HomeMy WebLinkAbout042-1071-80-000
AS BUILT SANITARY SYSTEM REPORT
OWNER I?etl lip? rjvpfk TOWNSHIP (~✓QRQ~r2 SEC.XLT.2%-R IV W
ADDRESS Ro ke,K tS ST. CROIX COUNTY, WISCONSIN.
7
~ e.
SUBDIVISION LOT LOT SIZ
PLAN VIEW ' j`9lFa ~
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FgET OF SYSTEM °
ff] 3 v& 1'o d A6 I
Mdi( r h rr w
BENCHMARK: (Permanent reference Point) Describe:
Elevation of Aertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: 4/0,41GW. Liquid Capacity: !V y
Number of rinbs on colter _ Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle gallons; Total capacity of
distribution lines gallon: size of pump head;
gallon per minute horsepower ;brand name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Number of gallons _
Elevation of manhole cover
SAFETY & BUILDINGS
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR DIVISION
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING
P.O. BOX 7969`
M A D~SON, W 153707 ❑ A LTE R NATIVE r(if e Plan I.D. Number:
® CONVENTIONAL ssig ned)
' ❑ Holding Tank ❑ In-Ground Pressure ❑ Moun a
ION [1A3E:
F ADDRESS OF PERMIT HOLDER: N u CVO Q Nb
NAME O PERMIT HOLDER: Roberts, WI
Rev. Tim Wengert 7EF. T. ELEV.: CST REF PT. -V
BENCH MARK (Permanent reference point) DESCRIBE IF DIEFERENT FROM PLAN: J` 7.to~At1 Of Warren
NyJ~ NW14, Section 26, T29N-R18W, Lrot #1, Permit Number:
MP/MPRSW No.County ~13
Name of Plumber: 5184 St. Croix 1
Stephen Aaby
SEPTIC TANK/HOLDING TAUK: WARNING LABEL LOCKING COVER
a. LIQUID CAPACITY TANK INLET ELEV.: TANK OUT LET E PROVIDED PROVIDED
MANUFACTURER:
6~.,:~+/ u /~,U /tk(wa ❑YES ❑NO ❑YES ❑NO
~
!f P OP TV WELL BUILDING: VENT TO FRESH
HIGH WA •ER NUMBER OF ROAD: LI lA1R tNl ET.
BEDDING. VENT DIA.. VENT MATL: gLARM FEET FROM ~~~r•. lee ❑YES lJ O - gf ❑YES ❑NO NEAREST
DOSING CHAMBER: LIQUID CAPAC TY PUMP MOD L PUMP/SI H N MANUF UR WARNING LABEL LOCKING COVER
IE PROVIDED: PROVIDED:
MANUFACTURER: BEDDING: AYES ONO ❑YES ❑NO
❑YES ❑NO PROPERTY WELL. BUILDING: AER NLOET FRESH
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. ! BE OF LINE.
! FRET OM
(DIFFERENCE BETWEEN ❑ ST
PUMP ON AND OFF) ❑YES NEAR TAM ETER MATERIAL AND MARKING
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth Of plowing F R
or excavation. (If soil can be rolled into a wire, construction shall cease until M
the soil is dry enough to continue.) unuiD
DEPTH
CONVENTIONAL SYSTEM: NSIDE DIA #PITS
WIDTH` LENSiTH. NO. OF DISTR. P PE S ACING DE
. MAT IA L: PIT
BED/TRENCH a TRENCHES
DIMENSIONS PROP TV WELL BUILDING: VAERNI TOF
MBER OF LINE
GRAVEL DEPTH FILL D H DISTR. PI DISTR. PIPE DISTR. PIPE MATERIAL: POE FENUET FROM
2
BELOW P ES A E COVER. E. IN.~LET ELEV. END.
Z NEAREST in
MOU SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
ON REVERSE SIDE. SHOW ELEVA-
and furrows thrown upslope: mound systems to make certain that ON RE MEASURED.
meets the criteri medium sand. TIONS ❑YES ONO PERM E TMARKERS OBSERVATION WELLS
SOIL COVER TEXTURE
YES ❑NO ❑YES NO
SEEDED: MULCHED:
OVER TRENCH/BED DEPTH OF TO IL SODDED
. ❑
DEPTH OVER TRENCH/BED EDGES
CENTER S ❑NO ❑YES ❑NO ❑YES NO
PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER
WIDTH: LENGTH. NO. OF ATER SPACING: G VEL DEPTH B LOW PIPE
BED/TRENCH TRENCHES:
' ANIFO LD MATERI L NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
DIMENSIONS
MANIFOLD PUMP LEV PIPE PIPES . DIA.:
E LE V. . ELE V.. DIA ELE.-.
ELEVATION AND PERMANENT MARK VERTICAL LIFT CORRESPONDS TO APPROVED
DISTRIBUTION COVER MATERIAL: PLANS
INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY ❑YES ONO
r
YES El NO PROPERTY WELL: BUILDING:
❑
ERS: OBSERVATION WELLS: NUMBER OF COMMENTS: FEET F LINE:
ROM
❑YES ❑NO NEAREST
❑YES ❑ NO
7,77
44 P4-n
f
I
,rye!
Retain in county file for audit.
Sketch System on t ~
ITLE.
Reverse Side. SIGNATURE:
01
DILHR SBD 6710 (R. 01/82)
00=00.M APPLICATION FOR SANITARY PERMIT ~/couG COUNTY
1D' L H R (pEB 67) UNIFORM SANITARY PERMIT #
-V1 ^~EPRfiTRW,n.r or- AELPTIOI75 ' / /
NlpLrSTgV, LQB~ra 6 HI.IT~
Pfor the system, LEASE PRINT on paper not less than 8Y_ x 11 inches in size.
Attach complete plans in accord with s. H 63.0 5, is Ad. Code
-See reverse side for instructions for completing this application. MAILI NG AD , DRESS
5b,023 orts W1 PROPERTY OWNER ~ NG • SS Red' in ~d~~t CITY:
PROPERTY LOCATION VILLAGE: Warren
NW 1/41NW S 26 , T29, N, R E (or) W ld TOWN OF:
LOTNUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
peadiag CtY . Y
Y
TYPE OF BUILDING OR USE SERVED
❑ Public (Specify):
1 or 2 Family Number of Bedrooms:3
THIS PERMIT IS FOR A: ❑ New System Repair
El Tank Replacement Privy
❑
El Replacement Soil Absorption System Revision ❑ Reconnection El Petition for Modification
Alternate System
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑Seepaye Pit ❑ Holding Tank
1U Seepaye Bed ❑ Seepage Trench ❑ Pit Privy
❑ In-Ground Pressure ❑ Vault Privy
System-In-Fill
issued
❑ Existing, For Which A Previous Permit Is On File, Permit #
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditi Sit Steel Fiberglass Plastic
Total #of Prefab.
Gallons Tanks Concrete Constructed
1000 1 X.
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: W-4- eoaerete Froducta
#of ❑pM u d s eIn-GrounStPeressure Fiberglass Plastic
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK:
Total
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
PERCOLATION RATE
(Minutes per inch): REQUIRED 3cl. (Square PROPOSED
sq:Sgfuat. Feet Private ❑ Joint ❑ Public
4,.5. O 5J
I, the undersigned, hereby assume responsibility for installation of the private sewage stem shown on he atta Ned plans. Numb er:
Signature r) 514 hone 6'r+-240?
Name of Plumber (PrAnat)
Name of Designer: 3111 (715 )
3tepllen L. DY
Pl124rMaine5t•., aoodrille, WI 54026 Gtep- f As~b
COUNTY/ DEPARTMENT USE ONLY Disapproved
Signature of Issuing Agent: Fee: Date: LJ Owner Given Initial
/ Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
One Copy To, Bureau of Plumbing, Owner. Plumber
6ILHR S8D-6398 (R. 5,'82) DISTRIBUTION. Original to County,
r
CERTIFIED SURVEY MAP
JOHN H.W. & CLARICE GRAHAM
Part of the Northwest. 1 /4 of the Northwest 1/14 of' Sec t j on ~6, Township 20 North,
Range 18 West, 'T'own of Warren, St. Croix County, Wisconsin.
o Indicates 1" x 24" iron pipe weighing 1.13 lbs./lin. ft. set
UNPLATTED LANDS
N LINE NW 1/4
C C.T.H. TT - a
W
3
NW COR.SEC. 26,T29N.Ri8W. N99.19'09"E 233.00'
(COUNTY SURVEYOR'S MONJ a N p pW
= S
0
° 33.Od I 22 0.0-
~ o
_ 0 0
W =
UNPLATTED LANDS 3 a LOT I N t- °W
■ UNPLATTED LANDS
o
I N I- 1.728 ACRES ~ W r
75,199 80. /T. N It O
I W g N E T■ 1.293 ACRES W m
p Itl 68,314 SO. PT. 8 Y F
a ~
0 N n 8 0
O N
0 IL
O • W
I
O Z G C =
O dl N
& Z F
I N
3 I <
O
~ [33. 220.00' o
S89.19'09"W 253.00'
J LL
< O
UNPLATTED LANDS
- - SCALE I"•.100`_._.
W 1/4 CON. SEC 28,T29N,R18W, 0 so, 100' 200' 300'
(COUNTY SURVEYOR'S MON.(
DESCRIPTION:
That certain parcel of land located in the Northwest 1/4 of the Northwest 1/4 of
Section 26, Township 29 North, Range 18 West, Town of Warren, St. Croix County,
Wisconsin, more fully described as .follows;
COMMIENCING at the Northwest corner of said Section 26, the POINT OF BEGINNING of
the parcel to be herein described;
thence N 89° 19' 09" E on the North line of the Northwest 1/4 of said Section 26
a distance of 253.00'; thence S 00° 00' 00" E 297.251; thence S 89° 19' 09" W
253.00'; thence N 00° 00' 00" E on the West line of the Northwest 1/4 of said
Section 26 a distance of 21)7.25' to the POINT OF BEGINNING, containing 1.726
acres, more or less, being subject to easement over the Northerly 41.25' thereof
for C.T.H. "TT" R.O.w. purposes, and also being subject to easement over the
Westerly 33.00' thereof' for Town Road purposes.
State of Wisconsin)
County of Pierce)
7 T - . .w. • - - - -
Form - S T C 100
Owner of Property Barbara and Timothy jenp:ert
Location of Property NE 14 NB k, Section 26 ,T_29 N R 18 w
Township _ Warren
Mailing Address Roberts. Wiscon ;n 54023
Subdivision Name
Lot Number
Previous Owner of Property John Graham
Total Size of Parcel 1.7 Acres
Date Parcel Was Created September 1983
Are all corners identifiable? x Yes No
Include with this application one of the following:
.Certified Survey Map
.Deed
"
.Land Contract, or
.Other Legal Document which describes the property
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 r c,Q led in the Office of the
County Register of Deeds as Document No. ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the some has been duly recorded in the Office
of the County Register of Deeds, as Document No.
lip
jTU~R O ER SIGNATURE OF CO-0WNER (IF APPLICASLEl
DATE SIGNED
GATE SIGNED
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
i p Q STATE BAR OF WISCONSIN FORM 2-1982
J-ohn- A W.-.-Graham- an-d- -Cla-rice -E.---Graham,
_--husband--and..w- fe_,:--a.s. j_oint te~nants
_......_•------d-_
conveys and warrants to .._aml-- 0¢ _ r_-- o-a EA_
,---h-usb_and--a-nd---wif.e--as--•1o_int------....
tenan-ts
-
RETURN TO
-
_ .
the following described real estate in S't' ___t;i x--•-------------County,
State of Wisconsin:
Tax Parcel No-
Part of the Northwest Quarter of the Northwest
Quarter (NW-1 of NW;;) of Section Twenty-six (26),
Township Twenty-nine North ('1'2QNRange Eighteen
West, (R18W), more particularly described as
follows: Lot One (1) of the ('I~rtified Survey Map
recorded September 12, 1983 ill Volume "5", page
1343, document number 387683, in the Register of
Deed's Office, St. Croix County, Wisconsin.
This .___is-__n------ homestead property.
6►s,) (is not)
Exception to warranties: 1 ions and encumbrances of record and those created
or, suffered to be created by the grantees, their heirs, successors
or assiglrs. -l
Dated this - % day of dC ~ 10-3.-.
(S
- - - (SEAL) EAL)
Jolilr A.W._.G_r-aliarrL......
- (SEAL) c Y 4 cwr-' . (SEAL)
* - - - ('.1 ar'ic:e--E• -Graham--------
AUTHEN'T'ICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
ss.
S t, . C r o i- x County.
-
10 Par -llv eame before me this _.__..___day of
o
t //,4/ y G~i9ryi9M
DEPARTMENT OF 00UA J'? y 4rAdo
.INDUSTRY REPORT ON SOIL BORINGS A
II All
HUMAN RELATIQNS PERCOLATI D SAFETY & BUILDINGS
ON TESTS (115) DIVISION
CTIpN; (H63.09(1) & Chapter 145.045) P.O. BOX 7968
LOCATION S MADISON
E , WI 53707
COUNT ~ ~ ir19 (o TOW ~P/MUNIICCIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
C,OY: 3UYE N/R/~ NAME: r
s/ ~y/~( R~ v E• MAILING ADDRESS:
USE ~L/✓~E~° PI~a f G(J/S
NO.BEDRMS.: COMMER IALDESCRIPTION:
Residence DATES OBSERVATIONS MADE
XNew PROFILE DESCRIPTIONS:
❑Replace ER CATION TESTS:
RATING: S= Site suitable for system / " ZZ U= e3
CONVENTIONAL: Siteunsuitableforsystem ~C7 ~q8 1~~{jf~ r s
T S E]U M UND: IN-GROUND-PRESSURE: S STEM-IN-FILL HOLDING tT7ANK: RECOMMENDED S~ EM oo a~S
IwxJl U ,
IS pU ES ❑
SENU DS®U av s
If Percolation Tests ar N UENTioA~jgG s4' F7;
are NOT required DESIGN RATE- ,Z
under s.H63.09(5)(b), indicate: %'T /2QL 3E~~0
O If any portion of the tested area is in the
D iV T Floodplain, indicate Floodplain elevation:
3ORING TOTAL PROFILE DESCRIPTIONS
NUMBER DEPTH. ELEVATION D PTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE
OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
Q AND DEPTH
3- O ~0 0• /QD ' 1' Q r r. 92 ' I. s:L
2 7 O 9 ~y Co , F' Ar. 'o'/3,v. sit S r~, o c,~E~s of All 5,,9.vv
I. 3 .3 aF S T6 7 'I! - BN si L , . -03 /QA~ sic , 3.
• 7 wE 7- TA,V s 4i o NiX
.3
6/. 5114 0j) P. 5, 3T,qN Si a. 17' h/X. 4,C 7.qu LS
/ Xn f . O ? 7AA1 7,1f.
J fJ ..'S ~D z.ss , FT • 5,f "gN. 31 . SO 1- G "l ~ , - T Al LS --.1 7,1,v 3-/
/ Ell
,
°-,Q 7,4,J L5 ! 33' 13,✓. S, 7f 'MiY. d0 TA-
PERCOLATION TESTS hiy L/ /3 o S~ a.a G/ GS
EST DEPTH WATER IN HOLE TES S.
14BER IN r AFTER SWELL ING INTER VA MMIN.
i J S S PERIOD t DROP IN WATER LEVEL-INCHES
3 PERIOD 2 P R RATE MINUTES
PER INCH
2
L
3, ~
Z S
PLAN: Show locations of ~ /
percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the III
i slope,
and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings
ITE~A ~ ~ T To M ~F /3E ~ EXL.~9(! and the direction and percent
ELEVATION &--/o4o Urfr. /P,-,,-.-
Z,pl--T.
1 77 77, 7a -,c~
F
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INSTRUCTIONS FOR COMPLETING FORM 116 - S - 6395
To be. a complete and accurate soil test, your report Must include:
Project;
1. Complete legal description;
2. The use section must clearly korms orc mme,cia'use planned residence or commercial 3. MAXIMUM number of bedro
FOR T HOLDING TANK ONLY IF AL
4. is this a new or replacement system;
5. Complete }ASE use the the suitability rating boxes. A SITE IS SU AIL LE COND'
OTHER SYSTEMS ARE RULED OUT BASED ON completing the plot plan; desCIA locating yc}g your prtestofile locations. 3 to scale is preferred. A
7. MAKE A LEGIBLdiagram abbreviations ac cu rately e for writing
~ ~n
Sheet may be used if desired;
and vertical eleevation reference point are clearly shown, and are permanent;
3. e sure your benchmark names, addresses, flood plain data, percolation test. exemp-
0. Complete all appropriate boxes as to dot box;
tion, if appropriate; ~ly. place N.A. in the appropriate
10. if information (such as flood plain, ele° anon} does not apply,
11, form and place your current address and your certification number;
legible copies and distribute as required, ALL SOIL TESTS MUST BE FILED WITH THE
1
l ;r-AL AUTHORITY WITHIN 30 DAYS OF COMPLET.
ABBREVIATION FOR CERTIFIED SOIL TESTERS
other Symbols
Separates and Textures
BR Bedrock
st Store 1011} SS Sandstone
cob - Cobbie (3 - 10") LS Limestone
gr - Gravel (;.rider 3") HGtiV _ High Gror.nFdv,,ater
*s - Sand perc - Percolation Rate
cs - Cot~rW _ r~ir~li
me(9 s Medir r d
Bicfg - E'
1s Fine S~ Gte,~._f Than
is -Loamy S~ Id Les Than
sl Sandy Loam
Bn - Brown
~l - Loam BI Black
Silt Loam Gy Gray
si Silt
y yell-w!
~cl Clay Loam R Re
sc4 - Sandy Clay Loam
mat - ly'
sicl - Silty Clay Loam ,
w
Sc _ S-Idy Clay fff fE .
Sir- - 3 i Clay
Y
c mm - M
p1' - F d - distinct
rr7 -Muck p _ 1.)romin
HWL High r'= levei, ter
Six general s- textures SM Bench
for lirlr.ri,' disposal c point
VRP _ Vertit
REPORT oN SOIL i o l &S ~ P'RCo LATION T
• ESTS JIS
PL.o T 0496, ,1 Lo T
o Emirs ~ ~s -
DA rE-
HOME-SITE TESTING Co.
RT. 3, O'NEIL ROAD BOB Uf b'X ?t
ilriDSi~, WIS.. 5,4016 C5T- SS.-
a2 y,fZ
PROPOSED MwSE MosT LIE Fr. pe MO,PE F~QO•y gLt TEST ~jiPE~S
PROPOSED WELL M v5r LIE g FT
D o,Q o F F.Pan ALL 7"~'sT
~ - a~¢f+~j~/dE" PST, f ~ =EXIST/w1 G- ~CJEGG
X ~ ~E,QG /dCh~ro4A~f ~ _ f/A,il~ A~t1 E~PED o,Q S~ddEL
r a eiZ. 6 ~ ~C1PE5
yo 4,-rte' V-rRrlc,►1- RC rAAZV44r -r6 a =
A3 V"T ,pE -,off jPo:~r r ~c~~Pn~ya,~s
w d o T /~Cf ~tI
E GE N J) /EV4r e~ 1/E~r. ~PEF.
fir.
_ o U,U
7-Y ►e ~
~ ~ s ~ ~ O Ago
9-r f I
A
T T
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Ir
~ -tea w S
S
~ ~I R
G
FI s s • 1~
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F-i
- - - - - = - - - - - !ni
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ski <
F:
COMMERCIAL TESTING LABORATORY, INC.
1
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 8378 (WI)
F
800 - 962 - 5227
ST. CROIX ZONING REPORT NOA 31242/01 PAGE 1
ST. CROIX COUNTY REPORT DATEI 7/13/89
COURTHOUSE DATE RECEIVED: 7/12/89
HUDSON, WI ;4416
ATTNI THOMAS C. NELSON
OWN S Timothy Wenger
LOCAT 795- ~St, Roberts, WI
COLLECTOR: Mary Jenkins - St. Croix County Courthouse
SOURCE OF SAMPLE: Kitchen Faucet
COLIFORM; 0 /100 mL
INTERPRETATION! BacteriologicaLLY SAFE
NITRATE-N: 13 ppm
Under 14 ppm is safe for human consumption.
COLIFORM + NITRATE
07
0
i
LAB TECHNICIAN: Pam Gane
WI Approved Lab No. 19 L 7 X89
1.. 3T CHUx
COUNTY
\ ZONINGOFFlCC
~.\NDEVENDEry
.
i
< Means "LESS THAN" Detectable Level Approved by:
® PROFESSIONAL LABORATORY SERVICES SINCE 1952
c
July 13, 1989
ert Box 190A
Timothy We Street Rt• 1r
795 130thWI 54023 ropertY
goberts' on your pWI was
t c system erts, ed a
Wenger the Sept 1Box 190A Rob o obtain
Dear 14r - ation of I also for
investi9 Street Rt• a same time the after
on Site 130th At th a to to You
An 'located at 7952. 1g89 • ted the san►pl i11 be sent
loc d July 1 submit testing w
nspects from that ed to be
i samPThe aresults t appear of this
water system on of
tests eive them back 1
tart ec t: n we rec inspection r . tl g us a• Surf ace p inso~ec ct1O heicaen
of the the eYLIS base upon vatin9 hidd
At the time roperly to was bavolVe any exossibilitY of This
er
functioning osal sy did not In the P insPectlon-
t at
there 1 able by this continued per
sewage Stem. and 3-y
said sy According ot discover uarantee the is recommen reforer
analysis the sYstem warrant or g stem- It ears- Tile upon
f one a eris htotally dependent
de es tnot in any operation ed
do oning or stem ee]
ed la f e P of th sh sYst m . ect please f
he sYstem Sho'
t olong this sub?
he proper r maintenance of regarding
you have any questions
ice
free to Should contact this
SincerelY,
J. J kl Administrator
Assistant Zoning
MJJ/sa
- Bill
~ ?,(~~/yam
ST. CROIX COUNTY ZONING OFFICE
St. Croix County Courthouse
911 4th Street p
Hudson, WI 54016-•~
Telephone - (715)386-4680 7
The St. Croix Count
y Zoning Office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion o this form is essential so that the
located. property can be
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING---------------- -FEE: $ 25.00 $25.00
(For nitrates and coliform bacteria)
WATER TESTING FEE: $175.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00 $25.00
(Determines if system is properly functioning at time of
inspection)
Property owner's name Timothy Wengert
Property owner's address 795 130th St. Rt. 1 Box 190A Roberts, WI 54023
Legal Description 1/4 of the 1/4 of Section , T N-R
Town of Lot Number Subdivision Name
FIRE NUMBER LOCK BOX NUMBER
Color of house Realty sign by house? If so, list firm:
PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services: Edina REalty
Telephone Number 715/386-8236
REPORT TO BE SENT TO: Roger Hetchler -Edina R alty
Closing dat
signature
I
~v
STC - 104 REcev~
AS BUILT SANITARY SYSTEM RE I~
• s,v R 1907
OWNER
67~ Y ZONiNAC)FFlGE
ADDRESS l 3
SUBDIVISION / CSMI o LOT
SECTION _!!!g~T;~2 O/N-RQ Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
® a ~ s8 ~ 1
r~
.INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
i
BENCHMARK: ~
ALTERNATE BM: = SOB. DO
SEPTIC TANK / PUMP CHAMBER
/ HOLDING TANK INFORMATION
Manufacturer:
Liquid Capacity: pDp
Setback from: Well 1~~_ I l
House Other
Pump: Manufacturer
Model#---_ Size
Float seperation
G ons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: .6 Length 7,T--
Number of trenches
• rv' ~
Distance & Direction to nearest prop: Dine:
Setback from: well:-4 ('~D
House Other X07 • = 9 ~
ELEVATIONS'
Building Sewer.. -
ST Inlet: -
• ST outlet:
PC inlet PC bottom
Pump Off
Header/Manifold
~ Bottom of system
Existing Grade
Final grade kn
v 5
DATE OF INSTALLATION: /yo I/,
PLUMBER ON JOB:
t
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Countyk - CROIX
,Wisconsir, Department of Industry, PRIVATE SEWAGE SYSTEM
Labor and Human Relations INSPECTION REPORT Sanitar Permit N
SAety and Buildings Division (ATTACH TO PERMIT) B9125~
GENERAL INFORMATION City( aa village Town o : State Plan ID No.:
Permit , HOWARD
EBMEIev.: Name: Tn1c N
~o-:1071-80-000
Ins BM Elev.: BM Descri tion: Parcel T(~4l
P r
LEV ION DATA A9700442
TANK INFORMATION BS HI FS ELEV.
CAPACITY STATION
TYPE MANUFACTURER /
UO
a~ Benchma fP3 r ! o(.*3
Septic
Dosing
Bldg. Sewer
Aeration
St / Ht Inlet
(oS
Holding 94 Outlet tiv 17,
TANK SETBACK INFORM ION
vent to ROAD Dt Inlet
TANK TO P / L WELL BLDG. Air intake
3 r ~~~1 NA Dt Bottom
Septic ~ 4(0(3
NA Header / Man.
Dosing /n1 .76 i o~ Q287 9u
NA Dist. Pipe 6 3 ASS i 9
Aeration '?I.
Bot. System ~/.b~
Holding Final Grade /-76 9523 414.6s
PUMP/ SIPHON INFORMATION 93'26,.
Manufacturer Demand e
GPM ~bxZ I~! t4s~ ~2 ,oq
Model Number
TDH Lift Friction ystem TDH Ft
Fi
Loss
D' Dist. To Well
Forcemain Length
SOIL ABSORPTION SYSTEM No. Of Pits Inside Di Liquid Depth
7 , No.O Trenches PIT
BEDX.I61i~1 ' Width 5" Length 5
DIMEN I N Manu cturer:
DIMEN 1 N WELL LAKE/STREAM LEACHING
p / L BLDG BER M e Num er:
SETBACK SYSTEM TO CHAM
.t q ' ~
INFORMATION Type O OR UNIT
System (r.+1
STM 27
DISTRIBUTION SYSTEM Vent To Air Intake
h_~• ~q x Hole ize x Hole Sp in9 q r
11-04- Distribution Pipe(s)' Dia
Length . Ll spacing
I
Length Dia-
x Pressure Systems Only xx Mound Or At-Grade Systems Only
SOIL COVER xx Seeded/Sodded xx mulched
xx Depth Of Yes ❑ No
Depth Over Depth Over Topsoil El Yes ❑ No [I Bed /Trench Center
Bed /Trench Edges
COMMENTS: (Include code discrepancies, persons present, etc.)
AVENUE
LOCATION: WARREN 26. 29.18.404C,NW,NW 77,95 130TH
9 '7,
elt
~~ts c~ `'If',
z) ~Vfj gvn VOW iyaw,
~ n4 I I( 17 Yes F\
PI~4nl
revision requirediiona ❑I nfor ation.No~Use other side for add Date SBD-6710 (R 05/91)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: a
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
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 n
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15,04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
PropertyOwne Name //II Propert Location
0-Sc/t K All,)' 1!4;fa 1/4rS ?6 T ;;ZN,R18 E(o00
Property Owner's Mailing Address Lot Numbef BIG Number
7 , s 1-3611 1 h/
City, State, . Zip Code Phone Number Subdivision Name-or CSM N mb r l~G~
ts III 79%Y% r>~ ca7 S
11. TYPE F BUILDING: (check one) ❑ State Owned city Nearest Road
Public 1 or 2 Family Dwelling -No. of bedrooms _ o Vown of aln.i^`-AG/V /-34 S 7,
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
/07~-$0
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 13E] Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing 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 ❑ S page Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ®Zeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14E] System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
q~! 75--
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. . I a1 Grade
Required (sq. ft.) Proposed (sq. ft) (Gals/da /sq. ft.) (Min./inch) /I, g 1.7S Elevation ~
set 9yFeet
1-1111 /7 O-q
VII. TANK Capa y
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks 14
Septic Tank or Holding Tank f~ /04,0 O h~C>GL1{~
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: (Print) Plumber's Signature: (No Stamps MP PRSW N Business Phone Number:
-71
Plumber's ddress (Street, City; State, Zip code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Ag t Sign No am
`
pproved E] Owner Given initial $Ize 60 Surcharge Surcharge F ee)
Adverse Determination D
X. CONDITIONS OF APB O R ASO ,S FOR D Z A~ ~
SBD-6398 (R. 05/94) DISTRIBUTION: Original w County. One cupy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS E
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 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 dtnTensions, 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.
E I,t L) A r~a~S
1-32-
3 3
/FE-S i 10,
m~ Zts~" 3E,v yes ,x 7~
30
D 1m) = Ra 77,o ,,-f more o~
A OMB S ~D~N 6-
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I_
G,PAu-~.~ f»Piu-e I pi • _ -
1 I ~ I
BZ p io 3
1/01
I ' is I O g~j
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I i I I 9A
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations '
Division of Safety and Buildings in accordance with s. ILHR 83.09, WIS. Page of
Attach complete site plan on paper not less than 6 1/2 x 11 inches in size. Plan must County
d
Include, but not limited to: vertical and horizontal reference point (BM), direction and •ST C~[
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Parcel I. D. #
0112-_ 1071• O
APPLICANT INFORMATION - please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner
/ Property Location
a 04 P Govt. Lot f W 1/4 /V &)1/4,S l T 2-f ,N,R E (o Vy
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
7~S- .S/q 3Y7683 Uo/- S P • 1383
City State Zip Code Phone Number Nearest Road
ST1023 (7!S )71111 3yp ❑ City illa~ Town
❑ New Construction Use: esidential / Number of bedrooms Addition to existing building
replacement ❑ Public or commercial - Describe: V /V 7' CO,,q Af
Code derived daily flow gpd ~ Recommended design loading rate bed, /ft2
9Pd trench, gpd/ftz
Absorption area required '~b~ ft 29 trench, ft 2 Maximum design loading rate bed, d/ft2
9P trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations ~,fE ~~(1~ cif ~jJj,~e~~• Gjr ~~~p ,~~j( a~STi~~%~VT~O
Parent material 14011K S'/G .SE.07/;1WA1Tf A94Qr T GL Flood plain elevation, if applicable ft
S = Suitable for system Conventional Moun InG~rou~nd Pressure AT G de System in Z Holding Tank
U = Unsuitable for system S El U S El U IBS ❑ U [S ❑ U El S ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure
in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots GPD/fiz
i
Gr. Sz. Sh.
/ Bed Trench
9-7 1o y 373 s 77 9S ZV y ;
Z 7•2.P 10YX Y11K - L S~ 441fe /v f . S
Ground 3 .S o SL / ti
elev. ~'S' _ .Cf S
Depth to
limiting
factor
} 4 U in.
T~ Remarks:
Boring #
E
11 10 ./,o 1,011-4 313 - L S .20- ; . S
/0 Y9 YM. 5'14 24'Shle '-'c- 5- 14 57
3
3 • 119 - - YL 2~,, s cs • s
Ground Z • ~Q L U~
elev-
f3'- S
Depth to
limiting
fac or
~`Q9-in. RI
CST Name (Ple, Teleph,,one-No.
Address
Date CST Number
SOIL DESCRIPTION REPORT Page 2, of 3'
PROPERTY OWNER JUG//K vr'!L~
PARCEL I.D.#
Horizon Depth Dominant Color Mottles Structure 2
Boring # Texture Consistence Boundary Roots GED/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
yo y,~ 3, z s sti es z ~f . s : .
2- "1 10YX 313 e5* 1U+ -'5
Ground 3 16 YR 31 Y1Z_ 2f S~ /111 i/C CS / S' • (P
elev. • J G' l S /1~ (/t°9 ~ . ,S
'~ff• lp C7 /
Depth to
limiting
factor
7 /0&- in.
Remarks:
Boring #
Ground
elev. ;
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Structure GPD/ft2
Texture Consistence Boundary Roots
in. Munsell Qu: Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring
Ground
elev.
ft. '
Depth to
limiting
factor "
In. Remarks:
SBDW-8330 (R. 08/95)
E I,t v~ 1-ra~S
I~
;rNSf*1/ 3
Q " - iP~G~•y y~vf~ r~
6-'y
M Zis&IF 3
- 30
13M . ~0 770,tr 5 e o
APW
zy
B ~0 3
/01
C 4133 i~ I I ill I
L Imo(' IX' IJ~ I 1
1 , Er,sr~N sYsj ra
Gz
Pol,~~'~~ol✓~ So . 4 69 T ~ .
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the cz~-~~~ f~~ r o
residence located at:
Section
TN, R_ lam; Town of
Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced: ~ 9 ~ T
Did flow back occur fro.4,absorption system?
Yes k-1 No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity: /000
Construction: Prefab Concrete /
Steel Other
Manufacturer: (If known):
Age of Tank (If known) : ci~cgi~ 19 '
( ignat re)
(Name) Please print
~G" rGc~~~l
(111 3--1
(Title)
(License Number)
r 2 7 9 7
Date
Form to be completed by licensed plumber (s.145.061 Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR 83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name
L ~`"~z Signature
~Yu~~~'~MP MPRS
9
38' 393. UI) A14 t-A
a 83
CERTIFIED SURVEY MAP 1qd
JOHN A.W. & CLARICE GRAHAM
Part of the Northwest 1/4 of the Northwest 1/4 of Section 26, Township 29 Nor Z
Range 18 West, Town of Warren, St. Croix County, Wisconsin.
o Indicates 1" x 24" iron pipe weighing 1.13 lbs./lin. ft. set
-UNP-LAT_ED-LANDS e
N LINE NWI/4 -
~
C C . T. H . TT W
NW COR.SEC.26,T23N,R18W, N89.19'09'E 253.00 F=-
(COUNTY SURVEYORS MON.) w q p!W
N N Z O
W O
X 0
=
33.00' i 22 O.OOT O
3 4 O
= 0 O
W W Z
I r Z N
J
J IN I _ Q
UNPLATTED LANDS 3 N F- W
- - - - - LOT I s UNPLATTED LANDS H c
I N I- 1.726 ACRES ti - -
W Q'
75,199 SQ. FT. N ; O
I W o N E T- 1.293 ACRES W W
p to 56 ,314 SQ. FT. 8 x
O N ~
I q 0 O CD
O
P70 W VED I " O ~ -
0 0 W-
o _
c z 0 z
a I o
O N co N
S E P 07( 1983 0 z~
3 I Cl!
o W 0
S1. COON" ~ I 33. 220.00' W
d 0W
00mP;tviE: iu'de PARKS PL;'' S 89. 19' 09 " W 253.00' 'J
AND ZOMNG COMMITitt "
a o
UNPLATTED LANDS
- _ - SCALE I"■ 100'
W I/4 COR. SEC.26,T29N,R18W, 0 50' 100' 200' 300'
(COUNTY SURVEYOR'S MON.)
DESCRIPTION:
That certain parcel of land located in the Northwest 1/4 of the Northwest 1/4 of
Section 26, Township 29 North, Range 18 West, Town of Warren, St. Croix County,
Wisconsin, more fully described as follows;
COMMENCING at the Northwest corner of said Section 26, the POINT OF BEGINNING of
the parcel to be herein described;
thence N 89° 19' 09" E on the North line of the Northwest 1/4 of said Section 26
a distance of 253.00;.; thence S 00° 00' 00" E 297.25'; thence S.89° 19' 09" W
253.00'; thence N 00° 00' 00" E on the West line of the Northwest 1/4 of said
Section 26 a distance of 297.25' to the POINT OF BEGINNING, containing 1.726
acres, more or.less, being subject to easement over the Northerly 41.25' thereof
for C.T.H. "TT" R.O.W. purposes, and also being subject to easement over the
Westerly 33.00' thereof for Town Road purposes.
State of Wisconsin)
County of Pierce)
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS E2-6:Sel!~ 112 -3 , ill syn `
PROPERTY ADDRESS 7 a 6 s--~O
(location of septic system) Please ob in from the Plan
ning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, - aC 1/4, Section T'~_N-R_ I W
1,;76 A 11,x,1
TOWN OF mss, ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP 36 -7 VOLUME S, PAGE /3 y ~ 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: ~ K , *~~2~1G~C
DATE: ~g
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 Oveo-1-1
Location of roperty iu l 1/4 1 l C,1 1/4 , Section , T N-RW >CA
Township(~rs^~e, Mailingaddress ~
v~
Address of site
Subdivision name Lot no.
other homes on property? Yes No
Previous owner of property , p r
Total size of property
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)? Yes _X_No
Volume 3'16, 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. yy 9 2 , 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 oCo-Applicant
Date ~fignature Date of Signature
i DOCUMENT NO. STATE BAR OF WISCONSIN FORK 1- 1!M ME SPACE RESERVED NO RReami"o 041%
~I
wARaMrir oEEc REGISTER'S ONCE
i
ST. CM Co.,
Recd for Rawd
Timl y 7egj mengeerb€t"aneen d B--a
rbara A: Werigert at JUL 191M `
I~ fius6aii Arid wife as pointeriarits 11 .
I~ and--- Hoivard__ ICriischke Arid Doreen D: Rru~ci~ce ~~,,r
husband an..... i'e as•survivorship ty marl-tat'
Proper.------•---------------
Grantee,
1~tne38@tty Thtt the said Grantor for a valuable consideration
Timo y anuQ tsar ara engert
-il
conveys to Grantee the following described real estate in _ _-T'OiX ED*u"~'°
County, State of Wisconsin: -~I
Part of the NWT of the NW's of Section 26, TownsFrpPared No- -
I)
29 North, Range 18 West, Town of Warren, St. Croix ~I
County, Wisconsin, described as follows: Lot 1, j
Certified Survey Map filed September 12, 1983 in
Vol. 5, page 1343, as Doc. No. 387683. i
1'T~1tS 0 O
FU
This -.----i s homestead property.
(is) (is not)
it
! Together With all and singular the hereditaments and appurtenances thereunto belonging;
And..... Timothy..and..Barbara-_ Weagert..........
warrants that the title is good
, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions and rights-of-way of record, if any.
and will warrant and defend the same.
Dated is 1-4 "
. day of .Tul-y----
19.89....
is
- f-- - (SEAL) A ..Timo.. J._Weng t - Barbara A. Wengert
---------(SEAL) (SEAL)
is
s
-
AUTHENTICATION ACKNOWLEDGMENT
Signature(a) STATE OF WISCONSIN
St. Croix as.
--••-----••-----•-•----•--------------County.
authenticated this ........day of 19.-...- Jul Personally came before me t is .14---------- dad- of
y---------•----•-•--------------- 198 the above named
_'himo£h-y.-J-* --'Wenger£; Barbara A-
TITLE: MEMBER STATE BAR OF WISCONSIN werigert-------------------
(If not- - -
authorized by § 706.06, Wis. State.)
to me known to be the person S-.-, who executed the