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s Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP o~~ bSe(~^ SEC. T N-R W
ADDRESS pC~SnA? ST. CROIX COUNTY, WISCONSIN
CS ~ ~ 1
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1RR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATENNORTH ARROW
ORAN 5~
BENCHMARK: Describe the vertical reference point used ~ ~ IN
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: I D Length: 5 Number of Lines:.3 Area Built: 75Y
Fill depth to top of pipe:
V a"
Number of feet from nearest property line: Front, O Side, O Rear,O It.
Q
Number of feet from well: 80I
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.13OX 790 BUREAU OF PLUMBING
MADISON, !NI 53707
CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
Ilf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ODR ESS OF PERMIT HOLDER: INSPECTION DATE.
James Burton A R. R. 2, Hudson, WZ 54016 D a f/ ~JS"
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV..
SW NW, Section 34, T30N-R19W, Town of St. Joseph
Name of Plumber: MP/MPRSW No. County. Sanitary Permit Number:
Richard Hopkins 1059 St. Croix 69638
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
_ PROVIDED: PROV19MOr-
~Z YES ❑NO 4 ❑NO
BEDDING: VENT DIA.. VHIGH WATER NUMBER OF ROOPERTY WELLLDINGVENT TO FESH
ALARM 1~ FEET FROM AIR INLET❑YES NO ' ❑YE EJNO NEAREST J
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. JPUMP, SIPHON IF ACTUALEY WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL P~OMBER F PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN EET F LINE AIR INLET
PUMP ON AND OFF) ❑YES LINO NEARE -]b
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing „1 H 1111AMf TER 1111ATEHIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH JNO~OFDISTH PIPE SPACING, COVER INSIDE DIA =PITS LIQUID
BED/TRENCH S3 rN~CHES M EHIAL' PIT DEPTH
DIMENSIONS
G RAVEL UL PT II FILL DEPTH UIST It. PIPE UISTH PIPE. DISTR. PIPE MATERIAL NO D.. TH NUMBEFR ROM OF PROPERTY WELL BUILDING. VENT TO FRESH
LI AIR INLET:
BELOW PIP S ABOVE COVER E V. INLE EL V. END PIPE FEET
,C G(~
5.~ c L NEAREST D ( l1~
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES LINO
SOIL COVER TEXTURE PEHMANE Ni MAHKFHS OBSERVATION WELLS
❑YES LINO ❑YES LINO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED OFPTH OF TOPSOIL SOIIOFII SEEUFD FULCHED
CENTER EDGES
❑YES. LINO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO. OF LATE NAL SPACING CiNAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH ID:STRPIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVELEVDIA ELEVPIPES DA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CONNECT LY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
❑YES LINO
COMMENTS: PERMANENT MARKERS~YES ❑oFSSE VATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
c/ ❑YES LINO ❑YES LINO NEAREST
12- to-7.
I ~
`f - t15 11 ~4 ~//1/S
Sketch System on ii Retain in county file for audit.
Reverse Side.
SIGNATURE: ` TITLE-.
DILHR SBD 6710 (R. 01/82) `
wlsconsln APPLICATION FOR SANITARY PERMIT
I ~e' &,~:;
COUNTY
~a DILHR (PLB 677
DEARgTmEnT PF UNIFORM SANITARY PERMIT #
- inotjSTRYLRB01 to 4-39,
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPEL ~,NeER U o MAILI ADDRESS
f~J+
PRO ERTY nL~OLC~►~IlATION Ct~'f
h11 /4 /Y/4, S 97, T30N, R 19E (o W owN
QD. LOT NUMBER BLOC NUMBER ISUBDIV SION NAME NEAREST ROA,Q~LAKE O~AN MARK 77;K NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: E-1 Public (Specify): 007 en/ /1-ed
THISI,I ~PERMIT IS FOR A:
N New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Z Seepage Bed El Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity ~~m(}
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
f 3 ✓ ~ ~9 / f Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Sign e: fe}P7MPRSW No.: Phone Number:
Plum is Address: t ✓ Name f Designer: i
. A-y
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
/ y0 ❑ Owner Given Initial
J 5 Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
1 i
i f , Lam'
i
4403198
CERTIFIED SURVEY MAP
Located in the SW 1/4 of the NW 1 /4 and in the NW 1/4
M of the SW 1/4 of Section 34, T30N, R 19W , Town of
so NW Corner St. Joseph, St. Croix County. Surveyed for:
.0 Section 34 James Burton
T30N, R.19W Rt. 2, 60th St.
N= UNPLATTED LANDS Hudson, Wi.
a „ PO - - -
ip S 87'41'23"E 54016
~t 501. 4'
6a LOT 1 LEGEND
InN ~ p1 M
~
OO `U X292093 Sq. Ft:..' c,uding ; County Section Corner Monument
a tv N roa right-of-
p U N .71 Acres. n • 3/4" I.D. iron pipe found
(V ao 2909 9 Sq . Fe. exclu ing ;u ao 0 1"x24" round iron pipe weighing
o v ro right-of Tway c m 1.68 lbs. per foot set
I 68 Acres N--~'- existing fence
30.82' 00 57'43"W
` it i 31' ~ ~ NOS
--341.68 ~SCALE IN FEET v2W
N 89' 58' 20"W
I e 2.59' 381.99' s Yap 0 100 200 300 °
• (1".200') x
- Ow
~ ~ Page 575 ~ ~ s
I '118.30' Olt)
M z
S 89'58' 20"E z N 85-42'16"E s 75057'
E N M
v~i q ii) ; &356.60 ' 319.90 246. 9007„
W
= N 31 I --338.35'-- a 3
219.75' $ g
Oo 20g q0LOT 2
~~S 89 58 20 E
19.7s' D ~
w I 439058 Square Feet ' RI~ ;
• including road right-of-way JUL :11 c ( LOT 3 10.08 Acres s ~yy 9,85
to W 1W *#9_0*004
of 0406
yV
e a I Q , 204683 Sq. Ft . 437804 Sq. Ft. excluding f Oak
o (D incl. R /W N road right-of-way
z 4.70 Acres 10.05 Acres g
m
o r N•F F
0 to 189797 Sq. Ft.
~N excl. R /W
s 8' I 4.36 Acres
W1/4~-
Cor .
3I a 29.82'
i~ 462.45' 697.31'
of I I 89'49'4 "W
DESCRIPTION
A parcel of land located in the SW 1/4 of the NW 1/4 and in the NW 1/4
of the SW 1/4 of Section 34, T30N, R19W, Town of St. Joseph, more
particularly described as follows: Beginning at the W 1/4 corner of
said Section 34; thence N 0°20'17"E (recorded as North) (assumed
bearings referenced to the West line of the NW 1/4 of said Section 34,
bearing N0°26'17"E) 529.40' along said West line; thence S89°58'20"E
356.60' (recorded as East 373.31) along the monumented South line of
that parcel recorded in Volume 486, page 575; thence NO°25'00"W
350.18' (recorded as North 350.00') along the monumented East line of
said parcel; thence N89°58'20"W 351.99' (recorded as West 373.31)
along the monumented North line of said parcel; thence NO°20'17"E
438.22' along said West line; thence S87°41'23"E (recorded as S870
30'40"E) 501.04' along an existing fence as previously monumented by
Surveyor 5-1042; thence S202111211W 388.761; thence S27037'28"E
(recorded as S27029120"E) 401.76'; thence S75°57'07"E (recorded as S750
48'00"E) 146.901; thence S30°42107"E (recorded as S30°33'E) 725.921;
thence S89°49'47"W 1189.38'; thence N1°17'54"W 110.21' along the West
line of the SW 1/4 of said Section 34 to the point of beginning,
containing 935,834 square feet (21.48 acres), and being subject to an
undelineated easement to St. Croix County Electric Cooperative as
recorded in Volume 263, page 307, and also being subject to Town Road
right-of-way as shown on the attached map.
I James E. Rusch, registered Wisconsin Land Surveyor, hereby certify
that I have surveyed and mapped the above described property; that
such map is a true and correct representation of the exterior
boundaries of the land surveyed; that I have complied with the
provisions of Chapter 236.34 of the Wisconsin Statutes and the St.
Croix County Subdivision Ordinance to the best of my professional.
kno edge, unders nding and belief.
J mes E. Rusch %AGOnI
sconsin Land Surveyor 5-1376 •••~•`~/~,~i
407 Second Street ~i
Hudson, Wisconsin 54016 JAMES E.
R
SU-13H
6
June 24, 1985
r Hudson,
O
SUM
This map is,hereby approved the To n Board of the Town of St..
Joseph
6/215/es
Dat Carol Barrette, Clerk
Volume 6 Page 1547
l
APPLICATION I01( SANITARY PERMIT
S '1' 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/contractgr, ("spec;-;;,
house"), then a ser..ond form should bra reC.olnod and completed when the property is
sold and Submitted t:ii Hilo (4 1 l.co w i t li t io appropriate deed recording.
- - - - - - - - - - - - - - - - - - -
>
Owner of 1 ro[ t.t. t y Pu A-
Location of Property 14 n/~K!sc„ ;l~,rt loll T N - R W
'township • 714
Mailing Address 2,
~~l
Subdivision Name
Lot Number
Previous Owner of 7P_r.`opt rty
'Total Size of Parcel
Date Parcel was CrL'atutl
Are all corners zinc[ lot. Ilne:s ident.lfJuble? _ Yes No
Is this property being; developed for resale (spec house) ? Yes No
Volume and Page Number -/54f/7as recorded with the Register of Deeds
INCLUDE W1111 THIS APNIACATION ONE OF THE 1nLLOWINC:
1. Warranty Decd
2. Land Contract.-„3. Other recordlugLi filed with Lhu Register of Deeds Office
In addition, a certli'.ied survey, if available, would be helpful so as to avoid delays
of the reviewing proc:e.ss. If the deed description references to a Certified Survey
Map, the the Certified Survey Mah shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) ce,t,a6y that al a.tatemeri.t6 on .tli.b~ ho)un ane tAue to .the but o6 my (ou)d
Knowledge; .ghat 1 (we-) am (one-) tile owne~t (b) 06 -tile pnWpeAty deec&Zbed in tW
(We)Jte
.trt6o/uiiatt:on 16onm, by vi tue o6 a wcvtvtaxt.ty ddeeed~ Leco)tded .i.nathe~O~ Ice .t
County 1Zegcdte~t o6 Deect~ a~, Doeturic.t No. Ato.? - '
nnmemteii oun .the pnopoaed site 6o,,c .tile aetoage cePo~al~zy.6tem (on 1 (we) have
N
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S T C I05
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SEPTIC TANK MAINTENANCE AGREEMLNT
0
St. Croix County
• d
H
OWNER/BUYER r H
ROU'T'E/BOX NUMBER 8ax Fire Number
-_i~l [ Q ~O
CITY /STATE 7 1 Z111
PROPERTY LOCATION Section , I' M, R / 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 co11-
silts of pumping out the septic tank every three years or sooner,
if needed, by a licensed Septic tank LumL)er. What you put into
the system can affect the function of the _L'pLic tank as a treat-
mcut stage in the waste disposal system.
St. Croix County residents iu_a~ 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, will, the requirement that
owners of all new systems agree to keep their systems properly
maintained. _
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on- site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. a
I/WE, the undersigned, have read the above requirements and agree Lnn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ~o
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Z 1g Office within 30 days
of the three year expiration date.
SIGN
'6
DATE
St. Ct~oix C.:)unty Zoning Office
P.O. 1' o x 98
Ilammord, WI 54015
715-7S:6-2239 or 715-425-8363
Sign, date and return to above address.
Z
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTR,,, - DIVISION
P.O. BOX 76
LABOR AND . PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOW F(4WMUNICIPALITY: L T ]BLK.,NQ.: SU VISION NAME:
u1 1/411/4 '39 /T3o N/RJ E (o ~'Jase ~I
C NTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: lI
<qL C>blk' TA!'1~~ ar' n Z f lIAAhA^
USE DATES OBSERVATIONS MADE
NO. BEDRMS : COMME=ION: ~1 ="_S, PTIONS: ER ATI N TESTS:
Residence Y New ❑ Replace z 3
.3 1 RATING: S= Site suitable for system U= Site unsuitable for system
C VENTIO❑NAL: MOUND: ❑U IN-GROUIND-P URE: SYSTEM-I -FILLHO~LDING TA K: RECOMMENDED SYSTEM •.Ioptional)
If Percolation Tests are NOT required DESIGN RATE://3` If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH LEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
,22 IN 4 l 2 6 I I..S"an s ~ 9. ~ ~ ~a>7 S1
B- d, /3 ~6 ~•~.3 . 4z~ al l fvC' :t / ,3313,, s sL/ S/
B- 3 Q,9d
y4/ l
B- -7.0 pi A 7'13 1 1. 2,3y 6P. 5)
q3 &s/A
B-
PERCOLATION TESTS
TEST DEPTH, : WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES
NUMBER INCHES AFT RSWELLING INTERVAL-MIN. PERIOD I PERIOD 2 P RI D
2 /0 2
'7. 11d
P
D 9 /6 13,33
P- 0
P--
P-
P- _
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
Q~
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 93, ~1~
~A1 ei6
$ N
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k
J- 7,
v✓ 3
E ~
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Ilk
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INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 5395
To be a complete and accurate soil test, your report mast include:
1. Complete legal description;
2. The use section r, t clearly indicate whether this is a residence or commercial project;
3. MAXIMUM r i, of bedrooms or commercial use planned;
4, Is this a new ;r cement system;
5. Complete the sui . , rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEN;S ARE RULED OUT BASED ON SOIL CONDITIONS;
5. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred, A
separate sheet: may be aase:d if desired;
3. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all ropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, if ap, , ,
10. If the inform as flood plain, elevation) does not ly, place N.A. in the appropriate box;
11. Sign the form !OUr current address and your certi_ -tion number;
12= Make legible cot, s and distribute as re<itrired. ALL SOIL TESTS MUST BE FILED WITH THE"
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION'
AF _s _ _'IATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") SR - Bedrock
cob - Cobble (3 - 10") SS - Sandstone
gr -Caravel (under 3") LS - Limestone
*s S' :.d - Nigh Gror
cs - C _rbe Sand Percolation i
rned s - i Sand W - Well
fs - Sand Bldg - Building
Is - L~rny Sand > G: c:=ter Than
"sl - 4- (_oam < _ L. , Than
*I l Bn E;
*sil - Si=? Loarn BI _ B
si - u Gy - Gr
cl Loam Y Yel! ~w
scl SaI y Clay Loam R _ R
sicl - Sil' Clay Loam mot
sc _ Sand; Clay wr - l," `
sic - Silty Clay fff fr f
.c Clay CC r~
pt - Peat Inm - Ctrs
rn - MUCk ;K d - dis`
p - prom
HWL - H vel,
Six general soil textures bv,~~er
for liquid v4aste disposal BM - BE---h 1,
VRP Vertic I r
. L. 6 7 P LOT A F, c RI 0 S S SECT PROJECT
(-D L U M IL~_~
NAME
-
I C ENS
L
E ff
L 0 C A ION Y.
T
S
13ed,e o o r~
rl Metal rah in S Zvvnj I'g' f~~,r1 r~~~ -
M e
DOI
By era'
c 4c
! P
N
FRESH AII' N LETS AND OBSERVATION PI-PE
CROSS SECTION
Approved Vent Cap
Minimum 12" Above
Final Grad --I J
Y 0 X 4" Cast Iron
v
• 10 1~
~O
STC - 104 M
AS BUILT SANITARY SYSTEM REPORT r N~v „ 619°.
COX ti
OWNER S1
i~Cf~' ~iJ ll1C3E
Zd't 4.+
ADDRESS
SUBDIVISION / CSM# LOT
SECTION 'r /6
N-R W, Town of 5f- J
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
azo
INDI NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
v
i
BENCHMARK:/c'
ALTERNATE BM•
EPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:-(~CL~! Liquid Capacity:
Setback from: Well= House Other® ~r
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: r Length Number of trenches
Distance & Direction to nearest prop. line: /
Setback from: well: House® Other ,,2zl' cvz
ELEVATIONS
Building Sewer ST Inlet: ST outlet: !y•
PC inlet PC bottom Pump Off
Header/Manifold - 11 Bottom of system
;aaLyt'' ~ "
Existing Grade 46 Final grade DATE OF INSTALLATION: PLUMBER ON JOB:
LICENSE NUMBER: /ig
INSPECTOR:
3/93:jt
Wiscqnsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT ST. C
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION cmd"fibm
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
14ARTINSCIO, FVJL X. 6T. JOSFM
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION EVATION DATA A9 60 AIQ
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 47v Benchmark 10a52'" fao:
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet i
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic -1967 ' tSj /.S, NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe fig' 9
o
Holding Bot. System 9, (o y' q3
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS o2 ` ;0) ' DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
Model Number:
INFORMATION Type O
System: gip" 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
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCAT,UM : ST. JOSEP . 3 4. $0. ~ 11*6 4, I,ilCfZ', aREET
44 ~e_lt
Plan revision required? ❑ Yes [3~No r
Use other side for additional information.
SBD-6710 (R 05/91) Date sp ct Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
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 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
~ 8Z/7c Q
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)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Own ame Property Location
4 /4, 5 T N, R
4L lc Y~ n
Property Owner's Mailing Address of Num er Block Number
f~ f
City, S a Zip Code ~ Phone Number Subdivisio a e r CSM Number
Q CS f5e/7
TYPE F BUILDING: (check one) ❑ State Owned 11 qty Nearest Road
Public 1 or 2 Famil Dwellin - No. of bedrooms own of
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) wl J
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 X 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. ❑ New 2...Weplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System 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 1&?'~eepage 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) Elevation
6B~ ~}C} ;0 e ,y'-Feet Feet
VII. TANK Ca
in9alloacitns Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank w~ ❑ - ❑ ❑ ❑ ❑
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' ame: (Print) / Plumbe ' nature: (No Sta s) MP/MPRSW No.: Business Phone Number:
P b s Address (Street, City, St te, Zip Code):
IX. CO NTY / DEPARTMENT USE ONLY
❑ Disapproved Sa%aary-~P-e~r+m(iit Fe (Includes Groundwater ate Issue Issuing Agen Signatu a
N~CJU~ Surcharge Fee)
Approved ❑ Owner Given Initial //V( ~lj
Adverse Determination ~Ga
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-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
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.
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 all septic, pump/siphon and
hold jig tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated {practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
FLU i FLAN
PROJECT L u / ADDRESS d f`
1 /4/01/~A /4/SN/R W TOWN Ios~° COUNTY
MPRS Byron Bird r. 3318 ATE ' eta'
BEDROOM CLASS PERC CONVENTIONAL,-GROUND P SURE
CONVENTI NAL LIFT MMOU ND H LDING TANK
SEPTIC TANK SIZE? i; LIFT TANK SIZE -
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA ,>/-7 ERC RATE R S BED SIZED
` 16 Benchmark V.R.P. 'Assume Elevation 100'
Location of Benchmark ' T ~X~
* H.R.P.
O Borehole Q Well Scale Feet
0 Perc Hole System Elevation
Uent
12"
Gradp
TYPAR COVERING -
2^
12" 3- 4 6- 4O 3- ®~1 6 Sewer Rock
0 4W
~rf
d 1 a
r
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited 4o: vertical and horizontal reference point (BM), direction and ~I^L7
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
d..3e 0e'~' sS-fin
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
~ ` Govt. Lot 1/4 /4,S 3il T'3 {,7 N,R E (o
Property Owner's Mailing Address Lot # Block# Subd. Name or CS M#
City State Zip Code Phone Number rte. Nearest Road
❑ City ❑ Village ~I Town
c (715- ).S yy3 7 S'_ T s a° c>
❑ New Construction Use: Residential / Number of bedrooms _ Addition to existing building
Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate - 5 bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate jbed, gpd/ft2trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound. In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system S ❑ U J2 S ❑ U J°1 S ❑ U 1 /10, S ❑ U ❑ S ~`u ❑ S -O u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
g Texture Consistence Boundary Roots
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Z
Ground
elev.
7-
--Depth to
limiting
factor
3. Remarks:
Boring # t,
7 ~L~ Lr " fn r
Ground
elev.
fti
5 5
Depth to
limiting
factor
in. Remarks:
CST Name (P se Print)) / nature Telephone No.
Address Date CST Number
1
SOIL DESCRIPTION REPORT .
PROPERTY OWNER Page of
PARCEL LD.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~Dtft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground
elev.
Depth to
limiting
factor
Jr-
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
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)
~rr„ t
Soil Test Plot Plan
Pro1edt Name AL °-0~7 Byron Bird Jr.
Address
ow,/C 3479
Lot Subdivision. - Date ~ay-mac
/4 TAN/R /7W Township lS ~.o
0 Boring O Well PL Property Line County J Gy~~ r
L BM or VRP = Assume Elevation 100 ft.t `
System Elevation 5 *HRP
t 3 ~
4
Scale 1/4 10 Ft. When dimensions aren't stated
63~ X81 ' CERTIFIED SURVEY MAP
Located in the SW 1/4 of the NW 1 /4 and in the of /4
of the SW 1/4 of Section 34, T30N, R 19W, row
NW Corner St. Joseph. St. Croix County. SurveyBedufrtoorn
W ° Section 39 Rt, 2, 60th St.
N n~ T30N, R 1qW
UNPLATTED LANDS_ H
z, PO 5 87'41'230E
om 501.04'
LEGEND
N- - { . LOT 1
` County Section Corner Monument
n8R w!4. m
292093 Sq. Ft, including a .
.-V cv `n° road right-of-way 0 3/4" I.D. iron pipe found
a 6.71 Acres v4 ^ 1"x24" round iron pipe weighing
N m 290969 Sq. Ft. excluding a cOOo ° 1.68 lbs. per foot set
°o v road right-of-way o m T existing fence 00 1 1ZI 6.68 Acres to -
r5o.6z' N0P3r'43'w
I I ~ 10.31'
I f Nd,
, s
o
•-341.68' ~SCALE IN FEET
8 b
N 89'58'200W W~ t
351.99' YQ` 0 100200 300 \o
:
; (111=2001)
Page 575 in
N °
I ( 16.30 oin
R
m
~I~a' r1.ss' z 85-42 *160E s 730 ilsf~ S 89'58'20"E N 8319.90' 1g6.9o:7.,E HW0
356.60
`n -338.35'- -
z ' 219.75' 8 4
~W~ tog . q0'. LOT 2
~S89 5820 E RAC ED
± 19.75 439058 Square Feet
JUL 2 1985
w including road right-of-way
I LOT 3 10.08 Acres #A 0
a m 119 . 204683 Sq.Ft. 437804 Sq. Ft, excluding c° y~. Wiay~ '
oo in incl. R/W ~tr~t~. road right-of-way
4.70 Acres •D~ " 10.05 Acres
11 m
Z
Io r .c~
1n 189797 Sq. Ft.
~un excl. R /W
I d I 4.36 Acres
W 1/4
Cor. 0
31N 29.62'
° 'te 462.45' 697.31'
89.49'4 "W
o !189.38'
I
zj UNPLATTED_LANDS
I S W Corner
Section 34 APPROVED
Proj. 485-836 Drafted by H.P.P. Jul. 02 1985
vc-e llaws-~,,,7 / 0 - t/-,? 4
CUIIIJTY
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St Croix County
OWNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, 1/4, Section T N-R-W
TOWN OF ~X J'0 5ST. CROIX COUNTY, WI
SUBDIVISION 3 'f 7 LOT NUMBER
_.,~,PAGE / /7LOT NUMBER i
CERTIFIED SURVEY MAP L VOLUME
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: 3ar cl
DATE:1
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 l a r~ o h
Location of property L~ 1/4,///el/4,Section T -Fe N-R_ W
Township D Mailing address 7 ~ ~7&
/1c~ ~/5o s'l Z'L
Address of site
subdivision name G~ Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created f-,
Are all corners and lot lines identifiable? Yes N,o
Is this property being developed for (spec house) ? Yes X 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 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 J;o 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 of ice of the County Register of
Deeds as Docent 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 o Applicant Co-Applicant
Date of Signature Date of Signature
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify at I have inspected the septic tank presently
serving the 4u /_//mar/j~rjo~ residence located at:
Section TN, R /y W, 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. ~1
Last time serviced: ,,1
Did flow back occur from absorption system?
Yes _ No (If no, skip next line)
Approximate volume or length of time: gallons minutes
capacity:
Construction: Prefab Concrete Steel Other
Manufacturer: (If known) :
Age of Tank (If known):
(Si ure) (Na Please print
(Title) (License Number)
Date
Form to be completed by licensed plumber (s.145.06, 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 Signature P/MPRS l
I
• THIS SPA:.[ ai5[RYED FOR Pf CONOING V. TA
r DOCUMENT No. WARRANTY DEED
STATE BAR OF WISCONSIN FORS 2-1982
500330 pes i REGISTER'S OFFICE
St. CROU( Co., WI
MICHAEL WAYNE INMAN AND SUSAN WILDER I-SMAN, Rec'dWRewd
husband and wife as survivorship marital JUN $ 199
QroperL........ 8:30 .M
N at
-
PAUL MARTINSON AND A N
conveys and warrants to
ReQS5t0►01I)ies3;
..MARTINSON, ..husband _aLztd...W~.fe .
-
-
RETUNN TO
.
St . -fro -x
nnty,
the following described real estate in
State of Wisconsin: Tax Parcel No_
Part of the SW1/4 of NW1/4 of Section 34-30-19 described as6followgss:
Lot 1 of Certified Survey Map filed July 25, 1985 in Vol. "1",
1547•
I
This homestead property.
(is) (is not)
Exception warranties: easements, restrictions and rights-of-way
of record, if any.
.
103
June.
Dated t day of
....(SEAL)
(SEAL)
Susan Wilder Inman
-
Michael ayne Inman - -
-(SEAL) I
-----(SEAL) -
±R
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN
Signature(s)
St. Croix County. as
_-.day of
anthenti.:ated this .___....day of 19 Personally came before me this _-0_
-___.June............ 19.93_. the above named
-
- ----------------------------icha~l Wayne..lzlman....uac?..Wils?er
TITLE: MEMBER STATE BAR OF WISCONSIN Inman . •
(If not, ----------g-------- .
s.thorized by 7Q6.OE, is. Stats.) to me known to be the person .5....... who executed the
in instr ent and a now ledge the same.
II THIS INSTRUMENT WAS DRAFTED BY
i-- -
_ _