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AS BUILT SANITARY SYSTEM REPORT
JA P.! ~ 7
- Sr CRQX
OWNER ,n,.4) COUNTY
,,X ZONING OFFICE /
ADDRESS
SUBDIVISION / CSM# S ~J LOT #
SECTION -3b
r _T N-R lel W, Town of ✓f and
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
p . Lr
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d
17 c-
3~ r C
oA5(JgwSfbl~_
V ct,,
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: S C~-owl C' r~
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
6~4 67
Setback from: Well 17~ Other
Pump: Manufacturer A Modell Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
i
Width: Length Number of brenehes
Distance & Direction to nearest prop, line: -50, Svc
"7 i
Setback from: well: H u Other
' _
ELEVATIONS
Building Sewer ST Inlet:--& ~i-5 ST outlet:
PC inlet j✓ PC bottom Pump Off
Header/Manifold 4033 ~ Bottom of system
Existing Grade /0 j616--!~'Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: J,56-~3
INSPECTOR: lam. 4`1173
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
~dfety and d Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 299145
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
LEWERER, DAVID RICHMOND
CST BM Elev.: Insp. BM Elev.: BM Description: / Cf If Parcel Tax No.:
Op - I`v ~vt ayr,' 026-1046-50-000
TANK INFORMATION ELOVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
, ZS~ Benchmar 17.5 /j7, /csv
Septic
-7
Dosi ng
Aeration " Bldg. Sewer
Holding Q Inlet
TANK SETBACK INFORMATION a/4Y Outlet S osS L /
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
'Septic Dl V\V / r NA Dt Bottom
Dosing NA Header / Man. 3 -75- 103•x/
Aeration ALA Dist. Pipe 13 q 100.25-
Holding Bot. System OJ /0z
PUMP/ SIPHON INFORMATION Final Grade 10.75- /tom-~
Manufacturer Demand Mao ►4 1/ 1.2°/
Model Nu ber GPM
TDH Lift`` Friction yeste TDH Ft
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
E RENCH Width Length / No. Of Trenches PIT No. Of Pik - -tnsoe Dia. Liquid Depth
bTM-ENSIONS lZ .S~ DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacture .
SETBACK
INFORMATION Type O r r CHAMBER Mode Ner: 's..
System: 325 V12 OR UNIT..-.
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s), x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length S# Dia. Spacing _ !21AA (.•r L 7G 3Jr~f
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over Depth Of >3'eeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LO TION: RICHMOND 15.30.18.230A,NE,SE 1536 HGWY 65
c,
Plan revision required? ❑ Yes No 7 g_> f ~S's
Use other side for additional information. ~j {
SBD-6710 (R 05/91) Date Inspector's Signat a rt. o.
Safety and Buildings Division
NOsconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave.
P.O. 7969
adBox
Madison, WI
WI 53707-7969
in accord with ILHR 83.05, Wis. Adm. Code M
Department of Commerce
• . Attach complete plans (to the county copy only) for the system, on paper not less County r-o `X
than $ 112 X 11 Inches in size. State Sanitary Permit Number
• See reverse side for instructions for completing this application cj I L-11,54 '
The information you provide may be used by oth r gov rlt a ency programs ❑ Chec if revision to previous application
(Privacy Law, s. 15.04 (1) (m)]. 754- 4N/ y. 6 State Plan I.D. Number
1. APPLICATION INF RMATION - PLEASE PRINT ALL INF RMATION q -7 -1-10 G7
Pyqperty n Name Properly.Wcation
114,4.5 / r W
U c ~1 4 3 1/4,'1~ T 3 0, N, R )
Pro pert Owner's Mailin Ad res~ Lot Number Block Number,^
9 -t O I\ V
City, Stat Zip Code Phone Number Sub vi qq AM o CSM Num
u > + B w\ W1 r- 5 p G ( Z(S )Q3 SOS It~ Nearest Road
II. TYPE F BUILDING: (check one) ❑ State Owned Q I
Public 1 or2 Family Dwelling - No. of bedrooms ► - Pt Town OF
Number(s)
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax /a SD
1 Apartment/ Condo ~S• 410. /O - a 304
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
rs ❑
3 ❑ Campground 7 Merchandise: Sales./ Repai 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)
New 2. Replacement 3. E] Replacement of 4. Reconnection of 5. Repair of
A) 1.X System System Tank Only______________ ExlstingSystem 9 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 21 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
❑ 42 ❑ Pit Privy
12 E] Seepage Trench 22 ❑ In-Ground Pressure 43 E] Vault Privy
13 E] Seepage Pit
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. E. Final Grade
IN f-1 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ~O a~ t d Elevation
Feet
Al QV41 ~ 7.5 Fee . T
VII. TANK Capacity Site Fiber- Exper. Prefab. in gallons Total # of Manufacturer's Name Concrete Con- Steel glass Plastic App
INFORMATION New Existing Gallons Tanks structed
Tank Tanks ❑ ❑ ❑ ❑ El
Septic Tank or Holding Tank ELI 1:1 El 1:1 ❑ 11 El
Lift Pump Tank /Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installa ' n of the onsite sewage system shown on the attached plans.
Plum 's Signatur :(No ps) ifs/MPRSW No.: Business Phone Number:
=bee m e: (PY C o -7
IJ
Plumber's Ac dress (Street, City, tate, Z Code): t O /
IX. COUNTY / DEPARTMENT USE ONLY
Disapproved sl itary Permit Fee (includes Surcharge fee) Groundwater ate Issued Issuing Agent Signature (No Stamps)
❑ ~O /
Approved ❑ Owner Given Initial `
Adverse Determination 11
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber -
SBD-6398 (R.1 1/96)
INSTRUCTIONS
t.
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable-
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your ornsite sewage system, contact your local code administrator or the State of
Wisconsin,, Safety-and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
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.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material- Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches fnust 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.
PRIVATE SEWAGE SYSTEM Department of Commerce
Safety and Buildings Division
REVIEW APPLICATION Bureau of Integrated Services
Hayward Office LaCrosse Office Madison Office Shawano Office Waukesha Office
209 W. 1st St. 2226 Rose S!r,.-! 201 E. Washington Ave. 1340 E. Green Bay St. 401 Pilot Court, Ste. C
Rt 8, Box 8072 La Crosse, N" 113 P.O. Box 7969 Suite 300 Waukesha, W153188
Hayward, WI 54843 Phone (608) 1334 Madison, WI 53707 Shawano, WI 54166 Phone (414) 548-8606
Phone (715) 634-4804 Fax (608) 785-9330 Phone (608) 266-3151 Phone (715) 524-3626 Fax (414) 548-8614
Fax (715) 634-5150 Fax (608) 267-9566 Fax (715) 524-3633
INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this form
together with fees and piansMformation. Your submittal must be received at least two working days prior to the appointment at the office where your review
was scheduled. Please call any of the listed offices If you need help filling out the form or have questions o wha f ation to submiL PLEASE PRINT
VERY CLEARLY. A sample of a completed forth Is on the reverse side for your reference. ~fl
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1)(m)). l•/ 67 6
1. APPOINTMENT INFORMATION - If you have scheduled an appointment, fill in the information requested below to save time:
App tment Date Reviewer Na a Plan Identification Number
30 ~
2. PROJECT INFORMATION If this review is a revision or xtension to your existing
' plan Identification number, provide that number here:
Proj Name County
❑ City ❑ Village Town of.
9 k M 6yA L1 VAVA 1 '01
Project Location D (
O`rG` ~ ~ C ~'d ~X
GOVT. LOT JJ a 114 Sr- 1 /4,S 15T30 N,R l ~l ftr) W R i CUNY%
3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED
System Type (check one): System Type' (include new and existing tanks) 10
A ❑ At-Grade Up To 1,500 gallon septic tank ...............................:$110.00...................... a
H ❑ Holding Tank 1,501 - 2,500 gallon septic tank .....................................$120.00......................
M ❑ Mound 2,501- 5,000 gallon septic tank .....................................$160.00......................
N Non-Pressurized In-Ground (Conventfonaq 5,001- 9,000 gallon septic tank .....................................$200.00......................
P ❑ Pressurized In-Ground 9,001 -15,000 gallon septic tnik .....................................$300.00......................
0 ❑ Other. Over 15,000 gallon septic tank .....................................$500.00......................
Up To 1,000 gallon dose chamber 70.00......................
Building Type (check one): 1,001- 2,000 gallon dose chamber 80.00......................
D ❑ Dwelling,1 or 2 Family 2,001- 4,000 gallon dose chamberRECelv.C.....$100.00
P Public Building 4,001 - 8,000 gallon dose chamber .Q.$120.00......................
S ❑ State-Owned Building 8,001-12,000 gallon dose chamb@ . $140.00
Over 12,000 gallon dose ct@mber j... Z~...~..~~.$160.00
Up To 5,000 gallon holding to ff ! &..U.LUGS,..p.1IVo.00
-7 Or) Code Derived Daily Flow gpd 5,001-10,000 gallon holding tank ...................................$100.00......................
Over 10,000 gallon holding tank ..................................$150.00......................
❑ Check If Replacing Existing System Experimental System (additional one time fee) ................$300.00......................
Revisions to Approved Plan s x0.00......................
Petitions for Variance: Setback ...................................$100.00....................
❑ Petition for Variance Site Evaluation .........................$225.00....................
Plumbing ..................................$225.00......................
Revision 75.00......................
❑ Groundwater Monitoring Groundwater Monitoring - Per Site 60.00......................
other than a roosed subdivision
❑ Site Evaluation In Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring 60.00
Subtotal: Priority Review. Enter same amount as Subtotal:
MAKE ALL CHECKS PAYABLE TO:" SAFETY AND BUILDINGS DIVISION Total Fee: . 116
S. SUBMITTING PARTY INFORMATION
Telephone No. (include area code 8 extension) any Name Contact Person
ex CA CX AA~
No. 8 Street Addressor P.0 Box City, Town or V'lla a State Zip Code
Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and do a chambers.
2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals.
NOTE: Fees are pursuant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually. OVER
SOD-6748 (P. 07/96)
Plb. 60 '
1/78
PROJECT DETAIL DATA SHEET
NAME OF BUSINESS.. EA).Mard
LEGAL DESCRIPTION _ S7Z5 ~ j, ' M& C-) OWNER _"mod f~2 L&_ ~ y-, E=r MAILING ADDRESS /O ~q /30'40
2.
AU0R/C"rMd' (1-117IP 5"5/Di7
ARCHITECT, ENGINEER, 0,J)IV~ •~c~e-rS T" ADDRESS
PLUMBER OR DESIGNER RJG~yn U}-tz IP 5Y 0
TELEPHONE NUMBER 7 /S` _ o~6 r,S/ 3
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed. Please consult Section H 62.20.
Existing building New building x Addition
( ) Apartments and condominiums . . . . Number of bedrooms
( ) Assembly hall . . . Seating capacity
( ) Bar . . . . . . . . . . . Seating capacity # of meals served
( ) Bowling alley . . . . . . Number of lanes ( ) With bar
( ) Campground and camping resorts . . . Number of sewerea s tes
Number of unsewered sites
Total number of sites
( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons
( ) Day and night Number of persons
Catchbasin Number
( Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons
( ) Dance hall ( ) With kitchen Number of persons
. Number of persons
( ) Dining hall . . . . . . . . Number of meals servec daily
( Dog kennels . • . . . . Number of enclosures
Drive-in restaurant . . . . Inside seating caPaciY
Car-service Number of car spaces
H Dump station . . . . Number of dump stations
Employees ( total of all shifts) Number of employees 4~:
Hotel O Motel O Cottages . . . . Number of units, with 2 persons per unit
Number of units with 4 persons per unit
( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff
Number of office personnel
Number of patients
( ) Mobile home parks . . . . . . Number of sites
( ) Nursing homes . . . . . . . . Number of beds
( ) Parks . . . . Number of persons ( ) Toilets ( ) Showers
( ) Restaurant . Seating capacity
( ) Dishwasher and/or disposal?
( ) 24-Hour service
Retail store . Total number of customers
Schools . . . . . . . . . . . Number of classrooms __FT Meals ( ) Showers
( ) Self service laundry . . . . . . . Total number of machines
( ) Service station . . . . . . . . . . Number of cars served dairy
( ) Swimming pool bathhouse . . . . . . Number of persons
( ) OTHER . . . (Specify) . . . . . . .
COMPLETE OTHER SIDE
2. 'Indicate whether the following facilities are present.
Floor drain yes no Number of drains
Food waste grinder yes no
Dishwasher yes no
Automatic clothes washer yes no Number of clothes washers
3. Septic tank capacity _ JaSp c~-l Wes,
Holding tank capacity
Septic or holding tank manufacturer.
4., SEEPAGE TRENCHES: total square feet width of trenches
length of trenches depth
number of trenches
SEEPAGE BEDS: total square feet 75, width
length of bed depth r6 aoc k
SEEPAGE PITS: total square feet outside diameter
depth below inlet
total depth from top to bottom of pit
Signature of p n completing form: FOR DEPARTMENTAL USE ONLY
Address 1691 R rc ~l cy. z i P Sya / 7
Telephone Number } j S-- 41,6 Date _ ZQ --/D -
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fifth Alt InIth And Optbrrollon pipe
uwm 12'Abovo ~APPvovbl Von$ Cot
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20. 42• Above Plpp „ 1' Cast bon
To final coeds Vonl pipe
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OR MARSH 1{qy
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DISTRIOUTIOU PIPE T LEh qUU AT LCASTLO 11J-HE C BUT 1,10S IJ
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"~CHES BELOW ORIGOJAL GRADE
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M OfTrlt of ExcAv^rImN Ro» 14IItqL GRAADA WILL AD WILL BE IuCHES
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DATE:
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Wisconsin. Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of ~
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
IL
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. 026-1046-50
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R VIEW VD BY DAT
r '°C?
PROPERTY OWNER: PROPERTY LOCATION
Wm. Derrick Sr. Construction Tnc. GOVT. LOT NE 1/4SE 1/4,S15 T 30 N,R 18 E3jor) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK# SUED. NAME OR CSM #
1505 Hy. #65 5 na csm endin
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE EITOWN NEAREST ROAD
New Richmond, WI. 54017 (715)246-2320 Richmond St. HY. #65
jc ] New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building
] Replacement [x] Public or commercial describe plumbing shop, 4 employees, 1 floor drain
Code derived daily flow 130 gpd Recommended design loading rate .4 bed, gpd/ft2 .5 trench, gpd/ft2
Absorption area required 325 bed, ft2 260 trench, ft2 Maximum design loading rate .4 bed, gpd/ft2 .5 trench, gpd/ft2
Recommended infiltration surface elevation(s) 102.40 ft (as referred to site plan benchmark)
Additional design / site considerations --alt. area system el.= 102.40' & 101.20'
Parent material spitted outwash plain 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 fors stem CRS ❑ U CRS ❑ Ll iE7 S ❑ U 0 S ❑ U ❑ S CCU ❑ S C3il
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GP /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0-11 10 r3 4 none 2msbk mfr CrW if .5 .6
2 11-26 7.5 r4/6 none sici lcsbk mfr if .2 .3
Ground 3 26-84 7.5 r4/6 none is os mvfr na na .7 .8
elev.
105-6i ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0-9 Ol r3 4 none 1 2msbk mfr crw if .5 .6
2 9-25 10 r4/4 none scl lcsbk mfr (TW if .2 .3
Ground 3 25-60 7.5 r4/4 none si lcsbk mvfr CrW na .4 .5
elev. 4 60-80 5 r4 4 none sl lcsbk mfi na .Iia" 5
109 - 5 ft. ,
Depth to
limiting 1~`~' ` 1dEQ
factor
+80" 7
Remarks: sT G~
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 S' Z
Address: 1554 200th. e. New is nd WI 54017
Signature: Date: 5-8-97 CST Numbe .
PROPERTYOWNER Win. Derrick Sr. Const. SM DESCRIPTION REPORT Page_2__~of 3
PARCEL IA # 026-1046-50
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPU/ft
Boring # Horizon in Munsell Cu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 1 0-10 10 r3 3 none 1 2msbk mfr Crw if .5 .6
2 10-25 7.5 r4 4 none scl lcsbk mfr if .2 .3
Ground 3 25-78 5 r4/4 none sl lcsbk mfi na na .4 .5
elev.
105.4 ft.
Depth to
limiting
factor
+78"
Remarks:
Boring #
1 0-10 10 r3 3 none 1 2msbk mfr if .5 .6
w:: 4•..: ' 2 10-22 7.5yr4/4 none scl lcsbk mfr 9w if .2 .
3 22-50 7.5 r4 6 none s os mvfr na .5 .6
Ground
elev.
104. 2 ft 4 50-78 7.5 r4 6 none sl lcsbk mfi na na .4 .5
.
Depth to
limiting
factor
+78"
Remarks:
Boring #
1 0-9 10 r3 3 none 1 2msbk mfr if .5 .6
2 9-17 7.5 r4 4 none sicl lmsbk mfr if .2 .3
Ground 3 17-80 7.5 r4 4 none sl lmsbk mfr na na .4 .5
elev.
103.4 ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
t STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Wm. Derrick Sr. New Richmond, WI 54017
MPRSW 3254 NE4SE4 S15-T30N-R18W (715) 246-6200
town of Richmond
lot #5-csm
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ACCESS EASEMENT °o N TT-
o- F 0.48 Acres - o - o rt
•°0 21,121 Sq. Ft. C I~ 6
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SURVEYOR'S CERTIFICATE
I, Douglas J. Zahler, Registered Wisconsin Land Surveyor, hereby
Certify that by the direction of Bill Derrick, I have surveyed and
mapped a part of the NE1/4 of the SE1/4 of Section 15, Township 30
North, Range 18 West, Town of Richmond, St. Croix County, Wisconsin;
described as follows:
Commencing at the 81/4 corner of said Section 15; thence SOO037140"E,
along the east line of the SE1/4 of said section, 845.00 feet; thence
S89056120"W, 55.00 feet to the west right-of-way of State Trunk
Highway 1165" and the point of beginning; thence continuing
S8905612011E, along the south line of Lot 4 of Certified Survey Map
recorded in Volume 5, Page 1454 at the St. Croix County Register of
Deeds office, 660.00 feet, to the SW Corner of said Lot 4; thence
SOO037140"E, 264.02 feet; thence N89056120"E, 660.00 feet; thence
NOO037140"W along said right-of-way, 264.02 feet to the point of
beginning. Described parcel contains 4.00 acres (174,245 Sq. Ft.).
Above described parcel is subject to all easements, restrictions and
covenants of record.
I also certify that this Certified. Si;-vey Map is a correct
representation to scale of the exterior boundary surveyed and
described; that I have fully complied with the provisions of Chapter
236.34 of the Wisconsin Statutes and the Land Subdivision Ordinance of
the County of St. Croix and the Town of Richmond in surveying and
mapping same.
26K- C, /6; /'Q 7 OF WISc
Dougl er RLS 2145 ,t4. O
S & N Land Surveying ,P,v DOUGLAS J. ~(P
212 Walnut St. cry ZAHLEA _
Hudson, WI 54016 * S-2145
HUDSON,
f'9 Wis.
sum
Each parcel shown on this map is subject to State, County and Township
laws, rules and regulations (i.e., wetlands, minimum lot size, access
to parcel, etc.).. Before purchasing or developing any parcel contact
the St. Croix County Zoning Office and appropriate Town Board for
advice.
ACCESS RESTRICTIQK CT-:,USE
As owner, I hereby restrict all lots, in that no owner, possessor,
user, nor licensee, nor other person shall have any right of direct
vehicular ingress and egress with S.T.H. "6511, as shown on the
Certified Survey Map; it being expressly intended that this
restriction shall constitute a restriction for the benefit of the
public according to Section 236.293, Wisconsin Statutes, and shall be
enforceable by the Department of Transportation.
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER .S- w 7-kE-L
MAILING ADDRESS ( Q L CI I -b d U rl t--
PROPERTY ADDRESS 1536 ~ 1'1f ' kd ito Np , Uj .
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE eW_lei (-k 0&0 W) (A) i S" fJ sj IJ S go 17
PROPERTY LOCATION lI f _ 1/4, -S J~ 1/4, Section, T_3 0 N-R _E~_W
TOWN OF i C~h1~r~ n c . ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER S
CERTIFIED SURVEY MAP VOLUME 1,;~, PAGE3 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 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
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: Lfr~
DATE: /U ~~3dt N r.~z, f 1 N77
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 ,'11/93
t • 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 LJc~v l,~ e r~ II
Location of property 1'~E 1/4 S< 1/4, Section is T3jD N-R W
Township kMailing address (30
\
~Z c C l
Address of site ~5 w
Subdivision name Lot no.s
Other homes on property? Yes No
c c
Previous owner of property Lo
Total size of property = a,~
Total size of parcel d.~ CA .
Date parcel was created - (V
7
Are all corners and lot lines identifiable? Yes No
Is this property being developed for ('spec house)?, Yes __X-No
volume /,a(aS and Page Number .0xl_ 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 AND 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 S U/ , 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 office of the County Register of Deeds as Document No.
so
Signature of App icant / Co-Applicant
Date of Signature Date of Signature
STATE BAR OF WISCONSIN FORM 1 - 1982
566541 WARRANTY DEED
r DOCUMENT NO.
This Deed, made between REG~ST~ (~~F~W
William H Derrick and Diary Ann Derrick- husband and wi f ST, ST6I1 OO I
Read for AegA
Grantor,
j and David M Lewerer and Evelyn D. Lewerer, husband OCT 0 6 1997
and wife
Grantee, Register of Doode ipw
Wi nesseth, That the said Grantor, for a valuable consideration
j. one do lar and other valuable consideration
THIS SPACE RESERVED FOR RECORDING CATA---
I conveys to Grantee the following described real estate in St. Croix
Ij County, State of Wisconsin: NAME AND RETURN ADDRESS
I)AUia m Lti~>r2~i~
'
Sao `7
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Pending, Part of 026-1045-50 ~
PARCEL IDENTIFICATION NUMBER Ii
i i
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Part of the NE 1/4 of the SE 1/4 of Section 15, Township 30 North, Range.~.18,West, !
Town of Richmond, St. Croix County, Wisconsin further described as: Lot 5, Certified
Survey Map filed 7-23-97 in Volume 12, Page 3308, as Document No. 562759.
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I This is not homestead property. I~
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And William H. Derrick and Mary Ann Derrick
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except II
covenants, reatrictionsaand easements of record, if any,
and will warrant and defend the same.
l 97
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Dated this ~ day of ,19
(SEAL)
J
(SEAL)
William H. Derrick « Mar Ann Derrick
i
(SEAL) (SEAL)
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ACKNOWLEDGMENT
II AUTHENTICATION
State of Wisconsin,
Signature(s) ss.
St. Croix i~
County.
I