HomeMy WebLinkAbout020-1356-19-000 AFFIDAVIT
Document Number
Document Title
I, Douglas J. Zahler, Registered Land Surveyor No.2145, hereby
certify:
Recording Area
That the plat of Grass Range Second Addition, recorded in Volume Name and Return Address
7, page 59, as Document No.607627, shows a Storm Water Retention S &N Land Surveying
Area in the southwest corner of Lot 19 with a High Water Line 2920 Enloe Street
elevation of 922.0 Hudson, WI 54017
That said Storm Water Retention Area was part of a Storm Water 20- 1356 -19 -000
Management Plan approved by St. Croix County for said plat. Parcel Identificati Number (PIN)
That the stormwater pond and grading plan shown on the attached
sheet maybe implemented to replace said Storm Water Retention Area. " � pF Wis
DOUGLAS J. S�
co ZAHLER
5-2145
�d S -2145
Douglas J. Z er, RLS 2145 Date � SON
9 'U
'U SUR'�
Approved by the St. Croix County Zoning Office
this day of 1 2003.
Jon Sonnentag
This information must be completed by submitter: document title, name & return address, and PIN (if required). Other information such as the granting
clauses, legal description, etc. may be placed on this fist page of the document or may be placed on additional pages of the document.
Note: Use of this cover page adds one page to your document and L2.00 to the recording fee. Wisconsin Statutes, 59.43 2m WRDA 2/99
P ROP ER TY LIN
BENCHMARK - TP OF ALUMINUM MONUMENT = 92415.
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LPC•ATION SI(bTCN GRASS RANGE SECOND ADDITION
LOCATED IN PART OF THIS NW114 OF THF.' NW1 14 AND IN PART OF
- •Y • ': 7'HF, NF, i/4 OF 7'Hf.' NW I14 OF SE'l.'TION 14, T29N, RI9M; TOWN
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ST. CROIX COUNTY
WISCONSIN
ZONING DEPARTMENT
1 \ N / / N ■ N ■ roll■ ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
Phone: (715)386 -4680 Fax (715)386 -4686
To: Pete Kling From: Jon Sonnentag
Fax: 715 -684 -2666 Pages: 2 + cover
Phone: Nate: 10/16/2003
Re: Grass Range II — lot 19 CC:
❑ Urgent O For Review ❑ Please Comment O Please Reply 0 Please Recycle
• Comments:
Pete
I received this information yesterday. Is this consistent with the plans and calculations that you have
seen? Do you have a copy you could send me for our file? Let me know if you have any comments.
Thanks.
Jon
J .
AFFIDAVIT
Document Number
Document Title
RECEIVED
I, Douglas J. Zahler, Registered Land Surveyor No.2145, hereby OCT 1 5 2003
certify: ST. CROIX COUNTY
ZONING OFFICE
Recording Area
That the plat of Grass Range Second Addition, recorded in Volume Name and Return Address
7, page 59, as Document No.607627, shows a Storm Water Retention S &N Land Surveying
Area in the southwest corner of Lot 19 with a High Water Line 2920 Enloe Street
elevation of 922.0 Hudson, WI 54017
That said Storm Water Retention Area was part of a Storm Water 20- 1356 -19 -000
Management Plan approved by St. Croix County for said plat. Parcel IdenMenfim Number (PIN)
That the stormwater pond and grading plan shown on the attached
sheet may be implemented to replace said Storm Water Retention Area. �� OF W1.9
Z
y� DOUGLAS J. ��
Z -2145
/o fs o S -2145
Douglas J. ZMAer, RLS 2145 Date H W SON
'U
SUPN
Approved by the St. Croix County Zoning Office
this day of 1 2003.
Jon Sonnentag
This information must be completed by submitter: document title. name & return address and PIN (if required). Other information such as the granting
clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document.
Note: Use of this cove page adds one to our document and .00 to the fee. Wisconsin statutes, 59.43 2m WRDA 2199
J
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P LIN _
`� -7 1 1
1 BENC14MARK - TbP OF ALUMINUM MONUMENT = 924.5.
(� I RECEIVED
1
OCT 1 5 2003 \� �
1
ST CROIX COUNTY `—
ZONING OFFICE
I
+ 1
1
1 FILL AREA TO \
92250
Z 1 No
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1 POND TOP
EL EV. �922.0
WI
0 / OND BOTTOM
( LEV. = 919.6C 100' X 100 P
d 1 I 1 PAD ELEV. - 923.50
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CENTERLINE PAUL BURCH DRIVE W
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AFFIDAVIT OF CORRECTION
1581FACE 637687
Document Number "' S REGISTER H. WELSH
Documea tTitle REGISTER R OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
I, Douglas J. Zahler, Registered Land Surveyor, S -2145, hereby 01 -30 - 2001 1:30 PM
certify: that the plat of Cottonwood Ridge recorded in Volume 7
lets, Page 45, Document No. 603431, St. Croix Count Register CORRECTIVE AFFIDAVIT
of
P g Y g EzE. PT *, W
of Deeds, shows storm water retention area on Lot 52 with a CERT COPY FEE
High Water Line Elevation of 942.0.
COPY FEE:
That due to some additional grading on said Lot 52 said Storm Water RECORO.rNG FEE 12.00
Retention Area is amended as follows: the High Water Line Elevation PAGES: 2
is 942.0 and is now configured as shown on attached Exhibit A. Recording Area
Name end Return Address
Jeff Cernohous
4635 Trenton Cir. N.
Plymouth, MN 55442
Lot 52 Cottonwood Ridge
020 - 1353 -52 -000
Parcel Identification Number (PIN)
D� a this �h day of l , n , 2001
Douglas J r, .S. S -2145 �� DOUGLAS
N ZAHLEF( Z
S -2145
State of Wisconsin ) HUCfsON,
w1s.
ss. )
St. Croix County ) 3
Personally came before me this t" day of , 2001, to me known to be the
person who executed the foregoing instrument an ac ow d the same.
My Commission Expires .0••
NOTARy
(' a
ST. CROIX COUNTY ~ ' 4 4 9 '•••••. r°
APPROVAL CERTIFICATE OFwn
Approved for recording by the St. Croix County Zoning Office
Date , 30 2-001
I Cl
This instrument was drafted by Douglas J. Zahler, S &N Land Surveying, nc., 2920 Enloe Steet, Hudson, Wl 54016.
This information must be completed by subminer document title_ name & rctum address and BN (if required). Other information such as the granting
clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document.
Use of this cover page adds one pW to Your document and Wisconsin Statutes 59.43 2m W RDA 2N9
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CERNOHOUS PROPERTY :..••■ .o unr�
COTTONWOOD RIDGE SUBDIVISION �»'•� •F ^LL �•+^�
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.rYYµ.l : +° rr nO w7 @MAUD FOR Rtl[r aJ [1M/m
IOWN OP IMgSON. Si. CROIM COUNTY. WIS00M51N 'M••
SITE PLAN ■Aulh•Colsm /ossocioles .:.•s.= - .«[w[ -p '�•'° �"'"
t t
ST. CROIX COUNTY ZONING DEPARTME T
AS BUILT SANITARY REPORT
Owner sT'
G«UN
Property Address 4odalee ZON1NGOPFIct:
City /State CikfjoF
Legal Description:
Lot f _ Block — Subdivision/CSM # er,& sl 402E'
' /a. 'k/ /4, Sec. , TAN -RZf`W, Town of PIN # 0-2o — /e-2 /— eo
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer -Cl Size ST/PC / Setback from: House Well; P/L'
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service roa Ve fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Z Len 7 Number of Treaahes Z
Type of system: � �y Width / Len
Setback from: House Well ?p P/L Vent to fresh air intake > !DV
ELEVATIONS
Description of benchmark .13� Gtioob',�/ /��'T - Elevation — s^
Elevation
Description of alternate benchmark 6{ pVA� .8yeA . - /27 V�
Building Sewer GO1 j � 7 ST/HT Inlet l0/ ST Outlet /O/ i PC Inlet --�
PC Bottom Header/Manifold f7. U Top of ST/PC Manhole Cover /b r
Distribution Lines ( ) ?7, 33 ( ) ( )
Bottom of System () -0 5-3 () ( )
Final Grade O 10-3 O ( )
Date of installation / O"f y
Permit nu er ? Y6 State plan number �—
Plumber's signature License number 11 ,1r/ Date
Inspector
Complete plot plan �
f
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
>/��
/Vo f �o
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT St. Croix
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)]. 344606
Permit Holder's Name: ❑ City ❑ Village ❑ x Town of: State Plan ID No.:
Bast Kernon Town of Hudson
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
//
db O Z n ffe ' s- 020-1356-19
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic d Uc Benchmark
Alt. BM Z. 13 II O Z.
Aeration Bldg. Sewer y Z4 / 10/ , 37 —
Hol St Ht Inlet y
TANK SETBACK INFORMATION / Ht Outlet , 2- 2-
TANK TO P/ L WELL BLDG. Ai to ROAD
iClalake
Septic S / 7 4 16' Z r NA -Dt Rollo-
ing Header /Man. 3 Z
Aeration NA Dist. Pipe
Iding Bot. System 10- 3Z f-6 3(
PUMP/ SIPHON INFORMATION Final Grade
-M anufacturer Demand St cover 3 -l` /6 Z
Model Num
TDH rF riss System TDH Ft
orcemain Length Dia. Fi Dist. To well
SOIL ABSORPTION SYSTEM
ED )TRENCH width Length No. Of I re ches PI No. Of Pits Inside Dia. Li uid Depth
EN I N Z� S� r t DIMEN
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA - ufacturer::
SETBACK Number:
INFORMATION Type Of CHA /
System: _3 3 i Z >4�G O NIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe s / x Hole Size x Hole Spacing Vent To Air Intake
Length C9 Dia. ! ( Length Dia. L Spacing 30 3 1- Z
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 E] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: // 111 f ' Inspection #2:
Location: 704 Paul Burch Drive, Hudson, WI (NWI /4, NWIA, Section 14 T29N- R19W) 14.29.19.2081
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GII.CSIOv�-
ve ®( atte cr 6 p r!` '40 Jt1r' r 3' .c O
Plan revision require
Use other side for additional information. Z p ( it
JO SBD -6710 (R.3/97) Dat Inspecto 's Signature Cert. No
M
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
Visconsin In r w ILHR Wi . A m. Code P O Box 7302
Department of Commerce acco d t 83 O5, s d Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. .5r.
o
• See reverse side for instructions for completing this application State sanita Per i NymTe
revisi
Personal information you provide may be used for secondary purposes ❑ Check if on to previous ppllcation
[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
Zia, S T�f , N, R E (or
Propert Owner's Mailing Address Lot Number Block Number
Ea
City, State Zip Code Phone Number Subdivision Name or CSM Number
� Wt Tvqlz Lr? a- 5 1r"
II. TYPE F BUILDING: (check one) ❑ State Owned E] ,t Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 3 ❑ vll�in
own Of 0 � CII
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
)35&
1 ❑ Apartment/ Condo — D
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar.lDining
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. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System ______ __Tank Only ___ _______ Existing System ________ Exi -- 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 m eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure t P. 42 ❑ Pit Privy
13 []Seepage Pit /��S y 43 ❑ Vault Privy
14 ❑ System -In -Fill 001P
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. S stem Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft_) (Min. /inch) sm Elevation
2 Feet , J Feet
Capacit
VII TANK in Ca gallo Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name concrete Co Steel glass Plastic App
New Existin structed
Tanksl Tanks
Septic Tank ork ��' ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installat4nf he onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu er're: Stamps) A4%IVIPRSW No.: Business Phone Number:
2 D 7 9T —A 4 51 / p
P tier's Addr s (Street, ty Stat , Zip C e):
v rr D2
IX. COUNTY/ EP RTMENT OSE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate su ISSUin g nt ignatur (No Stamps)
[Approved E] Owner j t T •)
Owner Given Initial C� j°� e Fees
Adverse Determination //
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (8.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be 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:
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 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 ofstandards.
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Lor i 9 ..P. ArAcr
s / "� crb' ' FOGERTY PLUMBING
& PERK TESTING. INC.
ll v c' ROBERTS, P.O. ox 1530
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Wisconsi nDepartme Industry SOIL AND SITE EVALUATION REPORT 9
labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM, direciior'r" % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distnca to nearest roads 020- 1021 -00
APPLICANT INFO RMATION PLEASE/i fjNT i FO MA1iA REVIEWED BY DATE
PROPERTY OWNER: ROPERTY LOCATION
Kernon Bast 't ^ OVT. LOT NW 1/4 NW 1/4,S 14 T 29 N,R 19 IE (or) W
PROPERTY OWNER':S MAILING ADDRESS ST CROIx OT # BLOCK # SUBD. NAME OR CSM #
i'
948 LaBarge Rd. ` 19 na Grass R n ec
CITY, STATE ZIP COD'h - ` PHOM&ftdkaffiCE CITY ❑VILLAGE [MOWN NEAREST ROAD
Hudson, WI. 54016 ..(71J 3 6—
New Construction Use [ :g Residential/ Number- �e i 4 [ ] Addition to existing building
(] Replacement ( ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd/ft
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd/ft
Recommended infiltration surface elevation(s) 95.25 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem CA ❑ U EIS ®U C3 ❑ U EIS N U CA ❑ U ❑ S C#11
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Y Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -9 10 r 3/3 none 1 2msbk mfr
LU
2 9 -21 7.5 r 4/4 none
Ground 3 21 -84 7.5 r 4/6 none ms osa m
elev.
99.5
Depth to �
limiting
factor � I �31 g 3
+8 4"
S�
Rem r : *36x26 10zr 5/4 non contIQuous sil lens
Boring #
1 0 -10 10 r 3/3 none 1
2 10 -24 10 r 4/4 none sil icsbk
.................
3 24 -40 7.5yr 4/6 none ms OSQ ml QW na .7 .8
Ground
elev. 4 40 -44 5 r 4/6 none
100. A{
Depth to 5 44— • 8
limiting
factor
+84
Remarks:
CST Name: -- Please Print GaU L. Steel Phone: 715- 246 -6200
Address: 1554 200th. Ave. ew Richmojid, WI 54017
Signature: Date: 8_19 -98 CST Number: m02298
'ALM
PROPERTY OWNER Kernon Bast SOIL DESCRIPTION REPORT Page 2 of 3
—
PARCEL I.D. # 020 - 1021 -00
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trerxh
3 1 0 -8 10 r 3/3 none 1 2msbk mfr cs 2f .5 .6
2 8 -24 10yr 4/4 none sil lcsbk mfi gw if .2 .3
Ground 3 24 -84 5 r 4/6 none ms osct ml na na .7 .8`
elev.
100. 5 .5 $ itr - wl
Depth to ti ��
limiting L
A Ng
Remarks:
Boring #
1 0-12 10 r 3/3 none 1 2msbk mfr cs 2f . 5 � .6
4 2 12 -20 10 r 4/4 c2d7.5 r 5/6 sil lcsbk mfr gw 2f .2 .3
Ground 3 20 -30 10 r 4/3 none fs osg mvfr gw if .5 .6
100. 4 30 -84 7.5 r 4/6 none ms osg ml na na .7 .8
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0 -10 10 r 3 3 none 1 2msbk mfr cs 2f .5 .6
>..5...<' 2 10 -24 10yr 5/4 none sil lcsbk mfi gw if .2 .3
Ground 3 24 -30 10 r 5 4 c2d7.5 r 5 6 sil lcsbk mfi gw if .2 .3
4 30-84 7.5 r 4/6 none cos osg ml na na J .8
Depth to
limiting
factor
=84 (� 0
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Kernon Bast New Richmond, WI 54017
MPRSW -3254 NWkMik s14- T29N -R19w (715) 246 -6200
town of Hudson
lot #19 -Grass Range second addn.
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. The location of the test may or may not be as shown
as pervianent lot lines were not established at the time the test was conducted.
N
1" =40'
EI.= top fo 2" pvc pipe 0 el. 100'
Alt. BM.= nail in wooden corner post @ el. 95.25'
$ 24 Pc
pw
fi A-
1. 3 pmt
101
Gary L. Steel
8 -19 -98
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerlBttger _x, , *, SST
Mailing Address ;?419 �/_
Property Address
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number llAA
LEGAL DESCRIPTION
Property Location ' /., A/ ' /,, Sec. 1,W, TZ�N- R,,/Q_W, Town of 11660So/ll
Subdivision e rx A�SS A/, 4,P1',' ' g � , Lot # � .
Certified Survey Map # , Volume , Page #
Warranty Deed # �' f 7 Llr Volume 1 Page # 5
Spec house ❑ yes no Lot lines identifiable 11 yes ❑ no
SYSTEM MAI
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 syste�
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
days f the three year expiration date.
12- 24 'I
SIGNATURE 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
tl�pyroperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
a
--- tip '-zt f
12
SIGNATURE 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
`�
�---.
r
DOCUMENT N O, WARRANTY DEED TN,s SPACE RESERVED FGM REf,ORDIN6 DATA
STATE BAR OF WISCONSI Rat 2
5
ST CRS., .
is
RAY .. G -, BROWN , and . ELEANORE, BROWN _ a /kJa_Elinor J. Brown, 2lbdcii�r� -
hu band- and -wife - • . .. ...... ..........
...... .......... .....
JUN 5 1995 _
4�
conveys and warrants :o .. QQ�A�DA -.J $PEER - BAST . ...... .... .. ...._ . - i
al ,
s � ,
�.
............. ....
._ ....... ........... . .... . ...... ................ . - - -
.. ..... ...... .. . . .. .. . R6TVRY TO
j for
t - 66 , valuable consideratio . n
,— -
the following described real estate in ... ... ..... ..... ........... .... . . ... County, i
i 020- 1019 -40 ,
State of Wisconsin:
024- 1020 -90 j
ii Taz Parcel No: i
it of Section 14 -29 - EXCEPT part to Hudworth, Inc. in
NWk of NE's
Vol. 604, Page 226.
NE's of NWk of Section 14 -29 -19 EXCEPT part to Thomas Wiley in Vol. 958,
Page 577. i
Subject to torn road right -of -war along the southerly line of said lands
t of i%
Grantee is responsible orapdysubsequentayearsate taxes for the
year 1994, payable i
u
This ...... J_-%_RQt--------- homestead property.
(is) (is not)
Exception to warranties:
Dated this ........... ........ day of __... -_ - - -- Junk _ _ _ ._ - - ls. ` i
i
_p
I ( SEAL) (SEAL)
- _.... - ..._... - . .. ........ .........
it
Rav • G. Brown
_(SEAL) (� --�"t - - ts£ALi
s Eleanore Brown
i�
�I AU.THBNTICATION AGSM.: WLSDGMENT
signature(s) ------- STATE OF WISCONSIN
i
Brown uncy
- - - - - --
------ - - - - -- ---- • -• - - -- - •--- •- - - - - --
l
___._. 19. Personally came before -------- - -• - Y
of
' II authe 'ca .__d y 95 be me this - - _da .�I
j d
I f --•°----- -- ------- -- •-•--.._..--•------•
19 ........ the above named 'f
' - -- Wi 1__ i am J. i 1 bert.• -• ------ - - - - --
- - - - -- - - - - ----- - -.. -_ .- •-------- _- -- - - - -. --- - - - - -- ----------- --
r TITLE: MEMBER STATE BAR OF WISCONSIN --------------------------------- -._. ........ ............. ................. ..
(If not, ............ . -- .-- ••- - - -- _ ----- J
Y i authorized by 4 'i06.06, Wis. Stste.) to me k to be the person ............ who executed the I
foregoing instrument and acknowledge the same.
?i THIS INSTRUMENT WAS DRAFTED BY
Willia . m J. Gilbt. Attorney -- ------ - - - - -- - - - - - -- - - - - -- - - -- - - - - -•- - - -•- - - -- -- . _...._. - - -- ;I
II ............... er �................
- -- ........... - - - - --
`
------- ---- ---- . - Hudson, WI .,4016 ____ __ :• _._. , - -. , County, Wis.
...._
`I My C .m�siio it permanent. (If nut, state expiration
Signatures may be authenticated or acknowledged. Both
e riot necessary) date
!I
*Names of persons signing in any capacity should be typeA or framed brio, the" ,�' °•'>:'' -
i „ Wiscone. legal Blank Co. Inc
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WAhAANTT DE °D STATE BAT or WISCt"'S8v n �au:ee Wt onsin
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