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Parcel #: 030 - 2106 -60 -100 05/08/2007 11:49 AM
PAGE 1 O F 1
Alt. Parcel #: 06.29.19.890A 030 - TOWN OF SAINT JOSEPH
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 - BENSCHINE, BRUCE G & LIV M TR
BRUCE G & LIV M TR BENSCHINE
363 117TH AVE
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): " = Primary
Type Dist # Description 363 117TH AVE
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 3.035 Plat: 3939 -CSM 14/3939
SEC 6 T29N R19W SW NE FORMERLY LOT 6 Block/Condo Bldg: LOT 12
EVERGREEN RIDGE NKA LOT 12 CSM 14/3939
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
06- 29N -19W SW NE
Notes: Parcel History:
Date Doc # Vol /Page Type
11/02/2006 837960 QC
03/22/1999 599766 1412/162 WD
08/27/1998 585886 1351/629 WD
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.035 76,000 275,200 351,200 NO
Totals for 2007:
General Property 3.035 76,000 275,200 351,200
Woodland 0.000 0 0
Totals for 2006:
General Property 3.035 76,000 275,200 351,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
FILED
AUG 2 5 2000 01 6 2"
A7 KATHLEEN H. WALSH
Register of Deeds
� SL Croix Co.,WI
ti
CEP T I F I ED SUP V E Y MA P
Located in the Southwest quarter of the Northeast quarter of Section 6, Township
29 North, Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin, being
Lots 6 and 10 of the plat of Evergreen Ridge.
Owner: Bruce Benschine
363 117th Ave.
Hudson, W i . 54016
117TH_ AVENUE n
S 8 9'52'23 " E 466.)60'
12 EASE MENT
I /00' N i
0 m LU
e y
Q01
f\ N ....- . ....................... 3.035 acres .... .........sFrap .K........4t^1E.............. N
W 132, 186 sq. ft. 3
W ' O .-� Z'
�' o !L ®7T' 12 �� w�
i
I (fka Lot 6)
j l O HOUSE O LIJ
LUI WI
206.89' 265.00'
S 89' 53 ' 16 "w1 S 89'53' 16 "W SO 3.00' E
NOO °20'2/ "W
3.00'
Legend
Aluminum county section corner
monument found.
1 "X24" iron pipe weighing 1.68 `
pounds per lin. foot set. 3.010 acres ~ i
1" Iron pipe found. m 131, 122 sq. ft. n
W : r n 1
Bearings referenced to the (D 0) Q
East -West 1/4 section line p `r
assumed S89 0 52'22 "W . 10): :X (� ®�7�'' / 1 h W CO
co LOI
Note: This CSM is a sale N v (fka Lot 10) v m
or exchange of land be- Z O (D I
tween adjoining owners. W 1 N `pv (U 0-1
Town and county approvalLU I J & I
is not required. The � I p O O rh I
North line of Lot 11 has C: N
been moved three (3') LIJ Z J
feet South to accommo-
date building setback W I _ SETBACK LAVE
requirements.
Jo ; /00' I Q:
J '
UTILITY EASEMENT
SEC.TION -29- 9 S89 °5222 'W � S 89 26' M '
3138.79' n S89 5222 "W 2
0 r 1S,99 °5,9'20 "W) -
SCALE IN FEET I"_ /00' �., RIVER ROAD err
0 100 2 0 — — — — — — — — — — — — — — — — —
N00020'21 11W 4002683
This instrument drafted by 33.00
Vol. 14 Page 3939
�* ST. CROIX COUNTY ZONING DEPARTME
• AS BUILT SANITARY REPORT
M..` 4� ST CFO 99
Owner
Property Address l 3Co 3 ll 7 .� !/ z+r Z A
OFF/ l k City /State
Legal Description:
Lot Lot Block Subdivision/CSM #
SGcI t /a � V4, Sec. , TAN -R _W, Town of PIN # 0 30- 2 166 - 6 13
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC Ids. /_ Setback from: House 33 Well "" P/L
Pump manufacturer Model _—
Alarm location — -
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
e
Type of system: ��_ Width 3 L� gth e7 Number of Trenches
Setback from: House R�? Well '— P/L �� Vent to fresh air intake 7 - O
ELEVATIONS
Description of benchmark Elevation JD
Description of alternate be nchmark Elevation l42 9 y
Building Sewer / J 02 ST/HT Inlet / D ST Outlet V PC Inlet
�
PC Bottom "" Header/Manifold l Top of ST/PC Manhole Cover 4 07
Distribution Lines 0 ) 7 ( ) '? e ( )
Bottom of System () 77 ( ) (? 7 d L ( )
Final Grade () l 3, / / ( ) 163,
Date of installatioirl number State plan number
Plumber's signature License number �'�1'� �ad 15 ADate
Inspector �{�A r
Complete 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
0
D �8
INDICATE NORTH ARROW
l
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
$afety an &.Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: ST CR IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 3 38 8 3 9
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
HENSCHii:E, Lj1XQ U ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/ -� I Lod S4r C 03U- 2106 -60 -000
TANK INFORMATION ELEVATION DATA A99 OZ 0
TYPE MANUFACTURER
n CAPACITY STATION BS HI FS ELEV.
eptic ji'Lf. `+G�n- Ptr,c - CZerb Bend} r4 la.-'y /tom C o0
Dosing ) -I. D, v I li -95/
Aeration Bldg. Sewer `a Da ,�L
Holding Inlet Z,o/
TANK SETBACK INFORMATION Outlet
TANK TO P/ L WELL BLDG. Air l*ntake ROAD Dt Inlet
e 3?, NA Dt Bottom
Dosing NA too. i7
Header /Man. 1 G -h 6
io.y7
Aeratio NA Dist. Pipe Z
Holding Bot. System it '43
3 •o
PUMP/ SIPHON INFORMATION Final Grade 7 UD /03
Manufacturer Demand 2- /09. 29
Model Numb GPM
TDH I Ift Friction ystem TDH Ft
I Forcem a ,- L Dia. I f Dist. To Wei
SOIL ABSORPTION SYSTEM
BED CB M idth Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 5 DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer:
SETBACK / 'A
INFORMATION Type Of Mode Num er:
Syste : dYt vl 7 t ' '��- OR UNIT CHAMBER frr A, Ea aci
DISTRIBUTION SY STEM yo g
Header/Manifold Distribution Pipe(s) Dia. x Hole Size x Hole Spacing Vent To Air Intake
Length _ Dia. y h Length —B1a. 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.)
LOCATION: ST. JOSEPH 6.29.19,SW,SE 363 117TH AVE — EVERGREEN RDG LOT 6
T f2
-A 46P
11ti. 'T ' 1�'I
Plan revision requlrN ❑ Yes �o
Use other side for additional information. S
SBD -6710 (R.3/97) Date Inspector's gnature ert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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...» ew....°9..,- . °. °. °-i
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Safety and Buildings Division
VicoS/1S %n S ANITARY PERMIT APPLICATION 2 1 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 -�- I
than 8 112 x 11 inches in size. 1 + CA_00$
• See reverse side for instructions for completing this application State sanit Permit Num
5 Nu
Personal information you provide may be used for secondary purposes OA .k if revision to previous ap ication
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATI N
Property Owner Name Property Location
60(,(114 5 �=i/4, 5 T a �(, N, R J E (orO
Prort Owner's Mailing Address , Lot Number Block Number
City, Statel SS/ Zip Code Phone Nurr�er Subdivision Name or CSM Number
1 ��. s ( 715 _5 K- ,q
II. TYPE 'OF BUILDING: (check one) ❑ State Owned
3 ❑ t st Road
I y Near
❑ Village �
Public 1 or 2 Family Dwelling No. of bedrooms Town OF 0 4015 " o
111. BUILDING E: (If building type is public, check all that apply) Parcel Tax Number(s) ` v, w
1 E] Apartment/ Condo O T l _ D
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. k New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
System
- _____ -------- System _ ____________ Tank Only________ ____ Existin _g System _________Exist) g System
B) E] A Sanitary Permit was previously issued. Permit Number 3 s 7 Date Issued 7
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
12 Seepage Trench oZ ; q - ❑ In- Ground Pressure 7 42 E] Pit Privy
13 E] Seepage Pit 54�x� Ca x 5 - & . 43 E] Vault Privy
14 E] System-In-Fill `� Y T 0.
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. nl�Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/da sq. ft.) (Min. /inch) Elevation
f l ✓C/ J 22, Feet Feet
L Ca acct
VIA. TANK in g allons Total # Of Prefab. Site Fiber- Exper
INFORMATION g Gallons Tanks Manufacturers Name Concrete con- steel glass Plastic App
New Existin strutted
Tanksl Tanks /
Se is Ta w+h*�,R� /Qp�i / ❑ ❑ ❑ ❑ ❑
El Lift Pump Tank /Siphon Chamber ❑ ❑ El El 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber' natur (No S ) /MPRSW No.: Business Phone Number:
/ , 9 S
Plumber's Address (Street, Ci te, Zi d
v J e - c
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ; Issued Issuing Agent Signature (No Stamps)
[�i Approved E] Owner Given Initial D o® Surcharge Fee) Adverse De termination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
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:
1. 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 AM
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 mustsign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
I 'f
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 Foss; 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.
-1 = YO
1�G
x
WisconQyDepartm SOIL AND SITE ent of Industry P a g e 1 of 3
14 and Human Relations
EVALUATI RORT g —
Dhrision of S i afety &Buildings in accord with ILHR 83.05 �k OUNTY
`ti
dde
Attach complete site plan on paper not less than 8 1/2 x 11 inches in siz . Plan must iW1,
St. Croix
F� CEL I.D. #
not limited to vertical and horizontal reference point (BM), direction and o Q`f slope, scale or
dimensioned, north arrow, and location and distance to nearest road. 30—
' rT BY DAT
APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATI .N
PROPERTY OWNER:
\qd .V� , LOT SW I /4 "\.' ./4,S 6 T 29 ,N,R 19 for) W
Florian Wecky
PROPERTY OWNER':S MAILING ADDRESS L Lgcf NAME OR CSM #
115 Dr.
6 Evergreen Ridge
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE SOWN NEAREST ROAD
Hudson, WI. 54016 ( 716 549 -6449 St. Joseph Corey Dr.
c ] New Construction Use [x] Residential / Number of bedrooms 3 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd /ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd/ft
Recommended infiltration surface elevation(s) 7 _ nn —gA _ 00_ It (as referred to site plan benchmark)
Additional design / site considerations alt area= 1 01- 001 -99-00 1
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem CAS 0 L CRS ❑U IRS ❑U flS El $7S ❑U ❑S ®U
SOIL DESCRIPTION REPORT
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 -12 10 r3/3 none sl 2m r mvfr 9W 2f .5 1.6
2 12 -88 7.5yr4/4 none is Osg ml na na .7 .8
Ground
elev.
100 - �•
Depth to
limiting
factor
+88"
Remarks:
Boring #
1 0 -8 10yr3 /3 none 1 2msbk mfr gw 2f 1 .5 .6
2 > 2 8 -20 10yr4 /4 none sicl lcsbk mfr gw if 1.2 1 .3
3 20 -88 7.5yr4/6 none co s Osg m1 na na .7 .8
Ground
elev.
Depth to
limiting
factor
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. Aviv., New Richmoud WI 54017
Signature: Date: 4_20 -99 CST Number: mO2299
PROPERTY OWNER Florian Weckworth SOIL DESCRIPTION REPORT Page 2" * Of y 3
PARCELI.D.# 030-
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon Texture Consistence Botuhdary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 -10 10yr4 /3 none 2msbk m r ,5 .6
3
2 10 -21 10yr4 /4 none sl 2mgr mvfr gw if .5 .6
Ground 3 21 -10 7.5 r4/4 none co s Osg ml na na .7 .8
elev.
10 ft.
Depth to
limiting
factor
+104
Remarks:
Boring #
1 0 -12 10yr3/3 none 1 2msbk mfr gw 2f .5 .6
>; 4 2 12 -23 10yr4/4 none sicl lcsbk mfr gw if .2 .3
3 23 -94 7.5yr4/4 none co s Osg ml na na .7 .8
Ground
elev.
i CI - Qt. —
Depth to --
limiting
factor
', T 7
Remarks:
Boring #
1 0 -9 10yr4 /3 none 1 2msbk mfr gw 2f .5 .6
€€ 5 2 9 -16 10yr4 /4 none sicl 2msbk mfr gw if .4 .5
3 16 -99 7.5yr4/6 none co s Osg ml na na .7 .8
Ground
elev.
1 07.0 ft.
Depth to
limiting
factor
Remarks:
Boring #
13
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEELS SOIL SERVICE
Gary L. Steel Florian Weckworth 1554 200th Ave.
CSTM2298 SW4NE4 S6 T29N - R19W New Richmond, WI 54017
MPRSW -3254 town of St. Joseph (715) 246 -6200
lot #6- Evergreen Ridge
N
1 =40'
BM.= top of SE lot stake @ el. 100.00
Alt. BM. = top of lot 5 &10 lot stake C el. 103.45'
(.- o t2Ly 01;x,
95
k �
N
2' q�•
Gary L. Steel
4 -20 -99
a ,
V& Safety and Buildings Division
M SANITARY PERMIT APPLICATION 201 E. Washington Ave.
S/�I P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 - 7%9
• 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.
• See reverse side for instructions for completing this application State Sanitary Permit Number
y ou p rovide may be used b other government agency programs �� /
y p y y 9 g y p g Check if revision to pr appr•c
The information ation
(Privacy Law, s. 15.04 (1) (m)].
State Plan L Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Pro erty Owner Name _ !l Property Location
U ;`�,,
s(W 1 /4g C 1 /4, S T -D T 2C1, N, R )a `& f 0dC::J
Property Owner's Mailing Address Lot Number Block Number
83 . E-
City, State, Zip Code Phone Number Subdivision Name or CSM Nu ber_
ZjV 11731 --353 (7 564 -';0
II. T E OF BUILDING: (check one) ❑ State Owned " It� earest Road
p Vil age
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
111. BUILDING USE (If building type is public, check all that apply) Parcel Ta Number(s) IF
1❑ Apartment/ Condo 0 3 0 6 m • 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. ❑ Replacement of 4_ ❑ Reconnection Of 5. ❑ Repair of an
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 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench Qqe oZ mbOR— 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 1•�1� -�4` n 1 • SG .2- 43 ❑ Vault Privy
14 ❑ System -In -Fill f 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
7 5� Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
7 115601 . 5 57A . 4 4 e AJIA '7 n 6 tW Feet q L1. 5 Feet
VII. TANK Capacity Total # Of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks
SepticTa o� MO ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Cham ❑ ❑ ❑ 1 ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumb is Sig /f+Ji2BS1t1/ No Business Phone Number:
lbraa- 9 Chc2 1 oV 0 35 - 715 - 3-
Plumber's Address (Street, City, State, Zip Cod ):
Po KLIk6 Afly. 0j -
IX. COUNTY / DEPARTMENT USE ONL
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate I ssued Issuin gent Signature (No Stamps)
Approved ❑ Owner Given Initial ]1, Surcharge Fee) !
Adverse Determination v�5 � � ( 7 �g
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
S8101-ISM (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety 8 Buildings Division, Owner, Plumber
I
INSTRUCTIONS "
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
.1. 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.
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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 ___Z9 ND SITE EVALUATION
Division of Safety and Buildings Page l of
Bureau of Integrated Services n *6dWA*'*tks. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not I 1/2)()X size. must County
_*
include, but not limited to: vertical and hozontEWd referehes di
percent slope, scale or dimensions, north rrow, anon IQWtion and distance to. road. Parcel I.D. #
P 1998
APPLICANT INFORM ATION - Pl �s' 0 print 4 4ix 610 Re by Date
lla 0
Personal information you provide may be used for ry
'7z2ff
Property Owner
Property Location I S
�oe ( - �1/4,S T,
Govt. Lot _5 (Aj 1/4 _3�^R 9 E (049
r1c re'cA /\ &I
Property Owners Mailing Address Lot # I BbW Subd. Name or CSM#
057_3 1 4 - !�z /24r7 6 1556 '�Orl r. e e rA ' e,
City State Zip Code Phone Number ❑ city 1:1 Village T own Nearest RoM
'S w j(71-5 i eevr
f
New Construction Use: [gResidential / Number of bedrooms � Addition to existing building
❑ Replacement LJ Public or commercial - Describe:
Code derived daily flow C) gpd Recommended design loading rate 7-bed gpive,-e—ftench. gpd*
Absorption area required _8;�bed, ft2_7.5 0 tren ft2 Maximum design loading rate • 7—bed. gpd* trench, gpd4l
Recommended infiltration surface elevation(s) 1 701-30 ft (as referred to Site plan bench=*)
Additional design/site considerations
Parent material 4r- ' s a e' _S .4
Flood plain elevation, U applicable ft
/ 4w
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system S F] U 5as El U I tO s ❑ u CK-q Elu I Ds [9u ❑ S W 11
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Boots GPD/ft2
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
46 lD y1nX r ----------- J - -
C_ 5
13
. /0-% /0 Y r _Srf �I , ?Xlzf m-C.t r -5 5
Ground 415 6.51 W/ C _S
elev.
11 Y
Depth to
limiting
factor
? in.
Remarks:
Boring #
13 C'5
Ground
elev.
Depth to
limiting
factor
min. Remarks:
CST Name (Please Print) Sig natu Telephone No.
4do U vy. at Z- -e 7k� -,
Address Date CST Number
PROPERTY OWNER 6)Z SOIL DESCRIPTION REPORT page ,02--, of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
Z /03 /G 3/46 `n
Ground 3 3 13 y/6 w/
elev.
Depth to
limiting
factor
-"—in. 36
7a-
Remarks:
Boring #
0 " 1 0'r 3 CQ "•��� /YLGt j76f' i G it GO
3z-1Y 152v 4 7 1 16 01 6sq 4kn -7
Ground
elev.
Depth to
limiting
factor
�Rin.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
/� �+
Boring # G_ r 3 S ' `nod A&4- — 1+ + 'r�
C-
Ground
elev.
Depth to
limiting
factor '7
29' in. Remarks:
Boring #
Ground
elev.
Depth to
limiting
factor
' Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer ,
Mailing address Q31 yt:,(, z a r _ 3S 33
Property Address �o �s ALI
(Vedriication requited from Planning Department for new construction)
City/State _l�t.►,�� fi _ Parcel Identification Number /Q Q
_LEGAL DESCRIPTION '
Property Location k.) �/ St y Sec. � T 'I
e LN -RR_W, Town of _
Subdivision , ✓c�r. a y„� �, �t . Lot # t�
Certified Survey Map # Volume Page #
Warranty.Deed # _s52 < 7 7(1/o Volume oZ , Page # l{
Spec house ❑ yes 0 no Lot lines identifiable El El no
Y
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, joumeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 p sewage di system with the stands
set forth, herein,• as set by the Department of Commerce and the Department of Natural Resources, Stat
e of Wisconsin. Certiftcation
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Off - ice within 30
days of the three year expiration date.
SIGNATURE OF APPLICANT
DATE
OW�YER CERTIFICATION_
I (we) certify that all statements on this forth are true to the best of my (our) knowledge. I (we) am (are) the owner(&) of
the property 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 suit in the sanitary permit being revoked b the Zoning Department.
Y g * *s *s*
!* Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey a if reference y p is made in the warranty deed
VOL 1412PAcE162 599766
STATE BAR OF WISCONSIN FORM 2 -1998 KATHLEEN H. WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
sT. cROIx co., WI
This Deed, made between Richard LaCasse, a /k/a Richard W. RECEIVED FOR RECORD
LaCasse, a married aerson, , Grantor, and 03 -22 -1999 8:00 AM
Bruce G. Benschine and Liv M. Benschine, husband and wife.
Grantee. WARRANTY DEED
Grantor, for a valuable consideration, conveys and warrants to Grantee EXEMPT #
CERT COPY FEE:
the following described real estate in St. Croix County, State of Wisconsin (The COPY FEE:
"Property "): TRANSFER FEE: 134.70
RECORDING FEE: 10.00
PAGES: 1
Recording Area
Name and Return Address
F-FL a Qx osS
030- 2106 -60
Parcel Identification Number (PIN)
This is not homestead property.
Lot 6, Plat of Evergreen Ridge in the Town of St. Joseph, St. Croix County, Wisconsin.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of March, 1999.
* * ichard LaCasse, a /k /a kicirard W. LaCasse
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
) ss.
St. Croix County )
authenticated this _ day of Personally came before me this / day of
March, 1999, the above named Richard LaCasse, a /k/a
Richard AV—LaCasse, husband and wife
to me n o be the person(s) who executed the foregoing
* inst 'me a acknowledge the sa
TITLE: MEMBER STATE BAR OF WISCONSIN
authorized by § 706.06, Wis. Slats.)
1
THIS INSTRUMENT WAS DRAFTED BY �� �O� N Public, State of Wisconsin
Attorney Kristina Ogland ;F ��. >�ommissio s permanent. (If not, state expiration date:
Hudson, WI 54016 ��' )
(Signatures may be authenticated or acknowledged. &T `are
necessary.) aZ *b
*Names of persons signing in any capacity should be typed or pri nted cures
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 -1998
INFORMATION PROFESSIONALS COMPANY FOND DU LAC, WI 800Fi55 -2021
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