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HomeMy WebLinkAbout014-1047-50-000 r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count INSPECTION REPORT S Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Personal information you provice maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 353236 Permit Holder's Name: ❑ City ❑ Village ❑ 4own of: State Plan ID No.: Janssen, David Town of Forest CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: d M,t 014- 1047 -50 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ©C�tJ Benchmark Z, _ /02, Oct Dosing �3 "� Alt. BM Aerab Bldg. Sewer Holding Ht Inlet TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. Ventto ROAD Air Intake Septic > �y / 7� Z i Z / NA Dt Bottom S Dosing - � S "�S / / NA Header /Man. A NA Dist. Pipe Ho ding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer emand St cover S( S S� Model Number C C 2�P, OPPM s o 0 TDH lift Friction System 4 TDH 1 6. Ft j Z 1,P1 1P Loss Forcemain Length �C { Dia. '' Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length Of Trench s PIT No. Of Pits Insid id Depth DIMENSIONS 9 ra IM SYSTEM TO P/ L BLDG WELL LAKE/STREAM L NG Manufacturer: SETBACK AMBER INFORMATION Type Of Number: System: t ff Q , >/ b/ OR UNIT DISTRIBUTION SYSTEM Asa Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Aa Dia. Length 1� Dia. Z Spacing "' 1 A , / / -- SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over FBed h Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Tren ch Edges Topsoil ❑Yes E] Nod/ ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #14' 116 /C'Dlnspection #2: Location: 2044 County Road P, Emerald, WI (NE1 /4, SE1 /4, Section 22 T31N -R15W) - 22.31.15.349 1.) Alt BM Description= 2.) Bldg sewer length = 26 - amounj of cover = >� 3.) Contour Plan revision required? ❑ Yes C7 No Use other side for additional information. x SBD -6710 (R.3197) Dat Inspector's SigAdure Cert. No. I� ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ell SC A °�......«,..- v'me.�. �p.».:...s n m 77 . ..,.. �. ...w ..,.._...,. �. � e..>..«.... o-m,. �+ 4.....«... v+ �f e....�«.........�.� .......m ! .».�.,:,.......,. ®�....b„ „. „�„„ ' -�- �_ � d t 3 Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Asconsin In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County , than 81rz x 11 inches in size. G df / X • See reverse side for instructions for completing this application State Sanitary Permit Number 3 "3 Z Personal information you provide may be used for secondary purposes E] Check if revision fo previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location S-s�o O1 is va, S T3 , N, R/ 5-r) W Property Owner's Mailing Address Lot Number Block Number O City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned E] rt Nearest Road it age Public g 1 or 2 Family Dwelling - No. of bedrooms town of )COX 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 'L 2_. f (-5-- 3 1 ❑ Apartment/ Condo 2 f 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 ;K Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5_ ❑ Repair of an ------ System -------- System ------------- Tank Only -------------- Exi sting System - -------- - Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 [@ Mound 30P Specify Ty a 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: (J raver _� -�5 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6 Elev. 7. Final Grade Required (sq. ft.) Pro osed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) q Elevation et 9�f- )"r Feet Ca acct VII. I NFORMATION in.gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Exper. Gallons Tanks Concrete glass Plastic App New Existing strutted Tanks Tanks I /-, eptic Tank /d W e ❑ ❑ ❑ 11 11 ii"ump Tan 1 Fv eaA j ctcgmAgl IN I ❑ 1 ❑ ❑ 1 ❑ 1 ❑ VIIL "RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb is Signature: o Stamps) MP�RS=lWO.: Business Phone Number: PI mber's Address (Street, City, State, Zip Code): A( w 00 W e - 2' It'l" v/ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued I 1 71., Agent Signature (No Stamps) Approved E] Owner Given Initial }� Surcharge Fee) Adverse Determination �' ZS UCJ 1 i Z Z X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: /1 GrG,3- -t�ert e4 Pf r- e Original f it in Div' i r Plumber DISTRIBUTION: to Count , One co To: Sa et & Buildings s �s on, Owner, u be r SBD- 6398 R.11197 r °Y r e 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 -3151. To be complete and accurate this sanitary permit application must include: h legal description m r fw r I. Pro ert owner s name and mailing address. Provide the e a and parcel tax nu be (s) o where the Property 9 9 P system is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 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 is to 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. Safety and Buildings 10541 N RANCH ROAD HAYWARD WI 54843 TDD #: (608) 264 -8777 Vhsconsin www•commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary November 02, 1999 CUST ID No.222234 ATTN: POWTS INSPECTOR ZONING OFFICE GALE W SMITH ST CROIX COUNTY SPIA 3228 HWY 170 1101 CARMIC1 AEL RD GLENWOOD CITY WI 54013 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 11/02/2001 I dentification Numbers Transaction ID No. 271343 Site ID No. 182364 SITE: Please refer to both identification numbers, Site ID: 182364 above, in all correspondence with the agenc ST CROIX County, Town of FOREST; 2044 CO RD P, EMERALD 54012 NE 1/4, SE1 /4, S22, T3 IN, RI 5W RICHARD TIBERG 2044 CO RD P FOR: MOUND, 450 GPD, REPLACEMENT Object Type: POWT System Regulated Object ID No.: 495716 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes P.0 and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: ; ;�E of 1. This plan action is subject to designer comments on the plan. D;V: & 'LT) 2. The orientation of the mound system must be such that the mound's longest dimension is perpendicular,��� to the direction of maximum slope. -- 3. The area 25' below the downslope edge of the mound must remain undisturbed. S` c Cott ES 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 10/20/1999 FEE REQUIRED $ 180.00 �,� FEE RECEIVED $ 180.00 P RICIA L SHA ORF , PO WTS AN 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 WiSMART code: 7633 MINNOW ■�'/■ ■ ■� ■ ■■■■ ■■ ■ �: - - ■ i m mo m ■■ ■ ■r ■■ ■ ■■■■ ■ ■N�1 ■ ■■ ■ ■ v � 1 � • ■ �s :c page .? Of 5 Straw, Marsh Hay, Or Synthetic Covering Distribution Pipe Medium Sand G Topsoil - F . E D b %Slope Qed 0 Z�- 2 % ( Force Moin 1'lu.,ed Aggregote From Pump l oycr D Cross Section (, A Mound Systern Using F L � r A Bed For the Absorption Arcc - A Ft. H Signed: �.�' G g Ft. License Number I F t. Date. 2//,— 'T 2 rt K v, F ��. v A 14 . O'RScr•Yat'ivn Pi — �-- 01 � \f - once Main W From PUMP — - - Distribution E3ed Of l�_ 2 /2. Pipe Aggregote 1 Observation Pipe Permanent Markers Y ' t For The Absor �tion llrea View Of Mound Using A bed i Pion Vre 9 Page- Of .� Perforated Pipe Detail End View peR FPR Ate pVC PlPe' M� Q I Force Main PVC /7� Holes located on bottom of force main are equally spaced End cap -- ,� Last hole should be next to end cap Distributation pipe layout — P Ft Invert Elevation of Laterals R Inches S Inches j� S i g ne d s X�I nche s �? %G��f2. J ,,� Licenses Y4Inches � �. �- ,�, � jr� � / fJ j �. G Hole Diameter hes Dates � / '' ` -- 7— L Lateral 2— Inches Manifold -- Inches Force Main " _Inches # of holes pipe Page/ Of­,�L COMBINATION SEPTIC TANK /PUMP CHAMBE (No Scale) 4" Cl Vent Pipe with Approved Locking Manhole Cover Approved Cap, +25' With Warning Label Attached From Buildings Weatherproof Approved _ Warning Label Junction Box Vent Cap 7 mum Final Grade 6" Mini m - 4" 6" Maximum 4" C.I. Quick 18" Minimum Insp. Pipe _ _ Disconnect i 1/4" Weep Hole Baffles D � LA i Alarm � On *APPROVED Off O� JOINTS WITH ' APPROVED PIPE D 3' ONTO Conc. Block SOLID SOIL , i 3" of Bedding Under Tank-/ Note: Pump and Alarm Are On Separate Circuits Number of Doses 3 Per Day ' Gallons Per Day / oFDoses: Jam/ Gallons Volume of Backflow: ....... + Gallons Tank Manufacturer: M/olla e to sN / d,4 Total Dose Volume: ........ — l on Tank Size - Septic /Pump: lepp 1AL2 Gallons Alarm Manufacturer: SJ e c f"Ro Model Number: I 4 f-/ bu Capacities: A2_,2 _inches or jZ.,e l ons Switch Type: A4 e g dlq R + B - inches or � alIons Pump Manufac 6; 0 q d + C or . 2 o Gallons Model Number: �o + D inches or Minimum Discharge ate: 2 GF9 Total ..... inches or 6 S- Gallons Vertical Difference Between Pump Off and Distribution Pipe: ,D Feet Minimum Required Supply Pressure :....... ..................+ F eet $p Feet of Force Main x ,,Y Friction Factor /100 Feet: + ,o Feet _Inch Diameter Force Main Total Dynamic Head:... Feet Internal Tank Dimensions: Length -- Width Z; Liquid Depth' " / Signature o z, License Number 2 , Z 40ate �U ✓� T WESTSURNE SUPPLY INC. 12 DUSTRIAL RD Goulds ON, WI 54016 Submersible Effluent Pump i a 3871 EPO4 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel, grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. . • Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas- • Homes components. tic cover with integral handle Motor: Available for automatic and •Farms manual operation. Automatic and float switch attachment Heavy duty sump • EPO4 Single phase: 0.4 HP, models include Mechanical points. • Water transfer RP , 230 V, v Hz, 15 it Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload with automatic reset. preset at the factory. rated oil and water resistant. SPECIFICATIONS • EP05 Single phase: 0.5 HP, ■ Bearings: Upper and lower 115 V, 60 Hz, 1550 RPM, FEATURES heavy duty ball bearing Pump: EPO4 built in overload with construction. • Solids handling capability: automatic reset. ■ EPO4 Impeller: Thermo 3 /4" maximum. • Power cord: 10 foot plastic Semi -open design AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO with pump out vanes for • Total heads: up to 24 feet. with three prong grounding mechanical seal protection. Canadian standards Association • Discharge size: 1 1 12" NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo SP • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for (CSA listed model numbers rotary/ceramic - stationary, three prong grounding plug Improved performance. end in "F" or "AC ".) BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40'C) continuous superior strength and 140" F (60'C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET _ stainless steel 10 -- --- • Capable of running dry thou damage to s so` _. __ __ -_ _ .. __ -- - -- ►-s— GPM components. ! iii���JJJ - - -I Pump: EP05 a 2.5 FT i • Solids handling capability: e 25 - 3 /4" maximum. w • Capacities: up to 60 GPM. • Total heads: up to 31 feet. 6 20 • Discharge size: 1'/2" NPT. • Mechanical seal: carbon- >_ 5 C 15--- - - -_.. Temperature: e1 stomers.na 4 i I I ry , ry, ;EP05; • e perature: 3 10 -- - - -- -- b 104 °F (40 °C) continuous — - -- 140 °F (60 °C) intermittent. 2 — E 5- - -. 1 0 10 20 30 40 50 GPM 0 2 4 6 8 to 12 ml /h CAPACITY m 1995 Goulds Pumps, Inc. Effective May, 1995 B3871 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page _Z_ of Bureau of Integrated Services in accordance wit HRt83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches Plan n ist .:<. County include, but not limited to: vertical and horizontal reference point (BM }, /direction and ` ir .sue C 0 percent slope, scale or dimensions, north arrow, and location an4 distance to nearest road:'' p Parcel I.D. # 1 6 ` o / - - o APPLICANT INFORMATION - Please print all info�mhtion. A Revigwe� b y Date q� r . Personal information you provide may be used for secondary purposes (Priv�cy Law,`i'fp)). i Property Owner f � � �� / v >" PropiiK 1 I Q / Govt. Lot 1/4 1/4,S 2 2 T 3 N,R NWW Property Owner's Mailin f Address - Let - # - - -- Block# Subd. Name or CSM# k ity State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road G ' I o (7i,,r')�6.s x'36 a 1 1 c a d ❑ New Construction Use: Residential / Number of bedrooms Addition to existing building E4 Replacement ��--,,,, ❑ Public or commercial - Describe: 0 Code derived daily flow &5 gpd Recommended design loading rate bed, gpd/ft gpd/ft Absorption area required bed, ft 27 ft Maximum design loading rate �bed, gpd/f1 trench, gpd/ft Recommended infiltration surface elevation(s) ✓� ft (as referred to site plan benchmark) Additional design /site considerations Parent material f9�A,- C/ L 7 Flood plain elevation, if applicable . & A ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system ❑ S W U I ® S ❑ U [Is ®U I ❑ s ®U i ❑ s ®U [Is W U SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench Ground = 71 Y R . i1A C 0_4 2. d Ar 16 !F '.t elev. y Depth to limiting factor 2J-in. Remarks: Boring # 040 / ,5 - 1 4 a M Sik MFR Ground elev Depth to limiting factor in. Rem arks: CST Name (Please Print) 00 SrLt/ Telephone No. Address Date CST Number !tit 1 orl elwvoo o/ c Lrx 4 LJ& a /o- 9`9 ; :;� --2 PROPERTY OWNER R/91A y' R d Z'Ii S OIL DESCRIPTION REPORT Page of ' /i nr PARCEL I.D.# O ZI &V •/ " Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench .........................: o S/� .2M .6� M G' ........................... .......................... Ground 2 41 . J . '5- Cr ^ O� f- 2. e k J- � ' i �✓r elev. , �. ' , Depth to limiting factor Remarks: Boring # [3 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 # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Act- 4b - 4R. 0 4 -OW I I t I _ I I -! - - - - -- - -- - - ! - - - -- - -- - - -- - -- - - - - - - - -- - �- - - -- - - - i I ----- - - - - - - -- - I- - -- -- - - -- �- I -- i I I I i - -- - -- - I i I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 29w a J xxm/ - -re /V Mailing Address o? 4 Ll f Oor Property Address .S M (Verification required from Planning Department for new construction) City /State ,Me,QIfLd/ /� 4 p arcel Identification Number O /�' �O�/ —.S LEGAL DESCRIPTION 22 Property Location f Y G ' /a, S7� ' /a, Sec. , TV N -R 1S W, Town of / of e s7 . Subdivision Lot # Certified Survey Map # . Volume , Page # Warranty Deed # Volume 60 Page # 6 Spec house ❑ yes A no Lot lines identifiable ❑ yes 0 no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system r operating condition and/or after inspection and pumping if necessary), the septic tank is less than 1/3 full of sludge. is m prope pe g 2 () msp p p g ( �Y) I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATME 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. ////9 SIGNAT[fRE OF 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 VOL 1460"GE 169 t61 1303 d55Da STATE BAR OF WISCONSIN FORM 2 -19H KATHLEEN H. WALSH REGISTER OF DEEDS Document Number WARRANIV DEED ST. CROIX CO., WI This Deed, made between Richard E. Tibere and Lorna A. Mere, RECEIVED FOR RECORD busband and wife. 03- 30-1339 9:30 AM Grantor, conveys and warrants to WARRANTY DEED David W. Janssen and Laura L. Goetzke both sinile person, as ioint EXEMPT N CERT COPY FEE: tenants, COPY FEE: TRANSFER FEE: 460.20 RECORDING FEE: 10.00 Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. . Croix County, State of Wisconsin (The "Property "): Recording Area L)f'v,f' J EST` 30" ..JCUST ! WDSON, WI 540' 014 - 1047 -50 -000 Parcel Identification Number (PIN) This is homestead property. NE1 /4 SE1 /4, Sec. 22- T31N -R15W, St. Croix County, Wisconsin. Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this _ day of September, 1999. • • Ric E. Tiberg / * * Lorna A. Tiberg AUTHENTICATION ACKNOWLEDGMENT Signature(s) Richard E. Tiberg and Lorna A. Tiberg, STATE OF WISCONSIN ) husband and wife. ) ss. County ) authenticated this - 2 y of September, 1999. Personally came before me this _ day of VV4I 1999, the above named « Krishna Ogland to me known to be the person(s) who executed the TITLE: MEMBER STATE BAR OF WISCONSIN foregoing instrument and acknowledge the same. (If trot, authorized by § 706.06, Wis. Stats.) « THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin Attorney ICristina Ogbmd My Commission is permanent. (If not, State expiration date: Hudson, W154016 ') (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 BAR OF WISCONSIN FORM No. a -1996 INFORMATION PROFESSIONALS COMPANY FOND DU LAC, WI 8 D4553021 1 i 1 f OR A4 Aj — — — -- -- � -- U — — —, — .— — — — — i ! - - -- - _ -� j I - i I -_ o __ -- -- — - -- _ LL Ll I , I I I - -! -- -- : I i � I ' I , I I : I : I I � - i I V I i 4 I r I L . I i i I I � I : I I _ 1 L I I 4 1 1 i �10 J-1 l j I, ST. CROIX COUNTY t WISCONSIN ZONING OFFICE \• INNMNNNN■ :...i ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road '• •' __ _ _ _� Hudson, WI 54016 -7710 (715) 386 -4680 Fax (715) 386 -4686 September 1, 2000 Eagle Valley Bank Attn: Marlene Linn 1301 Coulee Road - Unit 2 Hudson, WI 54016 RE: Septic Inspection for David Janssen located at 2044 County Road P, Forest Township, St. Croix County, Wisconsin Dear Ms. Linn: A septic inspection of the above referenced property was conducted on 08/21/2000. This property is located in the NE 1/4 SE 1/4 of Section 22, T31 N R1 5W, Forest Township, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for three (3) a bedroom home. If an ou have questions regarding this, please contact our office at (715) 386 -4680. Y Y Sincerely, ors J n Son entag Zoning staff /sm cc: file