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038-1072-70-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 567232 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Wittstock, Roger Star Prairie, Town of 038-1072-70-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: oo,() L v'~, / 0 C) 1 17.31.18.301g TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Zoo Alt. BM ion 1~ Bldg.r ~1 15iuk, , St/Ht Inlet H TANK SETBACK INFORMATION St/Htutlet ~0~4 7 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD D t 1 ~ v ! 10 Septic / / , T S I I ~ `1M D J~Rottom r ^ ~ ✓ 3~ 3` 7i Dosing Meader Man. ' 15 Ii. q5. 94. Aeration Dist. Pioe Holding Bot. S l ~ s S sit. Final Grade d dAz 40 PUMP/SIPHON INFORMATION uk; ed //AS q0 Manufacturer Demand St Cover GPM ALI- Model Number 1 - TDH Lift Friction Loss Syste ad TDH Ft UL 0 Vv 40 Forcemain Length IDia. Dist. to Well Q~(J( SOIL AB PTION SYSTEM 14/ BEDITRENCH Width I Length , o. Of Trench PIT DIM IONS No. Of Pits Ifiside Dia. Liquid Depth DIMENSIONS J e7 N2 SETBACK SYSTEM TO P/L BLDG WE jLAkSTREAM LEACHING Man ture INFORMATION CHAMBER O Type~f "ycs 1tem: el\ , 1) 70 >I W, ) lob' U Model Number: PLVMBUTION SYSTEM ,7 Heade anifoldt Distribution ~ N x Hole Size xg Vent to it Intake r Pipe(s) Length Dia Length Dia Spacing L,. SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only> Depth Over r-/ Depth Over xx Depth of xx Seeded/Sodded xx M the Bed/Trench Center S Bedfrrench Edges Topsoil ~~yQf3~ ~ Yes No 0 Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 / /(I Inspection #2: Location: 923 214th Ave Somerset, WI 54025 (NE 1/4 SW 1/4 7 T31 N /R11(88W-) NA Lot 7 ol,f Parcel No: 17.31.18.30lg 1.) Alt BM Description = , ~J~S YL~ ~'L► C.! S1~'[7w~ x/13 C e4w wd 2.) Bldg sewer length - amount of cover = - (L , SZf J~~~ R KJCK Plan revision Required? Yes No + 2 I Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. N _...~_DCS~~ ---w•-.~ ems' - - - . _ T = - r s~ a~e+~a~atq,T County Safety and Buildings Division y D y 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (t be filled in by Co.) p Bison, WI 53707-7162 7 Z 3 2- Sanitary R&#-i ~p1lCatlOri F~ State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Co&,'submisslon of this form to the appropriate go~C~l It is required prior to obtaining a sanitary permit. Note: Application forms for state-own ~ ~~ii WTS are suu 11 to Project Address (if different than mailing address) dor secondary ll4 the Department of Safety and Professional Servies. Personal information you provide'filabeu purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. < f 1. Application Information - Please Print All Information T CPA, Prope wner's Name COUNT Parcel # w 20 - AM Pro erty Owner's Mailing Address Property Location/ Govt. Lot 4~:41 ~t4_ City, State Zip Code Phone Number Section 17 (circle one zl!~5 _d Lot # II. Type of Building (check all that apply) T~ N; R E J 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name Block # El Public/Commercial - Describe Use ❑ City of , ❑ State Owned - Describe Use CSM Number ❑ Village of 4 4 XTown of_ iJt~ lei III. Type of Permit: (Check only one box on line A. Complete line B if applicabl A. ❑ New System ~ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New p Before Expiration Owner D 2- ( 3 1 D IV. Type of POWTS System/Component/Device: Check all that a 1 Non-Pressurized In-Ground ❑ Pressurized In-Ground At-__Grade ❑ Mound > 24 in. of suuiitaablso 1 ❑ ound < 2 1 of su able it ❑ Holding Tank ❑ Other Dispersal Component (explain tC 1 v"44Te~reatment Deviceeex~~~(~ ~D✓ . V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (s fl Dispersal Area Proposed (sfJ System Elevation VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o New Tanks fisting Tanks o 3 ~U Septic or Holding Tank Dosing Chamber I lzzn 1-14 1->-/l VII. Responsibility Statement- I, the undersigned, assume res nsibility for installation of the POWTS shown on the attached plans. Plumber's ame rint 1 Plumber' Si r MP/MPRS Number Business Phone Number -7 Plu ber's Address (Str et, City, late, Zip Co VIIVCountyll)epartment Use Only Permit Fee Date Issued Is mg Agent ignatur Approved ❑ Disapproved $ Y ~ 57, Ov /~//s// ❑ Owner Given Reason for Denial IX. (Lqygi~Ws(% oval/Reasons for Disapproval s d ;0 a, 2 1. Septic tank, effluent filter and 6y dispersal cell must t@servimd., / maintained ` 0 / s as per management plan provided by plumber' 5 s O IM_5j~ 0M/ IOAW_.9n 4'~ ~ 2. All setback requirements must be maintained y Ilt4l✓~~~~ as per applicablo 43z Attach to complete plans for the system and submit the C un only on paper not less th 8 1/2 x 11 incpegg in size a,- Z31/ 3 1 3.33 , SBD-6398 (R. 11/11) 17 .S A4 0 Q _ Lj~ 13,E POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page z-or_ FILE INFO TION SYSTEM SPECIFICATION Owner , Septic Tank Capacity 1 o NA Permit # Z Septic Tank Manufacturer - ❑ NA Effluent Filter Manufacturer o ]NA DESIGN PARAMETERS Effluent Filter Model o NA Number of bedrooms ❑ NA Pump Tank Capacity al o NA Number of Commercial Unit o NA Pump Tank Manufacturer ❑ NA Estimated flow (avers a) al/du Pump Manufacturer ❑ NA Design flow (peak), Estimated x 1.5) al/da Pump Model c3 NA Soil Application Rate 1/da /ft Pretreated Unit Influent/Effluent Quality Monthly Average* o Sand/Gravel Filter o Peat Filter Wetland Fats Oils & Grease (FOG) 530 m * b/L Mechanical Aeration n Disinfection ❑ Other; Biochemical ❑ n Dtstn Mccha Oxygen Demand BODs Ox ( ) <220 m Yg _ 1~- Total Suspended Solids (TSS) <150 mg/L Manufacturer Monthly Average" Dispersal Cell(s) Pretreated Effluent Q NA Quality lif In-ground (gravity) o In-ground (pressurized) Biochemical Oxygen Demand (BODs) <30 mg/L ❑ At-grade ❑ Mound Total Suspended Solids (TSS) <304mg/L ❑ Drip-line ❑ Other: <10 cfu/100mL Fecal Coliform (geometric mean) Maximum Effluent Particle Size '/s inch diameter * Values typical for domestic (non-commercial) wastewater and septic tank effluent. Values typical for pretreated wastewater. INIAINTENANCE SCHEDULE Service Frequency Service Event Ins ect condition of tank(s) At least once eve o months ear s) (Mmdmum 3 rs) Pump out contents of tanks When combined sludge and scum equals one third of tank volume- Inspect dispersal cells At least once eve o months ears (Maximum 3 rs) Clean effluent filter At least once eve ❑ months a ear(s) Ins ect um um controls & alarm At least once eve ❑ months ❑ ear(s) .dNA Flush laterals and pressure test At least -once eve ❑ months ❑ ear(s) a NA Other: At least once eve ❑ months ❑ ear(s) ® NA Other: At least once eve o months o year(s) i&NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the and to ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes check for any Ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third ('/s) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatment components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION ` For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other :hemicals that my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks(s) removed by•a septage servicing operator prior to use. Page ;7' of START UP AND OPERATION of products or other chemicals For new construction, prior to use of the POWTS check treatment tank(s) for the presence painting that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. l System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. the Reduction or elimination of the following from the wastewater stream may improve the performance and prolong d isthe ife of fat; POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall tie taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon b required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wi . result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. I~ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NO ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLE POWTS MAINTAINER Name E Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone _ Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. INSTALLATION INSTRUCTIONS ft** A otPd lkbc PL-525/PL-625 FALTER Fr1w INSTALLATION INSTRUCTIONS Centerfilter with opening f 1 2i K yri y!i~J 1C~iir_61~✓ tT a s 4 ai tz~ r `ta i ~ `~'~1< r Step 1: Step 2: Step 3: (A) Locate the outlet of the septic tank- (A) Before installation, place the (A) Glue the titter housing on the (B) Remove tank cover and pump tank fitter housing on to the outlet pipe. outlet pipe. If necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank far cartridge is properly aligned and maintenance and service, completely inserted in the housing. MAINTENANCE INSTRUCTIONS .p7.. x,f. r, 3`~S ~ r•~ Y ~ aM ~ ? ~2. ~§F • ~ °'ea~- ` L a r~~ ~ 43 w ~;EYYr 53 41W Firm ,'J,~ F~ 4 S t•{~: ~"~y wnL~`Vc i`'Tfia=. ~i ~v. F, .7 € it a,... ~ s~ '~r.~+"`j r~x~''1-` f `.k~L]-i•LC~'s. ~ R 7ey Try ~ ~ s£ J:y,. ~ ~ rl Ai s'1'~ 4> ! .i.ty..^: 7 3.~•• -9. - r~ a a 1 s} Kf ~'+~t~~~T". n 3 ~ ~~sr,..€' ~ S flats C Ste 1. Step 2: Step 3: Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back if necessary. into the the housing matdrng sure DO NOT USE PLUME31NG (B) Pull the fitter out of the housing. the filter is properly alighed WHEN FIL - r and completely inserted. (C) Hose off 0* Miler over Me septic tank. " `7;Z' t9 1BR.GL~ VET-~ Make sure all solids fall back into the (B) Replace septic tank cover i tNtiEt+t„ €F-1 I ihtC FiLTEt septic i ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: located (Street address) 3 , at: 1/4, I/4, Section Towne-N, Range IS Town of St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes_ No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: Construction: Prefab oncrete Steel Other Manufacturer (if known): Age of Tank (if known): Permit n ber, (if known) ~~o-1yy J (Licensed Plumber Signature) (Print Name) (Title) (License Number) MP/MFRS '/~2 - :2 /3 (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 Property Owner Parcel ID # Page of L-31 Boring # Boring pit Ground surface elev., r ft. Depth to limiting factor in. Soil Application Rate s Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 *W2 - , 4 4 Boring # I~~ Boring l~J Pit Ground surface elev. ~ ft. Depth to limiting factor in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * 02 -Z22 ZZZ2 r F Boring a Boring # Pit Ground surface elev. RJ~(~ft. Depth to limiting factor 2//o in. Soil Application Rate z Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Co t. Color Gr. Sz. Sh. f" ff#2 l rZ -/IS& 0-5 2i 5 Q S ' S I * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-8330 (RI 1/11) Wis. Dept. of Safety and Professional Services SOIL EVALUATION R Page of 3 Division of Safety and Buildings in accordance with SP SO, Wis. Adm. Cody Cj ounty Attach complete site plan on paper not less than 8 x ze. Plan must include, but not limited to: vertical and horizontal r irection and Sr Pa ~C. percent slope, scale or dimensions, north arr=a ance to nearest 1,94 _ ~Ie _ Please print all m ' ed /Date Personal inform ation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). C `v S Prope wrier Property Location Govt. Lot 1/4 1/4 S17 T3 N R E (or Pro erty Owner s Mailing Address Lot # Block Subd. Name or C_ J~ s - s-? City Stat Zip Code Phone Number ❑ City ❑ Village O Town Nearest Road ❑ New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate GPD ® Replacement ❑ Public or commercial - Describe: Parent material /ja-ly Flood Plain elevation if applicable ft. General comments 1 - and recommendations: /*404AS S Boring # F-/ I ❑ Boring I01 Pit Ground surface elev. ft. Depth to limiting factor91-9 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 *$02 o? s,' r1l) 11125 s q Boring # Boring ® Pit Ground surface elev. ft. Depth to limiting factor _ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. * ff#1 102 `Xc~ 3 _ * fflue 61 = D > 0 < 0 mg/L and TSS >30 < 150 mg/L * E nt #2 = BO < 0 mg/L and TSS < 30 mg/L All CST Nam ase Pri Signature CST Number Address ate Evaluation Conducted Telephone Number --3:0-791 25 SBD-8330 (RI 1/11) r I ~ ' - I I I laNIl3 I I ' i I I -71 , } I t I i t r i I 3 I I _ r- r I I I i I I I I I ; ~ r ; I I i i 1 , I 13' 'Del I I ; ~p , : - i CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: 1K-- Owner's Name: Owner's Address: s Legal Description: Y Y- ~ iz~iiIAI - e n Rj Township: ✓ % n°~ X County: Subdivision Name: 6 3 Lot Number: 7 Parcel ID Number. - Page I Index and title Page 2 Plot Plan Page 3 System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 ---Maintenance &_Management Plan Page 7 Se tic Tank Maintenance Form Page 8 Warranty Deed Page 9-- CSM or Plat /o Designer/Plumber. License Number. 7_ Phone Number `7Z Date: Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SSD-10705-P (N.01101). Page 1 _ - l 1 X I, I f II I I I I ' , _ I I - X7'8 ~ Y I i II I I i I I ~L I I l I _ r 'll -r- i I , r _ _ I I I I Soil Absorpfon System Cross Section f t Final Grade 4' Sdmdule 40 PVC Vent yips $ Wrfh Vent Cap Leaching --j, Chamber System 8wadon ft ~ft Soil Absorption System Plan View t ft } ~ - Ming TrBnc~r 9 #t Vent Or Observation Pipe Charnors 4° Dla. Trench 2 Heavier Leaching 9 ber S eaxficaf ko-M Manufacturer And Model EISA Rafing_-2 I _ sq ft per chamber Soil Application Rate gpd/aq ft gpd Design Flow - Soli Application Rate _ EISA Chambers 2 rows of chambers each. Page of • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address z7 4 eg, Property Address (Verification required from Planning Department for new construction) City SWC Parcel Identification Number 9- i 03,V-1 0 72- 7d-ca 1<.EGA1 DESCRIPTION Property Location A2C- -SaAL yt, Sec. ~L TZU_N RL!g~„W. Town of Subdivision Lot # 7 Certified Survey Map # W,-- -2 it c~2 Volume S. $ Page # -Jzg zr- Warranty Deed )66 Volume (~9 Page # Spec house ❑ yes ❑ no Lot lines identifiable. ❑ yes ❑ no ooasists aseand oeofyMseptiesystemoomldwsaltiaitspcr attae~ tohandlawasbes.Propermam~aaoe ofpmq&g out &0 aia:ffaex dre a of hie ~ ~ ~ ~ or Nona. if needed by a Yi ense d pnmpen Wlmt yom pre into the gstem sepciatsalc-as.a tneatmeatstage in do Vste dispo¢a1-system, T~ P~P~Y ovraex sgt oes m submit to SL Cmk Zbaing Dot a caWation foam. signed by the -owaa and by a ~P=qn npLmdcrgiuti*d kmberorahcosedpamperve iiYiag6 (IjdCoaaite~ lit pad q3telh is m PxqpaoPcraftcondiittion aWor(2) after hupeedw and puwpmg (if n ccosM), dre scp i r tmk is k= dram i/3 almdgc, Uwe, the inch =pod havatead tLe above requires and agree to maintain 6rc private sewage disposal system wi& die st;ndatds set fOtd. ha+ei, as set by ft Depzttmamt of Gbmmaoe and the Department of Natural Resoas+ecs-. State of Wisconsin.. Cad4caft 5taiingdIxt Yaw Septic days- of die tbtne Las bom maintained must be completed and rctumcd to We St: Croix -Canty Zoning 0W= wi1h m 30 year expiration date. 1i1 C z'~ SI TURE OF APPLICANT DATE OWNER CERTXRIC NITON I (w") oatify d w all statemmu on this form are tine to the best of my (our) knowledge, I (we) am (are) the ownaa(s) of dw property described above, by virtu of a wamudy deed reom&d in Register of Dads Of$er 0 , .ZEGZLJ-SI 1U W OF APPLICANT / / fe, DATE s.ss.s Any information, that is mis-teprtseruod may result in the Unitary permit being revoked by the Zoning Department 's••ss .s Indude with this application: a stamped warranty deed fmm the Register of Deeds office a COPY of the certified survey map if referanee is made in the warranty deed TNM MMiCe aaMaYm /M a0Oem11e MTA DOCUMENT No. STATS BAR Or W1800NUN FORK I IM,~ WARRANTY 0=0 4 iNet REGISTER'S. CWKE ttnn= I~arir°er a ri angy!---••- °-wi-.'emain.: and. ST. CROIX CO., WI Reed for Roooind AUG2 21989 A0.6.Fl Grantpr, Of 8:30 A. M end Roger..:;::'i~i............... tstoc'k"and"1~'itann.. 1~:-"Wittstoc d 9 oN N)rYMw Oagi Grantee, WitneWMth, That the said Grantor, for a valuable consideration...... conveys to Grauto e this folleTriag described real estate in t Yo l x "e"'a" TO Count;, State of Wisconsin: See attached Schedule "A". ~ Tax Parcel No:........ This warranty deed is given in satisfaction of that land contract between Grantors and Grantees dated November 8, 1984, and recorded in the St. Croix County Register of Deeds office on November 8, 1984, in Volume 700 of Records on Page 9 as Document No. 39702. FEE E This i s,. no t homestead property. (isj (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; . r . _ - And Granto. warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal zoning ordinances and easements of record. and will warrant and defend the same. Dated this 1~ day ,r ALgUst............................------ (SEAL) . (SEAL) Edward E. Germain ..XeLir,1-1112 :444r....t/< Z-I-,.i.G~lact.(SEAL) (SEAL) Ann Marie Germain . AUTHNNTICATION ACHNOW LSDGMENT Signature(4 ...A 1..1d)Kax.d._ Fa,..... l~J)......... STATE OF WISCONSIN and Ann Marie Germain ss. .............................County. authenticated this ..day of-. p►11 u.s.t...-....., 1919. Pe..onally came before me this day of 19.._..... the above named •.....G.~... HA3 ~n TITLE: MEMBER STATE BAR OF WISCONSIN ( to me known to be the person who executed the foregoing instrument and acknowledge the same. L " ~ ~9nrc1~ SCHEDULE "A" A parcel of land located in the Northeast 1/4 of the Southwest 1/4 of Section 17, Township 31 North, Range 18 West, Town of Star Prairie, being part of Lot 7 of the Certified Survey Map recorded in Volume 5 on Page 1232 as Document No. 381274 in the St. Croix County Register of Deeds Office, described as follows: Commencing at the West 1/4 corner of said Section 17; thence South 0°29'03• East (Assumed gearing) 1011.45 feet along the West line of said Southwest 1/4; thence South 88°50'34" East MM.77 feet to the point of beginning; thence South 88°50'34" East 386.25 feet; thence North 0°42'16" West 711.51 feet along the East line of said Southwest 1/4; thence South 67°3204" West 484.13 feet; thence Southwesterly 134.70 feet along an 80.00 foot radius curve concave Northwesterly w'nose. chord bean South 25046'18' West 119X feet; thence South 16930'26" East 42&85 feat to the point of beginning. This parcel contains 274,836 square feet, more or less, being 631 acres, more or less. Including a perpetual easement for the right of ingress and egress to the town mad known as 90th Street over this private roadway shown on said Certified Survey Map and adjoining Certified Survey Maps. DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE flESERYEDFORRECORD(NGOkTA; r 4 WARRANTY DEED s3 VOL 70 PAGE ROCa ERS 01`14CE Edward E. Germain and Ann Marie Germain ~ . WM , SL C"X; CO.; ::3 Roe d for :6=d this 8th Nov $4 XD. 19 d of _ oePr n Dianne at 0 P convoys and warrants to M 4.2 Wittstock, husband and wife, as Job Tenants tQWW M Deer RE RN TO the following described real estate in St. Croix County, State of Wisconsin:; Tax Parcel'No: M A .parcel of land located in the NEI of the SW* of Section 17,,T31N, R18W, Town of Star Prairie, St. Croix County, Wisconsin, being part of Lot 7 of the Certified Survey Map recorded in Volume 5,.<Page 1232, Document Number 381274, St. Croix C6unty Register of Deeds, described a's follows: Commencing at the Wa corner of said.Section 17.; thencei S002910311E (Assumed Bearing) 1011.45' along the West line 'of.said SW}; thence S88°50'34"E 1815.87' to the point of beginning; thence S8805013411E 384.901; thence N16030126"W 428.851; thence-S74°00'5,2"W 105.291; thence Southwesterly 188.66' along a 5331. radius curve eoncaye Northwesterly whose chord bears S6102212111W 187.681; thence -E 284.50' to the point of beginning. S0036 This paeel contains 117,766 Square Feet, more or less,"kbeing 2.70 f Acres,.,more or less. F£ This is not homestead property. his) (is not) Exception to Warranties: I Dated this Eighth -day of November 17 (SEAL) i~C'Lh27/i'~f9GLcs+G- (SEAL, i Edward E. Germain (SEAL) C ~ L a e~ AL) -Ann Marie Germain fy?' - AUTHENTICATION ACKNOWLEDGMENT 7 Signature(s) STATE OF WISCONSIN as. St. Croix County. 1 ` authenticated this day of .19 PerannalIV came before me this 8th day of . H ~-i r r y SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 0 9 OWNER/BUYER ROUTE/BOX NUMBER 1 Fire Number I .CITY/STATE_GQM+E~~jF, y~ WI ZIP Sa-0Z Cj PROPERTY LOC.ATION:NC.'Z, SV~ 1, Section T N, Rle)_W, Town of 1~fL ~j'LItitE St. Croix County, Subdivision Lot number Improper use d'nd maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents May be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. - The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H C E I/WE, the undersigned, have read the above requirements and agree z v~ to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- o ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. ~ n SIGNED X /ALA DATE_ ~O - $G} St. Croix County Zoning Office P.O. Box 227 Hammond, WI 54015 715-796-2239 Sign, date and return to above address. FORM NO. 9&5.A 11 Stock No. 26273 FILED NOV 24 1982 [N m JA" O• CONKlLI ty, 127.4 CERTIFIED SURVEY MAP wb0°°'k 'q LOCATED IN THE NE1/4 OF THE SW1/4, SECTION 17, T31N, R18W WEST LINE OF SW 1/4 °29'03"E 1011.45' ASSUMED BEARING REFERENCED TO THE WEST Cn cn 000 •d rw, n ' LINE OF THE SW1/4 t7i ::E: - ~ n~ Or Z .H H 1 C o ° N ;0 °z ~ } 6 6 DRAFTED BY DOUGLAS J. 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I ~ I I I I I I 0 I °p I I i o A O I O H b CD I ~ ~ a <0 0 o i o 0 00 o a o 0- Parcel 038-1072-70-000 05/08/2006 05:28 PM PAGE 1 OF 1 Alt. Parcel 17.31.18.301G 038 - TOWN OF STAR PRAIRIE Current XI ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - WITTSTOCK, ROGER L & DIANE ROGER L & DIANE WITTSTOCK 923 214TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 923 214TH AVE SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 2.700 Plat: N/A-NOT AVAILABLE SEC 17 T31N R1 8W NE SW 2.70 THAT PART OF Block/Condo Bldg: LOT 7 CSM 5/ 1232 DESC AS COM W 1/4 COR Twn-Rn 40 1/4 160 1/4) SEC 17 S 1011.45' S 88 DEG E 1815.87' TO Tract(s): (Sec- 9 POB S 88 DEG E 384.90'N 16 DEG W 17-31 N-1 8W 428.85'S 61 DEG W 187.68'S 284.50' TO POB VOL 700/11 Notes: Parcel History: Date Doc # Vol/Page Type 07/2311997 700/98 07/23/1997 /162 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.700 42,900 166,800 209,700 NO Totals for 2006: General Property 2.700 42,900 166,800 209,700 Woodland 0.000 0 Totals for 2005: General Property 2.700 42,900 166,800 209,700 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 206 Specials: User Special Code Category Amount Special Assessments Special Charges 00 Delinquent Charges 00 Total 0.00 ~eiv~l~►~ Form - S T C - 04 AS BUILT SANITARY SYSTEM REPORT OWNER ~b ~2 1 57~r~C 'r TOWNSHIPcS Jy e A ri,; SEC. ~ 7 T ~N-R h3 W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR; 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 00" asp lot io, n i (r% II INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used DEPARTMENT OP INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS DIVISION PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O. BOX 7969 MADISON, WI 53707 El Plan I.D. Number. CONVENTIONAL ❑ ALTERNATIVE State (If assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound IN PE TION DATE: NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: Roger Wittstock R. R. 1, Star Prairie, WI Al -~REF. PT. ELEV.: CST REF. PT. ELEV.. BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. NE SW, Section 17, T31N-R18W, Town of Star Prairie, Lot#7 1MF/.1HSW No.. County: Sanitary Permit Number: Name of Plumber: Gary Steel 3254 St. Croix 58902 SEPTIC TANK/HOLDING TANK: LIOUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKI COV MANUFACTURER: Q P VID D: PROVI E. /00, S V ES ❑ NO NO HIGHWATER RO P~D~ PROPERTY WELL: D :VENT FRESH BED a G: VENT DIA.: VENT MATL. NUMBER OF O UN yN/ AIR I LEET: AL ARM: FEET FROM ❑YES NO ❑YES ❑NO NEAREST DOSING C AMBER: MANUFACTURER'. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MA CTIIR ER: RWARNING OV D DLABEL PROVIDED OVER ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTR S ERATI AL'. NUMBE OF PROPERTY WELL BUILDING: I VENT TO FRESH LINE' AIR INLET. (DIFFERENCE BETWEEN FEET OM PUMP ON AND OFF) ❑Y O NE ST LF. ,TH'. DIAMETER. MATERIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: JINDIA uPlrs LIQUID OT WIDTH: LENGTH'. NO. OF DISTR. PIPE SPACING. COVER DEPTH'. BED/TRENCH TRENy CHEES: MATERIAL: PIT DIMENSIONS NUMBER OF FPR OP ERTY WELVENTTOFRESH GRAVEL DEPTH FIL DEPTH DISTVRPIPE DTR. PIPE DISTR. PIPE MA ERIAL: PNOE ISTR. AIR LETBELOW P PE ABQy OVER ELEINLEELEV. ENDt FEET FROM NO ` • O 3 7 2 ~ NEAREST W MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑ YES ❑ NO PERM NENT MARKER OBSERVATION WELLS. SOIL COVER TEXTURE. YES ❑NO ❑YES ❑NO S EDED'. MULCHED'. DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL'. SODDED. C ENTER EDGES ❑ Y YES ❑NO ❑YES ❑NO ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE covER: WIDTH'. LENGTH: NO. OF LATERALSPACING'. GRAVELDEP BELO PIPE. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MA RIAL'. P PES:STR. pDISATR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.: ELEV.: DIA.'. ELEV.: ELEVATION AND ,DISTRIBUTION COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY PLANS. ❑YES ❑NO ❑YES ❑NO NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: PERM AN ENT MAR K E RS: OBSERVATION WELLS: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST 3•yt 9• ~ Sketch System on Feet in ounty file for audit. Reverse Side. IGNATUR TITLE DILHR SBD6710 (R. 01/82) I.7 WI~consln APPLICATION FOR SANITARY PERMIT / DILHR s y- 1 2,1.4 rOUNTY (PLB 67) UNIFORM SANITARY PERMIT # ~ dEPRRTTEnT OF a 2 InOUSTR 0, LRBOR 6 HUMRn RELRT10n5 1.~4?9 0Z -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOCATION X1/4 1/4, S T3 1, N, R (Or) W TOWN OF: ior4-r f OT NUMBER JBLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER l11 "1~-- TYPE OF BUILDING OR USE SERVED do" r~ad -`l07a- X Grp 7~-1 or 2 Family Number of Bedrooms: Public (Specify): THIS PERMIT IS FOR A: [It-idew System ❑ Tank Replacement ❑ Repair El Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. '®-Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 0 30 Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name f Plumber (Print): Signature MPRSW No.: Phone Number: Plumber's A ress: Name of Designer: G ~ COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved JV~ El Owner Given Initial sy~ / Approved Adverse Determination t Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property lZOC-Ae0_ \p` tTTS'TOCA,- Location of. Property ,NC 14 SVN '4, Section T '31 N - R $ W Township T~12l T Mailing Address LAI-c ,~o Nkc rL s ft - Subdivision Name Sj-kwey Lot Number Previous Owner of Property ~p ~~YL,f1P( pr(, r-1 Total Size of Parcel C Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes x No Volume 1' and Page Number In 2, as recorded with the Register of Deed's INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTy OWNER CERTIFICATION I (We) eeAti. y that aU .6tatementz on ,this 4otm ante tAue to the best o6 my (o0A) knowledge; that 1 (we) am ( aVi e ) the owneA (s) o U the pnopen ty dens cAibed in .th.is inAoAmation ~otm, by viAtue o{ a watvtanty deed uconded in the 04~ice oU the Of „in-hl vnn: Atnh ni nnndA FA nnnlimnw-f Aln 'Z, 41 -1 "-1 Zi - norl that T (uw I DOCUMENTNO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE-RESERVED FOR RECOROINO DATA WARRANTY DEED 39'76'73 VOL I OO PAGE 1 Edward E. Germain and Ann Marie Germain RTERS 4ffIC1: ST. CRO CO., WIS. Reed, for Rf rd this 8th day of NSA. D. 19 $4 a" conveys and warrants to Roger L. and Dianne M.- 4:20 P Wittstook, husband and wife, as Joint Tenants Rs9iQa at DNd, RE RN TO 1 the following described real estate in St. Croix County, State of Wisconsin:. Tax Parcel 'No: A parcel of land located in the NE4 of the SW4 of Section 17,'T31N, 3 R18W', Town of Star Prairie, St. Croix County, Wisconsin, being `part of Lot 7 of the Certified Survey Map recorded in Volume 5,.,Page 1232, Document Number 381274, St. Croix C6unty Register of Deeds, described as follows: Commencing at the W14 corner of said Section 17-; thence 1 said SW S0°29 03"E"(flssumed Bearing) 1011.45 along the West line of I; thence S8805013411E 1815.87' to the point of beginning; thence S8805013411E 384.901; thence N16030126"W 428.851; thence_S74°001~2"W 105.291; thence Southwesterly 188.66' along a 5331. radius curve 11W 187.681; thence concave Northwesterly whose chord bears S61022121 S00361E 2$4.50' to the point of beginning. This parcel contains 117,766 Square Feet, more or less,,being 2.70 Acres, .,more or less. t . TWAS This is no t homestead property. (is) (is not) Exception to Warranties: Dated this Eighth day of November ,1984 (SEAL) i~C4 CG~`[2 ~/Ll?f~c~ (SEAL) .Edward E. Germain (SEAL) •Ann Marie Germain { AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. S t . Croix county. -a - authenticated this day of . 19 Pprsnnally ramp hefnre ma this 8th day of H y C-' y SEPTIC TANK MAINTENANCE AGREEMENT H C St. Croix County d y OWNER/BUYER (aE~ c~ C,~ ROUTE/BOX NUMBER t t _ Fire Number .CITY/STATE- W1 ZIP J40 (i C7 PROPERTY LOCATION: 14, Section_ T 51 N, Rle)_W, Town of rWkI4t~ , St. Croix County, Subdivision Lot number I Improper use Snd maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new stems agree to keep their systems properly maintained The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. y 0 E I/WE, the undersigned, have read the above requirements and agree 7 v~ to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- I'd ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED - $C} DATE I\- 10 St. Croix County Zoning Office P.O. Box 227 Hammond, WI 54015 715-796-2239 Sign, date and return to above address. v w r x s m N3 O O (/1 W -i W o cp < V N w w IV A f7 fD in ~9'C<1 c cowwu,`< o ~np C A N FD- • a a 12D ° ,Jill `~D ° a 0 0 w o (-p o ODD O A o (D 'C (D w w A _ w 91 Er I q r o3a o0 °M ~DOOD, owo owe Coo ~m~ > o woo < <-c w w 3.Zo °c~ 3 o a 7 Ewa oa (D w co C A < o N Q' tp Q o cotn -r- oyc C S 'R o CL •wi ^A- ~ w °a 5 ~a~'_v, C .0 ju OPM -,-Mm co L M M CD Z a ?w .tn+W =.-I ' 3 v _Z m CD M -0 N w 3 C -DI m ?a c o a CD , co v,co = ~v,. ° f ° m was =r C°w°_ M cr CD co u, ?arc j o•~o ~~,w~w°~ C m mC~ 0CL 2 o a cQ - 44 1 o 0 o _ Cs D w 0 r o ~ 4 ao f cn c c 1w o m Sr- a w o aaC aC C w v c 3 M. c ~ tp ° C vi 0 c1D o ao~ occ° c ~`~m 5zi -1 (D c 14 = o a ~C ~,w''►o ' fCL ° 3 o w°3 M a~ aw v ° 3 a ° < C cc ee , c 0 DEPARTMEVT'OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, cc DIVISION LAOR AN P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION:T~ I NIA ON W TOWNSHIP/MWAjIGI PALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: ' /7 N/AI ON (or) n r ro'~ 6 COUNT Lj.~OWNEff'SniW*4R'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: New (PROFILED RIPTIONR OLAT ON TESTS: Kesidence ❑Replace 4 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUNDPRESSUR_E: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) CAS OU 0S ❑U ®S OU Os ©U 0S ©U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: •p~SIrYIA r PROFILE DESCRIPTIONS ef D BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER QW244;-IN, ELEVATION OBSERVED EST. H GHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) S 7~ 4AZ as 1-7 B- Caa~ o >(o zs ' 1. ' S 1. /7 / ! r 3-7 7 B- X10 119- Alooe- > G0- # B>.. 01- NO N T to PERGOLA ION TE S Sf' TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- P- P- P-_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. ,5SYSTEM ELEVATION 3 E 1L. 7 Q-<~z•s 3 - ! j 1 A 6 < x~. f 0'. A ~-'i t9 , Ate OS~r 6J,~s~l5 R R 7 f3j.,O 2/8 0 ' ~ 174-,^ Pv'~4r ~ E., ~ s~-S h • I~ a 20 3 I Lk , U~ 76 r S~4,. ~S ?.5 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT sanitar~r 20279 GENERAL INFORMATION (ATTACH TO PERMIT) 3 Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ~TY 17 PIla9 I TEown o : State Plan ID No.: WITTSTOCK, ROGER A~ KA CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Td 1072-70-000 TANK INFORMATION ELEVATION DATA A9800470 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing 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 NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. hi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS Manufacturer: SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING SETBACK INFORMATION Type O CHAMBER Mode Number: OR UNIT System: DISTRIBUTION SYSTEM Header/ Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / Soddfxx Mulched Yes ❑ No ❑ Yes ❑ No Bed /Trench Center Bed /Trench Edges Topsoil ❑ COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRARIE 17.31.18.301G,NE,SW 923 214TH AVENUE Plan revision required? ❑ Yes ❑ No Use other side for additional information. Date Inspector's Signature Cert. No. SBD-6710 (R.3/97) Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7302 In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7302 Department of Commerce • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. StateSanitar er NtNumber • See reverse side for instructions for completing this application y20 Personal information you provide may be used for secondary purposes C] Check it revision to previo s application [Privacy Law, s. 15.04 (1) (m)l- State Plan I.D. Numb 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property Owner Name Property Location N 1 /4 1 4S f T eic N R (Or) Property O er's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Su division Name or CSM Number ~ I1. --TYPE LDI : (check one) ❑ State Owned o !ty TN;, est Road Public 1 or 2 Family Dwelling - No. of bedrooms Towan OF III. BUILDIN SE: (If building type is public, check all that apply) Parcel Tax Number(s) 0 "t 03q Z0 1 ❑ Apartment/ Condo CSC Outdoor Recreational Facility 2 C] Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 C] Restaurant/ Bar/ Dining 3 E] Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ 4 1-1 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) oe ~ . A) 1 SyNew stem 2-❑ Replacement 3. Replacement of 4. ❑ Reconnection of 5.A Repair of an E] Tank Only Existing System ✓ Exist) S tem - 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 1~ Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation y~G , 6 Feet v3 Feet VII. TANK Capacity Site Fiber Exper. in gallons Total # of Manufacturer's Name Concrete e Con- Steel glass Plastic App INFORMATION New Existing Gallons Tanks structed Tank Tanks Li Li a eptic Ta k 1:1 El 1:1 Lift Pump Tank /Siphon Chamber VIII. RESPONSIBILITY STATEMENT I he undersigned, assume respon 'bilit for' stallation of the onsite sewage system shown on the attached plans. Name: (Print) Mire: (No Stamps) MP/MPRSW No.: Business Phone Number. _ 2 Plumber's Address r et, City, State, Zip Code): IX. COUNTY/ DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) surcharge Fee) / Approved ❑ Owner Given Initial 8 1// X13%!8 /~pd Adverse Determination 0 CID X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: DISTRIBUTION: Original to County, Onecopy To: Safety & Buildings Division, Owner, Plumber SBD- 6398 (R.11197) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is t,,/o~~ certify that I have inspected the septic tank presently serving the //~er ~v►'if~r~x~ residence located at: ~1/,, sw 1/,, Sec. , TAN, R_j_,~_W, Town of sTlc re~;.i St. Croix County, Wisconsin. 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- Did flow back occur from absorption system? Yes NoK (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of Tank ('f known): (Signa r (Name) Please int (Title) (License Nu er) (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 to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature " 11 MP/MPRS S'"~~ 09/22/98 TUE 15:10 FAX 715 386 4686 ST CRX CO ZONING 10002 ST. CROIX COUNTY ' WISCONSIN 'War - • ZONING OFFICE $T. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, Wl 54016-7710 ~--(715) 386-4680 AFFIDAVIT OF SYSTEM REJUVENATION Property Owner: Address:. Day time phone: (a'% 2k2- '<-x3a rarcel I.D.# 3g-/v7~~-I Jegal Description of pzoperty:6✓~ Sec..T.-_N. , R. 1 r W. , Tn. of at. Croix county, WX owner of the above described property, I acknowledge that the ,ITtic system serving this residence (is/is not) undersized by current code standards. X understand that the issuance of a anitary permit to allow the attempted rejuvenation of the septic !stem does not imply that the system meets current code sizing equirements, nor does it imply that the proposed procedure will be uccessful. X also acknowledge that I will make this information vailable to any future parties interested in purchasing this roperty. .gnature : Date : fe, 5/97 Wisbonsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and 5 r D t percent slope, scale or dimensions, north arrow, and I XrWW fttanc@ to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please1Sl~ alllnf*ma /on. Reviewed b Date Personal intonnstion ' V 9 Za .1 you provide may be used for sec lfrpurr r. t w, s. 15"{l) ~ 7 ( CJ Property Owner 1 Location 2. Y` r T f 5 ~ K, C, 1 of Of- 1/4 SW 1/4,S 7 T N•R Q E (or)(@ Property ses Mailing Address g-( T`! Block# Subd. Name or CSM# t4 9a3 a) aw~. ofFI~ csM s P . Ia3 City State Zip Code Number 5O r S e.'fw `r City ❑ Village ®Town Nearest Road W~ SyDaS ( •f- 2 5+cLr /'altY`i o?/ y ~f1 Q • ❑ New Construction Use: ® Residential / Number of bedrooms- Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: 59 Rej U13ZV.6t+; 0 . Code derived daily flow 4/50 gpd Recommended design loading rate - bed, gpd/ft2 - trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate _ bed, gpd/ft2 trench, gpd/ft2 ftgr 11\+ Infiltration surface elevation(s) 9q-(05 ft (as referred to site plan benchmark) Additional desigNsite considerations h0,.v\ r~ ~n 12 V- . „ c.. v Parent material A \ 0. C Flood plain elevation, if applicable ft v S Suitable for system Conventional Mound 7 In-Ground Pressure AT-Grade System in Fill Holding Tank U Unsuitable for system ®S ❑ U ®S ❑ U [9 S ❑ U .1 S ❑ U ❑ s W1 U ❑ S 91U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trenct y L_ _ 0-16 ►I.-a3 I t> 4 IQ gI L - Ground 3 A6 "1.5 ~ R t - L-. lev. 9 r.o3 ft. N w3~ -7 s ti Rq 5 5 M R fs~ _ Depth to 3.94 LS ~ limiting 4 3$-l5 T 5 y RS/ - - - factor ISin. •I: Remarks: Boring # j Ott o *A Ck. , I; Q_ V\ Ti C) RZ V Ground elev. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. --bob A 14 b~cn~ v ~J0.~r 1s- a Yb- Address Date CST Number X7 + + Y w q-IS-g y 6 YD; (o Se C'. tl Ir 3 W acr I o A- CAI At.-SAC. T QJ ` ~ 'IX a, 0v} 1 e X i 60 a°r 4 / Orr/ ta s Po~~ 501 _ 9 (ob J~ { Sao s n TopoF: ~ 0py~n 1'{eSer4 ~ra~KF~eI~ i.~"I + rif Tj for:ho~2. w-i1 i3~ 7,u3 , ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address aRm~ y z7 Xylp, Property Address _ V (Verification required from Planning Department for new constmctioa) City/State /ttt* t,,, Parcel Identification Number ,3X'JO)7-LEGAL DESCRIPTION Property Location MC_ Sec. /T,'3a_N-RAW, Town of ; Subdivision Lot # Certified Survey Map # 2a 2V Volume s , Page # /29 Z~- Warranty Deed # Volume ~J~ . Page # Spec house ❑ yes ❑ no Lot lines identifiable. ❑ yes ❑ no SYSTEM?4A32WENANCE ImgtWmuseandmadeofyoursepticsystmcouldresultisitspr=atraefa mtohandlewastes.Propermamft= ce Hof pmmping ~ die tak c~y ~ ~ or sooner, if n~oeded by a licensed pumper What you put into the system septic tank as-a treatmeat stage is the waste disposal-icystem- The Property- owner agrees to submit to St. Crone Zoning Department it certification form. Aped by the -owner and by a zaasterphu ber jow3eymanPhmixr, restrictedphmmberor a licensed pumperverifying that (1) the on-cite wastewaterdisposal system is in Propet operating condition and/or (2) after inspection and PumPh'8.(f necessary). & iep&t mk.is less than 1/3 full of sludge. Uwe, tba tmdexsig ned have read the above requiretnents and agree to maintain the private sewage disposal system with the standards set forth. herein."as set by the Department of Commence and the Department of Natural stating tbat year tic Rasoun~ State of Wisconsin.. Cecti~catioa system has bom maintained mast be completed and =turned to the St, Croix.County Zoning Office within 30 days- of the dam year expiration date. do cA, A) zr. _ SI TURE OF APPLICANT DATE OWNER. CERTIFICATION I (we) certify that all statements on this form ate true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the AProperty described above, by virtue of a warranty deed recorded in Register of Deeds Office. V r Md SI TURE OF APPLICANT / DATE E Any information that is misAtpreseated may result in the sanitary permit being revoked by the Zoning Department. Include with this application: a stamped warranty do od from the Register of Dads office a copy of the certified surrey map if reference is made in the warranty deed ~ . I DOCUMENT NO. BTATZ BAR OF WISCONSIN FORK 1-1M. T'"a WACS was" eD FOR ascamnle DATA WARRANTY CUID ' N9%E162 RMIsTERS CfflcE This n Edward E. Germain and ST. CROD( CO. W1 Ann-~= a rermain!'iusbiiid...Arid__;; fe Reed for Reegd AUa 22 2 09 M , Gran .na Roger- L.•• i ittstock..and. 1S.iann...........h~xttstoc . _ wdD~dr , Grantee, Witneweth, That the said Grantor, for a valuable consideration...... St Croix atruaN'° conveys to Grantee the following described real estate in --t----•.--.-.•••-••--•••-- County , State of Wisconsin : See attached Schedule "A". Tu Pared No: This warranty deed is given in satisfaction of that land contract between Grantors and Grantees dated November 8, 1984, and recorded in the St. Croix County Register of Deeds Office on November 8, 1984, in Volume 700 of Records on Page 9 as Document No. 397672. FEE • P#10 E EMP'T This iS.-nOt•...__. homestead property. 6(s not) Together with all and singular the hereditaments and appurtenances thereunto belonging-, And. rantor---- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal zoning ordinances and easements of record. and will warrant and defend the same. Dated this - --------------A day u' August... , 1989 - - - - -----...(SEAL) Edward E. Germain - - c I .(SEAL) - - - ....(SEAL) Ann Marie Germain „ AUTHENTICATION ACKNOWLEDGMENT Signature(s~ f--.Ux?T-d __E,-.. G-c-I'ifla R_--._.... STATE OF WISCONSIN and Ann Marie Germain $s. authenticated this ~4_day of._ Au.9q$A..___..... 109_ Pe-zonally came before me this day of 19---- the above named ~ e G_,_... a,-- Norman-------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN ( t+ - ~Q- ~aQ to me known to be the person who executed the foregoing instrument and acknowledge the same. " f W163 SCHEDULE "A" A parcel of land located in the Northeast 1/4 of the Southwest 1/4 of Section 17, Township 31 North, Range 18 West, Town of Star Prairie, being part of Lot 7 of the Certified Survey Map recorded in Volume 5 on Page 1232 as Document No. 381'74 in the St. Croix County Register of Deeds Office, described as follows: Commencing at the West 1/4 corner of said Section 17; thence South 0°29'03" East (Assumed Bearing) 1011.45 feet along the West line of said Southwest 1/4; thence South 88°50'34" East ;2200.77 feet to the point of beginning; thence South 88°50'34" East 386.25 feet; thence North 0°42'16" West 71151 feet along the East line of said Southwest 1/4; thence South 67°32'04" West 484.13 feet; thence Southwesterly 134.70 feet along an 80.00 foot radius curve concave Northwesterly winose chord bears South 25°46'18" West 119X feet; thence South 16°30'26" East 428.85 feet to the point of beginning. This parcel contains 274,836 square feet, more or less, being 6.31 acres, more or less. Including a perpetual easement for the right of ingress and egress to the town road known as 90th Street over this private roadway shown on said Certified Survey Map and adjoining Certified Survey Maps. A , e FORM NO. 985-A 11 HCMMNrCmpry~ ~ ~ Stock No. 26273 FILED NOV 24 1982 LN JADES O' CONNELL bp4Nr of Doodi Comty, CERTIFIED SURVEY MAP LOCATED IN THE NE1/4 OF THE SW1/4, SECTION 17, T31N, R18W WEST LINE OF SW1/4 S0029'03"E A :z 1011.45' ASSUMED BEARING Cn y Cn REFERENCED TO THE WEST 00 w rn M 1 I LINE OF THE SW1/4 C n cn 00 ~ 'd n Cn I 0ca nor zyy 1 • O i H on o Ln ~;O \ 6 b' } DRAFTED BY DOUGLAS J. ZAHLER. o w 00 N A 1 00 N v O z 167.75 116.75' ~ S0036'E 284.50' ,d s 1 00 N \ ` O w O ♦ V~ H ` z ~ y o O n CD ul z 000 0 z w o, C 0 r? y Ln N z o \ o \ \ \ o U4 L,l r O M C) y wo V i trJ I-' ~ ~ O i-' O n v s Y tTj z C W 00 O N ~ S ~e7 N m i v O z . C "C3 z<<:: ,-p n a c3~ 0