HomeMy WebLinkAbout002-1074-20-000 (3)I LQCAI'sT'OU &'tH *[ *fl'f $,' P
Labor and [i.rman Relatrons
Safetl and Eurldrngs Divrsron
e '2e ' 16wer?UarEBevF86etv#isF*'v L2
INSPECTION REPORT
(ATTACH TO PERMTT)
GENERAL INFORMATION
TANK INFORMATION
TANK SETBACK INFORMATION
PUMP / SIPHON INFORMATION
SOIL ABSORPTION SYSTEM
ELEVATION DATA A9400027
Permit Holder's Name I
,rirl?ErTrrlrc rrE T ltr
fltity ! Village
Etl I r{tri n
fl rown of
-CSTBMEIE-vI ?lfr'sp BM Elev BM Descript ron
ounty
an it
State Pla-nJFNol -
ParcelTax No
TYPE MANUFACTURER CAPACITY
Septic
Dosing
Aeration
Holding
STATION B5 HI F5 ELEV
Benchmark
Bldg.Sewer
5t/ Ht lnlet
St / Ht Outlet
Dt lnlet
Dt Bottom
Header / Man
Dist. Pipe
Bot.System
Final Grade
TAN K TO PIL WE LL BLDG Vent to
Arr lntake ROAD
Septic NA
Dosing NA
Aeration NA
Holding
Manufacturer Demand
GPMlModel Number
TDH Lifr Friction
Loss
Svstem
Head TDH Ft
Forcemain Length Dia Drst. To Well
BED / TRENCH
DIMENSIONS
Wrdth Length No Of Trenches PIT
DIMENSIONS
No. Of Prts lnside Dra Lrquid Depth
SETBACK
INFORMATION
SYSTEM TO Ptt BLDG WELL LAKE / STREAM LEACHING
CHAMBER
OR UNIT
Man uf actu rer
Type Of
System:
Model Number
DISTRIBUTION SYSTEM
Header / Manrfold
Length Dta
Distribution Pipe(s)
Length
x Hole Size x Hole Spacing
Dra Spactng
Vent To Air lntake
SOIL COVER x Pressure. Systems Only xx Mound Or At-Grade Systems Only
Depth Over
Bed / Trench Center
Depth Over
Bed /Trench Edges
xx Depth Of
Topsorl
xx Seeded /Sodded
IYes ilNo
xx Mulched
fl Yes E No
COMMENTS: (lnclude code discrepancies, persons present, etc.)
LOCATION: Ba1dwin.29.2g.16W, SW, SW, Lot L, Highway L2
Plan revision required? [ Yes E No
Use other side for additional information.
sBD-6710 (R 05/91)Date lnspector's Srgnature Cert No
Wisconsrn Department of lndustry,
Labo''and Ll uman Relatrons
Salet/ and Burldrngs Drvrsron
GENERAL INFORMATION
TANK INFORMATION
TANK SETBACK INFORMATION
PUMP / SIPHON INFORMATION
PRIVATE SEWAGE SYSTEM
!NSPECTION REPORT
(ATTACH TO PERMTT)
County
Sanitary Permit No
State Plan lD No
Parcel Tax No
ELEVATION DATA
m o 5 m e I Vr age Town
CST BM Elev lnsp BM Elev BM Descrrption il- r
TYPE MAN U FACTU RE R CAPACITY
Septic-
Dosing
Aeration
Holding
STATION BS HI F5 ELEV.
Benchmark
Bldg. Sewer
st/ Ht lnlet
St / Ht Outlet
Dt lnlet
Dt Bottom
Header / Man
Dist. Pipe
Bot. System
Final Grade
TANK TO PIL WELL BLDG Vent to
Arr lntake ROAD
Septi<-NA
Dosing __-[J*-
Aer*tioo-NA
Holding ry 33',</
wanrffi Demand
Model Number
TDH Lifr tem TDH Ft
Forcemain Length Dia Drst. To Well
BED /,fAEN€H-
DIMENSIONS
Length No. Of Trenches PIT -------------
DIMENSIONS
o Of Prts lnsrde Dra Lrqurd Depth
SETBACK
INFORMATION
SYSTEM TO PIL BL lvl LEACHING
CHAMBE
UNIT
ufacturer
Type Of
System:
**o#1\lffiber
DISTRIBUTION SYSTE
SOIL COVER
COMMENTS: (tnclu :&/4ftwdal
d?fu&,^y Cr*-u4 $
Mound Or At-Grade Systems Only
#
-7'6-,*-ry,
x Pressure Sys tems
de code discrepanc
t' /
/r"'tt'/; '
tes,persons pre
Gi/(,
{
4{n4
I
Plan revision required? ! Yes Wfro
Use other side for additional information.
sBD-6710 (R 0s/91)
rze xHo Spacine Vent To Air lnta e
Dra Spacrng
H rl Distrrbut ron pe
LengthLength Dia
xx Seeded / Sodded
DYes DNo
xx Mulched
! Yes fl No
Depth Over
Bed / Trench EdgesBed / Trench Center
Depth Over xx Depth Of
Topsorl
///5 *r ,/?
Date lnspector's Srgnature Cert No
.-'\--_
SOIL ABSORPTION SYSTEM
tarFl I
-
nnAlnl 7
drQ //o//qa.
I
-
trII HFI SANITARY PERMIT APPLICATION
ln accord with ILHR 8i1.05, Wis. Adm. Code
-Attach cgmplete plans (to the county copy only) for the ,system, on paper not less than
81Ax 11 inches in size.
-See reverse side for instructions for completing this application.
!. APPLICANT INFORTIATION - PLEASE PRII{T ALL INFORIIATION.
"o'n(+ Cno , {
STATE SANITARY PERMIT#
"n*rl, ?o?^? r$-k,app r icati on
"gqg I.D. NUMBERt4t b r//
nRLar..)*J ,^ Ptcil<_-Ft
PROPERTYOWNER
I n Sd%lidvt,s -fr rJgN,R il e(orr6
PROPERWLOCATION
BLOCK #LOT#
I
STATEC!TY,fl ALDbtro AIC
ZIP CODE PHONE NUMBER(v{ 6t*?fi1 SUBOIVISION NAME OR CSM NUMBER
r E Aovcondo
z Z Assemblv Hallg E Gampground
a [l Church/School
s E Hotet/Moter
Ltt
6
7
8
I
trtrtrtr
NEA ROAD
trtrtr
rg E other: Specity
c74-
t lt,
lll. BUILDING USE: (lf building type is public, check allthat apply)
ll. TYPE OF BUILDING: (Check one)State Owned
Medical Facility/Nursing Home
Merchandise: Sales/Repairs
Mobile Home Park
Otf ice/Factory
10
11
12
Outdoor Recreational Facility
RestauranUBar/Dining
Service Station/Car Wash
E prOti. E r or 2 Fam. Dwelling-f of bedrooms
-
!V. TYPE OF PERtllT: (Check only one in line A. Check line B if applicable)
A) 1. E ru"* ,. Etr Replacement g. E Reptacement ofSystem System Tank Only
B) E n Sanitary Permit was previously issued. Permit #
4.5.tr
Date lssued
Repair of an
Existing System
Reconnection of
Existing System
Seepage Bed
Seepage Trench
Seepage Pit
System-ln-Fill
Other
+t fi.nolding Tank
42 l-l Pit Priw€ E vault eiivy!tr
trtr
V. TYPE OF SYSTEM: (Check only one)
Experimental
30 E Specity Type
Non-Pressurized Distribution Pressurized Distribution
21 E uound
22 Z ln-Ground
Pressure
11
12
13
14
7. FINAL GRADE
ELEVATION
Feet
6. SYSTEM ELEV.
Feet
VI. ABSORPTION SYSTEM INFORMATION:
4. LOADING RATE
(Gals/daylsq. ft.)
5. PERC. RATE
(Min./inch)
2. ABSORP. AREA
REQUIRED (sq.ft.)
3. ABSORP. AREA
PROPOSED (sq. ft.)
CAPACITY
in gallons Prefab.VII. TANK
INFORTIATION New
Tanks
Existing
Tanks
Tota!
Gallons
Site
Con-
structed
Steel Fiber-
glass Plastic Exper.
App.
#ol
Tanks Manufacturer's Namg
Seotic Tank or Holdino Tank -x-4r."r.T t
Lift Pump TanUSiphon Chamber
VIII. RESPONSIBILIW STATETIENT
l, the undersigned, assume responsibility for installation of f{f667tsi(t sewage system shown on the attached plans.
MP/MPRSW No.:
."D;,L
Plumber's Name (Print):Signature:u
DT ()/ft 6s-Jtt=l
Business Phone Number:
u
IX. COUNTY/DEPARTMENT USE ONLY
{or*ou"o
Disapproved
Owner Given Initial rutSurcharge Fee)
it Fee (lncludes
X. CONDITIONS OF APPROVAL'REASONS FOR DISAPPROVAL:
c
IIXI
W
SBD€398 (formerly Plb67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Salety & Buildings Division, Owner, Plumber
tr
t_ P\lt tr LI
1
2
,l
4
5
b
INSTRUCTIONS
A sanitary permil is valid for two (2) years.
Yqur sanitary permit may be renewed before the expiratioh\date. dnd at the lirrre ci (e ewal any new
criteria in the Wisconsin Adminisrrative Code will be appiicable.
All revisions to this permit must be approved by the perniil issuing authontv
Ghanges in ownership or plumber requires a Sanitary Permil Transie riF e..1rr v.,i, i iorr|,r (SRo 63!91 to be
submitted to the count) prio. to installation. i
Ons'te sbwsge sy,\ln,ns musl bc properi'y rra., ,lai:ei,. Thc '. -':i:, tarr 'is) n'L -' trs 1,,- r, ' .a;,1 1,, 'r ii!.'ls1d
pumper whenever necessary, usually every 2 to 3 years.
ll you have questions concerning your oncite sewage systern, co!lacl your i\y:al ioCe adnrinistrall)r or the
Stale ol Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include
Property o\Mner's name and mailing address. Provide the legal description and parcel tax number(s) oi
where the system is to be installed.
Typ€ of buifding bein$ served. Check onl, one arid complete # ol bedrooms tl 1 u 2 Family Dwell:n0.
Building use. lf building type is Public, check all appropriate boxes that apply.
Type oI permit. Chock only one in line A- Complete line B il permit is for tank replacement, reconneclion, or
rePa ir.
Type _oI system. Check appropriate box depending on system type.
Absorpticn system inlormation. Prcvide all inlormation requested in til /
Tank information. Fill in the tiapacity of ever/ :'rcr1, ,,rJlor 'lx;!l ,r:, i.i ii.r, ,.jl thrj iul,i' qi-:r )''q ,f ,ni,! i)'
tanks and maflufaclu:el's rlanle. l.tdlcate preli,i: crr sile lil,r!. i.I;i, li :inrj t::.iri( ,r,<.ia,,:il ('Qmq"lr.i ;Ji riii
septic. pump/siph('!r and holding tanks lor this s-vstem Ctiec( r \-. r" r,:;, 11.: i ,crlri-),/a: ,rr" / if ari.:-r rr:r:.:;,,?r'
experimental product approval from DILI-1Fi
iesf\.Jnsrbility Statemenl lnstalliog plumFer ;rr r^ I:li ;r' e re. rr'...,..: ,,-r{!.s- !.,',, ?1tc.o,-'r i.',., :.'.i.rr ie,=:
MP, etc.), address and pirone nu,nbqr. Piumber '!:rrsl - r9,1 al)f i,.,,li.f ,r {, :m
Countyi Departnrent Use Only.
County/De0a!'tment Use Only.
.
t
vtl
vlI
tx
x
ComFiet- !ians and :Dec;tiiat;on" oot smaler thair 6r': 'i l1 ir:. \i:: r- . .r I'i. .r,bi ,l:r.C i! th. rif .::,ly The
pl?1s !'rr,>1 i/r( li..rde ihe lolluwi'rg: '!) plOt pliin, ,iriw' rr.' \-.'.rs ,'r .,"'i'tL .:r',,;,itl;: , i ,:,i!',:: '1r. -.' .r'.:'i i-f
holding t;161'15i :ieit:i. t:,'rkl -r or riiler trealr!16,,'. 13ri(:i .. ...-ir.' . ,:.. tll.'r'j ,,,i:i,..- ; .... r".'r..., ,,iivi('r.'
Slrealrrr arii iares, f,,,n7, 1" 5;ph.],r tarrl.s distr,f)r'!xrn {i.'rqij !':. : .. , ; ,., ...\,r' ( 'r,.,ra, -,. 2.,,:,si'.Ir
area.-j, art(i lh6-, lO:aiior, Ol rr,p buti-ii:lg Se!.,/rliJ, il: .l,i;c.'-,i.,r'i. . i:,.:i: -l--7. .. 1[;Lr(,.1.e.,j. :J
C) comptete specilicatrors foi punrps anJ conir.J;s: dose vt,ir.r'ic : r)r:,'r.lr J,iidJ:-eilces: liiciiur, :ci:s. [),,'t,
pertormance curve; pump model and punlp manufacturer D) cr,.,rs sectron {\f ii,e :;c,il absorption sysJorn it
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROU DWATER EURCHAAGE
'1983 Wisconsin Act 410 included the crealion of surcharges (fees) for a num:er of
regulated practices which can erfect groundwalcr.
The nron res collected thro,rgh these sttrcharges aru used for 5nri','ir, ii. r'iwdl.i. 'i, c.r-rd
watef Contarnirlation investi0atiorls and establishntpr,i $r star'.rirrils
sBD-6398 (R.11/88)
PLB 68
OWNER
PLUMBER
TOWN OF
or Jvl
N9 199936
CHAPTER 145.135 WISCONSIN STATUTES
(al The purpose of lhe senitsry permit ia lo sllow in.tallation of the
privaie tewsge ayatem d€acribed in the application for pcrmit.
(b) The approval of lhe .anitary permit is based on regulationa in
lorc€ on rhe date ot i$ue.
(c) The ssnitary permit ia valid tor 2 Years from original det. ot
issuanc€ snd may be renewed for iimilar periods therettl€r. Applicrtion
for renewal rhell be made lhrough the county snd.hall comply with
regul6tions in eftect at the time.
(dl Changed regulstionr lyill not impair the validity of a sanitary p.rmit
until ihe time ol renewal.
(e) Renewal of the $nirsry plrmit will be based on rcgulrtion! in
lorce at the time renewal ia soughl. Changed .egulationt may impede
{rl The ,enit.ry permit i3 trans{crable. A ,aniltty petmil trantfcr
shall be obteined from the county authority.
' lf you wish to renew the permit, or transfer ownerahip of th€
p€rmit. plee3e contscl the county authority.
a fl
LIC #
LOCATED
SEC N E
AND/OR LOT- BLOCK
SUBDIVISION
AUTHORIZED ISSUING OFFICER. DATE tl- tl-it
THIS PERMIT EXPIRES 3 UNLESS RENEWED BEFORE THAT ATE
(niro YEARS FBO ORTGTML OA1E OF lsltlr NCq
VISIBLE FROM THE ROAD FRONTING THE LOT
DIJ ft ING CONSTRI
'CTION
REPORT ON SOIL BORINGS AND SAFE, .DEPARTMGNT OF
INDUSTR.Y, '
LABOR AND
HUT.,IAN RELATIONS PERCOLATION TESTS l-lfl1 tl 4 I f;rr.
P.O. BOX 79ov -
MADISON, WI 53707
DATES OBSE RVATIONS MADE
FFOFTIFDESCHIPT!ONS:PEFCOTATION TESTS:
(tLHR 83.09(1) & Ch
RATING: S- Sitc ruitable tor ryitem U- Sitc unsuitrblc for rystcm
BLK NO.SugOIVISION NAME
1
IC IPALITY:
,n)EilR
l_d hl,UOUNTY
\T Max
E ru",, E neptaceDResidence
I.IO. BEDRII/IS.:COMMERCIA L DESCRI PTION
Dug Qaromal
LDI A
S U
ECOMMENDED SYSTEM: (optional)
DS DU s
IL
s U
U
U
D
s
lf Percotation Tests are NOT required
under s. ILHR 83.09(5){b), indicate:
DESIGN RATE:tf any portion of the tested area is in the
Floodplain, indicate Floodplain elevat ion :
PROFILE DESCRIPTIONS
BORING
NI,I\/!BER
TOTAL
DEMH IN.ELEVATION
EXTURE, AND DEPTH
TO BEDROCK IF OBSERVED (S EE ABBRV. ON BACK.)
B.\fnrtkE HSrp &r.rSd/5
B.\-/nF Bu,lD iN
B.{
B.
B--/ta
B-/\
PE RCOLATION TESTS
!i
r
TES:5-
NIJ\4BER
WATER IN HOLE
-AFTER SWELLING
TEST TIME
INTERVAL.MIN.
s RATE MINUTESPEBjNCH-'lNcrt&PERIOO 1 PERIOD 2 PERIOD 3
P-
-
-.-. _
P.
P.
P.,--
P.
-
P- '.1
____.-
PLOT pLAN: Show locrtiona ol parcol.tion taat5, loil boringa and the dimentiont o, tuit.blc 3oil !r.ar. lndic.la acal. o. diatu6t. O.3c.iba whal a.a th. holi'
zontal and r.nical .l.vatlon ratarenc! pointa and ahow thrir locltion on th. plot phn. Shorv tha !ud!c. alavrtion ar all borinea tnd lha diraclion lnd p"a'nl
ot land rlopo.
SYSTEM ELEVATION
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L-1-
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_t
il
f-I-1
I ffi
-*_l-
+-j
_t_J_llLJ__*J
l, thr und.rrign.d. h.r.by ct.tify rh.t th. .oil t..t! reponed on thia lorm wcr! msd. by me in accord with lhe proc?durcs and mcthod. rp.citird in th. Wi.londn
AdminiatEtiv! Cod., rnd th.t th! d.ta.aco.dcd and th. loc.tion of lh. testa src corrccr to the bert of my knowledg. end bclicl.
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RE COMPLETED N
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7frDl
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DISTRIBUTION: Origrnal and one copy to Local Authority. Property Owner an,
oILHRSBo€395 (R. 10/83) - ov
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,drJP fit elt)io e Aa rs
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SAFETY & BUILDINGS DIVISION
State oflVisconein
Department of Industry, Labor and Human Relations
Septenber 28, 1993 2226 Rose Street
La Crosse I{I 54603
TIM MIDDLESTADT
RRl
KNAPP WI 547 49
RE PLAN S93-41041
IDEAL DOOR CO
sI{, sI{,29,29, 16W
TOI{N OF BALDWIN
HOLDING TANK
FEE BECEIVED:100.00
COUNTY OF ST CROIX
The Departnent has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the syste[ plan subnittal. AII
noted items nust be corrected, The review and approval of the systen is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, I{isconsin
Adninistrative Code, and is contingent upon conpliance with any stipulations
shown on the plans. This systen has not been reviewed for the code
requirenents set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary perrit is obtained, plan approval will expire on the day theinitial sanitary pernit expires, The licensed plunber responsible for this
installation shall keep one set of plans with the Departnent's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be aade,
AII pernits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to De at the nunber listed below. Please refer
to the plan nurber shown above.
Si rely
rard Swin
Plan Reviewe
Section of Private Sewage
(608) 785-9348
2247R/ 1
gBrr{a8 I n" 0lor,
tI :t""?'i
tu
':Aq;fity Business Co.
A B o c
RECE,VED
S tP I t, lgg3
S ewu S ervicAf* E BLocs' orv'
-L1 u+l
o
se3
Complete
Er,lsfi rvo e-
Cnl ilolDteG
KNAPP, WISCONSIN 54749
Phone: 665-21 12
l" lg'fi 6,aro bl grp€ LtlotPrll 'faPX
f,xlsf,roe Sfo,qP#
llrsO
DooB ASSE til/
I(sf 56r',5,
.5 oo 4fl\*o,.r.,
ISo eauot \
3,000
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flrE ntgotwEi
Utvtotl Denf
l6o'
WSCONSIN 54751
35-1666
Ff rsvrO
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ts
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DEPT.
5O fngloyers
3 - ftntt DetutnS
OF( et-
PF;iVA SEWAGE SYSTEfT
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JuOr 70 5c/{,E
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ditionaily
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HIGH 'flATm 'ilARNlllc tEVIE
H63.t'm INI 7, PR t[r I +" 'vf[f P IPE Im[,l IMT IiIG U" ,{EOVE CUt[
LOC{TE AffiOS TCP OR Ol{ IIAI#AY MWR
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riES . 18 PR rNr /,
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A= 6'-6"
B= 24'-0"
C= {'-6"
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f= E"
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l0IE: THI AmW lE\S Sl.lCtN lN D0TIED LIIIS ARt I0 Bt StfPLlD Al'D ll,SiALLD BY
THt CNIRACIOR AI IHt llt\t ffi IAII( lNTAlLtIlON,
ffiIPD IENI OF StTffi:
IETH ,JF SiilM FRO{ FINI$M OP,\D[:
rffi 0F
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pO nro (lz" PI.,{IE)
IAi\K IIA,M.FACIffiffi: I !
a
I NIEMhT ITSUL PMilf,T IO}{ 9EC DI. ISTS
S]EL TAM FAMIUTOM
STTH UILTAUIG, [I 5J172
ffiFA}ff:
TAM
SSLE: l\ClE A[t: i2
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tEshtPTtcN: 60ffi u[0] HIntrc
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24"
HOLD tNG TANK CAPAC ITY(GALL0NS)
(4,' ['r."u': 6050) (6" rt-Lil': 5ga5) (8" lN.fl': 5s20)
rr.l SES
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C o fl
PF$JA1
dt6ut UrAl€A. WanruNt, DtrL<E
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}IOLDING TANIK AG*EMFMT
Docunrcnl 1,.1o.. 428552 , I
Aurccnrcnt Date:
ur 4r
This agrcement is ma<lc betwecn thc local governmcntal unit
Town o Il;rl,lwin
and the holding tank(s) owncr(s)lllnrlch.s Prooenti es
Wc ucknowlcdgc rhut applicirtion is bcing madc for thc installation of (a)
hotding tank(s) on thc lbllowing propcrty. (Provitlc lcgal land
dcscription.)
l'( Sv'l % .St'J %, Srxtion 29 fj9 N, R 16 W, Town sg Baldwin
, Vot. Z9SL
, Subdivision
Page{ll9 , CSM
or lhut continucd us,c of the cxisting Prcmisos requires thal a holding tank
bc insrrlleJ on the propcrty lbr rh-e'purposc of proper containmenl of scwage. Also, the prop€rry cannol now be sewed by
u nrunicipal ..*"r,.r, oi,y.rih., ryp.:irf privatc s&irgc systcm as pcrmittcd undcr Ch. ILHR 83. Wis. Adm. Codc' or Ch. 145,
st..ts' st. tto,.x
,ds an induccment to tlre Counry of E6ill{ ro issue a sauirary permit for the sbove described ProPerty, wc rglec ro thc followlnS:
t. Owncr agre€s to confornr ro all applicable requirements of Ch. ILHR E3, Wis Adm. Code relating to holdltrS t8nks.
lf rhe owner fails ro havc thc holdi'ng tank properly service.d in responss to orders issued by the municipslity to Pr6'ent
or abalc a nuisance as describcd in ss. f,if.ti o,itl l.t6.ll Stlts.'the municiPality may enter uPon thc ProP€rty and
servicc ths mnk or cause to htve the bank serviced and charge lhe owner by placing the charges on rhc tax bill as a
spccial assessment for currenr seryicrs rcndered. Ttre charges will be assesse{t as Prescdbed by s 66.60' Suts.
2. Owner agrees ro pay alt charges and cosrs incurred by the municipality for inspection, pumpin& haulilg or.o]h:r*it
scrvicinglnd maintaining rni not.ting rank in such i manner as to prevent or abarc any nuisan@ or be3ltll hazard
r-rused 6y rhc holding raif. L. municipality shall noury the owner of any cosls which shaU bG Psid Dy tht-owoer
wirhin thirry (30) Oays from the da.c of notice. In lhe event the ownet does nol Pay thc cosls within thirty (30) days'
lhe owner specifiuuy agr".s rhar all of lh€ mstE and charges may be placed on rhe tax roll as 8 sPecisl assessmcnl for
the abatemCnt of a nuisance, and thc tax shatl be collected as provided by law.
3. The owner, exc€pr as providcd by s. 1.16.20(3Xd), Stats., agrees to conlract with a person who is licens€d undel Ch.
NR f13, Wis. A,tm. boOc ro have the not.tiig rant serviceO anO to lilc a copy of the oontra€t ot thc ownsr's
rcgistration wirh rhc municipatity and with the county. The owncr further agrees to lile a roPy of any cbanges to.ahe
sefoice contract or a copy oia new service contracr with the municipalily and the counry within ten (10) busincss day6
lrom lhe dale of chtnge to thc service conlract'
4. The owner agrecs ro contracr wirh a peson licans€d under Ch. NR 113, Wis. Adm. Crdc who shall submit !o tbc
municipaliry;nd ro rhc county a repoit in accor4$rith s. ILHR 83.18(4)(a) 2., wls. Adm. Codc for rhc.GMdng on
a semiannual basis. tn thc case of registrarion undcr s. 146.20(3)(d), ShB., the ovner shall submit thc rcPort to the
municipality and the county,
5. This agrcement will remain in effear only until the local governmental unit respotuible for thc regulation of Private
."r"ugi.yrr"*r c€rrifics rhat rhe prope;ty is served by either a municipal sewer or a soil absorPtion sFtem thst
comp-lies wirh ch. ILHR 83, Wis. Adm: Code. In addition, rhis agreement ma, b€ canoeled by €xecuti!8 aad recosding
said certiricadon with refcrence to this agreemenl in such manner which wilt Pcrmit lhe odstencc ol thc ccnincadon
to bc dctermined by reference to the ProPerty.
6. This agr€emenr shau be binding upon rhe owoer, the heirs of lhe owner and assigne€s of me owDcr. T[c owrer sbalt
submiithe agreemenr ro rhe registcr of deeds and rhs sgre€ment shall bc recorded by the regisEr ofdccds i[ aEsoscr
which will peimit rhe exisrence of rhe agreement lo be determined by rcfercnce to thc proP€rty whelc thc holdlBg-tank
is insmlled.
Ow (s)(s) (pri ) Owner's Sig nStur Town Chairman Name (print)Ctainrm SIgBDre
-..\
AS) 2^ //o Q1,,<- U)ooJ-,//e
Block _
Subscribed anil sworn to before me on tltis datc:Subscribed and sworn to before me on this date:
a
lvly conrmission expires:My commission expires:
S-)f sf-)3-.i sS
It0t.r.f frr:ll:,: l:..'r Jl ti.'''ic:':l;l
1.,'-.-^-,.. ' 'r 'tt'll,l\
?s
- ,t,
tlI HoLD ING TAr{K sERvr6ftb-SrVril-cr
Contract Da
This contract is made the holding tank owner(s) name(s)
nd the pumper's name
the
of
I
2.
The owner agre€s to file a copy of this conEacl with the local governmental unit hereinafter called the 'municipattf,
which has signed the pumping ageement required in Ch. ILHR 83.18(4Xb), Wis. Adm. Crde and with the County of
Dunn.
The owner agre€s to have the holding tank(s) serviced by the pumper and guaranlees to permit the pumper to have
aooess 8trd to enter upon the property for the purposo of s€rvicing the holding tank(s). The owner agrees to mainrain
fte all-wather acc€ss road or drive so that the pumper catr service the holding tank(s) with the pumping equipment.
The oumer further agrees to pay the pumper for all charges inctrred in servicing the holding tank(s) as mutuauy agre€d
upon by t[d owner and pump€r.
The Pumper agtees to submit to rhe municipality which has signed the pumping agre€menr required by s. ILHR
83.1E4)O) Wis. Adm. Code and to the county, a repon for thc serviclng of the holding tank(s) on a s€miannual basis.
The pumper further agrees to include the following in the semiantrual report:
a" The name and sddr€ss of the peEon responsible for servicing rhe holding tanhb. The name of rhe owner of rhe holding tanbc. The location of the property on which the holding tank is installed;d. The sanitary permit number issued for the holdlng tanke. The dates on which the holding lank uEs serviced;f. The volumes in gallons of the oontetrts pumped ftom the holding tank for exch s€Mcing;
& The disposal sites to which rhe contents ftom the holdhg tank were delivered.
This agreement wlll remain in efrect until the owner or pumper termlnates this contact. ln the event of a change tn
this oostract, the owner agre,st to 6le a opy of any changes to this seMce oontract or a oopy of a new seMce @ntract
with Oe municipality and Dunn County within ten (10) buslness dap ftom rhe date of change to this service contract
Otmer(s) Name(s) (print) Ovmer's Signature(s )Pumper's Name (print)
3.
4.
c
' .t*lBr,fta.""' !. r
Subscribed and srvorn to before me on this date:
C,I ,Q--
My commission elpires:
,ta -/'3 76
Subscribed and sworn to before me on this dats:
My commission expires:
5
/d ^./3 7G
of
R
s T C - L00
Tltis applicatlon form is to b.e.completecl in fuIl and signed bylbh" owner ( s ) of the property
. b:lr! 'J;roped , ony inadequaci es
11 1 1 . only rosult ln &qrny. 6r the'pJrmtt i;;;ance . , Should rhtsdeveloprnent be intended f or r?:q.i" by qwn er/cohtractor, (specItouse ) , then r.a second f orm should be r"tained ;;; compreted whenthe property-' is sold and submltiea - lo this office with theappropriate deed recordlng.
Owner of property Hinrichs Properti'es
Location of'property Sw L/4 sw t/q, section zg t T zg N_R 16 w
Towns h i p
Maillng
a ldwin
address 545 Midwest TraiI No, Lake EImo, MN 55042
Address of site Hwv 1? F st
Subdivision name Lot ho.
Other homes on property?o
Prevloue own€r of, property
TotaI slze of parcel
Date parcel .uraB created
Are all corners and lot LLnes ldentlflable?Yes _No
re this propercy belng deveroped f or ( spec house ) ?_yes ,,\ No
:;tBl:#q-and Pasa Number 439 aa recorded wlrh rhe Regisrer
INCLUDE WITI{ THIS APPLICAT.'ION THE FOLLOT^IING:A I{ARRANTY DEED which includes a DocuHENT NLTHBER, voLUHE Ar.rD pAGENUHBER & TIItr StrAt oF TI{E REGISTER otr DEEDS. ,ID addition, acertified survey, if avairabre, would be herpfut'to;:-a; avoidderays of the revi.e.w-l.ng process. rf th; deed descript,ion' references to a certlfleit Survey Map, the certlfiea- I"r""v Mapshall also be required.
best of my (our ) knowled ge that, I (we ) am ( are ) the owner ( s ) oftho property abecrlbad I n thls inform atJ.on form, by vlrtu eofawarrant.y deed recordecl t n th of f lce of the Count y Register ofDeeds as Document No., and that I ( we ) presentlyown the pro posed slte for th e sewage d lsposal sys tem or I (we)obbairred an easement to run the above descrlbed property, forthe constructlon o f sald s yst,em, and the Eame h as been dulyrded
L/ ./tyPt
I(we) certif
r eco
No.
S gnature of appllcant
)
I
PR,OPERTY O}Ti{trR CERTIF'ICATION
y that, alI statements on thls fo rm are true to the
off lce of C ounty RegJ.ster of deed 6 as Docurnent
co-appI lcant
Date of gnat,ure Date of Signature
X
0
9'S
i """('rl{!"{ ""-
F
STATE BAR OF WISCONSIN FORM 2-IE62
WARRANTY OEEI)
rHIt sPACG HE3€RVEO FOR RECOROINO OATA
of .I"ty___A D. I 9_! 7
a
t
Automat ic Garag
4e8554
lt.,
1l Uo 786p^cr 4 U 4.Lr5r urs oFrce
sT. Clotx Co., wlsr
RoCd. for Rocond tfil, 28rhe Do<ir Co.', a corP ora t ion
unde r I aws or Mr nne sota
4:45 p
*^'flif,ff3li"J'u?oPerE.les,aMr nn eso generat
ar S r.p
i
RETURH TO
Tex Parcel No:
ro x Counly,thr tollowlng dcacrlbcd rcrl coleto ln
St!lc of Wlsconrln:
/
See Adden,Jum for Legal Description
ruE#Js _
E\t:LtpT
Thlr is not homealeed ProPerlY.
(1.) (lr not)
Exccptlon to Wlrrenllco:
I
Oatcd lhlr
ln30'
(sEAL)
AUTHEHTICATIOH
Slgnrturc(r)
eulhcntlcatcd thlr-daY ol , l9-
TITLE: MEMBER STATE BAn OF Wl SCONSIN
(lf not,
euthorlzed by $ 700.06, Wll. Sletr.)
deyol D€cember , ro-85
Automat Gara Door C FErt-1.O...'
q.,
nr
(sEAL)
rve Hinrichs,,t,llta
Secre tar Y/"TfiEtutE6&fexr
ol
od
lo mc known to b€ thc Person s who thc
rec,
E NT WAS ORAFTEO 8Y
t r)
:Z"t I ^'l-&vtr Pu
ure! may be aut hentlcated or acknowledged. Both My
ars nol necessarY.)dale:
.Nlrnat ol perlon! rlgnlng ln lrry cap.cl!y rhould ba tygcd or Dtlnlad balow lhalr algn'luI"'
*ARRA,TY oEEo tr^rE IAR o:r1t"#tt*
c
County, Wlr.
ate cxplrallo:t
, l9
-.)xr7 22UJ
Nelco Fotmt. P.O. Bor 1020O. Orccn Brv. Wl 51307-0208
ol lntlrument
f'
rcr^ffY
stTtErur 5, 1990
a
O
5E.
res en
c Gara Door
veresure rrea
I -i
a I
rIt
t
t
i
i
I ri;. ?86,i 439
-41 u +9'
$98
Addendum to glarranty Deed dated December 30, 1985 between
Automatic Garage Door Co. and Hinrichs Properties.
Parcel l1--Part of SWL/A of SWL/4 of Section 29, Township 29
North, Range 15 West, St. Croix County, Wisconsin,
described as follows: Lot 1 of Certified Survey
Map filed June 28, 1979 in VoI. '3', page 819,
Doc. No. 357888. TOGETHER WITH an easernent for
.. road PurPoses over and across that part of said' Section described as follows: Commencino at the
Southwest corner of sairl Section; thence 588 o 17 ' 41"8
llg:il"53ii H"::: ;;t35,?33*1"i3:i.'l::;; Ifl:":l' 00"w
soIo27'0onE 348.09 feet; thence N88"17'4I"W 50.18
feet to the Point of Beginning.
Parcel *2--that part of the Southwest L/4 of the Southwest L/4
of Section 29 , Township 29 North, Range 15 Vlest, To'arn
of Baldwin, St. Croix County, Vlisconsin, more Par-ticularly desc=ibed as follows: ComrnPncing at the
Southwest corner of said Section 29; thence S88"L7'AI"E,
684.0I feet to the point of beginning; thence
Nolo2'7t39"W, 947.80 fee!; thence 579-45'.27"E,
306 .37 feeti th"r,c. s0lo 27 | 39"8, 567 .91 f eet;
thence N88o33'00'8, 222.02 feet; thence' s0L"25' 52"8,
346.57 feet, thence lI88"L7'41"w, 522.64 feet to the
Point of Beginning. Said parcel contains 353 r 055
square feet of 8.105 acres.
/
I
ir,.. 102f-tt^rr 332 41s' 41
S EPTI C
$98-
S T C 1O5
TA}{K },IAINTENANCE AGREEHENTSL. Croix County
Propertiesot^tN EI\/ BUY E Hinrichs
ADDR ES S Hwy. 72 East
C TTY /STATE Baldwin, llrJI
PROPER?Y L9CATIoX: SW L/4 , SW Lya ,S ECTION
Tor{N op Baldwin
SUBDIVISION None
, sC.
, LOT
29 , T 29N-n 16 w
crolx Count,y,
NUHBER None .
IRE NUHBE
ZTP 54002
rmproper use and maint.enance of y.our pE,ic syst,em courdrcsur t in its premature fair;;; e thundre-- *.=tei . propermaint'enance consist's of -fi"rIing out ttre septic tank every threeyears or sooner' if needed by a licensed-supti" tanx pumper. what,you puE int'o ttie system can irrect the irn"tion oi- tn" septic tankas a treatment stage in the waste disposar system. :st' ' croix county residentss may be- erigidr" to' ="."ive a grantfor a maximum of oot of the cost, of re-pracement, of a failingsys t'em, which was in. operation prior- to Jury 1 , 1g7B . st,. croixcounty accept.ed this- profr.^- in August-of I9BO, wit,h the:;:l:;"1;:;",'ff',"."rX11X.::';;'i #; 1i3..*= ie'"1 ro keep theirThe property owner agrees to submit, to st,. croix zoning acerti f icarion 'f oim, sig":d=-.;; the ourr,"i and by-; .mater prumber,journeyman
. .
prumber, .rLstricceo prurnul-r or a r rcensed pumperverifying ttiat' (1)' tlre ".-iiL" wastewater disposar system is inproper operating condltion and- (z) "ft;; in=pection_and pumping (ifnecessarY ) ' the septic tank is i"ss tnan i/l furr of srudge andSCUM.
I/lte, tlre undersi gned have read the above re quirementsagree to maint,ain the p ri.vate sewa q e disposal syste m ln accordawi th the st.andards set, forth, here I n, as set b y the Wisconsin DCert.ification st.ati ng thaE, your se ptic has bee n naint,ained rnustcompleted and retur ned to the SE.Crolx Co. Z oning OffLcer w tr30 days of the thre e year explratl on
S IGNED
and
nce
NR.
behin
DATE:
St. Croix co. Zoni.g Office9II 4t.h SL.
l{udsot'l , t,lI 540I6
\ _
^S/. Croix County Plunning and Zoning
Detail Sanitary Information
Friday, September 22, 2006 ot 5:19:10 PM
Page I of2
Computer #:
Parcel #:
Municipality:
oo2-1o74-20-000
29.29.16.441E
Baldwin, Town of
Sub/Plat:
Lot:
CSM:
NA
1
Vol. 03 Pg. 819
Section:
TN/RNGr
114114:
29
T29N R16W
SW 1/4 SW 1/4
Owner:
State Permit:
County Permit
ldeal Door Company 2231 Highway 12 East Baldwin, Wl il002
12987 lssued: 1013011979 POWTS Dispersal: Holding Tank
279 lnstalled: 1013011979 POWTS Detail: NA
POWTS Pretreatment: NA
Permit: New
Bedrooms: 0
Permit: Replacement of Tank
Bedrooms: 0 Wl Fund:
Permit: Replacement of Tank
Bedrooms: 0 Wl Fund:
Wl Fund:
Owner: ldeal Door Company 2231 Highway 12 East Baldwin, Wl il002
State Permit: 34792 lssued: 04/04/1983 POWTS Dispersal: Holding Tank
County Permit: 0 lnstalled: 0410411983 POWTS Detall: NA
POWTS Pretreatment: NA
Notes
lssuer/lnsoector
Harold Barber
Tom Nelson
Notes
lssuer/lnsoector
Harold Barber
Tom Nelson
Notes
lssuer/lnsoector
Harold Barber
Tom Nelson
As Built
No
Signed Off: Yes
Plumber
Boldt, Everett
Plumber
Boldt, Everett
Plumber
Mittlestadt, Howard M
Other Requirements
Other Requirements
Other Requirements
As Built
Yes
Signed Off: No
As Built
Yes
Signed Off: Yes
Additional Notes Monev Owed
lnspection form not completed. commercial $0.00
facility - moving tanks from 1979 permit due to
addition on the existing building per plot plan. File
with others in 1993 folder. This building located on
lot 1, CSM Vol. 1/319, adjacent to lot 2, CSM
511420, plus parcel A to the east.
Owner: Automatic Door Company 2231Highway 12 East Baldwin, Wl 54002
State Permit: 7329 lssued: 08/03/1978 POWTS Dispersal: Holding Tank
County Permit: 0 lnstalled: 08/16/1978 POWTS Detail: NA
POWTS Pretreatment: NA
Additional Notes Monev Owed
Howard Mittlestadt installed tank - check location $0.00
of parcel and building site compared to other ldeal
Door permits
Maintenance
Scheduled Pump Date Pumped
2t1512006
1st Notification
0412012006
2nd Notification 3rd Notification
Additional Notes Monev Owed
this is a new building near existing buildings, south $0.00
of railroad and north of 'old Hwy 12". 3000 gal.
holding tank in NE portion of parcel
^S/. Croix County Planning and Zoning
Detail Sanitary lnformation
Friday, September 22,2006 at 5:19:10 PM
Page 2 of 2
Computer #:
Parcel #:
Municipality:
oo2-1074-20-000
29.29.16.441E
Baldwin, Town of
Sub/Plat:
Lot:
CSM:
Section:
TN/RNG:
114114:
29
T29N R16W
SW 1/4 SW 1/4
NA
1
Vol.03 P9.819
Owner: Hinrichs Properties 2231 Highway 12 East Baldwin, Wl 54002
State Permit: 199936 lssued: 1111111993 POWTS Dispersal: Holding Tank
County Permit: 0 lnstalled: 1111511993 POWTS Detail: NA
POWTS Pretreatment: NA
Permit: Replacement
Bedrooms: 0 Wl Fund:
Notes
lssuer/lnsoector
Tom Nelson
Jim Thompson
As Built
Unknown
Signed Off: Yes
Plumber
Mittlestadt, Tim
Other Requirements
2nd Notification 3rd Notification
Additional Notes Monev Owed
ldeal Door Manufacturing - now owned by Hinrich's $0.00
as well as properties for permit #17581, Baldwin
Equipt. Company in Sec. 25, Hammond, which are
annexed into Village of Baldwin (see CSM 511420-
Lot 2 assessed with lot 1).
Maintenance
Scheduled Pumo Date Pumoed
1 1/15/1996
1st Notification
04t20t2006
I
b.arQz-V
T 1 nrE UT AALU VY
27"E 852.8 7',
---s 88'33 '00 " w 222.02'---
w 522.66'
2.64'
vy 549,61
w 2686.9J'----
E
u.E, __
s88'34'5 5"w 157,94
R.A. S 88 '33' W 158,5'
UNPLATTED
LANDS
s6 2'.01 '41 "W 56.30'
R.A. s 60'29'2 56.J'
N.P
t)b
bo
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1.15'souTH
PIP€
SPIK€R.R,sEr
oF Fo. 2'tRoN
LEANING NORTH
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BEARINGS ARE REFERENCED
TO THE SOUTH LINE OF THE
SOUTHWEST QUARTER OF
SECTION 29, T29N, RI6W'
(itconoro AS N 88'17'41" w)
I
t
It,
tI
I
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-a
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r'1
t^)
i*)5
..npFRArtV€
ILf{T
lT cqotx
PA IER zC,LFt
7 tN st-f?tNe 8"
CA- ET F'TRIC
ttttt-
dot
NOTE "A,:
EOIH fHE RAILROAD SPUR
ANO IHE CONCNEIE PAD
ARE ENCROACIIMEN|S,
NEIHER SEEH TO 8E
USEO ANY MORE,
O)
N
ELOwtRS
8/trS
s-
0
v
q
22,
199,50'
tt.
I
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SEPflC
NANHOLE
NOTE ,,8":
IHE AOilnoN fo IHE SIGINAL
EUILOING EN6OACHES ON IHE
P0ttlER LINE EASEUENT.NO|E,t.
.4''l l*
is,ErI
SI{ADED AREA,
.l$.......Scr.A
1 . .. " '
I
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PARCEL A
127,520 SQ, FT.*
2.9J ACRES
126,630 SQ, FT.t
2,91 ACRES
s
$w/o nono R/w)o
a.
1-l
lbl-.DAIRYLAND TOWER
COOPERATIVE
I
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26.97'
TOth AVE,
/
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tn(o
CI..- ol(, (\tlc5l3-l
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=
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((,q- o-o c(uo+,(d U)+,Ou', 6
z-
;=,.r ([lo>Ll-(J=
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.,/) +-
(+- +,o!(u>c)+,
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a+t L(/,E =@ a ua
,S/. Croix County Plunning ond Zoning Friday, September 22, 2006 at 12:36:39 PM
Page I of IDetail Sanitary Information
q[-6Y-6(
Computer #:
Parcel #:
Municipality:
002-107
29.29.1
Baldwin,
Section:
TN/RNG:
114114:
29
T29N R16W
SW 1/4 NE 1/4
Notes
lssuer/lnsoector As Built
Harold Barber Yes
Tom Nelson Signed Off: Yes
Maintenance
Scheduled Pump Date Pumped
2t15t2006
NA
I
Vol.03 819
Plumber
Mittlestadt, Howard M
Other Requirements
Permit: Replacement of Tank
Bedrooms: 0 Wl Fund:
Permit: Replacement
Bedrooms: 0 W! Fund:
Additional Notes
Howard Mittlestadt installed tank
of
Sub/Plat
Lot:
CSM:
1ro
etrrl-tqf,a
l-
ct)
=*Ef,o(D
tu\l-
tl-ot
Ht
sGt-(/)
l{t
=Ef,o(,)
k,tt-
=at{l-
3o
J
I
s
a_s(
=\
s
s
cr)
a
&Jt
l-.t
UJ()
Owner: Automatic Door
State Permit: 7329 I
County Permit: 0
2231 Highway 12 East Baldwin, Wl
ssued:I POWTS Dispersal: Holding Tank
tnstalled: 08/16/1978 POWTS Detail: NA
POWTS Pretreatment: NA
Monev Owed
$0.00
1st Notification
0412012006
2nd Notification 3rd Notification
Other Requirements
2nd Notification 3rd Notification
Additional Notes
ldeal Door Manufacturing
Owner:b Hinrichs Properties 2231 Highway 12 East Baldwin, Wl 54002
State Permit: 199936 lssued: 1111111993 POWTS Dispersal: Holding Tank
County Permit: 0 lnstalled: 11/15/1993 POWTS Detail: NA
POWTS Pretreatment: NA
Notes
lssuer/lnsoector As Built
Tom Nelson NA
Jim Thompson Signed Off: Yes
Maintenance
Scheduled Pump Date Pumped
1 1/15/1996
Plumber
Mittlestadt, Tim
Monev Owed
$0.00
1st Notification
04t2012006
357888
Part of the Southwes
'I 5 West, Town of Ba'l
CERTIFIED SURVEY MAP
t 1/4 of the the Southwest l/4
dwin, County of St. crolx, Sta
Town 29 North, Range
r')
UI
n
f,r:.'i.,l
Vol ume of Certified Survey maps, pa
of Sectlon 29,
te of [,li scons i n819 as Cert
'-;B/R..E
qiv..:_ _
JtrN 26 1979
sI. crolx -.. .., r
co&P.i€r{o{lva ?^Irs, i^}i,.;Ne
.|O TC{I{O @IIIIIEG
APPROVAT OF THIS TAINOR SUBDIVISION
DOES NOT MEAN APPROVAI. FOR
EUll.DlNG SIIE OR SEPTIC SYSTEIIL
RSFER I9 H6220!
s
G...a..o,aa.
lcc#z
EE!efr1 fIE:,#E
?
aI
q
C
o.
!a
=-{lr|
BEARING REFERENCE TO
THE EAST LINE OF LOT I
sEc. 29, T29{,r, Rr6W.
ASSUMED BEARING
N oto25's2"w
2I
o ior!<>
F3
i;I:,.ro
LEGEND
o FouNo z" tnou ape
a SET 3/4'r3O' ROUNO IRON ROO
WEIGHING I.5O2 LBILF
SCALE l"=lOO'
50l
UNPLATTED LANDS
..ogN.-EP. .F[.AIHFn9. . .
s r'E t206.65
i, THOMAS G.
veyor, hereby c
ividied and ma
Sl,lk of Secti on
County of St. C
parti cul arly de
Commencing at the S
Thence S.88ol 7'41 " E
Thence N.0l025'52"W
Thence S.88033' 00"v{
Thence N.0l027'39"t^l
Thence s.79o45'27"E
Thence S.0lo25'52"E
, 1979.
Su rveyor
KUESTER, Registered Land Sur-ertify that I have surveyed,
pped a part of the SWL of the
29, I29N, Rl 6W, Town of Baldwin,
roix, State of l.lisconsin, more
scribed as fol I ows :
l,J corner of said Section;
,206.65 feet;
46.57 feet to the p.o.b. j
22.02 feet;
67.91 feeti
27.0i feet;
?l.90 feet to the p.o.b.
o6
33 222 ,l
rJ
2
,5,2
22.
I
oN(,-(,Said parcel contains 2.7 acres, more or less.
That I have made such survey, Iand division
FoUND l'rRoN
sw coR. sEc.29
SOUTH LI NE SW IA and plat by the direction of 0rland Henrichs.
That such plat is a correct representation of
al'l exterior boundaries of the Iand surveyed and the subdivision thereof
made.
T29N RI
That I have fully complied with the provisions
f Chapter 236 of the t.lJsconsin Statutes and the subdivision regulationsf the Town of Baldwiri and the County of St. Croix in surveying,
ivid'ing and mapptng the same.
DATED THIS V*A OAt Or
ry I an
vey is part of a survey for
d Power Cooperati ve shownin Book 489, page 561 St, Croix
County Courthouse, HudFon, 4i sconsin.
lt
Vcl-lno 3 PaL:e U19
Irt
otn-mz{
l'lot-{
io
d.d
rs"
a1
t
rn
E
b.,
LOT I
2.78 ACnES.
(R.as 2oo.oo)
r99.50'
t
rl
n
ilB
I s n
Parcel #: 002-107 4-20-000 0912212006 12:43 PM
PAGE 1 OF 1
Alt. Parce! #:
Current X
Greation Date
29.29.16.441E
Historical Date Sales Area Application #
0
Map #
00
2.780
Fair Market Value:
0
Parcel History:
Date Doc #
0712311997
07t2311997
OO2 . TOWN OF BALDWIN
ST. CROIX COUNTY, WISCONSIN
Permit # Permit Type
Vol/Page
786i438
7071179
Type
Assessed with:
Tax Address:
HINRICH'S PROPERTIES
4231 PALACIO DR
SARASOTA FL 34238
Districts:
Type Dist #
sc 0231sP 1700
SC = School SP = Special
Description
BALDWI N-WOODVI LLE AREA
WITC
Legal Description: Acres:
SEC 29 T29N R16W IN SW SW LOT 1 CSM VOL
3/819 ORD INCLUDES P441F TOTAL ACRES
10.489
Notes:
2006 SUMMARY Bilr #:
Owner(s): O=CurrentOwner, C=CurrentCo-Owner
O - HINRICH'S PROPERTIES
Property Address(es):" = primary
Plat: N/A-NOT AVAILABLE
BlocUCondo Bldg:
Tract(s): (Sec-Twn-Rng 40 114 160 114)
29-29N-16W
Valuations:
Description
COMMERCIAL
Class
G2
General Property
Woodland
General Property
Woodland
Acres
10.489
10.489
0.000
10.489
0.000
Land
37,800
37,800
0
37,800
0
lmprove
517,000
Last Changed:
Total State
554,800 NO
06/04/2003
Reason
Totals for 2006:
Totals for 2005:
517,000
517,000
554,800
0
554,800
0
Lottery Credit: Gtaim Count: o Gertification Date: o4t17lzoo1 Batch #: PRGRM
Specials:
User Special Code Category Amount
Total
Special Assessments
0.00
Special Gharges Delinquent Charges- 0-.00 0.00
a
Parcel #: 002-1 074-20-001 0912212006 12:40 PM
PAGE 1 OF 1
AIt. Parcel #:
Current X
Creation Date
29.29.16.441F
Historical Date $ales Area Application #
0
OO2. TOWN OF BALDWIN
ST. CROIX COUNTY, WISCONSIN
Permit # Permit TypeMap #
00
Tax Address:
HINRICH'S PROPERTIES
C/O CLOPAY TAX DEPT
8585 DUKE BLVD
MASON OH 45040
Districts:
Type Dist #
sc 0231sP 1700
SC = School SP = Special
Description
BALDWI N-WOODVI LLE AREA
WITC
Legal Description: Acres:
SEC 29 T29N R16W SW SW 8.105 A LOT 2 CSM
511420 ASSESSED WITH P441E
Notes
2006 SUMMARY Biil #:
Owner(s): O=CurrentOwner, C=CurrentCo-Owner
O - HINRICH'S PROPERTIES
C . C/O CLOPAY TAX DEPT
Property Address(es):
* 2231 HWY 12
* = primary
Plat: N/A-NOT AVAILABLE
BlocUcondo Bldg:
Tract(s): (Sec-Twn-Rng 40 114 160 114)
29-29N-16W
8.105
Fair Market Value:
0
Parcel History:
Date Doc #
0712311997
0712311997
0712311997
Vol/Page
7861438
7071179
702110
Assessed with:
002-1074-20-000
Type
Valuations:
Description Class
General Property
Woodland
Land lmprove
Last Ghanged: 11111/1996
Total State ReasonAcres
0.000
0.000
Totals for 2006:
Totals for 2005:
General Property 0Woodland 0
0
0
0
0
0
0
0
0
0
0000
000
Lottery Credit:Claim Count: 0 Certification Date:Batch #:
Specials:
User Special Gode Category Amount
Total
Special Assessments
0.00
Special Charges Delinquent Ghar-ges- 0-.00 0.00
AP1TMENT qF !NDUSTRY,
R & HUMAN RELATIONS
INSPECTION REPORT FOR
PRIVATE SEWAGE SYSTEMS
n coruvENTroNAL E[aurenNATtvE
fl xoloing Tank . D ln-Ground Pressure D Mound
SAFETY & BUILDINGS
DIVIS!ON
BUREAU OF PLUMBING
2-
P.O. BOX 7869
MAD|SON, Wt 53707
NAME OF PERMIT HOLOER
Ideal Door Company
AOOBESS OF PERMIT HOLOER
RR/l 1, Baldwin, Wisconsin
INSPECTION DATE
EENCH MARK {Permanent relerance pornr) DESCRIBE lF OIFFERENT FROM PLAN
StrILa SWLo, Section 29 , T 19N-R16W, Baldwin Township
REF. PT. ELEV CST REF, PT ELEV
Name ol Plumber
Everett Boldt
MPAreB9{6/trld(
4489
County
St. Croix
Srnitry Pcrmrt Numbcr
34792
SEPTIC TAN LDING TANK:
MANUFACTUREB
Dves Er.ro Eves Ir.ro
TANK OU ELEV
ROVIDED
NLIOUID CAPACITY TANK INLET ELEV
EEODING
lYes Er'ro
VENT DIA WELL
l8urLDrNG
VENT TO FRESH
AIR INLET
VE
LARM NEFEET FROM
EAREST
DOSING E
SOIL ABSORPTION SYSTEM. Chec the I moisture at the depth of plowing
or excavation. (lf soil can be rolted into a wire, construction shall cease until
the soil is dry enough to continue.)
MANUFACTURER BE DDI NG
nyes Eruo
LIOUID CAPACIIY PUMP MODEL TI,'R E RMANUF L
Eves fJr.ro trves Eruo
PROVIDEO
N LOCKIN
DED;
GALLONS PER CYCLE:
(DIFFERENCE BETWEEN
PUMP ON AND OFF)
PUMP ANO CONTROLS OPERATIONAL
Dves Druo
NUMBER OF
FEET FBOMNEAREST-+
PAOPERTY
LINE
WE LL BUILOING VENT TO FRESH
AIR INLET
MATTFIIAL ANO MARKIN(;
FORCE
MAIN
AMT TE HLENGx
EM:
BED/TRENCH
DIMENSIONS
WIOTH LENGTH NO, OF
THENCHT S TEH IAL
,,PIIS LIOUID
DEPTHPIT
INSIDE DIA
SUILOINGGRAVEL DEPTH
BE LOW PIPES EOVE COVEB LEV INLF T ELEV. END PIPES NUMEER OF
FEET FROMNEAREST-+
PROPERTY
LIt{E
WE LL VENT TO FRESH
AIB INLET
MOUND YSTEM:
Mound site plowed perpendicular to slope
and furrows thrown upslope:
D ves Drvo
Check the texture of the fill material for
mound systems to make certain that it
meets the criteria for medium sand.
PROVIDE A DIAGRAM OF SYSTEM
ON REVERSE SIDE. SHOW ELEVA.
TIONS MEASURED.
PERMANENT MARKERS
nves !r.ro
OBS€RVAIION WT LLS
Xves Iruo
solL covER lrExruRE
-
DEPTH OVEFI TBENCH/BED
CENTER
DEPTH OVER TRENCH/BED
EDGES
TOPSOI L D
Dves Dr.ro
SEEDED
D ves fl r.ro
MULCHE D
E ves D rvo
PRESSURIZED DISTRIBUTION SY EM:
ELEVATION AN
DISTRIBUTION
INFORMATION
ENTS:
Sketch System on
Reverse Side.
SIGNAIUHT TITTE
IDTH
l,,
BED/TRENCH
DIMENSIONS
L E NGTH NO. OF
TRENCHES
LATETIAL SPACIN(;FILL OCPTH ABOVE COVER(;,iIAVE L DEPTH BE LOW PIPF
ELEV
NIF OL O PUMP
ELEV
MANI F OLt)
orA
OISTR PIPE
ELEV.
TH
IPE S
L L DISTHIEUIION PIPT MATt.HIAL & MAHKIN(;
HOLE SI/F IY TO APPROVED
PLANS
E Yes Druo
WE LL BUILOI
LIN€
[-Jv
{R
FE
n o[-J ves [- ]r.ro NEARES
NUMBER OF
FEET FHOM
DrLHR SBD 6710 (R.01/82)
Retain in county file for audit.
I
NO IJ|SrH
J-- DEPARTMEryT OF
INDUSTRY,,
LABOR AND
HUMAN RELATIONS
APPLICATION
FOR SAN]TARY
PERMIT
(PLB 67}
Attach plans for the systsm on paper not less than 8% x 11 indres in size. lncluda a plot plan that is dim€n3ioned or drawn to scals' Horizontal
and vertical elevation reference points must be shown. All appropriste separating distances and physical charactaristics as spscified in chapter
H.6il, Wis. Adm. Code, must be shown. An index page or sach page must be signed, sealed and dated by the dssigner. lf dosignsd by a Master
Plumber, the date, signature and licensa number must be shown. The owners copy or a legibls rsproduction of the soil test rsport must bs
included.
Mailino Address:
BnL4.ur*,a))s'A4"eL eoo* Ao^pouyProperty Owner
flu % f^) %s eq fi,9 7 rurn /6 Oior) w
Township:
L4r.u-t f
County:
6f 'QPot xProperty Location |],
A
Lot Number: - I Blk No.:rv* I Nft Nearest State lan l.D. Number(lf assigned)
or Landmark:
cpt 4
Subdivision Namen
TYPE OF BUILDING
E puutic* E Variance* D Otner (specify)*
fl 1 or 2 Family *State Approval Required.
COrTtrv-reR.C./n L Number of
Bedrooms:
Nft.
TOTAL
GALLONS
NUMBER
OF TANKS
PREFAB
CONCRETE
POURED.IN
PLACE STEEL F I BERG LASS NEW
INSTALLATION
R EPLACE.
MENT
OTHER
(Specif y )
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY 5oaa Tttt o X x
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER p R-*tCAC e-
EFFLUENT DISPOSAL SYSTEM
PERC LATION RA
(Minutes per inch)
J4o Nn.
ABSORPTION AREA
PROPOSED (Square feet) :Experimental E Seepage Bed I Seepage Pit
A*t;r6Lo/ffi Reptacement
ternative (specify)n Seepage TrenchElf
Water Supply:
I Prir.rc D Joint I Pubtic
Owner's'Name as Listed on Soil Test Report (lf er than present owner)
m OVIoJ €Se tv 4*t 5-oR e.rL olAL' /O-o-7
l, the undersigned, hereby assume responsibility falflation ol the private sswaga systom shown on the attached plans.
Name f Plumber 8"r4/MP MPRSW No.:
v e-r" e tf p-4'18 ?
Phone Number
t7/g 6?+-t37,
PI gDbet's Address:'6nL4*,n,u), s
**frZnZ'uff E"L4f
COUNW/DEPARTMENT USE ONLY
Fee:
d0 d2 '"'"/-y4 ffir^ourof] orsnppRovED
Sanitarv Permit Number:?q79 L)
Reason for Disapproval :
Alternate course(s) of Action Available:
Change of ownership, building us€ or plumber requires a Sanitary Permit Transfer Form (67.T) to be submitted to the county prior to in'
stallation. Failure to comply will void th€ sanitary permit.
DISTRIBUTIONT White-County, Canary-Bureau ol Plumbing, Pink-Owner, Goldgnrod'Plumber
or LHR.sBD6398 (N.0381)
SAFETY & BUILD!NGS
DIVISION
P.O. BOX 7969
MADISON, WI 53707
7 EH I IC
LOCATION
Lot No.
Owner's Name:
Mailing Address
.l.WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
. - DlvlsloN oF HEALTH, BUREAU OF ENVTRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
fitut",fuJn,secrio, a? ,TA?'r R/be to,rlg,' Tow.shrp ", n ; -6" t-Jr-, t ^t
, Block No courrty - 5t, Ceot x
K+
TYPE OF OCCUPANCY: Residence
EFFLUENT DISPOSAL SYSTEM: NEW X
No. of Bedrooms - Other --Ct -*-:r,c,g.g--te-l
-ADDITION -REPLACEMENT
DATES OBSE RVATIONS MADE: SOILBORINGS 4'3A '7g PERCOLATION TESTS I. / -7?
sorLMApsHEEr , f- 7a , .-_ sorLrypE .. VL esar'.1 $tf Loa,n
PERCOLATION TESTS
TEST
NUM-
8ER
DETTH
INCHES
CHARACTER OF SOI L
THICKNESS IN INCHES
t+'so'ub,5',Ll D ofltn)tt a10o
3G"ll lt 6"
al e46u
lt It b l(t 7o'J+
WATER IN
HOLE AFTER
SWELLING
TEST TIME
INTERVAL
IN MINUTES
DROP IN WATER LEVEL, INCHES RATE
MIN/INPERIOD 'I
,/8 "
u/'n"
PERIOD 2 PERIOD 3
,/l"tl"
3"'/s
"
,ls
'/r
"#'
P e\$o ,ls 1lP,-J Yrs 7o ,lt l,
'1tr"
,lt frp'
SOIL BORING TESTS
TEST
NUMBER
DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS. INCHES
(DEPTH TO EEDROCK IF OBSERVED)ESTIMATED HIGHEST
tl
B-+/
4?-73"pn t'"p So, u
It
6" 6t*
zUb
,>,4/e6"
,A6 'tl 40"tl
B_*
*
3
+
72'
720
tl €,J tt
t,a qil
B_*S*b 7>"
72"
lt
It
PLAN VIEW (Locate percolarion tests,sorl bore holes and suitabl
lndicate on the plan the locatronand square feet of surtable areas
needed for building type and occupancy.
lt
rlt
e soil areas.)
. lndicate number of square feet of a
Ir
tl
/1 6
6
{
al
36
3€,
lt
tl
bsorpt ion area
lndicate scale
,?
, ,lI
t
I
I
r!
o
a
*f
of
o
I
k o
o
a
5
se.
?6' '
,n?p
i
I
-e
I
o :*i
<
//-4
I
I
OJ
l-?
o 4
.\/1-
I
X 5'
c)
/,L ?f/
?-'
*r* {, L4r-d,
i,4f
t N
l, the undersigned, hereby certify that the soiltesti reported on this form were made by me in accord wirh the proccdures
and methods specilicd in the Wisconsin Administrative Code, aod thal the data recorded and locatioo of test holes arc correctto the best of my knowledge and belief
e-l /ErL,{*Certification No._-Name (print)/
Address--
Name of rnstaller if known
COPY A-LCCAL AUTHORITY
rS
CST Signatur
,{d_iaa
.Td.-oL O
i &l--d rl
HOURS
SINCE HOLE
lST WETTED
TOTAL DEPTH
INCHES OESERVED
->-7*>.r,
S,/
5'
+4 ,l 3-6 c
,12 tllr
or distances. Give horizontal and vertical refererrce points. lnclicate slope.
3D
I
I
I
I
I
l
o
o
+
q.
fr
fr
$,
i
it
I
J-
I
I
I
I
1.
I
I
-*T
i
_. _l
I
I
I
1
l
4diit-dil;a
oa o C=ak HalJr'!,fiots
e ceme^tf fr ReA t}
*lt,ls"tLnle- P,PLw4,
fe P4t't
L e.*ll
IJ
E
a)
0q
-l
V)v
1
iI
h
,Y
q).t
U
, *{,
'*ffs.
a€f 'o
Neu)
t-.r.f+t
f.
mF6, eo'
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7
i
t
:
'[
;
1
i
t
?i
I
I
oL I llureY /e.
F
- -<(+h+t-,
t
Outrrzr-'e :
fr4e'nL Qoo*
ft+*1ffi"t'4'*'in' (A)
>q
?
t,>tg
,,
(
t
a
r'.lofttI
& eLe*
- 1D
t, g HrI -TNa
Department of lndustry, Labor & Human Relations
Division of Safety & Bldgs.
Bureau of Plumbing Platting & Fire Protection
P.O. Box7969
Madison W1.53707
Tel. 608-266-3815
IN ALL CORRESPONDENCE
REFER TO PLAN
IDENTIFICATION NO.$ clr-dT's ?L'.6z, wlA;N
Bauddr,UJr,
St t" of Wi""onsin
a
t/
s'7,
S{ooz-?3otilL
s37
NAME OF PROJECT
Sincerely,
James Sargent-Bureau Di
For Private Sewage SYstem-s OnlY:
fnis aPProval is valid for two
;;ilU ii will be valid until
fi;';6iration date of the initial
sanitary Permit.
yt\
TYPE OF APPROVAL
e./€-a-o
STR
CI ztP
L
ER
Gentlemen:
Examination of plumbing plans and specifications for the above-mentioned project has been completed. ln accord with Chapter 145,
Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and speciflcations are approved continqent upon com'
pliance with the stipulations indicated on the plans. Please review your code for the requirements ot each code section noted.
The architect. professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of
plans bearing the stamp of approval of the department,
t
.
ln granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan
omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary.
This approval is based on Wisconsin Administrative Code requirements. lt shall be necessary to obtain and fulfill the permit require-
ments of the city, village, township or county in which this installation is to be constructed. Failure to obtain local permits will auto'
matically void this acceptance.
cc:Owner
Plumber
Mfg. Bep.
DI LHR
H&R(2)
Bur. of Health Fac. & Services
Rec. & Env. Services
COU STATE T
l-t)
County
DATE:
DILH R (N. 06/80)
// -/a(
/
/l/
I a
PLANS REV|eWeO sY: { ,/4-t(.r,-€--.I -,//2 //,3bt
I SBD 6678 (9/81) (Plb lOoa)
Detachlqnd Return Upper
-Portioh Of This Form With
Any Return Correspo nd
srArE oF wtscoNsrN DTLHR ftfl,'
I
DIVISION OF SAFETY & BUILDINGS
BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 178
P.O. BOX 7969
MADISON, WI 53707
608-266-3815
DATE:
PROJECT NAME
PROJECT
PLAN ID. #
it',,'PLAN ID. # ', ,
ns for the above-indicated project.
Fee Received is $Preliminary review indicates the required fee is
This is to acknowledge reeipt of your plans gd tp*ificatio
bO-
C. Und"rp"y."nt - Please submit the additional fee. ! Or"rp"y-"nt - Refund forthcoming.
-
Plan accepted for review. LJ Plans being returned.
I No fee has been remitted. Plans submitted with no fees will be E eaaition"i intormation required. SEE BELOW.
held in abeyance.
A
offlcE
l. Plan Submission
f] Additional information shall be submitted in duplicate un-
less specifically noted.
I Plans not clear, legible or permanent-
D nll information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2)(a) Wisconsin
Administrative Code. f] RttiOavit enclosed.
ll. Pressurize Distribution Systems (Mound or ln Ground Pressure)
I Application for use of an alternative system signed by owner
and notarized. (1 copy)
f] County onsite required (1 copy). I Design calculations
for pressurize distribution. E Soil boring & percolation
test data.
I Cross section of system. E eipe lateral layout.
E Plan view of system. E Plot plan.
E Verification of Exception Status Form by County. (1 copy)
lll. Private Sewage Disposal Systems
E Ground slope with 2' @ntours in entire area of soil absorp-
tion system extending 25'on all sides.
E Elevation of permanent reference point (benchmark).
E Location of area suitabte for replacement system - provide
soil data.
D plot ptan showing lot size and all lateral distances from
sewage disposal system to buildings, lot lines, well, water
course, swimming pools, water service piping, Etc.
D Construction detail of septic, holding or lift pump tank if
site constructed or tank manufasturer if precast.
fl Construction detail and cross-section of soil abaorption
system.
E Soit boring and percolation test on 115 completed by cer-
tified soil tester (1 Copv).
E Complete data relative to anticipated use of bldg.
E 2 copies of PLB 6O enclosed.
E Oeea restriction required (1 copy).
E Condominium declaration. (1 copy)
lV. Holding Tanks
f] Profile of holding tank showing vent, manhole alarm and
manufacturer if precast. Complete construction details if
site constructed.
BUotalng tank agreement signed by owner and local unit of
government (sample enclosed).
E Reason for installing holding tank. Soil test or statement
from county (1 copy).
E ptot plan showing location of holding tank with lateral dist-
ances to any building, wells, water service piping, water
course, lot lines, swimming pools, all weather service road,
Etc. Provide benchmark with elevation reference point.
V. Lift Pump
E Calculations for total lift pump discharge, head and gallons
pumped per cycle.
E Sire, length & depth of force main.
E Detail & model of pump or automatic siphons including
size, pump curves, drawdown and average flow rate GPM.
tr Cross section of tift pump tank showing pump(s) or
siphon(s).
Vl. Svstems ln Fill (Fill must be placed prior to plan submission)
E Total area filled (fill to extend 20' beyond edge of trench
before side slope begin).
E Depttr and type of fill.
E Copy of onsite report by county or district staff.
DETACH HERE
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, r.3q44&$i'H&!ffiil,ffit . voL . S6d rnrrl48 8a-o (+(G
a
Thrs documen t rs a full, true and correct coPY
oi the original on file and ol record in
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office 19,S-certrlied
NOTE: BThl t fo. be recorded ln the Tract Index at theReglster of Deeds in the county lndleated below.
,Hixr'.)E::l\filii '
HOLDING TANK AGREEMENT
t'riAY 1 I ffi83
'\FETY cq Bl-DqffirBlusreement ts made and entered into thls
{
Eg3 and be ween the
herelnafter ealled r
W
or{&t3rsfr&SoFFtcE
ST. C,tQlX CO., m.
Rec'd. for Record this 6th
dcy
ql 2:45 P
of Ma
l&
D.83I
a
lrsblr
day of
It and OR
herelnafter ealled the nowner.I
tle hereby acknowledge that appllcation has beon tuade for a bui.1dfi{g,;.,,..-pernlt on the followlng deecribed i"op"rii, to wlt: -,,/a..1.)
.equlres that a. ^"rr:r::#;:::::lnstalled on the property.for the pu"pl"u"oi-p"oper contalnment of set{age. one ',:.,;ilalso aeknowr.edae that sald property ""nnot-iol'i" served by a munrclpal seweron septLc tark - soll absorptlon system.
Therefore, as an lncrucement, to the county ofto lssue a sanltary permlt for the above descrlband blnd ourgelves as fo1lows.
_s*,Ceotx
ed premlses, we here by agree
Owner agrees to eonform to all applieable requlrements of the p lumblng
Co,
't?: 'Cod2ryIattng to holdlng
- . '/dn L./ r^t , ^., _ )it necesaary to purnp out
tanks.Any tlme the Town or ffiofthrough tts plumblng Ins pee tor of Health Offleer, deemsthe subJeet holdi tank the Owner shall have samepumped out 1n twenty_four (24) hoursr oF /w111 have sald workdone and eharge same baek to Ovrner and pl ace same on the tax b111 as a speeialchargeThe Owner further agrees that the Town or mofmay enter upon the pnoperty descrlbed above at anyreasonable ttme,to lns pect r otr pump and haul r.rast es from the subJect holdlngtank.
2. Omer agrees pay all. eharges and costs incurred by the Town orffiofL4U7 pu for Lnspeebton, pumplng,haullng or othe rwlse servlc tng and ma lntalnl ng the subJect holdlng tankin sueh a mannen as revent or abate any nulsance or health hazard caused bsueh holdlng tank.shall notify the Onner of any sueheost whlch sha11 be paid by t he Owner thln thlrty (30) days from th e date ofnotlce and ln the ev ent that, the Otmer does not pay satd eost wlthln thlrty(30) days, 0wner h eneby speelflcally ag rees that all of said costs a nd ehargesmay be placed on the tax ro11 as a spee tal assessnent for the abat ement ofnulsance, and sald tax s haII be eollect ed as provided by Wisconsln Statute.
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DILHR-SBD-6123 (R.4 /92)(ovER)
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t,
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L ,al
6!\t
Pit r
cr i
?"t of s l/2 of ritll l/4 of s*crion zqszt)-l(,. d.-'9.- lbcd as follows: comnencing on S.line of sald
lion 29. ll?1.4 fc,et E of SW lorn.ir thtreof, tt,cnce
:27'!', 3iI4.6 feet, thencc s 88''33'w 200 teeri thonce
"27'w 569.3 feet to s'Iy 1in.] r:f Chlcaqo, salnt Parrl
..1 l-
T.. X.r I
t\,., ," nOt h,lh..rr.d |,,lt.rrl.
. Minneapol i.g and
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.,-ry
6,
liec
NINI
-€
Omaha Railway Company R/w, thencc^f:ly on said Sly ljrre 546.s^feet; thence
Sl3"O5' W I65.0 fqet, thence' S 60"?9'H 56.1 fl(.t. thcrrct. S 6"2I'w 2'r4.9
feet; thence S 88":l'W I58.5 fect; th.rncrr ri I"27'E 146:'=! feet to S line of
Baid Sectlon 29; thence hl on said S llne ''0.1 fi(.t tc Place of Reqinnino.
Subject to powe r Iine-easemL'nt.
)
Page -
v0t 664 mer140
3. Orrner agrees to have a quarterly pumplng report submltted to the local
Eovernment and the county wtrlch w111 state the Omerrs naoe, Ioeatlon of the i
property on which the hol<llng tank ls locat€d,the punper i s nane, th€ dates,voluues puDped and, the dls I puDplns repont or the fourthquarter repont lncludlng a sulmary of the punping hlstory of the prevlous yeartted, to the of.Industry, Labon and Relatlons bythetal uhlt responslble, per seotlon lll5.01 (15),
posal slte. An annua
shall be aubEl
s1
4. lle guarantee that the holdlng tank oontents rlII bete ueetlng the requlrelents of ohaptet" tIR 113, t,lsconsln
lflloonsln Statutes.
dlgposed of at a
Adnlnlstratlve Code.
rl11 rernaln ln tary pernltlssulng agent ln s*.County certlfies that the subJect property lsIlc seger or a sep tlc tank soll absorption systeD thaton, thls Agreenenb nay becancell,ed by executlng and recordlng sald a€rtlfl catlon wlth r€ferenoe to thlsAgreenent ,ln the Tract Index lndlcated above.
5. Thls agreement affect onLy untll !h6 BanlCeot *
served by elther a
conplles wlth eh. H 53, Ills. Adm. Code. In addltl
6. Thls agreenent shall be blndlng upon the lndlcated BovernDentar unltand the Owner or helrs and asslgnees and shall run rdlth the deed.
fr*r.UITIIESS our hands and seals thls day oF
SIGNA OF TOWII ON MUNICIP AL OFFICIAL ( Include Tltle):
SIGIiIATURE OF
Personally caoe before ne thls
the above naned
H ? 7 ,o-t),day of
Rtep l-j t ^r tztc
RT
L , to Ee known to bb
the persons uho exeeuted the lng lnstrunent and acknouledged the sane.ilt
NA D
of wi
h -o-"*^-THIS INSTRU{EIIT
DRAFTED BT:
c*x-
colulsslon explres :
taatlll
I'IOTARY
PUBLIC
_ No0ory publicIy C<|Illrdrslon
- SIoto of Wlsconsln
Expire! Mqr, tO. lg8s
MFR. OF
REEIDEXNAL
I DL
COUUERCIAL IXDUSTAl^t
a
SECTIONAL OVERHEAO OOORS
P.O.BOX 106
(715)68+3223
BALDWIN, WI 54002
(612) 4381139 I
January 20, 1988
pt
(',
a'r..^.d'Thomas C. Nelson
St. Croix Cty. Zoning Admin.
Hammond, I^II 54015
Ref: Change pumping report from quarterly to semi-annually.
Dear Mr. Nelson:
The three (3) documents requested in your notice of
December 8, 1987, have been recorded at the office of Reg-
ister of Deeds. Copies of the same are enclosed for your
records .
ncere ly ,
Je y Heston
Safety Administrator
Enc Io sure
JHlK
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4
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433?90 800l(801 ror,22E
HOLDING TANK AGREEMENT
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Rclurn To
Document No
Agreement
1-5-88
County or Local Governmontal Unlt
Baldwin Townshlp
This agreement is made between the
Thlr rpacc rcrcrvcd tor rccordlng dett
A
teglster of Doodr
REGISTER'S OFFICE
sT. cRolx co., w
Rec'd for Recotd
,ian lc, l'triR=€
(-a,ss
Holding Tank(s) Owner(s)
Hlnrichs Propertles
M'1-
We acknowledge that appllcation is being made for the installation ol (a) holdlng
tank(s) on the following property, (provide regal land description:)
Ideq.l-1 gL. of SInrL of secrion Zg-Zg_26W
__- .._rDc - slnrk of QI.If_- of sec rlon zg_zg_L6]W
Baldwin, Wlsconsin
(see next page)
or lhal continued use ol the exisilng premlses re quires that a holdlng tank be lnstalled on lhe property lorgetf,ago. Also, the property cannot now be served by a munlclpat sower, or any other type ol prlvateCh. ILHR 83, Wis. Adm. Code, or Ch. 14S. Sta
91 c
p nt
m?itted un
to lssue a sanitary permit for the above descr ed property,
JNI?\s$
ts.
As an inducement to the Coun
we agrea to the lollowing:
ty ol Sr Cro{ w
l owner ag'ees lo conlorm lo all spplicable requlroments ol ch. ILHR 83, wis. Adm. code rsls ng lo holding ranks. tt the owner tails lo have lheholding lank prop€rly sorvlcod lo ,ssponss lo orders lssued by the munlcipslily to prevent or aiaie a nri""n""
"" described in ss. 146.13 end'146 1'l' slals tho munlclpality may ent€r upon lhe property and servlce th; ta;k o; csuse ro rtar" rrre i"nt sor"iced and chargo th6 ownsr byplacing tho chargos on tho tax blll as a speclal assessment lor currenl services rendsred. rrrr"r,"tg"" will be asssssed as proscribed bys. 68.60, St8ts.
2 owner agrees to pay allcharges andcosts incurred-by the municipality lo-r inspeclion, pumping, hauling or olherwise servicing and maintainingthe holding Ianrin such a mann€r-as lo prevent or abate any nuisJnce.orteaturla..ri".riuiuy irru titaing tanr. The municipatity sha norirylhe owner ol any cosls whlch shall be pald by.tho. owner wiihln thlrty (30) days lrom the dale or ,ioir"". -in lt,"
"r"nt the owner do6s not pay theco!l! wlthln thltty (301 dry!, the ownlr specillcslly agroos that atl & ihe costs_ana_ "h"rg"" r"i-;piacer, on the tar roll as a 3r,eclal assess-ment lor tho abatamont ol a nuisance, and th8 tax ahait be colloctsd as providad by law.
3 The owner' exceptas ptovlded by s. 146.20 (30) (d), sl8ts., agrees to conlract wilh a porson who is licensed under ch. NR 1.t 3. wis. Adm. code tohave the holdlng tank ssivlced and to tile a coiy ot tne contiact or ttr" o*n"r" ,egljtration wittr ttre muntcipatiry ano wittr tho county. Th6 ownerlurther agraes lo llle a copy ol any chsnges to ihe servlce conri""i or
" copy or a niw servlcs contracr wlth Iho municipality and tho county withinlen (10) busines3 days trom the date ol change to the service co;iiact.
4' Tho own6r agrees to conlract wilh a porson licensed uoder ch. NR | 13, wis. Adm. codo who shall submil to the munlcipality and lo the county areport io accord with 3. ILHR 83'18 (4) (a) 2., wls. Adm. cooe for'the servicing ;;; ""rr"^Jiii"ln. tn ths case ot registrarion under3. ra6.20 (3) (d). srats.. the owner shar submrt the report ro ttre municipatrty ano tt,i "or.tv.-
-""--' ---
S Thls agreemenl will temain ln ell€ct only unlil lhe local govornmental unll .esponslbte lo, th€ regulation ot prlvalo sewage aystems cortities tharlh6 p'oporly ls served by ollhor a munlclpat sewer or a-soil auloifiion "y"t". ttrat complies wltlh ch. i1ni os, w". lo,n. cods. ln addirion. thisagreemenl m8y bo cancollod bv ereculing and recording sald ce;tlticalion wtth rerer;;i"il; ";r;;;ent in such manner which wi permirthe €xistence ot th6 cer tication to be d6teimineO Oy reteience ti1n" prop"r,y.
6' Thl" aEieemenl shall bs blndlno upon lho owner, lhe helrs ol the ownor and assrgne6s ol the owner. The owner shafl submil the aoreement rolho t'01llor ol derd! rnd ths agroemrr-t !hall bo recoJdedb, iie r-eliste. or aeeai rn a ,"nn"irr,r"rr wiiipermit tte existonce ol tho aoreementto ba dora,mtned by retaronco to the property where ttre troijtngl"ii r" in"r"rr"a.
Own er(s) Name(s) (Prtnt)
Hinrichs Properti_es
Municipal Oiliciat Name (print)Municipal Olf iciat Signature
.J
{eat.
(V*t /,. Nolarv Publcr'F/ttlCt^tttrr/My commission
/oTshiChain
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SBD'6123 (n. t0/85) Thls tnstrumont was dralted by lhe State ol Wisconsin Oepartmenlol lndustry . Labor and Human Relations. Bureau ol plumbing.
\
it.
the of
Subscribed and sworn to before me on this date:
I
MunicipatOfiiciat Ti[e (prtnt]
|
{3S789 801 r:h&250001(
CANCELLATION OF A HOLDING TANI( AGREEMENT
As the sanltary permlt issulng agent in the county
stated be]-ow, r hereby certLfy that the following
descrlbed property is now under a new Holdlng Tank
MaLntenance and servlce contract that complles wtEh
ILHR 83. 18 (4), Wls. Adm. Code.
S-k of SW-k of secrion ZT-29-Z6W
Baldwin, Wis.
THIS SPACE RESERVED FOR RECORDING DATA
REGISTER'S OFFICE
sr. cRolx co., wl
Rec'u'l for Record
l98Jan. I 9
ot
RETURN TO:
B: 35 A. lA
teglster of Decds
n
,(
l0t
PTTt\
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Ih$
rn addltion, r understand thac execuElon and recordlng of thls docuryrent ca
holding tank agreement between the ID DOOR CO and
T SI{TP that was recorded on the 6th da yof Y
r98r. r n voluune 664 , page !48 r 8s documenE number 384448
Witness my hand and seal this 5rh day of T NIIARY 1988
County of St. Crolx
by Thomas C. Nelson, Zontng Admlnlstrator
9r
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t[' g\c-
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3o^'' "ufl
,of, '
Ur-'* tL
er (s) s nature (s)Subscrlbed and sworn to
before me on thls date:
\74,1/4A/e ,t/
Not ry Pubilc&,t/i/7" oF,tT &6yy
My Conunlsslon plres:
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t**^16"4r'51,'c-t
NOTE:Thls document to be recorded in Ehe Tract rndex at the offlce of Register of Deeds.
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\
433?9tr * 801 rinZ?B
HOLDING TANK SERVICING CONTRACT
Conlract Date
r-4-88
Holdlng Tank Owner(s) Name(s)
This contract is made between the
REGISTER'S OFFICE
sT. cRolx co., w
Rec'd for Record.l9. I qgJan.B
and Pumper's Name
Reglster of DeodsIdeal Door Co.
We acknowledge the installation of (a) holding tank(s) on the following property: (provide legal descripti :)
IDC S -oj-q!%-o-f--s.ec-qlon- 2g-29-!-6-!{.--__n_aldwln' _wr.sc_o_n-s-i_n : t,r*-r'- t tarf*t*,
ldea.l : _Sk _qf _ S_I^l! qf seclion Z}-29-Z6W
Lsse_ng.x! pug.l-
1. The owner agrees to lile a copy of this contract wlth the tocal governmental unlt hereisigned the pumplng agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
nafter called the "mu s
with the County of St. Crolx
2 The owner agrees to have the holding tank(s) serviced by lhe pumper and guarantees to permit the pumper to have access and toenler upon the properly lor the purpose ol servicing the holding tank(s). The owner agrees ro maintain lho all-wearher accessroad or drive so lhal the pumper can service lha holding tank(s) wlth ttre pumplng equipment. Tho owner lurther agrees to paylho pumper lor all charges incurred ln servicing tha hototng tanilsl as mutuatty agLei upon by lhe owner and pumper.
3' The pumper egroes to submit lo th€ munlclpallty whlch has signed the pumplng agrEement requirsd by s. |LHR 83..t8 (a) (b), wis.Adm' code, and to tho county, a report lor th6 servicing ol lhe-holding tank(s) on a semiannual Lasls. The pumper lurlher agreeslo lnclude th9 tollowlng in tho semiannual reportl
a. The name and address ol the psrson responsible lor servicing the holdlng tankib. The name ol the owner o, the holding tank:c. The locatlon ol tho property on which the hotding tank is lnstalled:d. The Banitary permit nlrmber issued lor the holdi;g tank;e. The dates on whlch the holding lank was serviced:l' The vorumes ln garons or the contents pumped rrom thE hording rank ror each sgrvicing;g. Tl.o disposar sites ro which the conrents trom the hording tank wore derivored.
4' This agreement will rgmain in ellect untll lhe owner or pumper terminates lhis contract. ln the evenl ol a change in this contract,lho ownor ag's€s lo llls a copy ol any changes to this service contract or a copy ol a new servtce contract wilh the munlclpa[tyand the county namsd above wlthln ten (10) buslness days lrom thg datE ol chan!e to thls service contract.
!,J '
Ownc r(s) Name(s) (Prlnt)
_ _ -.Hinr.ichs -Fr.ppe-fties
P umper'3 Name (Prlnt)
AbillEies Business Co. I
Pu mper's Registralion Number
Pumper's Signalure eaqanv
My commission
This instrument was drafted by the state of wisconsin Deparrment
Of lndUStfv. Labor anrl l"{rrrnln Ratatiano Er..r^^.. ^, ht..-r-:- -
Owner's S ign (s)
.-
t"#Subscribed and sworn to before me on this date:
sBD-7s71 (N. 1llss)
,/a
Or.
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,\
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
796-2239 (HAMMOND)
425-8363 (RTVER FALLS)
HAMMOND, WI 54015
TO: Holdlng Tank Users
FROM: Thomas C. Nelson, St. Croix County Zoning Administrator
DATE: December 8, 1987
RE: Holdlng Tank Pumplng Agreements
As you know, in the past, you were required to submit a Quarterly Pumping
Report to the St. Croix County Zoning Office. However, you nos, can change
your reportLng to a seml-annual basls. In order to do this, you would need
to cancel out the old Holding Tank Agreement by filltng out the enclosed
CancellaElon of a Holding Tank Agreement Form and havlng it notarized and
recorded aE Ehe Regi-ster of Deedts Office. You would also need to fill out
a new Holdlng Tank Agreement and Holding Tank Servicing Contract which are
also enclosed.
If you so chose to change to the semi-annual report, w€ request that you
send us copies of Ehe above-mentioned recorded documents for our files by
February 1, 1988. In 1988 \re will again be sending out Quarterly Pumplng
Reports aE the end of the Ist Quarter or Semi-Annual Pumping Reports at the
end of the 2nd Quarter dependlng on which report you chose.
If. we do not hear from you by February 1, 1988, w€ will presume you are
keeping the Quarterly Pumping Report Agreement.
If you should have any questions regardlng this matter, please feel free to
give Ehis office a call.
Alsor w€ w111 be dolng onslte vlsits perlodlcally starting ln 1988 to lnspect
holding tank septlc systems.
TCN : rmc
THIS SPACE RESERVED FOR RECORDING DATA
. CANCELLATION OF A HOLDING. TANK.AGREEMENT
As the sanitary permit issuing agent in the county
stated below, I hereby certlfy that the following
described property ls now under a new Holdlng Tank
Malntenance and Service Contract that complies wlth
ILHR 83.18 (4), Wis. Adm. Code.
RETURN TO:
In addltlon, I understand that executLon and recordlng of this docunent cancels a
holdlng tank agreement between the and
that was recorded on the day of
19 ln voh-rne r PaB e , 8s document number
Witness my hand and seal this da yof 19_.
County of St. Croix
by Thomas C. Nelson, Zoning Administrator
Owner(s) Name(s) (Print)Owner(s) Slgnature(s)Subscribed and shrorn to
before me on thls date:
Notary Public
My Connnission Explres :
NOTE: Thle document to be recorded ln the Tract Index at the offlce of Reglster of Deedg.
HOLDING TANK AGREEMENT
)ocument No.
Agreement Date This agreement is made between the
Holding Tank(s) Owner(s)County or LocalGovernmental Unit
Thlr epacc rercrved lor rccordlng dete
We acknowledge that application is being made for the installation ol (a) holding
tank(s) on the following property, (Provide legal land description:)
Return To
or that continusd us6 ot the sxlsting premls€B r€quirBs that a holdino tank be lnstalled on the property lor the pu.pose ol prop€r conlainmenl ol
sewage. Also, the property cannot now be served by a municlpal sewer, or any other type ot privat€ sewage system as permitted under
Ch. ILHR 8lr, Wls. Adm. Code, or Ch. 145, Stats.
As an inducement to the County of
we agree to the lollowing:
to issue a sanitary permit for the above described property,
Owner agrees lo conlorm lo all applicable requlrements ol Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. ll th€ owner tails to have lhe
holding tank properly servicod ln response lo orderg ls9u6d by the municipality lo prevent or abale a nuisence as d€scribed in ss. 146.13 and
146.14, Sl6ts. the munlclpality may enter upon lhe propgrty and servlce the tank or cause to have the tank servicod and charge thg owner by
placing tho charges on the tax blll as a spscial asssssment lor current servic€s rendered. The charges will be assessed as p.oscribed by
s. 06.60, Stats.
2. Owner agrees to pay all charges and costs incurred by the munlcipality for inspection, pumping, hauling or olherwise servicing and maintaining
the holding tank in such a manner as to pr€vent or abate any nuisance or health hazard caused by the holding tank. The municipalily shall notily
the owner ol any co3ts which shall be pald by the owner within thirty (30) days trom the date ol notlce. ln the event th€ owner does not pay the
cogt! within thirty (30) days, the owner specilically agrees that all ol the costs and charges may be placed on the tax roll as a special assess-
ment lor the abalgmsnl ol a nuisance, and the tax shall be collgcted as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrses to conlract wilh a person who is licensed under Ch. NR 113. Wis. Adm. Code to
have the holding tank serviced and to lile a copy ol the contracl or the owner's rogistration with the municipality and with tha county. The owner
lurther agreos to tile a copy ol any changes to the servica contract or a copy ol a ngw s€rvice contract with the municipality and lhe county within
ten (10) business days trom the dats ol change lo the servico contract.
4. The owner agrees to conract wlth a psrson llcsnsed und6r Ch, NB 't13, Wis. Adm. Code who shall submit to th€ munlclpality and lo the county a
.eport ln accord with s. ILHR 83.18 (4) (a) 2.. Wls. Adm. Code lor the servicing on a aemiannual basis. ln the casE ol registration under
s. 146.20 (3) (d), StaE., the owner shall submil the reporl to the municipality and the county.
5. This sgre€ment wlllremain in ollect only untilthe local governmenlal unit responsible lor thg regulation ol privale sewage systems certilies lhal
th€ property ls ssrvod by €ilher a munlcipal sewor o. a soil absorpllon syslem that complies with Ch. ILHR 8i), Wis. Adm. Code. ln addition. this
agreement may b9 cancelled by execuling and recording sald certilication with relerence to this agreement in such manner which will pe,mit
thg existencs ol lh€ cartilicatlon lo be determined by relerenco to the property.
6. Thls agreement shsll be blndlng uponth€owner, the heirsolth€ owner and assigneosolth6 owner. Thoownsrshall submit the agreemsnt lo
tho regigt6r ol d€eds and the agregmsnt shall b9 rgcorded by the register ot deeds in a manner which will permit tho eristence ol the agreement
lo b€ d6t€rmlned by relersncs to the proporty wh€re tho holding tank is inslalled,
Owner(s) Name(s) (Print)I Owner(s) Signature(s)
Subscribed and sworn to before me on this date:
Municipal Ollicial Name (Print)Municipal Olf icial Signature
My commission expires:
Municipal Ollicial Title (Print)
SB0-6t23 (8. t0/85) Thia ingtrumonl was drallod by the Slale ol Wisconsin Departmenl ol lnduslry, Labor and Human Belalions. Bureau ol Plumbing
Notary Public
lontract Date
HOLDING TANK SERVICING CONTRACT
This contract is made between the
{olding Tank Owner(s) Name(s)and Pumper's Name
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
l. The owner agrsss to li16 a copy ol thls contract yvith the local governmental unit hereinalter called lhe "municipality", which has
sign6d lhs pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
2. The owner agrees to have lhe holding tank(s) serviced by the pumper and guarantees to permit the pumper to havB access and to
enter upon tho propsrty for the purpose ol servicing the holding lank(s). The own€r agrees to mainlain tho ell-weathor accasg
road or drive so that the pumper can service lhe holding tank(s) wilh the pumping equipment. The owner lurlher agrees to pay
the pumper lor allcharges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit lo lhe municipality which has slgned the pumping agroement required by s. ILHR 8ii.18 (4) (b), Wis.
Adm. Code, and to the counly, a report lor the servicing ol lhe holding tank(s) on a semiannual basis. The pumper lurther agrees
lo include the following in the semiannual report:
a. The name and address ol the person responsible lor servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit nrrmber issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement wlll remain in eftecl until the owner or pumper terminates lhis contract. ln the evenl ot a change in this contract.
lhe ownqr agrees to llla a copy ot any changes to lhls sorvlce contracl or a copy ol a new servlce contrect with ths municipallty
and the County named above within len (10) busingss days ,rom the date of change to this service contract.
Owner(s) Name(s) (Print)
Pumper's Name (Print)
Pumper's Registration Number
Owner's Signature(s)
Subscribed and sworn to before me on this date:
Pumper's Signalure
My commission expires:
This instrument was drafted by the state of wisconsin Department
of lndustry, Labor and Human Relations, Bureau ol Plumbing.
sBD-7574 (N. 11/8s)
Notary Public
with the County of
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- REPART ''JF IyS PECrI c^J_I N0lvlOuAI SEtt/AGE SySTE,tl ,
Sanitany Permit'- -.State S e p tic3
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iJAM E I ownt hip
Building -.' ,- {t.
Highwat,e.,L_ - 6t.
S{. Cnoix Countq
Lo catlo n S ectio nt)l
SEPTIC TAI\IK
Size a aLLonL . Numb en- o { Compattmzntt _
0iA tanee F nom: W eLL -, '* ,'6t.lLt on grLeaten dlope 6t
_6t -
-
B uilding_6t.
Highw ate,L_6t.
FIELO OIMENS IONS :
Wid'th od tneneh dt.
Length o d each Line _6t.
Numb en o d t-ine6 _
T o tat t eng th o { Linus _6t.
OiA tancz b etut een t-inet d t .
T o tdl aba o nb tio n an-ea. 6t2
?IS POSA L S YS TEII
Oia tanee F nom: W eLI-
' Reg ulned a.lLea,
I AJS ?ECTED
APPRO V ED
REJ ECTEO
W etLanda
I 2* o ,L gneaten a Lo p e_dt.
$l etlanda F t.
O epth o d tto ch b elow tiLe in.
Oepth o{ noelz ove,L tile in.
Depth o$ tiLe below gtade in-
SLopz od tteneh Ln Pe,L 100 6t-
O epth to b edto cb-dt.
O epth to gtloundwatL,r-dt.
TApe o( Covzn: ?aPen orL SLttutt
Gnav eL a"tlo und pitt _U e6 _no
D epth b eLow Lnlet-dt.
2dt.
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PIT OI I'IENS I O IJS :
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Numbett od pLtA
OuLtide diametet dt.
TotaL abao,Lbtio^ *uo
Atea tlequined
4/ ,IATE
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PtB 67,'ilL1/State and County
Permit Application
for Private Domestic Sewage Systems
t r- t
State Permit #
County Pe
Coun
-DENOTES STATE APPROVAL REOUIRED
Date Approval Received from State if Required ate Plan l.D. #
A
B
OWNER OF PROPERTY
ZJ,AL ?ooK O, rnqep/
Mail Address
W Lot#
-City
Village
Township
Y"LOCA T I ON
Subdivision Name,
%, Section
nearest
T R
road, lake or landmark
O (or)
Blk#
,J
C TYPE
Single
OF OCCUPANCY:Commercial * lndustrial )(.*Other (specify)_*Variance
No. of Personsfamily Duplex_No. of Bedrooms
D SEPTIC TANK CAPACITY_ToIa| galtons
HOLDING TANK CAPAC fiY Soeo Total sallons
No. of tanks
No. of tanks T
Prefab concrere ------..rX- Poured-in-Place
-
St"el
-
F iberglass
-
Orher (specify)
New lnstallation X Replacement _
Lift Pump Tank or Siphon Chamber-Total gallons Prefab concrete
-
Poured-in-Place
-
Other (Specify)-
E. EFFLUENT DISPOSAL SYSTEM: percotation Rate otal Absorb Area-sq. ft
New-Replacement- Alternate (Specify)
Seepage Trench:-No. of Lineal Ft.-Width_Deprh Tile depth (topl_No. of Trenches_
SeepageBed:-LengthWidth-Depth-Tiledepth(top No. of Lines-SeepagePit:-lnsidediameter-LiquidDepth-No.ofSeepagePits-
Percent slope of land Distance from critical slope
WATER SUPPLY: Private ffi loint E Commrni,v E lfn,-,"ipuf E
Owners name as listed on EH 115 if other than present owner:
l, the undersigned, do hereby
Wisconsin Administrative Code,
by the
NAM E
obtai ne,
Plumbe
Plumber
Certif ied o il Tester,
dfrom
r's Signature
r's Address
certify that the information I have reported
and that I trave sized the effluent disposal
L t-C.S.T
(owner/builde
MP/MPRSW#
# -.fl-g4l and other rnformation
'm.grgg Phone # 6 fl 37r
is in accord
system f rom
with Section H62.2O,
the EH-115 prepared
Provide sketch below of system (include direction of slope and alldistances in accord with H62.20. Well loca-
tion shall be included on the sketch. lndicate or dimension location of allwells on the property or neighbors
property. lf well has not been drilled please indicate.
PLAN V I EW
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Do Not Write in Sp F COUNTY AND ST
Date
Perm
of Application Fees Paid: St
it lss
E DEPARTMEN USE Y /o-3 0-7/
lssuing Agent N
State Valid#
D
Date Rec'dlnspection
3
4
owner (green copy)DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 537011. county
ace low
plumber (canary copy)
Revised Date 711178
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--EH 115
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WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOI L BORINGS AND PERCOLATION T
County .rf, Ccor x
Other Oo rY1 -n2 o-t4L
R EPLACEMENT
PERCOLATION TESTS
SOIL TYPE VLn {L/ /-o,+,n
PERCOLATION TESTS
LocATlo tt, fut,fu/o,section Ai-,T&rl, R/Le (or) l& Township or lVluaHF*lity W.tJ,ri^tI
Lot No. , Block No.-,
L tvtslon ame
Owner's Name:
Mailing Address:r1 i)
TYPE OF OCCUPANCY: Residence
-
No. of Bedrooms
EFFLUENT DISPOSAL SYSTEM: NEW x ADD I TI ON
DATES OBSERVATIONS MADE: SOIL BORINGS 4-Jo - z?
SOIL MAP SHEET Faa
TEST
NUM-
BER
DEPTH
INCHES
CHARACTER OF SOI L
THICKNESS IN INCHES
HOURS
SINCE HOLE
1ST WETTED
WATER IN
HOLE AFTER
SWELLING
TEST TIME
INTERVAL
IN MINUTES
DROP IN WATER LEVEL, INCHES RATE
MIN/INPERIOD 2 PERIOD 3
P-/*o',so'ur't 5',1 t'uo;,4 Lt e'/l"t 3",lt u ,/8 "
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P- .te\3L*t/tl /trtO
t,a,P erl l.t $o ,/,n",ls ,ls lt#
,-J *.o bn ?o"l(tt J+Yrs 7o ,ls l,
'lP"'lt fl'
SOIL BORING TESTS
TEST
NUMBER
TOTAL DEPTH
INCHES
DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
(DEPTH TO BEDROCK IF OBSERVED)OESERVED ESTIMATED HIGHEST
,_* [4a 72"po >5'.
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> 3'.
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26"
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72',
72'
lt
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al lr tr
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72"
>t,>5'lr
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(t 36'36'
fi tu
3o
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f(lt a(
PLAN VIEW (Locate percolationtests.soil bore holes and suitable soilareas.)
lndicate on the plan the locationand square feet of suitable areas. !ndicate number of square feet of absorption area
needed for building type and occupancy.!ndicate scale
or distances. Give horizontal and vertical reference points. lndicate slope.
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l, the undersigned, hereby certify that the soiltests reported on this form were made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct
to the best of my knowledge and belief
y',el{E,L4*Certification No.Name (print)
A LJcti'u
ORITY
IJ;,
CST Signatu
ls--{4*
Address
Name of installer if known
PERIOD 1
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PUMPERAGREEMENT
sT. cR0lx c0uilTY
tllsc0l{sl }l
G OFFTCE 796-2239
dddice Box 227d, wt 54015
n notl{ied, I wLLL
ZONIN?o,st 0
H ammo n
OWNER
PLEASE BE AOVTSEO,
co ntnaet. wlth ,A '
T |tat until-
B.o ,9;r^l
a o u ilLe a,9 a.L
l*lr;- o
<a
{
ItlLt cona in, (Punpeal , {on the purlpote of, nenoving aLL watte {non the
sanltatq tqaten to be Lo cat.ed on tltz prLopetltt! and {ututte home tite
Loeated Ln St. Cnolx Countq, ttlideonain, Townahip o{
b eing in the
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o { the S U)ho{9.a1 ,4? u.-R./LrT
l0 n mo ,te {uLLq d ea enib ed a"6 6 o Llowt : I
O ated thla 3e' daA o {i-4 ,
q o{
,to
te71
-( OUAJER )cb&,
State o { Wid co ntin)
A8
Cno ixlCountq o ( Sf.
P end o nnaLlu epp eo"tLthe ab ov e named
edone m thL,sJ"bh lo d,a ,;fu
me notiln to ETbe
p erLA o n w ho e.xecut e t
T h*ne/ /h)*a/e silt ,
8-orL eg o,Lng L n6 um ent o,nd aetznowledg ed tb"e I Am e.
1-+
o ilLa u c,
'LO
LX aun
tlq Comm.l,@lExpinzal
,loi ie
0w nett a"6 ab o v e d tated .
henelnb e6one )Le-6 etned to aa ?umPLL ,
extent tlna"t I have a eontnaet with
t14 (trtr"C
a/,il4 8,v '-'l t)/r?rAA C07rP "
lPur,lPER.
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v 7 -a
r vt/)I AGEEENiEI\tT
1q ulb
T'his agreernent, maae ;"qgrtered on thts
and between the Township ot_-frg Ld r^t i,o
?a,
4 ddress
v 7-e+, bv,1
( ' l,'< r
t
nEERE.e S: 3ri application has been made for a sanitation ,r.r""ltfftYrl3-^
following described property: MAY 81979
PLUMBING SECTPN
!'TF.EREAS: Septic tank drainage does not meet the minirnurn standards of the
ordinance of St. Croix County and state codes.
VTF.,.EREAS: The owner agrees to install a holdlng tank for septic tank purposes
purpoges.
NCVI',T FORE: For and in consideration of the issuance by the Town-
ship of Ldat ,\)of a permit for the above prernises, the parties
elves as follows:do hereby agree and bin therns
Owner agrees that they will conform to all the rules and regulations
pertaining to a holding tank systern. They agree that anytime said
township deems it necessary to pump out said tbnk, the owners shall
have same pumped out in 24 hours, or township will have said work
doneanC charged to owners and place sarne on their tax bill as a
special charge.
2. The Township reserves the right to as$ess a bond if they desire to
cover any possible purnping charge in the surn of, $ o( .
IT IS UNDEFiSTOOD that this agreernent shall be binding on the owners,
their heirs and assigns.
IN !t II'NESS WI:EREOF, the parties have hereunto set thelr hands and seals
the day and year first above wrltten.
Township of
by partvrtont ol "nJ='"1,1:
' L----- lndustry. Labor & Humbn Relalone " :
Drvrsron of SaletY 6 Buildlngs
/",,
I
Developer
or owner
)
STATE OF. V,ISCONSIN)
SS:
couNTY CF ST. CRCD()
Subscribed and sworn to before rne this :i day of
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Ttrrs document rs a lull, true and corect copy
of the original on file and ol record in my
of f ice /-
certrfied L /./3 ',s3f
D 'WLc,/
'I
hr Corot
i\rota u ,st.roix County *lr;;l$ffi:i:t'i'
By
, Lsi%
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z I REPORT OI lNSPECTION INOIVIDUAL SE[/ AGE SYSTEI,I
(Zt.a74*', /l*k,^^,I\IAM E
SE?TTC TAAJK
Size a aLI-o n6 .
0ia tanee Fnom: N zLl
cU_,cWt- St. Cnolx Count
o{ noctz overL tilz in.
197_
Sanitanq Pen
State Septic eJb
p U
R
DISPOSAL SYSTEM
Oidtance Fnom: WeLL
Lo eatlo n$-a),tr, Se ctiorrffi&u,/a
{ C o myt antm ent,s \
6t. I 22 o rL grLeatzn ,s Lo pe "-- dt
W et L-o"ndt _6t.
6t.122 orL gtLeatet ,sLopL_6t.
W etLand,s F t.
o{
Numb en o
FIE LD DIMENS I ONS :
Length od eacl,t
Numben,o( I-inea
T o tat Lzngtll o d
0Ld tance b etw Li
' Rzquined atLea
?TT OT TTEI\JS l ONS :
Numben o[ pltd
T otaL aba o nb tion
Anea ,Leq uinzd
Building 6t .
Hishwaten
- dt.
BulLding_6t.
H ighw aten_6t.
Line dt
/B
A)id'ttl od tn-e-nelt [t. Dzp tll o 6 no cb b eLow tLLe Ln.
oep
Total aba on-btion a.tLea. 6* 0 epth to gtLoundwatuL-dt.
t.
.LL.
2
tl,L o { tiLe b elow gttadz Ln.
Lope o$ tnzncl,t Ln pQ-tL 100 6t.
0 epth to b edno ctz _6t.
G nav e-L o")Lo und pitl _A e6 _no
0 epth b elow inLet _6t .
26t. .
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PECT E
APPRO V EO
RE J ECT EO
DBY TIT L -1,,1 Rt\lv ,0 ATE
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P1ts67
- 14":ffi State and County
Permit Application
for Private Domestic Sewage Systems
!rr!
State Permit #??
County Per #
County
a
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o
*DENOTES STATE APPRoVAL REoUIRED
Date Approval Received f rom State if Required State4|ar#. #
A. OWN E R OF PROPE RTY
nearest road,.-lake or landmark Blk#
Mailing Address R otlrF /
q W Lot#
-City
Village
Township
Ufo/UnT/C CO
B LOCATION:
Subdivision
Y^Yo, Section T N,R
Name,
C. TYPE OF OCCUPANCY: *Commercial X *lndustrial
Single family Duplex_No. of Bedrooms
*Other (specify) *Variance
No. of eersons 2 O
D TYPE OF APPLIANCES: Dishwalher
-
YES I NO Food Waste Grinder VeS_XruO
Automatic washer
-YES
---(rno -o,hr,
(rprcTd)
# of Bathroomr 3
E sEPTlc rANK cAPAdrwsaltons rlo@
*Holding tank capacity
New lnstallation
* Pou red in Place
Total gallons No. of tanks
Replacement x Prefab Concrete xAddition
Steel Other (specify)
F. EFFLUENT DlSPOSAL SYSTEM: Percolation Rate 1) 21 3) Total Absorb Area
New Add ent *stem
Seepage Trench h
sq. ft.
slope
Seepage Bed:
Seepage Pit: I
Percent slope of land_
e
Tile Depth _ No. of Trenches
No. of Lines
Tile Size
Distance f rom critical
Liqu'iil Depth
l, the undersigned, do hereby certify that the information I have reported is in accord
Wisconsin Administrative Code, and that I have sized the eff luent disposal system f rom
by the Certif ied Soil Tester,
NAM E c.s.T. #
obtained f rom (owner/lf).
Plumber's Sig nature I,/MPRSW#
Plumber's Address
with Section H62.2O,
the EH-1 15 prepared
and other rnformation
Phone M
PLAN V IEW:Provide sketch below of system {include direction of slope and all distances in accord with
H62.2O, including well).
- cl- lH
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,trx ) S rtyrr
l/uf, Qol + rVaRTtr oF
WAI?F lotlStr
aI
- e6CO eAL SEP|rrr.fAluKia sdRFlj6rI r//Q,/ " l?tSEx
)/.,,
L,wfltAs
cfi/!51)G E t tsT /,/L'
Q)r il
Et ts It{e
tilltRE HA)SE
-)ODo Not Write in Sp
Date of Application
FOR DEPARTMENT
Fees Paid: State
Bel USE
1( ),
ON LYco -rLcqy
-7y lssuing Agent Name
Valid#
7
Date Rec'd
3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, W! 53701
4' plumber (canary copy) Revised Date 611176
ate (pink copy)
(date)
ow
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Dty
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county
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