HomeMy WebLinkAbout022-1089-30-000 • a
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner . �� %� R�CE VED /
Property Address " y -
City /State ° ` ~ i' ^ ` ' n tQ98
ST CROI
COUNTY
Legal Description: ZONINGOFFiCE
Lot " Block Subdivision/CSM # '
'/a t /4, Sec.' , T N -R�tW, Town of t C r PIN # 0a� .Ly �3�
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer Size ST/PC / Setback from: House Well P/L
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
� ��
Type of system: 1. h l;, F5Width 7? Length Z 3 Number of Trenches
Setback from: House Well P/L �U ` Vent to fresh air intake
ELEVATIONS
Description of benchmark rn E r c h C 1' tt 51 Elevation AM, C
Description of alternate benchmark Le, ' �" Elevation/tl
Building Sewer ST/HT Inlet ST Outlet �> PC Inlet
PC Bottom Header/Manifold ► < J Top of ST/PC Manhole Cover
Distribution Lines 13O O .:
Bottom of System / () U A • b ( ) �°
Final Grade (3 It
Date of installation 1110 /,,. / 9 Permit number 3z44bO State plan number
Plumber's signature "(�.�4 License number - /~' Date`D 1
Inspector Roo e5c,m�G l
Complete plot plan
a i
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
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• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
X
PLAN VI W
(W
A
J'o S'� 4
INDICATE NORTH ARROW
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1
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division ST. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3PrjnitJyA.:
Personal information you provice may be used for secondary purposes [Privacy LaXy, s.15.04 (1)(
amePAUL q j a j%W j&vn o : State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description Parcel Td' -1089- 30-000
6 b c 00
TANK INFORMATION ELEVATION DATA A9800519
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
eptic Pi�GfS�r Pw � Bench k 2-0 /
Dosing tj
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic r NA Dt Bottom
Dosing NA Header /Man.
Aera 'on NA Dist. Pipe .6 4 7/./ - a
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand .
Model Nu er GPM
TDH Lift Friction TDH Ft
Forcemain Length Dia. Dist. To well
SOIL ABSDRPTION SYSTEM
BED / idth Length No. Trenches PIT No. Of Pits Inside E Liquid Depth
DIMENSIONS DIMENSION
SETBACK SYSTEM TO /L I BLDG WELL LAKE/STREAM LEACHING
Manufacturer:
INFORMATION Type O a?, , CHAMBER Mode Number:
Syste 13 OR UNIT
DISTRIBUTION SYSTEM Go we,&+ t4 Ltirc
Header /Manifold Distribution Pipe(s) / ^ , x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length G Dia. 3 Spacing lD P {y 7
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: KINNICKINNIC 30.28.18.P477C,NE,SE 945 QUARRY ROAD
w" i r�� cu, r- ,,�•�t G"r r�1 r�s
i0 7,0 q�
Plan revision requ red. ❑ Yes No
Use other side for additional infor Pation.
SBD -6710 (R.3/97) Date Inspector's Signature Cer
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
V SCO/1S %D SANITARY PERMIT APPLICATION . E. 796 ngton
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 f�
than 8 1/2 x 11 inches in size. x—
• See reverse side for instructions for completing this application State Sanitary Permit Number
y ou p rovide may be used b other g overnment agency p rograms �
The information
y p y y g 9 y p 9 ❑Check if re%ftf6n to previous application
[Privacy Law, s. 15.04 (1) (m)]. [��
v State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Propert ner ame Q PJD a ocation
u C �1 /4 ) 1/4, S 3 T,0,0 , N, R/ f E (or&
Propeqp w 's M ing Acl ress Lot Number
ty/ j 4 l
Cit , gate Subdivision Name or CSM Number
� f J Zip M �� j PhoneNumber )
11 . TYPE OF BU ILDING : (check one) ❑ State Owned ° v y a e / I Near Road
ID Public 1 or 2 Family Dwelling - No. of bedrooms Town OF <
111. BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s)
1 ❑ Apartment/ Condo 30- R8 18- ®dP e r g ~30
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. F� Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------ -------- System Tank Only
_____________ y E System
_____________ Existing Sye ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one) i �I tkk�� " S �CE��/IY�d ,l 31. ��
Pe
Non-Pressurized Distribution Pressurized Distribution Experr ental _ Other
11 ❑ Seepage Bed 121 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12C Seepage Trench � `j 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 6Seepage 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 15. Perc. Rate 6. Sy tem Elev. 7. Final Grade
�to 11 Requ' d sq. ft.) Prop ed ft. (Gals/da sq. f (Mi A h) p Qp p, EI v tion
, 1 Feet .0 Feet
VII. TANK Capact
in g allons _ Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name concrete Con Steel glass Plastic App
New Existin strutted
Tanks Tanks
eptic Tank 9 ❑ ❑ ❑ 1 ❑ ❑
Li ump Tank /Siphon Chamber 11 ❑ 11 El 11 El
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage shown on the attached plans.
PI is Name: (Print) PI ignature: o amps) P /MPRSW Business hone Nu r�
0 � GtJ oo l S J S
Plumber's gddre ( eet,City, a Zip ,/�w
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permi Fee (Includes Groundwater D ate Issued Issuin Agent Signature (No Stamps)
Approved E] Owner Given Initial (/D Surcharge Fee) �O
Adverse Determination bb IV u �V
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
- - �lsf�(( �yslcw► per 0; T15 r�cow►►��v, � r
SBa639a (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division. Owner, plumber
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INSTRUCTIONS }
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608 - 266 -3151.
To be complete and accurate this sanitary permit application must include:
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.
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GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
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and establishment of standards.
PLOT PLAN Pa 3 of 3
' SCALE 1 "=
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sv��LE 1�T `C'1w1� 0 1= cn�sl�c�io�v.
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9 ZZ�
( 715 ) 425 -0165 1400576
CST Signature Date Signed Telephone No. CST #
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to cef t t have inspected the septic tank presently
serving the Al Q residence located at:
�; ,L h, Section -� , T N, R_W, Town of
Al t !/l l�� t— /n i Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced: 1 �
Did flow back occur from absorption system?
Yes / — No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity: 100 d
Construction: Prefab Concrete Steel Other
Manufacturer: (If known):
Age of Tank ( If known) : ,' A t
(Signature) (Name) Please print
(Title) (License Number
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform the requirements of ILHR 83, Wis. Adm. Code (except for
inspec opening over outlet baff
4 4AY � � � Name ��j-� Signature MP /MPRS /V
Wisconsin Department of Industry
Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page \ of I s
Division 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•�(
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. O __Lz - 10 bq - :90
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
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PROPERTY OWNER: PROPERTY LOCATION
L o�'I'1t
Lf (l? ANN 1- E$T- 1/4 SST 1 /4,S 30 T 2- N,R ZQi E (oi W
PROPERTY OWNERS MAILING ADDRESS LOT # . BLOCK # SUBD. NAME OR CSM #
a q S Q vtmR�r �� -.Z —
CITY, STATE ZIP CODE PHONE NUMBER [)CITY []VILLAGE &OWN NEAREST ROAD
RwM PtIAS w SutiZz hIS) cols -Sa19 `tctkx,). e\ 0unavLy
[ j New Construction Use Residential / Number of bedrooms 3 ( j Additn to existing building
J, Replacement [ j Public or commercial describe S No`S a) • I>NGN 2
Code derived daily flow u.So gpd Recommended design loading rate bed, gpd/ft - u c o , trench, gpd/ft
Absorption area required — bed, ft c ib0 trench, ft Ma)amum design loading rate S bed, gpd/ft2 b trench, gpd/ft
Recommended infiltration surface elevation(s) SZV_r 'M it (as referred to site plan benchmark)
Additional design / site considerations \ i j 9- . $Lrit 0 y) �P G e - 3
r
Parent material W la�SS o y � o�JZwfs N Flood plain elevation, if applicable 1.1 I)- ft
S = Suitable for system CONVENTIONAL MOUND IWGROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for stem [� S ❑ U ❑ S ❑ U [R S ❑ U ®S ❑ U 11 S [�tl El U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed recd
I o -to
r) -t TL 3 I Z — sib z.►n bh m\j
Z �oz8 to�tL
Ground 3 Z$ 39 'y.S `f R y C .. • .
elev.
°1 of -Ss tibmRSIL 4S4 � 1 cSbVt. Y \ i\_
Depth to R S 1 i, - TS o S9
limiting
factor C-0 lo N S't 0 \3 s
� O1 t o"
Remarks:
Boring #
El o -ty 1u f Z L ZWI S bk
h;
Ground
elev. 3z�Z ').S HrLL /% — se 1 l eSbl� 1 t�' p $ S
q S.3 ft GRC \+ Av- S i x
Y+�t
Depth t0
limiting b Su_ l ll`2RSlL S .6
factor
N
Remarks:
CS T Name Print Arthur L. We erer Phone. 715- 425 -0165
Ad dress Soil Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022'
Signature: ui� �g -ZZ� Date: IT Num 00 5 76
i
PROPERTYOWNER SOIL DESCRIPTION REPORT Page i• of 3
PARCEL I.D.# OZZ_ LO 3h
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
E l In. Munsell Qu. Sz. Cont. Color Gr, Sz, Sh, Bed Trench
o - �,z to �.�cz L Zwu r+� e S _ •s •�
Z vz - wit 2 31 L - s� 2`¢sbk `f�. S • S
Ground o 2 sL C sbNt M u e S • S .
elev.
0\� -S ft. y u6A.3 LO`-t 2
Depth to '
limiting
factory
\
i
i
Remarks:
Boring #
13 �� 1� 1 v• t S ")_1 b In
S5 , uF 1s 8 Mts.
3
' 3
Ground '
elev.
ft.
i
Depth to '
limiting
factor
Remarks:
Boring #
13
Ground
elev.
ft i
t
Depth to '
limiting '
factor
1
Remarks:
Boring #
}
Ground
elev. `
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
PLOT PLAN Pa 3 of 3
SCALE 1 "= 40 '
3 CDR k
X01" ll,
x ,
I �
2.- S'qw OuTYpf'I OF S10W6,
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WAG w/ v"614 QAVA" siDEw«!D_t
�2�ue Let es K'— -
-
Or-
uNE v owu�s w2
a lp P1zC]JT �1 -1701V .
L'Z, I ��r��l- tt.�u�. '
OQ C-UNI-tJ%F� ' dF
(715 425 -0165 1400576
CST Signature Date Signed Telephone No. - CST #
wisconsinDepartrnentofindusby - SOIL AND SITE EVALUATION REPORT Page � of 3
=safe Human Relns
Division of safety a Buikfings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site an on ST•
pl pl paper not less than 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BK, direction and % of slope, scale or. PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. O ZZ - D - 3D
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REV DBY DA
PROPERTY OWNER: PROPERTY LOCATION
9mit . vo) FF`I'1L Lf (FR WW--l:- F 114 SE 19,S 3D T Zb ,N,R l$ E(a1 ow
PROPERTY OWNER'S MAILING ADDRESS LOT # . BLOCK # SUBD. NAME OR CSM # _
qqs QvTMRY IRIZWI�:) — —
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE &OWN NEAREST ROAD
"?-W Z _-S ►� Sklozz ()IS) y,z �c1►. �e�L�,UtC 0J'AlLa zokt�
[ ] New Construction Use [x] Residential / Number of bedrooms 3 [ ] Add'itign to existing building
j,>LReplacement [ ] Public or commercial describe 59-E No`s Q h) - Pf�G e 2
Code derived daily flow qSZ gpd Recommended design loading rate — bed, gpdfit2 - trench, gPd/f t2
Absorption area required — bed, ft c l bO trench, 11 Ma&um design loading rate • S bed, gpd& - ' 0 trench, gpol(t
Recommended infiltration surface elevations) %IZ'E t.w ' 'vp It (as referred to site plan benchmark)
Additional design / site considerations 1►v sTa of al") � (3N' 3
Parent material �-Q eSS o v NM oy S N Flood plain elevation, I applicable ft
S =Suitable for system CONVENTIONAL I MOUND 14- GROUND PRESSURE AT -GRADE SYS W IN RLL I HOLDING TANK
U = Unsuitable fors stem Gas ❑ U QS ❑ U ®S ❑ U ®S ❑ U [is au ❑ S QV
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon in. Munsell Q, Sz, Cont Color Texture Gr. Sz. Sh. Consistence Beunciary Roots Bed rerxfi
1 o -t0 V) Sit z �nv`fv a.s .S •�
L
Ground 3 l z� - '� `1R - -*-J V _ 1 S � e S Uk mV C ti1 .. • - 1 .
CN O ft 3°I SS %'l 4S 4t 1 cSb1z V4 V'94'- C S
Depth to S S T io � u`t TL 'S
limiting
factor
Remarks:
Boring #
0 -14 k
1u�2 - I L Zwts wt vi S
2 2. ly - 10`�l2 �!(, si 1 Z'QS�k >n'� LS _ 'S
3 2-11-1 Z S %1 rL S/ /� S — .y .S
Ground
° 3 IL 3 �-u z '),S 4 rL V% — s� 1 1 d-sbk
Depth to S 4Z -30 � W lZ S / yn 0-S S • U
ti Su_ l ll`Z RSII `FS O S%
factor
q z " S
Remarks:
TName.— Please Print Arthur L. We erer Phone: 715 - 425 -0165
ld d ,ess:
egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022
Signature: L i -t � �� v Date: ` 5 _ q CST Number 00 5 7 6
� T
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PROPERTYOWNER SOIL DESCRIPTION REPORT Page? of 3
PARCELI.D.# 0ZZ- 10 "--30
Boring # FlAoriz Depth Dominant Color Mottles Texture Structure Consistence Botxcbjy Roots GPD /ft
In. Munsell' Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 y r �-° S - •S •�
Ground VW- f,2.S /. 4 s M U-& e S �• S.�
elev.
��•S ft. y 4A. 10` -1 2 Slc.
Depth to I
limiting
factor
'2 *L S" n
I
n
_
I� Remarks:
Boring # _
.13 �� — b1�IG 1 0• �S l�tf✓1 D�
Ground
elev.
ft. s
Depth to
limiting
factor
Remarks:
Boring #
13
Ground
elev.
ft. I
Depth to
limiting
factor
. 1
Remarks:
Boring #
_
i
Ground I
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
PLOT PLAN Pa I. of 3
SCALE 1 "= 1 4
s�'Re-
J
1 - 2 - � . Vs1.S'um %IOY"H OF S aMW6
9
r
Lk1"6 W / MA611 CAPV''OTY S1D.�1.iu_vQ
`nw z - or= Czv'isyTwc7poN.
I R 'f1 �ti Sv. p L N E Pak
c, 0 �� S I erg t4 I - Cum oU C- ,J tM OF
uim-
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a.z
9 8 —2Z�•
( 715 ) 42.5 -(), 65 14 00576
CST Signature Date Signed Telephone No. CST #
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
,Q `I O RSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address % 0 14 4rel l f rd. l U -7p rwll? Cc/!
Property Address _ s41 4
(Verification required from Planning Department for new construction)
1 '
City /State �((1 F41 L S ZYJ Parcel Identification Number 009) la 9— 36
LEGAL DESCRIPTION
Property rtY
P Q-
Pro a Location /`/ p F 1 /4, S ' /a, Sec. �0 , T 0 R / O N- D W, Town of
Subdivision ��� , Lot #
Certified Survey Map # Volume , Page # 1
Warranty Deed # 7 , Volume , Page # ° 3
o?1
Spec house ❑ yes Iff no Lot lines identifiable )Z 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 put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, joumeymanplumber, restricted plumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the 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
ri 61—JA
j th ee year expiration date.
SIGN F LICANT DATE
OWNER CERTIFICATION
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 props scribed above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIG14A TUIK OF PLICANT 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
MY 488 PA -E214 i
And the said..... George E. H ..... .. -
for ----- ._themselves and -- their ........ _ . .._heirs, executors and administrators, do ------ . ----- covenant, grant, bargain and ".
agree to and with the said parties of the second part, and their respective heirs and assigns, that at the time of the
ensealing and delivery of these presents - - -- -they age_ . well seized of the premises above described, as of a good,
sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and
clear from all encumbrances whatever,- ---------------- - - -- - -- - -
...... ........ ..... .......... ............ __.......-- ...... ...._......... ......... .............._---------- - - - - -- .. ........ ._.. - - -- -- - ........ __.
.. ..
-.... .. _ .. ..................... .......... ...... . ..... .. _....... ........ - -- - .. _......._._ ... . _
and that the above bargained premises in the quiet and peaceable possession of the said parties of the second part,
as joint tenants, and their respective heirs and assigns, against all and every person or persons lawfully claiming the.
whole or any part thereof,_.. ... ..they will forever WARRANT AND DEFEND.
In Witness Whereof, the said part. ies of the first part have hereunto set. their .- hand s
and seal_ s- this... -___ 15th _ day o f August - -_. -- _ - _ -._ _.., A. D., 1972 .
-...- (SLAL)
SIGNED AND SEALED IN P ESENCE OF Ge r'ge E. Hof r
(SEAL)
Ethel M. Hoffineyer
Ga Or _ - - (SEAL)
Sandra rice _ _ _ . (SLAL)
STATE OF WI CONSIN,
SS.
.Pierce - _ - County.
Personally came before me, this......- - 15th„ day of _ _. August---- A. U., 19. 22.. ,
the above named _.... ..._ . - . ..George E. Hoffineyer and Ethel M. Hoffineyer ... ... . _
to me known to be the person-.s.. who executed the foregoing instrument and ackno dged the side. �.� V
L. Gaylord �� a
Pierce. % Count, Wfs.- y
Notary Public,_ _ __.... y
My Commission Fs is permanent,
Drafted by C. L. Gaylord, Attorney.
River Falls, Wisconsin.
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TENANTS. (Section 23045 Wisconsin Statute H
FORM 339 —� � d NTY DEED—TO JOINT . s c .!1-- .".. — i
311
This Indenture Made this 15th day of.. August A. 1) 19 72
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between... George E. . Hoffineyer and Ethel M. Hoffineyer, husband and wife, and each
in his and her own right, _ part ies of the first part,
and.......... __.. Paul D. Hoffineyer and Connie D. Hoffineyer, husband and wife,
r
; as )oust tenants, parties `of the second part.
Witnesseth, That the said part -_ies o f the first part, for and in consideration of the sum of
..._ ...Twelve Thousand and No /100 Dollars - - - - - - - - - - - - - - - - - ($12,000.00)_ `
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_..them _ in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and
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acknowledged, ha. ve given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by
these presents do_ give, grant, barga;n, sell, remise, release, alien, convey :uul confirm unto the said parties of
the second part, in joint tenancy, their heirs and assigns forever, the following dew-tilted real estate, situated in the
County of._... -_ St. Croix and State of Wiscow;in, tee wit
All that portion of the N� of Wt. of Section 30 -28 -18 which lies E
and S of the highway crossing said 80, also being described as
follows: Commencing at the SE corner of said NEk of SEA of said
Section 30; thence running W on the S line of said 40 to the center
of highway crossing said 40; thence in a NEly direction along center
of said highway to E line of said 40; thence S on said E line to
beginning, except a parcel of land located in the NE'k of SEA of
Section 30- 28 -18, further described as follows: Beginning at a point
on the S line of said NE'k of SE a distance of 1317 feet N and 328
feet W of the SE corner of said Section 30; thence N 44 W a
''. distance of 450 feet, more or less, to the centerline of the town
road; thence SWly along said town road to the S line of said NE14 of
SE thence E along said S line of the NE'k of SE's of section 30 a
distance of 585 feet, more or less, to point of beginning, containing
approximately 2 acres.
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TRANSFER
FEE
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Together, with all and singular the hereditaments and appurtenances thereunto belonging or in any wise
appertaining, and all the estate, right, title, interest, claim or demand whatsoever, of the said part ies of the first
part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their
hereditaments and appurtenances.
To have and to hold the said premises as above described with the hereditaments and appurtenances, unto
the said parties of the second part, in joint tenancy, and not as tenants in common, and to their respective heirs and
assigns FOREVER.
i eooK 488 PacE2