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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division INSPECTION REPORT Sanitary Permit No:
479426 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City village X Township Parcel Tax No:
Manore, William & Janice I Warren, Town of 042 - 1104 -90 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No:
!oG (31M 1 CS T 20.29.18.579
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / 7 Benchmark
19eciag Alt. BM
"1 n
Aeration Bldg. Sewdr
k t et,.,__ 0
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet 11.5 qZ Z$
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD DMI t
i! -tole 4 �
Septic Dt Bottom
`.n F;1 C>.*
j Header/
Aeration Dist. Pipe 1 ! '61 ,
Holding Bot. System
15.i 'vo-
h � 1
PUMP /SIPHON INFORMATION Final Grade V
Manufacturer Demand St Cover` 3, 16b
Model Number
TDH Lift Friction Loss System Head J T6H Ft
Force main Leng Dia. . to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width 1 Length f No. Of Trenches 1 PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS t 7 e,4X
SETBACK SYSTEM TO P/L jBLDG WELL LAKE /STREAM LEACHING Manufacturer. �--
INFORMATION Type f System: 1 �� r CHA UNET OR Model Number. �`���—
3o1 5 1 4 '
DISTRIBUTION SYSTEM / e I c L <J 1 1_b t b Z
Header /Manifold Distribution x Hole Size x Hole Sp cing Vent to Air Intake
I /j Pipe {s) \5
Lengt Dia T Length Dia Spacing - T_ ' �v: I a
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over r Depth Over xx Depth of xx Seeded /S ded xx Mulched
Bed/Trench Center �` Bedrrrench Edges Topsoil \ Yes E] No Yes No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / t / CIS 0 Inspection #2: ! !
Location: 1074 89th Avenue Roberts, WI 54023 (NE 1/4 NE 114 20 T29N R18W) Pleasant Acres Lot 7 1a I �S Parcel No: 20.29.18.579
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover
Plan revision Required? Yes
Use other side for additional information.
Date i lnsepctor's i ature Cert. No.
SBD -6710 (R.3/97)
l
Safety and Buildings Division County
201 W. Washin P.O. Box 7162
iseons %n Madison I _ Sanitary Permit Number (to be filled in by Co.)
(60 -q 7 y Z
Department of Commerce u
tat Plan I.D. Number
Sanitary Permit Applica n RO D t J ' ► f "
in accord with Comm 83.21, Wis. Adm. Code, personal in f on you provide
may be used for secondary purposes Privacy Law, sIS. lxm) Pro ct Address (if different than mailing address)
1. Application Information- Pkase Print All Information rJ
r
Property Owner's Name ZONING OFFICE 1 # Lot # - 7 Block #
A-1 0"4 - ?o _ csov
Property Owner's Mailing Address Property Location
i v -7q / 8 ? rk f� Gam. AJ �. y, �y4, Section rl
Ci State 7 [ Zip Code Phone Number
(� r, b e ►• + S l / .� S� �3 � l S - 3S`lo T � ° o e ,� )
II. Type of Building (check all that apply) Exi �� �-- Subdivision Name CSM Number
91 or 2 Family Dwelling- Number of Bedrooms
❑ Public/Commercial - Describe Use
❑ State Owned - Describe Use ❑City ❑Village Ckownship of 0 M
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only Dther Modi.ficalign to Existing System
. a `
�— List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New
Before Expiratfoa Plumber Owner
IV. Type of POWTS System: Check all that apply) u
WNon - Pressurized In -Ground ❑ Mound >24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter Cl
Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching chamber ❑ Drip Line ❑ Gravel-less Pipe ❑ Other (explain)
V. Dispersal/Treat ent Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (so Dispersal Area Pro ed (sf) System Elevation R .
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass l ) t I
New Existing Qe ) j e r \
Tanks Tanks t i l
Septic or Holding Tank I / t� 0 r l 0 ,vy,. x
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. `✓
Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number
Wal fC,h ! 1 Oo. Z; �� I ;U - 7 - 7/ 0 let 9
Plumber's Address (Street, City, State, Zip Code) {�
VIll. County/ e artment Use Onl
A¢proved ❑ D' Sanitary Permit Fee (includes Groundwater Date Issu Issuin ent Signatur Sta
Surcharge Fee) ao , �� pG D5
❑ er Gi eason for (� /
Ix. Conditions of Approval /Reasons for Disapproval ` T wc-
I . `se0l; 0101* en wt t ow slid
dispersal cell must all be services / Milydained
as per management plan provided by plu nbei.
2. A0 setback requirements must be maiMainad
as per applicable code / ordirwari es.
Attach complete plans (to the County only) for the system on paper not kss titan 81/2 x 11 inches in size
SBD -6398 (R. 01/03)
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Ulhscorein Dgmknent of Commerce T Page 1 of 3
Derision of Samar and &ddings in aw"clax:e D e }}s. Adm. Code A.C.E. Sol & Site Evaluations
Attach site plan on paper not less than 8 x 11 " in size. rust /�QQ� St Croix County
include, but not limited to: vertical and horizontal reference (BM) aid
percent slope, scale or dimensions, north arrow, and location d q ,5oadd Parcel I.D.
ZONING 042 - 049
Please pd7ntall iMf�m►a>tron. OFFICE R p q
Penal rdarmali n tw panda may be used for semWay NI ( Y Low, s 1504 (1) (m)). Z i
Property Owner Property Location
Wiliam J. & Janice R. Manore Go vt. Lot NE 19 NE 19 20 T 29 N R 18 W
Property Owners Ltdhg Address Lot # Block # Subd. Nana or CSLW
1074 89th Ave. 7 Pleasant Acres
City State Zip Code Phone Nurnber City _j Vtlage M Town Nearest Road
Roberts 1 WI 1 54023 (715) 749 - 3590 Warren I 89Th Ave.
I New Cwaftuction Use: X_ f/ Residential / Num1w of bedrooms 3 Code derived design flow rate 450 GPD
Replacement I Public or commercial - Describe:
Parent material Glacial outwash Flood pin won, if applicable na
General co merts
and : Instal cony. POWTS using three trenches with combined E.I.S.A. = 643 sq. ft at elev. 88.50' Install r
diversLOn- valve to allow reuse of existing hydraulically faded system.
Grp 4Sg • � �
Boring # Bori
Pit Ground Surface eim. 94.71 ft. Depth to friting factor >1 in. Sad AMlicatice Rabe
Horizon Depth Dominant Color Reft Description Texture Structure Consistence Boundary Rom GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2
1 0-9 10yr4/l6 none slfid na na aw 2f,1m na na
2 9-18 10yr3/3 none so 2fsbk mvfr as if 0.6 0.8
3 18-37 10yr4/4 none sil 2fsbk mvfr cw - 0.6 0.8
4 37 -50 10yr4/6 none Is 089 ml cw - 0.7 1.6
5 50 -108 10y616 l none s & gr. 0sg ml - - 0.7 1.6
a Boring # Boring
vi Pit Ground Surface elev. 93.55 ft. Depth to wrong factor >100" in. Sod Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDNF
in. Mansell Qu. Sz. Cont. Color Gr. Sz_ Sh. *0101 *Eff#2
1 0 10yr3/3 none sd 2fsbk mvfr aw 2fm,1 c 0.6 0.8
2 12-28 10yr4/4 none sd 2fsbk mvfr as 1fmc 0.6 0.8
3 28-41 10yr4/6 none sl 2msbk mfr cw Urn 0.6 1.0
4 41 -100 10yr5A6 t none s & gr. 089 ml - - 0.7 1.6
x
• Effluent #1 = BOD 30 < 220 nrg/L TSS >30 < 4 rng/L Effluent #2 = BOD <30 mglL and TSS <_0 mg/L
CST Name (Please Print) CST Number
James K Thompson ; 3602
AddnM A.C.E. Sol & Site Evaluations Date Evaluation Concluded Telephone Number
340 Paulson Lake Lane, 0sceoIXWI 54020 8222005 715 - 248 -7767
property Owner Wdliam J. & Janice R. Manore pares 1p # 042- 1104 -90-000 Page 2 of 3
❑ f Bo(M
3 On g pd Ground Surface elev. 93.25 ft. Depth to Nmfting factor >98" in. Soil App Rate
Horizon Depth Domawit Color Redox Description Tedure Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Coat. Color Gr, Sz. Sh. 'Eff" 'Eff#2
1 0-10 10y13l3 none ad 2fsbk mvfr aw 2fm,1c 0.6 0.8
2 10-24 10yr414 none Sil 2fsbk mvfr as 2fm,1c 0.6 0.8
3 24-46 10yr4/6 none SI 2msbk mfr cw 1fm 0.6 1.0
4 46-98 10yr5/6 none s & gr. Osg ml - - 0.7 1.6
,S ti
F] BorkV# j BorirV
Pit Ground Surface elev. ft to factor in. Sol Application Rate
Hor¢w Depth Dominant Color Redox Desaiption Textiue Str wtwe Consistence BWKWy Roots GPDR
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
F-I S or k V #9
pit Ground Surface elev. ft. Depth to limiting factor in. Rate
Ho&m Depth Dominant Color Redox Descrow Texture Structure Corwstai a BowxWy Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'E
'
Effkxmt #1 = SOD ? 30 -c 710 mg1L and TSS >30 < 150 mg/L ' Effluent #2 = SOD <30 mgtL and TSS <30 nV&
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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AUG -29 -2005 07:47 AM A.C.E. Soil & Site Eval. 715 248 7764 P.01
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
(Ow;e uyer L3 � 0 Q- r n
Mailing Address / o - 7 q 8 A &A- - g a" , L,3 ' S a 3
Property Address 5 m-'Vv -
(Verification required from Planning Department for new construction)
City /State w ' Parcel Identification Number
LEGAL DESCRIPTION
Property Location Ale r /a, � � ' /,, Sec. � ° , T�_N -R _ W, Town of
Subdivision 14 CA-M-4.- , Lot #
Certified Survey Map # P y '' 1 °-�. , Volume 4 . Page #
Warranty Deed # `! °Z $ �' ° Volume 7 8 - . Page # ° °
Spec house ❑ yes X no Lot lines identifiable CK 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 fiwction 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
mastorplumber, journeyman plumber, 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.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year piration date.
MW W / ?!d 0
SIGNATURE OF PLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described abo , by virtue of a warranty deed recorded in Register of Deeds Office.
L - 1- /— - - - - - - - '�-- /;42
SIGNATURE OF APWCKNt DATE
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
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the 1,J;,�.��,,,,,. S �! /c o.M.�.. residence located at: 14 X
Sec. 'J40 T N, R I e _ W, Town of St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes ,� No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: /0 00
Construction: Prefab Concrete ✓' Steel Other
Manufacturer (if known) : W L.14a.--
Age of Tank (if known) :
(Signature) (Name) Please Print
—m 1 0 aA 710
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or
licensed disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank condition, I
certify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except for ition opening over
o tt baf f le) ate+ -��A .& �+r*+. * -ri-�1. -Qe , , a -,A. ns ec ;Z41 7�04 t;.A
Name LJ u, 14-t- -r - t -. F e- g L3
1'J4.Cf1 ✓�.+ � � rC.. Si
MP /MPRS �LX 1 ( o
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner - �yl Septic Tank Capacity Jai f a l 13 NA
Permit # Septic Tank Manufacturer '- 13 NA
DESIGN PARAMETERS Effluent Filter Manufacturer7 ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model J 70 u o 78 ❑ NA
Number of Public Facility Units j4 NA Pump Tank Capacity a l WNA
Estimated flow (average) 9 .00 al /day Pump Tank Manufacturer Of NA
Design flow (peak), (Estimated x 1.5) 5O g al/day Pump Manufacturer IR NA
Soil Application Rate • 7 al /day /ft' Pump Model IR NA
Standard Influent /Effluent Quality Monthly average" Pretreatment Unit NA
Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD,) 530 mg /L W In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :530 mg /L ($. NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. ❑ NA Other: K NA
Other: 19 NA Other: IS NA
'Values typical for domestic wastewater and septic tank effluent. Other: Fl NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) 13 NA
ear(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ year( 1(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: 19 month(s) ❑ NA
lar(s)
Inspect pump, pump controls & alarm At least once eve
• mo ye ar(s)
($�NA
Ins
P every: ❑ years)
• month(s) CKNA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: At least once every: ❑ month(s) I&NA
❑ year(s)
Other: 09 NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW (4/01)
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cells) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
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
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
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
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
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 toreplace the failed POWTS.
0% The site has not been evaluated to identify a suitable r'e acement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area.
❑ 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 GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone -7 ! S 7 q 4 dZ Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name R ur•-e S�t,�� S.A �,�rt -t.0 Name f _ �y,.
Phone 7 y Y _ O J ?� Pho ne ? $ 16 -
This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
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.�Kt REfERVEO saw REG9RDIkt DATA
DOCUMENT Na. STATE BAR OF WISCONSIN FORM 1 � y99p � ^'t•
WARRANTY DEED
4 +1 C7 nu 2W
I RECASTERS 4FFll•E
ST. CROIX CO., WIS.
This Deed made between .... _ --------- .-- -•• -•• ... a
Feed. for Remrd this 4th
.L
l R3rtd.,t... a T,zltavTlt?.tT �: .. _,_..
hu�bard ani wife as „rind en ;xlt�.. ......._............ A . D . 1
Aus. 9
Grantor ' at
ana..Wil] ism.. ..�...�anono...an.d...� R., ...;T.�n0.T0.... AL
husband and as survi- vo .rship..,ma.r.l- t- al...... -.... f
ro ert' ..... .. ............ ..+E.
.. o..+. I
Grantee, I
Witnesseth That the said Grantor, for a valuable consideration...... '
Grant. or . ....................... ....... I ....... ............ ........- T a RSt MA11n
.- ...
Tn n4"===
conveys to Grantee the following describ ^d real estate in A IG 1
l RIVER FALLS, 'vVlSCO;1SIN 5
County, State of Wisconatn:
l l
Lot 7, Pleasant Acres Subdivision, Town of
{ Tax Parcel No: .... ...............................
Warren, St . Croix County, Wisconsin
i 1
. �i
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i 1
I l jV�
k l
i
This .......j .................. homestead property.
l (is) (is not)
;I Together with all and singular the hereditaments and appui c,nances thereunto belonging;
And - - - - -- ir.an.t.Qr- a.... -- - ................ ...... .._............ . ...... - ..... __ .. .................. ...........
warrants that the title is good ' .defeasible in fee simple and free and clear of encumbrances except
f i easements, restrictions and rights- of -wai of record, 1
if any.
and will warrant and defend the same. {I
Dated this day of ...... Tiny . ........... ........... 19 - 87 -- - . ..........
... (SEAL) �- - _. t!4G..- ....(S EA L)
---- Randy... L.... .La-Ven.tur.e ................... Norma - -- ean...La�Jenture........ - -- ;{
(SEAL) ..................(SEAL)
i
I ....._ . .................. ............. l
if
AUTgENTICATIUN ACKNOWLEDGMENT
Rand L. LaVeritUre STATE OF WISCONSIN
Signature (s) ....... .
Norma :lean LaVenture ss.
.. ............ . .. ..........- °..............._. County. Ju
aut�heentii t this . 31..day of..........1= ..--- - - -... 19 7. Personally came before me this ................day of
i i 7fi "}�I ��?CsG- �ILn.... . ........ 19........ the above named
... .. • - -••. ...__
I .Kristian Ogland Lundeen ------------------- ---------------------- -..... --------•--.........-----------
.
} ...
••- ................
...... . . . . .. .................................. .........
TITLE: ME11BER STATE BAR OF WISCONSIN •---------• ..................................... ............................... li
k (If not, -----•........ — .......... ............................... .... ............ .....- -----.... ---- --
! authorized by j 706.06, Wis. Stats.) to me known to be the person _- _- ... who executed the
ij
foregoing instrument and acknowledge the same. I
THIS INSTRUMENT WAS DRAFTED BY t�
Kristina Ogland Lundeen ....... . ....... . . .. ...................
_ - - ----
-------------
N .ttorney at l:a �.. ... ._ . - _....- -. _ - - -- - - -- ........ .. .............•----------
tiotary Public .... -.. ..........Counts. Wis.
(Signatures may be authenticated or aekr(,w1cd�ed. loth �I ' CtH1 `s'On is pt rn::utcnt. (If nob, state expiration
are not necessary.) date: ........ ...... 19_.._._ -)
*N or persons siigninR in any rapacity sh.u!3 he I,i—i ar vrint, - t their
STiTF . Nk:L OF R'!S \' : :,1 ___ P:' 7, N!, r•�. r.. t..,.
Parcel #: 042 - 1104 -90 -000 08/29/2005 10:59 AM
PAGE 1 OF 1
Alt. Parcel M 20.29.18.579 042 - 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): O = Current Owner, C = Current Co -Owner
WILLIAM J & JANICE R MANORE O - MANORE, WILLIAM J & JANICE R
1074 89TH AVE
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description * 1074 89TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 1.190 Plat: 2334- PLEASANT ACRES
SEC 20 T29N R18W 1.19A PLAT OF PLEASANT Block/Condo Bldg: LOT 07
ACRES LOT 7
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
20- 29N -18W
Notes: Parcel History:
Date Doc # Vol /Page Type
07/23/1997 7871290
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/2012004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.190 27,500 165,600 193,100 NO
Totals for 2005:
General Property 1.190 27,500 165,600 193,100
Woodland 0.000 0 0
Totals for 2004:
General Property 1.190 27,500 165,600 193,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 206
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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7
AS BUILT SANITARY SYSTEM REPORT; y ,�
R'e' �C
co
OWNER �
TOWNSHIP ' C. W
�74 � �c�St�
ADDRESS o ST. CROIX COUNTY, WISCO
SUBDIVISION -?ea LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 F EET OF SYSTEM
3G'
WLI
4b _
u`� V
I di a oath Arrow I
SC L
BENCHMARK: (Permanent reference Point) Describe: A QoJ(
Elevation of vertical reference point: M o Slope at site: ° 7a
SEPTIC TANK: Manufacturer: L✓►c s e- 4 Liquid Capacity : / U 0 Q
Number of rings on cover 5 Tan g manhole cover elevation: 9G ,g( e
Tank Inlet Elevation: 'jo.yq Tank Outlet Elevation: v,
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle gallons; total capacity o
distribution lines gallon: size of pump head;
gallon per minute horsepower brand name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Tyge e
of warning device
SEEPAGE PIT SIZE: um er o pits et iameter
feet liquid depth seepage pit inlet ipe- elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines _ wi th leitgth34o tile depth ' o
SEEPAGE TRENCH: width length
PERCOLATION RATE / Sjn AREA REQUIRE REA AS BUILT G q J 0
G INSPECTOR
DATED 1 U 0 PLUMBER ON JOB o-,
LICENSE NUMBER I r 461 I
DEPART OF INDUSTRY INSPECTION REPORT FOR < � SAFETY &BUILDINGS
LABOR & RELATIONS PRIVATE SEWAGE SYSTEMS -��` DIVISION
P.O. BOX 7969 d BUREAU OF PLUMBING
MADISON, WI 53707
kCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number:
(If assigned)
❑ Hol ing Tank ❑ (Pressure ❑Mound
N F PERMIT HOLDER: A HOLDER: INSPECTION DATE:
NCH MARK (Permanent reference polntl DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV. -
.
Name of Plumber: IMP/MPRSW No. County: Sanitary Permit Number.
SEPTIC TANK /HOLDING TANK: ! 1 .12-
MANUFACTURER: LIQUID CA CITY: TANK INLET CLEV. ITANK OUTLET ELEV. WARNING LABEL LOCK( G C V
Nom- ` P V ED: PROV E
G � � •1t YES ONO YE ONO
BEDDING. VENT CIA.. VENT MATL, - . HIGH WATE ROAD: PROPERTY WELL: BUI DING: VENT F E
ALARM ' .�;,, LIIq
❑YES ONO NO
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID ACITV PUMP MODEL. PUMP (SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
- ]YES ❑ ❑YES ONO DYES ONO
GALLONS PER CYCLE: UMP AND CONTROLS OPERATIONAL OPERTY WELL BUILDING: V NT TO FRESH
(DIFFERENCE BETWEEN
1 n P. LINE AIR INLET
PUMP ON AND OFF) DYES 1:1 NO R
SOIL ABSORPTION SYSTEM. (!heck the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until
I the soil is dry enough to continue.
Y 9 )
CONVENTIONAL SYSTEM:
WIDTH: LENG 7H NO. OF DISTR. P�P COVER INSIUE DIA_ #PITS: LIQUID
THE Cf�NES MA IAL: DEPTH:
3 I r PROPERTY WELL: BUILDING: VENT TO FRESH
.
G RAVE L DEPTH FILL DEPTH r DISTR. PIPE DISTR. PIPE DISTR. PIPE ATERIAI: N . D S
BELOW PIP 5 ABOVE COVER ELEV. INLET ELEV. END. PIPES: ,'. LINE: AIF✓INL T-
2?
MOUND SYSTEM: I(7 (TA
z
Mound site e lowed perpendicular to slope P P P P
r C ck the to ure f the for fill material o PROVIDE A DIAGRAM O F SYSTEM
and furrows thrown upslope: and sy e ; to `ake certain that it ON REVERSE SIDE. SHOW ELEVA-
ets th cri ria, or edium sand. TIONS MEASURED.
DYES ONO
SOIL COVER. TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS.
f
Y
DYES ONO ❑ ES ONO
PTH OVER TRENC H
I N H/BED:: P ODDED SEEDED. MULCHED
CENTER EDG .
:B PTH OVER TRENCH/BED C � DEP O TO SOIL. S
j`
E E ED E
D D
t
T R ES r e
� ❑YES El OYES ONO DYES 0 N
PRESSURIZED DISTRIBUTION SYSTEM:
�* WIDTH: LENGTH: NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER:
TREN HES:
2
MANIFOLD PUMP NI LD DI R IPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.: ELEV_ IA. E V PIPES: DIA-
t HOLE SIZE HOLE SPACING DR LE CORRE TL COVER MATERIAL: VERTICAL LIFT CORAE$PONDS TO APPROVED
PLANS.
YJ NO DYES ONO
COMMENTS: PERMANENT VAKERS: p SERVATION WELLS. PROPERBUILDIN G.
LINE:
S NO ❑ YES ❑ NO
cv III !
i G .ca
Sketch System on Retain i county file for audit.
Reverse Side.
SIGNATURE .. -_ - -•- ^- TITLE:
�L
DILHR SBD 6710 (R. 01/82)
l�
I
APPLICATION
`DEPAR�i'MNT E OF SAFETY & BUILDINGS
tNDU'ST Y, FOR SAWARY DIVISION
LABOR AND + PERMIT P.O. BOX 7969
HUMAN RELATIONS (PL8 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be
included.
Property Owner: Mailing Address:
3 c- l ,,- .r7z X l w: o n vi
Property Location: 'elLy,'Jfffap%orTownship: County:
t /a 1 /4, 1 , D� IT NCR le 8io) W A ,r, h- C C r✓ 1 X
Lot Number: Blk No.: Subdivision Name: r;: t Road, Lake or Landmark: State Plan I.D. Number:
p LE t KT Z f• (If assigned)
T YPE OF BUILDING /
Number of
❑ Public* ❑ Variance* ❑ Other (specify) Bedrooms:
1 or 2 Family * State Approval Required. 1116 3
TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY X
HOLDING TANK CAPACITY
LIFT PUMP TANK /SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): t9 New ❑ Replacement ❑ Experimental X Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
X Private El Joint El Public )rc /< G
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber; Signature: MP /MPRSW No.: Phone Number:
?.� 11X Z -5
Plumbe s Address: Name of Designer:
-r7
COUNTY /DEPARTMENT USE ONLY
Signatu of Issuing Agent- Fee: Date: APPROVED Sanitary Permit Number:
/ v� Q 7 DISAPPRn% 1 ED 7.35
e sort for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White - County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber
DILHR -SBD -6398 (N.03/81)
DEP OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUStRY, DIVISION
HUMAN NDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
LOCATION: SECTION: TOWNSHIP /MUNICIPALITY: OT N LK. NO.: SUBDIVISION NAME:
ti �/�',C 1 / a /T ;� N /R x x^ ' xos N r z tz -5:
COUNTY: OWNER' LI
S BUYER'S NAME: A N ADDRESS:
r"c 0 e rc Fo s x � x �► �, �
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESZC!RIPTIONS: 1PERCOLATION TESTS:
Residence New ❑Replace
RATING: S= Site suitable for system U3 Site unsuitable for system ! A g ?C G
C NVENTI NAL: MOUND: IN- GROUND - PRESSURE: S S -IN- ILL OLD TANK: RECOMMENDED SYSTEM: (optional)
S U
�8l � U OS D EIS ❑U
EIS ❑u au
If Percolation Tests are NOT required DESIGN RATE: Symwn7m. If any portion of the lot is in the
under s.H63.09(5)(b), indicate: gO q N I I Flo indic Floo e l e vation:
PROFILE DESCRIPTIONS
BORING TOTAL P H TO GR UND ATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION — OBSERVED EST. HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B -% S 16 1 . /1 1 B n, SL. 4 /
G ay r Qc. l t o, 8&7 s z G A _ G G"
e-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PE RIOD 1 — PE RIOD 2 PERIOD 3 PER INCH
P _ 'f.t" WA/0
P_ a 3 3 4
P-
P-
P-
PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slop.
SYSTEM ELEVATION '?6 -'K
�L
- r r
.a._ 7 1 1-4--_ . _ _. _
_
r � �•,
do
..
f
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNATURE:
DISTRIBUTION: Original -Local Authority, 2nd page- Bureau of Plumbing, 3rd page - Property Owner, 4th page Soil Tester.
DILHR -SBD -6395 (N. 03/81)
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