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Witconsin Department of health aDd Social Services
P1b„ x{67 3 70 Division of Health
SEPTIC TANK PERMIT APPLICATION
r TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Code)
Be LOCATION OF PROPERTY W „ERE SYSTEM WILL BE CONSTRUCTED ALT OR E XTENDED COUNTY •
Check One:
CITY VILLAGE LEGAL DESCRIPTION / r d S t
TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons -NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS= Prefab Concrete x Poure in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: t
E. TYPE OF OCCUPANCY
Check One= One or Two Family Residence Commercial Industrial Other
Specify
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer �, YES NO
Dis!washer YES --— NO Automatic Potato Peeler YES NO
Other (Specify)
G. MASTER PLUMBER FAKING INSTTALLATION
Name. A d XISIV (7 ' 4/11 Address= _7 �/ C �sC V � License Number:
Signature of Applicant: ,1 �?, u'rr �t /L /.r _t2� _ - — MP RSW
Address: l��a�J� �.11 /1:5
g, ( o bee ompleted by Issuing Agent)
Date of Application C / / C _ Fee Paid $
Permit Issued (date) G /9 Permit Number .f
�,
Agent (Name) ,� A'trF I<</! i Fort ✓/� i 1 ✓, /'�
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above ejuestions are answered and the
fee paid. Agents wi'l forward application, the fee of $1.00 for each septic taruc and the third cop;
of the permit (canary) to the Division of Health. Checks and money orders should be made payable tc
the Division of Health.
Do not write in space below FOR DEPART::ENT USE ONLY
I. DATE RECEIVED - 1 d ACCEPTED BY RETURNED
(Initials) (Date) See (`orres.)
FEE RECEIVED V VALID. No, �� �� PERMIT NO.
i es or No
I REVIEWED BY APPROVED DATY
(Initials) Yes or No
COMPLETE OTHER SIDE
I
SEPTIC TANK PERMIT N0,
R S P 0 R T O N S 0 I L P S R C 0 L A T 1 0 N T E S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLUMBING SECTIN
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Otis. Administrative Code
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in or Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to I Last To Fall
1st Wetted Overnight in Minutes Last Period Last Period Period One Inch
Example
P - 0 36 Top Soil 10 Cla 26 25 Yee or No 30 1 2 1 2 1/2 60
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 His. Administrative Code.
S 0 I L B O R I N G S- Minimum 36 Below Pro osed Absorytion System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Cbservod Estimated Observed Estimated Character of S oil with Thickness in Inches
Example
B — 0 72" 72" Black Top Soil 12 C
L8 Sand 18 Gravel 24
C / • ,f � t j � �f �(` ` , mot � '�
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
PE OF OCCUPANCYs
RESIDENCES Number of Bedrooms OTHER (Specify) Number of Persons
D WASTE GRINDERS Yes No Di3bwashars Yes No �/ Automatic Clothes Washers Yes No
FFLUENT DISPOSAL SYSTEMS NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diaaeter� Liquid Depth
I, the undersigned, hereby oert_fy that the percolation tests reported on this form were made by me or under i.y super
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME �,k' ��,Q //� TITLE
~Type or Print
REGISTRATION NO. �I �^ /, oor MASTER PLUMBER LICENSE NO.
ADDRESS _� / , C A.�l� L) /T 171 ✓�
DATE f;� : UZ2 r SIGNATURE !.'✓L�� Z t= `� •JCL -t i/�
� 1
c
3 2T '
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Parcel #: 020- 1029 - 70-000 03/22/2007 11:31 AM
PAGE 1 OF 1
Alt. Parcel #: 16.29.19.134 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
O - JACOBS, LORRAINE
LORRAINE JACOBS
526 CTY RD A
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description " 526 CTY RD A
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE
SEC 16 T29N R19W SE SW Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
16- 29N -19W
Notes: Parcel History:
Date Doc # olI age Type
11/02/1999 613135 1467/592 TI
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 38.000 4,200 0 4,200 NO
OTHER G7 2.000 51,300 134,000 185,300 NO
Totals for 2007:
General Property 40.000 55,500 134,000 189,500
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 55,500 134,000 189,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 134
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
t
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SAM[TARY REPORT
Owner �� L c(z A' ) W t v� s
Property Address L C w
City /State ub r ou
Legal Description:
Lot Block Subdivision/CSM #
5 F t /4 5 ' W t /a, Sec. I T -RAW, Town of PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer U)kA�S Size ST/PC IGOU ! Set back from: House � Well SU t P/L
Pump manufacturer Model
Alarm location
(HOLD ONL
Setbacks: Service road s e Water Line
Meter location
Alarm locati
SOIL ABSORPTION SYSTEM
Type of system: - N� ` A � O Width Length - 66 5 Number of Tre
Setback from: House Well 5 b 't P/L a b' Vent to fresh air intake 56 -'
ELEVATIONS
Description of benchmark Q oo>M a s b) N c, Elevation 6) U 0
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet �} ST Outlet 5 0 9 PC Inlet .--,
PC Bottom f Header/Manifold 3 Top of ST/PC Manhole Cover 17A-3
Distribution Lines ( ) l a - F ( O () a - �� ( )
Bottom of System O 1 1 - '5 (� O ( )
Final Grade O S - S (-)
Date of installation / / Permit number 3 State plan number
Plumber's signature ��Wr License number aka Date
Inspector ON S O N N Y �Jy) -9_
_ - Complete plot plan �+
s
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
a -1'K uJa
jw�l
8'
Sb. 3s'
St ('R
N
INDICATE NO TH ARROW
I
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 3445 19 Permi IX
Personal information you provice may be used for secondary purposes [Privacy La I x.15.04 (1)(m)].
Perrr3mabm'a ROBER & LORRAINE E] Cit � IdgQ Town of: State Plan ID No -:
CST BM Elev.:- Insp- BM Elev -: BM Description: V1V Parcel TU N$._1029 -70 -000
1 oo jba t1ZZGO
TANK INFORMATION E VATION DATA
TYPE MANUFACTURER CAPACITY f &ION BS HI FS ELEV.
Septic e Benchmark '� �� 35
Dosing
Aeration Bldg. Sewer
Holding dy Ht Inlet S '33
TANK SETBACK INFORMATION Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD et
Air I e
Septic 7 p NA D
Dosing Header / Man.
Aeration NA Dist. Pipe
rz z. qi
Holding Bot. System t T I -z
2
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM -
TDH I Lift Friction System TDH Ft
oss Forcemain Length Dia. H Dist -To well
SOIL ABSORPTION SYSTEM R d * s 4t e
BED REN H Width ( Length No. Of Trenches PIT No- Of Pits Inside Dia. Liquid Depth
DIM I DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER r
INFORMATION Type Of Model Mumber:
System: A."v 7 S 30 OR UNIT G c
DISTRIBUTION SYSTEM
Header/Manifold r Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Ai`Intake
Length / Dia Length � Dia. Spacin� � J
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.)
LOCATION: HUDSON 16.29.1.134 SE,SW 526 COUNTY ROAD A
6, o, ye h t V r/ r� r� Cori/
(6Lff n�s -� � sf •tio/ = 8 1• 4 - 3
arst reir 6"
I I rokV row^ GernC✓
eI d
Plan revision required? ❑ Yes ® No
Use other side for additional information. 3 Z2 OU
�G SBD -6710 (R.3/97) Dao pector's Sign t e Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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V isconsin SANITARY PERMIT APPLICATION 2 01 afety and E. WashhingtonAve
P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less count
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Nu
Check The information you provide may be used by other government agency programs ❑Check if revis�io previous" ap ication
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
y caner ame joperty Location
S 1/4 A1/4,5 T ,N,R E(or W
Property Owner's M ing A Lot Number _ Block Numb r
A �
City, at Zip Cod Phone Number Subdivision Name or CSM N b r /'
( )
PE F BUILDING: (check one) ❑ State Owned ❑ it� N Road
E] VII age
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF .�
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) IL - . q
1 ❑ Apartment/ Condo 00 �o —
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 [3 Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an
______System _____ �5ystem____ _________TankOnly______________ Existing System _________ExistingSystem
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 30 ❑ Specify Type 41 ❑ Holding Tank
12KSeepage Trench 22 ❑ In- Ground Pressure t 42 E] Pit Privy
13 E] Seepage Pit ` ' Z , 43 ❑ Va It Privy
14E] System-In-Fill A�, F$
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
Required (sq. ft.) Pro osed (sq. ft.) (Gals/d y /sq. ft.) (Mi /inch) I � tion
q S() 5 3 7 Feet Feet
VII. TANK Ca c
in al allo s Total # of n Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tank Tanks
0 ❑ ❑ ❑ ❑ ❑
Li Pump Tank /Siphon Chamber 11 ❑ ❑ ❑ 13 El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Nam (P t ) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
Alh -E30 9d ' �f / X8,6 - Z. Q
Plumber's Address (Str et, City, State, Zip Code):
t ✓
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing nt Signature (No Stamps)
[r(pproved []Owner Given Initial � ,� urcharge 1 4 � & Vf e l l �j ,l�L i � Adverse Determination Fee)
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD (R.11F>IB) DISTRIBUTION: Original to County, One copy To: Safety & Buildings DWision, Owner, flnrnber
i
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 compiete and accurate this sanitary permit application must include:
. Property ow, — name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
I1. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
YP 9 9 Y P Y . 9
111. 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.
V11. 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.
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code
AC .E. Soil &Site Evaluations
Attach complete site plan on paper not less than 8' /z x 11 inches in size. Plan must Coun
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and Ioc i�.� distance to nearest road. parcel I .#
`' 020- 1029 -70 -000
APPLICANT INFORMATION - pl ►Ynt all infon��ron.
Personal information you provide may be used ary pu (Privacy l aw 15.04 (1) (m)). y D81�
Property Owner �' ; Property Location
Robert &Loraine Jacobs
ovt. Lot NA SE 1/4 SW 1/4 S 16 T 29 N,R 19 W
R -
Property Owners Mailing Address - - y v ► p =trot # Block # Subd. Name or CSM#
526 Co. H A ='� NA NA NA
-: . , Sr rn
City Stat 2 Code r f City Village Town Nearest Road
Hudson WI +4 1 yc QfF f ~� Hudson County Hwy. A
New Construction F7 ideptpl - flu bi`� rooms 3 [_]Addition to existing building
Use:
Z Replacement ❑ Public escdbe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ftz •8 trench, 9pd/ft
Absorption area required 643 bed, ft' 562 trench, ftz Maximum design loading rate .7 bed, gpdfft .8 trench, gpd/ft
Recommended infiltration surface elevation(s) 91.50' ft (as referred to site plan benchmark)
Additional design / site considerations In stall trenches using hig cap infiltrators.
Parent material Out wash s & gr. Flood plain elevation, if applica ble NA
L Su ft table for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank
suitable for system ❑ S ❑ U ❑ S [I U ® S ❑ U ❑ S El [IS ®U [_1 S ❑ U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Borin Horizon Texture Consisten Boundary Roots
9# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -12 10YR2 /1 None sl 2fgr mvfr gs 2f, lm 0.5 0.6
2 12 -19 10YR3/2 None sl 2fsbk mvfr gs 2f, lm 0.5 0.6
Ground 3 19 -38 10YR3/4 None sl 2msbk mfr cw If,m,c 0.5 0.6
elev
97.23' ft 4 38 -46 10YR5/6 None sil 2fsbk dsh aw I f & m 0.5 0.6
Depth to 5 46 -82 7.5YR4/6 None s 0 sg dl gs if 0.7 0.8
limiting
factor 6 82 -12 10YR5/6 None s 0 sg dl - - 0.7 0.8
>121" 7 10 -"
Remarks ID q —
Z 1 0 -12 10Y /1 None A 2fgr mvfr gs 2f, Im 0.5 0.6
2 12 -17 10YR3/2 None sl 2fsbk mvfr gs 2f, Im 0.5 0.6
Ground 3 17 -36 10YR3/4 None sl 2msbk mfr cw 2f, Im 0.5 0.6
elev
96.77' ft 4 36-48 10YR5/6 None sil 2fsbk dsh aw 1 f & m 0.5 0.6
Depth to 5 48 -78 7.5YR4/6 None s & gr 0 sg dl gs if 0.7 0.8
limiting
factor 6 78 -118 10YR5/6 None s 0 sg dl - - 0.7 0.8
Remarks: �
CST Name (Please Print) Sign ture: Telephone No.
James K. Thompson 715 - 248 -7767 —
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, WI 54020 5/15/99 3602 1029
PROPERTY OWNER; Robert & Loraine Jacobs SOIL DESCRIPTION REPORT tots Page 2 of 3
PARCEL LD.# 020 - 1029 -70-000 A.C.E. Soil & Site Evaluations
Depth Dominant Color Mottles Structure GPDIft
Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. nsistence Boundary Roots
Bed Trench
3 1 0 -11 i 10YR2 /1 None s1 2fgr mvfr gs 2f, lm 0.5 0.6
2 11 -17 10YR3/2 None sl 2fsbk mvfr gs 2f, lm 0.5 0.6
Ground
elev 3 17 -39 10YR3/4 None sl 2msbk mfr cw 2f,lmc 0.5 0.6
97.02' ft 4 39 -49 10YR5 /6 None sil 2fsbk dsh aw 1 f & m 0.5 0.6
Depth to
limiting 5 49 -8 L 7.5YR4/6 None s & gr 0 sg dl gs if 0.7 0.8
factor 6 81 -123 10YR5 /6 None s 0 sg dl - - 0.7 0.8
> 123"
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
Ground -- —
elev
Depth to - - - - - -- — - - -- - - - --
limiting
factor
I
Remarks:
Ground
elev
Depth to
limiting _
factor
Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerAguW -1
Mailing Address p9
Property Address o�
4 (Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location %,, .5WL 1 /4, Sec. le, T -,2 N -RAW, Town of . ",o
Subdivision , Lot #
Certified Survey Map # J Volume , Page #
Warranty Deed # c l /o� �1�n Volume ,Page # 91
Spec house ❑ yes Vno Lot lines identifiable ❑ yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the 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 the
signed b owner and b
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master plumber, journeyman lumber, restricted lumber or a licensed um in
7 Y� P , p pumper venfy g that 1 the on -site wastewater disposal . () � system
is in proper operating condition and/or ( 2) fter in and pumping if necessary), the septic to a e.
) P P tank is less than 1/3 full of sludge.
P g ( �') P g
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.
SlMATURE OF AP CANT 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.
SI NATURE OF ICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked b the Zoning Department.******
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** 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
FORM 184 -P (Adopted 1138) ANCILLARY JVnd MF"NT. - M. e. nuiR CO., enIVuete
291296
STATE OF WISCONSIN —_ S COUNTY COURT IN PROBATE
ANCILLARY JUDGMENT
E
I TIi SR H E OF
AT
send** �o Tai u
Ztts� Jaoob�r "d " NM I
_____ Deceased.
File No. 25665
PETITION for final settlement of the Wisconsin estate having been presented and heard, and the petitioner
having appeared in - person - and by attorne}s
M a 9" Md as V Ar&UM ad U and L.P. Qher
_— _- ____—_. having appeared as Public Administrator,
And on all the evidence, records and proceedings herein, the Court now finds:
°.`:.. J. _.That the
-petition came on for hearing -tiporr notice as prc�ided ks .laur o all- �eFSSO s ►nter ted;. .
2. That notice has been given of the taking of proofs of who are the heirs of said deceased;
3. That the expenses of administration, and the debts of the deceased have been paid; that the certificate of
the Assessor of Incomes shows that there is no unpaid income tax; that said estate is subject to inheritance tax which
has been paid
4. That there remains personal property for distribution as follows:
xats
S. That the deceased died seized of the following real property situated in the County o f — At. Cr
State of Wisconsin; f1
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IT IS FURTHER ADJUDGED AND DECREED
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That all accounts of the executor -on file herein are allowed.
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That the real property described at Finding 5 is hereby assigned and transferred as of the date of the death of the
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deceased, as follows:
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To Robert Dal* Jacobs for life, with the remainder over arter his
life estate to Gary Jacobs, Robert Jacobs, Jr., Lani Age Jacobs and
Laurraine Jacobs, provided that it Laurraine Jacobs shall re- marry,
I1 *r• intereat snail terminate and be vested in Oary Jacobs, Robert
Jacooa, Jr. wed LAni figs Jacobs.
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`hhat the interest of the deceased as joint tenant in real and personal property terminated at
That the life estate-of the deceased in the real and personal, property terminated at death.
Dated. _BbbrUary b ' 196a
.
By the Court,
TWA. J_# WIWAAM
j County judge.
H L. C4 i :: '1 `:. i` S J Q r Y' - 14- t
ST. CRC;IX CO.. VV
C document Is a full Recd for R °cord this. - 7t _
the ongin ;d on flb day of_F_cb.=arY _ -A. -. 19
ce and has bean D M.
'� Atlest 19
Regls er o" f ePd
MAAW M. Sch lo,
ster in Probate p ��
Boof