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014-1046-30-000
(D 0+ G `r1 m 2. e'+1 K ccn N O 0 O W ci K O N O I � <. a ro Co n 77 m � P �yl cl. O_ O N Va - j . N Pi C � � (D O A N � � � 41 O O to O O' (o W W O 1 0 0, M C CD n O (D O (O (J7 3 d O L N p = ;1 u CD N � O C S (D (D = O O N I� a N W w Lo OD = O O N W ZY N I� n r cn tai N O O < I ;-! ff CD C Z 9 N "w• O O O m °' A 3 N c 0 O a ID cn N O ?o zz� O D D o o' O N N 3 CL Al o �• 0 0 O N O C (D C (D 3 _ O `A Z m A Z O Z W N � fD CL z a 0 0 " z cn m M (D A W p� O (D 0 N O (D co - 0 W 3 (D O O N a a V N o O 'O 6 _ CL N 7 Q (D .; , IR T 5 7 N Q (D O Cn � "i � C O. _. < D7 ? ? ( - O 0 o O - - , 0 , � = a 7 O 3 i(n � 2 pO as b " <D z 3 (D O U O 7 a O< O_ Xk (D O_ O d +� Co " (� O p p 0) 7 X (D O . C p N (D A. p '0 3 O? A 7 CD O p 0 `< = CO N 0) N CD 0 7 o- o o o a CD a s o Q= 00 p�. 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CROIX CO., WI I I I RECEIVED FOR RECORD I I I 05/04/2005 10:30AM I I I I Document No. I I EASEMENT I I I EXEMPT # REC FEE: 13.00 TRANS FEE: COPY FEE: I CC FEE: PAGES: 2 I I I I I Return to: I 014- 1046 -20 -100 014- 1046 -20 -000 Parcel Numbers DRAINFIELD EASEMENT Easement made this day of 11 W 2005, between Brenda Salseg and Robert Salseg, her husband, Em ald, Wisconsin (hereinafter referred to as GRANTORS), and Dean Sickenberger, Emerald, Wisconsin (hereinafter referred to as GRANTEE). 1. GRANTORS are the owners and occupants of a tract of land described as: The East Half of the West Half of the Northeast Quarter (E ;i� of W '-2 of NE 'yi) of Section Twenty -two (22) , Township Thirty -one (31) North, Range Fifteen (15) West, Town of Forest, St. Croix County, Wisconsin. 2. GRANTEE is the owner and occupant of a tract of land described as: The West Half of the West Half of the Northeast Quarter (W 1 -i of W 4 1 of NE k) of Section Twenty -two (22), Township Thirty -one (31) North, Range Fifteen (15) West, Town of Forest, St. Croix County, Wisconsin. 3. GRANTORS desire to convey the right, and GRANTEE desires to continue to operate, an existing sewerage absorption unit (mound system) and sewerage pumping pipe across a portion of the above described tract of land of GRANTORS. 4. Therefore, GRANTORS, in consideration of the sum of One and No /100s ($1.00) Dollar, receipt of which is hereby acknowledged, do hereby grant, sell and convey to GRANTEE the right to operate and maintain said unit and pipe in, on, and about the property of GRANTORS, more particularly described as: Commencing at the North Quarter corner of Section Twenty - two (22), Township Thirty -one (31) North, Range Fifteen (15) West, Town of Forest, St. Croix County, Wisconsin. Thence S89 ° 03 1 17 "E, along the north line of the Northeast Quarter (NE A-s) of said Section Twenty -two (22), a distance of 700.06 feet to the centerline and beginning of a 50 foot wide sanitary easement, herein described: Thence S00 ° 35 1 24 "E, along said centerline, a distance of 100.00 feet, therein terminating. �I 2 P 153 The rights herein granted may be assigned by the GRANTEES in whole or in part. The easement contained herein is for a sanitary drainage purposes only, which may not be extended or changed. No plantings on the easement property are allowed and GRANTEE, his successors and assigns, shall be responsible for maintenance, cleaning and care of the system, and shall keep it in compliance with all applicable zoning and sanitary laws and regulations, including regularly scheduled pumping. GRANTORS shall not be responsible for any damage to the system from GRANTORS' adjoining property, whether from adjoining trees, plantings, barriers, or other characteristics or activities located on or emanating from GRANTORS property. To have and to hold such right and easement to GRANTEE, his heirs, successors and assigns, forever, provided, however, that said right and easement shall expire in the event said sewerage absorption unit (mound system) shall fail. For clarification purposes, "failure" of said system shall be construed to mean the necessity of replacing, rather than ordinary and necessary maintenance to and pumping of, said System. In the event of failure, GRANTEE, or his successors or assigns, shall be responsible to obtain and pay for cleanup and restoration of the easement property to the condition it was in prior to installation of the system, including but not limited to removal of the mound, piping and drainage tile, in default of which GRANTEE, his successors or assigns, will hold harmless and indemnify GRANTORS, their successors or assigns, for any costs incurred by them, and in which event GRANTORS, their successors or assigns, shall have a lien on the land of GRANTEE, together with interest at the rate of 12% per year, for any such costs incurred by GRANTORS or their successors and assigns in performing the cleaning and restoration of the premises, which lien shall be enforceable as though a mortgage under Chapter 846 of the Wisconsin Statutes. IN WITNESS WHEREOF, GRANTORS have hereunto set their hands on the date first above ritken . Clean Sickenberger Br en Salseg - a�g-Z/7� Robert Salseg Subscribed and sworn to before me this - ,� &J d ay of ry-\ 2005. ') 060^J Notary Public St. Cro x County, Wisconsin My commission: THIS INSTRUMENT DRAFTED BY: Thomas A. McCormack Attorney at Law 1020 10th Ave. Baldwin, WI 54002 State Bar No. 01011884 . a r 0) ° 2 CD � .. ■ @ e z o w e.-n to CD & 2 $ , o % 7 ; o # 0-4 c ° 3 a m E q® [ ■ �kk \\ \� ^ / §\ k/ 2 G @ 9 / k 6 � ` � � 8 § 8 « / E ; CD ' @ 4 » a q / 3 a $ (n e .. w e T g m co m �_ a ° e 3 3 \ § C \ \ / § S / 2 E c _ <.■ z 0 0 0 m J = § § 2 / # § @ @ ■ @ 7 _ o q « r; Mk § � M z 0 0 m o o / ƒE» E . K] \ B. § / _ Em§ 0 / \ j k / / \ {0 §R { ±} = a z a N) � a o ■ � « ® .i 2\ E �z 7 $ CL Md co (D 7\72 / §7] %/ 2 D o (D3 E2 § f = �Escnf�= 0, c E]EM :ZR -N \&\ W0 R CL 3 So 3- 7a)w /° ID F . g 'Rg0) Ei3m k go0. U) E -CD » o < - &m�CL ; , aE2 o_ =CC mCr E E = aC® > D- -CL0\ k . _ = ,�, =a aE�$E Eao 2w72 0 S CD / ]- =§IL�a 2 { a - = -m= �Re@CD Q ° 0 / < { % 4A �\ \i �\ � .i FOREST PLAT T-31—N'• R -15 —W t , (Landowners) See Page 112 For Additional Names. t: - Q11 ��a' POLK CO. 7 ,W 26W POLK / ST CROIX RD 2700 2800 2900 3000 3100 3200 H"old & O` °` Sandra Paul a Delores Patrick Strelf z o�� ,, wn Myri r € $Roger JACk Ros 69 6a Levendoski gr� et „ p j g u ; $ Ruth � °g IOZ Q 7 Reed "Priebe Mazl 137 cREEK Sandra r � UC Trust 't„ GeraldZur er 167 tga day 80 GREE 43 DHaKB 133 s Cormiean 224 6 161 �� thy Iagan 90 Is R $ R Fuller J Lonnie Chad Aaron F - GRdd s3 sen Farms t & W & N veld Koss- Klos- Beau- corm- s 90 70 b R 19 Blskupski 80 'rZ' 4o ner , ner vais� m two Gerald w ToddS L zo Robert David $ Fred pemas 34 "m 68 Pietz g Frank &Rm 39 80 50 gy" z ro Q60 m 60 P Blomberg 0 Nitrhey m 80 39 40 156 4g 37 230TH VE V9 `� $ N aobml t Four Nan & S Pete & Properties so 40 WXI n P��s & F r'U'a Star Walu$ +u 0 & gevo jy� Bradley Ha rold Shirla & Brooks 40 - _ , Lombardo Al an s 88 Michael n 12 80 s S 120 Cms 60 Brooks 120 160 son Ce & H 60 y Rt ond&a Helgesoa ^ Richard E Leon & au<bad Ira Walana Pete & £ 3 NBssen 160 $Eileen I dith '�O rn e bo Ulrich 160 `� 147 t3 WBBam & Phy N 15 Bergmann z 40 'Er, oaaa Clarmu Raid D Patricia 40 Dennis Patrick o F Lynx Odin a Dons fudd r Richard Hall Hall &Kathy & Trade g0 .a �o r Gale 40 CAFFk M a / opoe Heibel Eggert 96 Steinberger 160 9 f i y 7y 39 Imish 80 dad 80 omits senley L 220th AVE pro Ndi & Te b r Lo David a q 195 00 bernidr 97 40 S t Gleemds Ulrich NRges g poe l 4o Sam & 39 N N David & & Kreltss ° &avi Sc V. h & ^ •• Wilma Crean Anderson st p Yi 74 us r boer 20 160 Schmidt 80 -� ` Jeffrey lu 160 U,�°�y � $ u g i o gar $ oo a ' Place °$ °° p ,T ^ 270 '� ~ Funks a0 a .'tl Inc ,,qq Kurt M g Iaidls Ivy ^A .3 S O rFi m V alien D4J! -� oG 48 ��e Mon & AaM 20 0 0 1 F4 Renee a 8 52 160 m s 340 lacsum 40 °'d t 220 Edwards C Z N Robert R&1 20 Kurtis Lo 0 210th AVE _ _ David S e Scott f. 1od a 1 , d 24 Fitter Eggert ® / °` '- dma. & Rita U) sbdt, S� cam' -) Z 51 40 ROE 40 40 40 l Lorelei� " Buhr s 40 u m otca Bernard Ellis David $ Swatyf9oel & Lucille Ellevold ' r Dennis Laurie S �! Moll Trust ^ t $ 112.4 Debra Tumor 160 a m 80 155 160 1 Rosen 120 40 160 40 - Eric $ NN.0 &oa — a naarew oi°m o .� $ 205th VE ' ' Melissa Edwin Dhich eWjoIm I bas "1+ a0 3 f' ^' aI 49 Paul Hall 40 198 ,� oa Tells 40 s ` G A N 40 do N c �Saura & n $v 168 O 160 160 7g �°B Incrry 116 �� 4 '�� �aZ+ "' ;Duvall 5r�ce M F lndi I--- -� -..�.. 200th AVE tnp & w 7 s h w+ - 4 0 $Lawr ce $� Terrance RlrLard• a Q , Bradley vov a m en wa &Rhea D ��� oboss td T"' u BazBle 76 .oa 4o Deboer P ]60 ao 40 Alice u - 80 Lawrence 49 �& p James $ Keith rdutdas Alfred & it VoeRz m G ary $ McNamara Storm Cann ette In, EBason 80 80 e 40 +o Lucille 200 233 s =J°'dZ Jackem 75 s 160 111 1 121 Orville �� I •��+ n 9 31' s o nme C!tto aime:& s 9.V w� w °$ ml CaPlr Bormet Robert aureea aowk Ted I _� treat 40 Gary , Annette er Bethell l i e a 6H 0 am�lr ffi Frances MIDer �� im R saadm Heinbuch aaen gz 229 4 201 120 120 ]60 131 +o eo 80 "' x Qus Z6 m 3 - r 64 ^ e 1 Ill 13 a W r u n Dale & Diamond $Arlene Sh K Farms ffi elley Y �'� $ a ' 34 Susan t g Hill 80 Inc au u Pl �y I Endres 60 cis So o RRsa _ p. p. vuiz§ .�� u A t•� ' a 240 m 80 80 r- 155 40 .� 9+tlF. C7s�S 220 �f Vw5 128 8 i Sheldon D 00 Str deu Forest ` E Ryan $ M� a Gerald & F ° m & Ruth ro EA / All en & Melvin & & e Ridge g u v Kazea u 1 Sande u Stmooson m X35 Warner Laura Michie 100 Hunt G' o ax s Ludemamru7 g +o ti Carutel u u = '� Simonson Kenneth Club cd" Harol C� ' I Eac cart .1: Schmidt s 2s & Ida D� a land- c 120 255 s . 158 160 80 S 160 ctasstmd Abbott 79 121 EMERALD PAGE 54 GLENWOOD PAGE 56 '. MARY - t LIE',i GLENWOOD CITY, WI 84013 (715) 265 -4429 (715) 265 -4384 (715) 265 -7255 FAX (715) 265 -7604 72 iL •-� ST. CROIX COUNTY WISCONSIN vo\ . ` PLANNING & ZONING DEPARTMENT 1 2 N I N N N M N veto _ ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 ` yam— Phone: (715)386 -4680 Fax (715)386 -4686 FAX To: 2 C /`� ��1 &S C From: & t)/A.1J Fax: �l S 2 - 3 d Pages: 3 - f - Phone: Date: Re: / l s�/S�n CC: - ❑ Urgent �or Review 0 Please Comment ❑ Please Reply ❑ Please Recycle dam- - w yAa� a44tJ - 31 - 716 4,) Ax �- d1pt )dkl& � 44t-4-e Parcel #: 014 - 1046 -20 -000 03/07/2005 10:24 AM P A G E 1OF1 Alt. Parcel #: 22.31.15.338 014 - TOWN OF FOREST 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 ` SICKENBERGER, JEANEEN JEANEEN SICKENBERGER 2953 210TH AVE 'P SOLD EMERALD WI 54013 Districts: SC = School SP = Special Property Address(es): ` = Primary Type Dist # Description SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE SEC 22 T31 R1 5W PT NE 1/4 W 1/2 OF W Block/Condo Bldg: 1/2 NE 1/4 ASM'T INC 014 - 1046 -30 (339) Tract(s): (Sec- Twn -Rng 401/4 1601/4) 22- 31N -15W NE Notes: Parcel History: Date Doc # Vol /Page Type 03/17/1999 599536 1411/184 QC 07/09/1998 582703 1339/069 QC 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 17629 Use Value Assessment Valuations: Last Changed: 04/17/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 10.000 10,000 50,600 60,600 NO AGRICULTURAL G4 30.000 3,000 0 3,000 NO Totals for 2004: General Property 40.000 13,000 50,600 63,600 Woodland 0.000 0 0 Totals for 2003: General Property 40.000 13,000 50,600 63,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 12/29/1997 Batch #: 501 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 014 - 1046 -30 -000 03/07/2005 10:25 AM PAGE 1 OF 1 Alt. Parcel #: 22.31.15.339 014 - TOWN OF FOREST 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 SICKENBERGER, JEANEEN JEANEEN SICKENBERGER 2953 210TH AVE EMERALD WI 54013 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 20.000 Plat: N/A -NOT AVAILABLE SEC 22 T31 R1 5W SW NE EXC E 1/2 SW NE Block/Condo Bldg: ASSESSED W/014- 1046 -20 (338) Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 22- 31N -15W SW NE Notes: Parcel History: Date Doc # Vol /Page Type 03/17/1999 599536 1411/184 QC 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/04/2000 Description Class Acres Land Improve Total State Reason Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 0 0 0 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 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner - .�1 - r) zS�J i C /L� 13 �2� -� 1 b Property Address City /State Zmiaz.az. r 1 Legal escription: �o �o�k 99 / . a Lot Block �) A Subdivision/CSM # °7` /lLa) '/a /., Sec. �Z, TAN -R fW, Town of .2v - vr>vc) SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INF ON: M .0 uJEs�n Tank manufacturer R AZ 041 #3 0- Size ST/PC/ LOd 45'0 Setback from: House Well/,Za P/LC Pump manufacturer Model C00 Alarm location (HOLDING TANKS ONLY) Setbacks: Service road V t to fr esh air ° �� Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: _ Width r ° _Length --�- -- Number of Trenches D Setback from: House Well P/L .3S` Vent to fresh air intake 64� At ELEVATIONS Description of benchmark L� Elevation Description of alternate benchmark fir" .0 Elevation 271 Building Sewer 13 • ST/HT Inlet h2 ° E/ ST Outlet PC Inlet PC Bottom g Header/Manifold sg Top of ST/PC Manhole Cover Distribution Lines( f 7 5 Z O ( ) Bottom of System O ��• �� O ( ) Final Grade O ► O ( ) Date of installation 1-/Y-Opermit number _ State plan number -2 r,7o6Z /9 Plumber's signature / " - X CIA License number �2 ,*/7 Date Inspector R Complete plot plan r NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW © v Sze •. . c 4j yy . INDICATE NORTH ARROW If Wisconsin Department of Commerce �.(� Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT mot - n GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ��S Permit Holder's Name: ❑ City ❑ Village own of: State Plan ID No.: �n pan . ,r CST BM Elev.:- Usp. BM EI BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA S • 5� 5 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Pre��� �D 6� A Benchmar � 5- / &0 ' Dosing (� M --- /.21, �n /:Z4 0� r Aeration Bldg. Sewer 6'. 20 Holding 0/ ftrt rt gf `l2• `f 5 TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 8'' —^ NA Dt Bottom /5:r6 Dosing �/ a - p ' h ' _a 3 NA Header/ Man. 3. Aeration NA Dist. Pipe � ' 5 Holding Bot. System • PUMP/ SIPHON INFORMATION Final Grade '71. vp Manufacturer Dem nd 51 Gam/ 6,'x,2 , Model Number 09 �JIPM q 7 -5_ TDH Lift 1(0 Lriction� foir Syetem2 ain Len TDH J..3 Ft Forcem 9,S Dia. H 2 a Dist. To Well SOIL ABSORPTION SYSTEM BED / RENCH Width L/ Length / No. f Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 7 I DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of 35 �_, Model Number: System: 6 6 I OR UNIT DISTRIBUTION SYSTEM S Header/Manifold u Distribution Pipets) of x Hole Size x Hole Spacing Vent To Air Intake Length :!:�y Dia. Z Length � Dia. —1 Spacing A( 3 1 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) a. y cLv For�s�t- 22.31. I S 2515 210+ A an re ision require . es ❑ No r 5 a 6 Use other side for additional information. 9 �q �� SBD -6710 (R.3/97) �_ .t� 9 Si9 t �� C1 � Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: m me , a I 3 9 eme ... « � . e.e .,•� ,eme .� ... ..... _ ....,. �,,e e.ere e r n. c t 3 7 meeo.. eme .._ esm e., e e t 9 � L e d t `e 9 t i ....... —. a� .. a..: .....£.. _ —„ eme.. m .v.. a 4 � } 6 3 F e w e 3 x � f i 1 x e e. .. .d..n. ..... r. ...»ea .. ... e r 3 t .:e..eee ve mmm .. t F t E .. .»ne e... ....A ... �. ..., ., ...._ ,... .e r .. .e . .......... i E 5S a F E s i s 3 s ; e 0 r G E b 3 F f � a r c 3 z r S o r � e r . t Safety and Buildings Division �� ■�i.r. SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 33IRTO c ir The information you provide may be used by other government agency programs ❑ Check i( revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number !. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I Prope Own er Name Property Location 1i4 1/4, S Z T 3 ( , N, R E (or Property Owner's Mailing Address Lot Number Block Nu b C , State Zip Code Phone Number Subdivision N me or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned 77 ity rN Road ❑ Village Public 1 or 2 Family Dwelling No. of bedrooms 3 Town of "� III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) / � / �2.31. 15.335 �� �c0 1 ❑ Apartment/ Condo 22_, S - ©/ G 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 ❑ New 2 Replacement 3 E:] Replacement of 4. ❑ Reconnection of 5. E] Repair of an System System Tank Only______________ Existing System - --------- Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) [Von- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 )&Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Requ (s . 3 ft.) Proposed ft.) (Gals/day /sq. ft.) (Min. /inch) Elevatio V � ? � �. �, g7.OD Feet 9a -? Feet Capacit VII. TANK in allons Total # of Prefab. Site Fiber- Ex p INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic A p p New Existin strutted T Tanks � eptic Tank or g Tank at ❑ ❑ ❑ ❑ ❑ Lift Pump Tank . /S - 1 f� ❑ ❑ ❑ ❑ ❑ SPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plu beI'ZNme: (Print) Plum is Si ture: ( Sta ) MP PRSW No Business Phone Number: r 25 Plum v is Address (Street, City, S ate, Zip Co IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issue Issuing in Signature (No Stamps) Vpproved [-]Owner Fee) Owner Given Initial 2 CX5 Adverse Determination [ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: S8D -6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement_ Installing plumber isto fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards MOUND SYSTEM DESIGN Residential Application INDEX AND TITLE SHEET Project 3 Bedroom Mound Owner Jeaneen Sickenberger Address 2964 210th Ave. Emerald WI 54012 1- 715- 263 -3490 Legal Description NW NE sec 22 T31 N R1 5W Township Forest County St. Croix Subdivision Name N/A Lot No. N/A .1� 0i l 30 -6 o ©v fla Parcel ID Number old/ •- /o y!P- ;219 -at"'CU )NJ ED Plan Transaction Number V0 v p piNGs Index and title sheet Page 1 p Mound calculations Page 2 Mound drawings Page 3 THOMAS D. `: Pres. dist. calcs. and laterals Page 4 GUSTUM Z TDH and pump tank drawing Page 5 2, 1201 Plot Plan Page 6 '�^• Pump Curve Page 7 Designer Thomas Gustum License Number D1201 Signature Phone No. 715 -658 -1344 Date 4/6/99 Notice: Tampering with this file by unauthorized persons is prohibited. Deliberate modification will result in disciplinary action under s. 145.10, Wis. Slats. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. SBD- 10462 -E (R.05/98) Page 1 of 7 a i Safety and Buildings 15837 USH 63 HAYWARD WI 54843 -8107 TDD #: (608) 264 -8777 Vhscons www•commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary April 23, 1999 CUST ED No.227618 ATTN.' POWTS INSPECTOR ZONING OFFICE TOM GUSTUM ST CROIX COUNTY SPIA N13450 937 ST 1101 CARMICHAEL RD NEW AUBURN WI 54757 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 04/23/2001 Identification Numbers Transaction ID No. 219980 Site ID No. 170749 SITE• Please refer to both identification numbers, Site ID: 170749 above, in all correspondence with the agency. ST CROIX County, Town of FOREST; 2964 210TH AVE, EMERALD 54012 NW 1/4, NE 1/4, S22, T3 1N, R1 5W Facility: JEANEEN SICKENBERGER 2964 210TH AVE, EMERALD 54012 FOR: MOUND SYSTEM, 450 GPD Object Type: POWT System Regulated Object ID No.: 463206 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes la�j l and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in p,0 • 4 chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. colldi4l The following conditions shall be met during construction or installation and prior to occupancy or use: 1. This plan action is subject to designer comments on the plan. 2. The orientation of the mound system must be such that the mound's longest dimension is perpendicular DfPpR SAF�� to the direction of maximum slope. ptiV150k Of 3. The area 25' below the downslope edge of the mound must remain undisturbed. 4. Abandon failing system per COMM 83.03(2). -IP_ G A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 04/08/1999 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 PATRICIA L SHANDORF , POWTS PLAN REVIEWER BALANCE DUE $ 0.00 Integrated Services (715) 634 -7810, FAX: (715) 634-5150, M -F 7:45 AM - 4:30 PM PSHANDORF @COMMERCE.STATE.WI.US I WiSMART code: 7633 07/20/1999 08:18 6581344 TOM GUSTUM PAGE 05 a o Alm _ r � a ry .24. Sri( of lz ` 40 g %coca OL , fi y J� oits W 11 h -C cvl m B,� E L /00, d' Alo. l n gi ` "M tp /G N 1 ! 2 s J /P- d a�c GXee�l4,5 e V eq )i t,e,n ke vi b. r e' c r P104 Pl a v� At e- b o a9 �T 7/6 9 wh tJ v-) A) 5 T3 l K 1 r W ru3r� C� �"orc 7 S4. C ro %X Cp 04/20/1999 08:18 6581344 TOM GUSTUM PAGE 01 MOUND SYSTEM DESIGN Complete red boxes as necessary. 1000 gpd maximum design flow. In ounds Metric Residential or commercial? r (r or c) (y or n)� Replacement system? Creviced bedrock site? IN (y or n) Slope 7.5 % Wastewater flow rate 450 gpd 1703 Lpd Depth to limiting factor 26 in 66.0 cm In situ soil infiltration rate 0.3 gpd/ft' 12.2 Lpd/m� Contour line elevation 96.0 ft 29.26 m Use standard fill depths? x OR Design depth? in cm Place X In box to use standard depths (24 and At4Inclusive) OR specify design fill depth. 0.179, o.166, 0.185, 0.219, 0.25. Center or end manifold c (C or.) Mole diamet 0.26 in 0281, or 9.313 Inch only. Lateral spacing 0.00 rt Use 0 lateral spaoing for tmnchas_ Estimated hole space 2.50 ft Not a final calculation. Number of laterals 2 Pump tank elevation 88 ft Outside bWom of tank_ Forcemain length 90,0 ft Foroemain diameter 2.0 in 1.5, 2 3 or 4Inch only. 057 in Actual l.0- HOLE DIAMETER CONVERSIONS 1/8 =0-12s 1/4=0.2W SYSTEM SOLUTIONS Inch unds Metric 5/32 -0,156 9/32 =0281 Estimated daily flow 450 gpd 1703 Lpd 3/18' 0.186 5/16=0.313 7132 = 0.219 Absorption cell Design load rate & area 1.2 gpdAe 375.0 fe 34.84 m Linear loading rate (LLR) 4.79 gpd/ft 59.4 Lpd/m Design width (A) 4A0 ft 1.22 m Cell length (B) 94.0 ft I 2$.65 m Depth of cell (F) =in 24.1 cm Sand filter Upslope fill depth (D) Zfe in 30.5 cm Downslope fill depth (E) in 39.6 cm Basal area required (gpd/infiltration rate) 139.36 m Supporting components Topsoil depth 6.0 in 15,2 cm Subsoil depth at center 12.0 in 30.5 cm Subsoil depth at cell wall 6.0 in 15.2 cm End slope toe length (K) 10.33 ft 3.15 m Up slope toe length (J) 6.80 ft 2.07 m Down slope toe length (1) 12.00 ft 3.66 m Total mound length (L) 114.66 ft 34.E Im Total mound width (W) 22.80 ft 6.95 Im Project: 3 Bedroom Mound Page 2 of 7 Transaction Number: �� " /l v o2 64/26/1999 68:18 6581344 TOM GUSTUM PAGE 02 MOUND PLAN VIEW observation pipes (typical) �J 22.81 ft A A = 4.00 ft 1.22 m 6.951 m B = 94.0 ft 28.65 m W B J = 6.80 ft 2.07 m ! K I = 12.00 ft 3.68 m K = 10.33 ft 3.15 m _ 114.66 ft 34.95 m typ. obs. pipe (anchored swuv0y) I = down slope dimension = absorption cell (AxB) J = up slope dimension = plowed area (LxW) K = end slope dimension [L s° (152 mm) T MOUND CROSS SECTION subsoil cap D = 12.0 in 30.5 cm lateral 'topsoil G H E = 15.6 in 39.6 cm invert 97. 1i .. _ . _ _ F= 9.5 in 24.1 cm 29.72 m elev. F G = 12.0 in 30.5 cm . ' ASTM C33 H = 18.0 in 45.7 cm ° sand Fin E Sys. ft 97.00 elev. 1 29.57 m 96.00 ft contour 29.26 m elev- 7.5% slope D = upslope fill depth. plowed layer E = downslope fill depth Note: Absorption cell media wIU C M510 F = absorption Cell depth of aggregate and pipe with laterals G = subsoil + topsoil depth at cell wall centered acmes AxB media. The cell H = subsoil + topsoil depth at cell center media is Covered with geotextile fabrio. Designer notes: deep chisel plowingJo break up top la er Project; 3 Bedroom Mound Transaction Number Rage 3 of 7 f 1 ✓,s i on 04/20/1999 08:18 6581344 TOM GUSTUM PAGE 03 PRESSURE DISTRIBUTION CALCULATIONS AbsonWon cell Inch-pounds Metric Width (A) 4 ft 1,22 m Length (B) 94.0 d ft 28.65 m Lateral specificatlons Number laterals 2 Holes/lateral 18 hales Lateral length (P) 45.21 ft 13.78 m Hole diameter 0 -250 in 6.35 mm Let. dis. rate 20.97 gpm 1.32 Us -- Sys_ dis. rate 41.94 gpm HE= Us Hole spacing (X) 31 i in Lateral diameter Pips diameter veale^ options D®[on choke Designermust 1 in (25 ntm) Place X In red "X" One choice 1 114 in (32 mm) box of chosen from the options 1 1/Z in ( 40 mm) x x diameter. provided. 2 in (50 mm) x 3 in V5 mm) X Manifold diameter Pipe dlanteW aw ° °e 19 n` t d-- Designer must 1 In (25 mm) '?C" one choice 1 1/4 in (32 MM) None required. from the options 1 1/2 in (40 mm} No Ch oice necessary, provided. z in (50 Itwtt) 3 In ( mm) 4 in (100 mm) LE J Distribution system contains, 2 Laterals) LATERAL DIAGRAM - CENTER CONNECTION Place correct lateral diagram by clicking in one of the drawings at right and dragging the diagram into this area - end coP y l P � I • w �Xri�trr2 et2�l [pe�COMMTabie1es30 GSeh40 ) Last hole driiwo ne "t to end cap Holes: drilled oo t8e bottom of the WOW � � permonom end marker equally Fpaoed inch -pounds Metric Lateral length (P) 45.21 ft 13.78 m Lateral spacing (S) 0.00 ft 0.00 m Hole spacing (X) 31 in 78.7 cm Manifold length 0 ft 0.00 m Hole diameter 0.250 in 6.4 mm Lateral diameter 1.50 in 1 40 Imm Forcemain diameter 2.00 in 50 mm Project; 3 Bedroom Mound Transaction Number: Page 4 of 7 04/23/1999 13:10 6581344 TOM GUSTUM PAGE 01 TDH and Pu>rnp Tank Drawing Total Dynamic Head Operational head 2.50 ft 0.76 m vertical lift 8.70 ft 2.65 m Are laterals the highest point in th Friction loss 2.59 ft 0.79 m system? Yes °x° "we Total dynamic head 13.79 ft 4.20 m If no, what Is the highest elevation Dose Volume downstmn of pump? =,1 Dose is > 10 times lateral volume Foroenrain brain Lateral void volume 9.6 gal 36.3 L back to tank? Cx" one) Minimum dose 112.5 gal 425.9 L x es Drain back 15.7 gal 59.128.2 4 L No Dose volume gal 485.3 L Typical Pump Chamber Layout In combination with state approved treatment tank. Tank construction as per Comm 83.20(3) WAC. approved manhole cover with 71� weather proof warning label and W inq device grade levers junction boor disconnect 9,ade IeMs Oltemete 41' vent pipe electric as per NEC 300 and �- outlet Corm 1628 WAC location 16"(46 cm) min. wail of pump �� approved chamber or outletldnt combination tank A Provide 1/4" weep hole or anti- alarm on siphon device ss necessary pump on B Grade level4 pump 88.8 ft C - pump tank menhole = X' (1 0 cot Off elev. 27.1 m minimum above finished grade D _ vent =12" (30.5 cm) rt hvAm above finished grade L 88.0 ft PWV tw* devotion 3" (75 mm ) of bedding under tank 26.8 Im bottom of tank Tank manufacturer Midwestem Pre -Cast Pump tank capacity 17 gal in Pump tank volume 650 gal Pump manufacturer H dromatic Inches Gallons Pump model number [O 33 c A 22.7 385.8 B 2 34.0 Alarm manufacturer 38.1 Ele c� C 7,5 128.2 E Alarm model number 101 O D 6 102.0 Project: 3 Bedroom Mound Transaction Number- �I� Page 5 of 7 � ' V / Si� 3�7 M ODEL 1 MO Vertical • P •04 •0 Su bmersible Effluent Pump a 1 a Pump Specifications ' /3HP a' ERS FEET Up to 40 GPM 10 MODEL: 3871 Discharge size 1 NPT 9 30 Solids: 3 /3" maximum i 6 Motor , 25 Single phase: 115V _ Materials of Construction 6 5 w�i v Brass /thermoplastic a 15 EPOS Features and Benefits o •Top suction eliminates a 3 '° impeller clogging. 2 EPOa 5 *Corrosion resistant + construction. 30 4F 1 50 U ° *Float actuated switch. °° 10 20 0 2 4 6 8 10 12 r CAPACITY METERS FEET MODEL DVP03 Pu Specifications Features and Bene 4 / 10 an P EPO4 impeller- pen design 6 Up to 60 with pu nes to protect 5 + Maximum hea seal. F= ' Discharge size 1'/2" NPT • EP05 impeller - enclosed design 0 3 10 Solids:' /•" maximum for improved performance. 2 5 Motor • Rugged glass - filled thermoplastic 1 All motors feature ball casing and base design provides 0 0 bearing construction. superior strength and corrosion 0 5 10 15 20 25 30 3s 40 U.S.6PM resistance. Single phase: 115V ° 2 4 CAPACITY 6 6 100TH Materials of Construction *Cast iron motor housing for Cast iron efficient heat transfer, strength, Thermoplastic and durability. Stainless steel •Corrosion resistant threaded stainless steel shaft. *Available for automatic and manual operation. •CSA listed models available. All Models are designed for continuous operation and feature stainless steel hardware. ENGINEERING DETAILS - OSP33 t Performance Data 32 Pump Characteristics Pump /Motor Unit Submersible Manual Models OSP33M1 OSP33M2 LL z4 0 113 HP Automatic Models OSP33A1 I OSP33A2 W x Horsepower 1/3 M 1s Full load Amps 1.8 4.6 Motor Type Split -Phase a R.P.M. 1150 o s Phase 0 1 Voltage 115 1 230 Hertz 60 0 0 10 20 30 40 50 80 CAPACITY -U.S. G.P.M. Operation Intermittent Temperature 140 °F Ambient Total H d (feet) 4 8 12 16 20 25 NEMA Design B GPM 1/3 NP 60 55 48 39 28 7 0 Insulation Class F Discharge Size 1 -1/2" NPT Solids Handling 5/8" I mensional Data Unit Weight 50 lbs. 3 .7/8 6-3/4 Power Cord 18/3, S1TW, 18/3, SJTW 5 -1/8 10 std. (20' opt.) 20' std. 1. All dimensions in inches 4 -1/4 1 -1/2 NPT 2. (omponeMdimensions may vary t 1 t inch Materials of Construction 3.Notoesesnlesscon _ purposes unless terrDied Handle Steel 3.3/4 4. Dimensions and weights are approximate lubricating Oil Dielectric Oil 5 5. we reserve the * to Motor Housing Cast Iron make revisions to our troducts and Ibeir Pump Casing Cast Iron specificationswidW notice Shah Steel ! Mechanical Soul Faces: Carbon /Ceramic I Shah Seal Soul Body: Brass Spring: Stainless Steel Bellows: Bunn -N 12-1/8 Impeller Bronze PUMP 11 -3/4 ON Upper Bearing Single Row Ball Bearing Lower Bearing Single Row Ball Bearing —� Bose Cost Iron 2-3 3 Fasteners Stainless Steel PUMP OFF AURORA /HYDROMATIC Pumps, Inc. 1 1840 Etaney Road, Ashland, Ohio 44805 (419) 289 -3042 A- 7a 7 Wisconsin Derartment of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bure of Intec.ated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S f G�/^v / x percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 0 J l o IIZ © - a' APPLICANT INFORMATION - Please print all information. R d b Date� / Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner _ Property Location r� -.� eU� ,eq 3 /, -, / /_ c'T ^Q!^ Govt. Lot ��1/ �1/4,S T N R �S E (° Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# y/ ;;?/ O f6 h,4-e— C State Zip Code Phone Number ❑ City El Village IN Town Nearest Road ew Construction Use: Residential / Number of bedrooms Addition to existing building 9k Replacement Public or commercial - Describe: Code derived daily flow 4 t; O gpd Recommended design loading rate . J bed, gpd/ft2 gpd /ft2 Absorption area required /_ bed, ft 1- trench, / ft 2 Maximum design loading rate _ bed, gpd /ft gpd/ft Recommended infiltration surface elevation(s) 3�r �ro _ �� ft (as referred to site plan benchmark) Additional design /site considerations / �— Parent material " c a / / i��s Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system El S �K U �0 S El ❑ S E2 ku ❑ S a [Is oU ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 .... in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ............................... ...................... AZ .......................... o ✓� ���1� r / G Ground fl 104 S� �- I V L�— ft• Depth to limiting factor ,' 0 in. Remarks: Boring # r Ground °� ele �ft. ' Depth to limiting Uri factor D in. Remarks: CST Nam (Please Print) Signature jneN, Address/ Date CST Number f to �,�� `` cC� _�� SOIL DESCRIPTION REPORT � PROPERTY OWNER �� /'� ,C/ %� y �^ Page of PARCEL I.D.# I`► Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground elev. Depth to limiting factor � in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor in. Remarks: Boring # 13 Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Soil Test Plot Plan Project Name ` ` ,f j���� Byron rd Jr. Address ,� e��r, S 2 CS M �v sue' Lot Subdivision Date —/s 4111 /4 /4S 4 &��- T & N /R�- -- Township Boring 0 Well PL Property Line County j e BM or VRP Assume Elevation 100 ft �� /�« a �mti l� �/u, - '/ // /gq�sc System Elevation 4� *HRP 7h 4 4,0 O f \ Scale 1/4" = 10 Ft. When Dimensions aren't stated ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer C /c Mailing Address f Property Addres (Verification required from Planning Department for new construction) City/State —n /p / Parcel Identification Number cvi V- i© 546 LEGAL DESCRIPTION Property Location ' /a, C %4, Sec. , , T.�aLN -R /S W, Town of AQ 2 Subdivision _ 4) Lot # �. Certified Survey Map # Volume , Page # Warranty Deed # S 9� s�� , Volume Page # `f Spec house ❑ yes X no Lot lines identifiable ❑ yes �dno 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 The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 ds oree year expiration date. � / OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. �J' A2 +=RE 70F APPLICANT 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 GATHLEE', H WAL.SH a, ty Rf *G STER OF DEEDS � . GR co. , W RAINED FOR RECORD P-45 PP, G 1 0. i / 0 m � 0 9 %k k$ T CD rr _ = s z o w 2� -n o§ o . o ; o a o ¥ *• Z m§ E § o \± F a@ E® E 7 = 9 k° / / \ / J , 0 / C4 7 \ 2 2 G / / \ A, � ` E � = E K [ CD n @ / m e \ c Q, § \ 9 S 2 / k CX k / CO S ƒ § E CA _ CD ] CD \ % � Z o o = o ƒ & ƒ = S § § 2 A \ \ q -0 v o \ q OIQ �� /� $k�/ cn � ) §. � / � / 2 § § c ® [ �. � 2 . (D / \ 3 z CD � \ f N) 0 l 7 2 o r z G M E � = f / � X7 /2]/ƒ¥ 2 \ao= ±,= & �a oCD o CD ) \ \ /J� /w { CL 0) ® R . Bo <x� #@cD Emzm z f2 \ { % §\ o =§ 0 {] $ 0n = ® � . §k / } \ \� �ao, , \ f[§] - § }2$ƒ/ \ i \ §f [°'2»} ® �\ 0 cz Jq§ & f ƒ \ G \CD o� �k Parcel #: 014 - 1046 -20 -100 03/07/2005 10:24 AM PAGE 1 OF 1 Alt. Parcel #: 22.31.15.338A 014 - TOWN OF FOREST 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 * SALSEG, BRENDA BRENDA SALSEG 2969 210TH AVE EMERALD WI 54013 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 2969 210TH AVE SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE SEC 22 T31 R1 5W PT NW NE & SW NE BEING Block/Condo Bldg: THE E 1/2 NW NE & SW N Tract(s): (Sec- Twn -Rng 401/4 1601/4) 22-31N-15W Notes: Parcel History: Date Doc # Vol /Page Type 07/09/1998 582703 1339/069 QC 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 17630 Use Value Assessment Valuations: Last Changed: 04/17/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 3,500 95,000 98,500 NO AGRICULTURAL G4 28.000 2,800 0 2,800 NO PRODUCTIVE FORST LANC G6 11.000 6,000 0 6,000 NO Totals for 2004: General Property 40.000 12,300 95,000 107,300 Woodland 0.000 0 0 Totals for 2003: General Property 40.000 12,300 95,000 107,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 135 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00