HomeMy WebLinkAbout030-2073-70-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER0Tr
ADDRESS /fo
SUBDIVISION / CSM# CS/'~ ✓nL_ .2 555 LOT # 3
SECTION ?~T 30 N-R o?!o W, Town of ~T moose)014
ST. CROIX COUNTY, W SCONSIN
PLAN VIEW
SHOW EV YTHING WITHIN 100 FEET §F SYSTEM
f( ~)E5ti~ICN/L9A7?I! So/~'t i/V /•2" A.
~RoO~PfY -re4E i Etc' U. _ /00.00,
WELL
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L '5 7z~'
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QQoP QoxFs
INDICATE NORTH ARROW
/~cc 4rN~.P lPkovlR~Y ~~,~€s ooze /oo' /Jo !5c,ELE
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1 0
BENCHMARK: JN V ' OA T~~ • = /Oo. ov
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: I-J.ESFR Liquid Capacity: /000
Setback from: Well 4-'3 House Other -
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S Length Number of trenches
Distance & Direction to nearest prop. line: 3G' G~JcSr
Setback from: well: House Other
ELEVATIONS
Building Sewer ~9'• " ST Inlet, ST outlet g y '
PC inlet PC bottom Pump Off
Header/Manifold rJ~ 35" Bottom of syste /477,5-1
Existing Grade 5-6, D 1Av&.Final grade Q. Cr.)
DATE OF INSTALLATION:. '7
- 1 - 9~
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
rtmentofindustry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284,274
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
FOLEY SCOTT J & JOHNSON JANICE AST JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
app, 007 j0 0 -00 030-2073-70-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI ~FS ELEV.
Septic 1 y~ Benchmark ~Gb<00
Dosing
Aeration Bldg. Sewer a~ -7910-
Holding St/Ht Inlet j
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. vent to ROAD Dt Inlet
Airlntake
Septic sZS' NA Dt Bottom
1 4 . 7,71-, ~ z
Dosing NA Header /Man. / , 3.37
-17.17
tF.35r Aeration NA Dist. Pipe
Bot. System S`~ v;os'
Holding
PUMP/ SIPHON INFORMATION Final Grade ~a.3}' So aD
Manufacturer Demand
Model Number GPM
TDH Lift Fri * n System TDH Ft
Forcemain gth Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH 2YS LeKP/LBLDG Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 DIMEN I N Manufacturer:
M TO WELL LAKE / STREAM LEACHING
INFORMATION J SETBACK CHAMBER Model Number: IxeAd ja
OR UNIT
~LP/~+~
DISTRIBUT ION 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 p°t~7 Bed/Trench Edges Topsoil E] Yes E] No E] Yes El No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST JOSEPH.36.30.20,SE,SE 1216 COUNTY ROAD V LOT 3
Plan revision required? ❑ Yes [a-No
Use other side for additional information.
ignature Cert. No.
LIZ LA I 2j 21 SBD-6710 (R 05/91) Date I
r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT ,Sf
,1 R TRANSFER/RENEWAL UNIFORM PERM.
(PLB 67-~ ~y~ y
PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMB
PROPERTY LOCATION: Cl
CI
'/4 '/4,S ,Tp N R E (or TOWN OF
LO NUMBER: BLOCK NUMBER: SUBDIVISION NAME:
NEAREST ROAD, LAKE OR LANDMARK:
~',i'/~7 VOL S
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED):
SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME:
PHONE NUMBER:
DDRESS: PHONE NUMBER: ADDRESS:
1, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
property.
PLUMBER'S NATUR
PREVIOUS MBER'S N E (IF CHA GED):
PLUMBER'S D PREVIOUS PLU ER'S ADDRE
/ PRSW NUMBER: PHONE NUMBER: MP/MPRSW NUMBER:
PHONE NUMBER:
SIGfV~tTURE OF ISS NG AGENT: DATE APPROVED:
DISTRIBUTION: Original -County
-~-y 7 Copy - Bureau of Plumbing
~R-SBD-6 9 (R. /82) Copy -Owner
Copy -Plumber
;
Safety and Buildings Division
~•■`r■■, SANITARY PERMIT APPLICATION Bureau of Building Water System!
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 0_/
than 8 112 x 11 inches in size. ~'T (ieo/X
• See reverse side for instructions for completing this application State Sanitary Permit Number
~O
-LC
The information you provide may be used by other government agency programs ❑ Check if revision to pr vious application
(Privacy Law, s. 15.04 (1) (m)]. /a i 4 cly. Rd V Wud• State Plan I.D. Number
1. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION
Pro rty Owner Name Property Location
r t .,~SO A.1 C 114 114, S (o Tip , N, R oZ0 E (or)~
Property Owner's M (ling Address Lot Number Block Number
City State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned It Nearest Road
Public B-1-or 2 Family Dwelling - No. of bedrooms C] Vil age own of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo 3&. 30' a d ' to a5 O S d - as -7 3 - 74
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. Iew 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. PermiVNumber 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
12 Qa 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. S stem Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) -441 4l t,&4r4 ' krfevation
&y 1 14.2 -4 to- 9ho A___4 90b - 16- ,3' `Feet Feet a I' VII. TANK Capacity
gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank / U-4r' ' 4P-_r ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Prin _ Plu be ' ignature: (No Stamps) PRSW No.: Business Phone Number:
Plumber'sAddress (Street, City, State, Zip Code):
-5--5-4 V /ate e UC E~r+e~►nQ.e//! /
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing A ent Signatur (No St ps
pproved ❑ surcharge Fee)
Owner Given Initial
A, 15
dverse Determination Q ~Y
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
_,"y To: Safety & Buildings Division, Owner, Plumber
L~-K
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.
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 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.
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wiacgr►sin Department of Industry. SOIL AND SITE EVALUATION REPORT Page \ of
Labor and Human Relations -
Division of Safety S Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
S-r.
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
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. 030 - Z p 3 - 0
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: _ PROPERTY LOCATION
Scot r iPtLQ{ It ?t LL S>,t Sp N 6A1FF. 60T SEE 1/4 S F 1/4,S 3 6 T 3(J N,R Z,p E (or)W)
PROPERTY OWNER':S MAILING ADDRESS LOT ff BLOCK # SUBD. NAME OR CSM #r
ty 9-r* Yr- 3 - C-sm Vo\- z SS5
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE WOWN NEAREST ROAD
~'l~w►ptJ tts wl S~-1 S) (~1S) z3S ,344 9 s . S'o s~ C71~ ~ V `
New Construction Use [Xl Residential / Number of bedrooms y j AdditiQn to existing building
j j Replacement [ J Public or commercial describe
Code derived daily flow bcso gpd Recommended design loading rate bed, gpd/ft2 . S trench, gpdtft2
Absorption area required - bed, ft2 NZo o trench, 112 Maximum design loading rate'L_bed, gpd/ft2 5 trench, gpd/fl2
Recommended infiltration surface elevation(s) SOZ V:INGe 1-1 ft (as referred to site plan benchmark)
Additional design/ site considerations 3 'fVLE~ e1W- C?Re.H S' )L-'hQ' l_W G . 3tz It P} J- vP a Lo>>~_- ~OCnt_ .
Parent material L,o Q73% ovL~2 -Ti L.L Flood plain elevation, if applicable tv . R - It
S = Suitable for System DONyEMONAL MOUND ❑ U I® ROUND lU ESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem NS ❑U MO o s ❑ U ❑ S W U ❑ S _1 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rends
1 ) 31 - s) Zwt Soh MU~ cg S b
Z Cl -11 lWA Z 3J3 si } Z ~sbk m~F~ cw _ , s
Ground 3 1-) -3 Z 101 3! 6 . G~ S1 ~.s~h 1v1`1- c5 5 , b
elev.
°11.0tt y 3i_R8 -~.S`iR 3Cy - G~ S ` Sbh >n U~r • 4 •S
Depth to -
limiting
fact 98"
Remarks:
Boring #
~O`L0.3)Z 1 S I Zms~k rnv1~- a-S
Z 8 3$ tio\-j a- 3[L 31 2-~n s b h m u i~ cc_.~ • 5? b
Ground
elev.
$6.3 ft
Depth 0
limiting
factor
Remarks:
CST Name-please Print Arthur L. We erer Phone. 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: Date: CST Number:
L' 11 ~1tiZ ~l7 c i. q~-LIS")yl"1Z _7, 1~1`97 M00576
PROPERTYAWNER FQ~-~`f SOIL DESCRIPTION REPORT Page, of
PARCEL I.D. # O 3(3 - Z Q)1 - ^1 0
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
0-9 ~ 0 3 1 z - s 1 z►nsb mu cS s
3.
Z. 9-Z LD`tR 3 13 S21 Z ~SbYc rn Cw . S
Ground 3 1,4 -31 S `f R 31 S 1 1 5 D m
elev.
b ft. L/ )4? -7)•S `tR 3! - s ft [S 1 eS't>)r-\ v, u • ~L s
Depth to
limiting
factor
> 88"
Remarks:
Boring #
-
0-~3 ~o~i~ 312 L -2-M51 k YVrvi~- c- S - • 5
.
Z $-3~ lo`11Z 3!G - s) Zn1Sbk u`F~ c~ - -S
C3
3 30-BY ~-s`iii 3!y - s) tr lS 1 LS mU-k • L • S
Ground
elev.
ft.
Depth to
limiting
factor
> 9v
Remarks:
Boring #
o-~o lp~l23Lz _ s • ~m b m cg - •5
S Z Ib-ZI lo`i2 3!3 Grsi z-5b`rt w\~~ • S' '
Ground 3 ZI-~3 S`1R 3! g 1 1 eSb11 yM CA S
elev. 63 9S lo`i R- Y/6 _ S s s w, • 1 8
R~ ft,
Depth to
limiting
factor
q1 S"
Remarks:
Boring # s) Z s~k m v ~h a, S
6 2 &-3a ~o~t2_ 31~ \ e s",\-t- mv~tr Cw y S
3 38-1S z.5y ~ 31 _ S ~ G~,. o s9 ~ ~ .1 8
Ground
elev.
z .o ft.
Depth to
limiting
factor
'7
1ST
Remarks:
SBD-8330(R.05/92)
PLOT-PLAN Page 9 of
SCALE 130 ~Jc
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(715 ) 425 - a --6 9 1400576
CST Signature Date Signe Telephone No. I CST #
PROPERTY OWNER SOIL DESCRIPTION REPORT Page 3 of ,
PARCEL I.D. # O J O• Z D 3- -1 O
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence 8curci3y Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mach
0-S t o`1 tz- z L -L - L -yn v ~Fr- c S , s • b
Z S -I z. l ~t (L 31 b S 1 2 'F s bVt m `{h c S s• b
Ground 3 13Z.--Z7 ').S1,1IR 3)y G~ s 1 1 C S IC 1r, u f~.
;ySft.
Depth to
limiting
factor a
Remarks:
Boring #
E3 IZET---C~ tvo s St E SV~, t s~ s CI-9
U k o S a
Ground O>~►,1~\Z S T1 M~ L Mil U
elev.
ft. S~t SrZ1L g b 87 ~tzt~v~ v _
.
Depth to lZ ~f1 FO rU i'r LD=1' L /t `f1 l
limiting
factor
Remarks:
Boring #
E3
Ground
elev.
ft.
Depth to
fiaNng
factor
Remarks:
Boring #
Ground
elev.
It.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
p Al .S,-.1 kke--
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CERTIFIED SURVEY MAP
CERTIFIED
HIGHLANDS"
SECTION_ NORTH 1259.13' N
LINE C.T.H. "V" D=
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p X O I O O W N Pn Z WW cr
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z. 6 6' I O Z w J U J U J ~m X U
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to
o •
S 0°1235"W 666.99'
0 90°1648 302.61' 364.38'
ROAD EASEMENT ~d opt
cD
N 0° 12'35" E
223.00' cp.
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CERTIFIED SURVEY
I, Arthur L. Wegerer, registered land surveyor, hereby
certify: That in full compliance with the provisions of
Chapter 236.34 of £he::_Wisconsin Statutes and the provisions of
the St. Croix County Subdivision Ordinance and under the direction
of Boyd Emerson, owner of said land, I have surveyed, divided,
and mapped said parcel of land,.that such plat correctly represents
all exterior boundaries and the subdivision of the land surveyed;
and that this land is located in the SE 1/4 of,the SE 1/4 of
Section 36, T30N, R20W, Town of St. Joseph, St. Croix County,
Wisconsin, To-wit:
Lot 2 of the parcel recorded in Volume 2 of Certified Survey
Maps, Page 523. Being further described as commencing
at the Southeast corner of Section 36; Thence North (assumed
bearing) along the Section line 1259.131; Thence N 89°30137" W
652.021 to the point of beginning; Thence S 0012135" W
666.991; Thence N 89°30t37tt W 654.451 to the East line of
a parcel recorded in Volume 1, page 68 of Certified Survey
Maps; Thence N 0°25t0711 E (Recorded as N 1°001 E) 666.9$1;
Thence S 89°30'37'' E 652.021 to the point of beginning.
Contains 10.002 acres of land.
Dated this \Z- day of December, 1977• ~ t.
Arthur L. Wegerer
Wis. R.L.S. No S-963
Dittloff Engineering Co.
River Falls, Wis. 54022
%
'
ARTHUR L
Q WEGERER •
5-963
ELLSWORTH
. WIS.
0
•
N
• D SURDEJ
~
~~heuneee~t~
AIPROVAL OF T11,
M.-AN APP;,CVAL FOR
BUILDI,VG 6,T~ OR SEPTIC SY„ TEM
REFER TO H62.20.
APPROVE
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
/ St. Croix County
OWNER/BUYER J Q'~ l J
MAILING ADDRESS 7~ q • 7~
PROPERTY ADDRES V~
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, _5~ 1/4, Section 3, T-10_N-R aO W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER 3
CERTIFIED SURVEY MAP , VOLUME a , PAGE .5;0?3 , 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:
DATE: /3-Z7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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 ')5~
Location of property SE 1/4 SSE 1/4, Section 3~e ,T0 N-R oZ0 W
Township .24 Sae,Sb~ Mailing address
Address of site G~ ~~Is~ , (-J~
Subdivision name LA~j ~ " Lot no. 3
Other homes on property? Yes~No
Previous owner of property a~,L :Ik„/ D ~
Total size of property v3. ) SO J~S
Total size of parcel JVMnvw-
Date parcel was created 2 " d3-79 /921
Are all corners and lot lines identifiable? 2t Yes No
Is this property being developed for (spec house)? Yes 'V No
Volume 0~ 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 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. , 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.
i
Signature of A icant Co (~fppi
3-1-?17 3 3 III
Date of Signature Date A Si nature
STATE BAR OF WISCONSIN FORM 2 - 1982
5V ! WARRANTY DEED
DOCUMENT NO. ~
- - VOL 1~1 ~PArrl 7f .4~
Earl R Duckett and Janis G Duckett, husband and
wife. F.;coaaea~a .
- JAN. 2 0 1997
conveys and warrants to Scott J. Foley and Jill-A. Johnsw 11:45
'f{wlstar of U~ew
1
i
THIS SPACE RESERVED FOR RECORDING DATA
it NAME AND RETURN ADDRESS
the following described real estate in St. Croix County
~ I
State of Wisconsin:
~ Y l~ I ,{;"y
Y►bIYtL!,(I
030-2073-70
PARCEL IDENTIFICATION NUMBER i
Part of SE1/4 of SE1/4 of Section 36-30-20 described as follows: Lot 3 of
Certified Survey Map filed February 23, 1978, in Vol. "2", Page 555.
i f
TOGETHER WITH road easement Ps shown on said Certified Survey Map and on Certified
Survey Map in Vol. "2", page 523.
SUBJECT TO an easement for driveway purposes over Lot Three(3) of the certified
Survey Map recorded in St. Croix County Register of Deeds office in Volume 2 4 R
of Certified Survey Maps on Page 555, as Doc. No. 346802 as said driveway is
now laid out and travelled.
k h
This is not homestead property. "
XW (is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
January 97,; a t
Dated this dry of A.D., 1-9
Y K - '{~~LC n V4e (SEAL) ~t L ct GL1i t (SEAL) .t
Earl R. Duckett Janis G. Duckett '
(SEAL) (SEAL)
~I
AUTHENTICATION ACKNOWLEDGMENT I `
'v
Signature(s) Sttate of Wisconsin, se
u.
St. Croix`
County
authenticated this day of '19- r elonally came before me this dry of
-Taffutary 1 , ig 97 , the above named
Earl R. Duckett and Janis G. Duckett, ,
husband and wife
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by $706.06, Wis. Stats.) to iiiint known to be the person S who executed the foregoing
I iitt~aasezt and acknowledge the same. n
THIS INSTRUMENT WAS DRAFTED BY
i a