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HomeMy WebLinkAbout008-1057-20-100 a o j ~ °o I a~i o 0 4 j c 0 e• w, is c 3 fO v p c v sa O C 2 Y - ~ E v N N ~ .p - c~ wr a>~ E Q~ma)c E m o 0 N E ~ o 'C CL a) c O O Y O O -O OU O C ; L 2 T° ~ N i 3 p c csi o" ` d m. n~ a)° ° o o EUU o mU L U O T C L O° n> L o m V CL O d a) C N C L O y V! 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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. P/of Piave `,r- qO S c, a t<. (..e ?o y Ca r,-, y f'~ous.e ~ttl lo~~ Gtaeas+✓ $e~~' ic. Tcewk • 5k~ C~,, Trenc%s I1Y73 a i q $M1 /ev, l00 0 ' Flev, /oz.t TC b~ 06/15/98 YON 15:18 FAX 715 986 4686 ST CRI CO ZONING X009 ti J b~ , pf- pry y < y \ Q~ Y y s r, bo ,h ~ / !rt 2 /0 2. / i '10 6; fee I i ST. : . CO. -A K' j 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 ~ I c s 1 1 ~ ad i F r, 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. Ye WY 5 trJ ~ ` u i rtv iv3 e ~ t 5 P sa. ?sue rv J r ox ~ 'S` BBL y~UG 3/j f /o G l 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 B-H . cr- a o~ 6S cb Z SO~ ~ C. u~° s~ts-na,~ ~t . q b , g VrZ fit, 99 Xyl- Z ' '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/ O 0 (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: i O Y 3 41 a Y ti ~ x W y ~ Y 3 O A l i z v c p o ` L LO n L I t7 ~N-C ` ~ i lI; n 579915 R` CC f Ln G + n ~ 41 run °o y c/) C/) m ~ THIS INSTRUMENT DRAFTED BY ED FLANUM JOB NO. 98-39 m Z Z UNPLATTED LANDS °z o _z o S. T. H. "s3 " WEST LINE OF THE FRACTIONAL `D m - - - SW1 /4 OF SECTION 19 - - - - - - - - - - - - - - - - CENTERLINE °o N 0'33'41 "E 1269.88' o Noo•33'4"E o 0 367.74' 577.83' S00.33'41 "W 0 1365.64' - - - - - - - o 0. NJ X324.31'- --f? N00'2345' E 332.94' ; , i 00'23'45' E 572.44 rn 0 og0 z co CO 00 DD I w = 133 3'I~' ~ ~i \ 1 O r v - : M n I A N N 00 m 1 wN O No v . h nO Z > y o 00 v~ 0xco~ p 14 (n co L4 (.0 4LO C O- n I AN rnrn: BARN p n 1 N n y cli O Z M 00 (Ji U: nZ Q c, 2'+/_ (11 p m I p m v N O ~u; v a V ~n x cn . rQ -pt cj) (o 4 Iv t]N pp I Oc,'1~ ~ O c;l Z~ 33.02: 317.79' N L~ g~'gZ°~~S m Y r OD I 2.5'+/- v " " n. NID L-) 00 j,,L co 6„W zv N) v I S0350.81 N y 00 „ y '~Tj - N I I 0) I (-A VI 0 I o~ 00~ 0~ D U I I y_ cy L') o * O ® • B o oft 10 N~ m I~ 11 n\ b ~'1 n O N w -Tj 10~ N I o y ICI NI Z° 0 U)~ Vic: I I I~ m x m m N D o m ° r I J 1 O Z r Z O co W -N z N) m -n c: 0 I m co m - D m 0 55 ~ O 0° iz 01 °52'38"E 362.29' m m o m N c: -0 o~ c: -n K 334. o z o D c m z rn 06' I~ 28.23' p m z ~ o 00 W mm C ICI i u' m ° m z D Xw O I ao oN 0 m ° n m m ;rl 0041 D m O~ b 1~~ 1 > ° Q: ° ~z ° c~ 00 z y N 1 cn U1 D ° _ " pm b p v I°~ (o 'may c'o K: Ns" 0 b) t -ss mNr p aI bI m' ° cn 0 -P 4 ej z o D m y b z ml J: N m c0 rb,I k..~.. s- . = z X ml I r^ OZM ml 24.15''. 338.14' 0 m ~ O Cp t D ~gi S01 *52'38"W 362.29' w i EAST LINE OF THE 6 FILED 2 m ° ~~01 SW1/4 OF THE SE1/4 MAY 2 8 1998 I NI V KM VLW&Sli 3 8 ism of I I I~~ n m 5L C[* C0. n r 60 z UNPLATTED LA z T, INGS ARE REFERENCED TO THE l co EST LINE OF THE SW1/4 OF SECTION 19, ASSUMED TO BEAR N00'33'41 "E VOL. 12 PAGE 3458 JJ 301,49# god r~ t t ' r N t~~~ Vy 1 ~ ~;1 t ~r. ' ..5\„y k, ; r• phi. k•. t y♦ 4 10* • N jai K« l . L r ZI. gip. < ~ ; • ~ .r ~ : . r Y 1+ M w 1~ f S ~ NTH{~ r as : r y ; .1 . t 4 Z. J walb t JUN-18-1998 THU 12:56 ID:STEINER PLUMB & ELEC TEL:71S 42S 8818 P:02 ~S M ~ . 4; S ice: Wt 4~ ..q' Y 71d 9. L M ':,5 T :r ■ S7 as y 9915 ~ ~ : ~ o n THIS INSTRUMENT ORAFTEO 6Y ED FLANUM f S NO, 98-39 r~ ° Z LA ATTED LANDS S' 7: "63 " WEST LINE OF THE `j - Z. FRACTIONAL ~i o o~ SWI/4 OF SECTION 19 z ''4 _ CENTERLINE_ _ _ 91 II _ 0 367,74' N0O'331"E 1269, o N00'33'41" E - SOO'33'4f " o ° N00'23'45" 577.83' g E 332,94' 324.31 N Cn 1 cane 00'23'45"E 57_2.44' - 1363.64 3] ;1'~ I N x z I.. ........................N.. pi 0 2 ~fb Q I > m (n v rn I Q N co >4h _7 -40 'n 33 q0 ~y y P 317.79 5 r `s ~z 3 9,SZ.S 1.S O C fTl l1 y K) y 2•: Q3ii N boo w ~ I SQ I ~ a » ~i1 b h x v) I ~ rj VD v> r f I I y sr, o • 8 O ovb U I ~ A -1 ~ N ' ICI n1$ ~ ~ ~ I ~ O"al y I N o 41 ~-j I 0 r N n- ;p E4 9 z z 01'52'38"E 362.29' c om -n o m m IA c c N, W rn 28.23" 334.06 ~ C ?i a s =1 m m ~ ICD I I 4L> Q' 4 g 8 y krJ cil 71 zm .11 mi o wtig ti~ I I I~ OA n •S e. Z O Z X ~I bl,, b ~0 i o p co rw ~'c~► C'n m 1• M II x loll -n Nam cii ' n u R1 pul IZ Im ~.Cp r,I 24.15' 338.14' n y ~ 501'52r38►rW 362.29r ~ Z ~F F FILED L., .I EAST LINE OF THE 1998 I1;~ SW1 /4 OF THE SEI /4 MAY 2 8 10 • rinizWK lst+ 3 v, SL I n UN PLATTED LA ST LNGS ARE REFERENCED To THE INE OF THE SWi /4 OF SECTION ~c Y 19, ASSUMED TO SEAR N00'33 41"E I VOL. 12 pALGE 3458