HomeMy WebLinkAbout034-1036-70-000 ST. CROIX COUNTY ZONING DEPARTME - , -7-;_--
r AS BUILT SANITARY REPORT
Owner s�4 n 1 C C d r cSt - 44 nS�+s't �j'=` f�•T
Property Address G c �✓a.�t l 2 �'
City /State
Legal Description: E
Lot Block Subdivision/CSM #
S ' /4 d '/4, Sec. , T N -R _W, Town of S e �' h *e- d PIN # ``- - - =--�
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC / Setback from: House Well PAL
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road 1 0 Vent to fresh air intake Water Line
Meter location f
Alarm location N r C g, h c K e. n 5
SOIL ABSORPTION SYSTEM
Type of system: Width Length Number of Trenches
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark 4' r' .Sr ��� °'�'1 Elevation O�
Description of alternate benchmark Elevation
Building Sewer 1? 1�' .S /HT Inlet ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines () () ( )
Bottom of System () () ( )
Final Grade O O ( )
Date of installation I / 171q Permit number S 4 State plan number q q
Plumber's signature License number 2 ), 3 �� S Date I / 121
Inspector ! u g, 1 h
Complete plot plan �
f
t ,
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
(t
�o
INDICATE NORTH ARROW s, t 12
' Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Per sonal in f o r mat ion you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 353264
Permit Holder's Name: ❑ City ❑ Village ❑ To%r of: State Plan ID No.:
Caress Janice Town of Springfield
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
034 - 1036 -70 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark I&/ O t
Dosing Alt. BM IVIA
Aeration Bldg. Sewer `jZ ` 15 , 88
Holding St Onlet 8,8a °f 80
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding I ti ��� ' Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand St cover
Model Number GPM
TDH Lift Friction System TDH Ft
oss m ead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING manu
SETBACK CHAMBER
INFORMATION Type of mo Number:
System: OR UNIT
DISTRIBUTION SYSTEM 3 3 �3
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing I 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: / /`/94 Inspection #2: J- --1- -.
Location: 968 Highway 128, Glenwood City, WI 54013 (SE 1/4 NE 1/4 16 T29N R15W) - 16.29.15.244B
1.) Alt BM Description= W14
2.) Bldg sewer length=
U
- amount of cover = t'v '' �Z, -- ( K
Plan revision required? ❑ Yes No
Use other side for additional information. la ®D _ ( 2 6
v SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ice-'
Safety and Buildings Division
201 W. Washington Avenue
Vi scons i n SANITARY PERMIT APPLICATION P O Box 7302
Depaftment of Commerce In accord with ILHR 83.05, Wis. A �c�e `` o Madison, WI 53707 -7302
0 Attach complete plans (to the county copy only) for the system' per t leq> Count
t .. 6 /
than 8 vi x 11 inches in size. ai;�t.; �� 'r
• See reverse side for instructions for completing this applicati Z State Sankary Permit Num
Personal information you provide may be used for secondary purposes Sr Fs Ch@cM revision to previous application
[Privacy Law, s. 15.04 (1) (m)1. L"\ k State Pla I.D. Number
I. APPLI ATION INFORMATION - PLEASE PRINT ALL IA r , J
Property Owner Name erty Loc I
Ce, r e - IZ C h r! T g r N, R I f — J�(or) W
Pro erty Owner's Mailing Address n C, Lot Nu Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number V6 Q
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest Road
E3 Village
Public o r 2 Family Dwelling - No. of bedrooms Town OF ? 11 eC l d fA
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 110. 2A . 1 A 4 y
1 ❑ Apartment/ Condo 0 3 4� _ ! 6 3 ` _ 2 0
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. em E] Replacement of 4_ an C] Reconnection of 5. [3 Repair of an
______System ---- - - `i'" System Tank Only ------ - - - - -- Existin 9 y
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 oldin Ta
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 Pit Privy
13 ❑ Seepage Pit 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
Feet Feet
Capacity
VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank �OG d jYl r` pw eS�C n ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber El ❑ El 4
1:1 11 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installat' n of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum is Signature: amps) n No.: Business Phone Number:
�f ?S ?ls �f�/- 2�Z�lo
Plumber's Address (Street, G4, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved itary Permit Fee (includes Groundwater D ate I ssued Issuin Age t Signat a (No Stamps)
Surcharge Fee)
Approved E] Owner Given Initial
Adverse Determination — `I
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
r
INSTRUCTIONS '
1
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling,
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber isto 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 81/2 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.
• Safety and Buildings
• PO BOX 7162
MADISON WI 53707 -7162
TDD #: (608) 264 -8777
Visconsin www.commerce.state.wi.us
Department of Commerce Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
October 29, 1999
CUST ID No.267341 ATTN: POWTS INSPECTOR
WEGERER SOIL TESTING & DESIGN ZONING OFFICE
421 N MAIN ST ST CROIX COUNTY SPIA
PO BOX 74 1101 CARMICHAEL RD
RIVER FALLS WI 54022 HUDSON WI 54016
RE: CONDITIONAL APPROVAL Identification Numbers
APPROVAL EXPIRES: 10/29/2001
Transaction ID No. 271449
Site ID No. 183186
SITE: Please refer to both identification numbers,;'
ST CROIX County, Town of SPRINGFIELD above, in all correspo th the agency.
SE1A, NE 1/4, S16, T29N, R15W
JANICE M CARESS - HANSON RESIDENCE STH 128, SPRINGFIELD
FOR: _
Description: HOLDING TANK SYSTEM ;
Object Type: POWT System Regulated Object ID No.: 498419
The submittal described above has been reviewed for conformance with applicable Wisconsn.ftrative Corte
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. Tlae`owner, as defi4d in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirzments.
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead. J
Sincerel , 1 DATE RECEIVED 10/22/1999
FEE REQUIRED $ 60.00
/ FEE RECEIVED $ 60.00
PE R� PAGEL , P WTS PLAN REVIEWER II BALANCE DUE $ 0.00
Integrated Services
(608)266-2889, M - F, 0745 - 1630 HRS
PEPAGEL @COMMERCE.STATE. WI.US WiSMART,pode:, 763
cc: JANICE M CARESS - HANSON
-
1 HOLDING TANK Page t of 3
For
A 3 Bedroom residence
LOCATED IN THE S E 4 OF THE NE 4 OF SECTION lb ,T N R 1S Tas
TOWN OF _ s��ZtN 6 �l�.p ST. ctx CCUNTY, WISCONSIN.
INDEX'
PAGE 1 of 3 TITLE STiEET
PAGE 2 Cf 3 PLOT PLAN
PAGE 3 of 3 HOLDINt- TANK SECTION
PREPARED FOR
°t b g �-1 t� � ►may �z�
'LEQw C50b
RECEI
PREPARED BY OCl 2'
WE - =(SEF E: FR SCI I L TEST I hiC
AND
ICES I G{n! SEF:V I CE
0 ® ��� ®9949d1
P.O. BOX 74.421 N. RAIN ST.��
RIVED. FALLS. NI 54022
f 715'425 -0165
C01ld i`lf>I'1'ail _ w� " " A i
A .Y _ P
R OV ED 6 u]4`: .;R iH.
WfS..
4
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DE MEN
DIVI O F CO ERCE "' 1') .. .......< YA
BUILD S
SEE CORRESPO p' _ Z Z_ C11
EM i y�
JOB NO.
ICI
PLOT PLAN Page Z of
SCALE 1 "= lo(3 '
$ g s
8 LO "y7UN
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HOLDING TANK CROSS- SECTION
Approved Weather Proof
Vent Cap Junction Box
411 C.I. / Approved Locking Manhole Cover
Vent Pipe With Warning Label Attached
Minimum 12
/Final Grade
+ 4" Minimum
Approved Joint '
18" Minimum
Water Tight Seal \ High Water '
r.,F Ex tending 3"
ECIFICATIONS Alarm Switch NK New x Existing
Manufacturer: `r- �1�O�v� PRs� �w c. Approved Joint
Blind C.I.
Tank Size: 3 Oc)p Gallons w/ C.I. Pipe
Plug Onto Solid Soi
ARM Manufacturer: S,S. ��,p Sks��.ts
Model Number: tc) W COP- S-Oc PiPE�
Switch Type m �1ZCC�t i
NUMBER OF BEDROOMS: 3
GALLONS PER DAY: tLSp
3 " of Bedding Under Tank
019/99 TUE 10:24 FAX 71.5 386 46 REGISTER OF DEEDS 2001
1)OcUIY Numbcr1P1an 10. ,No, v
HOLRIN K A
GIR
EMENT
This � . io�a � AGf s afire - Mer i be e e governmerit � �- :2:;_;
` Name and Return Address unit and hoidinq tank owners . KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX Co., W
Cx 6 b "AG �A�PN t-zz RECEIVED FOR RECORD
C- Lt'1) L-J OUP L � J S 10 -19 -1999 9: 30 Afl
i �d L�
Psrcal idendfcr number HOLDING, TANK AGREEMENT 0
Agreement Date EXEMPT
U — ::� 1 4 - tp --`: C F
Goverrimen COPY iai Unit holding Tan; Owner(sj
m U r- S TRANSFER FEE
6 V— i�'7..1� ') `- q� 0.pm -ev icf SQhl RECORDING FEE: 1,2.00
We acknowledge that tapplication is being made for the installation of (a) holding tank(s) on the P F
following property: (Provide legal land description. Use reverse side if additional space is needed)
C�SJ7 1h4 U0L VZ.U
or that , - - -�
..oatay.ued use of the e�asti.ng prcn±ise.a requ that a aoa¢in6 tr — --- - - - -`.
o properly cannot °note .;e sir rve,5'by`ii riunicipalsev,e or any other type f private sewage vs e permitted under Ch. ILHR 83, Wis. Adm.
p•urpcse of:proper contaSnment of sewage.
Code, or Ch. 145, Stars. `
ys ar, inducement Wthey - nL Qf L — 2r ' t om° k ,.
to issue a sanitary permit for the above described property, we ageee to do the following;
1. Owner agrees to conform to all applicable requirements of Ch. ILPM 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the governmental unit to prevent or abate a human health hazard as described in s,
234 -60, Stars the governmental unit may enter upon the property and service the tank or cause to have the tank to be serviced and charge the
owner by placing the charges on the tax bill as a special assessment for current services rendered- The charges will be assessed as prescribed by s.
66.60, Stats.
2. The owner agrees, pursuant to s. ILHR 83.18 (10), Wis. Adm. Code, to have a water meter installed in a new building or new structure. The water
meter shall be installed by a plumber authorized by the State to conduct such installations, with said installation complying with State regulaons
and manufacturers specifications. The owner agrees to be finally responsible for the purchase, irscaIlation, maintenance, and ti repair of the water
meter, and agrees to allow the governmental unit to enter the above described property on a regular basis to read and/or inspect the water meter.
3- Owner agrees to pay all charges and cost ircurred by the governmental unit for inspection, pumping, hauling, or otherwise servicing and
maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank_ The governmental unit
shall notify the owner of any costs which shat! be paid by the owner within thirty (30) days from the date of notice. In the event the owner d
pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charge oes not
s may be placed on the tax rolE as a special assessment
for the abatement of a human health hazard, and the tax shall be collected as provided by law.
The owner, a -,cept as provided by s- 146.20 (3) (d), Stat ., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have
the holding tank serviced and to file a copy of the contract or the owner's registration with the governmental unit. The owner further agrees to file a
copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business days from the
date of change to the service contract,
The owner agrees to contract with a person licensed under Ch_ NR 113 Wis. Adm. Code, who shall submit to the governmental unit and the county
on a semiannual basis a report in accordance with s. ILHR 83.18 (4) (a) 2 -, Wis. Adm. Code, for the servicing of the holding _ _.
reg- stratian tinder s. 1.6.20 (y) (d), $rata., the owner shall submit the report to the governmental unit and the county. 7'he governmental nit or the case of
county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the
holding tank is not being properly maintained.
This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems certifies that the
property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHX 83, Wis. Adm. Code. In addition, this
agreement may be canceled by executing and recording said certification with reference to this agreement in such manner which will permit the
existence of the certification to be determined by reference to the property.
This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to the
register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be
determined by reference to the property where the holding tank is installed.
�vncr(s) N ame
{$) . please print ernmental Unit Otlicisl Name - Please Print
f� ' �i y1 / >✓ N . r y ` p Subscribed and 1 sworn to bcforeme on ;ttis Mateti
^tarized Owncr(s) Si
7 mull! C'
GovemmctWUnitOf &cialTitic - Pleas Print
�Q
GOTIMJ)iental Unit
QA
tcial S' nature M commission expirei .�.
Q 4 1
'3f1Cd by ��� � � , 1,.,.} ���"`� Personal inFcmisiicn you protiide may be used for second ' .,- ..• '- ^..'"_- �';' -�.�-
�!' Pu�posec %Y�cytaw, s•t:��l ?(m}J•
! 9/99 TUE 10:25 FAX 715 386 4637 REGISTER OF DEEDS 00
r
va 1464PA,E201
Commencing at the Northeast corner of the South .East Quarter
( SEA ) of the North East Quarter ( NEE ), thence South 291 feet
to the Place of Beg,rxnino; thence Jest 207 feet thence North
Ill feet, thence west 201 feet; thence South 180 feet; thence
East 201 feet; thence North 33 feet; thence East 207 feet;
thence North 36 feet to the Place of Peginnina, 411 in
Section 16, Township 29 North, Range 15 West,
HOLDING TANK SERVICING CONTRACT
��ontract Date
This contract is made between the
Holding TankOwner(s) Name( s) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
and I Pumpers Name — — — — —
I
l ti J S U\j I
We acknowledge the Installation of (a) holding tank(s) on the following property: (Provide legal descriptions:)
C S TE
-----------------------------------------
1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement
OX3Mr1
required in Ch.1giiliR 83.18(4) (b), Wis. Adm. Code and with the County of Q, C°_� !K
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and
to enter upon the prolerty for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or
drive so that the pumper-can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the
pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the local governmental unit which has signed the pumping agreement required by s. ILHR
83.18 (4) (b), Wis. Adm. Code, and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The
pumper further agrees to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
C. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local
governmental unit and the County named above within ten (10) business days from the date of change to this service contract.
C wner(s) Name( (PPrrint,) � 11 Owner nature
9 s Si s
UJO YJ Subscribed and sworn to me on this date:
I
lo- i3 - q9
t Today's Date
I
I
Pumpers Name (Print) Pumpers Signature
Notary Public Signature
I
0&
Pumpers Reg' tration Number Commission Expiration
�s
Drafted by fflZ-7p�tj Z L . 1.J e L1?Z
Commencing at the Northeast corner of the South East Quarter
( SEy ) of the North East Quarter ( NE4 ), thence South 291 feet
to the Place of Beginning; thence West 207 feet; thence North
111 feet; thence West 201 feet; thence South 180 feet; thence
East 201 feet; thence North 33 feet; thence East 207 feet;
thence North 36 feet to the Place of Beginning. All in
Section 16, Township 29 North, Range 15 [Jest.
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
labor and Human Relations —
Division of Safety & Buildings in accord with ILHR 83.05, Wis. m Cddd
r f RCEL�D.#
LINTY
' Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. PI must include E`AAoi - ,
not limited to vertical and horizontal reference point (BM), direction and % o sTdpb, scale or
dimensioned, north arrow, and location and distance to nearest road. D APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATIO WEBBY DATE
PROPERTY OWNER: ROPE
LGT T - 2.P ,N,R \ S E ( W
PROPERTY OWNERS MAILING ADDRESS • LO BLOCK# SUBDt. OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY E]VICLAGS ' NEAREST ROAD
��-ti.�wouv etiy'WI Sg1)a r) L - ) - )2 -g6s3 s p 1ZjAi F1( S 1 j )_�-8
[ J New Construction Use Residential / Number of bedrooms 3 [) AdditiQn to existing building
JK Replacement [ J Public or commercial describe
Code derived daily flow qSo gpd Recommended design loading rate N ed, gpd/ft Q trench, gpd/ft
Absorption area required ► 3N bed, ft Q f`1 trench, ft Maximum design loading rate U T bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) fy f� ft (as referred to site plan benchmark)
Additional design/ site considerations x`01 w 6 '�Zzs� r b - s bou Get Gjl�tyl �A A� (;p
Parent material L �g oyLn h t-�- Flood plain elevation, if applicable iQ fl • ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem El 13 U ❑ S ®U ❑ S FI U ❑ S �U El RU ZS ❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure . Bou>dary Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh Bed jTrench
• 'iii $t4
y.: e 8 N�s w �vrt w
..: -
Ground IT b Q p Z 11b S pfl L ce
elev.
t A ft
Depth to
limiting
factor L. \y Ww k ,
< Rt
Remarks:
Boring #
o
Ground
elev.
It.
Depth to
limiting
factor
Remarks:
CST Name:- Please Print Phone:
Arthur L. We erer 715 - 425 -0165
egerer Soil Testing & Design Service -P.O. Box 74 River Falls,Wl. 54022 '
Signature: _ Z50 Date: ZZ...Q CST Number.
g- 9 220254
PLOT PLAN Pag Z of z
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CST Signature Date Signed Telephone No. CST #
PLOT PLAN Page z of z
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( 715 ) 425 -0169
CST Signature Date Signed Telephone No. CST #
Wisconsin Department Industry,
Labor and Human Relations tions g SOIL AND SITE EVALUATION REPORT P of
_
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
AttaBtt complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
t not limited to vertical and horizontal reference point (SM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. Z 03.6 . D
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
1/4 1 /4,S l o T �2.q ,N,R 1 S E (or W
PROPERTY OWNER':S MAILING ADDRESS. LOT # BLOCK # SUBD. NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®TOWN ' NEAREST ROAD
S wouv eLiV Wl S y o L3 (-) 0 -)> > _ L4 6S a sp aJ AJ G Ft SnI + tz-S
[ J New Construction Use ( Residential / Number of bedrooms 3 (J AdditiQn to existing building
j� Replacement [) Public or commercial describe
Code derived daily flow qSo gpd Recommended design loading rate fJ Im bed, gpd/ft Q trench, gpo1ft
Absorption area required V-3(N- bed, ft2 Q trench, ft Maximum design loading rate ► 1a bed, gpolft _ trench, gpd/ft
Recommended infiltration surface elevation(s) fy A _ft (as referred to site plan benchmark)
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Additional design /site considerations �j (S 14q� 3 bou Gpy� ILZ_ ) EkAb g
Parent material Lu g_ Qv \ Tt t_%_ Flood plain elevation, if applicable i�) fl • ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ❑ S ® U [Is ®U I ❑ S O U ❑ S R_ U [IS IaU Z S Ell)
SOIL DESCRIPTION REPORT
Boring # Horizon
Depth Dominant Color I Mottles Texture Consistence Eotr>dary Roots Structure GPD /ft
in. Munsell Cu. Sz. Cont Color Gr. Sz. Sh: B� mnch
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Ground 0 "Ai T Valy p
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elev.
N � •8�11?J>vG
Depth to
limiting
factor
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Remarks:
Boring #
Ground
elev.
ft
Depth to
limiting
factor
Remarks:
CST Name: -Please Print Phone:
Arthur L. We erer 715 - 425 -0165
egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI. 54022 '
Signature: Date: a ZZ- CST Number.
CL
-7 9 220254
PLOT PLAN Page Z of Z
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( 715 ) 425-0
CST Signature Date Signed Telephone No. CST #
12!09/99 THU 08:39 FAX 715 386 4686 ST CRX CO ZONING 1&02
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer t L r. e. re 11 So P1
Mailing Address 5' AS G G- !e 6✓a , `c j -q uq
Property Address SAL K,
(Verification required from Planning Department for new construction)
City/State 6 wov, Cif W Parcel Identification Number D / —
LEGAL DESCRIPTION
Property Location s ` / <, v., Sec. 1 , TILN -R-11 Town of
Subdivision Lot #
Certified Survey Map # , Volume _ . Page if
Warra ty e # O 2 Volume y . page # 2
house ❑yes no Lot lines identifiable ❑ yes ❑ no
SYSTEM rVIAIlYTENANCE
Improper use and maintenanceof 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
maste,rplumber, journeymanplumber, restrictedplumber 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.
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
lays of the three year expiration date.
TURF OF APPLICANT DATE
CERTIFICATION
1 certify that all statements on this form are twe to the best of my (our) knowledge. I (we) am (are) the owncr(s) of
'cribed above, by virt J e ' of a warranty deed recorded in Register of Deeds Office.
�j/1 J ✓/ L^ 1
APPLICANT DATE
rmation that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ««
tits 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
DOCUMENT NO. II WARRAXT! n111111p
310 i, BOQK 484 PA•�E26U STATIC o w1sooroa(N —IRORM s
THIS MACK RKSKRVKD FOR RtCOIWIN* DATA
us B. Booth and
'ITS IND8IVT[J�btade Cassius ..._.._..
........_......- •-- •- ..._ -•.... ...ian ... goo.7i; us ancT• e' REGIST .. a
..... ........ wif ...................._.. OFFICE
................... ...................... _ ..................... .. ......................................... _..... � ..
........._....... ST. CROIX CO.. WIS. I
grantor ... S. of. ...... _ .....St. - _.Croix ..•........... _ ................_.......County Wisconsin Recd for Record this-
hereby conveys and warrants to......Jamgs .y,..,.Ca�,� d •••, „•......•••_ I y
JAni�ce...M.....Cars•cs - .huiaba d••a d ••w fe• de of ---- *, --- A. D .'19 7
.................. _ ...... _._ as .... jaint ... tenants ........................... ............................... . II at_ 1 44 ___N M. I_
...__ ...._...... .
.. .
_ ._.._ .........................................
. _ ..
_.._...............
....... grantees . of r &
c h o
_ ............ .........5- t.... ......... _ ........... County, Wisconsin for the sum of
ThX' .9..lho- usamd --- and..n J2.ajaths....(•$ 3.,IIIIl� VO. -- — RETURN TO
..... Tri, r4oLlnt y 3.ay. & .hoan
...... _.......... _.-•--•••••-•••-••-•--•-•••••-•••---•••••••••---••••••--...-..•-••- ........... _ ................... _ ................... Hud son, Wis s+ .
the following tract of land in ........ Et. ---- CrQ ix ....... ....................... .........County,
Wisconsin: ....................................................................................... ...............................
Commencing at the Northeast corner of the
South East Quarter (SE 1/4) of the North East
Quarter (NE 1/4) thence South 291 feet to the j
Place of Beginning; thence West 207 feet; thence i
North 111 feet; thence West 201 feet; thence
South 180 feet, thence East 201 feet; thence
North 33 feet, thence East 207 feet, thence North
36 feet to the Place of Beginning. All in ,
Section 16, Township 29 North, Range 15 West.
I
$ S,1 0 �.
In Witness Whereof, the said grantor..S. ha...... a hereunto set ----- _...theiLp. hand.- i s d seal..s. this
.............. 8th------ day Of..__ ----------- Ma .. A. D., 19... -9/ �
AND LED (SEAL)
8I D IN HENCE OF .....
...-
Cassius B. Bo oth
7�
! ' ! .... ....................... (SEAL)
_.......... ........ ............. ......
ichard P. Rivard Vivian C Booth
1 .................... ......................................................................... ( SEAL )
Charlotte Clai
.... •-•--....• ............................ .........................•..... ........(SEAL)
State of Wisconsin, ,• « .,
...... St... .C.roa.x._... _--County ersonal�y+ a before me, this.... 8th of......... MU A. p. 19 ..... ...,72
the above named .................... - ,
a . Booth.a...hi _wife.,
I ...............
• �r- cif".- �': -l•�, ., ----------- - ---- .. ..-• ------- ------------------------ •-•-
to me known to be the perpn_ gkei;eFflted. a inst ent an knowledge the same.
r
THIS INSTRUMENT WAS DRAF'1Erl-11f - ' � ,.` `•�!, V ` �i�� �.
lJ V i
Notary Public, .........St.....Cr.Q iX .....................County, Wis. j
Richard P. Rivard 3 .......... `% ���
� My commission (4 '7) (is)._ ....... Pez'mc gna.._...._
(Salim 39.31 (1) of the Wisconsin Statutes provides that all instruments to be recorded shall have plainly printed or typewritten thereon
thmmtal� of the grantors, grantees, witnesses and notary - Seaton 59.313 similarly requires that the name of the ptsson who or govero•
agency which, drafted such instrument, shall be printed rinses, s�am or written the in a legible manner.)
�YSRBANTY DEED STATE dISCONSIN wt[oon.m r,.aa1 Bunt aotnp
FORM No. f ,.; ltllwaatN. WL,