HomeMy WebLinkAbout042-1034-95-000 (2)0
St. Cro County Planning and Zoning
Wednesdaj,, October 18, 2006 at-4:55:53 PM
Detail Sanitary Information
',age I of' I
Computer #:
042-1034-95-000 Sub/Plat: metes & bounds Section:
13
Parcel #:
13.29.18.207B Lot: TN/RNG:
T29N R18W
Municipality:
Warren, Town of CSM: 1/4 1/4:
NW 1/4 SE 1/4
Owner:
Foss, Leo 1472 Highway 12 E Roberts, WI 54023
State Permit:
4277 Issued: 07/22/1970 POWTS Dispersal: Non -Pressurized In -ground
Permit: New
County Permit:
0 Installed: 08/03/1970 POWTS Detail: Bed- Seepage
Bedrooms: 3 WI Fund:
POWTS Pretreatment: NA
Notes
Issuer/ Inspector As Built Plumber Other Requirements
Additional Notes
Money Owed
Harold Barber No Cudd, Paul
seepage bed 12' x 50' w/1 000 gal. Septic tank
$0.00
Not determined Signed Off: No
file with replacement permit
Owner:
Greenfield, Donald 1472 Highway 12 E Roberts, WI 54023
State Permit:
199834 Issued: 09/10/1993 POWTS Dispersal: Non -Pressurized In -ground
Permit: Replacement
County Permit:
0 Installed: 09/17/1993 POWTS Detail: Trench - Seepage
Bedrooms: 3 WI Fund: yes
POWTS Pretreatment: NA
Notes
Issuer/Inspector AsBuiltPlumber Other Requirements
/V11ditional Notes
Money Owed
Not determined NA Powers, Calvin
$0.00
Jim Thompson Signed Off.- Yes
Maintenance
Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification
9/17/1997 5/25/1999 04/01/2005
5/25/2002 12/13/2003 04/01/2005
12/13/2006
r
ro-
STC - 104
AS BUILT SANITARY SYSTEM REPOIZT
OWNER
1 -Q\ CA
ADDRE S
LA
SUBDIVISION / CSMV
LOT f <z-_
SECTION T N-R Irr-W, Town of (,J Q�r�
LP
ST. CROIX COUNTY, WISCONSIN
Provide setback and elevation Information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover -
BENCHMARK:��/mila
�--/U � CUtJI't� � j�r�'�.q� .___ �_�___._1�_'
ALTERNATE BM:_
SEPTIC TANK R fHe hr5l
Manufacturer : Liquid Capacity: ,/JZrO
Setback from: well 7c� House w�3 other
Pump: Manufacturer Modelt Size
Float seperation ,,ki Gallons/cycle:
rj/
Alarm Location d1A
I/
SOIL ABSORPTION SYSTEM
_5
Width: Length Z,� ,3 Number of trenches
Distance & Direction to nearest prop. line: 369
Setback from: well: House 3 2 Other
ELEVATIONS
Building Sewer ST Inlet.- ST outlet 9.S 0
PC inlet PC bottom Pump Off
Header/Manifold 9Y. Bottom of system q3, %
Existing Grade_?d Final grade .9,, a/v
DATE OF 1NSTALLATION:
PLUMBER ON JOB:
LICENSE NU14BER:
3/9 3: j t-
2 9. 18. 2qq#VATE SEWAGE SYSTEM
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT)
Permit, Holder's'Name: E] City [] Village Town of:
.1-0EEUR:LR1 rN TIONAI-D R la DI-14 RWAIR7DEN
CS " IF `TrWl5-8TQTElj—v.: 1- ffm F lev. e1Z F-iff`i7ri lo
c„ ,�'- ,
4�0
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septi c
Dosi ng
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P / L
WELL
B LDG.
gent to
Air Intake
ROAD
Septic
>
NA
Dosi ng
NA
Aeration
NA
Holding
PUMP/ SIPHON INFORMATION
Manufacturer emend
Model Number GOM
TDH Lift Friction I S stem Ft I Loss Z, d
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County:
OT11 0, X V
San1tarrrn1tN6"`J-'1%
I CIQQ 4
State P1^11)1'
Parcel Tax No.:
A9300240
STATION
BS
HI
FS
ELEV.
Benchmark
Bldg. Sewer
St/ 1;K Inlet
St / outlet
Dt Inlet
Dt Bottom
Header /Idm
Dist. Pipe
=;7
5,/�
Bot. System
;7,2
Final Grade
BED/TRENCH
width
Length
No- Of Trenches
PIT
No. Of Pits
Inside Dia.
Liquid Depth
DIMEN51ONS
DIMENSIONS
SYSTEM TO
P / L
BLDG
WELL
LAKE / STREAM
LEACHING
M a n Of actwer--
SETBACK
INFORMATION
CHAMBER
Type Of
Model Number:
System:
%OR
UNIT
DISTRIBUTION SYSTEM
Header / Aft*v6):Id--
Distribution Pipe(s)
��
x Hole Size
x Hole Spacing
Vent To Air Intake
Length D i a
-14L
Length JDia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Syst&ns�nl
Depth Over
45
Depth Over
_�T_
9
xx Depth Of
xx Sejedet!'�Sodclecl
xx MulchT e
Bk4l-Trench Center
;) 14-T
gtrdl Trench Edges e- d
Topsoil —"�
®Yes e s No
0 Yes 0 No
COMMENTS: (include code discrepancies, persons present, etc.)
LOCATION: WARREN 13a29-18o207B � �d-a,V`6
. . .............
?
Plan revision required? Yes R-No
Use other side for additional information.
S13D-6710(R 05/91) Date inspector's Signature r Cert No
SANITARY PFRMIT APPLICATION
11-J Li i LM In accord with ILHR 83.05, Wis. Adm. Code
WLW�Lm
COUNTY
STATE SANITARY PERMIT #
—Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size.
❑ CneCK if reVil previous application
—See reverse side for instructions for completing this application.
STATE PLAN I.D. NUMBER
I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER
5'�'Nj,�J'14
PROPERTY LOCATION
'/4 S /3 Tc�? N, R le W
Mtn r vr%
r)
PROPERTY OWNER'S MAILING ADDRESS
LOT #
BLOCK #
W y ) :1-
tul A
Cl STATE
STATE
ZIP CODE
PHONE NUMBER
SUBDIVISION NAME OR CSM NUMBER
0
11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
State Owned 0 VILLAGE: rt Y'%
TnWU k�%�
rN71 QF:
OPublic 1 2 Fam. Dwelling—# bedrooms
or of PARCEL TAX NUMBER(S)
111111. BUILDING USE: (if building type is public, check all that apply) 15)
1 F1 Apt/Condo
2 El Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑Outdoor Recreational Facility
3 FI Campground 7 0 Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining
4 1:1 Church/School 8 1:1 Mobile Home Park 12 El Service Station/Car Wash
5 El Hotel/Motel 90 Off ice/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. El New 2. XReplacement 3. El Replacement of 4. El Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) A Sanitary Permit was previously issued. Permit # Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
110 Seepage Bed 21 El Mound 30 El Specify Type 41 El Holding Tank
12 %[71 Seepage Trench 22 1:1 In -Ground 42 ElPit Privy
/'In'4 —
13 El Seepage Pit Pressure 43 El Vault Privy
14 F] System -In -Fill
V1. 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
//Oz� in 3, 7
11130 a 74 Feet I �10,0 I Feet
Vill. TANK
INFORMATION
CAPACITY
in gallons
Total
Gallons
of
Tanks
uN
Manufacturer's Marne
Prefab.
Concrete
Site
Con-
Steel
Fiber-
glass
Plastic
Exper.
App.
New
Existing
Tanks
Tanks
strutted
Septic Tank or Holding Tank
L—Laus g P%
F]
El
Lift Purne Tank/Siph,on Chamber
El
Vill. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print
Plumber's Signatur o Stamps)
r
h*/MPRSW No..
1
Business Phone Number:
1
OW40-0�
aL...
IL5&3
-�
Plumber's Address (Street, City, S te, Zip Code):
W
fie on C/ 6&C
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved
Sanitary Permit Fee (includes Groundwater
Surcharge Fee)
ate Issued
Issuin ent Si r o Stamps)
Approved
❑ Owner Given initial
Q
Adverse Determination
NNON"
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
398 (formerly Plb-67) (R. 11/88)
DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the. Wisc onsin Administrative Code will be E7 pplicable.
3. All revisions to this permit must be approved t,,y the pes s1-it "ISSU"Ig
4. Changes in ownership or plurnb :, requires a Sarlitaru Permit LSFZ, 63`vt
subrnj�ted to the;otint� prior to instailit;off.
5. 0 \�. 1 , � O l;. 1,2-f f� t , � Y � .-� •.+�. y T- �! C '.�. : .r'
r,.i;t sew'a�e sys.his nriu-s, be proper,y ;� ���,taii��U , he t: tcan, `icl)
.. k_ v � � is 'f 'v' • 1 ,
purnper whenever- necessary, usually every 2 to 3 years.
8. If you have questions concerning yoLrr onsite sewage system, contact your locar code agrninlstrator or the
State of Wisconsin, Safety & Buildings Divisiian, 508-266-3815-
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to bp installed.. -
11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling -
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or.
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption systems' informatir;. Provide a!I ir�f�armt�on re,�0�>} n
II Tank wformat'on. Fill in tyi t,eapa�_Ay f evr'iY S'r�+�' Ca���.��i•t e[.�.
1'YZ { L V T ; ,x, ( I _ i g , 4� 4 . �` 1 _ 7 f. ` }} •.t ♦ "� f "'
tanks and mar- �. �'�c�,.. Lure- `S 1 a c ie. I Iti. i'�1_i� �i-�,.Y !if .!fir ! R�y�" lt'_ � �f 'K ��Iti'.��: lal +,.Car.^I
s�+ �% ! -� +� C.y. + // �• Y. t 1 Y'� }� ^� �� �n ! � � � � 1 � .^� 1 �� / f-` � r': t G x
V p t i S.r ., t F ! 5 ! .f } 4.J i '../ C S a r ! a.i 4i . l L. �� : t L 4 L� 1 f- _ t i G i . i. `r 1 ! 1 �"'. 1! t "" l f . - ..r. ! % % y L ` f a i .-. _, i.i i,. 5. ►.
i
e�,pe+irr� an' 0d._Fi� . L�pt;:r01, P,1 frr,M D I =E
'JIII. RF'SpC?f1s11�#rty statement lns!atI# ?( pig r r NI!rt P,-°�-'C�7rJrj: rc� ►,x c-� r
4.
VP, etc.) address and phonitx number. Plum-=b� f);:i :: ��: s�� -�:<
IX. County; apartment Use only.
X. CountylDf aartment Use or,!y.
)� r. ',il'i Lt�l ri4G�'.; ���r ,S t Sr�a�le� tl+ -rl �'!r• R Gr�� a•l� .? ti }C-1 I..1JT'!lfiA.ilY l 1 1. '.1 r.S.r� T� �•
i 1 r G : + � l S C.• i : f d 1 i;'ki j :y1. f Yyc rl ' ¢
Il,�iQ'rlyi�r�l�j�,, F�:,�rS. ..•��(i. .`' ',JF L:`!�.a� Sr��C4�E�:!' .i _1_:�' ��:' e
�: +i; 1�1 iY"1�YI �':� �Fi .ij 1 �t1�(Ir r 1t1 4a
strearx? A �r.. �1 ��- rl �� «�, ;F. {
areas, ar, she f ir�j =0V0{
�s
C;) complete specificat I or is fo. ;:cur; ps and co1')'0'0,S; a0,S,' V,., 'L1r ¢ frt;;n
!
performance curare; purnp model and pump rrianufactUrer- D) cross sec -lion of rI e sciil ab.;orptior� syLterr� if
t (equired by' -the -county; E) spoil test data cin a 11°i farm; and F) all st i�g� }nforrr�ation.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges Nees) for a �,rarnb, r of
regulated practires which car: effect gr oundwat.- r
�T�e monies c:ol'ected throti:g�i ti��ese'si1rc!�arge� r�_ ,��t�� { ,r r ,,f� . •fY.l-�',�<:: s
Vliate4''rontamIricilion invesz'' -, nS ano eStabl�s;;�:":+'�';
S B D-6398 (R. 11/88)
� I c
rt-ew)i
.5 cj sc— �. ) 5 Tc;) y /V (os w I
SCa.�le. � i ^ y p
6:�cl+mu�iP, =d A- �1 Cm�• ��Id�.3�..• Sf s�einy e/ ��%
tom- /azn�../ Wes:- -6
93,
DO TO
3
00'
0000
k— o-ow— Cr6
� OA
W t� � y I �.
FA
WG. f r � Y-N -
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT
Labor and Human Relations
Division of Safety & Buildings
in accord with I LHR 83.05, Wis. Adm. Code
Page of
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (13M), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION
COUNTY
S1, G V-- o I )"J�
PARCEL I.D. # I
REVIEWED BY
DATE
PROPERTY OWNER: PROPERTY LOCATION
pc,qs\& G GOVT. LOT & _Aj 1/4 54t:� 1/4,S 13 T N,R /**or) W
PROPERTY OWNER.-S MAILING ADDRESS LOT # BLOCK# SUBD.NAMEORCSM#
LAJ V I - . NJ �4_ . Vol N - 1i AN,
STATE ZIP CODE PHONE NUMBER [:]CITY MALAGE
/JIFOVQN NEAREST R,QAD Eli
New Construction Use Residential / Number of bedrooms Addition to existing building
Replacement Public or commercial describe
Code derived daily flow gpd Recommended design loading rate IJIA- bed, gpd/ft2 J_trench, gpd/ft2
I
Absorption area required A;1A . bed, ft2 Jd .5 trench, ft2 Maximum design loading rate -NIA. bed,gpd/ft2 eq trench,gpd/ft2
Recommended infiltration surface elevation(s) 93, 7 ft (as referred to site plan benchmark)
Additional design / site considerations !e. Y. C_k__S cnn _C2 _4 's- )( 11 g �)
Parent material. CL C0.1Or I Flood plain elevation, if applicable I j ft
S = Suitable for system CONVENTIONAL MOUND IN -GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDINQ TANK
U = Unsuitable for system D� S [:] U Q? S o U US❑ U El S ZU 0S 'W U El S W
Ground
elev.
rft.
4 ts-74
Depth to
limiting
,,factor
,a
Ground
elev.
ft.
Depth to
limiting
factor
SOIL DESCRIPTION REPORT
Horizon
Horizon
Depth
in.
Dominant Color
M unsell
Mottles
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Bounciary
Roots
G P D/ft
Bed iTrench
/
0-
� R
—
Sit
/-f •
C Lj
- ! 5
51
16
3
-5/
JD14
� leySt
a- bk
rN IV%
C LA)
rn
—
- y
joy
.51
0) fil- 5
rr, V _Sr 10
C LJ
s
Gb-
/OV lyi
V
C �
—
— y
1W
Remarks:
m
C w
a
9-33
16y R S
—
5iJ
�-3-s k
rn ��-
c�
I ti.
� ,.3
3
.33- Yo
6lv
�
s
.?- -5 1<
rA v � ,.
�w
� w,
— , 11_/
6_1
Lj
Remarks:
.'?ST Name --Please Print Phone-
:Rwer-:5
V14 Zr-- 71.d�
kddress: chp 9 _tA L el�rh� Yyz)/
Signature: Date- CST Number-
PROPERTY OWNER Dd�►w�I G ��+...lrj.ekl SOIL DESCRIPTION REPORT
PARCEL I.D. #
Page of 3
Boring #
Ground
elev.
A ft.
Depth to
limiting
factor
Boring #
Ground
elev.
Depth to
limiting
factor
Boring #
Ix......s -
s:: ..
Ground
elev.
ft.
Depth to
limiting
factor
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Horizon
Depth
in.
Dominant Color
Munsell
Mottles
Qu. Sz. Cont Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Barxfary
Roots
GPD/ft 2
Bed,
Trends
0 MWJ
s IV, k
Mi k--
C (Z
in
WAMMMS
a
1_33
/- -ShK
Mfh
C0
—
� 5
33j,
S,//.
CCZ
j
yo'SS
S
5 -
/ �Q .5
`�
1- -� • Sbk
YMA(S r
C w
Remarks:
3,1
ks- bik
n\
A R��i
-
/
; k
Mir
�W
M
-'•S
5-
/Ogg 5
—
5
l5'�kL
mo�)
—
—',,b
S
71.9L
s
a m.s
m
cur
Remarks:
Remarks:
SBD-8330(R.05/92)
,
f
1
I °
r 1
F
1
i
! t I I I I I
i
° r I
I f
I I , I I
l f
I
h 1 1_. 4
,
y I
l�or� a1�\ . G r-�.e,r � � �\d
Y,
cro o� A
SYo23
S y 5 t e 0--)
Fre 6h Air Inlet c And ®b w%fa tfon Pips
(� Approved Vent Cap
Minimum 12" Above
Final Grade
20- 42" Above Pipe 4" Coot Iron
To Final Grade Veal Pipe
Marsh Nay Or Synthetic Covering
Kin 2" Aggregate
Over Pipe
Distribution Tee
Pipe 0 0 0 0 0
� 6" Aggregate Beneath Pipe o Perforated Pipe ®clove
0 Co%oing Terminating At
Bottom Of System
4 .
SOIL FILL
PAGE�oF�
to
Di STkIBL1T"1 pU P1 PE
-7 APPROVED S4r}JTI4ETIC CC)VER.
M &T 1: R i N- O R 9 ` OF 5-rR A W
VA ef h6G9 EGAIE t i�R IAARSW kAy
r � Q0
q'CLEV 1 OF rj2 2t�z AGGREGATE.
f UT
DI-S-rRIa1JT1,rJIJ PirE TO BE AT LEAST IUCHES BELOW OR1G1"At,,._ GRADE
AUD AT LEAST" ZO IMCHES BUT K10 MORE THA0,1 y2 IUCHES BELOW Fi UAL GRADE
MnxIMurt DEPTH of EXCaynTim►j rKOM aKI&WqL 6KAoF. WILL gE IUCNES
JAI KIMUM ASP" OF FXCAVATImN f KOtA 01�1 6 1MgL 6 R 4 9 E WALL BE ZEL - INCNES
SIGNED :
LIC E U SE UWABE R :
D AT E
L7
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 0' �a'\ 6 L :: I '111_k.� \
ROUTE/BOX NUMBER Z_ %-�Z FIRE NO.
CITY/STATE zip 4�qc> �-S
PROPERTY LOCATION: 1/4 1/4, Section _J? T IN, R W.V
Town o f Wv.1 I St. Croix County,
Subdivision 1%.) ) P4- I Lot No.
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 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 verifying that (1) the on -site
wastewater disposal system is in proper operating condition and ( 2 ) after
inspection and pumping (if necessary), 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.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department 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 t� a
DATE- C-1 Z W z �13
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
(715) 796-2239 or (715) 425-8363
Sign, Date, and Return to above address
APPLICATION FOR SANITARY PERMIT
STC-100
pp This application form is to be completed in full and signed by the owntr(s) of
the being developed. Any lnadequacles will only result in delays Of
property
the P
permit Issuance. Should this development be intended for resale y
wnet contractor,(speC house), then a second form should be retained the
nd
o /
completed when the property is sold and submitted to this office with
appropriate deed recording. -------------------------- ---------
- - - - - - - - - - - - - - - - - - - - - - - - rr r r - _ - - - r - - _ -
Owner of property
���, ( /r Sect ton __/ , T2—H-R-LL-V
Location of property �1/'i 1 / �
Township
MaIIIng address I 7
Addtess of site 0- "
Subdivision name A
YA
Lot number
Previous owner of property S S �I �� ✓1A
Total size of parcel
Dat• parcel was created
Are all corners and lot lines identifiable? �_yen No
is this property being developed for resale (spec house)? Yes No
Volume and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PACE NUMBER, and
the ORAL OF THE REGISTER OF DEEDS. 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 Certified Survey
Map shall also be required.
_ - - r _ - - - - - - - - - - - - - - - - - - - - - - r r r r - - - - - - - - - - - - - - - - - - - - - - - _ - _ -----------
PROPERTY OWNER CERTIFICATION
I(Me) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recur d in the Office of
the County Register of Deeds as Document No. ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of sald system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No. 1•
Signature of Owner Signature of Co -Owner (If Applicable)
ct q3
Date of Ifignature
Date of Signature
• DOCUMENT NO.
"01708
STATE BAR OF WISCONSIN—FORM 1
rWARRANTY DEED
VOL 55`3
�Auf 2''18
THIS SPACE RESERVED FOR RECORDING DATA
Russell D. Klint and Deanna
REGISTERS OFFICE
THIS DEED Xnade beWyn
V. Klint,sban and wife, and each in his
ST• CROIX CO., WlS.
and her own right,.-,
Rec'd. for Record this
.. 0 - Grantor
_2nd.
day of May A.D.19 77
and Donal E. Greenfield an BernadineVogt,
--
t 8: j0 A.
as joint tenants "'
r e Grantee,
jj Thirtlei
W y
�.
i t n e s e e t h, That'ahe skid Grttor` for a valuable considerati n
Seven Thousand.-IRive Hundred Dollars ( 372500.00)
itfQlttet of Deeds
�f
conveys to Grantee the following descl�bed�real estate in St Croix County,
—
RETURV 70
State of Wisconsin:
A parcel of land located in the SW4 of the
SE4 of Section 13-29-18 , St. Croix County,
Tax Key #
Wisconsin, described as follows
This is homestead property.
Commencing at the S4 corner of said Section 13;
thence East (assumed bearing) 1040 feet along the South line of said
SE4 of Section 13 to the point of beginning; thence
N10421W 484.5
feet; thence East 280 feet, ' more or, less, to the
East line of said
SW4 of SE 4 ; thence South along the East line of
SW4 of SE 4 to the
Southeast corner of said SW4 of SE4; thence West
along the South
line of Section 13 280 feet more or less to the
point of beginning.
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining;
A"A Russell D. Klint and Deanna V. Klint
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements and rijzhts of way of record
and will warrant and defend the same.
Executed at
SIGNED AND SEALED IN PRESENCE OF
_ this
TRANSFE11
R
FEE
day of
(SEAL)
(SEAL)
Signatures of
authenticated this day of
, 19
Title: Member State Bar of Wisconsin or Other Party
Authorized under Sec. 706.06 viz.
r
STATE OF 'Vfi��N
MI � 4 S 8l�_ O t/� County. ss.
Personally came before me, this
the above named Russell D
to me known to be the person S who executed the foregoing instrument and acknowled d the sp me"..-, V.
This instrument was drafted by
`..,. .
..� ^ i - fl
C . L . Gaylord, Attorney Notary Public county. !
River Falls , WI MY ]Qmmisslon , piresAC I1 27' 1977
My Commission (ExpITL%s ' (I � •. �`�-
The use of witnesses is optional. Y �•' O '
r, R•
day of , 19 7 7
Klint and Deanne Klint
Names of persons signing in any capacity should be typed or printed below then signatures. H.C.MiIIorcompartiylrY'JI
M i1t iN.1.. WK0•Iw
WARRANTY DEED —STATE BAR OF WISCONSIN, FORM NO. 1 — 1971
VV -7 Wisconsin DepP_rtu.,,jnt or Health and 500iftl Servioes
Plbo #67 3/7 0 4r^ pall Mvision of, Health
V T:) A 1) V A 13 D T T 0 A 10 T n'XT
• 0 al
ffrl or WE BLACK INK
Ae OWNER Or FROPERV
vame
L1_ f
Address (Street, city, zip code)
Be LOCATION OF PROPERTY WHERE SYSM WILL BE CONSTRUCTED, _ALTERED OR EXTENDED
Check One:
CITY VILUGE LEGAL DESCRIPTION
COUNTY.
C. IS LOCAL PEILLN11T RE�UIRED FOR THIS WORK? YES NO PERMIT NUMBM
D. SEPTIC TA xK CAPACITY Gal.Lons NLW INSTALLATION REPLACEMENT MM.MMMMV AD D 1 T I ON
gas -am-,
IIATERIALS: Prefab Conorete Poured in Place Steel Other
NUZ-2ER OF TANKS TO BE ISSTALLED:
..........
E. TYPE OF 0!!,,CUPk1CY
Check One: One or Two Family Residence Commercial IndQstrial Other
(specify)
Number of Persons to be Accommodated 1// Nampa.**" Number of bedrooms
Fe APPLIANCES, ETC: Food Waste Grinder YES NO Autov.qtic Clothes Washer YES NO
Dishwasher YES NO Automatio Potato Peeler YLS Flo
Other (specify)
G. MASTLR PUMER MING INSTALLATION
License Numbert
Name;" Address
MP
Si&naturo of Applicant: i" MP REW
Address:
H. (To be Cwpieted by Issuing Agent)
% �=_� .J
Date of Application Fee Paid $
Permit Issued ( date) /7 Permit Number
� f.-•'� /'#
Agent (Name) rci
Town, Vijlage, City, County, etc.
(specify)
Note-, The application cannot no considered fcr filin�:, until all of the abcve questions are answered and the
fee paid. A,gents wili for,,ard application, the fee of $1.ou or each septic, tam an% -A' the tnirJ copj
of the permit (canary) to the Division of Health. Checks an-d money orders should be &ado Payable to
the Division of Heaith.
Do not -Pxite in space belo-a FOR DF-?ARITIENT USE ONLY
I. DATF, 10 ACC'!"PTI:D BY
(Initia.19) (see %',Ulrrc,5o
E RF 0 k; IV ED VALID. No. 3610 pu\�11T Noe
Yes or No
REVIEWID BY AP P R 0 V Fu DATE
(Initials) JYes or No
P% ^%a r% I m rMV r" 1 -:1 n C T n V
SEPTIC TANK PERMIT NOO
R X P 0 R T 0 N S 0 1 L P X R C 0 L A 7 1 0 N T E S T
A N D S 0 1 L B 0 R I N G S
TO
DIVISION 0" HEALTH " PLUqB1NyG Sn3,TI&,N
POO'Box 309, Madison, Wi3, 53701
Pursun-at to H 62,o20.* if is Administrative Code
P X R C 0 L A T 1 ON TEST
Test
Depth
Charaoter of Soil _JHours
Water
Test T:Liso
Dma. Iii Water Level Inohes
Minut a s
Numbor
Inohes
Thiolmoss in ln(�hos
Since Holo
in Hole
Interval
Second to Next to
Last
To Fall
...
1st Vetted
0110:6niaht
in Mtiutcs
Last Period Last Period
Period
On3- Inch
Example
P NO, 0
3611
To Soil 101114y 26 , C
25
Yes or No
30
1L2
2
1/2_
60
C4
MIND
L
.3 Y
RECORDDATAFROM MINIMitN. OF 3 TEST HOLES
Compute size of absorption area in aocord with H 62,20 Wis, Aeuinistrative Coda.
S 0 1 L B 0 R I N G S hint=z 3611 Below Proposed Abso!2tion.systele
Boring
Total Depth
De2th to Ground Water
ropth to Bedrock
Num b e r
Inches
Observed Estimated
Character or Soil rith Thiolzness in Inohes
Observod
Estimated
Ex& -AP 19
B — 0
7211
7211
Black To Soli 12"1 CL 0,1Sand 1 Gravel 2411
L
—do loft-
2
4. IL a; �j
RMRD DATA FROM MINIMUM OF 3 BORE HOLES
?YPE OF OCCU?ANCY:
RESIDENCE s Number of Bedrooms OTHER: (Spooify)
Nun -bar of Persons
OD WASTE GRLVDERi Yes No Dls�iashor: Yes No
Y Automatic Clothes iTasher: Yes No NOD
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION
REPLACETENT
Tile '."Uza No, Lin. Feet Trench Width Depth Number of Lines
Raw
Seepage Bed: Length - '4) Width Depth Tile Size No. LJ-n as ON r0L
Saopage Pit: Inside Diameter Liquid Depth
the und,) 5i..ed, hereby eertiy that the peroolation tests reported c.i this fors were made by me or under m:- super—
vision in accord rith the procedures and method speoified in Chapter H 62.20 (13). Wisoonsin Administrative Code, and
that the data recorded and location of test holes are oorreat to the
best of ay knowiedgg and belief.
/0
A-- ( / 6
NAME /) T IT LX
T+pe or Print)
REGISTRATION NO. KASTER PUMER
LICF2NSE NO, ONN
ADDRESS 4L
Ll-
DATE J S I G N A rJ RE