HomeMy WebLinkAbout008-1057-20-100
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,y County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
Hudson, WI 54016-7710
(715)386-4680 Fax(715)386-4686
Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
Count Sanitary Per it # ❑ Check if revision t ious application
1. Application Information - Please Print all Information Location:
Property Owner Name l Q9 O S i X 5*/1/4, Sec
0 S ! T 0,D 412 T 2~ N, R E (or) W
Property Owner's Mailing Address sNO Lot Number Block Number
City, State Code Phone Numer Subdivision Name or CSM Number VIP
II Type of Building: (check one) ~I 94#ap []Town of
1 or 2 Family Dwelling - No. of Bedrooms: 11'3 ' Wit` `
Public/Commercial (describe use): a J
/ Nearest Road
❑ State-owned ~
II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) IW5 63
Parcel Tax Number(s)
1.[] Repair 23.[]Non-plumbing 4. []Rejuvenation j ~2 Q p'/^
A) Sanitation 0.0e /D /0 ° 1 0 /4-4
B) Permit Number Date I~~su d~ J
tate Sanitary Permit was previously issued G~ lY /
IV. Type of POWT System: (Check all that apply)
Non-pressurized In-ground Mound2: 24 in. suitable soil Mounds 24 in. suitable soil ❑ Mound A+0
Sand Filter ❑ Constructed Wetland ❑ Peat Filter Drip Line
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass Other
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation
y- s-0 7. ,q 7SG <0 96 . S" goy. .
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks >
/000 -4 ❑ ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non-plumbing sanitation system.
Plumber's Name (print) Plumber's Signa (no stamps): MP/MPRS No. Business Phone Number
r 1aa.h~ GG ?Q- - z y; .zetiv
Plumber's Address (Street, City, State, Zip Code)
3Z/ (t/
VIII. Count Use Only
Disapproved Sanitary Permit Fee _Df to Issued uing Age t Sig ur stamps)
Approved Owner Given Initial Adverse Z Z d0 5> 12_ 0 13 ,C
Determination
IX. Conditions of Approval/Reasons for Disapproval:
SYSTEM OWNER: , t Y!'lf~ y"YL¢LJt Q.~ Gv' A-txcl~~~
1. Septic tank, effluent filter and
,~,`'¢`~,`~-o~ dispersal cell must be serviced / maintained Q, (1
as per management plan provided by plumber.
2. All setback requirements must be maintained I VV%(M~ of L K'
S 14 .5-as per applicable code/ordinances.
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06/15/98 YON 15:18 FAX 715 986 4686 ST CRI CO ZONING X009
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ST. : . CO. -A K'
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Matfing Address
Property Address e;
{ ~ripc<si±co-~ a-equ€red ~ r r ;~~ninl ! :_eri~ra,1
A D- CTIO
Propei 4, See. j ---if
Subdivisi4 PI tit _L-
tr-v4 Map 'S- 7M /,7/5-
C~/ Yq
Warrant, (bc > 200?) oiurr e
Spec house Lot lines ideritifable y",E]no
t l~rs . ` "aarc a w €es. a-)per
-_wc
~
ier. What you p€ into
t' s ` . 4.. U aae<r maintenance
resp(
t{ a rres o sz~ i s ss _ Eaed irr the
pl@Il?Iber,j®t33"?➢eytru p Aber, i'
owner and I
~3 s * i wc, l ic trial is
wastevv^+=r : tern is in proper apt j c r
less th t, l e.
undergivnexd have read the abnw wee tom tats a s a with the
standards sed here as :t a P ~ rt >r 11a i ~ -ources„
E`roir
State 01. C ~ tl r s,, rf
County-
t t ` r - s Ierl e V we am are the owner(s) of the
N ber bedrooms ay is i e -e tecl may resu4t irr.'
by tla n Zoning Depanment_
I Eaade it' t Ci as rs rd wazranty deep of the certified survey wap if
reference is made is warranty dead.
(REV. 04112)
11/201201.2 13:48 IFAX HudsonRealt-vFAX BBurnet-c0m , Bud,sonRealtsFAX 003/003
Nov 201212:36p Microsoft 715-886-2231 p3
T --County Saala ° o
1.029 a St.
jaudsoo W1 54016
Beta l msnoski
21.9 Aw•y 3
Baldwin
concern , 63, Rol wrio WL was
9 H
To whom it may w3'
An inspection of the septic system at the d~e~e o
fZl tac tstak wath a tWO trench drain field.
conducted on 11-19-12. ThU septic rem made n Of a stp.
Vin.
The septic tank was pumped at the time Of ins This opinion rased on a
At this time, the system appears to functioning properly. the inlet wa Pipe *001 the
ma This inspection w linxited to chechnoag if the exit pipe
snrfa inlet and exit bafft is the septic tank ,and Checking the
~ iuspectiofincotasak, chec the
house to the sep the helps determine two things, first,
liquid leve of the septic tank. By doing if the drain field is able to absorb water fast
back up into the septic
frown the septic to the drain field is open, and secs enoughy it would
enough- if itcould. not absorb the household water bast
d checkiag for any'wv tear in the inspectIOD
task raising the lent. It also involved measuring n the s steno is
t cheswere dry, indkafi g mat et
, Both pipes. at the end or the drain fie t circa.
f, ning properly- please p in ind a gain Geld is like any other altpl" determine
repInl aat some p oint< It '
every day, it will ~aear out a need to
exactly when that will happen. ~ determine soil gwal" or code compliance-
The in trop did not involve any excavating
Therefore, it is understood and agreed . that there remains the passibility of hidden defects in the
which are not discoverable by a surface inspection- Tri-County Sanitation wn n
system, a or conditiea of the septic system.
guarantee as car rcp ntadon as to the ag inncti tying or
Tri-County itatlON makes guarantee as the continued proper
that 2 years. if there
peration of the septic svsftm after the date of this transaction-
itatioa recommends the septic system be pumped ever Y
powdered
possible. Als% to out use
is an existing gat a d` t ii be a Ilttle as
sad gwth+er nt+n-i kola ante ' not be trio through the pt' depending an I~
la dry aaa , a fatuity of four, and can vary
ttl; estimate is cur au averag
rha 1. Therefore, the future and
age of children, wariz oa `de rite htaars ~ sa d tie of a ga a d ~the
msiateaaa~acse of the homeowner. it's
the
prolonged life of this system is en eaat on proper .m a inst TrrtCoua .'M
By the s cof th' ro e O,u aive su ° c • dam es alts taraued a
em ro 'ce'3 or as t& now or ins t future son count of "+Un on .
r sit of an failure or o rssbi g" the s b`ect ul from this surfa+ee ins.
Ben Morgan
Tri-Ciaunty Sanitation
W1 License # 81587
PO S# 2009050
State Bar of Wisconsin Form 6-2003 ~
SPECIAL WARRANTY DEED 8 1 1 ~ Z
Tx:40B9207
Document Number Document Narne 968992
This Deed, made between Goldman Sachs Mortgage, BETH PABST
Company, ("Grantor," whether one or more), and Benjamin J. - REGISTER OF DEEDS
Kiosnoski, ("Grantee," whether one or more). ST. CROIX CO., WI
Grantor, for a valuable consideration, conveys to Grantee the following 12/07/2012 11:34 AM
described real estate, together with the rents, profits, fixtures and other appurtenant EXEMPT#: NA
interests, in Saint Croix County, State of Wisconsin (the "Property") (if more space REC FEE: 30.00
is needed, please attach addendum): TRANS FEE: 202-50
Lot One (1) of CERTIFIED SURVEY MAP recorded in Volume 12 of Certified PAGES- 1
Survey Maps at page 3458, as Docunent No. 579915, being a part of the South
One-half (1/2) of the Southwest One-quarter (1/4) of Section Nineteen (19), in .
Township Twenty-eight (28) North, Range Sixteen (16) West, in the Town of
Eau Galle, St. Croix County, Wisconsin.
Recording Area
Name and Return Address
Benjamin J. Kmsnosld
of t ti , g1nwQ--Y 3
008105721100
Pareel Identification Number (PIN)
This is not homestead property
Grantor warrants that the title to the Property is good, indefeasible, in fee simple and free and clear of encumbrances arising by,
through or under Grantor, except
uc
Dated this f day of fdatl< tri! Goldman Sachs Mart ng_aeC omoanv (N~ LOAN sEtvrCtNG
fACT
-(SEAL) _,Wyy a (SEAL)
by
w Sandra Cast ite
pqr=R10 PIT
*
(SEAT.) (SEAL)
M
AUTHENTICATION ACKNOWLEDGMENT
STATE OF 3-e~ >
Signature(s) authenticated this day of, ) ss.
lIA13kt r5 COUNTY)
Personally came before me this day of f jx
the above named Sandra f'ast' to
me know e y~It used t e foregoing, instrument
TITLE: MEMBER STATE BAR OF WISCONSIN and a owle g e me,
(If not, _ _ authorized by § 706.06, Wis. Stats.) < l
THIS INSTRUMENT WAS DRAFTEr) BY
Ryan H Wolter, Esq
Notary Public, State of -rX_
My Commission is permanent. (If not, state expiration date ,
'CAROL C CHAftLTOh
< Notary Putitic
121 1.801 97/2 1 9 HWY 63 STATE oP.EXAs
MY Cumm. Erg Aprti 19, 2Vta
(Sigurttures may be authenticated or acknowledged. Both are not necessary) ~T.
NOTE= THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDF.NTIFIE FORM NO.6 2003
SPECIAL WARRANTY DEED &P 2063 STATE BAR OF W1SCONSIPI
" Type name below signatures .
1 of l
Parcel 008-1057-20-100 05/09/2013 03:59 PM
PAGE 1 OF 1
Alt. Parcel 19.28.16.284A 008 - TOWN OF EAU GALLE
Current ❑ ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
0 - KROSNOSKI, BENJAMIN J
BENJAMIN J KROSNOSKI
219 HWY 63
BALDWIN WI 54002
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 219 HWY 63
SC 0231 SCH D BALDWIN-WDVILLE
SP 1700 WITC
Legal Description: Acres: 5.071 Plat: 3458-CSM 12-3458 008-98
SEC 19 T28N R16W PT S1/2 OF SW FRL 1/4 Block/Condo Bldg: LOT 01
BEING LOT 1 CSM 12/3458 5.071AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
19-28N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
12/07/2012 968992 WD
06/06/2012 957711 SD
01/10/2003 705426 2107/368 WD
06/25/1998 581779 1335/042 QC
more...
2013 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/07/2008
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.071 39,000 135,000 174,000 NO
Totals for 2013:
General Property 5.071 39,000 135,000 174,000
Woodland 0.000 0 0
Totals for 2012:
General Property 5.071 39,000 135,000 174,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 513
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
ST. CROIX COUNTY ZONING DEPARTMENT
AS QUILT SANITARY REPORT
Owner
Address a [ r A
City/State A
Legal Description:
Lot _L_ Block Subdivision/CSM # C'5 a l2 6;dAN 3 j J-3
14-) 5t3 ,Sec. a, T gig N-R fb W, Town of ~aa~. 6a lle #
SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer ° e Size ST51elw / Setback from: House Well 3 -P/L,
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY
Setbacks: Service Vent to fresh air intake
Meter locatio Water Line
Alarm 1 on
SOIL ABSORPTION SYSTEM:
Type of system:Go n ueh iiow,, ( Width 15" Length 78 Number of Trenches o~Z-
Setback from: House a o' Well 6b PA,
L_ ;rb Vent to fresh air intake > 7,3 n
ELEVATIONS:
Description of benchmark 3,~ Q//C /~„off o p1 Elevation /ODD, n
Description of alternate benchmark
Elevation
Building Sewer Q "4 ' ST/HT Inlet `j ST Outlet
PC Bottom Header/Manifold 9 Top of ST/PC Manhole Cover .'?,Y
Distribution Lines (d 9&15 ( )
Bottom of System (J) (-.Z) elf yy ( )
Final Grade ( )
Date of installation 7464 /99 Permit number
State plan number
Plumber's signature C 'cerise number a ° - Y
- -6'/ Date b?y/
Inspector ~ fA-
Complete plot plan a
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
INDICATE NORTH ARROW
48/15/98 MON 15:18 FAX 715 986 4686 ST CRX CO ZONING 449
a ~
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P/of Plan
S c, air-, L/0'
t.e O?o~ Carti y
HDUS2
f~pd~ I,U.e,sw
54Vf Tank
N
\ C2, Trenckss I'.v78'
q
-41- 7Z
Bmi 8MZ Fenc~
f eV► 1oo,o' flev, M2
71Ag~y~
ns`n Department of Commerce PRIVATE SEWAGE SYSTEM County"
•Wisco and Buildings Division ST. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitartleEM"7
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)).
Permit Holder's Name: ❑ City ❑ Villa Town of: State Plan ID No.:
CAREY, LEROY EAU GALL
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9800246
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic K a . 1~ Benchmark y r~~
Aeration Bldg" Sewer V_<,~
Holding St/yt Inlet 7~
TANK SETBACK INFORMATION St/kK Outlet
TANK TO P/ L WELL BLDG. Vent
Intake ROAD Dt Inlet ti
Septic NA Dt Bottom
Dosing NA Headers
96,
Aeration NA Dist" Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand ~,J arm
Model Number_ -GPM
TDH Lift Fri,ct S stem TDH. Ft
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
SYSTEM TO P/L BLDG WELL LAKE/STREAM L~RCFIIIAI. Manufacturer:
SETBACK CHAMBERkv
INFORMATION Type 0 OR UNIT Model Num er:
System: r ~ C.' cF
DISTRIBUTION SYSTEM
Header /mod Distribution Pipe(s) x Hole Size x Hole SSpob ag•--- Vent To Air Intake
Length Dia. Lengthy Dia. `f Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade s`yste`m"s
Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Rd /Trench Center ' n - and /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: EAU GALLE 19.28.16,SW,SW 219 HIGHWAY 63
4~
y f
PI revis o Lreq wted? ❑ Yes ❑ No
Use other side for additional information. I F
SBD 6710 (R.3 r?) Date Inspector's Signature Cert. No
( f,. r,r P j~ c a . d.~ Lam
SANITARY PERMIT COUNTY
~ DILHR TRANSFER/RENEWAL UNIFORM PERMIT #
" (PLB 67-T)
PERMIT RENEWAL DATE: 717 TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER:
PROPERTY LOCATION: errr '
S It) /45 t1' S ,T Aff N,R /6 t, 4p, W TOW O '
LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK:
4!~s 3
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME: PHONE NUMBER:
ADDRESS: PHONE NUMBER: ADDRESS:
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
property.
PLUMBE GNATUR PREVIOUS PLUMB 'S NAME (IF CHANGED):
PLUMBER'S ADDR SS: PREVIOUS PLUMBER'S ADDRESS:
3 S r D7 Sea f "fW ~d0-4V." -141
M OAR4i$W-NUMBER: PHONE NUMBER: MP/MPRSW NUMBER: PHONE NUMBER:
o~ (715- ► 4/.Z S ~a 227 Q5' O ( )
SIGN' RE O=SG A ENT: DAT APP VED DISTRIBUTION: Original - County
ILK] Copy - Bureau of Plumbing
J
Copy - Owner
)ILHR•SBD 3 5/82) Copy -Plumber
f Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. Cyr"
• See reverse side for instructions for completing this application State SaDitary Permit Number
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
GQne 4jI114.5a 114,5 T N, RIG E(or)
Property Own is Mailing Address Lot Number Block Number
2. 10a ,10 l 7% A e r'
City, State Zip Code Phone Number Subdivision Name or CSM Nu b r
44 d/a or ~2
II. TYPE F BUILDING: (check one) E] State Owned ❑ Ity a st Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Y &r Town OF 4 e- C!
111. BUILDING USE: (If building type is public, check all thatapply) Parcel Tax Number(s)
~G// IrrJ
1 ❑ Apartment/ Condo f~
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. g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
______Syfstem ________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
1210Seepage 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) QG~ S Elevati n
Q6r
? S~ 7 j-6' r 6 Feet Feet ItIA- 9Z,11 VII. TANK Capacity
in gallons Total # Of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New I Existin strutted
Tanks
Tanks
Septic Tank or Holding Tank l oo d 1 f12 i`pLrJi!9 I V~ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: o Stamps) MP PRSW No.: Business Phone Number:
r ~ !~L
.J 38ti
Plumber's Address (Street, City, State, Zip ode):
/070 r- .0 -;I- 4/a G
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater EDate Issue Issuing Agent Signature (No Stamps)
I Surcharge fee)
Approved E] Owner Given Initial c
Adverse Determination X. C
ONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
Sf (F1.11/B6) M RSIMON: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS w
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 maintai ned. 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 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.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
La'jor and Human Relations
Divsion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but "ST - <ZAZklX
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. IP S1 1N G
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R IW,,BY T
`L 9
PROPERTY OWNER: PROPERTY LOCATION IN, I (t
U~7_% 'f C° 'P' R-LI GOW. AT- 5W 1/4 &u 114,S 19 T ZF3 ,N,R Ilo E (ar~
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
Z ti o 6 -Z-,3
` r'svE . - ~cw~ os ~swt
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE QrOWN NEAREST ROAD
kj sgooz (GIs) 0y- ~/b6Z ~ v Grrt, Ust+ 6 3
[~Q New Construction Use jq Residential /Number of bedrooms [ j Addition to existing building
(j Replacement [ ] Public or commercial describe
Code derived daily flow 4S3 gpd Recommended design loading rate - bed, gpd/ft2 trench, gpd/ft2
Absorption area required 0""d bed, ft2 -1 S o trench, ft2 Ma)amum design loading rate s bed, gpd/ft2 ' b trench, gpd/ft2
Recommended infiltration surface elevation(s) a 6 - q6.O ft (as referred to site plan benchmark)
Additional design / site considerations s pal PSG E Z
Parent material Lo NZs % oueil- ov~w S Flood plain elevation, if applicable ~j • A - ft
S = Suitable for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ®S ❑U [0 S ❑U OS ❑U ®S ❑U ❑S ®U ❑S [$U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxialy Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tertdi
0-S 1~'-t2 313 ~ s i l Z`(' Sbl2 Yh'~}- C S -S . ~
Z -3~ Lo ti tz-3/~ _ S i) Z V" eb~n rn'Fh Giv • S ` 6
Ground 3 36-Sy 1. S `i R- V/y Gti. g 1 1 -'-3'61T Yrt` `l- C tv - S
elev.
101.'1 n y Sy -1Z..Z S `t 1z V/L - S O s~ W1 - - ( •
Depth to tCX_% C_Cj1V ti S 1,J z`PC1~t-L ~o LU~L~
limiting
fact`
Remarks:
Boring #
o- 9 10'1 tZ L 3 s i t Z'F s~`r~ w~'~h F_ S
, g . ~
Z Z 9-31~. 10 tL 31 to SO 1 Z vvls ~ Y. II,- CL,
- 4
3 31-Lo 1_SYR y! 61-51 1 ~a~k M`F~ ew € •S
Ground
elev. 60 118 -I. S '-n L `I/G S ~t `FS o S 9 wf •
99.8 ft. -
Depth to
limiting
factor
> 1\$' - i`
1
Remarks:
TName:-Please Print Arthur L. We erer Phone. 715- ' 165 N,j
Address: Soil Testing & Design Service-P.O. Box 74 River Falls, W
Signature: j C Date: CST Number: .
M00576
PROPERTY OWNER SOIL DESCRIPTION REPORT Page? of 3
PARCEL I.D. # P~l`J~ wa
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxby Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 e-9 X0`-12313 - Sit Z.jsb "--e (%-S _ ,S .
•b
z 9-uy ~0~2 3l` sit Zn-lS~1~ ~n~>• Cw -S
Ground y~-6o -),3LlR yly Sbk 1~Tt^ Ck3 -L1 .s
elev. S , fs
~Ob.b ft. 6b-1LL 1•S `12 YI'- - G~ U s3 wt _ . S b
Depth to '
limiting
factor '
?
Remarks:
Boring #
0-9 1ZS \-tkz 3! 3 s'~1 Z~sU1~ wr`~y. as
• S i.~
z q-36 ~o~iZ 3!6 - s.11 zrnsub
3d-`l3 n•S Lt(Z-/!y
Ground
elev
ft. y ~3 -CZ ~S LIP- l to ` S $ S Yn 1 , 5
Depth to
limiting '
factor
l ZV"
Remarks*
Boring # o _ 1o`t R 313 - S) Z'~s bk Mm' C-S
El, Z $ 10 `-i Q 31(. s i 1 Z. s b1~c w►`~' 1- c.~, _ . 5 - ~
3 V! -coo -i• S Lm MY S 1 1 t` sbh ~j \j z w , ~j i • S
Ground
elev. L/ Lo -fin -1.S -fv V/6 - S ~~S v S9 yn
loZ.7 ft. `
Depth to
limiting
factor
L Z1',
Remarks:
Boring #
t~ C ` 1 )"j C. w 1 \Z
S` c t~v P R" wt wl N i
:Ground
elev. ft. 0F$ I >u. l STf~ Z Q S S 1S ►v 6 w~ 1'CCG1
ti
Depth to Wl f~ - ^Z.~' c~ Ov LZ l5` 11Z 1 U (Y\1 ~J L1 S lei Er i J
limiting ~rS r Sv Tr- X1Z," t . Y"tio~ ` Z,N uU 1.
factor
Pt1- c~v ~ L e ~ s ,
Remarks:
SBD-8330(8.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= 30 '
- 1jUUSi= NCO 8E ITT . LQIt;41
Y~~L,~ N k N t C~ • k h J
i
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' '1 a) \00.0 ON 8\116 ti , C 6 ~FZ - -1- LbZ . ~ O N
31y" bif C P~Pe 91t►SN~ 31y bit
/~WOb UM RUC PIPC~ w/
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(715 ) 42,q-0169 1400576
CST Signature Date Signed Telephone No. CST #
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
i
Mailing Address D~~O 10
Property Address
(Verification required from Plamiidg Department for new construct; a) 41
City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Location S Sec. T a FN=R ~W, Town of v .flu ~/e
Subdivision Lot #
Certified Survey Map # /S Volume 1.2 . Page # 3 Y,(-r .
Wan anty Deed # 412 .S' IA 2 Volume 7 7l Page # S' d~'d
Spec house yes R no Lot lines identifiable yes; o
6YSWM7- 1AtMNANCE
ImpmpcraseandmahtenanceofyuursVacsysGcmcouidrewhiaitsprrmatiu+efailuneto handle wastes. mainteaaaoe
consists of pumping out the septic tank every yeats or Proper
can affect the boa of the f00~ zf'needed by a hoensedpumpcr. What you pat into the system
septic tt*-as a treatment stage in the waste disposal_systcm.
The property owner agrees to submit to St. Caonc Zoning Department a certification foam. signed by the owner and by a
is in =sWplumbcrjourneymanphmjKT, restrictedplumbuor a lieensedpamperverifying that (1) the on-site wastewaterdisposal system
IxOM Operating condition and/or (2) after inspection and pm*g.(if necessary), the septic-tank-is less than 113 full of sludge.
Uwe, tyre uadd6rdgued have read the above required and agree to maintain tare private sewage disposal system with the standards
set fork herein. as set by the Departat 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.
SIGMA OF APP CANT ~ / p¢3
DATE
OWNER. CERTIFICATION
I (we) certify that all statements on this form are am to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the 'bed above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNAII~t OF APP CANT / ~ / p
DATE
Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Deparmrent.
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
421.
776?AGE 58
LDAW tU WAAAArrtY Urban
Thb I1IMd nture, Ala& this 16th dry of October between Federal Land Bank of
St. Paul a corporation, organized under the Laws of the United States, with a pos: office addrrss of . 37S Jackson
Street, St. Paul FN 55101 parry of du prst pars.
and LeRoy J. Carey and Beverly J. Carey, husband and wife
Wwu post ofce address Lt Route 2, Bo-c 203A, Belle Plaine, FN 56011
She of Mi nnasota , parr i-es of the second,
w7INESSE7N, lister the said party of the first part, for and in consideration qf the rum of 76,700 ----DOLLARS.
To it paid by Ae said pert leS of the second part, the receipt whereof is hereby acbnoxledged, does Grant, Bargain. SeM and Convey unto the
aaid~ of the second P~ their heirs, successors and assigns forever. the following described rent estate. situated in the County
of St. Croix
wd Stae of Wisconsin I~wif;
SA of SE4
Shof SW Fracnl 1/4;
Wl~ of S~ of NW Fracrl 1/4
h"i of N' of SW Frac' 1 1/4;
All in Section 19, T28N, R16W EXCEPT part to George N. Peterson
in Vol. 1130011, Page 81.
• MT
(this deed is to release land contract registered in vol. 724, p. 247)
subject to all existing easements and rights of way; also subject to all taxes on said premises for the year 19 - and following years; also subject
to all unpaid pans and installments of special assessments on said premises which have fallen due, or will fall due ~wreafier.
70GE771ER with all and singular the hereditaments and appurtenance., thereunto ue;onging or in any wise appertaining; and all the, estate, right,
title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession er expectancy of, in ar d to
the above bargained premises, and their hereditaments and appurtenances.
TO HAVE AND 70 HOLD the said premises as above described, with the herediraments and appurtenances unto the said pan ies of the se-
cand pan, and to heirs, successors and assigns FOREVER.
AND ME 1.411) party of the first part, for itself and its successors, does covenant, grata, bargain and agree to and with the said part ies of
the second pan, their heirs, successors and assigns, that the above bargained premises, in the quiet and peaceable possession of the said
part ies of the second pan, their heirs, successors and assigns, against all and every person or persons lawfully claming the whole or
any part thereof, by, through or under said.rvrty of the first part, and none other, it will forever WARRANT and DEFEND.
1N WIINESS WHEREOF, the said party of the first part, has caused these presents to be executed in its corporate name by its duly authorized of-
ficers, the day and year first above written.
br Presence of.• THE FFDERAL LAND BANK OF SAINT PAUL
By: ~cetI /v
Paul Moe, Regional Vice President of the
,r 7bk
Federal Land Bank iuociation of Northwest Wisconsin
Acting as Attorney-in-fact for the Federal Land Bank of Saint Paul
or:
Production Credit Association
41
06140 9166
r
Stmt of
~If -_Wisconsin-
~
St. Croix
County
Januar 1187 X
7b: foregoing instrument wns ac k wwIeJg,,,f bef -ee a cu _ ~ ` -
aw
Paul Moe+ = ' i Tonal Vice President
6y of Me Federal Card Bank Association
Ir..N :w
of Northwest Wisconsin ---as anorn in fad on behalf of The Federal Land Bank of Saint Pact
My commission ttpitm 5-10- 9()
Y; WehkinS, ^'°'°`r~v
Pierce Wisconsin
co a County !Uwe
Staler`- iI
) SS.
The foregoing instrument wns acknowledged before me on
ow
by of the Production Credit Association of
tmk
on behalf of said corporation.
My commission expires
County State
Drafted By:
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