HomeMy WebLinkAbout042-1066-90-100 Parcel #: 042 - 1067 -95 -000 12/10/2007 12:10 PM
PAGE 1 OF 1
Alt. Parcel #: 24.29.18.382 042 - 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
O - GILLIS FARMS INC
GILLIS FARMS INC
1486 CTY RD TT
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1486 CTY RD TT
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 39.100 Plat: N/A -NOT AVAILABLE
SEC 24 T29N R18W 39.10A SE SE Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
24- 29N -18W
Notes: Parcel History:
Date Doc # Vol /Page Type
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
226775 Use Value Assessment
Valuations: Last Changed: 07/11/2003
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 28.100 4,200 0 4,200 NO
OTHER G7 11.000 42,000 150,800 192,800 NO
Totals for 2007:
General Property 39.100 46,200 150,800 197,000
Woodland 0.000 0 0
Totals for 2006:
General Property 39.100 46,200 150,800 197,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 143
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
i
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Bbilding Division
INSPECTION REPORT sanitary Permit No: 506225 i
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:
Gillis Farms, Inc. I Warren, Town of 042- 1066- 90 -'00
CST BM Elev: Insp. BM Elev: BM Descriptio Section /Town /Range /Map No:
/ t5b tv, , l `.7 I 24.29.18.373A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER K • h CAPACITY STATION BS HI FS ELEV.
Septic W2kl,5 3 ` ZGd Benchmark �•�� /�. r6 �
F; + JA4 e'S d-- CAP :1 Z • 5 f gal 1 ` 6
Aeration Bldg, Sewer Jr Jq 1
Holding St /Ht Inlet �37
St/Ht Outlet 'lL 97•
TANK SETBACK INFORMATION ��JJ
TANK TO P /L %_ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 11 1 / 65 Z�/ /bb Dt Bottom
Dosing :J Header /Man. ,6
Aeration Dist. Pipe /b. 31 ? .7
Holding Bot. System /1 Qz • 5$
PUMP/SIPHON INFORMATION Final Grade - T7• �P � I
Manufacturer Demand St Cover /�� • S
M F \�,,.. Z•
, Model Number
I T DH Lift Friction Loss System He TDH Ft
Forcemain Length Dla. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width / Length No. Of Tren l , PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / b� z ! f
SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufay�r:
INFORMATION CHAMBER OR
Type Of System: 57 � ,40� , ] /k UNIT Model Nury�e J r
O % _ p
DISTRIBUTION SYSTEM Sp J z =
Header /Manifold IDistribution X Hole Size x Hole Spacing Vent to r Int
` Pipe(s) 1
Length ✓ Dia 4 f Lengt Dia ` Spacing \
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed /Trench Center 5 � Bed /Trench Edges Topsoil Yes No Yes No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:__/ / Inspection #2:_ %_
Location: 855 140th Street R berts, WI 54023 (SW 1/4 NW 1/4 24 T29N R18W) NA Lot Parcel No: 24.29.18.373A
1.) Alt BM Description = �
2.) Bldg sewer length = 3 5
- amount of cover
Plan revision Required? Yes ><Flo
Use other side for additional information. — Y � ' Cart. No.
Date nsepctors Si lure
SBD -6710 (R.3/97)
r
ce.wi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
t . conn ' melr Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.)
nt of Commerce 5c) Z Z S
Sanitary Permit Application State Transaction Number
a r
�g-e In accordance with s. Comm. 83.21(2), Wis. Adm. Code, s ubmission of this form to the PP unit is required prior to obtaining a sanitary permit. Note: Application
forms for stat ect Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be use � D
p urposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. /(
I. Application Information - Please Print A formation (J
Property Owner's ame el #
04 Z /10 �0 `_j;- -
i -
Property Owner's Mai ing Addre s Fjj N 0 Property Location 3 73
Govt. Lot '
City, State Zip Code )gibn /., - Azi Section '
circle one
$ T RSEot�
II. Type of Building (check all that apply)
Pf l or 2 Family Dwelling - Number of Bedrooms _ Subdivision Name
Z P
d loc
Public /Commercial - Describe Use awm • ' 22 Cl City of
CSM Number El Village of
State Owned - Describe Use i� -� _
�0
I C1 ci5 OTown of _� ; /�iPF I✓
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. _Nr New System El Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
LB. ❑Permit Renewal ❑ ❑ Change of Plumber Permit Revision El Permit Transfer to New (( ��
Before Expiration Owner ZwF' �tT�7a�f1�-
IV. Type of POWTS S stem /Com onent/Device: Check all that appl
X Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
Design Flow (g pd) Design Soil Applicatioq Rate(gpdsl) Dispersal Area Re SO Di=:!772n
// v/
VI. Tank Info Capacity in Total # of Manufacturer y c v
Gallons Gallons Units o V g H
New Tanks Existing Tanks / p :; Y Cd
�✓ 1ge5d" l� /?� a. V inn H to w c7 a
Septic or Holding Tank
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume respon ibility for installation of the POWTS shown on the attached plans.
Plumb 's "ame (print) Plumber' Signa MP /MPRS Number Business Phone Number
Plu bees Address (Street, City, State Zip Code)
t7 l
VIII. County/Department Use Onl
isa d Permit Fee Date Iss ed Issuing t Signature
Approved p $ Sv
❑ lven Rcaso i'fer Denial (J
IX. Conditions of A pproval/Reasons for Disapproval
SYSTEM OWNER:
1. Septic tank, effluent finer and
dispersal cell must all be services / maintained
as per management plan provided by plumber.
Z. An setback requirements must be maintained
system and submit to the County only on paper not less than 81/2 x 11 inches in size
SBD -6398 (R. 01/07) Valid thru 01/09
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Wisconsin Department of Commerce IL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. Revie by Date
Personal Information you provide may be , a. 15.04 (1) (m)). ( P/Y/ 0 7
Property Owner Property Location
Govt. Lot j 1/4 AW 1/4 T N R(or) W
Property Owner's Mailing Address Lot # Blo Subd. Name or�CCSW
City Sta Zip C e h ❑ City ❑ Village 593own Nearest Road
New Construction User Residential /Number of bedrooms Code derived design flow rate el% GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable ft.
General comments
and recommendations: � � �� '9
Boring # Boring
121 pit Ground surface elev. � ft. Depth to limiting factor �_ in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
/ QL
_ s
s s -
9Z•
Boring # El Boring �I
pit Ground surface elev. 91;1 9,5 Depth to limiting factor - in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
In 7i� / d?
3
S
/ 4
q:5 .r
*
Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < mg/L 4 * Effl 91 #2 = BOD < 30 mg/L and TSS _< 30 mg/L
CST N I Print Signature CST Number
,J v
Address ate Evaluation Co ducted Telephone Number
- /
Property Owner . Parcel ID # Page of
1 Boring # ❑ Boring
pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
- C
�? 3
s •-
a y
❑ Boring # ❑ Boring 3�
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
* Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30:5 150 mgA- " Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777.
SBD -6330 (R07 /00)
Property Owner ;S Parcel ID # Page - _sZ�2 — of
Boring # ❑ Boring
pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Colo r Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2
3 - 4,J -
? s a y
r
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eif#2
Boring # ❑ Boring
❑ pit Ground surface elev. ft Depth to limiting factor in.
Sol Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. 8h• *Eff #1 *Eff#2
* Effluent #1. = BOD > 30 < 220 mg/L and TSS >30 < 180 mg& * Effluent #2 = BOD < 30 mg/L and TSS < 30 rng/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777.
SBD -9330 (R07 /0D)
RECEIVED
"R202007
ST. CROIX COUNTY
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page --,— of
FILE INFORMATIO SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity ga l ❑ NA
Permit #
Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units NA Pump Tank Capacity gal RNA ...
Estimated flow (average) gal /day Pump Tank Manufacturer MNA
Design flow (peak), (Estimated x 1.5) , gal /day Pump Manufacturer ,ANA
Soil Application Rate gal /day /ftz Pump Model 0 NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit &NA
Fats, Oil & Grease (FOG) 5_30 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) ❑ N.A.
Biochemical Oxygen Demand (BOD 530 mg /L X In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ' 06A ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) _510 cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
* Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once eve ❑ month(s) (Maximum 3 ears) ❑ NA
n'' 0 ear(s) y
Pump out contents of tank(s) When combined sludge and scum equals one -third (%) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
-0 year(s)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
iff' year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s
) -a NA
❑ yeaarr((s) s)
;s` laterals and pressure test At least once every: ❑ month(s) _'NA
❑ year(s)
At least once every: ❑ month(s) _0a NA
❑ year(s)
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (% or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other ser; ices. including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and a.,,.; servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report s ~a'' be provided to the local regulatory authority within 10 days of completion of any service event.
START UP AND OPERATION Page,Z of
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 cell(s) 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 to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the 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 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 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
='s document was draf et - = c'ance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
START UP AND OPERATION Page---,,,?— of
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 cell(s) 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 to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the 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 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 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone
Phone
=`s document was dra`:et '- _. —::' ante with chapter Comm 83.22(2)(b)(Md) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 1 1 F C LL, I t i,:1-, a rn n C
Mailing Address W , ft3h
Property Address 1 4
(Verification (Verification required fron & Zoning Department for new construction.)
City /State Pqk ���s . t',, s-- ;�.3 Parcel Identification Number
LEGAL DESCRIPTION
Property Location r/4 , AW r /4 , S ec. , T 2 9 N R 1 g W, Town of Wa irre '1
Subdi vision , Lot # �.
Certified Survey Map # , Volume Page #
Warranty Deed # Volume , Page #
Spec house yes no Lot lines identifiable no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
;maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/ the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
s:andan ds set forth, herein- as set by u e Depar unent of Commerce and the Department of Natural Resources, State of Wisconsin.
Ceruficat;on stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Depa; tment within 30 days of the three year expiration date.
1 /we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
p/ q / b� l
SIGNATURE OF APPLICANT(S) %4PV4,1 / DATE
Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department * **
:-.:1Ude with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
_C-ence is made in the warranty deed.
CERTIFIED SURVEY MAP
LOCATED IN PART OF THE SW 1/4 OF THE NW 1/4 OF
SECTION 24, T29N, R18W, TOWN OF WARREN, ST.
CROIX COUNTY, WISCONSIN.
SURVEYOR:
TY DODGE
S & N LAND SURVEYING, INC.
2920 ENLOE STREET
HUDSON, WI 54016
PREPARED FOR:
SHAWN GILLIS
111 W. ASH STREET
ROBERTS, WI. 54023
8
GILLIS FARMS
1486 CTY RD. TT
ROBERTS, WI. 54023
I, Ty R. Dodge, Registered Wisconsin Land Surveyor, hereby certify that by the direction of Shawn Gillis, I
have surveyed, divided and mapped part of the SW 1/4 of the NW 1/4 of Section 24, T29N, R18W, Town of
Warren, St. Croix County, Wisconsin, described as follows:
Commencing at the West 114 comer of said Section 24; thence along the west line of the Northwest 1/4 of
said Section 24, N00 °19'41"W a distance of 157.76 feet to the point of beginning, thence continuing along
said west line. N00° 19'41 "W a distance of 330.00 feet; thence N89 °40'1 WE a distance of 363.00 feet:
thence S00 °19'41 "E a distance of 330.00 feet; thence S89 °40'13"W a distance of 363.00 feet to the point of
beginning. Contains 2.75 Acres (119,790 sq_ ft.).
I also certify that this Certified Survey Map is a correct representation to scale of the exterior boundary
surveyed and described; that I have fully complied with the provisions of Chapter 236.34 of the Wisconsin
statutes and the land subdivision ordinance of St. Croix County and the Town of Warren in surveying and
mapping the same.
Ty RLS #2484 Date
S & N Land Surveying * ,
2920 Enloe St. DODGE
�r ?
DGE
Hudson WI 54016 APPROVED s -2484 _
M CIOIX I�f
COtTY = CLEAR LAKE, i
JUN 0 4 2007
if rat recorded within 30 data of
approval date approval shat[ be
null and void
COUNTY TREASURER'S CERTIFICATE
State of Wisconsin)
County of St. Croix)SS
1, Cheryl Slind, being the duly elected, qualified and acting treasurer of St. Croix County, do hereby c rtity that the records in my
office show no unredeemed tax sales and no unpaid taxes or special assessments as affecting the land
included on this Certified S y Map.
7 (6 - 1 I flo - 1
C eryl pr1he, Date
Count Tre surer
EACH PARCEL SHOWN ON THIS MAP IS SUBJECT TO STATE, COUNTY AND TOWNSHIP LAWS, RULES
AND REGULATIONS (I.E., WETLANDS, MINIMUM LOT SIZE, ACCESS TO PARCEL, ETC.) BEFORE
PURCHASING OR DEVELOPING ANY PARCEL CONTACT THE ST. CROIX COUNTY ZONING OFFICE
AND THE TOWN OF WARREN FOR ADVICE.
DRAFTED BY: WES ANDERSON PROJECT#
2 °` z SHEET 2 OF 2 SHEETS 6712 -01 DATE: 4124/07 REVISED:5 -22 -07
851895
KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
CERTIFIED MAP 0 CERTIFI SURVEY 4 AP
VOL: 22 PAGE: 5401
LOCATED IN PART OF THE SW 114 OF THE NW 1/4 OF REC FEE: 13.00
W z SECTION 24, T29N, R18W, TOWN OF WARREN, ST. PAGES: 2
►- CROIX COUNTY, WISCONSIN.
SURVEYOR:
W 11 z TY DODGE
w z 0� S & N LAND SURVEYING. INC.
O 2920 ENLOE STREET
,w 2 V HUDSON, WI 54016
= m Z
W ° PREPARED FOR:
Er O w X NW COR, SEC. 24 SHAWN GILLIS
N W
O z j p ^ (FOUND SURVEY 111 W. ASH STREET
i y U W MARKER NAIL) _ J� ROBERTS, WI. 54023
r- ¢ r N &
' •ni
u� Q v y > - 4 GILLIS FARMS
N
4
CONS / %, lass crY RD. TT
*oG ROBERTS, WI. 54023
DODGE •_
S -2484
N .
% li LAKE,
••'
UR
•..
' °
{ ZI 1
z { NSW40'13 "E 363.00'
33.001 330.00'
{ PROPOSED DRIVEWAY
I{ {
t� ${ I { LOT 1 (/Q�
t I I O I$ TOTAL AREA c �
j i I a 2.75 ACRES (119,790 SQ. F.T.)
o f t I m EXCLUDING RIGHT -OF -WAY rn
I I CA l w 2.50 ACRES (108,900 SQ. F.T.) Ci C r� Q
�' 1 0
{ 33' 33'
I I
33.00 330.00'
I I y SW40'13`W 363.00'
Im I Mfi`:]G?C�GQ44CD dQGfID�
I 4
r
I - 0
lz
1 A
WEST 1/4
COR. SEC. 24
LEGEND
D ALUMINUM FOUND LUM UM COU NTY
SECTION CORNER MONUMENT
Q SET 1" OUTSIDE DIAMETER BY 18" LONG IRON
PIPE, WEIGHING 1.13 LBS. PER LINEAR FOOT
SCALE: 1"- 100'
1 o DRAFTED BY: WES ANDERSON PROJECT#
100 200 SHEET 1 OF 2 SHEETS 6712 -01 DATE: 4 /24/07 REVISED:5 -22 -07
U 2474P 275 -7 -.4. <D 1.2E! s `
KATHLEEN H. WALSH
STATE. BAR OF WISCONSIN FORM 2 - 1998 REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between Bernard M. Lewis and Bernice H. Lewis,
12/15/2003 10:00A1M
husband and wife, Grantor, and Gillis Farm, Inc., Grantee.
Grantor, for it valuable consideration, conveys and warrants to Grantee WARRANTY DEED
the following described real estate in St. Croix County, State of Wisconsin ('The EXEMPT #
"Property "): REC FEE: 11.00
TRANS FEE: 1080.00
The Southwest Quarter (SW 1/4), EXCEPT the South 268 feet of the West COPY FEE:
CC FEE:
238 feet of the Northwest Quarter of the Southwest Quarter (NW 1/4 of SW PAGES: 1
1/4), Section Eighteen (18), Township Twenty -nine (29) North, Range
Seventeen (17) West. The East Half of the Southeast Quarter (E 1/2 of SE
1/4), EXCEPT the West 231 feet of the South 1320 feet thereof, Section
Thirteen (13), Township Twenty -nine (29) North, Range Eighteen (18) West.
The West Half of the Northwest Quarter (W 1 /2 of NW 1/4), EXCEPT a a n Area
Namme e and
parcel of land located in the Northwest Quarter of the Northwest Quarter Name Return Address
(NW 1/4 of NW 1/4) described as follows: Lot One (1) of Certified Survey Ilendrik W. Van Dyk
Map tiled January 6, 1983, in Volume "5" of Certified Survey Maps, page VAN DYK, O'BOYLF. & SiLER, S.C.
1243, as Document No. 382030, Section Twenty -four (24), Township Twenty- Post Office Box 118
New Richmond, WI 54017
nine (29) North, Range Eighteen (18) West.
SUBJECT to easements and highway conveyances of record. 018- 1040 -50 -000
018 - 1040 -60 -000
018 - 1040 -80 -000
018 - 1040 -90 -000
042- 1034 -70 -000
042 - 1035 -30 -000
042 - 1066 -7 -000 & 042— ),066 -90 -000
Parcel Identification Number (PIN)
This is not homestead property.
This conveyance is given in Satisfaction of that certain Land Contract between Bernard M. Lewis and Bernice It- Lewis, as Vendors, and William
A. Gillis, Gregory ,l. Gillis, Patrick W. Gillis and Robert E. Gillis, as Purchasers, dated December 3, 1984 and recorded December 4, 1984 in Vol.
701, page 442 as Doc. No. 398267. Said Purchasers interest was assigned to Gillis Farm, Inc. by Assignment of Land Contract dated June 26, 1990
and recorded April 5, 1991 in Vol. 897, page 404, as Doc. No. 467956. Said Land Contract was amended by Amendment to Land Contract dated
.lantmry 6, 1995 and recorded January 10, 1995 in Vol. 11.08, page 258 as Doe. No. 525020_
Exceptions to warranties: Subject to all easements, restrictions and covenants of record, and any lien created by act
or omission of Grantee.
Dated this 10th day of December 2003.
di
*Bernard M. Lewis *Bernice H. Lewis
*
*
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Bernard M. Lewis and STATE OF WISCONSIN )
Bernice H. Lewis )ss. I
County )
authen c cd th' 10 hda of De b r 2003
Personally came before me this day of
2003 the above named
* Hendi: k W Van Dyk to me known to be the person(s) who
TITLE: MEMBER STATE BAR OF WISCONSIN executed the toregoing instrument and acknowledge the same.
(If not,
authorized by § 706.06, Wis. Stats.)
THIS INS'T'RUMENT WAS DRAFTED BY
Hendrik W. Van Dyk Notary Public, State of Wisegnsin
Post Office Box 118, New Richmond, WI 54017 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 should be typed or printed below their signatures
WARRANTY DEED STATE aAR OF WISCONSIN
FORM Nn. 2 - 1998
INFORMATION PROFESSIONALS COMPANY FOND DU LAC, Wt 600 -655 -2021
Y-6° 6/ _ 0 „ 6-0` V -6N 7' -7 ". 7' -6 3/8"
I
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POST BASE FUTURE DECK
-- 11/2" A.B.
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2x10 LEDGER 1 ITDH3048 A CANT A80VE
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____ __ __ __ __ --
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BEDROOM
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1/2" CONCRETE � • I EASED LO D AREA.
SLAB OVER
2" CERTIFOAM 25 /2/8
218
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--
1/2' A.B. 0 5' O.C. N r ^`
R -19 IN5UL. co t. 1
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3/0 INCREASED LOAD AREA
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Parcel #: 042 - 1066 -90 -000 06/08/2007 04:24 PM
s PAGE 1 OF 1
Alt. Parcel #: 24.29.18.373 042 - TOWN OF WARREN
Current ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
06/04/2007 00 0
Tax Address: (
wner s ) : O = Current Owner, C = Current Co -Owner
O
O - GILLIS FARMS INC
GILLIS FARMS INC
1486 CTY RD TT
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): ` = Primary
Type Dist # Description
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE
SEC 24 T29N R1 8W SW NW 40A Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
24- 29N -18W
Notes: Parcel History:
RETIRED FOR 2008 - -CSM 22 -5401 TAKES Date Doc # Vol /Page Type
PT. - -CSM LOT 1 22 -5401 NKA PCL
06/04/2007 851895 22/5401 CS
M
042 - 1066 -90 -100 (373A) & REMAINDER NKA 12/15/2003 749125 2474/275 WD
PCL 042 - 1066 -90 -200 (3738) 07/23/1997 897/404
07/23/1997 701/442
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/11/2003
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 39.000 6,000 0 6,000 NO
UNDEVELOPED G5 1.000 100 0 100 NO
Totals for 2007:
General Property 40.000 6,100 0 6,100
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 6,100 0 6,100
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