HomeMy WebLinkAbout022-1027-10-000
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AS BUILT SANITARY SYSTEM REPORT 4
OWNER ~/7u,cn e S' / iaa //e v S7 CRO"X
bJJN'i Y'
ZONING OF IC
ADDRESS.`
SUBDIVISION / CSM#_ LOT
SECTION 4~7 T~,K_N-R_Z,,~1_W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
jjd
V' q
I'
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: ~5e_
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 2z,) e. ~ 7G~v Liquid Capacity:
Setback from: Well ,,Llgpo House ;~p other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S^ Length ~tj Number of trenches _5Distance & Direction to nearest prop. line:
Setback from: well: GG)v` House 3C~~t Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
.Wisconsi'h Department of Industry, PRIVATE SEWAGE SYSTEM County:
'Labor andHutnanRelations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 268528
Permit Holder's Name: ❑ City [I Village JE] Town o : State Plan ID No.:
HELMUELLER, CHARLES Kinnickinnic
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION EVATION DATA 41
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic - u Benchmark S,1>: 7 ' is/- '
Dosing
Aeration Bldg. Sewer
Holding St / Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic U~ NA Dt Bottom
7T-S-7- 7 7. '
Dosing NA Header/Man. .2-T, 9J17,
y
' 6
7Aeration NA Dist. Pipe 8
0 9 '7 '
Holding Bot. System oa : 9
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand i03.
Model Number GPM
TDH Lift Friction System TDH Ft
Loss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / a DIMEN I N
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM CHAMBER
INFORMATION Type O Mode Number:
System: zed d 'DSO N J¢ 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 xx Depth Of xx Seeded /Sodded xx Mulched
A
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No C] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Kinnickinnic.9.28.18W, SW, SE, Coulee Trail
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Plan revision required? ❑ Yes eNo
Use other side for additional information.' 02/ q
SBD-6710 (R 05/91) Date I p or's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
t s
F
SANITARY PERMIT NUMBER:
z 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, Wl 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County 0,
than 8112 x 11 inches in size. ~4 • /o /V.
• See reverse side for instructions for completing this application State Sanitary Permit Numb r
acs ?5 a
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
(Privacy Law, s. 15.04 (1) (m)l. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owne~N~r~e t! ~Y ^ ,1 4Property Location
- 1/4, S T ,
!.u N, R E (or)
Property Owner's Mailing Address Lot Number Block Number
7
City, State Zip Code Phone Number Subdivision Name or CSM Number
s. Q~r~C ( ) • go-ye- d e
II. TYPE F BUILDING:- (check one) ❑ State Owned o it Nearest Road
❑ vll age
Public 1 or 2 Family Dwelling- No. of bedrooms Town of r AAe 6c ~ ~ e 7r-,%,; L
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
Q22_ lO R -7-/d
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- X_New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
------System ________System Tank Only______________ Existing System Ex)-----System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 &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. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) f7, t;- 4C. 8Q ;e6va it /66.
G~ O d SOD fr IS- Feet Feet
VII. TANK Capacity Site
INFORMATION in gallons G otal Tan of Manufacturer's Name Conc eb. Con- Steel Fiber- Plastic EAxper.
New Existing strutted
Tanks Tanks ` l
Septic Tank or Holding Tank a~ m,r41 r,<Je$ ~'`evr/ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature- (No Stamps) MP PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code): )
A0 7 U orJ G•~ 4~
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Si nat ps)
Surcharge Fee)
~Qtpproved Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy 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
S. 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.
il. 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 al! 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 8 112 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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wiisconsin Department of Industry, SOIL AND SITE E V A L U AT T Page of 3
Labor and•Human Relations
Division of Safety & Buildings in accord with ILHR 83.05 o T
A ~ S 1 - ~ ~ZU ~X
Attach complete site plan on paper not less than 81/2 x 11 inches in siz mualud L I.D. #
not limited to vertical and horizontal reference point (BM), direction and pe, S446oi
dimensioned, north arrow, and location and distance to nearest road.'
~ s*~ Y D BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATI `C
PROPERTYOWNER: GQkrGa" 1k.P~►v►.t6 liISiTt_ VJROPER ATION
Bu`1kTR : 01y&( !fit L h U e u_ 314,S °L T Z. ,N,R L8 E(00@
PROPERTY OWNER':S MAILING ADDRESS LOT NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD
IZtU~Z ~%►"~1-LS, k► I StLoZL (~l~ ZS- ~1~10 5.L1Jtl~tC~c~ NIVLC C~uL ~11iL
[DQ New Construction Use [D9 Residential / Number of bedrooms 3 [ ] Addition to existing building
j I Replacement [ ] Public or commercial describe
Recommended design loading rate _bed, gWt? ~•3 trenctf, gpd/ft2
Code derived dairy flow X150 gpd
Absorption area required bed, ft2 S °K~ trench, ft2 Maximum design loading rate o • 3 bed, gpol0°'qtrerfch, gpo1ft2
Recommended infiltration surface elevation(s) S e'E' P tGe- 3 ft (as referred to site plan benchmark)
Additional design/ site considerations 3 `nom CAS , Ir1 S 'x L4tj LAiu (S4z~ ~ P f1T tjas LtPGr e!bG e- .
Parent material Flood plain elevation, if applicable N •A ft
CONVBNTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
S =Suitable for system S
U =Unsuitable for system ❑ U ®S ❑ U ® S ❑ U ® E ❑ U ❑ S MU ❑ S call
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistanoe Boundary Roots GPD/ft
Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ranch
0-9 Lo't.tz z L Z - S ZV45 w,. `g~• w = 0-S 0-17
Z 01 -z8 ~o%-t I_ qlf, - St 1 Z~'sbk v~ es o•S 0.6
Ground
3 Z8 Az -)-S4R W1. - S l 7 W1s" m\3Cw _ o• s o. L e, a q01 zfL 4 ~z~Z lb~ttz~14 - s e c."`j
Depth to S Z$ l0 7 cZ O Yr\ 0, y
limiting
factor
7 a p+
Remarks:
Boring # S Z r"'`~^ e tv - o • S o.
o-t Y 1,uyL Q Z- l Z
Z )y-yo Lo`tvt 3[` sLl IJSb~ vn` V C-Lv Z u• g o• L
3 t!o-8s \b`-ttZ ~l6 o s _ o..~ n y
Ground
elev.
'i %11 ft
Depth to
limiting
factor
S N
Remarks:
T Name:-Please Print Arthur L. We erer Rhone' 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: p Date: CST Number:
o~ °lS-Z-Z ftPNL 1b,R15 M00576
PROPERTY OWMER LTL►wW.ULER SOIL DESCRIPTION REPORT Page of 3
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
El J 0 -11 Lo `-t. R Z-l Z - %0 ~ ZW Sbkc a
Z 1.1-Z7 10k~31~O - s~1 Z~Jb1rt vvt`f~ ~S d,S o.L
Ground 3 Z~-3b l 0 `lam J/ G - s~ l S bk m~ i ~g o. Z o, g
elev.
101.•3 ft. 6-8.3 l0`t 2 -5 - S Own %M
Depth to
limiting
factor
Remarks:
? Boring #
o-LI Lb~-f iZ Z-C2 - si 1 Z,r1s~k `rh`~1~ fit." - o. o.
b
S
i 4 z ti~~z~ lo~,rZ 31` sic, I4%'bk o.q o.S
3 z~ 3y 10 `t (Z 3/S~ - sc lmSbV c-S o Z a•3
Ground
j elev. y 3y-8Z t p y 2 3/G S 1 c s b~ - >n U
d 0 3o.Y
1111(A-1 ft.
i
Depth to
limiting
~ factora 2k
Remarks:
y Boring #
o_v lk_ 1\t2 zlZ - S~J Z,'F3b~ m`f h eS o. S o•~
El 2 tz z lu `12 ~~L - gi l-'~Sbk Y►-r ` g o, S o, b
3 vz `1, ~L -t s o m h _
Ground YK o 3 o.y
elev
°!q ft.
Depth to
limiting
factor y
-1 8q
i
Remarks:
Boring #
L3
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
~An azan~A nFro~~
PLOT PLAN Page 3 of 3
SCALE 1"= SO'
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`1..1,1. ZJL Lg9S (715 ) 425-n7Fi5 - M00576
CST Signature Date Signed Telephone No. CST #
W'scdnsin DepartmeW of Industry. SOIL AND SITE EVALUATION REPORT Page \ of 3
Labor arKf Human Relations
Division of Safety a Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
ST - ~.\ul 1X
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTYOWNER: G2ZGo" E,;.t.1X-fgVjQ% %lSLL. PROPERTY LOCATION
eVy EsR : Cb~ VfeLhUeu-e'R 691FF-E@~ S W 1/4 S q 1/4,S °L T -2~8,.NR L8 E (o
PROPERTY OWNERS MAILING ADDRESS LOT #i BLOCK If SUED. NAME OR CSM #
N -nqq C.ourt,`M %w" y - ~R.o~o ~-Swl
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE DOWN NEAREST ROAD
IZlllfr'iL _WW,L.j sgeovL (7!S) LtZ.S- 9140 S ~cCLfur.~\C~R~N)VLC CeuL. 'T¢fytL
[04 New Construction Use [Dq Residential /Number of bedrooms 3 [ J Addttljn IUD existirg buildutg
j ] Replacement [ ] Public or commercial describe
Code derived daily flow LM gpd Recommended design king rate 1 bed, gpd$ 0.3 trench, gpoltt2
Absorption area required - bed, ft2 \s-ox) trench, ft2 Maximum design loading rate o •3 bed, gpW 0 -4 trench, gp W
Recommerided infiltration surface elevation(s) S>? E' Ptctr ft (as referred to site plan benchmark)
Additional design/ site corsideiations 3 Ca'e5, ~tcC.N S 'Y-LUti OhJ G . 414 ~ Q Rt yPSLAPS G
Parent material Rood plain elevation, l applicable N-A - ft
S = Suitable for system cONVENnONAL MOUND KGROUND PRESSURE AT-GRADE SYSTEM IN FILL T71 U = Unsuitable for sys INS ❑ U ®S ❑ U O S ❑ U INS
❑ U ❑ S CCU S ~U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Idlottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rench
] 0-9 XA:~~`'Lt z-[ Z - '50 lwtS wt `g~• e,w - O -S o• 6
Z °I_zs \.o `t tL q A s i 1 2,,Ir'3bk w► Cs - o- S o-6
Ground 3 --Qz S 4 Q VI6 - S~ ? ►vl .S ~ 1~v►v `F~. C W ci• S o . L
elev. S o s 9 W,'
qq.Z 4 qz--IZ twr tz v1C - st t^ C-w o~~ °'S
y
Dept to S -)Z-80 10 7 tZ 3/~ - S J O V., 0-110,
limiting
factor Remarks: -
Boring #
o-ly 1,u~R zlZ stil Z~~~~ ti+1'~ ew - o-S
Z Z )4-~!o Lo`(R 3L` sLl Zsb~ wt`F'ti _ u. S o, l
KT-
- 3 ~$S lib`-lcZ til6 s o s -
Ground t1
elev.
R8= I It
Depth to
limiting
factor
S M
Remarks:
T Name:-Please Print Arthur L. W e e r e r Phone. 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Fa11s,WI 54022
Signature: _p CL S _ ZZ Date: ~~PPJL It T Number:
[qcjs M0057'6
~U`l6R .
PROPERTY OWNER "ELM-)~ -ER SOIL DESCRIPTION REPORT Page? of 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munseil . Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trento
3 J o -t 1 t.o `-f, Q Z~ Z - S i 1 Zwt. Sb12 Yn `~t•- C,~-~, - o . S o.
Z t.l-Z-1 K~ -tt'Z- (o - Sit Z~ ~bk vvt`~'I. cS - a. S o. L
Ground 3 Z~-3b lO`~R. 3/L - sal 1~'► 51~1~ >~`~i cS o.Z o.3
elev.
101.•3 ft. 36-~3 to`t 2 3~G - S) oil l,~ `F1- 0 3 ; a.w
Depth to
limiting
factor
Remarks:
Boring # I o~~1 ZL2 - SZ) Z►mS~k vv\.'~4. LL." v-
`F4. cS o•~( a.S
U 2 tit-Z~ 10`-L CL X16 - sicl 2.4tb t.,
3 20-) t~`t23/V - sc\ lmsbk Y., 0S 0.3
Ground C s b12 -
elev. y 3y-8z t `1 2 3~L - S c~ >n U o '3 0
101.3 ft.
Depth to
limiting
factor8
;
r 1
I
Remarks:
Boring #
~.`F>.. eS - o• S ~ o•~
o-` 10`1,2 ZLZ - 51,E \b \t
5 Z lZ Z 10 `1 2 3~L Si J Z'~S~k Yvt S - a' s 0, ~
3 ~o~1z -t L (a s o m r - 0 3 a.y
Z4-$4 \,O `-l q16 5 0 9 vn
Ground
g4Sft.
Depth to
limiting
factor
~ f3 ~l
;
Remarks:
Boring #
i3
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
PLOT PLAN Page 3 of 3
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1 E2 g6 s, r
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V1~`1ZLL 2ZL L019S (715 } 425-n~ ~5 1400576
CST Signature Date Signed Telephone No. CST #
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a KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN,
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER eY
MAILING ADDRESS x2 77 `V C~ / /?,`6 / .ISt62
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CrrY/STATE F-411,-r Y~ 0 2
PROPERTY LOCATION -5-A)_ 114,15 1/4, Section q , T_pZ~N-R_W
TOWN OF ; /~e' GGl ~,U.~ / G ST. CROIX COUNTY, WI
SUBDIVISION (::5J~_,~!? , LOT NUMBER
CERTIFIEDSURVEY MAP VOLUME*_, PAGE ! tLOT 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.
1/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 ex iration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8TC-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
Location of property SL J 1/4_1/4, Section T vk7P' N-R /~N
Township ~u c%;~~.rlT Mailing address _z cZy r_a A2 ej
~,~rrcvq7 Its i.) .t
Address of site /-//Jl ✓ftongln eltl 4ad
subdivision name C 3 rn Lot no.
Otherhomes on property? Yes___Z~_No
Previous owner of property Total size of property
Total size of parcel 2 a c~e.s
Date parcel was created
Are all corners and lot es identifiable? Yes No
Is this property being developed for (spec house): Yes _.K _No
Volume _llo?_6 and Page Number 5-7,r as recorded with the Register
of Deeds.
ZXCLUDN WITH THIS APPLICATION =8 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) an (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.
Signa re of Applicant Co-Applica t
ilato of Cirr»a+•„rn n..a.. ..r ..s....._~..._.__
i~~ .S, I 1. COI, M611i ['Olin z - iyaz
WARRANTY DEED
DOCUMENT NO. Z
r ~ 79 T Erg :a
i- von" Est:~
R
I
Gregor A. Bisel and Roxanne D. Bisel, MAY 8 1995
11
husband and wife, _ at 11:15 At'l
Ft~g of I~ev~s
conveys and warrants to Charl PS T HP1 muel 1 er and
Rosemary A Helmueller, husband and
wife,
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS ,t
the following described real estate in St. Croix
County, State of Wisconsin:
i
(Parcel Identification Number)
~ I
j! -That part of SW1/4 SE1/4, Sec. 9-T28N-R18W described as follows: Lot 4
of.Certified Survey Map recorded in Vol. 10 of Certified Survey Maps, page 2911,
as Doc. No. 528246. II
~i
'i
i'
i
I I j
This is not I
homestead property.
(is not)
I I
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
ii
jl
Dated this
day of M
I
i
(SEAL
* (SEAL)
G 'sel "
(SEAL)
(SEAL) I~
* * Roxanne D. Bisel
i
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ss.
St. Croix
- - - County. 1
authenticated this day of 19 Personally came before me this
day of
'1995 the above named