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Parcel 038-1172-80-000 04/14/2005 07:36 AM
PAGE 1 OF 1
Alt. Parcel 29.31.18.843 038 - TOWN OF STAR PRAIRIE
Current X I ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
JEROME JR & HEIDI ANDERSON `ANDERSON, JEROME JR & HEIDI
1987 NIGHTHAWK DR
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1987 NIGHTHAWK DR
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.970 Plat: 0202-COUNTRY LIVING
SEC 29 T31N R1 8W PT NW NE LOT 12 COUNTRY Block/Condo Bldg: LOT 12
LIVING 5.97 ACRES
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
08/15/2002 687137 1949/447 WD
07/23/1997 1187/16 WD
2004 SUMMARY Bill M Fair Market Value: Assessed with:
31034 262,000
Valuations: Last Changed: 10/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.970 51,900 221,700 273,600 NO
Totals for 2004:
General Property 5.970 51,900 221,700 273,600
Woodland 0.000 0 0
Totals for 2003:
General Property 5.970 25,400 141,800 167,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
f ~
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
~c 2
ADDRESS
SUBDIVISION / CSM# LOT #
SECTION .2 T,2/ N-R l W, Town of
ST. CROIX COUNTY, WIS SIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Jn~ f-/o vsC
xo~
~ r
Id
BfJ~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
~ t
BENCHMARK : ' o ,Q l HS - Ali > ' [CdL~
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: 11154)j ja
Setback from: Well '7Z House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 4_ Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well:-- House- Other
ELEVATIONS
Building Sewer 9 S ST Inlet: ST outlet: }K
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: - 97
PLUMBER ON JOB: - l
LICENSE NUMBER: S~
INSPECTOR:
3/93:jt
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 No.:
GENERAL INFORMATION 284310
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
STONE, SCOTT STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
,s_~ 038-1172-80-000
TANK INFORMATION ELEVATION DATA ACMInnfln
TYPE MANUFACTURER CAPACITY STATION BS Hl FS ELEV.
Benchmark
Septic
Dosing S
Aeration Bldg. Sewer ,0 ; 43 "
Holding St/ Ht Inlet 3 (oL '
TANK SETBACK INFORMATION St/Ht Outlet a~~' 93?9'
Verit
TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Septic -/Q `2 ~"7' NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe 90,7 '
Holding Bot. System p, CJ Q1, 91,
PUMP/ SIPHON INFORMATION Final Grade , .S. S S
Manufacturer Demand
Model Number GPM
TDH Lift Fr' ion System TDH Ft
Head
Forcemain Le gth Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O 1U_zW,J CHAMBER Model Number:
System: 02 -7 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 I xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges s, Topsoil ❑ Yes C] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE.29.31.19,NW,NE NIGHT HAWK DR LOT 12
Plan revision required? ❑ Yes No
Use other side for additional information. /7 1971 1)))00121 1- ; '`J Oil
SBD-6710 (R 05/91) Date In , or's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH Y a
SANITARY PERMIT NUMBER: '
..I.I.•w~~" SANITARY PERMIT APPLICATION Safety and Buildings Division
Bureau of Building Water System!
In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave.
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 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Nuum er
The information you provide may be used by other government agency programs 'Q p ` s ` O
[Privacy Law, s. 15.04 (1) (m)). ❑ Check if revision to previous application
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property wner ame Property Location
. /4 - 1/4, 5 T . N,
E (or&
Property wner's Mailing dress Lot Number /
Block NurrylSer
City Zip oclPhone Number Subdivision me ISM Nu ber
II. TYPE F UILDIN : (check one) ❑ State Owned ❑ Ity Near aad
,
Public 1 or 2 Family Dwelling - No- of bedrooms _ village
Town OF
Z_ A
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) p
1 ❑ Apartment/ Condo
2 t • l~. t g_ ~`T~j ~o~
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10E] 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 online B, if applicable)
A) 1. Z SyNew stem 2. ❑ System 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
___Y=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
1 ~ Seepage 21 E] Mound 30E] Specify Type 41 Holding Tank
Page T 22E] In-Ground Pressure 42E] Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14E] System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp- Area 3. Absorp- Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade
Regl re (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./y~ich) Elevation
Feet Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Prefab. Site Fiber- Ex per-
New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber LJ
I -1 ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility for inst ation of the onsite sewage system shown on the attached plans.
Plum er' a7(P f ) Plumber' Si to S m MP/MPRSW No.: T~inhon
use
ss Pe Number:
P umber's ddress (Street, City, tate, Zip Codpj.
^f
fC~ n
A J__
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved sanit ry Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
(Approved ❑OwnerGivenInitial Surcharge Fee)
Adverse Determination 0
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 0"4) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS y
1. A sanitary permi t 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 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.
---------7------------------------------------------------
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.
A)YV
/~-~iYA~~~/,%~~~ .x'-.9-~LUbib S'Nfit•%~/~.CA,~5~1f~ ~/~i~ ,
-97
i
ctr Gg `
- i i
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
Labor and t` rnan Relations
Djvision of safety & Buildings in accord with ILHR si Code COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inche 'e. Plan- 9e4nclude *ut~
not limited to vertical and horizontal reference point (BM), directi ~rar~d % of sib} gt;&tle or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest gad.
REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFQFi[ATION
t.
PROPERTY OWNER: - F,RTY LOCAT
U~CPT~,~C~T 1/4,S~ T N,R E (or
PROPERTY OWNER':S MAILING A DRESS f t4 S D. NAME OR CSM
CITY, STATE ZIP cDE PHONE NUMBER VILLAGE ~f )WN INEATIESTROAD
g.T- 7111 07y,
New Construction Use ],4 Residential / Number of bedrooms [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow. 7~~J gpd Recommended design loading rate • 7 ed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) 9S It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable It
S =Suitable for system COVvVENTIONAL MOUND 717 ROUND PRESSURE AT GRADE SYSTEM II FILL HOLDING TANK
U=Unsuitable for s stem ®S ❑ U EKS ❑ U S❑ U S❑ U ❑ S fl~U El S U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
Ground
elev.
~ZEZft.
Depth to
limiting
~
factor
Remarks:
Boring # S• .5
01
3
Ground /
elev
Depth to
limiting
Remarks:
CST Name:-Please Print Phone: 6
Address: Oct f, Signature: Duet _ CAT Nu ber:
PROPERTYOWNER G /ld,~~fl" 4 ,~/iJB01L 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 Trench
0-9 ld~jr,21n , s
Ground W 7,F
pellev
Depth to
limiting
factor
7~
Remarks:
Boring #
Ground
v.
Depth to
limiting
C2' 0 Remarks:
Boring #
5 C - -7
Ground
ev.
ft.
Depth to
limiting
factor
S Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
M f
Soil Test Plot Plan
Project Name Charles Borgstrom Byro Bird Jr.
Address 2033 Co. Rd. C
Somerset Wi 54025
M #3479
Lot 12 Subdivision Country Livin Date 8/31/94
NW 1 /4 NE 1/4S29 T 31 N/R19 W Township Star Prairie
Ej Boring O Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Base of Wood Stake Red Ribbon
System Elevation 95.9 * H R P Same as Benchmark
330' 620' to Property Line
5'
z
x M.
C.
0
B-1 60' Pri A
30' _ a-2
15' B-3
'
15'
Rep A
B-4 -5
% Slope
. t
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS 53 cl 5, (t-,~1S5e v Lam. / 305
PROPERTY ADD rNI 6& #4t"' bA. l0r /z
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE _ Itm ~'•9 (J63 PROPERTY LOCATION 1/4, J F 1/4, Section, T- ~_N-R~ W
TOWN OF ST. CROIX COUNTY, WI
Y
SUBDIVISION COV/4-Ky Li lffN l LOT NUMBER 7-
CERTIFIED SURVEY MAP , VOLUME 6 , PAGE Z I , LOT NUMBER Z
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: o GI
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
• 8 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 S 0-0-d- Aj'o AI E-
Location of property &l/4 1/4, Section,,?9,T~_N-R~-W
Township ,5)4k ILRX Mailing address n!j 5< Wf~ 50 / Lit/
~
f ~ I Lf - K S v✓ .5 %7i Z '
Address of site u/K bKitj;-
Subdivision name 00o/V9 V 1 WA)6, Lot no. Z-
Other homes on property? Yes ~ No
Previous owner of property ff4--AL~3 3a~ `Ci 4/~I
Total size of property q7 &K~S
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? X Yes No
Volume IJ 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.
Signature of Applicant Co-Applicant
/,0/17 A~
Date o Signature Date of Signature
WARRANTY DEED
Document Number p
16 T C~SC
11~7PA,!
5116032 ST. CROIX Cr(., i
Return Address J UN 2 i 9
at 10.30 A
Peg s!-3r .
Parcel I.D. Number: 038-1172-80
-Ids
Charles H. Borgstrom and Dolores Borgstrom, a.!k/a Dolores S. Borgstrom, husband and wife, conveys
and warrants to Scott R. Stone and Andrea L. Stone, husband and wife, the following described real estate
in St. Croix County, State of Wisconsin:
Lot 12, Plat of Country Living in the Town of Star Prairie. St. Croix County. Wisconsin.
This is not homestead property. *f
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this TRANSFER
- 20 day of June, 1996. $ .5,5-0 _
FEE-
f,, ;~EAL)
(SEAL)
-
Charles H. Borgstrom DikAt -es Borgstrom, a/lJa 1 lores S. Borgstrom
AUTHENTICATION '
Signature(s) Charles H. Borgstrom and Dolores
Borgstrom, a/k/a Dolores S. Borgstrom, husband and
wife, authenticated this 2D`s'`" day of June, 1996.
Kristina Ogland
TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristina Ogland
Hudson, WI 54016
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