HomeMy WebLinkAbout020-1357-22-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
U2��h y
Owner 0 h4 t �•AN
Address
M1. • I
� r
City /State �,t,l) 0 40
�,
Legal Description:
Lot Z 7 � Block — Subdivision/CSM # ils P Aff
'/• 0 '/, S W , Sec--a , T $ N -R W, Town of IAnl�i 0-1 PIN #
x. 9. A 11 4
SEPTIC TANK -- DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer d Size ST/PC NT)'GP� Setback from: House Well � /L �t
Pump manufacturer - Model --"- -
Alarm location
(HOLD G TANKS ONLY)
Setbacks: Service roa
Meter location
Alarm locati
SOIL ABSORPTION SYSTEM:
Type of system: u Width 3 Length U Number of Trenches 3
Setback from: House _ � 0 Well 1 S'-' P/L X15 Vent to fresh air intake
ELEVATIONS
Description of benchmark C
Elevation jou,o
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet ST Outlet 100.8( PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover SU
i
Distribution Lines (• ) g g. 3 (o ( ) (o
Bottom of System
Final Grade ( ) �- U U ( ) UU . S, J ( ) 4 9 , U (�
Date of installation 2/08/ Permit number 3 44613 State plan number
Plumber's signature V ,,,�\ License number a�a g oy Date
Inspector K&\ t 0
('omplcic 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
Duel
3��d�,
�3 a$
ai o
0
ra' 36
a'
a.
3 TK4
INDICATE NORTH ARROW N �'�
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
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)]. 344633
Permit Holder's Name: ❑ City ❑ Village W Town of: State Plan ID No.:
an on Town of Hudson
C T BM E10. I Insp. BM Elev.: BM Description: Parcel Tax No.:
CFO •Z t U0'0 r l 2 tr C- D 020-1357-22-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic f Tt7 Benchmark o r
Dosing Alt. BM - l• Y2_ A 7 . 91
Aeration Bldg. Sewer 40 02.44
Holding St /Ht Inlet 7.4 5—
TAN SETBACK INFORMATION St/ Ht Outleto�
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic r NA Dt Bottom
Dosing A Header / Man..( O
Aeration A Dist. Pipe
o
Holdi Bot. System _41fo `� .
PUMP/ SIPHON INFORMATION Final Grade +t*Y
Manufacturer Demand St cover 2. Y O
Model NVrq G M LV loz. e .. ;.►c ;�
TDH Lift Fri ' n System TD Ft
ss
Forcemai ength H ist. To well
SOIL ABSORPTION SYSTEM g
BED /TRENCH Width / Lengt ( No. f renches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION 3 DIMENSION
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufactu er�_
CHAME
INFORMATION Type Of } .� S i t �S' ��— OR UNBT R Model Number:
System:
DISTRIBUTION SYSTEM
Header / anifold �, Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length �_ Dia. 1 ;28
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 I ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l: / /9? Inspection #
Location: 844 Waldroff Farm Road, Hudson, WI (NW1 /4, SW1 /4, Section 23 T29N -R19W) - .2 . . 096 , (A) wl�w
I- .00
13 r • Ewa/ a l8 "i' c y. 9� • so Z.9g 03
( I�n re sio edluirda ? Yes No
Use other side for additional information. Fa s Z- C S
SBD-671 0 (R.3/97) ce . 441t f r'sSignature Cert No.
• r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
k
e
V A -
- 1 � -- Inn
LEI a
f
s
a
�m
a
S
°s q
,
E
7
i
S 6
3
111 1 : 1, �e
( f
4 € S
E o ,
F � i
? e x
+ t
t e
E
F F
k @ E
q z;
P 4 3
# i
3
_. €
6 EE
s
m
{
� a
i k 7
..
-s. ®. .e .� ....
x
I @ e k E @ k ..:
' 2 !
f a�.
x ,
t k t I
, k :
. ,e,.e. >_ ..._..,... ,.:. , ... ,.. ,. . .,.. _,.e
.. g .....
F a
4
__ __ , ....
r
a g
1
Safety and Buildings Division
201 W. Washington Avenue
N*Isc SANITARY PERMIT APPLICATION P O Box 7302 g
Department of Commerce accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. (`T}
• See reverse side for instructions for completing this application State Sanitary Permit Numtl
y ou p rovide may be used for seconds ���
Personal information
Y p y second purposes ❑Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
P rty Owner Islalne Property Location
/4 r5W 1/4, S 13 T 9 , N, R (? E (or) v
Property Own 's ailin ddress L Number Block Number
Cit , tate I Zip Code, Phone Number Su divi 'on Name or CSM Numbe
����^ �-
11. TYPE OF BUILDING: (check one) ❑ State Owned Its Nearest Road
p Vil age 1 /
Public 1 or 2 Family Dwelling - No. of bedrooms y Town OF 7y
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) �w 135l — 22-04DO
1 ❑ Apartment/Condo
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 M it 1 Service Station/ Car W
� 00 8 ob a Home Park 2 Se ce Stat o as h
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 ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pre
Distribution Pressurized Ex erimenta/ Other
ed p
11 Seepage Bed 21 []Mound 30 if T ype 41 Holding Tan
❑ ❑ ou d ❑ Specify yp ❑ o g IC
12 ®,Seepage Trench 22 ❑ In- Ground Pressure , 42 ❑ Pit Privy
13 ❑ Seepage Pit z �` 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. Sy to Elev. 7. Final n Gra
3
s , n
Required sq. ft. Proposed (sq. ft. (Gals/ /sq. ft (Min. /inch) m 4.7 e � � F�
V 7 S �r ✓ . (p et e
Capacit
VII. FORMATION in gallo Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Exper.
Gallons Tanks Concrete lass Plastic A
New Exlstln strutted
9 PP-
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I I I I � 01 ❑ ❑ ❑ 1 ❑ ❑
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on attached plans.
Plun er's N Print) r �/j Plumber's signature: (No Stamps) MP /MPRSW / N � o.: / B / / u \ / siness P e Number:
Plumber's (Stmt, City, H Zip C de): /
6 ��( � � � T om . r
IX. CO UNTY // DEPARTM USE ONLY
❑ Disapproved Sanitary Permit Fee (i ncludes Groundwater ate slue Issuing agent Si nature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination
- Z zr O v - —.
X. CONDITIONS OF APPROVAL / REASON FOR DISAPPROVAL:
Fever Ou Pc ,'�'.
Sew- e
SBD- 6398 (R.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.
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.
?J 04
Pr'l 'Phi mAer
-'Ri� Alwaan A M MF Tim = LU P-,P �ex
9
AMP
= $okekol�s
i
Nig(Luu i-"
Q /450
p �o L eo
k
I M 1 38 O A � I O N ok /vvp �, k.
plfi NPd IN Dtpp
p rze � g � i� e �I-ev - P ° P 1 '�'�
3
I ov $0
a `3° NA MPn� X01' 0'
Q "PUC-
Q`►lbh IZ�w GI,, �UV -� Ono
S
c, �9. as
ILI c c b 2
-p E c cfl
o C = (� ` r C7
j
to o f c3 p N x sri vi
to
EE c x rncn
W - -- ..
� m 'm C to
.�
IT . . . . . . . . . . U)°OO co
z a� 3 CD acv
b c*) O N F� -� cn U
a� �_� a ,a v O W
uj a c�,E x
(ii > c J
. .
J
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
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 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distant - ;clad. 020- 1020 -90
,` `' ' / ' MID B DATE
APPLICANT INFORMATION PLEASE I1�.
PROPERTY OWNER: P� , ` �C PROPERTY LOCATION
Kernon J. BAst
�! � GOVT. LOT NW 1/4 SW 1 /4,S 23 T 29 N,R 19 R(or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
948 LaBar a Rd. � '; 22 na Evergreen Estates II
CITY, STATE ZIP C HO R ❑CITY ❑VILLAGE EJOWN NEAREST ROAD
Hudson, WI. 54016 775 Hudson Waldroff Fm. Rd.
I New Construction Use [x j Residenti NiOber.of_bedrpdms, 2 [ j Addition to existing building
[ J Replacement [ ] Public or comnlefs des rib
Code derived daily flow 300 g pd Recommended design loading rate • 5 bed, gpd /ft - trench, gpd /ft
Absorption area required 600 bed, ft 500 trench, ft Maximum design loading rate • 5 bed, gpd /ft •6 trench, gpd /ft
Recommended infiltration surface elevation(s) 97.95 - 97.50 -96.85 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material LIMESTONE UPLANDS Flood plain elevation, if applicable na ft
L S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
IJ = Unsuitable fors stem ®S ❑ U NS ❑ U ®S ❑ U ®S ❑ U ❑ S ERU E3 13U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed I lTrerich
1 0 -12 10yr4 /3 none sl 2mgr mvfr gw 2m .5 ( .6
2 12 -66 10yr5 /4 none fs Osg mvfr gw if .5 .6
Ground 3 66 -84 10yr7 /1 none limestone res duum na na np np
elev.
1.
Depth to
limiting
6t
Remarks:
Boring # 1 0 -15 10yr4 /3 none sl 2mgr mfr gw 2m .5 .6
'.'.....2... 2 15 -62 10yr5 /4 none fs Osg mvfr gw if .5 .6
3 62 -66 10yr4 /4 none sl 2msbk mfr gw na .5 1 .6
Ground
elev. 4 66 -84 10yr7 /1 none limestone residuum na na np i np
100.
Depth to
limiting
fat
(M .1 1
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200t e. New Richmqind, WI 54017
Signature: e Date: 6' -17 -99 CST Number: m02298
o t
PROPERTY OWNER Kernon J. Bast SOIL DESCRIPTION REPORT Page 2 of 3
I
PARCEL I.D. # 020 - 1020 -90
Boring # Horizon
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -18 10yr4 /3 none sl 2mgr mvfr gw 2m .5 .6
{ 3
2 18 -53 10yr5 /4 none fs Osg mvfr gw if .5 .6
Ground 3 53 -63 10yr4 /4 none sl 2msbk mfr gw na .5 .6
elev. 4 63 -84 10yr7 /1 none limestone residuum na na np p
Vw
Depth to ,(�
limiting Z
63"
Remarks:
Boring #
1 0 -10 10yr4 /3 none sl 2mgr mfr gw 2m .5 .6
2 10 -62 7.5yr4/6 none fs Osg mvfr gw lm .5 .6
LM
3 62 -66 7.5yr4/4 none sl 2msbk mfr gw na .5 .6
Ground
elev. 4 66 - 10yr7 /2 none limestone residuum na na np np
9 s
w -U .
Depth to g
-
limiting �, '>✓
Remarks:
Boring #
1 0 -12 10yr4 /3 none sl 2mgr mfr gw 2f .5 .6
<_' 5 2 12 -56 7.5yr4/6 none fs Osg mvfr gw if .5 .6
3 56 -67 7.5yr4/4 none sl 2msbk mfr gw na .5 .6
Ground
elev. 4 67 -84 10yr7 /1 none li stone residuum na na np np
99 ft.
t$c ° Nl
D
Ah
epth to
limiting 30 Z
67" _�
Remarks:
Boring #
Ground
elev. j
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
J .
STEEL'S SOIL SERVICE
Gary L. Steel Kernon J. Bast 1554 200th Ave.
CSTM2298 NW4SWy S23 -T29N R19W New Richmond, WI 54017
MPRSW -3254 town of Hudson (715) 246 -6200
lot #22- Evergreen Estates II
N
1 =40'
BM. =top of 2 pvc p ipe C el. 100.00
Alt. BM.= nail in dead poplar tree C el. 101.80
lb
3 V
Gary L. sTeel
6 -17 -99
Y. SUIL ANU ,11 t LVALUA 11Uh "IMPUH I rap s — at --
taborand FMmun Rdatlona
f)ivWa► of Safsh► i 8uibnQs in accord with ILHR 83.05, Wis. Adm. Code
St. Croix
Anach'oi nmplats siti on paper not less than 81/2 x 11 inches in size. Plan must include, but F020-90 N
not limned to vordosl and horizontal reference point (BK, cirection and % of a". scale or
drrrtsnsiorwd, north "snow, and Nation and distance to nearest road.
REVIEWED BY
LIA FE
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION
FHUdism,�'. PERTY OWNER: PROPERTY LOCATION
GOVT. LOT NIN U4 SW vo 23 T 29 ,NA 19 1(0) W
J. BAst
PERTY OWNER'S W UNG ADDRESS ' LOT to BLOCK+t'• SUED. NAIL OR CSM •
948 Rd. 2
STATE CODE PHONE NUMBER OG� ILLAGE 0M NEAREST ROAD
WI. 5401 X1 151386 - 7775 Hudson WaldirOff Fla• Rd.
J New Canslrtxdort' Use pc l Resider" / Number of bedrooms 2 t 1 Addition ID exis*V building
Public or oomrnerdal dexd
R eplaaernent , ILj 300 Reoortsnended design boding rate • 5 bed, gpd/tt •6 trertoh, WW Code OW d* k 30 13
600 500 trench. It MaxGnum design bactlng rale_, 5 ._. bed. g • 6 ,
k t surface sle++alion(s) 97,95-97.5n-96-85 a R (as neNrred Igo site plan benc wwk)
Reaortsttter+ded , , _ -
Addrtlori111 design t 8 c01111k calm na
Parent tlteMtiai LIMPSl"M [JPZ.AWAS Flood plain *VOW. tl appik:" nt► K
$ a S{ {e CONVENTIONAL MOUND SYSTBI N
W- GROUND PRESSURE AT-GRADE U MOLM TANK
SsUrrs ®S ❑U ®S ❑ ®s ❑U ®S ❑U ❑S [SU 0 d
SOIL DESCRIPTION REPORT
Horizon
Depth Dominant Color Mottles Structure Roots 4GPD/:ft ring #I Texture
In. Munsell tau. Sz. Cont Color Gr. Sz. Sh. Bo 0 -12 10yr4 /3 none sl 2mgr mvfr gv 2m . 2 12-66 10yr5 /,4' none fs Osg mvfr gw
1f • t--
Gtowtd 3 66-84 10yr7 /1 none li tone riss dtnam na ap AP
e�. I
1.I�L9n�
!
Deptl► b
tlniRng i
facto
66"
Remarks:
Boring .6
1 0-15 10yr4 /3 none sl 2mgr mfr gv 2m .5 E
2 15 -62 10 r5/4 none fs O.9 tttvfr gw if .5 6
.
2 Y
6.
3 62-66 10yr4/4 none sl 2msbk mfr •5••
Goixtd 4 66-84 10yr7/ 1 none ii stone res duutn na na nP nP
elev.
100.
m
6edting
66"
Remarks:
CST Na -_pWuc 1►rint G L. Steel Ptwne: 715- 246 -6200
me
Address: 1554 200E e. New Rich W1540 i
Date: 6 -17 -99 CST Nunkbw. m02298
I
,oPERr110WNER `� J. Bast SOIL DESCRIPTION REPORT. - A
PARt:EL IA # , 020 = 1020 -
Boring H orizon Dominant Color Mottles Texture `Structure ConsWenoe Bounday Roots OPD/ft
In. " Munsell Ou. Sz. Cont. Color Gr. Sz. "Sh. Bed
Ll
1 c0-•18 10yr4/3 none si Zmgr mvfr gw
21A .5
2 18-53 10yr5 /4 none fe Deg mvfr gw if .5 .6.
Ground 3 53-63 10yr4 /4 none sl 2mebk mfr gw na .5 .6
4 63-84 10yr7 /1, none 1 tone 'res duum na na np
j
DeWID �..•
factor
--63 »
Remarks:
Boring #.,;
1 0-10 10yr4 /3 none sl, 2myr mfr gw 2m .5 .6
4 2 10-62 7.5yr4/6 none fs Deg mvfr gw lm .5 ;.6
3 62 -66 7.5yr4/4 none sl 2msbk mfr gw na. .5 .6'
Ground .
Nev. 4 66-84 10yr7/2 none 1 � tone resi duum na na np
9 9.39 t.e .
to _
IMitirp
factor
66 11
Remarks: •
Boring #f .1 0-12 10yr4 /3 none sl 2mgr mfr
gw 2f .5 .6
5 2 12 -56 7.5yr4/6 none fs Osg mvfr gw if .5 .6
ANtwd 7 7 s 1Wv4 /A "0040 0#1 M"W%w "pop rwr . r M
slow. 4 67 -84 10yr7 /1 none lin otone res L duum na na np np
9 9.35 tt.
OepIh tD
loft
factor
67"
Remarks: '
Boring e
Lj
j
I'
�pf j
ft
r wo a
Gutting
larzor
STEEL'S SOIL SER''VIE
Gary Steel Kernon J. Bast 1554 200th Ave.
CS M2298: NVAsWc s23-T29N_R19w New RIchmond,_WI, 54017
MPRSW -3254 , a : town of Hudson ' (715) .246 -6200
lot #22- Evergreen Estates,:....,
i w=40 1 > .
BM.=tcp of `F2 "'pvc p ipe el. 100.00'
Alt. BM.= trail in dead poplar tree ! el. 101.80'
y '
tl 3 B ,
Gary L. sTeel
6 -17 -99
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
i >
Owner/Buyer � /V /4 e 0( /� w► A /l!
Mailing Address 5 7 G C V . Rd A .
Property Address y '� L t R c FF r �► 2 M C,AD , n
11 (Verifica ion required from Planning Department for new construction)
City /State / - /c, o / So .,j U11 S Parcel Identification Number
Cgs C) 0
LEGAL DESCRIPTION
Property Location IV GtJ ' /a, S w ' /a, Sec. 3 , T y N -R �I W, Town of /4L4 r] So AJ
Subdivision CV A 2 ! (2 c e; L— S 1A9 f cS .- , Lot # a .
\J
Certified Survey Map # , Volume / , Page #
Warranty Deed # 6 U &0 61 , Volume � `� `� ? , Page #
Spec house ❑ yes 7 no Lot lines identifiable Cg 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, signed by the owner and by a
masterplumber, journeyman plumber, restricted plumber or a licensedpumper 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.
Uwe, 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
day the three year expiration date. ��++
'V
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
the nroperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
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
I
r
STATE BAR OF WISCONSIN FORM 2 — 1982 605061
WARRANTY DEED KATHLEEN H. WALSH
► REGISTER OF DEEDS
DOCUMENT NO. �
VI.1 1 44 I PAGE 16 ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between KERNON J. BAST and 08-04 -1999 3:45 PM
DONALDA J. SPEER - BAST, husband and wife, WARRANTY DEED
EXEMPT li
_
,Grantor, CERT COPY FEE:
conve and warrants to _ RC1AiAT .M. *__HOUMAN._ a RP.TH A COPY FEE:
co
y TRANSFER FEE: 173.70
and wife, - RECORDING FEE: 10.00
PAGES: 1
,Grantee,
W i t n e s s e t h, That the said Grantor, for THIS SPACE RESERVED FOR RECORDING DATA
valuable consideration, conveys to the Grante NAME AND RETURN ADDRESS
the following described real estate in St. C r O i x County, FF/I
State of Wisconsin:
Lot 22, Plat of Evergreen Estates II, Town
of Hudson, St. Croix County, Wisconsin.
06,
PARCEL IDENTIFICATION NUMBER
This is not homestead property.
(is) (is not)
Exception to warranties:
easements, restrictions, and rights —of —way
Dated this ✓/ day of August A.D., 1999
*Kernon J. Bast (SEAL) Donalda J. Speer —Bast (SEAL)
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix County.
authenticated this day of , 19 Personally came before me this day of
August , 19 9 9_, the above named
Kernon J. Bast and
* Donalda J Speer —Bast
TITLE: MEMBER STATE BAR OF WISCONS
(If not, DIANE M. BARRON
authorized by §706.06, Wis. Scats.) Notary Public to me known to be the person _ s who executed the foregoing
State of Wisconsin instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kernon J. Bast
«
948 LaBarge Rd.
Notary Public, County, Wis.
(Signatures may be aut Locate or acknowledged. Both are not My commission is permanent. (If not, state - e date:
necessary.)
* Names of persons signing in any capacity should by typed or printed below their signatures.
STATE BAR OF WISCONSIN Wisconsin Legal Blanc Co.. Inc.
WARRANTY DEED Form No. 2 — 1982 Milwaukee. Wis.
L ' I
,; m, 0
UNPLATTED LANDS ` 5 c
'q or
KELLY ROAD N0O 51"E WLSI LINE Of Fill NWI/4
N00*12'57"W 280.82' 7-
DEDICATED TO THE PUBLIC I NOO 7075
_S90*12*57"L , '83.5 0'
BEARINGS ARE REFEP[Ncrb tu ipst V( St LINE
[IF THr NW1/4 Of SECTION ?I ASSUMED
TO BEAR N00*04•51't
x
ro :44,
c �
r
C ?
w
,D C-3
" qP
0
IX C
a, ru 4 W y1
a, r
c"
V) f') NOO*34'14"E 364.99'
V)
. 0 ;u
ill .
' V) 81 ow AT
Y
y
V
X
r r
CW
L, Wilt
ai
I J -, t,
.41i' 3 . 5, . Its )
,"
4T ji. 19 � VA
Lit
ij.& * N;
79 C;
op
v
64 U0 7 4.94' I tv]
A 160.94'
01 At
tvj
ru
V)
co au A470 w"I
00
NOO 1(rU.94' -c'
co
1 ; 7
b j --24 Zv co Y
do
of
cq
f
AT
01)
00
%D
p
1 4
0 M
z rl (71
!I ,, ' l u l
0 in
in �
z X
i'o 0 <
'u
C3 c: t:j
> -V M
Q)
N z V)
LIT
rx) r%J
z
>
Ln
FIT
-c to rFi
u 10
i.,
LJ!
C ,
,D
%
Il e
LA
1 A
lip
29"1 643.