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Sat m;4- "' -V 1411 Z 7 S_ DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COON Y
mom STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 �t,�
8% X 11 inches in Size. Cheek if ev sion to prev ous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. AP PLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
%aS�Y., S _T TZ9, N, R If E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
Aa z /K
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
L S D /ry Zy 3233 Gldr t4.
Check one CITY NEAREST ROAD
11. TYPE OF BUILDING
( ) ❑ State Owned ❑ VILLAGE w A �
• L�oi Wo
❑Public 1 or 2 Fam. Dwelling -# of bedrooms' NuM ( )
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/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 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 in line A. Check line B if applicable)
I
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 # — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ® Se i ge Bed 21 El Mound 30 ❑ Specify Type 41 El Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System -in -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION
�. b 1 7L0 7 Z cp O, G 2- S Feet / U s s' 1 Feet
VII. TANK CAPACITY Site
in allons Total ## of Prefab. Fiber- Exp
INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Ta or Holding Tank x / 000 5
Lift Pump Tank/Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plum er's Signature: (No Stamps MP /MPRSW No.: Business Phone Number:
r (St `o, n /�l /'- �' 3 2 ?-
7
Plumb r' Aress reet, City, State Zip Cod•
e
IX. COUNTY /DEPARTMENT USE ONLY
Lj Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signature (N Stamps)
0 Approved El Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: '
SBD-6398 (formerly Plb -67) (R. 11/88) 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 the 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 (SRD 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 & Buildings Division, 603- 266 -3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be jostalled.
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 in 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 in ##1 -7.
Vil. Tank information. Fill in the capacity of every new aid /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 ` 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 8Yh 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; wei!s; water main:, /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; close 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, ground-
water contamination investigations and establishment of standards.
SBD -6398 (R.11/88)
ST. CROIX COUNTY ZONING DEPAR
AS. BUILT SANITARY REPORT f �
i
Owner 4
Property Addr
'^UNl Y ,
City /State 6..
.,
Legal D scription:
Lot T Block -- M # Subdivision/C Il e'll;p-
Sec. , T-.2 -1� -W, Town of PIN # /��O
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer ,� Size ST/PC Setback from: House A / Well
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake er Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system::/ Width 3 Length �� Number of Trenches 4=�Z
Setback from: House 3S' Well J d' P/L a s - Vent to fresh air intake
ELEVATIONS
Description of benchmark
` Elevation
Description of alternate benchm Elevation� yob
Building Sewer ST/HT Inle ` ST Outlet / 3 PC Inlet
PC Bottom r--- Header/Manifold I 6 Top of ST/PC Manhole Cover d
Distribution Lines ( ) �� Z 6" ( ) i 0.7— 1� ( )
Bottom of System ( ) Z - Z , /1V 3 ( )
Final Grade O O ( )
Date of installatio> /--? r a it number State plan number
Plumber's signature License number 2. �99
Inspector
Complete plot plan Or
s
w
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.
VIA AN VIEW
i
G z
s /
s
ue
INDICATE JNRTH ARROW
�Sr
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County
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)]. 353268
Permit Holder's Name: ❑ City ❑ Village ❑ TRwn of: State Plan ID No.:
Richmon Jerry Town of Hudson
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
Oro '� 0'0. �� GO S 4� 020-1281 -20 -000
TANK INFORMATION ELEVATIO DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �-� Benchmark
Dosing V Alt. BM ,O
Aeration Bldg. Sewer -�
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic Wpb i NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
I e .vo oa •:gib
Holding Bot. System
0 4
PUMP/ SIPHON INFORMATION Final Grade
Manufacture Demand St cover 2. (off �-
Model Number GPM
TDH Lift action System TDH Ft
Forcemain Length ID:ia. H Dist. To well
SOIL ABSORPTION SYSTEM
_TRENCV Width I Length No. f enches PIT No. Of Pits Inside Dia. Liquid Depth
DIME IM N I N
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuya�ure:
SETBACK CHAMBER
INFORMATION TypeO M e Numb
System: -2 ti(01 I --�� OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold V Distribution Pipe(s) Ix Hole Size x Hole Spacing Vent To Air Intake
Length Dia._ _ Length Dia. Spacing �
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.) Inspection #1: Inspection #2: / !
Location: 641 Cherrywood Lane, dso WI 4Q16 (NE I/ 4 SW 1/4 34 T29N R19W) - 34.29.19.1349
1.) Alt BM Description
2.) Bldg sewer length= I� N
- amount of cover= y I�
S Ys� w
4Y,- 0% calk s ys., 4115, bps �P
Plan revision required? ❑ Yes m0 No Z
Use other side for additional infor ation. (a, I .. ) _ 0 �4 (I
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
. 41, �.m,-� -
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Safety and Buildings Division
Ifisconsin SANITARY PERMIT APPLICATION 201 Box Washington Avenue
Department of Commerce In 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 '51, ,
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State sanitary Permit Numb
- 35-3, :24!
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRkNT ALL INFORMATION `—!"—
Property Owner Name Property Location
/ ► ii4 14, S 3 T , N, R 40E ( 6W)
Property Owner's iling Address U Lot Number Block Number
Cit , Sta Zip Code Phone Number Subdivision Nam or CSM Numb
II. TYPE OF B ILDI ' (check one) ❑ State Owned Cit I Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms j VIl OF
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s 29j
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 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 online B, if applicable)
A) 1. ❑ New 2 e lacement 3, [3 Replacement of 4. [] Reconnection of 5_ E] Repair of an
------ System -------- System------------- Tank Only -------------- Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed j 1 ❑ Mound 30 E] Specify ype 41 ❑ Holding Tank
12V(Seepage Trench / ❑ In- Ground Pressure 42 ❑ Pit Privy
13 C] Seepage Pit (� 43 ❑ Vault Privy
14 ❑ System -In -Fill a— 3 JC 7 7
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. Sys em Edgy. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min_/inch) s Elevation
�_ o C 3 eet 0 b Feet
acct Site
VII. TANK in gallo s Total # of Prefab. Fiber- plastic Exper.
INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete st C Steel glass App.
Tanks Tanks
j Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
! Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for inst lation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber'sS re: No ps) MPIMPRSW No.: Business Phone Number:
PiVber's Addre State, Zip Code . — -
l 8 env All' i
IX. COUNTY /DEPARTMENT SE ONLY
❑ Disapproved CL-6 ary Permit Fee (Includes Groundwater ate I ssued Issuing Agent Signature (No Stamps)
NPApproved ❑ Owner Given Initial surcharge Fee)
Adverse Determination QD
X. CONDITIONS OF APPROVAL / REAS NS FOR DISAPPROVAL:
s+ti•, ,Q �,�e., I„>`.� 6&_ AW.QV ,w., ��)c,1�0 .�t ate, , __._
SB - 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.
I
PLOT PLAN
PROJECT Jerry Richmond ADDRESS 641 Cherrvwood Lane Hudson Wi 54016
NE 1/4 SW 1/4s 34 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 12/10/99 BEDROOM 3
CONVENTIONAL XXX IN -G UND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .8 ABSORPTION AREA 763 # of chambers 24
IL BENCHMARK V.R.P. Top of Survey Pipe ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
Vent
SYSTEM ELEVATION ,
V '
>12" Sidewinder High
of Cover Capacity Leaching
Chamber with 31.8
6' Long
1 6" ft ^2 per chamber
3 4" Grade at System Elevation
Driveway to CherryWood Lane
TWell
10'
Existing 3 30'
Bedroom House
35'
5 '
0 2 -3' X 77'
Trenches with T
6' Spacing
20'
15'
B -4
System is to be oversized
B -3 due to concerns of owner
60' L 60'
30' Failing System
B 30' 7 3 0'
Vent B -2
18
Vents
"BA 30' Property Line
12/09/99 THU 14:26 FAX 715 386 4686 ST CRX CO ZONING 0002
OEP ENT OF RE PORT ON SOIL BORINGS AN D SAFETY &BUILDINGS
INDUSTRY, DIVISION
t-ABOR AND PERCOLATION TESTS (115) P. °•• BO 7969
MADISON.
HUMAN REL TIONS SON, WI 53707
;
(ILHR 83.09(1) & Chapter 145)
1 . I p TONSH /Mki1QfCTPACLT'!•9: LOT NO.: LK. NO,: St BL VISI N N E:
� N�R19. E` (Or) w W i4 �- e>J� >�'y fits
COUNTY: O E NAME:
ed 1�L ,a .1 L Lce - _
DATES OBSERVATIONS MADE
US T R a
Reside nc� NNENeCwA �Replacs ... y M�Q fE. 11 3 �9 Z �' , a7 QC!`''� - r7 .
• RATING: S- Site suitable for system
u- S a unsuitable for system6 •�I(� - 4XC-Z '
E ON NT A_ : M �: O� 1{V-G�� ❑� : S S - S U M•tN.FILLHO� L NG K: RES^OMNV1= VTlba.lrQt .( �1 all
gg S U' f��7V1 1�
It Percolation Tests are NOT required OESI RATE: f If any portion of the tested arcs is in the
under s. ILHR 83.09115111b), Indicate: ♦:,Jt15� J..• -�• F indicate Floodplain elevation:
IL PROFILE DESCRIPTIONS
80RING AL PTH T R NDWATER -INCH S C ARA R O OIL WITH THICKNESS, COLOR TEXTURE, AND DEPTH
NUMBER DEPTH .4P0. ELEVATION gS VE TO BEDROCK IF OBSERVED (SEE A68RV. ON BACK.I
B- J g •`d' -� o7.1S E >
s� ` s'B�sc C . - rs Zs "&e.� Ls , 4 'b p er' .. '79 [ " �
B ` .6 S Oln(£ >
3
i. Z�gk - I5 /l� 1/ �`6T4w►�CNS /
B_3 9• . Na�� >9.7S 63"$¢.��11s
B.d 9• O /.9t. >9.so 4"$�5�,szz'sati>'►�s ��s " s�MS
B /O•� / z.a3 " y %D.OFS /1BzSt'rS 2b'B�N Ms 44 1R`i9P_ ,MS 41;' ELSL
B-
' D PERCOLATION TESTS
TEST NUMBER DEPT AFTER 5 EL�ING INTERVAL T DROP A V -1 HE RA PER I MI NU TE S
H
P_ 1 6.10 07., o O < <
P_ Z 5aa to [yS0 < < >
P. O /O O sir
P_ A C16 '- -'- AT t1t P—G-
P_
PLOT PLAN: Show locations of percolation tests,,, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical levation reference points and show their, location on the plot plan. Show the surface elevation at all borings and the direction and per-cent
of land slope,
SYSTEM .ELEVATION ..
ID 3
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I, 4: ounclersign hereby certify that the soil tests reported on this form were made by mein accord with the procedures and m4thods specified in the Wisconsin '
Ad'ministrat(ve f� and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
AME print 4E STSWEFI g MPLETED Of,
J + o� Joel �1 Sv2V - Y/nK, J4 �� 9 � ryAU oNNS N NUMBER: P ON U BERR(opptional):
AQDR S r U RE:
DISTRIBUTION: Original and one copY to Local Authority, Property Owner and Soil Tester.
DILHR- S80.6395 (R. 10 /831 — OVER —
ST CROIX COUNTY
4EPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
i
OwnerBuyer 2i
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
Z
City/State / ¢.'a &o Parcel Identification Number _ o�z `o
I
LEGAL DESCRIPTION
i
Property Location/ ' /4, /,, Sec. & T4L -R, W, Town of
Subdivision Lot #
Certified Survey Map # , Volume ._— - , Page #
Warranty Deed # 5 Volume �` Page # J 6
Spec house ❑ yes B-no Lot lines identifiableg 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
master plumber, journeymanplumber, restrictedplumber 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.
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 D artment of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your se . c stem been maintained must be completed and returned to the St. Croix County Zoning Office within 30
ys of the ee r irati n date.
/Z%1.
A PLIC DATE
R CERTIF ON
I (we) certi t state tints o� this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
perry desc ' b by a of, warranty deed recorded in Register of Deeds Office. /
l Z
S ATU ICANT DATE
* * *. Any information that is - - representedmay 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
L
i
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have 'nspec ed the septic tank presently
serving the residence located at:
ction �=� T N, R/�--W, Town of
Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced: �2� /� r / /
Did flow back occu rom absorption system?
r
Yes No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concret Steel Other
Manufacturer: (If known)
Age of Tank (If known),:
M
(Signature); (Name) Please print
0 a c
(Title) (License Number)
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR 83, Wis. Adm. Code (except for
inspection pe ing er outlet baffle). 01/
Name / Signature .S -/'Z/ - MP /MPRS
DOCUMENT NO. STATE BAR OF WISCONSIN Ft,= 3 -198x{ TMU srACC RCSCR -OR R CCOROiNe DATA
GlllT CLAIM DEED
- ...............•.............................................. ...................._--•- -• - --- ----•-- - - - - -- V U L 17 1995
.......... ....... ... - - - -_•. --- ........ '
�afil.cia � : - • Richmond .......... .....................
gn3t- claim. to .... JerY. 1...L�...Richmond ............ . 9:30 A.
............................................... .. :........................ ---- - -• - - ---
"
................................ ............................... ....... . . ............ .......... .............
........... .................................................. ...................... _
the following deuribed real estate In ..............St. C ZOlx CAan x-4-
State of Wisconsin: ,veN T ,Wagner & Todryk, S-
393 Red Cedar Street
Meno WI 5 4751
i� 020- 1281 -20
Tax Parcel Not . ....................
Lot 14, Plat of Cherry Hill in the Tarn of Hudson,
St. Croix County, Wisconsin.
TOGETHER WITH a driveway easement over that portion of Lot 15,
Plat of Cherry Hill as shown on said Plat.
I� This Deed is given pursuant to a Findings of Fact, Conclusions of Law,
and Judgment of Divorce, signed May 31, 1995, and filed in the Circuit
Court for St. Croix County, Wisconsin, in Case No. 95- FA -38, In re
The Marriage of Jeryl L. Richmond and Patricia Richmond. By said
Judgment of Divorce and this Deed, Patricia A. Richmond relinquishes
all right, title and interest in the above- described property.
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This ... ls ................. homestead property.
(is) (is not),
Dated this - 1 ............ 5.. ..... ......................... day of .....__.. � ........................ � 19..95..
......... -- ..............................................
{ .......( SEAL) ' �4�: 4. R.. Q :.�c_filrr..r..r- �a�S,�..(SEAL)
I • ------------------------------------- I ............................ PATRICIA A., RICHMOND
......--• ... ...... ......................... .........................(SEAL) --- — -------- ........................................ .__. ........ (SEAL)
AUT133INTi ATION OF ACSNOWLSDOMBNT
PATRICIA t �RI HMO /��,,
Signature a),is� ..l�Ll_ th :-e STATIC OF WISCONSIN
-- . .......................... county.
authenticated thii 5 /:/.day of ..__.e ....... 0 19. 1_ paisonaliy came before me this ........ ........day of
............................ , 19........ the above named
.. ......................•-...------........_.........--
-- ..........................--••--... ............................... i
• - ZST1XA...E.t._ WI LL I AMSON ......_.. I
-- - - ------ ------------ -------- TITLE: MEMBER STATE BAR OF WISCONSIN
(If not . ............................................................ - -- - -- ......
authorised by ; 706.08, Wig. Stats.) to sae known to be the person ............ who executed the
feeevaisg instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Wa ner & Todr
y k, S.C. ------•-• ............................. •-- •-- •-- •••.._.__.............
�.. ...........................................
(? - -, -- Cedar St, r "Menomonie, WI__ Nola" Public ............. ....... County, Wis.
es
(Signatur may be sutl enticated or aeknowle XT asesfsission is . ..
are not necessary.) ` "a"" a°th perm anent. If f not, , state ex piration
dam= ...................... ........ .._ .................. 1 19.._.._...)
.X. of persons si"Iea in any eapaeity should M typed or printed below ilea ailrtures.
iyy1e )STATE SAM OiP WWAtCOPM11M
FORM Me. r — sa-_ Stack No, 13003
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SCALE IN FEET
0
TO
TO 0' 100' 200'
3
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v I STEWART'S AODITIO
tn
UNPLATTED LANDS F I
— — — -" — — — — —
m^ I EAST LINE OF STEWART' S A
ROADS Z �
I N 01 E
N 00 E 335.88' 86.92'
NOTE: THIS CORNER
IS OCCUPIED BY A
18" WHITE OAK.
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AL CL I CID m 155.957 S.F.
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N 0120' 48' E S
200.00' N42'06 "W '0
35.00' EASEMENT FOR A
JOINT DRIVEWAY TO
SERVE LOTS 15 & 16
9
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N 29 Jp. `���• >� 7v�. 69.95'
.01
14 DRIVEWAY N18.23'48
3.819 AG. EASEMENT TO
SERVE LOT 14 )O
0 166,372 S.F.
0
0 N06'55'47 "E
m ^ 60.28'
0 13
3 s S 08 44'28 E
m c 290 i11 BENCHMARK - TOPS
M a - _ OF 2" IRON PIPE -
m ° — ELEV. 935.11
H w I N6'00'E 185.00•
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3 00 • EASEMENT FOR y g. \\
2A °o SANITARY SEWER
5 3 05• s SYSTEM THAT WILL
t . 0 4 e SERVE LOT 12
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4.420 AC. '� o N �-
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