCES: Dishwasher X YES NO Food Waste Grinder_ YES k NO # of Bathrooms Automatic Washer X YES NO Other (specify) E. SEPTIC TANK CAPACITY 1000 Total gallons No. of tanks / *Holding tank capacity Total gallons No. of tanks New Installation X Addition Replacement _ Prefab Concrete �C *Poured in Place Steel Other (specify) — F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _ 2) i.S~ 3) _Total Absorb Area sq. ft. / NewX Addition Replacement *Fill System 6 /S�'' Re4 -td Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length -76" Width Depth yZ •, Tile Depth 34 � � No. of Lines 3 CXAL s /•� Seepage Pit: Inside diameter_ Liquid Depth Tile Size t/ Percent slope of land 2 C - 5 - //. � / SyS i¢r�t7 Dis a ce from critical slope .34 le cK f a 0 FF' s Ys / 4. e,� �' I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the CeJ ified Soil ter / NAME [/,�' �i� * � h P�Se.� C.S.T. # -S other information obtained from j; Plumber's Signature /MPRSW# .�l /A3 Phone # 9/.S� 3g6 3(� Plumber's Address "A/ / S PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). o sc,a /4-1 f 3 3 I 3 � Q e ' E F ,} i f .. ff E cat ` Qe-� rc3r ,o ++y� `7v 3 Do Not Write in Space Below FOR DEPARTMENT USE ONLY Date of Application / Fee d: State � County ' -- Dat Permit Issued /R ' (date) 7 Issuing Agent Name Inspection YesNo Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 f ti j i V I 444677 CERTIFIED SURVEY MAP LOCATED IN THE SWI /4 OF THE SE I/4 AND IN THE SE I/4 OF THE SEI /4 OF SECTION 19, T29N, R16W, TOWN OF WARREN, ST.CROIX CO., WI. OWNED BY: NELSON POLEN R T. 1 ROBERTS, WI 54023 UNPL ATT ED' LANDS SEAST LINE OF THE S W 1/4 OF THE SE S80 °O T 0 E 4 S8 p e 0'� T pn in "' \ •' . 2 il �� 3 m kA w � 2 JAW soco m Wt r. 4 \ 5� OO V1, \ ti F" W Q Q C3. 10 drive •'N 0 N j►/ cwi0 Z• 0 house /• QUIT -CLAIM DEED Z Q. VOL. T9 T, PG. 59 -j ' - S 7 °34' 59" W tu w '°' shed garage IL m 269 .77 (REC. AS 269.79') W a cr w of shed w y 0' m aw W N (n• 0c p y►- H• 3 Z o ~ • bare Q w Q • J . W E m= Z o LOT I o � wl1- ° 3 �> > z ' 13.90 ACRES = W. Z y (605,271 SQ. FT.) N 13. 38 AC. TO R.O.W. LINE (582, 770 SQ. FT.) �t Q. 0 J• ° a. - ° Z• 2 7- 70I.20� N89.44'10 "W S89 °44�f0 "E 17•. N89 0 44'I0"W 616.41 1304.79' 30 - SI /4 CORNER OF SECTION 19, SOUTH LINE OF THE SE 1/4 SE CORNER SEC. 19 7 (I" IRON PIPE T29N, R18W. (COUNTY FOUND ). MONUMENT FOUND). plffNtU,Tj �'. UNPLATTED LANDS I Ztt JAMES M. s WEBER +®► 8-1804 SPRING VALLEY O = SET 1 "x 24 "IRON PIPE WEIGHING WIS. t l � 1.13 185. PER LINEAL FOOT. S` *'0 0 = I" IRON PIPE FOUND. < �, +; ® SUR " ' JAMES M. ESER S -1804 SCALE I = 200 JA U. �p�� �s. 1 cotav DATED 0� 100 200 400' SHEET I OF 2 88 -210 THIS INSTRUMENT DRAFTED OY XlnAZt -V VOL 7 PAGE 2063 r JAN 51996 �.. su. T �,_ CERTIFIED SURVEY MAP LOCATED IN THE SW 1/4 OF THE SE 1/4 AND IN THE SE 1/4 OF THE SE 1/4 OF SECTION 19, T29N, R 18W, TOWN OF WARREN, ST. CRO I X CO., W l . NOTE; BEARINGS ARE PREPARED FOR: FLORENCE POLEN REFERENCED TO THE SOUTH LINE OF THE SE 114. Z (RECORD BEARING). APPROX. EAST UNPLATTED LANDS L INE of THE SW -SE " S 800 07 20 40 39 • 40 7, 3 !9 39. � o I W 3 331 40 1 , o S 80007.20" W 62. ! w. •. Cn 30 2 I • 37. X 40 x •. FENCE x ) C4 I N " o 2 HOUSE N S 07 59 " W z: ° (:] 269.77 Q: LOT 2 7.67 ACRES $ SHEq I W; co (333,943 SO. FT.) I � GARAG c0 7.41 AC. EXC. R/W g , J; ( 322, 754 SO. FT.) CA A vi N W BARN• to LOT 3 to CA 6.23 ACRES a: (271,328 SO. FT. ) , 3 J: 5.97 AC. EXC. RIW 0 : (260,014 S0. FT.) N W; Q: �e J: o a• o z: FENCE co x I x _ 7 01.20' 27 �1 334. 00' 282.41 ' 1304. 79 —s-- - S89 10" E 17 - X — N 89 10 616. 4 /'_ X - X - lO_ N89 44 10" W S 1/4 CORNER OF SEC. SOUTH LINE OF THE SE 114 FENCE SE CORNER OF SEC. 19. 19. (COUNTY MONUMENT (COUNTY MONUMENT FOUND) UNPLATTED LANDS FOUND) ............................. N OTE: THIS MAP IS A SUBDIVISION OF LOT I OF THE C. S.M. REC. IN VOL. 7, PAGE 2063. o - SET I' X 24' IRON PIPE WEIGHING 1. 13LBS PER LINEAR �y'; t ✓ �'J��, FOOT. > ,, •�� • " 1 IRON PIPE FOUND. JAE9ES M, "n a° bWlr[t -A a � S • 1804 SPRING VALLEY WIS. n 200 0 200 400 600' GRAPHIC SCALE - FEET JAMES M. WEBER S -1804 NELSEN -WEBER LAND SURVEYING 95 -145 THIS INSTRUMENT DRAFTED BY JIM WEBER DATED THIS %'V— DAY O F - - - Y&- - - 1995.