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002-1008-30-100
i 'O O 'I 'L5 O 4• p 0 O O Ci •V pq I r., .Y I. O I, N FF 0.' O _ O ~C co c ~ N 4 E •r~. I'I U) CZ N .41 Z (u C O N > Q) O O 6` co U L ~1 N y ~ O t'i N O L ~~`111 O C N « C Z 7 (d - . cc LLLL •0 r` LL O N O a ~ I a I I d co z N Z N I O = O w O W Z N ~ •6 L •O ~ W d m d m a H c 0 o z v °c w aUi Z d c o) c Z 7 o E c ~ ~ N -O CO M CD CO N N • O Ai O L L L C CL U ~i ~ ~ ~ C C O U 'N O O Q 4= Q Z aI Z F- Z _ Z C C 16 E U y W E V N o l 2 L R ~ C,L CD r N G O L V a N ,i N y d a i .0 a^ o c N a o °o <n vim I °o to to rn O Z~> ~3~ava X333 ° N z o O 0=,0 O O O •N 5aaya~ ~aaa a C~( U Z rn rn m O ~ > O O N Q L D N O c0 O •O cn Q Z O •O N d 1- Ci7 co d (y d to ~ O O W N C OOp N C M O C 'O C) O C E O 0) C ® N U O O N U O N O O r m m O1 a) > a) o. N O a Y c .O N N It (1) E v 'yOi O (D C L co o C W O N_ C ° 3 N o~ v v; a~ F- Z c c r• C° CV O '6 W 3 C N Co ( U N O N (p ) O N O E E c -,t CN .0 CC _ 7 a .2 • a w J CL 7@ w w E U c C C w 3 r C v a E 0 U) i) 0 v) u o C) Q ° d N I M a 0 i 0 N I h N i I m I a z C {L c O 3 w I I 3 ~ I a~ o E w a) € o z N d y N a m vF-~ I I o I O z c m d o z U) ~ °D co ~~ww N m = CD (D N n `~+J • a c LO Q Z F= z z E OOi O N {p E U 01 d d m ~~yy d C y~ C f0 N C G arr L N N a Z.- Zo ~aaa CL c 0) toJV mrnrn } a~ N C y E o o _ j Q m y c d L 'O ~ N m ~ O d Q fn f6 CD ~'Y O O y Or - r.+ Cl) O C E O O O m N N C y a o C? Cl CL C N C co ~ ` E c ch O fD C O N y N N y C O n • IN O N m co N N 10 U co N O - g C~ 4t Q 4 a L: (L U 0 CL *84 E r A c°~a~ 0U)0 ST. CROIX COUNTY ZONING DEPA AS BUILT SANITARY REPO Owner (7 -f P ~ eb►S "j ~VCIT 1 ° . a Mci. I v tf, /~~e,✓c Address 2-- City/State U%> C 01x .;k JCL"~ ~ Legal Descriptio n"I"GFrC Lot BlockV Subdivision/CSM # ' ' Sec. T N-R W, Town of al Idwt h 4 4 2 SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: 11 ~~,y~ 2 plod' Tank manufacturer ),te0- AfcOSize ST/PC W / Setback from: House JS Well P/L Pump manufacturer l tee Model R Alarm location Servicc. Roc." (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width 5- Length 106 Number of Trenches Setback from: House ~ D Well 130, P/L2 (G 4 Vent to fresh air intake > !3 D ELEVATIONS: Description of benchmark dh a e_ Elevation _6 V el Elevation Description of alternate benchmark U Building Sewer qd ' g~- ST/HT Inlet D' 1 ST Outlet 7 PC Inlet y3, 69 1'~~, r~~ ~ D ~ PC Bottom ~T Header/Manifold 9~'gl b,rh-' Top of ST/PC Manhole Cover 9369---~ 93. q6 7- 1p Tv~eltA Distribution Lines ( ) Bottom of System O + w1C~) 9~- 77 Final Grade / 1 CIG~ ) ` , 9,,,,7- Date of installation /oV Perm><t number y State lan mber Plumber's signature - License number C;77- Date/!2/ Inspector Complete plot plan r ~ a mo' Rw RLXOM alvoiallu 3 Cb- V P V S a ~ g~ 4 T o s ' Z Y MHIA NV Id -olgvoildde 3! `)lmuzgouoq olumol1t, togs •Ianoo alogMtU 31=1 oiId2s 30 JaJuao 01 sluiod ooualojaz p luozuoq ones -tualsAs aqp jo Jaa3 001 utgpinn SuigVaana Suinnogs goIaxs Matn urld V :Suimopo; aqj apino.id asuai j : aljLON ~ f Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County ' Safety and Buildings Division ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar!pP89kt"_: Personal information you provice may be used for secondary purposes [Privacy Lev, s.15.04 (1)(m)]. fiv' ftl olc~ ffw: [ 9&§W ji#pge ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel 1008-3 0-100 R l v z TANK INFORMATION E EVATION DATA A970025 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 00 Benchmark 11 Dosing1+,,~~ is Aeration Bldg. Sewer ,yt ' Qp_ Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet avo o,d'I Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air 67o aZ O./J`- ~ Septic NA Dt Bottom 17„ t~ g 2 NA Header/ Man. p• s 8• 4 3 . C_ 9 ; Dosin s 35 ' Sv 3 y6 Aeration NA Dist. Pipe al (o ' Holding Bot. System 4.x-7 77 PUMP/ SIPHON INFORMATION Final Grade Z:5 A~o ~ - 7 Manufacturer Demand Model Number 19 GPM TDH Lift 5, Friction System, a TDHI1.`,? Ft Force main Length Dia. Head Dist. To well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS son ' DIMENSIONS SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION TypeO r CHAMBER model Number: system: ir!~v 'act ~D a IvIA OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe($) x Hole Size x Hole Spacing Vent To Air Intake Length ___L1_ Dia. IS, Length G Dia. Spacing Y41 ! i ` ~JU r SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Q t Depth Over xx Depth Of f xx Seeded/ 5edd2d xx Mulched No Bed/ Trench Center ' u Bed /Trench Edges Yj Topsoil ~o UKes ❑ No &<es El COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION-. BALDWIN 4.29.16,S,SE 2384 110TH AVENUE Plan revision required? ❑ Yes No Use other side for additional information. 7-' . SBD-6710 (R.3197) Date Inspector's Signature Cert. No. t t ADDITIONAL COMMENTS AND SKETCH - SANITARY PERMIT NUMBER: t • 1 t Bureau o off B Building Water System ~ti~'■•in SANITARY PERMIT APPLICATION Safety and Building Water Sn 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less Count than 8 112 x 11 inches in size_ Cr171 • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used b other government agency Checi 'fJ . y y by programs k f revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT AL INFORMATION Property Owner Na e _ ! property at on V~ P_ & 5 j $"I 1pi 1/4, 5 T Z.0), N, (or W Property Owner's Maihn Address Lot Number Block Number 7 v- I vr)l a^ ,e City, State ip Code Phone Number Subdivision Name or CSM Nu b r g~ wry WAS 110)-2 (7/57) s moo6 II. TYPE F MIMING: (check one) ❑ State Owned 0 ltd, Nearest ad Public 1 or 2 Family Dwellin - No. of bedrooms Town OF WI` I 8 Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax/Number(s) 1 ❑ Apartment / Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1-X New 2. E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5_ ❑ Repair of an System System Tank OnlyExisting System Existing System B) A Sanitary Permit was previously issued. Permit Number 2.u7 $ .9- 7 6 Date Issued ei 1;7 ;l4d&7 V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 121~--24eepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. S~,stem Efev. 7. Final Grade Required (s . ft.) Proposed (s - ft.) (Gals/day/sq. ft.) (Min./inch) ql,~d .7y-,f Elevatior~V,(7 t? Q is V ,-z. $ Feet .5' 95',1 Feet VII. TANK Ca in gallons Total # of Prefab. site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 1 75-01 11, 1 / to ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu is Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: PI mbe ' Address (Street, City, State, Zip Code U ~s IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Ag t Sig ature (No m A roved surcharge Fee) pp ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6399 (R. 05/94) 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 a time of renewal any new criteria in the Wisconsin Adm nistrative Code will be applicable. 3. All revisions to.+i d&nrt` u' st be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintaihed. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. I1. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line 13 if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of. holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. od ~J ~ ~ s ~ ~ C~ ~ ~ ~ ~ ~ ~ °-s 3 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 4- Labor and Human Relations Division of Safety & Buildings i r %ith/IL, 83.05, Wis. Adm. Code ? COUNTY Attach complete site plan on paper not les ifs 8 1/ W s in siz' . Ian must include, but s''P C r 0-[ not limited to vertical and horizontal refer int (n and o slope, scale or PARCEL I.D. # dimensioned, north arrow, and location stance to nearest road. APPLICANT INFORMATION-PLEA ~RINrj4L0RFdAATIf & REVIEWED BY' DATE 7 PROPERTY OWNER: rYCJrY~ sX toy PROPERTY LOCATION .KONINGQV3 l0` GOVT. LOT ~l.L>f~F 5r1/4,S T 2 N,R 6 (or PROPERTY OWNER':S MAILI ADDRESS Z LOT # BLOCK # SUBD. NAME OR CSM # d r ) Ldt;t ✓•/ewe ,2- CITY, STATE ZIPOODE PHONENUVISS ❑CITY ❑VILLAGE OWN NEA EST ROAD I t"J, 4,,, SYao 2 n O 6 - 4006 11ii, o New Construction Use Residential / Number of bedrooms [ ] Addition to existing building ] Replacement ~1 [ j Public or commercial describe Code derived daily flow. 6 f/ ® gpd Recommended design loading rate s 6 bed, gpd/ft2 O~ trench, gpd/ft2 Absorption area required bed, ft2 QU~trench, ft2 Maximum design loading rate ~_bed, gpd/ft2 0' S^trench, gpd/ft2 Recommended. infiltration surface elevation(s) A. g 12. I ya 3 (as referred to site plan benchmark) rf- Additional design/ site considerations n6 ~ 22 e.'( rn4bit- 7r'ehc 4 6' k<r TP-vh gy Parent material L o r.S se, c Flood plain elevation, if applicable 11,9- ft S = Suitable for system c VENTIONAL OUND 7$N-?GR0UN11R1SSUR1 T RADE SYSTEM IN ILL HOLDING T K U= Unsuitable fors stem S❑ U El U S❑ U S❑ U El S El S Eyl SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bwxlary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0_S 10 YR y - s F dk E►~ c S 2v; 0.5 66 r 2 F-157 7.5rR PQlk d -5 /V-~ 0-7 0,6 Ground 3 1526 ~0 r»P h~~~, S C t, t' d, 7 rk 16 elev. oft. 26" 6 5%c b C W y d. iofR04 4h a,rd+'~~+ Depth to j S~ , C V limiting 10YRV/6 a.a factor 6 SQ' 1 R 16 I S YR s~8 h s Remarks: 10-11 f Y R Y N s 2 v 2 v 1~ 5 G. 6 3 10-50 co r 514 1 Fr G 5 Ground elev. y fD~j3 IoYR 516 zsrR z ~~3 slc 1 2 jp9~k rti Gv j bekyZi- ft. Z. s A,- Depth t o 5` 63-7z 7,5-YR V I Y ),5 Q 2 4q G - - limiting factor Remarks: Holc Inoi- o~ voreo- CST Name:-Please Print U G- / . Phone: 6 G Lt0 J Address: ~4' ~ j Oct) v Signature: ~7l Da 11,97 te: (f 5T11 CST Number: 5- so j PROPERTYOWNER Sfeve Rees SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerch 1 D-I toY 11q s?!_ z F r, re G S ~F v•r 0,C 2 13-24 7,5"8 q16 a,ha Z 1 c s I~ 0,7 D, Ground J 24-27 to i R 516 S1 I P ,t F✓ C 0' 7 04 elev. rti sd:Vvn PKI ft. y 2910 o 6 0/ 7 oli Depth to 5' 40-58 to Y s /ti - ! s~ a 6 G ? C?-~ limiting facto 6 9-72 10TR s4ha - 0 7 :0 fl FT Remarks: Boring # ` d"`~ ~oYR l~! s;~ 2 Fadk c 2-A 5' 0,6 2 -22 R y - s 1 .2 q S 1 vf 0,7 10 Ground ?2- 12 10YR satid S d 1 1 0,7101 y Row 9 elm. G2 J~ 0 Jq IC - 2SIR 1--y, 6o w~ Z ~Sb r v~ d Lft. Depth to ✓ JrI 6~ !D YR S o v c s limiting factor 70 10YR K 512 Remarks: Boring# 1 Q-10 toiR 5h 0,4 10-12- 7STR S 6 M # °a zF I~ ~S c ~F 0,7 0,~ 22-40 M 6 s z Fal r. r Fr c v 0.7 ` 0.9 Ground elev. 7,S 16 !s 2 s c l ✓F D ft. Jr ~ 10 Y coax-se to+K sS v(_ 'DAD Depth to co-73 w ra rs16 And C w limiting f ct i 7 ~77 -93 to G - nd s w 0 $ Kk?6 7,5- 6 CMrf! sqJ 2 ~ `k d s - 0,710,51 Remarks: Boring # 1 o -1,0 R Y "/q s;1 A f 444 s cq- 1 vF Z -I o 104twN xit 411 h) f4_ c, s vF V r 6 wars= ;..6 3 17-41 60 YR 516 sued c w 1 1 D%K Ground<::< 41-13 Lo Y Q1 l S 2- ejk c 7 45T le.. t. S 63-6 to YR s; 1 svYJ s c 0-7 id Depth to 0-7v 6 `5 ,25-YR P/V h) 5 ! L 2,7 0,fl limiting -7 97-91 - 2 KA - , 7 OHO factor ~ I Remarks: SBD-8330(8.05/92) PROPERTY OWNER -Sfrft ~nta, SOIL DESCRIPTION REPORT Page 3 of~ PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Banndary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends !dY 2 2vF V-3 7 sr Y A s h d F 414 C ~ ~ t= rt- Ground 10 SJ n► Fr c elev. nd c~ q 3 . ' ft. Depth to 5347 !D $ y S raj wt G limiting factor 67-7.5 mg 6 1 - Syw~ s d ~ 7 7 73-71 1011 L/y f X 54A air- 110YR r)4 st'J~ r 1 1r, Remarks: Boring # .r•::<.::••.,::..L_{ ~ d~~ ld [R.l'l sr1 z T'a~R s ~ 2 ✓f' r 'us}.~r:::.w R ti 1 $°N0 7,5 s yd l s t 3 ~o-sb 7,0`"s F g1 k s s Ground elev.' 1 0 /6 s~►o1 V, r ft. Depth to limiting factor 7 77 Remarks: Boring # hg •:vtin ii hh k:5•::4:::;;cc Sri{{•rivitvi...... Ground elev. ft. Depth to limiting factor Remarks: Boring # 't'i4rv1'•":iti: t r Ground elev. ft., Depth to limiting factor Remarks: top of c.-er~e++t WS ON gmams c elT"Offi r, /Od SBD-8330(8.05/92) I , ,Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit N GENERAL INFORMATION 4~ ZX Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: RENS STEVEN J. BALDWIN CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 002-1008-30-100 TANK INFORMATION ELEVATION DATA A9700019 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Loss mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSION DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O CHAMBER Moe Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: BALDWIN.SE.SE.4.29.16 110TH AVENUE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: , r^~ ~trirr'i SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuilBuildinWater Systems ing Water 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. C Kd f ' brV&e • See reverse side for instructions for completing this application Stat mber The information you provide may be used by other government agency programs ❑ Ch if revision to r us appli Lion 2 lPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 1/4 E 1/4, S T 2°~ , N, R 1-~ E (or) W SE v Property O ner's Mailin Aclress Lot Number Block Number r cive City, Stat Zip Code Phone Nu be SubdivisionN~a me or CSM umber I - (71 8` 6 t_nT V,)I,,r►t V c 300 t1l II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City f Nearest Road _ ❑ Village Ve"t' Public 1 or 2 Family Dwelling - No_ of bedrooms town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/ Condo 00 2 _ 100 2 ^ 30 00 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/ Factory 130 Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. )TNew 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting System _________Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued' V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21XMound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Propos d (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation ~O 5,00 2. , LIZ Feet 10 Feet VII. TANK Ca in galtoacits Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed Tanks Tanks Septic Tank or Holding Tank f/ ' + W ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber w rf ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print)I A / Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: SW VV D umber's Ad e s (Street, City, State, Zip Code): P43 I<,Zg ccowvll IX. COUNTY] DEPART ENT USE ONLY d (N uing Agent Signature (N to ps) ❑ Disapproved Sa tary Permit Fee (Includes Groundwater ate Issue Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL SBD•6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit.issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. il. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. f SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations February 11, 1997 2226 Rose Street La Crosse WI 54603 WEBSTER PLUMBING ELECTRIC N3659 CTH C ELLSWORTH WI 54011 RE: PLAN S97-40034 FEE RECEIVED: 180.00 RENS, STEVE SE,SE & SW,SE,4,29,16W TOWN OF BALDWIN COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements 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 permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely N# rd M. Sw Plan Reviewer Section of Private Sewage (608) 785-9348 SHDA-7997 (R. 10/84) ' nmm~p~y~ A ~SCoNv o~ d ~ ~sr Ot unmtn+au~ RECEIVED 1 FE B 0 7 1997 SAFETY & DLDGS. DIV. 14 o r% T N 4 T ~'Q i P I 1 T j P. i i S'~' I r" t 1011 i X t i 1 1 I ! ± a 1. G, i i. E..t i .i_: 7 1 1 t•, r_'s -t j L'am'} r "A 1 ~ i i ~ ~ c.+ . f r_J E=' % ± I L ; is ~ `_1 7 ~ i r > i~q f 7) 4- a _ P ii14T~ SEWAGE SYSTEM I tr~i i 1 `•1. I I Yr\ I i ank L ~u L Lp DEn. OF IHDUSTRY, Lk&U6 2i HUMAN RELATIONS r ; a - - CdYiSIQN CjF SAFETY {D 13UiLDIREG$ SEE COR E PONDENCE i~ ^1 i ' f' p ! p v Y S Y 1 _ `,,gyp\\\ tfu UI III 00, n~ ~ 8RV ~ ~J T coNs~N A LIIv. I -L1 1 4~" I f tYrJ 1. r'•, 1,w,'F_' i, i_rJ •''rt•~'~''.. Nor f i'Y ea j ~ { z C- ' , Ci l~l f tia r` ' c: sit r I Wei f rrv r,, U r 1 , {tr tom- L i I I - 1 11 •--I C!" (A ' tt 1 i; ( ; i J- ` i 1 I `S 1 i_ 't J. 1 t i LLj 11 1 6} J`~''s H; It i ; i I I p Q 1 00 ,t I I 1~' y"' I r t 1 ^t `h t T t I L1 I i ~ I y},I I r ~J , { li tr 7 i ~ ~•5t 1 S L J~+ ~l~t: ~::3 feet f~rLr~ center !.Ini~~ , w fj 110th avenue t s A ;A el i, ~rr y= _ r 77 ```auiinuun unrrangir.,,, a`a~~~~ 1S C DNS ALLEN WEBS .WO SL _ r mitt re94 m-Dul-IM t--.!D 1 inert Stec" G'ip ie62 110,0 i 4 `'l± .'encz 1 near road top F'ip ?iC :'patio I k Page [ Of Cross Section Of A Mound Using A Trench For The Absorption Area F, a ' f o y• 7 Medium Sand Fill ~I ° F 6" Topsoil 3 E D Trench Of 211" Aggregate, Plowed Layer Act- 6" Below Pipe, Covered With D Ft. Straw, Marsh Hay Or Synthetic Fabric E Ft. G Ft. F 0-4 Ft. H Ft. Plan View Of "found Using A Trench For The Absorption Area Force Main Distribution Pipe Permanent Markers Observation Pipe A J- 601 A o , W g K \Trench Of - 2k" Aggregate I r L aa`aaautuuauw;,ni~,~i r~ W_ Ft. A'-'~~CONSl F t. K ..J.SL. Ft. B Ft. L Ft. SIR D-1195 • i ELL SW N 4.f p,✓✓ _'1 , ' License r 9 2- ~ Signed: _ Number: ` Date: e d!2 rage ur y Distribution Pipe Detail For Two Lateral Network Holes Located On Bottom Are Equally Spaced PVC Force Main End Cap 2 r X X PVC Distribution Pipe P P X Last Hole Should Be Next To End Cap f P Ft. Hole Diameter Inch r X Inches Lateral Diameter Inch(es) Y 7b T-22- Inches Force Main Diameter 2 Inches # Of Holes/Pipe v Invert Elevation Of Laterals rQ~- Ft. Top o~ p15rr"l ' tto" pip t /0 3.0~~. Signed: License Number: p t 9 Date: `0 rv,3, r&V YV rAf F ,F Z ` PUMP CHAMBER CROSS SEC7101,1 A►JO SPECIFICATIOK!S PVC VEtJT CAP y'•~. VEMT PIPE WEATHERPROOF APPROVED LOCKIMG JUKJCTIOKJ BOX MAIJHOLE COVER - 25' FROM DOOR, WINDOW OR FRESH 12"MIU. AIR INTAKE GRADE I I 'i" apllll. IB"MIU. COKJDUIT-- t8"MIN. ' ll~ MILET PROVIDE AIRTIGHT SEAL i III -7 A I III I I I I ALARM 1 q 6S I 1 $ 1, dos 4h a *APPROVED i I ou o JOINTS WITH ELEV. J-1= FT. APPROVED PIPE 3' ONTO PUMP OFF I g , 7z D SOLID SOIL CONCRETE BLOCK RISER EXIT PERMITTED OIJLy IF TAUK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFICATIOAIS DOSE- Q TANKS MAKIUFACT URER: ~~~WCi~PvPi iVPCtJ ~ UWMBER OF DOSES: PER DAy TAWK SIZE: 100 0 GALLOUS DOSE VOLUME ALARM MANUFACTURER: tyrh INCLUDIMG BACKFLOW: GALLONS MODEL KIUMBEK: ~D- V CAPACITIES: A= INCHES OR J l" GALLONS SWITCH TYPE: INCHES OR _ GALLOKIS PUMP MAUUFACTURCR: `GALLOU_ C- IKILNES OR ~ MODEL MUMBER: D= INCHES OR -2-2-0 GALLONS SWITCH TYPE: ~R NOTE: PUMP AMD ALARM ARE TO BE MIUIMUM DISCHARGE RATE GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND OISTRIBUTIOU PIPE.. ` ) FEET + MIUIMUM METWORK SUPPLY P~R~E~SSURE , , 2.5 FEET + ~ FEET O 51 t.' M MAIN X _.-L_FJpp ftFRICTIOLl FACTOR. 3' o FEET t-OTAL Oti JAMIC. HEAD = 2.Q FEET JUTERKIAL Dih'EIJI I L ©F T'AIJK: LEKIGTH _;WIDTH ;LIQUID _ LIQUID DEPTH cw- 51GUED:_~d LICEUSE DUMBER: 0 ~ e7 -)d DATE. 1 ME Series MWW 1/3 through 1-1/2 HP Effluent Pumps TWO a+~ rG y ~~~`,ur F X16 ~---.r;~ Performance Curve c Vtw &I t", Leis I$*., Joo ~ o)r 2. 6 5 .rNCy FORCE MBTN TD~ -T 3 t 1St 6-S CAPACITY LITERS PER MINUTE 5 ° 38 PM 0 50 100 150 200 250 300 350 0 450 100 90 28 80 M 24 U) /So W H 70 tiJ w w/OO 20 2 LL 60 Z Z 50 M~~$ 16 w W = = J Q 40 MF$o 12 0 O 30 8 20 MF33 ® 10 4 0 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130 CAPACITY GALLONS PER MINUTE Pry rs Mje,j Pum Mvsj-- ~ 7 I P P -F '~P'e ? Feb 2~ 199 . r r R , 571 • 1101 Myers Parkway, Ashland, t`3,bio LCy 448(5-~ , M"419/FAX 419/289-6658 Telex 98-7443 I0 K3327 8/92 Printed in U.S.A. Wiscori'sin Department of Industry, SOIL AND SITE EVALUATION REPORT Page i of 3 " Labor and Human Relations Division of Safety ri Buildings . in aCC r ILHR 83.05, Wis. Adm. Code CS COUNTY T St . Croix Attach complete site plan on paper not less,, an 8 1x Plan must include, but not limited to vertical and horizontal refergnce point (BMtion P f slope, scale or PARCEL I.D. dimensioned, north arrow, and location and~distanco tg adpending WED BY DATE APPLICANT INFORMATION-PLEASE>PRINT AtOOXAT ( ! PROPERTY OWNER: PROPERTY LOCATION Russ Johnson GOVT. LOT SE 1/4 SE 1/4,S4 T29 N,R 16 vfor)W PROPERTY OWNERS MA!i_ING ADDRESS - LOT # BLOCK # SUED. NAME OR CSM # 103 W Maple na na pending CITY, STATE ZIP CODE U ❑CITY ❑VILLAGE MOWN NEAREST ROAD Roberts, WI. 54023 (7 88 Baldwin 110th. ave. (x] New Construction Use [ x] Residential /Number of bedrooms 3 Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate -4 bed, gpd/ft2 -5 trench, gpd/ft2 Absorption area required 375 bed, ft2 375 trench, ft2 Maximum design loading rate • 4 bed, gpd/ft2 ' 5 trench, gpd/ft2 Recommended infiltration surface elevation(s) 102.68 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material glacial drift Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for svstem I ❑ S ®U El s ❑ U ❑ S 01.1 ❑ S CRU ❑ S ®U ❑ S o u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence I Bandary Roots GPD/ft in. Munsell Du. Sz. Cont Color Gr. Sz. Sh. Bed Trer><ft 1 0-13 10yr4/3 1 2m5bk mfr gw 2f .5 .6 1 s I? 2 13-20 10yr4/4 s icl 2msbk mfr gw if .4 . 5 Ground 3 20-36 7.5yr4/4 scl lmsbk mvfr gw n .3 .4 elev. 5/2 101.f8 4 36-50 7.5yr4/4 c2p7.5yr5/8 scl lmsbk mvfr na n .2.3 Depth to limiting factor 36" Remarks: Boring # 1 0-11 10 r4/3 1 2msbk mfr w 2 .51 .6 2:..: 2 11-20 10yr4/4 sicl 2msbk mfr gw 1 .4 .5 3 20-30 7.5yr4/4 scl 2msbk mfr gw n .3.4 Ground 5/2 elev. 4 30-50 7.5 r4/4 c2 7.5 r5/8 scl Ilmsbk mfr na n .21 .3 Depth to limiting t!pr Remarks: CST Name:-Please Print Gary L. Steel Phone. 715-246-6200 Address: 1554 200th Ave. New Richmond, 9-6-95 Signature: Date: CST Number: PROPERTY OWNER Russ Johnson SOIL DESCRIPTION REPORT Page.. 2 of .3 PARCEL I.D. # pending Boring # Horizon Depth Dominant Color Mottles I I Structure I GPD/ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bourylary Roots Bed ITn& 3 1 0-12 10 r4 3 none 1 2msbk mfr w 2f .51;.6 `'><-v««<? 2 12-2 10yr4/4 none sicl 2msbk mfr gw if .4 1.5 i Ground 3 22-2 7.5yr4/4 none scl lmsbk mfr gw 1 f .3 ; .4 100e1$~8 yr 5/2 ft. 4 29-5 7.5yr4/4 c2p7.5yr5/8 scl lmsbk mfr na na .3 .4 Depth to limiting factor 29" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. j ft. f Depth to limiting factor Remarks: SBD-8330(R.05/92) STEEL'S SOIL SERVICE r Gary L. Steel Russell Johnson 1554 200th Ave. CSTM2298 SE4SE4 S4-T29N-R16W New Richmond, WI 54017 MPRSW 3254 town of Baldwin (715) 246-6200 i N 1"=40' BM.= top of 1" steel pipe C el. 100' 1 ~s Alt. Bin. =top of 111 steel pipe C el. 100.081 Z 2 r cY N MOUND ~Ui P- ~ o~ 35 65 6 14 2~ ` ►~'\3 Gary L. Steel 9-6-95 552815 CERTIFIED SURVEY MAP LOCATED IN THE SE 1/4 OF THE SE 1/4 AND IN THE SW 1/4 OF THE SE 1/4, ALL IN SECTION 4, T29N, R 16W, TOWN OF BALDW I N, ST. CR01 X CO., W I . PREPARED FOR: KEN GRAF 1996 I UNPLATTED„LANDS ~EC03 0j Deeds 1y S 86°54' 36"E 581. 8l' NOTE: BEARINGS ARE tilr REFERENCED TO THE SOUTH LINE OF THE SE 114. AS$UMED BEARING). ( APPROX. WEST LINE OF THE SE-SE 2 p: LOT I (i z _ 10.00 ACRES -4 : t 4 EEG J '96 W: . o ( 435, 600 SO. FT. ) 9.56 AC. EXC. RAW oo or Q; I (416, 400 SO. FT.) rn CROIX COUNTY J: ~1 a: o V 4'oAprehensive Plannir z: o I o z Zoning and ~q I marks Committee °o - If not recorded within 30 days of approval date _ ....................J1J.QU1YA,.Y..B.V.I4 P.IN.G.AE9TpA approval shall be 1KK. JNf null & void w w rn ~ w _ N 86054'36'W 581.81' o rn 1173.00' M - - - - (10TH„AVE. S 86054'36 T- rn - N 86°54' 36'W _ 885. l6' N 86°54' 36"W S 114 CORNER OF SEC. 4. (COUNTY MONUMENT FOUND). SOUTH LINE OF,THE SE :0 CORNER OF SECTION 4. (COUNTY MONUMENT UNPLATTED LANDS FOUND). ``~MtitotvkNgM~o' r ' DESCRIPTION A parcel of land located in the SE 1/4 of the SE 1/4 and in the SW 1/4 of the SE 1/4, all in Section 4, T29N, R16W, Town of Baldwin, St.Croix County, Wisconsin, more fully described as follows: Commencing at the S 1/4 corner of said Section 4: Thence S86°54'36"E along the South line of the SE 1/4 1173.00' to the POINT OF BEGINNING: Thence NO0°17' 18"W 750.00'; Thence S86°54'36"E 581.81'; Thence S00°17' 18"E 750.00' to a point on the South line of the SE 1/4 of said Section 4; Thence N86°54'36"W along said line 581.81' to the point of beginning. Contains 10.00 acres (435,460 sq.ft.) subject to 110th Avenue right-of-way over the southerly 33' thereof. Also subject to any and all additional easements, right-of- ways or conveyances of record. SURVEYOR'S CERTIFICATE I, James M. Weber, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the SLCroiz County subdivision Ordinance and under the direction of Ken Graf, I have surveyed and mapped the above described parcel of land and that this map is a correct representation of the boundary thereof. AGO y.i Dated this Sr day of pc-Ry3 ,1996. 'y tr JAMES M. WEBER James M. Weber S-1804 S,1804 NELSEN-WEBER LAND SURVEYING SPRING VALLEY or < Wis. eV ,~y r f NOTE: The parcel shown on this map is subject to State, County an Waal laws, rules and regulations (i.e. wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any land, contact the St.Croiz County Zoning Office and the appropriate Town Board for advice. { S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property ~~~°{jLQ~ _ ~PKS Location of property_.:5LF_ 1/4 61/4 , Section L(T SLq N-R_ f6W Township Rd /,/,&j , L, Mailing address Y- A4 / Address of site a~ /O' Subdivision name Lot no. Other homes on property? yes. No Previous owner of property kPert o 6 ra t' Total size of parcel S Date parcel was created Are all corners and lot lines identifiable? _,~C_Yes No Is this property being developed for (spec house)? Yes No Volumed 1jj and Page Number fo v~( as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL 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. PROPERTY OWNER CERTIFICATION I(we) 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 recorded in the office of the County Register of Deeds as Document No. S-/-/6~ --5- , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the nffit a of ne..;e+--- -.P a....a_ S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER -ST eC S. ECM .S ADDRESS o1394, moW Ave, FIRE NUMBER _a ;S 7:~ CITY/STATE ZIP PROPERTY LOCATION: SE 1/4,-SE 1/4, SECTION L , Tc'~q N-R_Z6W TOWN OF St. Croix County, SUBDIVISION , LOT NUMBER 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 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater 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. 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 DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning officer within 30 days of the three year expiration da e. SIGNED: DATE: 2-h 7/q 7 St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 i PaU VOL 1?'1 !I STATE 13AR OF WISCONSIN FORM I - 1982 WARRANTY DEED is DOCUMENT NO. F AEGIST',I. i r.-I tiT, CRCC( CdO., V.1 This Deed, made between Kenneth J. Graf and f' poc'dforf0cord Marcia J. Graf - - - - - JAN. 2 T 1997 Grantor, 9:30 A. t4'. and Steven J. Rens an Caroline L. Rens_ 'at Grantee, Witnesseth, That the said Grantor, for a valuable consideration Iconveys to Grantee the following described real estate to St. Croix THIS SPACE RESERVED FOR RECORDING DATA County, State of Wisconsin: III NAME AND RETURN ADDRESS Heywood & Cari, S.C. 'j P.O. Box 125 j Hudson, WI 54016 jl 002-1008-30 PARCEL IDENTIFICATION NUMBER Part of SE 1/4 of SE 1/4 and Part of SW 1/4 of SE 1/4 of Section 4-29-16 described as follows: Lot 1 of a Certified Survey Map filed December 3, 1996 in Volume till'', page 3190. Ij This deed is given in fulfillment of a land contract between the above I~ parties dated December 16, 1996, recorded December 20, 1996 in Volume 1214 page 315, document No. 553531 in the office of the Register of Deeds for (i St. Croix County, Wisconsin. FEE This is not homestead property. EXEMPT- X(X)X (is not) i Together with all and singular the hereditaments and appurtenances thereunto belonging; And Kenneth J Graf and Marcia J Graf warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and any liens or encumbrances created by act or default of grantees i and will warrant and defend the same. Dated this 24th day of January 19 97 ! ~~2Y (SEAL) A zlj (SEAL) KENNETH J. G F (SEAL) (SEAL) + + MARC_IA J ! AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County authenticated this day of 19 Personally came before me this 2 4th day of UIIIST' r, ,t., For completion see wrarate "Instructions for Real P.stste Transfer Remm".ptr50 - - °ONSIN REAL. ESTA3F r f3AM afF +td Mul E !AL Submit all parts to Register of Deeds with document(s) to be recorded. I. GRANTOR: V. PHYSICAL DESCRIPTION AND PRIMARY USE BY GRAN1EE 1. Nano(, , h t t 11 ! 1, ) ~a r t_ i a J . G r 1.( 15. Kind of pro pertly 16. Primary use 2. Address - New address 0 property transferred was primary residence H Land only a. ❑ Residential: 11.)6 - Z45 t h St r e e t ❑ Land and buildings ❑ Primary Residence for Lottery Credi a O ) d V i 110 , i l l S4010 ❑ Other (explain) ❑ Single Family/condominium 17. Estimated land area and type ❑ Multi-family - t units 3. Grantor Is X9 ] Individual ❑ Partnership ❑ Corporation ❑ Other a. Lot size x ❑ Timeshare unit 11. GRANTEE: b. tOTAL ACRES b.0 Commercial c. MFL / FC / WfL acres c. ❑ Manufacturing 4. Name .`~t_F~ven J r Ul i11e L iieli 5. Address d. Ft. of water frontage d. ®Apricultural ❑ Yes No 112 U 1; r an }:1 i I t Street adjoining land within 3 miles? ❑ Yes No L a i u w i n, W l '34002 e. ❑Other (explain) VI. TRANSFER C] ~y 18. Type of transfer, n Sal ❑ Gift Exchange ©Other (explain) 6. Grantor /grantee related: C None Co hareholder/5ubsid' ❑ Partnership g C l t l U l f Y 1 l7 l l L UL18 a U t: U Tl t e$ c t to Financial E] Family or Otlier; explain i---; 4 19. Ownership Interest trans(erredJM Full ❑ Partial (explain) r 7. Send tai bill to: Name and addretn t 20. Does the grantor retain any of the following rights?❑ Life estate "ement i same as g r a. i1 t e e above 21. ❑X Deed in satisfaction of original land contract? Dated?---j 2 16 9 6 22. Points (prepaid interest) paid by seller $ 111. ENERGY B. Is this property subject to the Rental Weatherization Standards, ILHR67? 23. Value of personal property transferred but excluded from (25) $ i [ Yes [ X No Exclusion cod4yZ if W-11, explain 24. Value of property exempt from local property tax Included on 25 $ VII. COMPUTATION OF FEE OR STATEMENT OF EXEMPTION j IV. PROPERTY TRANSFERRED 9. ❑ City F] Village ) Town !s a 1 clw i n 25. Total value of REAL ESTATE transferred $ 15 , U U 0 . U U 26. Transfer fee due (line 25 times .003) $ PYen1 t County St. Croix 10. Street address _ Vacant 1 and 27. TRANSFER EXEMPTION NUMBER, sec. 77.25 _L7 j 11. Tax parcel number U U L _1 U U u - 3 U 28. Grantee's financing obtained from a. ❑ Seller 12. Lot no.(s) Blk no.L) If box a or b is checked, b. ❑ Assumed existing financing Plat name complete Part VIII - Financial institution / Other 3rd party 13. Section___-_ Township Range Flnandng Terms dc.. F1 No fiFinanc nancing involved 14. Legal DesuipUt►n metes and bounds: (attach 2 copies it necessary) tart. of S'L: 1/4 of SE 1/4 and Part of Slit 1/4 of SE 1/4 of Section 4,-29-16 uescribed as follows: Lot 1 of a Certified Survey Map filed Decembe3 3, .19_16 iii Vultime "11", pale 3190. j i i i i VIII. FINANCING TERMS (FOR SELLER/ASSUMED FINANCED TRANSACTIONS ONLY) 29. Total down payment $ (Line 29 = Line 25 minus Lines 30a and b excluding payments for personal property) 30. Amount of mortgage/land 31. Interest 32. Principal and interest 33. Frequency 34. Length of 35. Date of any lump sum 36. Amount of lump j contract at purchase rate (stated) paid per payment of pymts contract (balloon) payments sum S $ a. 5. - - - - b $ - - % $ - - $ 37. If the dollar amount paid per payment (32) Is scheduled to change (not as a result of a change in the interest rate), fill In the line letter from above _ Enter the date of change - - - - and the amount it will change to $ IX. CERTIFICATION We declare under penalty of law, that this return has been examined by us and to the best of our knowledge and belief it Is true, correct and complete. Grantor or agent t Date Grantor's telephone number - 3 d SIGN (715) 684 HERE Grantee or agent Date Grantee's telephone number 684-45,15 Print name and address of grantor's agent Agent's telephone number Document number VoIJJac. Pagelim. Date recorded Date and kind of conveyance Conv. code 554365 1_19 6''.1 1/27/9; 1 24/97 WD 1 2 3 4 FOR ASSESSOR'S Parcel number Assiutyear 19._ Field Sales number ~ USE L County Parcel classification i Tax dist ❑ Use ONLY R1S C2M M3 A4R S5 6R T Assmt.dist. ❑ Reject I Wisconsin Department of Revenue K soo M. 6-95) PROPERTY OWNER'S COPY