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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor andHuman Reis INSPECTION REPORT ST. CROIX
Safety and Buildings Div Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284198
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
ANDERSON, MARSHA SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9600452
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift `riction System TDH Ft
oss 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 DIMEN 1 N
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM
INFORMATION TypeO CHAMBER Moe Number:
System: 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.)
LOCATION: SOMERSET.5.30.19W, SW, NW, HWY 35/64
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH d
SANITARY PERMIT NUMBER:
r::•i`'r'■~ SANITARY PERMIT APPLICATION BSafeureaty u oan ' f BuiluildiinWater Systems
gWater 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 x
than 81/2 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 if re sion to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Propert O er Name Property Location
yZ 3[,/1A 1/4, S T , N, R f E (or)(D
Property Owner's Mailing Address Lot Number Block Number
lC s ItT
City, State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
❑ Village
❑ Public 1 or 2 Family Dwelling - No. of bedrooms -1.2_ M,rown of 4.J
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 03 2' zczC7
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. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5X Repair of an
_ _ System_______ _ System Tank TankOnly _______________Existing System Exi-sting -------7
_
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,WSeepage Bed 21 E] Mound 30 ❑ Specify Type 41 E] 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
Re wired (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
O~ V 140 Feet Feet
Capacity Site VII FORMATION in gallonTotal # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New Existing Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank mc> ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins Ilation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Prii~nt)>J Plumb Si a ur No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, ity, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing A ent Signature (No mps)
WApproved Surcharge Fee)
❑ Owner Given Initial ,l /(,e lleo /
Adverse Determination / b v/ C
X. CONDI IONS OF AP ROVA / REASONS FOR ISAPPROVAL:
44~_,r
~7
SBD-6398 (R. 05194) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Di-,on, 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.
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 8 112 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.
Wisconsin DQparlment of Industry, SOIL AND VALUATION
Labor i;f1d Human Relations q~ Page of
Division of Safety and Buildings in accordanc li I tf Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 in size.'Pa st County
include, but not limited to: vertical and horizontal reference i M) rid s-r• C r
percent slope, scale or dimensions, north arrow, and locatio~ dista o nejre d. arcel I.D. #
APPLICANT INFORMATION - Please print all n. Reviewed by ate
Personal information you provide may be used for secondary purposes law, s. 15..
Property Owner Property,Loc ` n
d~t,Lo SW 1/4 NW1/4,S 5 T 30 N,R 19 E (or) 10
Property Owner's Mailing Address o # Block# Subd. Name or CSM#
y Aw 3S/
City State Zip Code Phone Number nn City ❑ Village ® Town Nearest Road
SQvn~r Wt AS -14 7 ~I ) -65 -71 1 5"i r* 4r '1r' 35 41
❑ New Construction Use: Residential / Number of bedrooms -3- Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow SQ gpd Recommended design loading rate 1 bed, gpd/ft2- 5-trench, gpd/ft2
Absorption area required 3l5 _bed, ft2 *ID trench, ft2 Maximum design loading rate
bed, gpd/ft2trench, gpd/ft2
Recommended infiltration surface elevation(s) 9 2. ;L4 ft (as referred to site plan benchmark)
Additional design/site considerations \
Parent material A' 0 Q L" a \ 11 ~i S Q C. ) 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 ® S ❑ U IX S ❑ U ®S ❑ U ❑ S 69 U ❑ S 5A U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
0_ 1 0-1E D Q3/3 51 L 1 F56K m Fr A5 aF • a .3
-4 a R4/ ; eL IF L SFr C1 F NP '3 OF
Ground ( -25 -7• 5 R Y1 1V e L a rh sbk F e c w 1 F - y 5
elev.
le .~t ft. 4 5-y0 It'YR S - S; .L am 6K Fe w I VF 'S
Depth to 5 YO-Sy b y/ C L a r^ s 6k v-4 Fe C. w - ' .6
limiting /a Sy- 14 77, 5 Y 3f 5 L. M sbk rAFr Ct+.J •4 i5
factor
-70 in. ? D 7o 7, !6 1 - S & M s b K M Fr ► to
Remarks:
Boring #
A- .0
Ground
elev.
ft. '
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
ar l~CS> Is -2,9 3ssg
Address Date CST Number
X710 abb-11" St. "tat r l X _12 - to 4~D 1
11 -9 ycak
L -
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
Ground
elev.
ft.
Depth to
limiting ;
factor
in.
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)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS
(loc tia on of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 114,IV60 1/4, Section , T 3o N-R_Z(?_W
TOWN OF ~Di1'~21 ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP _9 VOLUME , PAGE , 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.
Me, 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: V_
DATE: j - ~ 3 L D
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
Location of property6L, ~ 1VLjj 1/4, Section TS~N-RZ9 _W
Township Jar Mailing address
~ c~3n ~ l✓t~ ~~a~S~~ ~arrc~~~-et~u '
Address of site
Subdivision name Lot no.
Other homes on property? Yeses-No
Previous owner of property
Total size of property
Total size of parcel 3 G
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 AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Q AA J74
Signatu e of 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 that I have inspected the septic tank presently serving
the,- residence located at:
Sec. T_ ~N, R_Z(7_W, Town of St. Croix
County, Wisconsin. 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
Did flow back occur from absorption system? Yes Noe (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)
(Signa re) ~'L~'~~~~ °
(Name) Please Print
(Title) ' (License Number)
G
(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
c~`rtify 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
tte. ii1 Warranb Deed•-To Husband and Wife as Joint Tenants BJOK 511 yl Z~ PuDWhed bs Dau Claire Book t tlntlonav (b,
;i
322097
This Indenture, Made this 21st day of May , 19 74 .
between Henry F. Lange and Clarice M. Lange, husband and wife,
part i e s of the first part, and
• Wayne Anderson and Marsha Anderson
husband and wife, as joint tenants, parties of the second part.
WftnrOirto, That the said part ies of the first part, for and in consideration of the sum of
. One dollar and other good and valuable consideration Dollars,
to them in hand paid by the said parties of the second part, the receipt whereof is hereby
confessed and acknowledged, have :given, granted, bargained, sold remised, released, aliened, conveyed
and confirmed, and by these presents do give, grant, bargain, sell, remise, release, alien, convey and
confirm unto the said parties of the second part, as joint tenants, the following described real estate
situated in the County of St. Croix , Wisconsin, to-wit:
A parcel of land located in the NE4 of the SW-4 the NW4 of
the SW4 and the SW4 of the NW4 of Section 5, T 30 N. R 19 W,
Town of Somerset, St. Croix County, Wisconsin, being
further described as follows:
Commencing at an iron pipe at the Center of Section 5;
thence West along the Quarter-Section Line 477.99' to the
Northwesterly Line of S.T.H "35" and "64" being also the
point of beginning! thence S 54039'35" W along said highway
Line 962.641; thence N 40042155" W 1106.87'; thence
N 11026155" W 373.87' to the North Line of the Sz of the
SA of the NW4 of Section 5; thence N 880 59'33" E along
said Line 665.27' to the East Line of the SA of the NW-4;
thence S 3000159" E along said Forty Line 661.76' to the
Southeast corner.of said Forty• thence East along the
Quarter-Section Line 880.78' to the point of beginning..
The above described parcel contains 16.749 acres of land.
.TRANSFER
FEE
ZLOQttYtr, with all and singular the hereditaments and appurtenances thereunto belonging or in anywise
appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said parties
of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained
premises, and their hereditaments and appurtenances.
Zu 12abt anti to 1?0I13, the said premises as above described with the hereditaments and appurtenances,
unto the said parties of the second part, as joint tenants.
Anti tit gafb,
part i e s of the first part, for their heirs, executors and administrators,
do covenant, grant, bargain and agree to and with the said parties of the second part, and to and
with the survivor of them, his or her heirs and assigns, that at the time of the ensealing and delivery of
ds of a good, sure, perfect, ah.solute and indefeasible estate of inheritance in the law, in fee simple, and
that the same are free and clear from all incumbrances whatever.
and that the above bargained premises, in the quiet and peaceable possession of the said parties of the
second part, as joint tenants, against all and every person or persons lawfully claiming the whole or any
part thereof they will forever WARRANT AND DEFEND.
In Mitntoo MDtrtot, the said part ie s of the first part have hereunto set their hands and
seal this 21st day of May ,19 74 .
Signed, Sealed and Delivered in Presence of (Seal)
Henr F. nee _
JClarice M. Lange
ace Wakeling
(Seal)
(Seal)
Harry E. Eliason
Minnesota
Matt 0t7J rXMPr,
SS.
Washington County.
On this the 21st day of May , 19 74, before
me, a Notary Public , the undersigned offircer, personally
appeared Henry F. Lange and Clarice M. Langeknown (or satisfactorily proven) to be the
person s whose namO subscribed to the within instrument and acknowledged that t heY executed
the same for the purposes therein contained.
In witness whereof I hereunto set my hand and official seal.
Harry E. Eliason _
HARRY E. EIIASON Minnesota
NOTARY PUBLIC - MINNESOTA
WASHINGTON coUNTY Notary Public, Washington CountyXi~flaz
Ity CM-ISelan Uplm July 26. I9BO
y
IF
y Commission expires July 26 19 74
(To be filled In if si¢ned by a Notary Public.)
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(N.B. -M 69 Wis. Sato. provides &Mt all anetrosento to be reeorded shall have plainly printed or typewritten thereon the names of the Grantors, j
`ranteas, witnesses and notary.)
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