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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER CUA S k o e ni
ADDRESS kuRG 1411~S
SUBDIVISION / CSM# Hwy\ A ~ '615 PlAse 3 LOT # S3
SECTION Q_~_Ta_N-R W, Town of H"1)5oiy
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3 &OkooM t~ o n•,p
aa' 35
W&-. MANOR f~
Ovw 0Lj1Q'j (3A~f~P
f ~
"~KQNGhPS
5x57'
I I
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
e r~ 7
BENCHMARK:
S R, 0~ s l"
ALTERNATE BM: ~/C V 00, U
SEPTIC TANK / PUMP C
HAMBER / HOLDING TANK INFORMATION
Manufacturer: JQ~ ~S
Liquid Capacity: 0
Setback from: WelloVQR T
House o~ Other
Pump: Manufacturer
Float seperation Model Size
- Gallons
/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: ~
Length 21
Number of trenches a
Distance & Direction to nearest prop. line:_opR 36
Setback from: well. S() I
(.6we(L S2,,rC'k 6V- _ House Other
Ll?P (R
~\QPn21( (00 3
~N~i ~~•la tN" 9914y ELEVATIONS
C6Ve((()5" (es
Building Sewer ST Inlet ; )U ( ~(a
PC inlet - - ST Outlet U
PC bottom
Header Pump Off
/Manifold
Bottom
Existing Grade of system (-014q9- wpS ?7.00 enrtcd ~8 a0
S~~
Final grade UthR9 3 3 PpR ~ 7, 0
~b .
t°a SV
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: v
INSPECTOR:
3/93:jt
Wisconsin Department of Industry,, PRIVATE SEWAGE SYSTEM County:
'[.9borJIndMumanRelations INSPECTION REPORT ST. CROIX
~`afety andtBuildings Division Sanitar Permit No.:
GENERAL INFORMATION (ATTACH TO PERMIT) 68612
Permit Holder's Name: Cit Village Town of: State Plan ID No.: 11 :!11I_ SHOEMAKER, CURTIS & SUSANNE ~iU)[~SON
Parcel Tax No.:
CST BM Elev.: Insp. BM Elev.: BM Description:
TANK INFORMATION E EVATION DATA A9600310
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark i ,90 /DDS o
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet
ir
Septic NA Dt Bottom 17, 912' rf 1, ? Dosing NA Header / Man. a
g,61, 94.4411
Aeration NA Dist. Pipe ' 2- a'
IC?
Holding Bot. System 9k. ao
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Ff Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width _ Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 7 DIMEN I N Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING
SETBACK CHAMBER Mode Num er:
INFORMATION Type O S , YJ~O OR UNIT
System: i
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) 11 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 =Trevnch xx Depth Of xx Seeded / Sodded xx Mulched
Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
Bed /Trench Center Edges
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON.27.29.19W, SE, SE,O/R'IELE LANE
dl' of /v A
Plan revision required? ❑ Yes [H'No
Use other side for additional information. /p 4p,
Date ' Signature Cert No.
SBD-6710 (R 05/91)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:.}
71s o iPi eta ~ti / fv o~ ,s yon
Safety and Buildings Division
v~•~:~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
than 81/2 x 11 inches in size. 5/ • CiCOf
• See reverse side for instructions for completing this application State Sanitar Permit Number
it 9 Permit s &I,
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 N/~ ~
/
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Propert Owner Name / Property Location
647-15 a,,, A 5*03 71,u1~ SG D~/~l~~t~ie :5 114 5,2F, 1/4, S Z7 T 2 , N, R 44 E (o W
Property Owner's Mailiw Address Lot Number Block Number
,5r34 5 City, State Zip Code Phone Number Subdivision Name or CSM Number
,for ~yN Lk
AJl / V S 5~2 c lvrz > 53/-1joi U.~l I ,ev il~~
11. TYPE F BUILDING: (check one) ed it Nearest Road
Vil(ag vi I-Al
Public or 2 Family Dwelling - No. of bedrooms o
wn OF
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. lew 2 ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S.,❑ 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 ❑ Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 F~fleepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill C~4~L~. 5 /X 5 7-'
VI. ABSORPTION SYSTEM INFORMATION: 175 10 - 103.0
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation ,
5^0 S71603 570 / 4F"70 Feet /04 O Feet
VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks 1 11
y~,p
Septic Tank or Holding Tank ~ ❑ ❑ ❑ ❑ ❑
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 Si nature: (No Stamps) fv1P/MPRSW No.: Business Phone Number:
Rbb&-; T ?~/6,RAZ 7 3 . 7 ~~s ~3U fO l (J /~rS`
Plumber's Address (Street, City, State, Zip Code) M s J16 1
&SJ d7L, (r°
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (Includes Groundwater ate Issue Iss g Agent Signature ( Stamps)
XApproved E] Owner Given Initial Surcharge Fee)
Adverse Determination 7b
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One (opy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1- A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin 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-
V11. 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 Mth 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 i-)'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.
SANITARY PERMIT 54-_ • Cro ix COUNTY
~ OILHR TRANSFER/RENEWAL UNIFORM PERMIT #
- (PLB 67-T)
PERMIT RENEWAL DATE: PERMIT TRANS FE DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER:
If - 1-7 -
PROPERTY LOCATION: C~ If CITY:
VILLAGE: ~fv
%a,SZ~,T 2-f N,R I ( E (or) TO
WN OF:'
LOT NUMBER: BLOCK NUMBER: JSUBQIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK:
3 HVM/l/M %1
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME: PHONE NUMBER:
t2o (3 r Zt l din rot
ADDRESS: PHONE NUMBER: ADDRESS:
BOSS O'er 40/k S
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
property.
PLUMB R'S SIGNAT RE: PR' ~ IO S PLUMBER'S ^E~
'I~J~NI "/E~CH D):
PLUM 'S ADDRESS: PREVIOUS PLUMBER'S ADDRESS:
10-7U w ~•S~ CoS S 0lv eo /
MP/MPRSW NUMBER: PHONE NUMBER: /MPRSW NUMBER: PHONE NUMBER:
p (71S) 3$ l - 4 330
S GNATU OF IS U G T• FDA_
APPROVED: DISTRIBUTION: Original -County
Copy - Bureau of Plumbing
bbbb Copy - Owner
LHR-SBD-6399 (R. 5/82) Copy - Plumber
s ' ,
1
kn W
YJ Ih 1 V\l W W \ ~0 p-
G
W
~Cb
G
03
~~s Lo T 1 Q ~ ~
o
b
Fresh Air Inlets And Observation Pipe
a' A Approved Vent Cap
Minimum 12" Above
Final Grade
/0.3 .0 /
Above Pipe 4" Cast Iron
Vent 'Pipe'
'to Final Grade
Synthetic Covering
min. 2" Aggregate
Over Pipe
Distribution Tee
Pipe 0 0 0 0 0
Aggregate v PerfOroled Pipe Below
Beneath Pipe 0 Coupling Terminating At
$ y57- Bottom Of System
90
r
Fresh Air Inlets And Observation Pipe
Approved Vent Cop
Minimum 12" Above
Final Grade
3Co Above Pipe 4" Cast Iron
Vent Plea'
W
to w r
C
m~ lr w W 0 Z
6N
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~ NA ~ o o y
Q$ ri
p
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ti
*30 10 W 664.12'
` ' , v 1 ' 4p/Op~F ~ V
N y6 30 f
11 ? F'' - - -'3>
S45°50'00"W
86.82' f..
t S44° 10'00"E
66.00' I
S76127, 41"e
' 463.13'
Zf8
~I
So S9
1S z S~
S~8
~ S(n ~
Sy
S89'30'15"W 942742 a.`
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W w \ ~
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Lk,
3~' N - n
vN ~
``-9s T- ~o T ~ I Q ~
O
b
n
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade
~0 3.O
_ 4" Cast Iron
3CP Above Pipe Vent 'Pipe'
-to Final Grade
Synthetic Covering
Min. 2" Aggregate
Over Pipe
h
Distribution - Tee
Pipe --T 0 0 0 0 0
Aggregate o Pertbrated Pipe Below
Beneath Pipe 0 Coupling Terminating At
S V ~cj- Z Bottom Of System
r
n N •
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade
_ 4" Cast Iron
3~ Above Pipe Vent Pipe'
t
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety if Buildings in accord with II-HR 83.05, Wis. Adm. Code
COUNTY
sr. c~o~x
Attach complete site plan on paper not less than 8 1/2 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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
F Y OWNER:PROPERTY LOCATION
L GOVT. LOT1/4 1/4,S 2 7 T 2.Y N,R /f (or) W
Y OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NME OR M #
*o-168APeTs 57 y) ~3 iIUMRi X17 HQIS (Ptins- 3
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE aftN NEAREST ROAD
Mv6 141 N• 55/0/ lG~i) z2- 2- -55'55 +fUVSO/J D'Pi'Elle--
New Construction Use [ krAesidential / Number of bedrooms ' 3 [ ] Addition to existing building
[ j Replacement [ I Public or commercial describe
a-
Code derived dally flow Y1,,vo gpd Recommended design loading rate bed, gpd1ft2 trench, gpd/tt2
Absorption area required 112 ---trench, 112 Maximum design loading rate bed, gpdm2 -e trench, gpd,12
Recommended infiltration surface elevation(s) S~ P 3 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material SCS 5 Flood plain elevation, if appli6able tiff- It
S = Suitable for system M=~ ❑ U IN-GRO a U ESSURE AT-G BIT E ❑ U SYYSTBf IN FILL HOLDING TANK
U = Unsuitable fors stem UK 11 U [91 0'S ❑ U ❑ S WW'
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure~~ Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rttctt
/ 0-9 /oYk 3/z s S' s 7 2- ly,50 lo re Ar '-/S e -V
Ground D ' 7• Y" "44p, S' 69
K.Ltt.
Depth to
limiting
factor
Remarks:
Boring #
/ o-6 /o ye 3/z - ~S 1'e Mr S i -F 7
1.3 Z 6-2 0 ,,e y z s/ 2-. S Ae e's L f , s
-3G 7,5yi1''/l
Ground
-9o 75Y,e y~
poio~ rt.
Depth to
limiting
factor
7
f .
PROPERTY OWNER SOIL DESCRIPTION REPORT Page L. of 3
PARCEL I.D. ! t ,S3 fIy yl3i pv hi///S - Al s e 3
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bmfx* Roots GPD/ft
In. Munseli Qu. Sz. Cor t. Color Gr. Sz. Sh. Bed Twich
Z P- yam oy~ 14-f elf
Ground 3 - yp 7•$ y e v . S ZZ
elev.
3I& It.
Depth to '
limiting t
factor
i
Remarks:
Boring # lo- /o f R 5/Z ~S I m e ooS S , ?
IF-30 7,S Ye /l rT D s e.,C C'S
Ground 3 40 ye JVT.
elev.
;
/63• o It.
i
Depth to i
limiting
factor
Remarks:
Boring #
Ground yp- 44 f 621
_
elev. !
/dS it.
Depth to
limiting :
factor
Remarks:
Boring # i
Ground
1
q.
Wisconsin DepartntentofIndustry, SOIL AND SITE EVALUATION REPORT Page 3
Labor and Human Relations
I)Wlslon of Safety d, Bullrings in accord with ILHR 83.05, Wis. Adm. Code FARCEL sT o~~x
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must i ~ tee, but I.D. /
not limited to vertical and horizontal reference point (BPM, direction and % of slope,
dimensioned, north arrow, and location and distance to nearest road IEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
/ll/~1~/iP~ GOVT. LOT 1 /4 1/4,S 2 7 T ~9 N,R /f (or) W
F-PROPERY NER:PROPERTY LOCATION
j p - GSABLOCK 1► SUEOR CSM s
Ts ~sr f /D.~£~? 10/9ly3 6 UD H 1N/SEST ROADS r 3
ZIP CODE PHONE NUMBER []CITY ~111LLAGE N
CITY. STATE 95 /D/ lG/~) 222' SSS u v-50"1 D,Pi'FJ~ L,,tl.
New Construction Use (k"esidential I Number of bedrooms ' °'P 3 l) Addition to existing building
( ) Replacement ( ) Public or commercial describe
Code derived dally flow yeoo go Recommended design loading rate • 7 bed, Opdfg.. trench, gPd&2
Absoption area required . ~ bed, 112 trench, 112 Maximum design loading rate ' bed, gpddt2 ' ? trench, WW
Recommended Infiltration surface elevation(s) f~ P 9 3 it (as referred to site plan benchmark)
Additional design I sfte considerations S Flood plan elevation, it appliEable tip' It
Parent materif~ 5C5;
D TAW
MIND- INARO Vs Suitable lor [LJ U [I U ESSURE AT G O U SYSTQ U ❑ S~
_UN • Unsuitable for stem D U
SOIL DESCRIPTION REPORT WON Structure GPD/ft
th Dominant Cblor Texture Gr. Sz. Sh. Consistence BoLJnd3Y Roots Bed fr~rtdt
Boring #1 Horizon [De
Munsell Qu. Sz. Cont Colo.
& YX 312- -77 '7
Los z o /o r4 Y/2- ~s
S.
-~yR .
Ground
eley.
f1 jL(L
Depth to
limiting
facto
Remarks:
Boring # ~S ~'H+ ~ie M► S 1 f 7
K3;11- /o ye 3Z / 0 y z S o f Ground 0 •7 '00
-90 ~syR y~
Depth to
limiting
facto ~i
7
F
z
PROPER1YOWNER SOIL DESCRIPTION REPORT Page L of 3
PARCEL I.D. ! Gd t = .S3 110,4-f1j1pv fjKil/S - Plvsz 3
Bering # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft
In. Munsell Qu. Sz. Coat. Color Gr. Sz. Sh.
1-3
O- ie /off 3/t ged rena,
Ground 3 y -yO 7•S YR y` . , S. O, S ,2
elev.
~o I I&
Depth to
limiting
fackir
Remarks:
Boring #
Ye ee 9•P~r.Sr O 5 es .7
Ground D /O f
elev.
/cs 3, o n.
Depth 10
Smiting
fac~
Remarks:
Boring # IJC
140,
o - y ~sye y/~ o, s c~~.. cs
Ground
rev.
/as frt.
Depth to
limiting
factora
Remarks:
Boring #
Ground
elev.
4
W W \~V W W
V1 ~ W N •
C
46% . I
m
tv G
b N~ ~
N n
zoT
H \u
oa
{
1 S
1~ f
R '
V Y
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1
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D r
y - n I LZ N01133S ' b/13S 3.H1
v CO
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S T C - V05
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County 494) -
OWNER/BUYER
ADDRESS --FIRE NUMBER
CITY /STATE zip 4,!9
PROPERTY LOCiTIONs 1/41 S~ 1/4, SECTION Z ~ , T 27 NR /i W
TOWN OF St. Croix County,
SUBDIVISION LOT NUMBER.
Improper use and maintenance of your septic system could
result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three
years or sooner, if needed by a licensed septic tank pumper. What
you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant
for a maximum of 60% of the cost of replacement of a failing
system, which was in operation prior to July 1, 1978. St. Croix
County accepted this program in August of 1980, with the
requirement that owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or a licensed pumper
verifying that (1) the on-site wastewater disposal system is in
proper operating condition and (2) after inspection and pumping (if
necessary), the septic tank is less than 1/3 full of sludge and
scum.
I/We, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix Co. Zoning officer within
30 days of the three year expiration date.
SIGNED: At(-
DATE:
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
STC - 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), thenia second form should be retained and completed when
the property' is sold and submitted to this office with the
appropriate deed recording.
--------------------------,-C---------------
0 -
wner of property C0eT'~ 5k6&M :FA-
Location of property 1/4 - fl/4, Section T N-R _W
fj~vOSo,~
Township
Mailing address,.
PO
Address of site
Subdivision name hil*1✓/XP ~j% Lot no. S
Other homes on property? yes No
Previous owner of property 1101 AX 19
Total size of parcel 2
Date parcel .was created
Are all corners and lot lines identifiable? _Yes No
Is this property being developed for (spec house)? Yes -::-No
Volume 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 & 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
(s) the
I(we) certify that all statements t~ha~ ti on this h am (are) the true to
best of my (our) knowledge ( virtue of a
the property described in this information form, by
warranty deed recorded in the. office of the County Register o.
Deeds as Document No. SS ~l^_2~and that I ( we) ; presently
own the proposed site for the sewage disposal system or I (we)
n1,f-ainarl an easement. to run the aboZe described property, for
• /tp~>r 1 - lfla1~ rei• ...rr .r.ae.rr re. wcwr,w• o.•• .
DOCUMENT 140. ~l STATE BAR Oir WISMPIS 7I
WARRANTY OMO
6929 II vft
This Deed. made between } I
II Humbird Land Corporation, a Mli,oesota Corvaratiun
crtwtor.,
li sod Curtis J. Shoemaker and.Susanne _M. St.-he"a
Husband and Wife
Witnesseth. That the s.W Granter, for a ralwa&I °rn skegu"n
nr,,,.Iw ro ~
Croi:
,
rnmeya to Grantee the following deArrTed real estate in St.
County. State of Wisconsin: ,
Lot 53, Humbird Hills Third Addition,
I No.-
Town of Hudson, St. Croix County, WiscOns"p Tex rarel Ne - ~ Y
I PE, J I Gri J r 'r-
ST. CRUIX CTY., ti
I
P.~e'a'x P:•xr! ~ i
i FM 'JUL 17, 199
*Mv- d 3:30 P M s
FEE
' This not - hsawsteed property.
( l
Toaet%or with all sad singular the hereditamento nod arv-ft-a.res thereunto belenRinr;
And....... .
warrant. that the title is Good. indefeasible in fee simple sad firee ama cord,ai if any e
Easements, restrictions and rights-Of-tay o t•
and win warrant and defend the same-
July . 1996 .
Dated the 10th day of
ISEAL) MooILAND RAT L) .
- - Austin J. Baillon, Its President
(SEAL)
(SEALI
AOTHiMTICATION ACKNOWLSDGMRNT
giRRaanre(s) trATZ OAT 11XN111WL Minnes~ta
- . - as.
rem-MAY _.-----............-.-.Csanty.
came before me tbb .-10th-.-. day of
anthentketed this -day N
- ---Z fl.~ the abaa named
J,.-.Iti.l-oi..._......
- rti
ibt . na..Corpoyk _4!~ . .
- T- -9- - - - - .
TITLE: h/T.IitBR.R STATE BAR OP WISCONSIN
F17 n
aotborize1l b7 Wis. Stata.) tti ,ae I... b De the prrSnw 'LL
went and nAnoorg'a•' t ~~r(~..~~~i~~►►11//~~~}1//G~'~a~-E~MI. A
TMIa INSTnVM(MT WAS OH.FTeO nr ._i YiiMY~•liA]TVn• '
/ >~y corr+ E Jan. 2io
khpilbir.d.hand..Gus-FS~r-aS.ion in faa A. -
~kaic Washington. Gn.ty J7
. W ~1.31y 6 prTmeaent. (If seR State PT~~Tathn
iI
(Sixnaturea may Iw antheaticated or arknmrle4vd. Both - JinUary..3~.r.... 020001
ore not neee•sary.) ~r_ ;1
~I •A.wM it IiYA rri.,4d l.~i.~ ~i '
•M•w..u .r e•r+~• dz.i.a N yr e•,rRr W -is 1-0 /t..Y r. it
I~ sTATR SAN ow arieS>~ rl,~•Y• w►
wARRANTT rMRO rop.10 t-ems tea- Ir y,: i i!._
~r ~ .