HomeMy WebLinkAbout006-1023-70-000 ST. CROIX COUNTY ZONING DEPARTMENT V
AS BUILT SANITARY REPORT
Owner
Address
City/Stat
I � _ +fit
Legal Description: �� ST CRO,x f998
Lot Block Subdivision/CSM # i^ z° "vl�ooF cE
'/. ' /., Sec. T,L_N -RAW, Town of PIN #
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC h Setback from: House Well
Pump manufacturer Model 1d eo_ ?11 Z
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: _ "a aA Width Length Number of Trenches
Setback from: House �s —, Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark Elevation ,>aq, D
Description of alternate benchmark ,6'0 s „ , �p Elevation
Building Sewer , /R ST/HT Inlet 9 7 Vg ST Outlet .s' PC Inlet 93, 7l
PC Bottom Header/Manifold 99,, 7l Top of ST/PC Manhole Cover
Distribution Lines ;7 () ( )
Bottom of System O 7 9, O ( )
Final Grade O ,� , gs O ( )
Date of installation 9VjZ Pe it nu er State plan number
Plumber's signatur License number /�,,3 Date 1 2
Inspector
Complete plot plan or
x
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
�3
f �31ti
!'
INDICATE NORTH ARROW
• Wiscortsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
�afety and Buildings Division ST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarX
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)].
,A,eripi HaIc1�: &ge: R Gtv R Village Town of: State Plan ID No.:
CST BM Elev.: oo Insp. BM Elev.: BM Description: Parcel TaX 'We-4023-70-000 -000
l ' roo
TANK INFORMATION ELEVATION DATA A9800047
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
eptic t 67 Bench m k 3•
Dosing �¢ -go A tir, PyK
f
Aeration Bldg. Sewer 0 4. S�_ , 3�
Holding Inlet
TANK SETBACK INFORMATION Illlt Outlet ?
TANK TO P/ L WELL BLDG. Airl to ake ROAD Dt Inlet 1
A'rint
NA Dt Bottom
Dosing 6 S 3 9 NA Header / Man. • 7 ( �, 76
Aeration NA Dist. Pipe 5- 1r, 7
Holdin Bot. System 6 - 7 7.
PUMP/ SIPHON INFORMATION - 7� Final Grade
Manufacturer Oy(01S Demand g„/1 00
Model Number 6 0 31 / 4-- X•72
TDH Lift '? s3 Friction, Syste TDH0,t'�t ead
Loss Forcemain Length IZV Dia. Z" Dist. To Well ,
S L ABSORPTION SYSTEM - r-6
E RENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid pth
EN I N GP 3 DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM EACHING Manu acturer:
SETBACK MBER mber:
INFORMATION s Y ypemw� ���� �± OR UNIT
DISTRIBUTION SYSTEM
Header /manifold Distribution Pipe(s) y x Hole Size x Hole Spacing Vent To Air Intake
Length - I 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.)y
LOCATION: CYLON 11.31.16.155,NW,NW 2392- CTY RD H
6m, — 6 t&M 16 5, OK 04 1
a(t7(qv,
Plan revision requited? [:]Yes %b No
Use other side for additional information. &l 1 1 - 7 1 17 3
SBD- 6710(R.3/97) Date lnspectoA Signature Ce.No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER: <
i
I
SANITARY PERMIT APPLICATION 2 01 afety and E W shn
V P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. �5 r
• See reverse side for instructions for completing this application State sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check if revision to previous appication
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Propert Ow er Name Property cation
1/4 1/4,5 T , N, R j (or)
Property O ner's Mailing Ad ss Lo t Number Block Nu ber
City, - state Zip Code Phone Number Subdivision Name or CSM Number
y
,vicy 00�/ ( >
II. TYPE 13111 DING: (check one) ❑ State Owned ❑ i
y
❑ villa Nearest Road
ge
Public 1 or 2 Family Dwelling - No. of bedrooms _-D:� Town OF
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numb r(s)
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 on line B, if applicable)
A) 1. 1M New 2_ ❑ Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5 ❑ Repair of an
- _____System ________ System____ _________TankOnly______________ Exi iq_ystem ________ Existing - - - yytem
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 2110 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
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
] 12 5 - 7 r- 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 Existing structed
Tanks Tanks
o Ing a Q ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank r 11 El El 11 ❑
SPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for in allation of the onsite sewage system shown on the attached plans.
Plumber' Na : (Pant) Plumb 's S �U. ( amps rP/MPRSW No.: Business Phone Number:
r
P mber's Ac dress -(Stre t, City. Sta Zip Code):
�p
IX. COUNTY DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
roved A 0 b Surcharge Fee)
R A
pp ❑Owner Given Initial `(� 1 3 / ./9,6
Adverse Determination
X. CONDITIO OF AP REASONS FOR DISAPPROVAL:
i
SBD -6398 IRA 1/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, owner, Plumber
INSTRUCTIONS i
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:
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.
111. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
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) hoirizontal 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 DIVISION
15837 USH 63
Visconsi Hayward, WI 54843
Department of Commerce Tommy G. Thompson, Governor
13- Jan -98 William J . McCoshen, Secretary
K O Construction
Kim A O'Connell
504 Third Ave
Osceola WI 54020
Marlys Orf Plan ID 9810044
NW, NW, 11,31,16W
Municipality of Cylon Inspector: Leroy G. Jansky
County of St Croix (715) 726 -2544
Private Sewage plans including the following element(s):
MOUND 300 gpd
The submittal described above has been reviewed for conformance with applicable Wisconsin
Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY
APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for
compliance with all code requirements.
This plan action is subject to comments on the plan.
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. All permits required by the state or local
municipality shall be obtained prior to commencement of construction /installation /operation.
This project is under the supervision of a state inspector. As inspection concerns arise feel free to
contact the state inspector at the number listed. The inspector for this project is listed above.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or
at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when
making an inquiry or submitting additional information.
Sincere,
� v
Thomas Braun
Plan Reviewer
(715) 634 -3026
r
Private Sewage System Plan Index/Checklist
All plan sets should be legible and permanent copies, organized into sets, bound with staples and covered
by an index sheet such as this sample. No other pages need be signed as long as the index sheet for each
set is signed. Your cooperation expedites your plan review and shortens plan entry time.
Plan ID k Owner'
s
Legal)?acn tipn Address ,
Citylvillag County
i
Contents Comments /Special Instructions
Page M Included Two copies needed for all
plans
1 Plot Plan
2 Plan View/<_ ["Return by Mail
3 -,y
4 Tank & Pump/ ❑ Fax Letter to (County) ( Submttter)
Siphon Information Circle One and Provide Fax #: ( )
System Sizing (Public)
6 r ❑ Call for Pick -Up: ( )
9'
❑ Other
I, the undersigned, hereby certify that the r- (' le)
plans and specifications submitted �
herewith were prepared under my Conditionally
direction and control. A ROV ED
Plum ' ./Designer LicettselRegistratioa t!
DEP MENT OF COMMERCE
City State DMA F SAFETY AND WINGS
Signaturb rn!?4 �IDENCE
For Office Use Only
Attachments:
Application
Soil & site evaluation r
Fee
Needed for Holding Tank Submittal: JA 12 1998
One copy of notarized holding tank
agreement. (Orlglaab to County) ••�, i r � �^'
Needed for At -Grade Submittal:
Original signed and notarized
Application for "Use of an At-
k
Grade° 4 4
County on -site
One additional set of plans SBD -10268 (N.01/96)
A ,4 s cif Aax /of
a
�400
8
y /.2
79, 7
aE e
Designer.
Pate Non -Woven Filter Fabric
4" Observation Pipe
,Di&IribvIion Pipe
ASTM C 33 Sond
M H o Alter. Pos.of
Topsoll - -, r Force Main
E b D
/ % Slope
Bed Of % 2 Force Main \�,\ Plowe d
Drain Rock From Pump Layer
- Cross Section Of A Mound System Using E -
A B*V For The Absorption Areo F ,83
A Ft. H
B Ft.
I 4 Ft.
J ,3 Ft.
K Ft.
Alterna e P sition L 7q, 7 Ft.
Fo a Main W 2 Ft.
— L
F ~ Observation Pipe
I. B —K
CL A
a Force Main
W i •� — From Pump
3 „
o ° Distribution Bed Of �/ — 2
Pipe Drain RocK
I
4 Observation Pipe Permanent Marker
Pipe or Rods.
Plan View Of Moun U sing A Bed For The Absorption Area
PAGE -VOF�
PERFORATED PIPE DETAIL
and
DISTRIBUTION PIPE LAYOUT
Perforated Schedule 40
PVC Pipe
End
Cap
• � -' � a'��asnoe � Q
Holes Located On
Bottom Are Equally
Spaced
'h
End
, Cap � Q
Last Hole
Should Be
Next,' To
End Cap
Owner's Names p - �� feet
.Plumber /desiigner's Signatures x inches
y ---- inches
Dates License No.: Hole Diameter inch
Lateral Diameter 1.6L_ inch(es)
Force Main Diameter a inches
Holes per Lateral
feet. Invert Elevation
of Laterals
Page 0 f ,
• •o
a
to w
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m ° h
y a
m o
to
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PUMP COMER CROSS SECTION AND SPECIFICATIONS
V E NT CAP
VENT PIPE APPROVED LOCKING
WEATHERPROOF -
JUWCTIOtJ BOX MA WHOLE CoVLR W ITM
ZS' FROM DOOR, W AAIUNG LABEL
WINDOW ,OA FRESH It�MIU.
AIR INTAKE
GRADE i
I y "
18' KIN.
COWDUIT L __ _____
IB•nIN. ---- - - - - --
PROVIDE ( - --- --
LAILET AIRTIGHT SEAL I I
4,
APPROVED JOINT A I I I ( APPROVED JOI►17
II / W/ RIPE
C TC 0,(Mf. 3' I i I I ALARM EXTENDING 3'
ONTO SOLID SOIL I I I OIJTO SOLID SOIL
ON
CLEW FT j
PUMP —` - - r
b orF
O Install per manufacture
requir�ipOts>zSE BLOCK
RISER EXIT PERnITfED OIJLy IF TAMP, MAUUFACTURCR HAS SUCH APPROVAL
3" fcPPAoVEa BEDCING undcr Tr%wV,
SEPTIC +E SPEr- IFICATI0US
DOSE � _
TANKS MANUFACTURER: L� (JUMBER OF DOSES: PER DA.4
TAWK `,IZE : ^ GA LOWS DOSE VOLUME
ALARM MAUUFACTUKER: S G' INCLUDING BACKFLOW: GALLONS
MODEL 1JUM15EK. z4, CAPACITIES: A= LEC2 I U CHES OK :57YL GALLOIJs
SWITCH TYPES _ F ' d g = INCHES OR _ GALLOWS
PUMP MAWLIFACTURCK: 1 C = INCHES OR GALLONS
MODEL MUMBER: I' IEIISIM - -- D NCHES OR GALLOWS
SWITCH TYPE: 2 MOTE: PUMP AMD ALARM ARE TO BE
MINIMUM DISCHARGE RATE X17,-2 GPM INSTALLED O1J SEPARATE CIRCUITS
VERTICAL DIFFEKE.WCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. A:Z� FEET
+ MIIJIMUM METWORK SUPPLY PRESSURE . . . . . . . 2.5 FEET
- /S _ FEET OF FORCE MAIM X /g/9 /S-0 FACTOR.. // ,I 2 FEET
TOTAL DyIJAMIC. HEAD = � �� n,� FEET
)UTERMAL DIMEWSIOAIS OF TA►JK LEWGTH ,WIDTH LIQUID DEPTH
SIGNED:— _ LICENSE NUMBER: OAT E:
r C t l u t I I I d I I u e %fe " 0-0 t/ . %.✓ , v 1 RwP a %V L-4 J I
"Curves Pump
METERS FEET
90
MODEL 3885
25 60 SIZE 3 /4 " Solids
WE15H
70
WE10H
60
p WE07H
15
W E05H
40
10 90 WE03M
20 WEOJL f
S
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 .GPM
L I
0 10 20 30 MI/h
CAPACITY
GOULDS PUMPS, INC.
$&*CA pu rlv •CSk .�,�..
METERS FEET
120 MODEL 3885
110 WE15HH SIZE 3/4" Solid
S
100
30
90
25
70
20
60
O
F-
WE05HI
1 5
40
10 30
20
5
10
0 0
0 10 20 30 40 50 60 10 60 90 1C0 110 120 GPM
I i
0 10 20 30 m'/h
CAPACITY
•i "S Gould& Pumps, Inc. EMcpvsJuly, IM
CISA&
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of -�
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 i eA, In iizb Plan mU-K County
include, but not limited to: vertical and horizontal referen r�it (f3fiA), direction'and
percent slope, scale or dimensions, north arrow, and I Tr:Nid disc e Wearest"froa Parcel I.D. #
° ��� /023 — 70
APPLICANT INFORMATION - Please pri infp�tn. Re 'wed Date
Personal information you provide may be used for secondary (Privac 6�1 (m)) V
u
Property Owner ZaNfNQ Govt` lion 1/4 1 /4,S T ,N,R(orl
f - ti
C
Property er's Mailing / Address r,` CO Block Subd. Name or M#
- Q G
City Stat Zip Code Phone Number
❑ City ❑ 'llage ®T Nearest Road
t, P I ( ) 7
JZ New Construction Use: ® Residential / Number of bedrooms 2 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow QQ_ gpd Recommended design loading rate y �Z bed, gpd* , .� trench, gpd/fl
Absorption area required E ,2�6 bed, 11: ft2 Maximum design loading rate . bed, gpd* _,.�j�_ trench, gpd*
Recommended infiltration surface elevation(s) it (as referred to site plan benchmark)
Additional design/site considerations
Parent material �� Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holing Tank
U = unsuitable for system ❑ S 0 U '0 S ❑ u ❑ S ®U I ❑ S [A U 1 ❑ S El U ❑ s IR) u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/11
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
AS
,
1 L
Ground
elev. _
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ah" V
Ground
elev.
Depth to
limiting
factor
42Z.- Remarks:
CST Name (PI a Pr' t) 2gna e Telephone No.
Address Date CST Number
)eW .S 5
14L
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
El A
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
r/ r
Ground 53f°s� I
elev.
Depth to
limiting
factor
Remarks:
Boring #
C3,
Ground
elev.
tt. '
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Sp in 3 .
k
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
Boring #
Ground
elev.
tt. ,
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer M 0..i' I 5 r
Mailing Addross
Pro:�erty At' 'Tess ;Z S�y007
(Verification required om Planning Department for new construction)
City'State Otel t!4 I Parcel Identification Number
LF, GAL DESCRIPTION
Property Location Ulf '/4, Sec. �, T_ -R _ 140 W, Town of G y I 0 Ah
Subdivision , Lot # �.
Certified Survey Map # , Volume , Page # M
s& 7 55 5
Warranty Deed # , Volume /l 7 3 , Page # D
Spec house ❑ yes 0 no Lot lines identifiable N 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 part 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, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and ri.imping (if necessary), the septic tank is less than 1 13 full of sludge.
I /we the undersigned have read the above req uirements and agree to maintain the private sewage disposal system • the standards
g q g P
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
- �9 " /_� nj :� /74ig-S
SIGNATURE O APPL CA T DATE
OWNER CER
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of i warranty deed recorded in Register of Deeds Office.
i OF PPLIC NT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
'* Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
l
J WS Z) VOL T27 3PA
DOCUMENT NO. State Bar of Wisconsin Form 2 -1982
'r.
WARRANTY DEED RtE.vi ST E .R'S 0* FiCE
ST. C^ - )IX CO-- WI
OCT 2 s 1997
LEMoyne Evenson &Wa LeMoyne Evenson, a single person, 2:45 ) P
conveys and warrants to Marlys Orf the following described real , -A
Wisconsin.
Re +.t.• �f Deed•
!` estate in St. Croix County, t
r
E. NAME AND RETURN ADDRESS
REMINGTON LAW OFFICES
P.O. Box 177
New Richmond, WI 54017
' 006- 1023 -70 and 006- 102160
(Parcel Identification Number)
North half (N/Z) of the Northwest Quarter (NW` /4) of Section 11, Township 31 North, Range 16 West. 1K
TRAASFER
This is not homestead property.
s Dated this o 4 - 11 � day of October 1997.
LEMoyne Evenrn aWa LeMoyne Evenson
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
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